General Surgery Board Review Case Studies & Practical Application 3 — Questions and Answers
Question 1: A 28-year-old unrestrained driver is brought in after a high-speed MVA. BP is 88/60, HR 124. FAST exam shows free fluid in the abdomen. Despite 2L IV crystalloid, BP remains 90/62. What is the next step?
- CT scan of the abdomen and pelvis
- Repeat FAST exam
- Emergent exploratory laparotomy (Correct answer)
- Angiographic embolization
Correct answer: Emergent exploratory laparotomy
Hemodynamically unstable blunt abdominal trauma with positive FAST and failure to respond to resuscitation mandates emergent exploratory laparotomy.
Question 2: A 65-year-old male diabetic presents with a 3-day history of scrotal swelling, pain, and fever. Exam reveals crepitus and skin necrosis of the perineum. WBC is 22,000. What is the definitive treatment?
- IV antibiotics alone
- Emergent surgical debridement plus IV antibiotics (Correct answer)
- Hyperbaric oxygen therapy
- Incision and drainage at bedside
Correct answer: Emergent surgical debridement plus IV antibiotics
Fournier's gangrene requires emergent wide surgical debridement of all necrotic tissue plus broad-spectrum IV antibiotics; delay increases mortality dramatically.
Question 3: A 72-year-old woman with atrial fibrillation on warfarin presents with sudden severe periumbilical pain out of proportion to exam. CT angiography shows SMA thromboembolism with bowel ischemia. INR is 3.2. What is the most appropriate management?
- Anticoagulation alone with heparin drip
- Endovascular thrombectomy if available
- Emergent exploratory laparotomy (Correct answer)
- Vasopressin infusion and observation
Correct answer: Emergent exploratory laparotomy
Acute mesenteric ischemia with signs of bowel infarction (peritoneal signs) requires emergent surgical exploration for bowel resection and revascularization.
Question 4: A 45-year-old male presents to the ED after a stab wound to the left chest below the nipple line. He is hemodynamically stable with BP 110/70, HR 94. FAST exam is negative. What diagnostic study is most critical?
- CT chest/abdomen/pelvis with contrast (Correct answer)
- Emergent thoracotomy
- Bronchoscopy
- Serial abdominal exams only
Correct answer: CT chest/abdomen/pelvis with contrast
A stable patient with thoracoabdominal stab wound requires CT imaging to evaluate for pneumothorax, hemothorax, and occult intra-abdominal injury.
Question 5: A 58-year-old male with Crohn's disease presents with a 1-week history of RLQ pain, low-grade fever, and a tender palpable mass. CT shows a 5 cm abscess adjacent to the terminal ileum. What is the best initial management?
- Emergent ileocecal resection
- CT-guided drainage plus IV antibiotics and bowel rest (Correct answer)
- High-dose steroids and bowel rest
- Total parenteral nutrition and anti-TNF therapy
Correct answer: CT-guided drainage plus IV antibiotics and bowel rest
An intra-abdominal abscess from Crohn's disease is best initially treated with CT-guided drainage and antibiotics to allow elective resection under optimized conditions.
Question 6: A 55-year-old woman undergoes laparoscopic cholecystectomy. Intraoperatively, bile is noted in the abdomen and the common bile duct appears divided. What is the most appropriate intraoperative response?
- Primary repair over a T-tube and proceed
- Place a drain and complete the case, repair later
- Convert to open and consult hepatobiliary surgery (Correct answer)
- Clip both ends of the duct and abort the case
Correct answer: Convert to open and consult hepatobiliary surgery
An intraoperative major bile duct injury should prompt immediate conversion to open laparotomy and consultation with an experienced hepatobiliary surgeon for definitive repair.
Question 7: A 40-year-old male presents 72 hours after a Whipple procedure with high-output (800 mL/day) amylase-rich drain fluid. He is afebrile and tolerating oral intake. What is the likely diagnosis and management?
- Bile leak — ERCP and stenting
- Postoperative pancreatic fistula — octreotide and continued drainage (Correct answer)
- Chyle leak — switch to medium-chain triglyceride diet
- Delayed gastric emptying — nasogastric decompression
Correct answer: Postoperative pancreatic fistula — octreotide and continued drainage
High-amylase drain output after pancreaticoduodenectomy defines a postoperative pancreatic fistula, managed conservatively with drainage, octreotide, and nutritional support.
General Surgery Board Review Case Studies & Practical Application 3
A 28-year-old unrestrained driver is brought in after a high-speed MVA.
BP is 88/60, HR 124.
FAST exam shows free fluid in the abdomen.
Despite 2L IV crystalloid, BP remains 90/62.
What is the next step?