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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. What are the common injuries from lightning?
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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Dm neuropathy; stocking glove pattern
50%; tunneling between rectum or kin

2. What is terrible triad
Abd pain and tenderness; bloody diarrhoea or hematochezia
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

3. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Low anterior resection and radio; add chemo if node positive
Headache - ataxia - bulbar dysfunction
Subphrenic abscess or other abdominal abscesses; order US or CT

4. beta HCG
Seminomas
Progressive fibrosis of palmar fascia. etiololgy not known;
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

5. When do we see complications due to hypophosphatemia
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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;
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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. several knee pain after being tackled in football game
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
S2-S4
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

7. How to manage obesity
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

8. popping sensation; rapid onset of knee effusion. athelet
Next best step surgery; not ultrasound
Displaced ORIF ; nondisplaced sling immobilization
ACL injury
Supraglottic edema; low threshold for intubation

9. tx distal rectal ca
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Sphincter sparing surgery (local resection) - abdomnio perineal resection
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

10. How to dx ACL tear?
Even after ochiopexy risk of ochiopexy higher then general population
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
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;
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

11. 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;
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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;
24-48 hours of supportive therapy followed by cholecystectomy

12. clavicle fx
Elderly and critically ill patients
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
When urethral catherization is unsuccessful
Displaced ORIF ; nondisplaced sling immobilization

13. 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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

14. indication of ursodeoxycholic acid
Brardycardia - HTN - resp depression
Subphrenic abscess or other abdominal abscesses; order US or CT
Unilateral vocal cord paralysis
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

15. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Meniscus injury; medial most common; pain/swelling; popping sensation
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

16. Why initial xrays are negative in scaphoid fx
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
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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
Epi and chest compressio for prolong period of time; atropine is given after epi;

17. ipsilateral deviation of tongue upon protrusion
4-6 weeks for noncontact sports and longer time for contact sports
Ispilateral hypoglossal nerve injury
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

18. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Displaced ORIF ; nondisplaced sling immobilization

19. anal sphincter tone
Saline and silicone
Meniscus injury; medial most common; pain/swelling; popping sensation
CRPS
S2-S4

20. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Strok and traumatic brain injury
Mammogram
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Carpal tunnel syndrom

21. lacerated wound in palmer surface of hand. what structure is injured?
If patient ambulatory - surgery and pain control; if not nonop mx
Tendons more likely
Malignancy until proven otherwise
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

22. beta hcg and AFP
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Elevated non seminomas

23. swelling and tenderness in anterior part of knee
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Strok and traumatic brain injury
Mammogram
Patellar tendon tear; difficulty in extension

24. When to do surgery in undesceneded testis?
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Seminomas

25. conservative Tx of varicose veins
Elderly and critically ill patients
Compression stocking - weight reduction - leg elevation
If patient ambulatory - surgery and pain control; if not nonop mx
ACL injury

26. 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
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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Next best step surgery; not ultrasound

27. inhalation of hot air - steam - smoke in burn victim
Study showed no adverse effect; but they are contraindicated for PVD
Displaced ORIF ; nondisplaced sling immobilization
Supraglottic edema; low threshold for intubation
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

28. acute colonic ischemia
Next best step surgery; not ultrasound
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Abd pain and tenderness; bloody diarrhoea or hematochezia

29. cat/dog bites
Saline and silicone
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Amoxicillin-clavulanate

30. aspiration of breast cyst is bloody
Epi and chest compressio for prolong period of time; atropine is given after epi;
Mammogram
Study showed no adverse effect; but they are contraindicated for PVD
Even after ochiopexy risk of ochiopexy higher then general population

31. management of stone 8-10mm
Malignancy until proven otherwise
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

32. dumping syndrome after gastrectomy
15-40%; self limiting;doesn't require tx
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

33. how ABI help dx of PVD
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Sphincter sparing surgery (local resection) - abdomnio perineal resection

34. Dupuytren contracture
Strok and traumatic brain injury
Progressive fibrosis of palmar fascia. etiololgy not known;
4-6 weeks for noncontact sports and longer time for contact sports
Compression stocking - weight reduction - leg elevation

35. What is the contraindication of hyperventilation in inc ICP
Displaced ORIF ; nondisplaced sling immobilization
Study showed no adverse effect; but they are contraindicated for PVD
Low anterior resection and radio; add chemo if node positive
Strok and traumatic brain injury

36. What is most common lung injury after blunt chest trauma?
Patellar tendon tear; difficulty in extension
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
Unilateral vocal cord paralysis
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

37. How to manage a patient with asystole
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Epi and chest compressio for prolong period of time; atropine is given after epi;
Less than 5mm

38. How to confirm achiles tendon rupture
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

39. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Elderly and critically ill patients
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Dm neuropathy; stocking glove pattern
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

40. diarrhoea after gastric bypass
Dumping syndrome; small and frequent meals; no simple sugar
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

41. When to stop raloxifene before surgery
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Carpal tunnel syndrom
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Low anterior resection and radio; add chemo if node positive

42. How mcmurray manuver perform
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Amoxicillin-clavulanate
Even after ochiopexy risk of ochiopexy higher then general population
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

43. when scaphoid fx patient needs to be referred to orthopedic
Carpal tunnel syndrom
Subphrenic abscess or other abdominal abscesses; order US or CT
Fx displace >1mm - nonunion during followup - osteonecrosis
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

44. most frequent complication of TURP
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
Progressive fibrosis of palmar fascia. etiololgy not known;
Retrograde ejaculation
Ampicillin sublactum - pipercillin - ceftriaxone and metro

45. Incidence of AF in CABG patient

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46. What is cushing's triad
Supraglottic edema; low threshold for intubation
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
Brardycardia - HTN - resp depression
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

47. What is prehn sign?
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
When urethral catherization is unsuccessful
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

48. complications of TPN
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Next best step surgery; not ultrasound

49. dorsiflexion and planter flexion
Headache - ataxia - bulbar dysfunction
L5 to S2
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

50. mangement of localized lymphadenopathy
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Fx displace >1mm - nonunion during followup - osteonecrosis
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
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

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USMLE Step3 Surgery

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