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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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1. What is terrible triad
Low anterior resection and radio; add chemo if node positive
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
MAT; medial meniscus injury; ACL and Tibial colateral ligament

2. tx distal rectal ca
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Sphincter sparing surgery (local resection) - abdomnio perineal resection
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Progressive fibrosis of palmar fascia. etiololgy not known;

3. dorsiflexion and planter flexion
Dm neuropathy; stocking glove pattern
L5 to S2
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

4. Can we use beta blocker for pvd?
4-6 weeks for noncontact sports and longer time for contact sports
Study showed no adverse effect; but they are contraindicated for PVD
S2-S4
Sphincter sparing surgery (local resection) - abdomnio perineal resection

5. varicocele
L5 to S2
Subphrenic abscess or other abdominal abscesses; order US or CT
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Pure motor stroke; limited neurological dysfunction

6. characteristics of ureteral stone?
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Cystic scrotal fluid collection between parietal and visceral layers of testis

7. How to confirm achiles tendon rupture
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

8. management of stone 8-10mm
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Subphrenic abscess or other abdominal abscesses; order US or CT
Saline and silicone

9. cat/dog bites
Amoxicillin-clavulanate
Urethral stricture; pelvic of urethral trauma
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Subphrenic abscess or other abdominal abscesses; order US or CT

10. Why right varicocele is more concerning?

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11. pregnant patient with asymptomatic gall stones
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Dumping syndrome; small and frequent meals; no simple sugar
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;

12. management of hip fracture
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
If patient ambulatory - surgery and pain control; if not nonop mx
Twisting force with the foot fixed on the ground seen in football and basketball games;
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

13. When do we see complications due to hypophosphatemia
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;
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;
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

14. beta HCG
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
Check ET tube placement if correct needle decompresion
Seminomas

15. aspiration of breast cyst is nonbloody
Compression stocking - weight reduction - leg elevation
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

16. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
SAH due to post communicating artery aneurysm;
Check ET tube placement if correct needle decompresion
Headache - ataxia - bulbar dysfunction
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

17. How to confirm dx of compartment syndrom
Brardycardia - HTN - resp depression
Displaced ORIF ; nondisplaced sling immobilization
Saline and silicone
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

18. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Amoxicillin-clavulanate
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Klinefelter syndrome; 50 fold increase;
SAH due to post communicating artery aneurysm;

19. Most common of sudden death due to steering wheel injury
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

20. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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
Urethral stricture; pelvic of urethral trauma

21. How to perform lachman test
Tendons more likely
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Compression stocking - weight reduction - leg elevation
50%; tunneling between rectum or kin

22. Valgus and Varus tests
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;
Cystic scrotal fluid collection between parietal and visceral layers of testis
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

23. What is the contraindication of hyperventilation in inc ICP
10-12 months
Strok and traumatic brain injury
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
SAH due to post communicating artery aneurysm;

24. When patient can go back to sports after clavicle fx
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
4-6 weeks for noncontact sports and longer time for contact sports
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

25. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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
Next best step surgery; not ultrasound
CRPS

26. What is most common lung injury after blunt chest trauma?
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 patient ambulatory - surgery and pain control; if not nonop mx
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Dm neuropathy; stocking glove pattern

27. ct scan; cystic lesion in head of pancreas; next step
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Dm neuropathy; stocking glove pattern
Elderly and critically ill patients

28. 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
Dm neuropathy; stocking glove pattern
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

29. When to stop raloxifene before surgery
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
S2-S4
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Ampicillin sublactum - pipercillin - ceftriaxone and metro

30. Why ruq calcificaion is concerning
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

31. What percent of anal abscess deveolop fisutula
Increased size during the day and valsalva means it is communicated with peritoneal cavity
50%; tunneling between rectum or kin
Supraglottic edema; low threshold for intubation
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

32. management of gunshot wound
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
S2-S4
10-12 months
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

33. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
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;
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

34. severe pain in leg after MVC
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Low anterior resection and radio; add chemo if node positive
Seminomas
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

35. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
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
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

36. management of nondisplaced scaphoid fx
Less than 5mm
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
4-6 weeks for noncontact sports and longer time for contact sports
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

37. What is the complications of undescended testis
Even after ochiopexy risk of ochiopexy higher then general population
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

38. varicose veins with ulcer - bleeding and thrombophlebitits
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Less than 5mm
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
24-48 hours of supportive therapy followed by cholecystectomy

39. anal sphincter tone
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;
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
S2-S4
Dm neuropathy; stocking glove pattern

40. beta hcg and AFP
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Patellar tendon tear; difficulty in extension
Elevated non seminomas
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

41. 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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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

42. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Study showed no adverse effect; but they are contraindicated for PVD
Compression stocking - weight reduction - leg elevation
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;

43. Dupuytren contracture
Progressive fibrosis of palmar fascia. etiololgy not known;
Klinefelter syndrome; 50 fold increase;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

44. managment of animal bite in hands
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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;
Ispilateral hypoglossal nerve injury
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

45. SAH due to posterior inferior cerebellar aneurysm
Study showed no adverse effect; but they are contraindicated for PVD
Low anterior resection and radio; add chemo if node positive
Headache - ataxia - bulbar dysfunction
Mammogram

46. SOB - confusion - petechial rash after trauma - fracture
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Tendons more likely
Dumping syndrome; small and frequent meals; no simple sugar
Saline and silicone

47. 3 mo with groin bulge; bulge appears when child cries
Study showed no adverse effect; but they are contraindicated for PVD
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

48. How to dx ACL tear?
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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
Patellar tendon tear; difficulty in extension

49. lacunar stroke
Less than 5mm
Even after ochiopexy risk of ochiopexy higher then general population
If patient ambulatory - surgery and pain control; if not nonop mx
Pure motor stroke; limited neurological dysfunction

50. most common fx when falling on outsretched hand
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
CRPS
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

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USMLE Step3 Surgery

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