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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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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. antibiotics of acute cholecystitis
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

2. complications of TPN
Retrograde ejaculation
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

3. What percent of anal abscess deveolop fisutula
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
50%; tunneling between rectum or kin
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Seminomas

4. acalculus cholecystitis
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Elderly and critically ill patients
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Malignancy until proven otherwise

5. management of stone 8-10mm
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

6. when patient with severe lung disease have C02 retention
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

7. When to do surgery in undesceneded testis?
4-6 weeks for noncontact sports and longer time for contact sports
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;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

8. cremasteric reflex
Less than 5mm
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

9. beta hcg and AFP
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Elevated non seminomas
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

10. How to perform lachman test
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Meniscus injury; medial most common; pain/swelling; popping sensation
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
Patellar tendon tear; difficulty in extension

11. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

12. management of hip fracture
Patellar tendon tear; difficulty in extension
Carpal tunnel syndrom
If patient ambulatory - surgery and pain control; if not nonop mx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

13. first line of management of PVD
If any compressive symptoms eg. dysphagia
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

14. What is terrible triad
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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

15. What is most common lung injury after blunt chest trauma?
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
If patient ambulatory - surgery and pain control; if not nonop mx
50%; tunneling between rectum or kin
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

16. 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.
Ispilateral hypoglossal nerve injury
Saline and silicone
Supraglottic edema; low threshold for intubation

17. sudden onset of postoperative hyperglycemia when patient on TPN
Urethral stricture; pelvic of urethral trauma
Ispilateral hypoglossal nerve injury
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

18. How to differentiate communicative and non-communicative hydrocele
10-12 months
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Unilateral vocal cord paralysis

19. How to manage obesity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

20. when scaphoid fx patient needs to be referred to orthopedic
When urethral catherization is unsuccessful
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
Fx displace >1mm - nonunion during followup - osteonecrosis
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

21. prostate enlarged - nontender - no nodularity - elevated PSA
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

22. SOB - confusion - petechial rash after trauma - fracture
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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

23. Complications of breast impant
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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

24. SAH due to posterior inferior cerebellar aneurysm
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Headache - ataxia - bulbar dysfunction
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
L5 to S2

25. 27 yo with scrotal mass; warm tender testes feel like bag of worms
If patient ambulatory - surgery and pain control; if not nonop mx
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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
Unilateral vocal cord paralysis

26. suprapubic catheterization
Strok and traumatic brain injury
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
When urethral catherization is unsuccessful
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

27. lacunar stroke
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Pure motor stroke; limited neurological dysfunction
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Brardycardia - HTN - resp depression

28. transrectal prostate biopsy
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

29. DD of acute scrotal pain
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

30. common complication of inadequate mx of scaphoid fx
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Nonunion and avascular necrosis; fx can block blood supply;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

31. Most common of sudden death due to steering wheel injury
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

32. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Saline and silicone

33. cremasteric reflex test?
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

34. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Low anterior resection and radio; add chemo if node positive
Urethral stricture; pelvic of urethral trauma
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

35. Tx of proximal non metastatic rectal ca
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
Meniscus injury; medial most common; pain/swelling; popping sensation
Low anterior resection and radio; add chemo if node positive
Strok and traumatic brain injury

36. beta HCG
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Seminomas
Carpal tunnel syndrom

37. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
24-48 hours of supportive therapy followed by cholecystectomy
Check ET tube placement if correct needle decompresion
Saline and silicone
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

38. Dupuytren contracture
Progressive fibrosis of palmar fascia. etiololgy not known;
Abd pain and tenderness; bloody diarrhoea or hematochezia
Epi and chest compressio for prolong period of time; atropine is given after epi;
Displaced ORIF ; nondisplaced sling immobilization

39. cat/dog bites
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Amoxicillin-clavulanate
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

40. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
4-6 weeks for noncontact sports and longer time for contact sports
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

41. acute colonic ischemia
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
Pure motor stroke; limited neurological dysfunction
4-6 weeks for noncontact sports and longer time for contact sports

42. Tx of pulmonary contusion
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Compression stocking - weight reduction - leg elevation
Strok and traumatic brain injury

43. swelling and tenderness in anterior part of knee
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Patellar tendon tear; difficulty in extension
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Fx displace >1mm - nonunion during followup - osteonecrosis

44. How to differentiate ACL and meniscus injury
Elevated non seminomas
Ispilateral hypoglossal nerve 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
ACL injury

45. painless testicular mass in young male
Increased size during the day and valsalva means it is communicated with peritoneal cavity
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
24-48 hours of supportive therapy followed by cholecystectomy
Malignancy until proven otherwise

46. dorsiflexion and planter flexion
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
L5 to S2
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

47. Valgus and Varus tests
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

48. When goiter needs surgery
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
If any compressive symptoms eg. dysphagia

49. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
24-48 hours of supportive therapy followed by cholecystectomy
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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

50. stress fx
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Urethral stricture; pelvic of urethral trauma
Check ET tube placement if correct needle decompresion

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USMLE Step3 Surgery

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