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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. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
24-48 hours of supportive therapy followed by cholecystectomy
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

2. transrectal prostate biopsy
CRPS
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

3. How to confirm dx of compartment syndrom
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
15-40%; self limiting;doesn't require tx
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Cystic scrotal fluid collection between parietal and visceral layers of testis

4. Valgus and Varus tests
Pure motor stroke; limited neurological dysfunction
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

5. What are the common injuries from lightning?
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Study showed no adverse effect; but they are contraindicated for PVD

6. characteristics of ureteral stone?
If any compressive symptoms eg. dysphagia
Abd pain and tenderness; bloody diarrhoea or hematochezia
Pure motor stroke; limited neurological dysfunction
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

7. What percent of anal abscess deveolop fisutula
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
50%; tunneling between rectum or kin
Even after ochiopexy risk of ochiopexy higher then general population
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

8. What types of breast implants are available
Carpal tunnel syndrom
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Pure motor stroke; limited neurological dysfunction
Saline and silicone

9. complications of TPN
If any compressive symptoms eg. dysphagia
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Cystic scrotal fluid collection between parietal and visceral layers of testis
L5 to S2

10. SAH due to posterior inferior cerebellar aneurysm
Abd pain and tenderness; bloody diarrhoea or hematochezia
Headache - ataxia - bulbar dysfunction
Brardycardia - HTN - resp depression
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

11. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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
SAH due to post communicating artery aneurysm;
Dumping syndrome; small and frequent meals; no simple sugar

12. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS
Displaced ORIF ; nondisplaced sling immobilization
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

13. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

14. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Headache - ataxia - bulbar dysfunction
Abd pain and tenderness; bloody diarrhoea or hematochezia
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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

15. cremasteric reflex test?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
15-40%; self limiting;doesn't require tx
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Pure motor stroke; limited neurological dysfunction

16. most frequent complication of TURP
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Retrograde ejaculation
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Malignancy until proven otherwise

17. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Unilateral vocal cord paralysis
Meniscus injury; medial most common; pain/swelling; popping sensation
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

18. What time frame required for bone remodeling
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Elevated non seminomas
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
10-12 months

19. Complications of breast impant
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
Check ET tube placement if correct needle decompresion
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Amoxicillin-clavulanate

20. acute colonic ischemia
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Less than 5mm
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;
Abd pain and tenderness; bloody diarrhoea or hematochezia

21. beta HCG
Amoxicillin-clavulanate
Seminomas
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

22. 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;
L5 to S2
Tendons more likely
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

23. painless testicular mass in young male
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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
Malignancy until proven otherwise
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

24. Dupuytren contracture
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Progressive fibrosis of palmar fascia. etiololgy not known;
Seminomas

25. Incidence of AF in CABG patient

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26. management of hip fracture
If patient ambulatory - surgery and pain control; if not nonop mx
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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

27. xray finding of stress fx after 3-4w
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

28. dorsiflexion and planter flexion
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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
L5 to S2
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

29. most common complication of acute cholecystitis
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

30. Can we use beta blocker for pvd?
Tendons more likely
Study showed no adverse effect; but they are contraindicated for PVD
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

31. sudden onset of postoperative hyperglycemia when patient on TPN
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Pure motor stroke; limited neurological dysfunction
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Displaced ORIF ; nondisplaced sling immobilization

32. What is terrible triad
S2-S4
Unilateral vocal cord paralysis
If patient ambulatory - surgery and pain control; if not nonop mx
MAT; medial meniscus injury; ACL and Tibial colateral ligament

33. When to stop raloxifene before surgery
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Pure motor stroke; limited neurological dysfunction
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

34. dumping syndrome after gastrectomy
Subphrenic abscess or other abdominal abscesses; order US or CT
Fx displace >1mm - nonunion during followup - osteonecrosis
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
10-12 months

35. How to differentiate ACL and meniscus injury
Klinefelter syndrome; 50 fold increase;
Progressive fibrosis of palmar fascia. etiololgy not known;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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

36. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Carpal tunnel syndrom
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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

37. varicose veins with ulcer - bleeding and thrombophlebitits
Displaced ORIF ; nondisplaced sling immobilization
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

38. surgery for acute cholecystities
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
If patient ambulatory - surgery and pain control; if not nonop mx
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
24-48 hours of supportive therapy followed by cholecystectomy

39. what size of ureteral stone for non op mx
Less than 5mm
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

40. when scaphoid fx patient needs to be referred to orthopedic
Fx displace >1mm - nonunion during followup - osteonecrosis
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;
ACL injury
Ampicillin sublactum - pipercillin - ceftriaxone and metro

41. anal sphincter tone
Pure motor stroke; limited neurological dysfunction
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Abd pain and tenderness; bloody diarrhoea or hematochezia
S2-S4

42. when patient with severe lung disease have C02 retention
Supraglottic edema; low threshold for intubation
Displaced ORIF ; nondisplaced sling immobilization
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
Unilateral vocal cord paralysis

43. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Amoxicillin-clavulanate
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
Meniscus injury; medial most common; pain/swelling; popping sensation
Displaced ORIF ; nondisplaced sling immobilization

44. diarrhoea after gastric bypass
Meniscus injury; medial most common; pain/swelling; popping sensation
Nonunion and avascular necrosis; fx can block blood supply;
Ispilateral hypoglossal nerve injury
Dumping syndrome; small and frequent meals; no simple sugar

45. cremasteric reflex
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
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;
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

46. How to manage obesity
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

47. SOB - confusion - petechial rash after trauma - fracture
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

48. When to do surgery in undesceneded testis?
If any compressive symptoms eg. dysphagia
Urethral stricture; pelvic of urethral trauma
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

49. When patient can go back to sports after clavicle fx
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
4-6 weeks for noncontact sports and longer time for contact sports
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
If any compressive symptoms eg. dysphagia

50. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Check ET tube placement if correct needle decompresion
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

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USMLE Step3 Surgery

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