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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. Patient underwent CABG; postoperatively drowsy. most likely cause?
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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
Abd pain and tenderness; bloody diarrhoea or hematochezia

2. acalculus cholecystitis
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
If any compressive symptoms eg. dysphagia
Elderly and critically ill patients
CRPS

3. Valgus and Varus tests
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Compression stocking - weight reduction - leg elevation
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

4. What is the contraindication of hyperventilation in inc ICP
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Low anterior resection and radio; add chemo if node positive
Strok and traumatic brain injury

5. dumping syndrome after gastrectomy
CRPS
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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
Mammogram

6. management of hip fracture
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
15-40%; self limiting;doesn't require tx
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;
If patient ambulatory - surgery and pain control; if not nonop mx

7. beta HCG
Seminomas
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
10-12 months
Twisting force with the foot fixed on the ground seen in football and basketball games;

8. several knee pain after being tackled in football game
Klinefelter syndrome; 50 fold increase;
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
4-6 weeks for noncontact sports and longer time for contact sports
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

9. What types of breast implants are available
Check ET tube placement if correct needle decompresion
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Saline and silicone
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

10. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
Elevated non seminomas
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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

11. management of nondisplaced scaphoid fx
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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
Klinefelter syndrome; 50 fold increase;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

12. How mcmurray manuver perform
ACL injury
Headache - ataxia - bulbar dysfunction
Meniscus injury; medial most common; pain/swelling; popping sensation
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

13. management of stone 8-10mm
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Tendons more likely
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Seminomas

14. 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
Ispilateral hypoglossal nerve injury
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
Displaced ORIF ; nondisplaced sling immobilization

15. conservative Tx of varicose veins
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Compression stocking - weight reduction - leg elevation
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

16. What is cushing's triad
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Brardycardia - HTN - resp depression
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

17. differential of ultrasound finding of breast mass
Study showed no adverse effect; but they are contraindicated for PVD
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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
Epi and chest compressio for prolong period of time; atropine is given after epi;

18. midline neck swelling moves with protrusion of tongue
Compression stocking - weight reduction - leg elevation
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Cystic scrotal fluid collection between parietal and visceral layers of testis

19. Dupuytren contracture
Nonunion and avascular necrosis; fx can block blood supply;
Displaced ORIF ; nondisplaced sling immobilization
Supraglottic edema; low threshold for intubation
Progressive fibrosis of palmar fascia. etiololgy not known;

20. indication of ursodeoxycholic acid
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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
15-40%; self limiting;doesn't require tx
50%; tunneling between rectum or kin

21. most common fx when falling on outsretched hand
Even after ochiopexy risk of ochiopexy higher then general population
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Strok and traumatic brain injury
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

22. 3 mo with groin bulge; bulge appears when child cries
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Sphincter sparing surgery (local resection) - abdomnio perineal resection

23. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Saline and silicone
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

24. ct scan; cystic lesion in head of pancreas; next step
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
50%; tunneling between rectum or kin
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Pure motor stroke; limited neurological dysfunction

25. what size of ureteral stone for non op mx
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Ispilateral hypoglossal nerve injury
Less than 5mm
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

26. anal sphincter tone
S2-S4
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Saline and silicone
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

27. management of gunshot wound
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
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
ACL injury
If any compressive symptoms eg. dysphagia

28. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

29. varicose veins with ulcer - bleeding and thrombophlebitits
If any compressive symptoms eg. dysphagia
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Saline and silicone
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

30. How to confirm achiles tendon rupture
Unilateral vocal cord paralysis
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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

31. antibiotics of acute cholecystitis
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
Elevated non seminomas
4-6 weeks for noncontact sports and longer time for contact sports
Ampicillin sublactum - pipercillin - ceftriaxone and metro

32. perioral numbness after parathyroidectomy
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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
Brardycardia - HTN - resp depression
Pure motor stroke; limited neurological dysfunction

33. transrectal prostate biopsy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
S2-S4

34. Complications of breast impant
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
50%; tunneling between rectum or kin
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

35. What percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
CRPS

36. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
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
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
ACL injury
Check ET tube placement if correct needle decompresion

37. mx of stress fx
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Abd pain and tenderness; bloody diarrhoea or hematochezia
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

38. contraindication of urethral catheterization
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Urethral stricture; pelvic of urethral trauma

39. xray finding of stress fx after 3-4w
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
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
10-12 months

40. What is the complications of undescended testis
Even after ochiopexy risk of ochiopexy higher then general population
Strok and traumatic brain injury
Next best step surgery; not ultrasound
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

41. surgery for acute cholecystities
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
24-48 hours of supportive therapy followed by cholecystectomy
Amoxicillin-clavulanate

42. Why right varicocele is more concerning?

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43. 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;
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Fx displace >1mm - nonunion during followup - osteonecrosis
4-6 weeks for noncontact sports and longer time for contact sports

44. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Strok and traumatic brain injury
When urethral catherization is unsuccessful

45. severe pain in leg after MVC
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
ACL injury

46. When to do surgery in undesceneded testis?
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Progressive fibrosis of palmar fascia. etiololgy not known;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

47. when patient with severe lung disease have C02 retention
Unilateral vocal cord paralysis
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
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;
Epi and chest compressio for prolong period of time; atropine is given after epi;

48. What is the strongest risk factor for male breast cancer
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Klinefelter syndrome; 50 fold increase;
Tendons more likely

49. first line of management of PVD
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Dm neuropathy; stocking glove pattern
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

50. How to dx ACL tear?
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
Displaced ORIF ; nondisplaced sling immobilization
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
If any compressive symptoms eg. dysphagia

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USMLE Step3 Surgery

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