Professional Documents
Culture Documents
Mcqs PDF
Mcqs 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
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
7. In critically ill victims of trauma, high circulating levels of IL-6 are:
A. Associated with an increased risk of death
B. Associated with a high likelihood of survival
C. Rarely detectable
D. A measurement artifact
8. Which of the following is the main cell type that is activated by IL-8?
A. Enterocytes
B. Macrophages
C. Monocytes
D. Neutrophils
9. HMGB1 is:
A. A late-acting proinflammatory cytokine
B. A nuclear protein that supports DNA transcription
C. A protein with high electrophoretic mobility
D. All of the above
4. In the management of enteral feeding associated diarrhea, which of the following is the
most appropriate initial action?
A. Change of antibiotics in use.
B. Change to an elemental-type formula (e.g., EleCare).
C. Change to an enteral formulation with fiber.
D. Start a small dose of loperamide.
5. In performing perioperative assessments, the most reliable biochemical predictors of
operative morbidity and mortality across surgical specialties include which of the
following?
A. Serum albumin level
B. Defects in cellular immunity and phagocytic function
C. Serum urea nitrogen level
D. Prothrombin time
7. A previously healthy, 18-year-old man is admitted to the ICU after sustaining multiple
injuries in a motorcycle accident. Multiple facial fractures, as well as ribs, pelvis, and right
femur fractures, were found in the initial scan. In addition, multiple deep dermal abrasions
affecting 40% of his body surface area were apparent. Nutritional support should be
initiated by which of the following?
A. Preferentially via the IV route
B. Only via enteral feeding tube to decrease the patient's high risk of aspiration
C. Immediately after resuscitation is complete (i.e., within the first 48 to 72
hours)
D. After definitive treatment of the injuries has been completed
8. This question concerns the same patient as in question 7.) Two months postinjury and
after operative procedures that included tracheostomy, open reductions with internal
fixation, exploratory laparotomy, and persistent ventilator support, a 20% loss of body
weight is noted as compared with admission. By simply considering weight loss, which of
the following can be accurately expected?
A. 50% increased risk of mortality
B. Reduced risk for pressure sores and pneumonia
C. 10% increased risk of mortality
D. Increased difficulty healing and weaning of ventilator support
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
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 β-oxidation of fat in liver mitochondria
Chapter 07: Wound Healing
2. Elastin is:
A. Organized in mammalian skin in a basket weave pattern to resist
multidimensional tensile stress
B. Produced late in life; has a high turnover rate
C. An extremely hydrophilic molecule, which accounts for its functional
properties
D. An important component of the extracellular matrix of blood vessels;
mutations causing elastin protein deficiency result in intimal hyperplasia,
leading to arterial narrowing.
E. Affected in Ehlers-Danlos syndrome, which is characterized by fragile skin
4. Thromboxane causes:
A. Fibroblast chemotaxis
B. Vasoconstriction
C. Collagen cross linking
D. Endothelial proliferation
E. Bacterial lysis
10. Which of the following events occurs in the proliferative phase of wound healing?
A. Histamine release
B. Collagen cross linking
C. Thromboxane release
D. Phagocytosis
E. Collagen synthesis
4. Which of the following is not one of the transcription factors used in cellular
reprogramming to create iPS cells?
A. Oct-4
B. Sox-9
C. Klf-4
D. Nanog
5. Which of the following is not true of ASCs?
A. ASCs can be differentiated into bone, fat, and cartilage.
B. The major advantage of ASCs is their relative abundance and ease of
isolation from subcutaneous adipose tissue through standard lipoaspirate
techniques.
C. ASCs represent a homogeneous cell line derived from lipoaspirate cells.
D. None of the above
4. In any study, both the hypothesis and plan of analysis should be stated a priori to
decrease the risk of:
A. A negative study.
B. A type I error.
C. A type II error.
D. Low statistical power.
5. A group of investigators perform a randomized trial comparing a control intervention
(A) to an experimental intervention (B). Their hypothesis is that intervention B is superior
to A with regard to the outcome of interest. The trial is adequately powered to identify a
difference if one truly exists. However, the results demonstrate no statistically significant
difference between these two interventions. The investigators conclude that the two
interventions are likely equivalent with regard to this outcome. What can safely be stated
about the result and the authors' conclusions?
A. The authors are correct; intervention B is equivalent to A in terms of the outcome of interest.
B. Intervention B would likely demonstrate a statistically significant improvement over A if the
sample size were larger.
C. The authors are incorrect because equivalence can only be ascertained using a noninferiority
trial design.
D. The conclusions depend on the manner in which the authors chose to control for confounding
factors.
6. Which of the following is true regarding the commonly used P value significance level of
.05?
A. This has been mathematically shown to be the cutoff for statistical significance.
B. It is commonly used and should therefore always be chosen as the cutoff for statistical
significance.
C. If a statistical test attains this level of significance, it definitively proves a difference exists.
D. It is arbitrary and a different level for statistical significance can be selected.
7. In analyzing data from a randomized trial, which of the following analytic approaches is
most appropriate?
A. Per-protocol
B. Case-complete
C. Intent to treat
D. Meta-analysis
8. Which of the following is true when comparing the odds with the probability of an
outcome?
A. The odds can overestimate the probability if the outcome of interest is common in the
underlying population.
B. The odds can underestimate the probability if the outcome of interest is common in the
underlying population.
C. The odds can overestimate or underestimate the probability if the outcome of interest is
common in the underlying population.
D. The two values are the same.
Chapter 13: Surgical Complications
1. Which of the following are mechanisms for heat loss that contribute to the development
of hypothermia?
A .Cool environment
B. Direct body contact to cooler materials
C. Heat loss with evaporated water vapor
D. Exhalation of warmed air
E. All the above
3. Which of the following is not usually required for the clinical diagnosis of pneumonia?
A. Decreased breath sounds
B. Temperature that is usually greater than 38.5°C
C. Pleuritic chest pain with coughing
D. Elevated peripheral white blood cell count
E. Chest radiographic infiltrate
4. Which of the following criteria is indicative of the presence of acute lung injury (ALI)
rather than adult respiratory distress syndrome (ARDS)?
A. Pulmonary capillary wedge pressure < 20 mm Hg
B. PaO2/FIO2 ratio < 300
C. PaO2/FIO2 ratio < 200
D. Bilateral infiltrates on chest radiography
E. An acute change in lung function
5. What is the expected reinfarction rate for patients undergoing noncardiac surgery after
a recent acute myocardial infarction (AMI)?
A. No difference compared with other myocardial infarction patients
B. 8% at less than 3 months, 3.5% at 3 to 6 months, then similar to other myocardial infarction
patients
C. 20% in the first 6 months and then similar to other myocardial infarction patients
D. 15% at less than 3 months, 10% at 3 to 6 months, 5% at more than 6 months
E. 50% at less than 3 months, 25% at 3 to 6 months, 15% at more than 6 months
6. Components of the syndrome of inappropriate secretion of antidiuretic hormone
(SIADH) include:
A. Hyponatremia
B. Hypernatremia
C. Peripheral edema
D. Serum hyperosmolality
E. Hypertension
7. Which of the following is not a common cause of a small bowel obstruction in an adult?
A. Hernia
B. Tumor
C. Volvulus
D. Adhesions
E. Ileocolic intussusception
11. Postrenal causes of acute renal failure include all the following except:
A. Ureteral obstruction caused by stones
B. Bladder dysfunction caused by nerve injury
C. Urethral obstruction caused by prostatic enlargement
D. A blocked Foley catheter
E. Myoglobinuria
Chapter 14: Surgery in the Geriatric Patient
1. Which of the following statements is true?
A. Life expectancy of a patient 90 years old, who has no comorbid conditions, is 6 months.
B. The proportion of individuals 65 years old and older will remain constant over the next 50
years.
C. Age is frequently a risk factor in predicting postoperative morbidity and mortality.
D. There is a decline in physiologic function in all organ systems with aging.
E. It is estimated that approximately 25% of patients in most general surgical practices are older
than 65 years.
3. Which of the following is not a necessary part of the preoperative assessment in an older
adult?
A. Baseline cognitive evaluation
B. Exercise capacity testing
C. Determination of nutritional status
D. Advance directives and discussion of end-of-life wishes
E. Evaluation of ADLs and IADLs
4. In emergency surgery for perforated ulcer disease, a patient with preoperative shock,
more than 48 hours of perforation, and significant comorbid disease has a mortality rate
close to:
A. 0%
B. 25%
C. 50%
D. 75%
E. 100%
5. Which of the following is true regarding appendicitis in older adults ?
A. Most patients present with classic signs and symptoms of right lower quadrant pain, increased
white blood cell count, and fever.
B. Although there are typically delays in presentation to the hospital, the diagnosis is usually
made in a timely fashion.
C. Of these patients, 18% present with no abdominal pain.
D. Reported rates of perforated appendicitis in octogenarians are less than 50%.
E. The overall mortality in patients older than age 65 with appendicitis is approximately 18%.
6. In an older patient with suspected biliary disease, which of the following statements is
false?
A. The rate of gallstones is 30% to 40% of individuals older than 80 years.
B. There is an increased incidence of common bile duct stones in patients undergoing
cholecystectomy.
C. Gallbladder motility is typically normal.
D. The conversion rate from laparoscopic cholecystectomy to open procedures is higher than in
younger patients.
E. Biliary tract disease is a frequent cause of acute abdominal complaints in older adults.
8. Which of the following is not currently recommended for an older surgical patient?
A. Carotid endarterectomy
B. Carotid angioplasty and stenting
C. Open abdominal aortic aneurysm repair
D. Endovascular aneurysm repair
E. Peripheral arterial bypass
Chapter 15: Morbid Obesity
2. Currently accepted guidelines from the National Institutes of Health for preoperative
selection of patients for weight reduction surgery include all the following except:
A. Patients with Prader-Willi syndrome
B. BMI > 35 kg/m2 with associated medical comorbidity worsened by obesity
C. Failed medical therapy
D. Psychiatrically stable
E. Motivated patient
5. One specific problem that may arise with persistent vomiting after any of the bariatric
operations is Wernicke's encephalopathy, which can be treated with parenteral:
A. Vitamin B12
B. Omeprazole
C. Thiamine (vitamin B1)
D. Ascorbic acid (vitamin C)
E. Scopolamine
6. Morbid obesity is defined as:
A. 1.5 times ideal body weight
B. BMI > 40 kg/mg2
C. 20% above ideal body weight for adolescents
D. A function of physical activity, comorbid conditions, and weight
E. Weight > 40 kg
9. Medical therapy that has proven to have significant long-term success in morbidly obese
patients includes:
A. Low-calorie diets
B. Sibutramine
C. Ghrelin
D. Orlistat
E. None of the above
2. Which of the following drugs is useful as a premedicant because of its potent amnesic
effects?
A. Glycopyrrolate
B. Etomidate
C. Midazolam
D. Ketamine
E. Thiopental
3. Which of the following statements most accurately describes the differences between
subarachnoid block and epidural block?
A. Pancuronium
B. Vecuronium
C. Cisatracurium
D. Rocuronium
E. Atracurium
B. Patients who require major vascular surgery should undergo cardiac catheterization before
scheduling the vascular procedure.
C. Patients can be stratified for the need for cardiac evaluation based on symptoms and
magnitude of the anticipated surgery.
D. Patients with previous myocardial revascularization are at high risk for perioperative
myocardial infarction.
E. Ambulatory electrocardiography is sensitive and specific for the identification of patients at
high perioperative risk.
A. Aspiration of gastric contents is not a problem; all patients can take food and liquids freely
until immediately before surgery.
B. A fasting period of 2 hours or more is recommended after ingestion of clear liquids.
C. All patients should not receive food or liquids after midnight before surgery the next day.
D. A fasting period of 6 hours or more is recommended after ingestion of solids.
E. Both B and D
A. Delirium
B. Emesis
C. Hypoxemia
D. Hypertension
E. All of the above
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
14. Compared with patients who receive conventional, intermittent, nurse-administered
opioid delivery, patients who receive intravenous patient-controlled analgesia experience
which of the following advantages?
A. Prompt analgesia
B. Smaller doses of opioids
C. Better maintenance of blood concentration of drugs in the analgesic range
D. Lower incidence of drug-related side effects
E. All of the above
Chapter 19: The Difficult Abdominal Wall
1. Abbreviated laparotomy is the initial phase of damage control surgery. The indications
are as follows:
2. The most common indications for the use of the open abdomen technique in general
surgery are as follows:
A. Oliguria
B. Metabolic alkalosis
C. Increased peak inspiratory pressures
D. Intestinal ileus
E. A and C are correct
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?
6. The open abdomen technique has a high rate of nonclosure because of the following
complications:
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?
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?
1. Which of the following will increase the stiffness of an external fixation construct?
2. A patient is found to have an isolated fracture of the medial malleolus on an ankle series
x-ray. What other imaging should be performed?
A. AP, lateral, and oblique views of the foot to look for a fifth metatarsal fracture.
B. CT scanning of the ankle to look for a tibial plafond fracture
C. AP and lateral views of the tibia and fibula to look for a proximal fibular fracture
D. AP and cross-table lateral views of the hip to look for a femoral neck fracture
E. PA and lateral views of the lumbar spine to look for a lumbar burst fracture
4. A 36-year-old man presents to the trauma bay after a motorcycle crash. His systolic
pressures remain in the 70s despite resuscitation with packed red blood cells and
crystalloid. His chest x-ray is normal. His pelvic x-ray is shown in Figure 20-30. What is the
next most appropriate treatment?
A. Application of a pelvic binder
B. Placement of a chest tube
C. CT of chest, abdomen, and pelvis
D. Emergent exploratory laparotomy
E. Arteriography
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
Chapter 21: Burns
1. The zone of stasis in a burn wound is associated with which of the following?
A. Direct thermal damage
B. Vasodilation
C. Neutrophil adherence
D. Platelet degranulation
E. Non-nutrient shunting
3. A patient with burns to the entire back, scalp (50% of the head and neck), and posterior
thighs has what percentage of his or her total body surface area (TBSA) burned?
A.40%
B.28%
C.20%
D.32%
E.36%
4. Severe burns are associated with which of the following immunodeficiencies in the acute
phase?
A. Neutropenia
B. Granulocyte colony-stimulating factor deficiency
C. Decreased cytotoxic T cell activity
D. Increased neutrophil apoptosis
E. Antibody overproduction
5. After major burn injury, the metabolic changes are characterized by an ebb and flow
phase. Changes consistent with the ebb phase include:
A. Increased oxygen delivery
B. Low cardiac output
C. Hypermetabolism
D. Hyperthermia
E. Hyperglycemia
6. Which of these therapeutic approaches to attenuate the hypermetabolic response can
lead to hyperglycemia?
A. Insulin
B. Growth hormone
C. Metformin
D. PPAR-γ agonists
E. Oxandralone
7. A 40-year-old, 100-kg man is involved in a house fire with burns to 45% of his TBSA.
He comes to the emergency department with two peripheral IV lines that are not being
used. It is 2 hours since his injury, and he has not received any resuscitation. His initial IV
fluid rate should be:
A. 250 mL/hr
B. 500 mL/hr
C. 1000 mL/hr
D. 1500 mL/hr
E. 2000 mL/hr
8. The relative surface area of regions of the body used in calculating burn surface area
differs in children from adults. Which of the following statements describes these
differences?
A. Children have relatively less surface area in the arms and legs and more in the trunk.
B. Adults have relatively more surface area in the trunk and less in the upper extremities.
C. Children have relatively more surface area in the head and neck and less in the lower
extremities.
D. Adults have more surface area in the head and neck and less in the lower extremities.
E. Children have relatively less area in the head and neck and more in the trunk
9. Which of the following synthetic and biologic dressings are currently used for burn
wound closure?
A. Allograft
B. Xenograft
C. Stem cells
D. Biobrane
E. Integra
10. Injury from smoke inhalation during a house fire occurs from which of the following?
A. Thermal injury
B. Excessive coughing
C. Splinting leading to atelectasis
D. Plugging of airways from concentration of soot
E. Toxic chemicals in smoke particles
11. What are the three zones of injury after burn?
A. Coagulation, stasis, necrosis
B. Fibrinolysis, stasis, injury
C. Coagulation, injury (stasis), hyperemia
D. Edema, injury, necrosis
12. What proinflammatory mediators are responsible for the postburn hypermetabolic
response?
A.TNF-α, IL-1, IL-6, catecholamines, glucagon, cortisol, endotoxin, nitric oxide
B. Cortisol, IL-5, IL-2, epinephrine, insulin
C. IL-10, CD4, insulin, TNF-α, glucosamine
D. Glucose, cortisol, norepinephrine, nitric oxide
13. One cause of multisystem organ failure after severe burn injury is:
A. Decreased intestinal permeability to macromolecules
B. Diminished blood volume and cardiac output
C. Decreased peripheral vascular resistance
D. Decreased presence of endotoxin
14. Severely burned patients with no other complications can lose 25% of total body mass
after acute burn injury. This loss is associated with:
A. Pneumonia and pressure ulcers
B. Pneumonia and decreased wound healing
C. Immune dysfunction and death
D. Decreased wound healing and immune dysfunction
2. Which of the following injuries is considered low risk for becoming infected and can be
repaired by primary closure?
A. Dog bite to the face
B. Cat bite to the upper arm
C. Human bite over the dorsum of the metacarpophalangeal joint
D. Primate bite to the foot
5. Prophylactic antibiotics should be administered for all of the following injuries except:
A. Cat bite to the foot
B. Human bite to the ear
C. Dog bite to the arm of a diabetic patient
D. Dog bite to the scalp of a child
6. Management of spider bites should include:
A. Prompt administration of antivenom for any victim of a black widow spider bite
B. Application of local cooling measures and conservative wound care
C. Empirical administration of dapsone for wounds believed to be consistent with brown recluse
spider bites
D. Early (≤1 hour) excision of the bite site to limit venom spread
1. A patient is defined as having brain death if the patient has complete absence of cortical
brain function and which of the following?
A. Loss of pupillary reflex to light
B. Loss of the vestibulo-ocular reflex
C. Loss of oropharyngeal reflex (gag reflex)
D. Apnea on consecutive tests despite adequate stimulation (PaCO2 >60 mm Hg)
E. There is no one accepted definition of brain death nationally
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
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.
Chapter 27: Liver Transplantation
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
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
Chapter 29: Small Bowel Transplantation
1. Which of the following patients would be considered an appropriate candidate for intestinal
transplantation?
A. A 2-year-old boy with long-segment Hirschsprung disease extending into the jejunum with an end
jejunostomy. He receives a combination of continuous tube feeds via a gastrostomy tube and supplemental
intravenous fluids via a tunneled central venous catheter. He has had the central venous line replaced once
because of a break in the line but has not had a known central venous line infection.
B. A 23-year-old woman with a history of Crohn disease who has had multiple bowel resections because of
strictures. She is currently dependent on TPN, although she can tolerate small amounts of oral intake. Her liver
function is normal. She has had one central venous line infection owing to Staphylococcus epidermidis, which
was successfully treated with antibiotics.
C. A 1-year-old girl who was born prematurely and lost most of her small intestine secondary to necrotizing
enterocolitis. She is currently dependent on TPN and has been hospitalized five times for central venous line
infections, two of which were due to Candida albicans.
D. A 10-year-old boy with pseudo-obstruction who has recurrent episodes of abdominal pain and distention.
He has recently had to begin TPN because of failure to maintain adequate growth.
2. A 2-year-old boy with intestinal failure secondary to gastroschisis and parenteral nutrition–associated
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 nutrition–associated 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
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.
7. What is most essential for the development of a tumor?
A. Successive genetic alterations
B. The ability to produce growth factors
C. Deletion of p53
D. Immunosuppressed or immunodeficient host
10.A false-positive CEA test can occur in which of the following benign conditions?
A. Ulcerative colitis
B. Cirrhosis
C. COPD
D. Gallstone pancreatitis
E. All of the above
11.Which of the following is not correct regarding the use of alpha-fetoprotein (AFP) as a tumor marker
for hepatocellular carcinoma (HCC)?
A. AFP levels may be elevated in other gastrointestinal malignancies.
B. The combination of ultrasound with AFP improves the sensitivity of screening for HCC.
C. Following complete resection, AFP levels should fall below 10 ng/mL.
D. The rate at which the AFP level rises is not associated with a worse prognosis.
E. None of the above.
13..A highly specific test for a tumor marker may still yield a large number of false-positive test results:
A. When the test has low sensitivity
B. When the prevalence of the disease tested for is low in the tested population
C. When the test is done with urine samples instead of serum samples
D. When the assay is a radioimmunoassay
E. When the test has to be done on fresh tumor samples instead of preserved samples
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
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
Chapter 32: Melanoma and Cutaneous Malignancies
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
Chapter 34: Bone Tumors
1.Factors that limit local recurrence in low-grade extremity soft tissue sarcoma include all of the
following except:
A.Complete local resection
B. Histologically negative margins
C. Adjuvant external beam radiation therapy
D. Adjuvant brachytherapy
E. Primary presentation
2.Risk factors for local recurrence in extremity soft tissue sarcoma include all of the following except:
A. Positive microscopic margin
B. Fibrosarcoma histopathology
C. Deep location
D. High histologic grade
E. Previous recurrence
3.Risk factors for distant metastasis in extremity soft tissue sarcoma include all of the following except:
A. Recurrent presentation
B. Size = 10 cm
C. Deep location
D. Fibrosarcoma histopathology
E. High histologic grade
5.Which one of the following is an important factor indicating poor prognosis in extremity soft tissue
sarcoma?
A. High histologic grade
B. Liposarcoma histopathology
C. Size < 8 cm
D. Distal limb site
E. Prior incisional biopsy
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 non—HPV-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 non—alcohol
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 fine-
needle 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
Chapter 37: Breast Reconstruction
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
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
Chapter 38: Thyroid
1.The recurrent laryngeal nerve provides motor innervation to all muscles of the larynx.
A. The recurrent laryngeal nerve provides motor innervation to all muscles of the larynx.
B. The thyroid forms as two lateral projections from the developing alimentary tract that fuse in the midline
during development.
C. Unilateral vocal cord paralysis may have minimal clinical symptoms.
D. All cells in the adult thyroid are of endodermal origin.
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 ultrasound-
detectable 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
Chapter 39: The Parathyroid Glands
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
1. The endocrine tumor of the pancreas with the lowest rate of malignancy is:
A. Glucagonoma
B. Somatostatinoma
C. Gastrinoma
D. Insulinoma
5. Which of the following endocrine tumors of the pancreas has the best prognosis for cure?
A. Insulinoma
B. Somatostatinoma
C. VIPoma
D. Glucagonoma
E. Gastrinoma
6. The most effective intraoperative technique for localizing a pancreatic gastrinoma
involves palpation plus:
A. Intraoperative endoscopy with transillumination
B. Selective venous sampling
C. Intra-arterial injection of vital blue dye
D. Intraoperative ultrasonography
E. Caudal pancreatectomy
7. MEN1 syndrome is usually associated with tumors in all but which of the following
glands?
A. Thyroid
B. Adrenal
C. Pituitary
D. Pancreas
E. Parathyroid
8. The most accurate method for localizing an insulinoma before operation is:
A.MRI
B. CT
C. Somatostatin receptor scintigraphy
D. Selective angiography
E. Intra-arterial calcium stimulation
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
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
5. Paraesophageal hernias:
A. Have a high likelihood of acute strangulation, and all should be repaired when identified even
if asymptomatic
B. Are rarely associated with chronic gastrointestinal blood loss
C. Should be repaired only in patients with symptoms
D. Are best diagnosed by endoscopy
Chapter 45: Abdominal Wall, Umbilicus, Peritoneum, Mesenteries,
Omentum, and Retroperitoneum
1. Which of the following statements is true regarding the anatomy of the abdominal wall?
A. The inguinal or Poupart's ligament is the lower free edge of the aponeurosis of the transversus
abdominis muscle.
B. The rectus sheath is composed of aponeurotic fibers from the internal and external oblique
and transversus abdominis muscles.
C. The rectus sheath completely envelops the anterior and posterior surfaces of the rectus a
abdominis muscle from its origin in the costal cartilages to its insertion on the pubis.
D. The lymphatic vessels of the abdominal wall drain almost exclusively into the superficial and
deep inguinal lymph node chains.
E. The abdominal wall is innervated almost exclusively from branches of the first through fourth
lumbar spinal nerves.
3. Which of the following are not contained within the preperitoneal space?
A. The medial umbilical ligaments, which are the remnants of the obliterated umbilical arteries
B. The median umbilical ligament, which is the remnant of the obliterated allantoic stalk (or
urachus)
C. The inferior epigastric arteries and veins
D. The superior epigastric arteries and veins
E. The falciform ligament containing the round ligament of the liver, which is the remnant of the
obliterated umbilical vein
4. All the following are abnormalities related to persistence of the omphalomesenteric duct
except:
A. Meckel's diverticulum
B. Omphalocele
C. Enterocutaneous fistula
D. Umbilical sinus
E. Intestinal obstruction from volvulus
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
9. Which of the following are important causes of ascites?
A. Cirrhosis
B. Peritoneal carcinomatosis
C. Traumatic injuries to the retroperitoneal lymphatic channels
D. Nephrotic syndrome
E. All of the above
10. All the following are valuable diagnostic measures in the evaluation of cirrhotics with
new-onset ascites except:
A. Physical examination showing a full bulging abdomen, with dullness of the flanks on
percussion
B. Paracentesis with measurement of ascitic fluid cell count and differential
C. Paracentesis with measurement of ascitic fluid albumin concentration
D. Determination of the serum-albumin to ascites-albumin gradient (SAAG)
E. Paracentesis with Gram staining of the ascitic fluid
11. All the following statements are true regarding spontaneous bacterial peritonitis (SBP)
except:
A. SBP occurs almost exclusively in patients with high protein concentrations in the ascitic fluid
(i.e., SAAG < 1.1 g/dL).
B. The most common pathogens in adults are Escherichia coli and Klebsiella pneumoniae,
whereas in children streptococcal species and Staphylococcus aureus play a greater role.
C. The diagnosis of SBP is made initially by showing >250 neutrophils/mm3 of ascitic fluid in
the setting of abdominal pain, fever, or peripheral leukocytosis or some combination of these.
D. Gram staining of ascitic fluid usually does not show bacterascites.
12. All the following statements are true regarding intra-abdominal hernias except:
A. Mesocolic (or paraduodenal) hernias result from abnormalities of embryonic midgut rotation.
B. The superior mesenteric artery and vein course along the medial border of the neck of right
and left mesocolic hernias.
C. Patients with intra-abdominal hernias present most commonly with signs and symptoms of
intestinal obstruction.
D. Internal hernias may result from the creation of mesenteric windows at the time of bowel
resections.
E. All of the above are true.
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
Chapter 46: Hernias
1. The best outcome for recurrent inguinal hernia repair is achieved by:
A. Selecting the same approach used for the initial repair
B. Experienced hernia surgeons at hernia centers
C. Cooper ligament repair
D. Using prosthetic mesh
E. Bassini repair
3. Failure to recognize which of the following during repair of a sliding inguinal hernia is
associated with increased complications?
A. The colon usually constitutes part of the hernia sac.
B. Sliding hernias are usually direct hernias.
C. A separate incision is necessary for reduction.
D. Tension-free repair should be avoided.
E. High ligation of the sac is usually necessary.
5. Nerve injury during laparoscopic hernia repair is best avoided by not placing tacks:
A. Medial to the pubic tubercle
B. Superior to the lateral iliopubic tract
C. Inferior to the lateral iliopubic tract
D. In the Cooper ligament
E. In the peritoneum
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
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
Chapter 47: Acute Abdomen
1. A common organism responsible for primary peritonitis in children is:
A. Candida albicans
B. Streptococcus pneumoniae
C. Clostridium perfringens
D. Escherichia coli
E. Epstein-Barr virus
2. A common organism responsible for primary peritonitis in adults with cirrhosis is:
A. Candida albicans
B. Streptococcus pneumoniae
C. Clostridium perfringens
D. Escherichia coli
E. Epstein-Barr virus
4. Referred pain to the right lower abdomen when compressing the left lower abdomen is:
A. McBurney sign
B. Obturator sign
C. Rovsing sign
D. Cullen sign
5. Right lower quadrant pain induced by gentle traction of the right testicle in the setting of
acute appendicitis is an example of:
A. Cruveilhier sign
B. Danforth sign
C. Carnett sign
D. Kehr sign
E. Ten horn sign
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
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
Chapter 49: Stomach
1. Which of the following groups represents the major vascular supply of the stomach?
A. Celiac, left gastric, short gastrics
B. Celiac, proper hepatic, splenic
C. SMA, right gastric, short gastrics
D. SMA, left gastric, right gastric
3. A 35-year-old man presents with a history of gnawing epigastric pain that worsens with
eating. He has no early satiety, no history of bleeding, and no weight loss. Which of the
following diagnostic and treatment options would be the most appropriate?
A. Endoscopy without biopsy followed by 2 weeks of proton pump inhibitor
B. H. pylori serology followed by 2 weeks of antisecretory medication, amoxicillin, and
metronidazole
C. Empirical triple therapy
D. Proton pump inhibitor and sucralfate
E. Endoscopy with multiple biopsies followed by antrectomy and highly selective vagotomy
4. A 65-year-old woman presents 4 hours after sudden onset of severe epigastric pain. An
upright chest radiograph shows air under the diaphragm. Her only medication is an
antihypertensive, and she has no prior history of ulcer disease. On exploration, there is a 2-
cm perforation on the anterior aspect of the first portion of the duodenum. What is the
most appropriate management of this patient is?
A. Omental buttress of the perforated ulcer, testing for H. pylori, and medical treatment of H.
pylori with triple therapy
B. Omental buttress of the perforated ulcer with highly selective vagotomy
C. Antrectomy
D. Antrectomy with truncal vagotomy
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:
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.
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
Chapter 51: The Appendix
1. The best antibiotic management of appendicitis should include agents targeted against:
A. Aerobic gram-negative rods and anaerobes
B. Anaerobes
C. Aerobic gram-negative rods
D. Aerobic gram-positive cocci and anaerobes
2. Patients with acute appendicitis typically have a white blood cell count > 20,000/µL.
A. True
B. False
3. In evaluating patients with acute abdominal pain, the most effective tools for diagnosing
appendicitis are:
A. Computed tomography
B. Ultrasound
C. Complete blood cell count
D. History and physical examination
5. A 1.5-cm carcinoid tumor located at the base of the appendix should be treated with:
A. Appendectomy
B. Right hemicolectomy
C. Subtotal colectomy
D. Chemotherapy alone
2. The short-chain fatty acid produced in the greatest quantity by colonic bacterial
fermentation that is used in cholesterol synthesis is:
A. Butyrate
B. Acetate
C. Propionate
D. Linolenic acid
5. The best modality to detect the most common fistula complicating diverticulitis in
women is:
A. Cystoscopy
B. Tampon detection with rectal methylene blue
C. CT scan
D. Physical examination
6. The most common cause for recurrent diverticulitis after sigmoid resection is believed to
be due to:
A. Pancolonic diverticular disease
B. Inadequate distal resection margin
C. Use of a side-to-end stapled technique
D. Dietary indiscretion
7. The internal anal sphincter is most closely related embryologically to:
A. Embryologic ectoderm
B. Embryologic endoderm
C. Longitudinal muscle layer of the rectum
D. Circular muscle layer of the rectum
8. What are the most common location and position of the tip of the appendix?
A. Retroperitoneally; retrocecal
B. Retroperitoneally; retroileal
C. Intraperitoneally; pelvic
D. Intraperitoneally; pericecal
9. The primary blood supply to the midtransverse colon derives from the:
A. Celiac axis
B. Superior mesenteric artery
C. Ileocolic artery
D. Marginal artery of Drummond
10. Which pelvic floor muscle provides an important function in maintaining the rectal
angle?
A. Pubococcygeus
B. Iliococcygeus
C. Puboiliacus
D. Puborectalis
11. The most common neurologic complication that may be caused during IMA ligation is:
A. Sympathetic dysfunction—bladder dysfunction and retrograde ejaculation
B. Sympathetic dysfunction—bladder dysfunction and impotence
C. Parasympathetic dysfunction—cutaneous anesthesia and retrograde ejaculation
D. Sympathetic dysfunction—cutaneous anesthesia and impotence
12. A 70-year-old man from a nursing home admitted with obstructive symptoms is found
to have a cecal volvulus. The most appropriate management of this entity includes:
A. Right colectomy with end ileostomy
B. Right hemicolectomy with primary anastomosis
C. Cecopexy
D. Tube cecostomy
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
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
Chapter 53: Anus
2. All of the following statements are true regarding acute anal fissures except:
A. They produce pain and bleeding with defecation.
B. Women typically have anterior fissures.
C. They result from sphincter hypertonia and mucosal ischemia.
D. They can be treated successfully with medical therapies.
10. For melanoma of the anal canal, all of the following statements are true except:
A. They are often amelanotic.
B. Abdominoperineal resection is the procedure of choice.
C. Five-year survival rates are poor, at 10% to 17%.
D. Survival rates are stage-dependent.
Chapter 54: The Liver
1. The plane that divides the liver into right and left hemilivers contains which structure?
A. Left portal vein
B. Right hepatic vein
C. Umbilical fissure
D. Middle hepatic vein
E. Falciform ligament
3. In how much time of fasting is hepatic glycogen depleted and how does the liver produce
glucose in the absence of glycogen?
A. 48 hours; gluconeogenesis
B. 24 hours; glycogenolysis
C. 48 hours; glycolysis
D. 24 hours; gluconeogenesis
E. 12 hours; glycolysis
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
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%
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. α1-Antitrypsin deficiency
15. In recent trials of pegylated IFN-α and ribavirin for chronic hepatitis C, what was the
rate of viral clearance?
A. 10%
B. 20%
C. 35%
D. 55%
Chapter 55: Biliary System
1. All of the following are associated with development of cholesterol stones except:
A. Weight loss
B. Prolonged fasting
C. Vagotomy
D. Sickle cell anemia
2. A 36-year-old woman presents to your office after the delivery of a healthy baby. During
her pregnancy, she underwent an ultrasound to assess fetal growth and incidental
gallstones 5 mm in size were noted. The appropriate treatment for this presentation is:
A. Laparoscopic cholecystectomy
B. Repeat ultrasound in 6 months
C. Observation
D. Medical dissolution of the gallstones
3. A 45-year-old patient presents with recurrent right upper quadrant pain after eating
high fat meals. His ultrasound shows a common bile duct of 4 mm and no stones. The next
appropriate step is:
A. HIDA scan
B. ERCP with sphincterotomy
C. Observation
D. Transduodenal sphincteroplasty
5. A 78-year-old man who has been in the intensive care unit (ICU) requiring mechanical
ventilation for pneumonia develops abdominal pain, aspartate aminotransferase (AST)
level of 50 IU/liter, alanine aminotransferase (ALT) level of 70 U/liter, and bilirubin level of
2.2 mg/dL. He has a palpable tender mass in his right upper quadrant. Possible
appropriate steps include all the following except:
A. Ultrasound
B. ERCP
C. HIDA scan
D. Percutaneous cholecystostomy
6. A 50-year-old man develops gallstone pancreatitis. His ultrasound shows cholelithiasis.
He is taken to the operating room for a laparoscopic cholecystectomy. Intraoperatively,
three small stones are found in his distal bile duct. The next appropriate step is:
A. Administration of IV glucagon with flushing of the duct
B. Intraoperative ERCP
C. Postoperative MRCP
D. PTC for drainage
7. A patient returns 5 days after cholecystectomy with right upper quadrant pain, normal
liver function test results, and fluid in the gallbladder fossa. A percutaneous drain is placed
and shows bile. The next appropriate step is:
A. Observation
B. Laparoscopic reexploration
C. ERCP
D. PTC
8. During a routine cholecystectomy, while incising the cystic duct for the performance of a
cholangiogram, a surgeon determines that he or she has inadvertently incised 30% of the
circumference of the common bile duct. After converting to an open operation, the
appropriate next step is to:
A. Débride the duct and perform a Roux-en-Y hepaticojejunostomy.
B. Close the duct primarily.
C. Close the duct over a T tube.
D. Perform an intraoperative ERCP
9. A 70-year-old woman with gallbladder cancer presents to your office with painless
jaundice. Her CT scan shows a mass in the gallbladder, infiltrating segment IVB of the
liver and compressing the common bile duct. She also has intrahepatic and pulmonary
metastatic disease. The appropriate management of this patient is:
A. Palliative cholecystectomy with Roux-en-Y hepaticojejunostomy
B. External beam radiation to relieve the jaundice
C. ERCP with stenting
D. Cholecystostomy tube to alleviate the compression
Chapter 56: Exocrine Pancreas
1. Cyst fluid analysis reveals CEA of 500, mucin positive, low amylase, and no
communication with the pancreatic duct. The most likely diagnosis based on these imaging
and fine-needle aspiration results is:
A. Mucinous cystic neoplasm
B. Serous cystic neoplasm
C. Intraductal papillary mucinous neoplasm
D. Pseudocyst
2. Cyst fluid analysis reveals CEA of 3, mucin negative, high amylase, and communication
with pancreatic duct present. The most likely diagnosis based on these imaging and fine-
needle aspiration results is:
A. Mucinous cystic neoplasm
B. Serous cystic neoplasm
C. Intraductal papillary mucinous neoplasm
D. Pseudocyst
3. Cyst fluid analysis reveals CEA 400, mucin positive, high amylase, and communication
with pancreatic duct present. The most likely diagnosis based on these imaging and fine-
needle aspiration results is:
A. Mucinous cystic neoplasm
B. Serous cystic neoplasm
C. Intraductal papillary mucinous neoplasm
D. Pseudocyst
4. Cyst fluid analysis reveals CEA 2, mucin negative, low amylase, and no communication
with pancreatic duct. The most likely diagnosis based on these imaging and fine-needle
aspiration results is:
A. Mucinous cystic neoplasm
B. Serous cystic neoplasm
C. Intraductal papillary mucinous neoplasm
D. Pseudocyst
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
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. Non–pylorus-preserving pancreaticoduodenectomy
D. Side-to-side Roux-en-Y pancreaticojejunostomy (modified Puestow procedure)
2. Which of the following statements is true about ventricular septal defects (VSDs)?
A. In the setting of otherwise normal cardiac morphology and normal pulmonary vascular
esistance, the net shunt in patients with a VSD is right to left.
B. Newborns diagnosed with a VSD should always have surgical closure delayed until they are
older, when the surgery is less risky.
C. Aortic valve prolapse is associated with muscular VSDs.
D. Device closure is a widely applicable mode of therapy for most VSDs because VSDs are
located far from any intracardiac structures.
E.Surgical closure of VSDs can be achieved with a patch of autologous pericardium, Dacron, or
homograft material.
6. Which of the following statements about hypoplastic left heart syndrome (HLHS) is not
true?
A. Patients with HLHS have inadequate or almost completely absent left heart structures.
B. Balancing the systemic and pulmonary circulations becomes less challenging with the normal
decline in neonatal PVR because a more homeostatic physiology is approached.
C. Ductal patency must be maintained before surgery.
D. Treatment of HLHS requires a staged surgical approach.
E. The Norwood procedure is the primary mode of therapy for HLHS and includes aortic arch
reconstruction and establishment of a controlled source of pulmonary blood flow.
Chapter 60: Acquired Heart Disease: Coronary Insufficiency
1. The blood supply to the anteroseptal wall of the left ventricle is via the
A.Left coronary artery (LCA)
B. Left anterior descending (LAD)
C. Diagonal branches of the LAD
D.Left circumflex arteries
E. Posterior descending artery (PDA)
2. What vessel or vessels play a crucial role in oxygen and nutrient exchange with the
myocardium?
A. Resistance vessels
B. Epicardial conductance vessels
C. Septal perforators from LAD
D. Ramus intermedius
E. Dominant epicardial coronary vessel
4. Which one of the following metabolic substances plays a leading role in the
autoregulatory mechanism to increase the blood flow in the resistance coronary vessels?
A. CO2
B. O2 tension
C. Hydrogen ions
D. Potassium ions
E. Adenosine
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, silicone–coated membrane oxygenators, and
Carmeda BioActive Surface–coated 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
20. Total cardiopulmonary bypass is commonly established by cannulating the main
pulmonary artery and the ascending aorta.
A. True
B. False
21. Before planning for coronary artery bypass surgery, the extremities should be
evaluated for previous scar or fracture.
A. True
B. False
22. Risk reduction strategies should be used in all patients with chronic stable angina
regardless of the type of intervention planned on the coronary artery.
A. True
B. False
23. When an ECG is performed during chest pain at rest, 50% of the test is normal.
A. True
B. False
24. An exercise stress ECG is not helpful in unmasking underlying CAD and is not a more
reliable screening test than a resting ECG in patients older than 40 years.
A. True
B. False
25. Multidetector computed tomography (CT) is especially useful for imaging proximal
CAD and for imaging coronary artery bypass grafts.
A. True
B. False
Chapter 61: Acquired Heart Disease: Valvular
1. A patient with mitral stenosis is most likely to become symptomatic with which of
the following heart rhythms?
A. Sinus bradycardia at a rate of 55 beats/min
B. Atrial fibrillation with a ventricular response of 110 beats/min
C. Sinus rhythm at a rate of 100 beats/min
D. First-degree heart block
4. Which of the following is an indication for aortic valve replacement for aortic
stenosis?
A. Atrial fibrillation
B. Heart failure
C. Stroke
D. Valve area of 1.1 cm2
1. Symptoms of varicose veins are commonly aching pain and fatigue. These are greatest in
which of the following?
A. Telangiectasia
B. Reticular varicosities
C. Large subcutaneous varicosities
D. Symptoms unrelated to size
E. Symptoms may be equal in all of the above.
2. Venous leg ulcer may be caused by:
A. Saphenous reflux and varicose veins
B. Deep venous reflux without superficial reflux
C. Incompetent ankle perforating veins
D. All of the above
3. Severe venous dysfunction is characterized by ankle hyperpigmentation, induration, and
open leg ulcers. The most appropriate name for this condition is:
A. Stasis ulceration
B. Postphlebitic state
C. Chronic venous insufficiency
D. Marjolin's ulcer
3. Conservative treatment of severe venous dysfunction includes:
A. Induced hyperthermia
B. Intermittent pneumatic compression
C. Fitted support
D. All of the above
4. Which of the following statements is true regarding venous thrombosis?
A. The type of operation rather than its length increases the risk for deep venous thrombosis.
B. Contrast medium can be seen pooling in the soleal sinuses during any type of anesthesia.
C. Thrombus in a vein produces typical pain and swelling.
D. Coagulation studies can identify the postoperative acquired prothrombotic state.
15. The diagnosis of chylothorax can be established by the presence of which of the
following elements in the pleural effusion fluid?
A. White blood cells
B. Chylomicrons
C. High protein concentration
D. Lactate dehydrogenase
E. Amylase
Chapter 68: Neurosurgery
1. A patient presents to the emergency department with a sudden severe headache and stiff
neck without evidence of head trauma. The CT scan does not show acute blood. What is the
next step?
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
Chapter 70: Hand Surgery
1. Which of the following muscles of the hand is innervated by the median nerve?
A.Abductor pollicis brevis
B. First dorsal interosseous
C. Adductor pollicis
D. Abductor digiti minimi
E. Ring finger lumbrical
2. When exploring a volar laceration of the midforearm, the median nerve is
identified immediately deep to:
A.Flexor digitorum profundus
B. Flexor carpi radialis
C. Deep head of pronator teres
D. Flexor digitorum superficialis
E. Flexor carpi ulnaris
3.A patient has a transverse laceration just proximal to the volar wrist flexion crease.
When attempting to grasp a piece of paper by thumb adduction, the examiner notes
that the patient has to flex the thumb interphalangeal joint (Froment paper sign) to
accomplish this. The patient almost certainly has a laceration of what nerve?
A. Anterior interosseous
B. Ulnar
C. Median
D. Posterior interosseous
E. Radial
4.Replantation of amputated parts would generally be contraindicated in which of
the following circumstances?
A.Multiple digits
B. Child younger than 5 years old
C. Thumb with long flexor tendon avulsion
D. Index finger proximal to flexor digitorum superficialis insertion
E. Through the wrist
5.A 36-year-old woman experiences frequent nocturnal deep wrist aching that keeps
her awake. This pain is best relieved by nonsteroidal anti-inflammatory medications.
A radiograph of the wrist reveals a 3-mm round lucency with sclerotic edges in the
capitate bone. This patient most likely has:
A. Enchondroma
B. Aneurysmal bone cyst
C. Metastatic bone tumor
D. Exostosis
E. Osteoid osteoma
Chapter 71: Gynecologic Surgery
1.The embryologic origin of the uterus is the:
A. Wolffian duct system
B. Urogenital sinus
C. Müllerian duct system
D. Primordial germ cells
2. Where does the primary blood supply to the uterus originate?
A. The aorta
B. The internal iliac artery
C. The external iliac artery
D. The pudendal artery
4.The safest time to perform elective or semielective surgery during pregnancy is:
A. First trimester
B. Second trimester
C. Third trimester
D. Surgery is unsafe in all trimesters and should be avoided.
5.The major concerns of laparoscopy during pregnancy include:
A. Uterine injury
B. Decreased uterine perfusion
C. Fetal acidosis
D. Preterm labor from increased intra-abdominal pressure
E. All of the above
6.Compared with nonpregnant patients, women diagnosed with breast cancer during
pregnancy have:
A. A larger primary tumor
B. A higher risk of positive nodes
C. A higher incidence of estrogen receptor–positive tumors
D. All of the above
E. A and B
7.Oral contraceptive use is associated with:
A. Hepatic adenoma
B. Cholelithiasis
C. Splenic artery aneurysm
D. Hemangioma
E. None of the above
8.The timing for cholecystectomy for biliary colic during pregnancy is determined
by:
A. Patient age
B. Severity of symptoms
C. Gestational age
D. Effectiveness of medical management
E. B and C
9. In a pregnant patient with unexplained hypertension or fever within 48 hours after
delivery, the diagnosis of pheochromocytoma is best made by:
A.Metaiodobenzylguanidine (MIBG) imaging
B. Urinalysis
C. Urinary catecholamines
D. All of the above
10. In suspected acute appendicitis during pregnancy, the accepted negative
exploration rate is:
A. 10%
B. 20%
C. 30%
D. 50%
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 µg/kg/min.