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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. ct scan; cystic lesion in head of pancreas; next step
S2-S4
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
When urethral catherization is unsuccessful
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

2. transrectal prostate biopsy
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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 prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

3. management of nondisplaced scaphoid fx
When urethral catherization is unsuccessful
Pure motor stroke; limited neurological dysfunction
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

4. first line of management of PVD
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
50%; tunneling between rectum or kin

5. aspiration of breast cyst is nonbloody
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Less than 5mm
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

6. inhalation of hot air - steam - smoke in burn victim
Even after ochiopexy risk of ochiopexy higher then general population
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Supraglottic edema; low threshold for intubation
Seminomas

7. differential of ultrasound finding of breast mass
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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;
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
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

8. anal sphincter tone
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
Patellar tendon tear; difficulty in extension
Tendons more likely
S2-S4

9. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Strok and traumatic brain injury
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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;

10. how hyperventilation lowers ICP
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
If any compressive symptoms eg. dysphagia
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

11. Can we use beta blocker for pvd?
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Elderly and critically ill patients
If patient ambulatory - surgery and pain control; if not nonop mx
Study showed no adverse effect; but they are contraindicated for PVD

12. surgery for acute cholecystities
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
24-48 hours of supportive therapy followed by cholecystectomy
Brardycardia - HTN - resp depression
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

13. when scaphoid fx patient needs to be referred to orthopedic
Fx displace >1mm - nonunion during followup - osteonecrosis
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
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
Brardycardia - HTN - resp depression

14. What is the contraindication of hyperventilation in inc ICP
SAH due to post communicating artery aneurysm;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Strok and traumatic brain injury
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

15. How mcmurray manuver perform
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Urethral stricture; pelvic of urethral trauma
If any compressive symptoms eg. dysphagia
Study showed no adverse effect; but they are contraindicated for PVD

16. Why ruq calcificaion is concerning
Headache - ataxia - bulbar dysfunction
Pure motor stroke; limited neurological dysfunction
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
L5 to S2

17. contraindication of urethral catheterization
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Urethral stricture; pelvic of urethral trauma

18. What time frame required for bone remodeling
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
10-12 months

19. severe pain in leg after MVC
Low anterior resection and radio; add chemo if node positive
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Tendons more likely
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

20. What types of breast implants are available
Saline and silicone
Low anterior resection and radio; add chemo if node positive
Seminomas
Strok and traumatic brain injury

21. What is prehn sign?
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Supraglottic edema; low threshold for intubation

22. scrotal trauma
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
24-48 hours of supportive therapy followed by cholecystectomy
Saline and silicone
Next best step surgery; not ultrasound

23. Why initial xrays are negative in scaphoid fx
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
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
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

24. SOB - confusion - petechial rash after trauma - fracture
10-12 months
Elevated non seminomas
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

25. dorsiflexion and planter flexion
Supraglottic edema; low threshold for intubation
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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;
L5 to S2

26. antibiotics of acute cholecystitis
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Cystic scrotal fluid collection between parietal and visceral layers of testis
Strok and traumatic brain injury

27. tx distal rectal ca
Fx displace >1mm - nonunion during followup - osteonecrosis
Sphincter sparing surgery (local resection) - abdomnio perineal resection
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Ispilateral hypoglossal nerve injury

28. diarrhoea after gastric bypass
Low anterior resection and radio; add chemo if node positive
Dumping syndrome; small and frequent meals; no simple sugar
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;
Amoxicillin-clavulanate

29. first step for evaluation of testicular swelling
Saline and silicone
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Study showed no adverse effect; but they are contraindicated for PVD
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

30. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
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
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

31. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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
Low anterior resection and radio; add chemo if node positive

32. How to evaluate painless testicular swelling suspicious for cancer
24-48 hours of supportive therapy followed by cholecystectomy
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
50%; tunneling between rectum or kin
Urethral stricture; pelvic of urethral trauma

33. How to perform lachman test
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

34. mangement of localized lymphadenopathy
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

35. Complications of breast impant
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Next best step surgery; not ultrasound
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

36. dumping syndrome after gastrectomy
Progressive fibrosis of palmar fascia. etiololgy not known;
S2-S4
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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

37. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
SAH due to post communicating artery aneurysm;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Elderly and critically ill patients
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

38. 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
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Study showed no adverse effect; but they are contraindicated for PVD
Tendons more likely

39. complication displaced or communited distal radial fx
Epi and chest compressio for prolong period of time; atropine is given after epi;
CRPS
Carpal tunnel syndrom
Meniscus injury; medial most common; pain/swelling; popping sensation

40. cremasteric reflex
Retrograde ejaculation
Amoxicillin-clavulanate
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

41. What is the complications of undescended testis
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
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Even after ochiopexy risk of ochiopexy higher then general population

42. DD of acute scrotal pain
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
Malignancy until proven otherwise
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

43. management of stone 8-10mm
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Unilateral vocal cord paralysis
Twisting force with the foot fixed on the ground seen in football and basketball games;
Malignancy until proven otherwise

44. Valgus and Varus tests
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Abd pain and tenderness; bloody diarrhoea or hematochezia
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

45. 3 mo with groin bulge; bulge appears when child cries
Carpal tunnel syndrom
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

46. varicose veins with ulcer - bleeding and thrombophlebitits
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Fx displace >1mm - nonunion during followup - osteonecrosis
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;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

47. When do we see complications due to hypophosphatemia
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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;
10-12 months
Dm neuropathy; stocking glove pattern

48. aspiration of breast cyst is bloody
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;
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
Mammogram
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

49. What is most common lung injury after blunt chest trauma?
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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. swelling and tenderness in anterior part of knee
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
Patellar tendon tear; difficulty in extension
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Less than 5mm

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USMLE Step3 Surgery

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