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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. cremasteric reflex test?
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
Tendons more likely
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Elevated non seminomas

2. conservative Tx of varicose veins
Nonunion and avascular necrosis; fx can block blood supply;
Low anterior resection and radio; add chemo if node positive
Compression stocking - weight reduction - leg elevation
L5 to S2

3. SAH due to posterior inferior cerebellar aneurysm
Saline and silicone
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Headache - ataxia - bulbar dysfunction
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

4. 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
Pure motor stroke; limited neurological dysfunction
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

5. what size of ureteral stone for non op mx
Headache - ataxia - bulbar dysfunction
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Less than 5mm
Urethral stricture; pelvic of urethral trauma

6. surgery for acute cholecystities
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
24-48 hours of supportive therapy followed by cholecystectomy
S2-S4

7. When goiter needs surgery
If any compressive symptoms eg. dysphagia
Dm neuropathy; stocking glove pattern
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
L5 to S2

8. how ABI help dx of PVD
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Fx displace >1mm - nonunion during followup - osteonecrosis
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Meniscus injury; medial most common; pain/swelling; popping sensation

9. tx distal rectal ca
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Ispilateral hypoglossal nerve injury
Sphincter sparing surgery (local resection) - abdomnio perineal resection
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

10. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Pure motor stroke; limited neurological dysfunction
CRPS
Mammogram
Displaced ORIF ; nondisplaced sling immobilization

11. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Patellar tendon tear; difficulty in extension
15-40%; self limiting;doesn't require tx
If any compressive symptoms eg. dysphagia
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

12. when patient with severe lung disease have C02 retention
Low anterior resection and radio; add chemo if node positive
Subphrenic abscess or other abdominal abscesses; order US or CT
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

13. dumping syndrome after gastrectomy
Next best step surgery; not ultrasound
Epi and chest compressio for prolong period of time; atropine is given after epi;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Fx displace >1mm - nonunion during followup - osteonecrosis

14. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Check ET tube placement if correct needle decompresion
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Amoxicillin-clavulanate

15. How to perform lachman test
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Displaced ORIF ; nondisplaced sling immobilization
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Check ET tube placement if correct needle decompresion

16. How to differentiate ACL and meniscus injury
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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

17. most common fx when falling on outsretched hand
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Dumping syndrome; small and frequent meals; no simple sugar
Next best step surgery; not ultrasound
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

18. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Less than 5mm
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

19. What is hungry bone syndrome?
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Abd pain and tenderness; bloody diarrhoea or hematochezia
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

20. clavicle fx
Meniscus injury; medial most common; pain/swelling; popping sensation
Displaced ORIF ; nondisplaced sling immobilization
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
Cystic scrotal fluid collection between parietal and visceral layers of testis

21. varicocele
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Cystic scrotal fluid collection between parietal and visceral layers of testis
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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

22. scrotal trauma
S2-S4
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Patellar tendon tear; difficulty in extension
Next best step surgery; not ultrasound

23. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

24. sudden onset of postoperative hyperglycemia when patient on TPN
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
50%; tunneling between rectum or kin
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

25. What is prehn sign?
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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

26. ipsilateral deviation of tongue upon protrusion
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
Ispilateral hypoglossal nerve injury
Strok and traumatic brain injury
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

27. prostate enlarged - nontender - no nodularity - elevated PSA
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Next best step surgery; not ultrasound
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

28. management of nondisplaced scaphoid fx
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

29. mx of stress fx
CRPS
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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

30. beta HCG
Seminomas
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Klinefelter syndrome; 50 fold increase;
Urethral stricture; pelvic of urethral trauma

31. inhalation of hot air - steam - smoke in burn victim
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Supraglottic edema; low threshold for intubation

32. swelling and tenderness in anterior part of knee
Headache - ataxia - bulbar dysfunction
Patellar tendon tear; difficulty in extension
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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

33. xray finding of stress fx after 3-4w
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
L5 to S2
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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

34. management of stone 8-10mm
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Cystic scrotal fluid collection between parietal and visceral layers of testis
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;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

35. What are the common injuries from lightning?
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Study showed no adverse effect; but they are contraindicated for PVD

36. acute colonic ischemia
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
Abd pain and tenderness; bloody diarrhoea or hematochezia
SAH due to post communicating artery aneurysm;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

37. types of hip fracture
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
ACL injury
Tendons more likely
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

38. What is terrible triad
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
MAT; medial meniscus injury; ACL and Tibial colateral ligament
15-40%; self limiting;doesn't require tx
Progressive fibrosis of palmar fascia. etiololgy not known;

39. DD of acute scrotal pain
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Retrograde ejaculation

40. Patient underwent CABG; postoperatively drowsy. most likely cause?
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
Nonunion and avascular necrosis; fx can block blood supply;
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
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;

41. diarrhoea 4-5 days after cholecystectomy
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Study showed no adverse effect; but they are contraindicated for PVD

42. complication displaced or communited distal radial fx
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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
Carpal tunnel syndrom
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

43. Can we use beta blocker for pvd?
10-12 months
Study showed no adverse effect; but they are contraindicated for PVD
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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

44. 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
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

45. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
SAH due to post communicating artery aneurysm;
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
Meniscus injury; medial most common; pain/swelling; popping sensation
Malignancy until proven otherwise

46. SOB - confusion - petechial rash after trauma - fracture
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Elevated non seminomas
Carpal tunnel syndrom
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

47. anal sphincter tone
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
S2-S4
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

48. characteristics of ureteral stone?
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
L5 to S2
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

49. Why right varicocele is more concerning?

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50. How to differentiate communicative and non-communicative hydrocele
Low anterior resection and radio; add chemo if node positive
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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

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USMLE Step3 Surgery

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