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USMLE Step3 Surgery

Subjects : health-sciences, usmle-step-3

Instructions:

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. menisci 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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

2. recurrent laryngeal nerve injury
Abd pain and tenderness; bloody diarrhoea or hematochezia
24-48 hours of supportive therapy followed by cholecystectomy
Unilateral vocal cord paralysis
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

3. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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
Less than 5mm
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

4. dumping syndrome after gastrectomy
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Increased size during the day and valsalva means it is communicated with peritoneal cavity
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

5. 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Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery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
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
Supraglottic edema; low threshold for intubation

6. contraindication of urethral catheterization
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Urethral stricture; pelvic of urethral trauma
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

7. first step for evaluation of testicular swelling
Study showed no adverse effect; but they are contraindicated for PVD
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Compression stocking - weight reduction - leg elevation

8. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
S2-S4
Subphrenic abscess or other abdominal abscesses; order US or CT
4-6 weeks for noncontact sports and longer time for contact sports
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

9. How to dx ACL tear?
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Patellar tendon tear; difficulty in extension
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

10. Why initial xrays are negative in scaphoid fx
Next best step surgery; not ultrasound
Low anterior resection and radio; add chemo if node positive
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

11. What percent of anal abscess deveolop fisutula
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
50%; tunneling between rectum or kin
Klinefelter syndrome; 50 fold increase;
Dm neuropathy; stocking glove pattern

12. complications of TPN
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
If any compressive symptoms eg. dysphagia
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

13. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

14. Complications of breast impant
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Elderly and critically ill patients
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

15. dorsiflexion and planter flexion
Even after ochiopexy risk of ochiopexy higher then general population
Dumping syndrome; small and frequent meals; no simple sugar
Headache - ataxia - bulbar dysfunction
L5 to S2

16. How to differentiate ACL and meniscus injury
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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

17. Tx of proximal non metastatic rectal ca
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Fx displace >1mm - nonunion during followup - osteonecrosis
Low anterior resection and radio; add chemo if node positive
Patellar tendon tear; difficulty in extension

18. Why ruq calcificaion is concerning
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
ACL injury

19. conservative Tx of varicose veins
L5 to S2
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;
Malignancy until proven otherwise
Compression stocking - weight reduction - leg elevation

20. Why varicocele more common in the left side
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
15-40%; self limiting;doesn't require tx
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

21. How varicocele causes testicular atrophy
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
S2-S4
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

22. managment of animal bite in hands
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;
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
When urethral catherization is unsuccessful
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

23. What is hydrocele?
Even after ochiopexy risk of ochiopexy higher then general population
Cystic scrotal fluid collection between parietal and visceral layers of testis
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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

24. clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
Urethral stricture; pelvic of urethral trauma
Twisting force with the foot fixed on the ground seen in football and basketball games;
When urethral catherization is unsuccessful

25. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
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
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
SAH due to post communicating artery aneurysm;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

26. 3 mo with groin bulge; bulge appears when child cries
Dumping syndrome; small and frequent meals; no simple sugar
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

27. differential of ultrasound finding of breast mass
If any compressive symptoms eg. dysphagia
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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

28. management of nondisplaced scaphoid fx
Mammogram
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Supraglottic edema; low threshold for intubation
Dumping syndrome; small and frequent meals; no simple sugar

29. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Fx displace >1mm - nonunion during followup - osteonecrosis
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

30. how hyperventilation lowers ICP
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

31. painless testicular mass in young male
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Abd pain and tenderness; bloody diarrhoea or hematochezia
If patient ambulatory - surgery and pain control; if not nonop mx
Malignancy until proven otherwise

32. suprapubic catheterization
Even after ochiopexy risk of ochiopexy higher then general population
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
When urethral catherization is unsuccessful

33. antibiotics of acute cholecystitis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Cystic scrotal fluid collection between parietal and visceral layers of testis
If any compressive symptoms eg. dysphagia
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

34. Dupuytren contracture
If patient ambulatory - surgery and pain control; if not nonop mx
Progressive fibrosis of palmar fascia. etiololgy not known;
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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

35. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Unilateral vocal cord paralysis
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
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;

36. When to stop raloxifene before surgery
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Elevated non seminomas
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

37. what size of ureteral stone for non op mx
Less than 5mm
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
50%; tunneling between rectum or kin

38. when patient with severe lung disease have C02 retention
Urethral stricture; pelvic of urethral trauma
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
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
Retrograde ejaculation

39. DD of acute scrotal pain
Mammogram
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Epi and chest compressio for prolong period of time; atropine is given after epi;

40. Why right varicocele is more concerning?

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41. SOB - confusion - petechial rash after trauma - fracture
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
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;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
ACL injury

42. How to perform lachman test
Malignancy until proven otherwise
S2-S4
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

43. popping sensation; rapid onset of knee effusion. athelet
Pure motor stroke; limited neurological dysfunction
ACL injury
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

44. tx distal rectal ca
Sphincter sparing surgery (local resection) - abdomnio perineal resection
4-6 weeks for noncontact sports and longer time for contact sports
Pure motor stroke; limited neurological dysfunction
Unilateral vocal cord paralysis

45. inhalation of hot air - steam - smoke in burn victim
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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
Carpal tunnel syndrom
Supraglottic edema; low threshold for intubation

46. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Malignancy until proven otherwise
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

47. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
24-48 hours of supportive therapy followed by cholecystectomy
Elevated non seminomas

48. What is the strongest risk factor for male breast cancer
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Brardycardia - HTN - resp depression
Klinefelter syndrome; 50 fold increase;
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

49. mangement of localized lymphadenopathy
Ispilateral hypoglossal nerve injury
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

50. first line of management of PVD
Headache - ataxia - bulbar dysfunction
SAH due to post communicating artery aneurysm;
When urethral catherization is unsuccessful
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

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USMLE Step3 Surgery

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