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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. when patient with severe lung disease have C02 retention
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
SAH due to post communicating artery aneurysm;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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

2. management of nondisplaced scaphoid fx
Saline and silicone
Amoxicillin-clavulanate
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

3. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Subphrenic abscess or other abdominal abscesses; order US or CT
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

4. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Displaced ORIF ; nondisplaced sling immobilization
CRPS
4-6 weeks for noncontact sports and longer time for contact sports

5. 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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

6. cremasteric reflex test?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

7. When to stop raloxifene before surgery
Tendons more likely
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Fx displace >1mm - nonunion during followup - osteonecrosis

8. ct scan; cystic lesion in head of pancreas; next step
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Malignancy until proven otherwise
Displaced ORIF ; nondisplaced sling immobilization
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

9. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Dm neuropathy; stocking glove pattern
24-48 hours of supportive therapy followed by cholecystectomy
Retrograde ejaculation
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

10. How to manage obesity
Study showed no adverse effect; but they are contraindicated for PVD
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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
4-6 weeks for noncontact sports and longer time for contact sports

11. how hyperventilation lowers ICP
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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
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
Brardycardia - HTN - resp depression

12. first step for evaluation of testicular swelling
Brardycardia - HTN - resp depression
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

13. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Next best step surgery; not ultrasound
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

14. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Epi and chest compressio for prolong period of time; atropine is given after epi;

15. When patient can go back to sports after clavicle fx
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Fx displace >1mm - nonunion during followup - osteonecrosis
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
4-6 weeks for noncontact sports and longer time for contact sports

16. painless testicular mass in young male
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Malignancy until proven otherwise

17. mangement of localized lymphadenopathy
Nonunion and avascular necrosis; fx can block blood supply;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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
Brardycardia - HTN - resp depression

18. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Supraglottic edema; low threshold for intubation
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Compression stocking - weight reduction - leg elevation

19. How to differentiate ACL and meniscus injury
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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
10-12 months
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

20. beta hcg and AFP
Elevated non seminomas
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
MAT; medial meniscus injury; ACL and Tibial colateral ligament

21. 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
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;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

22. acalculus cholecystitis
Elderly and critically ill patients
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

23. When goiter needs surgery
Abd pain and tenderness; bloody diarrhoea or hematochezia
If any compressive symptoms eg. dysphagia
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

24. aspiration of breast cyst is nonbloody
Headache - ataxia - bulbar dysfunction
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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 scaphoid fx patient needs to be referred to orthopedic
Strok and traumatic brain injury
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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
Fx displace >1mm - nonunion during followup - osteonecrosis

26. lacunar stroke
When urethral catherization is unsuccessful
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;
Pure motor stroke; limited neurological dysfunction
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

27. lacerated wound in palmer surface of hand. what structure is injured?
ACL injury
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Tendons more likely
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

28. Indication for bariatric surgery in obese patients
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;
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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;
Unilateral vocal cord paralysis

29. perioral numbness after parathyroidectomy
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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
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;
Twisting force with the foot fixed on the ground seen in football and basketball games;

30. recurrent laryngeal nerve injury
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Study showed no adverse effect; but they are contraindicated for PVD
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Unilateral vocal cord paralysis

31. popping sensation; rapid onset of knee effusion. athelet
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
Dumping syndrome; small and frequent meals; no simple sugar
ACL injury
Nonunion and avascular necrosis; fx can block blood supply;

32. Patient underwent CABG; postoperatively drowsy. most likely cause?
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Klinefelter syndrome; 50 fold increase;

33. menisci injury
Pure motor stroke; limited neurological dysfunction
Twisting force with the foot fixed on the ground seen in football and basketball games;
Subphrenic abscess or other abdominal abscesses; order US or CT
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

34. contraindication of urethral catheterization
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Urethral stricture; pelvic of urethral trauma
SAH due to post communicating artery aneurysm;
Ispilateral hypoglossal nerve injury

35. antibiotics of acute cholecystitis
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

36. diarrhoea after gastric bypass
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;
Dumping syndrome; small and frequent meals; no simple sugar
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

37. When do we see complications due to hypophosphatemia
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

38. SOB - confusion - petechial rash after trauma - fracture
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
ACL injury

39. acute colonic ischemia
Abd pain and tenderness; bloody diarrhoea or hematochezia
Carpal tunnel syndrom
ACL injury
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

40. What percent of anal abscess deveolop fisutula
Brardycardia - HTN - resp depression
Epi and chest compressio for prolong period of time; atropine is given after epi;
50%; tunneling between rectum or kin
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

41. Tx of proximal non metastatic rectal ca
Less than 5mm
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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

42. How to confirm dx of compartment syndrom
Compression stocking - weight reduction - leg elevation
Dumping syndrome; small and frequent meals; no simple sugar
Pure motor stroke; limited neurological dysfunction
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

43. What is prehn sign?
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Retrograde ejaculation
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

44. How to evaluate painless testicular swelling suspicious for cancer
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Twisting force with the foot fixed on the ground seen in football and basketball games;

45. management of hip fracture
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Less than 5mm

46. Why initial xrays are negative in scaphoid fx
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
SAH due to post communicating artery aneurysm;
Mammogram
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

47. management of stone 8-10mm
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Progressive fibrosis of palmar fascia. etiololgy not known;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

48. What is hungry bone syndrome?
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)
Klinefelter syndrome; 50 fold increase;
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

49. common complication of inadequate mx of scaphoid fx
Nonunion and avascular necrosis; fx can block blood supply;
Study showed no adverse effect; but they are contraindicated for PVD
When urethral catherization is unsuccessful
Dm neuropathy; stocking glove pattern

50. Complications of breast impant
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Less than 5mm

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USMLE Step3 Surgery

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