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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. How to confirm dx of compartment syndrom
Cystic scrotal fluid collection between parietal and visceral layers of testis
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
Saline and silicone
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

2. When patient can go back to sports after clavicle fx
SAH due to post communicating artery aneurysm;
4-6 weeks for noncontact sports and longer time for contact sports
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Malignancy until proven otherwise

3. varicose veins with ulcer - bleeding and thrombophlebitits
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
CRPS
15-40%; self limiting;doesn't require tx
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

4. What is prehn sign?
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Displaced ORIF ; nondisplaced sling immobilization
Malignancy until proven otherwise
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

5. SOB - confusion - petechial rash after trauma - fracture
L5 to S2
Amoxicillin-clavulanate
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

6. scrotal trauma
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Next best step surgery; not ultrasound
Elevated non seminomas
CRPS

7. Why right varicocele is more concerning?

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8. cremasteric reflex
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Elevated non seminomas

9. Why ruq calcificaion is concerning
Patellar tendon tear; difficulty in extension
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

10. diarrhoea after gastric bypass
15-40%; self limiting;doesn't require tx
Dumping syndrome; small and frequent meals; no simple sugar
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

11. characteristics of ureteral stone?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

12. management of gunshot wound
Seminomas
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
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

13. most frequent complication of TURP
Retrograde ejaculation
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Ispilateral hypoglossal nerve injury

14. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Subphrenic abscess or other abdominal abscesses; order US or CT
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
4-6 weeks for noncontact sports and longer time for contact sports

15. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Meniscus injury; medial most common; pain/swelling; popping sensation
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

16. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Subphrenic abscess or other abdominal abscesses; order US or CT
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

17. How to manage obesity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Pure motor stroke; limited neurological dysfunction
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Meniscus injury; medial most common; pain/swelling; popping sensation

18. mx of stress fx
Carpal tunnel syndrom
Check ET tube placement if correct needle decompresion
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;

19. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
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;
CRPS
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Seminomas

20. How to differentiate communicative and non-communicative hydrocele
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

21. sudden onset of postoperative hyperglycemia when patient on TPN
Urethral stricture; pelvic of urethral trauma
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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

22. several knee pain after being tackled in football game
Check ET tube placement if correct needle decompresion
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)
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

23. Most common of sudden death due to steering wheel injury
Carpal tunnel syndrom
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

24. How varicocele causes testicular atrophy
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
If any compressive symptoms eg. dysphagia
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
MAT; medial meniscus injury; ACL and Tibial colateral ligament

25. Complications of breast impant
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;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
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;

26. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Seminomas
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
SAH due to post communicating artery aneurysm;

27. prostate enlarged - nontender - no nodularity - elevated PSA
Twisting force with the foot fixed on the ground seen in football and basketball games;
Subphrenic abscess or other abdominal abscesses; order US or CT
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

28. lacunar stroke
Pure motor stroke; limited neurological dysfunction
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Compression stocking - weight reduction - leg elevation

29. What percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Progressive fibrosis of palmar fascia. etiololgy not known;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

30. aspiration of breast cyst is nonbloody
Compression stocking - weight reduction - leg elevation
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

31. Incidence of AF in CABG patient

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32. painless testicular mass in young male
Twisting force with the foot fixed on the ground seen in football and basketball games;
CRPS
Seminomas
Malignancy until proven otherwise

33. inhalation of hot air - steam - smoke in burn victim
Supraglottic edema; low threshold for intubation
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;
4-6 weeks for noncontact sports and longer time for contact sports
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

34. What is the complications of undescended testis
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
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Dm neuropathy; stocking glove pattern
Even after ochiopexy risk of ochiopexy higher then general population

35. How to dx ACL tear?
Displaced ORIF ; nondisplaced sling immobilization
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Even after ochiopexy risk of ochiopexy higher then general population
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

36. severe pain in leg after MVC
Strok and traumatic brain injury
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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

37. What is terrible triad
24-48 hours of supportive therapy followed by cholecystectomy
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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

38. complications of TPN
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Pure motor stroke; limited neurological dysfunction
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

39. How mcmurray manuver perform
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Mammogram

40. transrectal prostate biopsy
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
24-48 hours of supportive therapy followed by cholecystectomy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Displaced ORIF ; nondisplaced sling immobilization

41. pregnant patient with asymptomatic gall stones
Dumping syndrome; small and frequent meals; no simple sugar
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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;

42. indication of ursodeoxycholic acid
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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
Elderly and critically ill patients
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

43. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Unilateral vocal cord paralysis
Sphincter sparing surgery (local resection) - abdomnio perineal resection

44. How to evaluate painless testicular swelling suspicious for cancer
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

45. popping sensation; rapid onset of knee effusion. athelet
Nonunion and avascular necrosis; fx can block blood supply;
ACL injury
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

46. antibiotics of acute cholecystitis
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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

47. anal sphincter tone
Unilateral vocal cord paralysis
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
S2-S4
Increased size during the day and valsalva means it is communicated with peritoneal cavity

48. cat/dog bites
Cystic scrotal fluid collection between parietal and visceral layers of testis
Amoxicillin-clavulanate
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

49. management of hip fracture
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
ACL injury
If patient ambulatory - surgery and pain control; if not nonop mx
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

50. When do we see complications due to hypophosphatemia
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
15-40%; self limiting;doesn't require tx
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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;

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USMLE Step3 Surgery

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