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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. management of gunshot wound
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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
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
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

2. perioral numbness after parathyroidectomy
Brardycardia - HTN - resp depression
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

3. SOB - confusion - petechial rash after trauma - fracture
CRPS
Check ET tube placement if correct needle decompresion
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

4. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Dm neuropathy; stocking glove pattern
Increased size during the day and valsalva means it is communicated with peritoneal cavity

5. Patient underwent CABG; postoperatively drowsy. most likely cause?
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
Elevated non seminomas
Low anterior resection and radio; add chemo if node positive
Next best step surgery; not ultrasound

6. mx of stress fx
Klinefelter syndrome; 50 fold increase;
When urethral catherization is unsuccessful
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

7. indication of ursodeoxycholic acid
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Meniscus injury; medial most common; pain/swelling; popping sensation
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant 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

8. How varicocele causes testicular atrophy
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Check ET tube placement if correct needle decompresion
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

9. management of nondisplaced scaphoid fx
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
L5 to S2

10. What time frame required for bone remodeling
15-40%; self limiting;doesn't require tx
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
10-12 months
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

11. What is the contraindication of hyperventilation in inc ICP
50%; tunneling between rectum or kin
CRPS
Strok and traumatic brain injury
If patient ambulatory - surgery and pain control; if not nonop mx

12. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
SAH due to post communicating artery aneurysm;
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;

13. 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
Carpal tunnel syndrom
Saline and silicone
Tendons more likely

14. SAH due to posterior inferior cerebellar aneurysm
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
Headache - ataxia - bulbar dysfunction
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
ACL injury

15. what size of ureteral stone for non op mx
CRPS
10-12 months
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Less than 5mm

16. contraindication of urethral catheterization
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Study showed no adverse effect; but they are contraindicated for PVD
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Urethral stricture; pelvic of urethral trauma

17. What types of breast implants are available
Saline and silicone
Malignancy until proven otherwise
Abd pain and tenderness; bloody diarrhoea or hematochezia
Low anterior resection and radio; add chemo if node positive

18. cremasteric reflex
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

19. antibiotics of acute cholecystitis
Patellar tendon tear; difficulty in extension
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Supraglottic edema; low threshold for intubation

20. most common fx when falling on outsretched hand
24-48 hours of supportive therapy followed by cholecystectomy
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
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
CRPS

21. Why initial xrays are negative in scaphoid fx
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
Urethral stricture; pelvic of urethral trauma
S2-S4

22. beta hcg and AFP
Elevated non seminomas
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Klinefelter syndrome; 50 fold increase;

23. scrotal trauma
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Next best step surgery; not ultrasound
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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

24. When to stop raloxifene before surgery
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
ACL injury
Ampicillin sublactum - pipercillin - ceftriaxone and metro

25. When patient can go back to sports after clavicle fx
4-6 weeks for noncontact sports and longer time for contact sports
Abd pain and tenderness; bloody diarrhoea or hematochezia
Tendons more likely
L5 to S2

26. complication displaced or communited distal radial fx
Strok and traumatic brain injury
Carpal tunnel syndrom
If any compressive symptoms eg. dysphagia
Klinefelter syndrome; 50 fold increase;

27. diarrhoea 4-5 days after cholecystectomy
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Study showed no adverse effect; but they are contraindicated for PVD
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

28. Complications of breast impant
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

29. 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;
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
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Abd pain and tenderness; bloody diarrhoea or hematochezia

30. 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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
10-12 months
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

31. diarrhoea after gastric bypass
Dumping syndrome; small and frequent meals; no simple sugar
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Twisting force with the foot fixed on the ground seen in football and basketball games;

32. varicocele
Study showed no adverse effect; but they are contraindicated for PVD
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Urethral stricture; pelvic of urethral trauma
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

33. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
When urethral catherization is unsuccessful
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

34. mangement of localized lymphadenopathy
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
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

35. cremasteric reflex test?
Carpal tunnel syndrom
Abd pain and tenderness; bloody diarrhoea or hematochezia
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Progressive fibrosis of palmar fascia. etiololgy not known;

36. characteristics of ureteral stone?
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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;

37. first line of management of PVD
When urethral catherization is unsuccessful
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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
Brardycardia - HTN - resp depression

38. DD of acute scrotal pain
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Epi and chest compressio for prolong period of time; atropine is given after epi;

39. anal sphincter tone
Epi and chest compressio for prolong period of time; atropine is given after epi;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
S2-S4
Displaced ORIF ; nondisplaced sling immobilization

40. how hyperventilation lowers ICP
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
<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

41. painless testicular mass in young male
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;
Malignancy until proven otherwise
Even after ochiopexy risk of ochiopexy higher then general population
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

42. severe pain in leg after MVC
Twisting force with the foot fixed on the ground seen in football and basketball games;
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
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
24-48 hours of supportive therapy followed by cholecystectomy

43. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
ACL injury
If patient ambulatory - surgery and pain control; if not nonop mx

44. when scaphoid fx patient needs to be referred to orthopedic
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Fx displace >1mm - nonunion during followup - osteonecrosis
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Subphrenic abscess or other abdominal abscesses; order US or CT

45. When goiter needs surgery
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
If any compressive symptoms eg. dysphagia
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

46. Why ruq calcificaion is concerning
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
If patient ambulatory - surgery and pain control; if not nonop mx
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

47. conservative Tx of varicose veins
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
Compression stocking - weight reduction - leg elevation
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

48. cat/dog bites
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Malignancy until proven otherwise
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Amoxicillin-clavulanate

49. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

50. first step for evaluation of testicular swelling
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Ispilateral hypoglossal nerve injury
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Displaced ORIF ; nondisplaced sling immobilization

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USMLE Step3 Surgery

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