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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. first step for evaluation of testicular swelling
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
Low anterior resection and radio; add chemo if node positive
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

2. mx of stress fx
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

3. indication of ursodeoxycholic acid
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

4. 3 mo with groin bulge; bulge appears when child cries
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Carpal tunnel syndrom
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Supraglottic edema; low threshold for intubation

5. menisci injury
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Twisting force with the foot fixed on the ground seen in football and basketball games;

6. aspiration of breast cyst is nonbloody
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
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 there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
When urethral catherization is unsuccessful

7. aspiration of breast cyst is bloody
Mammogram
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
24-48 hours of supportive therapy followed by cholecystectomy
50%; tunneling between rectum or kin

8. management of hip fracture
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
If patient ambulatory - surgery and pain control; if not nonop mx
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

9. What is terrible triad
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Elderly and critically ill patients
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
MAT; medial meniscus injury; ACL and Tibial colateral ligament

10. cremasteric reflex
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;
Next best step surgery; not ultrasound
Unilateral vocal cord paralysis
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

11. how ABI help dx of PVD
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Tendons more likely
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

12. Incidence of AF in CABG patient

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13. What types of breast implants are available
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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
Saline and silicone
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

14. differential of ultrasound finding of breast mass
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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
Next best step surgery; not ultrasound
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;

15. What is the complications of undescended testis
Even after ochiopexy risk of ochiopexy higher then general population
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
Sphincter sparing surgery (local resection) - abdomnio perineal resection
4-6 weeks for noncontact sports and longer time for contact sports

16. dumping syndrome after gastrectomy
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
50%; tunneling between rectum or kin
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

17. What is prehn sign?
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

18. swelling and tenderness in anterior part of knee
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
Patellar tendon tear; difficulty in extension
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

19. What are the common injuries from lightning?
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Subphrenic abscess or other abdominal abscesses; order US or CT
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

20. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Even after ochiopexy risk of ochiopexy higher then general population
If any compressive symptoms eg. dysphagia
SAH due to post communicating artery aneurysm;

21. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Ispilateral hypoglossal nerve injury
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

22. What is hydrocele?
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Dumping syndrome; small and frequent meals; no simple sugar
Cystic scrotal fluid collection between parietal and visceral layers of testis
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

23. scrotal trauma
Displaced ORIF ; nondisplaced sling immobilization
Next best step surgery; not ultrasound
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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

24. Tx of pulmonary contusion
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
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
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. When goiter needs surgery
Malignancy until proven otherwise
If any compressive symptoms eg. dysphagia
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

26. How varicocele causes testicular atrophy
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Malignancy until proven otherwise
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

27. Tx of proximal non metastatic rectal ca
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Low anterior resection and radio; add chemo if node positive
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
Pure motor stroke; limited neurological dysfunction

28. What is cushing's triad
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Seminomas
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

29. How to manage a patient with asystole
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Klinefelter syndrome; 50 fold increase;
Epi and chest compressio for prolong period of time; atropine is given after epi;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

30. tx distal rectal ca
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Klinefelter syndrome; 50 fold increase;
Tendons more likely
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

31. How to differentiate ACL and meniscus injury
Compression stocking - weight reduction - leg elevation
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Subphrenic abscess or other abdominal abscesses; order US or CT
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

32. Complications of breast impant
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
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
Meniscus injury; medial most common; pain/swelling; popping sensation
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

33. beta hcg and AFP
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Unilateral vocal cord paralysis
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Elevated non seminomas

34. severe pain in leg after MVC
Urethral stricture; pelvic of urethral trauma
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
Ispilateral hypoglossal nerve injury
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

35. how hyperventilation lowers ICP
Dm neuropathy; stocking glove pattern
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Mammogram

36. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Urethral stricture; pelvic of urethral trauma
Elevated non seminomas
Check ET tube placement if correct needle decompresion
Patellar tendon tear; difficulty in extension

37. How to evaluate painless testicular swelling suspicious for cancer
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
L5 to S2
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

38. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Dm neuropathy; stocking glove pattern
Low anterior resection and radio; add chemo if node positive
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Seminomas

39. How to differentiate communicative and non-communicative hydrocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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

40. Why varicocele more common in the left side
MAT; medial meniscus injury; ACL and Tibial colateral ligament
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Supraglottic edema; low threshold for intubation
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

41. inhalation of hot air - steam - smoke in burn victim
Supraglottic edema; low threshold for intubation
Less than 5mm
Unilateral vocal cord paralysis
Next best step surgery; not ultrasound

42. complication displaced or communited distal radial fx
Carpal tunnel syndrom
CRPS
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
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

43. When do we see complications due to hypophosphatemia
Brardycardia - HTN - resp depression
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;
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

44. when patient with severe lung disease have C02 retention
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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

45. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Amoxicillin-clavulanate
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Pure motor stroke; limited neurological dysfunction

46. When to stop raloxifene before surgery
Dm neuropathy; stocking glove pattern
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
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

47. recurrent laryngeal nerve injury
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
Retrograde ejaculation
Malignancy until proven otherwise
Unilateral vocal cord paralysis

48. How to perform lachman test
Cystic scrotal fluid collection between parietal and visceral layers of testis
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
S2-S4

49. What percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Sphincter sparing surgery (local resection) - abdomnio perineal resection

50. SAH due to posterior inferior cerebellar aneurysm
Low anterior resection and radio; add chemo if node positive
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Headache - ataxia - bulbar dysfunction
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram