An 18-year-old patient has a tibia/fibula fracture following a motorcycle crash. Twelve hours
later the patient presents with increased pain despite adequate doses of analgesics and
immobilization. Which of the following is the most likely diagnosis?
A avascular necrosis
B myositis ossificans
C compartment syndrome
D reflex sympathetic dystrophy - ANSWER C
Compartment syndrome is characterized by a pathological increase of pressure within a
closed space and results from edema or bleeding within the compartment. It may occur as
an early local complication of fracture.
A 38 year-old male sustained a fracture of the left distal tibia following a 25-foot fall and is
taken to the operating room for an open reduction internal fixation of the distal tibia.
Sixteen hours post-op, the patient develops sustained pain, which is not relieved with
narcotics. On passive range of motion of the toes the patient "yells" in agony. The patient
also states that the top of his foot has decreased sensation. On physical examination the
physician assistant notes that the leg is swollen and the foot is cool to touch. Based upon
this information what diagnostic testing should be done?
A X-ray of the lower leg and ankle
B Doppler studies
C Bone scan.
D Compartment pressure - ANSWER D
1
,Compartmental pressures should be obtained as soon as possible. If they are elevated this is
a surgical emergency.
A 35 year-old male placed in a thumb spica cast for a scaphoid fracture presents complaining
of forearm and hand pain that is not relieved with pain medication and elevation. Which of
the following is the earliest physical exam sign for his current condition?
A Slow capillary refill
B Loss of two-point discrimination
C Absent peripheral pulses
D Pain with passive stretch. - ANSWER B
Loss of two-point discrimination can be the earliest sign of compartment syndrome.
25 year-old male presents to the ED with left calf pain and cramping, as well as nausea and
vomiting. He admits to "partying with cocaine all night". He describes his urine as a dark
brown color. Serum creatinine kinase (CK) is 1325 IU/L (Normal Range 32-267 IU/L). Which
of the following is the initial mainstay of therapy for this condition?
A IV rehydration
B Fasciotomy
C Toradol (Ketorlac)
D Hydrotherapy - ANSWER A
IV rehydration with crystalloids for 24 to 72 hours is the mainstay of therapy for
rhabdomyolysis.
A 42 year-old male presents complaining of a sudden onset of a severe intermittent pain
originating in the flank and radiating into the right testicle. He also complains of nausea and
vomiting. On examination the patient is afebrile, but restless. Examination of the abdomen
reveals tenderness to palpation along the right flank with no rebound or direct testicular
tenderness. Urinalysis reveals a pH of 5.4 and microscopic hematuria, but is otherwise
unremarkable. Which of the following is the most likely diagnosis?
2
,A Bladder cancer
B Nephrolithiasis
C Acute appendicitis
D Acute epididymitis - ANSWER B
A sudden onset of severe colicky flank pain associated with nausea and vomiting as well as
the absence of rebound or direct testicular tenderness makes nephrolithiasis the most likely
diagnosis. This is further supported by the presence of hematuria on the urinalysis.
Which of the following pathophysiological processes is believed to initiate acute
appendicitis?
A Obstruction
B Perforation
C Hemorrhage
D Vascular compromise - ANSWER A
Obstruction of the appendiceal lumen by lymphoid hyperplasia, a fecalith or foreign body
initiates most cases of appendicitis
What is the term for blue discoloration about the umbilicus?
A Cullen's sign
B Murphy's sign
C Rovsing's sign
D Turner sign - ANSWER A
Cullen's sign is a blue discoloration about the umbilicus and can occur in hemorrhagic
pancreatitis and results from hemoperitoneum.
3
, A patient presents with abdominal pain in the right lower quadrant, examination reveals
increased pain in the right lower quadrant on deep palpation of the left lower quadrant. This
commonly known as which of the following?
A Psoas sign
B Murphy's sign
C Rovsing's sign
D Obturator sign - ANSWER C
A positive Rovsing's sign can be elicited in a patient with appendicitis when increased pain
occurs in the right lower quadrant upon palpation of the left lower quadrant.
A 25 year-old female presents with right lower quadrant pain, right flank pain, nausea, and
vomiting. Her temperature is 39.6 degrees C. There is right CVA tenderness and RLQ
tenderness. Pelvic exam is unremarkable. Urinalysis reveals pH 7.0, trace protein, negative
glucose, negative ketones, positive blood, and positive nitrates. Specific gravity is 1.022.
Microscopic shows 102 RBCs/HPF, 50-75 WBCs/HPF, rare epithelial cells, and WBC casts. The
most likely diagnosis is
A acute salpingitis.
B nephrolithiasis.
C acute pyelonephritis.
D appendicitis. - ANSWER C
Acute pyelonephritis presents with flank pain, fever, and generalized muscle tenderness.
Urinalysis shows pyuria with leukocyte casts.
A 26 year-old gravida 0 sexually active female presents to the emergency room complaining
of colicky pain in her lower abdomen for the past 12 hours. She passed out earlier in the day
while trying to have a bowel movement. Her last menstrual period was 6 weeks ago. She has
noted vaginal spotting over the last 24 hours. Vital signs show Temp 37 degrees C, BP
96/60mmHg, P 110, R 16, Oxygen Sat. 98%. Abdominal exam is positive for distension and
tenderness. Bowel sounds are decreased. Pelvic exam shows cervical motion and adnexal
tenderness. Which of the following is the most likely diagnosis?
4
later the patient presents with increased pain despite adequate doses of analgesics and
immobilization. Which of the following is the most likely diagnosis?
A avascular necrosis
B myositis ossificans
C compartment syndrome
D reflex sympathetic dystrophy - ANSWER C
Compartment syndrome is characterized by a pathological increase of pressure within a
closed space and results from edema or bleeding within the compartment. It may occur as
an early local complication of fracture.
A 38 year-old male sustained a fracture of the left distal tibia following a 25-foot fall and is
taken to the operating room for an open reduction internal fixation of the distal tibia.
Sixteen hours post-op, the patient develops sustained pain, which is not relieved with
narcotics. On passive range of motion of the toes the patient "yells" in agony. The patient
also states that the top of his foot has decreased sensation. On physical examination the
physician assistant notes that the leg is swollen and the foot is cool to touch. Based upon
this information what diagnostic testing should be done?
A X-ray of the lower leg and ankle
B Doppler studies
C Bone scan.
D Compartment pressure - ANSWER D
1
,Compartmental pressures should be obtained as soon as possible. If they are elevated this is
a surgical emergency.
A 35 year-old male placed in a thumb spica cast for a scaphoid fracture presents complaining
of forearm and hand pain that is not relieved with pain medication and elevation. Which of
the following is the earliest physical exam sign for his current condition?
A Slow capillary refill
B Loss of two-point discrimination
C Absent peripheral pulses
D Pain with passive stretch. - ANSWER B
Loss of two-point discrimination can be the earliest sign of compartment syndrome.
25 year-old male presents to the ED with left calf pain and cramping, as well as nausea and
vomiting. He admits to "partying with cocaine all night". He describes his urine as a dark
brown color. Serum creatinine kinase (CK) is 1325 IU/L (Normal Range 32-267 IU/L). Which
of the following is the initial mainstay of therapy for this condition?
A IV rehydration
B Fasciotomy
C Toradol (Ketorlac)
D Hydrotherapy - ANSWER A
IV rehydration with crystalloids for 24 to 72 hours is the mainstay of therapy for
rhabdomyolysis.
A 42 year-old male presents complaining of a sudden onset of a severe intermittent pain
originating in the flank and radiating into the right testicle. He also complains of nausea and
vomiting. On examination the patient is afebrile, but restless. Examination of the abdomen
reveals tenderness to palpation along the right flank with no rebound or direct testicular
tenderness. Urinalysis reveals a pH of 5.4 and microscopic hematuria, but is otherwise
unremarkable. Which of the following is the most likely diagnosis?
2
,A Bladder cancer
B Nephrolithiasis
C Acute appendicitis
D Acute epididymitis - ANSWER B
A sudden onset of severe colicky flank pain associated with nausea and vomiting as well as
the absence of rebound or direct testicular tenderness makes nephrolithiasis the most likely
diagnosis. This is further supported by the presence of hematuria on the urinalysis.
Which of the following pathophysiological processes is believed to initiate acute
appendicitis?
A Obstruction
B Perforation
C Hemorrhage
D Vascular compromise - ANSWER A
Obstruction of the appendiceal lumen by lymphoid hyperplasia, a fecalith or foreign body
initiates most cases of appendicitis
What is the term for blue discoloration about the umbilicus?
A Cullen's sign
B Murphy's sign
C Rovsing's sign
D Turner sign - ANSWER A
Cullen's sign is a blue discoloration about the umbilicus and can occur in hemorrhagic
pancreatitis and results from hemoperitoneum.
3
, A patient presents with abdominal pain in the right lower quadrant, examination reveals
increased pain in the right lower quadrant on deep palpation of the left lower quadrant. This
commonly known as which of the following?
A Psoas sign
B Murphy's sign
C Rovsing's sign
D Obturator sign - ANSWER C
A positive Rovsing's sign can be elicited in a patient with appendicitis when increased pain
occurs in the right lower quadrant upon palpation of the left lower quadrant.
A 25 year-old female presents with right lower quadrant pain, right flank pain, nausea, and
vomiting. Her temperature is 39.6 degrees C. There is right CVA tenderness and RLQ
tenderness. Pelvic exam is unremarkable. Urinalysis reveals pH 7.0, trace protein, negative
glucose, negative ketones, positive blood, and positive nitrates. Specific gravity is 1.022.
Microscopic shows 102 RBCs/HPF, 50-75 WBCs/HPF, rare epithelial cells, and WBC casts. The
most likely diagnosis is
A acute salpingitis.
B nephrolithiasis.
C acute pyelonephritis.
D appendicitis. - ANSWER C
Acute pyelonephritis presents with flank pain, fever, and generalized muscle tenderness.
Urinalysis shows pyuria with leukocyte casts.
A 26 year-old gravida 0 sexually active female presents to the emergency room complaining
of colicky pain in her lower abdomen for the past 12 hours. She passed out earlier in the day
while trying to have a bowel movement. Her last menstrual period was 6 weeks ago. She has
noted vaginal spotting over the last 24 hours. Vital signs show Temp 37 degrees C, BP
96/60mmHg, P 110, R 16, Oxygen Sat. 98%. Abdominal exam is positive for distension and
tenderness. Bowel sounds are decreased. Pelvic exam shows cervical motion and adnexal
tenderness. Which of the following is the most likely diagnosis?
4
