Professional Documents
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Question 1
• Which portion of the gastrointestinal tract is
most responsible for the absorption of iron?
– A. Stomach
– B. Duodenum
– C. Jejunum
– D. Ileum
– E. Colon
Answer 1
• B. Maximal absorption of iron occurs in the
duodenum
Question 2
• Which portion of the gastrointestinal tract is
most responsible for the absorption of bile
acids and folate?
– A. Stomach
– B. Duodenum
– C. Jejunum
– D. Ileum
– E. Colon
Answer 2
• D. Ileum
Question 3
• Which of the following parts of the duodenum
are not considered to be retroperitoneal?
– A. 1st proximal portion
– B. 2nd (descending)
– C. 3rd (transverse)
– D. All of the above are retroperitoneal
Answer 3
• A. The proximal portion of the first part of the
duodenum is intraperitoneal
Question 4
• All of the following are true regarding small
bowel anatomy and physiology except:
– A. Brunner’s glands produce an alkaline solution
– B. Enterochromaffin cells are involved in 5-
hydroxytryptamine release, APUD , serotonin
production
– C. Gastrin is produced by the parietal cells in the
stomach and are innervated by the vagus
– D. The ileum is around 150 cm in length while the
jejunum is about 100 cm
Answer 4
• C is false.
• Gastrin is produced by antral G cells in the stomach and
occasionally by pancreatic cells
• G cells are innvervated by the vagus.
• Gastrin releasing peptide is released by the post-ganglionic
fibers of the vagus during parasympathetic stimulation
• Bombesin also stimulates gastrin release
• Gastrin stimulates enterochromaffin-like cells to release
histamine
• Gastrin also targets parietal cells by increasing the amount of
histamine-> the parietal cells therefore increase HCl secretion
Answer 4
◦ The other statements are true.
◦ The jejunum is the maximum site of absorption, though
the terminal ileum absorbs B12, bile acids, and folate.
◦ Brunner’s glands produce an alkaline solution
◦ Enterochromaffin cells are involved in 5-
hydroxytryptamine release, APUD , serotonin
production
◦ The ileum is around 150 cm in length while the jejunum
is about 100 cm
Question 5
• A 52 yo who has had a complicated history of
multiple gastric and pancreatic procedures
complains of loose stools that float. Which of the
following is true of this condition?
– A. It can be caused by hyposecretion of gastric acid
– B. You should recommend higher intake of fats to
compensate for the loss
– C. Is a known sequlae of extensive terminal ileum
resection
– D. Pancrease is not effective
Answer 5
• C. Steatorrhea is a known sequlae of terminal
ileum resection. Interruption of bile salt
resorption interferes with micelle formation.
• Gastric hyper (not hypo) secretion of acid
increases intestinal motility and interferes with
fat absorption
• Treatment involves controlling diarrhea (Lomotil),
decrease PO intake (esp fats), Pancrease, and H2
blockers
Question 6
• Which of the following amino acids is a major
metabolic fuel for enterocytes?
– A. Alanine
– B. Glycine
– C. Leucine
– D. Glutamine
Answer 6
• D. Glutamine is a major metabolic fuel for
enterocytes and may play an important role in
modulating the cytokine release from
intestinal lymphocytes
Question 7
• You just performed a gastrectomy on a patient that had
previously been in-house receiving pre-operative TPN @ 90
cc/hr. 4 hours post-op, the patient seems unusually
somnolent, somewhat confused, and diaphoretic. His blood
glucose returns as 35 mg/dL. Which of the following is likely
to be true of this condition?
– A. It is unusual to see symptoms of hypoglycemia when serum glucose
levels are above 25 mg/dL
– B. This was probably caused by stopping the TPN altogether during
the operation
– C. TPN should not be administered intraoperatively as operative stress
puts the patient on TPN at risk for hyperosmolar, nonketotic coma
– D. This is likely due to post-operative dumping syndrome
Answer 7
• B. Most likely, this patient is hypoglycemic because
the TPN was not ran at all during the operation.
• TPN associated hypoglycemia is caused by the sudden
slowing of TPN administration, and is the most
common cause of hypoglycemia other than excessive
insulin administration
• Blood glucose levels less than 50 mg/dL can produce
profound symptoms (dizziness, coma, arrhythmia,
hypotension, diaphoresis)
Answer 7
• It is usually safe to run TPN @ ~ 50 cc/ hr
intraoperatively- it is unlikely that this will lead to
hyperglycemia that will cause nonketotic coma
• 10% dextrose can be given when TPN is to be
stopped
• Weaning from tPN can usually be stopped when
the infusions rates are 50 cc/hr or less
Question 8
• Which of the following is NOT true about pancreatic
exocrine secretions?
– A. The principal cations are sodium and potassium
– B. The concentration of the principal anions (bicarb and
chloride) varies depending on pancreatic stimulation
– C. When the stimulus to secrete fluid is minimal, the
chloride concentration is relatively high
– D. When the stimulus to secrete is maximal, the chloride
concentration is relatively high
Answer 8
• D is incorrect. When the stimulus for the pancreas to
secrete is maximal, the chloride concentration is
relatively low, not high
Pancreatic Exocrine
• The principal cations of pancreatic juice are sodium
and potassium
• The concentration of the principal anions (bicarb
and chloride) varies depending on pancreatic
stimulation
• When the stimulus to secrete fluid is minimal, the
chloride concentration is relatively high and bicarb
is low
• When the secretory stimulus is maximal, the bicarb
concentration rises and chloride falls
Pancreatic Exocrine
•The above is a result of the passive exchange of intraductal
bicarb for interstitial chloride
– This exchange occurs as juice flows through the larger pancreatic ducts on its
way to the duodenum.
– At slower rates, there is more opportunity for exchange to take place and bicarb
to subsequently be lost
– The alkaline juice helps to neutralize gastric acid in the duodenum, thus
providing optimal pH for the activity of pancreatic digestive enzymes.
Question 9
• Which of the following about bacterial sepsis is
NOT true?
– A. Gram positive septicemia usually has a poorer
prognosis than gram negative infection
– B. Lipid A of the LPS endotoxin is an importent
component for virulence
– C. TNF can cause self-stimulation of monocytes and
macrophages to their full state of activation
– D. IL-1 may stimulate T lymphocytes to produce TNF
Answer 9
• A is not true. Gram NEGATIVE septicemia
usually has a poorer prognosis than gram +
infection
Gram Negatives/ TNF
• Gram negative septicemia usually has a poorer
prognosis than gram + infection
• The endotoxin, which represents the LPS outer
membrane of these bacteria usually contains the
lipid A moiety, which is important in virulence
• TNF is produced primarily by T lymphocytes and
macrophages in response to many stimuli, including
IL-1, interferon, LPS, viruses, and BCG
Gram Negative Sepsis/ TNF release
• In gram – infections, a stimulated macrophage
produces TNF.
• TNF can cause self-stimulation of monocytes and
macrophages to their full state of activation
• Large array of cytokine and inflammatory signals
develop
• The paracrine function of TNF is to stimulate
neutrophils to full activation
Question 10
• A 45 yo male underwent extensive adhesiolysis with multiple
serosal tears. The operation took around 4 hours and at the
end of the case, his abdomen was slightly difficult to close. He
developed an ileus post-op, a wound dehiscence requiring
takeback, and then on day 9 started draining succus from his
midline excision. Which of the following is not true?
– A. Colonic fistulas are more likely to close compared to SB.
– B. High output fistula are more likely to be from the proximal bowel
and less likely to close with conservative management.
– C. 80% close spontaneously
– D. Iatrogenic enterocutaneous fistulas are more common than
spontaneous fistulas from inflammatory bowel disease
Answer 10
• C. Is not true. 40% of fistulas close spontaneously
• Colonic fistulas are more likely to close compared to SB.
• High output fistula are more likely to be from the proximal
bowel and less likely to close with conservative
management.
• Most fistulas are iatrogenic
• Tx initially with NPO, bowel rest, TPN, octreotide, output
management
• Best surgical option is takedown and resection
Answer 10
• FRIENDS
• Foreign body
• Radiation
• IBD
• Epithelization
• Neoplasm
• Distal obstruction
• Sepsis
Question 11
• Which of the following about bowel obstructions is
not correct?
– A. The most common cause of colonic obstruction without
previous surgery is cancer
– B. The most common cause of SBO in a patient without
surgery is cancer
– C. The most common cause of SBO with a history of
previous surgery are adhesions
– D. The most common cause of a SBO in a patient with no
history of abdominal surgery is an inguinal hernia
Answer 11
• B is false. The most common cause SBO with
no history of abdominal surgery is a hernia
(not malignancy)
• Most common cause of SBO with a surgical hx
is adhesions
• Most common cause of colon obstruction with
or with no PSuH is cancer
Question 12
• Which of the following is associated with vinyl
chloride exposure?
– A. Inflammatory bowel disease
– B. Ovarian cancer
– C. Angiosarcoma of the liver
– D. Leukocytosis
Answer 12
• C. Angiosarcoma of the liver is associated with
vinyl chloride exposure.
• Vinyl chloride is a known carcinogen of the
lung, liver, and brain.
• Is a chemical used in the plastics industry
Question 13
• Which of the following types of cautery
generates less heat on a slower frequency
causing tissue dehydration and vessel
thrombosis?
– A. Cutting mode
– B. Coagulation mode
– C. Bipolar mode
– D. None of the above
Answer 13
• B. Coagulation mode generates less heat on a
slower frequency causing tissue dehydration
and vessel thrombosis
Question 14
• Which of the following types of cautery leads
to heat being generated over the target area
quickly with minimum lateral spread?
– A. Cutting mode
– B. Coagulation mode
– C. Bipolar mode
– D. None of the above
Answer 14
• A. This best describes the cutting mode
Question 15
• Which of the following types of cautery is the
safest because it disperses energy only
between its tips?
– A. Cutting mode
– B. Coagulation mode
– C. Bipolar mode
– D. None of the above
Answer 15
• C. This best describes bipolar mode- this mode
is often safest as it only affects tissues within
the circuit or grasp of the instrument
Question 16
• Which of the following factors is NOT significant in
the amount of heat generated by a cautery device?
– A. Size of the contact area
– B. Power setting (frequency)
– C. Length of activation time
– D. Patient BMI
– E. Whether the waveform is continuous or intermittent
Answer 16
• D. Patient BMI has the least to do with the amount of
heat a cautery device can generate
Safest Electrosurgery Settings
• High frequency alternating current is delivered as either unipolar or
bipolar.
• Unipolar device has a generator and electrode
– When the system is activated the patient becomes a part of the circuit
– The energy is converted to heat inversely compared to the area of contact
– Thus, the application electrode is small compared to the returning
electrode to disperse the energy to prevent burning the patient
• In the cutting mode, heat is generated over the target area quickly
with minimum lateral spread (heating without coagulation.)
• In the coagulation mode, the electrocautery generates less heat on
a slower frequency, thus causing tissue dehydration and vessel
thrombosis
Safest Electrosurgery Settings
• Bipolar devices establish a short circuit between the tips of the
instrument without the need for a grounding pad.
– These are the most efficient and often safest as it only affects tissues within
the circuit or grasp of the instrument.
• Overall, the heat generated is dependent on 4 factors
– Size of the contact area
– Power setting (frequency)
– Length of activation time
– Whether the waveform is continuous or intermittent
• Other types of electro surgery include lasers, photodynamic therapy,
argon beam coagulator, high frequency sound wave techniques,
harmonic scalpel, ultrasonic tissue ablation, RFA, cryoablation,
microwave ablation, and ultrasonic cavitation devices
Question 17
• A 35 yo female with a known history of HSV and HPV in
the past presents with pelvic pain, fever, and
tachycardia. After you review her CT A/P you are
concerned for a small, contained tuboovarian abscess.
Which of the following management plans is most
appropriate at this time?
– A. Send UA, B-HCG, G & C cultures, and give her 14 days of PO augmentin
– B. Post her for a diagnostic laparoscopy
– C. Send UA, B-HCG, G & C cultures, admit her and initiate cefoxitin and
doxycycline
– D. Send UA, B-HCG, G & C cultures and consult interventional radiology for
aspiration
Answer 17
• C. In this patient with a contained TOA, send
UA, B-HCG, G & C cultures, admit her and
initiate cefoxitn and doxycycline
Question 18
• A 35 yo female that has been treated for
multiple STD’s presents with pelvic pain, fever,
and tachycardia. Which of the following are
indications to operate?
– A. Intraperitoneal rupture of a TOA on scan
– B. Persistence of pelvic abscess despite abx therapy
– C. Chronic pelvic pain
– D. All of the above are indications to operate
Answer 18
• D. All of the following are indications to
operate on a patient with PID
Question 19
• You work the above patient up and find a clearly
ruptured TOA. She states that she has one child
and would like to try to have another within the
next year. Which of the following is the most
reasonable treatment option?
– A. Observation and IV abx
– B. Unilateral salpingo-oophorectomy
– C. Hysterectomy and salpingooophorectomy
– D. Transvaginal drainage
Answer 19
• B. Unilateral salpingoophorectomy should be
attempted if possible
Treatment of Pelvic Inflammatory Disease (PID)
1 Central Pancreaticoduoden
retroperitoneum al injuries, injuries
to major abdominal
vasculature
2 Flank, perinephric Injuries to GU tract
area or colon
3 Pelvis Pelvic fractures
Answer 20
• In general, penetrating injuries to any of the 3
zones need to be explored
• Blunt zone 2 injuries that are stable can be
worked up radiographically to determine the
location of the injury. If they are found
intraoperatively and noted to be expanding,
they need to be explored.
Answer 20
• Blunt zone 3 usually can be managed by pelvic
fixation.
– Seventy percent of pelvic bleeding is from pelvic veins
– Restoring the pelvis to its normal configuration cause the
hematoma to compress the veins and stop venous
bleeding
– If the patient continues to be hemodynamically unstable,
an arteriogram with selective embolization of the bleeding
vessel coming from the internal iliac artery should be
performed
Question 1
• Which of the following is true regarding the efficacy of
prophylactic antibiotics following a GSW through the colon?
– A. Giving a single dose of abx 2 hrs preoperatively increases SSI in
these patients
– B. Infection rates are significantly lower when antibiotics are given for
a complete 5 day course
– C. There is no statistical difference when antibiotics are given within 2
hours of initial skin incision and when given within the first 3 hours
when the skin incision is made
– D. There is no evidence supporting continuing abx beyond 24 hours
even when the bowel is perforated
– E. The bullet is sterilized coming out of the handgun and the intra-
abdominal organs themselves are the major source of wound
infections in these patients
Answer 1
• D. The bullet is not sterilized coming out of the barrel
• The clothing draws the skin flora into the wound and is the
major source of wound infection
• There have been studies comparing length of abx therapy
and no proven benefit has been demonstrated by
extending therapy beyond 24 hours if no abscess is present
and the source of bowel contamination is removed
• There is a difference in SSI when an appropriate fose of abx
is given within 2 hours before the skin incision
Question 2
• Which of the following is the most important
prognostic factor in patients with malignant
melanoma?
– A. Surface size
– B. Tumor grade
– C. Depth
– D. SLN biopsy status
– E. Margins of resection
Answer 2
• D. The development of SLN Bx began an era where
micromets could be identified and staged more accurately,
allowing appropriate patients to receive total LN dissection
and treated with adjuvant therapy
• For patients with stage 1 and 2, SNLB status has become
the most important prognostic factor
• There is a survival benefit when patients with nodal
involvement receive high-dose interferon alfa 2-b adjuvant
• Thickness does parallel the percent positivity of SLN (3.6%
for lesions less than 0.75 mm to 44% in tumors greater
than 4 mm)
Question 3
• Which of the following is NOT a component of
informed consent?
– A. Disclosure
– B. Comprehension
– C. Competency
– D. Voluntariness
– E. Description of basic procedural standards of care
Answer 3
• E is not a part of informed consent
• Disclosure by the physician, patient
comprehension, competency, and
voluntariness all are.
Question 4
• Which of the following is true about the
secretory diarrhea seen in gastrinoma
patients?
– A. It partially is due to enterocyte damage from the
excessive acid
– B. It can be improved by NG suctioning
– C. It may be the only complaint in around 20% of
patients presenting with gastrinoma
– D. A and C only
– E. All of the above are true
Answer 4
• E. All of the above are true about gastrinoma
Question 5
• Which of the following forms does fat take to
enter the lymphatic system and eventually
reach the liver?
– A. Free fatty acids
– B. Chylomicrons
– C. Triglycerides
– D. Monoglycerides
Answer 5
• B. Chylomicrons
Etiology of Steatorrhea in Gastrinoma
Memorize T staging:
• T1- mucosa/submucosa
• T2- into but not through muscularis propria
• T3- through muscularis propria
• T4- invades other organs/structures
Question 35
• A 65 yo male presents with nonbilious emesis. He
has a of H. pylori for which he declined treatment
for 6 years ago. His films are suggestive of gastric
outlet obstruction. You suspect MALT lymphoma
based on EGD. Which of the following should you
recommend?
– A. Treatment of H. pylori
– B. Radiation only
– C. Gastrectomy
– D. Chemoradiation
Answer 35
• C. Gastrectomy is appropriate with
obstruction. Otherwise gastric MALT should be
treated by eradicating H. pylori
Treatment MALT of Stomach
• These are treated initially with eradication of
H. pylori
• If that fails-> chemo and/or XRT
• If that fails, then resect.
• Exception-> those presenting with symptoms
of gastric outlet obstruction, then surgery best
initial treatment
Question 36
• Which of the following myeloproliferative
disorders may benefit from splenectomy?
– A. AML
– B. CLL
– C. Myelofibrosis
– D. T-cell lymphoma of HIV
Answer 36
• C. Myelofibrosis
Myeloproliferative Disease Benefitting from
Splenectomy
• Myelofibrosis may benefit- patients can get
extramedullary hematopoeisis in spleen
• This condition is also associated with increased
incidence of splenic/portal vein thrombosis
postoperatively
Question 37
• A 57 yo male presents with chest pain 2 hours after
vomiting up a large meal where he feels he drank
too much wine. His workup in the ER is significant
for a left pleural effusion. Which of the following
should you do next to confirm the diagnosis?
– A. MRI
– B. EGD
– C. Esophagogram
– D. Left thoracotomy
Answer 37
• C. It is appropriate to confirm perforation with
an esophogram
Question 39
• You confirm perforation and proceed to the
operating room. Which side would you
perform the thoracotomy?
– A. Left
– B. Right
Answer 39
• A. Left
Question 40
• It is now ~ 3.5 hours after he developed symptoms. You
identify a lower esophageal perforation and that there
is fairly little contamination. The tissue appears
otherwise healthy and the patient is stable. Which of
the following is the appropriate next step?
– A. Esophagectomy and anastomosis
– B. Creation of a spit fistula, flap coverage of perforation
– C. Primary repair with placement of a G-tube and drains
– D. Mediastinal washout with planned return to OR in 24 hours
Answer 41
• C. Primary repair with placement of a G-tube and
drains
Boerhaave’s Perforation
• Classic history- chest pain, fever, respiratory distress after
emesis resulting from large meal
• Diagnosis usually suspected by left pleural effusion on CXR
• Confirmatory test- esophagram with H2O soluble contrast.
• If that isn’t a choice, then choose orally contrasted CT
• Treatment-
– If early, primary repair(left thoractomy) +/- g-tube and j-tube.
– If late, then consider spit fistula and g-tube/j-tube and delayed
restoration of GI continuity
– If severely ill, mediastinal washout/drainage alone can be done
initially with more definitive surgery after recovery.
Question 42
• A 21 yo female presents with abdominal pain and
subsequent workup reveals numerous
hamartomatous polyps throughout her bowel as
well as mucocutaneous hyperpigmentaiton. Which
of the following is true about this condition?
– A. Prophylactic colectomy should be recommended
– B. The polyps are usually adenomatous though have a low
malignant potential
– C. The oral lesions have a high malignant potential
– D. This is associated with sex cord tumors
Answer 42
• D. This is associated with sex cord tumors
Peutz-Jeghers Syndrome
• Autosomal dominant disease associated with colonic
polyps
• Thought to primarily represent hamartomas and
mucocutaneous hyperpigmentation (most often oral)
• No significant increased risk of cancer in these
polyps, so prophylactic colectomy not warranted,
just endoscopic removal.
• Syndrome is associated with unusual sex cord tumors
in women and Sertoli cell tumors in men
Question 43
• Which of the following deficiencies is
associated with glucose intolerance?
– A. Zinc
– B. Phosporous
– C. Biotin
– D. Chromium
– E. Vitamin A
Answer 43
• D. Chromium
Question 44
• Which of the following deficiencies is
associated with cardiomyopathy?
– A. Zinc
– B. Selenium
– C. Biotin
– D. Chromium
– E. Vitamin A
Answer 44
• B. Selenium
Vitamin Deficiencies
• Phosphorus: weakness, paresthesias
• Zinc: perioral rash, alopecia, poor wound healing, impaired
immunity, change in taste
• Copper: anemia, neutropenia, pancytopenia
• Iron: anemia
• Linoleic acid: dermatitis, alopecia, blurred vision, paresthesias
• Selenium: cardiomyopathy, weakness, alopecia
• Vitamin A: night blindness, skin keratosis
• Chromium: glucose intolerance (relative diabetes), peripheral
neuropathy
• Biotin: alopecia, neuritis
Question 1
• A 20 yo man who recently underwent an ex lap for
a bowel obstruction has had NGT output of over
1000 ml per day for 3 days. Which metabolic
derangement is most likely to be true?
– A. Hypochloremic, hypokalemic metabolic alkalosis
– B. Hyperchloremic, hypokalemic metabolic alkalosis
– C. Hypochloremic, hyperkalemic metabolic alkalosis
– D. Hyperchloremic, hyperkalemic metabolic alkalosis
Answer 1
• A. This person is losing water and HCl via the NG tube.
• To compensate for the water loss, the kidney reabsorbs Na in
exchange for potassium, leading to hypokalemia
• The kidney also recognizes that is losing K so it exchanges K for
H, which results in a paradoxical aciduria
• The end result is hypochloremic, hypokalemic metabolic
alkalosis with paradoxical aciduria.
• Tx- volume resuscitation with K+ containing solutions. This can
be D10 NS with 10 meq/L KCL in children or D5 ½ NS with 20
meq/L KCL in adults
Question 2 (4 part question)
• Sensitivity of a test reflects:
– A. Ability to detect disease
– B. Ability to say no disease is present
– C. Rejecting the null hypothesis incorrectly
– D. Accepting the null hypothesis when it is false
Question 3
• Specificity of a test reflects:
– A. Ability to detect disease
– B. Ability to say no disease is present
– C. Rejecting the null hypothesis incorrectly
– D. Accepting the null hypothesis when it is false
Question 4
• Type 1 error reflects:
– A. Ability to detect disease
– B. Ability to say no disease is present
– C. Rejecting the null hypothesis incorrectly
– D. Accepting the null hypothesis when it is false
Question 5
• Type II error reflects:
– A. Ability to detect disease
– B. Ability to say no disease is present
– C. Rejecting the null hypothesis incorrectly
– D. Accepting the null hypothesis when it is false
Answers 2-5
• 2- a; 3-b; 4-c; 5-d
• Sensitivity reflects ability to detect disease.
– Is equal to true positives / (true positives + false negatives)
– With high sensitivity a negative result means the pt is very unlikely to have the
disease
• Specificity reflects ability to state that no disease is
present
– Is equal to true negatives / (true negative + false positive)
– With high specificity a positive result means that the patient is very likely to
have the disease
Answers 2-5
• Type 1 errors reject the null hypothesis
incorrectly (thinking there is a correlation
when there really isn’t one)
• Type II errors accept the null hypothesis
incorrectly (you didn’t find a correlation but
one actually exists
• The most common reason for a type II error is
low sample size
Question 6
• Spontaneous closure is least likely in fistulae
originating from:
– A. Colon
– B. Esophagus
– C. Pancreas
– D. Stomach
– E. Small intestine
Answer 6
• D. Fistulae involving the stomach are the least
likely to close
Question 7
• Biliary-enteric fistula most commonly connect
the:
– A. Gallbladder and ileum
– B. Gallbladder and duodenum
– C. Common bile duct and jejunum
– D. Gallbladder and jejunum
– E. Common bile duct and ileum
Answer 7
• B. Biliary-enteric fistula most commonly
connect the gallbladder and duodenum. This is
usually caused by severe cholecystitis with
abscess and/or perforation and subsequent
erosion into the duodenal wall
• A large stone may erode into the duodenum
and subsequently cause gallstone ileus
Question 8
• Meckel’s diverticulum:
– A. Is a false diverticulum
– B. Is asymptomatic in most cases
– C. Commonly presents as gastrointestinal bleeding
in adults
– D. Commonly presents with intestinal obstruction in
children
– E. Is found in approximately 5-10% of the
population
Answer 8
• B. Meckel’s diverticulum are asymptomatic in most cases.
• They are true congenital diverticula
• Vestigal remnant of omphalomesenteric duct and most frequent
malformation of the GI tract
• 2% of population have them; males more likely to be symptomatic
• Rule of 2's:
– 2% (of the population)
– 2 feet (from the ileocecal valve)
– 2 inches (in length)
– 2% are symptomatic
– 2 types of common ectopic tissue (gastric and pancreatic)
– Most common age at clinical presentation is 2
– Males are 2 times as likely to be affected.
• It can also be present as an indirect hernia, typically on the right side,
where it is known as a Hernia of Littre
Question 9
• The most common site of gastrointestinal
lymphoma is :
– A. Small intestine
– B. Stomach
– C. Colon
– D. Duodenum
– E. Appendix
Answer 9
• B. The stomach is the most common site of
gastrointestinal lymphomas
Question 10
• Rightward shift of oxyhemoglobin dissociation
curve occurs with:
– A. Hypothermia
– B. Acidosis
– C. Decrease in 2,3-diphosphoglycerate (DPG)
– D. Hypocapnia
– E. Methemoglobinemia
Answer 10
• B. Acidosis causes a right shift of the
oxyhemoglobin dissociation curve. All of the
other listed factors shift it to the left.
Question 11
• Phosphorous:
– A. Is a major extracellular anion
– B. Is passively absorbed from the GI tract
– C. Deficiency may result in insulin resistance
– D. Deficiency is rare in hospitalized patients
Answer 11
• C. A patient that is suffering from
hypophosphatemia may demonstrate insulin
resistance.
Question 12
• Hemangioma of the liver:
– A. Is the most common benign hepatic tumor
– B. Is diagnosed with percutaneous needle biopsy
– C. Is associated with alpha fetoprotein level
– D. Should be resected as soon as diagnosed
Answer 12
• A. Hemangiomas are the most common benign tumor of the
liver.
• They are more common in women
• Rupture is rare. They are usually asymptomatic
• Avoid biopsy-> this risks hemorrhage
• Peripheral to central enhancement on CT
• Can operate or embolize if symptomatic
• Steroids can be used to treat masses that are unresectable
• Kasabach-Merritt syndrome- rare complication of
hemangioma.
– Mass causes consumptive coagulopathy and CHF
– This is more common in children
Question 13
• Leiomyoma of the esophagus:
– A. Commonly presents with dysphagia
– B. Is more common in females
– C. Is usually multiple
– D. Is usually diagnosed with endoscopic biopsy
– E. Is usually located in the lower 1/3 of the
esophagus
Answer 13
• E. Leiomyomas are usually located in the distal 1/3
of the esophagus
• They are the most common benign tumor of the
esophagus
• Dx- endoscopy, esophogram to r/o cancer
• Symptoms- dysphagia, pain
• Do not biopsy- scarring can make subsequent
resection more difficult
• Operate when they are >5cm or symptomatic.
Enucleation via thoracotomy is appropriate
Question 14
• The best operative approach to a choledochal
cyst is:
– A. Cystoduodenostomy
– B. Cystojejunostomy
– C. Roux-en-Y cystojejunostomy
– D. Cyst excision and hepaticojejunostomy
Answer 14
• D. Cyst excision with reconstruction via a
hepaticojejunostomy is the preferred treatment.
They need to be resected because of malignant
potential (15%).
• They are common in females and Asians
• 90% are extrahepatic
• Most are type 1- fusiform dilation of the CBD
• Possibly caused by angle of insertion of the duct
which leads to reflux of pancreatic enzymes during
development
Answer 14
Question 15
• Li-Fraumeni syndrome shows increased
incidence of:
– A. Colon cancer
– B. Ovarian cancer
– C. Lung cancer
– D. Breast cancer
– E. Pancreatic cancer
Answer 15
• D. Breast cancer
• Li-Fraumeni syndrome is due to a defect in the
p53 gene
• Patients are at risk for:
– Childhood sarcomas
– Breast cancer
– Brain tumors
– Leukemia
– Adrenal cancer
Question 16
• During cell cycle, DNA replication occurs in:
– A. G1 phase
– B. G2 phase
– C. S phase
– D. M phase
Answer 16
• C. DNA replication occurs during the S
(synthetic) phase
Question 17
• Small bowel obstruction in an elderly female
without external hernia or previous surgery is
most likely caused by:
– A. Small bowel neoplasm
– B. Volvulus
– C. Gallstone ileus
– D. Abdominal abscess
– E. Obturator hernia
Answer 17
• C. Gallstone ileus would be the most likely
cause of SBO in an elderly patient without a
clear hernia
Question 18
• Malignant small bowel neoplasms most
commonly present with:
– A. Weight loss
– B. Abdominal pain
– C. GI bleeding
– D. Jaundice
– E. Bowel perforation
Answer 18
• A. Of the choices, weight loss is the most
common presenting symptom of small bowel
malignancies.
• Small bowel adenocarcinomas are rare
• High proportion are in the duodenum
• When diagnosed, they need to be resected
with lymphadenectomy
Question 19
• A 50 yo man undergoes LAR followed by
chemo-XRT. 6 weeks after this is complete he
has severe proctitis and bleeding per rectum.
He has required several transfusions for this
problem. The best therapy for this pt is:
– A. Angio-embolization of the rectal arteries
– B. Abdominoperineal resection
– C. Formalin fixation of the rectum
– D. Antibiotics
Answer 19
• C. Radiation proctitis leading to severe
bleeding is best treated by formalin fixation of
the rectum
Question 20
• You perform laparoscopy for presumed
appendicitis on a 25 yo man. He has terminal
ileitis but the cecum looks normal. You should:
– A. Perform an appendectomy
– B. Close
– C. Place a drain
– D. Perform ileal resection
Answer 20
• A. Pts with presumed appendicitis but instead
are found to have terminal ileitis should
undergo appendectomy so that confusion of
ileitis and appendicitis will not occur in the
future.
• If the cecum is involved with the inflammation,
then leave the appendix- if you perform an
appendectomy in this situation you have a high
chance for a leak
Question 1
• The microtubule organizing center of the cell is
called a:
– A. Centrosome
– B. Lysosome
– C. Codon
– D. Kinetochore
– E. Leucine zipper
Answer 1
• A. The centrosome is the microtubule
organizing center.
• Other cell organelles and structures:
• Rough endoplasmic reticulum- synthesizes
proteins that are exported (increased in
pancreatic acinar cells)
• Smooth endoplasmic reticulum- lipid/ steroid
synthesis, detoxifies drugs (increased in liver
and adrenal cortex)
Answer 1
• Golgi apparatus- modifies proteins with
carbohydrates; proteins are then transported
to the cellular membrane, are secreted, or are
targeted to lysosomes
• Lysosomes- have digestive enzymes that
degrade engulfed particles and worn out
organelles
• Phagosome- Engulfed large particle; these fuse
with lysosomes
Answer 1
• Endosome- engulfed small particles; these fuse
with lysosome
• Protein kinase C- activated by calcium and
diacylglycerol (DAG)
– Phosphorylates other enzymes and proteins
• Protein kinase A- activated by cAMP
– Phosphorylates other enzymes and proteins
• Myosin- thick filaments, use ATP to slide along
actin to cause muscle contraction
Answer 1
• Actin- thin filaments that interact with myosin above
• Intermediate filaments- keratin (hair/ nails), desmin
(muscle), vimentin (fibroblasts)
• Microtubules form specialized cellular structures such
as cilia, neuronal axons, and mitotic spindles.
– Also involved in the transport of organelles in the cell (form a latticework inside
the cell)
– Centriole- a specialized microtubule involved in cell division (form spindle fibers
which pull chromosome apart)
Question 2
• Treatment for intractable abdominal pain from
chronic pancreatitis with a normal pancreatic
duct is usually:
– A. Percutaneous drainage
– B. Resection
– C. Lateral pancreatico-jejunostomy
– D. Nonoperative management
Answer 2
• B. Resection may be indicated in pts with
chronic intractable abdominal pain due to
pancreatitis
Question 3
• Treatment for intractable abdominal pain in a
patient with chronic pancreatitis and a dilated
pancreatic duct is usually:
– A. Percutaneous drainage
– B. Resection
– C. Lateral pancreatico-jejunostomy
– D. Nonoperative management
Answer 3
• C. Patients with intractable pain due to chronic
pancreatitis and a dilated duct may benefit
from lateral pancreaticojejunostomy (Puestow
procedure ) if the duct is greater than 8 mm
Question 4
• You operate on a 25 yo man with presumed
appendicitis, send a frozen section because
there is a mass at the tip of the appendix, &
path comes back as a 2.5 cm carcinoid. The
most appropriate step in his management is:
– A. Right hemicolectomy
– B. Close
– C. Post-op XRT
– D. Chemotherapy post-op
Answer 4
• A. Appendectomy is appropriate management
for carcinoid localized to the appendix, as long
as they are less than 2 cm, not at the base, and
there is no evidence for metastatic disease.
• If the above criteria are not met, perform a
right hemicolectomy
Question 5
• A newborn is found to be in severe respiratory
distress immediately following birth. CXR shows
loops of bowel filling the left chest. All of the
following are true except:
– A. Pts with this problem have about a 50% overall survival
– B. The incidence of this problem is higher on the left than
the right
– C. Both lungs are often dysfunctional
– D. Pts with this problem require immediate repair after
birth
Answer 5
• D. The above scenario is consistent with a
congenital diaphragmatic hernia. This is
associated with a 50% survival overall.
• It is more common on the left (80%) and both
lungs are usually dysfunctional- one from
compression by the bowel and the dysfunction
in the contralateral lung is not completely
understood
Answer 5
• Pulmonary hypertenstion is frequent in this
population
• Current treatment of choice in these children is
stabilization with high frequency ventilation,
ECMO, and/or inhaled NO before repair.
• Delayed repair after the patient is better able to
tolerate surgery is thought to improve survival
Question 6
• 57 yo man has a 3 cm mass in the RLL on chest CT.
Biopsy shows the mass is an adenocarcinoma. You
perform mediastinoscopy and a right paratracheal
lymph node is positive for cancer. The next best
step is:
– A. Right lower lobe resection only
– B. Right lower love resection and mediastinal lymph node
dissection
– C. Pneumonectomy and mediastinal lymph node
dissection
– D. Chemo & radiation
Answer 6
• D. Positive paratracheal nodes identified on
mediastinoscopy are considered N2 disease
and the pt is unresectable. Therefore, chemo/
XRT is the best answer.
• Some protocols would have the pt undergo
chemo/ XRT and if the pt had a great response,
resection of the primary along with
mediastinal lymph node dissection would be
offered.
Question 7
• A 50 yo woman comes in with a chief
complaint of a nodule in her neck. You get a
TSH and a T3, both of which are normal. The
most appropriate management is:
– A. Thyroid lobectomy
– B. Total thyroidectomy
– C. Ultrasound and FNA
– D. Neck MRI
Answer 7
• C. After getting baseline TFT’s you should get
an ultrasound and an FNA
Question 8
• Ultrasound of the nodule reveals a 1.2 cm
mass. The pathology comes back as follicular
cells. The next most appropriate step is:
– A. Thyroid lobectomy
– B. Nothing
– C. Neck MRI
– D. Neck CT
Answer 8
• A. Follicular cells on FNA end up being a
follicular cell cancer in 10% of cases. Therefore
you need to do a lobectomy to get a definitive
diagnosis
Question 9
• You take the above patient to the OR for a
lobectomy. Pathology shows a 1.9 cm follicular
carcinoma. The next best step is:
– A. Completion total thyroidecotmy
– B. Close
– C. Post-op chemotherapy
– D. Post-op radiation
Answer 9
• A. Thyroid cancer with a size > 1cm requires
total thyroidecotmy
• Indications for total thyroidectomy include:
– Tumor > 1 cm
– Extra-thyroidal disease (capsular invasion, clinical or
+ nodal disease, or metastases)
– Multicentric disease
– History of XRT
Question 10
• A 10 yo boy has a cyst and a cyst tract near the
angle of his mandible. The cyst has had
recurrent infections. This cyst most likely
connects to the:
– A. External auditory canal
– B. Tonsillar pillar
– C. Nasal septum
– D. Thoracic duct
Answer 10
• A. Type 1 branchial cleft cysts extend from the
angle of the mandible to the external auditory
canal.
Question 11
• A 10 yo boy presents with a cyst in his lateral neck
medial to the anterior border of the
sternocleidomastiod. This cyst most likely connects
to the:
–A. External auditory canal
–B. Tonsillar pillar
–C. Nasal septum
–D. Thoracic duct
Answer 11
• B. Type II branchial cleft cysts extend from the
anterior border of the SCM though the carotid
bifurcation to the tonsillar pillar.
Question 12
• The monoclonal antibody that specifically
blocks CD3 molecule on T cells is:
– A. OKT 3
– B. ATGAM
– C. Thymoglobulin
– D. Zenepax
Answer 12
• A. OKT3 binds the CD3 molecule on
lymphocytes. This inhibits formation of the T-
cell receptor complex and causes opsonization
of the T cell. This drug can be used to treat
rejection that is refractory to pulse steroids.
Question 13
• The monoclonal antibody that specifically
blocks IL-2 receptors is:
–A. OKT 3
–B. ATGAM
–C. Thymoglobulin
–D. Zenepax
Answer 13
• D. Zenepax is an antibody against human IL-2
receptors. It is often used with induction
therapy immediately after transplantation
Question 14
• All of the following are true of Paget’s disease
of the breast except:
– A. It describes scaly lesions on the nipple that when
biopsied demonstrate Paget’s cells
– B. Pts with this disease have underlying DCIS or
ductal carcinoma
– C. Modified radical mastectomy is appropriate for
pts found to have carcinoma
– D. Modified radical mastectomy must be done in
these patients who are found to have DCIS
Answer 14
• D. All of the options are true of Paget’s disease
of the breast. If only DCIS is found it is
appropriate to offer simple (not modified
radical) mastectomy
Question 15
• All of the following are true of familial hypocalcemic
hypocalciuria except:
–A. Patients usually have a calcium in the 9-11 range and
decreased levels of urine calcium
–B. Treatment requires parathyroidectomy
–C. The disease is caused by a defect in the PTH receptor in
the distal convoluted tubule of the kidney that causes
increased resorption of calcium
–D. Parathyroid hormone levels in these patients is normal
Answer 15
• B is incorrect. The calcium levels in these
patients is usually not that high; they do not
require parathyroidectomy
Question 16
• A 4 yo female is brought to see you because of a
painful limp. She has no other diagnosed past
medical history though there is a strong family
history for forming blood clots. X-ray shows
flattening of the femoral head. Which of the
following is most likely the cause of her limp?
– A. Osgood-Schlatter disease
– B. Legg-Calve-Perthes disease
– C. Slipped capital femoral epiphysis
– D. Congenital dislocation of the hip
Answer 16
• C. This most likely is Legg-Calve Perthes disease.
LCP is characterized by:
– AVN of the femoral head
– Usually appears in children older than 2 yrs
– Can result from a hypercoagulable state
– 10% are bilateral
– Painful gait limp
– X-ray- flattening of the femoral head
– Tx- maintain ROM with limited exercise
– Surgery if femoral head not covered by acetabulum
– Femoral head will remodel without sequlae
Question 17
• A 12 yo male that is fairly overweight presents
with painful gait. X-ray shows widening and
irregularity of the epiphyseal plate. The most
likely diagnosis is:
– A. Osgood-Schlatter disease
– B. Legg-Calve-Perthes disease
– C. Slipped capital femoral epiphysis
– D. Congenital dislocation of the hip
Answer 17
• C. This is most likely a slipped capital femoral
epiphysis. In addition to painful gait in a 10-13
yo male and the above stated x-ray findings,,
this disease is also characterized by:
– Increased AVN risk of femoral head
– Is treated by surgical pinning
Answer 17
• Regarding the other 2 listed diseases some key
points include,
• Congenital hip dislocation:
– 1.5 per 1,000 births, more common in Caucasians
– 8 times more common females
– The left hip is twice as often involved
– 25% have bilateral involvement
– Limited abduction of flexed hip, shortening of leg
– Tx- Pavlik harness- keeps legs abducted and femoral head
in acetabulum
Answer 17
• Osgood-Schlatter disease
– Tibial tubercle apophysitis
– Traction injury from the quadriceps
– Most common in adolescents aged 13-15
– Pain in front of the knee
– Irregular shape or fragmenting of tibial tubercle seen on
x-ray
– Tx either with rest for mild symptoms or cast x 6 weeks
for more severe symptoms
Question 18
• You are performing a Whipple on a patient with a
pancreatic head mass. You attempt to pass your
finger behind the pancreas from below and get a large
amount of blood return when you remove it. You
place pressure on the neck of pancreas to tamponade
the bleeding which seems to control it. You most
likely have injured:
• A. Aorta
• B. IVC
• C. Celiac artery
• D. SMV
Answer 18
• D. The SMV lies directly behind the neck of the
pancreas and is the most likely vessel injured
when attempting to get behind the neck of the
pancreas
Question 19
• The following are indications to resect MCN’s
– A. Asymptomatic masses > 4 cm in diameter
– B. Symptomatic masses of any size
– C. Small asymptomatic masses with internal
excresences or solid components
– D. All of the above
Answer 19
• D. All of the above are indications to resect
MCNs
Question 20
All of the following are true of mucinous cystic
neoplasms except:
• thyroid/trachea medially
base
• Other diseases that may lead to high gastrin and high acid-
ZES, antral cell hyperplasia, renal failure, gastric outlet
obstruction, short bowel syndrome
a) appendix
b) bronchus
c) rectum
d) stomach
e) ileum
1. A 55 year-old male, who is noted to have diarrhea, flushing and
bronchoconstriction as well as right-sided cardiac valvular disease, is most
likely to have his primary tumor where?
a) appendix
b) bronchus
c) rectum
d) stomach
e) ileum
2. A patient has a serum sodium of 115 but is asymptomatic.
His sodium is corrected by the next day and is 135. However,
the patient develops seizures and cerebral edema. What is
the most likely etiology of this?
a) glucagon
b) enteroglucagon
c) somatostatin
d) growth hormone
e) insulin-like growth factor
3. Which hormone can be used to stimulate small bowel
hypertrophy in order to lessen the symptoms of short gut
syndrome?
a) glucagon
b) enteroglucagon
c) somatostatin
d) growth hormone
e) insulin-like growth factor
4. Which is the only pancreatic enzyme which is not
secreted as a prohormone? It is active at the time of
secretion into the pancreatic duct.
a) phospholipase A2
b) chymotrypsin
c) colipase
d) carboxypeptidase A
e) lipase
4. Which is the only pancreatic enzyme which is not
secreted as a prohormone? It is active at the time of
secretion into the pancreatic duct.
a) phospholipase A2
b) chymotrypsin
c) colipase
d) carboxypeptidase A
e) lipase
5. In which portion of the gastrointestinal tract are
proteins mostly absorbed?
a) stomach
b) duodenum
c) jejunum
d) ileum
e) colon
5. In which portion of the gastrointestinal tract are
proteins mostly absorbed?
a) stomach
b) duodenum
c) jejunum
d) ileum
e) colon
6. Which of the following is the toxic component of
lipopolysaccharide (LPS)?
a) O-specific antigen
b) lipid A moiety
c) core M protein
d) M protein coat
e) capsule wall
6. Which of the following is the toxic component of
lipopolysaccharide (LPS)?
a) O-specific antigen
b) lipid A moiety
c) core M protein
d) M protein coat
e) capsule wall
7. Mechanism of inheritance in MEN I, MEN IIa and
MEN IIb?
a) genomic, non-dominant
b) X-linked
c) autosomal dominant
d) autosomal recessive
e) sex-linked
7. Mechanism of inheritance in MEN I, MEN IIa and
MEN IIb?
a) genomic, non-dominant
b) X-linked
c) autosomal dominant
d) autosomal recessive
e) sex-linked
8. Which bacterial genus produces the most potent
exotoxins?
a) Staphylococcus
b) Pseudomonas
c) Klebsiella
d) Streptococcus
e) Serratia
8. Which bacterial genus produces the most potent
exotoxins?
a) Staphylococcus
b) Pseudomonas
c) Klebsiella
d) Streptococcus
e) Serratia
9. A 22 year-old male undergoes extensive small bowel
resection for complications related to Crohn’s disease.
He develops short gut syndrome. Which vitamin is he
most likely to malabsorb?
a) riboflavin
b) niacin
c) vitamin B6
d) vitamin B12
e) vitamin C
9. A 22 year-old male undergoes extensive small bowel
resection for complications related to Crohn’s disease.
He develops short gut syndrome. Which vitamin is he
most likely to malabsorb?
a) riboflavin
b) niacin
c) vitamin B6
d) vitamin B12
e) vitamin C
10. What nerve injury is associated with a proximal
shaft of humerus fracture?
a) radial
b) musculocutaneous
c) axillary
d) median
e) long thoracic
10. What nerve injury is associated with a proximal
shaft of humerus fracture?
a) radial
b) musculocutaneous
c) axillary
d) median
e) long thoracic
11. What is the mechanism for suppression of gastrin
release?
a) antral distention
b) elaboration of secretin which has a reciprocal
relationship with gastrin
c) decreased levels of pancreatic polypeptide
d) direct vagal inhibition via release of gastrin-inhibiting
peptide (GIP)
e) antral acidification
11. What is the mechanism for suppression of gastrin
release?
a) antral distention
b) elaboration of secretin which has a reciprocal
relationship with gastrin
c) decreased levels of pancreatic polypeptide
d) direct vagal inhibition via release of gastrin-inhibiting
peptide (GIP)
e) antral acidification
12. Cholesterol solubility depends on which three
factors?
a) mucus
b) HCl
c) pepsin
d) intrinsic factor
e) bicarbonate
13. The surface gastric epithelial cell secretes which
substance?
a) mucus
b) HCl
c) pepsin
d) intrinsic factor
e) bicarbonate
14. Mass movement is the characteristic motility pattern
of which portion of the gastrointestinal tract?
a) stomach
b) duodenum
c) jejunum
d) ileum
e) colon
14. Mass movement is the characteristic motility pattern
of which portion of the gastrointestinal tract?
a) stomach
b) duodenum
c) jejunum
d) ileum
e) colon
15. The characteristic pattern of motility in the fasted
state is the migrating myoelectric complex (MMC).
Which hormone is responsible for regulating the MMC?
a) pancreatic polypeptide
b) bombesin
c) somatostatin
d) motilin
e) neurotensin
15. The characteristic pattern of motility in the fasted
state is the migrating myoelectric complex (MMC).
Which hormone is responsible for regulating the MMC?
a) pancreatic polypeptide
b) bombesin
c) somatostatin
d) motilin
e) neurotensin
16. When there is an increased stimulus for pancreatic
exocrine secretions, which electrolyte will decrease the
most in the pancreatic effluent?
a) sodium
b) chloride
c) bicarbonate
d) potassium
e) calcium
16. When there is an increased stimulus for pancreatic
exocrine secretions, which electrolyte will decrease the
most in the pancreatic effluent?
a) sodium
b) chloride
c) bicarbonate
d) potassium
e) calcium
17. What is the mechanism of activation of the
pancreatic proenzymes?
a) activation by enterokinase
b) activation by pepsin
c) activation by duodenal acidification
d) activation by trypsin
e) activation by lipase
17. What is the mechanism of activation of the
pancreatic proenzymes?
a) activation by enterokinase
b) activation by pepsin
c) activation by duodenal acidification
d) activation by trypsin
e) activation by lipase
18. Which of the following is the best indicator of
sepsis?
a) tachycardia
b) decreased oxygen consumption
c) decreased cardiac output
d) peripheral vasoconstriction
e) decreased systemic vascular resistance
18. Which of the following is the best indicator of
sepsis?
a) tachycardia
b) decreased oxygen consumption
c) decreased cardiac output
d) peripheral vasoconstriction
e) decreased systemic vascular resistance
19. What is the most common mechanism for the
development of resistance by a bacterial cell?
a) spontaneous mutation
b) development of multidrug resistance phenotype
c) chromosome transfer
d) bacteriophage infection
e) plasmid acquisition
19. What is the most common mechanism for the
development of resistance by a bacterial cell?
a) spontaneous mutation
b) development of multidrug resistance phenotype
c) chromosome transfer
d) bacteriophage infection
e) plasmid acquisition
20. You can declare someone brain-dead if they
exhibit one of these?
a) hypothermia
b) gag reflex
c) corneal reflex
d) brisk deep tendon reflexes
e) pupillary light reflex
20. You can declare someone brain-dead if they
exhibit one of these?
a) hypothermia
b) gag reflex
c) corneal reflex
d) brisk deep tendon reflexes
e) pupillary light reflex
21. A cirrhotic patient with intractable ascites has a
peritoneovenous shunt placed and is noted to begin
oozing from many sites including his incisions. What
is the best explanation for this?
a) Clostridium perfringens
b) Staphylococcus aureus
c) Staphylococcus epidermidis
d) Streptococcus pneumoniae
e) Group A Streptococci
22. A 70 year-old male is 3 months postoperative from an
aortobifemoral revascularization for aortoiliac occlusive disease.
He returns to the office complaining of pain and swelling in his right
groin. On physical examination, the right groin appears fluctuant
and tender. It drains 10 cc of clear, non-foul smelling material.
What bacterial species is most likely to cause this infection?
a) Clostridium perfringens
b) Staphylococcus aureus
c) Staphylococcus epidermidis
d) Streptococcus pneumoniae
e) Group A Streptococci
23. From a hematologic viewpoint, the loss of which
immune function performed by the spleen makes
patients susceptible to overwhelming post-splenectomy
infection (OPSI)?
a) loss of IgA
b) loss of IgM
c) loss of IgG
d) loss of IgE
e) loss of IgD
23. From a hematologic viewpoint, the loss of which
immune function performed by the spleen makes
patients susceptible to overwhelming post-splenectomy
infection (OPSI)?
a) loss of IgA
b) loss of IgM
c) loss of IgG
d) loss of IgE
e) loss of IgD
24. Which of the following statements is true concerning
intraperitoneal bacteria?
a) superficial epigastric
b) superficial circumflex
c) deep circumflex
d) pudendal
e) deep inferior epigastric
25. An axial groin flap is based on the blood supply of
which artery?
a) superficial epigastric
b) superficial circumflex
c) deep circumflex
d) pudendal
e) deep inferior epigastric
26. What is the most common type of bacteria in the
colon?
a) Escherichia coli
b) Lactobacillus spp.
c) Peptostreptococcus spp.
d) Peptococcus spp.
e) Bacteroides spp.
26. What is the most common type of bacteria in the
colon?
a) Escherichia coli
b) Lactobacillus spp.
c) Peptostreptococcus spp.
d) Peptococcus spp.
e) Bacteroides spp.
27. A patient undergoes total thyroidectomy with right neck
dissection. The surgeon injures the R hypoglossal nerve, the R
superior laryngeal nerve, and the L recurrent laryngeal nerve.
What deficits would you expect to find postoperatively?
a) liposarcoma
b) malignant fibrous histiocytoma
c) schwannoma
d) epitheloid sarcoma
e) dermoid sarcoma
28. Which of the following sarcomas has the greatest
tendency to metastasize to regional lymph nodes?
a) liposarcoma
b) malignant fibrous histiocytoma
c) schwannoma
d) epitheloid sarcoma
e) dermoid sarcoma
29. A 78 year-old female has a node-negative breast
cancer with positive ER/PR. Her stage is T1C N0 M0. What
is the most appropriate therapy?
a) gastrocolic ligament
b) splenocolic ligament
c) gastrosplenic ligament
d) greater omentum
e) splenic hilum
30. Where is the most common location to find an
accessory spleen?
a) gastrocolic ligament
b) splenocolic ligament
c) gastrosplenic ligament
d) greater omentum
e) splenic hilum
31. A patient undergoes laparoscopic cholecystectomy and 5
days later the pathology report reveals that there was a 0.9
mm foci of adenocarcinoma limited to the mucosa. What is
the next appropriate step in management?
a) observation
b) wedge resection of the liver of segment V with
lymphadenectomy
c) radiation
d) chemotherapy
e) hepatic infuse-aid pump
31. A patient undergoes laparoscopic cholecystectomy and 5
days later the pathology report reveals that there was a 0.9
mm foci of adenocarcinoma limited to the mucosa. What is
the next appropriate step in management?
a) observation
b) wedge resection of the liver of segment V with
lymphadenectomy
c) radiation
d) chemotherapy
e) hepatic infuse-aid pump
32. Which of the following is an absolute contraindication
to the use of an intra-aortic balloon pump (IABP)?
a) mitral stenosis
b) pulmonic stenosis
c) aortic stenosis
d) aortic insufficiency
e) mitral insufficiency
32. Which of the following is an absolute contraindication
to the use of an intra-aortic balloon pump (IABP)?
a) mitral stenosis
b) pulmonic stenosis
c) aortic stenosis
d) aortic insufficiency
e) mitral insufficiency
33. A 21 year-old jogger develops claudication after 100 yards. On
physical examination, he has normal pulses in his lower extremities
including the affected leg. What is the next most appropriate step
in management?
a) isoproterenol
b) milrinone
c) amrinone
d) norepinephrine
e) dobutamine
34. Which of the following drugs increases the cardiac
output and increases the systemic vascular resistance?
a) isoproterenol
b) milrinone
c) amrinone
d) norepinephrine
e) dobutamine
35. What period of time in wound healing is
synthesis of collagen at its maximum?
a) 0 –1 week
b) 3 – 6 weeks
c) 3 – 6 months
d) 6 – 9 months
e) 9 – 12 months
35. What period of time in wound healing is
synthesis of collagen at its maximum?
a) 0 –1 week
b) 3 – 6 weeks
c) 3 – 6 months
d) 6 – 9 months
e) 9 – 12 months
36. Which statement concerning the relationships in the
hepatoduodenal ligament is true?
a) The portal vein is posterior to the CBD and hepatic artery; CBD is
medial to the hepatic artery.
b) The portal vein is posterior to the CBD and hepatic artery; CBD is
lateral to the hepatic artery.
c) The portal vein is anterior to the CBD and hepatic artery.
d) The portal vein is lateral to the CBD and both are anterior to the
hepatic artery.
e) The portal vein is medial to the CBD and both are anterior to the
hepatic artery.
36. Which statement concerning the relationships in the
hepatoduodenal ligament is true?
a) The portal vein is posterior to the CBD and hepatic artery; CBD is
medial to the hepatic artery.
b) The portal vein is posterior to the CBD and hepatic artery; CBD is
lateral to the hepatic artery.
c) The portal vein is anterior to the CBD and hepatic artery.
d) The portal vein is lateral to the CBD and both are anterior to the
hepatic artery.
e) The portal vein is medial to the CBD and both are anterior to the
hepatic artery.
37. A patient who has suffered multi-organ trauma is taken back to
the operating room to repair intra-abdominal injuries. He receives
multiple transfusions in the OR and it is noted that there is oozing
from the retroperitoneum where the R colon was mobilized. After
packing and allowing adequate time to stop, it is still noted to be
oozing. Intra-operatively his coags and platelets are checked and
found to be within normal limits. What should be done at this
time?
a) administer platelets
b) administer FFP
c) administer cryoprecipitate
d) administer DDAVP
e) continue to cauterize the area of bleeding
37. A patient who has suffered multi-organ trauma is taken back to
the operating room to repair intra-abdominal injuries. He receives
multiple transfusions in the OR and it is noted that there is oozing
from the retroperitoneum where the R colon was mobilized. After
packing and allowing adequate time to stop, it is still noted to be
oozing. Intra-operatively his coags and platelets are checked and
found to be within normal limits. What should be done at this
time?
a) administer platelets
b) administer FFP
c) administer cryoprecipitate
d) administer DDAVP
e) continue to cauterize the area of bleeding
38. Which of the following tends to make bile
lithogenic?
a) oral chenodeoxylate
b) resection of the jejunum
c) resection of the distal stomach
d) resection of the terminal ileum
e) resection of the colon
38. Which of the following tends to make bile
lithogenic?
a) oral chenodeoxylate
b) resection of the jejunum
c) resection of the distal stomach
d) resection of the terminal ileum
e) resection of the colon
39. What is the most frequent complication after a level I
and II axillary lymph node dissection?
a) seroma
b) hematoma
c) winged scapula
d) loss of sensation on the posterior aspect of the upper
arm
e) lymphedema
39. What is the most frequent complication after a level I
and II axillary lymph node dissection?
a) seroma
b) hematoma
c) winged scapula
d) loss of sensation on the posterior aspect of the upper
arm
e) lymphedema
40. A patient sustained a blunt MVA and was noted to have a
liver injury which was managed non-operatively. Two months
later, he develops hematemesis and melena. EGD and
colonoscopy are noncontributory. What is the next most
appropriate step in management?
a) transperitoneal adrenalectomy
b) extraperitoneal adrenalectomy
c) MRI of the abdomen
d) selective venous sampling
e) observation and repeat CT scan in 6 months
42. A woman presents after blunt MVA. Abdominal CT shows
a 3 cm right adrenal mass. All endocrinologic studies are
negative and she has no identifiable signs of hormone excess.
What is the next most appropriate step in management?
a) transperitoneal adrenalectomy
b) extraperitoneal adrenalectomy
c) MRI of the abdomen
d) selective venous sampling
e) observation and repeat CT scan in 6 months
43. A 25 year-old female undergoes resection of one foot
of small intestine including her terminal ileum. Several
months later, she presents with renal stones. What kind
of renal stones did she most likely develop?
a) calcium phosphate
b) calcium oxalate
c) struvite
d) uric acid
e) magnesium ammonium phosphate
43. A 25 year-old female undergoes resection of one foot
of small intestine including her terminal ileum. Several
months later, she presents with renal stones. What kind
of renal stones did she most likely develop?
a) calcium phosphate
b) calcium oxalate
c) struvite
d) uric acid
e) magnesium ammonium phosphate
44. A patient with a lateral neck mass undergoes FNA which
reveals squamous cell carcinoma. Further work-up is
negative for the primary tumor. The patient’s Epstein-Barr
virus (EBV) titers are noted to be high. Where is the most
likely source of the primary?
a) tonsillar pillar
b) hypopharnyx
c) nasopharnyx
d) floor of mouth
e) pyriform sinus
44. A patient with a lateral neck mass undergoes FNA which
reveals squamous cell carcinoma. Further work-up is
negative for the primary tumor. The patient’s Epstein-Barr
virus (EBV) titers are noted to be high. Where is the most
likely source of the primary?
a) tonsillar pillar
b) hypopharnyx
c) nasopharnyx
d) floor of mouth
e) pyriform sinus
45. von Willebrand factor (vWF) is synthesized in
which of the following?
a) platelet
b) macrophage
c) endothelial cell
d) RBC
e) hepatocyte
45. von Willebrand factor (vWF) is synthesized in
which of the following?
a) platelet
b) macrophage
c) endothelial cell
d) RBC
e) hepatocyte
46. In performing a pericardiocentesis, the most
appropriate manner to ensure the needle is in the
pericardial sac is to:
a) liver
b) yolk sac
c) bone marrow
d) spleen
e) thymus
47. The initial site of blood cell production in the
embryo occurs in which of the following?
a) liver
b) yolk sac
c) bone marrow
d) spleen
e) thymus
48. Which of the following electrolyte abnormalities
exacerbates digitalis toxicity and also maintains
metabolic alkalosis?
a) hypernatremia
b) hyponatremia
c) hyperkalemia
d) hypokalemia
e) hypercalcemia
48. Which of the following electrolyte abnormalities
exacerbates digitalis toxicity and also maintains
metabolic alkalosis?
a) hypernatremia
b) hyponatremia
c) hyperkalemia
d) hypokalemia
e) hypercalcemia
49. In a patient with renal failure, which neuromuscular
blocking agent would you give in order to maintain
constant plasma levels?
a) succinylcholine
b) D-tubocurarine
c) pancuronium
d) atracurium
e) vecuronium
49. In a patient with renal failure, which neuromuscular
blocking agent would you give in order to maintain
constant plasma levels?
a) succinylcholine
b) D-tubocurarine
c) pancuronium
d) atracurium
e) vecuronium
50. Which of the following amino acids is an essential
amino acid?
a) tyrosine
b) proline
c) glutamine
d) valine
e) alanine
50. Which of the following amino acids is an essential
amino acid?
a) tyrosine
b) proline
c) glutamine
d) valine
e) alanine
51. Patients with kidney transplants have an increased
incidence of developing cancer. Which of the following
cancers has the highest incidence?
a) Kaposi’s sarcoma
b) lymphomas
c) skin cancer
d) lip cancer
e) vulvar cancer
51. Patients with kidney transplants have an increased
incidence of developing cancer. Which of the following
cancers has the highest incidence?
a) Kaposi’s sarcoma
b) lymphomas
c) skin cancer
d) lip cancer
e) vulvar cancer
52. An otherwise healthy 22 year-old pregnant female
who develops C. difficile colitis after antibiotic treatment
should receive which of the following regimens?
a) PO flagyl
b) PO vancomycin
c) IV flagyl
d) IV vancomycin
e) No treatment in pregnant patients
52. An otherwise healthy 22 year-old pregnant female
who develops C. difficile colitis after antibiotic treatment
should receive which of the following regimens?
a) PO flagyl
b) PO vancomycin
c) IV flagyl
d) IV vancomycin
e) No treatment in pregnant patients
53. What is the initial management of a patient with
a 5 cm amebic liver abscess?
a) metronidazole
b) percutaneous drainage
c) open surgical drainage
d) mebendazole
e) ampicillin, gentamicin, and flagyl
53. What is the initial management of a patient with
a 5 cm amebic liver abscess?
a) metronidazole
b) percutaneous drainage
c) open surgical drainage
d) mebendazole
e) ampicillin, gentamicin, and flagyl
54. Which of the following equations is correct for
the determination of oxygen delivery?
a) smoking
b) ulcerated plaque
c) race
d) TIAs
e) blood pressure
56. When looking at carotid endarterectomies
statistically, which of the following could be considered a
continuous variable?
a) smoking
b) ulcerated plaque
c) race
d) TIAs
e) blood pressure
57. In which portion of the pancreas are insulinomas
predominantly found?
a) head
b) neck
c) body
d) tail
e) equal frequency throughout pancreas
57. In which portion of the pancreas are insulinomas
predominantly found?
a) head
b) neck
c) body
d) tail
e) equal frequency throughout pancreas
58. A 45 year-old female is noted to have inflammatory
breast cancer without ulceration. Which of the following
is the most appropriate initial treatment?
a) “toilet mastectomy”
b) modified radical mastectomy
c) radical mastectomy
d) neoadjuvant chemotherapy
e) neoadjuvant radiation therapy
58. A 45 year-old female is noted to have inflammatory
breast cancer without ulceration. Which of the following
is the most appropriate initial treatment?
a) “toilet mastectomy”
b) modified radical mastectomy
c) radical mastectomy
d) neoadjuvant chemotherapy
e) neoadjuvant radiation therapy
59. Which of the following is true concerning splenic artery
aneurysms?
a) bone
b) liver
c) rectum
d) bladder
e) peritoneum
61. Which of the following is the initial site of spread
of ovarian cancer?
a) bone
b) liver
c) rectum
d) bladder
e) peritoneum
62. Resection of the terminal ileum results in which
one of the following?
a) iron-deficiency anemia
b) sideroblastic anemia
c) macrocytic anemia
d) pernicious anemia
e) calcium phosphate renal stones
62. Resection of the terminal ileum results in which
one of the following?
a) iron-deficiency anemia
b) sideroblastic anemia
c) macrocytic anemia
d) pernicious anemia
e) calcium phosphate renal stones
63. A critically ill patient has been receiving TPN via a two week-old
central line. Her TPN is turned off so that she may be given a blood
transfusion. She receives one month-old blood through her central
venous catheter. Toward the end of her four hour transfusion, she
is noted to be hypothermic, hypotensive and comatose. What is
the most likely explanation?
a) transfusion reaction
b) hypoglycemia
c) hyperkalemia
d) candidemia
e) line sepsis with bacteremia
63. A critically ill patient has been receiving TPN via a two week-old
central line. Her TPN is turned off so that she may be given a blood
transfusion. She receives one month-old blood through her central
venous catheter. Toward the end of her four hour transfusion, she
is noted to be hypothermic, hypotensive and comatose. What is
the most likely explanation?
a) transfusion reaction
b) hypoglycemia
c) hyperkalemia
d) candidemia
e) line sepsis with bacteremia
64. What is the chance that any two siblings share
one haplotype?
a) 0%
b) 25%
c) 50%
d) 100%
e) not enough information
64. What is the chance that any two siblings share
one haplotype?
a) 0%
b) 25%
c) 50%
d) 100%
e) not enough information
65. Which of the following statements is true concerning congenital
lobar emphysema?
a) 15 kcal
b) 20 kcal
c) 35 kcal
d) 50 kcal
e) none of the above
67. During normal activity, energy expenditure in a
healthy adult male in kcal/kg/day is approximately?
a) 15 kcal
b) 20 kcal
c) 35 kcal
d) 50 kcal
e) none of the above
68. In the performance of a femoral hernia repair,
which of the following structures must be divided?
a) transversalis fascia
b) lacunar ligament
c) inguinal ligament
d) internal oblique muscle
e) cooper’s ligament
68. In the performance of a femoral hernia repair,
which of the following structures must be divided?
a) transversalis fascia
b) lacunar ligament
c) inguinal ligament
d) internal oblique muscle
e) cooper’s ligament
69. This is the normal ultrasound anatomy of the rectal wall.
Which of the rings represents the muscularis propria?
a) gracilis
b) adductor magnus
c) rectus femoris
d) femoral vein
e) deep femoral artery
70. Concerning a femoropopliteal bypass: Which
structure is anterior to the graft at midthigh?
a) gracilis
b) adductor magnus
c) rectus femoris
d) femoral vein
e) deep femoral artery
71. Which is the most common benign tumor of
the parotid?
A) Adenoid cystic
B) Acinic cell
C) Mucoepidermoid
D) Pleiomorphic adenoma
E) Warthins tumor
71. Which is the most common benign tumor of
the parotid?
A) Adenoid cystic
B) Acinic cell
C) Mucoepidermoid
D) Pleiomorphic adenoma
E) Warthins tumor
72. During the performance of a parotidectomy, you notice
facial nerve involvement by the tumor. What is the most
appropriate step in the management of the tumor.
A) Resect the superficial parotid gland and radiate the facial
nerve and deep portion of the gland.
B) Abort the procedure since the patient is incurable.
C) Resect the nerve and perform a nerve graft.
D) Resect nothing and give chemotherapy and radiation
therapy to the entire gland.
E) Resect the nerve and plan on a staged repair of the facial
nerve.
72. During the performance of a parotidectomy, you notice
facial nerve involvement by the tumor. What is the most
appropriate step in the management of the tumor.
A) Resect the superficial parotid gland and radiate the facial
nerve and deep portion of the gland.
B) Abort the procedure since the patient is incurable.
C) Resect the nerve and perform a nerve graft.
D) Resect nothing and give chemotherapy and radiation
therapy to the entire gland.
E) Resect the nerve and plan on a staged repair of the facial
nerve.
73. After a neck dissection, you notice the patient
has lost taste over the anterior ipsilateral tongue.
What nerve has most likely been injured?
A) Buccal
B) Masseter
C) Hypoglossal
D) Lingual
E) Marginal mandibular
73. After a neck dissection, you notice the patient
has lost taste over the anterior ipsilateral tongue.
What nerve has most likely been injured?
A) Buccal
B) Masseter
C) Hypoglossal
D) Lingual
E) Marginal mandibular
74. You have performed a laryngectomy/
pharyngectomy and post-operatively you notice that there is
cellulitis and purulent drainage from your neck incision. The patient is
febrile with an elevated WBC. What is the most appropriate step?