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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. xray finding of stress fx after 3-4w
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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

2. varicocele
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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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

3. complications of TPN
Supraglottic edema; low threshold for intubation
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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;

4. What is the complications of undescended testis
Even after ochiopexy risk of ochiopexy higher then general population
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Fx displace >1mm - nonunion during followup - osteonecrosis

5. pregnant patient with asymptomatic gall stones
Dm neuropathy; stocking glove pattern
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Low anterior resection and radio; add chemo if node positive
Tendons more likely

6. management of nondisplaced scaphoid fx
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Nonunion and avascular necrosis; fx can block blood supply;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

7. beta HCG
Seminomas
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Ispilateral hypoglossal nerve injury

8. How varicocele causes testicular atrophy
L5 to S2
Supraglottic edema; low threshold for intubation
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

9. complication displaced or communited distal radial fx
Carpal tunnel syndrom
Twisting force with the foot fixed on the ground seen in football and basketball games;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Sphincter sparing surgery (local resection) - abdomnio perineal resection

10. Complications of breast impant
Urethral stricture; pelvic of urethral trauma
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

11. Tx of pulmonary contusion
15-40%; self limiting;doesn't require tx
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

12. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

13. What is hydrocele?
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Cystic scrotal fluid collection between parietal and visceral layers of testis
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

14. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

15. lacerated wound in palmer surface of hand. what structure is injured?
Progressive fibrosis of palmar fascia. etiololgy not known;
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
Seminomas
Tendons more likely

16. severe pain in leg after MVC
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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
Dm neuropathy; stocking glove pattern
CRPS

17. Indication for bariatric surgery in obese patients
15-40%; self limiting;doesn't require tx
When urethral catherization is unsuccessful
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
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;

18. transrectal prostate biopsy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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
Urethral stricture; pelvic of urethral trauma

19. types of hip fracture
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
Less than 5mm
Elderly and critically ill patients
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

20. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
CRPS

21. management of hip fracture
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
Ispilateral hypoglossal nerve injury
If patient ambulatory - surgery and pain control; if not nonop mx
Tendons more likely

22. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Meniscus injury; medial most common; pain/swelling; popping sensation
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Seminomas
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

23. antibiotics of acute cholecystitis
Unilateral vocal cord paralysis
Less than 5mm
Ampicillin sublactum - pipercillin - ceftriaxone and metro
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

24. aspiration of breast cyst is nonbloody
Nonunion and avascular necrosis; fx can block blood supply;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
SAH due to post communicating artery aneurysm;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

25. When goiter needs surgery
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
If any compressive symptoms eg. dysphagia
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
4-6 weeks for noncontact sports and longer time for contact sports

26. clavicle fx
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Displaced ORIF ; nondisplaced sling immobilization
ACL injury
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

27. how hyperventilation lowers ICP
Next best step surgery; not ultrasound
Strok and traumatic brain injury
Unilateral vocal cord paralysis
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

28. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

29. How to differentiate communicative and non-communicative hydrocele
Mammogram
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Unilateral vocal cord paralysis
MAT; medial meniscus injury; ACL and Tibial colateral ligament

30. What time frame required for bone remodeling
Carpal tunnel syndrom
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Study showed no adverse effect; but they are contraindicated for PVD
10-12 months

31. ipsilateral deviation of tongue upon protrusion
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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
Ispilateral hypoglossal nerve injury
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

32. What is the contraindication of hyperventilation in inc ICP
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Nonunion and avascular necrosis; fx can block blood supply;
Malignancy until proven otherwise
Strok and traumatic brain injury

33. tx distal rectal ca
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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
Sphincter sparing surgery (local resection) - abdomnio perineal resection

34. sudden onset of postoperative hyperglycemia when patient on TPN
If any compressive symptoms eg. dysphagia
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
Next best step surgery; not ultrasound
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

35. What is hungry bone syndrome?
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
L5 to S2
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

36. When to stop raloxifene before surgery
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Check ET tube placement if correct needle decompresion
24-48 hours of supportive therapy followed by cholecystectomy
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

37. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

38. differential of ultrasound finding of breast mass
Elderly and critically ill patients
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;
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
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

39. Why right varicocele is more concerning?

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40. What are the common injuries from lightning?
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Compression stocking - weight reduction - leg elevation
Saline and silicone
Displaced ORIF ; nondisplaced sling immobilization

41. dorsiflexion and planter flexion
Subphrenic abscess or other abdominal abscesses; order US or CT
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
L5 to S2

42. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Ispilateral hypoglossal nerve injury
Cystic scrotal fluid collection between parietal and visceral layers of testis
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

43. managment of animal bite in hands
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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;
L5 to S2
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

44. SAH due to posterior inferior cerebellar aneurysm
Unilateral vocal cord paralysis
Headache - ataxia - bulbar dysfunction
CRPS
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

45. When do we see complications due to hypophosphatemia
If patient ambulatory - surgery and pain control; if not nonop mx
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
Supraglottic edema; low threshold for intubation
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;

46. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
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
Check ET tube placement if correct needle decompresion
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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

47. What is the strongest risk factor for male breast cancer
Twisting force with the foot fixed on the ground seen in football and basketball games;
Retrograde ejaculation
Low anterior resection and radio; add chemo if node positive
Klinefelter syndrome; 50 fold increase;

48. What is terrible triad
Amoxicillin-clavulanate
Epi and chest compressio for prolong period of time; atropine is given after epi;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
MAT; medial meniscus injury; ACL and Tibial colateral ligament

49. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
ACL injury
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Ispilateral hypoglossal nerve injury
4-6 weeks for noncontact sports and longer time for contact sports

50. cremasteric reflex
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Cystic scrotal fluid collection between parietal and visceral layers of testis
10-12 months
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

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USMLE Step3 Surgery

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