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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. When goiter needs surgery
Pure motor stroke; limited neurological dysfunction
If any compressive symptoms eg. dysphagia
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Brardycardia - HTN - resp depression

2. diarrhoea after gastric bypass
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
4-6 weeks for noncontact sports and longer time for contact sports
Dumping syndrome; small and frequent meals; no simple sugar
Sphincter sparing surgery (local resection) - abdomnio perineal resection

3. lacerated wound in palmer surface of hand. what structure is injured?
If any compressive symptoms eg. dysphagia
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
Tendons more likely
Ampicillin sublactum - pipercillin - ceftriaxone and metro

4. DD of acute scrotal pain
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
When urethral catherization is unsuccessful
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Unilateral vocal cord paralysis

5. Can we use beta blocker for pvd?
CRPS
24-48 hours of supportive therapy followed by 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
Study showed no adverse effect; but they are contraindicated for PVD

6. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Subphrenic abscess or other abdominal abscesses; order US or CT
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
Progressive fibrosis of palmar fascia. etiololgy not known;
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

7. varicocele
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Ampicillin sublactum - pipercillin - ceftriaxone and metro

8. recurrent laryngeal nerve injury
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Patellar tendon tear; difficulty in extension
Unilateral vocal cord paralysis

9. aspiration of breast cyst is nonbloody
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Amoxicillin-clavulanate
Saline and silicone
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

10. first step for evaluation of testicular swelling
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
When urethral catherization is unsuccessful
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

11. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

12. What time frame required for bone remodeling
10-12 months
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

13. midline neck swelling moves with protrusion of tongue
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Carpal tunnel syndrom
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Nonunion and avascular necrosis; fx can block blood supply;

14. Indication for bariatric surgery in obese patients
When urethral catherization is unsuccessful
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
L5 to S2
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;

15. varicose veins with ulcer - bleeding and thrombophlebitits
Even after ochiopexy risk of ochiopexy higher then general population
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 large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Dumping syndrome; small and frequent meals; no simple sugar

16. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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
Dm neuropathy; stocking glove pattern
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

17. severe pain in leg after MVC
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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

18. SAH due to posterior inferior cerebellar aneurysm
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Dm neuropathy; stocking glove pattern
Headache - ataxia - bulbar dysfunction

19. management of stone 8-10mm
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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

20. antibiotics of acute cholecystitis
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Amoxicillin-clavulanate
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;
Ampicillin sublactum - pipercillin - ceftriaxone and metro

21. beta hcg and AFP
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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
Elevated non seminomas
Ispilateral hypoglossal nerve injury

22. complications of TPN
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;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

23. when scaphoid fx patient needs to be referred to orthopedic
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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
Fx displace >1mm - nonunion during followup - osteonecrosis
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

24. ct scan; cystic lesion in head of pancreas; next step
Malignancy until proven otherwise
Klinefelter syndrome; 50 fold increase;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

25. managment of animal bite in hands
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;
Meniscus injury; medial most common; pain/swelling; popping sensation
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

26. Tx of proximal non metastatic rectal ca
Compression stocking - weight reduction - leg elevation
Dm neuropathy; stocking glove pattern
Epi and chest compressio for prolong period of time; atropine is given after epi;
Low anterior resection and radio; add chemo if node positive

27. aspiration of breast cyst is bloody
Mammogram
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

28. swelling and tenderness in anterior part of knee
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
Pure motor stroke; limited neurological dysfunction
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
Patellar tendon tear; difficulty in extension

29. indication of ursodeoxycholic acid
Low anterior resection and radio; add chemo if node positive
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
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

30. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Carpal tunnel syndrom
CRPS
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

31. When patient can go back to sports after clavicle fx
When urethral catherization is unsuccessful
Saline and silicone
4-6 weeks for noncontact sports and longer time for contact sports
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

32. how hyperventilation lowers ICP
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
ACL injury
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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;

33. When to stop raloxifene before surgery
Check ET tube placement if correct needle decompresion
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Epi and chest compressio for prolong period of time; atropine is given after epi;

34. What percent of anal abscess deveolop fisutula
Retrograde ejaculation
50%; tunneling between rectum or kin
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

35. When to do surgery in undesceneded testis?
10-12 months
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Dumping syndrome; small and frequent meals; no simple sugar
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

36. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Subphrenic abscess or other abdominal abscesses; order US or CT
SAH due to post communicating artery aneurysm;
Sphincter sparing surgery (local resection) - abdomnio perineal resection

37. How to dx ACL tear?
Elderly and critically ill patients
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
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
Compression stocking - weight reduction - leg elevation

38. Incidence of AF in CABG patient

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39. What is hydrocele?
Strok and traumatic brain injury
Cystic scrotal fluid collection between parietal and visceral layers of testis
50%; tunneling between rectum or kin
ACL injury

40. What are the common injuries from lightning?
Abd pain and tenderness; bloody diarrhoea or hematochezia
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
L5 to S2
Elderly and critically ill patients

41. when patient with severe lung disease have C02 retention
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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Saline and silicone
Fx displace >1mm - nonunion during followup - osteonecrosis

42. dorsiflexion and planter flexion
L5 to S2
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;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

43. Patient underwent CABG; postoperatively drowsy. most likely cause?
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
10-12 months
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
Urethral stricture; pelvic of urethral trauma

44. How to differentiate ACL and meniscus injury
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Seminomas

45. What is hungry bone syndrome?
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
50%; tunneling between rectum or kin

46. How to manage a patient with asystole
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Patellar tendon tear; difficulty in extension
Cystic scrotal fluid collection between parietal and visceral layers of testis
Epi and chest compressio for prolong period of time; atropine is given after epi;

47. lacunar stroke
When urethral catherization is unsuccessful
Saline and silicone
Pure motor stroke; limited neurological dysfunction
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

48. Most common of sudden death due to steering wheel injury
Dm neuropathy; stocking glove pattern
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

49. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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
Klinefelter syndrome; 50 fold increase;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

50. popping sensation; rapid onset of knee effusion. athelet
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
ACL injury
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;
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

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USMLE Step3 Surgery

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