BRAINSCAPE1
General Surgery Smarty PANCE
Exam with complete solutions
latest version
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 - CORRECT ANSWER-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 - CORRECT ANSWER-Compartmental pressures should
be obtained as soon as possible. If they are elevated this is a surgical emergency
A 23-year-old patient presents to the emergency department after a motor vehicle
accident. The patient was an unrestrained driver involved in a head-on collision.
The patient is heavily intoxicated on what he claims is only alcohol. An initial
trauma assessment is performed and is notable for significant bruising of the
right forearm. The patient is in the trauma bay and complains of severe pain in his
right forearm. A physical exam is performed and is notable for pallor, decreased
, BRAINSCAPE1
sensation, and cool temperature of the skin of the right forearm. Pain is elicited
upon passive movement of the right forearm and digits. A thready radial pulse is
palpable. A FAST exam is performed and is negative for signs of internal
bleeding. The patient's temperature is 99.5°F (37.5°C), pulse is 100/min, blood
pressure is 110/70 mmHg, respirations are 12/min, and oxygen saturation is 98%
on room air. Radiography of the right forearm i - CORRECT ANSWER-
Compartment syndrome presents with the 6 P's: Pain, Paresthesias,
Poikilothermia, Pallor, Pulselessness, and increased Pressure, and the best initial
step in management is a fasciotomy
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 - CORRECT ANSWER-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 - CORRECT ANSWER-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 - CORRECT ANSWER-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
, BRAINSCAPE1
C Rovsing's sign
D Turner sign - CORRECT ANSWER-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 - CORRECT ANSWER-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. Psoas sign is right lower
quadrant pain with right leg extension. Murphy's sign is seen in liver and
gallbladder disease in which the patient abruptly halts deep inspiration due to
discomfort as the examiner's hand applies pressure to the right upper quadrant.
Obturator sign is right lower quadrant pain with internal rotation of the hip.
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 - CORRECT ANSWER-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 - CORRECT ANSWER-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
, BRAINSCAPE1
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. - CORRECT ANSWER-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 a symptomatic
abdominal aortic aneurysm?
A abdominal mass
B hypertension
C chest pain
D syncope - CORRECT ANSWER-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 - CORRECT ANSWER-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 - CORRECT ANSWER-This patient has the signs and
symptoms consistent with Marfan's syndrome. Ectopia lentis, aortic root dilation
and aortic dissection are major criteria for the diagnosis of the disease.
A 56 year-old male presents to the office with a history of abdominal aortic
aneurysm. He was told that he will need on going evaluation to assess whether
General Surgery Smarty PANCE
Exam with complete solutions
latest version
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 - CORRECT ANSWER-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 - CORRECT ANSWER-Compartmental pressures should
be obtained as soon as possible. If they are elevated this is a surgical emergency
A 23-year-old patient presents to the emergency department after a motor vehicle
accident. The patient was an unrestrained driver involved in a head-on collision.
The patient is heavily intoxicated on what he claims is only alcohol. An initial
trauma assessment is performed and is notable for significant bruising of the
right forearm. The patient is in the trauma bay and complains of severe pain in his
right forearm. A physical exam is performed and is notable for pallor, decreased
, BRAINSCAPE1
sensation, and cool temperature of the skin of the right forearm. Pain is elicited
upon passive movement of the right forearm and digits. A thready radial pulse is
palpable. A FAST exam is performed and is negative for signs of internal
bleeding. The patient's temperature is 99.5°F (37.5°C), pulse is 100/min, blood
pressure is 110/70 mmHg, respirations are 12/min, and oxygen saturation is 98%
on room air. Radiography of the right forearm i - CORRECT ANSWER-
Compartment syndrome presents with the 6 P's: Pain, Paresthesias,
Poikilothermia, Pallor, Pulselessness, and increased Pressure, and the best initial
step in management is a fasciotomy
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 - CORRECT ANSWER-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 - CORRECT ANSWER-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 - CORRECT ANSWER-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
, BRAINSCAPE1
C Rovsing's sign
D Turner sign - CORRECT ANSWER-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 - CORRECT ANSWER-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. Psoas sign is right lower
quadrant pain with right leg extension. Murphy's sign is seen in liver and
gallbladder disease in which the patient abruptly halts deep inspiration due to
discomfort as the examiner's hand applies pressure to the right upper quadrant.
Obturator sign is right lower quadrant pain with internal rotation of the hip.
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 - CORRECT ANSWER-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 - CORRECT ANSWER-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
, BRAINSCAPE1
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. - CORRECT ANSWER-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 a symptomatic
abdominal aortic aneurysm?
A abdominal mass
B hypertension
C chest pain
D syncope - CORRECT ANSWER-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 - CORRECT ANSWER-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 - CORRECT ANSWER-This patient has the signs and
symptoms consistent with Marfan's syndrome. Ectopia lentis, aortic root dilation
and aortic dissection are major criteria for the diagnosis of the disease.
A 56 year-old male presents to the office with a history of abdominal aortic
aneurysm. He was told that he will need on going evaluation to assess whether
