General Surgery End of Rotation Exam
Questions
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
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?
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.
,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?
A Ectopic pregnancy
B Appendicitis
C Crohn's disease
D Pelvic inflammatory disease - Answer A
High suspicion for ectopic pregnancy should be maintained when any possible pregnant
woman presents with vaginal bleeding or abdominal pain.
A 22 year-old male presents to the clinic complaining of scrotal pain that radiates into
the groin. Patient admits to being a weightlifter and was lifting 24 hours prior to this pain
developing into the scrotum. The patient admits to being sexually active with only his
male partner. Examination reveals a reddened scrotum and it is difficult to distinguish
, the epididymis from the testes on the right side. Elevation of the right testicle brings
relief of the pain. This is known as a positive
A Prehn's sign.
B Cullen's sign.
C Rovsing's sign.
D Murphy's sign. - Answer A
Prehn's sign is seen in epididymitis when elevation of the scrotum with the affected
epididymis to the level of the symphysis pubis brings relief from the pain.
Which of the following conditions is most suggestive of an asymptomatic abdominal
aortic aneurysm?
A abdominal mass
B hypertension
C chest pain
D syncope - Answer A
Symptomatic abdominal aortic aneurysm presents with pulsating upper abdominal
mass.
A 12-year-old boy presents to the office with pain in his legs with activity gradually
becoming worse over the past month. He is unable to ride a bicycle with his friends due
to the pain in his legs. Examination of the heart reveals an ejection click and
accentuation of the second heart sound. Femoral pulses are weak and delayed
compared to the brachial pulses. Blood pressure obtained in both arms is elevated.
Chest x-ray reveals rib notching. Which of the following is the most likely diagnosis?
A abdominal aortic aneurysm
B pheochromocytoma
C coarctation of the aorta
D thoracic outlet syndrome - Answer C
Coarctation is a discrete or long segment of narrowing adjacent to the left subclavian
artery. As a result of the coarctation, systemic collaterals develop. X-ray findings occur
from the dilated and pulsatile intercostal arteries and the "3"is due to the coarctation site
with proximal and distal dilations.
A 19 year-old female presents with complaint of palpitations. On examination you note
the patient to have particularly long arms and fingers and a pectus excavatum. She has
a history of joint dislocation and a recent ophthalmologic examination revealed ectopic
lentis. Which of the following echocardiogram findings would be most consistent with
this patient's physical features?
A right atrial enlargement
B aortic root dilation
C pulmonic stenosis
D ventricular septal defect - Answer B
Questions
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
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?
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.
,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?
A Ectopic pregnancy
B Appendicitis
C Crohn's disease
D Pelvic inflammatory disease - Answer A
High suspicion for ectopic pregnancy should be maintained when any possible pregnant
woman presents with vaginal bleeding or abdominal pain.
A 22 year-old male presents to the clinic complaining of scrotal pain that radiates into
the groin. Patient admits to being a weightlifter and was lifting 24 hours prior to this pain
developing into the scrotum. The patient admits to being sexually active with only his
male partner. Examination reveals a reddened scrotum and it is difficult to distinguish
, the epididymis from the testes on the right side. Elevation of the right testicle brings
relief of the pain. This is known as a positive
A Prehn's sign.
B Cullen's sign.
C Rovsing's sign.
D Murphy's sign. - Answer A
Prehn's sign is seen in epididymitis when elevation of the scrotum with the affected
epididymis to the level of the symphysis pubis brings relief from the pain.
Which of the following conditions is most suggestive of an asymptomatic abdominal
aortic aneurysm?
A abdominal mass
B hypertension
C chest pain
D syncope - Answer A
Symptomatic abdominal aortic aneurysm presents with pulsating upper abdominal
mass.
A 12-year-old boy presents to the office with pain in his legs with activity gradually
becoming worse over the past month. He is unable to ride a bicycle with his friends due
to the pain in his legs. Examination of the heart reveals an ejection click and
accentuation of the second heart sound. Femoral pulses are weak and delayed
compared to the brachial pulses. Blood pressure obtained in both arms is elevated.
Chest x-ray reveals rib notching. Which of the following is the most likely diagnosis?
A abdominal aortic aneurysm
B pheochromocytoma
C coarctation of the aorta
D thoracic outlet syndrome - Answer C
Coarctation is a discrete or long segment of narrowing adjacent to the left subclavian
artery. As a result of the coarctation, systemic collaterals develop. X-ray findings occur
from the dilated and pulsatile intercostal arteries and the "3"is due to the coarctation site
with proximal and distal dilations.
A 19 year-old female presents with complaint of palpitations. On examination you note
the patient to have particularly long arms and fingers and a pectus excavatum. She has
a history of joint dislocation and a recent ophthalmologic examination revealed ectopic
lentis. Which of the following echocardiogram findings would be most consistent with
this patient's physical features?
A right atrial enlargement
B aortic root dilation
C pulmonic stenosis
D ventricular septal defect - Answer B
