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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. clavicle fx
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Displaced ORIF ; nondisplaced sling immobilization
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Carpal tunnel syndrom

2. sudden onset of postoperative hyperglycemia when patient on TPN
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

3. complication displaced or communited distal radial fx
Carpal tunnel syndrom
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Compression stocking - weight reduction - leg elevation
Unilateral vocal cord paralysis

4. recurrent laryngeal nerve injury
Unilateral vocal cord paralysis
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
Ispilateral hypoglossal nerve injury
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

5. several knee pain after being tackled in football game
Klinefelter syndrome; 50 fold increase;
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Tendons more likely

6. varicocele
15-40%; self limiting;doesn't require tx
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

7. prostate enlarged - nontender - no nodularity - elevated PSA
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;
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Even after ochiopexy risk of ochiopexy higher then general population

8. mangement of localized lymphadenopathy
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
When urethral catherization is unsuccessful
Displaced ORIF ; nondisplaced sling immobilization

9. What is hydrocele?
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Cystic scrotal fluid collection between parietal and visceral layers of testis
Subphrenic abscess or other abdominal abscesses; order US or CT
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

10. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Strok and traumatic brain injury
Dumping syndrome; small and frequent meals; no simple sugar
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Twisting force with the foot fixed on the ground seen in football and basketball games;

11. how ABI help dx of PVD
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Less than 5mm
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

12. aspiration of breast cyst is bloody
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Mammogram
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
SAH due to post communicating artery aneurysm;

13. How to confirm dx of compartment syndrom
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
Abd pain and tenderness; bloody diarrhoea or hematochezia
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Strok and traumatic brain injury

14. What is the complications of undescended testis
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Cystic scrotal fluid collection between parietal and visceral layers of testis
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Even after ochiopexy risk of ochiopexy higher then general population

15. Valgus and Varus tests
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Fx displace >1mm - nonunion during followup - osteonecrosis
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Saline and silicone

16. characteristics of ureteral stone?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Supraglottic edema; low threshold for intubation
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

17. dumping syndrome after gastrectomy
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Abd pain and tenderness; bloody diarrhoea or hematochezia
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

18. DD of acute scrotal pain
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Compression stocking - weight reduction - leg elevation
Twisting force with the foot fixed on the ground seen in football and basketball games;
SAH due to post communicating artery aneurysm;

19. cat/dog bites
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Amoxicillin-clavulanate
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
10-12 months

20. Complications of breast impant
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Progressive fibrosis of palmar fascia. etiololgy not known;

21. pregnant patient with asymptomatic gall stones
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

22. tx distal rectal ca
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Sphincter sparing surgery (local resection) - abdomnio perineal resection

23. acute colonic ischemia
Abd pain and tenderness; bloody diarrhoea or hematochezia
10-12 months
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
If any compressive symptoms eg. dysphagia

24. management of gunshot wound
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
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
Study showed no adverse effect; but they are contraindicated for PVD

25. lacerated wound in palmer surface of hand. what structure is injured?
Malignancy until proven otherwise
Tendons more likely
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

26. beta hcg and AFP
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Elevated non seminomas
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Less than 5mm

27. 3 mo with groin bulge; bulge appears when child cries
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
L5 to S2
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

28. midline neck swelling moves with protrusion of tongue
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Supraglottic edema; low threshold for intubation
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

29. How varicocele causes testicular atrophy
Low anterior resection and radio; add chemo if node positive
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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

30. antibiotics of acute cholecystitis
Even after ochiopexy risk of ochiopexy higher then general population
Unilateral vocal cord paralysis
Retrograde ejaculation
Ampicillin sublactum - pipercillin - ceftriaxone and metro

31. suprapubic catheterization
When urethral catherization is unsuccessful
CRPS
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Ampicillin sublactum - pipercillin - ceftriaxone and metro

32. transrectal prostate biopsy
Compression stocking - weight reduction - leg elevation
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

33. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Mammogram
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
Dm neuropathy; stocking glove pattern

34. painless testicular mass in young male
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Retrograde ejaculation
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Malignancy until proven otherwise

35. 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.
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Subphrenic abscess or other abdominal abscesses; order US or CT

36. contraindication of urethral catheterization
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
Urethral stricture; pelvic of urethral trauma
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Increased size during the day and valsalva means it is communicated with peritoneal cavity

37. How mcmurray manuver perform
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
Subphrenic abscess or other abdominal abscesses; order US or CT
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

38. mx of stress fx
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
SAH due to post communicating artery aneurysm;

39. surgery for acute cholecystities
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
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;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

40. SAH due to posterior inferior cerebellar aneurysm
Headache - ataxia - bulbar dysfunction
L5 to S2
If patient ambulatory - surgery and pain control; if not nonop mx
SAH due to post communicating artery aneurysm;

41. What is hungry bone syndrome?
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
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;
If patient ambulatory - surgery and pain control; if not nonop mx
50%; tunneling between rectum or kin

42. What is cushing's triad
Brardycardia - HTN - resp depression
When urethral catherization is unsuccessful
Abd pain and tenderness; bloody diarrhoea or hematochezia
If any compressive symptoms eg. dysphagia

43. Why right varicocele is more concerning?

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44. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
CRPS
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

45. How to dx ACL tear?
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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

46. acalculus cholecystitis
Elderly and critically ill patients
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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
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

47. lacunar stroke
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Pure motor stroke; limited neurological dysfunction
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

48. conservative Tx of varicose veins
If any compressive symptoms eg. dysphagia
Compression stocking - weight reduction - leg elevation
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

49. What is the contraindication of hyperventilation in inc ICP
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
4-6 weeks for noncontact sports and longer time for contact sports
Dm neuropathy; stocking glove pattern
Strok and traumatic brain injury

50. anal sphincter tone
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
S2-S4
Abd pain and tenderness; bloody diarrhoea or hematochezia

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USMLE Step3 Surgery

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