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USMLE Step 2 CK High-Yield General Surgery Topics
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General Surgery
High Yield USMLE Step 2 CK Notes
Welcome to the General Surgery High-Yield Notes for Step 2 CK.
These are the most commonly tested topics on the exam—ideal for quick review in your last 2 weeks before the exam, when you’re short on time, or when you’re just starting out and want to focus on what is high yield. Created and peer-reviewed by physicians who scored 260+ on Step 2 CK in a Q&A style to reinforce active learning.
How to use this file
- Read the question ➔ cover the answer ➔ self-quiz before revealing.
- Review the NOTES ➔ they include high-yield details you don’t want to miss.
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- Don’t forget to watch the video lessons that go with this file. Learn more here.
Table of Contents
- General Surgery Principles & Post-Op Care
- Transplant & Immunologic Reactions
- Cardiovascular surgery
- Pulmonary & Chest Surgery
- Gastrointestinal Surgery & Emergencies
- Endocrine Surgery & Emergencies
- Skin & Soft Tissue
- Musculoskeletal & Orthopedic Surgery
- Neurologic & Spine surgery
- Genitourinary surgery
- Trauma & Emergency Surgery
- Environmental/Toxines
General Surgery Principles & Post-Op Care
1. Four days after surgery for a hip fracture, a 72-year-old woman develops fever, rigors, and hypotension. She has a central venous catheter and a clean, well-healing surgical incision. What could have prevented this complication?
➔ Use of maximal barrier precautions during catheter insertion (Post-op sepsis + central line + no other source → Central Line-Associated Bloodstream Infection→ Prevented with full sterile technique)
- Note: Prevention requires:
○ Hand hygiene
○ Chlorhexidine antisepsis
○ Maximal barrier precautions (sterile gloves, gown, cap, mask)
○ Remove catheter as soon as it is no longer needed
2. A 56-year-old ICU patient with a central line develops fever, hypotension, and leukocytosis. Blood cultures grow Candida albicans. What is the next step in management?
➔ Remove the central line and start IV antifungal therapy (ICU patient + central line + candidemia → Remove source + treat with IV antifungals)
- Note: Evaluate for complications of candidemia → Fundoscopic exam for endophthalmitis
Differentiation Table
| Condition | Clue | How to Differentiate |
|---|---|---|
| Candidemia | ICU, central line, Candida in blood | Remove line + antifungal |
| Bacterial sepsis | No fungal growth | Manage with antibiotics |
3. A 56-year-old woman receiving total parenteral nutrition through a central venous catheter develops a new fever and leukocytosis. What is the next step in management?
➔ Obtain blood cultures from the catheter and a peripheral site (New fever + central line + TPN → Suspect catheter-associated blood stream infection→ Start with blood cultures)
- Note: Removal of the central venous catheter is recommended in almost all circumstances
4. A 67-year-old man develops hypotension and tachycardia 6 hours after abdominal surgery. His hematocrit drops from 42% to 28%, and central venous pressure is low. He appears pale and has swelling around the surgical site. What is the next step in management?
➔ Aggressive IV fluid resuscitation and blood transfusion (Post-op hypotension → suspected bleeding → stabilize first, then consider re-exploration)
5. A 65-year-old obese man with COPD undergoes abdominal surgery. Post-op, he develops dyspnea, somnolence, and ABG shows hypoxemia and hypercapnia. What is the next step in management?
➔ Endotracheal intubation and mechanical ventilation (COPD + obesity + post-op + hypercapnic respiratory failure → suggest Perioperative Respiratory Failure → Intubate)
- Note: Mechanism includes → diaphragmatic dysfunction, splinting, pain → leading to hypoventilation
- Management:
○ Immediate: CPAP or BiPAP → improves oxygenation, ↓ work of breathing
○ Immediate intubation if signs of respiratory failure
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6. A 45-year-old man undergoes emergency abdominal surgery after a traumatic injury. The wound is left open with a wound vacuum dressing due to intraoperative contamination. What is the wound management strategy?
➔ Delayed primary closure (Contaminated wound → Leave open initially to prevent infection → Plan delayed closure)
- Note: Wound left open to drain → leads to reduced infection risk
- Often managed with negative pressure wound therapy (vac dressing)
7. A 60-year-old man is recovering from a laparotomy for bowel obstruction. On postoperative day 5, exam shows a gush of serosanguinous fluid from the wound without visible bowel. What is the next step in management?
➔ Abdominal binder and close monitoring (Sudden serosanguinous drainage without bowel exposure → think Wound dehiscence → Support and monitor)
- Note: If bowel or omentum is visible → this is evisceration
○ Requires immediate surgical exploration
8. A 42-year-old man with extensive burns has been on mechanical ventilation for 14 days and is scheduled for multiple upcoming surgical debridements. What is the next step in management?
➔ Perform tracheostomy (Prolonged intubation >7–10 days + need for ongoing airway access → Switch to tracheostomy)
- Note: Indicated after 7–10 days of mechanical ventilation
9. A 66-year-old woman with rheumatoid arthritis on prednisone and a TNF-α inhibitor presents with fever and hypotension. Labs show leukocytosis and elevated lactate. What is the diagnosis?
➔ Septic shock (Fever + hypotension + lactic acidosis + immunosuppression → Sepsis with distributive shock)
- Note: Serum lactate concentration is reflective of organ hypoperfusion and dysfunction.
- Risk factors: Immunosuppression, indwelling lines, recent procedures
- Treatment: IV fluids + broad-spectrum antibiotics + vasopressors if needed
10. A 60-year-old man is recovering from abdominal surgery and has moderate to severe pain but is unable to take oral medications. What is the next step in pain management?
➔ Initiate patient-controlled analgesia (PCA) (Severe pain + NPO or poor oral intake → PCA is preferred for safe, adjustable opioid delivery)
- Note: Ideal for moderate–severe postoperative pain
- Delivers IV opioids in controlled boluses with lockout timing
11. A 68-year-old man develops fever, mild dyspnea, and ↓ breath sounds in the right lower lung 24 hours after abdominal surgery. ABG shows hypoxemia with normal PaCO₂. What is the cause?
➔ Postoperative atelectasis (Post-op day 1–2 + fever + ↓ breath sounds + hypoxemia without hypercapnia → Think Atelectasis)
- Note: ↓ Ventilation (e.g., pain, splinting, shallow breaths) → leads to airway collapse atelectasis
- CXR shows → Lung opacity, loss of volume
- Management: Incentive spirometry, early ambulation, adequate pain control
- Incentive spirometry prevents both post-op atelectasis and pneumonia.
12. A 58-year-old woman is 6 hours post laparoscopic cholecystectomy. She is alert but appears uncomfortable and restless. Vitals: BP 158/92 mmHg, HR 112/min, RR 24/min. Temperature is 37.0°C. Physical exam reveals guarding at the incision site. What is the next best step in management?
➔ Administer intravenous analgesics (Post-op + tachycardia, hypertension, tachypnea + guarding + no fever → Pain-induced sympathetic activation → Treat pain)
- Note: Alert and afebrile status + guarding → points toward pain rather than sepsis or sedation
13. A 74-year-old man undergoes inguinal hernia repair. Eight hours after surgery, he reports lower abdominal discomfort and has not voided. Bladder scan reveals 600 mL of urine. What is the next step in management?
➔ Urethral catheterization (Post-op + distended bladder on USG + >500 mL urine → Postoperative urinary retention → Relieve with catheter)
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Transplant & Immunologic Reactions
14. A 55-year-old man with a kidney transplant 2 years ago presents with gradual rise in creatinine despite adherence to immunosuppressants. Imaging shows a shrunken graft. What is the cause?
➔ Chronic rejection (Gradual ↑ in creatinine + >6 months post-transplant + graft atrophy → Think chronic rejection)
- Note: Imaging shows → shrunken graft
- Treatment → No curative therapy → consider re-transplant
Differentiation Table
| Condition | Clue | How to Differentiate |
|---|---|---|
| Chronic rejection | Months–years, fibrosis | Irreversible, slow onset |
| Acute rejection | <6 month, lymphocytic infiltrate | Responds to steroids |
| Hyperacute rejection | Immediate graft failure | Preformed Abs, thrombosis |
15. A 64-year-old man develops fever, shortness of breath, and back pain within an hour of starting a packed RBC transfusion. Urine appears red, and Coombs test is positive. What is the cause?
➔ Acute hemolytic transfusion reaction (ABO incompatibility) (Fever + flank pain + red urine shortly after transfusion → Think acute hemolytic reaction due to ABO mismatch)
- Note: Next step → Immediately stop transfusion and start supportive care
Differentiation Table
| Reaction Type | Timing | Key Features |
|---|---|---|
| Acute hemolytic (AHTR) | <1 hr | Fever, back pain, hemoglobinuria, shock |
| Febrile non-hemolytic | 1–6 hrs | Fever/chills only, no hemolysis |
| Anaphylactic | Seconds–minutes | Hypotension, wheezing, IgA deficiency |
16. A 66-year-old woman develops fever and chills 2 hours after receiving a packed red blood cell transfusion. Vitals are stable. There is no hypotension, back pain, or hemoglobinuria. What is the cause?
➔ Febrile nonhemolytic transfusion reaction (FNHTR) (Fever + chills during or shortly after transfusion + no signs of hemolysis → Think FNHTR)
- Note: Caused by → cytokines or recipient antibodies against donor WBCs
- If symptoms arise → pause transfusion to rule out acute hemolytic reaction
- Prevention → use leukoreduced blood products
Cardiovascular surgery
17. A 70-year-old man with hypertension and a 40-pack-year smoking history presents with sudden severe abdominal and back pain. BP is 82/60 mm Hg. What is the next best step in management?
➔ Bedside transabdominal ultrasound (Older male + smoker + hypotension + back/abdominal pain → Think ruptured Abdominal aortic aneurysm→ Do bedside US)
- Note: Diagnosis → Bedside US is fastest and safest in unstable patients
- CT angiography → Used only if patient is stable
- Management:
○ Unstable or ruptured: Immediate surgical repair (endovascular or open)
○ Stable, unruptured AAA:
■ Monitor <5.5 cm
■ Elective repair if ≥5.5 cm or rapid growth
18. A 35-year-old man is brought to the emergency department after a stab wound to the left chest. He is alert but anxious. Jugular veins are distended, heart sounds are muffled, and his FAST scan confirms the diagnosis. What is the next step?
➔ Perform emergency pericardiocentesis (Penetrating chest trauma + hypotension + JVD + muffled heart sounds → Beck’s triad → Cardiac tamponade → Pericardiocentesis)
- Note: Unstable + signs of tamponade → Do FAST scan → if pericardial fluid → Do pericardiocentesis
19. A 65-year-old man develops dizziness and lightheadedness while using his left arm for yard work. A bruit is heard over the left clavicle. Which of the following physical exam findings would confirm the diagnosis?
➔ A BP difference between arms (Arm exertion + vertebrobasilar symptoms + subclavian bruit → Think subclavian steal syndrome)
- Note: Key clues → Dizziness, vertigo, imbalance triggered by upper limb activity
- Subclavian artery stenosis → leads to reversed vertebral flow with arm use
- Confirm with → Duplex US or angiography
- Manage with risk factor control ± stenting
Differentiation Table
| Condition | Clue | How to Differentiate |
|---|---|---|
| Subclavian steal | Vertigo + BP difference + arm use | Confirm with BP difference >15 mmHg |
| Carotid stenosis | Focal neuro deficits ± bruit | No arm exertion link |
| Vestibular disorder | Vertigo alone, no arm involvement | Normal BP, no bruit |
20. A 70-year-old man presents with right arm weakness and slurred speech that resolved within 30 minutes. He has a carotid bruit on the left side. What is the next step in evaluation?
➔ Carotid duplex ultrasound (Transient neurologic symptoms + carotid bruit → Suspect carotid artery stenosis → Confirm with duplex US)
- Note: First-line test → Duplex US
- All carotid artery stenosis cases should get intensive medical therapy (Aspirin + statin + BP control)
- If symptomatic:
○ <50% stenosis → No benefit from CEA
○ 50–69% → CEA in selected patients (low perioperative risk)
○ 70–99% → CEA recommended
21. A 75-year-old man with hypertension is found to have a carotid bruit on routine exam but has no neurologic symptoms. Duplex ultrasound shows 85% stenosis. What is the best next step?
➔ Carotid endarterectomy (Asymptomatic + high-grade stenosis → CEA is beneficial)
- Note: All asymptomatic patients should get intensive medical therapy
- If <50% stenosis → No CEA benefit
- 50–79% → CEA not routinely recommended (consider in men)
- 80–99% → CEA recommended
22. A 71-year-old man with atrial fibrillation presents with sudden onset of right leg pain, numbness, and pallor. The exam shows the right leg is cold, mottled, and pulseless. What is the next step in management?
➔ Start intravenous heparin (AFib + sudden limb ischemia → Acute arterial occlusion (Acute limb ischemia) → Anticoagulate immediately)
- Note: 6 Ps of acute limb ischemia: Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia
- IV heparin prevents clot propagation and distal thrombosis (always the first step)
- Confirm diagnosis with CT angiography or Doppler US (after heparin)
- Revascularization (thrombectomy, bypass) follows based on imaging and limb viability
Differentiation Table
| Condition | Key Clues | Diagnosis |
|---|---|---|
| Acute limb ischemia | Sudden 6 Ps, AFib, no Doppler pulses | CTA or Doppler US |
| PAD (chronic) | Claudication, slow onset, preserved pulses | ABI < 0.9 |
23. An 82-year-old immobile man with diabetes and chronic foot pain presents with black discoloration of the toes. He has absent pedal pulses and an ankle-brachial index of 0.3. What is the next step in management?
➔ Amputation (Gangrene + non-salvageable limb + ABI <0.4 → Indicates critical PAD → Amputation required)
- Note: ABI <0.9 → Confirms ; ABI <0.4 = severe disease
- Amputation → Required if revascularization not feasible or limb is non-viable
- Other options:
○ Medical therapy → aspirin, statin, smoking cessation, exercise if stable
○ Revascularization (angioplasty/bypass) → for salvageable limb
24. A 59-year-old man with diabetes and a history of smoking presents with bilateral thigh pain while walking and erectile dysfunction. Exam shows diminished femoral pulses. What is the diagnosis?
➔ Aortoiliac occlusive disease (Leriche syndrome) (Claudication + impotence + ↓ femoral pulses → Think Leriche syndrome)
- Note: Caused by → atherosclerotic occlusion at the aortic bifurcation
- Diagnosis: ABI + CT/MR angiography → treated with revascularization
25. A 58-year-old man presents with sudden tearing chest pain radiating to the back. BP is 190/110 mm Hg in the right arm and 140/85 mm Hg in the left. CXR shows a widened mediastinum. What is the next step in management?
➔ IV labetalol (Tearing chest/back pain + BP discrepancy + widened mediastinum → Think aortic dissection → Start IV β-blocker)
- Note: Diagnosis → CT angiography if stable; TEE if unstable or renal failure
- First step → Lower shear stress: IV β-blocker (e.g., labetalol)
○ Avoid vasodilators alone → Always control HR first
○ Surgical repair for ascending dissections (Type A)
Differentiation Table
| Condition | Clue | How to Differentiate |
|---|---|---|
| Aortic dissection | Sudden tearing pain, BP diff | CXR: widened mediastinum, CTA |
| MI | Crushing chest pain, ST changes | EKG, cardiac enzymes |
| PE | Dyspnea, pleuritic pain | V/Q mismatch, CTA chest |
26. A 30-year-old man presents with hypotension and chest pain after a high-speed motor vehicle collision. Chest x-ray shows a widened mediastinum. What is the next step in management?
➔ Immediate surgical evaluation (Blunt trauma + widened mediastinum + hemodynamic instability → Think traumatic aortic injury)
- Note: Confirm with → CT angiography if stable; skip if unstable
- Management: Urgent surgery.
27. A 32-year-old man presents after a stab wound to the left thigh. The leg is cool and pale with absent dorsalis pedis and posterior tibial pulses. What is the next step in management?
➔ Emergent surgical exploration (Penetrating trauma + absent pulses → Hard signs of vascular injury → Go directly to OR)
- Note: Hard signs: Absent pulses, limb ischemia, active bleeding = immediate surgery
- Do not delay OR for imaging in clearly unstable vascular injuries
- Soft signs (e.g. pulse deficit, cool limb) → do CT angiography if stable
| Hard Signs (Immediate Surgery) | Soft Signs (Needs Imaging if Stable) |
|---|---|
| Absent distal pulses | Diminished pulses |
| Active, pulsatile bleeding | Non-expanding hematoma |
| Expanding hematoma | Neurologic deficit |
| Bruit or thrill over injury site | History of bleeding without active hemorrhage |
| Signs of limb ischemia (6 Ps) | Wound near a major vessel |
28. A 67-year-old man with recent abdominal surgery for colon cancer presents with unilateral leg swelling and tenderness. What is the next step in management?
➔ Anticoagulation (DVT after surgery/malignancy → Treat immediately with anticoagulation)
- Note: Start anticoagulation (LMWH or IV heparin) immediately unless contraindicated
- IVC filter only if anticoagulation is absolutely contraindicated
29. A 28-year-old woman presents with left lower leg swelling, tenderness, and erythema. She smokes cigarettes and has been taking oral contraceptives for 2 years. What is the most significant risk factor for her current condition?
➔ Oral contraceptive use (Estrogen-containing contraceptives → ↑ risk of venous thromboembolism)
- Note: Most important modifiable risk factor for DVT in young women = OCPs (especially with estrogen)
- Other DVT risk factors: surgery, malignancy, immobility, pregnancy, inherited thrombophilia (e.g., Factor V Leiden)
Pulmonary & Chest Surgery
30. A 25-year-old man presents after a motor vehicle accident. He has left-sided chest wall bruising, dyspnea, and hypoxia. Chest x-ray shows patchy alveolar opacities on the left side. What is the next step in management?
➔ Supportive care (Blunt trauma + patchy infiltrates + hypoxia → Pulmonary Contusion → Supportive care)
- Note: Supportive care in pulmonary contusion includes:
○ Oxygen, Pain control
○ Pulmonary toilet
○ Positive pressure ventilation if severe or with respiratory failure
Differential Tip:
| Condition | Key Feature | Imaging Clue |
|---|---|---|
| Pulmonary Contusion | Trauma + hypoxia within 24 hrs | Patchy alveolar opacities near trauma |
| ARDS | Hypoxia, bilateral infiltrates | Diffuse infiltrates, no trauma history |
| Hemothorax | Trauma + decreased breath sounds, dullness | Fluid level on CXR/US |
31. A 58-year-old man develops fever, chest pain, and purulent sternal wound drainage 3 days after coronary artery bypass grafting. Chest x-ray shows mediastinal widening. What is the next step in management?
➔ Surgical debridement with IV broad-spectrum antibiotics (Post-op + fever + chest pain + mediastinal widening →Think Acute Mediastinitis → Urgent surgery + antibiotics)
- Note: Caused by → Post-sternotomy infection
- Next Step → Immediate surgical debridement + IV broad-spectrum antibiotics
32. A 32-year-old man is brought to the ED after a motorcycle crash. He is hemodynamically stable but has decreased breath sounds and dullness to percussion on the right. What is the next step in evaluation?
➔ Upright chest X-ray (Stable trauma patient + ↓ breath sounds + dullness → Suspect hemothorax → Start with upright CXR to confirm)
- Note: Stable patient → CXR first (look for pleural fluid, blunted costophrenic angle)
- Unstable patient → FAST exam (bedside ultrasound) to rapidly detect hemothorax or pneumothorax without delay
- If classic signs of large hemothorax are present with instability (↓ breath sounds + dullness + hypotension) → Chest tube first — do not delay for imaging
Hemothorax
Salim S, more on site, PMC2567296 1757-1626-1-225-2, CC BY 2.0
33. A 25-year-old man presents to the ED after a stab wound to the left chest. He is hypotensive, tachycardic, and has decreased breath sounds with dullness to percussion on the left side. What is the next step in management?
➔ Tube thoracostomy (chest tube insertion) (Chest trauma + ↓ breath sounds + dullness to percussion + hypotension → Think hemothorax → Insert chest tube)
- Note: First step in highly suspicious case → chest tube, both diagnostic & therapeutic:
○ Do NOT delay chest tube for imaging - Urgent thoracotomy if: >1500 mL initial output or >200 mL/hr bleeding
- Resuscitate with IV fluids + PRBCs if unstable
34. A 40-year-old man presents after blunt chest trauma. He has multiple rib fractures and a segment of the chest wall moves paradoxically with breathing. What is the next step in management?
➔ Supplemental oxygen and pain control (Blunt trauma + paradoxical chest movement → Flail chest → Stabilize with O₂ + analgesia)
- Note: ≥3 adjacent ribs fractured in ≥2 places → free-floating segment
- Key finding: Paradoxical chest wall motion
- Initial treatment: O₂ + pain control
- Intubation if: hypoxia, hypercapnia, or respiratory fatigue
35. A 56-year-old man develops sudden hypotension and tracheal deviation after central line placement. Breath sounds are absent on the right, and the chest is hyperresonant. What is the next best step in management?
➔ Immediate needle decompression of the right chest (Unstable + absent breath sounds + hyperresonance + tracheal deviation → Think tension pneumothorax)
- Note: Common cause → Central line placement (iatrogenic tension PTX)
- Do NOT wait for imaging in unstable patient
- Needle first (2nd intercostal space, midclavicular line), then chest tube (tube thoracostomy)
Pneumothorax
Differentiation Notes
| Condition | Clue | How to Differentiate | Management |
|---|---|---|---|
| Tension pneumothorax | Tracheal deviation + hypotension | No breath sounds, JVD, rapid clinical decline | Immediate needle decompression → chest tube |
| Simple pneumothorax | Dyspnea, ↓ breath sounds | Stable vitals, no tracheal shift | Supplemental O₂, observation or chest tube |
| Hemothorax | Dullness to percussion | Flat neck veins (hypovolemia), trauma history | Chest tube thoracostomy ± volume resuscitation |
Gastrointestinal Surgery & Emergencies
36. A 70-year-old man presents with progressive dysphagia, halitosis, and episodes of coughing while eating. Barium swallow shows a posterior outpouching at the pharyngoesophageal junction. What is the next step in management?
➔ Surgical repair (oropharyngeal dysphagia + regurgitation of undigested food + halitosis → Think Zenker diverticulum → symptomatic cases require surgical resection)
- Note: Diagnosis with → barium swallow
Zenker diverticulum
37. A 42-year-old man presents with chest pain, fever, and dyspnea after repeated episodes of vomiting. Exam shows crepitus over the neck and decreased breath sounds on the left. Chest x-ray reveals a left pleural effusion. What is the next step in diagnosis?
➔ Water-soluble contrast esophagography (Severe vomiting + chest pain + crepitus + pleural effusion → Boerhaave syndrome → Confirm with esophagogram)
- Note: Confirm with → Water-soluble contrast esophagogram
- Management: NPO, IV fluids, broad-spectrum antibiotics, emergent surgery
- Differentiation:
○ Mallory-Weiss = mucosal tear → hematemesis without mediastinal symptoms, stable vitals → managed with EGD
38. A 64-year-old man presents with epigastric pain, melena, and dizziness. He has mild hypotension and is receiving IV fluids and a proton pump inhibitor. What is the most appropriate next step in diagnosis?
➔ Upper endoscopy (Melena + hemodynamic stability after resuscitation → Perform endoscopy to identify and treat upper GI bleeding source)
- Note: Common UGIB causes: PUD, varices, Mallory-Weiss tear, gastritis
39 A 65-year-old man undergoes upper endoscopy for dysphagia. One hour later, he develops chest pain, fever, and tachypnea. What is the next step in management?
➔ Water-soluble contrast esophagography (Sudden chest pain + fever after endoscopy → Suspect perforation)
- Note: Management → IV antibiotics + emergent surgical repair
40. A 47-year-old man presents with sudden, severe epigastric pain, tachycardia, hypotension, and board-like abdominal rigidity. History of intermittent epigastric pain relieved by food over the past few months. What is the diagnosis?
➔ Perforated duodenal ulcer (Sudden severe pain + rigidity + hypotension + hx of ulcer → think perforation)
- Note: Upright CXR shows → free air under diaphragm
- Definitive treatment → Emergency surgical repair
- Complications of PUD: Perforation, bleeding, gastric outlet obstruction
41. A 42-year-old man presents with epigastric pain, vomiting, and loss of appetite. He has high-pitched bowel sounds and a tender mass in the right groin. What is the next step in management?
➔ Surgical exploration of the right inguinal canal. (Tender groin mass + signs of bowel obstruction → think incarcerated or strangulated inguinal hernia → treated with emergency surgical exploration)
42. A 42-year-old woman with a history of appendectomy presents with nausea, vomiting, abdominal distention and failure to pass gas or stool. What is the imaging finding on x-ray?
➔ Multiple air-fluid levels (Prior surgery + signs of bowel obstruction → think small bowel obstruction from adhesions → Multiple air-fluid levels is typical)
- Note: Always order imaging if there are systemic symptoms or signs of obstruction.
- Treat with bowel rest, nasogastric tube suction, and intravenous fluids.
○ Surgical exploration in complete/complicated cases (e.g., hernia, ischemia, perforation).
43. A 70-year-old man with prior abdominal surgery presents with vomiting, abdominal pain, and no flatus. X-ray shows dilated loops and air-fluid levels. What is the next best step?
➔ Nasogastric tube decompression and IV fluids (Post-surgical SBO + obstipation → Initial step = NG tube + IV fluids)
- Note: Treatment:
○ Partial obstruction → NPO, NG tube, IV fluids
○ Complete/complicated → Exploratory laparotomy
44. A 45-year-old woman presents with sweating, dizziness, palpitations, and abdominal cramping 30 minutes after eating a large meal. She underwent Roux-en-Y gastric bypass 3 months ago. Vitals are stable. What is the cause of her symptoms?
➔ Dumping syndrome (Post-gastric bypass + early postprandial symptoms → Think rapid gastric emptying)
- Note: Differentiate from other complications of gastric bypass:
○ Hypoglycemia: Occurs 1–3 hours post-meal with low serum glucose
○ Bowel obstruction: Presents with abdominal distension, no bowel movements, and no vasomotor symptoms
45. A 78-year-old man with chronic constipation presents with abdominal distention, pain, and obstipation. Abdominal X-ray shows a dilated loop of bowel with a “coffee bean” sign. What is the next step in management?
➔ Sigmoidoscopic decompression (Elderly + distention + coffee bean sign → Sigmoid volvulus → Endoscopic decompression)
- Note: Sigmoid volvulus = twisting of colon → large bowel obstruction
- If signs of peritonitis/perforation → emergent surgery
Sigmoid volvulus (coffee bean sign)
sigmoid volvulus (image on Wikimedia Commons)
46. A 28-year-old man with a history of Crohn disease presents with worsening abdominal pain, weight loss, and fecal drainage from an opening near the perineum. Imaging reveals a fistula between the small intestine and skin. What is the next step in management?
➔ Surgical resection of the affected bowel (Crohn + fistula/abscess/obstruction → Complicated disease → Needs surgery)
- Note: Complicated disease → Transmural inflammation → strictures, abscesses, fistulas
- Mild/moderate Crohn → treat with → 5-ASA, steroids, immunomodulators
- Complicated disease → bowel resection ± fistula repair
47. A 42-year-old man with a 15-year history of ulcerative colitis is found to have a sigmoid colon mass on surveillance colonoscopy. What is the next step in management?
➔ Proctocolectomy (Ulcerative colitis + colorectal cancer → Definitive treatment = proctocolectomy)
- Note: UC → ↑ risk of colorectal cancer with chronic inflammation
- Start screening colonoscopy at 8 years after UC diagnosis → then repeat every 1–3 years
48. A 77-year-old man with a history of constipation presents with passing air and fecal material during urination, and recurrent UTIs. What’s the cause?
➔ Colovesical fistula (Symptoms suggestive of diverticulosis → complicated to colovesical fistula → leading to fecaluria+ pneumaturia)
- Note: Diverticulosis (not cancer!) is the most common cause of colovesical fistula in elderly patients with chronic constipation.
- Diagnosis involves contrast CT imaging or direct visualization.
- Treatment: Antibiotics + surgical resection of affected bowel segment
49. A 68-year-old man presents with fatigue. Labs show microcytic anemia. Stool is positive for occult blood. What is the next step?
➔ Colonoscopy (Iron deficiency anemia + positive FOBT in older adult → Think right-sided colon cancer → Do colonoscopy)
- Note: Positive FOBT is sensitive but not specific
- Next step → Colonoscopy for visualization and biopsy
- If cancer present → Do CT for staging
Differentiation Table
| CRC Location | Clue | How to Differentiate |
|---|---|---|
| Right-sided (cecal) | Iron deficiency anemia, fatigue | Occult bleeding, no obstruction |
| Left-sided (rectosigmoid) | Change in bowel habits, obstruction | Visible blood, narrowing on scope |
| Rectal cancer | Tenesmus, hematochezia | Often palpable on DRE |
50. A 62-year-old man presents with intermittent rectal bleeding for the past month. He is hemodynamically stable and has no other symptoms. What is the next step in evaluation?
➔ Colonoscopy (Stable patient + isolated rectal bleeding → Rule out serious causes → Do colonoscopy)
51. A 23-year-old pregnant woman at 20 weeks gestation presents with right lower quadrant pain, fever, and nausea. Physical examination reveals focal tenderness without peritoneal signs. What is the next step in diagnosis?
➔ Abdominal ultrasound (Suspected appendicitis in pregnancy → Start with ultrasound)
- Note: Ultrasound is first-line imaging in pregnancy and children for right lower quadrant pain
- In nonpregnant patients → CT abdomen/pelvis is the most sensitive test
52. A 22-year-old pregnant woman at 22 weeks gestation presents with fever, nausea, vomiting, and right-sided abdominal pain. The exam shows guarding and peritoneal signs. What is the next step?
➔ Exploratory laparotomy. (Acute appendicitis + prescience of peritoneal signs → indicates exploratory laparotomy)
- Note: Treatment: appendectomy
- If perforation:
○ Abscess → IV antibiotics + drainage
○ Diffuse contamination → exploratory laparotomy
53. A 42-year-old obese woman presents with a 2-hour episode of colicky RUQ pain without fever, leukocytosis, or abnormal liver function tests. Ultrasound shows gallstones. What is the cause of the abdominal pain?
➔ Biliary colic (Suggested by postprandial pain <6 hours without fever or leukocytosis)
- Note: Manages with → Elective cholecystectomy
Differentiation Table
| Condition | Clue | How to Differentiate |
|---|---|---|
| Biliary Colic | RUQ pain < 6 hrs, no fever | Elective cholecystectomy |
| Acute cholecystitis | RUQ pain > 6 hrs, fever, Murphy sign | No jaundice, normal CBD size, ttt with Urgent cholecystectomy |
| Cholangitis | Jaundice + fever + RUQ ± sepsis signs | Needs ERCP + antibiotics urgently |
54. A 44-year-old man with a history of gallstones presents with persistent right upper quadrant pain for 12 hours, fever, and leukocytosis. On ultrasound, there is gallbladder wall thickening and pericholecystic fluid. What is the next step?
➔ Urgent cholecystectomy (persistent pain >6 hours + fever + leukocytosis → think cholecystitis)
- Note: Abdominal ultrasonography is the first diagnostic step
○ HIDA scan confirms cholecystitis if ultrasound findings are equivocal. - Treatment: NPO, IV fluids, antibiotics, urgent cholecystectomy
55. A 60-year-old woman with a history of gallstones presents with fever, right upper quadrant pain, and jaundice. Labs show leukocytosis. What is the next step in management?
➔ Administer IV fluids and antibiotics followed by urgent biliary drainage (ERCP) (Fever + RUQ pain + jaundice + infection signs → Think acute cholangitis → needs antibiotics + urgent ERCP)
- Note: CBD obstruction → leads to ascending bacterial infection → causes acute cholangitis
- Initial step → IV fluids + broad-spectrum antibiotics
- Definitive treatment → Urgent ERCP for biliary drainage
56. A 72-year-old man with a history of heavy alcohol use presents with 4 months of right upper quadrant pain, weight loss, elevated direct bilirubin, and alkaline phosphatase. Ultrasound shows dilated intrahepatic ducts. What is the next step in diagnosis?
➔ ERCP (Suspect cholangiocarcinoma when imaging shows biliary dilation without a mass.)
- Note: ERCP allows for direct visualization, biopsy, and possible stent placement if obstruction is present.
57. A 76-year-old woman presents with 3 days of vomiting, abdominal distension, and crampy pain. She has a history of gallstones. CT abdomen shows pneumobilia, small bowel obstruction, and a calcified mass in the terminal ileum. What is the next step in management?
➔ Surgical removal of the obstructing stone (SBO + pneumobilia + ectopic stone → Think Gallstone ileus → Treat with surgery)
58. A 42-year-old man develops fever and abdominal fullness several days after a splenectomy. The exam shows leukocytosis with a left shift and tenderness in the left upper quadrant. What is the next step in management?
➔ CT abdomen with contrast (Post-op fever + leukocytosis + localized tenderness → suspect intra-abdominal abscess → CT with contrast is diagnostic)
- Note: Treat with → IV antibiotics + percutaneous or surgical drainage
59. A 41-year-old man presents with bright red blood on toilet paper and anal pruritus. On examination, there are purple dusky lumps below the dentate line. What is the next step in management?
➔ Supportive care with high-fiber diet, sitz baths, and NSAIDs (painless defecation + bright red blood + dusky purple lumps → Think extenal hemorrhoids)
- Note: Key clue → bleeding during/after bowel movement
- Cause → Dilated veins below dentate line (external hemorrhoids)
- Initial treatment → Fiber, sitz baths, NSAIDs ± topical agents
- Sudden severe pain + bluish tender mass → this means thrombosed external hemorrhoids → consider excision
Differentiation Table
| Condition | Clue | How to Differentiate |
|---|---|---|
| Hemorrhoids | Blood on wiping, anal mass, pain | Pain if external or thrombosed |
| Anal fissure | Pain with defecation, blood streak | Linear tear on inspection |
| Rectal cancer | Blood + weight loss, older age | Irregular mass, needs colonoscopy |
60. A 30-year-old woman presents with severe pain during bowel movements and bright red blood on toilet paper. Exam shows a linear tear at the posterior anal canal. What is the next best step in management?
➔ Topical vasodilators with supportive care (Sharp pain during defecation + bright red blood → classic for anal fissure)
- Note: Tear usually in posterior midline, below dentate line
- First-line treatment → stool softeners, Sitz baths, topical lidocaine + vasodilators (nifedipine/nitroglycerin)
- Consider surgery if persistent despite medical therapy
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Endocrine Surgery & Emergencies
61. A 45-year-old woman presents with a 2-cm thyroid nodule found on physical exam. What is the next step in evaluation?
➔ Check serum TSH level (Thyroid nodule → Always start with TSH → Guides need for scintigraphy or ultrasound)
- Note: Avoid excisional biopsy due to bleeding risk
Thyroid Nodule Evaluation Algorithm
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62. A 60-year-old man with a recent thyroidectomy presents with neck swelling, voice changes, and stridor. Exam shows an expanding anterior neck hematoma. What is the next step in management?
➔ Immediate endotracheal intubation (Post-op neck hematoma + stridor/voice change → Airway at risk → Secure airway immediately)
- Note: Red flags → Stridor, hoarseness, dysphagia, anterior neck swelling
- Airway always comes first in surgical emergencies
- If intubation fails → do cricothyrotomy
- Hematoma evacuation may follow once airway secured
63. A 46-year-old woman undergoes total thyroidectomy. Postoperatively, she develops hoarseness but no signs of respiratory distress. What is the cause?
➔ Unilateral recurrent laryngeal nerve injury (Post-thyroidectomy + hoarseness without airway compromise → Think unilateral nerve injury)
- Note: Unilateral injury → hoarseness
- Bilateral injury → stridor, airway obstruction → may need reintubation
64. A 64-year-old woman is found to have elevated calcium (11.6 mg/dL) and an inappropriately elevated PTH level on routine lab work. She is asymptomatic but has a T-score of –2.7 at the femoral neck on DEXA scan. What is the next step in management?
➔ Surgical parathyroidectomy (Asymptomatic PHPT + osteoporosis (T-score < –2.5) → Surgical indication met → Refer for parathyroidectomy)
- Note: Surgical indications (any of the following):
○ Age <50
○ Symptomatic (nephrolithiasis, fractures)
○ T-score < –2.5 (osteoporosis)
○ Serum Ca >1.0 mg/dL above normal
○ Creatinine clearance <60 or nephrolithiasis - If no surgical criteria met → monitor with calcium, creatinine, DEXA
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Skin & Soft Tissue
65. A 68-year-old man with a history of extensive sun exposure presents with a pearly papule on his nose with central ulceration and rolled borders. What is the next step in management?
➔ Mohs surgery (Pearly papule + rolled borders + central ulceration on sun-exposed area → Think basal cell carcinoma)
- Note: Does not tend to metastasize but can → spread locally
- Confirm with → shave/punch biopsy
- Treatment → Mohs surgery for high-risk sites (face)
○ Excision with 5 mm–1 cm margins elsewhere
Differentiation Table
| Condition | Clue | How to Differentiate |
|---|---|---|
| BCC | Pearly papule, rolled edges | Rarely metastasizes |
| SCC | Ulcerated, scaly nodule | Higher metastasis risk |
| Melanoma | Asymmetric, pigmented, irregular | ABCDE criteria, more aggressive |
66. A 45-year-old man presents with a dark lesion on his upper back. It is asymmetric, has irregular borders and measures 9 mm. He reports that it has changed in size and appearance over the past few months. What is the next step in management?
➔ Surgical excision (Suspicious nevus → excise to rule out melanoma)
- Note: Suspicious features = ABCDE: Asymmetry, Border irregularity, Color variation, Diameter >6 mm, Evolution
- Initial management = excisional biopsy with narrow margins
- Sentinel lymph node biopsy and wide excision if melanoma is confirmed
- Observation only is indicated for a nevus without suspicious features
67. A 62-year-old man presents with fever and incisional pain 6 days after undergoing a right hemicolectomy. Exam reveals erythema, warmth, and purulent drainage from the surgical site. What is the next step in management?
➔ Open the incision and drain the wound (Post-op day 5–7 + fever + purulent drainage → Surgical site infection → Requires drainage)
- Note: Add → antibiotics if cellulitis/systemic signs
- Prevention: perioperative antibiotics + sterile technique
68. A 38-year-old man presents with fever, erythema, warmth, and swelling of his left leg after scratching it while hiking. There is no drainage or abscess. What is the next step in management?
➔ Start empiric antibiotics covering Streptococcus and MSSA (Non-purulent cellulitis → think Strep pyogenes or MSSA → treat with cephalexin or similar)
- Note: Non-purulent: Cover Streptococcus ± MSSA → eg. Cephalexin
- Purulent or abscess: Add MRSA coverage → eg. TMP-SMX, doxycycline
69. A 30-year-old man presents with a painful, fluctuant, erythematous skin lesion with purulent drainage after an insect bite. What is the next best step in management?
➔ Incision and drainage (Localized abscess + fluctuance + drainage → I&D is first-line treatment)
70. A 59-year-old man with a history of diabetes presents with fever and rapidly worsening erythema and swelling of the left thigh following a minor skin injury. Exam reveals crepitus and purple discoloration of the skin. What is the next step in management?
➔ Emergent surgical exploration and debridement (Rapidly progressive infection + crepitus + systemic signs → Think Necrotizing fasciitis → Requires immediate surgery)
- Note: Initial treatment → Broad-spectrum IV antibiotics + fluids
- Definitive treatment → Urgent surgical debridement
71. A 58-year-old man with a history of alcoholic cirrhosis presents with fever, hypotension, and rapidly progressive pain and swelling in his left leg after cutting himself while fishing. The exam shows hemorrhagic bullae and crepitus. What is the next step in management?
➔ Immediate IV antibiotics and surgical debridement (Marine wound + liver disease + bullae/crepitus → Think Vibrio vulnificus necrotizing fasciitis)
- Note: Risk ↑ with liver disease
72. A 35-year-old man is rescued from a house fire. He has facial burns, hoarseness, and carbonaceous sputum. What is the next step in management?
➔ Endotracheal intubation (Facial burns + hoarseness + carbonaceous sputum → Think airway injury → Intubate early)
- Note: Superheated air → leads to airway edema & obstruction
- Do not delay airway protection for imaging or labs
- Next step → Immediate endotracheal intubation (before airway closes)
| Condition | Clue | How to Differentiate |
|---|---|---|
| Smoke inhalation injury | Burns + hoarseness/stridor | Requires early intubation before edema |
| Anaphylaxis | Airway swelling + hypotension | Usually with allergen exposure |
73. A 44-year-old homeless man is brought to the ED after being found outside in freezing temperatures. His fingers are cold, pale, and insensate. What is the next step in management?
➔ Rapid rewarming in warm water bath (Cold exposure + pale/insensate extremities → Frostbite → Rewarm rapidly in warm (37–39°C) water)
- Note: Remove wet/cold clothing + transfer to warm setting
- Admit for wound care; consider thrombolysis for severe cases
Musculoskeletal & Orthopedic Surgery
74. A 64-year-old man presents with acute knee pain, swelling, fever, and inability to bear weight. Arthrocentesis shows WBC >95,000/mm³ with neutrophil predominance. What is the next step in management?
➔ Emergent surgical drainage and IV antibiotics (Septic arthritis → urgent drainage + empiric IV antibiotics)
- Note: Most commonly due to Staphylococcus aureus
- Diagnosis: Joint WBC >50,000/mm³ + neutrophilic exudate
75. A 17-year-old boy presents with worsening knee pain and swelling for the past month. X-ray of the distal femur shows a destructive bone lesion with a sunburst periosteal reaction. What is the next best step in management?
➔ Surgical resection with chemotherapy (Classic x-ray + long bone lesion in young male → Think osteosarcoma → Requires surgery + chemo)
76. A 62-year-old man with poorly controlled diabetes presents with fever, worsening foot pain, and a plantar ulcer with exposed bone. MRI reveals osteomyelitis of the second metatarsal. What is the most appropriate next step in management?
➔ Surgical debridement (A deep ulcer with exposed bone + MRI findings of osteomyelitis→ Proceed to surgical debridement + antibiotics)
- Note: Suspect osteomyelitis if: chronic ulcer >2 cm², exposed bone, or ulcer lasting >2 weeks
- Best initial test → MRI
- Treatment: Surgical debridement + empiric IV antibiotics (e.g., vancomycin + cefepime)
- Bone biopsy: only needed if diagnosis is uncertain or culture guidance is required before prolonged antibiotics
77. A 78-year-old woman with osteoporosis falls at home and cannot bear weight. Her right leg is shortened and externally rotated. What is the next best step in management?
➔ Surgical fixation (Elderly fall + shortened, externally rotated leg → Displaced hip fracture → Surgery)
- Note: Most common location → femoral neck or intertrochanteric region
78. A 24-year-old man presents with severe left leg pain after a tibial fracture. The leg is tense, and pain worsens with passive dorsiflexion. Pulses are present. What is the next step in management?
➔ Emergent fasciotomy (Severe pain out of proportion + passive stretch pain + tense limb → Compartment syndrome → Fasciotomy)
- Note: 6 Ps: Pain (early), Pallor, Paresthesia, Pulselessness, Paralysis, Poikilothermia
- Pain with passive stretch is earliest and most sensitive sign
Neurologic & Spine surgery
79. A 30-year-old woman involved in a high-speed motor vehicle crash presents with right-sided head trauma. She has clear fluid draining from the right ear and bruising behind the right ear. What is the diagnosis?
➔ Basilar skull fracture (Head trauma + otorrhea (CSF) + Battle sign → Think basilar skull fracture involving the temporal bone)
- Note: Signs include → CSF otorrhea/rhinorrhea, hemotympanum, Battle sign (retroauricular ecchymosis), raccoon eyes, CN palsies
- Diagnosis → clinical + CT head without contrast
80. A 45-year-old woman presents with a sudden, severe headache described as “the worst of her life.” She has photophobia, neck stiffness, and transient loss of consciousness. CT head is normal. What is the next step?
➔ Lumbar puncture to assess for xanthochromia (suspect subarachnoid hemorrhage) (sudden thunderclap headache + normal CT → rule out Subarachnoid Hemorrhage via LP)
- Note: 1st step in diagnosis is CT head → If CT negative → Lumbar puncture→ shows xanthochromia
- Complications:
○ Rebleed (within 24 hrs)
○ Vasospasm (days 4–10) → prevent with nimodipine
○ Hydrocephalus
81. A 22-year-old man is brought to the ED after being struck in the head with a baseball bat. He briefly lost consciousness but then appeared lucid. One hour later, he becomes confused and drowsy. What is the next step in management?
➔ Emergent neurosurgical evacuation (Blunt head trauma + lucid interval + rapid deterioration → Epidural hematoma → Surgery)
- Note: Caused by rupture of middle meningeal artery (often temporal bone fracture)
- Classic progression:
○ LOC → lucid interval → rapid neurologic decline - Diagnosis: CT head → biconvex (lens-shaped) hyperdensity
- Manage with → Emergent craniotomy
82. A 67-year-old woman has bilateral buttock, posterior thigh, and calf pain after walking or standing for 10 minutes. The pain is relieved by sitting or bending forward. She has failed conservative therapy including physical therapy, NSAIDs, and epidural steroid injections. What is the next step in management?
➔ Laminectomy (Neurogenic claudication + failed conservative therapy → Surgical decompression with laminectomy)
- Note: Caused by lumbar spinal stenosis leading to → nerve root compression
- Laminectomy indicated for disabling or refractory symptoms
83. A 59-year-old man presents with bilateral leg weakness, urinary retention, and numbness in the inner thighs and buttocks. Exam shows decreased rectal tone and saddle anesthesia. MRI confirms the diagnosis. What is the next step in management?
➔ IV steroids (signs of Cauda Equina Syndrome → urgent imaging + steroids + surgery)
- Note: Compression of cauda equina nerve roots (L2 and below) → leads to Cauda Equina Syndrome
○ Compression causes include Herniated disc, tumor, trauma, abscess - 1st step is → Emergent MRI of lumbosacral spine
- Treat with IV dexamethasone → urgent surgical decompression
| Feature | Cauda Equina | Conus Medullaris |
|---|---|---|
| Onset | Gradual | Sudden |
| Weakness | Asymmetric, LMN | Symmetric (UMN + LMN) |
| Reflexes | Hyporeflexia | Mixed (↓ or ↑) |
| Sensory loss | Saddle anesthesia (variable) | Perianal more symmetric |
| Bowel/bladder | Late (overflow) | Early (retention/incontinence) |
84. A 28-year-old man is brought to the ED after a motor vehicle crash. He is alert and hemodynamically stable. He reports neck pain but has no neurologic deficits. What is the next step in evaluation?
➔ Cervical spine CT scan (Blunt trauma + neck pain → High-risk → Needs cervical spine imaging with CT)
- Note: NEXUS criteria help rule out C-spine injury:
○ No posterior midline tenderness
○ No intoxication
○ Normal alertness
○ No focal neuro deficits
○ No painful distracting injury
→ If all negative → No imaging needed
→ If any positive (like neck pain) → CT C-spine - Stable trauma → CT first
- Unstable → Immobilize, then CT when stable
- Urinary catheter should be inserted to assess perfusion (urine output) and check for hematuria
85. A 28-year-old man is brought to the ED after a high-speed motor vehicle crash. He is comatose with a GCS of 4. CT scan shows multiple punctate hemorrhages at the gray-white matter junction. What is the next best step in management?
➔ Supportive care in the ICU (Severe TBI + imaging consistent with diffuse axonal injury → Supportive ICU management)
- Note: CT shows → Punctate hemorrhages at gray-white junction, corpus callosum, brainstem
Genitourinary surgery
86. A 15-year-old boy presents with sudden, severe left testicular pain and swelling. On exam, the left testicle is elevated, tender, and lies transversely. The cremasteric reflex is absent. What is the next step in management?
➔ Immediate surgical exploration of the scrotum (Teenage boy + sudden testicular pain + absent cremasteric reflex → Think testicular torsion → Go straight to surgery)
- Note: Do NOT delay for imaging if diagnosis is clear
- Doppler US only if diagnosis is uncertain → ↓/absent blood flow
Differentiation Table
| Condition | Clue | How to Differentiate |
|---|---|---|
| Testicular torsion | Sudden pain, absent cremasteric reflex | Surgical emergency, no relief on elevation |
| Epididymitis | Gradual pain, fever, pyuria | Lifting the Scrotum Relieves Pain, , normal cremasteric reflex |
| Torsion of appendix testis | Localized tenderness, not whole testicle | – |
87. A 38-year-old man presents with severe left flank pain radiating to the groin, nausea, and hematuria. Vitals show fever and tachycardia. Noncontrast CT shows a 9 mm obstructing left ureteral stone. What is the next step in management?
➔ Urologic intervention (Large obstructing stone + hydronephrosis ± infection → Requires surgical management)
- Note: Red flags for intervention → stone >10 mm, obstruction, infection, AKI, or intractable pain
- Management → ureteral stent or percutaneous nephrostomy
- Medical management: for stones <10 mm → hydration, pain control (NSAIDs), tamsulosin to facilitate passage
Differentiation Table
| Condition | Key Clues | How to Differentiate |
|---|---|---|
| Nephrolithiasis | Colicky flank pain, hematuria | Normal vitals, <5 mm stone → passable |
| Pyelonephritis | Fever, CVA tenderness, dysuria | No visible stone; positive urine culture |
88. A 25-year-old man sustains a pelvic fracture after a motor vehicle accident. He has blood at the urethral meatus and cannot void. What is the step in management?
➔ Retrograde urethrography (Pelvic trauma + blood at meatus + urinary retention → Think posterior urethral injury → Do retrograde urethrogram)
- Note: Depending on location:
○ Posterior urethral injury → caused by Pelvic fracture → leads to elevated prostate → definitive repair is delayed after inflammation resolves
○ Anterior urethral injury → caused by Straddle injury → causes penis hematoma → needs immediate repair - Confirm with → Retrograde urethrogram
- Do NOT insert Foley → Risk of worsening injury
Differentiation Table
| Condition | Clue | How to Differentiate |
|---|---|---|
| Urethral injury | Blood at meatus, pelvic trauma | Confirm with retrograde urethrogram |
| Bladder rupture | Suprapubic pain, gross hematuria | Intraperitoneal fluid on CT cystogram |
| Renal injury | Flank pain, hematuria, bruises | CT abdomen with contrast |
| Ureteral injury | Hematuria, flank pain, occurs esp with hysterectomy | Intraoperative dye test or delayed CT urogram |
89. A 25-year-old man presents after a motor vehicle collision. He has lower abdominal pain, gross hematuria, and a pelvic fracture. Foley catheter drains a small amount of blood-tinged urine. CT cystogram shows contrast extravasation into the peritoneal cavity. What is the diagnosis?
➔ Intraperitoneal bladder rupture (Pelvic trauma + gross hematuria + intraperitoneal contrast leak → Intraperitoneal bladder rupture)
- Note: Bladder rupture types:
○ Intraperitoneal (dome) → Contrast in peritoneal cavity → requires surgical repair
○ Extraperitoneal (neck, wall) → Contrast around bladder base → managed with Foley drainage - Confirm with CT cystography (not plain CT)
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Trauma & Emergency Surgery
90. A 30-year-old man presents after a motor vehicle collision. His right leg is shortened, adducted, and internally rotated. What is the next best step in management?
➔ Urgent closed reduction (MVC + flexed, internally rotated leg → Think posterior hip dislocation → Reduce immediately)
- Note: Shortened + adducted + internally rotated → classic for posterior dislocation
- It will be almost always due to dashboard injury
- Complications → Sciatic nerve injury, avascular necrosis
- Next step → Urgent closed reduction (do not delay for advanced imaging)
Differentiation
| Condition | Clue | How to Differentiate |
|---|---|---|
| Posterior dislocation | Internally rotated leg | Most common, motor vehicle collision |
| Anterior dislocation | Externally rotated, abducted leg | Less common |
| Femoral neck fracture | External rotation + no dislocation | Seen in elderly; no posterior force |
91. A 27-year-old man presents after a motor vehicle crash with blunt trauma to the abdomen. He is hemodynamically stable but has abdominal pain and gross hematuria. What is the next step in evaluation?
➔ CT scan of the abdomen and pelvis (Stable blunt abdominal trauma (BAT) + hematuria → Evaluate solid organ injury → Get CT abdomen/pelvis)
- Note: CT abdomen/pelvis → Gold standard for stable patients with BAT
- Unstable patients → FAST exam → laparotomy if positive
92. A 32-year-old man presents after a motor vehicle accident with left upper quadrant abdominal pain, hypotension, and shoulder pain. Ultrasound shows free fluid between the spleen and kidney. What organ is most likely injured?
➔ Spleen (Blunt abdominal trauma + LUQ pain + free fluid → Think splenic injury)
- Note: Most commonly injured solid organ in blunt abdominal trauma
- If patient stable → monitor and observe
- If patient unstable: → Do Exploratory laparotomy
93. A 21-year-old man is involved in a motor vehicle accident. He has epigastric tenderness and elevated serum lipase. Abdominal CT shows peripancreatic fluid but no necrosis or ductal injury. What is the next step?
➔ Supportive care and close observation (Blunt abdominal trauma + ↑ lipase + peripancreatic fluid → Think pancreatic contusion)
- Note: Common in steering wheel or bicycle injuries
94. A 29-year-old man presents with hypotension and tachycardia after sustaining a stab wound to the abdomen. He is alert but pale, with a distended abdomen and diffuse tenderness. What is the next best step in management?
➔ Exploratory laparotomy (Penetrating trauma + hemodynamic instability → Requires immediate surgical exploration)
- Note: Unstable patients or peritonitis with penetrating abdominal injury → immediate surgical exploration
- Stable patients → Start with imaging (eg, FAST, CT abdomen)
95. A 34-year-old man presents after a high-speed motor vehicle crash with chest pain and shortness of breath. Chest x-ray shows bowel loops and a nasogastric tube in the left thorax. What is the diagnosis?
➔ Traumatic diaphragmatic rupture (Blunt trauma + dyspnea + NG tube/bowel in thorax on CXR → Think diaphragmatic rupture)
- Note: Cause: Blunt trauma → sudden ↑ intra-abdominal pressure → diaphragmatic tear
- Most common on left side (liver shields the right diaphragm)
- Management → Surgical repair
96. A 29-year-old man presents to the ED after a motor vehicle crash with hypotension, bradycardia, and warm extremities. He has a cervical spinal cord injury. What is the most likely cause of his hemodynamic instability?
➔ Neurogenic shock (Spinal trauma + hypotension + bradycardia + warm skin → Think neurogenic shock due to loss of sympathetic tone)
- Note: Manage with IV fluids ± vasopressors (e.g., norepinephrine); atropine for bradycardia
- Must exclude hemorrhagic shock first (look for signs of bleeding)
- Urinary catheter should be inserted to assess perfusion (urine output) and check for hematuria
97. A 30-year-old man presents after trauma with GCS of 6, bradypnea, and unresponsiveness. What is the next step in management?
➔ Orotracheal intubation (Low GCS + poor respiratory drive → immediate airway protection needed)
- Note: GCS ≤8 → Intubate to protect airway
- Always assess Airway → Breathing → Circulation in trauma
- Signs of airway compromise: ↓ GCS, bradypnea, facial trauma
Environmental/Toxines
98. A 42-year-old farmer is brought to the ED after collapsing in a field. He is vomiting, diaphoretic, and bradycardic. Pupils are pinpoint. He has wheezing and copious oral secretions. What is the next best step in management?
➔ Administer atropine (Suspected organophosphate poisoning → Immediate atropine to block cholinergic effects)
- Note: Symptoms: DUMBELS (Diarrhea, Urination, Miosis, Bradycardia, Emesis, Lacrimation, Salivation)
- Pralidoxime → reactivates acetylcholinesterase at NMJ (use after atropine)
99. A 19-year-old athlete collapses during football practice on a hot, humid day. He is confused, hypotensive, and has a core temperature of 41°C (105.8°F). What is the next best step in management?
➔ Rapid external cooling (Heat + Core temp >40°C + CNS dysfunction → think heat stroke → Immediate cooling is lifesaving)
- Note: Cold water immersion is most effective
- Then supportive care and electrolyte monitoring
100. A 23-year-old marathon runner collapses near the finish line. He is alert but complains of dizziness, headache, and nausea. Vitals show T 38.8°C (101.8°F), HR 110/min, BP 98/60 mm Hg. What is the diagnosis?
➔ Heat exhaustion (Exercise + elevated temp + no CNS symptoms → think Heat Exhaustion)
- Note: Caused by inadequate fluid/salt replacement during exertion in heat
- Management: Cool environment + oral/IV hydration + rest
101. A 48-year-old homeless man is brought to the ED after being found outside in freezing temperatures. He is lethargic with a core temperature of 30°C (86°F), bradycardia, and shallow respirations. What is the next step in management?
➔ Active external rewarming (Core temp 28–32°C + bradycardia + altered mental status → Moderate hypothermia → Active external rewarming)
- Note: Mild (32–35°C) → Passive warming (blankets, warm room)
- Moderate (28–32°C) → Active external warming (heating blankets, warm IV fluids)
- Severe (<28°C) → Active internal rewarming (warmed O₂)
🏁 Final Thoughts
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Disclaimer
Version 1.0 August 2025. No part of this document may be reproduced or distributed without written permission. For personal study only. Medical information herein is for educational purposes and does not constitute clinical advice. Always confirm with current guidelines and your institution’s policies.
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