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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. acalculus cholecystitis
Elderly and critically ill patients
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
If any compressive symptoms eg. dysphagia
Study showed no adverse effect; but they are contraindicated for PVD

2. sudden onset of postoperative hyperglycemia when patient on TPN
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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

3. management of hip fracture
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
CRPS
If patient ambulatory - surgery and pain control; if not nonop mx

4. pregnant patient with asymptomatic gall stones
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Progressive fibrosis of palmar fascia. etiololgy not known;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

5. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Brardycardia - HTN - resp depression
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Ampicillin sublactum - pipercillin - ceftriaxone and metro

6. indication of ursodeoxycholic acid
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Meniscus injury; medial most common; pain/swelling; popping sensation
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
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

7. Complications of breast impant
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Patellar tendon tear; difficulty in extension
Low anterior resection and radio; add chemo if node positive

8. popping sensation; rapid onset of knee effusion. athelet
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
ACL injury
Check ET tube placement if correct needle decompresion

9. most frequent complication of TURP
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Retrograde ejaculation
Brardycardia - HTN - resp depression
Pure motor stroke; limited neurological dysfunction

10. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Meniscus injury; medial most common; pain/swelling; popping sensation
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

11. Why ruq calcificaion is concerning
Tendons more likely
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Elderly and critically ill patients
Displaced ORIF ; nondisplaced sling immobilization

12. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Check ET tube placement if correct needle decompresion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

13. menisci injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
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;
4-6 weeks for noncontact sports and longer time for contact sports
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;

14. characteristics of ureteral stone?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Carpal tunnel syndrom

15. How to manage a patient with asystole
Epi and chest compressio for prolong period of time; atropine is given after epi;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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

16. How to differentiate ACL and meniscus injury
Elevated non seminomas
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

17. When patient can go back to sports after clavicle fx
4-6 weeks for noncontact sports and longer time for contact sports
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Low anterior resection and radio; add chemo if node positive
When urethral catherization is unsuccessful

18. How to confirm dx of compartment syndrom
Meniscus injury; medial most common; pain/swelling; popping sensation
Progressive fibrosis of palmar fascia. etiololgy not known;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

19. Dupuytren contracture
Seminomas
Progressive fibrosis of palmar fascia. etiololgy not known;
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
When urethral catherization is unsuccessful

20. Why right varicocele is more concerning?

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21. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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;
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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

22. lacunar stroke
Pure motor stroke; limited neurological dysfunction
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
Cystic scrotal fluid collection between parietal and visceral layers of testis
Epi and chest compressio for prolong period of time; atropine is given after epi;

23. Can we use beta blocker for pvd?
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Elevated non seminomas
Study showed no adverse effect; but they are contraindicated for PVD
Urethral stricture; pelvic of urethral trauma

24. How mcmurray manuver perform
Urethral stricture; pelvic of urethral trauma
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Patellar tendon tear; difficulty in extension

25. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Study showed no adverse effect; but they are contraindicated for PVD
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

26. Patient underwent CABG; postoperatively drowsy. most likely cause?
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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

27. 27 yo with scrotal mass; warm tender testes feel like bag of worms
When urethral catherization is unsuccessful
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Unilateral vocal cord paralysis

28. Indication for bariatric surgery in obese patients
Amoxicillin-clavulanate
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Check ET tube placement if correct needle decompresion
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;

29. cat/dog bites
Less than 5mm
Amoxicillin-clavulanate
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
50%; tunneling between rectum or kin

30. What is the strongest risk factor for male breast cancer
Seminomas
Klinefelter syndrome; 50 fold increase;
Tendons more likely
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;

31. How varicocele causes testicular atrophy
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
10-12 months
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Compression stocking - weight reduction - leg elevation

32. What is hydrocele?
Amoxicillin-clavulanate
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Ispilateral hypoglossal nerve injury
Cystic scrotal fluid collection between parietal and visceral layers of testis

33. how hyperventilation lowers ICP
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
SAH due to post communicating artery aneurysm;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Meniscus injury; medial most common; pain/swelling; popping sensation

34. Why initial xrays are negative in scaphoid fx
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
When urethral catherization is unsuccessful
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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

35. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Compression stocking - weight reduction - leg elevation
SAH due to post communicating artery aneurysm;

36. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
SAH due to post communicating artery aneurysm;
Dm neuropathy; stocking glove pattern
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;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

37. Most common of sudden death due to steering wheel injury
Even after ochiopexy risk of ochiopexy higher then general population
Seminomas
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

38. When do we see complications due to hypophosphatemia
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;
L5 to S2
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

39. recurrent laryngeal nerve injury
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Unilateral vocal cord paralysis

40. varicocele
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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
Compression stocking - weight reduction - leg elevation
CRPS

41. diarrhoea after gastric bypass
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Tendons more likely
Amoxicillin-clavulanate
Dumping syndrome; small and frequent meals; no simple sugar

42. first line of management of PVD
Displaced ORIF ; nondisplaced sling immobilization
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

43. tx distal rectal ca
S2-S4
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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;
Sphincter sparing surgery (local resection) - abdomnio perineal resection

44. How to confirm achiles tendon rupture
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

45. What is the contraindication of hyperventilation in inc ICP
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Strok and traumatic brain injury

46. lacerated wound in palmer surface of hand. what structure is injured?
Even after ochiopexy risk of ochiopexy higher then general population
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Tendons more likely

47. DD of acute scrotal pain
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Progressive fibrosis of palmar fascia. etiololgy not known;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Less than 5mm

48. several knee pain after being tackled in football game
Mammogram
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;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

49. diarrhoea 4-5 days after cholecystectomy
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;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Less than 5mm
Strok and traumatic brain injury

50. beta HCG
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
Seminomas
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

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USMLE Step3 Surgery

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