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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. beta HCG
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Seminomas
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

2. acalculus cholecystitis
Strok and traumatic brain injury
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Mammogram
Elderly and critically ill patients

3. beta hcg and AFP
Strok and traumatic brain injury
Elevated non seminomas
Unilateral vocal cord paralysis
Ampicillin sublactum - pipercillin - ceftriaxone and metro

4. 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)
Saline and silicone
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

5. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
S2-S4
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
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
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;

6. sudden onset of postoperative hyperglycemia when patient on TPN
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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
15-40%; self limiting;doesn't require tx
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

7. tx distal rectal ca
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Sphincter sparing surgery (local resection) - abdomnio perineal resection

8. What is hydrocele?
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
Cystic scrotal fluid collection between parietal and visceral layers of testis
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Compression stocking - weight reduction - leg elevation

9. management of nondisplaced scaphoid fx
Less than 5mm
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Fx displace >1mm - nonunion during followup - osteonecrosis

10. most common complication of acute cholecystitis
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Fx displace >1mm - nonunion during followup - osteonecrosis

11. What is most common lung injury after blunt chest trauma?
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
50%; tunneling between rectum or kin

12. anal sphincter tone
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
S2-S4

13. most common fx when falling on outsretched hand
Urethral stricture; pelvic of urethral trauma
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Subphrenic abscess or other abdominal abscesses; order US or CT
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

14. When goiter needs surgery
Urethral stricture; pelvic of urethral trauma
If any compressive symptoms eg. dysphagia
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

15. Complications of breast impant
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
S2-S4
Seminomas
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

16. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Check ET tube placement if correct needle decompresion
Urethral stricture; pelvic of urethral trauma
Saline and silicone
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

17. What types of breast implants are available
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Saline and silicone

18. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Dumping syndrome; small and frequent meals; no simple sugar
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
SAH due to post communicating artery aneurysm;

19. Indication for bariatric surgery in obese patients
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
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
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;
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

20. complications of TPN
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Epi and chest compressio for prolong period of time; atropine is given after epi;
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

21. first step for evaluation of testicular swelling
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
When urethral catherization is unsuccessful
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

22. managment of animal bite in hands
Dumping syndrome; small and frequent meals; no simple sugar
Strok and traumatic brain injury
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
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;

23. Why right varicocele is more concerning?

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24. How to confirm achiles tendon rupture
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Epi and chest compressio for prolong period of time; atropine is given after epi;
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

25. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Headache - ataxia - bulbar dysfunction
Compression stocking - weight reduction - leg elevation
Elevated non seminomas
Subphrenic abscess or other abdominal abscesses; order US or CT

26. diarrhoea after gastric bypass
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Dumping syndrome; small and frequent meals; no simple sugar

27. first line of management of PVD
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Fx displace >1mm - nonunion during followup - osteonecrosis
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

28. Valgus and Varus tests
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
L5 to S2
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

29. when scaphoid fx patient needs to be referred to orthopedic
Dm neuropathy; stocking glove pattern
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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

30. scrotal trauma
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Next best step surgery; not ultrasound

31. What is terrible triad
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
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Elderly and critically ill patients

32. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Compression stocking - weight reduction - leg elevation
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Strok and traumatic brain injury
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

33. Tx of pulmonary contusion
Urethral stricture; pelvic of urethral trauma
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

34. varicocele
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
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
Strok and traumatic brain injury

35. characteristics of ureteral stone?
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Headache - ataxia - bulbar dysfunction
Strok and traumatic brain injury
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

36. lacunar stroke
Supraglottic edema; low threshold for intubation
Pure motor stroke; limited neurological dysfunction
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
50%; tunneling between rectum or kin

37. Dupuytren contracture
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Progressive fibrosis of palmar fascia. etiololgy not known;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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

38. How mcmurray manuver perform
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

39. midline neck swelling moves with protrusion of tongue
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;
Fx displace >1mm - nonunion during followup - osteonecrosis
Dm neuropathy; stocking glove pattern
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

40. What time frame required for bone remodeling
Meniscus injury; medial most common; pain/swelling; popping sensation
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
10-12 months
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

41. how hyperventilation lowers ICP
Even after ochiopexy risk of ochiopexy higher then general population
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Amoxicillin-clavulanate

42. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Dumping syndrome; small and frequent meals; no simple sugar
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

43. xray finding of stress fx after 3-4w
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

44. dumping syndrome after gastrectomy
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Progressive fibrosis of palmar fascia. etiololgy not known;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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

45. cat/dog bites
Amoxicillin-clavulanate
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
L5 to S2
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

46. How to manage a patient with asystole
Epi and chest compressio for prolong period of time; atropine is given after epi;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
SAH due to post communicating artery aneurysm;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

47. antibiotics of acute cholecystitis
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Ampicillin sublactum - pipercillin - ceftriaxone and metro
CRPS

48. 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
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
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Increased size during the day and valsalva means it is communicated with peritoneal cavity

49. What is the strongest risk factor for male breast cancer
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;
Klinefelter syndrome; 50 fold increase;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

50. dorsiflexion and planter flexion
ACL injury
L5 to S2
Klinefelter syndrome; 50 fold increase;
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

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USMLE Step3 Surgery

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