174

Surgery Review Questions

1. Regarding contrast study for intestinal obstruction: 6. Rightward shift of oxyhemoglobin dissociation
(a) Gastrografin is preferred to barium for studying curve occurs with:
distal small bowel (a) hypothermia
(b) Gastrografin has no therapeutic potential (b) acidosis
(c) Gastrografin is less hazardous than barium if (c) decrease in 2,3-diphosphoglycerate
aspiration occurs (d) hypocapnia
(d) Gastrografin can cause serious fluid shift (e) methemoglobinemia
(e) barium can convert partial small bowel obstruc-
tion into complete obstruction 7. The most common site of gastrointestinal lym-
phoma is:
2. An absolute contraindication to breast-conserving (a) small intestine
surgery for breast cancer is: (b) stomach
(a) large tumor (c) colon
(b) tumor of high grade (d) duodenum
(c) early pregnancy (e) appendix
(d) retroareolar tumor
(e) clinical axillary nodes 8. Meckel’s diverticulum:
(a) is a false diverticulum
3. The most common indication for surgery in chronic
(b) is asymptomatic in most cases
pancreatitis is:
(c) commonly presents as gastrointestinal bleeding
(a) jaundice
in adults
(b) pain
(d) commonly presents with intestinal obstruction
(c) pseudocyst
in children
(d) gastric outlet obstruction
(e) is found in approximately 5% to 10% of people
(e) endocrine deficiency

4. The most common cause of spontaneous intestinal 9. Biliary-enteric fistula most commonly connects:
fistula is: (a) gallbladder and ileum
(a) radiation injury (b) gallbladder and duodenum
(b) malignancy (c) common bile duct and jejunum
(c) Crohn’s disease (d) gallbladder and jejunum
(d) ulcerative colitis (e) common bile duct and ileum
(e) diverticular disease
10. Spontaneous closure is least likely in fistulae origi-
5. Gastrointestinal stromal tumors (GIST): nating from:
(a) occur most commonly in the duodenum (a) colon
(b) are almost always malignant (b) esophagus
(c) can be treated adequately with enucleation (c) pancreas
(d) are often radioresistant (d) stomach
(e) spread mainly via the lymphatics (e) small intestine
406 Part XVI. Surgery Review Questions and Answers

11. Gastrointestinal diverticula do not occur in: 18. Malignant small bowel neoplasms most commonly
(a) cecum present with:
(b) duodenum (a) weight loss
(c) rectum (b) abdominal pain
(d) jejunum (c) gastrointestinal bleeding
(e) ileum (d) jaundice
(e) intestinal perforation
12. The hepatic caudate lobe: 19. Small bowel obstruction in an elderly female
(a) drains directly into the inferior vena cava without external hernia or previous surgery is most
(b) represents segment IV likely caused by:
(c) is supplied by the left portal vein only (a) small bowel neoplasm
(d) is supplied by the right portal vein only (b) volvulus
(e) lies to the right of the inferior vena cava (c) gallstone ileus
(d) abdominal abscess
13. von Willebrand’s disease: (e) obturator hernia
(a) is an autosomal dominant disorder
(b) results in prolonged prothrombin time 20. During cell cycle, DNA replication occurs in:
(c) is associated with normal bleeding time (a) G1 phase
(d) is due to decreased hepatic synthesis of von (b) G2 phase
Willebrand’s factor (c) S phase
(e) is typically associated with joint bleeding (d) M phase

21. Li-Fraumeni syndrome shows increased incidence

14. Which of the following is consistent with syndrome of:
of inappropriate antidiuretic hormone (SIADH)? (a) colon cancer
(a) hypovolemia (b) ovarian cancer
(b) increased urine sodium (c) lung cancer
(c) hypernatremia (d) breast cancer
(d) plasma hyperosmolarity (e) pancreatic cancer
(e) excessive diuresis
22. The best operative approach to choledochal cyst is:
(a) cystoduodenostomy
15. Normal anion gap acidosis is associated with:
(b) cystojejunostomy
(a) ketoacidosis
(c) Roux-en-Y cystojejunostomy
(b) lactic acidosis
(d) Cyst excision and hepaticojejunostomy
(c) salicylate poisoning
(d) severe diarrhea 23. Leiomyoma of the esophagus:
(e) uremic acidosis (a) commonly presents with dysphagia
(b) is more common in females
16. Benign small bowel tumors most commonly present (c) is usually multiple
as: (d) is usually diagnosed with endoscopic biopsy
(a) small bowel obstruction (e) is usually located in the lower one-third of the
(b) gastrointestinal bleeding esophagus
(c) weight loss
(d) incidental finding on laparotomy 24. Hemangioma of the liver:
(e) intestinal perforation (a) is the most common benign hepatic tumor
(b) is diagnosed with percutaneous needle biopsy
(c) is associated with α-fetoprotein level
17. The diagnostic test of choice for suspected acute (d) should be resected as soon as diagnosed
sigmoid diverticulitis is:
(a) barium enema 25. Phosphorus:
(b) Gastrografin enema (a) is a major extracellular anion
(c) computed tomography scan of the abdomen (b) is passively absorbed from the gastrointestinal
and pelvis tract
(d) abdominal ultrasound (c) deficiency may result in insulin resistance
(e) colonoscopy (d) deficiency is rare in hospitalized patients
174. Surgery Review Questions
26. Hypermagnesemia is a complication of:
(a) extensive burns
(b) acute pancreatitis
(c) oliguric renal failure
(d) resection of the terminal ileum
(e) diuretic therapy
27. The optimal management of traumatic duodenal
hematoma is:
(a) angiography and embolization
(b) laparotomy and evacuation
(c) laparotomy and gastrojejunostomy
(d) observation
28. Hairy cell leukemia:
(a) can be cured with splenectomy
(b) is an aggressive form of leukemia
(c) death is usually related to infectious com-
plications
(d) is a T-cell leukemia
29. Overwhelming postsplenectomy sepsis:
(a) commonly occurs after splenectomy for trauma
(b) does not occur if accessory spleens are present
(c) can be fatal within hours of onset
(d) is most common in elderly patients
(e) most fatal cases occur 10 to 15 years after
splenectomy
30. The development of thrombocytopenia and arterial
thrombosis with heparin requires:
(a) continuation of heparin and platelet trans-
fusion
(b) continuation of heparin and thrombolysis
(c) doubling the heparin dosage
(d) changing the route of heparin administration
(e) discontinuation of heparin
31. A trauma patient has a Glasgow Coma Scale score
of 13, blood pressure 80/40; widened mediastinum
on chest x-ray, and bloody peritoneal tap. The next
step in management is:
(a) obtain head computed tomography scan
(b) perform thoracotomy
(c) perform arch angiography
(d) monitor intracranial pressure
(e) perform laparotomy
32. Insulinomas:
(a) are often multiple
(b) are mostly benign
(c) are a common component of multiple endo-
crine neoplasia type 1 (MEN 1)
(d) are commonly located in the head of the
pancreas
407
33. Intussusception in adults:
(a) is idiopathic in most cases
(b) usually requires resection
(c) is often successfully treated with hydrostatic
reduction
(d) is seldom recurrent
34. Optimal treatment for an ileosigmoid fistula in
Crohn’s disease is:
(a) closure of the fistula
(b) proximal ileostomy
(c) proximal ileostomy and closure of fistula
(d) ileocecectomy and sigmoid colectomy
(e) ileocecectomy and closure of the sigmoid
defect
35. Obturator hernia:
(a) is most common in older women with
cachexia
(b) is associated with pain in the sciatic nerve
distribution
(c) is repaired through a transverse incision in the
upper medial thigh
(d) is rarely strangulated
36. Gastrointestinal bleeding in Mallory-Weiss
syndrome:
(a) is occult in the vast majority of cases
(b) can be controlled with balloon tamponade
(c) stops with nonoperative management in most
cases
(d) is caused by mucosal tear in the lower one-third
of the esophagus
37. The risk of overwhelming postsplenectomy sepsis is
highest for patients requiring splenectomy for:
(a) thalassemia
(b) trauma
(c) immune thrombocytopenic purpura
(d) hereditary spherocytosis
(e) acquired hemolytic anemia
38. After mastectomy, winging of the scapula results
from injury to:
(a) the medial pectoral nerve
(b) the lateral pectoral nerve
(c) the long thoracic nerve
(d) the thoracodorsal nerve
(e) the intercostal-brachial nerve
39. von Willebrand’s disease:
(a) is the most common congenital bleeding
disorder
(b) commonly results in hemarthrosis
(c) affects males only
(d) results in prolonged prothrombin time
408
40. Disc lesion between L4 and L5 will lead to:
(a) reduced knee jerk
(b) reduced ankle jerk
(c) weakness of foot dorsiflexion
(d) reduced sensation on the small toe
41. Kidney transplant recipients are at increased risk
for:
(a) epidermoid skin cancer
(b) lung cancer
(c) colon cancer
(d) breast cancer
(e) uterine cancer
42. The optimum management of medullary thyroid
carcinoma in multiple endocrine neoplasia type 2
(MEN 2) is:
(a) thyroid lobectomy
(b) thyroid lobectomy and cervical lymphadenec-
tomy
(c) radioactive iodine
(d) radiotherapy
(e) total thyroidectomy ± radical neck dissection
43. Optimum management for a 2-cm mass in the head
of the pancreas with hypoglycemia and high insulin
levels is:
(a) total pancreatectomy
(b) Whipple resection
(c) local excision
(d) streptozotocin administration
44. Which of the following is not a risk factor for wound
infection?
(a) prolonged operative time
(b) prolonged preoperative hospitalization
(c) shaving the skin the night before surgery
(d) patient’s having upper respiratory tract infec-
tion
(e) surgeon’s hand scrub for 5 instead of 10 minutes
45. On the second day after abdominal aortic aneurysm
repair, the patient passes grossly bloody stool. The
next step is:
(a) immediate exploratory laparotomy
(b) sigmoidoscopy
(c) computed tomography scan of the abdomen
with intravenous contrast
(d) barium enema
(e) aortogram
46. Spontaneous pneumothorax:
(a) is more common in young females
(b) is typically postexertional
(c) is recurrent in at least 30% of cases
(d) often requires thoracotomy in the first episode
(e) is often associated with severe persistent pain
Part XVI. Surgery Review Questions and Answers
47. The most common cause of hypercalcemic crisis is:
(a) sarcoidosis
(b) primary hyperparathyroidism
(c) secondary hyperparathyroidism
(d) malignancy
(e) renal failure
48. A sudden onset of glucose intolerance in patients
receiving total parenteral nutrition often indicates:
(a) diabetes mellitus
(b) sepsis
(c) hypophosphatemia
(d) adrenal insufficiency
(e) zinc insufficiency
49. Pectus excavatum:
(a) is usually associated with respiratory dysfunc-
tion
(b) is usually associated with dysphagia
(c) is often associated with cardiac dysfunction
(d) cosmesis is usually the indication for surgery
50. Sacrococcygeal teratoma:
(a) is usually malignant
(b) is more common in males
(c) requires complete excision of the coccyx
(d) diagnosis is ruled out if calcification is absent on
radiography
51. Dry, scaly, pruritic rash on the trunk and extremities
of a patient receiving total parenteral nutrition is
caused by:
(a) zinc deficiency
(b) vitamin A deficiency
(c) vitamin C deficiency
(d) free fatty acid deficiency
52. The main cause of postoperative death in children
with chronic diaphragmatic hernia is:
(a) increased intra-abdominal pressure
(b) persistent lung collapse
(c) patent ductus arteriosus
(d) abnormal pulmonary microvasculature
53. A neonate has bilious vomiting and a double-
bubble sign on plain x-ray. The most appropriate
operation is:
(a) division of annular pancreas
(b) gastroenterostomy
(c) duodenoduodenostomy
(d) duodenal resection
174. Surgery Review Questions 409

54. The most common source of bacteria in wound 62. Pulmonary hilar adenopathy with noncaseating
infection after groin hernia repair is: granuloma is consistent with:
(a) the patient’s skin (a) Hodgkin’s disease
(b) the patient’s nasopharynx (b) lymphoma
(c) operating room air (c) sarcoid
(d) surgical instruments (d) tuberculosis
(e) operating room staff (e) metastatic carcinoma

55. Enterocytes’ energy requirements are provided by: 63. A solitary lung nodule with a popcorn pattern of
(a) arginine calcification is most likely:
(b) alanine (a) a primary lung cancer
(c) glutamine (b) a metastatic lesion
(d) glycine (c) an old tuberculosis lesion
(d) histoplasmosis
56. In critical illness, immune function can be enhanced (e) a hamartoma
by:
(a) arginine 64. The most common presentation of gastric lym-
(b) glutamine phoma is:
(c) alanine (a) abdominal pain
(d) glycine (b) weight loss
(c) upper gastrointestinal bleeding
57. Intra-aortic balloon pump: (d) gastric perforation
(a) increases pulmonary wedge pressure (e) nausea and vomiting
(b) increases afterload
(c) increases diastolic pressure 65. The protective immune function of immunoglobu-
(d) increases duration of systole lin A is mediated through:
(e) decreases duration of diastole (a) inhibition of bacterial adherence to epithelial
cells
58. Popliteal artery aneurysms: (b) activation of complement
(a) are less common than femoral aneurysm (c) opsonization
(b) are often bilateral (d) direct destruction of microorganisms
(c) are more common in females
(d) seldom result in limb ischemia 66. The most potent stimulus for antidiuretic hormone
secretion is:
59. The most common cause of pneumaturia is: (a) hypovolemia
(a) Crohn’s disease (b) hyponatremia
(b) ulcerative colitis (c) hyperkalemia
(c) malignancy (d) raised serum osmolarity
(d) radiation enteritis
(e) diverticular disease 67. Which of the following distinguishes adrenal insuf-
ficiency from sepsis?
60. The most common benign hepatic lesion is: (a) hypotension
(a) hemangioma (b) fever
(b) adenoma (c) tachycardia
(c) focal nodular hyperplasia (d) altered mental status
(d) hamartoma (e) hypoglycemia

61. The most common etiologic factor for hepatocellu- 68. For penetrating chest injury, thoracotomy is indi-
lar carcinoma worldwide is: cated if:
(a) hepatitis C virus (a) initial chest tube output is 500 cc
(b) hepatitis B virus (b) initial chest tube output is 1,000 cc
(c) alcoholic cirrhosis (c) initial chest tube output is 1,500 cc
(d) aflatoxin ingestion (d) initial chest tube output is 2,000 cc
(e) schistosomiasis (e) persistent chest tube output of 100 cc/hr
410 Part XVI. Surgery Review Questions and Answers

69. Which cell type is essential for wound healing? 76. Post-transplant lymphoproliferative disorders are
(a) neutrophil related to:
(b) macrophage (a) cytomegalovirus
(c) fibroblast (b) Epstein-Barr virus
(d) lymphocyte (c) human immunodeficiency virus (HIV)
(e) endothelial (d) herpesvirus
(e) hepatitis B virus
70. The treatment for osteosarcoma of the distal femur
is: 77. Which of the following requires surgical drainage?
(a) above-knee amputation (a) amebic liver abscess
(b) chemotherapy followed by above-knee ampu- (b) peridiverticular abscess
tation (c) appendiceal abscess
(c) chemoradiation (d) pancreatic abscess
(d) chemotherapy alone (e) subphrenic abscess
(e) chemotherapy and limb-sparing surgery
78. The main complication of topical silver nitrate is:
(a) metabolic acidosis
71. Abnormal bleeding with normal prothrombin time (b) metabolic alkalosis
occurs with: (c) hyperkalemia
(a) heparin overdose (d) hypocalcemia
(b) cirrhosis (e) hyponatremia
(c) hemophilia
(d) von Willebrand’s disease
79. The adverse effects of steroids on wound healing
can be reversed with:
72. The most significant prognostic factor for soft tissue (a) vitamin C
sarcoma is: (b) vitamin A
(a) site (c) copper
(b) size (d) vitamin D
(c) grade (e) vitamin E
(d) cell type
80. The most common source of infection in burn
73. After reduction of posterior knee dislocation, the patients is:
patient should undergo: (a) burn wound
(a) observation (b) urinary tract infection
(b) discharge (c) pneumonia
(c) splinting (d) thrombophlebitis
(d) angiogram (e) endocarditis
(e) internal fixation
81. The most common cause of death after kidney
transplantation is:
74. Metabolic acidosis is a complication of topical appli- (a) operative technical complications
cation of: (b) atherosclerotic complications
(a) sodium mafenide (c) infection
(b) silver nitrate (d) cancer
(c) silver sulfadiazine (e) graft rejection
(d) Betadine
(e) bacitracin
82. Which of the following is least appropriate
when evaluating a 14-year-old girl with a breast
75. Stored blood is deficient in: lump?
(a) factor II (a) ultrasound
(b) factor VII (b) clinical follow-up
(c) factor VIII (c) mammography
(d) factor IX (d) fine-needle aspiration
(e) factor XI (e) excisional biopsy
174. Surgery Review Questions 411

83. An absolute contraindication to renal trans- 90. Coumadin-induced skin necrosis is due to:
plantation is: (a) protein S deficiency
(a) chronic osteomyelitis (b) protein C deficiency
(b) diabetes mellitus (c) antithrombin III deficiency
(c) age >55 years (d) disseminated intravascular coagulation
(d) lung cancer treated 10 years ago
(e) exertional angina 91. A patient receiving 1,800 cal/day in total parenteral
nutrition will require:
(a) 125 g protein/day
84. Changes occurring in stored blood include:
(b) 150 g protein/day
(a) increased H+
(c) 200 g protein/day
(b) increased 2,3-diphosphoglycerate
(d) 250 g protein/day
(c) decreased red cell fragility
(e) 300 g protein/day
(d) decreased K+
(e) increased Ca2+
92. Apoptosis:
(a) is an energy-dependent cell death
85. The most effective method of treating hyperkalemia (b) results in cell swelling
is: (c) is associated with an inflammatory response
(a) intravenous calcium gluconate (d) is usually toxin induced
(b) intravenous sodium bicarbonate (e) is indistinguishable from necrosis
(c) hemodialysis
(d) cation-exchange resin 93. Splenic artery aneurysm:
(e) intravenous glucose-insulin (a) is usually asymptomatic
(b) is usually a pseudoaneurysm
(c) is more common in young males
86. The most common cause of hypercalcemia in hos-
(d) rupture is seldom fatal
pitalized patients is:
(a) primary hyperparathyroidism
94. The site of action of aldosterone is:
(b) metastatic carcinoma
(a) proximal renal tubules
(c) sarcoidosis
(b) distal renal tubules
(d) immobility
(c) collecting ducts
(e) milk alkali syndrome
(d) glomeruli
(e) loop of Henle
87. Smoke inhalation is most reliably excluded by:
(a) absence of carbonaceous sputum 95. The site of action of antidiuretic hormone is:
(b) normal carboxyhemoglobin level (a) collecting ducts
(c) normal xenon-133 inhalation scan (b) glomeruli
(d) normal chest x-ray (c) proximal tubules
(e) normal flexible bronchoscopy (d) distal tubules
(e) loop of Henle
88. Which of the following ligands bind to cell surface
96. The common bile duct:
receptors?
(a) lies to the right of the hepatic artery
(a) steroids
(b) is posterior to the hepatic artery
(b) catecholamines
(c) lies to the right of the portal vein
(c) retinoids
(d) is posterior to the portal vein
(d) thyroid hormones
(e) lies to the left of the hepatic artery
(e) vitamin D
97. A respiratory quotient (RQ) of 1 indicates that the
89. von Willebrand’s disease: main source of fuel is:
(a) is autosomal dominant (a) fatty acid
(b) results in prolonged prothrombin time (b) protein
(c) results in thrombocytopenia (c) carbohydrate
(d) is associated with normal bleeding time (d) ketone
(e) is corrected by factor VIII therapy (e) glycerol
412
98. Magnesium:
(a) deficiency can be accurately diagnosed with
serum level measurement
(b) hypomagnesemia is associated with hyper-
kalemia
(c) hypomagnesemia is associated with neuromus-
cular excitability
(d) hypomagnesemia is a complication of renal
failure
(e) is a major extracellular cation
99. The management of pancreatic pleural fistula is:
(a) distal pancreatectomy
(b) pancreaticojejunostomy
(c) cystogastrostomy
(d) tube thoracostomy
(e) thoracotomy and decortication
100. 48 hours after coronary artery bypass grafting,
nausea with epigastric pain and tenderness are most
likely due to:
(a) perforated peptic ulcer
(b) acute cholecystitis
(c) acute pancreatitis
(d) acute myocardial infarction
(e) mesenteric ischemia
101. Hypotension develops after pneumoperitoneum
and trocar placement for laparoscopic cholecystec-
tomy. The next action is to:
(a) convert to open cholecystectomy
(b) deflate the abdomen
(c) give intravenous fluids
(d) place the patient in head down position
(e) check for bowel injury
102. Delayed primary wound closure:
(a) results in increased angiogenesis
(b) results in decreased wound strength
(c) results in lower collagen content
(d) results in a wider scar
103. The most common cause of esophageal perforation
is:
(a) penetrating neck injury
(b) iatrogenic
(c) spontaneous
(d) foreign body
(e) malignancy
104. Multicentricity is characteristic of:
(a) squamous cell carcinoma of the lung
(b) small cell lung cancer
(c) bronchoalveolar carcinoma
(d) bronchial adenocarcinoma
(e) bronchial carcinoid
Part XVI. Surgery Review Questions and Answers
105. DNA alkylation is the chemotherapeutic action of:
(a) cyclophosphamide
(b) vincristine
(c) methotrexate
(d) doxorubicin
106. Spontaneous perforation of the esophagus:
(a) is usually seen in elderly females
(b) is the most common cause of esophageal perfo-
ration
(c) is usually located in the midesophagus
(d) is usually preceded by history of dysphagia
(e) typically presents with sudden onset
107. Fentanyl:
(a) is normally found in the body
(b) is 100 times more potent than morphine
(c) has twice as long a duration of action as mor-
phine
(d) results in hypotension because of histamine
release
108. Popliteal artery aneurysms:
(a) are commonly complicated by rupture
(b) occur equally in both sexes
(c) are not surgically treated unless size is >4 cm
(d) are bilateral in more than 50% of cases
109. The lower esophageal sphincter (LES) tone:
(a) is increased by gastrin
(b) is decreased by metoclopramide
(c) is increased by nicotine
(d) is increased by chocolate
110. Tachycardia is the main side effect of:
(a) fentanyl
(b) succinylcholine
(c) morphine
(d) pancuronium
111. Intralobar pulmonary sequestration often presents
with:
(a) chest pain
(b) dyspnea
(c) recurrent pneumonia
(d) hemoptysis
112. Doxorubicin:
(a) is an alkylating agent
(b) is an antimetabolite
(c) is an alkaloid
(d) is an anthracycline antibiotic
174. Surgery Review Questions 413

113. A 45-year-old man has an 8 × 4 cm soft tissue mass 120. Arrest of cell cycle in the metaphase is the action
in his right thigh. The most appropriate method to of:
confirm the diagnosis of sarcoma is: (a) cyclophosphamide
(a) fine-needle aspiration (b) methotrexate
(b) core biopsy (c) doxorubicin
(c) local excision (d) vincristine
(d) incisional biopsy
(e) enucleation 121. After an acute myocardial infarction, elective oper-
ation should be postponed for at least:
114. Appropriate treatment of malignant hypothermia is (a) 1 month
intravenous: (b) 3 months
(a) morphine sulfate (c) 6 months
(b) dantrolene (d) 1 year
(c) benzodiazepines (e) 2 years
(d) KCl
122. Succinylcholine is contraindicated for:
(e) calcium gluconate
(a) patients with hepatitis
(b) emergency intubation of burn victims
115. Volkmann’s contracture is a complication of:
(c) celiotomy 2 weeks after spinal cord injury
(a) humeral head fracture
(d) parotidectomy
(b) femoral neck fracture
(e) thyroidectomy
(c) posterior dislocation of the knee
(d) supracondylar humeral fracture 123. Splenic artery aneurysm:
(e) Colles’ fracture (a) can present with double-rupture phenomenon
(b) is more common in males
116. Decreasing glucose and increasing fat in total par- (c) is seldom multiple
enteral nutrition will: (d) will continue to enlarge if left untreated
(a) increase respiratory quotient
(b) increase C02 production 124. One week after Coumadin therapy, a patient devel-
(c) decrease minute ventilation ops severe pain in the right leg with areas of skin
(d) delay weaning from mechanical ventilation necrosis. Appropriate action is:
(a) transfusion of fresh-frozen plasma
117. Acute appendicitis in pregnancy: (b) intravenous vitamin K therapy
(a) has a higher incidence of wound infection (c) wound debridement and antibiotics
(b) is least common in the third trimester (d) stopping Coumadin and starting heparin
(c) leukocytosis is important in making the (e) lumbar sympathectomy
diagnosis
125. Mixed venous saturation is increased in:
(d) initial observation is recommended when diag-
(a) hypovolemic shock
nosis is suspected
(b) septic shock
(c) cardiogenic shock
118. Eight hours after esophagogastroduodenoscopy
(d) neurogenic shock
(EGD), a patient complains of severe substernal
(e) anaphylactic shock
pain. Chest x-ray film shows left pleural effusion.
The next test is: 126. Paraneoplastic syndrome is most commonly associ-
(a) repeated EGD ated with:
(b) celiotomy (a) bronchial adenocarcinoma
(c) computed tomography scan of the chest (b) small cell lung cancer
(d) water-soluble esophagogram (c) bronchoalveolar carcinoma
(e) thoracotomy (d) bronchial carcinoid

119. The initial site of distant metastasis in breast 127. The endothelial cells are the source of:
cancer is: (a) factor II
(a) lungs (b) factor V
(b) liver (c) factor VII
(c) bones (d) factor VIII
(d) brain (e) factor X
414 Part XVI. Surgery Review Questions and Answers

128. Which of the following is likely to be multiple? 136. Pulmonary fibrosis is a complication of:
(a) gastrinoma (a) bleomycin
(b) insulinoma (b) cyclophosphamide
(c) somatostatinoma (c) tamoxifen
(d) vasoactive intestinal peptide–producing tumor (d) vincristine
(e) gluconoma (e) methotrexate

129. The mechanism of action of heparin is: 137. The best indicator of adequate resuscitation in
(a) direct inhibition of thrombin shock is:
(b) prevention of factor II synthesis (a) normal blood pressure
(c) inhibition of cyclo-oxygenase (b) normal pulse
(d) potentiation of antithrombin III action (c) adequate urine output
(e) improved mental status
130. Which of the following is an aminoester? (f) decreased lactate level
(a) tetracaine
(b) lidocaine 138. Adrenal incidentalomas:
(c) bupivacaine (a) are commonly malignant
(d) mepivacaine (b) require endocrine evaluation
(e) etidocaine (c) are commonly associated with hyperaldostero-
nism
131. Vitamin K: (d) are not resected unless they are >6 cm
(a) is required for factor VIII synthesis
(b) is water soluble 139. Peaked T-wave on electrocardiogram is a feature of:
(c) is absorbed in the proximal small bowel (a) hypernatremia
(d) requires bile salts for absorption (b) hypermagnesemia
(c) hyperkalemia
132. Hyponatremia is a complication of topical ap- (d) hypocalcemia
plication of: (e) hyponatremia
(a) bacitracin
(b) povidone-iodine 140. Distinction between prerenal and renal azotemia is
(c) silver sulfadiazine best made by:
(d) Sulfamylon (a) urine sodium level
(e) silver nitrate (b) serum sodium level
(c) urine creatinine level
133. Which of the following is an etiologic factor in (d) serum creatinine level
occlusive vascular diseases? (e) urine microscopy
(a) arginine
(b) glutamine 141. During prolonged starvation, the brain’s main
(c) methionine fuel is:
(d) homocystine (a) glucose
(e) xanthine (b) amino acids
(c) ketones
134. Cardiomyopathy is a complication of: (d) short-chain fatty acids
(a) methotrexate
(b) tamoxifen 142. Dobutamine:
(c) doxorubicin (a) has a major chronotropic action
(d) cyclophosphamide (b) decreases cardiac filling pressure
(e) vincristine (c) increases systemic vascular resistance
(d) directly increases renal blood flow
135. Spontaneous antitumor activity is a function of:
(a) macrophages 143. Epidermal growth factor stimulates:
(b) B lymphocytes (a) angiogenesis
(c) cytotoxic T cells (b) wound contraction
(d) helper T cells (c) fibroblast proliferation
(e) natural killer cells (d) epithelialization
174. Surgery Review Questions 415

144. Magnesium: 151. Headache, vomiting, and seizure may develop with
(a) is an intracellular ion rapid correction of:
(b) deficiency leads to hyporeflexia (a) hyponatremia
(c) depletion is common in shock states (b) hypernatremia
(d) is excreted mostly in stool (c) hypokalemia
(d) hyperkalemia
145. The most commonly injured organ in a patient with (e) hypercalcemia
seatbelt sign is:
152. The most common microbial agent transmitted by
(a) the liver
blood transfusion is:
(b) the spleen
(a) Cytomegalovirus
(c) the colon
(b) human immunodeficiency virus
(d) the pancreas
(c) hepatitis C virus
(e) the small intestine
(d) hepatitis B virus

146. The development of necrolytic erythematous rash in 153. The most frequent major complication of blood
a diabetic patient requires assessment of the serum transfusion is:
level of: (a) volume overload
(a) insulin (b) hemolytic reaction
(b) somatostatin (c) human immunodeficiency virus infection
(c) cortisol (d) hepatitis C
(d) gastrin (e) hepatitis B
(e) glucagon
154. adenosine diphosphate–induced platelet aggrega-
tion is inhibited by:
147. Appearance of a U-wave on electrocardiogram
(a) aspirin
occurs in:
(b) heparin
(a) hyperkalemia
(c) dipyridamole
(b) hypokalemia
(d) Coumadin
(c) hypermagnesemia
(d) hypomagnesemia
155. Malignant hyperthermia
(e) hypercalcemia
(a) is rare in children
(b) is an autosomal dominant disorder
148. Seizures can be associated with the use of: (c) results in respiratory alkalosis
(a) aztreonam (d) is prevented by intravenous calcium gluconate
(b) Flagyl
(c) clindamycin 156. Colonic perforation in a patient with acquired
(d) ciprofloxacillin immunodeficiency syndrome is most likely due to:
(e) imipenem-cilastatin (a) Clostridium difficile
(b) Cytomegalovirus
149. Nasotracheal intubation: (c) Bacteroides
(a) is contraindicated for suspected cervical spine (d) Salmonella typhi
injury (e) Escherichia coli
(b) is contraindicated for apneic patients
157. Which of the following results of thyroid fine-needle
(c) is usually successful on the first attempt
aspiration indicates surgical treatment?
(d) is less tolerated by patients than is endotracheal
(a) a nodule that disappeared on aspiration
intubation
(b) clumps of follicular cells
(c) anaplastic thyroid cells
150. The most important initial management of sus- (d) lymphoma
pected blunt myocardial injury is:
(a) electroencephalographic monitoring 158. Somatostatin:
(b) chest computed tomography scan (a) is produced by antral G cells
(c) assessment of cardiac enzymes (b) has a half-life of 30 minutes
(d) insertion of pulmonary artery catheter (c) inhibits gastric motility
(e) echocardiogram (d) increases portal blood flow
416 Part XVI. Surgery Review Questions and Answers

159. The most common site for accessory splenic 166. Esophageal diverticula:
tissue is: (a) traction diverticula are false diverticula
(a) gastrosplenic ligament (b) pulsion diverticula are common in the
(b) gastrocolic ligament midesophagus
(c) splenic hilum (c) pulsion diverticula are usually associated with
(d) splenocolic ligament enlarged lymph nodes
(e) the pelvis (d) myotomy is always indicated for pulsion
diverticula
160. The most sensitive indicator of increased hemolysis
with hypersplenism is: 167. The primary fuel source for enterocytes is:
(a) reticulocyte count (a) short-chain fatty acids
(b) splenic enlargement (b) glucose
(c) bilirubin level (c) triglycerides
(d) hemoglobin level (d) lactulose
(e) haptoglobin level (e) glutamine

161. Howship-Romberg sign is characteristic of: 168. Infection caused by dog and cat bites is due to:
(a) femoral hernia (a) Pasteurella species
(b) Spigelian hernia (b) Mycobacterium
(c) obturator hernia (c) Staphylococcus aureus
(d) lumbar hernia (d) Actinomyces
(e) epigastric hernia (e) Candida

162. Which of the following is least indicated for evalu-

169. Which of the following is preserved in radical neck
ating adrenal incidentaloma?
dissection?
(a) magnetic resonance imaging
(a) internal jugular vein
(b) 24-hour urinary catecholamine testing
(b) sternomastoid muscle
(c) 24-hour urinary cortisol testing
(c) spinal accessory nerve
(d) low dexamethasone suppression test
(d) submandibular salivary gland
(e) fine-needle aspiration
(e) posterior belly of the digastric muscle

163. Lobular carcinoma in situ:

(a) is mostly found in premenopausal women 170. The organ most commonly involved in graft-versus-
(b) usually presents as a breast lump host reaction is:
(c) has characteristic calcification pattern on mam- (a) lungs
mography (b) kidneys
(d) is precancerous (c) heart
(e) associated cancer is lobular in nature (d) skin

164. Sequence of return of gastrointestinal motility after 171. The most characteristic of malignancy in a cystic
surgery is: pancreatic neoplasm is:
(a) intestine, stomach, colon (a) size >6 cm
(b) stomach, intestine, colon (b) wall calcification
(c) colon, intestine, stomach (c) multiple loculations
(d) colon, stomach, intestine (d) dense vascularity
(e) stomach, colon, intestine
172. Which of the following is contraindicated for a para-
165. The treatment of choice for Barrett’s esophagus plegic undergoing laparotomy?
with severe dysplasia is: (a) benzodiazepines
(a) follow-up endoscopy and biopsy (b) sodium thiopental
(b) esophagectomy (c) succinylcholine
(c) Nissen fundoplication (d) propofol
(d) Proton pump inhibitors (e) fentanyl
174. Surgery Review Questions 417

173. Which of the following is consistent with pleural 180. The most common retroperitoneal sarcoma is:
transudate? (a) liposarcoma
(a) red blood cells count of 1,000/mm3 (b) fibrosarcoma
(b) white blood cells count of 1,500/mm3 (c) leiomyosarcoma
(c) specific gravity of 1.120 (d) neurosarcoma
(d) protein concentration of 3.5 g/dL
181. Platelet dysfunction in uremia can be corrected
with:
174. Appropriate management of renal cell carcinoma
(a) fresh-frozen plasma
extending into the inferior vena cava is:
(b) cryoprecipitate
(a) radiotherapy
(c) desmopressin (DDAVP)
(b) chemotherapy
(d) factor VIII concentrate
(c) chemoradiation
(e) vitamin K
(d) radical nephrectomy and caval tumor extrac-
tion 182. Gynecomastia is a side effect of:
(e) radical nephrectomy, caval resection, and graft (a) ketoconazole
interposition (b) amphotericin B
(c) fluconazole
175. The gastroduodenal artery is a branch of the: (d) miconazole
(a) celiac axis
(b) right gastric artery 183. Optimum approach to inflammatory breast car-
(c) common hepatic artery cinoma is:
(d) right hepatic artery (a) total mastectomy
(e) left hepatic artery (b) modified radical mastectomy
(c) lumpectomy and radiotherapy
(d) chemotherapy
176. Inflammatory aortic aneurysm:
(e) chemotherapy, modified radical mastectomy,
(a) repair is associated with a higher incidence of
and radiotherapy
graft infection
(b) is more likely to rupture than is a noninflam-
184. A potent inhibitor of T cell proliferation is:
matory aneurysm
(a) transforming growth factor-β
(c) leads to circumferential thickening of the aorta
(b) platelet-derived growth factor
(d) may present with abdominal pain in the absence
(c) epidermal growth factor
of rupture
(d) basic fibroblast growth factor

177. The initial management of a diabetic patient with 185. The most reliable indicator of successful endotra-
fever, plantar ulcer, and foot edema is: cheal intubation is:
(a) antibiotics and elevation (a) chest x-ray
(b) hyperbaric oxygen (b) end-tidal CO2
(c) exploration and ulcer debridement (c) cord visualization
(d) midtarsal amputation (d) chest auscultation
(e) femoropopliteal arterial bypass (e) pulse oximetry

186. The layer responsible for the strength of an intes-

178. Male breast cancer is associated with:
tinal anastomosis is the:
(a) BRCA-1 gene
(a) mucosa
(b) BRCA-2 gene
(b) submucosa
(c) APC gene
(c) muscularis propria
(d) p53 gene
(d) serosa

179. The diagnosis of inflammatory breast cancer is 187. Healing of the donor site for a split thickness skin
confirmed by: graft is accelerated by:
(a) mammography (a) transforming growth factor-β
(b) fine-needle aspiration (b) recombinant human growth hormone
(c) ultrasound (c) epidermal growth factor
(d) skin biopsy (d) platelet-derived growth factor
418 Part XVI. Surgery Review Questions and Answers

188. Prevention of empyema in a patient with residual 195. The respiratory quotient in prolonged starvation is:
hemothorax and a chest tube in place is best (a) 1.0
achieved by: (b) 1.2
(a) intravenous third-generation cephalosporins (c) 0.8
(b) placement of a second chest tube (d) 0.7
(c) needle thoracentesis
(d) intravenous vancomycin 196. The most abundant amino acid in the body is:
(a) alanine
189. Popliteal artery entrapment: (b) valine
(a) is more common in females than males (c) leucine
(b) is diagnosed by passive dorsiflexion of the foot (d) glutamine
(c) results from compression by the medial head of (e) arginine
the gastrocnemius
(d) requires bilateral exploration in most cases 197. Maximum efficiency of glucose use in total par-
enteral nutrition occurs at the infusion rate of:
190. Cervical anastomosis after esophagectomy for (a) 4 mg/kg/min
cancer: (b) 5 mg/kg/min
(a) has a lower leak rate than thoracic anastomosis (c) 6 mg/kg/min
(b) leak is likely to heal spontaneously (d) 7 mg/kg/min
(c) has a higher long-term mortality rate than tho-
198. Refeeding syndrome is most commonly related to:
racic anastomosis
(a) hyponatremia
(d) has a lower operative mortality rate than tho-
(b) hypocalcemia
racic anastomosis
(c) hypophosphatemia
(d) hypokalemia
191. Appropriate management of 3-cm squamous cell
carcinoma of the anal canal is:
199. Eczematoid rash at intertriginous areas with pro-
(a) chemotherapy
longed total parenteral nutrition is caused by:
(b) abdominoperineal resection
(a) zinc deficiency
(c) local excision
(b) fatty acid deficiency
(d) radiotherapy + local excision
(c) copper deficiency
(e) chemotherapy + radiation
(d) magnesium deficiency
(e) niacin deficiency
192. Idiopathic thrombocytopenic purpura:
(a) is caused by antiplatelet immunoglobulin G 200. The volume of air moved with maximum exhalation
originating in the spleen after deep inhalation measures:
(b) is associated with splenomegaly (a) vital capacity
(c) is associated with prolonged prothrombin time (b) inspiratory reserve volume
(d) splenectomy is required for most pediatric cases (c) tidal volume
(e) occurs with a male to female ratio of 3 : 1 (d) residual volume
(e) total lung volume
193. The most common cause of death related to a
central venous catheter is: 201. Bleeding after adequate heparin reversal with pro-
(a) air embolism tamine is usually caused by:
(b) central vein perforation (a) protamine toxicity
(c) tension pneumothorax (b) heparin rebound
(d) catheter embolism (c) hypothermia
(e) catheter-related sepsis (d) thrombocytopenia
(e) factor VIII depletion
194. Postoperative morbidity after splenectomy for
hematologic diseases is highest for: 202. Ileocolic intussusception in children:
(a) idiopathic thrombocytopenic purpura (a) presents with rectal bleeding in 90% of cases
(b) hereditary spherocytosis (b) is commonly caused by an underlying pathology
(c) myeloid dysplasia (c) is ideally treated by operative reduction
(d) sickle cell anemia (d) is the most common cause of intestinal obstruc-
(e) thalassemia tion before the age of 3 years
174. Surgery Review Questions 419

203. Alopecia with prolonged total parenteral nutrition 210. Pulmonary sequestration:
may be caused by: (a) commonly occurs on the right side
(a) zinc deficiency (b) intralobar sequestration is supplied by the pul-
(b) magnesium deficiency monary artery
(c) vitamin A intoxication (c) extralobar sequestration is supplied by the
(d) essential fatty acids deficiency aorta
(e) selenium deficiency (d) intralobar sequestration drains into systemic
veins
204. A 1-cm carcinoid found in the midappendix after (e) extralobar sequestration drains into pulmonary
appendectomy requires: veins
(a) octreotide therapy
(b) right hemicolectomy 211. The most important diagnostic test for a thyroid
(c) streptozotocin therapy nodule is:
(d) no further action (a) ultrasound
(b) radioactive isotope scan
205. The most common complication of heparin reversal (c) thyroid function test
with protamine is: (d) fine-needle aspiration
(a) bradycardia (e) computed tomography scan
(b) hypotension
212. Pleomorphic parotid adenoma:
(c) thrombotic crisis
(a) requires core biopsy before resection
(d) thrombocytopenia
(b) is adequately treated with enucleation
(e) leukopenia
(c) commonly undergoes malignant transformation
(d) commonly results in facial palsy
206. The most common side effect of pancuronium is:
(e) is the most common parotid neoplasm
(a) tachycardia
(b) hypotension 213. The mean arterial pressure is:
(c) hyperkalemia (a) diastolic pressure + 1/2 pulse pressure
(d) hyperthermia (b) systolic pressure + pulse pressure
(e) renal insufficiency (c) systolic pressure + 1/3 pulse pressure
(d) diastolic pressure + 1/3 pulse pressure
207. The most common cause of massive lower
gastrointestinal bleeding in children is: 214. A contraindication to breast-conserving therapy is:
(a) anal fissure (a) age more than 70 years
(b) intussusception (b) coronary artery disease
(c) Meckel’s diverticulum (c) family history of breast cancer
(e) angiodysplasia (d) collagen vascular disease

215. Death from tension pneumothorax is caused by:

208. Fine-needle aspiration of bilateral upper cervical
(a) decreased venous return
lymphadenopathy shows squamous cell carcinoma.
(b) cardiac arrhythmia
No primary lesion is found on clinical examination.
(c) acute hypoxia
The most likely source is:
(d) acute hypercapnia
(a) lungs
(b) esophagus 216. The most important element in the history of an
(c) tongue infant with vomiting is:
(d) tonsils (a) the frequency of vomiting
(e) nasopharynx (b) the amount of vomiting
(c) the presence of fever
209. Analysis of pleural effusion shows red blood cell (d) if vomiting is projectile
count of 500/mm3, white blood cell count of (e) if vomiting is bile stained
600/mm3, protein level of 1.5 g/dL, and specific
gravity of 1.010. The most likely diagnosis is: 217. The substrate for nitric oxide synthetase is:
(a) congestive heart failure (a) glutamine
(b) parapneumonic effusion (b) alanine
(c) hemothorax (c) L-arginine
(d) bronchogenic carcinoma (d) valine
420 Part XVI. Surgery Review Questions and Answers

218. The most frequent complication of giant gastric 226. The rate of axonal regeneration after nerve injury
ulcer is: is:
(a) gastric outlet obstruction (a) 1 cm/month
(b) perforation (b) 1 mm/day
(c) upper gastrointestinal bleeding (c) 1 mm/week
(d) gastroenteric fistula (d) 1 cm/week

219. Mucosal defense is provided by immunoglobulin:

(a) A 227. The optimal treatment for bleeding gastric varices
(b) G in chronic pancreatitis is:
(c) M (a) distal pancreatectomy
(d) D (b) splenorenal shunt
(e) E (c) portocaval shunt
(d) splenectomy
(e) transjugular intrahepatic portosystemic shunt
220. The most common cause of nipple discharge is:
procedure
(a) duct ectasia
(b) breast cancer
(c) intraductal papilloma 228. Electrical burn injury:
(d) pituitary adenoma (a) can be estimated by the extent of skin damage
(e) fibrocystic disease (b) typically affects the trunk more than the
extremities
221. The most common agent transmitted by blood (c) requires close cardiac monitoring
transfusion is: (d) is inversely related to tissue resistance
(a) human immunodeficiency virus
(b) hepatitis B virus
(c) hepatitis C virus 229. The highest rate of metastasis occurs in carcinoid
(d) Cytomegalovirus arising from:
(a) appendix
222. Advantage of full thickness over split thickness skin (b) bronchus
graft is: (c) ileum
(a) less wound contraction (d) stomach
(b) better take
(c) more resistance to infection
(d) better sensory function 230. The most common presentation of ductal carcinoma
in situ is:
223. Cyclosporin A inhibits the production of: (a) breast pain
(a) interleukin–1 (b) breast lump
(b) interleukin–2 (c) nipple discharge
(c) interleukin–6 (d) microcalcification
(d) tumor necrosis factor-α
231. The main source of fuel in sepsis is:
224. The main component of urinary stones complicat- (a) glucose
ing resection of terminal ileum is: (b) fatty acids
(a) urate (c) ketones
(b) oxalate (d) amino acids
(c) phosphate
(d) ammonium
232. A patient with electrical burn of the leg complains
225. A characteristic feature of toxic shock syndrome in of pain on passive movement of the foot. The pedal
children with burns is: pulses are diminished. The next step is:
(a) purulent wound drainage (a) escharotomy
(b) leukopenia (b) femoral angiogram
(c) hypothermia (c) leg elevation and intravenous heparin
(d) bradycardia (d) fasciotomy
174. Surgery Review Questions 421

233. The most common complication of blood transfu- 240. Hypothermic coagulopathy:
sion is: (a) is associated with clotting factor depletion
(a) hemolytic reaction (b) can be corrected with fresh-frozen plasma
(b) human immunodeficiency virus transmission transfusion
(c) allergic reaction (c) is associated with prolonged prothrombin time
(d) volume overload and partial thromboplastin time
(e) coagulopathy (d) is a complication of massive transfusion

234. The highest concentration of immunoglobulin A– 241. Secretin:

producing cells is in: (a) stimulates gastrin secretion
(a) bloodstream (b) stimulates pancreatic enzyme secretion
(b) oral cavity (c) inhibits intestinal motility
(c) bronchial tree (d) stimulates gastric acid secretion
(d) small intestine
(e) urogenital tract 242. The use of inverse ratio ventilation will:
(a) decrease auto-positive end-expiratory pressure
235. In the treatment of coagulopathy: (b) improve alveolar ventilation
(a) calcium should be routinely infused with (c) increase incidence of pneumonia
massive transfusion (d) decrease mean airway pressure
(b) desmopressin (DDAVP) stimulates the release
of factor VIII 243. The optimal management of esophageal leiomyoma
(c) von Willebrand’s disease can be treated with is:
factor VIII concentrate (a) Ivor-Lewis esophageal resection
(d) the effect of aspirin can be reversed by fresh- (b) transhiatal esophageal resection
frozen plasma (c) segmental esophageal resection
(d) esophagomyotomy and enucleation
(e) endoscopic resection
236. The most common source of metastatic small bowel
tumor is:
244. Hand infection caused by a human bite is due to:
(a) lungs
(a) Staphylococcus aureus
(b) melanoma
(b) Clostridium difficile
(c) breast
(c) Herpes simplex
(d) soft tissue sarcoma
(d) Eikenella corrodens
(e) Candida species
237. Myeloid metaplasia:
(a) is a disease of young females 245. Gastric intrinsic factor is secreted from:
(b) is rarely associated with splenomegaly (a) parietal cells
(c) results in extramedullary hematopoiesis (b) chief cells
(d) results in increased bone marrow megakary- (c) antral G cells
ocytes (d) D cells

238. Which of the following is contraindicated in man- 246. 246 Which of the following directly induces
aging corrosive esophagitis? coagulation?
(a) gastric lavage (a) superglue
(b) esophagogastroduodenoscopy (b) oxidized cellulose
(c) corticosteroids (c) absorbable gelatin sponge
(d) tracheostomy (d) microfibrillar collagen (Avitene)

239. Which of the following is effective in treating refrac- 247. Which of the following inhibits gastric bicarbonate
tory Crohn’s fistula? secretion?
(a) total parenteral nutrition (a) prostaglandins
(b) prednisone (b) vagal stimulation
(c) infliximab (c) aspirin
(d) azathioprine (d) gastrin
422 Part XVI. Surgery Review Questions and Answers

248. A characteristic of prerenal azotemia is: 255. A colorectal tumor that invades through the mus-
(a) abnormal urine sediment cularis propria into the subserosa is a:
(b) fractional excretion of sodium value <1% (a) T1 lesion
(c) urine sodium level <40 mEq/L (b) T2 lesion
(d) blood urea nitrogen/serum creatinine level >10 (c) T3 lesion
(d) T4 lesion
249. At an operation for small bowel obstruction, cecal
volvulus is diagnosed. The cecum is viable. The pro- 256. Glutamine:
cedure of choice is: (a) is supplied in total parenteral nutrition
(a) cecopexy (b) increases intestinal cellularity
(b) tube cecostomy (c) is an essential amino acid
(c) right hemicolectomy (d) is a substrate for gluconeogenesis
(d) resection, ileostomy, and mucous fistula
257. Which of the following is a defect in the hemoglo-
bin chain that responds to splenectomy?
250. For a patient with a serum potassium level of (a) idiopathic thrombocytopenic purpura
7 mEq/dL and an absent P-wave on electrocardio- (b) hereditary spherocytosis
gram, the initial management is: (c) thalassemia
(a) intravenous Lasix (d) glucose-6-phosphate deficiency
(b) intravenous glucose/insulin
(c) Kayexalate enema
258. A central scar in a hepatic lesion is characteristic of:
(d) intravenous sodium bicarbonate
(a) focal nodular hyperplasia
(e) intravenous calcium gluconate
(b) hepatic adenoma
(c) hemangioma
251. Optimal management of mucosa-associated lym- (d) hamartoma
phoid tissue (MALT) lymphoma is: (e) hepatocellular carcinoma
(a) chemotherapy
(b) total gastrectomy 259. The initial step in management of a hypercalcemic
(c) chemoradiation crisis is intravenous:
(d) antibiotics (a) steroids
(b) calcitonin
(c) saline
252. Positive end-expiratory pressure therapy will result
(d) furosemide
in:
(e) mithramycin
(a) decrease in extravascular lung water
(b) increase in cardiac preload
(c) decrease in atrial natriuretic peptide 260. Hepatic focal nodular hyperplasia:
(d) decrease in functional residual capacity (a) usually occurs in women of reproductive age
(b) is related to oral contraceptive use
(c) presents with abdominal pain in most cases
253. At the initiation of swallowing, the pressure at the (d) carries the risk of spontaneous rupture
lower esophageal sphincter:
(a) remains unchanged 261. The most accurate measure of adequacy of nutri-
(b) decreases and then increases tional support is:
(c) increases and then decreases (a) serum albumin level
(d) increases and then returns to baseline (b) body weight
(c) triceps skinfold measurement
254. The serum sodium level in a 60-year-old man who (d) serum prealbumin level
weighs 70 kg is 125 mEq/L. His sodium deficit is:
(a) 130 mEq 262. Refractory hypokalemia can be caused by:
(b) 210 mEq (a) hypocalcemia
(c) 360 mEq (b) hyponatremia
(d) 520 mEq (c) hypophosphatemia
(e) 850 mEq (d) hypomagnesemia
174. Surgery Review Questions 423

263. A respiratory quotient of 1.2 indicates: 270. Perianal Crohn’s disease:

(a) lipogenesis (a) typically occurs late in the course of the disease
(b) ketogenesis (b) fistulas are usually multiple
(c) pure fat utilization (c) fecal diversion is usually curative
(d) carbohydrates are the source of fuel (d) lesions are typically located posteriorly
(e) proteins are the source of fuel (e) granulomas are seldom found on biopsy

264. Mallory-Weiss tear is located: 271. Appropriate management of chronic pancreatitis

(a) in the distal esophagus
(b) anteriorly across the gastroesophageal junction
(c) posteriorly across the gastroesophageal junc-
tion
(d) on the lesser curve of the cardia
(e) on the greater curve of the cardia
with pancreatic duct ectasia is:
(a) pancreaticoduodenectomy
(b) distal pancreaticojejunostomy
(c) longitudinal pancreaticojejunostomy
(d) near total pancreatectomy
(e) sphincteroplasty

265. The blood supply of the thoracic stomach used for 272. The most common cause of massive bleeding in
esophageal replacement depends on: chronic pancreatitis is:
(a) the left gastric artery (a) pseudoaneurysm
(b) the short gastric vessels (b) arteriovenous fistula
(c) the right gastroepiploic artery (c) mycotic aneurysm
(d) the left gastroepiploic artery (d) fibromuscular dysplasia

266. The most serious complication of gastric bypass pro- 273. Colonic distension in toxic megacolon is most
cedure is: prominent in the:
(a) hepatic failure (a) cecum
(b) anastomotic leak (b) ascending colon
(c) urolithiasis (c) transverse colon
(d) intestinal obstruction (d) descending colon
(e) hypocalcemia (e) sigmoid colon

267. Helicobacter pylori: 274. At the lung functional residual capacity:

(a) colonization is highest in childhood
(b) eradication does not influence ulcer recurrence
(c) is isolated in up to 90% of duodenal ulcer cases
(d) metronidazole achieves eradication as a single
agent
(a) chest wall exerts inward elastic recoil
(b) lungs exert outward elastic recoil
(c) alveolar pressure equals pleural pressure
(d) lungs and chest wall exert equal and opposing
recoil

268. L5–S1 disc lesion will result in: 275. Which of the following inhibits intestinal motility?
(a) weak plantar flexion (a) gastrin
(b) weak dorsiflexion (b) cholecystokinin
(c) absent knee jerk (c) epinephrine
(d) lost sensation in the big toe (d) motilin
(e) serotonin

269. A patient with head injury opens his eyes and with-
draws his arm to pain. He is making incomprehen- 276. The most common site of ectopic pheochromocy-
sible sounds. His Glasgow Coma Scale score is: toma is:
(a) 12 (a) lower pole of the kidney
(b) 10 (b) para-aortic tissue
(c) 8 (c) mediastinum
(d) 6 (d) pelvis
424 Part XVI. Surgery Review Questions and Answers

277. Which of the following is poorly absorbed in 285. Which of the following is an inhibitor of wound
achlorhydria? contraction?
(a) proteins (a) glucocorticoids
(b) fats (b) d-penicillamine
(c) bile salts (c) colchicine
(d) vitamin D (d) aspirin
(e) vitamin B12
286. Fetal wound healing is characterized by:
278. The most common cause of hypophosphatemia in (a) increased angiogenesis
hospitalized patients is: (b) increased hyaluronic acid synthesis
(a) renal failure (c) increased inflammatory response
(b) sepsis (d) decreased collagen
(c) glucose overload
(d) diarrhea 287. Death from postoperative renal failure is most com-
monly due to:
279. The main fuel for colonocytes is: (a) myocardial infarction
(a) glutamine (b) bleeding
(b) short-chain fatty acids (c) sepsis
(c) alanine (d) liver failure
(d) glucose
(e) ketones 288. Regarding graft rejection:
(a) hyperacute rejection is antibody mediated
280. Pulmonary fibrosis is a complication of:
(b) hyperacute rejection is reversed with steroids
(a) doxorubicin
(c) acute rejection is B cell mediated
(b) methotrexate
(d) acute rejection occurs over month
(c) bleomycin
(d) cyclophosphamide
289. The most important prognostic variable for
(e) vincristine
melanoma is:
(a) gender
281. The most useful serum marker for cancer screening
(b) age
is:
(c) Clark’s level
(a) prostate-specific antigen
(d) Breslow’s thickness
(b) CA 19.9
(e) complexion
(c) α-fetoprotein
(d) carcinoembryonic antigen
290. Follicular thyroid carcinoma:
282. The inferior parathyroid gland originates from (a) is the most common thyroid cancer
the: (b) is readily diagnosed with fine-needle aspira-
(a) first pharyngeal pouch tion
(b) second pharyngeal pouch (c) spreads via hematogenous route
(c) third pharyngeal pouch (d) is commonly multifocal
(d) fourth pharyngeal pouch
291. Multiple endocrine neoplasia is associated with
283. Hypotension and decreased end-tidal CO2 during germline mutation in:
laparoscopy are likely due to: (a) p53 gene
(a) tension pneumothorax (b) RET proto-oncogene
(b) inferior vena cava compression (c) N-myc gene
(c) CO2 embolism (d) APC gene
(d) anesthetic overdose
292. Optimal treatment of cloacogenic carcinoma of anal
284. The main fuel for most cancer cells is: canal is:
(a) butyrate (a) local excision
(b) glutamine (b) abdominoperineal resection
(c) L-arginine (c) chemotherapy alone
(d) glucose (d) radiotherapy alone
(e) ketones (e) chemoradiation
174. Surgery Review Questions
293. The most common hernia in women is:
(a) femoral hernia
(b) obturator hernia
(c) inguinal hernia
(d) umbilical hernia
(e) spigelian hernia
294. Gastroschisis:
(a) is usually associated with other anomalies
(b) is usually associated with chromosomal dis-
orders
(c) is located on the left of the umbilical cord
(d) repair is followed by prolonged ileus
295. The most common visceral aneurysm is:
(a) celiac
(b) superior mesenteric artery
(c) splenic
(d) hepatic
296. Gastroschisis is associated with an increased risk of:
(a) hepatomegaly
(b) intestinal atresia
(c) microcephaly
(d) cardiac anomalies
297. The cremaster muscle is derived from:
(a) the external oblique muscle
(b) the internal oblique muscle
(c) the transversus abdominis muscle
(d) the transversalis fascia
298. The time for platelet transfusion during splenec-
tomy for idiopathic thrombocytopenic purpura is:
(a) on making the incision
(b) after ligation of the splenic artery
(c) on induction of anesthesia
(d) after removal of the spleen
299. The most common congenital cardiac defect is:
(a) atrial septal defect
(b) ventricular septal defect
(c) transposition of great vessels
(d) aortic coarticulation
300. The most appropriate method to diagnose small
bowel injury in a conscious trauma patient with
seatbelt injury is:
(a) diagnostic peritoneal lavage
(b) ultrasound
(c) computed tomography scan
(d) serial abdominal examination
(e) plain abdominal film
425
301. On postoperative day 1, a patient develops a
temperature of 104°F and foul-smelling wound
drainage. The most likely isolate is:
(a) Gram-negative rods
(b) Gram-positive rods
(c) Gram-negative cocci
(d) Gram-positive cocci
302. A hemodynamic consequence of carbon dioxide
pneumoperitoneum is:
(a) decrease in cardiac index
(b) decrease in systemic vascular resistance
(c) decrease in mean arterial pressure
(d) increase in cardiac preload
303. In the diabetic foot:
(a) atherosclerosis often involves the pedal arteries
(b) foot sepsis is often polymicrobial
(c) ankle–brachial index accurately measures the
degree of ischemia
(d) diabetic neuropathy involves only sensory
nerves
304. Decreased hemoglobin affinity to oxygen at the
tissue level is caused by:
(a) increased body temperature
(b) decreased 2,3-diphosphoglycerate
(c) decreased pCO2
(d) increased pH
305. A patient with pelvic fracture is hypotensive and has
grossly positive diagnostic peritoneal lavage. The
next step is:
(a) angiography and embolization
(b) computed tomography of the abdomen and
pelvis
(c) celiotomy
(d) application of C-clamp
(e) application of pneumatic antishock garment
306. Heparin:
(a) prevents platelet aggregation
(b) prevents factor VII synthesis
(c) is a cyclo-oxygenase inhibitor
(d) potentiates the action of antithrombin III
307. Cholecystokinin:
(a) stimulates the sphincter of Oddi
(b) is secreted by the antral mucosa
(c) stimulates pancreatic enzyme secretion
(d) stimulates gastric emptying
426 Part XVI. Surgery Review Questions and Answers

308. The earliest and most specific sign of malignant 315. The lateral boundary of a femoral hernia is:
hyperthermia is: (a) the femoral nerve
(a) high fever (b) the femoral artery
(b) hypotension (c) the femoral vein
(c) increase in end tidal CO2 (d) the lacunar ligament
(d) tachycardia
(e) hypoxia
316. A characteristic of primary hyperaldosteronism is:
(a) hyperkalemia
309. The most frequent manifestation of blunt myocar- (b) hyper-reninism
dial contusion is: (c) hypertension
(a) atrioventricular block (d) hyperplasia of zona reticularis
(b) atrial flutter (e) hyperplasia of zona fasciculata
(c) premature ventricular contractions
(d) premature atrial contractions
(e) atrial fibrillation 317. Regarding the adrenal gland:
(a) the adrenal cortex does not have nerve supply
(b) the adrenal medulla is supplied by postgan-
310. The most commonly injured nerve under general glionic adrenergic fibers
anesthesia is: (c) the right adrenal vein drains into the renal vein
(a) radial nerve (d) the left adrenal vein drains into the inferior
(b) ulnar nerve vena cava
(c) median nerve
(d) brachial plexus
(e) common peroneal nerve 318. At an operation for appendicitis, the appendix is
found to be normal and the fallopian tube is found
to be thickened with surrounding purulent exudate.
311. Respiratory distress associated with goiter is most
The operative management should be:
commonly caused by:
(a) appendectomy
(a) recurrent laryngeal nerve palsy
(b) appendectomy and salpingectomy
(b) malignant tracheal invasion
(c) salpingectomy
(c) retrosternal goitrous extension
(d) no operative intervention
(d) hemorrhage in large goiter

312. Malignant hyperthermia: 319. In the preoperative preparation of pheochromocy-

(a) can be induced by local anesthetics toma, medications are given in the following order:
(b) can be induced by nondepolarizing muscle (a) diuretics and then α-blockers
relaxants (b) α-blockers and then β-blockers
(c) can be induced by nitrous oxide (c) β-blockers and then α-blockers
(d) is related to disordered K+ metabolism (d) diuretics and then β-blockers
(e) is more common in children than adults
320. Hyperinsulinism in a newborn is most likely caused
313. The most common cardiac anomaly found in adults by:
is: (a) nesidioblastosis
(a) atrial septal defect (b) glycogen storage disease
(b) ventricular septal defect (c) benign insulinoma
(c) transposition of great vessels (d) malignant insulinoma
(d) coarctation of the aorta
321. A patient with abdominal wall desmoid tumor
314. The most common complication of epidural anal- should be screened for:
gesia is: (a) lung cancer
(a) hypotension (b) colon polyps
(d) nausea (c) breast cancer
(c) respiratory depression (d) medullary thyroid carcinoma
(d) deep vein thrombosis (e) pancreatic cancer
174. Surgery Review Questions 427

322. Which of the following is a vasoconstrictor? 330. The colon secretes:

(a) procaine (a) water
(b) bupivacaine (b) sodium
(c) lidocaine (c) chloride
(d) cocaine (d) potassium

323. Paralytic ileus is a complication of: 331. Mild diabetes, skin rash, and glossitis are features of:
(a) cyclophosphamide (a) somatostatinoma
(b) vinca alkaloids (b) gastrinoma
(c) methotrexate (c) glucagonoma
(d) cisplatin (d) insulinoma
(e) doxorubicin
332. The most common intra-abdominal solid tumor in
children is:
324. Neutropenic enterocolitis is a complication of:
(a) nephroblastoma
(a) cytarabine
(b) neuroblastoma
(b) cyclophosphamide
(c) rhabdomyosarcoma
(c) doxorubicin
(d) fibrosarcoma
(d) cisplatin
333. Distinction between toxic epidermal necrolysis and
325. Severe peripheral neuropathy is a complication of: staphylococcal scalding skin syndrome is based on:
(a) vinca alkaloids (a) degree of erythema
(b) cyclophosphamide (b) bullae formation
(c) cytarabine (c) level of exfoliation
(d) cisplatin (d) response to steroids

326. Watery diarrhea, hypokalemia, hypochloremia, and 334. An indication for laparotomy in neonatal necrotiz-
acidosis are features of: ing enterocolitis is:
(a) insulinoma (a) distended bowel loops
(b) gastrinoma (b) thickened bowel wall
(c) vasoactive intestinal peptide–producing tumor (c) abdominal wall erythema
(d) glucagonoma (d) pneumatosis intestinalis

335. Regarding congenital diaphragmatic hernia:

327. Characteristics of somatostatinoma are:
(a) mild diabetes, skin rash, glossitis
(b) ulcer diathesis, diarrhea
(c) mild diabetes, diarrhea, gallstones
(d) diarrhea, hypokalemia, hypochloremia
328. An inhibitor of platelet aggregation is:
(a) prostacyclin I
(b) thromboxane A2
(c) adenosine diphosphate
(d) serotonin
(e) von Willebrand’s factor
329. Regarding gastrointestinal bleeding in children:
(a) anal fissure is the leading cause
(b) clear nasogastric aspirate rules out upper gas-
trointestinal bleeding
(c) Meckel’s diverticulum is seldom the cause of
massive bleeding
(d) bleeding is the most common presentation of
intussusception
(a) requires emergency operation if respiratory dis-
tress is present
(b) foramen of Bochdalek hernia is the most
common type
(c) foramen of Morgagni hernia presents with res-
piratory distress
(d) is rarely associated with underlying lung pathol-
ogy
336. Regarding neonatal Hirschsprung’s disease:
(a) diagnosis is confirmed by barium enema
(b) enterocolitis is the leading cause of death
(c) mainly affects females
(d) shows absent nerve trunks in the aganglionic
segments
337. Prosthetic graft infection is most commonly due to:
(a) Staphylococcus epidermidis
(b) Staphylococcus aureus
(c) Escherichia coli
(d) Streptococcus faecalis
428 Part XVI. Surgery Review Questions and Answers

338. Sinistral portal hypertension is most commonly due 345. The most common cause of small bowel obstruction
to: during pregnancy is:
(a) hypercoagulable states (a) incarcerated groin hernia
(b) schistosomiasis (b) adhesions
(c) alcoholism (c) gallstone ileus
(d) chronic pancreatitis (d) intestinal volvulus
(e) intussusception
339. Cervical sympathectomy is least likely to improve:
346. Which of the following is an analgesic?
(a) hyperhidrosis
(a) sodium thiopental
(b) scleroderma
(b) ketamine
(c) causalgia
(c) etomidate
(d) frostbite
(d) propofol

340. Management of deep vein thrombosis during
pregnancy is:
(a) 10-day intravenous heparin and then Coumadin
until term
(b) 10-day intravenous heparin and then Coumadin
for 6 months
(c) 10-day intravenous heparin and then prophy-
lactic subcutaneous heparin until term
(d) 10-day intravenous heparin and then therapeu-
tic subcutaneous heparin until term
341. A pleural fluid pH >6.5:
(a) is normal
(b) indicates esophageal perforation
(c) indicates pleural transudate
(d) indicates bacterial infection
342. The most accurate method to diagnose traumatic
aortic arch injury is:
(a) upright chest x-ray
(b) chest computed tomography
(c) magnetic resonance imaging
(d) transesophageal echocardiogram
343. Lung resection is contraindicated if:
(a) preoperative PO2 is 60
(b) preoperative PCO2 is 50
(c) FEV1 = 1 liter
(d) FEV1/VC is 75%
(e) MBC is 60%
344. Immediately after intravenous (IV) injection of
5,000 U of heparin, the effect can be reversed with
IV:
(a) 10 mg protamine sulfate
(b) 20 mg protamine sulfate
(c) 30 mg protamine sulfate
(d) 40 mg protamine sulfate
(e) 50 mg protamine sulfate
347. A contraindication to the use of ketamine is:
(a) hypotension
(b) head injury
(c) asthma
(d) hypoventilation
348. The cytokine directly responsible for hepatic acute
phase response is:
(a) interleukin-1
(b) interleukin-2
(c) interleukin-6
(d) tumor necrosis factor-α
349. In multiple endocrine neoplasia type 1:
(a) almost all patients have parathyroid hyper-
plasia
(b) almost all patients have pancreatic endocrine
tumor
(c) almost all patients have pituitary adenoma
(d) all patients have hyperparathyroidism, pancre-
atic, and pituitary lesions
350. Postoperative cardiac events are most likely if pre-
operative electrocardiogram shows:
(a) ST-T wave changes
(b) bundle branch block
(c) left ventricular hypertrophy
(d) Q-wave
351. An indication for preoperative angiography for
elective abdominal aortic aneurysm surgery is:
(a) suspected contained rupture
(b) suspected inflammatory aneurysm
(c) aneurysm larger than 7 cm
(d) history of claudication
352. An early feature of lidocaine toxicity is:
(a) arrhythmia
(b) muscle twitching
(c) respiratory depression
(d) hypotension
174. Surgery Review Questions 429

353. The superior pancreaticoduodenal artery is a 360. A 70-kg male with 50% body surface area second-
branch of: degree burn requires:358
(a) the celiac axis (a) 7,000 mL of lactated Ringer’s solution over the
(b) the superior mesenteric artery first 6 hours
(c) the hepatic artery (b) 7,000 mL of lactated Ringer’s solution over the
(d) the right gastric artery first 8 hours
(e) the gastroduodenal artery (c) 8,000 mL of lactated Ringer’s solution over the
first 8 hours
354. Which of the following pancreatic enzymes is se- (d) 10,000 mL of lactated Ringer’s solution over the
creted in an active form? first 8 hours
(a) lipase
(b) phospholipase A 361. A complication that enteral and parenteral feeding
(c) trypsin have in common is:
(d) elastase (a) increased incidence of sepsis
(b) intestinal villous atrophy
(c) elevated liver transaminases
355. A tracheostomy-related tracheoinnominate fistula
(d) hyperosmolar nonketotic coma
is best managed by:
(e) diarrhea
(a) division of innominate artery and ligation of
both ends 362. The most common organism isolated from bile is:
(b) division of innominate artery and vein graft (a) Escherichia coli
(c) division of innominate artery and polytetraflu- (b) Klebsiella
oroethylene graft (c) Staphylococcus aureus
(d) primary repair of the innominate artery (d) Bacteroides
(e) Proteus
356. Optimum calorie/nitrogen ratio for protein synthe-
sis is: 363. The protein loss equivalent to 100 g of negative
(a) 25–50 : 1 nitrogen balance is:
(b) 50–75 : 1 (a) 75 g
(c) 75–100 : 1 (b) 150 g
(d) 100–150 : 1 (c) 375 g
(d) 525 g
357. Aldosterone: (e) 625 g
(a) stimulates sodium resorption in proximal renal
tubules 364. The most common cause of cancer-related death in
(b) stimulates sodium resorption in distal renal females is:
tubules (a) breast cancer
(c) stimulates potassium resorption in proximal (b) colon cancer
renal tubules (c) ovarian cancer
(d) stimulates potassium resorption in distal renal (d) pancreatic cancer
tubules (e) lung cancer

365. The highest potassium concentration is found in:

358. Hypertension in cases of extra-adrenal pheochro- (a) saliva
mocytoma is caused by: (b) gastric secretion
(a) combined epinephrine and norepinephrine (c) bile
(b) pure epinephrine (d) small intestine
(c) pure norepinephrine (e) pancreatic secretion
(d) rennin, epinephrine, and norepinephrine
366. The risk of regional node metastases in 0.70 mm
359. The highest bicarbonate concentration is found in: thick melanoma is:
(a) saliva (a) <5%
(b) gastric secretions (b) 10%
(c) biliary secretion (c) 20%
(d) pancreatic secretion (d) 30%
(e) small intestine (e) 50%
430 Part XVI. Surgery Review Questions and Answers

367. The initial fluid bolus for an injured child is: 374. In the TNM staging, stage II colorectal cancer is:
(a) 10 mL/kg of lactated Ringer’s solution (a) T1, N1, M0
(b) 20 mL/kg of lactated Ringer’s solution (b) T2, N0, M0
(c) 30 mL/kg of lactated Ringer’s solution (c) T3, N1, M0
(d) 40 mL/kg of lactated Ringer’s solution (d) T4, N0, M0
(e) T3, N1, M1
368. Elevation of urinary 5-hydroxyindole acetic acid is
diagnostic of: 375. Postoperative radiation without chemotherapy:
(a) pheochromocytoma (a) improves survival in stage II colon cancer
(b) Cushing’s disease (b) improves local recurrence in stage II colon
(c) carcinoid syndrome cancer
(d) aldosteronoma (c) improves local recurrence in stage III rectal
cancer
369. Regarding hypertrophic pyloric stenosis: (d) improves local recurrence and survival in stage
(a) more common in males III rectal cancer
(b) most commonly presents in the first week of life
(c) vomit is typically bile stained 376. Risk of irreversible tissue damage in pressure sores
(d) diagnosis should be confirmed with upper gas- is highest with:
trointestinal contrast study (a) constant pressure of 50 mm Hg for 2 hours
(b) constant pressure of 70 mm Hg for 2 hours
370. A colon polyp with the highest malignant potential (c) constant pressure of 100 mm Hg for 30 minutes
is: (d) constant pressure of 150 mm Hg for 20 minutes
(a) 1 cm tubular adenoma
(b) 4 cm hyperplastic polyp 377. In caustic esophageal injury:
(c) 2 cm villous adenoma (a) upper endoscopy is contraindicated in the acute
(d) 2 cm tubulovillous adenoma phase
(e) 3 cm juvenile polyp (b) early induced emesis is helpful in minimizing
the period of mucosal contact
371. Gastric smooth muscle tumors present most com- (c) alkalis cause coagulative tissue necrosis
monly as: (d) acids cause severe gastric rather than eso-
(a) upper gastrointestinal hemorrhage phageal injury
(b) incidental finding on esophagogastroduode-
noscopy 378. Toxic epidermal necrolysis in children is most com-
(c) gastric outlet obstruction monly related to:
(d) intermittent epigastric pain (a) Pseudomonas aeruginosa
(e) weight loss (b) Escherichia coli
(c) Staphylococcus aureus
372. The desired minimum distal margin of resected (d) Streptococcus pneumoniae
rectal cancer is:
(a) 1 cm 379. The most essential step in management of
(b) 2 cm esophageal reflux and Barrett’s change is:
(c) 3 cm (a) Nissen fundoplication
(d) 4 cm (b) close endoscopic surveillance
(e) 5 cm (c) esophageal resection
(d) medical management of reflux disease
373. Regarding gastric adenocarcinoma:
(a) the intestinal type is more common in younger 380. A prominent “v” wave in the right atrial venous
patients waveform indicates:
(b) the intestinal type is often associated with peri- (a) tricuspid valve regurgitation
toneal spread (b) atrial fibrillation
(c) the intestinal type has worse prognosis than (c) pulmonary embolism
diffuse type (d) atrial septal defect
(d) the intestinal type is often distal in location (e) atrial flutter
174. Surgery Review Questions 431

381. The mainstay of treatment of blunt carotid artery 388. The initial step in management of a 25-year-old
injuries is: male with a painless scrotal mass is:
(a) surgical exploration and vein patch graft (a) fine-needle aspiration and cytology
(b) endoluminal stenting (b) abdominal computed tomography scan
(c) catheter thrombolysis (c) observation and repeat examination in 2 weeks
(d) anticoagulation (d) scrotal ultrasound
(e) orchiectomy
382. Regarding the anatomy of the esophagus:
(a) the cervical esophagus lies to the right of the
midline 389. The most common anterior mediastinal tumor is:
(b) the thoracic esophagus is anterior to the aortic (a) thymoma
arch (b) retrosternal goiter
(c) the left vagus nerve passes posterior to the (c) lymphoma
esophagus (d) teratoma
(d) the cervical esophagus is supplied by the infe-
rior thyroid artery
(e) the abdominal esophagus is supplied by the 390. The hallmark of multiple endocrine neoplasia type
right gastric artery 2 syndromes is:
(a) hyperparathyroidism
383. The most common cause of early postoperative (b) pheochromocytoma
death in elective abdominal aortic aneurysm repair (c) medullary thyroid carcinoma
is: (d) pituitary adenoma
(a) acute renal tubular necrosis (e) neural gangliomas
(b) ischemic stroke
(c) acute myocardial infarction
(d) respiratory failure 391. The cranial nerve most commonly injured during
(e) exsanguination from anastomotic disruption carotid endarterectomy is:
(a) IX
384. The initial test in cases of suspected gastroe- (b) X
sophageal reflux should be: (c) XI
(a) Barium swallow (d) XII
(b) upper endoscopy
(c) gastric pH monitoring
(d) esophageal manometry 392. Inadvertent tissue extravasation of intravenous
dopamine is best managed with:
385. Which of the following organisms is slime- (a) topical steroids and elevation
producing? (b) local ice packs and elevation
(a) Candida albicans (c) local infiltration of nitroglycerin
(b) Staphylococcus aureus (d) local infiltration of phentolamine
(c) Staphylococcus epidermidis (e) local infiltration of 1% lidocaine
(d) Klebsiella pneumoniae
(e) Enterobacter aerogenes
393. Hürthle cell thyroid carcinoma:
386. An increased incidence of adenocarcinoma of the (a) is adequately treated with thyroid lobectomy
esophagus is associated with: (b) is seldom bilateral
(a) achalasia (c) often metastasizes to the cervical lymph nodes
(b) lye ingestion (d) is often related to previous neck radiation
(c) Barrett’s esophagus
(d) Plummer-Vinson syndrome
394. Which of the following contributes to the arterial
387. Insulinomas: supply of the thoracic esophagus?
(a) are usually benign (a) right gastric artery
(b) are usually multiple (b) bronchial artery
(c) are commonly located in the tail of the pancreas (c) pulmonary artery
(d) are less common than gastrinoma (d) innominate artery
432 Part XVI. Surgery Review Questions and Answers

395. Regarding postoperative myocardial infarction: 401. Hürthle cell thyroid carcinoma:
(a) it is often associated with chest pain (a) can be readily diagnosed with fine-needle
(b) ischemic injury is more common postopera- aspiration
tively rather than intraoperatively (b) is often associated with previous neck radiation
(c) T-wave changes are the most specific finding for (c) is more aggressive than follicular thyroid carci-
acute myocardial infarction noma
(d) it occurs most commonly within the first 48 (d) typically shows avid 131I uptake
hours after surgery
402. Burn-associated inhalation injury can be ex-
396. The least appropriate test in the initial evaluation of cluded if:
adrenal incidentaloma is: (a) the chest x-ray on admission is normal
(a) magnetic resonance imaging of the abdomen (b) there is no abnormal finding on flexible bron-
(b) fine-needle aspiration biopsy choscopy
(c) follow-up computed tomography of the abdo- (c) the arterial oxygen saturation is over 90%
men in 6 months (d) the FEV1/FVC is normal
(d) 24-hour urinary vanillylmandelic acid (VMA)
level 403. The lateral boundary of a left paraduodenal hernia
(e) serum potassium level is:
(a) the splenic artery
397. A 58-year-old female with a tubo-ovarian abscess (b) the left renal vein
should be treated with: (c) the superior mesenteric vein
(a) antibiotics and laparoscopic drainage (d) the inferior mesenteric artery
(b) antibiotics with hysterectomy and bilateral (e) the inferior mesenteric vein
salpingo-oophorectomy
(c) antibiotics and unilateral salpingo- 404. The carotid body:
oophorectomy (a) is a pressure receptor
(d) antibiotics and computed tomography–guided (b) is an osmoreceptor
drainage (c) is a subintimal structure
(e) antibiotics and observation (d) is located in the adventia
(e) is located in the media
398. Cannon “a” waves on a right atrial waveform tracing
indicate: 405. Barrett’s esophagus:
(a) atrial flutter (a) is commonly congenital in origin
(b) atrial fibrillation (b) is associated with epidermoid carcinoma of the
(c) tricuspid regurgitation esophagus
(d) pulmonary embolism (c) is reversed by a successful antireflux surgery
(e) atrioventricular block (d) is an indication for life-long endoscopic
surveillance
399. Intralobar pulmonary sequestration:
(a) is supplied by the aorta 406. The most common causative agent in nosocomial
(b) is drained by the azygos venous system sinusitis in the ICU is:
(c) is commonly associated with diaphragmatic de- (a) Pseudomonas aeruginosa
fect (b) Staphylococcus aureus
(d) has a separate pleural covering (c) Staphylococcus epidermidis
(d) Streptococcus pneumoniae
400. Specific therapy for heparin-induced thrombocy-
topenia is: 407. The treatment of hyperacute kidney transplant
(a) low-molecular-weight heparin rejection is:
(b) Coumadin (a) administration of OKT-3
(c) dextran-60 (b) administration of massive doses of steroids
(d) aspirin (c) immediate transplant nephrectomy
(e) lepirudin (d) observation and dialysis
174. Surgery Review Questions
408. Blunt cardiac injury:
(a) most commonly affects the left ventricle
(b) most commonly results in ventricular arrhyth-
mias
(c) can be reliably excluded if cardiac enzymes are
normal
(d) should be suspected if admission electrocardio-
gram is abnormal
409. A characteristic of Buerger’s disease is:
(a) superficial migratory thrombophlebitis
(b) female predominance
(c) severe involvement of the aortoiliac segment
(d) the disease is restricted to the lower extremities
410. Recurrence of thyroid carcinoma after definitive
treatment is best detected by:
(a) ultrasound of the neck
(b) thyroid-stimulating hormone level measure-
ment
(c) thyroglobin serum measurement
(d) computed tomography scan of the neck
(e) triiodothyronine/thyroxine measurement
411. The primary regulator of aldosterone secretion is:
(a) angiotensin II
(b) serum K level
(c) adrenocorticotropic hormone
(d) prostaglandins
412. The optimum management of a T4 breast cancer is:
(a) modified radical mastectomy and radiation
(b) chemoradiation only
(c) simple mastectomy and radiation
(d) chemotherapy followed by mastectomy and
radiation
(e) radiation therapy only
413. The diagnosis of esophageal achalasia is confirmed
by:
(a) bird’s beak appearance on barium swallow
(b) subatmospheric intraluminal esophageal pres-
sure on manometry
(c) endoscopic evidence of distal esophagitis
(d) failure of lower esophageal sphincter relaxation
on manometry
(e) hyperperistalsis of the body of the esophagus
414. Factor VIII–related antigen is a marker of:
(a) Kaposi’s sarcoma
(b) melanoma
(c) postmastectomy angiosarcoma
(d) desmoid tumors
(e) Merkel cell carcinoma
433
415. The indication for fine-needle aspiration biopsy of
an adrenal incidentaloma is:
(a) suspected pheochromocytoma
(b) suspected aldosteronoma
(c) suspected adrenal carcinoma
(d) suspected adrenal metastases
416. Male breast cancer:
(a) has a peak incidence at the age of 40 years
(b) is typically hormonally dependent
(c) typically presents with bloody nipple discharge
(d) is seldom an indication for tamoxifen therapy
417. A non-anion gap metabolic acidosis is associated
with:
(a) diabetic ketoacidosis
(b) hemorrhagic shock
(c) excessive sodium chloride administration
(d) uremia
(e) ingestion of ethylene glycol
418. Inverse ratio ventilation:
(a) decreases mean airway pressure and increases
intrathoracic pressure
(b) decreases mean airway pressure and decreases
intrathoracic pressure
(c) increases mean airway pressure and increases
intrathoracic pressure
(d) increases mean airway pressure and decreases
intrathoracic pressure
419. Duodenal atresia:
(a) is caused by intrauterine mesenteric vascular
accident
(b) commonly exhibits normal muscular wall with
a mucosal web
(c) is seldom associated with normal passage of
meconium at birth
(d) is rarely associated with other congenital
anomalies
420. Angiotensin-converting enzyme is produced by:
(a) type I pneumocytes
(b) type II pneumocytes
(c) hepatocytes
(d) juxtaglomerular cells
(e) vascular endothelial cells
421. Hereditary nonpolyposis colorectal cancer:
(a) is an autosomal recessive disorder
(b) is associated with higher incidence of ovarian
cancer
(c) is associated with higher incidence of endome-
trial cancer
(d) is mostly left-side colon cancer
434
422. Auto-positive end-expiratory pressure in mechani-
cal ventilation is most likely to develop with:
(a) high rates and prolonged I : E ratio
(b) high rates and decreased I : E ratio
(c) decreased rate and decreased I : E ratio
(d) decreased rate and prolonged I : E ratio
423. Initial management of T4 invasive lobular breast
carcinoma is:
(a) tamoxifen therapy
(b) modified radical mastectomy
(c) radiation therapy to the breast and ipsilateral
axilla
(d) neoadjuvant chemotherapy
424. The fluid of chylothorax is composed of:
(a) pure fat
(b) fat and neutrophils
(c) fat and lymphocytes
(d) fat and macrophages
425. The most common cause of renovascular hyperten-
sion is:
(a) aneurysm of the renal artery
(b) fibromuscular hyperplasia
(c) renal artery calcinosis
(d) renal artery atheroma
426. Merkel cell carcinoma:
(a) is highly radiosensitive
(b) has the best prognosis when it occurs on the
trunk
(c) seldom spreads to regional lymph nodes
(d) is less likely than melanoma to recur after local
excision
427. A complication of tacrolimus therapy is:
(a) new-onset diabetes
(b) upper gastrointestinal bleeding
(c) thrombocytopenia
(d) cardiac arrhythmia
(e) bronchospasm
428. Extralobar pulmonary sequestration:
(a) typical presents with repeated pulmonary infec-
tions
(b) is drained by the pulmonary veins
(c) is supplied by the aorta
(d) is more common on the right side
(e) is commonly connected with the bronchial tree
Part XVI. Surgery Review Questions and Answers
429. Appropriate management of radiation mastitis is:
(a) local heat application
(b) danazol therapy
(c) therapeutic breast massage
(d) simple mastectomy
(e) pentoxifylline therapy
430. Optimum therapy for effort thrombosis of the axil-
lary vein is:
(a) therapeutic heparin followed by Coumadin for
3 months
(b) therapeutic heparin followed by Coumadin for
6 months
(c) thrombolysis, anticoagulation, and possible first
rib resection
(d) thrombolysis, anticoagulation, and balloon an-
gioplasty
(e) thrombectomy, anticoagulation, and stent place-
ment
431. Drooling from the corner of the mouth after sub-
mandibular gland excision is due to:
(a) injury of the lingual nerve
(b) injury of the ansa cervicalis
(c) injury of the hypoglossal nerve
(d) injury of the marginal mandibular nerve
432. The component of blood transfusion responsible for
immunosuppression is:
(a) red cells
(b) immunoglobulins
(c) white blood cells
(d) platelets
433. In therapeutic immunosuppression, rapamycin:
(a) blocks interleukin-1 production
(b) blocks interleukin-1 action
(c) blocks interleukin-2 production
(d) blocks interleukin-2 action
434. Gallstones diagnosed during pregnancy:
(a) may resolve spontaneously after delivery
(b) are the most common cause of jaundice during
pregnancy
(c) are seldom the cause of recurrent acute chole-
cystitis during the same pregnancy
(d) are most commonly pigment stones
435. Trauma cesarean section is indicated if the fetus is
viable and:
(a) the mother is unstable and cardiac arrest is anti-
cipated
(b) 5 minutes of cardiopulmonary resuscitation were
successful
(c) 5 minutes of cardiopulmonary resuscitation were
unsuccessful
(d) cardiopulmonary resuscitation has just been
initiated
174. Surgery Review Questions
436. The single most common abdominal operation for
the elderly is:
(a) adhesiolysis for small bowel obstruction
(b) closure of perforated duodenal ulcer
(c) resection of colon cancer
(d) cholecystectomy
(e) appendectomy
437. An age-related change in respiratory functions is:
(a) increased total lung capacity (TLC)
(b) decreased total lung capacity (TLC)
(c) decreased functional residual capacity (FRC)
(d) increased residual volume (RV)
(e) increased vital capacity (VC)
438. Fetal death during pregnancy is most commonly due
to:
(a) abruptio placentae
(b) subarachnoid hemorrhage
(c) penetrating fetal injury
(d) maternal demise
439. A physiologic change of aging is:
(a) increased total body water
(b) decreased antidiuretic hormone secretion
(ADH)
(c) decreased aldosterone secretion
(d) exaggerated thirst response
(e) decreased atrial natriuretic peptide (ANP)
440. Which of the following is contraindicated during
pregnancy for treating breast cancer?
(a) methotrexate
(b) 5-fluorouracil
(c) doxorubicin
(d) cyclophosphamide
441. In the elderly:
(a) there is decreased insensible water loss
(b) there is increased antidiuretic hormone re-
sponse
(c) there is increased volume of distribution of
water-soluble medications
(d) there is decreased volume of distribution of
lipid-soluble medications
442. During pregnancy:
(a) acute appendicitis is more common than in the
nonpregnant state
(b) intestinal obstruction is most commonly caused
by adhesions
(c) laparoscopic cholecystectomy is contraindi-
cated
(d) leukocytosis is often indicative of a surgical
abdominal pathology
435
443. An 80-year-old male is confused, lethargic, and has
tonic spasms. He has been receiving intravenous 5%
dextrose in water in one-half normal saline for 3
days after right hemicolectomy. The most likely
cause is:
(a) hypokalemia
(b) hyperkalemia
(c) hypocalcemia
(d) hypernatremia
(e) hyponatremia
444. A physiologic change in pregnancy is:
(a) increased gallbladder contractility
(b) elevated alkaline phosphatase
(c) elevated alanine aminotransferase (AST)/
aspartate aminotransferase (ALT)
(d) direct hyperbilirubinemia
(e) indirect hyperbilirubinemia
445. In the elderly:
(a) the myocardium is oversensitive to the effect of
catecholamines
(b) systolic function is more impaired than diastolic
function
(c) diastolic function is more impaired than systolic
function
(d) systolic and diastolic functions are equally
impaired
446. A Crohn’s disease–related internal fistula:
(a) most commonly presents with florid sepsis
(b) most commonly presents with Crohn’s disease
flare–up
(c) requires excision of both organs involved for
surgical treatment
(d) most commonly involves small bowel to small
bowel fistulation
(e) requires surgical intervention as soon as the
diagnosis is made
447. In inflammation, early “rolling” of neutrophils on
endothelium is a function of:
(a) selectins
(b) N-cahedrins
(c) immunoglobulin superfamily
(d) integrins
(e) complement activation
448. A paraesophageal hernia:
(a) is a type I hiatal hernia
(b) is most common in men <50 years of age
(c) may present with chronic anemia
(d) is often associated with reflux
(e) requires surgery only if symptomatic
436 Part XVI. Surgery Review Questions and Answers

449. The most common cause of large bowel obstruction 456. Eight hours after treatment for a scald injury, an
is: infant has a temperature of 40°C and a white blood
(a) colorectal cancer count of 5,000/mm3. The burn wound is clean. The
(b) Crohn’s colitis most likely diagnosis is:
(c) diverticulitis (a) Cytomegalovirus infection
(d) adhesions (b) clostridial wound infection
(e) volvulus (c) toxic shock syndrome
(d) Pseudomonas wound infection
450. Hypophosphatemia is associated with: (e) Pneumocystis pneumoniae
(a) increased hemoglobin p50, respiratory failure,
and encephalopathy
(b) decreased hemoglobin p50, hemolysis, and res- 457. The medial boundary of the femoral canal is:
piratory failure (a) the femoral vein
(c) respiratory failure, hypothyroidism, and hemol- (b) the femoral artery
ysis (c) the lacunar ligament
(d) ataxia, cardiomyopathy, and hypothyroidism (d) the inguinal ligament
(e) the femoral nerve
451. Preoperative radiotherapy for rectal adenocarci-
noma:
(a) improves survival 458. Hemorrhagic dermal bullae are characteristic of
(b) increases postoperative morbidity wound infection caused by:
(c) down-stages tumor in up to 50% of cases (a) coagulase-negative Staphylococcus
(d) is less effective than postoperative radiation (b) Streptococcus pyogenes
(c) Clostridium perfringens
452. The principal side effect of ganciclovir therapy is: (d) Clostridium tetani
(a) bone marrow suppression (e) Eikenella
(b) elevated liver enzymes
(c) acute pancreatitis
459. A marker with prognostic significance in cases of
(d) acute renal failure
seminoma is:
(e) prolonged ileus
(a) α-fetoprotein
453. In contrast to ulcerative colitis, Crohn’s disease: (b) human chorionic gonadotropin-β
(a) is not associated with increased cancer risk (c) alkaline phosphatase of hepatic origin
(b) may spare the rectum (d) testosterone level
(c) is more commonly associated with sclerosing (e) serum lactate dehydrogenase
cholangitis
(d) is more commonly associated with toxic mega- 460. Collagen synthesis in the actively healing wound is
colon best assessed by:
454. The negative predictive value of a test is: (a) glutamine content
(a) the proportion of patients with the disease who (b) arginine content
have a positive test (c) hydroxyproline content
(b) the proportion of patients without the disease (d) alanine content
who have a negative test
(c) the proportion of patients without the disease 461. The main motor nerve supply to the urinary bladder
who have a positive test is:
(d) the proportion of patients with a positive test (a) the pelvic nerve
who have the disease (b) the hypogastric nerve
(e) the proportion of patients with negative test (c) the pudendal nerve
who do not have the disease (d) the presacral nerve
455. Radiation enteritis of the large bowel most com-
monly affects: 462. Compared with hepatitis B virus, hepatitis C virus:
(a) the cecum (a) is an RNA virus
(b) the splenic flexure (b) less commonly results in persistent viremia
(c) the sigmoid (c) can be prevented with effective vaccination
(d) the rectum (d) can be transmitted via the fecal-oral route
174. Surgery Review Questions 437

463. The positive predictive value of a test is: 470. The thoracodorsal nerve:
(a) the proportion of patients with the disease who (a) is purely motor
have a positive test (b) supplies motor innervation to the serratus ante-
(b) the proportion of persons without the disease rior muscle
who have a negative test (c) injury during axillary dissection will lead to
(c) the proportion of persons with a positive test winged scapula
who have the disease (d) injury will result in loss of sensation on the
(d) the proportion of persons with a negative test medial surface of the upper arm
who do not have the disease
471. Hypocalcemia is a complication of chemotherapy
464. The circulating level of which cytokine can be used with:
as prognostic marker in sepsis? (a) cyclophosphamide
(a) interleukin-1 (b) vincristine
(b) interleukin-2 (c) methotrexate
(c) interleukin-6 (d) mithramycin
(d) interleukin-8 (e) Adriamycin
(e) tumor necrosis factor-α
472. Male breast cancer most commonly presents with:
465. Nitric oxide: (a) mastodynia
(a) is a potent vasoconstrictor (b) bleeding per nipple
(b) prevents platelets aggregation (c) breast mass only
(c) requires cyclic adenosine monophosphate for (d) breast mass and bleeding per nipple
its actions (e) breast mass with ulceration
(d) is normally stored in endothelial cells
473. Which of the following is a clear indication of
466. The most common cause of facial nerve paralysis is: surgery for necrotizing enterocolitis?
(a) parotid surgery (a) generalized gas distension of the intestine
(b) faciomaxillary injury (b) bleeding rectum
(c) Bells’ palsy (c) pneumatosis intestinalis
(d) pleomorphic adenoma of the parotid gland (d) gas in the portal vein
(e) carcinoma of the parotid gland (e) pneumoperitoneum

467. Most renal absorption of sodium takes place in: 474. An infected dog bite is most readily treated with:
(a) the proximal tubules (a) gentamicin
(b) the loop of Henle (b) ampicillin
(c) the distal tubules (c) vancomycin
(d) the collecting ducts (d) clindamycin

468. Distinction between hemorrhagic and cardiogenic 475. During CO2 pneumoperitoneum:
shock can be based on: (a) the mean arterial pressure increases
(a) level of urinary sodium (b) the mean arterial pressure decreases
(b) ventricular filling pressures (c) the systemic vascular resistance increases
(c) system vascular resistance (d) the systemic vascular resistance decreases
(d) serum lactate level (e) the cardiac output increases
(e) mixed venous oxygen saturation
476. In diabetic foot ulcers:
469. Renin–angiotensin system is activated by: (a) neuropathy is restricted to somatic nerves
(a) hyponatremia (b) the heel is the most common location
(b) hypernatremia (c) motor neuropathy mostly affects toe flexors
(c) hypokalemia (d) cold, dry foot is a classic finding
(d) hypocalcemia (e) the ankle–brachial index is an accurate measure
(e) hypercalcemia of the degree of ischemia
438 Part XVI. Surgery Review Questions and Answers

477. A sign of early sepsis is: 485. The most common fatal infection in burn victims is:
(a) metabolic alkalosis (a) pneumonia
(b) metabolic acidosis (b) venous line–related sepsis
(c) respiratory alkalosis (c) burn wounds sepsis
(d) respiratory acidosis (d) urinary tract infection

478. In contrast to a keloid, a hypertrophic scar: 486. The cardiac ejection fraction:
(a) is more likely to be familial (a) is normally 45%
(b) may subside spontaneously (b) is an accurate indicator of cardiac dysfunction
(c) may develop in delayed fashion years after in the elderly
initial injury (c) is increased in mitral stenosis
(d) often extends beyond the limits of the original (d) is decreased in mitral incompetence
wound (e) is increased in ventricular septal defect
479. In transplant recipients, there is an increased inci- 487. After 3 years, vein graft failure in the lower extrem-
dence of: ities is mostly caused by:
(a) colon cancer (a) technical complications
(b) anal cancer (b) anastomotic aneurysm
(c) lung cancer (c) atherosclerosis of the graft
(d) breast cancer (d) intimal thickening
(e) prostate cancer
488. The predominant parathyroid pathology in multiple
480. The most common cause of small bowel bleeding in
endocrine neoplasia is:
adults is:
(a) a single parathyroid adenoma
(a) Crohn’s disease
(b) multiple parathyroid adenomas
(b) arteriovenous malformation
(c) parathyroid hyperplasia
(c) leiomyosarcoma
(d) parathyroid carcinoma
(d) Meckel’s diverticulum
(e) carcinoid neoplasms 489. In renal artery stenosis, angiotensin-converting
enzyme inhibitors will:
481. A type IV hiatal hernia:
(a) decrease glomerular filtration rate
(a) is a sliding hiatus hernia
(b) increase glomerular filtration rate
(b) is a traumatic diaphragmatic hernia
(c) result in dilation of the afferent arterioles
(c) is a hernia that contains the stomach
(d) result in constriction of the afferent arterioles
(d) is a hernia that contains parts of the intestine
(e) result in constriction of the efferent arterioles
and colon

482. Isosulfan blue injection for sentinel node biopsy 490. The appropriate agent for prophylaxis in elective
may result in: colectomy is:
(a) cardiac arrhythmia (a) Flagyl
(b) inaccurate pulse oximetry (b) imipenem
(c) malignant hyperthermia (c) vancomycin
(d) hypercapnia (d) cefotetan
(e) skin sloughing (e) cefazolin

483. The most common complication of gastric ulcer is: 491. Which of the following is a dopamine antagonist?
(a) malignant transformation (a) phentolamine
(b) perforation (b) propofol
(c) upper gastrointestinal bleeding (c) haloperidol
(d) gastric outlet obstruction (d) clonidine

484. The preferred neuromuscular-blocking agent in a 492. Peripheral neuropathy is the main side effect of:
liver failure patient is: (a) cyclophosphamide
(a) vecuronium (b) vincristine
(b) atracurium (c) methotrexate
(c) pancuronium (d) mithramycin
(d) pipecuronium (e) Adriamycin
174. Surgery Review Questions 439

493. In liver transplantation, biliary complications are 499. The optimum management for stage II thyroid lym-
most commonly related to: phoma is:
(a) adequacy of hepatic venous outflow (a) total thyroidectomy
(b) adequacy of portal venous flow (b) total thyroidectomy and radical neck dissection
(c) adequacy of hepatic arterial flow (c) total thyroidectomy and chemotherapy
(d) length of the donor’s common bile duct (d) chemoradiation
(e) cervical radiation
494. The optimum management of aspiration pneu-
monitis is: 500. The most reliable indicator of successful ventilatory
(a) endotracheal intubation and mechanical ven- weaning is:
tilation (a) PO2 >100 with FiO2 of 40%
(b) endotracheal intubation, mechanical ventila- (b) PCO2 <40 mm Hg
tion, and bronchial lavage (c) negative inspiratory force less (more negative)
(c) endotracheal intubation, ventilation, bronchial than −30 cm HO2
lavage, and steroids (d) f/Vt <100
(d) endotracheal intubation, ventilation, bronchial
lavage, and antibiotics 501. Chronic allograft rejection:
(a) can be prevented with adequate immun-
495. Malignant hyperthermia: osuppression
(a) is triggered by the stress of surgery or anesthe- (b) is the main cause of death after liver trans-
sia only plantation
(b) is a contraindication to future general anesthe- (c) is more common with liver than heart trans-
sia plantation
(c) can be prevented by perioperative calcium (d) is more common with kidney than liver trans-
channel blockers plantation
(d) is associated with intraoperative rise of end
tidal CO2
502. The most accurate test to determine the need for
neoadjuvant therapy in esophageal carcinoma is:
496. The long thoracic nerve:
(a) endoluminal ultrasound
(a) is purely motor
(b) chest computed tomography scan
(b) provides sensation to the medial wall of the
(c) bronchoscopy
axilla
(d) barium swallow
(c) provides sensation to the medial aspect of the
(e) esophagogastroduodenoscopy
upper arm
(d) supplies motor innervation to the latissimus
dorsi muscle 503. The most characteristic metabolic abnormality in
(e) its injury results in weakness of arm abduc- glucagonoma is:
tion (a) hypoglycemia
(b) hypoaminoacidemia
497. The likelihood of malignancy in cystic pancreatic (c) hypocholesterolemia
neoplasm is related to: (d) hypercholesterolemia
(a) high glycogen content
(b) mucin content 504. A local anesthetic that can be safely administered
(c) sunburst appearance on computed tomography with tetracaine allergy is:
scan (a) lidocaine
(d) previous history of pancreatitis (b) cocaine
(c) procaine
498. Colovesical fistula: (d) chloroprocaine
(a) is most commonly caused by colon cancer
(b) is more common in females than in males 505. Clonidine is:
(c) is readily diagnosed with barium enema in most (a) an α1-agonist
cases (b) an α1-antagonist
(d) requires segmental colectomy and partial cys- (c) an α2-agonist
tectomy for treatment (d) a β1-agonist
(e) most commonly presents with pneumaturia (e) a β2-agonist
440
506. A definitive diagnosis of inflammatory breast cancer
is provided by:
(a) unique mammographic appearance
(b) finding tumor emboli in dermal lymphatics
(c) finding extensive inflammatory cell infiltration
of the tumor
(d) elevated white cell count, fever, axillary
lymphadenopathy
(e) ultrasound appearance of cavitation
507. Tissue loss almost always results from ligation of
the:
(a) popliteal artery
(b) common femoral artery
(c) superficial femoral artery
(d) brachial artery
(e) portal vein
508. Male breast cancer:
(a) is associated with the BRCA-1 gene mutation
(b) can only be of ductal origin
(c) is seldom hormone receptor positive
(d) develops at a much younger age than female
breast cancer
509. Keloid formation has been associated with an
increased amount of:
(a) transforming growth factor-β
(b) platelet-derived growth factor
(c) epidermal growth factor
(d) basic fibroblast growth factor
(e) tumor necrosis factor-α
510. The anteroposterior anatomic relationship at the
renal hilum is:
(a) vein—artery—ureter
(b) artery—vein—ureter
(c) ureter—artery—vein
(d) ureter—vein—artery
511. Endophthalmitis is characteristic of:
(a) Escherichia coli sepsis
(b) toxic shock syndrome
(c) systemic candidiasis
(d) facial necrotizing fasciitis
512. The most important determinant of survival of
retroperitoneal sarcoma is:
(a) the use of adjuvant chemotherapy
(b) the size of the primary tumor
(c) the histologic type of the primary
(d) the use of intraoperative radiotherapy
(e) complete surgical resection
Part XVI. Surgery Review Questions and Answers
513. A pulmonary embolus is associated with:
(a) decrease in pulmonary capillary wedge pressure
(b) decrease in mean pulmonary artery pressure
(c) decrease in central venous pressure
(d) decrease in dead space/tidal volume ratio
514. Pyoderma gangrenosum is typically associated with:
(a) advanced colonic adenocarcinoma
(b) rectal carcinoid
(c) ulcerative colitis
(d) villous adenoma of the colon
515. Popliteal artery aneurysms:
(a) commonly present with rupture
(b) seldom result in limb ischemia
(c) are the most common peripheral arterial aneu-
rysms
(d) require operation only if they result in em-
bolization
(e) are most commonly false aneurysms
516. After vigorous exercise, an athlete develops pain on
dorsiflexion of the foot and decreased sensation in
the first web space. Appropriate action should be:
(a) color duplex scan and immediate hepariniza-
tion
(b) leg elevation, ice packs, and nonsteroidal anti-
inflammatory medications
(c) immediate fasciotomy
(d) immediate femoral arteriogram
517. The most common presentation of testicular cancer
is:
(a) a painless scrotal mass
(b) acute testicular pain
(c) a secondary hydrocele
(d) gynecomastia
(e) retroperitoneal lymphadenopathy
518. Which of the following is most likely to cause a
false-positive fecal occult blood test?
(a) oral iron therapy
(b) Coumadin therapy
(c) aspirin therapy
(d) nonsteroidal anti-inflammatory medications
(e) dietary peroxidases
519. Aldosteronoma is associated with:
(a) hypertension, hypokalemia, high aldosterone
and high renin levels
(b) hypertension, hyperkalemia, high aldosterone
and low renin levels
(c) hypertension, hyperkalemia, high aldosterone
and high renin levels
(d) hypertension, hypokalemia, high aldosterone
and low renin levels
174. Surgery Review Questions 441

520. A PO2 of 90 torr, PCO2 of 28 torr, and pH of 7.16 527. Neurogenic bladder dysfunction with intact bladder
on room air are indicative of: sensation is associated with:
(a) hypovolemic shock (a) nerve injury with abdominoperineal resection
(b) alveolar hypoventilation (b) cauda equina lesion
(c) prolonged nasogastric suctioning (c) myelomeningocele
(d) hyperventilation (d) paraplegia
(e) cerebrovascular accident
521. Idiopathic thrombocytopenic purpura is most likely 528. Tumor necrosis factor-α antagonist is useful in
to respond to splenectomy if: treating:
(a) the spleen is enlarged (a) disseminated intravascular coagulopathy
(b) the patient is a female (b) septic shock
(c) the disease is chronic (c) Crohn’s disease
(d) the disease responded to steroids (d) metastatic melanoma

522. A marker that would distinguish nonseminoma 529. An 83-year-old female presents with vomiting and
from seminoma is: abdominal distension. She complains of pain in the
(a) lactate dehydrogenase medial aspect of the right thigh, and a palpable lump
(b) alkaline phosphatases can be felt on the right side on rectal examination.
(c) human chorionic gonadotropin The appropriate action is:
(d) α-fetoprotein (a) nasogastric tube, intravenous fluids, and
observation
(b) flexible sigmoidoscopy and drainage of the
523. Positive end-expiratory pressure: rectal mass
(a) increases cardiac output (c) urgent laparotomy
(b) decreases functional residual capacity (d) Gastrografin study with small bowel follow-
(c) increases right to left shunting through
(d) lowers PCO2 (e) right groin exploration and hernia repair
(e) decreases alveolar–arterial oxygen gradient
530. A normal-sized spleen is found in:
(a) idiopathic thrombocytopenic purpura
524. Estrogen therapy for postmenopausal women is (b) myelodysplasia
associated with: (c) Gaucher’s disease
(a) increased incidence of thrombophlebitis (d) thalassemia
(b) increased incidence of hepatic adenoma (e) schistosomiasis
(c) increased incidence of endometrial cancer
(d) increased incidence of breast cancer 531. Neurogenic bladder after extensive pelvic surgery is
characterized by:
525. A 10-year-old boy comes from a family of “bleed- (a) painful urine retention
ers.” His coagulation profile shows: prolonged (b) large bladder capacity with overflow inconti-
bleeding time, normal prothrombin time, and pro- nence
longed partial thromboplastin time. His platelet (c) small residual volume and uninhibited bladder
count is 150,000/mm3. The most likely diagnosis is: contractions
(a) idiopathic thrombocytopenic purpura (d) autonomic dysreflexia
(b) thrombotic thrombocytopenic purpura
532. Regarding cytokines:
(c) hemophilia
(a) serum level is not related to the severity of
(d) Christmas disease
illness
(e) von Willebrand’s disease
(b) are stored intracellularly as preformed mole-
cules
526. A single organism is usually the causative agent in: (c) are produced by a limited number of specific
(a) pelvic inflammatory disease cells
(b) perforated diverticulitis (d) most commonly function in an endocrine
(c) acute cholecystitis fashion
(d) primary peritonitis (e) low serum levels are normally detected in heal-
(e) diabetic foot infections thy individuals
442
533. Hypothermic coagulopathy is characterized by:
(a) normal prothrombin time and normal partial
thromboplastin time
(b) normal prothrombin time and prolonged partial
thromboplastin time
(c) prolonged prothrombin time and normal partial
thromboplastin time
(d) depletion of factor VII
(e) depletion of factor VIII
534. A patient with diagnosed pseudomembranous
colitis is developing a worsening clinical picture and
is taken for urgent laparotomy. The appropriate sur-
gical procedure should include:
(a) segmental colectomy and exteriorization of the
ends
(b) total abdominal colectomy
(c) diverting proximal colostomy
(d) segmental colectomy and primary anastomosis
(e) segmental colectomy, primary anastomosis, and
diverting colostomy
535. The specificity of a test is:
(a) the proportion of patients with the disease who
have a positive test
(b) the proportion of patients without the disease
who have a negative test
(c) the proportion of patients with a positive test
who have the disease
(d) the proportion of patients with a negative test
who do not have the disease
536. A 45-year-old-male complains of severe chest pain
after a diagnostic upper endoscopy. He has crepitus
on palpation of his neck. The next step in manage-
ment should be:
(a) repeated upper endoscopy
(b) immediate endotracheal intubation
(c) Gastrografin swallow
(d) administration of aspirin and sublingual
nitrite
(e) admission to ICU, administration of intra-
venous narcotics, and observation
537. Familial adenomatous polyposis:
(a) is caused by inactivation of a tumor suppressor
gene
(b) has normal life expectancy after prophylactic
colectomy
(c) is associated with increased risk of right-side
colon cancer
(d) is inherited as an autosomal recessive trait
Part XVI. Surgery Review Questions and Answers
538. The most common posterior mediastinal mass in
children is:
(a) neuroblastoma
(b) teratoma
(c) lymphoma
(d) pheochromocytoma
539. In the absence of sepsis, glucose intolerance with
total parenteral nutrition may indicate:
(a) copper deficiency
(b) zinc deficiency
(c) magnesium deficiency
(d) chromium deficiency
540. The most common presentation of gastric cancer is:
(a) hematemesis and melena
(b) acute abdominal pain due to perforation
(c) vague abdominal pain and weight loss
(d) an epigastric mass
541. In burn victims, the finding most indicative of
inhalation injury is:
(a) singed nasal hair
(b) soot around the mouth
(c) dyspnea
(d) carbonaceous sputum
542. A child with anaphylactoid purpura develops an
acute colicky abdominal pain and bleeding per
rectum. The most likely diagnosis is:
(a) perforated duodenal ulcer
(b) bleeding Meckel’s diverticulum
(c) enterocolitis with perforation
(d) intussusception
543. The most reliable means of preoperative nutritional
assessment is:
(a) clinical history of weight loss
(b) serum albumin level
(c) impaired cell-mediated immunity
(d) triceps skinfold measurement
544. In contrast to adults, fetal wound healing:
(a) has a higher content of type III collagen
(b) has a higher level of transforming growth
factor-β
(c) has an exaggerated inflammatory phase
(d) has much less hyaluronic acid content
174. Surgery Review Questions
545. The greatest amount of maintenance intravenous
fluids is required for:
(a) 21-year-old male athlete
(b) 55-year-old obese male office worker
(c) 21-year-old housewife
(d) 75-year-old female with recent weight loss
546. The most accurate test to detect subclinical
hypothyroidism is:
(a) radioactive iodine uptake
(b) thyroid-stimulating hormone level
(c) total thyroxine level
(d) free thyroxine level
547. A 28-year-old male has a closed head injury, pul-
monary contusion, grade III splenic injury, and
closed femoral shaft fracture. The ideal manage-
ment of his fracture is:
(a) external fixation
(b) skeletal traction
(c) intramedullary nailing within 24 hours of injury
(d) intramedullary nailing 1 week after the injury
(e) use of metal plates and screws
548. Accessory spleens are most commonly found in:
(a) idiopathic thrombocytopenic purpura
(b) thrombotic thrombocytopenic purpura
(c) schistosomiasis
(d) hereditary spherocytosis
549. The effectiveness of prophylactic antibiotics in
surgery is mostly related to the:
(a) use of broad-spectrum agents
(b) continuation of antibiotics for 24 hours after
surgery
(c) timing of initial administration
(d) use of two synergistic agents
(e) use of bactericidal agents
550. A 6-year-old boy has a right undescended testicle.
His parents should be advised that:
(a) right orchiectomy should be performed
(b) a course of endocrine treatment is advisable
(c) orchiopexy is performed to improve spermato-
genesis and prevent cancer
(d) orchiopexy is performed but with no effect on
spermatogenesis or cancer prevention
(e) the right testicle is probably atrophic and can be
left undisturbed
443
551. The sensitivity of the test is:
(a) the proportion of patients with the disease who
have a positive test
(b) the proportion of patients without the disease
who have a negative test
(c) the proportion of patients with a positive test
who have the disease
(d) the proportion of patients with a negative test
who do not have the disease
552. Regarding an amebic liver abscess:
(a) surgical drainage is usually required
(b) negative stool testing for amebiasis rules out the
disease
(c) it should be drained percutaneously under com-
puted tomography guidance
(d) it is treated with metronidazole
553. An infant has been having episodic coughing for 48
hours. On examination, he is wheezing with
decreased aeration of the left chest. A chest x-ray
shows an overinflated left lung. The next step in
management should be:
(a) insertion of left-side chest tube
(b) insertion of right-side chest tube
(c) endotracheal intubation
(d) administration of steroid inhaler and observa-
tion
(e) rigid bronchoscopy
554. A 40-year-old female has a 4-cm hemangioma in the
right lobe of the liver on computed tomography
scan. She is asymptomatic. Appropriate action
should be:
(a) fine-needle biopsy
(b) arrangement for elective resection
(c) no further action
(d) angiographic embolization
555. A non-anion gap metabolic acidosis is associated
with:
(a) methane intoxication
(b) large amount of saline resuscitation
(c) diabetic ketoacidosis
(d) cardiogenic shock
(e) hemorrhagic shock
556. The gold standard for the diagnosis of pelvic inflam-
matory disease is:
(a) vaginal microbiology swab
(b) pelvic ultrasound
(c) laparoscopy
(d) pelvic computed tomography scan
(e) endometrial biopsy
444 Part XVI. Surgery Review Questions and Answers

557. A 60-year-old alcoholic male presents with severe 558. Mediastinal granulomas may be associated with:
chest pain after repeated vomiting. A chest x-ray (a) epiphrenic esophageal diverticulum
shows a small left pleural effusion. The next step in (b) Zenker’s diverticulum
management is: (c) esophageal traction diverticulum
(a) obtain cardiac enzymes and admit to coronary (d) achalasia
care unit
(b) insert nasogastric tube, administer intravenous
fluids, and observe
(c) insert nasogastric and left-side chest tube and
antibiotics
(d) administer Gastrografin swallow test
(e) perform upper endoscopy