COMAT Surgery Exam V3 COMAT Surgery Exam V3
COMAT Surgery Exam V3
1. A 45-year-old female presents to the emergency department with a 12-hour history of
severe right upper quadrant pain that radiates to her right shoulder. She also reports nausea
and two episodes of vomiting. On physical examination, she has a temperature of 101.2 F and
palpable tenderness in the right upper quadrant with inspiratory arrest upon deep palpation.
Her laboratory results show a white blood cell count of 14,000/mm3. Which of the following
is the most appropriate initial imaging study to confirm the diagnosis?
A. Computed tomography (CT) of the abdomen and pelvis
B. Right upper quadrant ultrasound
C. Hepatobiliary iminodiacetic acid (HIDA) scan
D. Magnetic resonance cholangiopancreatography (MRCP)
Correct Answer: B
Explanation: This patient presents with classic signs of acute cholecystitis, including a
positive Murphy sign and leukocytosis. The initial imaging modality of choice for suspected
biliary disease is a right upper quadrant ultrasound, which has high sensitivity and
specificity for detecting gallstones and gallbladder wall thickening. If ultrasound is
inconclusive but clinical suspicion remains high, a HIDA scan is the most sensitive
confirmatory test for acute cholecystitis.
,2. A 68-year-old male with a history of atrial fibrillation and peripheral vascular disease
presents with sudden-onset, severe diffuse abdominal pain. He describes the pain as 10/10 in
intensity. On examination, his abdomen is soft, non-distended, and minimally tender to
palpation, which is disproportionate to his reported pain level. What is the most likely
diagnosis?
A. Diverticulitis
B. Perforated peptic ulcer
C. Acute pancreatitis
D. Acute mesenteric ischemia
Correct Answer: D
Explanation: Acute mesenteric ischemia typically presents with pain out of proportion to
physical exam findings, often in patients with risk factors like atrial fibrillation (embolic
source). The soft abdomen early in the course is a classic board-exam distractor, as
peritoneal signs only develop after bowel infarction. Immediate CT angiography and
surgical consultation are required to prevent extensive bowel necrosis.
3. A 24-year-old male is brought to the trauma bay after a motor vehicle accident. He is
awake but in respiratory distress. Vital signs show a blood pressure of 85/50 mmHg, heart
rate of 130 bpm, and oxygen saturation of 88% on room air. Physical exam reveals absent
breath sounds on the right side and tracheal deviation to the left. What is the most
immediate next step in management?
A. Obtain a portable chest X-ray
,B. Intubate the patient and initiate mechanical ventilation
C. Perform needle decompression in the second intercostal space, mid-clavicular line
D. Perform a focused assessment with sonography for trauma (FAST)
Correct Answer: C
Explanation: This patient demonstrates the classic triad of tension pneumothorax:
respiratory distress, hypotension (obstructive shock), and tracheal deviation. Tension
pneumothorax is a clinical diagnosis, and treatment must not be delayed for imaging.
Immediate needle decompression followed by tube thoracostomy is the standard of care to
relieve intrathoracic pressure and restore venous return.
4. A 72-year-old female undergoes an elective sigmoid resection for recurrent diverticulitis.
On postoperative day 3, she develops a fever of 101.8 F and a new cough. She has been using
her incentive spirometer infrequently. Her breath sounds are decreased at the left base.
What is the most likely cause of her fever?
A. Surgical site infection
B. Deep vein thrombosis
C. Pneumonia
D. Urinary tract infection
Correct Answer: C
, Explanation: Postoperative fever can be remembered by the 5 W’s: Wind
(Atelectasis/Pneumonia, days 1-2), Water (UTI, day 3), Walking (DVT/PE, day 5), Wound
(Infection, day 7), and Wonder drugs. Given the patient’s fever on day 3, new cough, and
poor incentive spirometry use, pneumonia is a high clinical suspicion. Atelectasis is a
common early cause, but persistent fever and pulmonary symptoms suggest progressing to
pneumonia.
5. A 55-year-old male presents with a 2-day history of left lower quadrant pain and low-grade
fever. He reports no nausea or vomiting. Physical exam shows localized tenderness in the left
lower quadrant without rebound or guarding. A CT scan shows thickening of the sigmoid
colon wall and pericolic fat stranding without evidence of an abscess. What is the most
appropriate management?
A. Urgent sigmoid colectomy
B. Inpatient IV fluids and NPO status
C. Percutaneous drainage
D. Outpatient management with oral antibiotics and a clear liquid diet
Correct Answer: D
Explanation: This patient has uncomplicated diverticulitis (Hinchey Stage 0 or Ia). For
patients who are hemodynamically stable, tolerate oral intake, and have no systemic signs
of sepsis, outpatient management with broad-spectrum oral antibiotics and dietary
modification is appropriate. Surgical intervention is reserved for complicated cases such as
perforation, obstruction, or recurrent episodes failing medical therapy.
COMAT Surgery Exam V3
1. A 45-year-old female presents to the emergency department with a 12-hour history of
severe right upper quadrant pain that radiates to her right shoulder. She also reports nausea
and two episodes of vomiting. On physical examination, she has a temperature of 101.2 F and
palpable tenderness in the right upper quadrant with inspiratory arrest upon deep palpation.
Her laboratory results show a white blood cell count of 14,000/mm3. Which of the following
is the most appropriate initial imaging study to confirm the diagnosis?
A. Computed tomography (CT) of the abdomen and pelvis
B. Right upper quadrant ultrasound
C. Hepatobiliary iminodiacetic acid (HIDA) scan
D. Magnetic resonance cholangiopancreatography (MRCP)
Correct Answer: B
Explanation: This patient presents with classic signs of acute cholecystitis, including a
positive Murphy sign and leukocytosis. The initial imaging modality of choice for suspected
biliary disease is a right upper quadrant ultrasound, which has high sensitivity and
specificity for detecting gallstones and gallbladder wall thickening. If ultrasound is
inconclusive but clinical suspicion remains high, a HIDA scan is the most sensitive
confirmatory test for acute cholecystitis.
,2. A 68-year-old male with a history of atrial fibrillation and peripheral vascular disease
presents with sudden-onset, severe diffuse abdominal pain. He describes the pain as 10/10 in
intensity. On examination, his abdomen is soft, non-distended, and minimally tender to
palpation, which is disproportionate to his reported pain level. What is the most likely
diagnosis?
A. Diverticulitis
B. Perforated peptic ulcer
C. Acute pancreatitis
D. Acute mesenteric ischemia
Correct Answer: D
Explanation: Acute mesenteric ischemia typically presents with pain out of proportion to
physical exam findings, often in patients with risk factors like atrial fibrillation (embolic
source). The soft abdomen early in the course is a classic board-exam distractor, as
peritoneal signs only develop after bowel infarction. Immediate CT angiography and
surgical consultation are required to prevent extensive bowel necrosis.
3. A 24-year-old male is brought to the trauma bay after a motor vehicle accident. He is
awake but in respiratory distress. Vital signs show a blood pressure of 85/50 mmHg, heart
rate of 130 bpm, and oxygen saturation of 88% on room air. Physical exam reveals absent
breath sounds on the right side and tracheal deviation to the left. What is the most
immediate next step in management?
A. Obtain a portable chest X-ray
,B. Intubate the patient and initiate mechanical ventilation
C. Perform needle decompression in the second intercostal space, mid-clavicular line
D. Perform a focused assessment with sonography for trauma (FAST)
Correct Answer: C
Explanation: This patient demonstrates the classic triad of tension pneumothorax:
respiratory distress, hypotension (obstructive shock), and tracheal deviation. Tension
pneumothorax is a clinical diagnosis, and treatment must not be delayed for imaging.
Immediate needle decompression followed by tube thoracostomy is the standard of care to
relieve intrathoracic pressure and restore venous return.
4. A 72-year-old female undergoes an elective sigmoid resection for recurrent diverticulitis.
On postoperative day 3, she develops a fever of 101.8 F and a new cough. She has been using
her incentive spirometer infrequently. Her breath sounds are decreased at the left base.
What is the most likely cause of her fever?
A. Surgical site infection
B. Deep vein thrombosis
C. Pneumonia
D. Urinary tract infection
Correct Answer: C
, Explanation: Postoperative fever can be remembered by the 5 W’s: Wind
(Atelectasis/Pneumonia, days 1-2), Water (UTI, day 3), Walking (DVT/PE, day 5), Wound
(Infection, day 7), and Wonder drugs. Given the patient’s fever on day 3, new cough, and
poor incentive spirometry use, pneumonia is a high clinical suspicion. Atelectasis is a
common early cause, but persistent fever and pulmonary symptoms suggest progressing to
pneumonia.
5. A 55-year-old male presents with a 2-day history of left lower quadrant pain and low-grade
fever. He reports no nausea or vomiting. Physical exam shows localized tenderness in the left
lower quadrant without rebound or guarding. A CT scan shows thickening of the sigmoid
colon wall and pericolic fat stranding without evidence of an abscess. What is the most
appropriate management?
A. Urgent sigmoid colectomy
B. Inpatient IV fluids and NPO status
C. Percutaneous drainage
D. Outpatient management with oral antibiotics and a clear liquid diet
Correct Answer: D
Explanation: This patient has uncomplicated diverticulitis (Hinchey Stage 0 or Ia). For
patients who are hemodynamically stable, tolerate oral intake, and have no systemic signs
of sepsis, outpatient management with broad-spectrum oral antibiotics and dietary
modification is appropriate. Surgical intervention is reserved for complicated cases such as
perforation, obstruction, or recurrent episodes failing medical therapy.
