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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. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Malignancy until proven otherwise

2. management of nondisplaced scaphoid fx
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
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

3. How to confirm achiles tendon rupture
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
Supraglottic edema; low threshold for intubation
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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

4. What percent of anal abscess deveolop fisutula
Less than 5mm
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
50%; tunneling between rectum or kin
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

5. first line of management of PVD
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
Klinefelter syndrome; 50 fold increase;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

6. clavicle fx
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
If any compressive symptoms eg. dysphagia
Patellar tendon tear; difficulty in extension
Displaced ORIF ; nondisplaced sling immobilization

7. management of stone 8-10mm
Displaced ORIF ; nondisplaced sling immobilization
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
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
Carpal tunnel syndrom

8. swelling and tenderness in anterior part of knee
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
Patellar tendon tear; difficulty in extension
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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;

9. Incidence of AF in CABG patient

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10. What is the strongest risk factor for male breast cancer
Strok and traumatic brain injury
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
4-6 weeks for noncontact sports and longer time for contact sports
Klinefelter syndrome; 50 fold increase;

11. What types of breast implants are available
10-12 months
Saline and silicone
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

12. 3 mo with groin bulge; bulge appears when child cries
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Tendons more likely
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

13. contraindication of urethral catheterization
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Mammogram
Urethral stricture; pelvic of urethral trauma

14. What is the contraindication of hyperventilation in inc ICP
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Headache - ataxia - bulbar dysfunction
Strok and traumatic brain injury
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

15. dorsiflexion and planter flexion
When urethral catherization is unsuccessful
L5 to S2
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

16. How to manage obesity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

17. dumping syndrome after gastrectomy
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

18. stress fx
Malignancy until proven otherwise
Meniscus injury; medial most common; pain/swelling; popping sensation
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

19. beta hcg and AFP
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Elevated non seminomas
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Mammogram

20. management of hip fracture
Low anterior resection and radio; add chemo if node positive
If patient ambulatory - surgery and pain control; if not nonop mx
15-40%; self limiting;doesn't require tx
Ampicillin sublactum - pipercillin - ceftriaxone and metro

21. SOB - confusion - petechial rash after trauma - fracture
Low anterior resection and radio; add chemo if node positive
Malignancy until proven otherwise
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

22. mx of stress fx
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Displaced ORIF ; nondisplaced sling immobilization
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

23. how hyperventilation lowers ICP
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

24. menisci injury
Fx displace >1mm - nonunion during followup - osteonecrosis
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Twisting force with the foot fixed on the ground seen in football and basketball games;
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

25. anal sphincter tone
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;
S2-S4
10-12 months
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

26. popping sensation; rapid onset of knee effusion. athelet
Even after ochiopexy risk of ochiopexy higher then general population
ACL injury
Klinefelter syndrome; 50 fold increase;
SAH due to post communicating artery aneurysm;

27. most frequent complication of TURP
4-6 weeks for noncontact sports and longer time for contact sports
Retrograde ejaculation
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Headache - ataxia - bulbar dysfunction

28. characteristics of ureteral stone?
Study showed no adverse effect; but they are contraindicated for PVD
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

29. How to perform lachman test
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

30. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
10-12 months
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

31. midline neck swelling moves with protrusion of tongue
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

32. mangement of localized lymphadenopathy
Elevated non seminomas
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

33. surgery for acute cholecystities
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Malignancy until proven otherwise
24-48 hours of supportive therapy followed by cholecystectomy
Study showed no adverse effect; but they are contraindicated for PVD

34. acute colonic ischemia
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Abd pain and tenderness; bloody diarrhoea or hematochezia
Elevated non seminomas
Check ET tube placement if correct needle decompresion

35. What is hydrocele?
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
Cystic scrotal fluid collection between parietal and visceral layers of testis
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
50%; tunneling between rectum or kin

36. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
CRPS

37. complications of TPN
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Strok and traumatic brain injury
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Patellar tendon tear; difficulty in extension

38. How mcmurray manuver perform
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
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Study showed no adverse effect; but they are contraindicated for PVD
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

39. What is cushing's triad
Brardycardia - HTN - resp depression
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
Subphrenic abscess or other abdominal abscesses; order US or CT
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

40. SAH due to posterior inferior cerebellar aneurysm
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Headache - ataxia - bulbar dysfunction
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

41. Complications of breast impant
Brardycardia - HTN - resp depression
Headache - ataxia - bulbar dysfunction
Urethral stricture; pelvic of urethral trauma
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

42. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
CRPS

43. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Subphrenic abscess or other abdominal abscesses; order US or CT
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Even after ochiopexy risk of ochiopexy higher then general population
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

44. When do we see complications due to hypophosphatemia
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;
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
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
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

45. severe pain in leg after MVC
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
SAH due to post communicating artery aneurysm;
4-6 weeks for noncontact sports and longer time for contact sports
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;

46. Dupuytren contracture
Dm neuropathy; stocking glove pattern
Retrograde ejaculation
Even after ochiopexy risk of ochiopexy higher then general population
Progressive fibrosis of palmar fascia. etiololgy not known;

47. What is most common lung injury after blunt chest trauma?
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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
Even after ochiopexy risk of ochiopexy higher then general population
Fx displace >1mm - nonunion during followup - osteonecrosis

48. Why initial xrays are negative in scaphoid fx
Seminomas
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
Subphrenic abscess or other abdominal abscesses; order US or CT
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

49. How to manage a patient with asystole
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Amoxicillin-clavulanate
Epi and chest compressio for prolong period of time; atropine is given after epi;

50. How varicocele causes testicular atrophy
Supraglottic edema; low threshold for intubation
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

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USMLE Step3 Surgery

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