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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 do we see complications due to hypophosphatemia
Twisting force with the foot fixed on the ground seen in football and basketball games;
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;
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
Study showed no adverse effect; but they are contraindicated for PVD

2. how hyperventilation lowers ICP
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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
Klinefelter syndrome; 50 fold increase;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

3. How to perform lachman test
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Fx displace >1mm - nonunion during followup - osteonecrosis

4. When patient can go back to sports after clavicle fx
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Increased size during the day and valsalva means it is communicated with peritoneal cavity
4-6 weeks for noncontact sports and longer time for contact sports

5. when patient with severe lung disease have C02 retention
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Seminomas
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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

6. How to confirm dx of compartment syndrom
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

7. contraindication of urethral catheterization
CRPS
Urethral stricture; pelvic of urethral trauma
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

8. What is cushing's triad
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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
Brardycardia - HTN - resp depression

9. beta hcg and AFP
Elevated non seminomas
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

10. lacunar stroke
Pure motor stroke; limited neurological dysfunction
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
SAH due to post communicating artery aneurysm;
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

11. When to stop raloxifene before surgery
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

12. Complications of breast impant
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
24-48 hours of supportive therapy followed by cholecystectomy
Retrograde ejaculation

13. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Amoxicillin-clavulanate
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Meniscus injury; medial most common; pain/swelling; popping sensation

14. characteristics of ureteral stone?
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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
Study showed no adverse effect; but they are contraindicated for PVD

15. Most common of sudden death due to steering wheel injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
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;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

16. prostate enlarged - nontender - no nodularity - elevated PSA
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Epi and chest compressio for prolong period of time; atropine is given after epi;
15-40%; self limiting;doesn't require tx

17. aspiration of breast cyst is nonbloody
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Retrograde ejaculation
Displaced ORIF ; nondisplaced sling immobilization

18. clavicle fx
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Displaced ORIF ; nondisplaced sling immobilization
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

19. acalculus cholecystitis
Elderly and critically ill patients
Cystic scrotal fluid collection between parietal and visceral layers of testis
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

20. differential of ultrasound finding of breast mass
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
Pure motor stroke; limited neurological dysfunction
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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

21. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Nonunion and avascular necrosis; fx can block blood supply;
Seminomas
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Dm neuropathy; stocking glove pattern

22. managment of animal bite in hands
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

23. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Less than 5mm
Patellar tendon tear; difficulty in extension

24. aspiration of breast cyst is bloody
Elevated non seminomas
Mammogram
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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

25. Indication for bariatric surgery in obese patients
Elevated non seminomas
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
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;
Low anterior resection and radio; add chemo if node positive

26. conservative Tx of varicose veins
CRPS
Compression stocking - weight reduction - leg elevation
If patient ambulatory - surgery and pain control; if not nonop mx
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

27. complications of TPN
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Unilateral vocal cord paralysis
Next best step surgery; not ultrasound
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

28. How varicocele causes testicular atrophy
Elevated non seminomas
Malignancy until proven otherwise
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Carpal tunnel syndrom

29. mx of stress fx
Malignancy until proven otherwise
Low anterior resection and radio; add chemo if node positive
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Check ET tube placement if correct needle decompresion

30. DD of acute scrotal pain
Pure motor stroke; limited neurological dysfunction
Less than 5mm
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

31. What is the strongest risk factor for male breast cancer
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Dm neuropathy; stocking glove pattern
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Klinefelter syndrome; 50 fold increase;

32. management of hip fracture
If patient ambulatory - surgery and pain control; if not nonop mx
Epi and chest compressio for prolong period of time; atropine is given after epi;
If any compressive symptoms eg. dysphagia
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

33. Valgus and Varus tests
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Twisting force with the foot fixed on the ground seen in football and basketball games;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

34. How to confirm achiles tendon rupture
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
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
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
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;

35. 27 yo with scrotal mass; warm tender testes feel like bag of worms
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Seminomas
Study showed no adverse effect; but they are contraindicated for PVD

36. menisci injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
Patellar tendon tear; difficulty in extension
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

37. 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
Fx displace >1mm - nonunion during followup - osteonecrosis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

38. Patient underwent CABG; postoperatively drowsy. most likely cause?
Cystic scrotal fluid collection between parietal and visceral layers of testis
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
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
24-48 hours of supportive therapy followed by cholecystectomy

39. sudden onset of postoperative hyperglycemia when patient on TPN
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

40. severe pain in leg after MVC
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
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament

41. cat/dog bites
Check ET tube placement if correct needle decompresion
Abd pain and tenderness; bloody diarrhoea or hematochezia
Amoxicillin-clavulanate
Displaced ORIF ; nondisplaced sling immobilization

42. Why varicocele more common in the left side
Mammogram
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

43. diarrhoea after gastric bypass
Dumping syndrome; small and frequent meals; no simple sugar
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Brardycardia - HTN - resp depression
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

44. lacerated wound in palmer surface of hand. what structure is injured?
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Tendons more likely
Subphrenic abscess or other abdominal abscesses; order US or CT

45. antibiotics of acute cholecystitis
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Cystic scrotal fluid collection between parietal and visceral layers of testis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

46. cremasteric reflex test?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

47. management of gunshot wound
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
If any compressive symptoms eg. dysphagia

48. most common complication of acute cholecystitis
Supraglottic edema; low threshold for intubation
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Less than 5mm

49. 3 mo with groin bulge; bulge appears when child cries
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Increased size during the day and valsalva means it is communicated with peritoneal cavity

50. Why initial xrays are negative in scaphoid fx
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
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

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USMLE Step3 Surgery

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