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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. xray finding of stress fx after 3-4w
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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
Tendons more likely
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

2. 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
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
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;

3. Indication for bariatric surgery in obese patients
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

4. several knee pain after being tackled in football game
Unilateral vocal cord paralysis
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Carpal tunnel syndrom

5. DD of acute scrotal pain
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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

6. What is most common lung injury after blunt chest trauma?
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Strok and traumatic brain 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

7. How varicocele causes testicular atrophy
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
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Retrograde ejaculation
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

8. Valgus and Varus tests
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

9. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Check ET tube placement if correct needle decompresion
Dm neuropathy; stocking glove pattern

10. Dupuytren contracture
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Progressive fibrosis of palmar fascia. etiololgy not known;

11. Incidence of AF in CABG patient

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12. how ABI help dx of PVD
When urethral catherization is unsuccessful
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Dm neuropathy; stocking glove pattern

13. contraindication of urethral catheterization
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Urethral stricture; pelvic of urethral trauma
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

14. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
When urethral catherization is unsuccessful
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

15. Complications of breast impant
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
10-12 months
CRPS
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

16. ipsilateral deviation of tongue upon protrusion
Progressive fibrosis of palmar fascia. etiololgy not known;
Ispilateral hypoglossal nerve injury
Elderly and critically ill patients
L5 to S2

17. stress fx
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

18. When patient can go back to sports after clavicle fx
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Saline and silicone
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
4-6 weeks for noncontact sports and longer time for contact sports

19. surgery for acute cholecystities
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
24-48 hours of supportive therapy followed by cholecystectomy
Sphincter sparing surgery (local resection) - abdomnio perineal resection

20. Tx of pulmonary contusion
50%; tunneling between rectum or kin
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

21. Tx of proximal non metastatic rectal ca
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Low anterior resection and radio; add chemo if node positive
Tendons more likely
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

22. What types of breast implants are available
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Saline and silicone

23. suprapubic catheterization
When urethral catherization is unsuccessful
Klinefelter syndrome; 50 fold increase;
CRPS
24-48 hours of supportive therapy followed by cholecystectomy

24. What is terrible triad
When urethral catherization is unsuccessful
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
15-40%; self limiting;doesn't require tx
MAT; medial meniscus injury; ACL and Tibial colateral ligament

25. aspiration of breast cyst is nonbloody
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Saline and silicone
Retrograde ejaculation
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

26. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Pure motor stroke; limited neurological dysfunction
Supraglottic edema; low threshold for intubation

27. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Fx displace >1mm - nonunion during followup - osteonecrosis

28. diarrhoea 4-5 days after cholecystectomy
L5 to S2
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

29. SOB - confusion - petechial rash after trauma - fracture
Elderly and critically ill patients
Patellar tendon tear; difficulty in extension
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
SAH due to post communicating artery aneurysm;

30. transrectal prostate biopsy
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Malignancy until proven otherwise
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

31. first step for evaluation of testicular swelling
Progressive fibrosis of palmar fascia. etiololgy not known;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

32. cat/dog bites
Amoxicillin-clavulanate
Urethral stricture; pelvic of urethral trauma
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

33. recurrent laryngeal nerve injury
Supraglottic edema; low threshold for intubation
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
15-40%; self limiting;doesn't require tx
Unilateral vocal cord paralysis

34. Why ruq calcificaion is concerning
Elevated non seminomas
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
50%; tunneling between rectum or kin
Brardycardia - HTN - resp depression

35. scrotal trauma
Supraglottic edema; low threshold for intubation
Next best step surgery; not ultrasound
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

36. How mcmurray manuver perform
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
24-48 hours of supportive therapy followed by cholecystectomy
Dm neuropathy; stocking glove pattern
Sphincter sparing surgery (local resection) - abdomnio perineal resection

37. acalculus cholecystitis
Elderly and critically ill patients
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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
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

38. complications of TPN
Mammogram
Seminomas
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Patellar tendon tear; difficulty in extension

39. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Elevated non seminomas
Urethral stricture; pelvic of urethral trauma
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;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

40. antibiotics of acute cholecystitis
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Fx displace >1mm - nonunion during followup - osteonecrosis
Pure motor stroke; limited neurological dysfunction

41. Patient underwent CABG; postoperatively drowsy. most likely cause?
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
Nonunion and avascular necrosis; fx can block blood supply;
Epi and chest compressio for prolong period of time; atropine is given after epi;
Seminomas

42. cremasteric reflex test?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

43. beta HCG
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Seminomas
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Mammogram

44. lacunar stroke
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
S2-S4
Pure motor stroke; limited neurological dysfunction

45. How to confirm dx of compartment syndrom
Meniscus injury; medial most common; pain/swelling; popping sensation
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
4-6 weeks for noncontact sports and longer time for contact sports
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

46. When to stop raloxifene before surgery
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

47. conservative Tx of varicose veins
Even after ochiopexy risk of ochiopexy higher then general population
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Compression stocking - weight reduction - leg elevation

48. how hyperventilation lowers ICP
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
MAT; medial meniscus injury; ACL and Tibial colateral ligament
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

49. Most common of sudden death due to steering wheel injury
10-12 months
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Mammogram
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

50. clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Patellar tendon tear; difficulty in extension

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USMLE Step3 Surgery

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