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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. cat/dog bites
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
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Amoxicillin-clavulanate
ACL injury

2. diarrhoea after gastric bypass
Dumping syndrome; small and frequent meals; no simple sugar
Fx displace >1mm - nonunion during followup - osteonecrosis
L5 to S2
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

3. SOB - confusion - petechial rash after trauma - fracture
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;
Compression stocking - weight reduction - leg elevation
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

4. lacunar stroke
Pure motor stroke; limited neurological dysfunction
When urethral catherization is unsuccessful
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

5. DD of acute scrotal pain
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Meniscus injury; medial most common; pain/swelling; popping sensation
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

6. how hyperventilation lowers ICP
Check ET tube placement if correct needle decompresion
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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;

7. What is most common lung injury after blunt chest trauma?
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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
Supraglottic edema; low threshold for intubation
Increased size during the day and valsalva means it is communicated with peritoneal cavity

8. 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
4-6 weeks for noncontact sports and longer time for contact sports
Sphincter sparing surgery (local resection) - abdomnio perineal resection
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

9. How to confirm dx of compartment syndrom
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

10. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Ispilateral hypoglossal nerve injury
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

11. beta hcg and AFP
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Elevated non seminomas
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

12. What time frame required for bone remodeling
10-12 months
Strok and traumatic brain injury
Seminomas
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

13. Can we use beta blocker for pvd?
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Less than 5mm
Study showed no adverse effect; but they are contraindicated for PVD
Increased size during the day and valsalva means it is communicated with peritoneal cavity

14. Dupuytren contracture
Progressive fibrosis of palmar fascia. etiololgy not known;
Saline and silicone
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

15. antibiotics of acute cholecystitis
Klinefelter syndrome; 50 fold increase;
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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

16. recurrent laryngeal nerve injury
Elevated non seminomas
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Unilateral vocal cord paralysis

17. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
CRPS
Nonunion and avascular necrosis; fx can block blood supply;
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

18. complications of TPN
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
Compression stocking - weight reduction - leg elevation
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

19. When patient can go back to sports after clavicle fx
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
4-6 weeks for noncontact sports and longer time for contact sports
Increased size during the day and valsalva means it is communicated with peritoneal cavity
S2-S4

20. most common fx when falling on outsretched hand
Meniscus injury; medial most common; pain/swelling; popping sensation
Unilateral vocal cord paralysis
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Patellar tendon tear; difficulty in extension

21. transrectal prostate biopsy
50%; tunneling between rectum or kin
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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

22. diarrhoea 4-5 days after cholecystectomy
10-12 months
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Retrograde ejaculation

23. Valgus and Varus tests
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Subphrenic abscess or other abdominal abscesses; order US or CT
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

24. mx of stress fx
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Less than 5mm
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

25. What types of breast implants are available
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
SAH due to post communicating artery aneurysm;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Saline and silicone

26. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
50%; tunneling between rectum or kin
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Check ET tube placement if correct needle decompresion

27. How to manage a patient with asystole
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
Unilateral vocal cord paralysis
Epi and chest compressio for prolong period of time; atropine is given after epi;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

28. Indication for bariatric surgery in obese patients
50%; tunneling between rectum or kin
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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. differential of ultrasound finding of breast mass
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
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Twisting force with the foot fixed on the ground seen in football and basketball games;

30. Why varicocele more common in the left side
Carpal tunnel syndrom
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Compression stocking - weight reduction - leg elevation
Next best step surgery; not ultrasound

31. what size of ureteral stone for non op mx
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Less than 5mm
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

32. SAH due to posterior inferior cerebellar aneurysm
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Headache - ataxia - bulbar dysfunction
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Dm neuropathy; stocking glove pattern

33. When goiter needs surgery
If any compressive symptoms eg. dysphagia
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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;
Carpal tunnel syndrom

34. Why ruq calcificaion is concerning
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Elderly and critically ill patients
When urethral catherization is unsuccessful
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

35. how ABI help dx of PVD
CRPS
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Pure motor stroke; limited neurological dysfunction

36. clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Pure motor stroke; limited neurological dysfunction

37. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Amoxicillin-clavulanate
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

38. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
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
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

39. cremasteric reflex
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
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;
Pure motor stroke; limited neurological dysfunction
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

40. How mcmurray manuver perform
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Patellar tendon tear; difficulty in extension
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

41. beta HCG
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Retrograde ejaculation
Seminomas
50%; tunneling between rectum or kin

42. What is prehn sign?
Subphrenic abscess or other abdominal abscesses; order US or CT
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

43. painless testicular mass in young male
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
Meniscus injury; medial most common; pain/swelling; popping sensation
Malignancy until proven otherwise
Seminomas

44. sudden onset of postoperative hyperglycemia when patient on TPN
S2-S4
If patient ambulatory - surgery and pain control; if not nonop mx
Headache - ataxia - bulbar dysfunction
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

45. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Pure motor stroke; limited neurological dysfunction
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

46. managment of animal bite in hands
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Seminomas
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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;

47. dumping syndrome after gastrectomy
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Nonunion and avascular necrosis; fx can block blood supply;
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;
S2-S4

48. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Klinefelter syndrome; 50 fold increase;

49. menisci injury
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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
Twisting force with the foot fixed on the ground seen in football and basketball games;
Check ET tube placement if correct needle decompresion

50. contraindication of urethral catheterization
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;
24-48 hours of supportive therapy followed by cholecystectomy
Urethral stricture; pelvic of urethral trauma
If patient ambulatory - surgery and pain control; if not nonop mx

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USMLE Step3 Surgery

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