A family doctor in a rural area is treating a patient for dyspepsia. The patient had chronic heartburn and abdominal pain for the last 2 months and peptic ulcer disease due to a suspected H. pylori infection. For reasons relating to affordability and accessibility, the doctor decides to perform a diagnostic test in the office that is less invasive and more convenient. Which of the following is the most likely test used?

Culture of organisms from gastric specimen

Detection of the breakdown products of urea in biopsy

A 45-year-old man comes to his primary care provider for a routine visit. The patient mentions that while he was cooking 5 days ago, he accidentally cut himself with a meat cleaver and lost the skin at the tip of his finger. After applying pressure and ice, the bleeding stopped and he did not seek treatment. The patient is otherwise healthy and does not take any daily medications. The patient’s temperature is 98.2°F (36.8°C), blood pressure is 114/72 mmHg, pulse is 60/min, and respirations are 12/min. On exam, the patient demonstrates a 0.5 x 0.3 cm wound on the tip of his left third finger. No bone is involved, and the wound is red, soft, and painless. There are no signs of infection. Which of the following can be expected on histopathological examination of the wounded area?

Deposition of type III collagen

Epithelial cell migration from the wound borders

Neutrophil migration into the wound

A previously healthy 5-year-old boy is brought to the emergency department 15 minutes after sustaining an injury to his right hand. His mother says that she was cleaning the bathroom when he accidentally knocked over the drain cleaner bottle and spilled the liquid onto his hand. On arrival, he is crying and holding his right hand in a flexed position. His temperature is 37.7°C (99.8°F), pulse is 105/min, respirations are 25/min, and blood pressure is 105/65 mm Hg. Examination of the right hand shows a 4 x 4 cm area of reddened, blistered skin. The area is very tender to light touch. His ability to flex and extend the right hand are diminished. Radial pulses are palpable. Capillary refill time is less than 3 seconds. Which of the following is the most appropriate next step in management?

Apply split-thickness skin graft

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 63-year-old man presents to the clinic complaining of burning bilateral leg pain which has been increasing gradually over the past several months. It worsens when he walks but improves with rest. His past medical and surgical history are significant for hypertension, hyperlipidemia, diabetes, and a 40-pack-year smoking history. His temperature is 99.0°F (37.2°C), blood pressure is 167/108 mm Hg, pulse is 88/min, respirations are 13/min, and oxygen saturation is 95% on room air. Physical exam of the lower extremities reveals palpable but weak posterior tibial and dorsalis pedis pulses bilaterally. Which of the following is the best initial treatment for this patient's symptoms?

Balloon angioplasty with stenting

A 54-year-old man comes to the physician because of a painful mass in his left thigh for 3 days. He underwent a left lower limb angiography for femoral artery stenosis and had a stent placed 2 weeks ago. He has peripheral artery disease, coronary artery disease, hypercholesterolemia and type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for 34 years. Current medications include enalapril, aspirin, simvastatin, metformin, and sitagliptin. His temperature is 36.7°C (98°F), pulse is 88/min, and blood pressure is 116/72 mm Hg. Examination shows a 3-cm (1.2-in) tender, pulsatile mass in the left groin. The skin over the area of the mass shows no erythema and is cool to the touch. A loud bruit is heard on auscultation over this area. The remainder of the examination shows no abnormalities. Results of a complete blood count and serum electrolyte concentrations show no abnormalities. Duplex ultrasonography shows an echolucent sac connected to the common femoral artery, with pulsatile and turbulent blood flow between the artery and the sac. Which of the following is the most appropriate next best step in management?

Ultrasound-guided thrombin injection

Wound assessment techniques for USMLE Step 2 CK: High-Yield Surgery Lessons

Initial Assessment - First Glance

Anatomy & Age: Location (e.g., distal limb, pressure area) and duration (acute vs. chronic).
Bleeding & Borders: Active hemorrhage? Well-defined or irregular edges?
Color & Circulation: Assess wound bed (red, yellow, black) and periwound tissue perfusion.
Dimensions: Measure Length x Width x Depth in cm.
Exudate & Edema: Note fluid type (serous, purulent) and amount; check for surrounding swelling.

⭐ A wound failing to heal by 3 months is typically classified as chronic. This timeframe is critical for escalating care and investigating underlying etiologies like ischemia or infection.

Wound Bed - Reading the Tissues

Assess tissue types (Viability):
- Granulation: Beefy red, bumpy, moist. Indicates healthy healing.
- Epithelial: Pink/translucent, new skin growing from edges.
- Slough: Yellow, tan, or white. Stringy or fibrinous. Non-viable tissue requiring removal.
- Eschar: Black or brown, dry, leathery, necrotic tissue. Non-viable.
Identify Tissue Percentage: Estimate the percentage of each tissue type in the wound bed (e.g., 70% granulation, 30% slough).
Exudate Assessment: Note color, consistency, and amount.
- Serous (clear), Sanguineous (bloody), Serosanguineous (pinkish), Purulent (pus).

⭐ In a non-infected, stable heel ulcer with dry eschar and poor arterial flow, do not debride. The eschar acts as a physiologic cover.

Wound bed with eschar, slough, and granulation tissue

Infection & Edges - Spotting Trouble

Clinical Signs of Infection:
- 📌 IFEE: Induration, Fever, Erythema, Edema.
- Also: ↑ pain, purulent or malodorous discharge, localized warmth.
- Systemic signs: Leukocytosis, fever > 38.5°C.
- Quantitative swab culture: > 10^5 CFU/g of tissue is diagnostic.
Wound Edge Assessment:
- Healthy: Pink, attached, migrating across the wound base (epithelializing).
- Unhealthy:
  - Macerated: White, boggy from excess moisture.
  - Epibole: Rolled, thickened edges that have stopped migrating.
  - Fibrotic/Calloused: Hard, raised, non-progressive.
  - Undermining/Tunneling: Indicates deeper tissue damage.

⭐ Acute wound infections (<30 days) are most commonly caused by S. aureus. Chronic or delayed infections suggest biofilm or atypical organisms.

Healing of infected pressure injury on heel over 108 days

High‑Yield Points - ⚡ Biggest Takeaways

The gold standard for wound culture is a tissue biopsy, not a surface swab, to distinguish infection from colonization.

Assess lower extremity ulcers with an Ankle-Brachial Index (ABI); an ABI < 0.9 is highly suggestive of peripheral artery disease (PAD).

A positive probe-to-bone test is highly specific for osteomyelitis in diabetic foot ulcers.

Wood's lamp examination helps identify certain pathogens, like Pseudomonas (green fluorescence).

Healthy wounds show red granulation tissue; yellow slough and black eschar require debridement.

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