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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. mangement of localized lymphadenopathy
Strok and traumatic brain injury
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
15-40%; self limiting;doesn't require tx

2. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Headache - ataxia - bulbar dysfunction
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Low anterior resection and radio; add chemo if node positive
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

3. clavicle fx
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
Displaced ORIF ; nondisplaced sling immobilization
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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;

4. severe pain in leg after MVC
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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
When urethral catherization is unsuccessful

5. menisci injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Ispilateral hypoglossal nerve injury
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

6. contraindication of urethral catheterization
Malignancy until proven otherwise
Urethral stricture; pelvic of urethral trauma
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

7. How to differentiate communicative and non-communicative hydrocele
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
Malignancy until proven otherwise
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Increased size during the day and valsalva means it is communicated with peritoneal cavity

8. inhalation of hot air - steam - smoke in burn victim
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Supraglottic edema; low threshold for intubation
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. What is the strongest risk factor for male breast cancer
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Klinefelter syndrome; 50 fold increase;
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Next best step surgery; not ultrasound

10. What are the common injuries from lightning?
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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;
Dumping syndrome; small and frequent meals; no simple sugar
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

11. Tx of pulmonary contusion
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

12. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Tendons more likely
Dm neuropathy; stocking glove pattern
Strok and traumatic brain injury
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

13. perioral numbness after parathyroidectomy
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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
Supraglottic edema; low threshold for intubation

14. How to confirm achiles tendon rupture
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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
Elderly and critically ill patients
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

15. antibiotics of acute cholecystitis
L5 to S2
Ampicillin sublactum - pipercillin - ceftriaxone and metro
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

16. Dupuytren contracture
Progressive fibrosis of palmar fascia. etiololgy not known;
Displaced ORIF ; nondisplaced sling immobilization
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

17. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
24-48 hours of supportive therapy followed by cholecystectomy

18. managment of animal bite in hands
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;
Meniscus injury; medial most common; pain/swelling; popping sensation
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Ampicillin sublactum - pipercillin - ceftriaxone and metro

19. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Mammogram
Progressive fibrosis of palmar fascia. etiololgy not known;
24-48 hours of supportive therapy followed by cholecystectomy

20. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

21. How to perform lachman test
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Progressive fibrosis of palmar fascia. etiololgy not known;
Headache - ataxia - bulbar dysfunction
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;

22. sudden onset of postoperative hyperglycemia when patient on TPN
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

23. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Check ET tube placement if correct needle decompresion
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Next best step surgery; not ultrasound
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

24. Indication for bariatric surgery in obese patients
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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;

25. 3 mo with groin bulge; bulge appears when child cries
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Dumping syndrome; small and frequent meals; no simple sugar
Compression stocking - weight reduction - leg elevation
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

26. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Fx displace >1mm - nonunion during followup - osteonecrosis
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

27. prostate enlarged - nontender - no nodularity - elevated PSA
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
Brardycardia - HTN - resp depression
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

28. 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;
Urethral stricture; pelvic of urethral trauma
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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

29. varicose veins with ulcer - bleeding and thrombophlebitits
50%; tunneling between rectum or kin
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

30. When patient can go back to sports after clavicle fx
Fx displace >1mm - nonunion during followup - osteonecrosis
4-6 weeks for noncontact sports and longer time for contact sports
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

31. How to evaluate painless testicular swelling suspicious for cancer
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

32. characteristics of ureteral stone?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Carpal tunnel syndrom
Epi and chest compressio for prolong period of time; atropine is given after epi;
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

33. when patient with severe lung disease have C02 retention
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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
10-12 months

34. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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

35. How to confirm dx of compartment syndrom
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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

36. How to manage obesity
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Elderly and critically ill patients
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

37. What is the contraindication of hyperventilation in inc ICP
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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
Strok and traumatic brain injury

38. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Dm neuropathy; stocking glove pattern
Subphrenic abscess or other abdominal abscesses; order US or CT
Ampicillin sublactum - pipercillin - ceftriaxone and metro

39. transrectal prostate biopsy
Meniscus injury; medial most common; pain/swelling; popping sensation
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity

40. When goiter needs surgery
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
If any compressive symptoms eg. dysphagia
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Headache - ataxia - bulbar dysfunction

41. anal sphincter tone
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
S2-S4
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

42. aspiration of breast cyst is nonbloody
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

43. management of stone 8-10mm
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Sphincter sparing surgery (local resection) - abdomnio perineal resection
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

44. What is prehn sign?
Unilateral vocal cord paralysis
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

45. Incidence of AF in CABG patient

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46. How to differentiate ACL and meniscus injury
SAH due to post communicating artery aneurysm;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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
Supraglottic edema; low threshold for intubation

47. acalculus cholecystitis
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;
Tendons more likely
Elderly and critically ill patients
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

48. What is cushing's triad
Displaced ORIF ; nondisplaced sling immobilization
Brardycardia - HTN - resp depression
Patellar tendon tear; difficulty in extension
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

49. How to dx ACL tear?
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Seminomas

50. DD of acute scrotal pain
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Patellar tendon tear; difficulty in extension
When urethral catherization is unsuccessful
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

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USMLE Step3 Surgery

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