Episode 53: General Surgery End of Rotation Exam – The Audio PANCE and PANRE Podcast

Answer: C. Compartment syndrome

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. Avascular necrosis occurs primarily in muscles post-traumatically and may not arise for several months after an injury.

B. Myositis ossificans is a late complication of fracture resulting from disruption of the blood supply to the bone.

D. Reflex sympathetic dystrophy is characterized by painful wasting of the hand muscles that may be secondary to injury and could occur as a late complication.

Answer: A. IV rehydration

IV rehydration with crystalloids for 24 to 72 hours is the mainstay of therapy for rhabdomyolysis.

B. Fasciotomy is indicated for compartment syndrome.

C. NSAIDs, such as Toradol (Ketorolac), should not be used due to the vasoconstrictive effects on the kidneys.

D. Hydrotherapy is not useful or indicated for Rhabdomyolysis

Answer: B. Nephrolithiasis

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.

A. While bladder cancer may have associated microscopic hematuria, it presents with painless hematuria or irritative voiding symptoms.

C. While an acute abdomen, such as acute appendicitis, is in the differential diagnosis, the absence of fever and peritoneal signs makes this diagnosis less likely

D. The absence of fever, as well as non-tenderness to palpation of the testes, suggests a renal rather than gonadal cause of the patient's symptoms

Answer: A. Cullen's sign

Cullen's sign is a blue discoloration about the umbilicus and can occur in hemorrhagic pancreatitis and results from hemoperitoneum.

B. Murphy's sign is seen in liver and gallbladder disease by which the patient abruptly halts deep inspiration due to pain in the right upper quadrant while the examiner's hand is keeping stable pressure to the area.

C. Rovsing's sign is positive when the patient experiences right-sided abdominal pain with palpation to the left side. This is generally seen in those with appendicitis.

D. Turner sign is also seen in severe, acute pancreatitis but is represented by a green-brown discoloration of bilateral flanks

Answer: C. acute pyelonephritis

Acute pyelonephritis presents with flank pain, fever, and generalized muscle tenderness. Urinalysis shows pyuria with leukocyte casts.

A. Acute salpingitis would be suggested if pelvic exam abnormalities were present.

B. Nephrolithiasis does not usually present with fever or casts. Urinalysis will have RBCs present.

D. This scenario is consistent with acute pyelonephritis, not acute appendicitis.

Answer: A. Ectopic pregnancy 

High suspicion for ectopic pregnancy should be maintained when any possible pregnant woman presents with vaginal bleeding or abdominal pain.

B. Appendicitis presents with nausea, vomiting and periumbilical pain that moves to the right lower quadrant of the abdomen.

C. Crohn's disease is more common in women and may present with an acute abdomen. However, the pelvic examination would be normal.

D. In pelvic inflammatory disease, the temperature is usually above 38 degrees C and pelvic pain usually follows onset of cessation of menses

Answer: C. coarctation of the aorta

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. Abdominal aortic aneurysm is usually asymptomatic until the patient has dissection or rupture. It is uncommon in a child.

B. Pheochromocytoma classically causes paroxysms of hypertension due to catecholamine release from the adrenal medulla but does not cause variations in blood pressure in the upper and lower extremities.

D. Thoracic outlet syndrome occurs when the brachial plexus, subclavian artery, or subclavian vein becomes compressed in the region of the thoracic outlet. It is the most common cause of acute arterial occlusion in the upper extremity of adults under 40 years old

Answer: A. Tetanus prophylaxis

Tetanus prophylaxis should be initially considered in all burn patients. 

B. Admission to a burn unit is not indicated for adult patients with uncomplicated partial thickness burns covering less than 15 to 20% of total body surface area (TBSA).

C. IV fluids are indicated for severe partial thickness burns covering more than 10% TBSA or in burns with complications.

D. Debridement of blisters is controversial, however blisters on the palms and soles should remain intact.

Answer: A. early ambulation 

Early ambulation is recommended for prophylaxis of venous thromboembolism in low-risk, minor procedures when the patient is under 40 years of age and there are no clinical risk factors.

B. Elastic stockings are indicated for patients at moderate risk of venous thromboembolism in ages 40-60 with minor procedures with additional thrombosis risk factor, or major operations for patients under age 40 without additional clinical risk factors.

C. Intermittent pneumatic compression is indicated in patients undergoing a major operation plus an increased risk of bleeding.

D. Low molecular weight heparin is indicated in patients undergoing orthopedic surgery, neurosurgery, or trauma with an identifiable risk factor for thromboembolism.

Answer: C. Rovsing's sign 

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. Psoas sign is right lower quadrant pain with right leg extension seen in acute appendicitis

B. 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.

D. Obturator sign is right lower quadrant pain with internal rotation of the hip seen in acute appendicitis

Appendicitis: RLQ pain, + Obturator and Psoas sign