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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. DD of acute scrotal pain
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

2. Complications of breast impant
ACL injury
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
4-6 weeks for noncontact sports and longer time for contact sports

3. What is terrible triad
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

4. popping sensation; rapid onset of knee effusion. athelet
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
ACL injury
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Increased size during the day and valsalva means it is communicated with peritoneal cavity

5. management of hip fracture
If patient ambulatory - surgery and pain control; if not nonop mx
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
10-12 months
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

6. diarrhoea 4-5 days after cholecystectomy
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Tendons more likely
10-12 months

7. acalculus cholecystitis
Compression stocking - weight reduction - leg elevation
Elderly and critically ill patients
If any compressive symptoms eg. dysphagia
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

8. When goiter needs surgery
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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
4-6 weeks for noncontact sports and longer time for contact sports
If any compressive symptoms eg. dysphagia

9. What types of breast implants are available
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
S2-S4
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Saline and silicone

10. How to perform lachman 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
24-48 hours of supportive therapy followed by cholecystectomy
Klinefelter syndrome; 50 fold increase;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

11. xray finding of stress fx after 3-4w
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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
SAH due to post communicating artery aneurysm;

12. first step for evaluation of testicular swelling
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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
Saline and silicone

13. dumping syndrome after gastrectomy
Klinefelter syndrome; 50 fold increase;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

14. How varicocele causes testicular atrophy
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

15. cremasteric reflex
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Saline and silicone
Meniscus injury; medial most common; pain/swelling; popping sensation

16. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

17. What percent of anal abscess deveolop fisutula
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
50%; tunneling between rectum or kin

18. How to differentiate ACL and meniscus injury
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
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;
Fx displace >1mm - nonunion during followup - osteonecrosis
When urethral catherization is unsuccessful

19. complications of TPN
Seminomas
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

20. SAH due to posterior inferior cerebellar aneurysm
Headache - ataxia - bulbar dysfunction
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

21. first line of management of PVD
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Patellar tendon tear; difficulty in extension

22. Can we use beta blocker for pvd?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Study showed no adverse effect; but they are contraindicated for PVD
Carpal tunnel syndrom
Compression stocking - weight reduction - leg elevation

23. cat/dog bites
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Amoxicillin-clavulanate
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

24. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

25. prostate enlarged - nontender - no nodularity - elevated PSA
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Seminomas
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

26. contraindication of urethral catheterization
Meniscus injury; medial most common; pain/swelling; popping sensation
Subphrenic abscess or other abdominal abscesses; order US or CT
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Urethral stricture; pelvic of urethral trauma

27. diarrhoea after gastric bypass
Compression stocking - weight reduction - leg elevation
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Dumping syndrome; small and frequent meals; no simple sugar
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

28. mx of stress fx
Unilateral vocal cord paralysis
Pure motor stroke; limited neurological dysfunction
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Seminomas

29. What is most common lung injury after blunt chest trauma?
Subphrenic abscess or other abdominal abscesses; order US or CT
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
Elevated non seminomas

30. most frequent complication of TURP
Retrograde ejaculation
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

31. tx distal rectal ca
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Supraglottic edema; low threshold for intubation
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

32. Valgus and Varus tests
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Elderly and critically ill patients
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Malignancy until proven otherwise

33. swelling and tenderness in anterior part of knee
Patellar tendon tear; difficulty in extension
Brardycardia - HTN - resp depression
50%; tunneling between rectum or kin
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

34. most common fx when falling on outsretched hand
10-12 months
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
4-6 weeks for noncontact sports and longer time for contact sports
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

35. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
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
Meniscus injury; medial most common; pain/swelling; popping sensation
Low anterior resection and radio; add chemo if node positive
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

36. How to manage obesity
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Elderly and critically ill patients
Check ET tube placement if correct needle decompresion

37. managment of animal bite in hands
Elevated non seminomas
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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;
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;

38. 3 mo with groin bulge; bulge appears when child cries
Meniscus injury; medial most common; pain/swelling; popping sensation
Fx displace >1mm - nonunion during followup - osteonecrosis
Progressive fibrosis of palmar fascia. etiololgy not known;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

39. How mcmurray manuver perform
Elderly and critically ill patients
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
10-12 months

40. What is the strongest risk factor for male breast cancer
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Carpal tunnel syndrom
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Klinefelter syndrome; 50 fold increase;

41. inhalation of hot air - steam - smoke in burn victim
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Subphrenic abscess or other abdominal abscesses; order US or CT
Supraglottic edema; low threshold for intubation
Mammogram

42. cremasteric reflex test?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
10-12 months
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

43. beta hcg and AFP
Elevated non seminomas
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Ispilateral hypoglossal nerve injury
If patient ambulatory - surgery and pain control; if not nonop mx

44. varicose veins with ulcer - bleeding and thrombophlebitits
Epi and chest compressio for prolong period of time; atropine is given after epi;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

45. painless testicular mass in young male
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Malignancy until proven otherwise
Elevated non seminomas
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

46. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Patellar tendon tear; difficulty in extension
Mammogram
Study showed no adverse effect; but they are contraindicated for PVD

47. perioral numbness after parathyroidectomy
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
If any compressive symptoms eg. dysphagia
S2-S4
Epi and chest compressio for prolong period of time; atropine is given after epi;

48. What is hydrocele?
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
L5 to S2
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Cystic scrotal fluid collection between parietal and visceral layers of testis

49. antibiotics of acute cholecystitis
24-48 hours of supportive therapy followed by cholecystectomy
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Mammogram
Ampicillin sublactum - pipercillin - ceftriaxone and metro

50. how hyperventilation lowers ICP
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

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USMLE Step3 Surgery

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