A 43-year-old woman comes to the physician because of a 3-month history of a painless ulcer on the sole of her right foot. There is no history of trauma. She has been dressing the ulcer once daily at home with gauze. She has a 15-year history of poorly-controlled type 1 diabetes mellitus and hypertension. Current medications include insulin and lisinopril. Vital signs are within normal limits. Examination shows a 2 x 2-cm ulcer on the plantar aspect of the base of the great toe with whitish, loose tissue on the floor of the ulcer and a calloused margin. A blunt metal probe reaches the deep plantar space. Sensation to vibration and light touch is decreased over both feet. Pedal pulses are intact. An x-ray of the right foot shows no abnormalities. Which of the following is the most appropriate initial step in management?

Sharp surgical debridement of the ulcer

Surgical revascularization of the right foot

Amputation of the right forefoot

Total contact casting of right foot

A 15-year-old boy is brought to the emergency department by ambulance after his mother found him having muscle spasms and stiffness in his room. His mother stated he scraped his foot on a rusty razor on the bathroom floor 2 days prior. On presentation, his temperature is 102.0°F (38.9°C), blood pressure is 108/73 mmHg, pulse is 122/min, and respirations are 18/min. On physical exam, he is found to have severe muscle spasms and rigid abdominal muscles. In addition, he has a dirty appearing wound on his right foot. The patient's mother does not recall any further vaccinations since age 12. Finally, he is found to have difficulty opening his mouth so he is intubated. Which of the following treatment(s) should be provided to this patient?

Wound debridement, antitoxin, and booster vaccine

Wound debridement and antitoxin

Wound debridement and booster vaccine

A 54-year-old male carpenter accidentally amputated his right thumb while working in his workshop 30 minutes ago. He reports that he was cutting a piece of wood, and his hand became caught up in the machinery. He is calling the emergency physician for advice on how to transport his thumb and if it is necessary. Which of the following is the best information for this patient?

Wrap thumb in saline-moistened, sterile gauze and place in sterile bag

Place thumb in cup of cold milk

Wrap thumb in sterile gauze and submerge in a cup of saline

There is no need to save the thumb

Place thumb directly into cooler of ice

A 72-year-old man is seen in the hospital for a sacral rash. The patient has been hospitalized for the past 3 weeks for a heart failure exacerbation. When the nurse went to bathe him this morning, she noticed a red rash over his sacrum. The patient reports mild discomfort and denies pruritus. The patient has chronic kidney disease, urinary incontinence, ischemic cardiomyopathy, gout, and poor mobility. His current medications include aspirin, furosemide, metoprolol, lisinopril, spironolactone, and prednisone that was started for a recent gout flare. The patient’s temperature is 97°F (37.2°C), blood pressure is 110/62 mmHg, pulse is 68/min, and respirations are 13/min with an oxygen saturation of 98% on room air. On physical examination, there is a 4 cm x 6 cm patch of non-blanchable erythema over the patient’s sacrum that is mildly tender to palpation. Labs are obtained, as shown below: Leukocyte count: 10,000/mm^3 with normal differential Hemoglobin: 15.2 g/dL Platelet count: 400,000/mm^3 Serum: Na: 138 mEq/L K+: 4.3 mEq/L Cl-: 104 mEq/L HCO3-: 25 mEq/L BUN: 26 mg/dL Creatinine: 1.5 mg/dL Glucose: 185 mg/dL A hemoglobin A1c is pending. Which of the following is the best management for the patient’s most likely diagnosis?

Prophylactic oral ciprofloxacin

An 8-year-old boy is shifted to a post-surgical floor following neck surgery. The surgeon has restricted his oral intake for the next 24 hours. He does not have diarrhea, vomiting, or dehydration. His calculated fluid requirement is 1500 mL/day. However, he receives 2000 mL of intravenous isotonic fluids over 24 hours. Which of the following physiological parameters in the boy’s circulatory system is most likely to be increased?

Interstitial hydrostatic pressure

A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

"Can you tell me more about the symptoms you have been experiencing?"

"Does the diarrhea typically precede the constipation, or vice-versa?"

"Is the diarrhea foul-smelling?"

"Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"

"Are the symptoms worse in the morning or at night?"

A 39-year-old man comes to the physician for a follow-up examination. He was treated for a urinary tract infection with trimethoprim-sulfamethoxazole 2 months ago. He is paraplegic as a result of a burst lumbar fracture that occurred after a fall 5 years ago. He has hypertension and type 2 diabetes mellitus. Current medications include enalapril and metformin. He performs clean intermittent catheterization daily. He has smoked one pack of cigarettes daily for 19 years. His temperature is 37.1°C (98.8°F), pulse is 95/min, respirations are 14/min, and blood pressure is 120/80 mm Hg. He appears malnourished. Examination shows palpable pedal pulse. Multiple dilated tortuous veins are present over both lower extremities. There is a 2-cm wound surrounded by partial-thickness loss of skin and a pink wound bed over the right calcaneum. Neurologic examination shows paraparesis. His hemoglobin A1c is 6.5%, and fingerstick blood glucose concentration is 134 mg/dL. Which of the following is most likely to have prevented this patient's wound?

Broad-spectrum antibiotic therapy

A patient presents to the emergency department with arm pain. The patient recently experienced an open fracture of his radius when he fell from a ladder while cleaning his house. Surgical reduction took place and the patient's forearm was put in a cast. Since then, the patient has experienced worsening pain in his arm. The patient has a past medical history of hypertension and asthma. His current medications include albuterol, fluticasone, loratadine, and lisinopril. His temperature is 99.5°F (37.5°C), blood pressure is 150/95 mmHg, pulse is 90/min, respirations are 19/min, and oxygen saturation is 99% on room air. The patient's cast is removed. On physical exam, the patient's left arm is tender to palpation. Passive motion of the patient's wrist and fingers elicits severe pain. The patient's left radial and ulnar pulse are both palpable and regular. The forearm is soft and does not demonstrate any bruising but is tender to palpation. Which of the following is the next best step in management?

Measurement of compartment pressure

Pressure ulcers staging and management for USMLE Step 1: High-Yield Surgery Lessons

Pathophysiology & Risk Factors - Under Pressure

Primary Injury: Sustained pressure on soft tissue, typically over a bony prominence, exceeds capillary filling pressure (>32 mmHg).
Ischemic Cascade:
- Obstructed blood flow → ↓ tissue perfusion (ischemia) & lymphatic drainage.
- Waste product accumulation → inflammation, endothelial damage, thrombosis.
- Leads to irreversible tissue necrosis.
Key Risk Factors:
- Immobility: sedation, paralysis, fractures.
- Sensory Loss: spinal cord injury, neuropathy.
- Extrinsic Factors: ↑ moisture (incontinence), friction, shear forces.
- Systemic Factors: poor nutrition (↓ albumin), anemia, altered mental status.

⭐ Shear forces, which stretch and distort tissue and vessels parallel to the skin, are more damaging than direct vertical pressure.

Pressure and shear forces on tissue over bony prominence

Pressure Ulcer Staging - Setting the Stage

Pressure Ulcer Stages: 1, 2, 3, 4, DTI, Unstageable

Stage	Depth of Tissue Loss	Clinical Presentation
Stage 1	-	Intact skin with non-blanchable erythema.
Stage 2	Partial-thickness	Shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or ruptured serum-filled blister. > ⭐ Exam favorite: Often mistaken for simple abrasion or tape burn.
Stage 3	Full-thickness skin loss	Subcutaneous fat may be visible, but bone, tendon, or muscle are NOT exposed. Slough may be present.
Stage 4	Full-thickness tissue loss	Exposed bone, tendon, or muscle. Slough or eschar may be present. Often includes undermining and tunneling.
Unstageable	Full-thickness tissue loss	Base of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black).
Deep Tissue Injury (DTI)	-	Purple or maroon localized area of discolored intact skin or blood-filled blister.

Management by Stage - Healing the Hurt

Core Principles: Offload pressure, optimize nutrition (protein, vitamins), manage incontinence, and maintain a moist wound environment.

Pressure Ulcer Management Pathway

Stage 1: Intact skin. Focus on aggressive pressure relief and protective dressings.
Stage 2: Partial-thickness loss.

⭐ Hydrocolloid dressings are often favored as they are impermeable to bacteria, provide a moist environment, and promote autolytic debridement.
Stage 3 & 4: Full-thickness loss. Requires debridement of necrotic tissue. Surgical consultation for advanced wounds.
Unstageable: Obscured full-thickness loss. Must be debrided to determine true depth.

Prevention Strategies - Stop the Sore

Risk Assessment: Regularly use the Braden scale to identify at-risk patients (score <18 indicates high risk).
Repositioning & Offloading: Key to prevention.
- Turn bed-bound patients at least every 2 hours.
- Shift weight for chair-bound patients every 15-30 minutes.
⭐ Bed-bound patients should be repositioned at least every 2 hours, while chair-bound patients require more frequent shifts, every 15-30 minutes, to effectively offload pressure from ischial tuberosities.
Support Surfaces: Use pressure-reducing devices.
- Examples: High-specification foam mattresses, alternating pressure air mattresses, or low-air-loss surfaces.
Skin Care:
- Keep skin clean, dry, and moisturized.
- Apply barrier creams to protect from incontinence.
Nutrition:
- Optimize protein and calorie intake to maintain tissue health.

High‑Yield Points - ⚡ Biggest Takeaways

Pressure redistribution (e.g., q2h turning) is the single most important step in prevention and management.

Stage 1 is intact skin with non-blanchable redness; Stage 2 is partial-thickness loss of dermis.

Stage 3 is full-thickness loss into subcutaneous fat; Stage 4 involves exposed bone, tendon, or muscle.

Unstageable ulcers have a bed obscured by slough/eschar and require debridement (except stable heel eschar).

Deep Tissue Injury is a localized area of purple or maroon discolored intact skin.

Management requires a moist wound environment, adequate nutrition, and continuous pressure offloading.

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