2, Direct inguizl bemia, Indirect inginal hemi, D. Oorster hemi E, Unblial henia, Answers DISCUSSION: Indirect inguinal! hernias are the most common emia in bath females and males, Femoral hemias ae ‘ore common ems am aes 2. Which ofthe following statrent regarding umsual eria in nore? A” Am obturator hernia may proce nerve compression dagtose by & postive Howship Romberg sin. 1 Gryafelts terns appears through the superior lumbur triangle, whereas Petts hemia occurs though the inferior lumbar angle. (CSc esas wualy poset witha pif rin mus elo the inguinal ligament. ‘. Lines hernia i defined bya MeckeTsdiverdcalu pescuting as the sole component ofthe hei a. E. Ricters hema involves the sovimesentere sutace of the intestine within te hernia sic an may present with url ines bsructon ‘anewers DISCUSSION: Sos hornias uly poset with inestinalebstuction or amas inthe plea or intalueal eon. 3 Staples may safly be placed during laparoscopic hori repr in each ofthe following structures excep A Cooper’ ligament B. Tsses superior tothe late itopubi tat, C. The wanwersisabdominis sponeurte arch. . Tisses inferior othe otra opubie ac. E. The logue tat at srton onto Cooper ligament, Answer: D DISCUSSION: Placement of stapes inferior to (below) the lata itiopubic tract may’ result in injury the tera femoral cutanecus sere ofthe gonteemorl nerve. Stiles should abo ot be laced ‘ihn the tangle of doom, ‘ong tothe isk of major vascular injury. A Recurrent dict 2B. diet inguinal hemi €: Kerra herin—Type D_ Diret inguinal berna Type Ila. .Indiet inguinal ra with destruction of tetransversalis fascia of Hesselbach’s wiangle—Type UL DISCUSSION: An indioet inguinal hersia with destsion of the uansverais facia of Hesseltuch$ tangle is lasified asa Type I heria. Aso cased as Type Il hernia are sliding, pntloon, and massive seul hess. ‘Type I hernia is a iret inguinal erin with a late internal ing but without displacement ofthe infrioe deep cpigasic vescels or destruction ofthe tanwerais fascia of Hesselbuch angle 5. Which ofthe following tarement about the cases of inguinal hernia is some? A Excessive hydroxyproline his Boe demonststed in the aponeucees of hernl pate 3B. Oblteraionof the processus vagndlis ia commibuing factor forthe develope ofan indirect inguinal era, (C._Physiealacivty and athletics have Been shown to ave a protective eect toward the development of inguinal erie D._ Elevated levels of i ‘uho smoke E.The majority of inguinal hems are aquired “Answer: D lating serum elastic activity have been demonstrate in patents with direst herniationDISCUSSION: A conelaton hetween cigarette smoking and an inguinal emia formation has been demenstated. "levate ciculing serum ease activity and reactive unbound neutrophil elastase has eon detested in stokes 6. The following satements about the epi of inguinal hernias rere excep {A Tha conjoined tendon is sures to Cooper ligament i th Basi hernia ea. B. The MeVay repair is a uitable option or the repair of feoral ria. (C. The Shouiice repair involves a multlye,imbricated epi ofthe floor ofthe inguinal canal. 1D. The Lichtenstein repr fs accomplisned by prose mesh fepsir ofthe ing canal Moor in tensions EThe laparoscopic tamsahdomina! preperitoneal (TAPP) and tually extrapritonel appreach (TEPA) repairs ae tase onthe prepertoneal eis cf Cale, Hens, Nyhus, nd Stop. DISCUSSION: The Bassin repairs accomplished by high ligation ofthe heria sac followed by suurng the conjoined ‘endon and he internal oblique musceo the igunaliguners. 1. Which ofthe following statements concerning the sial wal layers ae comet? ‘A Scarpa’ fascia alfrds ale strength in wound closure '5 The inca abdominal obligue mci have bes that conto int the erotun as cemastrie msc {C The wansvealis acai the most important yer ofthe somal wal reveting hemi D. The Iymphatis ofthe abdominal wall dan int the ipsistral axillary Iymph odes above the ubiius and nto ‘heise supericialingunal ymph nodes bow the umbicus. “Answer: ABCD DISCUSSION: The integrity ofthe sdoninal wall is maintained principally by the transversal fascia, Scarpa fascia efor ie srengt in wound closure, but its approximation cotibutes considerably to the retin of anaesetaly ‘eceptble scar. The cromasteticruscles of the spematic cord area continuation of muscle Tiber fom the intra ‘Hsia clique musculature. The Iymphatc supply ofthe abomial wal follows a sme patrn. These superficial Iymphaties mn parallel to the superficial veins, which above the umbilicus drain int the pstealailary vein and ‘low it imo the ipsatral femora en, 8. Whit ofthe following congenital abnormalities are corel defined? ‘A. Onphalecle represents defect i the abdominal wall ltl othe umbilical end, 1. The emiated viscera associated with ompalozces are usualy covered witha membranous 3. C. Anunblicl polyp is asmallexrestence of onphalomesetvie duet mucos that retained in the umbiias. 'D. Mecketsaiveicutu resus when the inesinl end ofthe ompalomescnerie duc persis nd represeas 4 wus “anvwer: BCD DISCUSSION: Onphalocle maybe seen innewborss and represent defect in the cowie ofthe umbilical sing. The ‘erited viscera are usally covered with a Ge. Gstosciss a defect ofthe abdominal wal ater the ambica ‘od cased by flute of eknue ofthe oxy wal. The intestines potude through the defect anda sts preset 12 over the embed Inestne. Inte fetus, the amphalomesentic duct may preset as abnermales slated 1D the ‘Seen wall when the dac il to oblcrte. Masel’ dvriculam the eat of the fie af Biteration of the Iesinal etd of te omphulomsieneric dct. This i a tue dveniculam wih al layers of the intestinal yall represented. An umbilical plsp is small excescence of emphalomesentarc duct mucoss reine in th umbicus. Sch polyps resemble ubilal granulomas ence tht they donot disappear afer silver nie castericton. “Appropiatewesiment i excision ofthe mucosal remnant. ‘The following staemens) are rue concerning the indications for toumen ofan inguinal here. Mest aut hernias will remain stable in size therefore ela seldom aes the technical aspects ofa surgical repair Th There is a diet comeltion hexwesn the length of ine that a hen complications The monty and morality asccated with emergent operation de to hernia compa eater than fr eleetive repair ofthe dena era 4A truss maimains a hema in the reduced sate, therefore, minimizing the isk of incarceration and strangulation Answer bye present and the vsk of major ifcaty“The indatons for hemi repuir must be individualized foreach patent and the particular sition. genera, the sence ofa hernia may be considered an adequate indian for hema rea. Ceranly the presence of complications due to feria ecesittes the cection of those complications and usally the repr of the Reria. AS with amy treatment, the benefits of operative repair mus be weighed aint te natural history ofthe disease, te exten to which the weatment can comet the probe, the pssibity of teatent-eated injury. and the interference of concomitant daca withthe treatment rss. With afew exepions the natural istry of ak abo! wall hema hat the ize of the defect and the se enlarges overtime, and ts eelargement increases the difficulty of adequate repair and the ‘hunces of recurrence of the hernia The isk of major complications is greater in an individu pate. the longer the fexpomue to etna and th ager the sa eave tothe erna deft. In addin, major complications necesste an {Snorgent operation with tlended high morality and msi relative to dt experienced with an elective repair The {Se of a uss an extemal suppor device using a stem of saps to exe realm pressure over the bern defect, ‘ould generally be avoided. Trusses do not conssicly maintain a heria i the reduced ste, and they may pat an ‘nreduced hea in ges eopurdy of strangulation The prssre exer induces edema by deeeasingIymphate and ‘enous ow ou of the heated bowel, Trusses ay ls ea nj tthe skin oerying he hei, 10. Which of the folowing statements) ire ue conceming the diagnosis and management of epigastric hernias? 4 Allarge pestoeal sac conning abdominal viscera is common 15 Atte ine of surpeal rer care search Tor other defects shuld be performed ©. Recuat egies hers eter simple stsure Is uncommon 4 _ Patents wih moms ofa pina midline abdominal mas fregucrly will contain incarcerated small bowel Answers ign hemias ae wll sal but hey vary comiderably i size. Most of thee defects occur in theming. The smal defecs contin only preperitoneal fat with no sac. With ineessng size, fain the faleform ignmen and ‘rentually a peritoneal sac and abdominal viscera maybe contained wit he hei. The preperitoneal fat in he small fect is usualy ncucerated. Muliple defects may te present in up to 205 of pains. Surgical weament ‘commended inal patients with symptoms or with emia defect reir than L$ to? ci diameter, Methods repair depend upon the sizeof the defect. For soall defects, simple cosuae with obliquely placed sues afer ‘eduction of removal of the prepvitoneal fat om the defect has been recommended. However recurrent sigs ‘emis in up to 10% ofthe case have Boen reported with ths method, mos ikely as result of addons! undetected or urepird weaknesses the pigs midine. 11, ‘The following statements) are ru concerning neurovascular structures inthe inguinal region. ‘The inferior epigastric anor and vein fun upward in the preperitoneal fat posterior to he tansveris fscia close tothe lateral margin of the intemal inguinal rng ‘bThelohypogastic and iloingital re motor and sensory nerves inthe inguinal region which lie beneath the cxeral eign apeneurosis ‘The loinguinal nerve runs anterior othe spermatic cord inthe inguinal canal and at he supe ring branches nt the sensory spp tothe pbc region and the upper scrotum o ab mors ("The genital ranch of the genofemoal nerve is sensory nerve only othe upper hh an genital rca Aniwers bye ‘Avising atviony fiom the extemal iliac artery te inferior epigastric artery wit its accompanying vein rns obliquely ‘medally and upward in the preperitoneal fat poster to the wansversals cs and close othe rior marino th Internal inguinal ring. Inguinal hernias arising sapere tothe inferior epigastric vente a indirect inguinal hei, ‘whoeas those arg inferior w the veses ave dec inguinal hamish. The ichypopasic and inguinal nerves ae ‘motor and sensory nerves tothe miscles and skin of the inguinal egon. The nerves penetrate the ransversasabomin's ‘usle athe pnt above the idle ofthe ia cet, ie Below the intemal obigut masse up othe pots jst medial land superior to the anterior supevior iliac spine. and then penewate te intemal oblique muscle and e Below the eral oblique aponeuoss. The inguinal neve suns anterior to he sperma cord in the inguinal eal tthe ‘Superficial inguinal games, branches ino sensory supply to the pub epin at the upp scrotum ot abu majrs. “The gental ranch ofthe geitferoral neve perioraes the tansersalis facia sully ust intros tothe intemal ng. Ie couss along the posterior surface ofthe spermutis ord and supplies motor lbs (othe eemner muscle At the superficial inguinal ng i divides to provide Sensory inaraton to the sroum and medial aspect othe uppe thigh.a patient preoperatively of potential complications of operative teatment of an inguinal hernia, ‘whlch ofthe following Matern) are re? 44 Severe symptoms due o sensory nerve entrapment ot injury can occur | ‘Themost common vascular stcture injured daring th course ow groin hernia epi isthe femoral atery © Recrtent hernia air primary grin repair shoul ecu ins han 10S fea {4 Wound infstion neetses the risk of recaren era Anvwersa. ed Many complications can cccur with operations to rep an ingialheria, Semiory nerve injury may eal dabling symtoms from neuronas or nerve entrapment dng igual hernia epi. Although vascular injuries ae uncom ‘ninguna rea the proximity ofthe Feral vein othe sacar sein the hrm ear makes nr hs seve (he meat Cent veal iy ebeerved. Harn worrence alice pinary gros heris mira sold ba iioqoet and varies in several large series from ess than one peeent © almost nine percent. The prevalence of reurent hernia ‘may be higher after repair of recut groin hemia Factors responsible for eri tecrene foci elosute undet ‘cessive teason faut deny and use av adequately suong musculoponeuroue tissue and wound infection 15, Ctylous ascites isthe acamulation of chyle within the peritoneal cavity. Which ofthe following statements) ‘Jae we concerning cyto ances? ‘4 ‘The cisterna cyl lies atthe anterior surface ofthe ist and second lumbar vertebrae and receives Iymphati ‘id tom the mesenteric ype 'b Chylous ascites is ost commonly asscated with abdominal Iymphoma €. _Paraconesis and analysis of claus Mid rypialy reveals elevated wilycries, rosea, and leukceyte levels ‘with elope analysis electing the underlying preseace of malignancy {4 Treatment ofehylus ass with dietary manipulation wl ke soeesfu in mt exes © _Themoraltyratein alts with hylos ascites sin excess of 50% Answera.te ‘Cylous ascites is accumulation within the peritoneal cavity of cle, a lymphatic fd witha high lipid comet. Access of imestinal ist the circulations via mesentereIymphatics that ere the cstera cle, which i ty ‘comes the theracic det which evenly enters the venoun system tthe jneton ofthe left subelvian and internal {guar seins. The eterna chy es at the anterior ura of he fist an second lb crea slightly othe ht sf the aot. Chyous ascites may reslt fom inary to major Lymphatic duct or the eterna. However fr lymphatic leakage to pers. widespread cxcesion of Iymphaticovenous collaerals. within the abdomen must be presen ‘Malignancy fs the predomitant cause (885) of spontaneous enyleus asc in adults. with Imphoma the most coma ‘ulignacy. Diggnsticstadles must lacie not only documentation of Iyphatc cig of the abdominal Mibu also {ten to delnete the ene af cyl snitn,Paaceteris and analy of chou fd typialy reveals elevated Uieyeerdes,protin, and leukocyte ves, with a predominance of lymphocytes. Unforanatly, cytology is seldom sive despite the presence of malignancy. Lyrphangiogephy may define the ite of lymphatic lak fer pints n Sthom the leak is from the cisterna or reuopertoncaliymphatcs but ot when ftom the mesenteric or hepatic lymphatics. OF noninvasive stdies, CT is te test of eboice. wih a hich dignostc ed in nontaunaiechyous ssc in adits Frequent, lparotony with node biopsy is veqaised for histology and typing in cases suspected tobe Cancer, parculasly for Iyrphoma.Teatmens for ciylous asces have been diected gnard decreasing Iymph and ‘lgcerdesccormlaion Succes resolution of etylous antes as eon achieved uning 3 fazed it ith ‘akled medum-chainaiglserides in an attempt . duce Iynghai transport of tiglycerides and perhaps intestinal ‘ymph Flow. Although there have boon reports of sucess using such dleury manipulation, many Flues have boon reported. Therefore, imo pens with cylous aces, treatment is ikely to be sues only when dicted tovard the underlying caus. For ptens with Iymphoms, terapyeffesive against Iymptons is kel so eliminate chyous “The prognosis for patents with chylous ascites such batter in infants ancien thn in ads, principally becuse the difereness in causes ofthe condition. A moral of 25 i reported in afas and eilten wheres «morality ff S85 has Deen noted in adults, Patiens with chyaus ascites with associated neoplsms typically have the gravest roprosis 1, Whichof the statement) ivare te concerning laparoscopic hernia repair? General anesthssia is oquited iter an abdominal: preperitoneal approach is posible ‘The ue of prosthetic mesh is eqired nal variations ‘Long-term rests suggest that the laparoscope approtch sequal or beter than atonal repairs PeerAnwwersa bye ‘Te lapwoscope approach tothe repair of groin hemias has been recently developed. Ether a tansabdoninal approach, wherein the peritoneum nthe inguinal are is opered, andthe epi i performed in the prperitoncum or an ately preperitoneal approach can be use. [nether technique which are both prfermed under genera anesthesia, ‘fer reducing the visceral contents out ofthe Resa th repairs performed by placing a sce of proshetic mesh over {he intemal aapect of tho inguinal floor and internal cing Although catty soni» and shert-term enftsappear Womisng lngterm follow-up datas sil not avaable to compare these techniques with titiona reais 15. A 28ysarold woman with a history ofan appordcctomy pests with a nntender palpable ms inthe ight lower quactant abdominal incision. The following stterents) hare rue concerning the daghosis and management of ‘hispatint. 44 The est diagnostic test involves imaging ofthe abdominal wal by either CT or MRL 'RResecton of the mass witha 2em margins usualy adequate Low dose radiation suitable altertiveto surgery fr pinay teament {&_Reressetin for recurrence wil likely hive ahighr ate of recurence than for primary resetion Answersa Desi tumor re fbromatous tamer tht may resemble low-grale fibrosarcoma but never metastasize. The tumor sftennfitvates adjacent muscle and asa high ineidenceofecurence despite sccrngly adequate gross resection The highest fequeney bin women of cildbering age of which over DOS of tuners are alma in Toction, For starial yall dsm tumors. approximately one-third ae associated with a previous operation atthe tuner sit. The ‘nos frequcn presenting symptom sa nomtende, palpable abdominal wall mass, Diagnostic iagig is best cried ont ty CT or MRI, which delineate the exten of involvement of the layer of the abomal wall and potent ‘ttaperitonealentzwsen. nial tetment of aorinal wall dead tumors ix srgical. Because the margins the tumor arent exsily determined and because the tumor often inftates muscle ahd periosteum limited margins around the row tumor fegucrly result in merosepie tumor at the margin. Recumence res for abdominal des! tems| sary ftom 9 tp 4%, and recunence i quent With inadequate margins. A Sem may af resction is considered ‘logis with mono bioe ressction of ib cage, pubic orilse hone or invlved potions of organ sch as adder #2 ‘ehieve these margins. Reconsruction of the abdominal wall with polypropylene mesh Is necesuy in most eases, fate in whom adequate maypns of resection af achiove, thre is mo tenet from adjuvant ratherapy. Second fn thndveections after securrence have en ssceatd with no higher fate of vecuence thn pin resection. Radiotherapy alone has ashieved local comot in desta nas any as TODS of tumers rested primarily and 75 of rocuten tums. Radiation doses a east 6 Gy ae considered secessury for consent cool. The lage ‘ution dene risks major damage to adjacent bowel and therefore primary radiaion {eaten of aon val smn tumors hs ited ale 16. Whichof te flloning statements) are tre concerning repair of inguinal hernias? ‘The Bassai repr approximates the transveras allominis aponewosis and tansverslis fala and the shelving ee ofthe inguinal igen. ‘The Bassin repiris an adequate repr fora femoral hema © Arelaxing inion is important for reps of it an! large inaret inguinal hernias wo prevent excessive ‘&"Anadhantage to the wse of prosthetic material isthe mesh incites formation of sear sue 0 furterinerease ‘emit strength provided by the mesh alone Answer aed ‘The Basin ropa an inguinal hernia repair used world-nde and has hoon the sandr against which ter reps ‘ae judged. Te repr involves approximation of the ansversusabomias spoteurois and transveas asia and the Teal edge ofthe rectus sheath 1 the shelving edge of the inguinal Iigameat_ A Temoral hernia cant be separ BS ‘he Basin par because the rfc to the femoral eana es dep to the inguinal ligament. A Cooper's ligament epair oes appoaimate he structures tb the tansverais fascia of the pectin (Coopers) Ligunet between the pubic tubercle andthe femoral vein and therefore fs appropiate for repro a feroal hei. A elaing incision for wep fect and lage iniec inguinal henias prevents eeesive tension inthe closure. There are an resin nae of roponents Tor the use of postctic mail forthe routine repr of inguinal hers. Prosthete material, such olyropslene mesh have been used for yeas for repair of lage or recueat inguinal and femal hernias The wosthetic mesh provides 2 fow-trsion repair for sch large defects which otherwise could net be closed without {excessive tension. In ation the mesh incites the foation of sear sue to further increase tensile strength Beyond‘Basie sued tuckground (iehenisy. Phd lols Heros, Shack. Sug efectos, Wand Hedge) 1. _ Skee muscle breakdown produces predominantly iteration of hick to ain ais? A Lysine © Alanine , Ghitamine E Arginine ‘Answers CD DISCUSSION: Alain is released irom skeletal muse and exacted by the lve, wher tis converted to new glucose. Cltamine is ao ‘eleuod fom muscle and parcipaes in fetal acsd-bse homeostasis abd serves as Tal fe rap’ ipowing cells such as enterocytes, sisted macopags, and fibroblasts. Togte, these to amino acids cout or {proximately two thirds ofthe mitrgenrelased fom skeletal muscle 2 in"etaboic”srgcl patents, which ofthe following change in boy composition do ot osu ‘A Leanbody iss increases. Toa dy water increases Adipose sue decreases D. Body weight decease ‘answer A DISCUSSION: Lean body mass represents the body compartment that conaits protein. Because cra less stimulates rotcolss and increased excretion of body nitogen this comparien is consis redced ot nese. The shange in Ray composition asociated with alos body weigh an crease ia toa body wae, and a decreas in badly fat 3. Thehomonal sertons hat follow operation and injury favor aceerated gluconeogenesis. This new pucose is consumed by which ofthe followieg issues A. Comma nervous stem, B Stl mack, ©. Bone D. Kidney. Tse inthe healing wound, ‘aster: ADE. DISCUSSION: Glucose is produced in increased amouts 1 sats the fue! requzemens ofthe Dealing wound I aon, ‘rvs tise andthe el medi also lize hese Skeletal muscle may ues fy cis and one wes tinea berate, 4 Cytokines ar endogenous signals that stimulate: [A Locale pelfaton within the wound. The conta navous sate nate fever C The production of acute phase pris.” , Hypoteremia. E Sepie stock. DISCUSSION: Akhough cytokines exer primal autsine and pac effets they may lo cause systemic effects. 5S. Thecharacteisic changes tat follow amor opeaion or modes Sever injury do ot itu the following:‘isi surgi tackgroud (ickembry. Pid, laos, Hepes, Shack, Suri fens Weaning.) DISCUSSION: The chactestic metabolic response to injiry iclndes hypemetabotim, ferer, aeselerted ‘fuconeosenes, and ovesed prose (cerings negative wegen hance). Food take is genraly impose Iopetphaza. A Hyposension, B. Hypoperision of sues D. Allo the above, newer B DISCUSSION: Shock, no mutter what he ease, ia spam asocated Wit tue hypopefsion. Tint hypopertsion leas toss hyponia which may or may not be due hypotemia. Hypatnsion i late sign of shock and hereto, ta good cine intro the presence of tsb hypopetusion. 71. Wich ofthe following aements sont cominvovs sardine opt monitoring are nie? ‘A. Cominucus cardia output monitoring may unmask vets nt deteced y intermittent calc output easements. 2. Cantnuous cade cup monitoring by the themoaion method resuces continuo ison of ad jae ot 2 ‘onsantate ant temperate Che major alsmtage ofthe Pek method over the themiltion method of cacuting casi op that tis ‘invasive, equing oly te determination of oxygen consumption by espiator as aa The echnigte of tera elctncal Bowmpedatce wlan senor fo determine sake volume By detcag changes resistance toa smal. plied aerating curent ‘Answer AD DISCUSSION: Various teciniqus are avis to measure canoe output continuously. The advantages of continsoat ‘exe tpt monitoring s compared with intermitem methods af (1) revel undetected events maybe unused (2) more prompt recognition of adverse events may be achieved and (3) eater erapeutc intervention may be posible COinicus caiac ouput monting using he tonmoduion mined appean to be as cue os We wanda” Intermiten olue mathod, But does Rot equre dd jects In ths ato, a medi pumonary atery eater incorporating a thermal lent heats Bloc i the right venticle at pulsed intervals, ad a dial teraistor detects the temperate change, whch canbe elated mathematically to cara ouput. The Fick method combines repo gs Shalit oxmzery to determine gen consumpion (V(oterda)O 2) ant etinute mined venous and eal Imeem conten ferences, respectively Cardia pet (CO) ie then determined fram the fori: CO w Viowerd)0 2! [Giavj0 2 « 10) @ Vioverdo0 27 (SaO 2 ~ SxO 2) « (Hb) x (39) x 10). Thoms eectical Noimpecance isa techrigue by which the resistance oa smul-amlitode aerating cuet (the impedance Is measred wir varias ‘Secon. The impalance change iced by ech ania jection i futon these vlums, whi hen can be (sed caleuate the casi ouput 8. Which of the flloing statements egardingcpokines ie incoect? A. tokines ac clretlyon target ells and may potentiate the actions of one snoter BB. Imerekin 1 (IL-1) sa major proinflarimstrs mediator wth multiple ees nlading regulon of skeletal muscle freteatas in pens wh sept or gntcan ery. CPlaeletacivating fictr (PAP) is « major cytokine tht results in platelet aggregation, bronchoonstrtion, and increased vascular permeability: D. Tumor necrosis factor alpha (TNFa), despite is shor pasta hl-fe, appears to be a principal mato inthe ht timaltes ‘answers DISCUSSION: Cytokines ae soluble peptide molecules tat ae spnerzed and secreted by numberof call ype in response to inj inflation, and infection. Cytokines, which ice the inefekin, mor necrosis aso, colony Simulating fort, and the interferons, comprise only one caegory of inflammatyy mediators invelved i the hostBasic surgical hackpround (Biohens wis Elecolyes, Hemostasis, Soc, Surgical nections, Wound Healing) 12. Which ofthe following statements about delivery-dependent oxygen consumpsion are rue? A. Below the estical oxygen delivery (Dyoverdo)O 2), one would expect o see a decrease in the lactate pynvate ratio. B, DeoverdonO 2erit may be increased in patients wih sepsis. A desirable goal in the treatment of shock ito achive delivery independent oxygen consumption 1D. The oxygen extraction ratio remains constat as long as oxygen delivery remains above Dioverdo)0 Zerit Answer: BC DISCUSSION: Oxygen consumption is sid to be delivery dependent below a eitical point, DYoverdet)O 2er, at which nuerobie maubolism supervenes. Above this poiat, oxygen consumption is relatively independent of oxygen delivery ecause the body's cells can compensate for alsin oxygen delivery by exacting more oxygen. Inthe delivery-dependent region, if cellar hypoxia is present, the lactate pyruvate ratio rss, owing to the switch to anaerobic metabolism, Generally, itis desirable to achieve delivery-independent oxygen consumption, 1 avoid ongoing tssue hypoxid. There is considerable debate, however, about the nature of the oxygen consumption-oxygen delivery relationship in cases of ‘Ssublished sepsis or wipe organ dysfunction syndrome In such cases, Byoverdos]O 2ctt may be increased, although the ‘herapeutc benefit of tying to achieve “Supranormal” oxygen delivery has not been Firmly established. 13. Allof the following may be useful inthe treatment of eadiogeni shock except: A. Debutumine. BB. Sodium airoprusside © Phoumaticantishock garment. D. Ints-ortic balloon pump. Answer: C DISCUSSION: Cardiogenic shock occurs when the hear fils to generte adequate cardiae output 10 maintain issue ‘perfusion, Ininsic causes suchas myocardial dysfunction secondary ¥ coronary ater disease, or exwinsc cases such 26 Fulmanary embolism, tension pneumothorax, and pericardial tamponade, may prodice cardiogenic shock. Principles of ‘reatmem of cardiogenic shock are aimed at optimizing preload, cardiac contact, and afterload. Preload is usually ‘xleqte or high n cardhogen shock, Dnbvtamine isa wsefl inotropic agent. parcolarly when filing pressures ae igh, ‘ecause ofits mild vasodilatory effect. as well asits effec to enhance cae conractiiy. Aterload-edacing agents, such 1 sodium nitoprusside, may be beneficial in cardiogenic shock inthe seting of elevated fling presures, low cardiac ‘urpu, and elevated sysiemic vascular resistance. Cardiac output may improve with use of afterloud-educing agents by decreasing myocardial wall tension and optimizing the myocardial oxygen supply-demand rato. The intrs-aoric balloon fpump (IABP), by providing dasiolic augmentation, reducing left veteiculr afterload, and reducing myocanial oxygen ‘consumption, is sometimes useful inthe treatment of eardiogeie shock. The LABP is especially useful in low-cardiae ‘utpit postcardiotomy patient, in pation awaling evasculaization, and inpatients with seule myocardial infarction ‘complicated by mivalinsuiceney or venicular seal defect, The pneumatic aftishock garment (PASG), which cases an Increase in systemic vascular resistance is contraindicated in cardiogenic shock, 14. Which ofthe following statements concerning monitoring techniques in the intensive care unit are true? ‘A. Pulmonary artery and pulmonary capillary wedge pressure readings should be made at end inspiration, 0 minimize venulatory artifacts. B. Continuous SvO 2 monitoring based on the technique of reflectance spectrphotometry has been shown t he accurate snd liable . Direct measurement of gastric intramucesal pH can be provided by gastrointestinal tonometry. 1D. Fyperlactatemia may be seen ina numberof cliscal condtions not associated with tissue hypoxia icloding liver Aisease and hypermetaboie state. “Answer: BD DISCUSSION: Many diferent monitoring techniques may be used to assess the adequacy of therapy for shock. The pulmonary artery caeter can provide imporant hemodynamic and oxygen transpon dat that are very useful in directing ‘horspy aimed at optimizing cardiac function and oxygen delivery. Pulmonary anery and pulmonary capillary wedge [resure readings should be made at end-expiration to minimize veniatory arifacts, Continuous SvO 2 monitoring, an ‘curate, reliable method that combines” pulmonary artery catheterzation wih the technique of rellecance Spectrphotometey, may provide early warning signs of hemodynamic compromise or inadequate oxygen delivery Gasroietinal wnomety provides information that allows one to infer the adequacy af splanchnic tissue perusion. In tisBreast 1. After ineaductal papilloma, unilateral bloody nipple discharge from one duct vite is mest commonly caused by shih of de following patologte conditions? ‘AL Pots disease of he nipple. 1, Inteadctl carcino. .faflarmatorycaeinowa D. Subureoar mastitis Answer B DISCUSSION: Nipple discharge i surgically sigifcam when tis grossly Mody and when it appears ata ingle duet caifice on one nipple. Bloody dactarge ix wally de to 3 henig inractal pupliona however, iat ‘arcioma inthe large dts ander the ripple can e the case of Bowdy discharge, and pathologically the lesion frequently large papillary tumor tha his become malignant. Pagets Unease ofthe pple is also duet inradtal carcinoma avning in suburcolar det, butt rarely iy accited wh pple charge, Suburolr mati my pode ‘ppl discharge. bu itis prulent and at bloods: Infaramatory carcinomas not associated with ple discharge. 2. Which ofthe following conditions i atocted with incest ak of breast cancer? ‘A. Fibocystie mastopay. 1 Sovere hyperplasia. . Aiypcalhyperpais, D. Papllonatosis Answers DISCUSSION: Fitvoeystic mastopathy, or ieystie disease, was one thought to ineease the Fisk of best cancer however, ater studies ofthe patologie findings in lroeystic complex found an inereased cancer isk onl fr pens whose biopsies showed apical hyperplasia, "Severe hyperplasia” is a pathologie term that refers to the amount of Inpeplasia and is frequently scen in the biopsy specimens of young women: it a misleading term and is not sasocated witha disease risk. Papillomatoss is abo part ofthe fbrcysic complex and is a requent Sing in Benign Iweast biopsies it does not confer an incessed isk of eancer. 4, Which ofthe folowing breast lesions ae noninsasive malignancies? ‘A. Iniatuca earinom of the comes type 1. Tubular susinoma and misinowe casino . Medullary carcino including atypical medulla lesions. Ansser 1 ariculrhisolopie vaiam of invasive breast cancer haracterized by permeation ofthe stoma with smal cells that resemble tose found in the breast lobule ee acinus. Towraacal carcinoma refer to malignancy of dacl origin tht remainn encloned within dat stractre Thi "oninasive proifeation can undergo cemral nero which frequently califies to form the mirockifcations seen cn mammography. The ceatal necrosis within eaarged and backo-back ducal sructres resembles comedoes and [ves settee “eomedocarlnoma,” now reserved fortis stlogie variety of invaducal carcinoma. 4. Which ofthe following re the most important and incall useful isk actos for breast cancer? ‘A Fibrcyscusease, age. and gender. |B Cysts amily history i immediate eaves, and gender (C. Age gender and fail history in immedi reatves. D. Obesity, nlpaity and aloha! ws. Anwwer DISCUSSION: The mest import risk fists for beat cancer are he patient's age, gener, and family hsery of ‘reas cancer in ime relatives (sisters, mote, daughter). The age-adjusted incidence of Breast cance neeases ‘wth age Breast cancer does occur in males, Bu the disease s Fr more common in wore Faily sion is important ‘when treast cancer curs within the immediate fami: history of breast cancer in more distant relatives (Grandmothers, cousins, aun) ses important In ation, age factors into the sk asociated wih fay history. AN effected young pinay relive is far mre sigiicart asa Fisk factor than an oder relative with breast caect. The ‘her imporant risk acorn sted ere sa hstory of breast ance, ether within the conserved ipsilateral breast orn the contalteral beast Agnn, age play an important ming role as the age at which breast cancer was fst Gdagnosed increases, te risk of a subsequent second ence decreases. Although patients with fibroeyse seas areaBreast increased rk for breast cancer, risk concentratesin those patents with fbreysic disease who show atypical pith Inpeplasia within east dots Okey, mulpart, and eotol all ppear to increase rskslghty and ae important 10 the epidemiologic sudy of Beast cancer; however, the efTest ofthese factors sot scent to Wagan thet seit ‘common clinical practice. ‘5. Which of the folowing pathologic findings isthe strongest ontrsndisation to breast preseratin (lumpectomy with ‘eas radiation asprinary weatment for anely diagnosed breast cance? ‘A Grae 3, pool feed infilating ductal eareinoma. 12, Extensive inact canoer around the invasive lesion, (6. Tarmor size greater than 3 em. D. Positive srpcal marin for invasive cancer, Answer: D DISCUSSION: The only im containdcation to wide excision and ration reas preservation, lumpectomy) as the ‘wimary surgical teatment fora newly discovered beast cancer isthe Inblity to achieve an uninvolved surges ‘usgin afer excision of th tumor. A positive surgical may reqies, at less, reperation with an attempt a = cision of the cancer Ifthe margin of removal is postive ale atemps at e-ekcision ths is a Srong reason 10 ‘commend maeton in preference to breast cansraton, Tumor size fu rlatvecontrindcaion when the cancer {sso lage in elation to the bresst that excision to clean supcal main seams unreasonable. Other histlogl findings. such as tumor grade oF vascular invasion, are not strong reasons to recommend mustctomy if the patient woul peer breast coneratin. 6. AillaryIymph node ssecton is routinely use or alo the folowing condition excep: ‘A. Dem, pure comedosype inradictal carcinoma 1 Lom iniltating lobular crsnoma. (Cn infiltrating ductal carcinoma, . pure medullary cancer inthe uperiner quadrant. Answers DISCUSSION: Inada carcinoma is carcinoma inst and doesnot metastasize to regional or distant sites, Lyng ‘node dissection i nt routelyreguied for a pure inst cancer ofthe beast I convastll f the oter cancers sted shove (inflating lobular, inflating ductal and medullary carcinoma) ate invasive malignasces that ae capable of ‘odal and distant metstss, Lyrph node sisetion is commonly recommended for these invasive: magnates Traduca esions that have grow lager than cm ate more apt to haye become focal invasive. Sie tis invasive component might be mised histologically many srgeous advocate selective use of auilay ode dissection fr lage Inadital lesions, parila high-grade tomers such asthe somedo variant, However, «purely natal cm. ‘ancer would mst Hsly be weated witout prfonning noe dissection, 1. Filet perform ration ler wide excision ofan invasive caver sks which ofthe fllowing oatsomes? [A Recurrence of cancer inthe ipsilateral Wess. 1 Shoner sural time Regional nodal recurence. D, Greater chance of tress ancermoxtality. DISCUSSION: Respective reviews and prospective suical ils agtee that omibson of breast adation after wide ison leads to a higher rat of iptral reat ecurence. However, survival and he risk ef saat dase are no ‘lord in patients eat by excision alone, with the lllow-ap tne of the statin and given their iheremt power 12 ‘tect difeences in outcome, Regional node metastasis isnot affected by the ehoie of masectamy venus Wide ‘ison and radaton. 4, Which ofthe following weatments shoud never be recommended toa patient wth pueyinadstal carcinoma? ‘A. Modified radial mastectomy. 3B. Lumpectoms to clear surgical margins fllowet by observation. C, Incistonal biopsy wit an involved agin, fllowe by radiation. '. Excision ops to clear gins fllowal by ration Answers29, Which of the following statement(s) is/are correct concerning cystosarcomsa phyllodes? a. The tumor is most commonly seen in post-menopausal women 'b. Total mastectomy is necessary forall patients with this diagnosis © Axillary lymph node dissection is not necessary for malignant cystosarcoma phyllodes Most patients with the malignant variant of eystosarcoma phyllodes die of metastatic disease Answers ystosarcoma phyltodes is a tumor arising in the mesenchymal tissue of the breast. ‘The tumors usually present as painless breast mass. Phyllodes tumor is most commonly encountered in women age 30-40 years of age but can occur at any age, even before puberty. The differentiation of a benign from a malignant phyllodes tumor may be difficult ‘About one-fourth of all phyllodes tumors are histologically malignant, but only a fraction of these patients actually develop metastatic disease. The optimum treatment for benign or malignant phyllodes tumor is wide excision with & ‘margin of normal breast tissue. The margin must be histologically free of involvement because even benign lesions can recur after incomplete excision. If this can be done leaving an adequate cosmetic appearance, mastectomy is not necessary, Total mastectomy is reserved for large lesions in small-breasted women oF recurrences after previous local ‘excision that i not amenable to repeat local excision. Axillary lymph node dissection is not performed in the absence of ‘biopsy-proven nodal involvement, even for malignant phyllodes tumors, because axillary metastases are uncommon. 32. Which of the following statement(s) is/are rue concerning adjuvant systemic therapy"? 8. Adjuvant tamoxifen in post-menopausal, node-positive, ER-positive women is equivalent to cytotoxic ‘chemotherapy b. Tamoxifen clearly improves survival in all ho c. CM patients 4. There i no evidence to suggest a role for chemotherapy in node-negative patients Answer: a sonal receptor-positve patients associated with improved overall survival in both pre-menopausal and post-menopausal node-positive Adjuvant tamoxifen leads to a prolonged disease-free interval in post-menopausal ER-positive women with histologically positive nodes and in pre-menopausal and post-menopausal ER-positive women with negative nodes. Because of similar results and, because tamoxifen is generally less toxic than chemotherapy, this treatment is the tteatment of choice for post-menopausal, node-positive, ER-positive women. CMF (cyclophosphamide, methotrexate, and 5-fluorouracil) is associated with both a longer disease-free survival and overall survival time in pre-menopausal patients with positive lymph nodes. In post-menopausal women with positive nodes, there is an improved disease-free survival, but there is no significant difference in overall survival. Several trials of adjuvant chemotherapy with CMF or related regimens have been conducted in node-negative patients, The early results of all of these trials have been Similar: disease-free survival is definitely improved with adjuvant chemotherapy. These studies are definitely not ‘mature enough to draw definitive conclusions regarding overall survival, Therefore, the National Cancer Institute has recommended the use of adjuvant chemotherapy for all patients with tumors large enough to have hormonal receptor levels measured,33, Which ofthe following statements) ivare true concerning tissue sampling techniques for breast masses? a. The semitivity of fine needle aspiration biopsy is such that mastectomy ean be performed in the ease of malignant diagnosis b. The accuracy of mammographic-directed fine needle aspiration biopsy is comparable to that achieved for that of palpable lesions ‘c. Core-needle biopsy showing normal breast tissue is an aeceptable diagnosis 4. The technique of core-needle biopsy is not applicable to radiographically detected lesions Answer: b ‘Whatever tissue sampling method is chosen, only biopsy (examination of eels or tissue) and not physical examination ‘or mammography can establish a definitive diagnosis and avoid delay in treatment. Fine needle aspiration biopsy (FNAB) permis rapid, minimally invasive diagnosis of many palpable and some non-palpable, radiologically detected breast masses. The technique is both reliable and accurate. The incidence of false-positive findings is generally less than (0.59. FNAB is not, however, so highly specific that definitive surgery (particularly mastectomy) should be performed ‘without prior intraoperative rozen-section confirmation of the presence of eancer. Reported sensitivity of FNAB ranges from 7S to 99%: with 85% a good estimate of the true sensitivity in elinically relevant settings. Recenily, x-ray-guided 37. A 33-year-old woman is referred with nipple discharge. Which ofthe following statement(s) is/are true concerning her diagnosis and management? Bilateral galactorrhea is suggestive of an underlying endocrinopathy [Brownish discharge is usually suggestive of old blood and is worrisome for an underlying breast cancer Expressibie bloody nipple discharge should be evaluated with a duetogram Milky breast discharge would not be expected one year after discontinuation of breast feeding Answer a € pere AC one time or another, many women notice « nipple discharge. The most common physiologic basis for nipple discharge is lactation, Milk may continue to be secreted intermitienly for as long as two years alter breast feeding has Stopped, particulaely with breast stimulation. A milky whitish discharge, usually bilateral, that is not related to lactation cor breast stimulation is termed “galactorrhea.” The presence of bilateral galactorrhea should prompt an evaluation for underlying endocrinopathy causing increased prolactin secretion by the pituitary. Classically, this is associated with amenorrhea, but galactorthea may be the only sign of hypoprolactinemia. Nipple discharges associated with fibrocystic disease are generally, ercen, yellow, or brown, Intraductal papillomas and cancer lead to a bloody or Hood:-tinged serous discharge. The brownish discharge of fibracystie disease can easily be confused with ofd blood. A guaiac test or simply dabbing the discharge with a gauze pad and examining the stain can usually differentiate the two. A bloody or blood-tinged discharge must be promply evaluated to exclude carcinoma, Ifthe discharge is expressible at the time the patient is seen, a contrast ductogram may be obtained. 138, Clinical features of breast cancer which are associated with a particularly poor prognosis include: ‘a. Edema ofthe skin ofthe breast b. Skin ulceration © Literal am edema 4d. Dermal lymphatic invasion Answer: a,b ed The histologic hallmark of inflammatory breast cancer is dermal lymphatic invasion demonstrable on skin biopsy. The stigmata of tis clinical syndrome include breast warmth, tenderness erythema, and edems.Cui surgery | Which spt tre of cardiopulmonary resustaton (CPR)? [A Closed chest massage iss effective as open chest masa . The success ate for ourohospital resusclation may be as high a 30% 1 60% . The most common cise of siden death is inchemic hear disease '. Standard chest massage generally provides les than 15% of ronal coronary and cerebral blood flow. Answers A DISCUSSION: Closed chest massage i nota ffetve as open-hest massage in normalizing blood pressure or perfusion of ‘ital organs. and closed chest massage does generally velver S819 138 of poral coenary and cereal bod flow. The ‘Beco cle for cut howial emseiation hasten ts igh sx 308 to IS when commis ae ropae tn nate CPR ‘erly afer cardiac aes sche heart seas is the most common cause of sudden death. 2. Which manewer generally snot performed early before chest compresin in basi life support onside the hospital? A. Callforhely 2. Oban rv. © Becca cwiovenion. . Ventilation, Answers DISCUSSION: Base lf suppor does involve calling For help. obsning an airway. and hesaning vention before starting ‘stew compression. Eketrical cardioversion reuies special equipment and tained personnel and this & part of advanced ‘ae ie support. 3. Which restment would be leat effi foraspstole? [A External pacemaker, 8B. Inavenos epnepvine, 10m. of 1:10.00, .Inravenous calcium gluconate, 10m of 106 sobsion. D. nravenous atropine 05 mg. AnsnersC DISCUSSION: Recommenied treatment for astle is administration of atropine. If atropine is unsaceessful epinephrine is jive Ultimately caring ping is nevessry if atropine and epinephrine dono establish an adegtate heat rat. Calum his ‘clear cole in rong soya 4. The mont importa factor that nluences te outcome of penetrating erie hres 1A. Comminted ten oa single camber, 5. Mulple-chamberinjrcs. © Cones ayn. Answers DISCUSSION: Mutiple studies nthe terature confirm ha inure to the coronary aneries ae the mos! Import factor la setermiing outcome ae 2 petting erine ijny Tangent njrien ae the eat nevous Into single chamker— ‘even comminated—rto multiple chambers ss Ekely toe ata than ar inj that involve mgr coronary ater. ‘5. The mos asf incision nthe operating room fr pins with pnctting cara inary is A Let anterior tractor 3B, Righ anerior thoracotomy: Bilateral anterior thoracotomy D, Median stercty. E. Subnyphoid Answer DISCUSSION: ‘The subxyphod incision is useful for determining if thee is Blood in the pericardium apd if thee is an intracardiac injury: however, exposure i extremly limited and Jefe repair can rarely be performed through the inci Let (or igh) anterior thoracotomy is easily performed, especialy inthe emergency oom, and gives adeyunte exposure 10 ‘erain areas ofthe hear However, each has significant linitations in exposure. Either may be extended across the thoracotomy int the oe ide ofthe ches, thus producing a bilateral anterior thoracotomy. Exposures excellent hough this ‘cision, and mos injuries ean be saisactoiy repaired through this appronc, Most cardiac operations today are performed6. In patients who present with a penetrating chest injury, injury tothe heart is most likely when the following physical sign(s)isfae present: A. Hypotension, 1B. Distended neck veins Decreased heart sound D. Allof the above Answer: D DISCUSSION: Hypotension, increased venous pressure (distended neck veins), and decreased heart sounds make up the lassie BeckS triad associated with cardiac tamponade If these tee findings ae present in a person who has a penewating chest wound, inacardiac injury is almost certain and operative intervention is mandatory. 1, The atrial sepa defect (ASD) most commonly associated with pata anomalous pulmonary venous return (PAPVR) is A. Secundum defect B, Sins yenosus defect. : Ostium primum dete. 1D. Compleeatrioventicular (AV) canal defect. E. Coronary sinus defect. Answer: B DISCUSSION: Athough partial anomalous return of the pulmonary veins can occur with any of the ASDS listed, itis pricularly common with sinus venowus defects and is considered by many to be par ofthis lesion, The most common ‘moma is drainage ofthe right superior pulmonary vein tothe lateral aspect of the superior vena cava 27. Which ofthe folowing anomalies isnot associated with tetralogy of Fallot? A. Absence of the left pulmonary artery BL Aright aortic arch. ©. A retroesophageal subclavian artery. DD. Anomalous origin ofthe left anterior descending coronary artery from the right coronary artery. E. Primary pulmonary hypertension. Answer E DISCUSSION: The first four defeets listed occasionally are associated with tevalogy of Fallot. right aortic arch is seen in 25% of patents with that lesion, Anomalous coronary arteries or a retrassophageal subclavian artery are found in ae many as ‘5% to 10% of patients. Absence of a pulmonary artery is unusual but can present in as many as 3% of patents. Pulmonary hypertension is distinctly unusual with tetralogy of Fallot unless the patient has had excessive pulmonary blood flow from collaterals or systemic to-pulmonery artery shunts for & longtime. I s because these patients usally do not ave pulmonary hypertension that infant correction with transannular patches ean be performed with sch great success 32. Management of a patient with tricuspid atresia within the first month of life may include: A. Creation of a systemic artery-to-pulmonary artery shunt, B. Observation. C. Creation of a bidirectional superior cavopulmonary anastomosi D, Pulmonary artery banding. E, Fontan procedure. Answer: ABDDISCUSSION: Initial management of newborn infants with tricuspid atresia is determined by the anatomic and physiologic factors that affect the balance of pulmonary and systemic blood flow. Infants with severely limited pulmonary blood flow and terial oxygen saturations of less than 70% should be sabilized with PGE 1 to maintain patency of the ducts arteriosus until a systemic-to-pulmonary artery shunt can be performed. Patients with unobstructed pulmonary blood flow may exhibit only mild cyanosis but suffer from significant congestive heart failure. Many of these patiens are best managed by pulmonary aarery banding to decrease the volume overload on the left ventricle and to prevent the early development of imeversible pulmonary vascular disease. Some patients with moderate retriction of pulmonary blood flow may have balanced delivery of blood to the systemic and the pulmonary circulation. These patients can be carefully followed until such ime as an imbalance develops or they become candidates fora bidirectional superior cavopulmonary (Glenn) anastomosis or a Fontan procedure. ‘The normally high pulmonary vascular resistance present in the first month of life precludes the performance of either the Glenn or the Fontan procedure inthe newborn, 49. I blood entering the normal arterial circulation of the heat ix 100% saturated with oxygen, oxygen saturation of blood in the coronary sinus canbe expected to be approximately: AL 75%. B60, ©. 50%, D. 354. E. Less than 208, Answer: D DISCUSSION: The heart has an unusually high rate of oxygen utilization and consumes approximatly two thinds of the ‘oxygen in the arterial blood. The ox}gensiturstion ofthe blood inthe coronary sinus is usually about 30% to 38% and varies with the magnitude of cardiac disease. The body as a whole exircts approximately 25% of the oxygen it receives, thus “emphasizing the great need of the heart for oxygen at restos wel us at exerese. ‘57. Which ofthe following statements about patients treated by placement ofan internal mammary artery (IMA) bypass graft a primary CABG is/are correct? 'A. The risk for morbidity and mortality from reoperatve coronary bypass grafting is increased. 1B Left ventricular function is better preserved al the time of reoperation. CC The risk of sternal wound complication is greatly increased ithe contralateral IMA is harvested atthe time of reoperation, 1D. A light clamp should be applied to the IMA pedicle to limit cardiae warming during cardioplegic arest atthe time of reoperation. EA functional study demonstrating lage portion of myocardium a risk should be obtsined before reoperation. Answer: BDE. DISCUSSION: Patients who hive an intact IMA grat should have severe anginal symptoms and a significant portion of ‘myocardium at risk before reoperative coronary bypass grafting is considered. A functional study may better define the ‘proportion of myaeardium at-risk for ischemia and infarction. Paten’s with an intact IMA. graft are les likely to require operation, but if stenosis distal to the IMA and disease in other vein grais have progressed or if a large portion of ‘myocardium isa risk, reoperation is recommended. The presence of an intact IMA. nota contraindieation to reoperation; in fact, this population of patients have better-preserved ventricular function and are, perhaps, better candidate for reoperation. Placement of an IMA graft at the time of the first operation was exitcally important, neutralizing the adverse effects o clevated serum cholesterol, hypertension, and smoking on reoperation-fee survival. The risk of damaging an intact IMA graft is 396 to 56. A lateral projection of the [MA at carte catheterization will define its course, particulary in relation to the ernum, to allow more careful seral re-entry. The IMA should be minimally dissected and a Tight clamp applied during cardioplegic amest to mit cardiac warming and improve myocardial protection. The IMA may be detached and recycled if needed. The use during reoperation ofthe contralateral IMA does not increase the risk of sternal wound complications.Endocrine surgery | When progressive enlargement of a multinodular goiter causes symptomatic tacheal compresion, the prefered management in othervse gosh pens 1 odin eaten. 3B, Thyroid hormone weatmen. . Surical resection athe abaormal hoi, , Ratioastivetodine weston. Answers DISCUSSION: When 2 multinodular goiter enlarges enough to cause symptoms of tracheal compression, surgical eaten ‘lyric if the patient x considered eatonable operative rk. Medial weatment maybe efcive in preventing the inital promt ofthe goter buts unlikely to exuse enough regression to elieve symptoms. Radioactive de can ocisionally be use to cate some regression in patients who are poor anesthesia sks, but us is a temporizing Weatment ater than 3 sefitive one 2. The most precise dagnostcsreeing procedure fr dtferentitng benign thyroid nodules from malignant ness: A. Thyroid lrsonogrphy. 3B. Thywidsciescan. C. Fh-necdleaspiation biopsy (FNAB). i, Thyroid oonone sppression. Answers DISCUSSION: Analysis of mule sres im which pants with thyroid nodules have undergone FNAB has demonstrated 3 flsenegaine rte of 245% and falheponkive rae of 3%, Semakvity for thn metal Is 92%} apecifcky 74%. Thin suupsss the ole methods for acura selection of pants who requ sual esetion. 4. The prefered operation fr inal maragemert ofa thyroid nodle that is considered suspicious for malignancy by FNAB A. Excision, 2, Paral best, Tot lobectomy and isthseciomy: , Total thyroidectomy. Answers DISCUSSION: ‘There is consensus tit the inal minimum operation fora rodule suspected to be malnant is total lobectomy ad istnsectomy. Pata! Ibectomy or excision ofthe nodule is assocated with higher rk of loa recumence the nalule poves vo be malignant. Reoperation oa he side ofa patil lobectomy ca be eel dificult aa associated ha higher rik of rcurent neve injry. Ordinarily, toa thyridecomy x not prformed uni 3 conclave dapnons of malignancy is established. 44. Advamagesof tal thyroidectomy fr management of papillary crcinorms ofthe thyroid larger tha 1S em. isle: |. Poss fusing radioactive fine postoperatively to Metiy and test masse. '3 The ably to we Myroplobuls levels as amaser for recurteace. © Lewe ovral ecumrnce re D. Lower isk of hypoparaistaiism, ‘nsners ABC DISCUSSION: Following toa thyroidectomy iodine 131 canbe used ve effcienly because ofthe absence of normal fhyroiddsue, which has geste afin fr fine than papillary encinoma sae. When ll normal thyroid tisue is removed, serum thyroglobulin, which is prevuced by normal ad malignant thyroid tse, becomes. a more effective marker for Iecurrene The overall reourence rate is ower for patents undeygeing toul tytoidctomy, but the fst of Iypopaathroaisn is higher fr patients who have wal thyoidetony stead of ulate! obec. 5. Which ofthe following statements aout flicuar carcinoma Ware tue? A presents a alter age than poplar carcinoma 1 Rhseminatos va homage rte, Its the most common type of well-Sierentated tyrid carcinoma, D, Extensive arginvason portend 3 poor prognosis Folislrcrcinomss ae equenty multe Anssers ABD4, Which of the following screening tests are important for preoperative evaluation of pulmonary function? A. History and physical examination, B, Room air arterial blood gases. © Chest film. D. Vital capacity and forced expiratory volume in 1 second (FEV 1). E. Cardiopulmonary exercise testing. Answer: ABCDE, DISCUSSION: The most important clues to impairment of respiratory Function are found in the history and physical ‘examination. A negative history and physical examination in combination with a relatively normal room air arterial blood ‘gs and normal chest film are sufficient sereen patients to support the clinical impression that there is minimal pulmonary disease. Patients with symptoms, positive physical findings, and/or abnormalities inthe anteral blood gases or chest film can be screened most effectively with an adaitional evaluation of the vital capacity and FEV 1, More elaborate tests such as Cardiopulmonary exercise testing ae reserved for tients with obvious and marked impairment of pulmonary function who are being evaluated forthe Feasibility of surgical intervention, 1, The effect of high positive end-expiratory pressures (PEEP) on cardiac output is A. None. B. Increased cardiac output CC Decreased cardiac output because of increased afterload to the left ventricle . Decreased cardiac output hecause of decreased effective preload to the left ventricle Answer: D DISCUSSION: Higher levels of PEEP can be associated with decreases in cardiae output as @ consequence of an effective decrease in the pret tothe left ventricle owing to impaired left ventricular filing “Trauma & Burns 1. Nasotracheal intubation: A. Ispreferred forthe unconscious patient without cervical spin injury. BB. Is preferred for patients with suspected cervical spine injury. C. Maximizes nec manipulation. 1D. Is contraindicated in the patient who is breathing spontaneously. Answer: B DISCUSSION: The fist principle inthe management of any injured patient isto secure an adequate airway. This can be particulary difficult in the presenee of facial or laryngeal trauma, of in the unconscious patient with a suspected ‘cervical spine injury. The mechanical removal of oral debris followed by the “chin lift" or “jaw thrust” mancuvers to relieve soft tissue obstruction of the pharynx are the first steps. However, when there is any question regarding the adequacy of the airway, or in the presence of severe head injury, or when the patient is in profound shock, more definitive airway control is required. In most patients this involves oral endotracheal intubation. However, the insertion ‘of an oral endotracheal tube often involves hyperextension ofthe neck with the potential for aggravating cervical spine ligamentous ot bony injury. Nasotracheal intubation is the preferred option for the patient with suspected cervical spine ligamentous or bony injury since the head and neck can be maintained in the neutral postion with minimal manipulation. This technique requires a breathing patient, as the passage of air must be heard through the nasotracheal tube prior to its insertion through the larynx into the trachea, Nasotracheal intubation is contraindicated in the presence of mid-fuce fractures. In this situation, a surgical nirway (ericothyroidotomy, tracheostomy, or needle ‘ricothyroidotomy) is the preferred option.2, Cardiac contusions caused by blunt chest trauma A. Are fairly easy to diagnose, B, Occur in upto 20% to 40% of patients with major blunt thoracic trauma. . Donot usually eause right ventricular dysfunction, . Demonstrate arrhythmia asthe most common complication, Answer: BD DISCUSSION: Cardiac contusions are often difffeult to diagnose, but have been estimated to occur in 5% of major teauma patients, and up to 20% 10 405 of pationts with severe blunt chest injury. The difficulty in diagnosing cardiac ‘contusions is that they remain a pathologie diagnosis, confirmed only at autopsy or on direct cardiac examination, The injury may vary from superficial epicardial petechise to complete transmural damage. Although significant myocardial injunes, such as ventricular rupture, coronary vessel thrombosis, and valvular disruption, have been reported, the most ‘common clinically significant result of cardiac contusion is the occurrence of arhythmias. Hence, an intial ‘lectrocurdiogram (ECG) and subsequent continuous eardiae monitoring for at least 24 hours is generally Fecommended. Alternative methods of diagnosing myocardial contusion include creatine phosphokinase cardiac isoenzymes (CPK-MB). two-dimensional echocardiography, gated ventricular scintigraphic angiography (GVA), radiouctive thallous chloride ( 20171) uptake, and right veniticular monitoring. Unfortunately, none of these tests is adequately sensitive or specific in the diagnosis of cardiac contusion, and their correlation with the presence of arhythmias or ECG changes is also imprecise. 4, Which ofthe following statements about head injuries ivare false? A. The majority of deaths from auto accidents are due to head injures BB, Head injury alone often produces shock. CC. A rapid and complete neurologic examination is part of the initial evaluation of the trauma patient, . Optimizing arterial oxygenation is part of intial therapy: Answer: B DISCUSSION: Head injuries cause the majority of deaths following automobile accidents, with rupture ofthe thoracie ‘sorta the second most common cause of fatality. Head injury itself rarely produces hypotensive shock. It is only in the terminal phases of brain death that hypotension may be attributable to head injury alone. Therefore, hypotension in trauma patients must be assumed to be secondary to volume depletion or ongoing hemorrhage. An occult site of hhemorthage (chest, absomen, pelvis, retroperitoneum, or extremities) must be strongly suspected and dealt with ccordingly. A rapid and complete neurologic assessment is a crucial part of the initial assessment of all trauma patients. Ths initial exam gives an excellent indication of injury severity and prognosis. Since the ultimate outcome of 1 brain injury is dependent on adequate cerebral perfusion and oxygenation, adequate airway control, ventilation, hemorshage control, volume restitution, and arterial oxygenation are crucial factors in the early management of head injuries, (6, What percentage of patients with thoracic trauma require thoracotomy? A. 10-15%, B. 206-256. C308 40%. D. 45-50%. Answer: A DISCUSSION: Twenty-five per cant of civilian trauma deaths are caused by thoracic trauma, and two thirds of these ‘deaths occur alter the patient reaches the hospital. Mortality of hospitalized patients with isolated chest injury ranges fom 4% to 8% and increases to 35% when multiple addtional organ systems are involved. Despite high mortality, only 10% to 18% of thoracic injuties require thoracotomy. Most injuries are successfully managed by the rather simple life saving maneuvers of airvay control and tube thoracotomy. Unrelenting hemorrhage following either penetrating oF bunt thoracic trauma isa primary indication for immediate thoracotomy. An initial thorcie blood loss of greater than 1300 mi, (30% of blood volume) or an ongoing loss of 250 mil. for 3 consecutive hours serves only as & practical ‘guideline. The patient's hemodynamic status and overall condition should be the mos influential factors,7. The radiographic findings indicating a torn thoracie aorta include: A. Widened mediastinum, B, Presence ofan apical “pleural exp.” C. Furst rib fractures. 1D, Tracheal deviation to the right E. Left hemothorax. Answer: ABCDE DISCUSSION: All of the listed radiographic findings should arouse suspicion of a possible torn thoracic aorta, The ‘most common abnormality noted is a widening of the mediastinal shadow, although only 20% to 40%e of patients with a wide mediastinum have aortic injury. In addition to the radiographic signs listed, other findings that may alert the physician to the possibility of an aortic tear include foss of aortic contour, elevation of the left mainstem bronchus, depression of the right mainstem bronchus, shift of the nasogastric tube to the lelt, and the presence of retrocardiae ensity. Aortography remains the “gold standard” diagnostic modality and is indicated if aortic injury is suspected on the basis of mechanism of injury and any ofthese suggested findings. 18. Hemomhage initiates a series of compensatory responses. Which of the following statements) isfare true concerning the physiologic responses to hemorrhagic shack? 4. An immediate response is an increased sympathetic discharge with resultant reflex tachycardia_and vasoconstriction ‘. -Transcapillary refi is a response serving to restore circulating volume ¢. Extracellular fluid becomes increasingly hyperosmolar dd. Adronergically mediated vasoconstriction is well maintained a the arteriolar and precapillary sphincters Answer: a, B.e Hemorthage initiates both rapid and slower, more sustained compensatory responses. The body responds to maintain hemostasis almost immediately after the onset of hemorrhage. Decreased activation ofthe atrial baroreceptors though a decrease in blood pressure or even more subily, a decrease in pulse pressute, causes an increased sympathetic discharge, resulting in reflex tachyeardia and vasoconstriction. Increased adrenergic ourput with increased secretion of ‘etecholamines also leads to vasoconstriction, increased heart rate, and incressed myocardial contractility. Sustained ‘compensatory responses include the release of vasoactive hormones and fluid shifts from the interstitium and the ‘nracllular space. Adrenergcally mediated vasoconstriction affects arterial precapillary and posteapillary sphincters and smmill veins and venules. The decrease in intravascular hydrostatic pressure distal tothe precapillary sphincter leads to reabsorption of interstitial uid into the vascular space and thereby functions to restore cireulaing volume. This is known as transcapillary refill. The increased release of stress hormones coupled with relative insulin resistance after shock leads 10 high extracellular glucose concentrations. In addition, products of anacrabie metabolism from hhypoperfused cells accumulate in the extracellular compartment, inducing hyperosmolarity. This extracellular hhyperosmolarty draws water from the intracellular space, increasing interstitial osmotic pressure, which in turn drives water, sodium and chloride across the capillary endothelium into the vascular space. Ifthe shock state continues, however, the posteapillay sphincter remains in spasm, but the arteriolar and precapillary sphincters cannot maintain the tension, and they become relaxed. As sphincters relax, the capillary hydrostatic pressure increases and sodium, ehloride and water move into the interstitium leading to further depletion of intravascular volume.19. Which ofthe following steps ivare part of the primary survey in trauma patient? Insuring adequate ventilatory support ‘Measurement of blood pressure and pulse ‘Neurologic evaluation withthe Glasgow Coma Seale 4d. Examination ofthe cervial spine Answer a,b, € The resuscitation team’s first priority isto simultaneously assess the airway, blood pressure and level of consciousness of the patient. The first priority is assessment of the airway. After establishment of an airway, the next priority is to insure adequate ventilatory exchange by rapid auscultation of both lung fields and assessment for mechanical factors that may interfere with breathing. After establishment of an airway, ventilation and appropriate pleural drainage, if necessary, the next priority is the assessmment of the patient's circulatory status. This includes an estimation of blood volume and cardiac function. The initial survey evaluates blood pressure, pulse, and skin perfusion. Its important 10 ‘emphasize that effective resuscitation from hemorrhagic shock requires both restoration of intravascular volume and: ‘control of hemorrhage. The final priority ofthe primary survey isa brief neurological evaluation using the components of the Glasgow Coma Scale, Although maintaining axial immobilization of the cervical spine is an imporant early ‘component ofall assessments and resuscitation protocols, examination of the cervical spine regardless of injury is part ofthe secondary survey. 20. Immediate life-threatening injuries that preclude air exchange which can be treated in the field include which of the following? a. Tension pneumothorax b. Massive open chest wounds fe. Sucking chest wounds 4. Tracheal disruption Answer: a, bye [After establishment of a patent and controlled airway, the next priority isto insure that air exchange is taking place. Immediate life-threatening injures that preclude air exchange include: tension pneumothorax, massive open chest ‘wounds, sucking chest wounds, and tracheal disruption. There are no maneuvers likely to correct tracheal disruption in the field. Both open chest wounds and sucking chest wounds will respond to endotracheal intubation and positive pressure ventilation. Tension pneumothorax may require field decompression in the rare patient. Feld techniques to ‘eal with tension preumothoras include needle thoracostomy and chest tube thoracostomny.