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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. What percent of anal abscess deveolop fisutula
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
50%; tunneling between rectum or kin
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

2. mx of stress fx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
MAT; medial meniscus injury; ACL and Tibial colateral ligament
ACL injury
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

3. When goiter needs surgery
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Dumping syndrome; small and frequent meals; no simple sugar
If any compressive symptoms eg. dysphagia
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

4. 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Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery
Unilateral vocal cord paralysis
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

5. diarrhoea after gastric bypass
Subphrenic abscess or other abdominal abscesses; order US or CT
Meniscus injury; medial most common; pain/swelling; popping sensation
Compression stocking - weight reduction - leg elevation
Dumping syndrome; small and frequent meals; no simple sugar

6. severe pain in leg after MVC
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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
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
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

7. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
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
S2-S4
Progressive fibrosis of palmar fascia. etiololgy not known;
SAH due to post communicating artery aneurysm;

8. acalculus cholecystitis
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Elderly and critically ill patients
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Elevated non seminomas

9. What time frame required for bone remodeling
10-12 months
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Tendons more likely

10. 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;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

11. What types of breast implants are available
Saline and silicone
Nonunion and avascular necrosis; fx can block blood supply;
CRPS
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

12. cremasteric reflex
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
ACL injury

13. aspiration of breast cyst is bloody
Mammogram
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

14. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Fx displace >1mm - nonunion during followup - osteonecrosis
15-40%; self limiting;doesn't require tx
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

15. Patient underwent CABG; postoperatively drowsy. most likely cause?
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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
Strok and traumatic brain injury
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

16. management of stone 8-10mm
Strok and traumatic brain injury
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Meniscus injury; medial most common; pain/swelling; popping sensation

17. Why ruq calcificaion is concerning
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

18. beta hcg and AFP
Elevated non seminomas
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Less than 5mm
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

19. Why varicocele more common in the left side
S2-S4
Amoxicillin-clavulanate
Low anterior resection and radio; add chemo if node positive
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

20. recurrent laryngeal nerve injury
Retrograde ejaculation
Brardycardia - HTN - resp depression
Unilateral vocal cord paralysis
Fx displace >1mm - nonunion during followup - osteonecrosis

21. How varicocele causes testicular atrophy
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
15-40%; self limiting;doesn't require tx
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

22. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
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
Dumping syndrome; small and frequent meals; no simple sugar
Ampicillin sublactum - pipercillin - ceftriaxone and metro

23. Valgus and Varus tests
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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
Klinefelter syndrome; 50 fold increase;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

24. surgery for acute cholecystities
Fx displace >1mm - nonunion during followup - osteonecrosis
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
24-48 hours of supportive therapy followed by cholecystectomy
Sphincter sparing surgery (local resection) - abdomnio perineal resection

25. How to differentiate communicative and non-communicative hydrocele
Carpal tunnel syndrom
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

26. How to dx ACL tear?
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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
Ispilateral hypoglossal nerve injury

27. anal sphincter tone
Mammogram
Retrograde ejaculation
Check ET tube placement if correct needle decompresion
S2-S4

28. 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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

29. How to evaluate painless testicular swelling suspicious for cancer
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

30. 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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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
Sphincter sparing surgery (local resection) - abdomnio perineal resection

31. aspiration of breast cyst is nonbloody
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
50%; tunneling between rectum or kin
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

32. What is prehn sign?
Unilateral vocal cord paralysis
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Retrograde ejaculation
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

33. lacerated wound in palmer surface of hand. what structure is injured?
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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
Tendons more likely
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

34. stress fx
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Compression stocking - weight reduction - leg elevation
24-48 hours of supportive therapy followed by cholecystectomy
S2-S4

35. What is the strongest risk factor for male breast cancer
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Fx displace >1mm - nonunion during followup - osteonecrosis
Klinefelter syndrome; 50 fold increase;
Meniscus injury; medial most common; pain/swelling; popping sensation

36. varicocele
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

37. What is most common lung injury after blunt chest trauma?
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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
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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

38. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
If patient ambulatory - surgery and pain control; if not nonop mx
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Carpal tunnel syndrom

39. What is terrible triad
Strok and traumatic brain injury
Mammogram
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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

40. scrotal trauma
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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;
Retrograde ejaculation
Next best step surgery; not ultrasound

41. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
CRPS
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Meniscus injury; medial most common; pain/swelling; popping sensation
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

42. conservative Tx of varicose veins
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Compression stocking - weight reduction - leg elevation
Pure motor stroke; limited neurological dysfunction
Twisting force with the foot fixed on the ground seen in football and basketball games;

43. Why right varicocele is more concerning?

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44. Incidence of AF in CABG patient

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45. common complication of inadequate mx of scaphoid fx
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Nonunion and avascular necrosis; fx can block blood supply;
4-6 weeks for noncontact sports and longer time for contact sports
Low anterior resection and radio; add chemo if node positive

46. 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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Unilateral vocal cord paralysis
Retrograde ejaculation

47. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
When urethral catherization is unsuccessful

48. most frequent complication of TURP
Retrograde ejaculation
Abd pain and tenderness; bloody diarrhoea or hematochezia
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

49. xray finding of stress fx after 3-4w
CRPS
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

50. What is the contraindication of hyperventilation in inc ICP
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
Strok and traumatic brain injury
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

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USMLE Step3 Surgery

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