USMLE Step 2 (Fach) / Surgery (Lektion)
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Step 2 CK
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- Discontinuation of drugs before surgery Antidiabetic drugs:- Metformin: discontinue 2 days before and after surgery- Discontinue other oral hypoglycemics on the day of surgery and postoperatively until the patient is no longer NPO.- Insulin: ...
- Preoperative preparation Discontinue certain medications Fasting:- 8 hours before surgery: no meat or fried, fatty food- 6 hours before surgery: no milk or solid food- 2 hours before surgery: nil per os (NPO) Anesthesia Perioperative ...
- Postoperative fever Temperature > 38°C in the postoperative period Etiology:- Immediate: Intraoperatively or within a few hours of surgery→ Infection acquired prior to surgery→ Febrile nonhemolytic transfusion reaction→ ...
- Boerhaave syndrome Transmural rupture of the esophagus following an episode of forceful vomiting/retching or increased intrathoracic pressure. Epidemiology: Sex: ♂ > ♀ (3:1) Associations:- Excessive intake of alcohol ...
- Small bowel obstruction Etiology:- Adhesions (e.g., postoperative, prior abdominal surgery)- Incarcerated hernia- Malignant tumors or metastases- Strictures (e.g., Crohn's disease, congenital, radiation enteritis)- Foreign body- ...
- Large bowel obstruction Etiology:- Malignant tumors (e.g., rectosigmoid, rectal, anal)- Strictures (e.g., diverticulitis, inflammatory bowel disease, congenital)- Volvulus- Adhesions (e.g., postoperative, prior abdominal surgery)- ...
- Pyogenic liver abscess Etiology:- Biliary tract (∼ 60%): Choledocholithiasis, cholangitis- Portal vein (∼ 20%): Acute appendicitis, diverticulitis, Crohn's disease, gastrointestinal malignancies, peritonitis (bowel perforation)- ...
- Rectal cancer - Treatment Transanal excision- Procedure: minimally invasive excision of small superficial tumors- Indications: early, localized disease (stage I) Low anterior resection (LAR)- Procedure: sphincter-preserving resection ...
- Pilonidal cyst A pilonidal cyst (intergluteal pilonidal disease) is a skin condition caused by local inflammation of the superior midline gluteal cleft, which may progress to a local abscess or fistula. Epidemiology:- ...
- Anal fissure Longitudinal tear of the anal canal; distal to the dentate line. Primary (due to local trauma)- Location: 90% of all anal fissures located at the posterior commissure (6 o'clock in the lithotomy position)- ...
- Hemorrhoids Etiology: - Excessive straining (e.g., from chronic constipation, frequent bowel movements, chronic cough, heavy lifting, benign prostatic hyperplasia)- Extended periods of sitting (e.g., due to occupation ...
- Venous leg ulcers Chronic defects of the skin that do not heal spontaneously Etiology: usually caused by chronic venous insufficiency Clinical features:- Most frequently occur just above the ankle (gaiter region)- Shallow ...
- Arterial ulcer Skin defect due to impaired blood flow to the lower extremities Etiology: most often seen in peripheral arterial disease Clinical features:- Punched-out ulcer with well-defined borders- Usually involves ...
- Diabetic foot Neuropathic diabetic foot- Warm, dry skin, foot pulses are palpable- Neurological examinations: evaluation of peripheral neuropathy- Malum perforans: painless neuropathic ulcers (usually located on the ...
- Marjolin's ulcer An aggressive form of cSCC that typically develops from areas of chronically damaged skin such as ulcers (e.g., pressure ulcers, osteomyelitis) and scars (e.g., burn scars)
- Peripheral arterial disease Etiology: - Insufficient tissue perfusion due to atherosclerosis in the aorta and peripheral arteries- Often coexists with coronary artery disease (CAD), stroke, atrial fibrillation, and renal disease ...
- Breast cancer Women < 30 years with a self-palpated breast lump- Ultrasound in women with a high probability of malignancy- In women with low probability of malignancy reexamine within 3-10 days after the onset of ...
- Breast cancer - Prevention Breast cancer screening- Mammography: every 2 years in average-risk women aged 50–74 years→ Two views of the breast are obtained: mediolateral oblique and craniocaudal- Physical examination plays ...
- Aortic dissection Etiology:- Hypertension- Trauma (e.g., deceleration injury in a motor vehicle accident, iatrogenic injury during valve replacements)- Vasculitis with aortic involvement (e.g., syphilis)- Use of amphetamines ...
- Acute limb ischemia Etiology:- Arterial embolism (∼ 80% of cases)- Arterial thrombosis (∼ 20% of cases)- Dissecting aneurysm Clinical features: - The 6 Ps (according to Pratt): Pain, Pallor, Pulselessness, Paralysis, Paresthesia, Poikilothermia- ...
- Rib fracture Etiology: mostly blunt trauma, pathologic fractures, nonaccidental trauma (child abuse) Clinical features:- Pain on inspiration- Focal chest wall tenderness- Crepitus- Chest wall deformity- Flail chest: ...
- Renal transplantation - Contraindications - Ongoing infection - Ongoing malignancy - Ongoing substance abuse - Reversible renal failure - Uncontrolled mental or psychiatric disease - Documented and ongoing treatment nonadherence - Significantly ...
- Lung transplantation - Contraindications - Malignancy in the last 2 years.- Acute medical instability such as acute sepsis, myocardial infarction, and liver failure.- Uncorrectable bleeding diathesis.- Active Mycobacterium tuberculosis infection.- ...
- Humerus fracture Classification:1. Proximal humerus fracture (common in the elderly) - The proximal humerus has four major segments: the anatomical neck, the humeral shaft, the greater tuberosity, and the lesser tuberosity ...
- Idiopathic scoliosis Deformity of the spine occurring during growth, characterized by a lateral curvature (Cobb angle > 10°) and simultaneous rotation of the vertebrae. Epidemiology: - Sex: ♀ > ♂ (∼ 5:1)- Peak incidence: ...
- Hip dislocation Posterior hip dislocation (90% of cases):- Dashboard injury in which a posteriorly directed force (e.g., dashboard during a motor vehicle accident) is directed towards an internally rotated, flexed, and ...
- Pelvic fracture Clinical features:- Pelvic pain caused by movement, weightbearing, and compression of the iliac crests- Tilted pelvis and unequal leg length with reduced range of motion in the hip joint- Pelvic instability- ...
- Post-amputation pain Acute stump pain:- Tissue & nerve injury- Severe pain lasting 1-3 weeks Ischemic pain:- Swelling, skin discoloration- Wound breakdown- ↓ Transcutaneous oxygen tension Post-traumatic neuroma:- Weeks ...
- Tracheobronchial injury Clinical features:- Dyspnea, hoarseness, dysphonia, bloody tracheal secretions- Subcutaneous emphysema- Treatment-resistant pneumothorax- Pneumomediastinum: Hamman's sign (= precordial crepitation that ...
- Hypothermia Mild: 32-35 °C- Tachycardia, tachypnea- Ataxia, dysarthria, increased shivering Moderate: 28-32 °C- Bradycardia, lethargy, hypoventilation, decreased shivering, atrial arrhythmias Severe: < 28 °C- ...
- Extremity vascular trauma Hard signs:- Observed pulsatile bleeding- Presence of bruit/thrill over injury- Expanding hematoma- Signs of distal ischemia (eg, absent pulses, cool extremities) Soft signs:- History of hemorrhage- Diminished ...
- Frostbite Severe localized tissue injury due to freezing of interstitial and cellular spaces after prolonged exposure to very cold temperatures. Clinical features:- Areas most frequently affected: Face, fingers, ...
- Drowning injuries Complications:- Acute respiratory distress syndrome- Cerebral edema- Arrhythmia Poor prognoistc indicators:- Submersion time > 5 min- Delay in initiation of CPR- Prolonged resuscitative efforts- Age > ...
- Bite wound Bite wounds (caused by animals or humans i.e., “fight bite”) are associated with an increased risk of infection, as the bacterial flora of the oral cavity hinders wound healing. Common pathogens: ...
- Preoperative evaluation Cardiac risk: - Contraindications: EF < 35%, MI within 6 months- Cardiac risk calculated with Goldman Index→ JVD is the worst prognostic factor on the index- Consider EKG, Echo, Angiogram, CABG Pulmonary ...
- Postoperative urinary retention Failure to void > 4 hours after surgery Risk factors:- Age > 50 years- Male patient- Pre-existing obstructive urinary tract symptoms (e.g., BPH)- Neurological disease (e.g., multiple sclerosis, diabetic ...
- Postoperative ileus Risk factors:- Open surgery- Excessive bowel handling during intra-abdominal surgery- Electrolyte imbalances (e.g., hypokalemia)- Use of opiates Clinical features:- Failure to pass flatus- Nausea and ...
- Pancreatitis - Complications Necrotizing pancreatitis:- Diagnosis: CT-guided percutaneous drainage + culture of the aspirate- Treatment: surgical debridement, antibiotics (e.g., meropenem) Pancreatic abscess:- Walled-off infected ...
- Pancreatitis - Predictors of severity - Age > 55- Gastrointestinal bleeding- Abnormal hematocrit within 48 hours→ Acute hemorrhagic pancreatitis: ↓ Hct→ Third space fluid loss: ↑ Hct- Hypocalcemia and/or hyperglycemia- Inflammatory ...
- Jersey finger Affected tendon: Flexor digitorum profundus tendon Mechanism of injury- Sudden hyperextension of a flexed DIP (forced extension)- Avulsion injury/rupture of the FDP tendon from its point of insertion ...
- Mallet finger Affected tendon: Extensor digitorum tendon Mechanism of injury:- Sudden hyperflexion of the DIP (forced flexion) → avulsion/rupture of the distal portion of the ED tendon from the distal phalanx- May ...
- Trigger finger Epidemiology:- Sex: ♀ > ♂ (6:1)- Age: > 40 years Pathophysiology: fibrocartilagenous metaplasia of the tendon sheath of the A1 annular pulley → loss of smooth gliding of the finger flexor tendons ...
- De Quervain's tenosynovitis Thickening of the abductor pollicis longus and extensor pollicis brevis due to myxoid degeneration Epidemiology:- Sex: ♀ > ♂- Age: 30-50 years Etiology:- Repetitive/prolonged abduction and extension ...
- Dupuytren's contracture Dupuytren's contracture (palmar fibromatosis) is a fibroproliferative disorder of the palmar fascia Epidemiology:- Peak incidence: 40-60 years- Sex: ♂ > ♀ Risk factors: these factors may cause ischemic ...
- Felon Definition: distal pulp space infection of the fingertip Etiology:- Wooden splinters, minor cuts, paronychia → cellulitis of fingertip pulp → abscess formation and edema Pathogen: Staphylococcus aureus ...
- Shoulder dislocation Anterior dislocation:- Most common- Risk of axillary nerve injury- Patients hold arm in slight abduction and external rotation Posterior dislocation:- Rare- Associated with seizure and electrocution- ...
- Colles fracture Involves the distal radius. Often results from a fall onto an outstretched hand, leading to a dorsally displaced, dorsally angulated fracture. Commonly seen in the elderly (osteoporosis) and children. ...
- Monteggia fracture Proximal ulnar shaft fracture with anterior dislocation of the radial head Mechanism of injury: Defensive injury- Low-energy trauma, e.g., fall on outstretched and pronated forearm- High-energy trauma, ...
- Galeazzi fracture Radial shaft fracture with dislocation of the ulna - More common in children Mechanism of injury: fall on outstretched and pronated forearm Clinical features:- Pain, deformity, and limited range of ...
- Scaphoid fracture Most commonly fractured carpal bone. Results from a fall onto an outstretched hand.May take 2 weeks for radiographs to show fracture. Assume fracture if there is tenderness in the anatomic snuff box with ...