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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. How to manage obesity
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
24-48 hours of supportive therapy followed by cholecystectomy
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

2. varicose veins with ulcer - bleeding and thrombophlebitits
If any compressive symptoms eg. dysphagia
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Less than 5mm

3. Patient underwent CABG; postoperatively drowsy. most likely cause?
Mammogram
Progressive fibrosis of palmar fascia. etiololgy not known;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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

4. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Patellar tendon tear; difficulty in extension
Meniscus injury; medial most common; pain/swelling; popping sensation
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. inhalation of hot air - steam - smoke in burn victim
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Supraglottic edema; low threshold for intubation
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Malignancy until proven otherwise

6. sudden onset of postoperative hyperglycemia when patient on TPN
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Study showed no adverse effect; but they are contraindicated for PVD
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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

7. beta hcg and AFP
Compression stocking - weight reduction - leg elevation
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Elevated non seminomas

8. 3 mo with groin bulge; bulge appears when child cries
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Abd pain and tenderness; bloody diarrhoea or hematochezia

9. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Twisting force with the foot fixed on the ground seen in football and basketball games;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Pure motor stroke; limited neurological dysfunction

10. DD of acute scrotal pain
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Displaced ORIF ; nondisplaced sling immobilization

11. How to dx ACL tear?
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

12. varicocele
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Ispilateral hypoglossal nerve injury
Pure motor stroke; limited neurological dysfunction

13. cat/dog bites
Urethral stricture; pelvic of urethral trauma
Amoxicillin-clavulanate
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Check ET tube placement if correct needle decompresion

14. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Dm neuropathy; stocking glove pattern
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
If any compressive symptoms eg. dysphagia

15. indication of ursodeoxycholic acid
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
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
Amoxicillin-clavulanate
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

16. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Low anterior resection and radio; add chemo if node positive
10-12 months
SAH due to post communicating artery aneurysm;

17. xray finding of stress fx after 3-4w
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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
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

18. management of nondisplaced scaphoid fx
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
ACL injury
Dumping syndrome; small and frequent meals; no simple sugar
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

19. most frequent complication of TURP
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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
Retrograde ejaculation
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

20. managment of animal bite in hands
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;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Retrograde ejaculation

21. How to differentiate ACL and meniscus injury
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

22. When to do surgery in undesceneded testis?
Subphrenic abscess or other abdominal abscesses; order US or CT
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

23. management of gunshot wound
Mammogram
Displaced ORIF ; nondisplaced sling immobilization
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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

24. How mcmurray manuver perform
Unilateral vocal cord paralysis
Supraglottic edema; low threshold for intubation
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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

25. When patient can go back to sports after clavicle fx
4-6 weeks for noncontact sports and longer time for contact sports
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

26. What is most common lung injury after blunt chest trauma?
Supraglottic edema; low threshold for intubation
Ispilateral hypoglossal nerve injury
Cystic scrotal fluid collection between parietal and visceral layers of testis
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

27. several knee pain after being tackled in football game
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
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

28. menisci injury
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
Supraglottic edema; low threshold for intubation
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Twisting force with the foot fixed on the ground seen in football and basketball games;

29. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Urethral stricture; pelvic of urethral trauma
Dm neuropathy; stocking glove pattern
If any compressive symptoms eg. dysphagia

30. mx of stress fx
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
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
Headache - ataxia - bulbar dysfunction

31. when scaphoid fx patient needs to be referred to orthopedic
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
Fx displace >1mm - nonunion during followup - osteonecrosis
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

32. acalculus cholecystitis
S2-S4
Elderly and critically ill patients
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
Strok and traumatic brain injury

33. conservative Tx of varicose veins
CRPS
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
Compression stocking - weight reduction - leg elevation

34. management of hip fracture
ACL injury
If patient ambulatory - surgery and pain control; if not nonop mx
Meniscus injury; medial most common; pain/swelling; popping sensation
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

35. how hyperventilation lowers ICP
Nonunion and avascular necrosis; fx can block blood supply;
Elderly and critically ill patients
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

36. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Dm neuropathy; stocking glove pattern
Saline and silicone

37. first line of management of PVD
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
S2-S4
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

38. dorsiflexion and planter flexion
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Study showed no adverse effect; but they are contraindicated for PVD
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
L5 to S2

39. what size of ureteral stone for non op mx
Less than 5mm
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Headache - ataxia - bulbar dysfunction

40. What time frame required for bone remodeling
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Check ET tube placement if correct needle decompresion
10-12 months

41. prostate enlarged - nontender - no nodularity - elevated PSA
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Strok and traumatic brain injury
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Study showed no adverse effect; but they are contraindicated for PVD

42. How varicocele causes testicular atrophy
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
L5 to S2
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

43. acute colonic ischemia
Unilateral vocal cord paralysis
Abd pain and tenderness; bloody diarrhoea or hematochezia
Supraglottic edema; low threshold for intubation
Meniscus injury; medial most common; pain/swelling; popping sensation

44. lacunar stroke
Pure motor stroke; limited neurological dysfunction
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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

45. most common fx when falling on outsretched hand
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Elevated non seminomas

46. perioral numbness after parathyroidectomy
Mammogram
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Next best step surgery; not ultrasound
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

47. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
If any compressive symptoms eg. dysphagia
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

48. What is prehn sign?
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Headache - ataxia - bulbar dysfunction
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

49. cremasteric reflex test?
If any compressive symptoms eg. dysphagia
ACL injury
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

50. When to stop raloxifene before surgery
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Seminomas
S2-S4

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USMLE Step3 Surgery

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