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USMLE Step3 Surgery

Subjects : health-sciences, usmle-step-3

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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. pregnant patient with asymptomatic gall stones
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;
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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

2. differential of ultrasound finding of breast mass
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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

3. first line of management of PVD
Headache - ataxia - bulbar dysfunction
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
Meniscus injury; medial most common; pain/swelling; popping sensation
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

4. When to stop raloxifene before surgery
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
15-40%; self limiting;doesn't require tx

5. How varicocele causes testicular atrophy
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
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Dumping syndrome; small and frequent meals; no simple sugar
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

6. what size of ureteral stone for non op mx
ACL injury
Less than 5mm
S2-S4
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

7. common complication of inadequate mx of scaphoid fx
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Nonunion and avascular necrosis; fx can block blood supply;

8. stress fx
Patellar tendon tear; difficulty in extension
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
SAH due to post communicating artery aneurysm;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

9. antibiotics of acute cholecystitis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Subphrenic abscess or other abdominal abscesses; order US or CT
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

10. cremasteric reflex test?
Malignancy until proven otherwise
Low anterior resection and radio; add chemo if node positive
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Compression stocking - weight reduction - leg elevation

11. SOB - confusion - petechial rash after trauma - fracture
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
If any compressive symptoms eg. dysphagia
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

12. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
SAH due to post communicating artery aneurysm;
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

13. most common complication of acute cholecystitis
SAH due to post communicating artery aneurysm;
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Unilateral vocal cord paralysis

14. complication displaced or communited distal radial fx
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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Carpal tunnel syndrom
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

15. swelling and tenderness in anterior part of knee
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;
Supraglottic edema; low threshold for intubation
Patellar tendon tear; difficulty in extension
Seminomas

16. Can we use beta blocker for pvd?
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
Study showed no adverse effect; but they are contraindicated for PVD
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

17. how hyperventilation lowers ICP
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

18. managment of animal bite in hands
Cystic scrotal fluid collection between parietal and visceral layers of testis
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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;

19. surgery for acute cholecystities
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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;
24-48 hours of supportive therapy followed by cholecystectomy

20. first step for evaluation of testicular swelling
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
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

21. perioral numbness after parathyroidectomy
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
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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

22. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Patellar tendon tear; difficulty in extension
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

23. What percent of anal abscess deveolop fisutula
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
50%; tunneling between rectum or kin
Mammogram
S2-S4

24. beta hcg and AFP
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
S2-S4
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Elevated non seminomas

25. How to evaluate painless testicular swelling suspicious for cancer
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;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
SAH due to post communicating artery aneurysm;

26. How to differentiate communicative and non-communicative hydrocele
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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 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

27. sudden onset of postoperative hyperglycemia when patient on TPN
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Supraglottic edema; low threshold for intubation
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

28. lacunar stroke
Pure motor stroke; limited neurological dysfunction
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

29. 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
10-12 months
Carpal tunnel syndrom
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

30. Complications of breast impant
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

31. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

32. How to confirm dx of compartment syndrom
Klinefelter syndrome; 50 fold increase;
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity

33. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Retrograde ejaculation
Subphrenic abscess or other abdominal abscesses; order US or CT
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

34. management of stone 8-10mm
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Dumping syndrome; small and frequent meals; no simple sugar
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

35. management of gunshot wound
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
Mammogram
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

36. What is hydrocele?
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
Meniscus injury; medial most common; pain/swelling; popping sensation
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

37. popping sensation; rapid onset of knee effusion. athelet
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
ACL injury
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

38. What is terrible triad
L5 to S2
Displaced ORIF ; nondisplaced sling immobilization
Progressive fibrosis of palmar fascia. etiololgy not known;
MAT; medial meniscus injury; ACL and Tibial colateral ligament

39. lacerated wound in palmer surface of hand. what structure is injured?
Subphrenic abscess or other abdominal abscesses; order US or CT
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Tendons more likely
Headache - ataxia - bulbar dysfunction

40. What is cushing's triad
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Brardycardia - HTN - resp depression
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Subphrenic abscess or other abdominal abscesses; order US or CT

41. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
If patient ambulatory - surgery and pain control; if not nonop mx
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

42. aspiration of breast cyst is bloody
Mammogram
SAH due to post communicating artery aneurysm;
Saline and silicone
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

43. Why ruq calcificaion is concerning
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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
Dm neuropathy; stocking glove pattern

44. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS
Elderly and critically ill patients
24-48 hours of supportive therapy followed by cholecystectomy
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

45. Why initial xrays are negative in scaphoid fx
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;
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
Supraglottic edema; low threshold for intubation
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

46. Dupuytren contracture
Progressive fibrosis of palmar fascia. etiololgy not known;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

47. Most common of sudden death due to steering wheel injury
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective 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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
15-40%; self limiting;doesn't require tx

48. What are the common injuries from lightning?
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Strok and traumatic brain injury
S2-S4
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

49. characteristics of ureteral stone?
Nonunion and avascular necrosis; fx can block blood supply;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Carpal tunnel syndrom

50. acute colonic ischemia
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Abd pain and tenderness; bloody diarrhoea or hematochezia
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

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USMLE Step3 Surgery

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