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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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1. Tx of pulmonary contusion
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Urethral stricture; pelvic of urethral trauma

2. managment of animal bite in hands
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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;
Nonunion and avascular necrosis; fx can block blood supply;

3. when scaphoid fx patient needs to be referred to orthopedic
Urethral stricture; pelvic of urethral trauma
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Fx displace >1mm - nonunion during followup - osteonecrosis
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

4. pregnant patient with asymptomatic gall stones
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Strok and traumatic brain injury
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

5. clavicle fx
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Patellar tendon tear; difficulty in extension
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Displaced ORIF ; nondisplaced sling immobilization

6. SOB - confusion - petechial rash after trauma - fracture
4-6 weeks for noncontact sports and longer time for contact sports
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Dm neuropathy; stocking glove pattern
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

7. beta hcg and AFP
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Elevated non seminomas
ACL injury
Meniscus injury; medial most common; pain/swelling; popping sensation

8. scrotal trauma
Headache - ataxia - bulbar dysfunction
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Next best step surgery; not ultrasound
Fx displace >1mm - nonunion during followup - osteonecrosis

9. Incidence of AF in CABG patient

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10. inhalation of hot air - steam - smoke in burn victim
Saline and silicone
Supraglottic edema; low threshold for intubation
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Elevated non seminomas

11. lacerated wound in palmer surface of hand. what structure is injured?
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Tendons more likely
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;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

12. What is hungry bone syndrome?
Supraglottic edema; low threshold for intubation
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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
Subphrenic abscess or other abdominal abscesses; order US or CT

13. What is cushing's triad
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
SAH due to post communicating artery aneurysm;
Brardycardia - HTN - resp depression

14. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Abd pain and tenderness; bloody diarrhoea or hematochezia
Progressive fibrosis of palmar fascia. etiololgy not known;
Seminomas

15. painless testicular mass in young male
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Study showed no adverse effect; but they are contraindicated for PVD
Malignancy until proven otherwise

16. Indication for bariatric surgery in obese patients
Headache - ataxia - bulbar dysfunction
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
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;
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

17. most common fx when falling on outsretched hand
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
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Brardycardia - HTN - resp depression
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

18. What time frame required for bone remodeling
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
15-40%; self limiting;doesn't require tx
10-12 months
Progressive fibrosis of palmar fascia. etiololgy not known;

19. Dupuytren contracture
Progressive fibrosis of palmar fascia. etiololgy not known;
Ispilateral hypoglossal nerve injury
Epi and chest compressio for prolong period of time; atropine is given after epi;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

20. 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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Carpal tunnel syndrom
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

21. How to manage obesity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

22. suprapubic catheterization
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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
When urethral catherization is unsuccessful

23. What is prehn sign?
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

24. diarrhoea after gastric bypass
Dumping syndrome; small and frequent meals; no simple sugar
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
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

25. indication of ursodeoxycholic acid
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
Saline and silicone
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

26. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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

27. management of hip fracture
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
If patient ambulatory - surgery and pain control; if not nonop mx

28. How to manage a patient with asystole
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
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;
15-40%; self limiting;doesn't require tx

29. Why ruq calcificaion is concerning
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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
Subphrenic abscess or other abdominal abscesses; order US or CT
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

30. What types of breast implants are available
Nonunion and avascular necrosis; fx can block blood supply;
Saline and silicone
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

31. aspiration of breast cyst is bloody
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Mammogram
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

32. How to differentiate ACL and meniscus injury
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
10-12 months
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

33. cremasteric reflex test?
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

34. Valgus and Varus tests
Twisting force with the foot fixed on the ground seen in football and basketball games;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Meniscus injury; medial most common; pain/swelling; popping sensation

35. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
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
Compression stocking - weight reduction - leg elevation
Dm neuropathy; stocking glove pattern
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

36. What is most common lung injury after blunt chest trauma?
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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
Check ET tube placement if correct needle decompresion

37. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Epi and chest compressio for prolong period of time; atropine is given after epi;
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Elevated non seminomas

38. acalculus cholecystitis
Elderly and critically ill patients
Headache - ataxia - bulbar dysfunction
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

39. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Saline and silicone

40. popping sensation; rapid onset of knee effusion. athelet
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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
ACL injury
Check ET tube placement if correct needle decompresion

41. When patient can go back to sports after clavicle fx
4-6 weeks for noncontact sports and longer time for contact sports
Fx displace >1mm - nonunion during followup - osteonecrosis
10-12 months
Displaced ORIF ; nondisplaced sling immobilization

42. How to confirm achiles tendon rupture
Klinefelter syndrome; 50 fold increase;
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;
S2-S4

43. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Progressive fibrosis of palmar fascia. etiololgy not known;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

44. Tx of proximal non metastatic rectal ca
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Twisting force with the foot fixed on the ground seen in football and basketball games;
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
Low anterior resection and radio; add chemo if node positive

45. 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
Elevated non seminomas
Study showed no adverse effect; but they are contraindicated for PVD
Pure motor stroke; limited neurological dysfunction

46. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Check ET tube placement if correct needle decompresion
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

47. When to do surgery in undesceneded testis?
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
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

48. Can we use beta blocker for pvd?
Study showed no adverse effect; but they are contraindicated for PVD
Abd pain and tenderness; bloody diarrhoea or hematochezia
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Compression stocking - weight reduction - leg elevation

49. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Headache - ataxia - bulbar dysfunction
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

50. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
SAH due to post communicating artery aneurysm;
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
Supraglottic edema; low threshold for intubation

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USMLE Step3 Surgery

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