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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. 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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Twisting force with the foot fixed on the ground seen in football and basketball games;

2. recurrent laryngeal nerve injury
MAT; medial meniscus injury; ACL and Tibial colateral ligament
ACL injury
Unilateral vocal cord paralysis
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

3. management of nondisplaced scaphoid fx
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Abd pain and tenderness; bloody diarrhoea or hematochezia
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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. cat/dog bites
Check ET tube placement if correct needle decompresion
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
10-12 months
Amoxicillin-clavulanate

5. How to differentiate communicative and non-communicative hydrocele
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Increased size during the day and valsalva means it is communicated with peritoneal cavity

6. How mcmurray manuver perform
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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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
Tendons more likely

7. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Subphrenic abscess or other abdominal abscesses; order US or CT
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

8. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Patellar tendon tear; difficulty in extension
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

9. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
SAH due to post communicating artery aneurysm;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

10. What is most common lung injury after blunt chest trauma?
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

11. ct scan; cystic lesion in head of pancreas; next step
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Compression stocking - weight reduction - leg elevation

12. When do we see complications due to hypophosphatemia
Ispilateral hypoglossal nerve injury
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;
Check ET tube placement if correct needle decompresion
10-12 months

13. menisci injury
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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;
Supraglottic edema; low threshold for intubation
Twisting force with the foot fixed on the ground seen in football and basketball games;

14. varicocele
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

15. first step for evaluation of testicular swelling
Mammogram
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

16. Complications of breast impant
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Brardycardia - HTN - resp depression
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

17. painless testicular mass in young male
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Compression stocking - weight reduction - leg elevation
Amoxicillin-clavulanate
Malignancy until proven otherwise

18. managment of animal bite in hands
CRPS
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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;

19. dumping syndrome after gastrectomy
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

20. DD of acute scrotal pain
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

21. several knee pain after being tackled in football game
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Supraglottic edema; low threshold for intubation
If patient ambulatory - surgery and pain control; if not nonop mx
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

22. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
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;
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;
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

23. most frequent complication of TURP
Retrograde ejaculation
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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
Elderly and critically ill patients

24. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
ACL injury
Elderly and critically ill patients
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

25. How to perform lachman test
When urethral catherization is unsuccessful
ACL injury
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

26. How to manage a patient with asystole
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
Cystic scrotal fluid collection between parietal and visceral layers of testis
Even after ochiopexy risk of ochiopexy higher then general population
Epi and chest compressio for prolong period of time; atropine is given after epi;

27. most common complication of acute cholecystitis
Epi and chest compressio for prolong period of time; atropine is given after epi;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Subphrenic abscess or other abdominal abscesses; order US or CT

28. severe pain in leg after MVC
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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
15-40%; self limiting;doesn't require tx

29. acute colonic ischemia
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Abd pain and tenderness; bloody diarrhoea or hematochezia
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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

30. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
24-48 hours of supportive therapy followed by cholecystectomy
Malignancy until proven otherwise
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Meniscus injury; medial most common; pain/swelling; popping sensation

31. how hyperventilation lowers ICP
Fx displace >1mm - nonunion during followup - osteonecrosis
Supraglottic edema; low threshold for intubation
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
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

32. aspiration of breast cyst is bloody
Even after ochiopexy risk of ochiopexy higher then general population
Mammogram
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Patellar tendon tear; difficulty in extension

33. 27 yo with scrotal mass; warm tender testes feel like bag of worms
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
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Patellar tendon tear; difficulty in extension
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

34. acalculus cholecystitis
Elderly and critically ill patients
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Headache - ataxia - bulbar dysfunction
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

35. tx distal rectal ca
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
Sphincter sparing surgery (local resection) - abdomnio perineal resection
ACL injury
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

36. What is hungry bone syndrome?
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
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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
Next best step surgery; not ultrasound

37. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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

38. 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
Low anterior resection and radio; add chemo if node positive
Patellar tendon tear; difficulty in extension
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

39. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Headache - ataxia - bulbar dysfunction
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

40. dorsiflexion and planter flexion
Dumping syndrome; small and frequent meals; no simple sugar
Abd pain and tenderness; bloody diarrhoea or hematochezia
L5 to S2
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. scrotal trauma
Next best step surgery; not ultrasound
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
Subphrenic abscess or other abdominal abscesses; order US or CT
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

42. What is hydrocele?
10-12 months
Even after ochiopexy risk of ochiopexy higher then general population
Cystic scrotal fluid collection between parietal and visceral layers of testis
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

43. What is terrible triad
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
Compression stocking - weight reduction - leg elevation
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament

44. what size of ureteral stone for non op mx
Abd pain and tenderness; bloody diarrhoea or hematochezia
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Less than 5mm
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

45. How to confirm dx of compartment syndrom
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Low anterior resection and radio; add chemo if node positive
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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

46. diarrhoea after gastric bypass
Dumping syndrome; small and frequent meals; no simple sugar
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Malignancy until proven otherwise
ACL injury

47. common complication of inadequate mx of scaphoid fx
Elderly and critically ill patients
Subphrenic abscess or other abdominal abscesses; order US or CT
Nonunion and avascular necrosis; fx can block blood supply;
Epi and chest compressio for prolong period of time; atropine is given after epi;

48. What is the strongest risk factor for male breast cancer
Klinefelter syndrome; 50 fold increase;
Subphrenic abscess or other abdominal abscesses; order US or CT
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
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

49. mx of stress fx
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

50. suprapubic catheterization
Twisting force with the foot fixed on the ground seen in football and basketball games;
When urethral catherization is unsuccessful
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
15-40%; self limiting;doesn't require tx

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USMLE Step3 Surgery

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