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USMLE Step3 Surgery

Subjects : health-sciences, usmle-step-3

Instructions:

Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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1. Indication for bariatric surgery in obese patients
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
15-40%; self limiting;doesn't require tx
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Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery

2. managment of animal bite in hands
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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;
ACL injury
Ampicillin sublactum - pipercillin - ceftriaxone and metro

3. What is prehn sign?
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

4. How to confirm dx of compartment syndrom
Displaced ORIF ; nondisplaced sling immobilization
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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

5. conservative Tx of varicose veins
Epi and chest compressio for prolong period of time; atropine is given after epi;
Compression stocking - weight reduction - leg elevation
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
4-6 weeks for noncontact sports and longer time for contact sports

6. management of gunshot wound
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
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
Displaced ORIF ; nondisplaced sling immobilization
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

7. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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

8. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Malignancy until proven otherwise
Carpal tunnel syndrom
CRPS

9. How to manage obesity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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 mesenteric ishemia; most SMA occlusion secondary to an embolism

10. aspiration of breast cyst is bloody
SAH due to post communicating artery aneurysm;
Low anterior resection and radio; add chemo if node positive
Amoxicillin-clavulanate
Mammogram

11. Incidence of AF in CABG patient

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12. How to manage a patient with asystole
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Low anterior resection and radio; add chemo if node positive
Epi and chest compressio for prolong period of time; atropine is given after epi;

13. when scaphoid fx patient needs to be referred to orthopedic
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Fx displace >1mm - nonunion during followup - osteonecrosis
Amoxicillin-clavulanate
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

14. Tx of proximal non metastatic rectal ca
Sphincter sparing surgery (local resection) - abdomnio perineal resection
15-40%; self limiting;doesn't require tx
L5 to S2
Low anterior resection and radio; add chemo if node positive

15. When patient can go back to sports after clavicle fx
4-6 weeks for noncontact sports and longer time for contact sports
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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

16. anal sphincter tone
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
S2-S4
Brardycardia - HTN - resp depression
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

17. How to differentiate ACL and meniscus injury
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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
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
Strok and traumatic brain injury

18. cremasteric reflex test?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Elderly and critically ill patients
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
10-12 months

19. What percent of anal abscess deveolop fisutula
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
50%; tunneling between rectum or kin
Carpal tunnel syndrom
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

20. common complication of inadequate mx of scaphoid fx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
ACL injury
Nonunion and avascular necrosis; fx can block blood supply;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

21. severe pain in leg after MVC
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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
Epi and chest compressio for prolong period of time; atropine is given after epi;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

22. types of hip fracture
Subphrenic abscess or other abdominal abscesses; order US or CT
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
24-48 hours of supportive therapy followed by cholecystectomy

23. SAH due to posterior inferior cerebellar aneurysm
Headache - ataxia - bulbar dysfunction
Abd pain and tenderness; bloody diarrhoea or hematochezia
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
MAT; medial meniscus injury; ACL and Tibial colateral ligament

24. acalculus cholecystitis
Subphrenic abscess or other abdominal abscesses; order US or CT
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Elderly and critically ill patients
When urethral catherization is unsuccessful

25. most common fx when falling on outsretched hand
Headache - ataxia - bulbar dysfunction
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Tendons more likely
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

26. when patient with severe lung disease have C02 retention
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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
Dm neuropathy; stocking glove pattern
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

27. Valgus and Varus tests
50%; tunneling between rectum or kin
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

28. complications of TPN
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

29. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Dm neuropathy; stocking glove pattern
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Displaced ORIF ; nondisplaced sling immobilization

30. What are the common injuries from lightning?
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

31. diarrhoea after gastric bypass
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Progressive fibrosis of palmar fascia. etiololgy not known;
Dumping syndrome; small and frequent meals; no simple sugar
Unilateral vocal cord paralysis

32. transrectal prostate biopsy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Retrograde ejaculation
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

33. DD of acute scrotal pain
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Elderly and critically ill patients
Even after ochiopexy risk of ochiopexy higher then general population
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

34. When to do surgery in undesceneded testis?
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Twisting force with the foot fixed on the ground seen in football and basketball games;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Pure motor stroke; limited neurological dysfunction

35. Why ruq calcificaion is concerning
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

36. dorsiflexion and planter flexion
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Brardycardia - HTN - resp depression
L5 to S2
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

37. When do we see complications due to hypophosphatemia
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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;
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

38. differential of ultrasound finding of breast mass
Even after ochiopexy risk of ochiopexy higher then general population
Seminomas
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

39. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Nonunion and avascular necrosis; fx can block blood supply;
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Check ET tube placement if correct needle decompresion

40. management of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Fx displace >1mm - nonunion during followup - osteonecrosis
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
If patient ambulatory - surgery and pain control; if not nonop mx

41. menisci injury
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Next best step surgery; not ultrasound
Twisting force with the foot fixed on the ground seen in football and basketball games;
Supraglottic edema; low threshold for intubation

42. antibiotics of acute cholecystitis
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

43. management of nondisplaced scaphoid fx
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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

44. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Unilateral vocal cord paralysis
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

45. How varicocele causes testicular atrophy
Urethral stricture; pelvic of urethral trauma
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

46. SOB - confusion - petechial rash after trauma - fracture
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Displaced ORIF ; nondisplaced sling immobilization

47. How to differentiate communicative and non-communicative hydrocele
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Progressive fibrosis of palmar fascia. etiololgy not known;
Ispilateral hypoglossal nerve injury
Increased size during the day and valsalva means it is communicated with peritoneal cavity

48. Complications of breast impant
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
If any compressive symptoms eg. dysphagia
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

49. prostate enlarged - nontender - no nodularity - elevated PSA
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Abd pain and tenderness; bloody diarrhoea or hematochezia
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Compression stocking - weight reduction - leg elevation

50. inhalation of hot air - steam - smoke in burn victim
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Supraglottic edema; low threshold for intubation
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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