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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. most frequent complication of TURP
Check ET tube placement if correct needle decompresion
Retrograde ejaculation
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Nonunion and avascular necrosis; fx can block blood supply;

2. Indication for bariatric surgery in obese patients
Cystic scrotal fluid collection between parietal and visceral layers of testis
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
Ispilateral hypoglossal nerve injury

3. inhalation of hot air - steam - smoke in burn victim
Fx displace >1mm - nonunion during followup - osteonecrosis
Supraglottic edema; low threshold for intubation
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

4. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Epi and chest compressio for prolong period of time; atropine is given after epi;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
ACL injury

5. complication displaced or communited distal radial fx
S2-S4
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
If patient ambulatory - surgery and pain control; if not nonop mx
Carpal tunnel syndrom

6. indication of ursodeoxycholic acid
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Supraglottic edema; low threshold for intubation

7. What is hydrocele?
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Cystic scrotal fluid collection between parietal and visceral layers of testis
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;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

8. How to confirm achiles tendon rupture
Headache - ataxia - bulbar dysfunction
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

9. Why right varicocele is more concerning?

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10. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Even after ochiopexy risk of ochiopexy higher then general population
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

11. DD of acute scrotal pain
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Ampicillin sublactum - pipercillin - ceftriaxone and metro
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Elderly and critically ill patients

12. ipsilateral deviation of tongue upon protrusion
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
Malignancy until proven otherwise
Ispilateral hypoglossal nerve injury
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. sudden onset of postoperative hyperglycemia when patient on TPN
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 prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Abd pain and tenderness; bloody diarrhoea or hematochezia

14. most common fx when falling on outsretched hand
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Subphrenic abscess or other abdominal abscesses; order US or CT
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

15. common complication of inadequate mx of scaphoid fx
Saline and silicone
Less than 5mm
Unilateral vocal cord paralysis
Nonunion and avascular necrosis; fx can block blood supply;

16. aspiration of breast cyst is bloody
Meniscus injury; medial most common; pain/swelling; popping sensation
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Mammogram

17. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
4-6 weeks for noncontact sports and longer time for contact sports
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

18. acute colonic ischemia
Abd pain and tenderness; bloody diarrhoea or hematochezia
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
L5 to S2
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

19. diarrhoea after gastric bypass
Mammogram
Dumping syndrome; small and frequent meals; no simple sugar
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Next best step surgery; not ultrasound

20. When to do surgery in undesceneded testis?
Low anterior resection and radio; add chemo if node positive
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Increased size during the day and valsalva means it is communicated with peritoneal cavity

21. What is prehn sign?
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Dm neuropathy; stocking glove pattern
Meniscus injury; medial most common; pain/swelling; popping sensation
Less than 5mm

22. dumping syndrome after gastrectomy
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

23. when patient with severe lung disease have C02 retention
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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 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

24. severe pain in leg after MVC
Tendons more likely
Study showed no adverse effect; but they are contraindicated for PVD
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

25. beta hcg and AFP
Unilateral vocal cord paralysis
Cystic scrotal fluid collection between parietal and visceral layers of testis
Dumping syndrome; small and frequent meals; no simple sugar
Elevated non seminomas

26. When do we see complications due to hypophosphatemia
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
Progressive fibrosis of palmar fascia. etiololgy not known;
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;
15-40%; self limiting;doesn't require tx

27. SOB - confusion - petechial rash after trauma - fracture
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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
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
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

28. suprapubic catheterization
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
When urethral catherization is unsuccessful

29. How varicocele causes testicular atrophy
Carpal tunnel syndrom
Urethral stricture; pelvic of urethral trauma
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

30. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Dm neuropathy; stocking glove pattern
Even after ochiopexy risk of ochiopexy higher then general population
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

31. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Carpal tunnel syndrom
Tendons more likely
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

32. first line of management of PVD
15-40%; self limiting;doesn't require tx
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Klinefelter syndrome; 50 fold increase;

33. How to manage a patient with asystole
Headache - ataxia - bulbar dysfunction
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Epi and chest compressio for prolong period of time; atropine is given after epi;

34. 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
Supraglottic edema; low threshold for intubation
24-48 hours of supportive therapy followed by cholecystectomy
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

35. Incidence of AF in CABG patient

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36. prostate enlarged - nontender - no nodularity - elevated PSA
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Elderly and critically ill patients
Progressive fibrosis of palmar fascia. etiololgy not known;

37. 3 mo with groin bulge; bulge appears when child cries
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
L5 to S2
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

38. managment of animal bite in hands
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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;
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
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

39. SAH due to posterior inferior cerebellar aneurysm
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
15-40%; self limiting;doesn't require tx
Headache - ataxia - bulbar dysfunction
Pure motor stroke; limited neurological dysfunction

40. What types of breast implants are available
Tendons more likely
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Saline and silicone
MAT; medial meniscus injury; ACL and Tibial colateral ligament

41. lacunar stroke
4-6 weeks for noncontact sports and longer time for contact sports
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Pure motor stroke; limited neurological dysfunction
Brardycardia - HTN - resp depression

42. beta HCG
Seminomas
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;
Supraglottic edema; low threshold for intubation
Sphincter sparing surgery (local resection) - abdomnio perineal resection

43. acalculus cholecystitis
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
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
Elderly and critically ill patients

44. mangement of localized lymphadenopathy
If any compressive symptoms eg. dysphagia
Brardycardia - HTN - resp depression
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

45. Why ruq calcificaion is concerning
Epi and chest compressio for prolong period of time; atropine is given after epi;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
S2-S4
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

46. management of gunshot wound
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

47. painless testicular mass in young male
Malignancy until proven otherwise
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
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;

48. anal sphincter tone
S2-S4
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

49. cremasteric reflex
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Abd pain and tenderness; bloody diarrhoea or hematochezia
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

50. conservative Tx of varicose veins
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
Next best step surgery; not ultrasound
Seminomas
Compression stocking - weight reduction - leg elevation

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USMLE Step3 Surgery

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