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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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1. mx of stress fx
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

2. painless testicular mass in young male
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
Compression stocking - weight reduction - leg elevation
Malignancy until proven otherwise
Ampicillin sublactum - pipercillin - ceftriaxone and metro

3. perioral numbness after parathyroidectomy
Amoxicillin-clavulanate
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
Meniscus injury; medial most common; pain/swelling; popping sensation
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

4. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Retrograde ejaculation
If patient ambulatory - surgery and pain control; if not nonop mx
Amoxicillin-clavulanate
Dm neuropathy; stocking glove pattern

5. How to confirm achiles tendon rupture
Retrograde ejaculation
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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. Why ruq calcificaion is concerning
Study showed no adverse effect; but they are contraindicated for PVD
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

7. SOB - confusion - petechial rash after trauma - fracture
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Meniscus injury; medial most common; pain/swelling; popping sensation
S2-S4

8. surgery for acute cholecystities
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
24-48 hours of supportive therapy followed by cholecystectomy
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Displaced ORIF ; nondisplaced sling immobilization

9. differential of ultrasound finding of breast mass
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Study showed no adverse effect; but they are contraindicated for PVD

10. cremasteric reflex
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Check ET tube placement if correct needle decompresion

11. severe pain in leg after MVC
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
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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

12. How to perform lachman test
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Displaced ORIF ; nondisplaced sling immobilization
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
10-12 months

13. When patient can go back to sports after clavicle fx
ACL injury
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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
4-6 weeks for noncontact sports and longer time for contact sports

14. 3 mo with groin bulge; bulge appears when child cries
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Strok and traumatic brain 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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

15. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
24-48 hours of supportive therapy followed by cholecystectomy
Retrograde ejaculation

16. 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
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
SAH due to post communicating artery aneurysm;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

17. diarrhoea 4-5 days after cholecystectomy
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Dm neuropathy; stocking glove pattern
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

18. most common fx when falling on outsretched hand
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
If patient ambulatory - surgery and pain control; if not nonop mx
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
If any compressive symptoms eg. dysphagia

19. When goiter needs surgery
If any compressive symptoms eg. dysphagia
50%; tunneling between rectum or kin
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
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

20. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
If any compressive symptoms eg. dysphagia
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
15-40%; self limiting;doesn't require tx
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

21. aspiration of breast cyst is bloody
Supraglottic edema; low threshold for intubation
Tendons more likely
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
Mammogram

22. sudden onset of postoperative hyperglycemia when patient on TPN
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Twisting force with the foot fixed on the ground seen in football and basketball games;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Ampicillin sublactum - pipercillin - ceftriaxone and metro

23. Tx of proximal non metastatic rectal ca
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
Low anterior resection and radio; add chemo if node positive
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;

24. DD of acute scrotal pain
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Compression stocking - weight reduction - leg elevation
Supraglottic edema; low threshold for intubation
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

25. When do we see complications due to hypophosphatemia
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Dumping syndrome; small and frequent meals; no simple sugar
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;

26. How to differentiate ACL and meniscus injury
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Progressive fibrosis of palmar fascia. etiololgy not known;
Supraglottic edema; low threshold for intubation
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

27. What is terrible triad
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Carpal tunnel syndrom
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Sphincter sparing surgery (local resection) - abdomnio perineal resection

28. beta HCG
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Epi and chest compressio for prolong period of time; atropine is given after epi;
Seminomas
Pure motor stroke; limited neurological dysfunction

29. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

30. lacerated wound in palmer surface of hand. what structure is injured?
Tendons more likely
Next best step surgery; not ultrasound
Pure motor stroke; limited neurological dysfunction
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

31. What percent of anal abscess deveolop fisutula
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
Abd pain and tenderness; bloody diarrhoea or hematochezia
50%; tunneling between rectum or kin
Sphincter sparing surgery (local resection) - abdomnio perineal resection

32. Most common of sudden death due to steering wheel injury
Carpal tunnel syndrom
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
10-12 months
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

33. What types of breast implants are available
Meniscus injury; medial most common; pain/swelling; popping sensation
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
Saline and silicone

34. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
SAH due to post communicating artery aneurysm;

35. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Ispilateral hypoglossal nerve injury
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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

36. when patient with severe lung disease have C02 retention
24-48 hours of supportive therapy followed by cholecystectomy
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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;
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

37. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Klinefelter syndrome; 50 fold increase;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Saline and silicone

38. indication of ursodeoxycholic acid
Nonunion and avascular necrosis; fx can block blood supply;
Check ET tube placement if correct needle decompresion
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 there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

39. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
CRPS
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

40. diarrhoea after gastric bypass
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Dumping syndrome; small and frequent meals; no simple sugar
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

41. tx distal rectal ca
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Fx displace >1mm - nonunion during followup - osteonecrosis

42. How mcmurray manuver perform
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

43. Incidence of AF in CABG patient

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44. How to differentiate communicative and non-communicative hydrocele
Strok and traumatic brain injury
Dm neuropathy; stocking glove pattern
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Increased size during the day and valsalva means it is communicated with peritoneal cavity

45. contraindication of urethral catheterization
Elevated non seminomas
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
Urethral stricture; pelvic of urethral trauma
15-40%; self limiting;doesn't require tx

46. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Check ET tube placement if correct needle decompresion
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Supraglottic edema; low threshold for intubation
If patient ambulatory - surgery and pain control; if not nonop mx

47. What is the contraindication of hyperventilation in inc ICP
If any compressive symptoms eg. dysphagia
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;
Strok and traumatic brain injury
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

48. What is hungry bone syndrome?
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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 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

49. When to do surgery in undesceneded testis?
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Cystic scrotal fluid collection between parietal and visceral layers of testis
15-40%; self limiting;doesn't require tx

50. Valgus and Varus tests
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

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USMLE Step3 Surgery

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