Usmle 3 Surgery

Front 1

breast cyst work up

Back 1

- aspirate --> grossly blood fluid --> mammogram and excision
- aspirate --> nonbloody --> residual mass --> mammogram and excision

- if no residual mass --> f/u with U/S if cyst returns or not:
- cyst returns --> mammogram and excision
- cyst doesn't come back --> routine screening

Front 2

old man with rectal mucosa protruding w/ bluish discoloration

Back 2

- rectal prolapse with strangulation, emergency surgery

Front 3

25 year old with sudden pulseless left leg

Back 3

- emboli originating from cardiac source: a fib, MI, ventricular dysfx, endocarditis, valvular disease, atrial myxoma, prosthetic aortic valve

Front 4

atrial myxoma

Back 4

- primary cardiac tumors found in left atrium -- diastolic murmur at apex
- sx: rapidly worsening heart failure in young individuals, new onset afib
- prompt surgical excision

Front 5

bicuspid aortic valve

Back 5

- leads to aortic stenosis

Front 6

venous vs arterial emboli

Back 6

- arterial: emobli from heart
- venous: clotting disease

Front 7

pain out of proportion to the extent of their injury?

Back 7

- compartment syndrome

Front 8

most life threatening complication of compartment syndrome?

Back 8

- rhabdo, not gangrene

Front 9

kid with blood stools and positive technetium-99?

Back 9

- meckel's diverticulum

Front 10

when do you see inussusception?

Back 10

- before 2 years of age

Front 11

early stages of compartment syndrome

Back 11

- pain with passive movement, later you have absence of pulses

Front 12

pt s/p mono with persistant LAD

Back 12

- if >4weeks since infx (or any persistant LAD) then get biopsy b/c may be lymphoma

Front 13

morbidity from breast implants?

Back 13

- contracture causing pain
- rupture
- no systemic, immune disease
- small increase in anaplastic T cell lymphoma

Front 14

s/p clavicle fracture, when can they return to sports?

Back 14

- 4-6 weeks

Front 15

pt with obvious PVD, but normal ABI?

Back 15

- do ABI after treadmill exercise

Front 16

symptomatic tx of PVD

Back 16

- cilostazol: PDI- inhibits plt aggregation and acts as arterial vasodilator, improves max walking distance, take in combo with asa and clopidogril is fine

Front 17

desmoid tumors

Back 17

- associated with gardner
- benign tumor
- abdominal mass, high rate of recurrence

Front 18

dermatofibroma

Back 18

- proliferation after trauma

Front 19

epidermoid cyst

Back 19

- keratin lodged in dermis, resolve spontanesously
- associated with Gardern's

Front 20

pyogenic granuloma

Back 20

- capillary proliferation after trauma, seen in pregnant women

Front 21

afib in pts s/p CABG

Back 21

- common, resolves spontaneously 6-8 wks

Front 22

risk of morphine in AKI

Back 22

- morphine builds up --> decreases resp rate --> give O2--> further decreases resp rate b/c get rid of drive to breathe

Front 23

evaluation of pancreatic mass found on CT?

Back 23

- EUS guided cyst aspiration
- not ERCP: more complications, less sensitive, used for therapeutic procedure to choledocolithiasis

Front 24

calcified gallbladder wall with gallstones?

Back 24

- porcelain gallbladder
- elective cholecystectomy
- don't do nothing because high risk of cancer

Front 25

tenderness along medial knee? lateral knees? anterior drawer? posterior drawer?

Back 25

- MCL injury
- Lateral collateral ligament
- ACL
- PCL

Front 26

3 month old with bulge in groin

Back 26

- indirect inguinal hernia: failure of processus vaginalis to obliterate --> elective repair ASAP

Front 27

pt w/ cauda equina, next step?

Back 27

- MRI, then BCx, Abx, CT guided drainage, followed by surgical decompression
- only give high dose glucocorticoids if neurologic sx (and not if from epidural abscess e.g. hx of epidrual inj)

Front 28

fat embolism

Back 28

- pt s/p orthopedic trauma --> 24-48hrs develops resp distress, fever, tachy, petechiae, AMS
- prevent w/ early immobilization and operative fixation
- heparin doesn't decrease risk

Front 29

nuchal rigidity and CN III palsy

Back 29

- CN III palsy: ptosis, anisocoria
- posterior communicating artery aneurysm

Front 30

most common cause of death in steering wheel injury

Back 30

- aortic rupture

Front 31

grossly displaced clavicle fracture vs minimally displaced

Back 31

- open reduction internal fixation
- conservative ice, analgesics, sling

Front 32

how to store amputated finger

Back 32

- wrap in saline moistened sterile guaze and seal in sterile plastic bag
- place in ice and saline container (not ice only b/c of frost bite)

Front 33

patient falls out outstretched hand, which fx?

Back 33

- scaphoid fx
- get xray, if neg, get MRI - must get diffinitive dx to prevent unnecessary splinting
- if untreated then complicated by nonunion

Front 34

scrotal trauma (kid kicked in balls --> scrotal hematoma)

Back 34

- must do surgical exploration

Front 35

animal bite

Back 35

- debride
- xray
- if face- suture (good vascular supply = decreased infx)
- if hand: leave open b/c high risk infx

Front 36

elevated PSA

Back 36

- check again in 2-4 weeks, if still high then further investigate
- if low then elevated PSA secondary to inflammation for many reasons

Front 37

which knee injury associated with popping?

Back 37

- ACL

Front 38

which knee injury associated with MVA dashboard injury?

Back 38

- PCL
- same as if athlete falls on flexed knee

Front 39

uilateral painless scrotal mass?

Back 39

- negative transillumination means solid mass
- next step is U/S to ddx solid vs cystic also intra vs extra-testicular
- if U/S suspicious then do CT w/ CXR for mets
- testicular cancer

Front 40

testicular tumor markers

Back 40

- beta hCG and AFP elevated in non-seminomas
- only hCG in pure seminomas
- tx: radical inguinal orchiectomy with lymph node dissection for staging

Front 41

hip fracture is old demented nonambulatory patient

Back 41

- recommend pain control
- surgery is high risk and only benefits those who walk

Front 42

left hypoglossal nerve injury in CEA?

Back 42

- tongue deviates to left side (side of injury)

Front 43

HypoCa2+ sx vs HyperCa2+ sx

Back 43

- hypo (seen in s/p parathyroidectomy): perioral numbness, muscle cramps, carpopedal spasm, +Chvostek sign, +Trousseu's sign; severe: AMS, seizures
- hyper: nausea, vomiting, constipation, polyurai, pleuritis, AMS if severe

Front 44

hungry bone syndrome

Back 44

- in s/p parathyroidectomy: hypoCa2+ due to relative hypoparathyroidism
- ** happens 2-4 days after surgery
- **HY

Front 45

anal abscess s/p I+D

Back 45

- need close follow up b/c 50% will develop chronic fistual

Front 46

most frequent complication of transurethral resection of prostate?

Back 46

- retrograde ejaculation, not erectile dysfx

Front 47

midline neck mass that moves with protrusion of tongue

Back 47

- thyroglossal duct
- may have the only functional thyroid tissue
- do imaging to see if any other thyroid tissue (CT scan) and do preoperative thyroid function testing

Front 48

complication of untreated varicocele?

Back 48

- testicular atrophy b/c of rise of temperature --> seminiferous tubules to atrophy
- doesn't not cause impotence

Front 49

right vs left varicocele?

Back 49

- if right sided then must do CT b/c of anatomy stuff...
- if both sides then also do CT (not US)
- left sided, common, ok
- if varicocele doesn't disappear in supine position, also do CT

Front 50

which test to check for testicular torsion?

Back 50

- cremasteric reflex: stroke upper inner thigh and testis should elevate if normal
- ddx testicular torsion (no reflex) from epididymititis (normal)
- pain relief w/ scrotum elevation is Prehn sign and is + in epididymitis and absent in torsion but is not a reliable test
- can also do doppler U/S

Front 51

Kleinfelter features
- what malignancy w/ higher incidence?

Back 51

- sparse hair, gynecomastia, long legs
- breast cancer

Front 52

diarrhea s/p cholecystectomy?

Back 52

- rx cholestyramine, not recommend dietary changes

Front 53

subphrenic abscess

Back 53

- develops 14-21 days after abdominal surgery
- get abd U/S to dx

Front 54

strongest risk factor for male breast cancer?

Back 54

- klinefelter (XXY)

Front 55

sphincter sparing rectal cancer surgery

Back 55

- node positive proximal cancer

Front 56

treatment of dumping syndrome

Back 56

- high protein, low carb diet
- low fiber will control diarrhea, but no the other sx of dumping syndrome

Front 57

most common cause of epididymitis?

Back 57

- Chlamydia

Front 58

orchitis

Back 58

- mumps infection
- sudden onset fevers, severe scrotal pain and swelling

Front 59

abx for dog bites

Back 59

- augmentin

Front 60

when to give tetanus toxoid

Back 60

- tetanus toxoid if dirty wound and received booster >5 years ago
- tetanus toxoid if clean wound and received booster >10 years ago
- if dirty wound and unclear of insufficient immunization history: give toxoid and immune globulin

Front 61

asystole

Back 61

- chest compression
- epinephrine

Front 62

ACS

Back 62

- asystole: epi followed by atropine
- defib for vfib, pulses vtach
- undiff and regular wide-complex tach: amiodarone

Front 63

Assessment of blunt cardiac injury

Back 63

1. CXR: fx, PTX, hemothorax, widened mediastinum, aortic injury --> if (+) then FAST, CT scan or TTE/TEE
2. if (-) then do EKG --> if negative then no further work up; if + then do TTE, TEE, FAST, etc

Front 64

complications in pregnant woman from ruptured appendix?

Back 64

- peritonitis, fetal death, abscess formation and pylephlebitis (infectious thrombosis of portal veins (not tubo-ovarian abscess)

Front 65

femoral nerve injury

Back 65

- can't extend knee against resistance
- sensory loss over medial of thigh, medial shin, arch of foot
- decreased knee jerk

Front 66

sciatic nerve injury

Back 66

- affects lower leg musculature, hamstrings
- preserved sensation ove knee, normal knee jerks

Front 67

obturator nerve injury

Back 67

- weak leg adduction and sensory loss over small area of medial thigh

Front 68

peroneal nerve injury

Back 68

- acute foot drop
- sensory loss over dorsum of foot and lateral shin
- injury at knee

Front 69

acute cholangitis tx

Back 69

- BCx and abx (amp and gent or monotherapy w/ imipenem or levo or piperacillin-tazobactam, or CTX+metronidazole)
- if cholangitis is controlled then do ERCP
- if not controlled do emergent ERCP for biliary drainage for decompression
- cholecystectomy is for acute or chronic CHOLECYSTITIS, but even so ERCP should be tried first

Front 70

abdominal pain w/ met acidosis

Back 70

- MESENTERIC ISCHEMIA
- negative imaging
- exam doesn't match severity of pain

Front 71

acute cholecystitis- when to put T tube

Back 71

- high risk surgical pts (advanced pulm, CV pts)

Front 72

tx of pulmonary contusion

Back 72

- if stable, then just supportive
- if really bad then may need intubation
- thoracentesis if resp compromise from hemo or PTX

Front 73

work up palpable breast mass?

Back 73

- <30: U/S --> if simple then needle aspirate if pt wants; if complex or sold then image guided core biopsy
- if >30 then mammogram/U/S --> if suspicious then core biopsy

Front 74

earliest sign of hypovolemia?

Back 74

- tachycardia

Front 75

PEx in patellar tendon tear?

Back 75

- can't maintain extended knee against gravity if complete tear
- ortho surgery

Front 76

positive click on McMurray's maneuver?

Back 76

- medial meniscal tear

Front 77

BMI >35 on orlistat, losing minimal weight?

Back 77

- bariatric surgery

Front 78

bariatric surgery guidelines?

Back 78

- BMI >40 and failed previous weight loss
- BMI >35 with obesity related comorbidities

Front 79

SBO with air in distal colon?

Back 79

- means not a complete obstruction
- can admit and observe

Front 80

inability to void secondary to BPH

Back 80

- urethral cath
- suprapubic only by urologist if urethral cath is unsuccessful or evidence of urethral or pelvic trauma

Front 81

O'Donohue's unhappy triad

Back 81

- most recognized knee injury complex
- if ACL and MCL injury look for medial meniscus injury

Front 82

ddx anterior chest traumas

Back 82

- PTX/hemothorax: hypotension, unilateral decreased breath sounds
- cardiac tamponade: hypotension, distended neck veings
- cardiac contusion: hemodynamic instability if massive, normal breathing
- flail chest: tachypnea, shallow breaths, tachy, peripheral cyanosis

Front 83

tx of mild gallstone symptoms?

Back 83

- ursodeoxycholic acid
- SE: diarrhea

Front 84

which med to stop prior to hold on morning of surgery?

Back 84

- diuretics--> hypovolemia/hypotension
- otherwise CCB, alpha agonist, statins, ACE-I, BB can be taken on day of surgery b/c of possible W/D sx causing HTN

Front 85

Cushing's triad

Back 85

- intracranial hypertension
- bradycardia, hypertension, respiratory depression

Front 86

loss of cremasteric reflex

Back 86

- secondary to DM (Erectile dysfunction) (preserved ambulation)
- loss of L1-L2 but would also see abnormal hip flexion and adduction (difficult ambulation)

Front 87

nerves that control sphincter tone

Back 87

- S2-S4

Front 88

tx of renal stones

Back 88

-5mm and less: pass spontanesously
- <10mm and proximal ureteral calculi: shockwave
- >10mm prox: flexible ureteroscopy w/ laser lithrotripsy
- if all fails then perQ approach

Front 89

grab a knife-- what's damaged?

Back 89

- tendons run anterior surface
- arteries, nerves and veins run on the side

Front 90

undescended testis

Back 90

- earliest surgery is 6months
- risk of cancer is still higher s/p orchiopexy
- risk of torsion if you don't do the surgery

Front 91

complication of IV nutrition?

Back 91

- hyperglycemia: most serious
- hypophos: resp weakness, hemolysis, impaired O2 release

Front 92

common cause of sudden hyperglycemia in ICU?

Back 92

- sepsis