NBME Surgery 2 — Questions and Answers
Question 1: A 45-year-old man presents with sudden severe epigastric pain radiating to the back, nausea, and vomiting. His serum lipase is 1,200 U/L. CT scan shows peripancreatic fat stranding but no necrosis. Which is the most appropriate initial management?
- Immediate surgical debridement
- IV fluids, bowel rest, and analgesics (Correct answer)
- Emergency ERCP
- Oral enzyme replacement therapy
Correct answer: IV fluids, bowel rest, and analgesics
Mild acute pancreatitis without necrosis is managed conservatively with IV fluids, bowel rest, and pain control.
Question 2: A 62-year-old woman undergoes elective sigmoid colectomy. On postoperative day 5 she develops fever, tachycardia, and a wound that appears indurated with thin brownish discharge. Crepitus is palpated along the wound margins. What is the next best step?
- Oral antibiotics and wound culture
- IV antibiotics alone
- Immediate surgical debridement and IV antibiotics (Correct answer)
- Wound vacuum-assisted closure
Correct answer: Immediate surgical debridement and IV antibiotics
Crepitus and thin brownish discharge indicate necrotizing soft tissue infection requiring emergent surgical debridement plus broad-spectrum IV antibiotics.
Question 3: A 28-year-old woman presents with a 3-cm tender mass in the right breast that has been present for 2 weeks. Ultrasound shows a well-circumscribed, anechoic, cystic structure. Fine-needle aspiration yields clear fluid and the mass resolves. What is the appropriate next step?
- Excisional biopsy
- Repeat mammogram in 6 months
- Reassurance and routine follow-up (Correct answer)
- Core needle biopsy
Correct answer: Reassurance and routine follow-up
A simple cyst that resolves completely after aspiration of clear fluid requires only routine follow-up with no further intervention.
Question 4: A 55-year-old man with a 30-pack-year smoking history presents with a pulsatile, non-tender periumbilical mass. Abdominal ultrasound shows an aortic diameter of 5.8 cm. He is otherwise asymptomatic. What is the most appropriate management?
- Surveillance ultrasound in 6 months
- Immediate open surgical repair
- Elective endovascular aneurysm repair (EVAR)
- CT angiography and referral for elective repair (Correct answer)
Correct answer: CT angiography and referral for elective repair
Asymptomatic AAA ≥5.5 cm warrants CT angiography for surgical planning and elective repair referral.
Question 5: A 70-year-old woman has a complete small bowel obstruction confirmed on CT. She has no peritoneal signs, no fever, and WBC is 9,000/μL. What is the initial management?
- Immediate exploratory laparotomy
- NGT decompression, IV fluids, and serial abdominal exams (Correct answer)
- Colonoscopic decompression
- High-dose IV corticosteroids
Correct answer: NGT decompression, IV fluids, and serial abdominal exams
A complete SBO without signs of strangulation or peritonitis is initially managed non-operatively with NGT decompression and fluid resuscitation.
Question 6: A 40-year-old man undergoes total thyroidectomy for papillary thyroid cancer. Six hours postoperatively he complains of tingling around his mouth and in his fingertips. His calcium level is 7.2 mg/dL. What is the immediate treatment?
- Oral calcium carbonate supplementation
- IV calcium gluconate (Correct answer)
- IV magnesium sulfate
- Parathyroid reimplantation
Correct answer: IV calcium gluconate
Symptomatic hypocalcemia after thyroidectomy requires immediate IV calcium gluconate to prevent laryngospasm and tetany.
Question 7: A 66-year-old man with known cirrhosis presents with massive upper GI bleeding. Upper endoscopy reveals actively bleeding esophageal varices. After band ligation, bleeding is controlled. What medication should be started to reduce rebleeding risk?
- Omeprazole
- Propranolol (Correct answer)
- Spironolactone
- Lactulose
Correct answer: Propranolol
Non-selective beta-blockers such as propranolol reduce portal pressure and are the mainstay of secondary prophylaxis against variceal rebleeding.
NBME Surgery 2
A 45-year-old man presents with sudden severe epigastric pain radiating to the back, nausea, and vomiting.
His serum lipase is 1,200 U/L.
CT scan shows peripancreatic fat stranding but no necrosis.
Which is the most appropriate initial management?