COMAT Surgery Exam V1 COMAT Surgery Exam V1
COMAT Surgery Exam V1
1. A 45-year-old female presents to the emergency department with a 6-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 positive Murphy sign and a
temperature of 101.2°F (38.4°C). Laboratory studies show a white blood cell count of
14,000/mm³. What is the most appropriate next step in the management of this patient?
A. Right upper quadrant ultrasound
B. Endoscopic retrograde cholangiopancreatography (ERCP)
C. Hepatobiliary iminodiacetic acid (HIDA) scan
D. Computed tomography (CT) of the abdomen and pelvis
Correct Answer: A
Explanation: The patient presents with classic signs of acute cholecystitis, including right
upper quadrant pain, fever, and a positive Murphy sign. Right upper quadrant ultrasound is
the initial imaging modality of choice due to its high sensitivity and specificity for detecting
gallstones and gallbladder wall thickening. While a HIDA scan is highly sensitive for
diagnosis when ultrasound is inconclusive, ultrasound is preferred first as it is non-
invasive and provides information on alternative diagnoses.
,2. A 68-year-old male with a history of atrial fibrillation presents with sudden onset of severe
periumbilical abdominal pain. On examination, the pain seems out of proportion to the
physical findings, which show a soft, non-tender abdomen. His lactic acid level is elevated.
Which of the following is the most likely diagnosis?
A. Sigmoid volvulus
B. Perforated peptic ulcer
C. Acute pancreatitis
D. Acute mesenteric ischemia
Correct Answer: D
Explanation: Acute mesenteric ischemia (AMI) typically presents with sudden, severe
abdominal pain that is ‘out of proportion to physical exam findings’ in a patient with risk
factors like atrial fibrillation. The elevation in lactic acid suggests bowel ischemia or
infarction. Prompt diagnosis with CT angiography is critical to prevent bowel necrosis and
death.
3. A 24-year-old male is brought to the trauma bay after a motor vehicle accident. He is
awake but tachypneic and cyanotic. His blood pressure is 80/50 mmHg, heart rate is 130 bpm,
and oxygen saturation is 85% on room air. Examination reveals decreased breath sounds on
the right side and tracheal deviation to the left. What is the immediate next step?
A. Perform an urgent chest X-ray
B. Perform needle decompression
,C. Endotracheal intubation
D. Obtain a Focused Assessment with Sonography for Trauma (FAST)
Correct Answer: B
Explanation: This patient has classic signs of a tension pneumothorax, characterized by
respiratory distress, hypotension, decreased breath sounds, and tracheal deviation.
Tension pneumothorax is a clinical diagnosis, and waiting for a chest X-ray can be fatal.
Immediate needle decompression in the second intercostal space at the midclavicular line
(or fifth intercostal space at the anterior axillary line) is required followed by chest tube
placement.
4. A 72-year-old male presents with a 3-day history of obstipation, abdominal distention, and
crampy pain. He has not had a bowel movement or passed flatus in 48 hours. Abdominal X-
ray shows a ‘coffee bean’ appearance of a dilated loop of bowel arising from the pelvis. What
is the most appropriate initial treatment?
A. Proctosigmoidoscopy with rectal tube placement
B. Emergency sigmoidectomy with primary anastomosis
C. Intravenous fluids and observation
D. Barium enema
Correct Answer: A
Explanation: The ‘coffee bean’ sign on X-ray is characteristic of sigmoid volvulus. In stable
patients without signs of peritonitis or bowel gangrene, the initial management is
, endoscopic detorsion using proctosigmoidoscopy and placement of a rectal tube. While
detorsion is often successful, the recurrence rate is high, and semi-elective surgery is
usually recommended later in the same admission.
5. A 30-year-old woman presents with a firm, mobile, well-defined breast mass in the upper
outer quadrant of her left breast. She states the mass has not changed in size during her
menstrual cycle. Ultrasound shows a solid, hypoechoic, circumscribed mass. What is the most
likely diagnosis?
A. Fibrocystic change
B. Fibroadenoma
C. Intraductal papilloma
D. Phyllodes tumor
Correct Answer: B
Explanation: Fibroadenoma is the most common benign breast tumor in young women
and typically presents as a firm, mobile, non-tender, rubbery mass. Unlike fibrocystic
changes, fibroadenomas do not typically fluctuate with the menstrual cycle. Ultrasound
features of a circumscribed, oval mass are classic, though biopsy is often performed for
definitive confirmation.
COMAT Surgery Exam V1
1. A 45-year-old female presents to the emergency department with a 6-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 positive Murphy sign and a
temperature of 101.2°F (38.4°C). Laboratory studies show a white blood cell count of
14,000/mm³. What is the most appropriate next step in the management of this patient?
A. Right upper quadrant ultrasound
B. Endoscopic retrograde cholangiopancreatography (ERCP)
C. Hepatobiliary iminodiacetic acid (HIDA) scan
D. Computed tomography (CT) of the abdomen and pelvis
Correct Answer: A
Explanation: The patient presents with classic signs of acute cholecystitis, including right
upper quadrant pain, fever, and a positive Murphy sign. Right upper quadrant ultrasound is
the initial imaging modality of choice due to its high sensitivity and specificity for detecting
gallstones and gallbladder wall thickening. While a HIDA scan is highly sensitive for
diagnosis when ultrasound is inconclusive, ultrasound is preferred first as it is non-
invasive and provides information on alternative diagnoses.
,2. A 68-year-old male with a history of atrial fibrillation presents with sudden onset of severe
periumbilical abdominal pain. On examination, the pain seems out of proportion to the
physical findings, which show a soft, non-tender abdomen. His lactic acid level is elevated.
Which of the following is the most likely diagnosis?
A. Sigmoid volvulus
B. Perforated peptic ulcer
C. Acute pancreatitis
D. Acute mesenteric ischemia
Correct Answer: D
Explanation: Acute mesenteric ischemia (AMI) typically presents with sudden, severe
abdominal pain that is ‘out of proportion to physical exam findings’ in a patient with risk
factors like atrial fibrillation. The elevation in lactic acid suggests bowel ischemia or
infarction. Prompt diagnosis with CT angiography is critical to prevent bowel necrosis and
death.
3. A 24-year-old male is brought to the trauma bay after a motor vehicle accident. He is
awake but tachypneic and cyanotic. His blood pressure is 80/50 mmHg, heart rate is 130 bpm,
and oxygen saturation is 85% on room air. Examination reveals decreased breath sounds on
the right side and tracheal deviation to the left. What is the immediate next step?
A. Perform an urgent chest X-ray
B. Perform needle decompression
,C. Endotracheal intubation
D. Obtain a Focused Assessment with Sonography for Trauma (FAST)
Correct Answer: B
Explanation: This patient has classic signs of a tension pneumothorax, characterized by
respiratory distress, hypotension, decreased breath sounds, and tracheal deviation.
Tension pneumothorax is a clinical diagnosis, and waiting for a chest X-ray can be fatal.
Immediate needle decompression in the second intercostal space at the midclavicular line
(or fifth intercostal space at the anterior axillary line) is required followed by chest tube
placement.
4. A 72-year-old male presents with a 3-day history of obstipation, abdominal distention, and
crampy pain. He has not had a bowel movement or passed flatus in 48 hours. Abdominal X-
ray shows a ‘coffee bean’ appearance of a dilated loop of bowel arising from the pelvis. What
is the most appropriate initial treatment?
A. Proctosigmoidoscopy with rectal tube placement
B. Emergency sigmoidectomy with primary anastomosis
C. Intravenous fluids and observation
D. Barium enema
Correct Answer: A
Explanation: The ‘coffee bean’ sign on X-ray is characteristic of sigmoid volvulus. In stable
patients without signs of peritonitis or bowel gangrene, the initial management is
, endoscopic detorsion using proctosigmoidoscopy and placement of a rectal tube. While
detorsion is often successful, the recurrence rate is high, and semi-elective surgery is
usually recommended later in the same admission.
5. A 30-year-old woman presents with a firm, mobile, well-defined breast mass in the upper
outer quadrant of her left breast. She states the mass has not changed in size during her
menstrual cycle. Ultrasound shows a solid, hypoechoic, circumscribed mass. What is the most
likely diagnosis?
A. Fibrocystic change
B. Fibroadenoma
C. Intraductal papilloma
D. Phyllodes tumor
Correct Answer: B
Explanation: Fibroadenoma is the most common benign breast tumor in young women
and typically presents as a firm, mobile, non-tender, rubbery mass. Unlike fibrocystic
changes, fibroadenomas do not typically fluctuate with the menstrual cycle. Ultrasound
features of a circumscribed, oval mass are classic, though biopsy is often performed for
definitive confirmation.
