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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. Indication for bariatric surgery in obese patients
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Tendons more likely
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;
Sphincter sparing surgery (local resection) - abdomnio perineal resection

2. 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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Twisting force with the foot fixed on the ground seen in football and basketball games;

3. acute colonic ischemia
Progressive fibrosis of palmar fascia. etiololgy not known;
Abd pain and tenderness; bloody diarrhoea or hematochezia
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

4. contraindication of urethral catheterization
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Urethral stricture; pelvic of urethral trauma
Meniscus injury; medial most common; pain/swelling; popping sensation
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

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

6. conservative Tx of varicose veins
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Compression stocking - weight reduction - leg elevation
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

7. What is hydrocele?
Cystic scrotal fluid collection between parietal and visceral layers of testis
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Unilateral vocal cord paralysis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

8. Why ruq calcificaion is concerning
Brardycardia - HTN - resp depression
Carpal tunnel syndrom
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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

9. common complication of inadequate mx of scaphoid fx
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Elevated non seminomas
Nonunion and avascular necrosis; fx can block blood supply;
24-48 hours of supportive therapy followed by cholecystectomy

10. When do we see complications due to hypophosphatemia
Seminomas
Twisting force with the foot fixed on the ground seen in football and basketball games;
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;
Tendons more likely

11. Can we use beta blocker for pvd?
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Nonunion and avascular necrosis; fx can block blood supply;
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Study showed no adverse effect; but they are contraindicated for PVD

12. surgery for acute cholecystities
24-48 hours of supportive therapy followed by cholecystectomy
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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
Strok and traumatic brain injury

13. cremasteric reflex
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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
ACL injury
MAT; medial meniscus injury; ACL and Tibial colateral ligament

14. managment of animal bite in hands
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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
Fx displace >1mm - nonunion during followup - osteonecrosis

15. What is the strongest risk factor for male breast cancer
Klinefelter syndrome; 50 fold increase;
Compression stocking - weight reduction - leg elevation
Nonunion and avascular necrosis; fx can block blood supply;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

16. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Meniscus injury; medial most common; pain/swelling; popping sensation
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
Less than 5mm
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

17. How to confirm dx of compartment syndrom
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
If patient ambulatory - surgery and pain control; if not nonop mx
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Supraglottic edema; low threshold for intubation

18. What is the complications of undescended testis
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Saline and silicone
Strok and traumatic brain injury
Even after ochiopexy risk of ochiopexy higher then general population

19. What is hungry bone syndrome?
Epi and chest compressio for prolong period of time; atropine is given after epi;
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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

20. ipsilateral deviation of tongue upon protrusion
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
Ispilateral hypoglossal nerve injury
Headache - ataxia - bulbar dysfunction
When urethral catherization is unsuccessful

21. When patient can go back to sports after clavicle fx
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Study showed no adverse effect; but they are contraindicated for PVD
4-6 weeks for noncontact sports and longer time for contact sports

22. clavicle fx
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Displaced ORIF ; nondisplaced sling immobilization

23. 3 mo with groin bulge; bulge appears when child cries
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Meniscus injury; medial most common; pain/swelling; popping sensation

24. diarrhoea after gastric bypass
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Less than 5mm
Dumping syndrome; small and frequent meals; no simple sugar

25. most common fx when falling on outsretched hand
Epi and chest compressio for prolong period of time; atropine is given after epi;
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Mammogram

26. first step for evaluation of testicular swelling
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Carpal tunnel syndrom
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

27. When to stop raloxifene before surgery
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Klinefelter syndrome; 50 fold increase;
Cystic scrotal fluid collection between parietal and visceral layers of testis

28. DD of acute scrotal pain
Elevated non seminomas
Study showed no adverse effect; but they are contraindicated for PVD
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

29. how ABI help dx of PVD
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Amoxicillin-clavulanate
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

30. ct scan; cystic lesion in head of pancreas; next step
Meniscus injury; medial most common; pain/swelling; popping sensation
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Unilateral vocal cord paralysis
Cystic scrotal fluid collection between parietal and visceral layers of testis

31. tx distal rectal ca
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Amoxicillin-clavulanate
Sphincter sparing surgery (local resection) - abdomnio perineal resection

32. How to differentiate ACL and meniscus injury
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Subphrenic abscess or other abdominal abscesses; order US or CT
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
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

33. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Dm neuropathy; stocking glove pattern

34. management of nondisplaced scaphoid fx
Study showed no adverse effect; but they are contraindicated for PVD
L5 to S2
Carpal tunnel syndrom
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

35. prostate enlarged - nontender - no nodularity - elevated PSA
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;
Headache - ataxia - bulbar dysfunction
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

36. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
L5 to S2
24-48 hours of supportive therapy followed by cholecystectomy
Supraglottic edema; low threshold for intubation
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

37. recurrent laryngeal nerve injury
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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;
Unilateral vocal cord paralysis
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

38. acalculus cholecystitis
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Sphincter sparing surgery (local resection) - abdomnio perineal resection
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;
Elderly and critically ill patients

39. beta hcg and AFP
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Elevated non seminomas

40. dumping syndrome after gastrectomy
Retrograde ejaculation
Brardycardia - HTN - resp depression
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

41. 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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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

42. lacerated wound in palmer surface of hand. what structure is injured?
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
CRPS
Tendons more likely

43. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Progressive fibrosis of palmar fascia. etiololgy not known;
Meniscus injury; medial most common; pain/swelling; popping sensation
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
50%; tunneling between rectum or kin

44. indication of ursodeoxycholic acid
If any compressive symptoms eg. dysphagia
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
Seminomas
10-12 months

45. What is most common lung injury after blunt chest trauma?
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
Progressive fibrosis of palmar fascia. etiololgy not known;
Epi and chest compressio for prolong period of time; atropine is given after epi;
Ispilateral hypoglossal nerve injury

46. painless testicular mass in young male
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Fx displace >1mm - nonunion during followup - osteonecrosis
50%; tunneling between rectum or kin
Malignancy until proven otherwise

47. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Displaced ORIF ; nondisplaced sling immobilization
Subphrenic abscess or other abdominal abscesses; order US or CT
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;

48. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
SAH due to post communicating artery aneurysm;
Low anterior resection and radio; add chemo if node positive

49. cat/dog bites
If patient ambulatory - surgery and pain control; if not nonop mx
Amoxicillin-clavulanate
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

50. scrotal trauma
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Next best step surgery; not ultrasound
S2-S4
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;