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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. acute colonic ischemia
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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
Abd pain and tenderness; bloody diarrhoea or hematochezia

2. scrotal trauma
Next best step surgery; not ultrasound
Headache - ataxia - bulbar dysfunction
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

3. types of hip fracture
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 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;
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

4. most common fx when falling on outsretched hand
ACL injury
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

5. What is the contraindication of hyperventilation in inc ICP
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Strok and traumatic brain injury
MAT; medial meniscus injury; ACL and Tibial colateral ligament

6. Indication for bariatric surgery in obese patients
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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;
Progressive fibrosis of palmar fascia. etiololgy not known;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

7. What is hungry bone syndrome?
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
Strok and traumatic brain injury
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
SAH due to post communicating artery aneurysm;

8. how hyperventilation lowers ICP
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
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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

9. How to manage obesity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Abd pain and tenderness; bloody diarrhoea or hematochezia
When urethral catherization is unsuccessful
Brardycardia - HTN - resp depression

10. complication displaced or communited distal radial fx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Carpal tunnel syndrom
Even after ochiopexy risk of ochiopexy higher then general population

11. indication of ursodeoxycholic acid
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
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
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
Progressive fibrosis of palmar fascia. etiololgy not known;

12. diarrhoea after gastric bypass
Pure motor stroke; limited neurological dysfunction
Dumping syndrome; small and frequent meals; no simple sugar
ACL injury
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

13. What are the common injuries from lightning?
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Epi and chest compressio for prolong period of time; atropine is given after epi;
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;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

14. Tx of pulmonary contusion
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
S2-S4

15. How to evaluate painless testicular swelling suspicious for cancer
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

16. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Nonunion and avascular necrosis; fx can block blood supply;
Dm neuropathy; stocking glove pattern
Retrograde ejaculation
Malignancy until proven otherwise

17. 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.
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

18. when scaphoid fx patient needs to be referred to orthopedic
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
Check ET tube placement if correct needle decompresion
Fx displace >1mm - nonunion during followup - osteonecrosis
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

19. cremasteric reflex
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Check ET tube placement if correct needle decompresion
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

20. management of nondisplaced scaphoid fx
L5 to S2
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

21. What is most common lung injury after blunt chest trauma?
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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;
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

22. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
Ispilateral hypoglossal nerve injury
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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

23. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
Saline and silicone
Compression stocking - weight reduction - leg elevation
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

24. Why varicocele more common in the left side
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;
S2-S4
Dm neuropathy; stocking glove pattern
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

25. DD of acute scrotal pain
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

26. pregnant patient with asymptomatic gall stones
Subphrenic abscess or other abdominal abscesses; order US or CT
Check ET tube placement if correct needle decompresion
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

27. What is the complications of undescended testis
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
L5 to S2
Subphrenic abscess or other abdominal abscesses; order US or CT
Even after ochiopexy risk of ochiopexy higher then general population

28. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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 any compressive symptoms eg. dysphagia

29. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Strok and traumatic brain injury
Even after ochiopexy risk of ochiopexy higher then general population
Less than 5mm
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

30. complications of TPN
When urethral catherization is unsuccessful
Progressive fibrosis of palmar fascia. etiololgy not known;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
24-48 hours of supportive therapy followed by cholecystectomy

31. xray finding of stress fx after 3-4w
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Ispilateral hypoglossal nerve injury
Compression stocking - weight reduction - leg elevation
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

32. How to differentiate ACL and meniscus injury
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
Twisting force with the foot fixed on the ground seen in football and basketball games;
CRPS

33. aspiration of breast cyst is nonbloody
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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;

34. When patient can go back to sports after clavicle fx
Saline and silicone
Meniscus injury; medial most common; pain/swelling; popping sensation
4-6 weeks for noncontact sports and longer time for contact sports
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

35. contraindication of urethral catheterization
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Urethral stricture; pelvic of urethral trauma

36. severe pain in leg after MVC
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
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

37. Incidence of AF in CABG patient

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38. diarrhoea 4-5 days after cholecystectomy
Pure motor stroke; limited neurological dysfunction
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

39. characteristics of ureteral stone?
Malignancy until proven otherwise
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

40. Dupuytren contracture
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
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
Subphrenic abscess or other abdominal abscesses; order US or CT
Progressive fibrosis of palmar fascia. etiololgy not known;

41. What is terrible triad
Mammogram
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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

42. When to do surgery in undesceneded testis?
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
CRPS
Abd pain and tenderness; bloody diarrhoea or hematochezia
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

43. what size of ureteral stone for non op mx
S2-S4
Less than 5mm
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Carpal tunnel syndrom

44. common complication of inadequate mx of scaphoid fx
Nonunion and avascular necrosis; fx can block blood supply;
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

45. first line of management of PVD
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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
Pure motor stroke; limited neurological dysfunction

46. anal sphincter tone
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Abd pain and tenderness; bloody diarrhoea or hematochezia
Less than 5mm
S2-S4

47. transrectal prostate biopsy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Abd pain and tenderness; bloody diarrhoea or hematochezia
Strok and traumatic brain injury
If any compressive symptoms eg. dysphagia

48. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Urethral stricture; pelvic of urethral trauma
Check ET tube placement if correct needle decompresion
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

49. dorsiflexion and planter flexion
L5 to S2
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Study showed no adverse effect; but they are contraindicated for PVD
Patellar tendon tear; difficulty in extension

50. 3 mo with groin bulge; bulge appears when child cries
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Mammogram
If any compressive symptoms eg. dysphagia

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USMLE Step3 Surgery

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