NBME Surgery 3 — Questions and Answers
Question 1: A 22-year-old man is brought to the ED after a motor vehicle collision with blunt abdominal trauma. He is hypotensive (BP 80/50 mmHg) despite 2L IV crystalloid. FAST exam shows free fluid in the abdomen. What is the next best step?
- Abdominal CT scan with contrast
- Diagnostic peritoneal lavage
- Emergent exploratory laparotomy (Correct answer)
- Repeat FAST examination
Correct answer: Emergent exploratory laparotomy
A hemodynamically unstable patient with positive FAST for free abdominal fluid requires immediate exploratory laparotomy without delay for CT.
Question 2: A 58-year-old woman presents with progressive dysphagia to solids over 4 months and a 10-lb weight loss. Upper endoscopy shows a mid-esophageal mass, and biopsy confirms squamous cell carcinoma. CT shows no distant metastases. What is the preferred treatment approach?
- Surgery alone (esophagectomy)
- Neoadjuvant chemoradiation followed by esophagectomy (Correct answer)
- Radiation alone
- Chemotherapy alone
Correct answer: Neoadjuvant chemoradiation followed by esophagectomy
Resectable esophageal squamous cell carcinoma is treated with neoadjuvant chemoradiation followed by esophagectomy to improve survival.
Question 3: A 35-year-old woman presents with a 1-cm solitary thyroid nodule. TSH is normal. Fine-needle aspiration cytology is read as 'atypia of undetermined significance' (Bethesda III). What is the recommended next step?
- Immediate thyroidectomy
- Repeat FNA in 3–6 months or molecular testing (Correct answer)
- Radioiodine ablation
- Levothyroxine suppression therapy
Correct answer: Repeat FNA in 3–6 months or molecular testing
Bethesda III (AUS/FLUS) warrants repeat FNA or molecular marker testing to stratify malignancy risk before surgery.
Question 4: A 50-year-old obese woman presents with right upper quadrant pain, fever (38.8°C), and jaundice. Labs show elevated total bilirubin, alkaline phosphatase, and WBC of 16,000/μL. Ultrasound shows gallstones and a dilated common bile duct. What is the diagnosis?
- Acute cholecystitis
- Ascending cholangitis (Correct answer)
- Choledocholithiasis without infection
- Acute pancreatitis
Correct answer: Ascending cholangitis
Charcot's triad (RUQ pain, fever, jaundice) in the setting of choledocholithiasis and a dilated CBD indicates ascending cholangitis.
Question 5: A 60-year-old man with a history of smoking presents with left calf claudication after walking 200 meters that resolves with rest. His ABI is 0.65 on the left. He has no rest pain or tissue loss. What is the first-line treatment?
- Immediate bypass surgery
- Percutaneous transluminal angioplasty
- Supervised exercise therapy and risk factor modification (Correct answer)
- Catheter-directed thrombolysis
Correct answer: Supervised exercise therapy and risk factor modification
Lifestyle-limiting claudication without critical limb ischemia is managed initially with supervised exercise, smoking cessation, and antiplatelet therapy.
Question 6: A 48-year-old man undergoes laparoscopic cholecystectomy. On post-op day 2 he develops RUQ pain, fever, and elevated liver enzymes. Repeat ultrasound shows a fluid collection near the liver. MRCP reveals a bile duct injury with bile leak. What is the initial management?
- Immediate surgical re-exploration and repair
- ERCP with biliary stenting (Correct answer)
- Percutaneous drainage of collection only
- Oral antibiotics and observation
Correct answer: ERCP with biliary stenting
Post-cholecystectomy bile leak from a minor duct injury is initially managed with ERCP and biliary stenting to reduce ductal pressure and allow healing.
Question 7: A 72-year-old man presents with crampy left lower quadrant pain, fever, and leukocytosis. CT shows pericolic fat stranding around the sigmoid colon with a 3-cm abscess. He is hemodynamically stable. What is the appropriate management?
- Emergency sigmoid colectomy with Hartmann's procedure
- CT-guided percutaneous drainage and IV antibiotics (Correct answer)
- Colonoscopy for diagnosis
- IV antibiotics alone without drainage
Correct answer: CT-guided percutaneous drainage and IV antibiotics
Acute diverticulitis with a pericolic abscess ≥3 cm in a stable patient is best managed with CT-guided percutaneous drainage plus IV antibiotics.
NBME Surgery 3
A 22-year-old man is brought to the ED after a motor vehicle collision with blunt abdominal trauma.
He is hypotensive (BP 80/50 mmHg) despite 2L IV crystalloid.
FAST exam shows free fluid in the abdomen.
What is the next best step?