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USMLE Step 2 — Lesson 1

Surgery Highlights for USMLE Step 2

Carlos Pestana, MD
Trauma Cases

Case #1:

A 19-year-old male is brought to the ER by ambulance after being shot in the abdomen 20
minutes earlier in a bar. On arrival, he is diaphoretic, pale, cold, shivering, anxious; he asks
for a blanket and water. Initial survey confirms the presence of an entry wound in the mid-
epigastrium, a blood pressure of 75/60, and a feeble pulse rate of 142.

Diagnosis: Hemorrhagic shock

• Most common shock post trauma: hypovolemic (hemorrhagic)

• If trauma to the chest occurs: must also consider pericardial tamponade and tension
pneumothorax. Look for elevated CVP and distended neck veins.


• If possible, control bleeding first and then fill up vascular tree

• Immediate laparotomy preceded by big bore IV lines, Foley catheter and IV antibiotics
• Once bleeders clamped, rapid infusion of Ringers lactate and packed RBC’s

Case #2:

A car accident victim arrives in the ER. Initial survey shows that he is fully conscious and
speaking with a normal tone of voice, but he is also pale, perspiring and shivering. He is
breathing well and his head and neck veins are not distended. Blood pressure is 85/62 and
there is a barely perceptible pulse at a rate of 115 per min.

Diagnosis: Hemorrhagic shock

• Unlike case 1 with penetrating injury, this patient sustained blunt trauma, perhaps to
the chest. Must r/o pericardial tamponade and tension pneumothorax.
• Normal JVD and breathing r/o both. Again, hemorrhagic shock is most likely


• Remember ABC’s. Source of bleeding unknown; can’t use the “stop bleeding first,
replace volume later approach”
• Two large peripheral IV lines with a couple of liters of Ringer’s lactate (no sugar)
infused over 20-30 minutes


• Prompt and lasting stabilization of vital signs in response to fluid bolus would suggest
bleeding has spontaneously ceased Prompt and lasting stabilization of vital signs in
response to fluid bolus would suggest bleeding has spontaneously ceased
• If shock not reversed with volume replacement, more aggressive blood replacement
and surgery likely required

Case #3:

An ambulance arrives at the site where a car ran into a tree on a remote rural road. The lone
occupant of the vehicle is cold, pale, perspiring and shivering. His blood pressure is 80/60, his
pulse rate is 120, and he has no visible distended veins in his head and neck. The nearest
hospital is at least an hour away.

Diagnosis: Hemorrhagic shock


• Infuse Ringer’s lactate while in transit to the hospital

Case #4:

An innocent bystander is shot in the chest and abdomen during a botched bank robbery. On
arrival in the ER he is pale, diaphoretic, cold, shivering, anxious, and thirsty. He has bilateral
breath sounds and is breathing well, but he has large distended veins in his neck and
forehead. His blood pressure is 65/45, and his pulse rate is 150.

Diagnosis: Cardiogenic shock due to pericardial tamponade

• Can r/o tension pneumothorax because he has normal breath sounds and is
breathing well
• By exclusion, correct diagnosis is pericardial tamponade


• Pericardial tamponade is a clinical diagnosis; do not need further diagnostic studies

• CXR and EKG NOT merited; in an unclear case, would order sonogram


• Must evacuate blood from pericardial sac

• Give patient blood or IV fluids despite high venous pressure as elevated pressure due
to mechanical impediment to ventricular filling, not ventricular failure

Case #5:

A 23-year-old gang member arrives at the ER with multiple gun shot wounds to the chest.
Breathing is labored, nostrils flared, and he has big distended veins in his neck and forehead.
He is pale, cold, sweating, shivering, and mumbles that he is going to die. Initial survey shows
a blood pressure of 60/40, barely perceptible pulse at a rate of 150, and a right hemithorax
that is hyperresonant to percussion and devoid of breath sounds. Palpation of the trachea
shows it to be deviated toward the left.

Diagnosis: Tension pneumothorax


• Clinical diagnosis of a life-threatening emergency: getting a CXR or waiting for ABG

results would be a deadly mistake
• Large bore needle or IV catheter into 2nd intercostal space
• Chest tube to follow

Case #6:

During a round of golf, a business executive is hit on the right side of his head with a golf ball.
He loses consciousness for a few minutes, but wakes up promptly and continues to play. 1
hour later he is found unconscious in the locker room. His right pupil is fixed and dilated, and
he has contralateral hemiparesis.

Diagnosis: Epidural hematoma

• Sequence of trauma, coma, lucid period, coma again, ipsilateral fixed dilated pupil
and contralateral hemiparesis suggests acute intracranial hematoma with
displacement of the midline structures.

Diagnosis: Epidural hematoma

• Epidural vs. subdural: subdural requires a much bigger trauma and presents with a
sicker patient.
• Blow to side of head where middle meningeal artery lies, as well as the very lucid
“lucid interval” suggests acute epidural bleed.
• In 90% of cases dilated pupil on same side as hematoma.


• CT scan of head to confirm location (right vs. left; epidural vs. subdural)
• Biconcave epidural hematoma on the right; deviation of midline structures to the left
• Cranionotomy and decompression

Case #7:

The front seat passenger of a car involved in a high-speed, head-on collision, arrives in the
ER in a deep coma. The EMTs report that he was unconscious at the site, woke up briefly in
the ambulance, and then lapsed into a coma again. His right pupil is fixed and dilated and he
has signs of contralateral hemiparesis with decerebrate posture.

Diagnosis: Acute subdural hematoma

• Severity of trauma and profound neurological deficits suggest acute subdural

hematoma, probably on the right side.


• Head CT
• Semilunar, crescent-shaped hematoma on the right; deviation of the midline
structures to the left
• Deviation provides rationale for surgery; without displacement more conservative
approach with ICP management
• With major blunt trauma to the head, remember to check the C-spine

Case #8:

An 82-year-old alcoholic man is rummaging under the sink looking for his last bottle of cheap
wine. While doing so, he bumps his head against the counter, but suffers no apparent injury.
Over the next week, however, he gradually loses his mental capacities, and becomes
obtunded and disoriented.

Diagnosis: Chronic subdural hematoma

• Shrinkage of brain (but not skull) in old people and alcoholics

• Torn venous sinuses with slow venous bleeding


• CT scan of the head

• Evacuation of clot

Case #9:

A 18-year-old male is stabbed in the right chest. He presents moderately short of breath, but
his other vital signs are stable. Physical examination reveals an absence of breath sounds in
the right hemithorax, which sounds hyperresonant to percussion.

Diagnosis: Pneumothorax


• Not life-and-death; time to confirm with studies

• CXR will confirm diagnosis and show extent of pneumothorax and whether there is
blood in the pleural space
• Chest tube

Case #10:

A 20-year-old male is stabbed in the right chest. He is moderately short of breath, but his
other vital signs are stable. Physical exam reveals no breath sounds at the right base, and
faint, distant breath sounds at the right apex. Right side of his chest is dull to percussion. A
CXR shows blood in the right pleural space, and a chest tube is placed at the right pleural
base. The tube initially recovers 270 cc of blood, drains another 35 cc in the next hour, and 12
cc in the second hour.

Diagnosis: Hemothorax

• Bleeding from penetrating chest injuries most often from lung


• While bleeding will stop by itself, expectant therapy not advisable because
contaminated blood in the pleural space may produce empyema


• Evacuation of blood is imperative

• One or more chest tubes placed and not removed until no blood draining
• Surgery seldomly required

Case #11:

A 19-year-old male is stabbed in the right chest. On arrival at the ER he is short of breath,
pale, with a pulse rate of 95 and a blood pressure of 90/70. His right hemithorax has no breath
sounds and is dull to percussion. CXR shows the entire pleural space to be filled with blood.
When a chest tube is inserted, 1600 cc of blood are recovered.

Diagnosis and Management:

• Hemothorax with systemic vessel bleeding (usually intercostals)

• Emergency thoracotomy to control bleeding
• Vigorous fluid and blood replacement

Case #12:

A 45-year-old woman involved in a car accident in which 3 other passengers died arrives at
the ER. She is moderately short of breath, but her other vital signs are stable. Initial survey
shows multiple bruises and minor lacerations, but the most impressive finding is the presence
of at least 8 rib fractures on the right side of her chest, and a very peculiar physical finding:
there is an area of the chest wall on the right that caves in whenever she inspires and bulges
out on expiration.

• Consider: severe trauma to the chest, deceleration injury
• Think of obvious injuries as well as hidden ones
• Broken ribs and flail chest are obvious
• Consider possibility of traumatic rupture of aorta
• Manage the obvious, uncover the hidden


• Deal with broken ribs first: local nerve blocks

• Flail chest: contused lung exquisitely sensitive to fluid overload; limit fluid infusion and
use colloids rather than crystalloids; maybe add diuretics
• Monitor blood gases for respiratory failure

Monitor blood gases for respiratory failure

• If she requires a respirator, must also insert prophylactic chest tubes

• Check CXR for aortic transection; wide mediastinum leads to aortogram. If
mediastinum not widened, spiral CT or transesophageal echo

Case #13:

A 23-year-old man crashes his car into a wall. When he arrives at the ER, a mirror image of
the word “Ford” can be seen imprinted as a bruise over his precordial region. He is exquisitely
tender at a point in the sternum, where palpation elicits a gritty feeling of bone grating on

Diagnosis: Sternal fracture

• Probable myocardial contusion

• Fracture of hard-to-break bones (sternum, scapula, first rib) suggest major trauma
• Sudden deceleration chest trauma- possibility of aortic rupture

• CXR will reveal sternal fracture and can check for widened mediastinum
• Diagnosis and management of myocardial contusion similar to MI; EKG more reliable
than enzymes

Case #14:

Two airplanes collide on runway and there are multiple casualties. One of the survivors is
found walking around in a daze, but otherwise seemingly unharmed. Over his objections, he
is taken to the hospital, where a CXR shows a wide mediastinum and a fractured left first rib.

Diagnosis: Traumatic rupture of aorta

• Intima and media may have cracked and be asymptomatic until adventitia gives way


• Aortogram
• Widened mediastinum on CXR not sufficient to rush to surgery; could be mediastinal
hematoma from other causes

USMLE Step 2 — Lesson 2

Case #15:

A 22-year-old man has been shot in the abdomen with a 38 caliber revolver. He is
hemodynamically stable, but has moderate abdominal tenderness. There is an entrance
wound to the left of the umbilicus, and x-rays show the bullet lodged in the right paraspinal


• Management of abdominal trauma straight forward in gun shot wounds and any
trauma that results in acute abdomen: exploratory laparotomy!
• Prep includes bladder catheter, big bore IV lines, broad-spectrum antibiotics
• Stab wounds more controversial

Case #16:

A 27-year-old man hits his abdomen against the steering wheel when his car collides with
another at an intersection. On arrival at the ER, his blood pressure is 95/75 and his pulse is
98. His abdomen is distended, tender in all four quadrants, with muscle guarding and rebound


• Presence of “acute abdomen” makes exploratory laparotomy mandatory

Case #17:

A 32-year-old woman has been involved in an automobile accident. She has facial
lacerations, a broken arm, and bruises over her chest and abdomen. CXR is normal. Shortly
after arrival at the ER, she becomes progressively hypotensive, tachycardic and diaphoretic.
Her hematocrit is dropping and her central venous pressure is low.

Diagnosis and Management:

• Shock with normal CXR and low CVP:

she’s bleeding somewhere
• Start infusion with Ringer’s lactate and follow with packed red cells

Where is the bleed?

• Head: No. Would have developed neuro signs . Hypovolemic shock can’t happen
from intracranial bleed.
• Chest: No. Pericardial sac not a possibility (low CVP in this patient); pleural spaces
could fill with blood but would have seen on CXR.
Where is the bleed?

• Pelvis or thighs: large enough spaces to hold that much blood, but vignette doesn’t
suggest these possibilities.
• Most likely: Abdomen

Diagnosis and Management:

• Abdominal CT: will show the blood and source and will give idea of magnitude.
• Note: abdominal CT requires that patient be hemodynamically stable!

Diagnosis and Management:

• When patient “crashing,” – diagnostic peritoneal lavage (DPL); alternatively, newer

option is sonogram done in the ER. DPL and sonogram provide less info that CT- just
yes or no on bleeding, not source or magnitude
• If indeed there is bleeding in the abdomen – emergency laparotomy

Case #18:

An 18-year-old college freshman is involved in a motorcycle accident. Among numerous other

injuries, he has a pelvic fracture. At the initial survey it is noted that he has blood at the penile
meatus, as well as a scrotal hematoma. He says that he feels the need to void, but can not do
it. Rectal exam reveals a “high-riding” prostate.

Diagnosis: Urethral injury

• Hallmark of urological injuries is hematuria after trauma

• High abdominal or flank trauma can lead to bleeding from kidney (lower rib fractures)
• Pelvic fracture- bleeding from bladder or urethra in males; blood at the meatus
suggests urethral injury

• Don’t attempt to pass a Foley!
• Retrograde urethrogram: anterior injuries repaired at the time; posterior ones delayed
• If urethrogram negative, pass a Foley and perform a cystogram. Look at post void film

Case #19:

A 55-year-old woman sustains multiple injuries in a car accident including fractures of the
lower ribs on both sides. There is no pelvic fracture. When a Foley catheter is inserted, gross
blood is recovered.

Diagnosis: Kidney injury

• Urethral injury rare in women

• Absence of pelvic fracture makes bladder unlikely; r/o with cystogram
• Confirm with CT of kidneys


• Most penetrating renal injuries need surgery; most blunt ones do not
• Avulsion of renal pedicle example of exception

Case #20:

A 26-year-old man is shot in the leg with a 22-caliber gun. The entrance wound is in the
anteromedial aspect of his upper thigh, and the exit wound is lower down in the posterolateral
aspect of the thigh. He has normal distal pulses in that leg, and a small, non-expanding
hematoma under the entrance wound. The bone is intact.


• Wound cleansing; tetanus prophylaxis

• Surgical challenge in reference to possible vascular injury
• Think about the anatomy: Femoral vessels at risk in this case

• Arteriogram (would skip this step if pulses absent or hematoma expanding)

• Repair dilemma of vascular injury PLUS bone injury

Case #21:

A 14-year-old boy complains of pain in his right knee. His family notices that he has been
limping. He is sitting on the examination table with both feet dangling, and the right foot is
rotated towards the left. Physical examination is completely normal for the knee, but it shows
limited hip motion. When the hip is flexed, the leg goes into external rotation and it can not be
internally rotated.

Diagnosis: Slipped capital femoral epiphysis


• Orthopedic emergency
• After AP and lateral x-rays confirm diagnosis, femoral head will be pinned in place

Hip pathology:

• Can show up as knee pain

• Age is important clue:

Hip pathology: By age group

In newborns: think developmental dysplasia (order sonogram; not CXRs); treat with
Pavlik harness

Painful hip in toddler after a febrile illness: think septic hip. Diagnosis established by
aspiration under general anesthesia. Emergency drainage required.
Hip pathology: By age group

Hip pain at age 6: think avascular necrosis of femoral head

Hip pain in early teens (boys): think slipped capital femoral epiphysis

Case #22:

A child complains of persistent, severe pain in his arm. He has a very tender area to palpation
at a very specific point in his radius, but he has no history of trauma to that area. For the past
several days he has had a febrile illness, for which he has received no treatment.

Diagnosis: Acute hematogenous osteomyelitis

• A febrile illness in a toddler, followed by refusal to move the hip is a septic hip (an
• A febrile illness in a child, followed by bone pain is osteomyelitis.


• Do a bone scan and treat with antibiotics.

• Do not order x-rays in this setting: they will not show anything for two weeks. Go with
the scan.


A 55-year-old homeless man comes to the ER complaining of extremely severe pain in his
right forearm. He has no history of trauma to that area, and relates that he was very drunk,
slept on a park bench, the next morning, the arm was numb, and began to hurt shortly
thereafter. The muscles in his forearm are very firm and tender to palpation . He has
excruciating pain when they are subjected to passive extension. Pulses at the wrist are

Diagnosis: Compartment syndrome

• Prolonged ischemia, followed by reperfusion, is the usual setting for the development
of compartment syndrome.
• Forearm and the lower leg are the two most common sites.
• Excruciating pain with passive extension is a classical finding.
• Presence of normal pulses does not rule out compartment syndrome.


• Emergency fasciotomy
• Permanent disability will ensue, if not promptly decompressed.

Case #24:

A 46-year-old man develops sudden excruciating pain, when attempting to lift heavy
object,“like an electrical shock,” in his lower back and down the posterior aspect of his right
leg. He suffered from very mild back pain for several months, which he attributed to “muscle
spasms.” At this time he is unable to ambulate, he keeps the right leg flexed, and says that the
pain becomes unbearable when he sneezes, coughs, or strains. Straight leg raising elicits
excruciating pain.

Diagnosis: Lumbar disk herniation

• The peak age incidence is 45-46.

• Discogenic pain precedes the neurogenic pain.
• The most common locations are L4-L5 or L5-S1.
• If the pain does not get worse with sneezing, coughing and straining, it is not a
herniated disc.


• MRI for diagnosis. Bed rest for several weeks, unless he develops progressive
neurological deterioration, or has sphincteric deficits.
• MRI is the best way to look at the cord and roots.
• Bed rest takes care of most herniated discs. Surgery is rarely needed.

• The cauda equina syndrome (distended bladder, flaccid rectal sphincter, perineal
saddle anesthesia) is a surgical emergency.

Case #25:

A 54-year-old, obese lady has a laparoscopic cholecystectomy that has to be converted to an

open procedure. The following morning she has a fever of 102.

Diagnosis: Atelectasis

• The most likely sources of fever in the surgical patient are:

• If over 104-105:
o Shortly after anesthetic induction: Malignant hyperthermia
o Shortly after instrumentation: Bacteremia

Diagnosis: Atelectasis

• “More standard fever” (101-102), by post-op:

Day 1: atelectasis

Day 3: urinary tract infection

Day 5: thrombophlebitis

Day 7: wound infection

Day 10-15: deep abscess (subphrenic, pelvic)


Rule out other causes of fever by checking the wound, IV sites, and her urine; Document
extent of atelectasis with chest x-ray, improve ventilation with deep breathing and coughing,
postural drainage, incentive spirometry.

Case #26:

On the seventh post-operative day after pinning of a broken hip, a 72-year-old lady develops
sudden, sever chest pain and shortness of breath. The pain is accentuated by deep breathing.
She is anxious, diaphoretic and tachycardic, and she has prominent, visibly distended veins in
her neck and forehead.

Diagnosis: Pulmonary embolus

• Timing of post-op chest pain gives the first clue:

o MI occurs on day one or two
o PE occurs after 5 to 7 days
• Doubt the diagnosis of PE if CVP is low, or blood gases do not show hypocapnia


• Confirm the diagnosis with blood gases (that will show hypoxemia and hypocapnia),
and ventilation-perfusion scan.
• Although pulmonary angio is the “gold standard,” ventilation-perfusion scan is more
commonly done.
• If PE’s recur while properly anticoagulated, place a Greenfield vena cava filter.

Case #27:

12 days after surgery for multiple gunshot wounds, a 27-year-old man becomes progressively
disoriented and unresponsive. He’s had multiple complications, including several
intraabdominal abscesses that have been percutaneously drained. He has bilateral pulmonary
infiltrates, and a PO2 of 65 while breathing 40% oxygen. Meticulous attention has been paid to
his fluid balance, and there is no evidence that he is in congestive heart failure.

Diagnosis: ARDS

• PEEP allowing enough hypercapnia to minimize pulmonary barotrauma. Continue the
search for other intraabdominal collections that may need to be drained.

Postoperative Disorientation and Coma Relevant Points :

a. Always check blood gases first.

b.On post-op day 2 in an alcoholic, think DTs.
c. Check serum sodium, both hyponatremia or hypernatremia can do it.

Postoperative Disorientation and Coma Relevant Points :

d. In the diabetic, or those on TPN, think blood sugar.

e. In a cirrhotic, ammonium is the culprit.
f. No obvious explanation? Look at the medication chart, we may be doing it.

Case #28:

Several hours after completion of surgery for multiple gunshot wounds to the abdomen, a 70
Kg., 52-year-old man is reported to have hourly urinary outputs of 17cc, 13cc, and 21cc, in
three consecutive hours. His blood pressure has hovered around 95 to 125 systolic during
that time.


• A urinary output of zero represents a mechanical problem, not a biological one.

• Normal hourly urinary output approx. 1cc (0.5 to 2) per Kg. of body weight, per hour.


• Oliguria occurs during shock.

• In the presence of adequate perfusing pressure, oliguria is either from dehydration or
from renal failure.

• Look at his urinary sodium. It will be low (under 10 or 20 mEq/L) in the dehydrated
patient (give him more fluid), while it will exceed 40 in the case of renal failure (restrict

Surgery Highlights for USMLE Step 2

Carlos Pestana, MD
GI/Abdomen Cases

USMLE Step 2 — Lesson 3

Case #29:

A 62-year-old African-American man reports progressive dysphagia that started three months
ago with difficulty swallowing meat, and progressed to inability to swallow other solid foods,
then soft foods and now liquids. He has lost over 25 lbs. during that time. He has a history of
heavy smoking and drinking.

Diagnosis: Cancer of the esophagus

• Probably squamous cell

• Had the history been one of long standing reflux, adenocarcinoma would have been a
better bet.


• Barium swallow first, then endoscopy and biopsies, eventually CT scan to determine
operability. Treatment will probably be palliative only.
• Although endoscopy and biopsy provides the diagnosis, the fear of perforation
prevents their use without a previous “road map” (provided by the barium swallow).

• Other esophageal tests, and when to do them:
o Questionable symptoms of reflux: pH monitoring
o Long standing clear picture of reflux: endoscopy and biopsies
o Dysphagia that is worse for liquids: manometry studies
o Hematemesis after prolonged vomiting: endoscopy

Case #30:

A 32-year-old man presents with a history of several days of protracted vomiting, progressive
abdominal distention, and colicky abdominal pain. He has not passed gas for the past 2 days.
On physical exam he’s found to have a distended, tympanitic abdomen with high pitched
bowel sounds that correspond to the colicky pain. X-rays show distended loops of small
bowel, with air-fluid levels, and no gas in the colon. 5 years ago he had an exploratory
laparotomy for a gunshot wound.

Diagnosis: Mechanical intestinal obstruction

• Mechanical intestinal obstruction in someone with a previous laparotomy is due to

• In the absence of prior abdominal surgery, look for a hernia to be causing the

Diagnosis: Mechanical intestinal obstruction

• When obstruction happens in the postoperative period the differential diagnosis is

with paralytic ileus. A barium tag may help differentiate them.


• Start conservative treatment expecting spontaneous resolution.

• NPO, NG suction, IV fluid, and watchful waiting. Surgery if no improvement within 24
hours, or if he develops fever, leukocytosis or a tender abdomen.
• Wait no more than 24 hours in complete obstruction (no gas in the colon, passing no
gas at all). Wait several days in partial obstruction. Watch for signs of strangulation.


• Surgery is indicated for unresolving obstruction or strangulated obstruction, but it can

only “save the bowel,” it can not get rid of the adhesions (they’ll form again).
• Always operate in obstruction due to hernias, because we can fix the hernia. Will do it
emergently if strangulation is suspected, electively if not.

Case #31:

An 18-year-old college student develops anorexia, followed by vague periumilical pain, that a
few hours later localizes to the right lower quadrant and becomes sharp and consistent. On
physical exam he has tenderness to deep palpation, muscle guarding and rebound
tenderness, all of them localized to the right lower quadrant of the abdomen. His temperature
is 100.5 and his WBC is 13,000 with a shift to the left.

Diagnosis: Acute appendicitis

• What makes it typical? The sequence:

1. Anorexia

2. Vague periumbilical pain

3. Sharp RLQ pain; plus the physical signs located rather than all over the


• Emergency appendectomy
• For typical acute appendicitis, the management is still emergency appendectomy
(rather than a lot of diagnostic studies).
• In doubtful cases, the standard approach is Sonogram or CT scan. Sonogram is
cheaper but it is operator-dependent.

Case #32:

A 62-year-old man seeks medical attention at the insistence of his family, who have noticed
that he looks extremely pale. He admits to being tired and occasionally having fainting spells.
He is found to have a hemoglobin of 5, and 4+ occult blood in the stools.

Diagnosis: Cancer of the right side of the colon

• 98% of colorectal cancers are adenocarcinomas.

• Large lumen and liquid content make obstructive symptoms very unlikely in the
cecum. Likewise, blood loss is not obvious. Thus, main presentation is anemia.
• In the left colon, change in bowel habits and blood coating the stools are the
predominant presentation.


• Colonoscopy and biopsies, eventually blood transfusions and right hemicolectomy.

Case #33:

A 34-year-old man has been passing large bloody bowel movements for the past 12 hours.
While in the office waiting to be seen, he has another very large evacuation of dark red blood.
On examination he looks pale and diaphoretic, has a blood pressure of 98 over 69, and a
pulse rate of 104.

Diagnosis: Probably upper GI bleeding

• Three out of every four GI bleeders are bleeding from the upper GI
• Lower GI bleeding happens mostly to old people (polyps, cancer, diverticulosis or
Diagnosis: Probably upper GI bleeding

• If patient is vomiting blood, the source is upper GI. If not vomiting (but presumed to be
actively bleeding at the time), the same information can be obtained by recovering
blood by NG tube.


• Start volume replacement. Pass nasogastric tube and aspirate. If blood is found in the
stomach, do upper GI endoscopy.
• The best diagnostic modality for upper GI bleeding is endoscopy (it allows treatment


• If bleeding is not from the upper GI, and it exceeds 2 cc per minute (one unit of blood
every 4 hours), best diagnostic modality is emergency angiogram. Before you do it,
look for bleeding hemorrhoids!


• Colonoscopy at the time of profuse lower GI bleeding is useless (anoscopy is OK).

• Best diagnostic modality for slow lower GI bleeding (less than 0.5 cc per minute) is
either tagged red cell study, or waiting for bleeding to cease and do colonoscopy then.

Case #34:

A 63-year-old woman began to feel discomfort in the left lower quadrant of her abdomen
about 12 hrs. ago. The pain gradually built up in intensity and is now constant and moderately
severe. She has a vaguely palpable mass in her left lower quadrant, is tender to deep
palpation, w/mild muscle guarding and no rebound. She has fever and leukocytosis and
previously had 3 similar episodes requiring hospitalization.
Diagnosis: Acute diverticulitis

• Acute abdominal pain can result from inflammatory processes, obstructive

phenomena, or perforation.
• Inflammatory processes have gradual build up, constant pain, signs of peritoneal
irritation in the area, and systemic signs (fever and leukocutosis).
• The “anatomical approach” is used to make the list of suspects.


• CT scan will confirm the diagnosis. NPO, antibiotics and IV fluids should “cool it
down.” With three prior episodes, elective sigmoid resection should be considered.

Case #35:

A 47-year-old man develops extremely severe, colicky right flank pain of sudden onset, that
radiates to his inner thigh and scrotum. He also has mild nausea and some dysuria. When
seen in the ER, he is thrashing around on the stretcher, looking for a position of comfort. He
has microscopic hematuria.

Diagnosis: Ureteral colic

• Abdominal pain from obstructive processes has sudden onset, is colicky , has specific
location and radiation patterns, and makes the patient move around seeking relief.
• Location and radiation patterns:
o Ureter: Flank, to inner thigh and scrotum or labia
o Biliary tract: RUQ, to back (as a belt) and right shoulder
o Pancreas: Epigastic, straight through to the back


• Start urological work up with sonogram, or plain film of the abdomen to be followed by
Case #36:

A 57-year-old man is brought to the ER in the middle of the night. About one hr. before, he had
sudden onset of extremely severe abdominal pain, described as constant and involving his
entire abdomen. He lies motionless on the stretcher, guarding his abdomen with his hands,
perspiring, and obviously in great pain. His abdomen is rigid, very tender to palpation, with
muscle guarding and rebound in all quadrants.

Diagnosis: Acute abdomen from perforated viscus

• Abdominal pain from perforations has sudden onset, is constant and generalized, and
makes the patient lie still.


• Emergency exploratory laparatomy

• The clear-cut diagnosis of an acute abdomen is sufficient indication for exploratory
laparatomy. Work up only needs to exclude myocardial ischemia (EKG), lower lobe
pneumonia (chest x-ray), and pancreatitis (amylase).

Additional Diagnostic Hints in Abdominal Pain:

• Fat, fecund female in her forties: biliary tract

• Alcoholic: pancreatitis
• Patient with chronic ascites: primary peritonitis
• Very old: sigmoid volvulus or mesenteric ischemia
• Atrial fibrillation: mesenteric embolus

Case #37:

A 62-year-old man presents with progressive jaundice that began six weeks ago. For the past
two weeks he has had severe pruritus, and he also describes choluria and acholic stools. He
has total bilirubin of 24, with 14 direct (conjugated) and 10 indirect (unconjugated). His SGOT
(transaminase) is only mildly elevated, while his alkaline phosphatase is ten times the upper
limit of normal.

Diagnosis: Obstructive jaundice

• Hemolytic jaundice has elevation of unconjugated bilirubin only, without bile in the
• Hepatocellular jaundice shows high levels of SGOT.
• Obstructive jaundice shows high levels of Alkaline phosphatase.


• Start with sonogram. It should confirm dilated ducts. If it shows gallstones as well,
continue with ERCP. If is shows thin walled, dilated gallbladder without stones,
continue with CT.
• A dilated gallbladder in a jaundiced patient suggests malignancy (Courvoisier-Terrier

Case #38:

A white, fat female, age 40 and mother of 5 children, has severe right upper quadrant pain
that began six weeks ago. The pain was colicky at first, radiated to the right shoulder and
around towards the back, and was accompanied by nausea and vomiting. The past 2 hours
the pain has been constant. She has tenderness to deep palpation, muscle guarding and
rebound in the right upper quadrant, a temperature of 101 and WBC of 12,000. Liver function
tests show a bilirubin of 2.5, and normal alkaline phosphatase.

Diagnosis: Acute cholecystitis

• The spectrum of gallstone-related disease includes:

a. Asymptomatic gallstones: No treatment needed

b. Biliary colic: Colicky pain, no inflammatory process. Elective

cholecystectomy indicated


• The spectrum of gallstone-related disease includes:

c. Acute cholecystitis: Constant pain, inflammatory process, mild fever,

normal or near normal liver function tests. Medical management first,
cholecystectomy soon thereafter.

d. Acute ascending cholangitis: Constant pain, inflammatory process, sick

patient, spiking fever with chills, king-size elevation of the alkaline
phosphatase. Emergency ERCP needed.


• Start with sonogram. It should show gallstones, thick walled gallbladder and
pericholecystic fluid. NPO and antibiotics should “cool down” the process.
Cholecystectomy will be eventually needed.

USMLE Step 2 — Lesson 4

Surgery Highlights for USMLE Step 2

Carlos Pestana, MD
Breast Disease

Case #39:

A 42-year-old lady has a 2cm. firm mass in her right breast, which has been present for three
months, and is steadily growing.

• Breast cancer has to be ruled out.

• The probability of a breast mass being cancer is directly related to the patient’s age.

Typical patterns of breast disease:

• 18 year-old, rubbery mass: Fibroadenoma

• 20-40, multiple lumps, tender, related to cycle: Fibrocystic disease
• Bloody nipple discharge: Intraductal papilloma
• Breast abscess: Found only during lactation

Typical patterns of breast disease:

• Older lady, hard mass, skin dimpling: Cancer

• Older lady, eczematoid lesion of areola: Cancer


• Start with mammogram to identify other lesions if present. Then, core biopsies.
• Mammogram should precede biopsies in women over 35, but it is done to identify
other potential lesions, not as a substitute for the biopsy (only the pathologist can
make the diagnosis).


• Do not order mammograms below age 20 (breast too dense – use sonogram if
needed) or in lactating women (will only see milk).
• Depending on the probability of cancer, a spectrum of progressively more aggressive
Tissue sampling is done: FNA, core biopsy, mammotome, ABBI, incisional biopsy or
excisional biopsy.
Case #40:

A 32-year-old lady has a solitary, 2cm., firm mass in the right lobe of her thyroid gland. The
mass has been present for at least three years, and is growing very slowly. Her thyroid
function tests are normal.


• Probably benign, but have to rule out cancer.

• Thyroid cancers can occur in young people, they grow very slowly and they do not
affect the thyroid function.
• Highest probability of cancer is in young male with single, solid, cold nodule and
history of radiation to the neck.


• DO FNA. Leave alone if reported benign. Operate if reported indeterminate of


Even with good case selection, most resected thyroid nodules are benign. Highest
yield of malignancy when selected by FNA.

Case #41:

A 42-year-old lady has had hypertension for three years, and is not responding well to therapy
with blockers. She has a potassium of 2.5. She has not been on diuretics.

Diagnosis: Hyperaldosteronism

• Either adenoma or hyperplasia

• Key finding to initiate work-up is low serum potassium not accounted for by diuretics.

Other surgically correctable causes of hypertension:

• thin, hyperactive lady with episodes of pounding headache, palpitations, pallor, and
perspiration: pheochromocytoma.
• Young person with high pressure in the arms, low pressure in the legs: coarctation of
the aorta.
• Either young woman or old arteriosclerotic man, with faint upper abdominal or flank
bruit: renovascular hypertension.


• Confirm diagnosis by finding high levels of aldosterone and low levels of renin. Verify
adenoma versus hyperplasia with lack of response to postural changes. Locate the
adenoma with MRI or CT.

Case # 42:

An 8-hr-old baby in the newborn nursery is noted to have “excessive salivation.” A small, soft
nasogastric tube is placed, and the baby is taken to x-ray to have a “babygram.” The film
shows the tube to be coiled back upon itself in the upper chest. There is normal gas pattern in
the abdomen.

Diagnosis: Esophageal atresia with tracheoesophageal fistula

• The most common type of TE fistula has a blind end of esophagus at the top, and a
fistula between the distal esophagus and the trachea (that is how air gets into the GI

• First rule out the other components of the VACTERL syndrome: look for an
imperforate anus by physical exam, look for vertebral or radial anomalies in the x-ray,
do sonogram for renal anomalies, do echocardiogram to rule out congenital cardiac
• Have a primary repair of the fistula, or if other problems delay it, a gastrostomy.
Case #43:

Half an hour after the first feed, a newborn baby vomits greenish fluid. X-ray shows a “double-
bubble,” i.e., a large air fluid level in the stomach, and a smaller air fluid level to the right of it,
originating from the first portion of the duodenum.

Diagnosis: Either duodenal atresia, annular pancreas or malrotation.

• Green vomiting in the newborn period has ominous significance.


• Although surgical correction will eventually be needed for either of the above,
malrotation represents a more dire emergency. Look for it with contrast enema, or
upper GI study.
• The main risk in malrotation is torsion of the mesenteric vessels with ischemic
necrosis of the entire small bowel.

Case #44:

A 3-wk-old baby boy has been vomiting repeatedly for 3 days. The vomiting is projectile, has
no bile, and follows each feeding. After vomiting, the baby seems hungry and eager to eat. He
looks somewhat dehydrated, and has a scaphoid upper abdomen with visible gastric
persitaltic waves. A small, olive-sized mass is palpable in the right upper quadrant.

Diagnosis: Hypertrophic pyloric stenosis

• The main problem in congenital diaphragmatic hernia is the hypoplastic lung.

• Feeding problems in the premature, think necrotizing enterocolitis. Dropping platelet
count signifies sepsis.


• Abdominal problems plus cystic fibrosis equals meconium ileus (do gastrographic
• Progressive jaundice at age 8 weeks, think biliary atresia. Rule out hepatitis, do HIDA
scan after one week on Phenobarbital.


• First correct the dehydration and the hypochloremic, hypokalemic metabolic alkalosis
likely to be present. Then do Ramsted Pyloromyotomy.

Case #45:

A well-fed, healthy-looking 9-month-old boy has experienced brief episodes of colicky

abdominal pain that make him double up, squat, and cry vigorously. They seldom last more
than one min., and once gone, the boy is happy. Examination done during an episode showed
an “empty” right lower quadrant,and a vague mass above it, along the right gutter. The mother
has reported the baby’s stool has been blood-tinged during these episodes.

Diagnosis: Intussusception

• For some reason everyone who describes a child with intussusception calls the blood-
tinged stools “currant jelly stools.” If you see that description in the exam question,
they have given you the diagnosis on a silver platter.


• Barium enema will show the pathology and reduce the intussusception. Surgery may
be needed to prevent recurrences.

Case #46:

A 15-month-old child is brought in with second degree burns on both buttocks. The stepfather
relates that the child is beginning to walk all around the house, and that he got into the kitchen
where he tipped a pot of boiling water.
Diagnosis: Child abuse

• All scaldings in babies should make you think of child abuse, but the pattern in both
buttocks is classic: the baby was held by arms and legs, and dipped into boiling water.
• Other classical presentations for child abuse:

Child abuse classic presentations:

• Subdural hematoma and retinal hemorrhages (shaken baby)

• Multiple fractures at different stages of healing


• Silvadene cream for the burned areas, reporting to the proper authorities to protect
the child.

USMLE Step 2 — Lesson 5

Case #47:

A 52-year-old chronic smoker gets a pre-operative CXR in preparation for bilateral,

laparoscopic repair of inguinal hernias. A 2cm. “coin lesion” is found in the upper lobe of the
left lung.

Diagnosis: Probably cancer of the lung

• After age 50, coin lesions have an 80% chance of being malignant. History of
smoking makes it more likely.


• Start by locating an older CXR if available. If the lesion was present and has
remained unchanged for a year or two, not cancer.
Management if this is a new lesion:

• Start with sputum cytology and CT scan (including upper abdomen to see liver).
• 2/3 of patients already inoperable when first seen. Thus the value of trying to
establish the diagnosis and extent in a non-invasive way (sputum cytology and CT


• Next steps to establish diagnosis (if needed): Biopsy via bronchoscopy for central
lesions, percutaneous for peripheral.
• Further diagnostic steps depends on potential for cure and ability to tolerate
pulmonary resection. Cure is not possible if there are mets at carinal nodes.
Resection is not possible if the residual FEV1 would be less than 800.


• Resectability is not an issue for small cell CA, which is treated with chemotherapy and

Case #48:

A 72-year-old man is found on physical exam to have a 6cm. pulsatile mass in the abdomen,
located between the xiphoid and the umbilicus. The mass is not tender, and the patient is
otherwise completely asymptomatic.

Diagnosis: Abdominal aortic aneurysm


• Size is the key-determining factor of the probability of rupture, and thus the need for
elective repair.
• Verify precise measurements with sonogram or CT scan. If indeed the aneurysm is 6
cm. in diameter, do elective surgical repair.

• Under 4 cm., watchful waiting is appropriate.

• Over 6 cm., repair should be done.
• Aneurysm tender to palpation is going to rupture within 1 to 2 days. Repair


• Excruciating back pain in a patient with an abdominal aortic aneurysm means the
aneurysm is already rupturing (leaking retroperitoneally, and about to blow up into the
peritoneal cavity). Surgery has to be done as a super-emergency.

Case #49:

A 63-year-old car salesman is having difficulty doing his job. He works at a large, suburban
used-car lot which is about 3 blocks long. When he walks about 1/2 a block, he gets severe
cramping pain in his right calf, and must stop and rest for the pain to go away. As soon as he
has walked another 1/2 block, pain recurs. He is the sole supporter of his family and he is
about to be fired. He does not smoke.

Diagnosis: Intermittent claudication, from vascular disease.


• Surgery for intermittent claudiaction is palliative. If symptoms do not interfere with

lifestyle, surgery is not indicated.
• The natural history of intermittent claudiacation is unpredictable; thus there is no role
for “prophylactic surgery.” Tobacco use however, leads to predictable progression.
Cessation of smoking is imperative.
• Start with Doppler studies looking for a pressure gradient. If there is one, do
arteriograms, and provide the appropriate vascular reconstruction.

• Revasculariztion options include: angioplasty and stenting (for short segments),

saphenous vein bypass (for obstructions below the common femoral) and prosthetic
grafts (when the aorta has to be the proximal vessel).
• If there is no pressure gradient by Doppler studies, the disease is in the small vessels,
and not amenable to surgery.

Case #50:

A blond, blue-eyed, 71-year-old West Texan farmer of Scandinavian ancestry, has a non-
healing, indolent, punched-out, 2 cm. ulcer in the skin over his left temple, which has been
slowly growing over the past 3 years. He has no palpable lymph nodes in the head and neck,
but his skin has a “weather- beaten” appearance, with multiple areas of actinic keratosis.

Diagnosis: Skin cancer, probably basal cell carcinoma.

• Skin cancer (basal cell, squamous cell, and melanoma) occur mostly in light-skinned
individuals with a lot of sun exposure.
• Most basal cell carcinomas are above a line drawn across the mouth, while most
squamous cell carcinomas are below that line.

Diagnosis: Skin cancer

• Melanomas occur in pigmented lesions that either have the ABCD mnemonic
(ASYMETRIC, irregular BORDERS, various different COLORS, and a DIAMETER
over 0.5 cm.); or else pigmented lesions that have recently changed (in any way).


• Full thickness biopsy at the edge of the lesion, including the bed of the ulcer and the
normal skin next to it. Resection with appropriate margins.
Case #51:

A 12-year-old boy has a round, 1 cm. cystic mass in the midline of his neck, at about the level
of the hyoid bone. The mass retracts when the tongue is pulled forward. Although the mass
has been present for at least 8 years, it had not bothered the patient until it got infected and
drained some pus a few weeks ago.

Diagnosis: Thyroglossal duct cyst

• Congenital masses in the neck are seen in young people, they typically have been
noticed for several years, but medical help is not sought until they become

Common congenital masses in the neck:

1. Midline, at the level of the hyoid: Thyroglossal duct cyst

2. Up and down the anterior edge of the sternomastoid: Branchial cleft cysts

3. Mushy, at the base of the neck, supraclavicular: Cystic hygroma


• Elective surgical resection, removing the mass, the middle segment of the hyoid bone
and a core of muscle from the tongue all the way back to the foramen cecum.

Case #52:

3 months ago, an 18-year-old woman noticed the presence of a 2 cm., firm, non-tender node
located in the left jugular chain, at the level of the hyoid bone. She thinks it is larger now than
when it first came to her attention. For the past 3 weeks she has had low grade fever and
night sweats. Physical exam confirms the presence of the node, and also shows 2 other
smaller nodes on that side of the neck, as well as enlarged nodes in both axillas.

Diagnosis: Probably lymphoma

• The timetable of inflammatory neck nodes is measure in weeks, while that of
neoplastic nodes is typically of months.

Best diagnostic bets

neoplastic neck nodes

• Young person, multiple nodes: Lymphoma

• Supraclavicular node: Primary below the clavicles (not head and neck)
• Old man who smokes and drinks and has rotten teeth: Metastatic squamous cell
carcinoma from the mucosae of the head and neck.


• Start with FNA of the most accessible, largest node. Excisional biopsy will probably be
needed to establish specific tumor type.
• When dealing with a node that has just been discovered, a delay of a few weeks (two
or three) is appropriate before doing invasive, expensive studies. If the node was
inflammatory, it may go away during that time.

Case #53:

A 72-year-old man seeks help for a 4 cm., fixed, hard mass in the left jugular chain, at the
level of the upper edge of the thyroid cartilage. Patient says that he found it a week ago, but
his wife claims that it has been present for at least 6 months. The patient has a long-standing
history of alcohol and tobacco abuse, and he has terrible oral hygiene.

Diagnosis: Metastatic squamous cell carcinoma, from a primary in

the head and neck mucosa.

Other potential presentations:

• Persistent unilateral ear ache with serous otitis media

• Persistent hoarseness

• Unhealing ulcer in the mouth


• Do not biopsy the mass! (FNA is OK, but do not take a piece of it.) Best way to
establish the diagnosis is with panedoscopy (“triple endoscopy”) looking for and doing
biopsy of the primary (or primaries). Then CT scan for determine operability. Platinum-
based chemotherapy and radiation therapy have central role in therapy.


• Another area where open biopsy is a no-no: Tumors of the parotid gland (anything in
front of the ear, or behind the angle of the mandible)

Surgery Highlights for USMLE Step 2

Carlos Pestana, MD
General Surgery Cases

USMLE Step 2 — Lesson 6

Case #54:

A 64-year-old right-handed man has transitory episodes of aphasia and paralysis of

his right upper extremity. The episodes occur suddenly without prior warning, are not
associated with headache, and last only 10 minutes or so, leaving no neurological
sequela. His neurological exam is normal, but he has carotid bruits on both sides of
his neck.

Diagnosis: Transient ischemic attack (TIA)

• Neurological problems of vascular nature have sudden onset; without headache if

they are occlusive, with very severe headache if they are hemorrhagic.


• Duplex scanning of his carotid vessels, looking for stenosis of at least 70%, or
ulcerated carotid plaque, on the left. Carotid endarterectomy for either of the above.
• TIA’s are a predictor of strokes. Elective surgery is indicated if stenosis of at least
70%, or ulcerated plaques at the carotid bifurcation are found.

Case #55:

A 32-year-old lady comes to the ER because of an extremely severe headache of sudden

onset. She describes it as a “thunderclap,”, different from any other headache she’s had.
Neurological exam is completely normal. She is sent home with analgesics. Ten days later
she returns with a similar history, but this time she has nuchal rigidity.

Subarachnoid bleeding from an intracranial aneurysm

• The sequence of an undiagnosed “sentinel bleed,” and a second bleed a few days
later is often seen.
• Prognosis depends on severity or neurological deficit at the time of presentation.
Identifying the “sentinel bleed” is crucial, because the next one may be devastating.


• Other conditions leading the intracranial bleeding include A-V malformations and
uncontrolled hypertension.


• CT scan to demonstrate the bleeding

• Angiogram to delineate the aneurysm
• Eventual clipping of the aneurysm

Case #56:

A 42-year-old right-handed man has a history of progressive speech difficulties and right
hemiparesis for five months. For the past two months he has had progressively severe
headaches, worse in the mornings. At the time of admission he is confused, has projectile
vomiting, blurred vision, papilledema and diplopia.

Diagnosis: Brain tumor, on the left side, affecting the motor strip
and the speech center, with signs of increased intracranial

• The timetable of brain tumors is typically measured in months.

• Progressive headaches, worse in the mornings, are typical of brain tumors.


• Location nay not be obvious, if the tumor is pressing on a “silent area” of the brain,
but it may be clear if a particular function if affected.
• Some typical locations:

o Inappropriate behavior, anosmia: base of frontal lobe

o Bitemporal hemianopsia: optic chiasma, sella
o Loss of upper gaze: pineal area
o Ataxia, unstable gait: posterior fossa


• MRI for diagnosis.

• Mannitol, hyperventialtion and high dose corticosteroids (dexamethasone) to lower his
intracranial pressure, while preparing for surgery.
Case #57:

A 13-year-old boy presents with excruciating pain of sudden onset in his right testicle. No
fever, pyuria or history of recent mumps. The testis is swollen, very tender, located high in the
scrotum, and with its long axis in a horizontal position. Cord above the testis is not tender.

Diagnosis: Testicular torsion

• The differential diagnosis is with epididimitis.

• Epididimitis happens in sexually active men, there is fever and pyuria, the testis is in
the normal position and the cord as well as the testicle are exquisitely tender.
Sonogram should be done, just to make sure it is not testicular torsion. Treatment is
with antibiotics.


• A urological emergency. Immediate surgery is indicated, with no time wasted on any

diagnostic studies. Once the testis is untwisted and fixed, orchiopexy may also be
done on the other side.

Case #58:

A 74-year-old man has a 3mm. ureteral stone lodged just above the ureterovesical junction.
He is receiving IV fluids and analgesics, with the expectation that the stone will pass. He
suddenly develops chills, his temperature shoots up to 104, and he complains of severe flank

Diagnosis: Another urological emergency: the dreaded combination

of obstruction plus infection

• Urinary tract obstruction alone is bad

• Urinary tract infection alone is bad
• Those two together are horrible (one of the few true urological emergencies)
Diagnosis: Another urological emergency: the dreaded combination
of obstruction plus infection.

• Urinary tract infections that are unexpected (i.e. on people who should not get them),
have to be worked up for possible unsuspected obstruction. Examples:
o Urinary tract infection in children
o Urinary tract infections in men


• Massive doses of IV antibiotics and immediate decompression of the urinary tract

above the obstruction. In the presence of infection, manipulating and attempting to
extract the stone would be hazardous.

Case #59:

A 59-year-old man reports an episode of gross, painless hematuria, without any history of
trauma. He has normal renal function.

Diagnosis: Cancer of the kidney, ureter or bladder has to be ruled


• Most cases of hematuria are from benign disease, but cancer has to be ruled out on
all of them.


• Start with IVP, follow with cystoscopy

• IVP is the standard test to look for renal and ureteral tumors. It can not be done if
renal function is poor (creatinine above 2). CT scan is an alternative. Neither is very
good for bladder cancer, thus cystoscopy is also required.

Case #60:
During a routine physical, a 64-year-old black man is found on digital rectal exam to have a
rock-hard, discrete, 1.5 cm. nodule in his prostate.

Diagnosis: Prostatic cancer

• Except for very advanced cases, prostatic cancer is asymptomatic and has to be
actively sought.
• The two complementary screening exams are the digital rectal exam and the prostatic
specific antigen (PSA).
• The classical palpable tumor is a rock-hard discrete nodule.

Diagnosis: Prostatic cancer

• A high PSA without palpable nodule should lead to transrectal sonogram.

• After age 75, screening is no longer indicated.


• Transrectal needle biopsy.

• Resection after determining the extent of the disease.
• Advanced metastatic disease responds for a few years to androgen ablation (surgical
or medical).