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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
Twisting force with the foot fixed on the ground seen in football and basketball games;
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
Epi and chest compressio for prolong period of time; atropine is given after epi;
ACL injury

2. how ABI help dx of PVD
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Malignancy until proven otherwise
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

3. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

4. What is cushing's triad
Seminomas
Pure motor stroke; limited neurological dysfunction
4-6 weeks for noncontact sports and longer time for contact sports
Brardycardia - HTN - resp depression

5. management of hip fracture
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
If patient ambulatory - surgery and pain control; if not nonop mx
Amoxicillin-clavulanate
MAT; medial meniscus injury; ACL and Tibial colateral ligament

6. What is hydrocele?
S2-S4
Cystic scrotal fluid collection between parietal and visceral layers of testis
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Epi and chest compressio for prolong period of time; atropine is given after epi;

7. SOB - confusion - petechial rash after trauma - fracture
Urethral stricture; pelvic of urethral trauma
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

8. lacerated wound in palmer surface of hand. what structure is injured?
Dumping syndrome; small and frequent meals; no simple sugar
If any compressive symptoms eg. dysphagia
24-48 hours of supportive therapy followed by cholecystectomy
Tendons more likely

9. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
SAH due to post communicating artery aneurysm;
Pure motor stroke; limited neurological dysfunction
50%; tunneling between rectum or kin
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

10. Tx of pulmonary contusion
ACL injury
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
If any compressive symptoms eg. dysphagia

11. varicose veins with ulcer - bleeding and thrombophlebitits
Study showed no adverse effect; but they are contraindicated for PVD
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Retrograde ejaculation

12. complications of TPN
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

13. Complications of breast impant
24-48 hours of supportive therapy followed by cholecystectomy
Study showed no adverse effect; but they are contraindicated for PVD
SAH due to post communicating artery aneurysm;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

14. cremasteric reflex test?
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Abd pain and tenderness; bloody diarrhoea or hematochezia
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

15. What time frame required for bone remodeling
Check ET tube placement if correct needle decompresion
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
10-12 months
Low anterior resection and radio; add chemo if node positive

16. mx of stress fx
10-12 months
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Saline and silicone
Strok and traumatic brain injury

17. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Pure motor stroke; limited neurological dysfunction
ACL injury
Subphrenic abscess or other abdominal abscesses; order US or CT

18. pregnant patient with asymptomatic gall stones
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;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

19. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
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;
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

20. How to confirm dx of compartment syndrom
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
S2-S4
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
ACL injury

21. How to differentiate communicative and non-communicative hydrocele
Saline and silicone
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Progressive fibrosis of palmar fascia. etiololgy not known;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

22. How mcmurray manuver perform
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

23. painless testicular mass in young male
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
Cystic scrotal fluid collection between parietal and visceral layers of testis
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Malignancy until proven otherwise

24. ct scan; cystic lesion in head of pancreas; next step
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;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Headache - ataxia - bulbar dysfunction
L5 to S2

25. what size of ureteral stone for non op mx
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
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;
Less than 5mm

26. sudden onset of postoperative hyperglycemia when patient on TPN
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Patellar tendon tear; difficulty in extension
Pure motor stroke; limited neurological dysfunction

27. How to manage obesity
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Study showed no adverse effect; but they are contraindicated for PVD
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

28. When goiter needs surgery
Study showed no adverse effect; but they are contraindicated for PVD
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
Unilateral vocal cord paralysis
If any compressive symptoms eg. dysphagia

29. When patient can go back to sports after clavicle fx
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
4-6 weeks for noncontact sports and longer time for contact sports
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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;

30. transrectal prostate biopsy
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
MAT; medial meniscus injury; ACL and Tibial colateral ligament
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

31. complication displaced or communited distal radial fx
Epi and chest compressio for prolong period of time; atropine is given after epi;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Carpal tunnel syndrom

32. inhalation of hot air - steam - smoke in burn victim
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Supraglottic edema; low threshold for intubation
Progressive fibrosis of palmar fascia. etiololgy not known;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

33. Why ruq calcificaion is concerning
Mammogram
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

34. severe pain in leg after MVC
4-6 weeks for noncontact sports and longer time for contact sports
Check ET tube placement if correct needle decompresion
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament

35. types of hip fracture
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery

36. managment of animal bite in hands
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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;

37. acute colonic ischemia
Abd pain and tenderness; bloody diarrhoea or hematochezia
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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
When urethral catherization is unsuccessful

38. When to stop raloxifene before surgery
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;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

39. first line of management of PVD
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Increased size during the day and valsalva means it is communicated with peritoneal cavity

40. What types of breast implants are available
Subphrenic abscess or other abdominal abscesses; order US or CT
Check ET tube placement if correct needle decompresion
Saline and silicone
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;

41. tx distal rectal ca
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Sphincter sparing surgery (local resection) - abdomnio perineal resection

42. ipsilateral deviation of tongue upon protrusion
ACL injury
Patellar tendon tear; difficulty in extension
Ispilateral hypoglossal nerve injury
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

43. differential of ultrasound finding of breast mass
Amoxicillin-clavulanate
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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

44. swelling and tenderness in anterior part of knee
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
10-12 months
Tendons more likely
Patellar tendon tear; difficulty in extension

45. Incidence of AF in CABG patient

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46. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Abd pain and tenderness; bloody diarrhoea or hematochezia
Patellar tendon tear; difficulty in extension
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
S2-S4

47. menisci injury
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
Amoxicillin-clavulanate
Twisting force with the foot fixed on the ground seen in football and basketball games;
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;

48. aspiration of breast cyst is bloody
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Pure motor stroke; limited neurological dysfunction
Mammogram
10-12 months

49. suprapubic catheterization
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
Low anterior resection and radio; add chemo if node positive
When urethral catherization is unsuccessful
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

50. How to differentiate ACL and meniscus injury
Retrograde ejaculation
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
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

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USMLE Step3 Surgery

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