MCCQE Acute Surgical Presentations 2

Question 1

A 45-year-old man presents with sudden onset severe epigastric pain radiating to the back, nausea, and vomiting after a heavy meal.
Serum lipase is 1200 U/L.
CT shows peripancreatic fat stranding but no necrosis.
What is the Ranson criterion at admission that most strongly predicts severity?

Accepted Answer

Serum glucose > 11 mmol/L

Answer

Age > 55 years

Answer

WBC > 16 x10⁹/L

Answer

LDH > 350 IU/L

Question 2

A 68-year-old woman with atrial fibrillation presents with sudden severe periumbilical pain out of proportion to physical exam findings, followed by bloody diarrhea 6 hours later. CT angiography shows filling defect in the superior mesenteric artery. What is the priority management?

Accepted Answer

IV heparin anticoagulation and urgent surgical or endovascular revascularization

Answer

Immediate exploratory laparotomy

Answer

Broad-spectrum antibiotics and bowel rest

Answer

Vasopressin infusion via angiography catheter

Question 3

A 55-year-old man undergoes elective right hemicolectomy. On post-operative day 3 he develops fever, tachycardia, and worsening abdominal pain with peritoneal signs. CT shows free air and fluid. What is the most likely diagnosis and appropriate next step?

Accepted Answer

Anastomotic leak — return to OR for washout and stoma creation

Answer

Ileus — nasogastric decompression

Answer

Wound infection — open wound and antibiotics

Answer

C. difficile colitis — oral vancomycin

Question 4

A 30-year-old woman presents with right lower quadrant pain, low-grade fever, and elevated WBC. Ultrasound is non-diagnostic. CT with contrast shows a 9 mm appendix with periappendiceal fat stranding. She has no perforation or abscess. What is standard of care?

Accepted Answer

Laparoscopic appendectomy

Answer

IV antibiotics alone with outpatient follow-up

Answer

Open appendectomy via McBurney incision

Answer

Interval appendectomy in 6 weeks

Question 5

A 72-year-old man with a known 5.5 cm abdominal aortic aneurysm presents with sudden onset severe back and flank pain, hypotension, and a pulsatile abdominal mass. BP is 80/50. What is the immediate management priority?

Accepted Answer

Permissive hypotension targeting SBP 50-70 mmHg and emergent surgical repair

Answer

CT angiography to confirm rupture

Answer

IV fluid resuscitation to normalize blood pressure before surgery

Answer

Endovascular aortic repair (EVAR) as first-line

Question 6

A 40-year-old man presents with a painful, irreducible bulge in the right groin below and lateral to the pubic tubercle that appeared during heavy lifting. He has nausea but no vomiting. What type of hernia is most likely and what is the next step?

Accepted Answer

Femoral hernia — urgent surgical repair due to high strangulation risk

Answer

Indirect inguinal hernia — elective repair

Answer

Direct inguinal hernia — conservative management with truss

Answer

Spigelian hernia — CT confirmation then repair

Question 7

A 25-year-old man sustains a stab wound to the left chest at the 5th intercostal space, midclavicular line. He is hypotensive with distended neck veins and muffled heart sounds. Trachea is midline. What is the immediate intervention?

Accepted Answer

Pericardiocentesis or emergency thoracotomy for cardiac tamponade

Answer

Emergency chest X-ray

Answer

Needle decompression at 2nd ICS midclavicular line

Answer

Bilateral chest tubes