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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. 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)
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
ACL injury

2. Dupuytren contracture
Progressive fibrosis of palmar fascia. etiololgy not known;
Brardycardia - HTN - resp depression
Check ET tube placement if correct needle decompresion
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

3. recurrent laryngeal nerve injury
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Tendons more likely
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Unilateral vocal cord paralysis

4. inhalation of hot air - steam - smoke in burn victim
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
Supraglottic edema; low threshold for intubation
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
Mammogram

5. When to do surgery in undesceneded testis?
Brardycardia - HTN - resp depression
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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;

6. How mcmurray manuver perform
If patient ambulatory - surgery and pain control; if not nonop mx
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

7. what size of ureteral stone for non op mx
Mammogram
Less than 5mm
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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;

8. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Meniscus injury; medial most common; pain/swelling; popping sensation
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

9. 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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Klinefelter syndrome; 50 fold increase;
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

10. What percent of anal abscess deveolop fisutula
S2-S4
Meniscus injury; medial most common; pain/swelling; popping sensation
Dumping syndrome; small and frequent meals; no simple sugar
50%; tunneling between rectum or kin

11. Valgus and Varus tests
Amoxicillin-clavulanate
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

12. Complications of breast impant
Dumping syndrome; small and frequent meals; no simple sugar
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Headache - ataxia - bulbar dysfunction
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

13. acute colonic ischemia
Abd pain and tenderness; bloody diarrhoea or hematochezia
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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

14. indication of ursodeoxycholic acid
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Brardycardia - HTN - resp depression
Saline and silicone
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

15. suprapubic catheterization
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
When urethral catherization is unsuccessful
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
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

16. anal sphincter tone
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
S2-S4
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

17. managment of animal bite in hands
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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

18. how ABI help dx of PVD
10-12 months
Nonunion and avascular necrosis; fx can block blood supply;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Tendons more likely

19. common complication of inadequate mx of scaphoid fx
Klinefelter syndrome; 50 fold increase;
Nonunion and avascular necrosis; fx can block blood supply;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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

20. complication displaced or communited distal radial fx
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
When urethral catherization is unsuccessful
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Carpal tunnel syndrom

21. differential of ultrasound finding of breast mass
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Cystic scrotal fluid collection between parietal and visceral layers of testis
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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

22. How varicocele causes testicular atrophy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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
Nonunion and avascular necrosis; fx can block blood supply;

23. Tx of pulmonary contusion
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
SAH due to post communicating artery aneurysm;
Cystic scrotal fluid collection between parietal and visceral layers of testis

24. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Meniscus injury; medial most common; pain/swelling; popping sensation
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

25. how hyperventilation lowers ICP
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Epi and chest compressio for prolong period of time; atropine is given after epi;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

26. When to stop raloxifene before surgery
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

27. characteristics of ureteral stone?
Patellar tendon tear; difficulty in extension
When urethral catherization is unsuccessful
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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

28. How to differentiate communicative and non-communicative hydrocele
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Dumping syndrome; small and frequent meals; no simple sugar
Retrograde ejaculation
Increased size during the day and valsalva means it is communicated with peritoneal cavity

29. How to dx ACL tear?
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Elevated non seminomas
Strok and traumatic brain injury

30. midline neck swelling moves with protrusion of tongue
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Sphincter sparing surgery (local resection) - abdomnio perineal resection
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

31. lacerated wound in palmer surface of hand. what structure is injured?
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Subphrenic abscess or other abdominal abscesses; order US or CT
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Tendons more likely

32. beta hcg and AFP
Next best step surgery; not ultrasound
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Elevated non seminomas
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

33. Why initial xrays are negative in scaphoid fx
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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

34. What types of breast implants are available
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
Saline and silicone
Urethral stricture; pelvic of urethral trauma

35. What is hydrocele?
Urethral stricture; pelvic of urethral trauma
L5 to S2
Cystic scrotal fluid collection between parietal and visceral layers of testis
Meniscus injury; medial most common; pain/swelling; popping sensation

36. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Ispilateral hypoglossal nerve injury
Compression stocking - weight reduction - leg elevation

37. Why ruq calcificaion is concerning
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Twisting force with the foot fixed on the ground seen in football and basketball games;

38. beta HCG
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
CRPS
4-6 weeks for noncontact sports and longer time for contact sports
Seminomas

39. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
If patient ambulatory - surgery and pain control; if not nonop mx
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
If any compressive symptoms eg. dysphagia
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

40. What are the common injuries from lightning?
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Brardycardia - HTN - resp depression
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

41. diarrhoea after gastric bypass
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
S2-S4
Dumping syndrome; small and frequent meals; no simple sugar

42. What is the strongest risk factor for male breast cancer
Subphrenic abscess or other abdominal abscesses; order US or CT
Klinefelter syndrome; 50 fold increase;
Displaced ORIF ; nondisplaced sling immobilization
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

43. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS
Progressive fibrosis of palmar fascia. etiololgy not known;
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

44. perioral numbness after parathyroidectomy
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Less than 5mm
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

45. prostate enlarged - nontender - no nodularity - elevated PSA
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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

46. How to confirm achiles tendon rupture
Abd pain and tenderness; bloody diarrhoea or hematochezia
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Mammogram

47. when scaphoid fx patient needs to be referred to orthopedic
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Fx displace >1mm - nonunion during followup - osteonecrosis
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

48. scrotal trauma
Check ET tube placement if correct needle decompresion
Next best step surgery; not ultrasound
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

49. transrectal prostate biopsy
Fx displace >1mm - nonunion during followup - osteonecrosis
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
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

50. mx of stress fx
Mammogram
Retrograde ejaculation
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
L5 to S2

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USMLE Step3 Surgery

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