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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. conservative Tx of varicose veins
Less than 5mm
Compression stocking - weight reduction - leg elevation
Study showed no adverse effect; but they are contraindicated for PVD
24-48 hours of supportive therapy followed by cholecystectomy

2. Tx of proximal non metastatic rectal ca
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Low anterior resection and radio; add chemo if node positive
Abd pain and tenderness; bloody diarrhoea or hematochezia

3. acalculus cholecystitis
Elderly and critically ill patients
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Epi and chest compressio for prolong period of time; atropine is given after epi;

4. Indication for bariatric surgery in obese patients
Even after ochiopexy risk of ochiopexy higher then general population
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;
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Sphincter sparing surgery (local resection) - abdomnio perineal resection

5. mangement of localized lymphadenopathy
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Dm neuropathy; stocking glove pattern
Urethral stricture; pelvic of urethral trauma

6. suprapubic catheterization
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
When urethral catherization is unsuccessful
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;

7. clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Carpal tunnel syndrom
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

8. aspiration of breast cyst is nonbloody
10-12 months
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

9. When to do surgery in undesceneded testis?
24-48 hours of supportive therapy followed by cholecystectomy
Headache - ataxia - bulbar dysfunction
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

10. first line of management of PVD
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Klinefelter syndrome; 50 fold increase;
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

11. What is the contraindication of hyperventilation in inc ICP
Check ET tube placement if correct needle decompresion
Strok and traumatic brain injury
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
Less than 5mm

12. Why right varicocele is more concerning?

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13. most common fx when falling on outsretched hand
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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
Next best step surgery; not ultrasound
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

14. Why initial xrays are negative in scaphoid fx
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
L5 to S2

15. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Nonunion and avascular necrosis; fx can block blood supply;
Patellar tendon tear; difficulty in extension
15-40%; self limiting;doesn't require tx

16. Tx of pulmonary contusion
Headache - ataxia - bulbar dysfunction
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

17. indication of ursodeoxycholic 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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

18. dumping syndrome after gastrectomy
Even after ochiopexy risk of ochiopexy higher then general population
Study showed no adverse effect; but they are contraindicated for PVD
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

19. What is hydrocele?
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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
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
Cystic scrotal fluid collection between parietal and visceral layers of testis

20. When patient can go back to sports after clavicle fx
S2-S4
4-6 weeks for noncontact sports and longer time for contact sports
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Saline and silicone

21. Why varicocele more common in the left side
Even after ochiopexy risk of ochiopexy higher then general population
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Less than 5mm

22. Patient underwent CABG; postoperatively drowsy. most likely cause?
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
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

23. when scaphoid fx patient needs to be referred to orthopedic
Fx displace >1mm - nonunion during followup - osteonecrosis
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Meniscus injury; medial most common; pain/swelling; popping sensation

24. acute colonic ischemia
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
Urethral stricture; pelvic of urethral trauma
Abd pain and tenderness; bloody diarrhoea or hematochezia
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

25. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

26. tx distal rectal ca
Low anterior resection and radio; add chemo if node positive
S2-S4
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Sphincter sparing surgery (local resection) - abdomnio perineal resection

27. 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
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Nonunion and avascular necrosis; fx can block blood supply;
Malignancy until proven otherwise

28. How to manage obesity
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

29. When goiter needs surgery
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
If any compressive symptoms eg. dysphagia
Nonunion and avascular necrosis; fx can block blood supply;
Check ET tube placement if correct needle decompresion

30. transrectal prostate biopsy
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

31. DD of acute scrotal pain
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Pure motor stroke; limited neurological dysfunction
24-48 hours of supportive therapy followed by cholecystectomy

32. How to evaluate painless testicular swelling suspicious for cancer
Fx displace >1mm - nonunion during followup - osteonecrosis
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Elevated non seminomas
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

33. What is the strongest risk factor for male breast cancer
Klinefelter syndrome; 50 fold increase;
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Increased size during the day and valsalva means it is communicated with peritoneal cavity

34. What is terrible triad
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
If any compressive symptoms eg. dysphagia
4-6 weeks for noncontact sports and longer time for contact sports
MAT; medial meniscus injury; ACL and Tibial colateral ligament

35. cremasteric reflex
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Tendons more likely

36. several knee pain after being tackled in football game
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Compression stocking - weight reduction - leg elevation
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

37. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

38. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Unilateral vocal cord paralysis
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

39. management of gunshot wound
If patient ambulatory - surgery and pain control; if not nonop mx
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
15-40%; self limiting;doesn't require tx

40. antibiotics of acute cholecystitis
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Nonunion and avascular necrosis; fx can block blood supply;
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Dumping syndrome; small and frequent meals; no simple sugar

41. when patient with severe lung disease have C02 retention
24-48 hours of supportive therapy followed by 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
SAH due to post communicating artery aneurysm;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

42. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
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
Twisting force with the foot fixed on the ground seen in football and basketball games;
Meniscus injury; medial most common; pain/swelling; popping sensation
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

43. How to differentiate communicative and non-communicative hydrocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
4-6 weeks for noncontact sports and longer time for contact sports

44. How to differentiate ACL and meniscus injury
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Headache - ataxia - bulbar dysfunction
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
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

45. When do we see complications due to hypophosphatemia
If any compressive symptoms eg. dysphagia
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;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

46. What types of breast implants are available
Saline and silicone
Subphrenic abscess or other abdominal abscesses; order US or CT
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Pure motor stroke; limited neurological dysfunction

47. diarrhoea after gastric bypass
Dumping syndrome; small and frequent meals; no simple sugar
Subphrenic abscess or other abdominal abscesses; order US or CT
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Ampicillin sublactum - pipercillin - ceftriaxone and metro

48. stress fx
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
Strok and traumatic brain injury
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

49. sudden onset of postoperative hyperglycemia when patient on TPN
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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 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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

50. types of hip fracture
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

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USMLE Step3 Surgery

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