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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. painless testicular mass in young male
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
Malignancy until proven otherwise
Twisting force with the foot fixed on the ground seen in football and basketball games;

2. Complications of breast impant
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Mammogram
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

3. Valgus and Varus tests
SAH due to post communicating artery aneurysm;
Pure motor stroke; limited neurological dysfunction
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

4. Why ruq calcificaion is concerning
Even after ochiopexy risk of ochiopexy higher then general population
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

5. how ABI help dx of PVD
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

6. What is hungry bone syndrome?
If patient ambulatory - surgery and pain control; if not nonop mx
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
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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

7. when scaphoid fx patient needs to be referred to orthopedic
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Elevated non seminomas
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Fx displace >1mm - nonunion during followup - osteonecrosis

8. 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)
Ispilateral hypoglossal nerve injury
Amoxicillin-clavulanate
24-48 hours of supportive therapy followed by cholecystectomy

9. complications of TPN
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Pure motor stroke; limited neurological dysfunction

10. What is terrible triad
SAH due to post communicating artery aneurysm;
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

11. Tx of pulmonary contusion
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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

12. severe pain in leg after MVC
Next best step surgery; not ultrasound
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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
Mammogram

13. cremasteric reflex test?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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

14. stress fx
Klinefelter syndrome; 50 fold increase;
Ampicillin sublactum - pipercillin - ceftriaxone and metro
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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

15. ipsilateral deviation of tongue upon protrusion
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Ispilateral hypoglossal nerve injury
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

16. How to manage obesity
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
CRPS
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

17. pregnant patient with asymptomatic gall stones
Less than 5mm
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Progressive fibrosis of palmar fascia. etiololgy not known;
If patient ambulatory - surgery and pain control; if not nonop mx

18. What types of breast implants are available
Fx displace >1mm - nonunion during followup - osteonecrosis
If patient ambulatory - surgery and pain control; if not nonop mx
Next best step surgery; not ultrasound
Saline and silicone

19. inhalation of hot air - steam - smoke in burn victim
Supraglottic edema; low threshold for intubation
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Nonunion and avascular necrosis; fx can block blood supply;
Even after ochiopexy risk of ochiopexy higher then general population

20. How to differentiate communicative and non-communicative hydrocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity
ACL injury
Check ET tube placement if correct needle decompresion
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

21. SOB - confusion - petechial rash after trauma - fracture
Dm neuropathy; stocking glove pattern
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

22. How to differentiate ACL and meniscus injury
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
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

23. How to confirm achiles tendon rupture
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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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

24. When goiter needs surgery
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
If any compressive symptoms eg. dysphagia
Twisting force with the foot fixed on the ground seen in football and basketball games;
Subphrenic abscess or other abdominal abscesses; order US or CT

25. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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

26. managment of animal bite in hands
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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;
Saline and silicone
Tendons more likely

27. conservative Tx of varicose veins
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
SAH due to post communicating artery aneurysm;
Compression stocking - weight reduction - leg elevation
Strok and traumatic brain injury

28. lacerated wound in palmer surface of hand. what structure is injured?
Tendons more likely
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

29. aspiration of breast cyst is nonbloody
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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

30. What percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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
Pure motor stroke; limited neurological dysfunction

31. midline neck swelling moves with protrusion of tongue
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Klinefelter syndrome; 50 fold increase;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

32. acalculus cholecystitis
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Elderly and critically ill patients
Tendons more likely

33. Most common of sudden death due to steering wheel 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
50%; tunneling between rectum or kin
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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

34. most common fx when falling on outsretched hand
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Increased size during the day and valsalva means it is communicated with peritoneal cavity
When urethral catherization is unsuccessful
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

35. When patient can go back to sports after clavicle fx
Pure motor stroke; limited neurological dysfunction
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Meniscus injury; medial most common; pain/swelling; popping sensation
4-6 weeks for noncontact sports and longer time for contact sports

36. cremasteric reflex
Less than 5mm
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Dm neuropathy; stocking glove pattern
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

38. What are the common injuries from lightning?
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
If patient ambulatory - surgery and pain control; if not nonop mx

39. how hyperventilation lowers ICP
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
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
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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

40. antibiotics of acute cholecystitis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

41. How mcmurray manuver perform
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

42. management of hip fracture
Less than 5mm
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
If patient ambulatory - surgery and pain control; if not nonop mx
Amoxicillin-clavulanate

43. beta HCG
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Seminomas
Twisting force with the foot fixed on the ground seen in football and basketball games;

44. What is the complications of undescended testis
Even after ochiopexy risk of ochiopexy higher then general population
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Supraglottic edema; low threshold for intubation

45. ct scan; cystic lesion in head of pancreas; next step
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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
S2-S4
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

46. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
15-40%; self limiting;doesn't require tx

47. mx of stress fx
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
L5 to S2
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

48. 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
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

49. management of gunshot wound
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

50. What time frame required for bone remodeling
Supraglottic edema; low threshold for intubation
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
10-12 months
Malignancy until proven otherwise

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USMLE Step3 Surgery

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