Surgery EOR practice questions

Why B) Surgical consultation for appendectomy is correct

• Classic appendicitis (Alvarado score 8–10): migratory periumbilical to RLQ pain, anorexia, fever, leukocytosis, positive Rovsing and psoas signs.
• Immediate surgical consultation is appropriate when the clinical diagnosis is classic.
• CT improves diagnostic accuracy in atypical presentations but should not delay surgery when the presentation is classic.
• Laparoscopic appendectomy is the treatment of choice.

Why A) Staphylococcus aureus is correct

• This is a surgical site infection presenting at the typical postoperative day 5–7 window with purulent wound drainage.
• Staphylococcus aureus, including MRSA, is the single most common organism causing surgical site infections overall, originating from skin flora.
• It is the best answer even after bowel surgery.
• Correct source control (opening and packing the wound) plus culture-directed therapy is the management here.

Why the others are wrong

• B) Pseudomonas aeruginosa — a gram-negative organism seen in burns, water-exposed wounds, and immunocompromised hosts; not the most common cause of typical surgical site infections.
• C) Bacteroides fragilis — an anaerobe that contributes to intra-abdominal and colorectal surgical infections and is plausible after a hemicolectomy, but as a single most-common isolate it ranks below S. aureus.
• D) Candida albicans — a fungal pathogen associated with prolonged antibiotics, parenteral nutrition, or immunosuppression; an uncommon cause of routine wound infections.

Why C) Pheochromocytoma is correct

• Pheochromocytoma is a catecholamine-secreting tumor arising from adrenal medullary chromaffin cells.
• The classic triad of episodic headache, palpitations, and diaphoresis combined with resistant hypertension in a young patient is highly suggestive.
• Elevated plasma free metanephrines with an adrenal mass on imaging confirms the diagnosis.
• Definitive treatment is surgical resection after preoperative alpha blockade (typically phenoxybenzamine) followed by beta blockade to prevent intraoperative hypertensive crisis.

Why the others are wrong

• A) Renal artery stenosis — typically produces an abdominal bruit and would not cause elevated metanephrines or an adrenal mass; more often occurs in older patients with atherosclerosis or in young women with fibromuscular dysplasia.
• B) Primary hyperaldosteronism — presents with hypertension and hypokalemia driven by elevated aldosterone with suppressed renin, not catecholamine excess.
• D) Cushing syndrome — causes hypertension along with central obesity, moon facies, striae, and elevated cortisol, not paroxysmal adrenergic symptoms.

Why B) Emergency open surgical aortic repair is correct

• Stanford Type A dissection (involves ascending aorta ± arch) is a surgical emergency with 1–2% mortality per hour without treatment.
• Immediate cardiothoracic surgery for repair is the standard of care.

Why the others are wrong

• A) IV labetalol and nitroprusside infusion — medical management with IV beta-blocker to lower HR and systolic blood pressure (SBP) is only a temporizing measure while arranging surgery, not definitive treatment for Type A.
• C) Endovascular stent graft (TEVAR) placement — thoracic endovascular aortic repair (TEVAR) is appropriate for complicated Stanford Type B dissection (descending aorta only), not Type A.
• D) Systemic alteplase thrombolysis — not indicated for aortic dissection.

Additional high-yield points

• Stanford Type B (descending aorta only) is initially managed medically unless complicated.

Why needle decompression at the 2nd ICS midclavicular line is correct

• Tension pneumothorax is a clinical diagnosis — do NOT delay for imaging
• Classic findings: respiratory distress + tracheal deviation away from affected side + absent breath sounds + hypotension + jugular venous distension (JVD)
• Immediate management: needle thoracostomy using a large-bore needle at the 2nd intercostal space (ICS) midclavicular line or 4th/5th ICS anterior axillary line to rapidly decompress
• Needle thoracostomy is followed by tube thoracostomy

Why emergency surgical exploration and detorsion is correct

• Testicular torsion is a urological emergency
• Salvage rate >90% if detorsed within 4–6 hours, ~50% at 12 hours, rare if >24 hours
• Classic presentation: sudden severe scrotal pain, high-riding testis, horizontal lie, absent cremasteric reflex, decreased Doppler flow
• Management: immediate surgical exploration without imaging delay
• Bilateral orchiopexy is performed because the contralateral testis has the same anatomical predisposition
• Manual detorsion can be attempted while arranging the OR