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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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1. 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
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

2. Why right varicocele is more concerning?

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3. pregnant patient with asymptomatic gall stones
Sphincter sparing surgery (local resection) - abdomnio perineal resection
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Dm neuropathy; stocking glove pattern
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

4. DD of acute scrotal pain
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

5. how ABI help dx of PVD
Malignancy until proven otherwise
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
SAH due to post communicating artery aneurysm;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

6. suprapubic catheterization
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
24-48 hours of supportive therapy followed by cholecystectomy
When urethral catherization is unsuccessful

7. prostate enlarged - nontender - no nodularity - elevated PSA
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
CRPS
Malignancy until proven otherwise

8. When to do surgery in undesceneded testis?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Urethral stricture; pelvic of urethral trauma
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

9. What is terrible triad
Tendons more likely
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

10. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

11. popping sensation; rapid onset of knee effusion. athelet
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
Dm neuropathy; stocking glove pattern
ACL injury
Klinefelter syndrome; 50 fold increase;

12. indication of ursodeoxycholic acid
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
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
If any compressive symptoms eg. dysphagia
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

13. management of stone 8-10mm
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

14. how hyperventilation lowers ICP
Progressive fibrosis of palmar fascia. etiololgy not known;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Subphrenic abscess or other abdominal abscesses; order US or CT
10-12 months

15. stress fx
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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
If any compressive symptoms eg. dysphagia
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

16. What is prehn sign?
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Less than 5mm
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

17. What is most common lung injury after blunt chest trauma?
Sphincter sparing surgery (local resection) - abdomnio perineal resection
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

18. surgery for acute cholecystities
Twisting force with the foot fixed on the ground seen in football and basketball games;
24-48 hours of supportive therapy followed by cholecystectomy
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
Dumping syndrome; small and frequent meals; no simple sugar

19. mx of stress fx
Check ET tube placement if correct needle decompresion
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Cystic scrotal fluid collection between parietal and visceral layers of testis
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

20. aspiration of breast cyst is nonbloody
Subphrenic abscess or other abdominal abscesses; order US or CT
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
CRPS

21. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Strok and traumatic brain injury
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;
Cystic scrotal fluid collection between parietal and visceral layers of testis
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

22. Why initial xrays are negative in scaphoid fx
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

23. swelling and tenderness in anterior part of knee
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Patellar tendon tear; difficulty in extension
Fx displace >1mm - nonunion during followup - osteonecrosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

24. What is hungry bone syndrome?
Headache - ataxia - bulbar dysfunction
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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
Fx displace >1mm - nonunion during followup - osteonecrosis

25. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Meniscus injury; medial most common; pain/swelling; popping sensation
If any compressive symptoms eg. dysphagia
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

26. How varicocele causes testicular atrophy
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Strok and traumatic brain injury
Mammogram
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

27. When patient can go back to sports after clavicle fx
24-48 hours of supportive therapy followed by cholecystectomy
4-6 weeks for noncontact sports and longer time for contact sports
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

28. management of gunshot wound
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Even after ochiopexy risk of ochiopexy higher then general population
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
Sphincter sparing surgery (local resection) - abdomnio perineal resection

29. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
Pure motor stroke; limited neurological dysfunction
4-6 weeks for noncontact sports and longer time for contact sports
S2-S4

30. Incidence of AF in CABG patient

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31. complication displaced or communited distal radial fx
Unilateral vocal cord paralysis
Dm neuropathy; stocking glove pattern
Carpal tunnel syndrom
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

32. varicocele
If patient ambulatory - surgery and pain control; if not nonop mx
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

33. acute colonic ischemia
Abd pain and tenderness; bloody diarrhoea or hematochezia
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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

34. Can we use beta blocker for pvd?
Next best step surgery; not ultrasound
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Study showed no adverse effect; but they are contraindicated for PVD
Carpal tunnel syndrom

35. when patient with severe lung disease have C02 retention
Twisting force with the foot fixed on the ground seen in football and basketball games;
When urethral catherization is unsuccessful
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro

36. What are the common injuries from lightning?
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Retrograde ejaculation
Elevated non seminomas
Mammogram

37. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

38. first step for evaluation of testicular swelling
Patellar tendon tear; difficulty in extension
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

39. managment of animal bite in hands
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
Ispilateral hypoglossal nerve injury
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;

40. What is the complications of undescended testis
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Mammogram
Even after ochiopexy risk of ochiopexy higher then general population
Retrograde ejaculation

41. scrotal trauma
Next best step surgery; not ultrasound
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

42. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Subphrenic abscess or other abdominal abscesses; order US or CT
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Carpal tunnel syndrom

43. dorsiflexion and planter flexion
L5 to S2
Mammogram
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
Headache - ataxia - bulbar dysfunction

44. How to differentiate ACL and meniscus injury
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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
Next best step surgery; not ultrasound

45. menisci injury
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
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
Ispilateral hypoglossal nerve injury

46. How to manage a patient with asystole
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Epi and chest compressio for prolong period of time; atropine is given after epi;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Amoxicillin-clavulanate

47. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
Supraglottic edema; low threshold for intubation
Mammogram
Abd pain and tenderness; bloody diarrhoea or hematochezia

48. SOB - confusion - petechial rash after trauma - fracture
Unilateral vocal cord paralysis
Amoxicillin-clavulanate
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

49. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Seminomas
Even after ochiopexy risk of ochiopexy higher then general population

50. Tx of pulmonary contusion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Tendons more likely

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USMLE Step3 Surgery

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