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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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1. What is cushing's triad
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Nonunion and avascular necrosis; fx can block blood supply;
Brardycardia - HTN - resp depression
Sphincter sparing surgery (local resection) - abdomnio perineal resection

2. stress fx
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Less than 5mm
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

3. clavicle fx
10-12 months
Displaced ORIF ; nondisplaced sling immobilization
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
CRPS

4. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
SAH due to post communicating artery aneurysm;
50%; tunneling between rectum or kin
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Increased size during the day and valsalva means it is communicated with peritoneal cavity

5. surgery for acute cholecystities
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
24-48 hours of supportive therapy followed by cholecystectomy

6. painless testicular mass in young male
Malignancy until proven otherwise
Low anterior resection and radio; add chemo if node positive
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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;

7. SAH due to posterior inferior cerebellar aneurysm
Headache - ataxia - bulbar dysfunction
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
It can take up to 2 weeks to show fx; if high clinical suspicion MRI is ideal test when xray neg - which differentiate ligament injury vs bone fx
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

8. suprapubic catheterization
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
When urethral catherization is unsuccessful
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

9. Why right varicocele is more concerning?

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10. How to dx ACL tear?
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Unilateral vocal cord paralysis
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
Cystic scrotal fluid collection between parietal and visceral layers of testis

11. aspiration of breast cyst is nonbloody
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Amoxicillin-clavulanate
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Supraglottic edema; low threshold for intubation

12. When patient can go back to sports after clavicle fx
4-6 weeks for noncontact sports and longer time for contact sports
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Seminomas
Next best step surgery; not ultrasound

13. Incidence of AF in CABG patient

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14. recurrent laryngeal nerve injury
Low anterior resection and radio; add chemo if node positive
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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;
Unilateral vocal cord paralysis

15. what size of ureteral stone for non op mx
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
Less than 5mm
If any compressive symptoms eg. dysphagia
Unilateral vocal cord paralysis

16. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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
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;

17. when scaphoid fx patient needs to be referred to orthopedic
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Amoxicillin-clavulanate
Fx displace >1mm - nonunion during followup - osteonecrosis

18. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Brardycardia - HTN - resp depression
Strok and traumatic brain injury
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

19. Can we use beta blocker for pvd?
Study showed no adverse effect; but they are contraindicated for PVD
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

20. How to evaluate painless testicular swelling suspicious for cancer
ACL injury
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

21. SOB - confusion - petechial rash after trauma - fracture
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Low anterior resection and radio; add chemo if node positive

22. DD of acute scrotal pain
Even after ochiopexy risk of ochiopexy higher then general population
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

23. management of nondisplaced scaphoid fx
Brardycardia - HTN - resp depression
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
It can take up to 2 weeks to show fx; if high clinical suspicion MRI is ideal test when xray neg - which differentiate ligament injury vs bone fx

24. aspiration of breast cyst is bloody
Mammogram
Cystic scrotal fluid collection between parietal and visceral layers of testis
Tendons more likely
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

25. antibiotics of acute cholecystitis
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Ampicillin sublactum - pipercillin - ceftriaxone and metro

26. how ABI help dx of PVD
MAT; medial meniscus injury; ACL and Tibial colateral ligament
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

27. What time frame required for bone remodeling
Compression stocking - weight reduction - leg elevation
Amoxicillin-clavulanate
Fx displace >1mm - nonunion during followup - osteonecrosis
10-12 months

28. Why ruq calcificaion is concerning
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
4-6 weeks for noncontact sports and longer time for contact sports
Headache - ataxia - bulbar dysfunction
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

29. scrotal trauma
Strok and traumatic brain injury
Meniscus injury; medial most common; pain/swelling; popping sensation
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Next best step surgery; not ultrasound

30. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Subphrenic abscess or other abdominal abscesses; order US or CT
Next best step surgery; not ultrasound
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

31. Dupuytren contracture
Progressive fibrosis of palmar fascia. etiololgy not known;
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Fx displace >1mm - nonunion during followup - osteonecrosis
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

32. When to stop raloxifene before surgery
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Dumping syndrome; small and frequent meals; no simple sugar

33. management of hip fracture
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
If patient ambulatory - surgery and pain control; if not nonop mx
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Saline and silicone

34. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Mammogram
50%; tunneling between rectum or kin
Meniscus injury; medial most common; pain/swelling; popping sensation
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

35. anal sphincter tone
Elderly and critically ill patients
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
S2-S4
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

36. varicose veins with ulcer - bleeding and thrombophlebitits
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Dumping syndrome; small and frequent meals; no simple sugar
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;

37. complication displaced or communited distal radial fx
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Meniscus; tenderness medial side of knee - it takes 24hours to form effusion; effusion not bloody; ACL: rapid effusion - most serious form of knee injury; profound pain - inability to ambulate ; popping sensation in both cases
Carpal tunnel syndrom

38. What are the common injuries from lightning?
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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
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

39. mx of stress fx
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
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;
Elevated non seminomas

40. What is the complications of undescended testis
Even after ochiopexy risk of ochiopexy higher then general population
Retrograde ejaculation
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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

41. cremasteric reflex
Subphrenic abscess or other abdominal abscesses; order US or CT
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

42. transrectal prostate biopsy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Compression stocking - weight reduction - leg elevation
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

43. How mcmurray manuver perform
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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;

44. How to confirm achiles tendon rupture
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
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;
Retrograde ejaculation
Increased size during the day and valsalva means it is communicated with peritoneal cavity

45. types of hip fracture
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Carpal tunnel syndrom

46. most common fx when falling on outsretched hand
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Meniscus; tenderness medial side of knee - it takes 24hours to form effusion; effusion not bloody; ACL: rapid effusion - most serious form of knee injury; profound pain - inability to ambulate ; popping sensation in both cases
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

47. lacerated wound in palmer surface of hand. what structure is injured?
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
Tendons more likely
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

48. Why varicocele more common in the left side
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Next best step surgery; not ultrasound
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

49. lacunar stroke
Pure motor stroke; limited neurological dysfunction
Strok and traumatic brain injury
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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

50. What is the strongest risk factor for male breast cancer
Epi and chest compressio for prolong period of time; atropine is given after epi;
MAT; medial meniscus injury; ACL and Tibial colateral ligament
If patient ambulatory - surgery and pain control; if not nonop mx
Klinefelter syndrome; 50 fold increase;

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USMLE Step3 Surgery

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