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The limitations of

The limitations of
mammography include
mammography include
( (A) 1015% false negative rate A) 1015% false negative rate
(B) 10% false positive rate (B) 10% false positive rate
(C) difficulty visualizing tumors in the tail of pence (C) difficulty visualizing tumors in the tail of pence
(!) all of the a"ove (!) all of the a"ove
(#) none of the a"ove (#) none of the a"ove
Explanation:
Explanation:

$here is a 1015% false negative rate of current mammography% &n 'omen $here is a 1015% false negative rate of current mammography% &n 'omen
(0() years old* nearly +5% of invasive "reast cancers are not visualized% (0() years old* nearly +5% of invasive "reast cancers are not visualized%
$his drops to 10% for 'omen 505) years old% Almost 10% of patients 'ho $his drops to 10% for 'omen 505) years old% Almost 10% of patients 'ho
have routine screening mammography are as,ed to return for additional have routine screening mammography are as,ed to return for additional
studies% $his is to "etter clarify the a"normality% $he additional studies may studies% $his is to "etter clarify the a"normality% $he additional studies may
include additional mammographic vie's or ultrasounds* or it may re-uire include additional mammographic vie's or ultrasounds* or it may re-uire
invasive studies such as a "iopsy% .ammograms in general are less invasive studies such as a "iopsy% .ammograms in general are less
sensitive in younger 'omen 'ith dense "reast tissue% Breast implants may sensitive in younger 'omen 'ith dense "reast tissue% Breast implants may
also o"scure a mammographic evaluation% /outine mammography has a also o"scure a mammographic evaluation% /outine mammography has a
difficult time visualizing lesions deep against the chest 'all* lateral in the tail difficult time visualizing lesions deep against the chest 'all* lateral in the tail
of "reast* or inferior in the inframammary fold% of "reast* or inferior in the inframammary fold%

Bi"liography0opans !% &maging analysis of "reast lesions% &n1 2arris 3/* Bi"liography0opans !% &maging analysis of "reast lesions% &n1 2arris 3/*
4ippman .#* .orro' .* et al% (eds%)* 4ippman .#* .orro' .* et al% (eds%)* Diseases of the Breast Diseases of the Breast* +nd ed% * +nd ed%
5hiladelphia* 5A1 4ippincott* 6illiams 7 6il,ins* +000* 1+819(% 5hiladelphia* 5A1 4ippincott* 6illiams 7 6il,ins* +000* 1+819(%
Phyllodes tumors
Phyllodes tumors

(A) present in postmenopausal 'omen (A) present in postmenopausal 'omen


(B) are often malignant (B) are often malignant
(C) re-uire mastectomy "ecause of their high recurrence (C) re-uire mastectomy "ecause of their high recurrence
rate rate
(!) tend to recur (!) tend to recur
(#) are responsive to hormonal manipulation (#) are responsive to hormonal manipulation
Explanation
Explanation

: : 5hyllodes tumors* also ,no'n as cystosarcoma phyllodes* are stromal tumors% $hey are 'ell 5hyllodes tumors* also ,no'n as cystosarcoma phyllodes* are stromal tumors% $hey are 'ell
circumscri"ed and do not have a true capsule% $he cut surface of one of these tumors tends to "e circumscri"ed and do not have a true capsule% $he cut surface of one of these tumors tends to "e
mucoid% $here are numerous small pro:ections that ma,e surgical enucleation difficult% mucoid% $here are numerous small pro:ections that ma,e surgical enucleation difficult%

5hyllodes tend to occur in an older population than fi"roadenomas (;As)% ;As are also stromal 5hyllodes tend to occur in an older population than fi"roadenomas (;As)% ;As are also stromal
tumors* and it is thought that phyllodes may arise from these "enign tumors% 5hyllodes tend to tumors* and it is thought that phyllodes may arise from these "enign tumors% 5hyllodes tend to
occur in the fourth decade of life% .ost of these tumors present as painless masses that are occur in the fourth decade of life% .ost of these tumors present as painless masses that are
round and smooth% <n mammogram and ultrasound they are similar in appearance to ;As= round and smooth% <n mammogram and ultrasound they are similar in appearance to ;As=
smooth* solid* multilo"ulated margins% $here may also "e fluid 'ithin the mass on ultrasound* smooth* solid* multilo"ulated margins% $here may also "e fluid 'ithin the mass on ultrasound*
suggesting phyllodes over ;A% suggesting phyllodes over ;A%

eventy>five percent of phyllodes tumors are "enign% imilar to other stromal tumors* malignancy eventy>five percent of phyllodes tumors are "enign% imilar to other stromal tumors* malignancy
is difficult to esta"lish and is "ased on histologic appearance% tromal overgro'th is no' is difficult to esta"lish and is "ased on histologic appearance% tromal overgro'th is no'
considered the most important predictor of aggressive "ehavior% <ther characteristics that are considered the most important predictor of aggressive "ehavior% <ther characteristics that are
considered are cellular atypia* mitotic activity* and tumor margins% considered are cellular atypia* mitotic activity* and tumor margins%

5hyllodes tend to recur regardless of "enign or malignant status% $he reported incidence is +0 5hyllodes tend to recur regardless of "enign or malignant status% $he reported incidence is +0
+5% of recurrence% Current recommendations for initial surgical treatment of theses tumors are +5% of recurrence% Current recommendations for initial surgical treatment of theses tumors are
'ide local e?cision 'ith a +9 cm margin% $his can usually "e done 'ithout re-uiring a 'ide local e?cision 'ith a +9 cm margin% $his can usually "e done 'ithout re-uiring a
mastectomy and is "ased on tumor to "reast mass ratio% @sually if the tumor recurs* a total mastectomy and is "ased on tumor to "reast mass ratio% @sually if the tumor recurs* a total
mastectomy is re-uiredA ho'ever* some 'omen may "e a"le to tolerate a ree?cision 'ithout poor mastectomy is re-uiredA ho'ever* some 'omen may "e a"le to tolerate a ree?cision 'ithout poor
cosmesis% 4ess than 5% of all phyllodes tumors metastasize% /egional lymph node metastasis is cosmesis% 4ess than 5% of all phyllodes tumors metastasize% /egional lymph node metastasis is
rare and an a?illary dissection is not 'arranted% /adiation therapy is also not indicated "ecause rare and an a?illary dissection is not 'arranted% /adiation therapy is also not indicated "ecause
this is not a multifocal disease li,e ductal "reast cancer% $he tumors are only 'ea,ly this is not a multifocal disease li,e ductal "reast cancer% $he tumors are only 'ea,ly
radiosensitiveA ho'ever* radiation therapy may offer some palliation for recurrent disease% radiosensitiveA ho'ever* radiation therapy may offer some palliation for recurrent disease%
2ormonal manipulation is not "eneficial for these patients% $his is felt to represent the mi?ed 2ormonal manipulation is not "eneficial for these patients% $his is felt to represent the mi?ed
epithelial (positive receptors) and stromal (no receptors) components% epithelial (positive receptors) and stromal (no receptors) components%

Bi"liography!onegan 6% arcomas of the "reast% &n1 !onegan 6* prattt 3 (eds%)* Bi"liography!onegan 6% arcomas of the "reast% &n1 !onegan 6* prattt 3 (eds%)* Cancer of the Cancer of the
Breast Breast* 5th ed% t% 4ouis* .<1 6%B% aunders* +00+* )18)+9% * 5th ed% t% 4ouis* .<1 6%B% aunders* +00+* )18)+9%
5etre, 3% 5hyllodes tumor% &n1 2arris 3/* 4ippman .#* .orro' .* et al% (eds%)* 5etre, 3% 5hyllodes tumor% &n1 2arris 3/* 4ippman .#* .orro' .* et al% (eds%)* Diseases of the Diseases of the
Breast Breast* +nd ed% 5hiladelphia* 5A1 4ippincott* 6illiams 7 6il,ins* +000* BB)BC5% * +nd ed% 5hiladelphia* 5A1 4ippincott* 6illiams 7 6il,ins* +000* BB)BC5%
6ood 6% Benign "reast disease% &n1 Cameron 3 (ed%)* 6ood 6% Benign "reast disease% &n1 Cameron 3 (ed%)* Current Surgical Therapy Current Surgical Therapy* Cth ed% t% * Cth ed% t%
4ouis* .<1 .os"y* +001* B)1% 4ouis* .<1 .os"y* +001* B)1%

The most common etiology of
The most common etiology of
senescent gynecomastia is
senescent gynecomastia is

(A) cirrhosis
(A) cirrhosis
(B) testicular tumor
(B) testicular tumor
(C) renal disease
(C) renal disease
(!) idiopathic causes
(!) idiopathic causes
(#) drug induced
(#) drug induced
Explanation
Explanation

: : Dynecomastia is the "enign proliferation of "reast glandular tissue Dynecomastia is the "enign proliferation of "reast glandular tissue
in males% $his tends to occur in infancy* at pu"erty* and in old age% in males% $his tends to occur in infancy* at pu"erty* and in old age%

Dynecomastia results from an im"alance of the normal hormonal Dynecomastia results from an im"alance of the normal hormonal
milieu or a change in "reast tissue sensitivity to estrogen% $he milieu or a change in "reast tissue sensitivity to estrogen% $he
testes secrete )5% of the total "ody testosterone and only 15% of testes secrete )5% of the total "ody testosterone and only 15% of
the circulating estradiol% $he vast ma:ority of circulating estradiol is the circulating estradiol% $he vast ma:ority of circulating estradiol is
from the peripheral conversion of testosterone and adrenal steroids from the peripheral conversion of testosterone and adrenal steroids
via the aromatase enzyme% .ost of the hormones are "ound to se?> via the aromatase enzyme% .ost of the hormones are "ound to se?>
hormone "inding glo"ulin (2BD)* a protein formed in the liver% hormone "inding glo"ulin (2BD)* a protein formed in the liver%
2BD has a higher affinity for androgens than estrogen% An 2BD has a higher affinity for androgens than estrogen% An
im"alance in any of these path'ays may results in an increase of im"alance in any of these path'ays may results in an increase of
free estrogen as compared to "ound estrogen (;ig% 15>5)% free estrogen as compared to "ound estrogen (;ig% 15>5)%
Tamoxifen
Tamoxifen

(A) is an estrogen receptor (#/) agonist (A) is an estrogen receptor (#/) agonist
(B) is an #/ antagonist (B) is an #/ antagonist
(C) has "een sho'n to decrease the incidence of (C) has "een sho'n to decrease the incidence of
recurrent "reast cancer "y (C% recurrent "reast cancer "y (C%
(!) has "een sho'n to decrease the ris, of future "reast (!) has "een sho'n to decrease the ris, of future "reast
cancer "y ()% in high>ris, patients cancer "y ()% in high>ris, patients
(#) all of the a"ove (#) all of the a"ove
Explanation
Explanation

: : $amo?ifen* a selective estrogen receptor (#/) agonist antagonist* first $amo?ifen* a selective estrogen receptor (#/) agonist antagonist* first
came into the mar,et in the 1)C0s% &t is a 'ell>studied drug% $he antagonist came into the mar,et in the 1)C0s% &t is a 'ell>studied drug% $he antagonist
effects of tamo?ifen are related to its competitive "inding of the estrogen effects of tamo?ifen are related to its competitive "inding of the estrogen
receptor* especially in "reast tissue% $his results in a reduced transcription receptor* especially in "reast tissue% $his results in a reduced transcription
of estrogen related proteins and effective "loc,ade of cell cycle in D1% $his of estrogen related proteins and effective "loc,ade of cell cycle in D1% $his
in turn then translates to ineffective tumor gro'th% in turn then translates to ineffective tumor gro'th%

$amo?ifen has apparent estrogen agonist effects on the endometrial lining* $amo?ifen has apparent estrogen agonist effects on the endometrial lining*
as sho'n "y the increase in endometrial cancer found in 'omen "eing as sho'n "y the increase in endometrial cancer found in 'omen "eing
treated 'ith the drug% $his ris, is a"out 1%% $he cancers are usually found treated 'ith the drug% $his ris, is a"out 1%% $he cancers are usually found
in stage & and are very treata"le% &n addition* there is an increased ris, of in stage & and are very treata"le% &n addition* there is an increased ris, of
venous em"olic phenomena that is related to the estrogen agonist effects% venous em"olic phenomena that is related to the estrogen agonist effects%
$amo?ifen also increases "one density and improves lipid profiles="oth $amo?ifen also increases "one density and improves lipid profiles="oth
related to #/ agonist activity% $he ma:or side effects that 'omen complain related to #/ agonist activity% $he ma:or side effects that 'omen complain
a"out 'hile ta,ing tamo?ifen are hot flashes and sleep distur"ances= a"out 'hile ta,ing tamo?ifen are hot flashes and sleep distur"ances=
similar to menopausal symptoms attri"uted to decreased estrogen% similar to menopausal symptoms attri"uted to decreased estrogen%
A 34-year-old lady is referred to your office for evaluation of breast pain. he describes the pain as burning! A 34-year-old lady is referred to your office for evaluation of breast pain. he describes the pain as burning!
occasionally sharp in nature. "t is mostly located in the subareolar area and seems to be fairly #ell locali$ed. occasionally sharp in nature. "t is mostly located in the subareolar area and seems to be fairly #ell locali$ed.
%hen as&ed #hen the pain occurs! she states that it is al#ays present and is very troublesome to her. 'n %hen as&ed #hen the pain occurs! she states that it is al#ays present and is very troublesome to her. 'n
physical examination! she has dense glandular tissue throughout both breasts! but no discrete nodules. physical examination! she has dense glandular tissue throughout both breasts! but no discrete nodules.
(our #or&ing diagnosis at this point is noncyclical breast pain. (our #or&ing diagnosis at this point is noncyclical breast pain.
(our next step in management is (our next step in management is

(A) reassurance
(A) reassurance
(B) start a diuretic
(B) start a diuretic
(C) refer her to a psychologist
(C) refer her to a psychologist
(!) give a steroid in:ection
(!) give a steroid in:ection
(#) perform a surgical e?cision of the painful
(#) perform a surgical e?cision of the painful
area
area
Explanation
Explanation

:
:
.astalgia* or "reast pain* is a common
.astalgia* or "reast pain* is a common
complaint and a common reason for referral to a
complaint and a common reason for referral to a
"reast center% #valuation of "reast pain should
"reast center% #valuation of "reast pain should
include a thorough history and e?amination% 6ith
include a thorough history and e?amination% 6ith
a good history* you can "egin to categorize the
a good history* you can "egin to categorize the
pain% $ypical types of mastalgia can "e
pain% $ypical types of mastalgia can "e
descri"ed as cyclical pronounced* noncyclical*
descri"ed as cyclical pronounced* noncyclical*
trauma* musculos,eletalEchest 'all* and
trauma* musculos,eletalEchest 'all* and
miscellaneous uncommon cause%
miscellaneous uncommon cause%

Cyclical pronounced pain is the most common% &t


Cyclical pronounced pain is the most common% &t
is related to the menstrual cycle* especially
is related to the menstrual cycle* especially
ovulation% $he average age is 9( years% 5atients
ovulation% $he average age is 9( years% 5atients
complain of FheavinessF and Ftenderness%F
complain of FheavinessF and Ftenderness%F
Godularity is common* especially in the upper
Godularity is common* especially in the upper
outer -uadrants% $his also tends to fluctuate 'ith
outer -uadrants% $his also tends to fluctuate 'ith
the menstrual cycle% $he pain is often in the
the menstrual cycle% $he pain is often in the
upper outer -uadrant* may "e "ilateral* and can
upper outer -uadrant* may "e "ilateral* and can
radiate do'n the arm%
radiate do'n the arm%

Goncyclical mastalgia is not related to the


Goncyclical mastalgia is not related to the
menstrual cycle% $he average age of the
menstrual cycle% $he average age of the
patient is again 9( years old% $he pain is
patient is again 9( years old% $he pain is
different from cyclical pain in that is more
different from cyclical pain in that is more
localized and descri"ed as a F"urningF or
localized and descri"ed as a F"urningF or
Fpulling%F Godularity is typically less
Fpulling%F Godularity is typically less
pronounced* "ut it is present in greater
pronounced* "ut it is present in greater
than 50% of the patients%
than 50% of the patients%
A 4)-year-old #oman presents #ith a * cm mass in her right breast first A 4)-year-old #oman presents #ith a * cm mass in her right breast first
detected by detected by
mammography +,ig. -.-*/. 0adiographic core biopsy of the lesion is mammography +,ig. -.-*/. 0adiographic core biopsy of the lesion is
selected for diagnosis and reveals infiltrating ductal carcinoma. he has no selected for diagnosis and reveals infiltrating ductal carcinoma. he has no
palpable axillary lymph nodes! core bx: invasive malignant! 123:P'"T"4E palpable axillary lymph nodes! core bx: invasive malignant! 123:P'"T"4E

A566/ T27 staging system is
A566/ T27 staging system is

(A) &
(A) &
(B) &&
(B) &&
(C) &&&
(C) &&&
(!) &H
(!) &H
(#) H
(#) H
$he A3CC $G. Clinical taging
$he A3CC $G. Clinical taging
ystem is as follo's
ystem is as follo's

1 1

1% 5rimary tumor ($) 1% 5rimary tumor ($)

$?1 primary tumor cannot "e assessed $?1 primary tumor cannot "e assessed

$01 no primary tumor $01 no primary tumor

$is1 carcinoma $is1 carcinoma in situ in situ

$11 tumor + cm% $11 tumor + cm%

$+1 tumor I + cm% "ut 5 cm% $+1 tumor I + cm% "ut 5 cm%

$91 tumor I 5 cm% $91 tumor I 5 cm%

$(1 tumor 'ith e?tension to chest 'all* s,in edema or $(1 tumor 'ith e?tension to chest 'all* s,in edema or
ulceration or inflammatory carcinoma ulceration or inflammatory carcinoma
/egional lymph nodes (G)
/egional lymph nodes (G)

% G?1 regional lymph nodes cannot "e assessed % G?1 regional lymph nodes cannot "e assessed



G01 no regional lymph node metastasis
G01 no regional lymph node metastasis



G11 metastases to mo"ile a?illary lymph nodes
G11 metastases to mo"ile a?illary lymph nodes



G+1 metastases to fi?ed* matted or clinically
G+1 metastases to fi?ed* matted or clinically
apparent a?illary lymph nodes or internal
apparent a?illary lymph nodes or internal
mammary nodes
mammary nodes



G91 metastases to a?illary and infraclavicular
G91 metastases to a?illary and infraclavicular
lymph nodes* clinically apparent internal
lymph nodes* clinically apparent internal
mammary nodes or supraclavicular lymph nodes
mammary nodes or supraclavicular lymph nodes
!istant metastasis
!istant metastasis



.?1 distant metastasis cannot "e
.?1 distant metastasis cannot "e
assessed
assessed



.01 no distant metastasis
.01 no distant metastasis



.11 distant metastasis
.11 distant metastasis
tage grouping
tage grouping

% %

tage 01 $isG0.0 tage 01 $isG0.0

tage 11 $1G0.0 tage 11 $1G0.0

tage +A1 $0G1.0* $1G1.0* $+G0.0 tage +A1 $0G1.0* $1G1.0* $+G0.0

tage +B1 $+G1.0* $9G0.0 tage +B1 $+G1.0* $9G0.0

tage 9A1 $0G+.0* $1G+.0* $+G+.0* $9G1.0* tage 9A1 $0G+.0* $1G+.0* $+G+.0* $9G1.0*
$9G+.0 $9G+.0

tage 9B1 $(G0.0* $(G1.0* $(G+.0 tage 9B1 $(G0.0* $(G1.0* $(G+.0

tage 9C1 Any$G9.0 tage 9C1 Any$G9.0

tage (1 Any$ AnyG .1 tage (1 Any$ AnyG .1


%hich of the follo#ing is false regarding
%hich of the follo#ing is false regarding
lobular carcinoma
lobular carcinoma
in situ
in situ
8
8

(A) &t is a mar,er for increased ris, of "reast cancer% (A) &t is a mar,er for increased ris, of "reast cancer%
(B) .irror image "reast "iopsy is indicated% (B) .irror image "reast "iopsy is indicated%
(C) u"se-uent invasive cancer is more often ductal in origin% (C) u"se-uent invasive cancer is more often ductal in origin%
(!) $reatment is close o"servation versus "ilateral prophylactic (!) $reatment is close o"servation versus "ilateral prophylactic
mastectomy% mastectomy%
(#) 5rognosis is solely related to the development of su"se-uent (#) 5rognosis is solely related to the development of su"se-uent
cancer% cancer%
Explanation:
Explanation:

$he histologic picture consists of many clusters of epithelial cells forming $he histologic picture consists of many clusters of epithelial cells forming
islands of neoplastic cells "ut maintaining a lo"ular architecture% &t occurs islands of neoplastic cells "ut maintaining a lo"ular architecture% &t occurs
more often in premenopausal 'omen and does not form a palpa"le mass% &t more often in premenopausal 'omen and does not form a palpa"le mass% &t
is most commonly found as an incidental finding on "iopsy* as it does not is most commonly found as an incidental finding on "iopsy* as it does not
have any mammographic findings% have any mammographic findings%

4o"ular carcinoma 4o"ular carcinoma in situ in situ carries a ris, of developing into an invasive ductal carries a ris, of developing into an invasive ductal
carcinoma in 1095% of patients over a period of 15+0 years% carcinoma in 1095% of patients over a period of 15+0 years%

Because the ris, of su"se-uent "reast cancer is almost the same for "oth Because the ris, of su"se-uent "reast cancer is almost the same for "oth
"reasts* mirror image "iopsies of the opposite "reast are not indicated% "reasts* mirror image "iopsies of the opposite "reast are not indicated%

2istologic e?aminations are generally favora"le and deaths are unusual in 2istologic e?aminations are generally favora"le and deaths are unusual in
'omen 'ith appropriate medical care% Any treatment of 'omen 'ith appropriate medical care% Any treatment of in situ in situ carcinoma is carcinoma is
aimed at preventing invasive disease% aimed at preventing invasive disease%

$reatment options include close o"servation or pharmacologic prophyla?is% $reatment options include close o"servation or pharmacologic prophyla?is%
A 5>year course of tamo?ifen has "een sho'n to reduce the relative ris, of A 5>year course of tamo?ifen has "een sho'n to reduce the relative ris, of
invasive cancer "y 5B% in 'omen 'ith 4C&% urgical options such as invasive cancer "y 5B% in 'omen 'ith 4C&% urgical options such as
"ilateral mastectomy or "reast>conserving surgery are considered only in "ilateral mastectomy or "reast>conserving surgery are considered only in
special circumstances in 'hich the patient may have multiple ris, factors special circumstances in 'hich the patient may have multiple ris, factors
The effective osmotic pressure bet#een the plasma The effective osmotic pressure bet#een the plasma
and interstitial fluid compartments is primarily and interstitial fluid compartments is primarily
controlled by controlled by

(A) Bicar"onate
(A) Bicar"onate
(B) Chloride ion
(B) Chloride ion
(C) 5otassium ion
(C) 5otassium ion
(!) 5rotein
(!) 5rotein
Explanation
Explanation

:
:
$he dissolved protein in plasma does not
$he dissolved protein in plasma does not
pass through the semipermea"le cell
pass through the semipermea"le cell
mem"rane* and this fact is responsi"le for
mem"rane* and this fact is responsi"le for
the effective or colloid osmotic pressure%
the effective or colloid osmotic pressure%
(ee ch'artz Cth ed%)
(ee ch'artz Cth ed%)
The simplest effective method of estimating the degree The simplest effective method of estimating the degree
of acidosis in a patient in shoc& is the measurement of of acidosis in a patient in shoc& is the measurement of

(A) Arterial p2
(A) Arterial p2
(B) #nd tidal C<+ concentration
(B) #nd tidal C<+ concentration
(C) p2 of mi?ed venous "lood
(C) p2 of mi?ed venous "lood
(!) erum C<+ level
(!) erum C<+ level
Explanation:
Explanation:

<nly the measurement of arterial p2 and


<nly the measurement of arterial p2 and
5C<+ gives an accurate picture of the
5C<+ gives an accurate picture of the
degree of acid>"ase im"alances% (ee
degree of acid>"ase im"alances% (ee
ch'artz Cth ed%)
ch'artz Cth ed%)
Each of the follo#ing is a symptom of a hemolytic Each of the follo#ing is a symptom of a hemolytic
transfusion reaction E96EPT transfusion reaction E96EPT

(A) Constricting chest pain


(A) Constricting chest pain
(B) ;lushing of the face
(B) ;lushing of the face
(C) 4um"ar pain
(C) 4um"ar pain
(!) yncope
(!) yncope
Explanation:
Explanation:

yncope is not associated 'ith a


yncope is not associated 'ith a
hemolytic transfusion reaction* 'hereas
hemolytic transfusion reaction* 'hereas
the other listed symptoms are common
the other listed symptoms are common
occurrences% (ee ch'artz Cth ed%)
occurrences% (ee ch'artz Cth ed%)
After drainage of a pelvic abscess! a 4.-year-old patient After drainage of a pelvic abscess! a 4.-year-old patient
receiving receiving
:); oxygen is found to have the follo#ing arterial blood gases: :); oxygen is found to have the follo#ing arterial blood gases:
p<! :.4=> P'*! .. mm <g> P6'*! 3) mm <g. These results are p<! :.4=> P'*! .. mm <g> P6'*! 3) mm <g. These results are
most consistent #ith the diagnosis of most consistent #ith the diagnosis of

(A) Chronic o"structive pulmonary disease


(A) Chronic o"structive pulmonary disease
(B) 5ostoperative pain and an?iety
(B) 5ostoperative pain and an?iety
(C) Adult respiratory distress syndrome
(C) Adult respiratory distress syndrome
(!) 5ostoperative atelectasis
(!) 5ostoperative atelectasis
Explanation:
Explanation:

$he com"ination of hypo?emia that is resistant to high $he com"ination of hypo?emia that is resistant to high
o?ygen concentrations and hyperventilation is o?ygen concentrations and hyperventilation is
characteristic of the adult respiratory distress syndrome characteristic of the adult respiratory distress syndrome
(A/!)% $here are four general causes of hypo?emia1 (A/!)% $here are four general causes of hypo?emia1
hypoventilation* a lo' ventilation>perfusion ratio* diffusion hypoventilation* a lo' ventilation>perfusion ratio* diffusion
a"normalities* and pulmonary shunting% Although the first a"normalities* and pulmonary shunting% Although the first
three conditions improve in response to an increased three conditions improve in response to an increased
inspired o?ygen concentration most of the hypo?emia inspired o?ygen concentration most of the hypo?emia
seen in A/! is secondary to shunting and so is not seen in A/! is secondary to shunting and so is not
ameliorated "y o?ygen% $he a"normalities seen in A/! ameliorated "y o?ygen% $he a"normalities seen in A/!
are thought to result from in:ury to the alveolar>capillary are thought to result from in:ury to the alveolar>capillary
mem"rane that causes an increased permea"ility of the mem"rane that causes an increased permea"ility of the
mem"rane* 'hich in turn leads to interstitial pulmonary mem"rane* 'hich in turn leads to interstitial pulmonary
edema and decreased pulmonary compliance% (ee edema and decreased pulmonary compliance% (ee
ch'artz Cth ed%) ch'artz Cth ed%)
All of the follo#ing result from the placement of an intraaortic All of the follo#ing result from the placement of an intraaortic
balloon pump in a patient #ith acute myocardial failure E96EPT balloon pump in a patient #ith acute myocardial failure E96EPT

(A) !iastolic "lood pressure elevation


(A) !iastolic "lood pressure elevation
(B) &ncreased cardiac output
(B) &ncreased cardiac output
(C) &ncreased pulmonary perfusion
(C) &ncreased pulmonary perfusion
(!) &ncreased pro"a"ility of survival
(!) &ncreased pro"a"ility of survival
The P.) value +the P'* at #hich .); of hemoglobin is saturated #ith The P.) value +the P'* at #hich .); of hemoglobin is saturated #ith
oxygen/ indicates the position of the oxyhemoglobin dissociation curve oxygen/ indicates the position of the oxyhemoglobin dissociation curve
along the hori$ontal axis. All of the follo#ing conditions can produce a along the hori$ontal axis. All of the follo#ing conditions can produce a
left#ard-shifted curve +decreased P.)/ E96EPT left#ard-shifted curve +decreased P.)/ E96EPT

(A) Car"on mono?ide poisoning


(A) Car"on mono?ide poisoning
(B) 2ypothermia
(B) 2ypothermia
(C) Acidosis
(C) Acidosis
(!) +*9>diphosphoglycerate deficiency
(!) +*9>diphosphoglycerate deficiency
Explanation:
Explanation:

!eterminations of 550 are used to monitor the affinity of o?ygen for !eterminations of 550 are used to monitor the affinity of o?ygen for
hemoglo"in* 'ith the normal value "eing appro?imately +B mm 2g% hemoglo"in* 'ith the normal value "eing appro?imately +B mm 2g%
A lo' 550* indicating an increased affinity of o?ygen for hemoglo"in A lo' 550* indicating an increased affinity of o?ygen for hemoglo"in
and a decreased release of o?ygen to the tissues* causes a left'ard and a decreased release of o?ygen to the tissues* causes a left'ard
shift in the o?yhemoglo"in dissociation curve% 4o' red "lood cell shift in the o?yhemoglo"in dissociation curve% 4o' red "lood cell
levels of +*9>diphosphoglycerate ('hich occur 'hen "lood is stored levels of +*9>diphosphoglycerate ('hich occur 'hen "lood is stored
more than + 'ee,s)* car"on mono?ide poisoning* and hypothermia more than + 'ee,s)* car"on mono?ide poisoning* and hypothermia
lo'er the 550% Conversely* the natural affinity of hemoglo"in for lo'er the 550% Conversely* the natural affinity of hemoglo"in for
o?ygen is decreased "y high levels of diphosphoglycerate* "y o?ygen is decreased "y high levels of diphosphoglycerate* "y
car"on dio?ide (Bohr effect)* "y heat* and "y hydrogen ions% &n car"on dio?ide (Bohr effect)* "y heat* and "y hydrogen ions% &n
acidosis* shifting of the o?yhemoglo"in dissociation curve to the acidosis* shifting of the o?yhemoglo"in dissociation curve to the
right (increased 550) reflects a protective mechanism to improve right (increased 550) reflects a protective mechanism to improve
o?ygen supply to the tissues% 2o'ever* in spite of elevations of the o?ygen supply to the tissues% 2o'ever* in spite of elevations of the
550* severe arterial desaturation (e%g%* pulmonary shunting) may 550* severe arterial desaturation (e%g%* pulmonary shunting) may
offset any potential gains in o?ygen availa"ility% (ee ch'artz Cth offset any potential gains in o?ygen availa"ility% (ee ch'artz Cth
ed%) ed%)
The earliest manifestations of serious gram-negative infection The earliest manifestations of serious gram-negative infection
may consist of a triad of signs that includes may consist of a triad of signs that includes

(A) $achypnea* hypotension* and an altered


(A) $achypnea* hypotension* and an altered
sensorium
sensorium
(B) $achypnea* hypotension* and lactic acidosis
(B) $achypnea* hypotension* and lactic acidosis
(C) $hrom"ocytopenia* hypotension* and lactic
(C) $hrom"ocytopenia* hypotension* and lactic
acidosis
acidosis
(!) .ild hyperventilation* respiratory al,alosis*
(!) .ild hyperventilation* respiratory al,alosis*
and an altered sensorium
and an altered sensorium
Explanation:
Explanation:

$he development of mild hyperventilation* respiratory $he development of mild hyperventilation* respiratory
al,alosis* and an altered sensorium may "e the earliest al,alosis* and an altered sensorium may "e the earliest
sign of gram>negative infection% $his triad may precede sign of gram>negative infection% $his triad may precede
the usual signs and symptoms of sepsis "y several the usual signs and symptoms of sepsis "y several
hours to several days% Although the e?act hours to several days% Although the e?act
pathophysiology of this manifestation is un,no'n* the pathophysiology of this manifestation is un,no'n* the
triad of signs is thought to represent a primary response triad of signs is thought to represent a primary response
to "acteremia% #arly recognition of the findings* follo'ed to "acteremia% #arly recognition of the findings* follo'ed
"y a prompt search for the source of infection* may allo' "y a prompt search for the source of infection* may allo'
diagnosis and treatment prior to the onset of shoc,% (ee diagnosis and treatment prior to the onset of shoc,% (ee
ch'artz Cth ed%) ch'artz Cth ed%)
6ardiac preload is determined by
6ardiac preload is determined by

(A) #nd>diastolic volume


(A) #nd>diastolic volume
(B) #nd>diastolic pressure
(B) #nd>diastolic pressure
(C) #nd>systolic volume
(C) #nd>systolic volume
(!) #nd>systolic pressure
(!) #nd>systolic pressure
Explanation:
Explanation:

tarlingJs la' of the heart states that the force of muscle contraction tarlingJs la' of the heart states that the force of muscle contraction
depends on the initial length of the cardiac fi"ers% @sing terminology depends on the initial length of the cardiac fi"ers% @sing terminology
that derives from early e?periments using isolated cardiac muscle that derives from early e?periments using isolated cardiac muscle
preparations* preload is the stretch of ventricular myocardial tissue preparations* preload is the stretch of ventricular myocardial tissue
:ust prior to the ne?t contraction% 5reload is determined "y end> :ust prior to the ne?t contraction% 5reload is determined "y end>
diastolic volume (#!H)% ;or the right ventricle* central venous diastolic volume (#!H)% ;or the right ventricle* central venous
pressure (CH5) appro?imates right ventricular end>diastolic pressure (CH5) appro?imates right ventricular end>diastolic
pressure (#!5)% ;or the left ventricle* pulmonary artery occlusion pressure (#!5)% ;or the left ventricle* pulmonary artery occlusion
pressure (5A<5)* 'hich is measured "y transiently inflating a pressure (5A<5)* 'hich is measured "y transiently inflating a
"alloon at the end of a pressure monitoring catheter positioned in a "alloon at the end of a pressure monitoring catheter positioned in a
small "ranch of the pulmonary artery* appro?imates left ventricular small "ranch of the pulmonary artery* appro?imates left ventricular
end>diastolic pressure% $he presence of atrioventricular valvular end>diastolic pressure% $he presence of atrioventricular valvular
stenosis 'ill alter this relationship% (ee ch'artz 8th ed%* Chapter stenosis 'ill alter this relationship% (ee ch'artz 8th ed%* Chapter
1+* Cardiac <utput and /elated 5arameters 1+* Cardiac <utput and /elated 5arameters
Positive end-expiratory Positive end-expiratory
pressure +PEEP/ ventilation is #idely pressure +PEEP/ ventilation is #idely
used in the treatment of acute pulmonary failure. The beneficial used in the treatment of acute pulmonary failure. The beneficial
effects of PEEP include all of the follo#ing E96EPT effects of PEEP include all of the follo#ing E96EPT

(A) !ecreased pulmonary shunting


(A) !ecreased pulmonary shunting
(B) !ecreased e?travascular lung 'ater
(B) !ecreased e?travascular lung 'ater
(C) &ncreased resting volume of the lung
(C) &ncreased resting volume of the lung
(!) &ncreased o?ygenation
(!) &ncreased o?ygenation
Explanation:
Explanation:

$he mechanism of action of 5##5 ventilation has not $he mechanism of action of 5##5 ventilation has not
"een completely elucidated% 2o'ever* the "eneficial "een completely elucidated% 2o'ever* the "eneficial
effects of 5##5 include (1) an increase in o?ygenation effects of 5##5 include (1) an increase in o?ygenation
(5a<+)A (+) an increase in resting volume (i%e%* functional (5a<+)A (+) an increase in resting volume (i%e%* functional
residual capacity* of the lung)A (9) an increase in residual capacity* of the lung)A (9) an increase in
pulmonary complianceA (() an increase in the ratio of pulmonary complianceA (() an increase in the ratio of
ventilation to perfusion 'hen the ratio is initially lo'A and ventilation to perfusion 'hen the ratio is initially lo'A and
(5) decreased pulmonary shunting (venous admi?ture)% (5) decreased pulmonary shunting (venous admi?ture)%
$here has "een no good e?perimental evidence that $here has "een no good e?perimental evidence that
5##5 leads to a direct decrease in lung 'ater% (ee 5##5 leads to a direct decrease in lung 'ater% (ee
ch'artz Cth ed%) ch'artz Cth ed%)
All of the follo#ing findings #ould indicate that a patient re?uires All of the follo#ing findings #ould indicate that a patient re?uires
mechanical ventilatory support E96EPT mechanical ventilatory support E96EPT

(A) /espiratory rate greater than 90 "reaths per


(A) /espiratory rate greater than 90 "reaths per
minute
minute
(B) Hital capacity less than 15 m4E,g
(B) Hital capacity less than 15 m4E,g
(C) .a?imal inspiratory force of (0 cm 2+<
(C) .a?imal inspiratory force of (0 cm 2+<
(!) Alveolar>arterial o?ygen gradient greater
(!) Alveolar>arterial o?ygen gradient greater
than 950 torr
than 950 torr
Explanation:
Explanation:

$he treatment of acute respiratory insufficiency is "ased primarily on $he treatment of acute respiratory insufficiency is "ased primarily on
ventilatory support% #ndotracheal intu"ation* prefera"ly through the ventilatory support% #ndotracheal intu"ation* prefera"ly through the
nose* is considered the techni-ue of choice% A ma?imal inspiratory nose* is considered the techni-ue of choice% A ma?imal inspiratory
force of (0 cm 2+< is force of (0 cm 2+< is not not a criterion for ventilatory support% <n the a criterion for ventilatory support% <n the
other hand* a patient 'ho has sta"le vital signs and 'ho (1) e?hi"its other hand* a patient 'ho has sta"le vital signs and 'ho (1) e?hi"its
ade-uate o?ygenation on an inspired o?ygen concentration of 0%( or ade-uate o?ygenation on an inspired o?ygen concentration of 0%( or
less* (+) has a resting minute ventilation less than 10 4Emin* (9) has less* (+) has a resting minute ventilation less than 10 4Emin* (9) has
a vital capacity greater than 15 m4E,g* and (() has a tidal volume a vital capacity greater than 15 m4E,g* and (() has a tidal volume
greater than 5 m4E,g almost certainly 'ill tolerate 'ithdra'al of greater than 5 m4E,g almost certainly 'ill tolerate 'ithdra'al of
ventilatory support% A ma?imal inspiratory force of 90 cm 2+< or ventilatory support% A ma?imal inspiratory force of 90 cm 2+< or
less (i%e%* more negative)* ho'ever* generally is necessary to less (i%e%* more negative)* ho'ever* generally is necessary to
maintain spontaneous ventilation% Consideration of all of these maintain spontaneous ventilation% Consideration of all of these
parameters together 'ould greatly assist in a decision 'hether or parameters together 'ould greatly assist in a decision 'hether or
not to 'ithdra' mechanical ventilation% (ee ch'artz Cth ed%) not to 'ithdra' mechanical ventilation% (ee ch'artz Cth ed%)
%hich of the follo#ing statements about organelle %hich of the follo#ing statements about organelle
function is function is incorrect incorrect8 8

(A) $he rough endoplasmic reticulum (r#/) is the site of protein synthesis and the (A) $he rough endoplasmic reticulum (r#/) is the site of protein synthesis and the
cotranslational modification of proteins% cotranslational modification of proteins%
(B) $he smooth endoplasmic reticulum (s#/) is the site of phospholipid synthesis* (B) $he smooth endoplasmic reticulum (s#/) is the site of phospholipid synthesis*
steroid hormone synthesis* drug deto?ification* and calcium store release% steroid hormone synthesis* drug deto?ification* and calcium store release%
(C) $he Dolgi comple? is the site of vesicular pac,aging of proteins* mem"rane (C) $he Dolgi comple? is the site of vesicular pac,aging of proteins* mem"rane
component recycling* and posttranslational modification of proteins% component recycling* and posttranslational modification of proteins%
(!) $he mitochondrion functions in acetyl>CoA production* tricar"o?ylic acid ($CA) (!) $he mitochondrion functions in acetyl>CoA production* tricar"o?ylic acid ($CA)
cycle* o?idative phosphorylation* and fatty acid o?idation% cycle* o?idative phosphorylation* and fatty acid o?idation%
(#) $he lysosome contains amino acid o?idase* urate o?idase* catalase* and other (#) $he lysosome contains amino acid o?idase* urate o?idase* catalase* and other
o?idative enzymes relating to the production and degradation of hydrogen pero?ide o?idative enzymes relating to the production and degradation of hydrogen pero?ide
and o?idation of fatty acids% and o?idation of fatty acids%
Explanation
Explanation

: 1ysosomes contain acid hydrolases or lysosomal en$ymes that include proteases! nucleases! lipases! : 1ysosomes contain acid hydrolases or lysosomal en$ymes that include proteases! nucleases! lipases!
and galactosidases that function at an acidic p< to degrade old intracellular organelles or phagocytosed and galactosidases that function at an acidic p< to degrade old intracellular organelles or phagocytosed
substances substances. 'rganelles have a relatively rapid rate of turnover +e.g.! liver mitochondria have a lifetime of . 'rganelles have a relatively rapid rate of turnover +e.g.! liver mitochondria have a lifetime of
-) days/ and are bro&en do#n in a process called autophagy. 'ld or damaged organelles are enveloped -) days/ and are bro&en do#n in a process called autophagy. 'ld or damaged organelles are enveloped
by an additional membrane to create an autophagosome! #hich fuses #ith a lysosome for degradation. by an additional membrane to create an autophagosome! #hich fuses #ith a lysosome for degradation.
,or phagocytosed or endocytosed substances! these are ta&en-up into early endosomes #here some of ,or phagocytosed or endocytosed substances! these are ta&en-up into early endosomes #here some of
the materials are recycled bac& to the plasma membrane and others continue as late endosomes. @olgi the materials are recycled bac& to the plasma membrane and others continue as late endosomes. @olgi
hydrolase vesicles containing inactive lysosomal en$ymes fuse #ith late endosomes to form mature hydrolase vesicles containing inactive lysosomal en$ymes fuse #ith late endosomes to form mature
lysosomes. The late endosomes contain proton pumps to produce a p< . environment to activate the lysosomes. The late endosomes contain proton pumps to produce a p< . environment to activate the
lysosomal en$ymes from the @olgi hydrolase vesicles. Although most lysosomes function in intracellular lysosomal en$ymes from the @olgi hydrolase vesicles. Although most lysosomes function in intracellular
digestion! a fe# cell types such as neutrophils and osteoclasts are able to release lysosomal contents digestion! a fe# cell types such as neutrophils and osteoclasts are able to release lysosomal contents
extracellularly for degrading materials. There are numerous lysosomal storage diseases +e.g.! <unterAs! extracellularly for degrading materials. There are numerous lysosomal storage diseases +e.g.! <unterAs!
<urlerAs! anfilippo A! Tay-achs! @aucherAs! 2iemann-Pic&! PompeAs! "-cell! and BrabbeAs disease/ each <urlerAs! anfilippo A! Tay-achs! @aucherAs! 2iemann-Pic&! PompeAs! "-cell! and BrabbeAs disease/ each
associated #ith mutations of different lysosomal en$ymes and abnormal accumulation of undigested associated #ith mutations of different lysosomal en$ymes and abnormal accumulation of undigested
materials. materials.

Peroxisomes are uni?ue organelles in that they are surrounding only by a single membrane and contain Peroxisomes are uni?ue organelles in that they are surrounding only by a single membrane and contain
amino acid hydrolase! hydroxyacid oxidase! urate oxidase! and catalase for the production and amino acid hydrolase! hydroxyacid oxidase! urate oxidase! and catalase for the production and
brea&do#n of hydrogen peroxide. The oxidative reactions performed by peroxisomes are important for brea&do#n of hydrogen peroxide. The oxidative reactions performed by peroxisomes are important for
the brea&do#n of toxic substances and fatty acid molecules. Peroxisomes are also essential for the the brea&do#n of toxic substances and fatty acid molecules. Peroxisomes are also essential for the
production of certain phospholipid classes in myelin> therefore many peroxisomal disorders result in production of certain phospholipid classes in myelin> therefore many peroxisomal disorders result in
neurologic disease. Although peroxisomes are self-replicating organelles! they do not contain their o#n neurologic disease. Although peroxisomes are self-replicating organelles! they do not contain their o#n
C2A or ribosomes and must import their proteins from the cytosol! #hich are mar&ed by a 3-amino acid C2A or ribosomes and must import their proteins from the cytosol! #hich are mar&ed by a 3-amino acid
signal se?uence. The peroxisomal import process involves doc&ing proteins! peroxins! and ATP signal se?uence. The peroxisomal import process involves doc&ing proteins! peroxins! and ATP
hydrolysis. Peroxisomal dysfunction is the etiology of Dell#egerAs syndrome +a&a cerebrohepatorenal hydrolysis. Peroxisomal dysfunction is the etiology of Dell#egerAs syndrome +a&a cerebrohepatorenal
syndrome/! #hich is an autosomal recessive neonatal syndrome characteri$ed by incomplete syndrome/! #hich is an autosomal recessive neonatal syndrome characteri$ed by incomplete
myelini$ation of nervous tissue and muscular hypotonia! hepatomegaly! and small glomerular cysts of the myelini$ation of nervous tissue and muscular hypotonia! hepatomegaly! and small glomerular cysts of the
&idney resulting in death shortly after birth. Adrenoleu&odystrophy +A1C/ is an 9-lin&ed recessive &idney resulting in death shortly after birth. Adrenoleu&odystrophy +A1C/ is an 9-lin&ed recessive
disorder involving the absence or dysfunction of peroxisomal en$ymes essential for fatty acid -oxidation. disorder involving the absence or dysfunction of peroxisomal en$ymes essential for fatty acid -oxidation.
A1C results in the myelin degeneration in the nervous system and abnormal intracellular accumulation of A1C results in the myelin degeneration in the nervous system and abnormal intracellular accumulation of
lipids! manifesting in progressive dementia! spastic paralysis lipids! manifesting in progressive dementia! spastic paralysis* and adrenal insufficiency in children (see ;igs% * and adrenal insufficiency in children (see ;igs%
1>1+ 1>1+ and 1>19)% and 1>19)%
A 4--year-old female presents to the emergency department after A 4--year-old female presents to the emergency department after
sustaining a gunshot #ound to the abdomen! #ith inEuries to the liver and sustaining a gunshot #ound to the abdomen! #ith inEuries to the liver and
large bo#el. Cespite successful resuscitation and operative intervention! large bo#el. Cespite successful resuscitation and operative intervention!
the patient dies * #ee&s later of multisystem organ failure in the intensive the patient dies * #ee&s later of multisystem organ failure in the intensive
care unit. %hich organ most li&ely first experienced dysfunction8 care unit. %hich organ most li&ely first experienced dysfunction8

(A) liver
(A) liver
(B) gastrointestinal tract
(B) gastrointestinal tract
(C) lung
(C) lung
(!) ,idney
(!) ,idney
(#) heart
(#) heart
Explanation:
Explanation:

!eath due to trauma 'ith hemorrhagic shoc, is arranged in a trimodal distri"ution1 immediate (at the scene)* !eath due to trauma 'ith hemorrhagic shoc, is arranged in a trimodal distri"ution1 immediate (at the scene)*
'ithin the first +( hours* and 1 'ee, or more follo'ing the in:ury% &n the acute period after trauma* mortality is 'ithin the first +( hours* and 1 'ee, or more follo'ing the in:ury% &n the acute period after trauma* mortality is
attri"uta"le to massive hemorrhage or neurologic in:ury% !irect in:ury to an organ contri"utes to a primary multiple attri"uta"le to massive hemorrhage or neurologic in:ury% !irect in:ury to an organ contri"utes to a primary multiple
organ dysfunction in this early period% &n contrast* late deaths* occurring at least 1 'ee, su"se-uent to the organ dysfunction in this early period% &n contrast* late deaths* occurring at least 1 'ee, su"se-uent to the
trauma* generally arise from secondary multiple organ dysfunction syndrome (.<!)% $his condition develops in trauma* generally arise from secondary multiple organ dysfunction syndrome (.<!)% $his condition develops in
90B0% of these trauma patients and is associated 'ith an 80% mortality rate% 90B0% of these trauma patients and is associated 'ith an 80% mortality rate%

.<! is defined as the failure of multiple organs in a critically ill patient in 'hom the maintenance of .<! is defined as the failure of multiple organs in a critically ill patient in 'hom the maintenance of
homeostasis re-uires intervention% $his syndrome appears as the end point in a variety of conditions* not isolated homeostasis re-uires intervention% $his syndrome appears as the end point in a variety of conditions* not isolated
to trauma and hemorrhagic shoc,% &n the case of trauma* the prevalence of .<! is ascri"ed to a t'o>hit to trauma and hemorrhagic shoc,% &n the case of trauma* the prevalence of .<! is ascri"ed to a t'o>hit
phenomenon* first proposed "y 5artric, et al% $his hypothesis suggests that trauma represents an initial insult phenomenon* first proposed "y 5artric, et al% $his hypothesis suggests that trauma represents an initial insult
'hich predisposes the immune system to react later to a lesser in:ury 'ith a massive response* mediated 'hich predisposes the immune system to react later to a lesser in:ury 'ith a massive response* mediated
primarily "y neutrophils* resulting in great collateral damage (;ig% B>1+)% $he primed neutrophils mediate further primarily "y neutrophils* resulting in great collateral damage (;ig% B>1+)% $he primed neutrophils mediate further
tissue in:ury "y means of proteolytic enzymes* reactive o?ygen species* and vasoactive su"stances% A study from tissue in:ury "y means of proteolytic enzymes* reactive o?ygen species* and vasoactive su"stances% A study from
;an et al% (1))8) demonstrated that* in a model of murine hemorrhagic shoc,* intratrachial administration of 45 ;an et al% (1))8) demonstrated that* in a model of murine hemorrhagic shoc,* intratrachial administration of 45
1 hour after successful resuscitation provo,ed enhanced neutrophil se-uestration and edema in the lungA this 1 hour after successful resuscitation provo,ed enhanced neutrophil se-uestration and edema in the lungA this
response 'as not generated in the a"sence of resuscitated hemorrhagic shoc, or 45% ;ollo'ing traumatic response 'as not generated in the a"sence of resuscitated hemorrhagic shoc, or 45% ;ollo'ing traumatic
hemorrhagic shoc,* the patient is resuscitated into not only a local "ut also a systemic inflammatory response hemorrhagic shoc,* the patient is resuscitated into not only a local "ut also a systemic inflammatory response
syndrome (&/)* 'ith generalized inflammation generated 'ithin 1 hour of in:ury% Geutrophils and monocytes are syndrome (&/)* 'ith generalized inflammation generated 'ithin 1 hour of in:ury% Geutrophils and monocytes are
first activated* releasing inflammatory mediators% $G;> * &4>1* and &4>B are particularly implicated in the evolution first activated* releasing inflammatory mediators% $G;> * &4>1* and &4>B are particularly implicated in the evolution
of .<!* found in studies to induce this syndrome and to "e present in elevated levels% Additionally* the of .<!* found in studies to induce this syndrome and to "e present in elevated levels% Additionally* the
coagulation and alternative complement cascades are initiated% &n the a"sence of further in:ury* &/ is "eneficial coagulation and alternative complement cascades are initiated% &n the a"sence of further in:ury* &/ is "eneficial
to recovery from the trauma% $he second* often trivial* insult* ho'ever* results in an enhanced immune response to recovery from the trauma% $he second* often trivial* insult* ho'ever* results in an enhanced immune response
from the already primed immune cells* nota"ly neutrophils% $his second hit may arise from a mild infection* from the already primed immune cells* nota"ly neutrophils% $his second hit may arise from a mild infection*
pulmonary aspiration* or "lood transfusion ($a"le B>+)% Bacterial translocation from the ischemic mucosa of the pulmonary aspiration* or "lood transfusion ($a"le B>+)% Bacterial translocation from the ischemic mucosa of the
gastrointestinal tract is a focus of investigation as a potential source of contamination% @ltimately* organs not gastrointestinal tract is a focus of investigation as a potential source of contamination% @ltimately* organs not
involved in the original trauma e?perience an alteration in function% @sually* the lung is affected prior to the involved in the original trauma e?perience an alteration in function% @sually* the lung is affected prior to the
,idneys* liver* and gastrointestinal tract% <ffiner and .oore (+000) attri"ute this predilection to direct lung in:ury* to ,idneys* liver* and gastrointestinal tract% <ffiner and .oore (+000) attri"ute this predilection to direct lung in:ury* to
the lungJs filtration of to?ins and cyto,ines as 'ell as to its sensitivity for developing vascular permea"ility the lungJs filtration of to?ins and cyto,ines as 'ell as to its sensitivity for developing vascular permea"ility
/is, ;actors Associated 'ith the !evelopment of .ultiple <rgan !ysfunction /is, ;actors Associated 'ith the !evelopment of .ultiple <rgan !ysfunction
;ollo'ing $rauma ;ollo'ing $rauma

-.Associated #ith the first insult -.Associated #ith the first insult

everity of tissue in:ury everity of tissue in:ury

hoc,>ischemiaEreperfusion hoc,>ischemiaEreperfusion

everity of the systemic inflammatory response everity of the systemic inflammatory response

*.Associated #ith the second insult *.Associated #ith the second insult

&nfection &nfection

$ransfusion $ransfusion

econdary operative procedures econdary operative procedures

3.<ost factors 3.<ost factors

Age Age

5ree?isting conditions 5ree?isting conditions


A *3-year-old male presents to the emergency department after being involved in a motor A *3-year-old male presents to the emergency department after being involved in a motor
vehicle accident. 'n physical examination! he opens his eyes to painful stimulation! he vehicle accident. 'n physical examination! he opens his eyes to painful stimulation! he
occasionally mumbles incomprehensible sounds! he locali$es to painful stimulation #ith his occasionally mumbles incomprehensible sounds! he locali$es to painful stimulation #ith his
right upper extremity! and he #ithdra#s his left upper extremity to pain. <is pupils are 4 mm right upper extremity! and he #ithdra#s his left upper extremity to pain. <is pupils are 4 mm
bilaterally and reactive. %hat is this patientAs @lasgo# 6oma cale +@6/ score8 bilaterally and reactive. %hat is this patientAs @lasgo# 6oma cale +@6/ score8

A) C
A) C
(B) )
(B) )
(C) 8
(C) 8
(!) 10
(!) 10
A 4*-year-old male presents to the emergency department as a level " trauma after being A 4*-year-old male presents to the emergency department as a level " trauma after being
involved in a motor vehicle accident. 'n initial examination! the patient has a @6 of : involved in a motor vehicle accident. 'n initial examination! the patient has a @6 of :
+locali$es to pain! no eye opening! and no verbal response/. The patient has multiple inEuries +locali$es to pain! no eye opening! and no verbal response/. The patient has multiple inEuries
including a long bone fracture. The patientAs vital signs are stable. (ou consult orthopedic including a long bone fracture. The patientAs vital signs are stable. (ou consult orthopedic
surgery! and they #ant to ta&e the patient to the operating room +'0/ to repair his fracture. A surgery! and they #ant to ta&e the patient to the operating room +'0/ to repair his fracture. A
6T scan of the head sho#s mild-to-moderate diffuse cerebral edema. %hat is the most 6T scan of the head sho#s mild-to-moderate diffuse cerebral edema. %hat is the most
appropriate course of action to ta&e #ith this patient8 appropriate course of action to ta&e #ith this patient8

A) Allo' the patient to go the </ immediately for repair A) Allo' the patient to go the </ immediately for repair
of his fracture% of his fracture%
(B) Consult neurosurgery to evaluate for placement of an (B) Consult neurosurgery to evaluate for placement of an
&C5 monitor prior to his going to the </% &C5 monitor prior to his going to the </%
(C) Consult neurosurgery to evaluate for placement of an (C) Consult neurosurgery to evaluate for placement of an
&C5 monitor after he returns from the </% &C5 monitor after he returns from the </%
(!) !elay surgery indefinitely until the patientJs (!) !elay surgery indefinitely until the patientJs
neurologic status improves neurologic status improves

Explanation: Explanation: Although there is much de"ate regarding the precise indications for and "enefit of &C5 monitoring* several recent studies Although there is much de"ate regarding the precise indications for and "enefit of &C5 monitoring* several recent studies have suggested that an have suggested that an
aggressive stance to'ard monitoring head>in:ured patients is associated 'ith a reduced ris, of mortality% &n +000* aggressive stance to'ard monitoring head>in:ured patients is associated 'ith a reduced ris, of mortality% &n +000*
the American Association of Geurological urgeons 3oint ection on Geurotrauma and Critical Care in association the American Association of Geurological urgeons 3oint ection on Geurotrauma and Critical Care in association
'ith the Brain $rauma ;oundation pu"lished guidelines relating to the indications for &C5 monitoring% &n this 'ith the Brain $rauma ;oundation pu"lished guidelines relating to the indications for &C5 monitoring% &n this
revie'* it 'as noted that &C5 monitoring helps in the early detection of intracranial mass lesions* limits the revie'* it 'as noted that &C5 monitoring helps in the early detection of intracranial mass lesions* limits the
indiscriminate use of therapies to control &C5 that may "e potentially harmful* helps in determining prognosis* and indiscriminate use of therapies to control &C5 that may "e potentially harmful* helps in determining prognosis* and
may improve outcome% $herefore* the Brain $rauma ;oundation guidelines state that a comatose head>in:ured may improve outcome% $herefore* the Brain $rauma ;oundation guidelines state that a comatose head>in:ured
patient (DC 98) 'ith an a"normal C$ scan should undergo &C5 monitoring% Additionally* comatose head> patient (DC 98) 'ith an a"normal C$ scan should undergo &C5 monitoring% Additionally* comatose head>
in:ured patients 'ith normal C$ scans should undergo &C5 monitoring if they have t'o or more of the follo'ing in:ured patients 'ith normal C$ scans should undergo &C5 monitoring if they have t'o or more of the follo'ing
features at admission1 age over (0* unilateral or "ilateral motor posturing* or a B5 of less than )0 mm2g% A features at admission1 age over (0* unilateral or "ilateral motor posturing* or a B5 of less than )0 mm2g% A
revie' of the <ntario $rauma /egistry from 1)8) to 1))5 'as completed to test the hypothesis that insertion of revie' of the <ntario $rauma /egistry from 1)8) to 1))5 'as completed to test the hypothesis that insertion of
&C5 monitors in patients 'ith traumatic "rain in:uries is not associated 'ith a decrease in the death rate% $he &C5 monitors in patients 'ith traumatic "rain in:uries is not associated 'ith a decrease in the death rate% $he
conclusions 'ere that monitor insertion rates varied 'idely from hospital to hospital and that* after controlling for conclusions 'ere that monitor insertion rates varied 'idely from hospital to hospital and that* after controlling for
in:ury scale and in:ury mechanism* insertion of an &C5 monitor 'as associated 'ith statistically significant in:ury scale and in:ury mechanism* insertion of an &C5 monitor 'as associated 'ith statistically significant
decrease in the death rate among patients 'ith severe traumatic "rain in:ury% ;inally* a retrospective revie' of decrease in the death rate among patients 'ith severe traumatic "rain in:ury% ;inally* a retrospective revie' of
data for consecutive patients 'ith severe closed head in:ury (DC 8) and long "one fracture admitted over an 8> data for consecutive patients 'ith severe closed head in:ury (DC 8) and long "one fracture admitted over an 8>
month period in 9( academic trauma centers in the @nited tates 'as completed% $he purpose of this study 'as month period in 9( academic trauma centers in the @nited tates 'as completed% $he purpose of this study 'as
to e?amine variations in the care of patients 'ith severe head in:ury* to determine the proportion of patients 'ho to e?amine variations in the care of patients 'ith severe head in:ury* to determine the proportion of patients 'ho
received care according to the Brain $rauma ;oundation guidelines* and to correlate the outcome from severe received care according to the Brain $rauma ;oundation guidelines* and to correlate the outcome from severe
traumatic "rain in:ury 'ith the care received% $he results revealed* in addition to considera"le variation in the rates traumatic "rain in:ury 'ith the care received% $he results revealed* in addition to considera"le variation in the rates
of &C5 monitoring* that management at an aggressive center (defined as those placing &C5 monitors in I50% of of &C5 monitoring* that management at an aggressive center (defined as those placing &C5 monitors in I50% of
patients meeting the Brain $rauma ;oundation criteria) 'as associated 'ith a significant reduction in the ris, of patients meeting the Brain $rauma ;oundation criteria) 'as associated 'ith a significant reduction in the ris, of
mortality% Another consideration regarding the patient in the a"ove -uestion is the anticipated use of intravenous mortality% Another consideration regarding the patient in the a"ove -uestion is the anticipated use of intravenous
fluids in the operating room under the situation of general anesthesia in 'hich the neurologic e?amination is fluids in the operating room under the situation of general anesthesia in 'hich the neurologic e?amination is
compromised% 6orsening cere"ral edema and secondary neurologic in:ury may progress unnoticed 'ithout the compromised% 6orsening cere"ral edema and secondary neurologic in:ury may progress unnoticed 'ithout the
a"ility to monitor &C5 and C55% 6ith all of these factors in mind* the most appropriate course of action is to a"ility to monitor &C5 and C55% 6ith all of these factors in mind* the most appropriate course of action is to
consult neurosurgery to evaluate the patient for placement of an &C5 monitor prior to his going to the operating consult neurosurgery to evaluate the patient for placement of an &C5 monitor prior to his going to the operating
room% room%
"ndications for operating on gunshot #ounds to the spine include "ndications for operating on gunshot #ounds to the spine include
all of the follo#ing all of the follo#ing except except: :

(A) persistent C; lea,


(A) persistent C; lea,
(B) neurologic deterioration
(B) neurologic deterioration
(C) compression of a nerve root
(C) compression of a nerve root
(!) operate on all cases
(!) operate on all cases
Explanation
Explanation

: : .ost penetrating 'ounds of the spine in the @nited tates of America today are caused "y .ost penetrating 'ounds of the spine in the @nited tates of America today are caused "y
gunshot 'ounds% $hese are more common in ur"an areas 'here the rates of violent crimes are gunshot 'ounds% $hese are more common in ur"an areas 'here the rates of violent crimes are
relatively high% Civilian gunshot 'ounds cause direct in:ury to the spinal cord "y the "ullet* relatively high% Civilian gunshot 'ounds cause direct in:ury to the spinal cord "y the "ullet*
'hereas high velocity military 'eapons tend to cause more indirect damage from cavitation and 'hereas high velocity military 'eapons tend to cause more indirect damage from cavitation and
shoc, 'aves% Although de"ated* surgery has "een sho'n to have little effect on recovery for shoc, 'aves% Although de"ated* surgery has "een sho'n to have little effect on recovery for
patients 'ith spinal cord in:ury secondary to gunshot 'ounds to the spine% ;or this reason* the patients 'ith spinal cord in:ury secondary to gunshot 'ounds to the spine% ;or this reason* the
trend seems to "e no' to treat patients 'ith gunshot 'ounds to the spine 'ithout surgery unless trend seems to "e no' to treat patients 'ith gunshot 'ounds to the spine 'ithout surgery unless
they have a specific indication to do so% <ne of the historically cited reasons for operating on all they have a specific indication to do so% <ne of the historically cited reasons for operating on all
gunshot 'ounds to the spine 'as to prevent infection% $his may li,ely remain pertinent 'ith gunshot 'ounds to the spine 'as to prevent infection% $his may li,ely remain pertinent 'ith
military gunshot 'ounds since these cause massive tissue in:ury% 6ith the creation of ne' military gunshot 'ounds since these cause massive tissue in:ury% 6ith the creation of ne'
anti"iotics* ho'ever* infections may "e prevented in civilian gunshot 'ounds 'ith ade-uate anti"iotics* ho'ever* infections may "e prevented in civilian gunshot 'ounds 'ith ade-uate
courses of anti"iotics alone% courses of anti"iotics alone%

$he more commonly accepted indications for operating on gunshot 'ounds to the spine include $he more commonly accepted indications for operating on gunshot 'ounds to the spine include
neurologic deterioration! compression of a nerve root! and persistent cerebrospinal fluid neurologic deterioration! compression of a nerve root! and persistent cerebrospinal fluid
lea& or lea& or fistula. fistula. &n addition* there are a fe' late complications 'hich may develop that re-uire &n addition* there are a fe' late complications 'hich may develop that re-uire
surgical treatment% ;irst* an a"scess could develop that re-uires surgical drainage* especially if surgical treatment% ;irst* an a"scess could develop that re-uires surgical drainage* especially if
there is compression of the spinal cord% econd* a syrin? may develop and "e the cause of late there is compression of the spinal cord% econd* a syrin? may develop and "e the cause of late
neurologic deterioration% $his could re-uire a shunting procedure to alleviate the symptoms% neurologic deterioration% $his could re-uire a shunting procedure to alleviate the symptoms%
$hird* lead into?ication may result if the "ullet is lodged in a disc space or :oint capsule% $he $hird* lead into?ication may result if the "ullet is lodged in a disc space or :oint capsule% $he
treatment for this 'ould include removing the "ullet fragment and administering a chelating treatment for this 'ould include removing the "ullet fragment and administering a chelating
agent% ;inally* spinal deafferentation follo'ing spinal cord in:ury may result in intracta"le agent% ;inally* spinal deafferentation follo'ing spinal cord in:ury may result in intracta"le
dysesthetic pain% 5lacement of a dorsal column stimulator or dorsal root entry zone lesioning may dysesthetic pain% 5lacement of a dorsal column stimulator or dorsal root entry zone lesioning may
help in these cases% help in these cases%
A -F-year-old army recruit presents to the emergency department #ith a *4-h A -F-year-old army recruit presents to the emergency department #ith a *4-h
history of right lo#er ?uadrant pain! fever to -))..G,! anorexia! and t#o loose history of right lo#er ?uadrant pain! fever to -))..G,! anorexia! and t#o loose
stools. <e #as ta&en to surgery for the presumptive diagnosis of appendicitis> stools. <e #as ta&en to surgery for the presumptive diagnosis of appendicitis>
ho#ever! the appendix loo&ed completely normal #hile the terminal ileum #as ho#ever! the appendix loo&ed completely normal #hile the terminal ileum #as
?uite inflamed. %hat procedure should be performed8 ?uite inflamed. %hat procedure should be performed8

+A/ appendectomy +A/ appendectomy


+3/ ileocecectomy #ith ileostomy +3/ ileocecectomy #ith ileostomy
+6/ full abdominal exploration to evaluate for further +6/ full abdominal exploration to evaluate for further
obvious lesions and colonoscopy prior to discharge obvious lesions and colonoscopy prior to discharge
+C/ 2one. The patient should be closed and re?uest +C/ 2one. The patient should be closed and re?uest
immediate medical discharge from the army as he immediate medical discharge from the army as he
no# must battle 6C no# must battle 6C
Explanation:
Explanation:

$his patient has acute ileitis% $his may or may not "e related to CrohnJs (and most often is not $his patient has acute ileitis% $his may or may not "e related to CrohnJs (and most often is not
related to C!)% $he correct procedure in this case is appendectomy only% Although the appendi? related to C!)% $he correct procedure in this case is appendectomy only% Although the appendi?
appears normal on direct e?amination* the right lo'er -uadrant 'ound or the laparoscopic appears normal on direct e?amination* the right lo'er -uadrant 'ound or the laparoscopic
'ounds that the patient already has 'ould "e confusing in the future% $here is no indication for an 'ounds that the patient already has 'ould "e confusing in the future% $here is no indication for an
ileocecectomy as this is an infectious process and 'ill heal 'ith anti"iotics% &f this is in fact an ileocecectomy as this is an infectious process and 'ill heal 'ith anti"iotics% &f this is in fact an
initial presentation of C!* additional therapy 'ill "e re-uired "ut 'ill heal 'ithout surgery% initial presentation of C!* additional therapy 'ill "e re-uired "ut 'ill heal 'ithout surgery%

Acute ileitis presents 'ith right lo'er -uadrant pain* fever* and anore?ia much the same as acute Acute ileitis presents 'ith right lo'er -uadrant pain* fever* and anore?ia much the same as acute
appendicitis% &t is often caused "y appendicitis% &t is often caused "y Campylobacter Campylobacter or or Yersinia Yersinia species% $hese can "e cultured species% $hese can "e cultured
from the appendi? and from the patientJs stool% &n one study of patients 'ith signs and symptoms from the appendi? and from the patientJs stool% &n one study of patients 'ith signs and symptoms
of acute appendicitis* nine patients had only thic,ened terminal ileum on ultrasound% ;ive of these of acute appendicitis* nine patients had only thic,ened terminal ileum on ultrasound% ;ive of these
proceeded to surgery in spite of these results% All nine had positive cultures of proceeded to surgery in spite of these results% All nine had positive cultures of C. jejuni C. jejuni* and all * and all
recovered easily 'ith no progression to C!% $here 'ere no adverse events from the recovered easily 'ith no progression to C!% $here 'ere no adverse events from the
appendectomies% imilarly* a study of 198 normal appendices e?cised for presumed appendicitis appendectomies% imilarly* a study of 198 normal appendices e?cised for presumed appendicitis
yielded positive cultures for yielded positive cultures for C. jejuni C. jejuni and and Y. enterocolitoca Y. enterocolitoca% At the time of surgery* the appendi? % At the time of surgery* the appendi?
appeared normal* "ut B+% of these culture positive patients had terminal ileitis or mesenteric appeared normal* "ut B+% of these culture positive patients had terminal ileitis or mesenteric
adenitis% $here 'ere no pathologic cultures of adenitis% $here 'ere no pathologic cultures of C. jejuni C. jejuni or or Y. enterocolitoca Y. enterocolitoca isolated from 9+B isolated from 9+B
normal appendices e?cised during gynecologic surgeries% Although acute terminal ileitis can normal appendices e?cised during gynecologic surgeries% Although acute terminal ileitis can
present as appendicitis and appear to "e early CrohnJs* the ma:ority are of infectious etiologies% present as appendicitis and appear to "e early CrohnJs* the ma:ority are of infectious etiologies%

Bi"liography#vers B.% mall "o'el% &n1 $o'nsend C.* Beauchamp /!* #vers B.* et al% (eds%)* Bi"liography#vers B.% mall "o'el% &n1 $o'nsend C.* Beauchamp /!* #vers B.* et al% (eds%)*
Sabiston Textbook of Surgery Sabiston Textbook of Surgery* 1Bth ed% 5hiladelphia* 5A1 6%B% aunders* +001* 8)9% * 1Bth ed% 5hiladelphia* 5A1 6%B% aunders* +001* 8)9%
"ntraabdominal adhesions follo#ing abdominal surgery have been associated #ith "ntraabdominal adhesions follo#ing abdominal surgery have been associated #ith
all of the follo#ing all of the follo#ing except except: :

(A) small "o'el o"struction


(A) small "o'el o"struction
(B) infertility
(B) infertility
(C) chronic pelvic pain
(C) chronic pelvic pain
(!) intestinal mala"sorption
(!) intestinal mala"sorption
(#) increased ris, for enterotomy on su"se-uent
(#) increased ris, for enterotomy on su"se-uent
laparotomy
laparotomy
Explanation:
Explanation:

;ollo'ing laparotomy* up to )5% of patients 'ill develop adhesions% Although the ma:ority of ;ollo'ing laparotomy* up to )5% of patients 'ill develop adhesions% Although the ma:ority of
patients 'ill not develop any clinical conse-uences from patients 'ill not develop any clinical conse-uences from adhesion formation* there are significant adhesion formation* there are significant
mor"idities associated 'ith their development% &n a retrospective study using the cottish mor"idities associated 'ith their development% &n a retrospective study using the cottish
Gational 2ealth ervice data"ase* 5%C% of all readmissions follo'ing a"dominal or pelvic surgery Gational 2ealth ervice data"ase* 5%C% of all readmissions follo'ing a"dominal or pelvic surgery
over 10 years 'ere found to "e related to adhesions% .id> and hind>gut procedures had the over 10 years 'ere found to "e related to adhesions% .id> and hind>gut procedures had the
highest num"er of adhesion>related readmissions* and most admissions occurred in the first year highest num"er of adhesion>related readmissions* and most admissions occurred in the first year
after surgery% after surgery%

&ntraa"dominal adhesions are the leading cause for small "o'el o"struction in the industrialized &ntraa"dominal adhesions are the leading cause for small "o'el o"struction in the industrialized
'orld% @p to 80% of admissions for small "o'el o"struction are secondary to postoperative 'orld% @p to 80% of admissions for small "o'el o"struction are secondary to postoperative
adhesions% $ypes of procedures most commonly associated 'ith adhesions>related small "o'el adhesions% $ypes of procedures most commonly associated 'ith adhesions>related small "o'el
o"struction are gynecologic operations* appendectomy* and small "o'el operations% <verall* o"struction are gynecologic operations* appendectomy* and small "o'el operations% <verall*
patients 'ho undergo any a"dominal procedure have a 5% incidence of developing adhesion> patients 'ho undergo any a"dominal procedure have a 5% incidence of developing adhesion>
related intestinal o"struction% <"struction may occur at any time follo'ing laparotomyA ho'ever* related intestinal o"struction% <"struction may occur at any time follo'ing laparotomyA ho'ever*
in 1C+)% of patients 'ho develop postoperative o"struction* it occurs 'ithin the first month after in 1C+)% of patients 'ho develop postoperative o"struction* it occurs 'ithin the first month after
surgery% &n terms of location* o"structions from adhesions tend to occur at the level of the ileum* surgery% &n terms of location* o"structions from adhesions tend to occur at the level of the ileum*
possi"ly "ecause of its greater mo"ility 'ithin the a"domen% possi"ly "ecause of its greater mo"ility 'ithin the a"domen%

"ntraabdominal adhesions account for up to *); of secondary infertility in #omen "ntraabdominal adhesions account for up to *); of secondary infertility in #omen% %
Adhesions in the pelvis can cause infertility "y "loc,ing the fallopian tu"es or interfering in ovum Adhesions in the pelvis can cause infertility "y "loc,ing the fallopian tu"es or interfering in ovum
transfer from the ovary to the tu"es% $he ris, of infertility is pro"a"ly related to the degree of transfer from the ovary to the tu"es% $he ris, of infertility is pro"a"ly related to the degree of
peritoneal trauma and severity of the ensuing adhesions% &n a retrospective study of 'omen 'ith peritoneal trauma and severity of the ensuing adhesions% &n a retrospective study of 'omen 'ith
tu"al infertility* a history of appendectomy 'ith appendiceal rupture significantly increased the ris, tu"al infertility* a history of appendectomy 'ith appendiceal rupture significantly increased the ris,
of infertility 'hile the history of simple appendectomy 'ithout rupture did not% &t is also "elieved of infertility 'hile the history of simple appendectomy 'ithout rupture did not% &t is also "elieved
that pelvic and a"dominal adhesions can cause chronic pain% $heoretically* adhesions may cause that pelvic and a"dominal adhesions can cause chronic pain% $heoretically* adhesions may cause
pain "y putting tension on the sensitive parietal peritoneum% 2istologic study has also sho'n the pain "y putting tension on the sensitive parietal peritoneum% 2istologic study has also sho'n the
presence of sensory nerve fi"ers 'ithin a"dominal adhesions% 5ain symptoms and degree of presence of sensory nerve fi"ers 'ithin a"dominal adhesions% 5ain symptoms and degree of
adhesions do not correlate 'ellA ho'ever* most studies in the gynecologic literature sho' at least adhesions do not correlate 'ellA ho'ever* most studies in the gynecologic literature sho' at least
short>term improvement in pain follo'ing laparoscopic lysis of adhesions% short>term improvement in pain follo'ing laparoscopic lysis of adhesions%

5atients 'ith adhesions from previous laparotomy 'ho undergo reoperation have an increased 5atients 'ith adhesions from previous laparotomy 'ho undergo reoperation have an increased
rate of inadvertent enterotomy% A study of +C0 of such patients sho'ed a 1)% incidence of "o'el rate of inadvertent enterotomy% A study of +C0 of such patients sho'ed a 1)% incidence of "o'el
in:ury% &n this group* increased age and more than three prior laparotomies 'ere independent in:ury% &n this group* increased age and more than three prior laparotomies 'ere independent
predictors of greater ris, of enterotomy% predictors of greater ris, of enterotomy%

&ntestinal mala"sorption is not associated 'ith the presence intraa"dominal adhesions% &ntestinal mala"sorption is not associated 'ith the presence intraa"dominal adhesions%

Bi"liography#llis 2* .oran B* $hompson 3* et al% Adhesion>related hospital readmissions after Bi"liography#llis 2* .oran B* $hompson 3* et al% Adhesion>related hospital readmissions after
a"dominal and pelvic surgery1 a retrospective cohort study% a"dominal and pelvic surgery1 a retrospective cohort study% Lancet Lancet 1)))A95911(CB1(80% 1)))A95911(CB1(80% K K
5u".ed 5u".ed1 10+9+919L 1 10+9+919L
#vers B* $o'nsend C* $hompson 3% mall intestine% &n1 ch'artz * hires D* pencer ;* et al% #vers B* $o'nsend C* $hompson 3% mall intestine% &n1 ch'artz * hires D* pencer ;* et al%
(eds%)* (eds%)* Principles of Surgery Principles of Surgery* Cth ed% Ge' Mor,* GM1 .cDra'>2ill* 1)))* 1+1C1+B9% * Cth ed% Ge' Mor,* GM1 .cDra'>2ill* 1)))* 1+1C1+B9%
4etterie D% 5elvic adhesive disease% &n1 4etterie D (ed%)* 4etterie D% 5elvic adhesive disease% &n1 4etterie D (ed%)* Structural bnormalities an! Structural bnormalities an!
"epro!ucti#e $ailure% &ffecti#e Techni'ues for Diagnosis an! (anagement "epro!ucti#e $ailure% &ffecti#e Techni'ues for Diagnosis an! (anagement % <?ford1 Blac,'ell % <?ford1 Blac,'ell
cience* 1))8* (C5501% cience* 1))8* (C5501%
.on, B* Berman .* .ontz ;% Adhesions after e?tensive gynecologic surgery1 clinical .on, B* Berman .* .ontz ;% Adhesions after e?tensive gynecologic surgery1 clinical
significance* etiology* and prevention% significance* etiology* and prevention% m ) *bstet +ynecol m ) *bstet +ynecol 1))(A1C0(5)119)B1(09% 1))(A1C0(5)119)B1(09% K K5u".ed 5u".ed
1 81C8880L 1 81C8880L
/ei:nen .* Bleichrodt /* van Door 2% 5athophysiology of intra>a"dominal adhesion and a"scess /ei:nen .* Bleichrodt /* van Door 2% 5athophysiology of intra>a"dominal adhesion and a"scess
formation* and the effect of hyaluronan% formation* and the effect of hyaluronan% Br ) Surg Br ) Surg +009A)015995(1% +009A)015995(1% K K
%hich of the follo#ing is %hich of the follo#ing is not not an indication for surgical an indication for surgical
intervention in ulcerative colitis8 intervention in ulcerative colitis8

(A) intracta"le "loody diarrhea (A) intracta"le "loody diarrhea


(B) perforation (B) perforation
(C) to?ic colitis (C) to?ic colitis
(!) diagnosis of ulcerative colitis for more than 5 years (!) diagnosis of ulcerative colitis for more than 5 years
(#) poorly controlled e?traintestinal manifestations (#) poorly controlled e?traintestinal manifestations
Explanation:
Explanation:

&ndications for surgical intervention in ulcerative


&ndications for surgical intervention in ulcerative
colitis include intracta"le symptoms* perforation*
colitis include intracta"le symptoms* perforation*
to?ic colitis* increasing cancer ris,* hemorrhage*
to?ic colitis* increasing cancer ris,* hemorrhage*
fulminating disease* and poorly controlled
fulminating disease* and poorly controlled
e?traintestinal manifestations% $he cancer ris,
e?traintestinal manifestations% $he cancer ris,
after initial diagnosis is appro?imately 5C%
after initial diagnosis is appro?imately 5C%
during the first 5C years* "ut increases to (0%
during the first 5C years* "ut increases to (0%
at +0 years postdiagnosis% $herefore* surgical
at +0 years postdiagnosis% $herefore* surgical
intervention is commonly recommended
intervention is commonly recommended
"eginning appro?imately 10 years after initial
"eginning appro?imately 10 years after initial
diagnosis%
diagnosis%
All of the follo#ing are associated #ith an increased ris& of All of the follo#ing are associated #ith an increased ris& of
perforation in acute colonic pseudoobstruction +'gilvieAs perforation in acute colonic pseudoobstruction +'gilvieAs
syndrome/ syndrome/ except except: :

(A) older age


(A) older age
(B) increasing cecal diameter
(B) increasing cecal diameter
(C) delay in decompression
(C) delay in decompression
(!) dia"etes mellitus
(!) dia"etes mellitus
(#) chronic ischemia
(#) chronic ischemia
Explanation:
Explanation:

Acute colonic pseudoo"struction is a syndrome of massive dilation Acute colonic pseudoo"struction is a syndrome of massive dilation
of the colon 'ithout mechanical o"struction that develops in of the colon 'ithout mechanical o"struction that develops in
hospitalized patients 'ith serious underlying medical and surgical hospitalized patients 'ith serious underlying medical and surgical
conditions% &ncreasing age* cecal diameter* delay in decompression* conditions% &ncreasing age* cecal diameter* delay in decompression*
and status of the "o'el significantly influence mortality* 'hich is and status of the "o'el significantly influence mortality* 'hich is
appro?imately (0% 'hen ischemia or perforation is present% appro?imately (0% 'hen ischemia or perforation is present%
#valuation of the mar,edly distended colon in the intensive care unit #valuation of the mar,edly distended colon in the intensive care unit
setting involves e?cluding mechanical o"struction and other causes setting involves e?cluding mechanical o"struction and other causes
of to?ic megacolon such as of to?ic megacolon such as Clostri!ium !ifficile Clostri!ium !ifficile infection* and infection* and
assessing for signs of ischemia and perforation% $he ris, of colonic assessing for signs of ischemia and perforation% $he ris, of colonic
perforation in acute colonic pseudoo"struction increases 'hen cecal perforation in acute colonic pseudoo"struction increases 'hen cecal
diameter e?ceeds 1+ cm and 'hen the distention has "een present diameter e?ceeds 1+ cm and 'hen the distention has "een present
for greater than B days% Appropriate management includes for greater than B days% Appropriate management includes
supportive therapy and selective use of neostigmine and supportive therapy and selective use of neostigmine and
colonoscopy for decompression% #arly recognition and management colonoscopy for decompression% #arly recognition and management
are critical in minimizing complications% are critical in minimizing complications%
%hich of the statements regarding cecal volvulus is %hich of the statements regarding cecal volvulus is
not not true8 true8

(A) Cecal volvulus accounts for 10% of cases of colonic volvulus% (A) Cecal volvulus accounts for 10% of cases of colonic volvulus%
(B) Cecal vovulus is thought to have a congenital etiology related to (B) Cecal vovulus is thought to have a congenital etiology related to
incomplete peritoneal fi?ation of the right colon% incomplete peritoneal fi?ation of the right colon%
(C) /adiographic evidence of a cecal volvulus includes a large* (C) /adiographic evidence of a cecal volvulus includes a large*
dilated loop of colon 'ith the loop of colon pointing to the left upper dilated loop of colon 'ith the loop of colon pointing to the left upper
-uadrant of the a"domen% -uadrant of the a"domen%
(!) !efinitive treatment for cecal volvulus includes a right (!) !efinitive treatment for cecal volvulus includes a right
hemicolectomy% hemicolectomy%
(#) /eduction of the cecal volvulus 'ith fi?ation of the cecum to the (#) /eduction of the cecal volvulus 'ith fi?ation of the cecum to the
a"dominal 'all provides a similar outcome to segmental resection% a"dominal 'all provides a similar outcome to segmental resection%
Explanation:
Explanation:

6hile sigmoid volvulus accounts for I80% of colonic volvulus cases* 6hile sigmoid volvulus accounts for I80% of colonic volvulus cases*
cecal volvulus is relatively rare* accounting for 10% of cases% cecal volvulus is relatively rare* accounting for 10% of cases%
igmoid volvulus is felt to "e Fac-uiredF through accumulation of ris, igmoid volvulus is felt to "e Fac-uiredF through accumulation of ris,
factors 'hile cecal volvulus is considered FcongenitalF "ecause of factors 'hile cecal volvulus is considered FcongenitalF "ecause of
individual anatomic variation% Both sigmoid and cecal volvulus individual anatomic variation% Both sigmoid and cecal volvulus
demonstrate a large* dilated loop of colon on plain radiograph% $he demonstrate a large* dilated loop of colon on plain radiograph% $he
loop FpointsF to the left upper -uadrant of the a"domen 'ith a cecal loop FpointsF to the left upper -uadrant of the a"domen 'ith a cecal
volvulus and to the right upper -uadrant 'ith a sigmoid volvulus% volvulus and to the right upper -uadrant 'ith a sigmoid volvulus%
6hile cecope?y has "een 'ell descri"ed and does have some 6hile cecope?y has "een 'ell descri"ed and does have some
success* the definitive treatment for cecal volvulus is right success* the definitive treatment for cecal volvulus is right
hemicolectomy 'ith primary anastomosis in the appropriate setting hemicolectomy 'ith primary anastomosis in the appropriate setting
'ith resection* ileostomy* and mucous fistula in the presence of 'ith resection* ileostomy* and mucous fistula in the presence of
perforation or peritonitis perforation or peritonitis
A previously healthy **-year-old male college football player presents to your emergency A previously healthy **-year-old male college football player presents to your emergency
department *4 h after the homecoming football game #ith complaints of severe left lo#er department *4 h after the homecoming football game #ith complaints of severe left lo#er
?uadrant abdominal pain! fever of -)*G,! nausea and vomiting. 1aboratory findings include a ?uadrant abdominal pain! fever of -)*G,! nausea and vomiting. 1aboratory findings include a
%36 count of -H!3)) #ith :; bands. 'n physical examination his abdomen is soft! but he has %36 count of -H!3)) #ith :; bands. 'n physical examination his abdomen is soft! but he has
mar&ed tenderness in the left lo#er ?uadrant. mar&ed tenderness in the left lo#er ?uadrant.
%hich of the follo#ing is the most appropriate diagnostic study in this patient8 %hich of the follo#ing is the most appropriate diagnostic study in this patient8

+A/ 6T abdomen and pelvis


+A/ 6T abdomen and pelvis
+3/ barium enema
+3/ barium enema
+6/ abdominal ultrasound
+6/ abdominal ultrasound
+C/ colonoscopy
+C/ colonoscopy
+E/ laparoscopy
+E/ laparoscopy
Explanation:
Explanation:

$his patient has acute uncomplicated diverticulitis% $his disease is characterized "y $his patient has acute uncomplicated diverticulitis% $his disease is characterized "y
localized diverticular perforation 'ithout a"scess formation* free perforation* or localized diverticular perforation 'ithout a"scess formation* free perforation* or
"leeding% "leeding% $he ma:ority of patients present 'ith left lo'er -uadrant pain* fever* and leu,ocytosis* $he ma:ority of patients present 'ith left lo'er -uadrant pain* fever* and leu,ocytosis*
ma,ing diverticulitis principally a clinical diagnosis% !iagnostic dilemmas do occur* ho'ever* and ma,ing diverticulitis principally a clinical diagnosis% !iagnostic dilemmas do occur* ho'ever* and
a 'ide differential including "o'el perforation or o"struction* appendicitis* inflammatory "o'el a 'ide differential including "o'el perforation or o"struction* appendicitis* inflammatory "o'el
disease* and ischemic colitis must "e considered% An imaging study is indicated 'hen the clinical disease* and ischemic colitis must "e considered% An imaging study is indicated 'hen the clinical
picture is not clear* or to help guide future therapy% picture is not clear* or to help guide future therapy%

#ndoscopy is contraindicated in the setting of acute diverticulitis "ecause the insuflation re-uired #ndoscopy is contraindicated in the setting of acute diverticulitis "ecause the insuflation re-uired
can distur" the tenuous seal containing the diverticular perforation and result in the conversion to can distur" the tenuous seal containing the diverticular perforation and result in the conversion to
free perforation and a need for more urgent surgical intervention 'ith su"stantially higher free perforation and a need for more urgent surgical intervention 'ith su"stantially higher
mor"idity and mortality% #ndoscopy can "e useful after the acute episode has resolved to mor"idity and mortality% #ndoscopy can "e useful after the acute episode has resolved to
evaluate for other distal pathologic processes% evaluate for other distal pathologic processes%

Barium enema is also contraindicated in the acute setting for reasons similar to those descri"ed Barium enema is also contraindicated in the acute setting for reasons similar to those descri"ed
a"ove% &t is a very important part of the preparation for elective resection after recovery* as it a"ove% &t is a very important part of the preparation for elective resection after recovery* as it
accurately descri"es the e?tent of involvement and severity of disease* including strictures that accurately descri"es the e?tent of involvement and severity of disease* including strictures that
may develop after acute diverticulitis% may develop after acute diverticulitis%

4aparoscopy has "een descri"ed as a highly sensitive diagnostic modalityA ho'ever* its invasive 4aparoscopy has "een descri"ed as a highly sensitive diagnostic modalityA ho'ever* its invasive
nature precludes its routine use for this purpose% nature precludes its routine use for this purpose%

Both C$ and ultrasound can accurately diagnose diverticulitis% C$ has a sensitivity of up to )5% Both C$ and ultrasound can accurately diagnose diverticulitis% C$ has a sensitivity of up to )5%
and specificity of C+%% Both modalities can also identify a"scesses* ma,ing it possi"le for and specificity of C+%% Both modalities can also identify a"scesses* ma,ing it possi"le for
patients to have early drainage of these collections% C$ is generally more availa"le in most patients to have early drainage of these collections% C$ is generally more availa"le in most
institutions and is su"stantially less operator>dependent% C$ findings such as presence of an institutions and is su"stantially less operator>dependent% C$ findings such as presence of an
a"scess* e?traluminal contrast or air strongly suggest that conservative treatment 'ith anti"iotics a"scess* e?traluminal contrast or air strongly suggest that conservative treatment 'ith anti"iotics
'ill not "e successful% 'ill not "e successful%
A :3-year-old male presents to your emergency department complaining A :3-year-old male presents to your emergency department complaining
of a large amount of bright red blood per rectum. <e is moderately of a large amount of bright red blood per rectum. <e is moderately
tachycardic! but other#ise is hemodynamically stable. tachycardic! but other#ise is hemodynamically stable.
%hich of the follo#ing statements regarding the management of this %hich of the follo#ing statements regarding the management of this
patient is patient is false false8 8

A/ Anoscopy follo#ed by proctoscopy should be performed to A/ Anoscopy follo#ed by proctoscopy should be performed to
exclude locali$ed anorectal disease as the cause of exclude locali$ed anorectal disease as the cause of
hemorrhage. hemorrhage.
+3/ 3efore surgical intervention is considered! he must +3/ 3efore surgical intervention is considered! he must
undergo esophagogastroduodenoscopy +E@C/. undergo esophagogastroduodenoscopy +E@C/.
+6/ <e should undergo colonoscopy if clinically stable. +6/ <e should undergo colonoscopy if clinically stable.
+C/ A positive tagged 036 scan should prompt segmental +C/ A positive tagged 036 scan should prompt segmental
surgical resection. surgical resection.
+E/ 2one of the above. +E/ 2one of the above.
Explanation:
Explanation:

4D&2 is defined as persistent gross "leeding from the rectum* 'ith or 'ithout 4D&2 is defined as persistent gross "leeding from the rectum* 'ith or 'ithout
hemodynamic insta"ility and hemorrhagic shoc,% $his patient has early signs of hemodynamic insta"ility and hemorrhagic shoc,% $his patient has early signs of
hemodynamic insta"ility* so aggressive resuscitation must "e underta,en prior to hemodynamic insta"ility* so aggressive resuscitation must "e underta,en prior to
engaging in any diagnostic studies% Anoproctosigmoidoscopy is the ne?t step in his engaging in any diagnostic studies% Anoproctosigmoidoscopy is the ne?t step in his
evaluation and management% <ccasionally* localized and treata"le lesions of the evaluation and management% <ccasionally* localized and treata"le lesions of the
anus may "e responsi"le for the hemorrhage% &n hemodynamically sta"le patients* the anus may "e responsi"le for the hemorrhage% &n hemodynamically sta"le patients* the
ne?t step 'ould "e to pursue colonoscopy% $his study can identify active "leeding or ne?t step 'ould "e to pursue colonoscopy% $his study can identify active "leeding or
stigmata of recent "leeding in up to )0% of patients% #ndoscopic hemostasis can "e stigmata of recent "leeding in up to )0% of patients% #ndoscopic hemostasis can "e
attempted* although the success rate varies 'ith the type of lesion (angiodysplasias attempted* although the success rate varies 'ith the type of lesion (angiodysplasias
have 85)0% success rate)% have 85)0% success rate)%

&n sta"le patients* #D! can "e deferred until after colonoscopy* "ut it remains an &n sta"le patients* #D! can "e deferred until after colonoscopy* "ut it remains an
essential part of the evaluation* and 'ith 515% of 4D&2 caused "y upper D& "leed* it essential part of the evaluation* and 'ith 515% of 4D&2 caused "y upper D& "leed* it
must "e performed "efore surgical intervention is considered% must "e performed "efore surgical intervention is considered%

$agged /BC scan allo's for identification of the source of "leeding do'n to 0%1 $agged /BC scan allo's for identification of the source of "leeding do'n to 0%1
m4EminA ho'ever* localization of these findings is some'hat vague* ma,ing m4EminA ho'ever* localization of these findings is some'hat vague* ma,ing
segmental surgical resection "ased on "leeding scan alone a ris,y proposition% segmental surgical resection "ased on "leeding scan alone a ris,y proposition%
;indings should "e correlated 'ith a mesenteric arteriogram or the endoscopist ;indings should "e correlated 'ith a mesenteric arteriogram or the endoscopist
should la"el the area 'ith dye 'hile performing the colonoscopy% should la"el the area 'ith dye 'hile performing the colonoscopy%
An =)-year-old female presents to the emergency room #ith abdominal pain. he complains that the pain seems to be radiating to the An =)-year-old female presents to the emergency room #ith abdominal pain. he complains that the pain seems to be radiating to the
right thigh! &nee! and hip. he also has nausea and vomiting that is bilious in nature. Although this pain has been intermittent for the right thigh! &nee! and hip. he also has nausea and vomiting that is bilious in nature. Although this pain has been intermittent for the
past year! she believes that this episode is more severe! #hich prompted her to see& assistance at the emergency room. he denies past year! she believes that this episode is more severe! #hich prompted her to see& assistance at the emergency room. he denies
any history of prior surgery. <o#ever! she suffers from diabetes mellitus and had a myocardial infarction in the past. 'n physical any history of prior surgery. <o#ever! she suffers from diabetes mellitus and had a myocardial infarction in the past. 'n physical
examination! the patient is tachycardic! normotensive! and afebrile. Abdominal examination reveals a distended abdomen! #ith examination! the patient is tachycardic! normotensive! and afebrile. Abdominal examination reveals a distended abdomen! #ith
guarding! rebound! diffuse tenderness and high pitched bo#el sounds. 2o obvious umbilical! nor inguinal hernias #ere detected. A guarding! rebound! diffuse tenderness and high pitched bo#el sounds. 2o obvious umbilical! nor inguinal hernias #ere detected. A
palpable mass #as discovered high in the medial aspect of the right thigh. %hat is your diagnosis palpable mass #as discovered high in the medial aspect of the right thigh. %hat is your diagnosis

A) femoral hernia
A) femoral hernia
(B) mesenteric ischemia
(B) mesenteric ischemia
(C) o"turator hernia
(C) o"turator hernia
(!) ruptured appendicitis
(!) ruptured appendicitis
(#) lymphoma
(#) lymphoma
Explanation
Explanation

: : <"turator hernias accounts for less than 5% of all mechanical "o'el o"structions% &t <"turator hernias accounts for less than 5% of all mechanical "o'el o"structions% &t
is most commonly found in females* on the right side* in the seventh and eighth is most commonly found in females* on the right side* in the seventh and eighth
decade of life% $he hernia passes through the o"turator canal* "ounded "y the decade of life% $he hernia passes through the o"turator canal* "ounded "y the
superior pu"ic ramus and the o"turator mem"rane% $he o"turator vessels and nerve superior pu"ic ramus and the o"turator mem"rane% $he o"turator vessels and nerve
passes through the canal and they lie posterolateral to the hernia sac% $here are four passes through the canal and they lie posterolateral to the hernia sac% $here are four
cardinal features of this hernia* the most common "eing intestinal o"structionA cardinal features of this hernia* the most common "eing intestinal o"structionA
another is the 2o'ship>/om"erg sign (pain do'n the inner surface of thigh* ,nee another is the 2o'ship>/om"erg sign (pain do'n the inner surface of thigh* ,nee
:oint* and hip)% $his is referred pain from the cutaneous "ranch of the anterior division :oint* and hip)% $his is referred pain from the cutaneous "ranch of the anterior division
of the o"turator nerve* 'hich is compressed "y the hernia in the canal% $he ne?t of the o"turator nerve* 'hich is compressed "y the hernia in the canal% $he ne?t
feature is a palpa"le mass high in the medial aspect of the thigh at the origin of the feature is a palpa"le mass high in the medial aspect of the thigh at the origin of the
adductor muscles% $he mass is "est felt 'ith the thigh fle?ed* adducted* and rotated adductor muscles% $he mass is "est felt 'ith the thigh fle?ed* adducted* and rotated
out'ard% $he last feature is repeated attac,s of intestinal o"struction that pass out'ard% $he last feature is repeated attac,s of intestinal o"struction that pass
spontaneously% $reatment entails operative intervention as soon as possi"le* spontaneously% $reatment entails operative intervention as soon as possi"le*
secondary to the high rate of strangulation% $he three preferred operative approaches secondary to the high rate of strangulation% $he three preferred operative approaches
are a midline transperitoneal approach* midline e?traperitoneal approach* and are a midline transperitoneal approach* midline e?traperitoneal approach* and
e?posure in the thigh% $he former t'o are "etter since these hernias can "e "ilateral e?posure in the thigh% $he former t'o are "etter since these hernias can "e "ilateral
and therefore one can e?plore the other side if needed% ;igures +B>+ and +B>9 sho' and therefore one can e?plore the other side if needed% ;igures +B>+ and +B>9 sho'
the classical radiologic findings of an the classical radiologic findings of an incarcerate! obturator hernia incarcerate! obturator hernia causing small causing small
"o'el o"struction% "o'el o"struction%

A H.-year-old male #ith a history of peptic ulcer disease presents #ith A H.-year-old male #ith a history of peptic ulcer disease presents #ith
an acute onset of epigastric pain and hematemesis. <e reports relief an acute onset of epigastric pain and hematemesis. <e reports relief
#ith antacids and proton pump inhibitors for - year. <is past medical #ith antacids and proton pump inhibitors for - year. <is past medical
history is significant for hypertension and coronary artery disease. 'n history is significant for hypertension and coronary artery disease. 'n
physical examination! the patient is hypotensive! and tachycardic. <is physical examination! the patient is hypotensive! and tachycardic. <is
abdomen is soft and tender at the epigastric region! but other#ise abdomen is soft and tender at the epigastric region! but other#ise
benign. Endoscopy reveals a large amount of clot in the stomach #ith benign. Endoscopy reveals a large amount of clot in the stomach #ith
an active arterial bleeder in the area of the duodenal bulb. 7ultiple an active arterial bleeder in the area of the duodenal bulb. 7ultiple
attempts of endoscopic therapy failed. The patient continued to attempts of endoscopic therapy failed. The patient continued to
re?uire additional "4 fluids and blood products. <e #as ta&en to the re?uire additional "4 fluids and blood products. <e #as ta&en to the
operating room! #here a laparotomy #as performed. A longitudinal operating room! #here a laparotomy #as performed. A longitudinal
incision along the pylorus spanning 3 cm on each side of the great incision along the pylorus spanning 3 cm on each side of the great
vein of 7ayo #as created. Traction sutures #ere placed superiorly and vein of 7ayo #as created. Traction sutures #ere placed superiorly and
inferiorly prior to the enterotomy. The ulcer #as readily identified at inferiorly prior to the enterotomy. The ulcer #as readily identified at
the posterior duodenal bulb and a clot #as removed. %hat is the next the posterior duodenal bulb and a clot #as removed. %hat is the next
step in the procedure8 step in the procedure8

(A) sclerotherapy (A) sclerotherapy


(B) perform a figure of eight stitch (B) perform a figure of eight stitch
(C) vasopressin infusion (C) vasopressin infusion
(!) three suture ligation encompassing the pro?imal and (!) three suture ligation encompassing the pro?imal and
distal "ranches of the gastroduodenal arteries and a @> distal "ranches of the gastroduodenal arteries and a @>
type stitch to transfi? the transverse "ranch of the type stitch to transfi? the transverse "ranch of the
pancreatic artery% pancreatic artery%
(#) 0ocherize the duodenum and perform a graham (#) 0ocherize the duodenum and perform a graham
patch patch

Explanation: Explanation: $his is an e?ample of a "leeding duodenal ulcer in the $his is an e?ample of a "leeding duodenal ulcer in the
posterior 'all% $here are some studies that state that the incidence of posterior 'all% $here are some studies that state that the incidence of
emergent or urgent operations for "leeding duodenal ulcers has remained emergent or urgent operations for "leeding duodenal ulcers has remained
unchanged over the past years% .ost patients 'ith this disorder are unchanged over the past years% .ost patients 'ith this disorder are
successfully treated 'ith medical or endoscopic management% #ndoscopy successfully treated 'ith medical or endoscopic management% #ndoscopy
remains the initial standard of care for the diagnosis and treatment of remains the initial standard of care for the diagnosis and treatment of
"leeding duodenal ulcers% urgery is indicated 'hen there is active "leeding duodenal ulcers% urgery is indicated 'hen there is active
hemorrhage 'hich is refractory to endoscopic techni-ues% &nitial hemorrhage 'hich is refractory to endoscopic techni-ues% &nitial
management should include replacement of "lood volume "y large "ore &Hs management should include replacement of "lood volume "y large "ore &Hs
as 'ell as continuous monitoring of vital signs and urinary output% #mergent as 'ell as continuous monitoring of vital signs and urinary output% #mergent
surgery is also indicated 'hen transfusion is in e?cess of B units in a +(>h surgery is also indicated 'hen transfusion is in e?cess of B units in a +(>h
period% Antrectomy and vagotomy 'as historically considered the gold period% Antrectomy and vagotomy 'as historically considered the gold
standard for this condition secondary to lo' recurrence rate* "ut has "een standard for this condition secondary to lo' recurrence rate* "ut has "een
replaced "y the three suture techni-ue* 'hich has a significantly lo'er replaced "y the three suture techni-ue* 'hich has a significantly lo'er
mor"idity and mortality in the elderly* and unsta"le patient% 6ith this mor"idity and mortality in the elderly* and unsta"le patient% 6ith this
techni-ue* 'e add pyloroplasty and truncal vagotomy% A highly selective techni-ue* 'e add pyloroplasty and truncal vagotomy% A highly selective
vagotomy can "e done for the young* hemodynamically sta"le patient 'ith vagotomy can "e done for the young* hemodynamically sta"le patient 'ith
minimal comor"idities minimal comor"idities

A .)-year-old male presents to the emergency room #ith a A .)-year-old male presents to the emergency room #ith a
history of melena! and most recently 3 episodes of history of melena! and most recently 3 episodes of
hematemesis. The patient denies attac&s of reflux or history of hematemesis. The patient denies attac&s of reflux or history of
peptic ulcer disease. <e has no other significant medical peptic ulcer disease. <e has no other significant medical
problems. <e had a right inguinal hernia repair -) years ago. problems. <e had a right inguinal hernia repair -) years ago.
The patientAs vital signs are stable. Physical exam of the The patientAs vital signs are stable. Physical exam of the
abdomen #as unremar&able. 0ectal examination reveals a abdomen #as unremar&able. 0ectal examination reveals a
positive fecal occult blood test. At this point in the exam! the positive fecal occult blood test. At this point in the exam! the
patient retches and vomits approximately *.) cc of maroon patient retches and vomits approximately *.) cc of maroon
emesis #ith spec&s of blood. Endoscopy reveals a large emesis #ith spec&s of blood. Endoscopy reveals a large
submucosal vessel along the lesser curvature that is not submucosal vessel along the lesser curvature that is not
actively bleeding. %hat is the management for this condition8 actively bleeding. %hat is the management for this condition8

A) endoscopic cauterization
A) endoscopic cauterization
(B) vagotomy and antrectomy
(B) vagotomy and antrectomy
(C) 'edge resection of gastric 'all
(C) 'edge resection of gastric 'all
(!) distal gastrectomy 'ithout vagotomy
(!) distal gastrectomy 'ithout vagotomy

Explanation: Explanation: $his is an e?ample of !ielafoyJs lesion* 'hich is a vascular $his is an e?ample of !ielafoyJs lesion* 'hich is a vascular
malformation and a rare cause of upper D& hemorrhage% &t is also called malformation and a rare cause of upper D& hemorrhage% &t is also called
Fcali"er>persistent artery%F $he malformation is a large su"mucosal or Fcali"er>persistent artery%F $he malformation is a large su"mucosal or
mucosal vessel that may "leed 'hen there is erosion into it% &t is usually mucosal vessel that may "leed 'hen there is erosion into it% &t is usually
found along the lesser curvature* middle aged individuals* and no found along the lesser curvature* middle aged individuals* and no
association 'ith any vascular* or peptic ulcer disease% $he hemorrhage association 'ith any vascular* or peptic ulcer disease% $he hemorrhage
produced from the lesion can "e massive and can cease spontaneously at produced from the lesion can "e massive and can cease spontaneously at
times% &t is difficult to diagnose endoscopically "ecause there is no ulcer times% &t is difficult to diagnose endoscopically "ecause there is no ulcer
surrounding the lesion% !iagnosis is "est achieved "y performing endoscopy surrounding the lesion% !iagnosis is "est achieved "y performing endoscopy
at the time of "leeding and visualizing a pinpoint mucosal defect 'ith "lood% at the time of "leeding and visualizing a pinpoint mucosal defect 'ith "lood%
<nce the lesion is identified* the area is mar,ed 'ith &ndia in, to delineate <nce the lesion is identified* the area is mar,ed 'ith &ndia in, to delineate
the area during surgical resection% !efinitive management calls for 'edge the area during surgical resection% !efinitive management calls for 'edge
resection of the gastric 'all* rather than an e?tended "lind gastric resection% resection of the gastric 'all* rather than an e?tended "lind gastric resection%
Hagotomy is not re-uired since it is not associated 'ith peptic ulcer disease% Hagotomy is not re-uired since it is not associated 'ith peptic ulcer disease%
#ndoscopic a"lation 'ith sclerotherapy or electrocoagulation has proved #ndoscopic a"lation 'ith sclerotherapy or electrocoagulation has proved
unsuccessful for this lesion% urgery is re-uired "ecause of recurrent "outs unsuccessful for this lesion% urgery is re-uired "ecause of recurrent "outs
of hemorrhage% Angiography and em"olectomy are no' also "eing used as of hemorrhage% Angiography and em"olectomy are no' also "eing used as
first line therapy% first line therapy%
<o# should loc&ed or perched facets in the cervical spine be <o# should loc&ed or perched facets in the cervical spine be
treated initially8 treated initially8

(A) open reduction and internal fi?ation


(A) open reduction and internal fi?ation
(B) closed reduction 'ith cervical traction
(B) closed reduction 'ith cervical traction
(C) ,eep patient immo"ilized in cervical
(C) ,eep patient immo"ilized in cervical
collar
collar
(!) no treatment is needed
(!) no treatment is needed
Explanation:
Explanation:

evere fle?ion in:uries of the cervical spine may cause unilateral or "ilateral loc,ed evere fle?ion in:uries of the cervical spine may cause unilateral or "ilateral loc,ed
facets% $ypically* unilateral loc,ed facets result from fle?ion plus rotation in:uries* and facets% $ypically* unilateral loc,ed facets result from fle?ion plus rotation in:uries* and
"ilateral loc,ed facets result from hyperfle?ion in:uries% Anatomically* loc,ed facets "ilateral loc,ed facets result from hyperfle?ion in:uries% Anatomically* loc,ed facets
refer to the condition 'hen the inferior articular facets of the upper dislocated verte"ra refer to the condition 'hen the inferior articular facets of the upper dislocated verte"ra
slide for'ard over the superior facets of the verte"ra "elo' (;ig% )>1B)% Bilateral slide for'ard over the superior facets of the verte"ra "elo' (;ig% )>1B)% Bilateral
loc,ed facets are e?tremely unsta"le given the e?tensive amount of ligamentous loc,ed facets are e?tremely unsta"le given the e?tensive amount of ligamentous
in:ury involved% $he forces applied in this type of in:ury rupture the posterior in:ury involved% $he forces applied in this type of in:ury rupture the posterior
ligamentous comple?* the :oint capsules* the interverte"ral disc* and* usually* the ligamentous comple?* the :oint capsules* the interverte"ral disc* and* usually* the
posterior and anterior longitudinal ligaments% &n a"out 80% of these cases* the posterior and anterior longitudinal ligaments% &n a"out 80% of these cases* the
patients 'ill present 'ith complete spinal cord in:uries% Gerve root in:uries are patients 'ill present 'ith complete spinal cord in:uries% Gerve root in:uries are
common as 'ell% @nilateral loc,ed facets are more sta"le than "ilateral* and these common as 'ell% @nilateral loc,ed facets are more sta"le than "ilateral* and these
patients are usually neurologically intact% 5atients in either of these groups should "e patients are usually neurologically intact% 5atients in either of these groups should "e
treated initially 'ith closed reduction using cervical traction% <nce reduction of the treated initially 'ith closed reduction using cervical traction% <nce reduction of the
cervical spine is achieved* patients may "e sta"ilized "y immo"ilization in a halo vest cervical spine is achieved* patients may "e sta"ilized "y immo"ilization in a halo vest
or "y internal fi?ation and fusion% urgical management is often preferred given the or "y internal fi?ation and fusion% urgical management is often preferred given the
high incidence of unsatisfactory fusion 'hen using a halo vest alone% urgical high incidence of unsatisfactory fusion 'hen using a halo vest alone% urgical
management should "e used if attempts at closed reduction are unsuccessful% ./& is management should "e used if attempts at closed reduction are unsuccessful% ./& is
helpful in evaluating for a herniated disc and determining the e?tent of damage to the helpful in evaluating for a herniated disc and determining the e?tent of damage to the
spinal cord (;ig% )>1C)% &t is also useful for preoperative planning% 5erched facets refer spinal cord (;ig% )>1C)% &t is also useful for preoperative planning% 5erched facets refer
to facets that have :ust reached the point of loc,ing 'ithout actually doing so% $hese to facets that have :ust reached the point of loc,ing 'ithout actually doing so% $hese
in:uries are treated in a similar manner to loc,ed facets% in:uries are treated in a similar manner to loc,ed facets%
*F-year-old male restrained passenger is brought to the E0 in stable condition follo#ing a *F-year-old male restrained passenger is brought to the E0 in stable condition follo#ing a
motor vehicle accident. <e is admitted for observation follo#ing an abdominal 6T motor vehicle accident. <e is admitted for observation follo#ing an abdominal 6T
demonstrating a moderate amount of free fluid in the pelvis. %ithin 4= h! patient develops demonstrating a moderate amount of free fluid in the pelvis. %ithin 4= h! patient develops
#orsening abdominal pain and undergoes exploratory laparotomy. A small bo#el perforation #orsening abdominal pain and undergoes exploratory laparotomy. A small bo#el perforation
is identified +,ig. -)-4/. %hich of the follo#ing statements regarding small bo#el inEuries is is identified +,ig. -)-4/. %hich of the follo#ing statements regarding small bo#el inEuries is not not
correct8 correct8

(A) thought to occur 'hen "o'el is crushed against (A) thought to occur 'hen "o'el is crushed against
spine spine
(B) fre-uently associated 'ith lum"ar spine fractures (B) fre-uently associated 'ith lum"ar spine fractures
(C) decreased incidence since the mandatory seat "elt (C) decreased incidence since the mandatory seat "elt
la's la's
(!) "elieved result of closed loop of "o'el under high (!) "elieved result of closed loop of "o'el under high
intraluminal pressure intraluminal pressure
Explanation:
Explanation:

mall "o'el in:uries secondary to "lunt a"dominal trauma are mall "o'el in:uries secondary to "lunt a"dominal trauma are
increasing in incidence "ecause of high velocity motor vehicle increasing in incidence "ecause of high velocity motor vehicle
accidents and mandatory seat "elt la's (.oore* ;eliciano* and accidents and mandatory seat "elt la's (.oore* ;eliciano* and
.atto?* +00()% $he Fseat "eltF syndrome is the comple? of in:uries* .atto?* +00()% $he Fseat "eltF syndrome is the comple? of in:uries*
'hich includes lum"ar fractures and small "o'el in:uries% 5hysical 'hich includes lum"ar fractures and small "o'el in:uries% 5hysical
finding of ecchymoses along the anterior a"dominal 'all is referred finding of ecchymoses along the anterior a"dominal 'all is referred
to as the Fseat "elt signF and may indicate underlying small "o'el to as the Fseat "elt signF and may indicate underlying small "o'el
in:uries (Apple"y and Gagy* 1)8))% in:uries (Apple"y and Gagy* 1)8))%

$he proposed mechanisms of in:ury include (1) crushing of "o'el $he proposed mechanisms of in:ury include (1) crushing of "o'el
against spine* (+) tearing of "o'el from mesentery "y sudden against spine* (+) tearing of "o'el from mesentery "y sudden
deceleration* and (9) rupture of a closed loop of "o'el under high deceleration* and (9) rupture of a closed loop of "o'el under high
intraluminal pressure (Duarino* 2assett* and 4uchette* 1))5)% intraluminal pressure (Duarino* 2assett* and 4uchette* 1))5)%
An E0 thoracotomy should An E0 thoracotomy should not not be performed in #hat setting8 be performed in #hat setting8

(A) a patient in shoc, 'ith a penetrating anterior chest 'ound (A) a patient in shoc, 'ith a penetrating anterior chest 'ound
(B) a patient 'ho sustained a penetrating chest 'ound and (B) a patient 'ho sustained a penetrating chest 'ound and
develops precipitous shoc, after endotracheal intu"ation and develops precipitous shoc, after endotracheal intu"ation and
positive>pressure ventilation positive>pressure ventilation
(C) a pulseless patient 'ith a penetrating chest 'ound suspected to (C) a pulseless patient 'ith a penetrating chest 'ound suspected to
have a massive hemothora? have a massive hemothora?
(!) a patient arriving 'ith no electrocardiogram (#CD) rhythm 'ith (!) a patient arriving 'ith no electrocardiogram (#CD) rhythm 'ith
,no'n "lunt trauma to the chest ,no'n "lunt trauma to the chest

#) C and ! #) C and !
Explanation:
Explanation:

$he primary o":ectives of resuscitative thoracotomy are (a) release of percardial tamponadeA (") $he primary o":ectives of resuscitative thoracotomy are (a) release of percardial tamponadeA (")
control of intrathoracic vascular or cardiac "leedingA (c) eliminate massive air em"olism or control of intrathoracic vascular or cardiac "leedingA (c) eliminate massive air em"olism or
"ronchopleural fistulaA (d) perform open cardiac massageA and (e) temporarily occlude the "ronchopleural fistulaA (d) perform open cardiac massageA and (e) temporarily occlude the
descending thoracic aorta% A left anterolateral thoracotomy incision is preferred% A right descending thoracic aorta% A left anterolateral thoracotomy incision is preferred% A right
thoracotomy is reserved for hypotensive patients 'ith penetrating in:uries to the right chest in thoracotomy is reserved for hypotensive patients 'ith penetrating in:uries to the right chest in
need of direct access to massive "lood loss or air em"olism% An #/ thoracotomy is initiated at need of direct access to massive "lood loss or air em"olism% An #/ thoracotomy is initiated at
the level of fourth to fifth intercostal space 'ith the proper level corresponding to inferior "order of the level of fourth to fifth intercostal space 'ith the proper level corresponding to inferior "order of
pectoralis ma:or muscle% $he incision is made through the intercostal muscle and parietal pleura pectoralis ma:or muscle% $he incision is made through the intercostal muscle and parietal pleura
is divided along superior margin of the ri"% $he ri" retractor is inserted 'ith the handle to'ard the is divided along superior margin of the ri"% $he ri" retractor is inserted 'ith the handle to'ard the
a?illa% 0ey resuscitative maneuvers are then initiated% a?illa% 0ey resuscitative maneuvers are then initiated%

A pericardiotomy incision is made in the presence of cardiac tamponade and incised 'idely* A pericardiotomy incision is made in the presence of cardiac tamponade and incised 'idely*
anterior and parellel to the phrenic nerve% Blood clots are evacuated from the pericardium and anterior and parellel to the phrenic nerve% Blood clots are evacuated from the pericardium and
cardiac "leeding sites should "e controlled immediately 'ith digital pressure on the surface of the cardiac "leeding sites should "e controlled immediately 'ith digital pressure on the surface of the
ventricle and partially occluding vascular clamps placed on atrium or great vessels% &n "eating ventricle and partially occluding vascular clamps placed on atrium or great vessels% &n "eating
hearts* efforts at cardiorrhapy should "e delayed until initial resuscitation measures have "een hearts* efforts at cardiorrhapy should "e delayed until initial resuscitation measures have "een
completed% &n the non"eating heart* suturing should "e performed prior to defi"rillation% completed% &n the non"eating heart* suturing should "e performed prior to defi"rillation%
$emporary control of the "leeding can "e accomplished 'ith a s,in>stapling device% Cardiac $emporary control of the "leeding can "e accomplished 'ith a s,in>stapling device% Cardiac
'ounds are "est repaired 'ith 9>0 nona"sor"a"le horizontal mattress sutures in the operating 'ounds are "est repaired 'ith 9>0 nona"sor"a"le horizontal mattress sutures in the operating
room% room%

&n cardiac arrest* "imanual internal massage of the heart should "e instituted% &f internal &n cardiac arrest* "imanual internal massage of the heart should "e instituted% &f internal
defi"rillation does not restore vigorous cardiac activity* the descending thoracic aorta should "e defi"rillation does not restore vigorous cardiac activity* the descending thoracic aorta should "e
incompletely cross>clamped at the level inferior to the left pulmonary hilum to ma?imize coronary incompletely cross>clamped at the level inferior to the left pulmonary hilum to ma?imize coronary
perfusion% Cardiopulmonary collapse from suspected intraa"dominal hemorrhage should "e perfusion% Cardiopulmonary collapse from suspected intraa"dominal hemorrhage should "e
temporized "y occlusion of the descending thoracic aorta% Air em"olism should "e suspected in a temporized "y occlusion of the descending thoracic aorta% Air em"olism should "e suspected in a
patient 'ith penetrating chest trauma 'ho develops precipitous shoc, after endotracheal patient 'ith penetrating chest trauma 'ho develops precipitous shoc, after endotracheal
intu"ation and positive>pressure ventilation% $reatment involves pulmonary hilar cross>clamping* intu"ation and positive>pressure ventilation% $reatment involves pulmonary hilar cross>clamping*
vigorous cardiac massage* along 'ith aortic root and left ventricle air aspiration (.oore* vigorous cardiac massage* along 'ith aortic root and left ventricle air aspiration (.oore*
;eliciano* and .atto?* +00()% ;eliciano* and .atto?* +00()%

$rauma patients arriving in e?tremis 'ith cardiopulmonary resuscitation (C5/) "eing initiated $rauma patients arriving in e?tremis 'ith cardiopulmonary resuscitation (C5/) "eing initiated
follo'ing "lunt in:ury should undergo thoracotomy only if they sho' electrical cardiac activity on follo'ing "lunt in:ury should undergo thoracotomy only if they sho' electrical cardiac activity on
#CD* cardiac activity or pericardial effusion visualized via ultrasound% 5atients e?hi"iting #CD #CD* cardiac activity or pericardial effusion visualized via ultrasound% 5atients e?hi"iting #CD
cardiac activity or 'ho have sustained penetrating thoracic 'ounds should undergo resuscitative cardiac activity or 'ho have sustained penetrating thoracic 'ounds should undergo resuscitative
thoracotomy (Cog"ill et al%* 1)89)% thoracotomy (Cog"ill et al%* 1)89)%

An unrestrained *3-year-old male drag racer involved in high-speed motor vehicle accident An unrestrained *3-year-old male drag racer involved in high-speed motor vehicle accident
presents to E0 #ith intense pain in right chest. The primary survey demonstrates decreased presents to E0 #ith intense pain in right chest. The primary survey demonstrates decreased
breath sounds over the right hemithorax #ith noted paradoxical motion of the right chest #all breath sounds over the right hemithorax #ith noted paradoxical motion of the right chest #all
during respiration +,ig. -)-./. The maEor pathologic se?uela of this inEury is during respiration +,ig. -)-./. The maEor pathologic se?uela of this inEury is

A) disruption of ventilation "ecause of parado?ical A) disruption of ventilation "ecause of parado?ical


motion of the chest 'all motion of the chest 'all
(B) "leeding from disruption of intercostal vessels (B) "leeding from disruption of intercostal vessels
(C) underlying pulmonary contusion (C) underlying pulmonary contusion
(!) pneumothora? (!) pneumothora?
(#) splinting from chest 'all pain (#) splinting from chest 'all pain
Explanation:
Explanation:

A flail chest consists of segmental fractures of three or more ad:acent ri"s* or one or more ri" A flail chest consists of segmental fractures of three or more ad:acent ri"s* or one or more ri" fractures 'ith associated fractures 'ith associated
costrochondral separation or fracture of sternum (;ig% 10>5)% $his causes an unsta"le or floating costrochondral separation or fracture of sternum (;ig% 10>5)% $his causes an unsta"le or floating
segment of chest 'all that moves parado?ically during respiration (A$4* 1))C)% A pneumothora? segment of chest 'all that moves parado?ically during respiration (A$4* 1))C)% A pneumothora?
or hemothora? may "e present% A more significant in:ury* ho'ever* is associated 'ith pulmonary or hemothora? may "e present% A more significant in:ury* ho'ever* is associated 'ith pulmonary
contusion leading to hemorrhage and edema of the in:ured lung% A chest 'all in:ury of this contusion leading to hemorrhage and edema of the in:ured lung% A chest 'all in:ury of this
magnitude is also associated 'ith significant pain* and respiratory efficiency is reduced% magnitude is also associated 'ith significant pain* and respiratory efficiency is reduced%

$reatment is directed to'ard reversing hypoventilation caused "y the pain* and hypo?ia caused $reatment is directed to'ard reversing hypoventilation caused "y the pain* and hypo?ia caused
"y the associated pulmonary contusion% Careful monitoring of ventilation and o?ygenation is "y the associated pulmonary contusion% Careful monitoring of ventilation and o?ygenation is
re-uired* and often time intu"ation and ventilatory support may "e indicated in +0(0% of re-uired* and often time intu"ation and ventilatory support may "e indicated in +0(0% of
patients% Control of pain "ecause of multiple ri" fractures "y using regional anesthetic techni-ues patients% Control of pain "ecause of multiple ri" fractures "y using regional anesthetic techni-ues
such as intercostal nerve "loc,* insertion of intrapleural catheter* or insertion of an epidural such as intercostal nerve "loc,* insertion of intrapleural catheter* or insertion of an epidural
catheter is important to improve respiratory mechanics% /arely is physical sta"ilization of chest catheter is important to improve respiratory mechanics% /arely is physical sta"ilization of chest
'all necessary (.oore* ;eliciano* and .atto?* +00()% 'all necessary (.oore* ;eliciano* and .atto?* +00()%

Bi"liography.oore #* ;eliciano !* .atto? 0% Bi"liography.oore #* ;eliciano !* .atto? 0% Trauma Trauma* 5th ed% Ge' Mor,* GM1 .cDra'>2ill* +00(% * 5th ed% Ge' Mor,* GM1 .cDra'>2ill* +00(%
American College of urgeons Committee on $rauma% American College of urgeons Committee on $rauma% merican Trauma Life Support merican Trauma Life Support* Bth ed% * Bth ed%
Chicago* &41 American College of urgeons* 1))C% Chicago* &41 American College of urgeons* 1))C%