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Sabiston Surgery Questions 17th Ed PDF
Sabiston Surgery Questions 17th Ed PDF
1. How many cases of severe sepsis occur in the United States each year?
A. 250,000
B. 500,000
C. 750,000
D. 1 million
2. Cytokines are:
A. Lipid mediators secreted by lymphocytes
B. Proteins that form the contractile elements of muscle cells
C. Toxins secreted by bacteria
D. Small hormone-like proteins secreted by individual cells
3. Which of the following mediators is a Th2 cytokine?
A. TNF
B. IL-1
C. IL-10
D. IL-12
4. Which of the following receptors is essential for activation of macrophages by bacterial
lipopolysaccharide (LPS)?
A. TLR4
B. IL-1RI
C. IRAK
D. LBP
5. Treatment with a monoclonal anti-TNF antibody has been shown to be effective for the
treatment of selected cases of which of these diseases?
A. Asthma
B. Septic shock
C. Myocardial infarction
D. Crohn's disease
6. Which of the following agents has been approved by the FDA for the adjuvant
treatment of severe sepsis?
A. Recombinant human IL-6
B. Recombinant human activated protein C
C. Recombinant human growth hormone
D. Recombinant human IL-1RA
9. A 9-year-old girl suffered an 86% TBSA, third-degree burn injury during a house fire.
She was found unconscious. The patient arrives to the burn unit with a heart rate (HR) of
130 beats/min, BP of 100/70 mm Hg, respiratory rate (RR) of 18 breaths/min, and
temperature (T) of 37.6 C. She receives standard care with adequate IV resuscitation,
thermoregulation of the room's thermostat to 33 C, and excision and grafting of her
wounds on postinjury day. What is the most reliable method to estimate caloric
requirements in this patient? (Questions 9 through 12 apply to this patient.)
A. Harris-Benedict equation
B. Curreri formula
C. Indirect calorimetry
D. Fick's equation
10. 7 days postinjury, HR = 165 beats/min, BP = 105/80 mm Hg, RR = 22 breaths/min, T =
38.5 C, plasma glucose level = 250 mg/dL, [Na] = 145 mEq/dL, [Cl] = 100 mEq/dL, and
[K] = 4.5 mEq/dL. You administer IV fluids, insulin, and potassium chloride. What should
be done to prevent mortality through the management of hyperglycemia in this critically ill
surgical patient?
A. Titrate patients to a glucose level goal between 80 and 110 mg/dL.
B. Consider starting the patient on an oral hypoglycemic.
C. Use insulin only if the plasma glucose level is >200 mg/dL
D. Minimize significant fluctuations of glucose and potassium carefully.
E. Request an endocrinology consultation.
11. Fifteen days following severe burns, excision, and autograft surgery, an increase of
>25% of insulin requirements is noted over the previous 24-hour period. What is the best
next step in the management of this patient?
A. Schedule further surgery to decrease hypermetabolic response.
B. Further increase the insulin drip until a glucose level of 140 to 180 mg/dL
is reached.
C. Order cultures and band neutrophil of peripheral blood.
D. Repeat blood glucose level testing and order a new metabolic panel.
12. Four weeks postinjury, during the daily abdominal examination, you palpate the lower
edge of the liver 4 cm below the edge of the ribs. No tenderness to palpation is reported and
there is no evidence of jaundice. Which of the following best explains the findings seen in
pathology?
A. Increased dietary intake of fats
B. Increased synthesis of fats from sugar-enriched diet
C. Excessive peripheral lipolysis.
D. Decreased -oxidation of fat in liver mitochondria
9. Which of the following problems is commonly recognized in the postanesthesia care unit
(PACU)?
A. Delirium
B. Emesis
C. Hypoxemia
D. Hypertension
E. All of the above
10. Characteristics of moderate sedation include which of the following?
A. Absence of movement in response to a skin incision
B. Preserved airway reflexes
C. Motor response only to painful stimuli
D. Moderate respiratory depression
E. Moderate hypotension
11. Which four steps accurately describe the process of nociception?
A. Transduction, transmission, modulation, and perception
B. Recognition, registration, amplification, and interpretation
C. Perception, integration, orientation, and implementation
D. Description, analysis, formulation, and recognition
E. Deformation, translation, registration, and formulation
12. Which of the following opioids is partially converted to a metabolite that can
accumulate and cause seizures in patients with renal impairment?
A. Fentanyl
B. Hydromorphone
C. Codeine
D. Morphine
E. Meperidine
13 .What is the correct term for the physiologic process in which a previously effective dose
of an opioid fails to provide adequate analgesia?
A. Addiction
B. Psychological dependence
C. Physical dependence
D. Tolerance
E. Malingering
4. There are several techniques for creating a temporary abdominal closure for the open
abdomen. The key to all techniques must include the following:
A. Quick application
B. Seal in moisture and temperature
C. Quickly removable
D. High tensile strength
E. A, B, and C are correct
5. During the staged abdominal repair phase of damage control surgery, the surgeon has
several challenging questions to answer on return to the operating room. Which of the
following approaches can be used to address small and large bowel injuries?
A. Resection of devitalized tissue
B. Primary repair
C. Externalization with creation of a stoma
D. Primary bowel anastomosis
E. All of the above
6. The open abdomen technique has a high rate of nonclosure because of the following
complications:
A. Intra-abdominal abscess and intra-abdominal sepsis
B. Acute lung injury
C. Atmospheric intestinal fistula
D. Urinary tract infection
E. A and C are correct
7. Which of the following mesh products should not be used in the open abdomen setting
because they have very high rates of intestinal fistula formation and mesh infection?
A. Human dermal acellular dermis
B. PTFE
C. Porcine dermal matrix
D. Polypropylene
E. B and D are correct
8. The decision to close an open abdomen with visceral edema can be complicated. Which
of the following physiologic criteria can be used to guide abdominal closure in the
operating room?
A. Decrease in urine output by 10 mL/hr
B. Change in peak inspiratory airway pressure less than 10 cm H2O while attempting to bring the
fascia together
C. Increase in intracranial pressure by 5 cm H2O
D. Sustained increase in intra-abdominal pressure less than 20 mm Hg
E. B and C are correct
5. A 26-year-old man presents to the emergency department with the fracture seen in
Figure 20-4A. A Hare traction splint was placed in the field. Traction on the injured limb
should be maintained. Which of the following is the most appropriate method of traction
for this patient?
A.Skin traction with a Buck boot
B. Distal femoral traction pin placed from medial to lateral
C.Proximal tibial traction pin placed from medial to lateral
D.Proximal tibial traction pin placed from lateral to medial
E. Hare traction splint left in place
6. A 47-year-old woman sustains the fracture shown in Figure 20-40. Which examination
tests the nerve most commonly injured with this fracture pattern?
A. Shoulder abduction
B. Elbow flexion
C. Wrist extension
D. Wrist flexion
E. Finger flexion
5. A postoperative patient with new-onset unstable atrial fibrillation with systolic blood
pressure of 70 mm Hg should be treated with which of the following modalities?
A. Direct current cardioversion
B. Intravenous beta blocker
C. Intravenous calcium channel blocker
D. Digoxin
6. Which of the following modalities has been shown to reduce mortality in adult patients
with the acute respiratory distress syndrome (ARDS) in prospective randomized trials?
A. Corticosteroid early in the course of ARDS (<7 days)
B. Surfactant replacement therapy
C. Nitric oxide
D. Maintenance of lower filling pressure with pulmonary capillary wedge pressure (PCWP) less
than 8 mm Hg
E. Lung protective ventilation with low tidal volumes of 6 mL/kg of ideal body weight
7. Abdominal compartment syndrome (ACS) is best described by which of the following?
A. Intra-abdominal pressure greater than 15 mm Hg
B. Intra-abdominal pressure greater than 25 mm Hg and evidence of decreased end organ
perfusion (i.e., oliguria, renal dysfunction, hypotension)
C. Intra-abdominal pressure greater than 35 mm Hg with hypoxemia
D. Peak airway pressure greater than 40 cm H2O
8. Which of the following have been shown to be clinical advantages of enteral feeding
versus total parenteral nutrition (TPN) in critically ill surgical patients?
A. Preservation of gut mucosal integrity and barrier function
B. Secretory IgA production of the gut
C. Decreased rates of catheter-related bloodstream infections
D. Lower cost
E. All of the above
9. Which of the following are strict indications to guide the institution of renal replacement
therapy in the form of intermittent hemodialysis or continuous venovenous filtration or
hemodialysis in critically ill surgical patients?
A. Increasing oxygen requirement and chest x-ray findings of interstitial edema and engorged
pulmonary vasculature
B. Blood pH less than 7.25
C. Potassium level greater than 6.0 mEq/L
D. There are no specific or strict indications to start renal replacement therapy
E. CO2 level less than 16 mEq/L on chemistry profile
10. Which of the following is most appropriate regarding glycemic control in critically ill
surgical patients?
A. Goal glucose should be 80 to 110 mg/dL to improve outcomes in patients with traumatic brain
injury.
B. Stress-related hyperglycemia should be managed with longer acting forms of insulin such as
insulin glargine.
C. Maintaining glucose levels less than 180 mg/dL compared with maintaining a range of 81 to
110 mg/dL results in fewer episodes of hypoglycemia and lower mortality.
1.The most common indication for liver transplantation in the United States is:
A. EtOH
B. Sclerosing cholangitis
C. Hepatitis B virus
D. Hepatitis C virus
E. Hepatocellular carcinoma
2.An infant with extrahepatic biliary atresia, chronic liver insufficiency, and failure to thrive may be
served by:
A. Whole pediatric liver transplantation
B. Split orthotopic liver transplantation
C. Live donor liver transplantation
D. All of the above
E. None of the above
3.The current risk of death to the donor for live donor liver transplantation is:
A. About the same as the risk to a potential kidney donor
B. 1/100
C. 1/1,000
D. 1/10,000
E. 1/100,000
4.The current system of liver distribution is primarily based on:
A. Insurance
B. Medical necessity
C. Region
D. Recipient age
E. None of the above
5.The liver can be divided into segments based on
A. Portal vein inflow
B. Hepatic artery inflow
C. Biliary outflow
D. Hepatic vein outflow
E. All of the above
6.Which are appropriate treatment(s) for hepatocellular carcinoma and cirrhosis?
A.Whole liver transplantation
B. Liver resection
C. Live donor liver transplantation
D. Resection with salvage transplantation
E. All of the above
1.A 50-year-old man arrives in the recovery room following an uneventful living donor kidney
transplantation. It was documented that there was good urine output in the operating room. When the
patient arrives, there is no urine output. The next best step would be to:
A. Order an ultrasound.
B. Perform an emergent biopsy to rule out hyperacute rejection.
C. Examine the patient.
D. Flush the Foley catheter.
2.A 50-year-old man arrives in the recovery room following an uneventful living donor kidney
transplantation. It was documented that there was good urine output in the operating room. When the
patient arrives, there is no urine output. The physical exam reveals BP, 134/70 mm Hg, HR, 76
beats/min, RR, 14 breaths/min, O2 saturation, 100%, Foley is intact. An inspection of the abdomen
reveals a distended right lower quadrant. The incision is dry. The next best step is to:
A. Order an ultrasound.
B. Open the wound at the bedside.
C. Flush the Foley catheter.
D. Return to the operating room.
3.A 50-year-old man arrives in the recovery room following an uneventful living donor kidney
transplantation. It was documented that there was good urine output in the operating room. When the
patient arrives, there is no urine output. The most likely diagnosis in this case is:
A. Lymphocele
B. Urine leak
C. Hyperacute rejection
D. Wound dehiscence
E. Arterial thrombosis
4.A 35-year-old woman with type 1 diabetes wishes to be evaluated for a kidney pancreas
transplantation. She has a history of hypertension and has recently started dialysis. There is no family
history of cardiac disease.
Her initial workup should include:
A. C-peptide level
B. Cardiac stress test
C. Pap smear
D. All of the above
5.A 35-year-old woman with type 1 diabetes wishes to be evaluated for a kidney pancreas
transplantation. She has a history of hypertension and has recently started dialysis. There is no family
history of cardiac disease. The patient presents at 3 weeks post-transplantation with an elevated amylase
level and her creatinine level is also somewhat elevated at 1.4 mg/dL, from a baseline of 1.0 mg/dL. Her
glucose level is normal and her urine output has been normal. Diagnostic tests should include:
A. Abdominal and pelvic CT scan
B. Urinalysis
C. CMV polymerase chain reaction assay
D. Ultrasound and kidney biopsy
E. C-peptide level
2. A 2-year-old boy with intestinal failure secondary to gastroschisis and parenteral nutritionassociated
liver disease (PNALD) is on the waiting list for a combined liver-intestine transplant. His blood type is
A, and he weighs 13 kg. Which of the following potential donors would be most appropriate?
A. A 1-year-old donor who sustained head traumas as a result of child abuse; the donor is blood type A and
weighs 8 kg
B. An 8-year-old donor who sustained head trauma as a result of a bicycle versus motor vehicle accident; the
donor is blood type A and weighs 25 kg
C. A 20-year-old donor who sustained head trauma as a result of a motorcycle accident; the donor is blood
type A and weighs 60 kg
D. A 2{1/2}-year-old donor who sustained head trauma as a result of a motor vehicle accident; the donor is
blood type A and weighs 14 kg
3.For patients who require a liver transplant in addition to an intestinal transplant owing to intestinal
failure and parenteral nutritionassociated liver disease (PNALD), what is the advantage of including
the pancreas en bloc with the other organs?
A. Most patients with intestinal failure and PNALD also have diabetes.
B. Including the pancreas avoids having to perform any hilar dissection in the donor organs and avoids having
to perform separate vascular anastomoses for the liver and the intestine during implantation in the recipient.
C. The native pancreas is removed from the recipient with the recipient's liver and remnant small intestine and
needs to be replaced.
D. Including the pancreas has been shown to decrease the incidence of rejection.
4. Which of the following is the most effective induction agent for intestinal transplantation?
A. Alemtuzumab (Campath)
B. Basiliximab (Simulect)
C. Daclizumab (Zenapax)
D. Rabbit antithymocyte globulin (Thymoglobulin)
E. No agent has been proven superior to the others
5.The most effective method of monitoring an intestinal allograft for rejection is:
A. Serum liver function tests
B. Endoscopically obtained mucosal biopsy specimens reviewed by a pathologist
C. Measuring stoma or stool output
D. Clinical signs such as abdominal pain and distention
6.Infection with which of the following pathogens may mimic rejection in intestinal transplant
recipients?
A. Epstein-Barr virus
B. Escherichia coli
C. Cytomegalovirus
D. Enterobacter species
E. Klebsiella species
7.Recipients of which transplanted organ are at the highest risk of developing post-transplant
lymphoproliferative disorder (PTLD)?
A. Kidney
B. Intestine
C. Heart
D. Liver
8.The most common cause of death after intestinal transplantation is:
A. Infection
B. Post-transplant lymphoproliferative disorder (PTLD)
C. Graft-versus-host disease (GVHD)
D. Chronic rejection
3.Which type of adjuvant therapy may provide the best strategy for the postoperative eradication of
residual microscopic disease?
A. Chemotherapy
B. Radiation therapy
C. Immunotherapy
D. Combination therapy
4.Germline mutations have been postulated to be associated with several tumors. Which of the following
is an example?
A. p53
B. APC
C. KRAS
D. All of the above
6.Which early events in the primary tumor are characteristic for the formation of metastases?
A. Angiogenesis
B. Intravasation and extravasation
C. Evasion of cell death
D. Detachment from extracellular matrix and intravasation.
14..Breast cancer specimens are now routinely tested for which of the following tumor markers?
A. Estrogen receptor
B. Progesterone receptor
C. Her2/neu expression
D. A and B
E. A, B, and C
15.Her2/neu expression status of a breast tumor is important for:
A. Monitoring the efficacy of therapy
B. Determining treatment for recurrent cancer
C. Diagnosis
D. Timing of second-look procedures
E. All of the above
16.Patients with metastatic colorectal cancer who lack a KRAS mutation in codon 12 or 1:
A. Are more likely to respond to anti-EGFR antibody therapy
B. Are less likely to respond to anti-EGFR antibody therapy
C. Have improved disease-free survival when treated with anti-EGFR antibody therapy
D. Have no change in overall survival when treated with anti-EGFR antibody therapy
E. A and C
F. A and D
17.Which of the following statements is incorrect regarding the use of the 21-gene assay, Oncotype DX,
in breast cancer?
A. Predicts likelihood of local tumor recurrence
B. Was designed for patients with node-negative, tamoxifen-treated breast cancer
C. Cannot be used in ER-negative tumors
D. Alters treatment choice in approximately 25% of cases
E. Assays 16 tumor-associated gene
1.What percentage of patients with BCC or SCC develop a second skin cancer within 5 years of the first
skin cancer?
A. 10%
B. 25%
C. 50%
D. 80%
E. 100%
3.Which form of skin cancer is associated with the highest risk of simultaneous internal malignancies?
A. BCC
B. SCC
C. Melanoma
D. Extramammary Paget's disease
E. Bowen's disease
4.Which of the following skin malignancies causes the highest number of deaths each year?
A. Squamous cell carcinoma
B. Basal cell carcinoma
C. Merkel cell carcinoma
D. Melanoma
7.Which of the following bone tumors are radiographic diagnoses and do not require biopsy?
A. Chondrosarcoma
B. Metastasis
C. Giant cell tumor
D. Osteochondroma
8.Impending fractures should be treated by:
A. Radiation therapy
B. Chemotherapy
C. Internal fixation
D. Bisphosphonates
9.Preoperative chemotherapy for osteogenic sarcoma is:
A. Needed to perform limb-preserving surgery
B. Predictive of disease-free survival
C. Useful to tailor postoperative chemotherapy
D. Determined by the translocation type causing the tumor
10.Joint replacement to reconstruct defects after a tumor resection is:
A. As successful as after removal of an arthritic joint
B. Not possible in children younger than 10 years old
C. Best for benign tumor cases
D. Can be combined with allograft bone transplantation
1.Which of the following statements regarding aerodigestive tract cancer associated with human
papillomavirus (HPV) is false?
A. The incidence of HPV-associated aerodigestive tract cancer specific to the tonsil and tongue base subsites is
increasing in North America.
B. HPV-related aerodigestive tract cancer tends to occur in older patients compared with nonHPV-related
aerodigestive tract cancers.
C. The incidence of HPV-related aerodigestive tract cancers is increasing at a higher rate in nonsmokers
compared with smokers.
D. Theincidence of HPV-related aerodigestive tract cancers is increasing at a higher rate in nonalcohol
abusers compared with alcohol abusers.
2.A neck dissection that resects nodal levels I through V but preserves the sternocleidomastoid muscle,
the spinal accessory nerve, and the internal jugular vein is referred to as a:
A. Selective neck dissection
B. Modified neck dissection
C. Radical neck dissection
D. Functional neck dissection
3.To reduce the chance of a vocal fold paralysis postoperatively, the preferred approach to the cervical
spine should be:
A. Left-sided because it reduces the tension on the recurrent laryngeal nerve during the exposure
B. Left-sided because of the incidence of nonrecurrent recurrent laryngeal nerve on the right side
C. Right-sided because it reduces the tension on the recurrent laryngeal nerve during the exposure
D. Right-sided because of the incidence of nonrecurrent recurrent laryngeal nerve on the left side
4.Why should percutaneous tracheotomy performed in the ICU be avoided in patients with prolonged
transoral intubation secondary to ventilator dependence?
A. Percutaneous tracheotomy has a higher incidence of postdecannulation stenosis in patients undergoing
tracheotomy owing to failure to wean from mechanical ventilation.
B. Percutaneous tracheotomy has a higher incidence of complications from accidental decannulation because
an inferiorly based trachea-to-skin flap specific to this procedure is not created.
C. Percutaneous tracheotomy has a higher incidence of "false lumen" creation than traditional open
tracheotomy performed in the operating room.
D. Percutaneous tracheotomy does not have a higher incidence of intraoperative or postoperative
complications and is as safe to perform in ventilator-dependent patients as traditional open tracheotomy
5.An adult patient presents with an asymptomatic, solitary 4-cm neck mass that has been present for 1
month. Physical examination and history are otherwise unremarkable. The initial step in the workup for
this mass would be:
A. CT scan with intravenous contrast agent
B. Open incisional biopsy
C. Fine-needle aspiration
D. Open excisional biopsy with conversion to neck dissection depending on intraoperative frozen section
diagnosis
6.A patient presents with a glottic squamous cell carcinoma involving both anterior true vocal cords but
not either of the arytenoid cartilages, and is not a candidate for endoscopic surgical treatment because
of the inability to expose the larynx for laser excision. A viable conservation surgical therapy would be:
A. Supraglottic laryngectomy
B. Supracricoid laryngectomy with cricohyoidoepiglottopexy
C. Vertical partial laryngectomy
D. Total laryngectomy with tracheoesophageal puncture
7. A 30-year-old woman presents with a slowly growing, asymptomatic, 3-cm parotid mass. Office fineneedle aspiration is inconclusive. Assuming that the intraoperative frozen section shows this mass to be a
benign salivary neoplasm, the most appropriate surgical plan would be to perform:
A. Incisional biopsy without the need for further surgery
B. Total parotidectomy with facial nerve dissection and preservation
C. Excisional biopsy without the need for further surgery
D. Superficial parotidectomy with facial nerve dissection and preservation
8.A patient has a recurrent laryngeal nerve resection as part of removal of an aggressive thyroid
malignancy. Postoperatively, her voice is breathy and weak and is insufficient for performing at her
profession. The goal of subsequent voice restoration surgery is to:
A. Create volitional abduction and adduction of the affected vocal cord to preserve both voice and airway
patency
B. Create volitional abduction and adduction of the affected vocal cord to preserve both voice and airway
protection from aspiration during swallowing
C. Medialize the affected vocal cord to create static contact with the opposite, mobile cord
D. Place a Silastic implant that is capable of directly contacting the opposite, mobile cord
9.An adult patient presents with a right-sided, 3-cm asymptomatic neck mass deep to the
sternocleidomastoid muscle at the level of the hyoid bone that has been growing over the past 3 months.
The most likely etiology in this patient is:
A. Branchial cleft cyst
B. Malignant lymphadenopathy
C. Lipoma
D. Carotid body tumor
10.The level of the neck nodes bounded by the laryngeal strap muscles anteriorly, the posterior border
of the sternocleidomastoid muscle posteriorly, a horizontal plane at the level of the cricoid cartilage
inferiorly, and the level of the hyoid bone superiorly is referred to as level:
A. Ia
B. II
C. III
D. IV
1.A 43-year-old woman is scheduled for reconstruction of the right breast with a latissimus dorsi flap.
She is at greatest risk for which of the following complications?
A. Chronic chest wall pain
B. Dorsal wound dehiscence
C. Partial flap necrosis
D. Seroma
E. Stiffness in the ipsilateral shoulder
2.A 58-year-old nulligravid woman who is scheduled to undergo bilateral prophylactic mastectomy
comes to the office for consultation regarding immediate breast reconstruction. She works full time as a
fitness instructor. The patient currently wears a size 34B brassiere and wants her bra size to be
increased to a C cup, but she wants to make sure that scarring is minimized. Her height is 5 feet, 5
inches and weight is 120 lb. Physical examination of the abdomen shows a paucity of extra tissue. Which
of the following is the most appropriate breast reconstruction procedure for this patient?
A. Bilateral autogenous reconstruction
B. Bilateral tissue expansion followed by implantation of prostheses
C. Delayed breast reconstruction after pathology is confirmed
D. Single-stage reconstruction with prostheses
E. TRAM flap followed by implantation of prostheses
3.A 55-year old woman undergoes a modified radical mastectomy with immediate first-stage
reconstruction of the right breast with a tissue expander. Before beginning the second stage, to exchange
the tissue expander with a permanent prosthesis, pathology results from analysis of tissue from the right
breast indicate metastatic carcinoma of four axillary lymph nodes. Radiation therapy is recommended.
Which of the following interventions will result in the best long-term appearance of the reconstructed
breast?
A. Complete the tissue expansion before radiation and exchange the tissue expander with a prosthesis after
radiation.
B. Deflate the tissue expander before radiation; reinflate the tissue expander and exchange with a prosthesis
after radiation.
C. Remove the tissue expander and reconstruct the breast with a TRAM flap before radiation.
D. Remove the tissue expander before radiation; after radiation, reinsert and expand a tissue expander and then
exchange with a prosthesis.
E. Remove the tissue expander before radiation and reconstruct the breast with a TRAM flap after radiation
5.A 45-year-old woman with T3N0 invasive ductal carcinoma in the inferior pole of the left breast is
scheduled to undergo segmental mastectomy and subsequent radiation therapy. She currently wears a
size 36DDD bra and is willing to accept any cup size from C to DDD. Which of the following
interventions will yield the best cosmetic result in this patient?
A. Bilateral reduction mammaplasty
B. Implantation of a prosthesis in the left breast and mastopexy of the right breast
C. Latissimus dorsi musculocutaneous flap reconstruction of the left breast and mastopexy of the right breast
D. TRAM reconstruction of the defect
E. No reconstruction
6.A 40-year-old woman is scheduled to undergo reconstruction of the right breast via a free TRAM flap.
She has smoked two packs of cigarettes daily for the past 8 years. This patient's smoking history
increases her risk of which of the following postoperative complications?
A. Hematoma
B. Mastectomy flap necrosis
C. Seroma
D. TRAM flap loss
E. Vessel thrombosis
7.A 48-year-old woman comes to the office for consultation regarding reconstruction of her right breast
after mastectomy because of cancer. The patient is concerned about maximizing the aesthetic result and
minimizing any donor site deformity. Physical examination shows a well-healed chest wall and a B cup
left breast with grade 3 ptosis. Soft tissue reconstruction with an SGAP free flap is planned. Which of
the following is a disadvantage of this procedure?
A. Difficulty molding the gluteal fat
B. Gait dysfunction
C. Inability to hide the donor scar completely
D. Inability to provide a sensate flap
E. Lack of abundant soft tissue
8.A healthy 27-year-old woman comes to the office for follow-up examination 3 months after undergoing
bilateral prophylactic mastectomy and reconstruction with saline prostheses. She is concerned about the
incision on her left breast because it is slightly swollen and warm to the touch. Physical examination
shows mild erythema of the left breast and normal healing of the right breast. Which of the following is
the most appropriate initial management?
A. Observation
B. Oral antibiotic therapy
C. Open lavage of the implant pocket
D. Removal of the prosthesis
E. Exchange of the prosthesis
9.A 36-year-old woman comes to the office for consultation regarding breast reconstruction 1 year after
undergoing a right modified radical mastectomy. The procedure was followed by 6 weeks of radiation
therapy. She has no history of other surgical procedures or serious medical illnesses. She is 5 feet. 4
inches in height and weighs 135 lb. She wears a size 32B brassiere. Which of the following is the least
appropriate breast reconstruction procedure for this patient?
A. Extended latissimus dorsi flap
B. Latissimus dorsi flap with saline-filled prosthesis
C. SGAP flap
D. TRAM flap
E. Two-stage reconstruction with a tissue expander and saline-filled prosthesis
10.Secondary breast reconstruction procedures such as nipple reconstruction and areolar tattooing are
considered:
A. At time of mastectomy and immediate breast reconstruction
B. Prior to the patient receiving chemotherapy
C. Prior to the patient receiving radiotherapy
D. After chemotherapy and radiation therapy
E. Prior to flap or expander placement
2.You evaluate a 35-year-old woman with a palpable nodule in the right lateral neck. No other lateral
neck masses are appreciable on examination. Fine-needle aspiration biopsy of this mass reveals thyroid
cells. Which of the following statements is true?
A. In the absence of a palpable thyroid nodule, this likely represents lateral aberrant thyroid, which is a normal
embryologic variant.
B. When found in the setting of the most common pathologic type of thyroid cancer, this finding does not
significantly alter the expected survival for this patient.
C. Given the pathologic finding, the appropriate surgical approach is total thyroidectomy and selective
excision of all lymph nodes that appear suspicious on operative evaluation.
D. In the absence of palpable adenopathy, it would be unlikely to find pathologic evidence of metastasis to
regional lymph nodes from the most common type of thyroid cancer.
3.You evaluate a 27-year-old woman with a thyroid nodule. Fine-needle aspiration biopsy is consistent
with medullary thyroid cancer. Which of the following statements is true?
A. Most cases of medullary thyroid cancer are sporadic and not associated with a familial syndrome.
B. The next appropriate step in management is to proceed directly to total thyroidectomy with bilateral central
compartment lymph node dissection.
C. In a case of the finding of RET proto-oncogene mutation in a patient with no palpable or ultrasounddetectable thyroid nodule, annual observation is indicated, and thyroidectomy should be performed when a
nodule is first appreciated on examination or imaging.
D. After resection for medullary thyroid cancer and recovery from surgery, radioiodine ablation with either
thyroid hormone withdrawal or thyroid-stimulating hormone (TSH) administration is the next therapeutic
intervention.
4.All of the following statements regarding the treatment of papillary thyroid cancer are true except
which one (which is false)?
A. Total thyroidectomy is indicated for cancers greater than 1 cm in greatest dimension and for smaller cancers
with adverse features such as a history of radiation exposure.
B. Reoperation is indicated for completion thyroidectomy for patients who have a papillary thyroid cancer
greater than 1 cm discovered on permanent section pathology after thyroid lobectomy.
C. Prophylactic lateral compartment neck dissection (ipsilateral modified radical neck dissection) is indicated
in most cases.
D. After resection, exogenous thyroid hormone should be titrated to achieve a subnormal thyroid-stimulating
hormone (TSH).
5.All of the following statements are characteristic of hormones produced by the thyroid gland except
which one (which is false)?
A. Iodine is essential for the production of thyroid hormones.
B. The enzyme thyroid peroxidase is an integral part of thyroid hormone production.
C. Thyroglobulin (Tg) is the storage form of thyroid hormone.
D. Thyroid hormone production and release are predominantly regulated by thyroid-stimulating hormone
(TSH) from the pituitary gland.
E. Most hormone released by the thyroid is triiodothyronine (T3).
7.Complete surgical resection (thyroidectomy) is first-line therapy for which one of the following?
A. Riedel thyroiditis (struma)
B. Toxic nodular goiter with marked compressive symptoms
C. Acute suppurative thyroiditis
D. Uncomplicated Graves disease (diffuse toxic goiter)
E. Hashimoto thyroiditis
8.You are preparing a patient for total thyroidectomy for treatment of Graves disease (diffuse toxic
goiter). To attempt to avoid complications from severe thyrotoxicosis, including life-threatening thyroid
storm, you could employ any of the following therapies except which one (which is not appropriate)?
A. Beta blockade with an agent such as propranolol
B. Large doses of thionamides such as propylthiouracil (PTU) and methimazole
C. Large doses of iodine after a thionamide
D. Rapid fluid replacement along with corticosteroids
E. Large doses of amiodarone
9.Which of the following is associated with an aberrant takeoff of the right subclavian artery?
A. Nonrecurrent left laryngeal nerve
B. Absence of the right thyroid lobe
C. Absence of the thyroid isthmus
D. Nonrecurrent right laryngeal nerve
E. Nonrecurrent right external branch of the superior laryngeal nerve
10.A palpable lymph node is found along the posterior-lateral border of the anterior belly of the
digastric muscle. This node lies in which anatomic lymph node basin?
A. IA
B. IB
C. IIA
D. IIB
E. VI
1.Embryologic aspects of the superior parathyroid gland include which of the following?
A. Origin from branchial pouch III
B. Origin from branchial pouch V
C. Typically associated with the thyroidal tubercle of Zuckerkandl
D. Frequent ectopic location within thyroid parenchyma
2.Normally embedded in fat and located within a 2-cm circumscribed area that is cranial to the
intersection of the inferior thyroid artery and recurrent laryngeal nerve is a description that applies to
the:
A. Superior parathyroid gland
B. Inferior parathyroid gland
C. Pyramidal lobe of thyroid gland
D. Thymus
4.An adult with a serum calcium concentration of 10.6 mg/dL (normal, 8.6 to 10.2 mg/dL), serum intact
PTH level of 90 pg/mL (normal, 10 to 65 pg/mL), and a 24-hour urinary calcium value of 25 mg/day has:
A. Secondary hyperparathyroidism
B. Tertiary hyperparathyroidism
C. A defect in the calcium-sensing receptor gene
D. A syndrome successfully treated with surgery
5.Parathyroid carcinoma:
A. Is most common at the extremes of age
B. Is often associated with mild hypercalcemia
C. Is optimally treated with en bloc resection of the ipsilateral thyroid lobe at the initial operation
D. Is always easy to recognize at the time of operation
4. Which of the following statements about the surgical treatment of esophageal carcinoma
is correct?
A. The finding of severe dysplasia in association with Barrett's mucosa is an indication for an
antireflux operation to prevent subsequent development of carcinoma.
B. Long-term survival at all stages is improved by radical en bloc resection of the esophagus
with its contained tumor, adjacent mediastinal tissues, and regional lymph nodes.
C. The morbidity and mortality rates for cervical esophagogastric anastomotic leak are lower
than the rates associated with intrathoracic esophagogastric anastomotic leak.
D. The leading complications of transthoracic esophagectomy and intrathoracic esophagogastric
anastomosis are bleeding and wound infection.
E. Transhiatal esophagectomy without thoracotomy achieves better long-term survival than
transthoracic esophagectomy.
5. The best management for a 48-hour-old distal esophageal perforation is:
A. Antibiotics and drainage
B. Division of the esophagus and exclusion of the perforation
C. Primary repair with buttressing
D. Resection with cervical esophagostomy, gastrostomy, and jejunostomy
E. T-tube fistula and drainage
6. A 42-year-old man with a history of alcoholism and tobacco use is diagnosed by barium
swallow with an esophageal stricture 10 cm from the gastroesophageal junction.
Esophagoscopy confirms a moderate stricture, and biopsy reveals fibrosis. What is the next
step in treatment?
A. Diet alteration and acid suppression with H2 inhibitors
B. Endoscopic stricture dilation and acid supression with high-dose proton pump inhibitor (PPI)
therapy
C. Fluoroscopy-guided stent placement
D. Esophagectomy with gastric pull-through
E. Laparoscopic fundoplication
7. The most common cause of morbidity after esophagectomy is:
A. Postoperative hemorrhage
B. Pneumonia
C. Anastomotic leak
D. Recurrent laryngeal nerve injury
E. Chylothorax
8. A 54-year-old woman has severe chest pain intermittently after meals. An extensive
cardiac workup has been negative. Esophageal manometry before and after swallowing a
5-mL water bolus shows lower esophageal sphincter resting pressure of 30 mm Hg, length
of 3 cm, and residual pressure of 5 mm Hg. Peristaltic contractions have an amplitude of
204 mm Hg 5 cm above the lower esophageal sphincter and a duration of 7 seconds. These
measurements are most consistent with:
A. Nutcracker esophagus
B. Achalasia
C. Diffuse esophageal spasm
D. Nonspecific esophageal dysmotility
E. Hypertensive lower esophageal sphincter
9. The most crucial step in the management of a patient with Zenker's diverticulum is to:
A. Identify the underlying motility disorder preoperatively
B. Perform a complete cricopharyngotomy at operation
C. Resect the diverticulum at operation
D. Drain the surgical site postoperatively
E. Perform an antireflux procedure at the time of surgery
10.Leiomyomas of the esophagus:
A. Require esophagectomy for definitive treatment because of submucosal spread
B. Appear as a distinct rough-edged mass on barium swallow
C. Account for <25% of benign esophageal tumors
D. Do not require biopsy for preoperative diagnosis
E. Metastasize primarily to supraclavicular nodes
5. All the following factors have been related to the development of rectus sheath
hematomas except:
A. Pregnancy
B. Strenuous muscular exertion
C. Anticoagulation
D. Benign and malignant tumors of the abdominal wall
E. Trauma
6. All the following statements are true regarding the natural history of desmoid tumors of
the abdominal wall except:
A. Patients with familial adenomatous polyposis syndrome have a much higher incidence of
desmoid tumors than does the general population.
B. Tumors manifest as painless enlarging masses, often with a relatively rapid rate of growth.
C. Most patients have systemic metastases to the liver and lung at the time of presentation.
D. The development of abdominal wall desmoid tumors is often temporally related to a recent
childbirth or abdominal operation or trauma.
7. The clinical features of an abdominal wall mass that should suggest a malignant cause
include all the following except:
A. The occurrence of severe unrelenting pain in an abdominal wall mass
B. Nonreducible masses arising from below the superficial fascia
C. Size > 5 cm
D. A recent increase in size
E. Fixation to the abdominal wall or underlying organs
8. The peritoneum and peritoneal cavity respond to infection by all the following except:
A. The rapid clearance of particulate matter, including bacteria, via the normal circulation of
peritoneal fluid toward and ultimately into the diaphragmatic lymphatic channels and thoracic
duct.
B. The generation of potent anti-inflammatory mediators by peritoneal macrophages, which
prevent the movement of leukocytes into the peritoneal cavity from the surrounding
microvasculature
C. The release of histamine and other vasoactive products by degranulating peritoneal mast cells,
causing the extravasation of protein-rich fluid into the peritoneal space
D. The opsonization of bacteria by proteins within the fluid generated by the inflamed peritoneal
Membrane
E. The sequestration of bacteria within fibrin matrices, promoting abscess formation and limiting
the generalized spread of infection throughout the peritoneal cavity
13. All the following are advantages to a retroperitoneal operative approach compared
with a transabdominal approach to retroperitoneal organs except:
A. Less postoperative ileus with a more rapid resumption of a normal diet
B. Less operative time and blood loss
C. No intra-abdominal adhesions, reducing the likelihood of subsequent small bowel
obstructions
D. Less intraoperative evaporative fluid losses with less dramatic intravascular fluid shifts
E. Fewer respiratory complications, such as atelectasis or pneumonia
6. The most common causative factor in the development of incisional hernias is:
A. Obesity
B. Malnutrition
C. Steroids
D. Postoperative incisional infection
E. Advanced age
7. Most surgeons agree that laparoscopic inguinal hernia repair is best for:
A. Obese patients
B. Male patients
C. Recurrent hernias
D. Type II groin hernias
E. Strangulated hernias
8. Spigelian hernias are usually:
A. Prone to recurrence
B. Located above the arcuate line
C. More common in adolescents
D. Interparietal hernias
E. Very large
9. Umbilical hernias should be repaired:
A. During infancy
B. Regardless of size
C. Using primary suture repair
D. Even when asymptomatic
E. In patients with leaking ascites
10. Perioperative antimicrobial prophylaxis is indicated for elective hernia repair in which
of the following situations?
A. ASA score 3
B. Use of prosthetic mesh
C. Recurrent hernias
D. Laparoscopic approaches
7. Which of the following pathologic stones are most likely to be visible on plain
radiographs of the abdomen?
A. Appendicoliths
B. Phleboliths
C. Gallstones
D. Renal stones
E. Primary common duct stones
8. Which of the following modalities would not be helpful in reducing mild to moderate
intra-abdominal hypertension?
A. Nasogastric decompression
B. Elevation of the head of bed 30 degrees
C. Bladder cannulation with a Foley catheter
D. Enemas
E. Pharmacologic muscle relaxation
9. Surgical decompression of abdominal hypertension should be considered for:
A. Grade 1 hypertension
B. Grade 2 hypertension
C. Grade 3 hypertension
D. Grade 4 hypertension
E. Both C and D
10. The most common nonobstetric disease requiring surgical intervention during
pregnancy is:
A. Biliary colic
B. Cholecystitis
C. Appendicitis
D. Small bowel obstruction
E. Tubo-ovarian abscess
11. Which of the following statements is true regarding patients with rebound tenderness
and free air seen on plain radiographs?
A. Parenteral steroids are helpful in treating peritoneal inflammation.
B. CT scanning is important in surgical planning.
C. Narcotic analgesics are contraindicated because they may mask changes in the abdominal
examination.
D. Abdominal ultrasound is superior to CT scanning in localizing an intra-abdominal abscess.
E. No further imaging studies are indicated.
12. A common electrolyte abnormality seen at presentation with acute abdomen is:
A. Hyponatremia
B. Hypernatremia
C. Hypokalemia
D. Hyperchloremia
E. Hypermagnesemia
13. A 60-year-old man presents with an 8-hour history of severe diffuse abdominal pain
with rebound tenderness. His blood pressure is 96/60 mm Hg, pulse is 116 beats/min, and
respiratory rate is 22/min. Oxygen saturation by pulse oximetry is 93% on room air. Plain
abdominal radiographs show subdiaphragmatic free air. The next step in preparation for
surgical intervention is:
A. CT scanning of the abdomen with intravenous contrast agent
B. Administration of 2 liters of isotonic crystalloid via peripheral IV
C. Placement of a central venous catheter for monitoring of central venous pressure
D. Endotracheal intubation
E. Broad-spectrum antibiotic administration
14. In the setting of abdominal pain, which of the following is not suggestive of abdominal
catastrophe?
A. Pallor
B. Hypotension
C. Jaundice
D. Confusion
E. Diaphoresis
5. A patient with epigastric pain is found to have a 2.5-cm ulcer on the lesser curvature of
the stomach near the incisura. The most appropriate management of this patient includes:
A. Biopsy of the ulcer followed by long-term proton pump inhibitor therapy
B. Multiple biopsies followed by triple therapy and repeat endoscopy
C. Antrectomy with highly selective vagotomy
D. Distal gastrectomy with D2 lymph node resection
6. A 53-year-old man who underwent distal gastrectomy with Billroth II gastrojejunostomy
for cancer complains of bloating, nausea, and severe diarrhea approximately 20 minutes
after meals. Initial treatment for these symptoms is:
A. Smaller meals with increased protein
B. Amoxicillin, metronidazole, and proton pump inhibitor
C. Conversion of Billroth II to a Roux-en-Y gastrojejunostomy
D. Postprandial serum insulin and glucose levels
7. Which of the following statements relating to risk factors for gastric cancer is true?
A. H. pylori may play a role but is not considered a definite carcinogen.
B. Nitrates are thought to contribute to gastric cancer by inhibiting natural gastric flora.
C. H. pylori is synergistic with nitrates in contributing to gastric cancer.
D. Adenomatous polyps have an 80% risk of becoming adenocarcinoma.
8. On upper endoscopy, an adenocarcinoma on the greater curvature of the stomach is
found in a 76-year-old man. Which of the following would be suitable to endoscopic
mucosal resection?
A. Tumor limited to the mucosa, 1.5 cm, no ulceration, liver lesions on CT
B. Tumor invades the submucosa by 750, no ulceration, 0.5 cm
C. Tumor limited to mucosa, no ulceration, no lymphovascular invasion, 1.5 cm
D. Tumor limited to mucosa, no ulceration, 1.5 cm, enlarged perigastric nodes on endoscopic
ultrasound
9. Which of the following statements regarding systemic therapy for gastric cancer are
true?
A. A limitation of the SWOG trial of adjuvant chemoradiotherapy was a relatively high rate of
D0 resection.
B. The MAGIC trial of perioperative therapy showed that patients tolerate adjuvant therapy and
neoadjuvant therapy equally.
C. Both the MAGIC trial and the SWOG trial stratified patients into early and advanced gastric
cancer and showed a benefit in both groups
D. Adjuvant therapy has been shown to decrease recurrence but not overall survival.
10. A patient whose GIST has which of the following characteristics is most likely to have
metastatic disease?
A. 7 cm, 10 mitoses/50 HPF
B. 12 cm, 3 mitoses/50 HPF
C. 3 cm, 7 mitoses/50 HPF
D. 4 cm, 5 mitoses/50 HPF
13. A 63-year-old woman is postoperative day 3 after a total knee arthroplasty and has
symptoms of large bowel obstruction. She is in minimal distress, and her WBC count is 7.8.
The most appropriate initial step in management is:
A. Neostigmine
B. Hartmann procedure
C. Epidural anesthesia
D. Gastrografin enema
14. A 50-year-old man with a 20-year history of quiescent ulcerative colitis undergoes
surveillance endoscopy and is found to have a focus of low-grade dysplasia on random
colonic biopsy in the transverse colon. The most appropriate next step in management is:
A. Transverse colectomy
B. Extended right hemicolectomy
C. Total proctocolectomy with end ileostomy
D. Total proctocolectomy with immediate J-pouch construction
15. A 55-year-old woman with a prior diagnosis of quiescent ulcerative colitis, who is
receiving no medication, undergoes a surveillance colonoscopy. She has had no prior
operations, and she has never been pregnant. She is found to have a normal rectum to 25
cm and moderate colitis extending from 25 cm to the mid-descending colon. She had a cecal
polyp removed, which showed a 0.2-cm focus of intramucosal carcinoma. She desires to
avoid an ostomy. The most appropriate step in operative management is:
A. Right hemicolectomy
B. Subtotal colectomy
C. Total proctocolectomy with end ileostomy
D. Total proctocolectomy with J-pouch reconstruction
16. A 70-year-old man with significant coronary artery disease undergoes an abdominal
aortic reconstruction. On postoperative day 2, he presents with worsening abdominal pain
and bloody diarrhea. He is hemodynamically stable and has a serum lactate level of 0.7. He
undergoes flexible endoscopy, which shows mucosal sloughing of the sigmoid colon. The
most appropriate next step in management is:
A. Emergent laparotomy with sigmoid resection and primary anastomoses
B. Emergent laparotomy with sigmoid resection and end colostomy
C. Angiography with intravascular papaverine injection
D. Angiography with sigmoid arterial embolization
E. Fluid resuscitation and expectant management.
17. A 55-year-old healthy man with rectal bleeding undergoes colonoscopy, which shows an
ulcerated mass in the midrectum, 10 cm from the anal verge. A 2-cm cecal polyp is
removed en bloc with snare polypectomy, which shows a 0.4-cm focus of high-grade
dysplasia. The margins are grossly negative, with the closest margin being 4 mm.
Endorectal ultrasound shows focal invasion through the submucosa with focal invasion of
the muscularis propria. No enlarged lymph nodes are seen. The most appropriate next step
in surgical management is:
A. Synchronous right colectomy and low anterior resection
B. Low anterior resection
C. Total proctocolectomy with J-pouch reconstruction
D. Neoadjuvant chemoradiation
18. A 60-year-old woman undergoes a left colectomy for a near-obstruction descending
colon cancer. Pathology shows a poorly differentiated tumor invading through the wall of
the colon into the serosa. Six lymph nodes are identified in the specimen, none of which
contain metastatic tumor. Microscopic evaluation of the specimen reveals lymph vascular
invasion. The most appropriate next step in management is:
A. No adjuvant treatment; serial CEA every 3 months for 2 years
B. No adjuvant treatment; serial CT scans every 3 months
C. Adjuvant radiation; serial colonoscopy every 6 months for 2 years
D. Adjuvant chemotherapy; serial CEA every 3 months for 2 years
19. A 73-year-old woman is admitted with a high-grade large bowel obstruction. CT scan
indicates a proximal rectal cancer with invasion into the pelvic sidewall and left
hydroureter. The most appropriate operation is:
A. Proctectomy and primary anastomoses
B. Proctectomy and end colostomy (Hartmann procedure)
C. Loop ileostomy
D. Diverting loop sigmoid colostomy
5. When unable to differentiate a pyogenic from an amebic abscess based on clinical data,
and amebic serologic studies are inconclusive, what is the next diagnostic step?
A. Three-month course of metronidazole
B. Laparotomy
C. Diagnostic aspiration
D. Therapeutic trial of metronidazole and, if no improvement in a few days, diagnostic aspiration
E. C or D
6. Free rupture of a hydatid cyst can result in which of the following clinical outcomes?
A. Anaphylactic shock
B. Disseminated echinococcosis
C. Nothing
D. A and B
E. A, B, and C
7. A patient with recurrent pyogenic cholangitis is best characterized as which of the
following?
A. Young Asian patient of lower socioeconomic status with recurrent bouts of cholangitis and
multiple biliary strictures involving the intrahepatic bile ducts
B. Young, Asian patient of lower socioeconomic status with recurrent bouts of cholangitis and
multiple biliary strictures involving the intrahepatic and extrahepatic bile ducts
C. Patient of any ethnic background with recurrent bouts of cholangitis and biliary strictures
involving the intrahepatic and extrahepatic bile ducts
D. Young Asian patient of lower socioeconomic status with recurrent bouts of cholangitis and no
demonstrable biliary strictures
8. The risk(s) of observing liver cell adenomas is (are):
A. Misdiagnosis
B. Rupture and hemorrhage
C. Malignant degeneration
D. All of the above
E. A and C
F. B and C
9. Potentially curative treatments for hepatocellular carcinoma include:
A. Total hepatectomy with transplantation
B. Partial hepatectomy
C. Transarterial chemoembolization
D. Transarterial chemotherapy
E. All of the above
F. A and B
10. Of the 50,000 cases of hepatic colorectal metastases seen annually in the United States,
what percentage of these patients are candidates for a potentially curative liver resection?
A. 1%
B. 5% to 10%
C. 25%
D. 50%
11. What is the expected 5-year survival of a patient who presents 2 years after a right
hemicolectomy for a node-negative colon cancer with a single, small (<5 cm) liver
metastasis and a carcinoembryonic antigen level less than 200 ng/mL who undergoes
complete resection of this lesion?
A. 50%
B. 35%
C. 25%
D. 10%
12. The most common cause of hemobilia is:
A. Accidental trauma
B. Gallstones
C. Iatrogenic trauma
D. Malignant hepatobiliary neoplasms
13. The test of choice for the diagnosis and potential treatment of hemobilia is:
A. Laparotomy and ligation of hepatic artery on affected side
B. Liver resection
C. Endoscopic retrograde pancreatocholangiography
D. Arteriography and transarterial embolization
14. The most common cause of chronic liver disease in the United States is:
A. Alcohol abuse
B. Hepatitis C
C. Hepatitis B
D. Hemochromatosis
E. 1-Antitrypsin deficiency
15. In recent trials of pegylated IFN- and ribavirin for chronic hepatitis C, what was the
rate of viral clearance?
A. 10%
B. 20%
C. 35%
D. 55%
5. Which of the following statements regarding neoadjuvant therapy for locally advanced
pancreas cancer is true?
A. Radiologic response to neoadjuvant therapy is common, occurring in more than 50% of cases.
B. Overall survival is improved in patients who receive neoadjuvant therapy compared with
patients who receive adjuvant therapy after resection.
C. Neoadjuvant therapy should be considered for a patient with a solitary liver metastasis from
pancreatic cancer in hopes of downstaging the disease for future resection.
D. Neoadjuvant therapy should be considered for a patient with borderline resectable pancreas
cancer with isolated portal vein involvement.
6. The most important stimulus that induces pancreatic secretion during the intestinal
phase is:
A. Gastric distention after the ingestion of food
B. Release of secretin by S cells in response to acidification of the duodenal lumen
C. Release of secretin by S cells in response to acidification of the stomach
D. Release of acetylcholine in response to the sight, smell, or taste of food
7. Randomized trials have shown that endoscopic retrograde cholangiopancreatography
(ERCP) in the setting of acute pancreatitis is indicated only in:
A. Patients with severe acute biliary pancreatitis or coexistence of cholangitis
B. Patients with mild acute biliary pancreatitis
C. Patients with acute biliary pancreatitis and alcohol-induced pancreatitis
D. Patients with severe pancreatitis regardless of the etiology
8. The best surgical treatment for a 55-year-old man who presents with multiple areas of
stenosis and dilation of the pancreatic duct in the body and tail of the pancreas and no
evidence of malignancy is:
A. Duval procedure
B. Beger procedure
C. Nonpylorus-preserving pancreaticoduodenectomy
D. Side-to-side Roux-en-Y pancreaticojejunostomy (modified Puestow procedure)
9. A 60-year-old woman with a history of chronic pancreatitis presents with jaundice.
ERCP and EUS show long symmetric narrowing involving the intrapancreatic portion of
the common bile duct in which malignancy cannot be excluded. The best surgical treatment
is:
A. Duval procedure
B. Roux-en-Y hepaticojejunostomy and no pancreatic resection
C. Pancreaticoduodenectomy
D. Side-to-side Roux-en-Y pancreaticojejunostomy (modified Puestow procedure)
12. Which of the following symptoms indicates severe ischemia and impending myocardial
infarction?
A.Resting angina
B. Accelerated angina
C. New-onset angina
D. Unstable angina
E. Dyspnea
13. An exercise stress electrocardiogram (ECG) is helpful in unmasking underlying
coronary artery disease (CAD) and is a more reliable screening test than a resting ECG.
With reference to exercise stress ECG:
A. The Bruce protocol involves about 30 minutes of nonstop exercise activity
B. About 24 metabolic equivalents of energy expenditure is a minimal requirement for executing
a stress ECG
C. Clinical evaluation of the patient to determine fitness to undergo an exercise stress test is
necessary
D. Sensitivity is 92% and specificity is 97%
E. Ventricular arrhythmias occur in about 20% of cases and are clinically irrelevant
14. The most influential trials that established superiority of coronary artery bypass
grafting (CABG) as a treatment modality for CAD were the Veterans Administration
Study of Chronic Stable Angina (VA Study), the European Coronary Surgery Study
(ECAS), and the Coronary Artery Surgery Study (CASS). Which of the following
statements is true about these trials?
A. Women and young patients were included in the trial causing contamination of results owing
to the potentially confounding factors.
B. These trials have been designed with very stringent quality control measures and have stood
the test of time and continue to support the superiority of CABG for symptomatic CAD in any
location.
C. About 75% of patients who underwent CABG received a bypass using a left internal
mammary artery (LIMA) conduit, and all patients were receiving either angiotensin-converting
enzyme (ACE) inhibitors or a combination of calcium channel blockers and lipid-lowering
pharmacotherapy.
D. All of the above
E. None of the above
15.With reference to neurologic sequelae or complications that occur during CABG, which
of the following statements is true?
A. Although the incidence of stroke is 2.5%, neurocognitive deficits are virtually nonexistent
because of advances in hemofiltration protocols, siliconecoated membrane oxygenators, and
Carmeda BioActive Surfacecoated bypass circuits.
B. Hypothermic circulatory arrest at 18 C is the best strategy for myocardial protection and
preservation of cerebral neurocognition in patients with multivessel CAD undergoing surgical
revascularization.
C. The use of spinal drains has been shown to decrease the incidence of paraplegia in patients
who undergo total cardiopulmonary bypass.
D. The development of advanced micropore arterial filters has eliminated the incidence of
cerebral microemboli, favoring cardiotomy suction as the most effective strategy for blood
conservation.
E. None of the above
16. Which of the following statements is true regarding the use of conduits for coronary
artery bypass surgery?
A. The gastroepiploic artery cannot be used as a pedicle graft because it would not reach the
mediastinum and is likely to be compressed by the diaphragm.
B. Saphenous vein grafts are the primary graft conduits of choice for patients with isolated
disease involving the LAD.
C. Subclavian artery stenosis can affect the long-term function of a LIMA graft owing to steal
syndrome from the axillary and vertebral arteries.
D. Radial artery conduits are unique in that they are quite resistant to spasm and are preferred in
patients with Prinzmetal angina.
E. The right internal mammary artery should not be used as a bypass conduit because most
patients are right-handed and steal syndromes can compromise flow into the right subclavian
artery affecting the performance of the dominant hand.
17. Approximately 15% of patients with CAD do not present with angina.
A. True
B. False
18. Patients with myocardial infarction often present with crushing chest pain associated
with nausea, diaphoresis, anxiety, and dyspnea.
A. True
B. False
19. At least 40% of ventricular mass has to be affected for cardiogenic shock to occur.
A. True
B. False
6. A 45-year-old man with a 2-day history of calf pain without swelling and without
antecedent trauma presents to the emergency department. What is your initial impression?
A. A positive Homan's sign should prompt anticoagulation.
B. A venogram is indicated for the diagnosis of DVT.
C. The absence of swelling speaks strongly against the diagnosis of DVT.
D. None of the above
7. Compared with unfractionated heparin, LMWH:
A. Carries a higher risk of hemorrhagic complication
B. Has more efficacy in anticoagulation, despite requiring more frequent monitoring of activated
PTT
C. Is contraindicated in a pregnant patient
D. Is administered subcutaneously
8. Indications of a vena cava filter include:
A. Recurrent thromboembolism despite adequate anticoagulation
B. Deep vein thrombosis in a patient with contraindications to anticoagulation
C. Chronic pulmonary embolism and resultant pulmonary hypertension
D. Complications of anticoagulation
E. Propagating iliofemoral vein thrombus in anticoagulation
F. All of the above
7. The most common cause of chronic unilateral lower extremity edema is:
A. Lymphatic disorder
B. Tendinitis
C. Venous insufficiency
D. Lipedema
E. Myositis
8. For patients with edema of unknown etiology and suggested lymphedema, the most
specific test to confirm the diagnosis is:
A. Computed tomography
B. Duplex ultrasound
C. Lymphoscintigraphy
D. Magnetic resonance imaging
E. Conventional contrast lymphangiography
9. General therapeutic measures that should be employed for lymphedema include all of
the following except:
A. Meticulous skin care
B. Avoidance of injuries
C. Continuous long-term antibiotic therapy
D. Range-of-motion exercises of the extremities
E. Maintenance of ideal body weight.
10. In regard to complex decongestive physical therapy:
A. Massage starts on the lymphedematous limb
B. Massage starts at the foot and progresses to the leg and thigh
C. The technique is effective in reducing the volume of the lymphedematous limb
D. Compression garments are not required
11. Which of the following medications is reported to be effective in the management of
lymphedema?
A. Aspirin
B. Coumadin
C. Coumarin
D. Corticosteroids
E. Unfractionated heparin
12. Best results from reconstructive operations are expected in patients with:
A. Lymphedema secondary to filariasis
B. Proximal obstruction of the lymphatic circulation with dilated lymphatics distal to the
obstruction
C. Lymphedema praecox
D. Lymphedema tarda
E. Stage III lymphedema
12. All of the following statements regarding brain abscesses are true except:
A. Brain abscesses may present as a seizure.
B. MRI shows a ring-enhancing mass.
C. Brain abscesses may be excluded in patients with a normal peripheral white blood cell count.
D. Brain abscesses should be drained surgically when causing significant mass effect.
E. Brain abscesses may be confused with a glioma on MRI.
5.An 84-year-old man has purulent drainage from a left groin incision site after a left
common iliac artery-to-common femoral artery bypass procedure performed for
critical stenosis of the iliac artery 3 weeks ago. His temperature is 38.8 C (101.8 F),
blood pressure is 140/90 mm Hg, and pulse rate is 100 beats/min. Physical
examination shows an exposed vein graft at the groin incision site. Magnetic
resonance angiography shows a patent bypass graft; the superficial femoral artery is
patent, but a profundus branch is occluded. After dbridement, wound coverage
with which of the following flaps is the most appropriate next step?
A. Anterior lateral thigh
B. Gracilis muscle
C. Rectus femoris muscle
D. Sartorius muscle
E. Vastus lateralis muscle
6. A frail 89-year-old man has had a large pressure sore on the sacrum for the past 2
months. Medical history includes type 2 diabetes mellitus and multi-infarct
dementia. He is incontinent of stool and urine. Which of the following factors is the
most important contributor to the development of the pressure ulcer in this patient?
A. Fecal and urinary incontinence
B. Inadequate cushioning on the wheelchair
C. Malnutrition
D. Poorly controlled diabetes mellitus
E. Prolonged bed rest
7. A 17-year-old boy is brought to the emergency department after sustaining a
traumatic injury to the left lower extremity in a motor vehicle collision. Physical
examination shows a large area of crush injury, loss of soft tissue, and open fracture
of the tibia with exposed bone. The lower leg is cool to touch and pale. No distal
pulses are palpable. Angiography shows transection of the popliteal artery. What is
the most appropriate Gustilo classification of this patient's fracture?
A. Type I
B. Type II
C. Type IIIA
D. Type IIIB
E. Type IIIC
8. A 12-year-old boy is struck in the face with a baseball and is brought to the
emergency department. He reports blurry vision and pain around the orbit, where
physical examination shows swelling and ecchymosis. All of the following symptoms
or physical examination findings may suggest extraocular muscle entrapment and
should prompt urgent CT scan followed by surgical intervention within 24 hours if
entrapment is confirmed except:
A. Pain with movement of the eye
B. Enophthalmos
C. Nausea or vomiting
D. Lagging excursion of the affected eye with superior gaze
E. Worsened diplopia when gazing in one particular direction
9. An infant boy is diagnosed with synostosis (premature fusion) of one of the coronal
sutures. What is the primary indication for surgical correction within the first year
of life in most patients with synostosis of a single cranial suture?
A. To promote normal growth of the brain
B. To decrease the risk of increased intracranial pressure
C. To correct the deformity of the forehead and orbit
D. To promote normal flow of cerebrospinal fluid
E. To prevent developmental delay
10.A child is born full-term with a wide bilateral cleft of the lip and palate. She is
undergoing evaluation by a craniofacial team, surgery is planned, and the family is
being educated regarding management of their child's condition. In counseling the
family, which of the following is not generally associated with this condition?
A. Physical deformity
B. Speech difficulty
C. A need for multiple operations during childhood and teenage years
D.Developmental delay
E. Chronic fluid buildup in the middle ear
7.A 20-year-old woman presents in the emergency department with pelvic pain,
temperature of 101 F, white blood count of 18,000/mm3 with left shift, and nausea
but no vomiting. Pelvic examination is remarkable for purulent cervical discharge
and exquisite tenderness, with fullness in the posterior vaginal fornix. On ultrasound
examination, there is a complex 8-cm pelvic mass in the cul-de-sac of Douglas. The
appendix is seen and appears normal. What is the most appropriate initial
management plan?
A. Laparotomy and excision of the mass
B. Laparoscopy with drainage of the mass
C. Transvaginal drainage of mass
D. IM administration of antibiotics with prescribed oral antibiotics for home care
E. Admission for IV antibiotics
8.During the course of a laparoscopy, you inspect the pelvis and note a 1- to 2-cm
cyst with apparent clear fluid in it on one of the ovaries. The patient is 30 years old
and asymptomatic. What should you do to the ovary?
A. Perform an ovarian oophorectomy to avoid any problems with that ovary.
B. Perform an ovarian cystectomy because she has undergone the risk of anesthesia, and you
do not want to have to come back at a later time when the cyst becomes symptomatic.
C. Aspirate cyst fluid for cytology.
D. Do not perform any operation on the ovary and observe.
9. A 32-year-old woman presents to the emergency department with heavy vaginal
bleeding and a hematocrit of 21%. On examination, she has a bleeding cervical
lesion, but the extent is difficult to determine. Which of the following would be
appropriate management?
A. Immediate simple hysterectomy
B. Radical hysterectomy, bilateral salpingo-oophorectomy, and pelvic and para-aortic
lymphadenectomy
C. Packing the vagina, transfusion, transfer to a center with gynecologic oncologist for
evaluation
D. Cervical biopsy
10.A 65-year-old woman presents with increased abdominal girth and a pelvic mass.
On examination, she has evidence of ascites and a 15-cm pelvic mass. Appropriate
management would be:
A. Laparoscopy to make the diagnosis
B. Laparotomy with biopsy to confirm the diagnosis
C. Exploratory laparotomy, bilateral salpingo-oophorectomy, total hysterectomy, debulking
surgery
D. Paracentesis for cytology
11.A patient presents at 32 weeks' gestation with complaints of nausea, vomiting, and
right upper quadrant pain. On examination, her blood pressure is elevated. Liver
transaminase levels also are increased. The most likely diagnosis is:
A.HELLP syndrome
B. Cholelithiasis
C. Appendicitis
D. Intestinal obstruction
12.A patient presents at 12 weeks' gestation with complaints of left lower quadrant
pain. Ultrasound reveals a 3- 4-cm ovarian cyst without evidence of torsion. There
is a small amount of fluid in the cul-de-sac. What is the most appropriate
intervention?
A. Immediate surgical exploration
B. Admit to the hospital for observation
C. Patient reassurance and pain control
D. Culdocentesis
E. CT
11.A 28-year-old woman at 30 weeks' estimated gestational age presents with trauma after
a motor vehicle crash. The patient is hypotensive on arrival and, after being given 2 liters
of crystalloid, she remains hypotensive. The appropriate next step is to:
A. Transfuse 2 U of packed red blood cells.
B. Place the patient in a left lateral decubitus position.
C. Administer 2 more liters of crystalloid.
D. Start dopamine at 5 g/kg/min.