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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. management of hip fracture
If patient ambulatory - surgery and pain control; if not nonop mx
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
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

2. recurrent laryngeal nerve injury
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Unilateral vocal cord paralysis
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
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

3. prostate enlarged - nontender - no nodularity - elevated PSA
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Saline and silicone
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;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

4. How to dx ACL tear?
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

5. aspiration of breast cyst is bloody
Mammogram
15-40%; self limiting;doesn't require tx
When urethral catherization is unsuccessful
Fx displace >1mm - nonunion during followup - osteonecrosis

6. What types of breast implants are available
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Saline and silicone
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
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;

7. diarrhoea after gastric bypass
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Dumping syndrome; small and frequent meals; no simple sugar
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

8. When patient can go back to sports after clavicle fx
4-6 weeks for noncontact sports and longer time for contact sports
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
50%; tunneling between rectum or kin
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

9. management of gunshot wound
S2-S4
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Supraglottic edema; low threshold for intubation
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

10. ipsilateral deviation of tongue upon protrusion
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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

11. DD of acute scrotal pain
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
Subphrenic abscess or other abdominal abscesses; order US or CT
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

12. What is the strongest risk factor for male breast cancer
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Klinefelter syndrome; 50 fold increase;

13. What percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
24-48 hours of supportive therapy followed by cholecystectomy
Displaced ORIF ; nondisplaced sling immobilization
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

14. 3 mo with groin bulge; bulge appears when child cries
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

15. Patient underwent CABG; postoperatively drowsy. most likely cause?
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

16. Why ruq calcificaion is concerning
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Mammogram
Klinefelter syndrome; 50 fold increase;
Progressive fibrosis of palmar fascia. etiololgy not known;

17. tx distal rectal ca
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Fx displace >1mm - nonunion during followup - osteonecrosis
ACL injury
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

18. beta HCG
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Twisting force with the foot fixed on the ground seen in football and basketball games;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Seminomas

19. surgery for acute cholecystities
24-48 hours of supportive therapy followed by cholecystectomy
CRPS
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament

20. contraindication of urethral catheterization
Subphrenic abscess or other abdominal abscesses; order US or CT
Urethral stricture; pelvic of urethral trauma
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

21. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
When urethral catherization is unsuccessful
Saline and silicone
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

22. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Seminomas
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

23. complications of TPN
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Progressive fibrosis of palmar fascia. etiololgy not known;
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

24. What is cushing's triad
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;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
ACL injury
Brardycardia - HTN - resp depression

25. xray finding of stress fx after 3-4w
10-12 months
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
L5 to S2

26. What is most common lung injury after blunt chest trauma?
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
Elevated non seminomas
Urethral stricture; pelvic of urethral trauma
10-12 months

27. mx of stress fx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
15-40%; self limiting;doesn't require tx
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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

28. indication of ursodeoxycholic acid
Supraglottic edema; low threshold for intubation
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
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;
Carpal tunnel syndrom

29. management of stone 8-10mm
Low anterior resection and radio; add chemo if node positive
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

30. acute colonic ischemia
Abd pain and tenderness; bloody diarrhoea or hematochezia
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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

31. painless testicular mass in young male
Malignancy until proven otherwise
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

32. How to differentiate communicative and non-communicative hydrocele
Dumping syndrome; small and frequent meals; no simple sugar
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Next best step surgery; not ultrasound
Increased size during the day and valsalva means it is communicated with peritoneal cavity

33. Incidence of AF in CABG patient

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34. What is the complications of undescended testis
24-48 hours of supportive therapy followed by cholecystectomy
Even after ochiopexy risk of ochiopexy higher then general population
15-40%; self limiting;doesn't require tx
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

35. acalculus cholecystitis
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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
Seminomas
Elderly and critically ill patients

36. How to differentiate ACL and meniscus injury
Retrograde ejaculation
10-12 months
Dumping syndrome; small and frequent meals; no simple sugar
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

37. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
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
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
10-12 months
Meniscus injury; medial most common; pain/swelling; popping sensation

38. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Meniscus injury; medial most common; pain/swelling; popping sensation
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

39. midline neck swelling moves with protrusion of tongue
10-12 months
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Supraglottic edema; low threshold for intubation

40. most frequent complication of TURP
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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
Retrograde ejaculation
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

41. Valgus and Varus tests
Elevated non seminomas
Amoxicillin-clavulanate
Klinefelter syndrome; 50 fold increase;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

42. How to manage a patient with asystole
Epi and chest compressio for prolong period of time; atropine is given after epi;
Abd pain and tenderness; bloody diarrhoea or hematochezia
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Elevated non seminomas

43. What is the contraindication of hyperventilation in inc ICP
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
Strok and traumatic brain injury
Increased size during the day and valsalva means it is communicated with peritoneal cavity

44. managment of animal bite in hands
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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;

45. management of nondisplaced scaphoid fx
L5 to S2
4-6 weeks for noncontact sports and longer time for contact sports
Check ET tube placement if correct needle decompresion
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

46. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Dm neuropathy; stocking glove pattern
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

47. how hyperventilation lowers ICP
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

48. aspiration of breast cyst is nonbloody
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Low anterior resection and radio; add chemo if node positive
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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

49. sudden onset of postoperative hyperglycemia when patient on TPN
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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
Study showed no adverse effect; but they are contraindicated for PVD

50. 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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Ispilateral hypoglossal nerve injury
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

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USMLE Step3 Surgery

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