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USMLE Step3 Surgery

Subjects : health-sciences, usmle-step-3

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1. stress fx
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

2. How to differentiate communicative and non-communicative hydrocele
Subphrenic abscess or other abdominal abscesses; order US or CT
Seminomas
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

3. inhalation of hot air - steam - smoke in burn victim
Supraglottic edema; low threshold for intubation
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
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

4. management of stone 8-10mm
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
Carpal tunnel syndrom
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Elevated non seminomas

5. Indication for bariatric surgery in obese patients
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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;
Unilateral vocal cord paralysis

6. What are the common injuries from lightning?
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

7. How mcmurray manuver perform
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
If patient ambulatory - surgery and pain control; if not nonop mx
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

8. What time frame required for bone remodeling
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
10-12 months
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

9. When to do surgery in undesceneded testis?
Study showed no adverse effect; but they are contraindicated for PVD
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Twisting force with the foot fixed on the ground seen in football and basketball games;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

10. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Malignancy until proven otherwise
Ispilateral hypoglossal nerve injury
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Meniscus injury; medial most common; pain/swelling; popping sensation

11. varicocele
Low anterior resection and radio; add chemo if node positive
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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
Progressive fibrosis of palmar fascia. etiololgy not known;

12. 3 mo with groin bulge; bulge appears when child cries
When urethral catherization is unsuccessful
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Next best step surgery; not ultrasound
Urethral stricture; pelvic of urethral trauma

13. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

14. Valgus and Varus tests
Headache - ataxia - bulbar dysfunction
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Even after ochiopexy risk of ochiopexy higher then general population
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

15. when patient with severe lung disease have C02 retention
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
15-40%; self limiting;doesn't require tx
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
Compression stocking - weight reduction - leg elevation

16. acute colonic ischemia
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Abd pain and tenderness; bloody diarrhoea or hematochezia
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

17. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Dm neuropathy; stocking glove pattern
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Displaced ORIF ; nondisplaced sling immobilization

18. How to confirm achiles tendon rupture
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Meniscus injury; medial most common; pain/swelling; popping sensation

19. Can we use beta blocker for pvd?
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Study showed no adverse effect; but they are contraindicated for PVD
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

20. What is the strongest risk factor for male breast cancer
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Klinefelter syndrome; 50 fold increase;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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

21. Why varicocele more common in the left side
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

22. painless testicular mass in young male
Dumping syndrome; small and frequent meals; no simple sugar
ACL injury
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
Malignancy until proven otherwise

23. suprapubic catheterization
CRPS
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
When urethral catherization is unsuccessful
Dm neuropathy; stocking glove pattern

24. prostate enlarged - nontender - no nodularity - elevated PSA
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Less than 5mm

25. What is hungry bone syndrome?
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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

26. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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 could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

27. how ABI help dx of PVD
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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
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

28. when scaphoid fx patient needs to be referred to orthopedic
Seminomas
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Fx displace >1mm - nonunion during followup - osteonecrosis

29. ct scan; cystic lesion in head of pancreas; next step
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

30. swelling and tenderness in anterior part of knee
Displaced ORIF ; nondisplaced sling immobilization
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Patellar tendon tear; difficulty in extension
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

31. complications of TPN
Compression stocking - weight reduction - leg elevation
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Retrograde ejaculation

32. cremasteric reflex test?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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
Headache - ataxia - bulbar dysfunction

33. Tx of pulmonary contusion
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Low anterior resection and radio; add chemo if node positive
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

34. cremasteric reflex
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Pure motor stroke; limited neurological dysfunction
Cystic scrotal fluid collection between parietal and visceral layers of testis
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

35. indication of ursodeoxycholic acid
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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

36. contraindication of urethral catheterization
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Urethral stricture; pelvic of urethral trauma
Subphrenic abscess or other abdominal abscesses; order US or CT
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;

37. When goiter needs surgery
If any compressive symptoms eg. dysphagia
4-6 weeks for noncontact sports and longer time for contact sports
Ispilateral hypoglossal nerve injury
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

38. conservative Tx of varicose veins
Study showed no adverse effect; but they are contraindicated for PVD
Strok and traumatic brain injury
Compression stocking - weight reduction - leg elevation
Patellar tendon tear; difficulty in extension

39. surgery for acute cholecystities
Low anterior resection and radio; add chemo if node positive
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
24-48 hours of supportive therapy followed by cholecystectomy

40. What is prehn sign?
ACL injury
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
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
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

41. perioral numbness after parathyroidectomy
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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

42. management of hip fracture
Dumping syndrome; small and frequent meals; no simple sugar
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
If patient ambulatory - surgery and pain control; if not nonop mx

43. several knee pain after being tackled in football game
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
SAH due to post communicating artery aneurysm;
Ispilateral hypoglossal nerve injury

44. types of hip fracture
Supraglottic edema; low threshold for intubation
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
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

45. 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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

46. complication displaced or communited distal radial fx
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Carpal tunnel syndrom
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

47. How to evaluate painless testicular swelling suspicious for cancer
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;
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
Epi and chest compressio for prolong period of time; atropine is given after epi;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

48. aspiration of breast cyst is bloody
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
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
Mammogram

49. Why ruq calcificaion is concerning
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
15-40%; self limiting;doesn't require tx
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

50. What is the complications of undescended testis
Meniscus injury; medial most common; pain/swelling; popping sensation
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Even after ochiopexy risk of ochiopexy higher then general population
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

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USMLE Step3 Surgery

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