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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. Why initial xrays are negative in scaphoid fx
Malignancy until proven otherwise
Elderly and critically ill patients
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

2. How to manage obesity
Saline and silicone
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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;
Abd pain and tenderness; bloody diarrhoea or hematochezia

3. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Brardycardia - HTN - resp depression
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Subphrenic abscess or other abdominal abscesses; order US or CT
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

4. What is most common lung injury after blunt chest trauma?
Next best step surgery; not ultrasound
Cystic scrotal fluid collection between parietal and visceral layers of testis
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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

5. Complications of breast impant
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Supraglottic edema; low threshold for intubation
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

6. SAH due to posterior inferior cerebellar aneurysm
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
L5 to S2
4-6 weeks for noncontact sports and longer time for contact sports
Headache - ataxia - bulbar dysfunction

7. What is the complications of undescended testis
Even after ochiopexy risk of ochiopexy higher then general population
4-6 weeks for noncontact sports and longer time for contact sports
S2-S4
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

8. Dupuytren contracture
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Check ET tube placement if correct needle decompresion
Progressive fibrosis of palmar fascia. etiololgy not known;

9. complications of TPN
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
Study showed no adverse effect; but they are contraindicated for PVD
Meniscus injury; medial most common; pain/swelling; popping sensation
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

10. clavicle fx
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Displaced ORIF ; nondisplaced sling immobilization
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

11. Why varicocele more common in the left side
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
ACL injury
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
If patient ambulatory - surgery and pain control; if not nonop mx

12. most common fx when falling on outsretched hand
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;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

13. How to manage a patient with asystole
Epi and chest compressio for prolong period of time; atropine is given after epi;
50%; tunneling between rectum or kin
Elderly and critically ill patients
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

14. menisci injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Low anterior resection and radio; add chemo if node positive

15. recurrent laryngeal nerve injury
Unilateral vocal cord paralysis
Displaced ORIF ; nondisplaced sling immobilization
Nonunion and avascular necrosis; fx can block blood supply;
Meniscus injury; medial most common; pain/swelling; popping sensation

16. lacerated wound in palmer surface of hand. what structure is injured?
Tendons more likely
Strok and traumatic brain injury
Check ET tube placement if correct needle decompresion
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

17. aspiration of breast cyst is nonbloody
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Compression stocking - weight reduction - leg elevation

18. DD of acute scrotal pain
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
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

19. cremasteric reflex test?
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
4-6 weeks for noncontact sports and longer time for contact sports

20. popping sensation; rapid onset of knee effusion. athelet
Check ET tube placement if correct needle decompresion
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
ACL injury

21. What is cushing's triad
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Brardycardia - HTN - resp depression
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Mammogram

22. contraindication of urethral catheterization
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
10-12 months
Even after ochiopexy risk of ochiopexy higher then general population
Urethral stricture; pelvic of urethral trauma

23. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Supraglottic edema; low threshold for intubation
If any compressive symptoms eg. dysphagia

24. diarrhoea 4-5 days after cholecystectomy
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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
Even after ochiopexy risk of ochiopexy higher then general population
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

25. acute colonic ischemia
Abd pain and tenderness; bloody diarrhoea or hematochezia
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Progressive fibrosis of palmar fascia. etiololgy not known;

26. Tx of proximal non metastatic rectal ca
Even after ochiopexy risk of ochiopexy higher then general population
Fx displace >1mm - nonunion during followup - osteonecrosis
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Low anterior resection and radio; add chemo if node positive

27. How to confirm dx of compartment syndrom
Study showed no adverse effect; but they are contraindicated for PVD
Seminomas
10-12 months
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

28. xray finding of stress fx after 3-4w
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
If patient ambulatory - surgery and pain control; if not nonop mx
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Saline and silicone

29. Valgus and Varus tests
Unilateral vocal cord paralysis
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
15-40%; self limiting;doesn't require tx
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

30. management of hip fracture
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Meniscus injury; medial most common; pain/swelling; popping sensation
If patient ambulatory - surgery and pain control; if not nonop mx
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

31. When do we see complications due to hypophosphatemia
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
Nonunion and avascular necrosis; fx can block blood supply;
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;
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

32. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

33. When to stop raloxifene before surgery
Patellar tendon tear; difficulty in extension
When urethral catherization is unsuccessful
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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

34. What is hydrocele?
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Subphrenic abscess or other abdominal abscesses; order US or CT
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Cystic scrotal fluid collection between parietal and visceral layers of testis

35. how ABI help dx of PVD
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Elevated non seminomas
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

36. dorsiflexion and planter flexion
L5 to S2
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Less than 5mm
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

37. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Nonunion and avascular necrosis; fx can block blood supply;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

38. prostate enlarged - nontender - no nodularity - elevated PSA
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Unilateral vocal cord paralysis
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

39. What percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
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
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

40. suprapubic catheterization
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
When urethral catherization is unsuccessful
4-6 weeks for noncontact sports and longer time for contact sports
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

41. anal sphincter tone
S2-S4
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Check ET tube placement if correct needle decompresion
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

42. indication of ursodeoxycholic acid
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
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
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

43. aspiration of breast cyst is bloody
Mammogram
Progressive fibrosis of palmar fascia. etiololgy not known;
If patient ambulatory - surgery and pain control; if not nonop mx
Unilateral vocal cord paralysis

44. several knee pain after being tackled in football game
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Next best step surgery; not ultrasound

45. What is prehn sign?
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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

46. How to dx ACL tear?
When urethral catherization is unsuccessful
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;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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

47. Can we use beta blocker for pvd?
Study showed no adverse effect; but they are contraindicated for PVD
10-12 months
Nonunion and avascular necrosis; fx can block blood supply;
Amoxicillin-clavulanate

48. Why ruq calcificaion is concerning
Twisting force with the foot fixed on the ground seen in football and basketball games;
SAH due to post communicating artery aneurysm;
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Tendons more likely

49. management of stone 8-10mm
Unilateral vocal cord paralysis
Low anterior resection and radio; add chemo if node positive
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
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

50. SOB - confusion - petechial rash after trauma - fracture
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Elderly and critically ill patients
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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

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USMLE Step3 Surgery

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