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USMLE Step3 Surgery

Subjects : health-sciences, usmle-step-3

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Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. How to manage a patient with asystole
If they are given excess glucose; glucose produces more C02 for each liter of 02 than other two nutrients; excessive C02 causes hypercapnia; weaning from ventilation will be difficult
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Epi and chest compressio for prolong period of time; atropine is given after epi;
Next best step surgery; not ultrasound

2. midline neck swelling moves with protrusion of tongue
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Amoxicillin-clavulanate
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

3. SOB - confusion - petechial rash after trauma - fracture
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Less than 5mm
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

4. xray finding of stress fx after 3-4w
Cystic scrotal fluid collection between parietal and visceral layers of testis
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

5. painless testicular mass in young male
Malignancy until proven otherwise
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Carpal tunnel syndrom
Check ET tube placement if correct needle decompresion

6. SAH due to posterior inferior cerebellar aneurysm
S2-S4
Headache - ataxia - bulbar dysfunction
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

7. antibiotics of acute cholecystitis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Unilateral vocal cord paralysis
Simple breast mass - well circumscribed disappear with aspiraiton; complex cyst; thick walled contain both solid and cystic materials; may need core biopy; solid mass-mostly fibroadenoma-f/you us and biopsy in 6m

8. 3 mo with groin bulge; bulge appears when child cries
Low anterior resection and radio; add chemo if node positive
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Dm neuropathy; stocking glove pattern

9. What is prehn sign?
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
ACL injury

10. diarrhoea 4-5 days after cholecystectomy
Simple breast mass - well circumscribed disappear with aspiraiton; complex cyst; thick walled contain both solid and cystic materials; may need core biopy; solid mass-mostly fibroadenoma-f/you us and biopsy in 6m
Ant drawer test; foot placed on exam table; both hand behind knee to push it anteriorly; a difference of 1 cm compared with the opposite side suggests complete ACL tear
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

11. managment of animal bite in hands
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Irrigated with normal saline; all deviatlized tissues need to debrided; plain xray to see if there is any FB; wound will be left open and examined for any signs of infection;
Mammogram
MAT; medial meniscus injury; ACL and Tibial colateral ligament

12. aspiration of breast cyst is bloody
Mammogram
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Less than 5mm
ACL injury

13. What types of breast implants are available
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Saline and silicone

14. severe pain in leg after MVC
Acute comparment syndrome; increased pain with passive movement of involved muscles; early sensory impairment-decreased vibration sense - two point discrimination - numbness and hypoesthesia; late feature-absent distant pulses
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

15. diarrhoea after gastric bypass
Dumping syndrome; small and frequent meals; no simple sugar
Unilateral vocal cord paralysis
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

16. When to stop raloxifene before surgery
Carpal tunnel syndrom
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
When urethral catherization is unsuccessful

17. how ABI help dx of PVD
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Subphrenic abscess or other abdominal abscesses; order US or CT
ACL injury

18. complication displaced or communited distal radial fx
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
ACL injury
Ant drawer test; foot placed on exam table; both hand behind knee to push it anteriorly; a difference of 1 cm compared with the opposite side suggests complete ACL tear
Carpal tunnel syndrom

19. varicocele
ACL injury
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Cystic scrotal fluid collection between parietal and visceral layers of testis

20. What is terrible triad
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
MAT; medial meniscus injury; ACL and Tibial colateral ligament

21. Why varicocele more common in the left side
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
If they are given excess glucose; glucose produces more C02 for each liter of 02 than other two nutrients; excessive C02 causes hypercapnia; weaning from ventilation will be difficult
SAH due to post communicating artery aneurysm;

22. Why right varicocele is more concerning?

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23. management of hip fracture
If patient ambulatory - surgery and pain control; if not nonop mx
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Elderly and critically ill patients

24. Can we use beta blocker for pvd?
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Twisting force with the foot fixed on the ground seen in football and basketball games;
Study showed no adverse effect; but they are contraindicated for PVD

25. popping sensation; rapid onset of knee effusion. athelet
ACL injury
L5 to S2
Strok and traumatic brain injury
Pulmonary contusion; p/w dyspenoea - tachypnoea - hypoxemia - hemoptysis; decreased breath sound in the affected site; cxr homogenous opacification; mild cases resolve in 3-5 days

26. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
10-12 months
MAT; medial meniscus injury; ACL and Tibial colateral ligament

27. management of gunshot wound
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Epi and chest compressio for prolong period of time; atropine is given after epi;
Pt hemodynamically stable and no sign of peritonitis: Ct scan ;unstable with sign of peritonitis - possible organ evicsceration (blood in urine) immediate laparatomy; most patients go for laparotomy

28. How varicocele causes testicular atrophy
Ant drawer test; foot placed on exam table; both hand behind knee to push it anteriorly; a difference of 1 cm compared with the opposite side suggests complete ACL tear
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Meniscus injury; medial most common; pain/swelling; popping sensation
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

29. What percent of anal abscess deveolop fisutula
Retrograde ejaculation
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
50%; tunneling between rectum or kin
Unilateral vocal cord paralysis

30. When goiter needs surgery
Acute comparment syndrome; increased pain with passive movement of involved muscles; early sensory impairment-decreased vibration sense - two point discrimination - numbness and hypoesthesia; late feature-absent distant pulses
Ispilateral hypoglossal nerve injury
If any compressive symptoms eg. dysphagia
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

31. What is most common lung injury after blunt chest trauma?
Pulmonary contusion; p/w dyspenoea - tachypnoea - hypoxemia - hemoptysis; decreased breath sound in the affected site; cxr homogenous opacification; mild cases resolve in 3-5 days
Pt hemodynamically stable and no sign of peritonitis: Ct scan ;unstable with sign of peritonitis - possible organ evicsceration (blood in urine) immediate laparatomy; most patients go for laparotomy
Amoxicillin-clavulanate
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

32. ct scan; cystic lesion in head of pancreas; next step
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Unilateral vocal cord paralysis
Helps to dissolve GB cholesterol stone; slowly dissolve in 3 years - symptoms relief in 3 months; for symptomatic gall stones who are poor candidate for surgery

33. acute colonic ischemia
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Abd pain and tenderness; bloody diarrhoea or hematochezia

34. cremasteric reflex test?
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
When phosphate levels fall below 1.0; 30% of patient on TPN has this prob; patient develop respiratory weakness - hemolysis - impaired oxygen release from Hb;

35. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Dm neuropathy; stocking glove pattern
Displaced ORIF ; nondisplaced sling immobilization

36. dumping syndrome after gastrectomy
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Right varicocele drains to inferior vena cava; unless patient has obstrction of inf vena cava by intra abdominal mass or big clot from DVT - varicocele doesn't occur; do ct scan to eval caUse of rt varicocele
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
15-40%; self limiting;doesn't require tx

37. perioral numbness after parathyroidectomy
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Hypocalcemia; other signs are muscle cramps - carpopedal spasm; postive chvostek sign (ipsilateral contraction of facial muscles on tapping the angle of jaw) trousseau sign (rapid carpopedal spasm on occlusion of blood supply to upper extremity
Seminomas
Fx displace >1mm - nonunion during followup - osteonecrosis

38. Incidence of AF in CABG patient

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39. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Look at pupil; are they small; check ABG; most likely respiratory acidosis due to opioids used for postop pain control; morphine decreases central chemoreceptor sensitivity to C02; although patient has rising C02 his respiratory drive is not working
Subphrenic abscess or other abdominal abscesses; order US or CT
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

40. dorsiflexion and planter flexion
Pure motor stroke; limited neurological dysfunction
L5 to S2
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Urethral stricture; pelvic of urethral trauma

41. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Look at pupil; are they small; check ABG; most likely respiratory acidosis due to opioids used for postop pain control; morphine decreases central chemoreceptor sensitivity to C02; although patient has rising C02 his respiratory drive is not working
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

42. Tx of pulmonary contusion
BMI<40 for low risk patient and >35 ofr high risk with obesity related comorbidites like OSA - OA - LBP - HTN - HLD; BMI >35 have high risk of complications and need to be managed aggresssively;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Irrigated with normal saline; all deviatlized tissues need to debrided; plain xray to see if there is any FB; wound will be left open and examined for any signs of infection;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

43. first line of management of PVD
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
If patient ambulatory - surgery and pain control; if not nonop mx
Progressive fibrosis of palmar fascia. etiololgy not known;

44. tx distal rectal ca
Strok and traumatic brain injury
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Sphincter sparing surgery (local resection) - abdomnio perineal resection
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

45. types of hip fracture
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
L5 to S2

46. Patient underwent CABG; postoperatively drowsy. most likely cause?
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Look at pupil; are they small; check ABG; most likely respiratory acidosis due to opioids used for postop pain control; morphine decreases central chemoreceptor sensitivity to C02; although patient has rising C02 his respiratory drive is not working
Epi and chest compressio for prolong period of time; atropine is given after epi;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

47. How to manage obesity
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
ACL injury
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

48. differential of ultrasound finding of breast mass
Simple breast mass - well circumscribed disappear with aspiraiton; complex cyst; thick walled contain both solid and cystic materials; may need core biopy; solid mass-mostly fibroadenoma-f/you us and biopsy in 6m
Thompson test; squeeszing of calf muscle cause plantar flexion; absence confirms dx; absence of active plantar flexion not reliable since patient can use accessory muscles
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
CRPS

49. swelling and tenderness in anterior part of knee
Patellar tendon tear; difficulty in extension
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Progressive fibrosis of palmar fascia. etiololgy not known;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

50. transrectal prostate biopsy
Nonunion and avascular necrosis; fx can block blood supply;
Urethral stricture; pelvic of urethral trauma
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
L5 to S2

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USMLE Step3 Surgery

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