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USMLE Step3 Surgery

Subjects : health-sciences, usmle-step-3

Instructions:

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. cremasteric reflex
S2-S4
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Dumping syndrome; small and frequent meals; no simple sugar
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

2. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Retrograde ejaculation
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
SAH due to post communicating artery aneurysm;

3. cremasteric reflex test?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Mammogram
Subphrenic abscess or other abdominal abscesses; order US or CT
If any compressive symptoms eg. dysphagia

4. several knee pain after being tackled in football game
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Abd pain and tenderness; bloody diarrhoea or hematochezia

5. What is terrible triad
Saline and silicone
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

6. severe pain in leg after MVC
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Elevated non seminomas

7. what size of ureteral stone for non op mx
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Ispilateral hypoglossal nerve injury
Less than 5mm
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

8. stress fx
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Carpal tunnel syndrom
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

9. management of hip fracture
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
If patient ambulatory - surgery and pain control; if not nonop mx
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
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;

10. SAH due to posterior inferior cerebellar aneurysm
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Headache - ataxia - bulbar dysfunction
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

11. 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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

12. anal sphincter tone
S2-S4
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

13. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Subphrenic abscess or other abdominal abscesses; order US or CT
Fx displace >1mm - nonunion during followup - osteonecrosis
Epi and chest compressio for prolong period of time; atropine is given after epi;
Next best step surgery; not ultrasound

14. What percent of anal abscess deveolop fisutula
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Carpal tunnel syndrom
SAH due to post communicating artery aneurysm;
50%; tunneling between rectum or kin

15. when patient with severe lung disease have C02 retention
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
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;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Fx displace >1mm - nonunion during followup - osteonecrosis

16. types of hip fracture
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Even after ochiopexy risk of ochiopexy higher then general population
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

17. Dupuytren contracture
4-6 weeks for noncontact sports and longer time for contact sports
Progressive fibrosis of palmar fascia. etiololgy not known;
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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

18. Why ruq calcificaion is concerning
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Retrograde ejaculation
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

19. What types of breast implants are available
Saline and silicone
SAH due to post communicating artery aneurysm;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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

20. scrotal trauma
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Next best step surgery; not ultrasound
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

21. 3 mo with groin bulge; bulge appears when child cries
Displaced ORIF ; nondisplaced sling immobilization
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Klinefelter syndrome; 50 fold increase;

22. How to perform lachman test
Progressive fibrosis of palmar fascia. etiololgy not known;
Check ET tube placement if correct needle decompresion
10-12 months
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

23. How to dx ACL tear?
Urethral stricture; pelvic of urethral trauma
Fx displace >1mm - nonunion during followup - osteonecrosis
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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

24. Tx of pulmonary contusion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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;
MAT; medial meniscus injury; ACL and Tibial colateral ligament

25. acalculus cholecystitis
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
Mammogram
Elderly and critically ill patients
Fx displace >1mm - nonunion during followup - osteonecrosis

26. What is hungry bone syndrome?
Displaced ORIF ; nondisplaced sling immobilization
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Fx displace >1mm - nonunion during followup - osteonecrosis

27. How to differentiate ACL and meniscus injury
Subphrenic abscess or other abdominal abscesses; order US or CT
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Klinefelter syndrome; 50 fold increase;
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

28. What is cushing's triad
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Brardycardia - HTN - resp depression
L5 to S2
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

29. management of stone 8-10mm
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
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
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
Dm neuropathy; stocking glove pattern

30. how hyperventilation lowers ICP
Displaced ORIF ; nondisplaced sling immobilization
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Epi and chest compressio for prolong period of time; atropine is given after epi;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

31. Valgus and Varus tests
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
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

32. most common fx when falling on outsretched hand
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Unilateral vocal cord paralysis
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

33. aspiration of breast cyst is bloody
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Unilateral vocal cord paralysis
Mammogram

34. What is the complications of undescended testis
Even after ochiopexy risk of ochiopexy higher then general population
When urethral catherization is unsuccessful
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
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

35. popping sensation; rapid onset of knee effusion. athelet
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
ACL injury
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

36. first step for evaluation of testicular swelling
ACL injury
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

37. suprapubic catheterization
When urethral catherization is unsuccessful
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

38. 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
ACL injury
If patient ambulatory - surgery and pain control; if not nonop mx
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

39. dumping syndrome after gastrectomy
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

40. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Supraglottic edema; low threshold for intubation
Check ET tube placement if correct needle decompresion

41. beta hcg and AFP
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Elevated non seminomas

42. characteristics of ureteral stone?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Ispilateral hypoglossal nerve injury
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

43. 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.
Epi and chest compressio for prolong period of time; atropine is given after epi;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
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

44. Indication for bariatric surgery in obese patients
Klinefelter syndrome; 50 fold increase;
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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;

45. When to stop raloxifene before surgery
If any compressive symptoms eg. dysphagia
Strok and traumatic brain injury
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Tendons more likely

46. How to confirm achiles tendon rupture
Supraglottic edema; low threshold for intubation
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
24-48 hours of supportive therapy followed by cholecystectomy

47. painless testicular mass in young male
Cystic scrotal fluid collection between parietal and visceral layers of testis
Malignancy until proven otherwise
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

48. varicocele
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
24-48 hours of supportive therapy followed by cholecystectomy
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Displaced ORIF ; nondisplaced sling immobilization

49. managment of animal bite in hands
Nonunion and avascular necrosis; fx can block blood supply;
Headache - ataxia - bulbar dysfunction
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;
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

50. Complications of breast impant
Elderly and critically ill patients
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

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USMLE Step3 Surgery

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