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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. perioral numbness after parathyroidectomy
24-48 hours of supportive therapy followed by cholecystectomy
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
Progressive fibrosis of palmar fascia. etiololgy not known;
Tendons more likely

2. most common fx when falling on outsretched hand
Saline and silicone
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

3. mx of stress fx
Carpal tunnel syndrom
50%; tunneling between rectum or kin
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

4. What is the complications of undescended testis
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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
Even after ochiopexy risk of ochiopexy higher then general population
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

5. What types of breast implants are available
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Saline and silicone
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

6. popping sensation; rapid onset of knee effusion. athelet
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
ACL injury
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

7. differential of ultrasound finding of breast mass
Elevated non seminomas
Brardycardia - HTN - resp depression
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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

8. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
10-12 months

9. Can we use beta blocker for pvd?
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Study showed no adverse effect; but they are contraindicated for PVD
SAH due to post communicating artery aneurysm;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

10. lacunar stroke
S2-S4
Progressive fibrosis of palmar fascia. etiololgy not known;
Pure motor stroke; limited neurological dysfunction
Meniscus injury; medial most common; pain/swelling; popping sensation

11. ct scan; cystic lesion in head of pancreas; next step
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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
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

12. most frequent complication of TURP
Abd pain and tenderness; bloody diarrhoea or hematochezia
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Retrograde ejaculation
Cystic scrotal fluid collection between parietal and visceral layers of testis

13. Why varicocele more common in the left side
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Cystic scrotal fluid collection between parietal and visceral layers of testis
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;

14. Tx of proximal non metastatic rectal ca
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Low anterior resection and radio; add chemo if node positive
Subphrenic abscess or other abdominal abscesses; order US or CT
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

15. diarrhoea after gastric bypass
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Dumping syndrome; small and frequent meals; no simple sugar
Unilateral vocal cord paralysis

16. recurrent laryngeal nerve injury
Pure motor stroke; limited neurological dysfunction
Unilateral vocal cord paralysis
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
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

17. management of nondisplaced scaphoid fx
Malignancy until proven otherwise
Low anterior resection and radio; add chemo if node positive
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Dumping syndrome; small and frequent meals; no simple sugar

18. first line of management of PVD
Study showed no adverse effect; but they are contraindicated for PVD
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
ACL injury
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

19. What is the contraindication of hyperventilation in inc ICP
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Strok and traumatic brain injury
24-48 hours of supportive therapy followed by cholecystectomy

20. Most common of sudden death due to steering wheel injury
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

21. How to dx ACL tear?
Seminomas
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
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
S2-S4

22. mangement of localized lymphadenopathy
Mammogram
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
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

23. How to manage obesity
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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
SAH due to post communicating artery aneurysm;

24. how ABI help dx of PVD
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Increased size during the day and valsalva means it is communicated with peritoneal cavity

25. How varicocele causes testicular atrophy
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Elevated non seminomas
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Ispilateral hypoglossal nerve injury

26. How to confirm achiles tendon rupture
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Supraglottic edema; low threshold for intubation
If patient ambulatory - surgery and pain control; if not nonop mx
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

27. What percent of anal abscess deveolop fisutula
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
50%; tunneling between rectum or kin

28. How to confirm dx of compartment syndrom
Study showed no adverse effect; but they are contraindicated for PVD
Tendons more likely
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Epi and chest compressio for prolong period of time; atropine is given after epi;

29. Why ruq calcificaion is concerning
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Elderly and critically ill patients
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

30. surgery for acute cholecystities
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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
24-48 hours of supportive therapy followed by cholecystectomy

31. beta hcg and AFP
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Epi and chest compressio for prolong period of time; atropine is given after epi;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Elevated non seminomas

32. management of hip fracture
10-12 months
When urethral catherization is unsuccessful
If patient ambulatory - surgery and pain control; if not nonop mx
Amoxicillin-clavulanate

33. what size of ureteral stone for non op mx
Less than 5mm
Even after ochiopexy risk of ochiopexy higher then general population
ACL injury
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

34. When to stop raloxifene before surgery
Less than 5mm
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Mammogram
Unilateral vocal cord paralysis

35. inhalation of hot air - steam - smoke in burn victim
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
24-48 hours of supportive therapy followed by cholecystectomy
Supraglottic edema; low threshold for intubation

36. transrectal prostate biopsy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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;
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;

37. sudden onset of postoperative hyperglycemia when patient on TPN
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Less than 5mm
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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. Why initial xrays are negative in scaphoid 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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Elderly and critically ill patients
Ispilateral hypoglossal nerve injury

39. ipsilateral deviation of tongue upon protrusion
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Ispilateral hypoglossal nerve injury

40. swelling and tenderness in anterior part of knee
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Less than 5mm
Patellar tendon tear; difficulty in extension
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

41. 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
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
10-12 months

42. When patient can go back to sports after clavicle fx
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Progressive fibrosis of palmar fascia. etiololgy not known;
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
4-6 weeks for noncontact sports and longer time for contact sports

43. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Carpal tunnel syndrom
SAH due to post communicating artery aneurysm;

44. when scaphoid fx patient needs to be referred to orthopedic
Fx displace >1mm - nonunion during followup - osteonecrosis
15-40%; self limiting;doesn't require tx
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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

45. contraindication of urethral catheterization
Klinefelter syndrome; 50 fold increase;
Urethral stricture; pelvic of urethral trauma
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
24-48 hours of supportive therapy followed by cholecystectomy

46. common complication of inadequate mx of scaphoid fx
ACL injury
Nonunion and avascular necrosis; fx can block blood supply;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

47. stress fx
Elderly and critically ill patients
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;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

48. lacerated wound in palmer surface of hand. what structure is injured?
ACL injury
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Tendons more likely

49. cremasteric reflex test?
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Cystic scrotal fluid collection between parietal and visceral layers of testis
When urethral catherization is unsuccessful

50. characteristics of ureteral stone?
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Elderly and critically ill patients
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

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USMLE Step3 Surgery

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