Welcome to episode 53 of the FREE Audio PANCE and PANRE Physician Assistant Board Review Podcast.

Join me as I cover ten PANCE and PANRE Board review questions from the Academy course content following the NCCPA™ content blueprint (download the FREE cheat sheet) and the PAEA End of Rotation™ Exams Blueprints & Topic Lists.

This week we will be covering ten General Surgery End of Rotation Exam Questions that are now part of the SMARTYPANCE website.

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Episode 51: General Surgery Endo of Rotation Exam Podcast Quiz

The following 10 questions are linked to NCCPA™ Content Blueprint lessons from the SMARTYPANCE and PANRE Board review website. If you are a member you will be able to log in and view this interactive video content.

1. 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

Click here to see the answer 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.

2. A 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 (Ketorolac)

D. Hydrotherapy

Click here to see the answer 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

3. 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

Click here to see the answer 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

4. 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

Click here to see the answer 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

5. 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. The 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. Microscopy 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

Click here to see the answer 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.

6. 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

Click here to see the answer 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

7. 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

Click here to see the answer 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

8. A 28-year-old male presents with burns sustained from hot grease splashed on his left hand earlier this afternoon. The burn extends from his palm to the volar aspect of his wrist and has an erythematous base, covered by an intact blister. There are a few small scattered blisters over the dorsum of the left hand. Which of the following is the initial intervention of choice?

A. Tetanus prophylaxis

B. Admission to a burn unit

C. Intravenous fluid administration

D. Debridement of blisters

Click here to see the answer 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.

9. Which of the following is the selected method for the prevention of venous thromboembolism in a 38-year-old male undergoing an inguinal hernia repair?

A. early ambulation

B. elastic stockings

C. intermittent pneumatic compression

D. low-molecular weight heparin

Click here to see the answer 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.

10. 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 is commonly known as which of the following?

A. Psoas sign

B. Murphy's sign

C. Rovsing's sign

D. Obturator sign

Click here to see the answer 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

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