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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. first line of management of PVD
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
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Strok and traumatic brain injury

2. 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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
If any compressive symptoms eg. dysphagia

3. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Brardycardia - HTN - resp depression
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

4. varicocele
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

5. How to dx ACL tear?
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
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
Displaced ORIF ; nondisplaced sling immobilization
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

6. How mcmurray manuver perform
Progressive fibrosis of palmar fascia. etiololgy not known;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Nonunion and avascular necrosis; fx can block blood supply;

7. What is the strongest risk factor for male breast cancer
Unilateral vocal cord paralysis
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
Klinefelter syndrome; 50 fold increase;
4-6 weeks for noncontact sports and longer time for contact sports

8. 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;
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Ispilateral hypoglossal nerve injury
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

9. How to manage a patient with asystole
Epi and chest compressio for prolong period of time; atropine is given after epi;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Increased size during the day and valsalva means it is communicated with peritoneal cavity

10. complication displaced or communited distal radial fx
Carpal tunnel syndrom
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Meniscus injury; medial most common; pain/swelling; popping sensation
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

11. Dupuytren contracture
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Less than 5mm
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Progressive fibrosis of palmar fascia. etiololgy not known;

12. What percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
4-6 weeks for noncontact sports and longer time for contact sports
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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

13. swelling and tenderness in anterior part of knee
If patient ambulatory - surgery and pain control; if not nonop mx
When urethral catherization is unsuccessful
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;
Patellar tendon tear; difficulty in extension

14. Incidence of AF in CABG patient

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15. surgery for acute cholecystities
If any compressive symptoms eg. dysphagia
Displaced ORIF ; nondisplaced sling immobilization
24-48 hours of supportive therapy followed by cholecystectomy
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

16. midline neck swelling moves with protrusion of tongue
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Abd pain and tenderness; bloody diarrhoea or hematochezia
Saline and silicone

17. xray finding of stress fx after 3-4w
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
15-40%; self limiting;doesn't require tx
Fx displace >1mm - nonunion during followup - osteonecrosis

18. painless testicular mass in young male
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Malignancy until proven otherwise

19. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
24-48 hours of supportive therapy followed by cholecystectomy
Meniscus injury; medial most common; pain/swelling; popping sensation

20. clavicle fx
Brardycardia - HTN - resp depression
Tendons more likely
Displaced ORIF ; nondisplaced sling immobilization
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

21. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Mammogram
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

22. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
If any compressive symptoms eg. dysphagia
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

23. contraindication of urethral catheterization
Pure motor stroke; limited neurological dysfunction
Urethral stricture; pelvic of urethral trauma
Epi and chest compressio for prolong period of time; atropine is given after epi;
Saline and silicone

24. beta hcg and AFP
Elevated non seminomas
Patellar tendon tear; difficulty in extension
Fx displace >1mm - nonunion during followup - osteonecrosis
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

25. antibiotics of acute cholecystitis
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Carpal tunnel syndrom
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Meniscus injury; medial most common; pain/swelling; popping sensation

26. What types of breast implants are available
Saline and silicone
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

27. common complication of inadequate mx of scaphoid fx
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Epi and chest compressio for prolong period of time; atropine is given after epi;
Nonunion and avascular necrosis; fx can block blood supply;
CRPS

28. When to do surgery in undesceneded testis?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
24-48 hours of supportive therapy followed by cholecystectomy

29. complications of TPN
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Unilateral vocal cord paralysis
S2-S4

30. What is prehn sign?
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

31. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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
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

32. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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
24-48 hours of supportive therapy followed by cholecystectomy

33. What is cushing's triad
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;
Brardycardia - HTN - resp depression
Carpal tunnel syndrom
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

34. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Amoxicillin-clavulanate
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

35. anal sphincter tone
S2-S4
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Cystic scrotal fluid collection between parietal and visceral layers of testis

36. sudden onset of postoperative hyperglycemia when patient on TPN
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Low anterior resection and radio; add chemo if node positive
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

37. diarrhoea 4-5 days after cholecystectomy
Fx displace >1mm - nonunion during followup - osteonecrosis
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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;
Pure motor stroke; limited neurological dysfunction

38. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Mammogram
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
Dm neuropathy; stocking glove pattern

39. when patient with severe lung disease have C02 retention
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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

40. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
SAH due to post communicating artery aneurysm;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

41. 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
Supraglottic edema; low threshold for intubation
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

42. management of stone 8-10mm
Less than 5mm
Twisting force with the foot fixed on the ground seen in football and basketball games;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
If patient ambulatory - surgery and pain control; if not nonop mx

43. acute colonic ischemia
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Abd pain and tenderness; bloody diarrhoea or hematochezia
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
If any compressive symptoms eg. dysphagia

44. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
4-6 weeks for noncontact sports and longer time for contact sports
Headache - ataxia - bulbar dysfunction
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

45. managment of animal bite in hands
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
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;
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

46. aspiration of breast cyst is nonbloody
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Mammogram

47. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

48. When patient can go back to sports after clavicle fx
4-6 weeks for noncontact sports and longer time for contact sports
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Sphincter sparing surgery (local resection) - abdomnio perineal resection

49. beta HCG
50%; tunneling between rectum or kin
Seminomas
Mammogram
S2-S4

50. What is terrible triad
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Carpal tunnel syndrom
Urethral stricture; pelvic of urethral trauma

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USMLE Step3 Surgery

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