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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. What is the contraindication of hyperventilation in inc ICP
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Strok and traumatic brain injury
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

2. how hyperventilation lowers ICP
Cystic scrotal fluid collection between parietal and visceral layers of testis
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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;
Nonunion and avascular necrosis; fx can block blood supply;

3. acute colonic ischemia
Abd pain and tenderness; bloody diarrhoea or hematochezia
Urethral stricture; pelvic of urethral trauma
Nonunion and avascular necrosis; fx can block blood supply;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

4. prostate enlarged - nontender - no nodularity - elevated PSA
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Subphrenic abscess or other abdominal abscesses; order US or CT
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

5. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Seminomas
Fx displace >1mm - nonunion during followup - osteonecrosis
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

6. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Saline and silicone
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

7. acalculus cholecystitis
Carpal tunnel syndrom
Elderly and critically ill patients
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;
Headache - ataxia - bulbar dysfunction

8. Most common of sudden death due to steering wheel injury
Fx displace >1mm - nonunion during followup - osteonecrosis
Brardycardia - HTN - resp depression
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

9. transrectal prostate biopsy
50%; tunneling between rectum or kin
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Ampicillin sublactum - pipercillin - ceftriaxone and metro
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

10. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Progressive fibrosis of palmar fascia. etiololgy not known;
Check ET tube placement if correct needle decompresion
MAT; medial meniscus injury; ACL and Tibial colateral ligament
S2-S4

11. How to manage obesity
Twisting force with the foot fixed on the ground seen in football and basketball games;
Tendons more likely
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

12. Why right varicocele is more concerning?

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13. management of nondisplaced scaphoid fx
Check ET tube placement if correct needle decompresion
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
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

14. pregnant patient with asymptomatic gall stones
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
Compression stocking - weight reduction - leg elevation
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

15. What is most common lung injury after blunt chest trauma?
Nonunion and avascular necrosis; fx can block blood supply;
Low anterior resection and radio; add chemo if node positive
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
Progressive fibrosis of palmar fascia. etiololgy not known;

16. cremasteric reflex test?
Unilateral vocal cord paralysis
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

17. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
10-12 months
Ampicillin sublactum - pipercillin - ceftriaxone and metro
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

18. ipsilateral deviation of tongue upon protrusion
Klinefelter syndrome; 50 fold increase;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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
Ispilateral hypoglossal nerve injury

19. When to stop raloxifene before surgery
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Ampicillin sublactum - pipercillin - ceftriaxone and metro
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Increased size during the day and valsalva means it is communicated with peritoneal cavity

20. diarrhoea after gastric bypass
Dumping syndrome; small and frequent meals; no simple sugar
Next best step surgery; not ultrasound
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Dm neuropathy; stocking glove pattern

21. 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;
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;
When urethral catherization is unsuccessful
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

22. diarrhoea 4-5 days after cholecystectomy
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
S2-S4
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Strok and traumatic brain injury

23. aspiration of breast cyst is bloody
Supraglottic edema; low threshold for intubation
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Mammogram

24. dorsiflexion and planter flexion
CRPS
L5 to S2
Mammogram
Patellar tendon tear; difficulty in extension

25. perioral numbness after parathyroidectomy
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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
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
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

26. How to differentiate communicative and non-communicative hydrocele
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

27. mangement of localized lymphadenopathy
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
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
24-48 hours of supportive therapy followed by cholecystectomy
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

28. stress fx
Low anterior resection and radio; add chemo if node positive
SAH due to post communicating artery aneurysm;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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

29. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Subphrenic abscess or other abdominal abscesses; order US or CT
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Headache - ataxia - bulbar dysfunction

30. How to differentiate ACL and meniscus injury
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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
Seminomas
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

31. cat/dog bites
Meniscus injury; medial most common; pain/swelling; popping sensation
15-40%; self limiting;doesn't require tx
24-48 hours of supportive therapy followed by cholecystectomy
Amoxicillin-clavulanate

32. complications of TPN
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Study showed no adverse effect; but they are contraindicated for PVD
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

33. How to perform lachman test
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
ACL injury
Meniscus injury; medial most common; pain/swelling; popping sensation
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

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

35. tx distal rectal ca
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Malignancy until proven otherwise
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Pure motor stroke; limited neurological dysfunction

36. How to confirm dx of compartment syndrom
S2-S4
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
50%; tunneling between rectum or kin
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

37. SAH due to posterior inferior cerebellar aneurysm
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
24-48 hours of supportive therapy followed by cholecystectomy
Headache - ataxia - bulbar dysfunction
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

38. management of hip fracture
If patient ambulatory - surgery and pain control; if not nonop mx
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

39. What is cushing's triad
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
CRPS
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Brardycardia - HTN - resp depression

40. lacunar stroke
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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
Pure motor stroke; limited neurological dysfunction

41. When goiter needs surgery
Nonunion and avascular necrosis; fx can block blood supply;
If any compressive symptoms eg. dysphagia
Carpal tunnel syndrom
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

42. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Saline and silicone
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

43. suprapubic catheterization
Patellar tendon tear; difficulty in extension
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
When urethral catherization is unsuccessful
Compression stocking - weight reduction - leg elevation

44. beta hcg and AFP
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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
Elevated non seminomas

45. How varicocele causes testicular atrophy
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

46. What is the strongest risk factor for male breast cancer
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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
Klinefelter syndrome; 50 fold increase;
Dm neuropathy; stocking glove pattern

47. types of hip fracture
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
L5 to S2
Cystic scrotal fluid collection between parietal and visceral layers of testis
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

48. Why initial xrays are negative in scaphoid fx
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
Displaced ORIF ; nondisplaced sling immobilization
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

49. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Carpal tunnel syndrom
15-40%; self limiting;doesn't require tx

50. What time frame required for bone remodeling
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
10-12 months
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Brardycardia - HTN - resp depression

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USMLE Step3 Surgery

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