A 34-year-old woman is recovering in the post-operative unit following a laparoscopic procedure for chronic endometriosis. She had initially presented with complaints of painful menstrual cramps that kept her bedridden most of the day. She also mentioned to her gynecologist that she had been diagnosed with endometriosis 4 years ago, and she could not find a medication or alternative therapeutic measure that helped. Her medical history was significant for surgery she had 6 years ago to remove tumors she had above her kidneys, after which she was prescribed hydrocortisone. An hour after the laparoscopic procedure, she calls the nurse because she is having difficulty breathing. The nurse records her vital signs include: blood pressure 85/55 mm Hg, respirations 20/min, and pulse 115/min. The patient suddenly loses consciousness. Intravenous fluids are started immediately. She gains consciousness, but her blood pressure is unchanged. Which of the following is the most likely cause of the hypotension?

Improper supplementation of steroids

Bleeding profusely through the surgical site

Infection involving the suture line

Loss of fluids during the procedure

A 68-year-old community-dwelling woman is transported to the emergency department with decreased consciousness, headache, and nausea. The symptoms began after the patient had a syncopal episode and fell at her home. She has a history of arterial hypertension and atrial fibrillation. Her current medications include hydrochlorothiazide, lisinopril, metoprolol, and warfarin. On admission, her blood pressure is 140/90 mm Hg, heart rate is 83/min and irregular, respiratory rate is 12/min, and temperature is 36.8°C (98.4°F). She is conscious and verbally responsive, albeit confused. She is able to follow motor commands. Her pupils are round, equal, and poorly reactive to light. She is unable to abduct both eyes on an eye movement examination. She has decreased strength and increased tone (Ashworth 1/4) and reflexes (3+) in her right upper and lower extremities. Her lungs are clear to auscultation. The cardiac examination shows the presence of S3 and a pulse deficit. A head CT scan is shown in the picture. Which of the following led to the patient’s condition?

Rupture of the cerebral bridging veins

Rupture of a saccular aneurysm in the carotid circulation region

Rupture of the middle meningeal artery

Laceration of the leptomeningeal blood vessels

Two hours after undergoing elective cholecystectomy with general anesthesia, a 41-year-old woman is evaluated for decreased mental status. BMI is 36.6 kg/m2. Respirations are 18/min and blood pressure is 126/73 mm Hg. Physical examination shows the endotracheal tube in normal position. She does not respond to sternal rub and gag reflex is absent. Arterial blood gas analysis on room air shows normal PO2 and PCO2 levels. Which of the following anesthetic properties is the most likely cause of these findings?

Low brain-blood partition coefficient

High minimal alveolar concentration

A 57-year-old man was brought into the emergency department unconscious 2 days ago. His friends who were with him at that time say he collapsed on the street. Upon arrival to the ED, he had a generalized tonic seizure. At that time, he was intubated and is being treated with diazepam and phenytoin. A noncontrast head CT revealed hemorrhages within the pons and cerebellum with a mass effect and tonsillar herniation. Today, his blood pressure is 110/65 mm Hg, heart rate is 65/min, respiratory rate is 12/min (intubated, ventilator settings: tidal volume (TV) 600 ml, positive end-expiratory pressure (PEEP) 5 cm H2O, and FiO2 40%), and temperature is 37.0°C (98.6°F). On physical examination, the patient is in a comatose state. Pupils are 4 mm bilaterally and unresponsive to light. Cornea reflexes are absent. Gag reflex and cough reflex are also absent. Which of the following is the next best step in the management of this patient?

Second opinion from a neurologist

Withdraw ventilation support and mark time of death

Repeat examination in several hours

A 24-year-old woman at 36 weeks pregnant presents to the emergency department with a headache and abdominal pain. The woman has no known past medical history and has inconsistently followed up with an obstetrician for prenatal care. Her temperature is 98.5°F (36.9°C), blood pressure is 163/101 mmHg, pulse is 90/min, respirations are 16/min, and oxygen saturation is 97% on room air. Prior to performing the physical exam, the patient experiences a seizure, which resolves after 60 seconds. Which of the following is the best management for this patient?

Diazepam, magnesium, and continuous monitoring

Magnesium and continuous monitoring

Nifedipine and cesarean section

A 55-year-old man presents to his primary care physician for a wellness checkup. The patient has a past medical history of alcohol abuse and is currently attending alcoholics anonymous with little success. He is currently drinking roughly 1L of hard alcohol every day and does not take his disulfiram anymore. Which of the following findings is most likely to also be found in this patient?

Increased transketolase activity

Neurological complications for USMLE Step 2 CK: High-Yield Surgery Lessons

Perioperative CVA - Brain Attack on Deck

Perioperative stroke: a neurological deficit of vascular cause, occurring within 30 days of surgery. Primarily ischemic (~80%) due to embolism or hypoperfusion.

Risk Factors: Advanced age (>65), prior CVA/TIA, cardiac surgery (esp. CABG), carotid stenosis, atrial fibrillation, intraoperative hypotension.

Feature	Ischemic CVA	Hemorrhagic CVA
Pathophysiology	Embolus, thrombus, watershed infarct	Vessel rupture, often from HTN
Key Feature	Focal deficit, often follows embolization	↑ICP signs (headache, vomiting)

⭐ > Highest risk is in cardiac surgery involving cardiopulmonary bypass due to aortic manipulation and potential for air/atheromatous emboli.

Post-Op Delirium & POCD - Confusion in the Wards

Post-Op Delirium: An acute, fluctuating disturbance in attention, awareness, and cognition. It's a common complication, especially in elderly patients.
POCD (Postoperative Cognitive Dysfunction): A more subtle and persistent decline in memory and concentration after anesthesia, lasting weeks to months.

Risk Factors: Advanced age (>65), pre-existing dementia/cognitive impairment, major surgery (cardiac, orthopedic), polypharmacy.
Precipitants: Infection (UTI, pneumonia), hypoxia, electrolyte disturbances, pain, and medications (e.g., benzodiazepines, anticholinergics).

⭐ High-Yield: The Confusion Assessment Method (CAM) is a key diagnostic tool, requiring features 1 (acute onset/fluctuating course) AND 2 (inattention), plus EITHER 3 (disorganized thinking) OR 4 (altered level of consciousness).

Post-Op Seizures - The Brain's Short Circuit

Etiologies: Metabolic disturbances (hyponatremia, hypoglycemia, hypocalcemia), hypoxia, drug toxicity (e.g., local anesthetics, meperidine), alcohol/benzodiazepine withdrawal, or underlying epilepsy.
Immediate Management:

⭐ Exam Favorite: Suspect acute hyponatremia as a cause in post-TURP or hysteroscopy patients due to absorption of hypotonic irrigation fluids.

Peripheral Nerve Injuries - Nerves Under Pressure

Most are traction or compression neuropathies from poor positioning.

Nerve Palsy Prevention in Surgical Positioning

Nerve	Mechanism of Injury	Presentation
Ulnar	Pressure on medial elbow (supine)	Claw hand (4th/5th digits), ↓ sensation
Radial	Arm over screen, compression in axilla	Wrist drop, ↓ grip strength
Common Peroneal	Stirrups, lateral knee pressure	Foot drop, ↓ dorsiflexion/eversion
Brachial Plexus	Arm abduction >90°, shoulder braces	Varies; arm/hand weakness/numbness

📌 PED: Peroneal Everts & Dorsiflexes.

High-Yield Points - ⚡ Biggest Takeaways

Central Pontine Myelinolysis results from rapid hyponatremia correction, causing spastic quadriplegia and pseudobulbar palsy.

Postoperative delirium is common in the elderly; rule out reversible causes like hypoxia, infection, and medications.

Perioperative stroke risk is increased by atrial fibrillation, carotid disease, and intraoperative hypotension.

Post-op seizures can be triggered by metabolic disturbances, hypoxia, or substance withdrawal.

Peripheral nerve injuries are usually due to improper positioning, affecting the brachial plexus or common peroneal nerve.

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