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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. severe pain in leg after MVC
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Abd pain and tenderness; bloody diarrhoea or hematochezia
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;

2. DD of acute scrotal pain
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
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Sphincter sparing surgery (local resection) - abdomnio perineal resection

3. cremasteric reflex test?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Klinefelter syndrome; 50 fold increase;
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

4. inhalation of hot air - steam - smoke in burn victim
Retrograde ejaculation
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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;
Supraglottic edema; low threshold for intubation

5. What percent of anal abscess deveolop fisutula
Twisting force with the foot fixed on the ground seen in football and basketball games;
50%; tunneling between rectum or kin
Tendons more likely
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

6. antibiotics of acute cholecystitis
Check ET tube placement if correct needle decompresion
Subphrenic abscess or other abdominal abscesses; order US or CT
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

7. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Strok and traumatic brain injury
Meniscus injury; medial most common; pain/swelling; popping sensation

8. Incidence of AF in CABG patient

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9. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Progressive fibrosis of palmar fascia. etiololgy not known;

10. ipsilateral deviation of tongue upon protrusion
Carpal tunnel syndrom
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Saline and silicone
Ispilateral hypoglossal nerve injury

11. how hyperventilation lowers ICP
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

12. Most common of sudden death due to steering wheel injury
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

13. surgery for acute cholecystities
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
24-48 hours of supportive therapy followed by cholecystectomy
Brardycardia - HTN - resp depression
4-6 weeks for noncontact sports and longer time for contact sports

14. What is prehn sign?
Unilateral vocal cord paralysis
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

15. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Cystic scrotal fluid collection between parietal and visceral layers of testis
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

16. When to stop raloxifene before surgery
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
When urethral catherization is unsuccessful

17. What is the complications of undescended testis
When urethral catherization is unsuccessful
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Even after ochiopexy risk of ochiopexy higher then general population
Cystic scrotal fluid collection between parietal and visceral layers of testis

18. What are the common injuries from lightning?
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

19. painless testicular mass in young male
Malignancy until proven otherwise
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
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
4-6 weeks for noncontact sports and longer time for contact sports

20. Tx of pulmonary contusion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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;
Supraglottic edema; low threshold for intubation

21. dorsiflexion and planter flexion
Meniscus injury; medial most common; pain/swelling; popping sensation
Amoxicillin-clavulanate
L5 to S2
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

22. ct scan; cystic lesion in head of pancreas; next step
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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;

23. midline neck swelling moves with protrusion of tongue
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
15-40%; self limiting;doesn't require tx

24. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Displaced ORIF ; nondisplaced sling immobilization
Subphrenic abscess or other abdominal abscesses; order US or CT

25. Valgus and Varus tests
Supraglottic edema; low threshold for intubation
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

26. How varicocele causes testicular atrophy
Saline and silicone
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

27. acalculus cholecystitis
Low anterior resection and radio; add chemo if node positive
SAH due to post communicating artery aneurysm;
Elderly and critically ill patients
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

28. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
SAH due to post communicating artery aneurysm;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

29. Why varicocele more common in the left side
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Supraglottic edema; low threshold for intubation
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
SAH due to post communicating artery aneurysm;

30. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
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;
Elderly and critically ill patients
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

31. scrotal trauma
ACL injury
Next best step surgery; not ultrasound
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
MAT; medial meniscus injury; ACL and Tibial colateral ligament

32. SAH due to posterior inferior cerebellar aneurysm
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Headache - ataxia - bulbar dysfunction

33. complications of TPN
Less than 5mm
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Mammogram
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

34. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
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;
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
SAH due to post communicating artery aneurysm;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

35. 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
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before 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

36. how ABI help dx of PVD
4-6 weeks for noncontact sports and longer time for contact sports
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

37. prostate enlarged - nontender - no nodularity - elevated PSA
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Less than 5mm
Dumping syndrome; small and frequent meals; no simple sugar
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

38. beta hcg and AFP
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Study showed no adverse effect; but they are contraindicated for PVD
Elevated non seminomas

39. How mcmurray manuver perform
If patient ambulatory - surgery and pain control; if not nonop mx
Epi and chest compressio for prolong period of time; atropine is given after epi;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Less than 5mm

40. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Progressive fibrosis of palmar fascia. etiololgy not known;
Next best step surgery; not ultrasound
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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;

41. indication of ursodeoxycholic acid
Subphrenic abscess or other abdominal abscesses; order US or CT
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
Strok and traumatic brain injury
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

42. management of hip fracture
If patient ambulatory - surgery and pain control; if not nonop mx
Ispilateral hypoglossal nerve injury
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

43. dumping syndrome after gastrectomy
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Amoxicillin-clavulanate
Brardycardia - HTN - resp depression
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

44. Can we use beta blocker for pvd?
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Study showed no adverse effect; but they are contraindicated for PVD
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

45. perioral numbness after parathyroidectomy
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
Urethral stricture; pelvic of urethral trauma
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

46. How to manage a patient with asystole
Epi and chest compressio for prolong period of time; atropine is given after epi;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Study showed no adverse effect; but they are contraindicated for PVD

47. What is the contraindication of hyperventilation in inc ICP
Amoxicillin-clavulanate
Elevated non seminomas
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
Strok and traumatic brain injury

48. What types of breast implants are available
Saline and silicone
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

49. sudden onset of postoperative hyperglycemia when patient on TPN
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

50. varicose veins with ulcer - bleeding and thrombophlebitits
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

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USMLE Step3 Surgery

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