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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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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. what size of ureteral stone for non op mx
Less than 5mm
Pure motor stroke; limited neurological dysfunction
If patient ambulatory - surgery and pain control; if not nonop mx
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

2. SOB - confusion - petechial rash after trauma - fracture
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Strok and traumatic brain injury
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

3. How to differentiate ACL and meniscus injury
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
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
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Dm neuropathy; stocking glove pattern

4. aspiration of breast cyst is bloody
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Mammogram
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

5. suprapubic catheterization
When urethral catherization is unsuccessful
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Retrograde ejaculation
Carpal tunnel syndrom

6. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

7. most common fx when falling on outsretched hand
Progressive fibrosis of palmar fascia. etiololgy not known;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

8. first line of management of PVD
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
If patient ambulatory - surgery and pain control; if not nonop mx

9. Complications of breast impant
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
If patient ambulatory - surgery and pain control; if not nonop mx

10. most frequent complication of TURP
Ispilateral hypoglossal nerve injury
Retrograde ejaculation
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Meniscus injury; medial most common; pain/swelling; popping sensation

11. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Elderly and critically ill patients
Dm neuropathy; stocking glove pattern
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

12. when scaphoid fx patient needs to be referred to orthopedic
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
Epi and chest compressio for prolong period of time; atropine is given after epi;
Fx displace >1mm - nonunion during followup - osteonecrosis
Nonunion and avascular necrosis; fx can block blood supply;

13. swelling and tenderness in anterior part of knee
Elevated non seminomas
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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
Patellar tendon tear; difficulty in extension

14. Most common of sudden death due to steering wheel injury
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Seminomas
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

15. Valgus and Varus tests
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
15-40%; self limiting;doesn't require tx
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Even after ochiopexy risk of ochiopexy higher then general population

16. What is prehn sign?
Elevated non seminomas
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

17. xray finding of stress fx after 3-4w
15-40%; self limiting;doesn't require tx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

18. mangement of localized lymphadenopathy
Strok and traumatic brain injury
4-6 weeks for noncontact sports and longer time for contact sports
When urethral catherization is unsuccessful
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

19. tx distal rectal ca
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Retrograde ejaculation
Low anterior resection and radio; add chemo if node positive
Abd pain and tenderness; bloody diarrhoea or hematochezia

20. How to manage obesity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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;

21. How mcmurray manuver perform
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
When urethral catherization is unsuccessful

22. What is hungry bone syndrome?
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Supraglottic edema; low threshold for intubation

23. first step for evaluation of testicular swelling
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
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
Tendons more likely
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

24. SAH due to posterior inferior cerebellar aneurysm
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Headache - ataxia - bulbar dysfunction
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

25. managment of animal bite in hands
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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;
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Urethral stricture; pelvic of urethral trauma

26. Patient underwent CABG; postoperatively drowsy. most likely cause?
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Subphrenic abscess or other abdominal abscesses; order US or CT
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
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

27. characteristics of ureteral stone?
Nonunion and avascular necrosis; fx can block blood supply;
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Klinefelter syndrome; 50 fold increase;

28. Tx of proximal non metastatic rectal ca
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Carpal tunnel syndrom
Low anterior resection and radio; add chemo if node positive
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

29. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Subphrenic abscess or other abdominal abscesses; order US or CT
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

30. When goiter needs surgery
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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
If any compressive symptoms eg. dysphagia

31. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
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;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
4-6 weeks for noncontact sports and longer time for contact sports

32. What is cushing's triad
Even after ochiopexy risk of ochiopexy higher then general population
Brardycardia - HTN - resp depression
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
MAT; medial meniscus injury; ACL and Tibial colateral ligament

33. when patient with severe lung disease have C02 retention
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

34. When to do surgery in undesceneded testis?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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;
Progressive fibrosis of palmar fascia. etiololgy not known;
Check ET tube placement if correct needle decompresion

35. diarrhoea 4-5 days after cholecystectomy
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
10-12 months
Meniscus injury; medial most common; pain/swelling; popping sensation

36. varicose veins with ulcer - bleeding and thrombophlebitits
Low anterior resection and radio; add chemo if node positive
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

37. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
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
Check ET tube placement if correct needle decompresion
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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

38. How to dx ACL tear?
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
Study showed no adverse effect; but they are contraindicated for PVD
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

39. common complication of inadequate mx of scaphoid fx
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Nonunion and avascular necrosis; fx can block blood supply;
Cystic scrotal fluid collection between parietal and visceral layers of testis
Pure motor stroke; limited neurological dysfunction

40. inhalation of hot air - steam - smoke in burn victim
Compression stocking - weight reduction - leg elevation
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Supraglottic edema; low threshold for intubation
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

41. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
CRPS
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
50%; tunneling between rectum or kin
Meniscus injury; medial most common; pain/swelling; popping sensation

42. mx of stress fx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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;
Tendons more likely

43. management of gunshot wound
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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
When urethral catherization is unsuccessful

44. Incidence of AF in CABG patient

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45. Can we use beta blocker for pvd?
Klinefelter syndrome; 50 fold increase;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Study showed no adverse effect; but they are contraindicated for PVD

46. how ABI help dx of PVD
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
Epi and chest compressio for prolong period of time; atropine is given after epi;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Patellar tendon tear; difficulty in extension

47. 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
Mammogram
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
15-40%; self limiting;doesn't require tx

48. What is most common lung injury after blunt chest trauma?
Dumping syndrome; small and frequent meals; no simple sugar
10-12 months
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
Malignancy until proven otherwise

49. acalculus cholecystitis
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Elderly and critically ill patients
Strok and traumatic brain injury
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;

50. 3 mo with groin bulge; bulge appears when child cries
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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
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

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USMLE Step3 Surgery

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