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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. sudden onset of postoperative hyperglycemia when patient on TPN
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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
Twisting force with the foot fixed on the ground seen in football and basketball games;
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

2. perioral numbness after parathyroidectomy
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Less than 5mm
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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

3. varicose veins with ulcer - bleeding and thrombophlebitits
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
MAT; medial meniscus injury; ACL and Tibial colateral ligament
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Supraglottic edema; low threshold for intubation

4. What is the strongest risk factor for male breast cancer
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Strok and traumatic brain injury
Klinefelter syndrome; 50 fold increase;
L5 to S2

5. common complication of inadequate mx of scaphoid fx
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Nonunion and avascular necrosis; fx can block blood supply;
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery
Mammogram

6. conservative Tx of varicose veins
Even after ochiopexy risk of ochiopexy higher then general population
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Compression stocking - weight reduction - leg elevation

7. What is the contraindication of hyperventilation in inc ICP
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
Strok and traumatic brain injury
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
15-40%; self limiting;doesn't require tx

8. complication displaced or communited distal radial 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
Carpal tunnel syndrom
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

9. How to perform lachman test
Less than 5mm
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

10. scrotal trauma
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Sphincter sparing surgery (local resection) - abdomnio perineal resection
CRPS
Next best step surgery; not ultrasound

11. How to differentiate ACL and meniscus 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;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

12. diarrhoea after gastric bypass
Urethral stricture; pelvic of urethral trauma
Dumping syndrome; small and frequent meals; no simple sugar
15-40%; self limiting;doesn't require tx
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

13. differential of ultrasound finding of breast mass
Pure motor stroke; limited neurological dysfunction
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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

14. recurrent laryngeal nerve injury
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;
Unilateral vocal cord paralysis
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

15. xray finding of stress fx after 3-4w
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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;

16. How to manage obesity
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
MAT; medial meniscus injury; ACL and Tibial colateral ligament

17. several knee pain after being tackled in football game
Supraglottic edema; low threshold for intubation
Klinefelter syndrome; 50 fold increase;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

18. Incidence of AF in CABG patient

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19. 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;
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;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

20. What time frame required for bone remodeling
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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;
10-12 months
CRPS

21. management of stone 8-10mm
Increased size during the day and valsalva means it is communicated with peritoneal cavity
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Saline and silicone
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

22. contraindication of urethral catheterization
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Urethral stricture; pelvic of urethral trauma
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

23. diarrhoea 4-5 days after cholecystectomy
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Epi and chest compressio for prolong period of time; atropine is given after epi;

24. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
If patient ambulatory - surgery and pain control; if not nonop mx

25. Complications of breast impant
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;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Carpal tunnel syndrom
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

26. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Subphrenic abscess or other abdominal abscesses; order US or CT
Epi and chest compressio for prolong period of time; atropine is given after epi;
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

27. When to do surgery in undesceneded testis?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Klinefelter syndrome; 50 fold increase;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
L5 to S2

28. most common complication of acute cholecystitis
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

29. indication of ursodeoxycholic acid
Dm neuropathy; stocking glove pattern
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

30. when patient with severe lung disease have C02 retention
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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
Unilateral vocal cord paralysis

31. What is hydrocele?
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;
Cystic scrotal fluid collection between parietal and visceral layers of testis
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

32. management of hip fracture
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
If patient ambulatory - surgery and pain control; if not nonop mx

33. How to manage a patient with asystole
Epi and chest compressio for prolong period of time; atropine is given after epi;
Retrograde ejaculation
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

34. What is prehn sign?
Fx displace >1mm - nonunion during followup - osteonecrosis
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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
When urethral catherization is unsuccessful

35. What is terrible triad
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
MAT; medial meniscus injury; ACL and Tibial colateral ligament
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

36. when scaphoid fx patient needs to be referred to orthopedic
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Fx displace >1mm - nonunion during followup - osteonecrosis
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

37. 27 yo with scrotal mass; warm tender testes feel like bag of worms
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

38. What types of breast implants are available
Seminomas
SAH due to post communicating artery aneurysm;
Klinefelter syndrome; 50 fold increase;
Saline and silicone

39. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

40. clavicle fx
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;
Displaced ORIF ; nondisplaced sling immobilization
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

41. how hyperventilation lowers ICP
Check ET tube placement if correct needle decompresion
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Supraglottic edema; low threshold for intubation
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

42. types of hip fracture
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Retrograde ejaculation

43. What is most common lung injury after blunt chest trauma?
Displaced ORIF ; nondisplaced sling immobilization
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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
Check ET tube placement if correct needle decompresion

44. SAH due to posterior inferior cerebellar aneurysm
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
24-48 hours of supportive therapy followed by cholecystectomy
Headache - ataxia - bulbar dysfunction
S2-S4

45. swelling and tenderness in anterior part of knee
Patellar tendon tear; difficulty in extension
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

46. When goiter needs surgery
L5 to S2
If any compressive symptoms eg. dysphagia
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Amoxicillin-clavulanate

47. characteristics of ureteral stone?
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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

48. How to confirm achiles tendon rupture
S2-S4
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
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;
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

49. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
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
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Check ET tube placement if correct needle decompresion

50. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Pure motor stroke; limited neurological dysfunction
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
SAH due to post communicating artery aneurysm;

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USMLE Step3 Surgery

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