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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. When patient can go back to sports after clavicle fx
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
Brardycardia - HTN - resp depression
4-6 weeks for noncontact sports and longer time for contact sports

2. beta hcg and AFP
Elevated non seminomas
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
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;
4-6 weeks for noncontact sports and longer time for contact sports

3. What is the complications of undescended testis
Even after ochiopexy risk of ochiopexy higher then general population
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

4. Indication for bariatric surgery in obese patients
Urethral stricture; pelvic of urethral trauma
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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
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;

5. varicose veins with ulcer - bleeding and thrombophlebitits
Strok and traumatic brain injury
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Mammogram

6. 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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Low anterior resection and radio; add chemo if node positive
Retrograde ejaculation

7. When goiter needs surgery
Supraglottic edema; low threshold for intubation
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
If any compressive symptoms eg. dysphagia

8. Incidence of AF in CABG patient

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9. management of nondisplaced scaphoid fx
Klinefelter syndrome; 50 fold increase;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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
Malignancy until proven otherwise

10. characteristics of ureteral stone?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Even after ochiopexy risk of ochiopexy higher then general population
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

11. Why right varicocele is more concerning?

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12. most common complication of acute cholecystitis
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
Twisting force with the foot fixed on the ground seen in football and basketball games;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

13. acute colonic ischemia
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Abd pain and tenderness; bloody diarrhoea or hematochezia

14. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Seminomas
When urethral catherization is unsuccessful
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

15. Dupuytren contracture
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Mammogram
Progressive fibrosis of palmar fascia. etiololgy not known;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

16. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
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
Ispilateral hypoglossal nerve injury
Tendons more likely
Check ET tube placement if correct needle decompresion

17. scrotal trauma
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
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
Next best step surgery; not ultrasound
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

18. most frequent complication of TURP
Malignancy until proven otherwise
Retrograde ejaculation
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

19. transrectal prostate biopsy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
L5 to S2
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

20. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Epi and chest compressio for prolong period of time; atropine is given after epi;

21. suprapubic catheterization
Meniscus injury; medial most common; pain/swelling; popping sensation
When urethral catherization is unsuccessful
SAH due to post communicating artery aneurysm;
Check ET tube placement if correct needle decompresion

22. diarrhoea after gastric bypass
Dumping syndrome; small and frequent meals; no simple sugar
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

23. dumping syndrome after gastrectomy
CRPS
Strok and traumatic brain injury
Displaced ORIF ; nondisplaced sling immobilization
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

24. How to differentiate ACL and meniscus injury
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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
Study showed no adverse effect; but they are contraindicated for PVD
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

25. How mcmurray manuver perform
SAH due to post communicating artery aneurysm;
Epi and chest compressio for prolong period of time; atropine is given after epi;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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;

26. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Compression stocking - weight reduction - leg elevation
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
If any compressive symptoms eg. dysphagia

27. stress fx
Increased size during the day and valsalva means it is communicated with peritoneal cavity
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
If any compressive symptoms eg. dysphagia
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

28. complications of TPN
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

29. management of gunshot wound
Progressive fibrosis of palmar fascia. etiololgy not known;
Dm neuropathy; stocking glove pattern
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

30. Valgus and Varus tests
Patellar tendon tear; difficulty in extension
Cystic scrotal fluid collection between parietal and visceral layers of testis
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

31. 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
Low anterior resection and radio; add chemo if node positive
Even after ochiopexy risk of ochiopexy higher then general population
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

32. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
S2-S4
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

33. how ABI help dx of PVD
Amoxicillin-clavulanate
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

34. How to manage obesity
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Ispilateral hypoglossal nerve injury
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

35. management of hip fracture
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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
If patient ambulatory - surgery and pain control; if not nonop mx
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

36. What is hydrocele?
Mammogram
Cystic scrotal fluid collection between parietal and visceral layers of testis
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

37. What is the strongest risk factor for male breast cancer
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

38. menisci injury
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
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Tendons more likely

39. How to evaluate painless testicular swelling suspicious for cancer
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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
Dumping syndrome; small and frequent meals; no simple sugar
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

40. common complication of inadequate mx of scaphoid fx
Nonunion and avascular necrosis; fx can block blood supply;
Amoxicillin-clavulanate
Pure motor stroke; limited neurological dysfunction
Displaced ORIF ; nondisplaced sling immobilization

41. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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;
Dm neuropathy; stocking glove pattern
Increased size during the day and valsalva means it is communicated with peritoneal cavity

42. first step for evaluation of testicular swelling
Mammogram
Check ET tube placement if correct needle decompresion
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

43. painless testicular mass in young male
Supraglottic edema; low threshold for intubation
Malignancy until proven otherwise
If patient ambulatory - surgery and pain control; if not nonop mx
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

44. management of stone 8-10mm
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

45. how hyperventilation lowers ICP
If patient ambulatory - surgery and pain control; if not nonop mx
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
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
50%; tunneling between rectum or kin

46. recurrent laryngeal nerve injury
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Unilateral vocal cord paralysis
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

47. What percent of anal abscess deveolop fisutula
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
50%; tunneling between rectum or kin
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Fx displace >1mm - nonunion during followup - osteonecrosis

48. contraindication of urethral catheterization
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Urethral stricture; pelvic of urethral trauma
Seminomas
Less than 5mm

49. How to perform lachman test
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Less than 5mm
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

50. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Epi and chest compressio for prolong period of time; atropine is given after epi;
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

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USMLE Step3 Surgery

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