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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. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
ACL injury
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

2. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Dm neuropathy; stocking glove pattern
Check ET tube placement if correct needle decompresion
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

3. varicocele
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

4. midline neck swelling moves with protrusion of tongue
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Elevated non seminomas
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

5. How to confirm achiles tendon rupture
Supraglottic edema; low threshold for intubation
Seminomas
Check ET tube placement if correct needle decompresion
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

6. lacunar stroke
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Displaced ORIF ; nondisplaced sling immobilization
Pure motor stroke; limited neurological dysfunction
Dumping syndrome; small and frequent meals; no simple sugar

7. diarrhoea 4-5 days after cholecystectomy
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Dumping syndrome; small and frequent meals; no simple sugar
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

8. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Pure motor stroke; limited neurological dysfunction

9. 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;
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
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

10. What are the common injuries from lightning?
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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;
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Ispilateral hypoglossal nerve injury

11. DD of acute scrotal pain
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
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
10-12 months

12. What is hydrocele?
Malignancy until proven otherwise
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
L5 to S2
Cystic scrotal fluid collection between parietal and visceral layers of testis

13. conservative Tx of varicose veins
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
If patient ambulatory - surgery and pain control; if not nonop mx
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Compression stocking - weight reduction - leg elevation

14. aspiration of breast cyst is nonbloody
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Brardycardia - HTN - resp depression
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
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

15. beta HCG
Patellar tendon tear; difficulty in extension
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Seminomas
L5 to S2

16. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

17. When goiter needs surgery
When urethral catherization is unsuccessful
Even after ochiopexy risk of ochiopexy higher then general population
If any compressive symptoms eg. dysphagia
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

18. surgery for acute cholecystities
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
24-48 hours of supportive therapy followed by cholecystectomy
Study showed no adverse effect; but they are contraindicated for PVD

19. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Displaced ORIF ; nondisplaced sling immobilization
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Dm neuropathy; stocking glove pattern

20. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Fx displace >1mm - nonunion during followup - osteonecrosis
Meniscus injury; medial most common; pain/swelling; popping sensation
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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

21. Complications of breast impant
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
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
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

22. Incidence of AF in CABG patient

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23. When patient can go back to sports after clavicle fx
4-6 weeks for noncontact sports and longer time for contact sports
Ispilateral hypoglossal nerve injury
24-48 hours of supportive therapy followed by cholecystectomy
Klinefelter syndrome; 50 fold increase;

24. 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
Supraglottic edema; low threshold for intubation
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
4-6 weeks for noncontact sports and longer time for contact sports

25. When do we see complications due to hypophosphatemia
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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;
Compression stocking - weight reduction - leg elevation

26. xray finding of stress fx after 3-4w
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
15-40%; self limiting;doesn't require tx
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

27. transrectal prostate biopsy
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
Unilateral vocal cord paralysis
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Progressive fibrosis of palmar fascia. etiololgy not known;

28. tx distal rectal ca
Sphincter sparing surgery (local resection) - abdomnio perineal resection
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;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

29. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
24-48 hours of supportive therapy followed by cholecystectomy
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Elevated non seminomas
Strok and traumatic brain injury

30. first step for evaluation of testicular swelling
Elderly and critically ill patients
Pure motor stroke; limited neurological dysfunction
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Dm neuropathy; stocking glove pattern

31. dumping syndrome after gastrectomy
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Fx displace >1mm - nonunion during followup - osteonecrosis
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
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

32. popping sensation; rapid onset of knee effusion. athelet
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
4-6 weeks for noncontact sports and longer time for contact sports
ACL injury
Meniscus injury; medial most common; pain/swelling; popping sensation

33. varicose veins with ulcer - bleeding and thrombophlebitits
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

34. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
4-6 weeks for noncontact sports and longer time for contact sports
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
CRPS

35. what size of ureteral stone for non op mx
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Ispilateral hypoglossal nerve injury
Less than 5mm

36. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
ACL injury
Subphrenic abscess or other abdominal abscesses; order US or CT
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

37. SOB - confusion - petechial rash after trauma - fracture
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Mammogram

38. inhalation of hot air - steam - smoke in burn victim
Supraglottic edema; low threshold for intubation
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Amoxicillin-clavulanate
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

39. What is the complications of undescended testis
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Carpal tunnel syndrom
Even after ochiopexy risk of ochiopexy higher then general population
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

40. complication displaced or communited distal radial fx
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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Carpal tunnel syndrom
ACL injury

41. How to manage a patient with asystole
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Epi and chest compressio for prolong period of time; atropine is given after epi;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

42. acalculus cholecystitis
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;
Epi and chest compressio for prolong period of time; atropine is given after epi;
Pure motor stroke; limited neurological dysfunction
Elderly and critically ill patients

43. Dupuytren contracture
Progressive fibrosis of palmar fascia. etiololgy not known;
Headache - ataxia - bulbar dysfunction
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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. beta hcg and AFP
Brardycardia - HTN - resp depression
Elevated non seminomas
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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

45. management of stone 8-10mm
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

46. When to stop raloxifene before surgery
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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
Epi and chest compressio for prolong period of time; atropine is given after epi;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

47. Most common of sudden death due to steering wheel injury
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

48. ct scan; cystic lesion in head of pancreas; next step
Dm neuropathy; stocking glove pattern
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Study showed no adverse effect; but they are contraindicated for PVD
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

49. Why varicocele more common in the left side
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Increased size during the day and valsalva means it is communicated with peritoneal cavity
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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

50. scrotal trauma
Next best step surgery; not ultrasound
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

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USMLE Step3 Surgery

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