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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. clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
Subphrenic abscess or other abdominal abscesses; order US or CT
L5 to S2
15-40%; self limiting;doesn't require tx

2. swelling and tenderness in anterior part of knee
Patellar tendon tear; difficulty in extension
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
Dumping syndrome; small and frequent meals; no simple sugar

3. Tx of proximal non metastatic rectal ca
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Carpal tunnel syndrom
Low anterior resection and radio; add chemo if node positive
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

4. anal sphincter tone
Cystic scrotal fluid collection between parietal and visceral layers of testis
S2-S4
Subphrenic abscess or other abdominal abscesses; order US or CT
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

5. popping sensation; rapid onset of knee effusion. athelet
ACL injury
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Displaced ORIF ; nondisplaced sling immobilization
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

6. mx of stress fx
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;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

7. contraindication of urethral catheterization
Tendons more likely
Patellar tendon tear; difficulty in extension
Urethral stricture; pelvic of urethral trauma
Low anterior resection and radio; add chemo if node positive

8. when patient with severe lung disease have C02 retention
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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

9. Why right varicocele is more concerning?

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10. first line of management of PVD
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Abd pain and tenderness; bloody diarrhoea or hematochezia

11. how hyperventilation lowers ICP
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Unilateral vocal cord paralysis
Malignancy until proven otherwise
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

12. Tx of pulmonary contusion
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Dumping syndrome; small and frequent meals; no simple sugar
15-40%; self limiting;doesn't require tx
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

13. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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

14. When do we see complications due to hypophosphatemia
If patient ambulatory - surgery and pain control; if not nonop mx
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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;

15. midline neck swelling moves with protrusion of tongue
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Next best step surgery; not ultrasound
Urethral stricture; pelvic of urethral trauma
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

16. cremasteric reflex
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Tendons more likely
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

17. recurrent laryngeal nerve injury
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Elderly and critically ill patients
Unilateral vocal cord paralysis

18. What are the common injuries from lightning?
15-40%; self limiting;doesn't require tx
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

19. complication displaced or communited distal radial fx
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Strok and traumatic brain injury
Low anterior resection and radio; add chemo if node positive
Carpal tunnel syndrom

20. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Next best step surgery; not ultrasound
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

21. Why varicocele more common in the left side
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
S2-S4

22. mangement of localized lymphadenopathy
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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

23. How to confirm dx of compartment syndrom
Abd pain and tenderness; bloody diarrhoea or hematochezia
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

24. When to stop raloxifene before surgery
Unilateral vocal cord paralysis
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
15-40%; self limiting;doesn't require tx
Study showed no adverse effect; but they are contraindicated for PVD

25. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
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
Pure motor stroke; limited neurological dysfunction
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

26. aspiration of breast cyst is bloody
Mammogram
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Nonunion and avascular necrosis; fx can block blood supply;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

27. How to perform lachman test
Fx displace >1mm - nonunion during followup - osteonecrosis
Retrograde ejaculation
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Ispilateral hypoglossal nerve injury

28. 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
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Malignancy until proven otherwise
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

29. beta hcg and AFP
ACL injury
10-12 months
Elevated non seminomas
Elderly and critically ill patients

30. beta HCG
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Klinefelter syndrome; 50 fold increase;
Seminomas

31. When to do surgery in undesceneded testis?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Unilateral vocal cord paralysis
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
10-12 months

32. What is prehn sign?
Strok and traumatic brain injury
Dm neuropathy; stocking glove pattern
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
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

33. scrotal trauma
Next best step surgery; not ultrasound
Displaced ORIF ; nondisplaced sling immobilization
Cystic scrotal fluid collection between parietal and visceral layers of testis
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

34. What is most common lung injury after blunt chest trauma?
Dumping syndrome; small and frequent meals; no simple sugar
Next best step surgery; not ultrasound
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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

35. SAH due to posterior inferior cerebellar aneurysm
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Meniscus injury; medial most common; pain/swelling; popping sensation
Klinefelter syndrome; 50 fold increase;
Headache - ataxia - bulbar dysfunction

36. management of hip fracture
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Strok and traumatic brain injury
If patient ambulatory - surgery and pain control; if not nonop mx
Even after ochiopexy risk of ochiopexy higher then general population

37. Patient underwent CABG; postoperatively drowsy. most likely cause?
Saline and silicone
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

38. Can we use beta blocker for pvd?
15-40%; self limiting;doesn't require tx
Study showed no adverse effect; but they are contraindicated for PVD
Urethral stricture; pelvic of urethral trauma
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

39. What is the strongest risk factor for male breast cancer
Klinefelter syndrome; 50 fold increase;
Unilateral vocal cord paralysis
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
Study showed no adverse effect; but they are contraindicated for PVD

40. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Progressive fibrosis of palmar fascia. etiololgy not known;
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
Compression stocking - weight reduction - leg elevation
Subphrenic abscess or other abdominal abscesses; order US or CT

41. types of hip fracture
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Amoxicillin-clavulanate
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
MAT; medial meniscus injury; ACL and Tibial colateral ligament

42. conservative Tx of varicose veins
Tendons more likely
10-12 months
Compression stocking - weight reduction - leg elevation
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

43. What is the contraindication of hyperventilation in inc ICP
L5 to S2
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Strok and traumatic brain injury

44. management of gunshot wound
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro

45. What types of breast implants are available
Retrograde ejaculation
L5 to S2
Saline and silicone
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

46. what size of ureteral stone for non op mx
MAT; medial meniscus injury; ACL and Tibial colateral ligament
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Less than 5mm
Subphrenic abscess or other abdominal abscesses; order US or CT

47. characteristics of ureteral stone?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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
Check ET tube placement if correct needle decompresion
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

48. painless testicular mass in young male
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Klinefelter syndrome; 50 fold increase;
Malignancy until proven otherwise
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

49. How to manage a patient with asystole
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Epi and chest compressio for prolong period of time; atropine is given after epi;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

50. Complications of breast impant
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
L5 to S2
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;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

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USMLE Step3 Surgery

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