USMLE ® • UP-TO-DATE ® STEP 2 CK STEP Updated annually by Kaplan’s all-star faculty STEP2 CK • INTEGRATED Lecture Notes 2018 Notes Lecture Packed with bridges between specialties and basic science Lecture Notes 2018 • TRUSTED Used by thousands of students each year to ace the exam USMLE Surgery Surgery Tell us what you think! Visit kaptest.com/booksfeedback and let us know about your book experience. ISBN: 978-1-5062-2822-8 kaplanmedical.com 9 7 8 1 5 0 6 2 2 8 2 2 8 USMLE® is a joint program of The Federation of State Medical Boards of the United States, Inc. and the National Board of Medical Examiners. USMLE® is a joint program of the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME), neither of which sponsors or endorses this product. 978-1-5062-2822-8_USMLE_Step2_CK_Surgery_Course_CVR.indd 1 6/21/17 10:58 AM ® STEP 2 CK Lecture Notes 2018 USMLE Surgery USMLE® is a joint program of The Federation of State Medical Boards of the United States, Inc. and the National Board of Medical Examiners. S2 Surgery.indb 1 6/20/17 9:15 AM USMLE® is a joint program of the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME), neither of which sponsors or endorses this product. This publication is designed to provide accurate information in regard to the subject matter covered as of its publication date, with the understanding that knowledge and best practice constantly evolve. The publisher is not engaged in rendering medical, legal, accounting, or other professional service. If medical or legal advice or other expert assistance is required, the services of a competent profes- sional should be sought. This publication is not intended for use in clinical practice or the delivery of medical care. To the fullest extent of the law, neither the Publisher nor the Editors assume any liability for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this book. © 2017 by Kaplan, Inc. Published by Kaplan Medical, a division of Kaplan, Inc. 750 Third Avenue New York, NY 10017 All rights reserved. The text of this publication, or any part thereof, may not be reproduced in any manner whatsoever without written permission from the publisher. 10 9 8 7 6 5 4 3 2 1 Course ISBN: 978-1-5062-2822-8 Retail Kit ISBN: 978-1-5062-2088-8 This item comes as a set and should not be broken out and sold separately. Kaplan Publishing print books are available at special quantity discounts to use for sales promotions, employee premiums, or educational purposes. For more information or to purchase books, please call the Simon & Schuster special sales department at 866-506-1949. USMLE® is a joint program of The Federation of State Medical Boards of the United States, Inc. and the National Board of Medical Examiners. S2 Surgery.indb 2 6/20/17 9:15 AM Editors Carlos Pestana, M.D., Ph.D. Emeritus Professor of Surgery University of Texas Medical School at San Antonio San Antonio, TX Adil Farooqui, M.D., F.R.C.S. Clinical Assistant Professor of Surgery Keck School of Medicine, University of Southern California Kaiser Permanente, West Los Angeles Medical Center Los Angeles, CA Mark Nolan Hill, M.D., F.A.C.S. Professor of Surgery Chicago Medical School Chicago, IL Contributor Ted A. James, M.D., M.S., F.A.C.S. Chief, Breast Surgical Oncology Vice Chair, Academic Affairs Department of Surgery Beth Israel Deaconess Medical Center Harvard Medical School Boston, MA The editors wish to also acknowledge Gary Schwartz, M.D., Baylor University Medical Center. USMLE® is a joint program of The Federation of State Medical Boards of the United States, Inc. and the National Board of Medical Examiners. S2 Surgery.indb 3 6/20/17 9:15 AM We want to hear what you think. What do you like or not like about the Notes? Please email us at [email protected]. USMLE® is a joint program of The Federation of State Medical Boards of the United States, Inc. and the National Board of Medical Examiners. S2 Surgery.indb 4 6/20/17 9:15 AM Table of Contents Part I. Surgery Chapter 1. Trauma...................................................... 3 Chapter 2. Orthopedics.................................................. 19 Chapter 3. Pre-Op and Post-Op Care ..................................... .35 Chapter 4. General Surgery ............................................. .45 Chapter 5. Pediatric Surgery............................................. 65 Chapter 6. Cardiothoracic Surgery ........................................ 71 Chapter 7. Vascular Surgery ............................................. 75 Chapter 8. Skin Surgery ................................................ .79 Chapter 9. Ophthalmology............................................... 81 Chapter 10. Otolaryngology (ENT) ....................................... .83 Chapter 11. Neurosurgery .............................................. .87 Chapter 12. Urology .................................................... 91 Chapter 13. Organ Transplantation ....................................... .95 USMLE® is a joint program of The Federation of State Medical Boards of the United States, Inc. and the National Board of Medical Examiners. v S2 Surgery.indb 5 6/20/17 9:15 AM USMLE Step 2 CK l Surgery Part II. Surgical Vignettes Chapter 1. Trauma..................................................... 99 Chapter 2. Orthopedics................................................. 131 Chapter 3. Pre-Op and Post-Op Care .................................... .149 Chapter 4. General Surgery ............................................ 163 Chapter 5. Pediatric Surgery............................................ 195 Chapter 6. Cardiothoracic Surgery ...................................... .201 Chapter 7. Vascular Surgery ............................................ 207 Chapter 8. Skin Surgery ............................................... .209 Chapter 9. Ophthalmology.............................................. 211 Chapter 10. Otolaryngology (ENT) ....................................... 215 Chapter 11. Neurosurgery .............................................. 221 Chapter 12. Urology .................................................. .229 Chapter 13. Organ Transplantation ...................................... 237 Index ..................................................................... .239 Additional resources available at www.kaptest.com/usmlebookresources USMLE® is a joint program of The Federation of State Medical Boards of the United States, Inc. and the National Board of Medical Examiners. vi S2 Surgery.indb 6 6/20/17 9:15 AM SECTIONPART I I Surgery USMLE® is a joint program of The Federation of State Medical Boards of the United States, Inc. and the National Board of Medical Examiners. S2 Surgery.indb 1 6/20/17 9:15 AM USMLE® is a joint program of The Federation of State Medical Boards of the United States, Inc. and the National Board of Medical Examiners. S2 Surgery.indb 2 6/20/17 9:15 AM Trauma Chapter Title 001 Learning Objectives ❏ List the ABCs of evaluating a trauma patient ❏ Demonstrate a head-to-toe review of a trauma patient ❏ Provide basic information about treatment of burns, bites, and stings PRIMARY SURVEY: THE ABCs Airway The first step in the evaluation of trauma is airway assessment and protection. • An airway is considered protected if the patient is conscious and speaking in a normal tone of voice. • An airway is considered unprotected if there is an expanding hematoma or subcutane- ous emphysema in the neck, noisy or “gurgly” breathing, or a Glasgow Coma Scale <8. An airway should be secured before the situation becomes critical. In the field, an airway can be secured by intubation or cricothyroidotomy. This is called a “definitive airway.” In the emergency department, it is best done by rapid sequence induction and orotracheal intuba- tion, with monitoring of pulse oximetry. In the presence of a cervical spine injury, orotracheal intubation can still be done as long as the head is secured and in-line stabilization is main- tained during the procedure. Another option in that setting is nasotracheal intubation over a fiberoptic bronchoscope. If severe maxillofacial injuries preclude the use of intubation or intubation is unsuccessful, cricothyroidotomy may become necessary. In the pediatric patient population (age <12), tracheostomy is preferred over cricothyroid- otomy due to the high risk of airway stenosis, as the cricoid is much smaller than in the adult. Breathing Breath sounds indicate satisfactory ventilation; an absence or decrease of breath sounds may indicate a pneumothorax and/or hemothorax and necessitate chest tube placement. Pulse oximetry indicates satisfactory oxygenation; hypoxia may be secondary to airway compro- mise, pulmonary contusion, or neurological injury impairing respiratory drive and necessitate intubation. Measurement of CO2 (capnography) is also very useful. USMLE® is a joint program of The Federation of State Medical Boards of the United States, Inc. and the National Board of Medical Examiners. 3 S2 Surgery.indb 3 6/20/17 9:15 AM USMLE Step 2 CK l Surgery Circulation Clinical signs of shock include the following: • Low BP (<90 mm Hg systolic) • Tachycardia (heart rate >100 bpm) • Low urinary output (<0.5 ml/kg/h) Patients in shock will be pale, cold, shivering, sweating, thirsty, and apprehensive. In the trauma setting, shock is either hypovolemic (secondary to hemorrhage and the most common scenario) or cardiogenic (secondary to pericardial tamponade or tension pneumo-