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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. prostate enlarged - nontender - no nodularity - elevated PSA
If patient ambulatory - surgery and pain control; if not nonop mx
Retrograde ejaculation
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

2. common complication of inadequate mx of scaphoid fx
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Nonunion and avascular necrosis; fx can block blood supply;
Displaced ORIF ; nondisplaced sling immobilization
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;

3. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
10-12 months
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

4. painless testicular mass in young male
Malignancy until proven otherwise
Brardycardia - HTN - resp depression
Sphincter sparing surgery (local resection) - abdomnio perineal resection
SAH due to post communicating artery aneurysm;

5. What is hungry bone syndrome?
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
Less than 5mm
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery

6. how ABI help dx of PVD
Klinefelter syndrome; 50 fold increase;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Pure motor stroke; limited neurological dysfunction
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

7. cat/dog bites
24-48 hours of supportive therapy followed by cholecystectomy
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Amoxicillin-clavulanate
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

8. tx distal rectal ca
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Progressive fibrosis of palmar fascia. etiololgy not known;
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Sphincter sparing surgery (local resection) - abdomnio perineal resection

9. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Saline and silicone

10. Patient underwent CABG; postoperatively drowsy. most likely cause?
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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
Seminomas
Dm neuropathy; stocking glove pattern

11. Valgus and Varus tests
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
If patient ambulatory - surgery and pain control; if not nonop mx
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

12. dumping syndrome after gastrectomy
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Amoxicillin-clavulanate
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

13. How to dx ACL tear?
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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
Next best step surgery; not ultrasound

14. popping sensation; rapid onset of knee effusion. athelet
ACL injury
Patellar tendon tear; difficulty in extension
Cystic scrotal fluid collection between parietal and visceral layers of testis
Headache - ataxia - bulbar dysfunction

15. management of stone 8-10mm
If patient ambulatory - surgery and pain control; if not nonop mx
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
50%; tunneling between rectum or kin

16. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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;
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

17. What is the complications of undescended testis
Even after ochiopexy risk of ochiopexy higher then general population
Mammogram
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
Seminomas

18. diarrhoea 4-5 days after cholecystectomy
10-12 months
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Urethral stricture; pelvic of urethral trauma
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

19. menisci injury
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
If patient ambulatory - surgery and pain control; if not nonop mx
Twisting force with the foot fixed on the ground seen in football and basketball games;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

20. What percent of anal abscess deveolop fisutula
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Twisting force with the foot fixed on the ground seen in football and basketball games;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
50%; tunneling between rectum or kin

21. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Klinefelter syndrome; 50 fold increase;
S2-S4
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

22. ct scan; cystic lesion in head of pancreas; next step
If any compressive symptoms eg. dysphagia
Brardycardia - HTN - resp depression
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

23. What types of breast implants are available
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
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
Saline and silicone

24. When goiter needs surgery
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
If any compressive symptoms eg. dysphagia

25. varicose veins with ulcer - bleeding and thrombophlebitits
Low anterior resection and radio; add chemo if node positive
Pure motor stroke; limited neurological dysfunction
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;

26. beta hcg and AFP
Elevated non seminomas
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
CRPS
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

27. differential of ultrasound finding of breast mass
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

28. How varicocele causes testicular atrophy
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;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Amoxicillin-clavulanate
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

29. When patient can go back to sports after clavicle fx
Twisting force with the foot fixed on the ground seen in football and basketball games;
4-6 weeks for noncontact sports and longer time for contact sports
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Headache - ataxia - bulbar dysfunction

30. How to manage obesity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Twisting force with the foot fixed on the ground seen in football and basketball games;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

31. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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
Elderly and critically ill patients
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

32. mx of stress fx
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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
SAH due to post communicating artery aneurysm;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

33. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
L5 to S2
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

34. What is most common lung injury after blunt chest trauma?
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

35. how hyperventilation lowers ICP
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Nonunion and avascular necrosis; fx can block blood supply;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

36. antibiotics of acute cholecystitis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

37. When do we see complications due to hypophosphatemia
Strok and traumatic brain injury
Carpal tunnel syndrom
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;
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

38. first line of management of PVD
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
S2-S4

39. What is the strongest risk factor for male breast cancer
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
Abd pain and tenderness; bloody diarrhoea or hematochezia
Klinefelter syndrome; 50 fold increase;
Sphincter sparing surgery (local resection) - abdomnio perineal resection

40. sudden onset of postoperative hyperglycemia when patient on TPN
Less than 5mm
Epi and chest compressio for prolong period of time; atropine is given after epi;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Klinefelter syndrome; 50 fold increase;

41. characteristics of ureteral stone?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Less than 5mm
Seminomas
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

42. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Meniscus injury; medial most common; pain/swelling; popping sensation
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Check ET tube placement if correct needle decompresion

43. xray finding of stress fx after 3-4w
24-48 hours of supportive therapy followed by cholecystectomy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased 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;
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

44. cremasteric reflex test?
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
When urethral catherization is unsuccessful

45. What is the contraindication of hyperventilation in inc ICP
Even after ochiopexy risk of ochiopexy higher then general population
Dm neuropathy; stocking glove pattern
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Strok and traumatic brain injury

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

47. lacunar stroke
SAH due to post communicating artery aneurysm;
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
Pure motor stroke; limited neurological dysfunction
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;

48. anal sphincter tone
S2-S4
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

49. when scaphoid fx patient needs to be referred to orthopedic
Brardycardia - HTN - resp depression
Fx displace >1mm - nonunion during followup - osteonecrosis
Check ET tube placement if correct needle decompresion
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

50. management of hip fracture
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
ACL injury
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
If patient ambulatory - surgery and pain control; if not nonop mx

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USMLE Step3 Surgery

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