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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 mcmurray manuver perform
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
4-6 weeks for noncontact sports and longer time for contact sports
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

2. Can we use beta blocker for pvd?
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
Nonunion and avascular necrosis; fx can block blood supply;
Study showed no adverse effect; but they are contraindicated for PVD
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

3. diarrhoea after gastric bypass
Elderly and critically ill patients
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
Dumping syndrome; small and frequent meals; no simple sugar
Meniscus injury; medial most common; pain/swelling; popping sensation

4. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Epi and chest compressio for prolong period of time; atropine is given after epi;
Subphrenic abscess or other abdominal abscesses; order US or CT

5. antibiotics of acute cholecystitis
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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
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

6. recurrent laryngeal nerve injury
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Unilateral vocal cord paralysis
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Amoxicillin-clavulanate

7. complication displaced or communited distal radial fx
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Urethral stricture; pelvic of urethral trauma
Carpal tunnel syndrom
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

8. What is the contraindication of hyperventilation in inc ICP
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Epi and chest compressio for prolong period of time; atropine is given after epi;
If any compressive symptoms eg. dysphagia
Strok and traumatic brain injury

9. cat/dog bites
Displaced ORIF ; nondisplaced sling immobilization
Amoxicillin-clavulanate
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

10. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
SAH due to post communicating artery aneurysm;
Dumping syndrome; small and frequent meals; no simple sugar
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

11. xray finding of stress fx after 3-4w
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

12. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
When urethral catherization is unsuccessful
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

13. Incidence of AF in CABG patient

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14. inhalation of hot air - steam - smoke in burn victim
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Supraglottic edema; low threshold for intubation
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

15. management of stone 8-10mm
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Subphrenic abscess or other abdominal abscesses; order US or CT
When urethral catherization is unsuccessful
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

16. What time frame required for bone remodeling
Abd pain and tenderness; bloody diarrhoea or hematochezia
Mammogram
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
10-12 months

17. beta hcg and AFP
Dm neuropathy; stocking glove pattern
Compression stocking - weight reduction - leg elevation
Elevated non seminomas
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

18. prostate enlarged - nontender - no nodularity - elevated PSA
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

19. common complication of inadequate mx of scaphoid fx
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Nonunion and avascular necrosis; fx can block blood supply;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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

20. suprapubic catheterization
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Meniscus injury; medial most common; pain/swelling; popping sensation
When urethral catherization is unsuccessful
SAH due to post communicating artery aneurysm;

21. management of hip fracture
If patient ambulatory - surgery and pain control; if not nonop mx
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
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
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

22. 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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

23. When to stop raloxifene before surgery
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
CRPS
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

24. Complications of breast impant
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

25. How to manage obesity
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
Klinefelter syndrome; 50 fold increase;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

26. swelling and tenderness in anterior part of knee
Patellar tendon tear; difficulty in extension
L5 to S2
Compression stocking - weight reduction - leg elevation
If any compressive symptoms eg. dysphagia

27. Dupuytren contracture
Progressive fibrosis of palmar fascia. etiololgy not known;
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
Dm neuropathy; stocking glove pattern
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

28. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Dm neuropathy; stocking glove pattern
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;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

29. anal sphincter tone
S2-S4
Compression stocking - weight reduction - leg elevation
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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. When goiter needs surgery
If any compressive symptoms eg. dysphagia
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
Twisting force with the foot fixed on the ground seen in football and basketball games;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

31. sudden onset of postoperative hyperglycemia when patient on TPN
If any compressive symptoms eg. dysphagia
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Subphrenic abscess or other abdominal abscesses; order US or CT

32. What is hungry bone syndrome?
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Headache - ataxia - bulbar dysfunction
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

33. How to manage a patient with asystole
Epi and chest compressio for prolong period of time; atropine is given after epi;
Carpal tunnel syndrom
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

34. What is hydrocele?
Dumping syndrome; small and frequent meals; no simple sugar
L5 to S2
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

35. tx distal rectal ca
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal 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
Sphincter sparing surgery (local resection) - abdomnio perineal resection
If patient ambulatory - surgery and pain control; if not nonop mx

36. How to confirm achiles tendon rupture
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Less than 5mm

37. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Meniscus injury; medial most common; pain/swelling; popping sensation
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

38. What is most common lung injury after blunt chest trauma?
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Dumping syndrome; small and frequent meals; no simple sugar

39. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Strok and traumatic brain injury
Retrograde ejaculation
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Study showed no adverse effect; but they are contraindicated for PVD

40. conservative Tx of varicose veins
Compression stocking - weight reduction - leg elevation
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

41. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Pure motor stroke; limited neurological dysfunction
10-12 months

42. surgery for acute cholecystities
24-48 hours of supportive therapy followed by cholecystectomy
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Urethral stricture; pelvic of urethral trauma
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

43. characteristics of ureteral stone?
L5 to S2
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Unilateral vocal cord paralysis

44. managment of animal bite in hands
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;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

45. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Patellar tendon tear; difficulty in extension
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

46. Indication for bariatric surgery in obese patients
Tendons more likely
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;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
4-6 weeks for noncontact sports and longer time for contact sports

47. severe pain in leg after MVC
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity

48. pregnant patient with asymptomatic gall stones
15-40%; self limiting;doesn't require tx
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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

49. ipsilateral deviation of tongue upon protrusion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Ispilateral hypoglossal nerve injury
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Study showed no adverse effect; but they are contraindicated for PVD

50. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Check ET tube placement if correct needle decompresion
10-12 months
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
SAH due to post communicating artery aneurysm;

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USMLE Step3 Surgery

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