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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. management of hip fracture
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
If patient ambulatory - surgery and pain control; if not nonop mx
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

2. What time frame required for bone remodeling
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Retrograde ejaculation
10-12 months
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

3. clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Retrograde ejaculation

4. pregnant patient with asymptomatic gall stones
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

5. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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
Meniscus injury; medial most common; pain/swelling; popping sensation
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

6. sudden onset of postoperative hyperglycemia when patient on TPN
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

7. management of nondisplaced scaphoid fx
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Pure motor stroke; limited neurological dysfunction

8. contraindication of urethral catheterization
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Urethral stricture; pelvic of urethral trauma
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Compression stocking - weight reduction - leg elevation

9. acalculus cholecystitis
Elderly and critically ill patients
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;
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;

10. How to evaluate painless testicular swelling suspicious for cancer
Study showed no adverse effect; but they are contraindicated for PVD
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Less than 5mm
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

11. What is hydrocele?
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Cystic scrotal fluid collection between parietal and visceral layers of testis

12. How to dx ACL tear?
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

13. midline neck swelling moves with protrusion of tongue
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Saline and silicone
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Pure motor stroke; limited neurological dysfunction

14. Dupuytren contracture
Progressive fibrosis of palmar fascia. etiololgy not known;
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

15. recurrent laryngeal nerve injury
L5 to S2
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Unilateral vocal cord paralysis
Elevated non seminomas

16. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
SAH due to post communicating artery aneurysm;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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

17. What are the common injuries from lightning?
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
10-12 months
SAH due to post communicating artery aneurysm;
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

18. When to stop raloxifene before surgery
15-40%; self limiting;doesn't require tx
Seminomas
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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

19. dumping syndrome after gastrectomy
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
4-6 weeks for noncontact sports and longer time for contact sports
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
24-48 hours of supportive therapy followed by cholecystectomy

20. anal sphincter tone
Subphrenic abscess or other abdominal abscesses; order US or CT
S2-S4
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Urethral stricture; pelvic of urethral trauma

21. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

22. severe pain in leg after MVC
Subphrenic abscess or other abdominal abscesses; order US or CT
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
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
S2-S4

23. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Elderly and critically ill patients
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
If patient ambulatory - surgery and pain control; if not nonop mx

24. What percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
Mammogram
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

25. aspiration of breast cyst is nonbloody
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

26. prostate enlarged - nontender - no nodularity - elevated PSA
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
SAH due to post communicating artery aneurysm;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

27. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Nonunion and avascular necrosis; fx can block blood supply;
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
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 ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

28. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
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;
CRPS
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

29. How to differentiate ACL and meniscus injury
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

30. inhalation of hot air - steam - smoke in burn victim
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Supraglottic edema; low threshold for intubation
Patellar tendon tear; difficulty in extension

31. mangement of localized lymphadenopathy
Compression stocking - weight reduction - leg elevation
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Study showed no adverse effect; but they are contraindicated for PVD

32. diarrhoea 4-5 days after cholecystectomy
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Brardycardia - HTN - resp depression
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Meniscus injury; medial most common; pain/swelling; popping sensation

33. What is most common lung injury after blunt chest trauma?
Dm neuropathy; stocking glove pattern
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;
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

34. beta hcg and AFP
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Elevated non seminomas
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

35. What is cushing's triad
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Brardycardia - HTN - resp depression

36. Incidence of AF in CABG patient

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37. indication of ursodeoxycholic acid
Retrograde ejaculation
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
Subphrenic abscess or other abdominal abscesses; order US or CT

38. 3 mo with groin bulge; bulge appears when child cries
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Pure motor stroke; limited neurological dysfunction

39. several knee pain after being tackled in football game
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Nonunion and avascular necrosis; fx can block blood supply;
Epi and chest compressio for prolong period of time; atropine is given after epi;

40. tx distal rectal ca
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Sphincter sparing surgery (local resection) - abdomnio perineal resection

41. lacerated wound in palmer surface of hand. what structure is injured?
Malignancy until proven otherwise
Tendons more likely
Dm neuropathy; stocking glove pattern
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

42. xray finding of stress fx after 3-4w
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

43. stress fx
Ampicillin sublactum - pipercillin - ceftriaxone and metro
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Compression stocking - weight reduction - leg elevation
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

44. lacunar stroke
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Pure motor stroke; limited neurological dysfunction
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
4-6 weeks for noncontact sports and longer time for contact sports

45. What is prehn sign?
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
4-6 weeks for noncontact sports and longer time for contact sports
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

46. transrectal prostate biopsy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Compression stocking - weight reduction - leg elevation
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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

47. most common complication of acute cholecystitis
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Urethral stricture; pelvic of urethral trauma
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

48. menisci injury
Patellar tendon tear; difficulty in extension
Progressive fibrosis of palmar fascia. etiololgy not known;
Twisting force with the foot fixed on the ground seen in football and basketball games;
S2-S4

49. Patient underwent CABG; postoperatively drowsy. most likely cause?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

50. What is the contraindication of hyperventilation in inc ICP
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Pure motor stroke; limited neurological dysfunction
Abd pain and tenderness; bloody diarrhoea or hematochezia
Strok and traumatic brain injury

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USMLE Step3 Surgery

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