A 56-year-old previously healthy woman with no other past medical history is post-operative day one from an open reduction and internal fixation of a fractured right radius and ulna after a motor vehicle accident. What is one of the primary ways of preventing postoperative pneumonia in this patient?

In-hospital intravenous antibiotics

A 21-year-old male presents to the emergency department after losing his footing and falling 20 feet off a construction scaffold. He hit his left side on a railing on the way down before landing on his left arm. He denies loss of consciousness during the event or feelings of lightheadedness. He has no significant past medical or surgical history and does not take any regular medications. Evaluation in the trauma bay revealed mild lacerations to the upper and lower extremities, pain to palpation in the distal left forearm, and bruising to the upper left quadrant of the abdomen as well as the lower left thorax. Free fluid was found in the abdomen by ultrasound, fluids were started, and he was rushed to the operating room for an exploratory laparotomy. A heavily lacerated spleen was discovered and removed. No other sources of bleeding were found. Further workup determined he suffered a non-displaced left distal radius fracture and non-displaced 9th and 10th rib fractures. Which of the following should be administered to this patient?

Total parenteral nutrition (TPN)

Open reduction internal fixation

A 66-year-old man is brought into the emergency department by his daughter for a change in behavior. Yesterday the patient seemed more confused than usual and was asking the same questions repetitively. His symptoms have not improved over the past 24 hours, thus the decision to bring him in today. Last year, the patient was almost completely independent but he then suffered a "series of falls," after which his ability to care for himself declined. After this episode he was no longer able to cook for himself or pay his bills but otherwise had been fine up until this episode. The patient has a past medical history of myocardial infarction, hypertension, depression, diabetes mellitus type II, constipation, diverticulitis, and peripheral neuropathy. His current medications include metformin, insulin, lisinopril, hydrochlorothiazide, sodium docusate, atorvastatin, metoprolol, fluoxetine, and gabapentin. On exam you note a confused man who is poorly kept. He has bruises over his legs and his gait seems unstable. He is alert to person and place, and answers some questions inappropriately. The patient's pulse is 90/minute and his blood pressure is 170/100 mmHg. Which of the following is the most likely diagnosis?

Pseudodementia (depression-related cognitive impairment)

A 25-year-old man comes to the physician for severe back pain. He describes the pain as shooting and stabbing. On a 10-point scale, he rates the pain as a 9 to 10. The pain started after he lifted a heavy box at work; he works at a supermarket and recently switched from being a cashier to a storekeeper. The patient appears to be in severe distress. Vital signs are within normal limits. On physical examination, the spine is nontender without paravertebral muscle spasms. Range of motion is normal. A straight-leg raise test is negative. After the physical examination has been completed, the patient asks for a letter to his employer attesting to his inability to work as a storekeeper. Which of the following is the most appropriate response?

I understand that you are uncomfortable, but the findings do not match the severity of your symptoms. Let's talk about the recent changes at your job.

“Yes. Since work may worsen your condition, I would prefer that you stay home a few days. I will write a letter to your employer to explain the situation.”

You say you are in severe pain. However, the physical examination findings do not suggest a physical problem that can be addressed with medications or surgery. I'd like to meet on a regular basis to see how you're doing.

The physical exam findings do not match your symptoms, which suggests a psychological problem. I would be happy to refer you to a mental health professional.

The physical exam findings suggest a psychological rather than a physical problem. But there is a good chance that we can address it with cognitive-behavioral therapy.

A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

"Can you tell me more about the symptoms you have been experiencing?"

"Does the diarrhea typically precede the constipation, or vice-versa?"

"Is the diarrhea foul-smelling?"

"Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"

"Are the symptoms worse in the morning or at night?"

A 66-year-old man weighing 50 kg (110 lb) is admitted to the hospital because of sepsis complicated by acute respiratory distress syndrome. The physician decides to initiate total parenteral nutrition and prescribes short-term hypocaloric intake of 20 kcal/kg/day with 20% of the total energy requirement provided by proteins and 30% provided by fats. The physician calculates that a total volume of 1100 mL/day should be infused during the parenteral nutrition therapy to maintain fluid balance. A colloid containing 10 g/dL of albumin and an emulsion with a fat concentration of 33 g/dL are used to prepare parenteral nutrition modules. Which of the following is the most appropriate module to meet the carbohydrate requirement in this patient over the next 24 hours?

500 mL of 25% dextrose solution

750 mL of 25% dextrose solution

750 mL of 10% dextrose solution

500 mL of 10% dextrose solution

250 mL of 50% dextrose solution

Frailty assessment for USMLE Step 2 CK: High-Yield Surgery Lessons

Frailty Fundamentals - Not Just Age

Definition: A clinical syndrome of ↑ vulnerability to stressors due to age-related declines in physiologic reserve and function across multiple systems. It's distinct from chronological age or disability.
Core Components (Fried Phenotype):
- Weight Loss: Unintentional, >10 lbs in the past year.
- Exhaustion: Self-reported.
- Low Activity: ↓ energy expenditure.
- Slowness: Measured by walking speed (e.g., over 4 meters).
- Weakness: Measured by grip strength.
Assessment: A patient is considered frail if they meet ≥3 of the five criteria. Pre-frail if 1-2 criteria are met.

⭐ Gait speed is one of the quickest and most powerful single predictors of adverse postoperative outcomes. A speed <0.8 m/s is a significant red flag.

Fried Frailty Phenotype Components

Frailty Metrics - The Measuring Sticks

Fried Frailty Phenotype (FFP): The most validated research/clinical tool. Defines frailty by the presence of ≥3 of 5 components.
- 📌 Mnemonic: WEAKS
- Weight loss (unintentional, >10 lbs in past year)
- Exhaustion (self-reported, e.g., "everything I did was an effort")
- Activity level low (e.g., <383 kcal/week for men)
- Kinetic slowness (timed 15-foot walk)
- Strength weakness (low grip strength by dynamometer)
- Scoring: 1-2 criteria = Pre-frail; ≥3 = Frail.
Frailty Index (FI): A cumulative deficit model. Ratio of deficits present to total deficits considered (e.g., 40-item FI). A score >0.25 often indicates frailty.
Clinical Frailty Scale (CFS): A judgment-based 9-point scale from 1 (Very Fit) to 9 (Terminally Ill). Fast and practical for clinical settings.

⭐ Frailty is a stronger predictor of poor surgical outcomes (complications, mortality, discharge to nursing home) than age or ASA score alone.

Prehab Power-Up - Boosting Resilience

Goal: Build physiologic reserve before surgery to mitigate stress & improve recovery.
Multimodal Approach (typically 2-6 weeks):
- Nutrition: High protein intake (1.5-2.0 g/kg/day); correct deficits (e.g., albumin, iron).
- Exercise: Tailored physical therapy; focus on strength, endurance, and mobility.
- Psychosocial: Manage anxiety/depression; smoking/alcohol cessation.

⭐ Prehabilitation can reduce major post-operative complications by up to 50% in frail patients undergoing major abdominal surgery.

High-Yield Points - ⚡ Biggest Takeaways

Frailty is a top predictor of post-operative morbidity, mortality, and prolonged hospital stay, independent of age or comorbidities.

It signifies a state of decreased physiologic reserve to cope with the stress of surgery.

Key markers include unintentional weight loss (>10 lbs/year), exhaustion, weak grip strength, and slow gait speed.

Simple screening tools like the "Timed Up and Go" test are highly effective.

Identifying frailty allows for prehabilitation to optimize patient outcomes.

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