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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. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Meniscus injury; medial most common; pain/swelling; popping sensation
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

2. What is the strongest risk factor for male breast cancer
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Klinefelter syndrome; 50 fold increase;
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

3. Why varicocele more common in the left side
50%; tunneling between rectum or kin
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

4. clavicle fx
Twisting force with the foot fixed on the ground seen in football and basketball games;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Displaced ORIF ; nondisplaced sling immobilization
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

5. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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;

6. perioral numbness after parathyroidectomy
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Less than 5mm
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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

7. tx distal rectal ca
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Elderly and critically ill patients
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

8. When do we see complications due to hypophosphatemia
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Cystic scrotal fluid collection between parietal and visceral layers of testis
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;
Mammogram

9. cremasteric reflex test?
Compression stocking - weight reduction - leg elevation
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Brardycardia - HTN - resp depression

10. Incidence of AF in CABG patient

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11. xray finding of stress fx after 3-4w
Elderly and critically ill patients
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

12. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
50%; tunneling between rectum or kin
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

13. common complication of inadequate mx of scaphoid fx
Nonunion and avascular necrosis; fx can block blood supply;
Next best step surgery; not ultrasound
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
10-12 months

14. Why right varicocele is more concerning?

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15. How to manage obesity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
CRPS
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
ACL injury

16. painless testicular mass in young male
Twisting force with the foot fixed on the ground seen in football and basketball games;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Less than 5mm
Malignancy until proven otherwise

17. prostate enlarged - nontender - no nodularity - elevated PSA
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
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
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

18. When to stop raloxifene before surgery
Subphrenic abscess or other abdominal abscesses; order US or CT
Malignancy until proven otherwise
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

19. How to differentiate ACL and meniscus injury
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
Tendons more likely
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

20. How to differentiate communicative and non-communicative hydrocele
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Klinefelter syndrome; 50 fold increase;
SAH due to post communicating artery aneurysm;
Increased size during the day and valsalva means it is communicated with peritoneal cavity

21. How to evaluate painless testicular swelling suspicious for cancer
Dumping syndrome; small and frequent meals; no simple sugar
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Headache - ataxia - bulbar dysfunction

22. Valgus and Varus tests
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

23. diarrhoea 4-5 days after cholecystectomy
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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
50%; tunneling between rectum or kin

24. indication of ursodeoxycholic acid
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Urethral stricture; pelvic of urethral trauma
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

25. dorsiflexion and planter flexion
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
L5 to S2
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

26. acalculus cholecystitis
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Elderly and critically ill patients
Next best step surgery; not ultrasound
Study showed no adverse effect; but they are contraindicated for PVD

27. diarrhoea after gastric bypass
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Dumping syndrome; small and frequent meals; no simple sugar
Malignancy until proven otherwise
10-12 months

28. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Check ET tube placement if correct needle decompresion
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

29. DD of acute scrotal pain
Meniscus injury; medial most common; pain/swelling; popping sensation
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
10-12 months
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

30. mangement of localized lymphadenopathy
Supraglottic edema; low threshold for intubation
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Malignancy until proven otherwise

31. What is cushing's triad
Unilateral vocal cord paralysis
Brardycardia - HTN - resp depression
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Ampicillin sublactum - pipercillin - ceftriaxone and metro

32. How to perform lachman test
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Seminomas

33. Patient underwent CABG; postoperatively drowsy. most likely cause?
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Ispilateral hypoglossal nerve injury
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
L5 to S2

34. severe pain in leg after MVC
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

35. management of stone 8-10mm
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
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

36. midline neck swelling moves with protrusion of tongue
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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
ACL injury
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

37. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Twisting force with the foot fixed on the ground seen in football and basketball games;

38. How varicocele causes testicular atrophy
Ispilateral hypoglossal nerve injury
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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

39. management of nondisplaced scaphoid fx
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Klinefelter syndrome; 50 fold increase;
Cystic scrotal fluid collection between parietal and visceral layers of testis

40. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
Headache - ataxia - bulbar dysfunction
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

41. anal sphincter tone
Tendons more likely
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Klinefelter syndrome; 50 fold increase;
S2-S4

42. When goiter needs surgery
If any compressive symptoms eg. dysphagia
S2-S4
Amoxicillin-clavulanate
Abd pain and tenderness; bloody diarrhoea or hematochezia

43. What are the common injuries from lightning?
Urethral stricture; pelvic of urethral trauma
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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

44. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Patellar tendon tear; difficulty in extension
Subphrenic abscess or other abdominal abscesses; order US or CT

45. what size of ureteral stone for non op mx
Less than 5mm
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;
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;

46. varicose veins with ulcer - bleeding and thrombophlebitits
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
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Nonunion and avascular necrosis; fx can block blood supply;
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

47. conservative Tx of varicose veins
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Headache - ataxia - bulbar dysfunction
Brardycardia - HTN - resp depression
Compression stocking - weight reduction - leg elevation

48. How to confirm dx of compartment syndrom
S2-S4
Malignancy until proven otherwise
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

49. Indication for bariatric surgery in obese patients
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;
Fx displace >1mm - nonunion during followup - osteonecrosis
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
Meniscus injury; medial most common; pain/swelling; popping sensation

50. most common fx when falling on outsretched hand
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

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USMLE Step3 Surgery

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