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A 76 yo HD dependant woan with a h/o mult abd surgeries presents to the ED with worsening abd pain. W/U raises your suspicion for ischemic bowel. She last underwent HD three days prior and is currently uremic. How will you best prepare the patient for emergent celiotomy? A. Arrange for HD B. Transfuse the patient with PRBCs C. Administer cryoprecipitate D. Administer desmopressin (DDAVP) E. Administer conjugated estrogens
D. Administer desmopressin (DDAVP)
A 76 yo man with aortoiliac occlusive dz undergoes percutaneious transluminal angioplasty of his left common iliac artery. What is the patency rate for patients who undergo angioplasty for Iliac occlusive disease? A. 20% at 5 yrs B. 30% at 5 yrs C. 60% at 5 yrs D. 80% at 5 yrs
C. 60% at 5 yrs
A 39 yo woman presents to the ED after experiencing watery diarrhea and upper abd pain for 2 wks. On w/u and CT can, she is found to have a small mass in the body of the pancreas. Lab abnormalitites include a hemoglobin of 8.7, WBC of 10, hypokalemia, and metabolic acidosis. She is subsequently scheduled to have an exploratory laparotomy. Intraoperatively, the mass is removed from her pancreas and multiple small nodules are found in her liver. Considering the most likely diagnosis what are her best treatment options? A. 5-fluorouracil and interferon alpha B. Octreodtide and glucocorticoids C. Intravenous steroids alone D. No further treatment is indicated E. Repetitive embolization of the hepatic artery
A. 5-fluorouracil and interferon alpha
A 46-year-old woman comes to the emergency department describing acute right lower quadrant pain. How could appendicitis be differentiated from acute ileitis? A. Elevated WBC count B. Presence of diarrhea C. Development of acute or subacute pain in the right lower quadrant D. Thickened mesenteric lymph nodes on radiographic imaging E. Colonoscopic biopsy
D. Thickened mesenteric lymph nodes on radiographic imaging
A 27-year-old man with idiopathic renal failure on hemodialysis is awaiting a kidney transplant. Multiple family members and friends have been evaluated for possible live donor transplantation. A sibling to the recipient is found to have a favorable human leukocyte antigen match. Which of the following conditions is acceptable for live-donor nephrectomy?
A. Uncontrollable hypertension
B. Human immunodeficiency virus (HIV) infection
C. Type II diabetes mellitus D. Unilateral duplicated collecting system
E. Current cocaine usage
D. Unilateral duplicated collecting system
A 39-year-old man is referred to your clinic for treatment of a cecal mass diagnosed by surveillance colonoscopy. His father, paternal grandmother, and paternal uncle all developed colon cancer by their fifth decade. Mutation of which of the following genes is associated with this man's disease? A. K-Ras B. hMSH2
D. APC E. BRCA2
B. hMSH2
A 68-year-old man presents with pain In his left leg. Exanimation and workup confirms diagnosis of a popliteal aneurysm. What is the most common complication that would result in the patient's leg pain? A. Popliteal aneurysm rupture B. Nerve impingement by the popliteal aneurysm C. Venous obstruction by the popliteal aneurysm D. Thromboembolic events associated with the popliteal aneurysm
D. Thromboembolic events associated with the popliteal aneurysm
A 52-year-old woman presents to your clinic with a palpable thyroid nodule. Ultrasonography shows a 3-cm lesion in the right thyroid lobe with solid and cystic components. Ultrasonography -guided fine needle aspiration (FNA) reveals a thyroid cancer. Which of the following is the most likely diagnosis?
A. Papillary carcinoma
B. Anaplastic carcinoma
C. Follicular carcinoma
D. Medullary carcinoma
A. Papillary carcinoma
A 60-year-old man who suffers from chronic alcoholism was admitted to the hospital with a bout of acute pancreatitis. He has suffered similar episodes in the past, all of which have resolved without complications. On laboratory studies, he is found to have an elevated serum amylase level. A 4-cm pancreatic pseudocyst is found on CT scan. What would be the best treatment?
A. Percutaneous drainage B. Simple aspiration C. observation and serial CT scans D. Surgical intervention
C. observation and serial CT scans
Which of the following is a characteristic of Merkel cell carcinoma?
A. Slow-growing, well-defined cutaneous lesion
B. Early distant metastases
C. Locally aggressive tumor with low chance of distant spread
D. FrequentIy cured with wide local excision alone
E. Histologically similar to squamous cell carcinoma
B. Early distant metastases
A 70-year-old man with ascites secondary to cirrhosis presents for elective umbilical hernia repair. Should he be offered repair of his hernia?
A. Yes, if it is significantly affecting lib lifestyle.
B. Yes, If he Is leaking ascites from the hernia
C. Yes, If he Is on the liver transplant list
D. No, he should not be offered repair
B. Yes, If he Is leaking ascites from the hernia
A 68-year-old man with atrial fibrillation presents to the emergency department with a cool, pulseless right foot Sensation Is Intact Duplex ultrasonography of the right leg reveals multiple femoral stenoses and tibioperoneal thrombosis with poor tibial flow, What Is the most appropriate management?
A. Amputation
B. Systemic anticoagulation only
C. Percutaneous embolectomy under Local anesthesia
D. Intraarterial site-directed thrombolysis
D. Intraarterial site-directed thrombolysis
A 55-year-old woman presents to your clinic with the new diagnosis of tertiary hyperparathyroidism. Which of the following operations has she most likely previ¬ously undergone?
A. Colectomy with resection of terminal ileum
B. Parathyroidectomy
C. Renal transplantation
D. Right middle lobectomy
C. Renal transplantation
A 63-year-old man presents with a "gnawing" upper ab¬dominal pain. He reports that he was diagnosed with a gastric ulcer years ago. Which of the following tests is most helpful In diagnosing the patient with Infection with Helicobacter pylori
A. Urease test of endoscopic antral biopsies
B. Urea breath test
C. Upper gastrointestinal (Gl) radiographic series
D. Histologic examination of endoscopic antral biopsies
D. Histologic examination of endoscopic antral biopsies
Which of the following is a characteristic of cutaneous lymphatic malformation ?
A. Bluish mass with overlying telangiectasias B. Pulsatile ballottable mass C. Cystic mass with overlying vesicles D. Firm, nodular mass E. Irregular mass fixed to the underlying tissues
C. Cystic mass with overlying vesicles
The fundamental goal of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) is which of the following?
A. To monitor surgical costs in order to allocate health care
B. To improve health care in underserved US populations
C. To collect outcomes data to measure and improve surgical care outcomes
D. To Identify those surgeons who deliver excellent surgical care
E. To model systems for improved used of healthcare resources
C. To collect outcomes data to measure and improve surgical care outcomes
A 73-year-old man has developed a pulseless left lower leg 8 days after experiencing a myocardial infarction (Ml) requiring cardiopulmonary resuscitation. On examination, he has diminished sensation in his left foot. What is the most appropriate definitive treatment?
A. Amputation
B. Anticoagulation using IV heparin
C. Percutaneous embolectomy under local anesthesia
D. Intra-arterial site-directed thrombolysis
C. Percutaneous embolectomy under local anesthesia
A 47-year-old woman presents with a rapidly enlarging 5-cm right breast mass without palpable axillary nodes. FNA is nondiagnostic. A core biopsy Is performed and results are equivocal but suggestive of a phyllodes neoplasm. The appropriate next step In management is A. tumor enucleation
B. tumor excision with a 2-cm margin and sentinel
node biopsy C. tumor excision with a 1-cm margin D. simple mastectomy E. close follow up
C. tumor excision with a 1-cm margin
A 72-year-old man undergoes percutaneous transhepatic cholangiography and percutaneous biliary drainage for obstructive jaundice secondary to pancreatic cancer, Following the percutaneous transhepatic cholangiography and percutaneous biliary drainage, he develops melena and blood is seen in the biliary drain. Laboratory work reveals a drop in hematocrit and an increase in his liver function tests. What is the definitive treatment for this change in his condition?
A. Catheter embolization
B. Hepatic resection
C. Endoscopic epinephrine injection at the site of the bleeding vessel
D. Biliary stent placement
E. Whipple procedure
A. Catheter embolization
During resection of a pelvic tumor, the left ureter is
inadvertently transected below the level of the pelvic
brim. Which of the following do you choose for immediate treatment of this problem?
A. Primary repair
B. Primary repair with ureteral stent
C. Diversion with ureteroentereostomy
D. Ureterocystostomy
E. Delayed repair and percutaneous drainage of urinoma
D. Ureterocystostomy
Four weeks after a cadaveric renal transplant, the recipient returns to the emergency department with bilateral lower extremity edema. In spite of normal fluid intake, he reports that he has had minimal urine output over the past 18 hours. Serum creatinine is now elevated to 1.4 mg per deciliter from the postoperative 1.0 mg per deciliter. After failure to respond to a fluid challenge, an ultrasound is obtained. This reveals good perfusion, minimal hydronephrosis and a 3x4x6-cm hypoechoic mass adjacent to the renal pelvis of the allograft. What is the most likely cause of the patient's oliguria?
A. lymphocele formation
B. Ureteroneocystostomy stenosis
C. Renal artery thrombosis
D. Renal artery stenosis
E. Compressive hematoma
A. lymphocele formation
Eighteen months after undergoing an aortobifemoral artery bypass, a 74-year-old man presents with a painful swelling in his left-side groin. Ultrasonography demon¬strates a pseudoaneurysm at the site of the distal anastomosis with surrounding fluid. What Is the likely-underlying cause of this condition?
A. Graft failure
B. Atheroembolism
C. Graft infection
D. Graft thrombosis
E. Suture failure
C. Graft infection
A 38-year-old woman is referred to your clinic after an elevated 24-hour urine cortisol measurement. She is not on any steroids, What is the most likely cause of this patient's disease?
A. Ovarian cancer
B. Adrenal adenoma
C. Adrenal carcinoma
D. Pituitary adenoma
D. Pituitary adenoma
You receive a phone call to your office by a 36-year-old woman who underwent banding for a hemorrhoid 6 days prior. She has a small amount of blood on toilet paper after defecation, but she denies increasing pain and fever. Which of the following do you tell her?
A. This is normal, start taking stool softeners and aspirin.
B. Go to the emergency room immediately.
C. Come in to my office as soon as possible.
D. This Is normal, start taking fiber supplements and sitz baths.
D. This Is normal, start taking fiber supplements and sitz baths.
A 32-year-old man is brought to the emergency de¬partment after his left leg was pinned between two cars. Upon examination, his left leg is swollen and tense be¬low the knee, and you suspect compartment syndrome. Which nerve is most commonly injured during fasciotomy of the lower leg? A. Superficial peroneal nerve B. Tibial nerve C. Deep peroneal nerve D. Saphenous nerve
A. Superficial peroneal nerve
During an elective laparoscopic cholecystectomy, you encounter difficulty during the initial placement of tro¬cars. During visualization of the gallbladder, the anes¬thesiologist informs you that the patient has a heart rate (HR) of 130 beats per minute and a dropping blood pressure, What do you do next?
A. Decrease Insufflation pressure
B. Give IV fluids
C. Stop insufflation
D. Place the patient in the left lateral decubitus position
E. Give an inotropic agent for blood pressure
C. Stop insufflation
Eighteen months after undergoing an aortobifemoral ar¬tery bypass;, a 69-year-old woman presents with a draining, cellulitic wound in her right-side groin, with exposed poly-tetrafluoroethylene graft. What la the most likely pathogen infecting this graft?
A. S. eptdermidis
B. Klebsiella pneumoniae
C. S aureus D. P. aeruginosa
A. S. eptdermidis
A 40-year-old premenopausal woman is seen by her physician for evaluation of a breast nodule. Physical ex¬amination confirms the presence of a 1-cm movable mass; mammography and ultrasonography evaluation are both found to be consistent with a fibroadenoma. A core biopsy confirms this diagnosis. The lesion is excised at the pa¬tient's request. Pathology results reveal a fibroadenoma with a small area of lobular carcinoma in situ in the sur¬rounding breast tissue, focally extending to one margin. The next step in management is to:
A. Counsel the patient about her future breast cancer risk and screening options
B. remove further tissue from the positive margin side
C. remove further tissue from the positive margin side with sentinel lymph node biopsy
D. remove further tissue from the positive margin side with axillary node dissection
E. perform sentinel lymph node biopsy alone
A. Counsel the patient about her future breast cancer risk and screening options
A 56-year-old man 2 years post left colectomy for stage IIA colon cancer Is now found to have rising carcinoembryonic antigen and two new lesions in the liver on follow-up CT scan. There Is no evidence of extrahepatic disease. How do you manage this patient?(See figures below.)
A. Extended left hepatectomy
B. Radio frequency ablation of the two tumors
C. palliative chemotherapy
D. Wedge resection of both lesions
A. Extended left hepatectomy
A 56-year-old man presents to your clinic with a 5 mm wide lesion confined to the middle of his lower lip. You suspect squamous cell carcinoma. What is the most appropriate management?
A. Radiation therapy followed by surgical resection
with 5-mm margin and primary repair
B. Surgical resection with 5-mm margin and primary repair
C. Surgical resection with 1-cm margin and primary repair
D. Surgical resection with 1-cm margin and primary
repair, followed by radiation therapy
C. Surgical resection with 1-cm margin and primary repair
A 26-year-old man is undergoing a nerve block for an outpatient orthopedic procedure on his left ankle. Dur¬ing injection of the superficial fibular nerve with lidocaine, he complains of tingling around his mouth and lips. What is the next symptom you would expect in the progression of lidocaine toxicity?
A. Cardiac arrest
B. Hallucinations
C. Seizures
D. Nausea and vomiting
B. Hallucinations
An 82-year-old man presents to your clinic for follow up 6 weeks after discharge from the hospital following abdominal aortic aneurysm (AAA) repair. His recovery was complicated by loss of the left femoral pulse, requiring thombectomy. You would like to evaluate his vascular graft for blood flow and to rule out stenosis and false aneurysm. Which of the following imaging modalities is the best test for this?
A. B-mode ultrasonography
B. Color-flow duplex ultrasonography
C. Digital subtraction arteriography
D. CT
E. Magnetic resonance angiography (MRA)
B. Color-flow duplex ultrasonography
A 64-year-old postmenopausal women with estrogen receptor +, stage IIB breast cancer presents following lumpectomy and radiation therapy and therapy with tamoxifen. She asks about the risks of tamoxifen therapy. You tell her that
A. tamoxifen increases bone resorption, increasing risk of long bone and pelvic fractures due to osteoporosis
B. tamoxifen is associated with a modest, but signifi¬cant increase in the risk of cardiovascular events seen in postmenopausal women with coronary artery disease
C. tamoxifen has been linked to an increased risk of developing endometrial adenocarcinoma and uterine sarcoma
D. tamoxifen increases the likelihood of developing breast cancer in the contralateral breast
C. tamoxifen has been linked to an increased risk of developing endometrial adenocarcinoma and uterine sarcoma
Workup for vomiting In a 46-year-old woman with Crohn disease reveals a stricture in the second portion ofthe duodenum. What is the best surgical manage¬ment of this problem?
A. Heineke-Mikulicz strictureplasty
B. Resection of the affected segment with primary astamosis
C. Side-to-side retrocolic gastrojejunostomy
D. Roux-en-Y duodenojejunostomy
A. Heineke-Mikulicz strictureplasty
A 17-year-old boy presents to the emergency depart¬ment after a right shoulder injury sustained while play¬ing football. Plain radiographs reveal the humeral head displaced medial to the glenoid fossa. Which nerve is most likely injured In this type of dislocation?
A. Suprascapular nerve
B. Median nerve
C. Radial nerve
D. Axillary nerve
D. Axillary nerve
An obese woman who underwent a transabdominal hysterectomy 10 years ago presents for an elective ventral hernia repair. She undergoes hernia repair via a laparoscopic approach, to which she responds well initially. However, she develops a recurrent bulge 2 months later. What is the most common reason for recurrence after laparoscopic ventral hernia repair?
A. Unrecognized defect
B. Failure of suture material or tacks
C. Separation of the mesh from the abdominal wall
D. Seroma
E. Inadequate dissection of the fascial defect
C. Separation of the mesh from the abdominal wall
What is the most common cause of late death after heart transplant?
A. Acute graft rejection
B. Accelerated atherosclerosis
C. Cytomegalovirus infection
D. Fungal infection
B. Accelerated atherosclerosis
A 43-year-old man presents with persistent peptic ulcers that have been refractory to proton-pump inhibitors. His workup includes a positive secretin stimulation test. His underlying tumor is:
A. associated with Whipple's triad
B. associated with hypoglycemia
C. frequently located in the tail of the pancreas
D. associated with multiple endocrine neoplasia (MEN)-2a
E. likely to be sporadic
E. likely to be sporadic
A 38-year-old man presents to the emergency department after attempted suicide via ingestion of oven cleaner. Upon rigid esophagoscopy, you observe erythematous, edematous mucosa with partially circumferential white ulcerations In the mid-esophagus. What is the degree of these lesions?
A. Grade I
B. Grade IIA
C. Grade IIB
D. Grade III
E. Grade IV
B. Grade IIA
A 32-year-old woman requires a split-thickness skin graft after being involved in a car accident A 12x6-cm site is taken from her lateral thigh and is implanted on her scalp without complications. The rate of the heal¬ing of the donor site is related to what? A. Amount of moisture kept on the donor site B. Epithelial appendages and width of the site C. Epithelial appendages and thickness of graft D. Quality of semi-ocdusive dressing
C. Epithelial appendages and thickness of graft
A 21 year old man is brought to the trauma bay after sustaining a superficial stab wound to the left shoulder. He reports that he received his full series of shots as a child and received his last tetanus booster shot when he was 15. What should he receive for his tetanus prophylaxis? A. Nothing B. Tetanus toxoid 0.5 mL intramuscularly (IM) C. Tetanus immune globulin 250 units IM D. Tetanus toxoid 0.5 mL IM and tetanus immune globulin 250 units IM
D. Tetanus toxoid 0.5 mL IM and tetanus immune globulin 250 units IM
A 72-year-old man is seen in clinic preoperatively to prepare for his upcoming femoral-tibial artery bypass for vascular insufficiency. The duplex scan demonstrates poor candidates for venous conduits, so the use of synthetic graft is anticipated. The long-term outcome for this patient could be improved by:
A. Daily use of 81 mg aspirin indefinitely
B. Clopidogrel use for the first 3 months after surgery
C. coumadin use with a goal international normal¬ized ratio (1NR) of 1.5
D. the use of support stockings
E. low—molecular-weight heparin injection for the first 6 weeks after surgery
A. Daily use of 81 mg aspirin indefinitely
A 25-year-old man sustains a superficial gunshot wound to his left outer thigh. His initial neurological exam in the emergency department reveals no motor deficits but numbness in the region of the left lateral cutaneous nerve of the thigh. When should surgery for repair of the suspected nerve injury be performed?
A. Immediately
B. 1 to 2 weeks
C. 2 to 3 months
D. 6 months to 1 year
E. Never
C. 2 to 3 months
A 40-year-old, former Australian lifeguard man with a history of melanoma presents to the emergency department with a month-long history of abdominal pain, nausea, and vomiting. What is the most likely cause for his symptoms?
A. Intussusception of the small bowel
B. gastroenteritis
C. Colonic obstruction
D. Diverticulitis
E. Duodenal adenocarcinoma
A. Intussusception of the small bowel
Which of the following characteristics is an advantage of full-thickness skin grafts over split-thickness skin grafts?
A. Superior skin pigment match
B. Better resistance to infection
C. Larger ana of coverage
D. Less blood supply required
E. Lower Incidence of contractures
E. Lower Incidence of contractures
A 56-year-old man is ventilator dependent because of an open abdomen secondary to trauma. On the third day following his injury, he develops hypoxemia and tachypnea, requiring an increase of the fraction of inspired oxygen (FIO2) and positive end-expiratory pressure. His partial pressure of oxygen in arterial blood (PaO2) increases minimally with these changes. Plain chest radiograph shows bilateral infiltrates and the pulmonary artery occlusion pressure is 16 mm Hg. Which combination of features supports a diagnosis of acute respiratory distress syndrome (ARDS) over ventilator associated pneumonia?
A. Pulmonary artery occlusion pressure >18 mm Hg
B. Temperature 38.7°C, WBC count of 14, pleural effusions, increased proteinaceous exudate on bronehoalveolar lavage (BAL)
C. Temperature 38.5°C, WBC count of 16, no effusions, increased protein on BAL
(g) Temperature 38.3°C, WBC count of 12, minimal pleural effusion, Increased protein on BAL, infil¬trates not seen on chest radiograph
(|) Pa02/FIOa ratio <200 mm Hg
C. Temperature 38.5°C, WBC count of 16, no effusions, increased protein on BAL
A 28 year old professional violinist woman presents with headaches, neck pain, and hand clumsiness In her right hand. She also reports occasional numbness in the hand and right-side chest pain. Which of the following is the likely cause of her symptoms?
A. Carpal tunnel syndrome
B. Coronary artery disease
C. Thoracic outlet syndrome
D. Paget-Schroetter syndrome
C. Thoracic outlet syndrome
A 72-year-old man with a history of diabetes and smok¬ing presents with a 2-day history of excruciating pain in the right lower extremity. The patient states that the pain started while he was sitting in a chair and that, unlike other pains he has had in the leg before, it was not re¬lieved by elevation of the extremity. Physical exam shows a pale, cool, pulseless, and numb right foot, and the calf is quite tender. No Doppler signal is obtainable. The pa¬tient is taken to the operating room where on-table angiogram reveals occlusion of the superficial femoral ar¬tery with no arterial flow below the knee in the right leg, A right femoral below-knee popliteal bypass is performed with restoration of the pulses. Postoperatively in the sur¬gical intensive care unit (ICU), the resident notices severe swelling of the right lower extremity and loss of the dorsalis pedis pulse. The most likely etiology of the edema is:
A. chronic venous occlusive disease
B. acute reperfusion Injury
C. acute popliteal venous occlusion
D. acute bleed from anastomotic leak
E. lymphocele
B. acute reperfusion Injury
A 22-week-pregnant, 31-year-old woman received 7 days of ampicillin for a urinary tract infection. The patient developed diarrhea on day 5 of therapy, and stool was positive for Clostridium difficile toxin. How would you treat the patient? A. Vancomycin 500 mg orally four times a day for 10 days B. Metronidazole 500 mg orally four times a day for
10 days
C. Do nothing, as this is usually self-limiting
D. Clindamycin 300 mg orally four times a day for 10 days
B. Metronidazole 500 mg orally four times a day for
10 days
You are performing a laparoscopic cholecystectomy on a 64 yo woman with cholelithiasis and vague abdominal pain. As you insert the camera through the supraumbilical trochar, you are surprised to find a white cake like tumor spreading from the left side of the pelvis across much of the large intestine. You should:
A. take a biopsy of the tumor, remove the gallbladder, and finish the case.
B. take a biopsy of the tumor, close, and await the
pathology report to plan open surgery
C. perform a left oophorectomy
D. perform a biopsy, convert to an open procedure,
and remove all involved organs
E. perform a biopsy, convert to an open procedure, and perform complete surgical staging
B. take a biopsy of the tumor, close, and await the
pathology report to plan open surgery
A 2 year-old is brought to the emergency department by his mother. She reports that he has been inconsolable for the past 24 hours and has refused his feeds. Upon further questioning, you find that the child has vomited twice and has not had a bowel movement. Examination reveals a slightly distended and diffusely tender abdomen, especially in the Inguinal area. What should be your first step?
A. Ice pack to the affected area
B. Elevation of the child's lower extremities with a pillow C. Emergent exploratory laparotomy
D. attempt manual reduction
E. Overnight inpatient observation
B. Elevation of the child's lower extremities with a pillow
An 82-year-old man with a history of severe chronic obstructive pulmonary disease presents with claudica¬tion and is found to have occlusive disease localized to the left common iliac artery. Which of the following procedures is the most appropriate for management of this patient's disease?
A. femoral to femoral artery bypass with venous autograft
B. Anticoagulation using IV heparin
C. Conservative treatment
D. Aortobifernoral artery bypass with synthetic graft
E. Percutaneous transluminal angioplasty under local anesthesia
E. Percutaneous transluminal angioplasty under local anesthesia
A 47 yo woman undergoes core needle biopsy of a lesion found on routine mammography in the lower outer quadrant of her right breast. Pathology is read as atypical ductal hyperplasia of the breast. What is the most appropriate next step in this patients's care? A. Follow-up mammography in 6 months B. Excisional biopsy with wire localization C. Partial mastectomy with sentinel lymph node biopsy D. Modified radical mastectomy
B. Excisional biopsy with wire localization
A 43 yo man presents to your clinic with the concern of intermittent blood spotting on toilet paper for 2 weeks. Anoscopy reveals a 1cm split in the anoderm posteriorly on the midline distal to the dentate line, lacking any hypertrophy or visible muscle fibers. What is the optimal managment? A. Bisacodyl suppositories B. Lateral internal anal sphincterotomy C. Observatoin only D. Initiate stool softeners
D. Initiate stool softeners
A 22-year-old man (65 kg) Is seen In the emergency department after a motorcycle accident that resulted in significant head and maxillofacial trauma. Following Initial evaluation and stabilization, he is admitted to the Intensive care unit and administered Lactated Ringer's (LP.) solution running at 125 mL per hour. During the first 60 hours of his stay, his urine output gradually de¬clines to 25 mL per hour and his serum sodium drops from 136 to 127 mEq per liter. His vital signs remain stable. Urine osmolatity is found to be 548 mOsm per liter. Which of the following is the next best intervention?
A. Increase his fluids to maintain urine output >0.5 mL per kilogram per hour
B. add demeclocycline 600 mg twice a day
D. Stop his fluids entirely
C. Convert his IV fluid from LR to 3% normal saline solution
C. Convert his IV fluid from LR to 3% normal saline solution
A 45-year-old woman with a history of gallstones is admitted to the 1CU after diagnosis with acute pan¬creatitis with hemodynamic instability. Her admission laboratory values were remarkable for a number of ab¬normalities, including hyponatremia, hyperamylasemia, hyperlipasemia and hyperlipidemia. What is die etiology of hyponatremia in pancreatitis? A. Salt wasting B. Pseudohyponatremia C. Hypoalbuminemia D. Renal failure
B. Pseudohyponatremia
A previously healthy 57-year-old woman had increased shortness of breath and chest pain while undergoing a root canal. After stopping the procedure, the patient's symptoms resolved, and the oral surgeon resumed drilling. She began experiencing right-side facial pain and peri¬orbital and neck swelling and subsequently com¬plained of severe dyspnea. The patient lost conscious¬ness and her blood pressure was undetectable. An emergent electrocardiogram showed nonspecific ST-T wave changes. Her pulse oximeter revealed an oxygen saturation of 89% to 90% throughout the procedure. Immediate action should be which of the following?
A. Administration of aspirin
B. Positioning of the patient in Trendelenburg and left lateral decubitus position
C. Initiation of IV antibiotics
D. IV heparin therapy and/or thrombolytic therapy, or both
B. Positioning of the patient in Trendelenburg and left lateral decubitus position
A 34-year-old Ukrainian immigrant man is seen in clinic for a right-side thyroid nodule, which shows no uptake on technetium scan. In 1986 he was living near the Chernobyl nuclear reactor during its meltdown. Given this history and probable etiology, what is the most likely diagnosis of his thyroid nodule?
A. Anaplastic carcinoma
B. Hurthle cell carcinoma C. Follicular carcinoma
D. Medullary carcinoma
E. Papillary carcinoma
E. Papillary carcinoma
A 54-year-old alcoholic man presents to the emergency department with severe substernal and epigastric pain after vomiting while drinking alcohol earlier that evening. Gastrografin esophagogram shows perforation of distal esophagus with drainage into the mediastinum. What is the most appropriate treatment?
A. Nonoperative management with total parenteral nutrition (TPN) and nasogastric decompression
B. Emergent primary repair
C. Esophagectomy and delayed reconstruction with Interposition graft
D. Esophagostomy and placement of a feeding jejunostomy tube
B. Emergent primary repair
The appropriate treatment for an 8-year-old with a completely displaced supracondylar fracture of the humerus (Garland type III) is:
A. splinting and immobilization
B. closed reduction and immobilization
C. Closed reduction and internal fixation
D. elbow replacement
E. intramedullary rod placement
C. Closed reduction and internal fixation
A 42-year-old woman is in the ICU immediately following removal of a left adrenal pheochromocytoma. Her blood pressure is 80/40 mm Hg. The most appropriate treatment of the patient's hypotension is which of the following?
A. Phenoxybenzamine
B. IV bolus of LR solution
C. Epinephrine
D. Phenylephrine
B. IV bolus of LR solution
A 24-year-old man comes into the emergency department after sustaining two gunshots through his chest. Which of the following would suggest that he has lost 30% to 40% of his blood volume?
A. HR 90, normal blood pressure, normal or increased pulse pressure, urine output >30 mL per hour
B. HR 110, normal blood pressure, narrowed pulse pressure, urine output 20 to 30 mL per hour
C. HR >120, decreased blood pressure, very decreased pulse pressure, respiratory rate 30 to 40 breaths per
minute, urine output 5 to 15 mL per hour
D. HR >140, very decreased blood pressure, respira¬tory rate >35 breaths per minute, negligible urine output
C. HR >120, decreased blood pressure, very decreased pulse pressure, respiratory rate 30 to 40 breaths per
minute, urine output 5 to 15 mL per hour
A 42-year-old woman presents with the presumed di¬agnosis of inflammatory carcinoma of her left breast. She Is 8 weeks postpartum. What is the appropriate management?
A. If the tumor responds to high-dose chemotherapy continue with mastectomy, postoperative radia¬tion, and then possible further adjuvant therapy.
B. If the tumor responds to an extended course of antibiotics, continue with local resection.
C. If the tumor does not respond to neoadjuvant chemotherapy, proceed to mastectomy.
D. If the tumor responds to high-dose chemother¬apy, continue with radiation therapy, followed by surgical resection and then chemotherapy.
E. If the tumor responds to neoadjuvant chemother¬apy, proceed to local excision.
A. If the tumor responds to high-dose chemotherapy continue with mastectomy, postoperative radia¬tion, and then possible further adjuvant therapy.
A 60-year-old man with a long history of smoking and heavy alcohol use undergoes a transhiatal esophagectomy for esophageal cancer. He does well and is discharged from the ICU on the second postoperative day. However, on the third day he develops a fever and malaise. A chest and neck CT scan demonstrate stranding, thickening, and severe Inflammation around the gastric conduit but no air. What artery may have been compromised during the transhiatal esophagectomy?
A. Left gastric artery
B. Right gastric artery
C. Left gastroepiploic artery
D. Right gastroepiploic artery
E. Gastroduodenal artery
D. Right gastroepiploic artery
On initial assessment using the Glasgow Coma Scale (GCS), the most important predictor of return of func¬tion in a patient with a severe head injury is:
A. poor motor score component of the GCS
B. poor verbal-score component of the GCS
C. poor eye-opening score component of the GCS
D. Intracranial pressure >15 mm Hg
E. overall GCS score
A. poor motor score component of the GCS
A 7-week-old boy is referred with a 3-day history of pro¬jectile nonbilious vomiting. He appears dehydrated and, on abdominal examination, an olive-shaped epigastric mass is palpable. The most appropriate initial IV Quid regimen for resuscitation is which of the fottowing?
A. Normal saline + 20 mmol per liter potassium chloride
B. 5% dextrose
C. LR solution
D. Normal saline
E. 2% sodium chloride
D. Normal saline
A 67 yo woman with long standing diabetes presents to the clinic stating that she has has some break down of the skin on the bottom of her right foot. Examination of the foot reveals a shallow ulcer overlying the area of the metatarsal heads. Radiograph of the foot reveals no bony involvement How should you council her?
A. She should obtain well-fitting shoes
B. She will need a transmetatarsal amputation
C. She should clean the wound with warm soaks and then put on clean socks
D. She will likely need a distal arterial bypass
E. She should be admitted to the hospital aggressive wound care.
E. She should be admitted to the hospital aggressive wound care.
A 65-year-old woman with weakness, fatigue and easy bruising is found to have guarding and distension of her upper abdomen. She reports a history of taking prednisone and weekly epoetin alfa. She believes her symptoms have become worse in the past year. What procedure would this patient need for definitive management of this condition?
A. Laparoscopic splenectomy
B. Bone marrow biopsy
C. Laparoscopic adrenalectomy
D. Gastrectomy
E. Patient requires no surgical managment
A. Laparoscopic splenectomy
You are called by the 1CU regarding a 45-year-old man intubated for ARDS for the past 3 weeks. Over the past 48 hours, he has developed increased abdominal distention. His last bowel movement was 4 days ago, and the ICU staff has attempted enemas without result. An abdominal plain radiograph has revealed diffuse dilation of the colon consistent with ileus, without an identifiable transition point. Your physical examination demonstrates a critically ill man with a rotund abdomen. There is no fluid wave or shifting dullness, just diffuse tympany. There is no stool in the rectal vault. How should you proceed with treatment?
A. Nasogastric-tube decompression and serial examinations
B. Manual disimpaction
C. Endoscopic decompression
D. Therapeutic enterodysis
E. Neostigmine
A. Nasogastric-tube decompression and serial examinations
For a 4 mm oral cavity epidermoid cancer without palpable lymph nodes, the appropriate surgical treatment entails:
A. sentinel lymph node biopsy using blue dye
B. radical neck dissection
C. supraomohyoid dissection
D. local excision
C. supraomohyoid dissection
A 45-year-old woman is in the surgical ICU 2 days af¬ter an orthotopic liver transplant for primary biliary cir¬rhosis. The patient's condition has rapidly deteriorated, with signs consistent with fulminant hepatic failure. Ultrasound of the graft is most likely to reveal which of the following?
A. Hepatic vein thrombosis
B. Hepatic artery thrombosis
C. Portal vein thrombosis
D.- Inferior vena cava (IVC) stenosis
B. Hepatic artery thrombosis
A 30-year-old man presents with facial swelling, engorged neck veins, and complaints of dizziness for the prior 3 months. He had been diagnosed with unresectable malignant thymoma 2 years earlier, but he com¬pleted only two rounds of radiotherapy. How should you proceed with treatment?
A. Internal jugular to right atrial bypass
B. Inpatient heparinization until therapeutic on coumarin
C. Balloon angioplasty and endovascular stenting of the superior vena cava
D. Extra-anatomic bypass from the internal jugular to the femoral vein
E. Exploratory thoracotomy
C. Balloon angioplasty and endovascular stenting of the superior vena cava
A 42-year-old man presents with progressive fullness and abdominal cramping increasing in severity over the past 4 weeks, CT reveals a large intra-abdominal mass with multiple enlarged inguinal and cervical lymph nodes visible. Which of the following tests is diagnostic of this patient's possible intra-abdominal lymphoma? A. CT scan
B. T2-weighted magnetic resonance Imaging (MRI) C. Positron emission tomography scan
D. CT-guided needle biopsy
E. Open biopsy
E. Open biopsy
A 74-year-old woman presents with increasing abdominal distension, pain, and fullness 4 days after her last bowel movement Her medical history is notable for mild obesity and gallstones. She has never had abdom¬inal surgery. She has never had an episode of abdominal pain like this before, but she does occasionally suffer at¬tacks of right upper quadrant pain after fatty meals. On examination, she is afebrile, normotensive, and has a heart rate of 95. Her examination is notable for the ab¬sence of right upper quadrant tenderness but remarkable for generalized abdominal distension and reso¬nance to percussion. A plain abdominal radiograph demonstrates an ileus pattern with no transition point. What is your proposed management?
A. Emergent laparoscopic cholecystectomy
B. Observation
C. Endoscopic decompression
D. Promotility agents
E. Surgical exploration
E. Surgical exploration
The cerebral perfusion pressure in a patient with head injury should ideally be greater than:
A. 50mmHg
B. 70 mm Hg C. 90mmHg
D. 110 mm Hg
B. 70 mm Hg
A 55-year-old man presents with a firm mass on his left thigh, which he noticed recently after bumping Into a chair. The mass Is painless, not discolored, and 5 cm In diameter. What is the next diagnostic test you should perfrom
A. FNA
B. Excisional biopsy
C. Incisional biopsy
D. Wide excision With 2-cm margins
E. MRI scan
E. MRI scan
A 34-year-old woman is brought to the emergency department after a high-speed motor vehicle crash. She is unresponsive, breathing spontaneously, and has absent breath sounds on the left part of her chest. A thoracos¬tomy tube Is placed and fails to yield any fluid. She con¬tinues to have absent breath sounds on the left part of her chest, and she appears to have a large air leak. What is the next step in the management of this patient?
A. Flexible bronchoscopy
B. Chest CT scan
C. Thoracotomy in the emergency department
D. Surgical exploration
A. Flexible bronchoscopy
A 35-year-old woman presents with a bloody discharge from the left nipple. Clinical breast examination confirms Inducible discharge from a single duct in the left nipple and a small palpable mass near the inferior areolar margin. Bilateral mammography and left-side ultrasonogra¬phy show a small density that appears to correspond to the palpable mass, which measures 8 mm by ultra¬sonography and is solid. The lesion Is amenable to ultrasonography-guided core biopsy. Which of the fol¬lowing is correct?
A. If core needle biopsy confirms intraductal papilloma, proceed to local excision with postoperative radiation and then chemotherapy.
B. This is most likely a benign process, does not need to be biopsied, and should be followed with clinical breast examination and mammogram every 6 months.
C. Unilateral bloody discharge is usually associated with a history of breast trauma.
D. If a core biopsy confirms a benign papilloma, no
further intervention is needed
E. If local excision shows an intraductal papilloma, the patient can return to routine breast screening with no further intervention needed.
E. If local excision shows an intraductal papilloma, the patient can return to routine breast screening with no further intervention needed.
A 54-year-old woman comes to your clinic 3 weeks after undergoing a common bile duct exploration for biliary stones refractory to endoscopic management. She was left with a T tube in place, which has been reliably drain¬ing bile until 2 days ago. Over the past 48 hours, the has noted increased right upper quadrant pain that Is simi¬lar to her pre-operative pain. You order a tube cholangiogram, which demonstrates a retained stone lodged in the common bile duct. How should you prodeed?
A. Admit patient to the hospital, feed nothing by mouth, give IV fluids, provide analgesia, and observe
B. Perform laparoscopic stone extraction
C. Repeat open common bile duct exploration
D. Perform endoscopic retrograde cholangiopancreatography (ERCP)
E. Remove the T tube and perform immediate choledochoscopy
E. Remove the T tube and perform immediate choledochoscopy
A 78-year-old African-American woman with hypertension and diabetes mellitus falls in her kitchen and lacerates her right great toe. Three hours later, her family brings her to the emergency department because she has developed severe erythema migrating up her leg, fever to 40"C and a marked change In her mental status. Examination of the wound reveals severe edema of the surrounding skin, marked erythema proceeding up the leg. and crepitus to palpation. Her laboratory val¬ues show a lactate of 6.7 mmol per liter. What is the most appropriate course of treatment?
A. Gram-negative antibiotic coverage, IV fluid resuscitation, surgical debridement
B. Gram -positive antibiotic coverage. IV fluid resuscitation, surgical debridement
C. Immediate surgical debridement, IV fluid resuscitation, broad-spectrum antibiotics
D. IV fluid resucitation, broad spectrum antibiotics, observation.
E. Observation, IV fluid resuscitation, surgical debridement after complete manifestation of disease (days).
C. Immediate surgical debridement, IV fluid resuscitation, broad-spectrum antibiotics
A 42-year-old man with marked ascites is being treated for hepatic encephalopathy secondary to alcoholic cirrhosis. What is the most likely acid base abnormality found in this patient?
A. Normal anion-gap metabolic acidosis
B. Metabolic alkalosis
C. Anion-gap metabolic acidosis
D. Respiratory alkalosis
E. Respiratory acidosis
A. Normal anion-gap metabolic acidosis
On his second postoperative day after a right lower pulmonary lobectomy for lung cancer, a 57-year-old man re¬mains intubated. Over the course of the day, he gradually becomes tahypneic and tachycardic and his hemoglobin oxygen saturation decreases to 85% requiring an increase in inspired oxygen concentration to 50%. An arterial blood gas reveals a PaO, of 68, and a chest radiograph shows diffuse bilateral infiltrates. The patient's pulmonary artery wedge pressure is 8 mm Hg. What Is the patho¬physiologic mechanism underlying this phenomenon?
A. Inappropriate fluid balance
B. Inflammatory-mediated vascular permeability C. Impaired lymphatic drainage
D. Cardiogenic shock
B. Inflammatory-mediated vascular permeability
A 40-year-old woman has been recently diagnosed with MEN-2a. Her most recent laboratory studies are significant for elevated urinary metanephrines and hyper¬calcemia. A cold thyroid nodule has been Identified on radioisotope imaging, and CT of the abdomen re¬veals a left-side adrenal mass. She has elected to undergo operative intervention and asks you which surgical proce¬dure should be performed first Based on current recom¬mendations, you schedule her for the following procedure:
A. Single-gland parathyroidectomy
B. Thyroid lobectomy
C. Total thyroidectomy alone
D. Adrenalectomy
E. Pituitaryadenectomy
D. Adrenalectomy
A 65 yo man presents with rectal pain, pencil-thin stools and occasional bright red blood per rectum. A rectal examination under anesthesia reveals a 1cm raised edge arising 2cm proximal to the anal verge, suggestive of squamous cell cancer, and extending for 3cm. There are no palpable lymph nodes or signs of systemic disease. Biopsy demonstrates squamous cell carcinoma. In your counseling, what do you tell him is the most evidence supported option?
A. Chemoradiation therapy with 5FU and mitomycin C
B. Abdominoperineal resection with total mesorectal excision and bilateral inguinal lymph node dissection
C. Chemotherapy with 5FU and cisplatin
D. Abdominoperineal resection with permanent colostomy
E. Low anterior resection
A. Chemoradiation therapy with 5FU and mitomycin C
A 59-year-old healthy woman has a palpable mass along the junction between the angle of her mandible and neck on the left side. A history and physical examination reveals no other symptoms. An ultrasound study shows a 2-cm mass in the deep parotid lobe. An FN A biopsy is performed and shows a mixture of epithelial and mesenchymal cells consistent with a diagnosis of benign pleomorphic ade¬noma. How should this parotid mass be managed?
A. Simple enucleation of the mass
B. Superficial parotidectomy with adjuvant radiation therapy
C. Total parotidectomy with preservation of the facial nerve
D. Close observation for change in size or development of symptoms
E. Radiation therapy
C. Total parotidectomy with preservation of the facial nerve
A 76-year-old man presents with a lesion on the left forearm suggestive of melanoma. Biopsy confirms a melanoma of 0.6 mm thickness (level III). What mar¬gin around the lesion do you need to take during exci¬sion to minimize the likelihood of recurrence!
A. None
B. 1cm
C. 2cm
D. >2cm
1cm
The conduit with the best patency for a coronary artery bypass graft (CABG) is.
A. saphenous vein graft
B. left internal thoracic artery
C. radial artery
D. D. right internal thoracic artery
B. left internal thoracic artery
A 2-month-old boy to a mother with a marfanoid habitus and a history of pheochromocytoma undergoes genetic testing. He is found to have a mutation in the RET oncogene. What should be the initial goal in management of this patient?
A. CT scanning to look for pheochromocytoma in retroperitoneal space
B. Total thyroidectomy with central lymph node dissection before 6 months of age
C. Total parathyroidectomy with heterotopic auto-transplantation by 5 years of age
D. Positron emission tomography scan to evaluate for other tumors
E. Careful observation
B. Total thyroidectomy with central lymph node dissection before 6 months of age
What is the most common etiology of common bile duct Injury during laparoscopic cholecystectomy?
A. Bleeding
B. Obesity
C. Congenital anatomical anomalies
D. Excess cephalad retraction of the gallbladder
E. Acute or chronic Inflammation
D. Excess cephalad retraction of the gallbladder
A 57 yo woman presents with a biopsy proven 4.5 cm buccal squamous cell carcinoma of her right cheek, with no lymph nodes palpable. What is the most appropriate management? A. Local excision
B. Wide resection with supraomohyoid neck dissection and postoperative radiation
C. Wide resection with supraomohyold neck dissection
D. wide resection with radical neck dissection
E. wide resection with modified radical neck disection and post-operative radiation
C. Wide resection with supraomohyold neck dissection
A 42-year-old diabetic woman presents to the emergency department complaining of nausea, vomiting, and abdominal pain. She had been in her usual state of health until the prior day when the symptoms began. Her temperature is 33°C and her WBC count is 17,000. Initial workup includes a right upper quadrant ultrasound that is negative for stones but suggests air within the lumen of the gallbladder. The most appropriate initial antibiotic choice for this patient would be which of the following?
A. IV pipercillln and tazobactam
B. IV amikacin
C. IV clindamycin
D. IV cefazolin
E. IV ampicillin and sulbactam
A. IV pipercillln and tazobactam
A 78-year-old man who originally presented with stable angina due to extensive coronary artery disease is undergoing preoperative evaluation for two-vessel CABG. Clinical examination reveals a faint, questionable carotid bruit from the left carotid artery. He is scheduled, for carotid angiogram, which reveals 20% and 45% stenoses of his right and left carotid arteries respectively. How should this patient be managed?
A. proceed to CABG without further treatment of his carotid disease
B. Combined coronary artery bypass-carotid endarterectomy (CEA) operation
C. staged CEA followed by coronary artery bypass
under separate anesthetic
D. Staged coronary artery bypass followed by CEA under separate anesthetic
A. proceed to CABG without further treatment of his carotid disease
A sestamibi scan reveals a hyperfunctioning parathyroid adenoma in the superior right position in a 53 yo woman with hypercalcemia. Preoperative parathyroid hormone (PTH) level is 200pg per milliliter. After removal of the suspected parathyroid adenoma, a decrease in PTH to which of the following levels within the specified time frame would signify that the only hyperfunctioning gland had been successfully removed?
A. 132 pg per milliliter in 5 min
B. 43 pg per ml in 30 mim
C. 65 pg per ml in 20 min
D. 99 pg per ml in 10 min
E. 125 pg per ml in 10 min
D. 99 pg per ml in 10 min
A 76-year-old man undergoes exploratory laparotomy for a suspected bowel obstruction. During the operation, you discover a mass in the duodenum just proximal to the ligament of Treitz, with no palpable lymphadenopathy. Intraoperative pathology confirms adenocarcinoma. What is the best course of management for this patient?
A. Pancreatoduodenectomy
B. Surgical resection with intraoperative chemotherapy
C. Surgical resection with duodenojejunostomy
D. Gastrojejunostomy
C. Surgical resection with duodenojejunostomy
A 58-year-old man presents with an asymptomatic right-side anterior neck mass in the thyroid region. What is the most appropriate diagnostic test for this man?
A. History and physical examination
B. FNA
C. Scintigraphy
D. Ultrasound
E. Exploratory surgery
B. FNA
A 53 yo man is brought into the ED after sustaining a gunshot wound to the left flank. You suspect a splenic injury with ongoing bleeding. The patient discloses that he is on coumadin and his INR is 3.0. What do you use to correct the coagulopathy en route to the operating room
A. IV vitamin K
B. Orally administered vitamin K
C. FFP
D. PRBC transfusion
E. Protamine infusion
C. FFP
A 67-year-old man with chronic obstructive pulmonary disease is in his third postoperative day following right lower lobe lung resection for adenocarcinoma of the lung. His clinical course has been complicated by a bronchopleural fistula with a rising partial pressure of carbon dioxide in arterial blood PaCO2. What is the optimal mode of mechanical ventilation to reduce his bronchopleural fistula?
A. Pressure-controlled ventilation
B. Synchronized intermittent mandatory ventilation
C. High-frequency jet ventilation
D. Inverse-ratio pressure-control ventilation
C. High-frequency jet ventilation
On postoperative day 3, after undergoing an exploratory laparotomy, distal pancreatectomy, splenectomy, and fixation of a left femur fracture, after a motor vehicle collision, a 46-year-old man is found to be lethargic, confused, and vomiting. His blood pressure is 90/40 mm Hg, serum glucose is 45 mg per deciliter, serum sodium is 121 mEq per liter, and serum potassium is 53 mEq per liter, and hemoglobin 11.2 mg per deciliter. Which of the following is the most likely cause accounting for his condition?
A. Volume overload with LR solution B. Pulmonary embolism
C. Internal bleeding
D. Acute adrenal Insufficiency
E. Pituitary Infarction
D. Acute adrenal Insufficiency
Two days after undergoing an abdominoperineal resection, a 64 yo man's colostomy stoma is dusky. On evaluation at the bedside on postoperative day 3 the dark bowel extends below the level of the abdominal wall fascia. What is the most appropriate management?
A. Exploration and revision in the operating room
B. Observation
C. wet-to-dry dressings to stoma
D. Arteriography
A. Exploration and revision in the operating room
A 58-year-old woman is experiencing bright red rectal bleeding after undergoing a lumbar laminectomy 3 days ago. She has been stable and was transferred out of the ICU in the morning following her surgery. What is the most likely etiology of her rectal bleeding?
A. Injury to the middle rectal artery during surgery
B. Injury to the median sacral artery during surgery
C. constipation
D. Injury of the sacral plexus during surgery
E. Rectal cancer
C. constipation
After a prolonged, open AAA repair, requiring large volumes of fluid resuscitation, a 75-year-old man remains paralyzed and sedated, on full ventilatory support in the ICU. Although he is hemodynamically sta¬ble, his core body temperature is only 34 C. What would have been the most effective way to maintain his core temperature intraoperatively?
A. Using forced-air warming devices
B. warmed IV fluids
C. Keeping the room temperature elevated
D. Warming intra-abdominal irrigation fluids
E. Surrounding the patient with blankets
A. Using forced-air warming devices
A 72 yo diabetic man is admitted for an infected left second toe. He has been previously treated with oral antibiotics for several weeks, with little benefit. On physical examination, he has a nonhealing infected ulcer on the volar aspect of his left second distal phalanx. The ulcer is purulent at the base and cultures reveal polymicrobial infection. What is the most appropriate next step in the management of this patient?
A. IV antibiotics
B. Single toe amputation
C. IV antibiotics and tight glucose control
D. Single toe amputation and IV antibiotics
D. Single toe amputation and IV antibiotics
An opera singer who recently underwent total thyroidectomy returns for her postoperative visit report¬ing voice fatigue and an inability to sing high notes. Her total calcium level is 9.1 mg per deciliter (normal, 9 to 10.5 mg per deciliter). This complication could have been prevented by:
A. the use of an intra-operative functional nerve stimulator to localize the recurrent laryngeal
B. ligating individual branches of the superior thyroid artery at the level of the thyroid capsule
C. performing a careful dissection to avoid injury to the parathyroid glands
D. nothing; it is unavoidable; symptoms are due to transient postoperative hypocalcemia and will resolve
B. ligating individual branches of the superior thyroid artery at the level of the thyroid capsule
While eating breakfast on the morning after undergoing resection of the right middle lobe of her lung, a 65-year-old woman has acute abdominal pain. Her stomach is distended and tympanitic; she is bradycardic, hypotensive, tachypneic, and sweating profusely. What is the most appropriate course of action?
A. Emergency exploratory surgery
B. Obtain supine and erect abdominal x-rays
C. Place a nasogastric tube
D. Increase the patient's pain medication
C. Place a nasogastric tube
A 24yo man is brought to the ED after being stabbed it the right flank. Urine is grossly positive for blood and CT shows contrast extravasation from the superior pole of the right kidney. Operative exploration confirms cortical injury, but no injury is noted to the hilum or pelvis. How should this kidney be managed?
A. Debride devitalized tissue and repair it primarily
B. divert the right ureter to the left ureter
C. Perform a partial right nephrectomy
D. Wash out and pack the right kidney
E. Perform a right nephrectomy
A. Debride devitalized tissue and repair it primarily
A 24-year-old man who tests positive for HIV presents to the emergency department with acute-onset pain and redness in his scrotum, penis, and perineum. Upon examination, you feel crepitance over the erythematous area described, which emits a foul-smelling gray dis¬charge. What is the most appropriate management for this patient's illness?
A. Initiate highly active antiretroviral treatment
B. Initiate penicillin G Infusion
C. Perform surgical debridement of affected tissue
D. Apply topical polymycin ointment
E. Give hydrocortisone Infusion
C. Perform surgical debridement of affected tissue
A 27-year-old construction worker is brought to the emergency department after suffering a fall from 15 ft On arrival, he is tachypenic with rapid shallow breaths and considerable pain on chest wall palpation. A CT scan of the chest, abdomen, and pelvis reveals fractures of ribs 6 through 10 on the left side and a left lower lung lobe contusion. He is gradually becoming hypoxic What is the most effective method of treatment for this patient?
A. endotracheal Intubation and mechanical ventilation
B. Fentanyl patient control analgesia
C. Fentanyl plus morphine thoracic epidural
E. Bupjvacaine thoracic paravertebral block
E. Bupjvacaine thoracic paravertebral block
A 38-year-old woman undergoes left-side thyroid lobectomy for a palpable nodule with indeterminate pathology on preoperative FNA. The specimen is sent to pathology for examination. Which of the following factors paired with the appropriate diagnosis is associ¬ated with the poorest prognosis for this patient?
A. Psammoma bodies with anaplastic carcinoma
B. MEN-2b with medullary carcinoma
C. Encapsulated, noncystic follicles with follicular carcinoma
D. presence of lymph node disease with papillary carcinoma.
E. 1.7-cm solitary nodule with medullary carcinoma
B. MEN-2b with medullary carcinoma
You are consulted by an emergency medicine physi¬cian who is treating a 48-year-old alcoholic man with painless jaundice. She says that the man has appeared drunk in the emergency department on numerous other occasions and was admitted to the medical serv¬ice for pancreatitis. She calls you now because he ap¬pears to have intrahepatic biliary ductal deilation on CT scan. The bilirubin level is 12.6 mg per deciliter with other liver function tests normal. Upon careful review of the CT scan with the radiologist, you can detect no obstructing mass. Magnetic resonance cholangiopan¬creatography demonstrates no stones in his biliary tree and dilation extending to the pancreas. The most likely cause of his ductal dilation is:
A. gallbladder carcinoma
B. pancreatic pseudocyst
C. pancreatic cancer
D. benign common bile duct stricture
D. benign common bile duct stricture
A 24-yr-old African-American woman presents to your clinic for excision of a suspicious skin lesion on her chest. She reports a history of keloid formation, as evidenced by a hypertrophic midline incision for a cesarean delivery from 6 months prior. Which of the
following techniques has the most favorable results for
inhibiting keloid formation?
A. Tumor necrosis factor-a (TNF-a) Injection following keloid excision
B. intralesional steroid injection following keloid excision
C. Tocopherol (vitamin E) topical application following keloid excision
D. Radiotherapy following keloid excision
E. Tretinoin ointment application following keloid excision
B. intralesional steroid injection following keloid excision
A 35-year-old former IV drug user with a history of hep¬atitis C infection has developed cirrhosis and has re¬cently been placed on the liver transplant waiting list He would like to know how sick he must be before the benefits of liver transplantation outweigh the risks as assessed by his model for end-stage liver disease (MELD) score. What do you tell him his MELD score has to be greater than?
A. MELD 10
B. MELD 15
C. MELD 20 D. MELD 30
E. MELD 40
B. MELD 15
A 78-year-old woman with a history of TIAs and coro¬nary disease presents to the emergency department with pain in her distal right lower extremity. She de¬scribes the pain as a dull aching sensation in her toes that Is worse at night when she lies flat in bed. She, therefore often sleeps in a chair. A careful Inspection of the extremity does not reveal any signs of necrosis or gangrene. The forefoot is purple red when the foot Is down while seated and very white when the foot Is elevated. To assess the severity of this patient's disease, an ankle-brachial (systolic pressure) Index (ABI) is per¬formed at the bedside. What is the most likely ABI value range to be found In this patient?
A. ABI between 0.7 and 0.9
B. ABI between 0.6 and 0.7
C. ABI between 0.5 and 0.6
D. between 0.3 and 0.4
E. ABI between 0.1 and 0.2
D. between 0.3 and 0.4
A 62-year-old woman with a serum calcium level of 11.4 mg per deciliter, elevated intact PTH, and a recent his¬tory of kidney stones underwent a bilateral neck exploration. Two normal parathyroid glands were identified on the right side, and one normal superior parathyroid gland was identified posterior to the superior pole of the left thyroid lobe. The thymus and the side of the neck with the missing gland were thoroughly explored but no abnormal masses were found. The surgeon should do what next?
A. Remove the Identified parathyroid glands one at a time, until the Intact PTH level drops to half the baseline level
B. Remove the three identified glands, and auto-transplant one of them into the nondoirunartt forearm
C. Biopsy each of the glands since visual inspection Is a poor indicator of abnormal pathology
D. End the operation and perform noninvasive imag¬ing to localize the abnormal parathyroid tissue

E. Perform a left-side thyroid lobectomy
E. Perform a left-side thyroid lobectomy
You perform an uncomplicated laparoscopic cholecysectomy on a 50-yr-old woman for symptomatic cholelithiasis. One week later, the surgical pathologist calls you to say that the specimen contains adenocarcinoma of the gallbladder wall. The cancer is limited to the muscular layer of the gallbladder and the cystic duct margin is negative. In your subsequent discussion with the patient, what should you recommend as the treat-
A. Resection of the gallbladder fossa and portal lymphadenectomy
B. Radiation and chemotherapy with 5-fluorouracil and mitomycin C
C. Resection of the laparoscopic trocar sites and chemotherapy with 5-fluorouracil and mitomycin C
D. No further treatment is needed
E. Extended right hepatectomy, portal lym¬phadenectomy. and resection or reconstruction of the extrahepatic biliary tree
A. Resection of the gallbladder fossa and portal lymphadenectomy
A 23-year-old pedestrian man is brought to the emergency department after he was pinned between a truck and a telephone pole. He has infraumblilical, pelvic, and hip pain. Pelvic plain radiographs reveal an open-book fracture with bilateral sacroiliac dislocation. Which of the following is the most appropriate initial manage¬ment of this patient?
A. Immediate open reduction and internal fixation while he is hemodynamically stable
B. External fixation of the pelvis when he becomes hemodynamically unstable
C. Placement of a pneumatic anti-shock garment when he becomes hemodynamically unstable
D. Nonoperative management of the pelvic fracture, with extended bed rest while he Is hemodynami¬cally stable
E. immediate placement of two 16-gauge peripheral IVs
E. immediate placement of two 16-gauge peripheral IVs
A 67-year-old man with a medical history of hyperten¬sion and insulin-dependent diabetes mellitus presents for counseling before an open AAA repair scheduled 3 weeks from now. He has never had a cerebrovascular accident or an MI and denies symptoms of angina or heart failure. His pre-operative labs are remarkable for a creatinine of 2.2 mg per deciliter, and he reports that he is able to walk up four flights of stairs before tiring. Which of the following measures is appropriate given his current level of cardiac risk?
A. He should undergo non-invasive stress testing (e.g., exercise stress testing, dipyramidole thallium imaging) and if negative for high-risk features, he should receive perioperative beta-blockade.
B. There is no indication for non-invasive stress testing. He should be started on perioperative beta-blockade.
C. He should have a coronary angiogram and be consid¬ered for coronary revascularization before surgery.
D. There is no indication for non-invasive stress test¬ing or perioperative beta-blockade in this patient.
A. He should undergo non-invasive stress testing (e.g., exercise stress testing, dipyramidole thallium imaging) and if negative for high-risk features, he should receive perioperative beta-blockade.
A 45-year-old man is admitted to the ICU with presumed sepsis. After the patient is stabilized, the deci¬sion is made to place a central venous catheter. The pa¬tient's platelets, INR, and partial thromboplastin time ratio are within normal limits. He is breathing at a rate of 20 breaths per minute on room air with an oxygen saturation of 99%. He has no other significant past med¬ical history. The preferred location for central venous access is:
A. right femoral vein
B. left internal jugular vein
C. left subclavian vein
D. right internal jugular vein
E. left femoral vein
C. left subclavian vein
A 45yo man undergoes endoscopic ultrasonography to further localize a 3cm insulinoma in the head of the pancreas. This solitary insulinoma is determined to be adjacent to the pancreatic duct. Which of the following procedures should be used to remove the tumor?
A. Laparotomy with pancreatoduodenectomy
B. laparotomy with enucleation
C. Laparotomy with cryoablation
D. Laparoscopic total pancreatectomy
A. Laparotomy with pancreatoduodenectomy
You are called to the ED to see a 68 yo woman who has undergone barium enema for ileocolic intussusception. The radiographs show that the intussusception has been only partly reduced. What is your next step?
A. Another barium enema
B. Colonoscopic reduction
C. Pneumatic reduction
D. laparotomy for manual reduction
D. laparotomy for manual reduction
Current guidelines for prophylaxis against venous thromboembolism call for risk stratification before deciding on a prophylaxis strategy for a particular patient. The group of patients with the highest risk for venous thromboembolism includes those undergoing hip arthroplasty, those with major trauma or spinal cord injury, and those with, history of prior venous
thromboembolism. What Is the approximate incidence of DVT in this group of patients?
A. 1 to 10%
B. 10 to 20%
C. 40 to 50%
D. 50 to 60%
B. 10 to 20%
A 50-year-old man is in the ICU with necrotizing pancreatitis. He is struggling to become weaned from the ventilator. Because he has been maintained on TPN, you suspect an overfeeding syndrome and elect to per¬form indirect calorimetry. Which of the following val¬ues for the respiratory quotient would be consistent with an overfeeding syndrome?
A. 0.65
B. 0.7
C. .8
D. 1.0
D. 1.3
D. 1.3
A 19-year-old man Is brought to a rural emergency de¬partment after being stabbed in the left side of the chest by farm equipment. His initial set of vital signs after 2 L of fluid are HR107 beats per minute and blood pressure 80/ 50 mm Hg. He is able to tell you what happened, but you are not able to hear heart sounds and breath sounds are dis¬tant on the left. What should be your next step?
A. Chest x-ray while preparing a thoracostomy set
B. Emergent pericardiocentesis
C. Intubation
D. Large volume resuscitation
C. Emergency thoracotomy in the operating room
B. Emergent pericardiocentesis
A 62-year-old woman undergoes laparoscopic splenectomy for idiopathic thrombocytopenic purpura. After recovery from the operation she continues to have a platelet count of 20,000 per cubic millimeter. What is the next step in her treatment?
A. Administer IV immunoglogulin
B. Do nothing
C. Reoperate for missed accessory spleen
D. Begin a 4month course of danazol
E. Perform a bone marrow transplantation
A. Administer IV immunoglogulin
A 56 yo man is seen in clinic 6 months after undergoing a redo laparoscopic Nissen fundoplication. He describes a bloated feeling after meals, dysphagia, inability to vomit, and dyspepsia. Which of the following is the cause of these concerns?
A. The wrap is too tight.
B. The esophagus is shortened.
C. The wrap has come undone.
D. The stomach has become denervated.
B. The esophagus is shortened.
A 74-year-old former gardener presents with a suspi¬cious, irregular mole on his left upper arm. Of note, there is no evidence of ulceration. Which of the following sce¬narios would warrant a sentinel lymph node biopsy?
A. 1.5mm thick melanoma of the arm with no clinical nodal metastases
B. 4.5-mm-thick melanoma of the arm with known metastasis to the brain
C. 0.5-mm-thick melanoma of the arm with no clinical evidence of nodal metastases
D. A 2.0-mm-thick melanoma of the arm with axillary lymphadenopathy
E. 3.0-mm-thick melanoma of the arm with pul¬monary metastases
A. 1.5mm thick melanoma of the arm with no clinical nodal metastases
Three men are admitted to the emergency department after developing severe hypothermia and dehydration while ice fishing. You decide to rewarm and resuscitate them with warmed IV fluids. The nurse asks how warm you would like the fluids. Which of the following do you tell the nurse is the highest temperature that is safe to administer to the patients?
A. 45 C
B. 55 C
C. 65 C
D 75 C
E. Rewarming with IV fluids above normal body temperatures Is not recommended.
C. 65 C
A 33-year-old man presents to the emergency department with a single gunshot wound to the left side of his chest The patient is able to talk but has severely decreased breath sounds on the left side. A 36-french tho¬racostomy tube is placed. Which of the following is an indication for operative management?
A. 1,000 mL sanguineus chest tube output upon insertion
B. 300 mL sanguineus chest tube output over the next 3 hours
C. A small air leak In the cheat tube that remains for 24 hours
D. The presence of gastric contents In the chest tube effluent
E. Hemodynamic instability on presentation to the emergency department
D. The presence of gastric contents In the chest tube effluent
A 52-year-old woman with a multifocal tumor in her left breast with palpable lymphadenopathy was advised to have a simple mastectomy with axillary lymph node dissection, followed by a postoperative course of chemotherapy and radiation. She has a history of hypertension and quit smoking 15 years ago. Her surgical history includes a tonsillectomy and a laparo¬scopic cholecystectomy. Which statement is most appropriate regarding the patient's inquiry about trans¬verse rectus abdominus myocutaneous (TRAM) flap reconstruction?
A. Breast reconstruction should not be pursued fol¬lowing postmastectomy radiotherapy.
B. Breast implantation is preferable to TRAM flap reconstruction because of the patient's history of hypertension and smoking.
C. Breast implantation is preferable to TRAM flap reconstruction because of the patient's history of laparoscopic surgery.
D. A TRAM flap should yield a more natural cosmetic result compared with breast implantation but is best performed months after radiotherapy.
E. A TRAM flap should yield a more natural cosmetic result compared with breast implantation, and is best performed immediately following the mastectomy.
D. A TRAM flap should yield a more natural cosmetic result compared with breast implantation but is best performed months after radiotherapy.
6 weeks after undergoing a vagotomy and antrectomy with Billroth II reconstruction for peptic ulcer disease, A 76 yo man presents with nausea, abdominal pain, and low-grade fever. Given his recent surgical history, your differential diagnosis includes afferent
limb obstruction. Which one test will best confirm this
diagnosis?
A. Hepatobiliary Iminodiacetic acid scan
B. CT scan
C. Upper GI series
D. Esophagogastroduodenascopy
B. CT scan
A 58-year-old woman is rushed to the emergency de¬partment following an explosion in her basement that resulted in a shower of metallic shrapnel and multiple penetrating injuries. Her GCS score on arrival is 8. Non-con trust CT of the her head reveals one of the metallic fragments to have penetrated the inner table of the skull. Which of the following characteristics of this sce¬nario portends the poorest prognosis given her pre-resuscitation GCS score?
A. Female gender
B. Penetrating mechanism of injury
C. Blast injury
D. Age >55
E. Time of transportation
B. Penetrating mechanism of injury
A 30-year-old man underwent pelvic fixation after a motorcycle accident 2 days ago. He has been vomiting episodically for the past 24 hours, has had a high naso¬gastric tube output, and is breathing at 8 respirations per minute. To correct the status of his acid-base sta¬tus electrolytes, you should do which of the following?
A. Give 2.2 meq per liter ammonium chloride
B. Administer acetazolamide
C. Perform emergency dialysis
D. Infuse 1 L normal saline solution with 20 meq KCl per liter
E. Infuse 1L LR solution
D. Infuse 1 L normal saline solution with 20 meq KCl per liter
A 65-year-old man with a history of severe atherosclerosis, hypertension, and bicuspid aortic valve presents to the emergency department in acute distress after a sudden onset of tearing chest pain directly below his sternum. The patient is hypertensive (196/110 mm Hg) and appears very anxious with an overwhelming sense of doom. Which of the following tests or interventions is contraindicated-in this patient?
A. Electrocardiogram
B. CT scan of the chest with contrast injection
C. Administration of antihypertensive medications
D. Thrombolytic treatment of a MI
E. Echocardiogram
D. Thrombolytic treatment of a MI
A 51-year-old man with diabetes and a 5.8-cm AAA undergoes a preoperative evaluation. He has the fol¬lowing laboratory results; sodium 144 mEq per liter, potassium 5.3 mEq per liter, chloride 117 mEq per liter, bicarbonate 18 mEq per liter, and creatinine 1.6 mg per deciliter. The plasma renin activity is 1.3 ng/mL/hour (normal, 1.9 to 3.7 ng/mL/hour) and the urine pH is 5.0, These laboratory tests are consistent with:
A. type 1 renal tubular acidosis (RTA)
B. type 2 RTA
C. type 4 RTA
D. inappropriate antidiuretic hormone secretion
E. Conn syndrome
C. type 4 RTA
A 68 - year- old woman presents with a history of weight loss and nausea, but she denies vomiting or early satiety. Workup ultimately leads to biopsy-proven B-cell mucosa-associated lymphoid tissue lymphoma confined to the stomach. What is the most appropriate treatment?
A. Antibiotics
B. Radiation
C. Chemotherapy and radiation
D. Subtotal gastrectomy followed by radiation
E. Proton pump inhibitor, clarithromycin, and amoxicillin for 10 to 14 days
A. Antibiotics
Which of the following statements is correct regarding anatomy of renal vasculature?
A. The left renal artery is superior to the left renal
B. The left renal vein lies posterior to the aorta.
C. The right renal vein is anterior to the aorta.
D. the right renal artery lies posterior to the IVC.
C. The left renal artery is longer than the right renal artery.
D. the right renal artery lies posterior to the IVC.
A 27-year-old man is shot in the leg and arm and arrives in the emergency department in hypovolemic shock from massive hemorrhage. After prolonged surgery to reconstruct his femoral and brachial arteries, he is hemodynamically stable. On arrival to the ICU. his arterial blood gas values are as follows: pH 7.50, PaO2 140 mm Hg, PaC02 5O mm Hg, HCOs 28 mEq per liter. What is the likely etiology of his acid-base disturbance?
A. Dilutional acidosis
B. Lactic acidosis
C. Contraction alkalosis
D. Ingestion of an excessive amount of antacid before the Injury
E. Hyperventilation
C. Contraction alkalosis
A 54-year-old man presents to his gastroenterologist after 3 weeks of right upper quadrant pain, jaundice, and intermittent hemobilia. An ultrasonography and duplex scan are performed, showing a 2.5-cm intrahepatic artery aneurysm in the left lobe of the liver. The best option for treatment is:
A. serial radiological studies to evaluate for expan¬sion over time
B. Coil embolization of the aneurysm with radiological guidance
C. open surgical ligation
D. left hepatectomy
E. resection of the aneurysm and reconstruction of the hepatic arterial tree
B. Coil embolization of the aneurysm with radiological guidance
After radiographic localization of a solitary 3-cm insulinoma in the tail of the pancreas of a 56-year-old woman, you perform a distal pancreatectomy and splenectomy. Which of the following statements regarding the distri¬bution of insulinomas is true?
A. Ninety percent of insulinomas are found in the head, uncinate process, or body of the pancreas.
B. Insulinomas are evenly distributed throughout the pancreas,
C. Most insulinomas are found in the tail of the
pancreas.
D. Malignant Insulinomas are more frequently found in the head and uncinate process of the pancreas.
E. Fifteen percent of insulinomas are found in the tall of the pancreas.
B. Insulinomas are evenly distributed throughout the pancreas
Your sister states that she has been diagnosed with focal nodular hyperplasia of her liver. How should you advise her to proceed with treatment?
A. She will likely require surgery for this condition
B. she may be observed with this condition.
C. She should visit a medical oncologist for chemotherapy.
D. She should visit a radiation oncologist for radia¬tion therapy.
E. She should visit a medical oncologist for an oral TNF-alpha inhibitor.
B. she may be observed with this condition.
A negative side effect of delayed primary wound closure compared with healing by secondary intention includes which of the following?
A. Increased width of scar
B. Longer time to epithelialization
C. Prolonged dressing changes
D. increased risk of formation of delayed abscess or wound Infection
E. Painful dressing changes
D. increased risk of formation of delayed abscess or wound Infection
A 40 yo unrestrained male driver is involved in a high-speed motor vehicle crash with a 5 min extrication time. First responders find him breathing shallowly, with a pulse rate of 113 and blood pressure of 110/70 mm Hg. He has a scalp laceration but no obvious extremity fracture. He is given a large volume of IV fluids en route to the hospital. Upon arrival, his GCS score is 8, and he is intubated and placed on a ventilator. Shortly thereafter, the patient becomes markedly hy¬potensive and is found to be in pulseless electrical activity arrest. Cardiopulmonary resuscitation is initiated. What is the next best step in management of this patient?
A. Chest x-ray.
B. Bilateral needle decompression
C. Emergenct thoracotomy
D. Transfusion of blood products
E. Close scalp laceration
B. Bilateral needle decompression
A 72-year-old man with a history of coronary artery disease and hypertension is found to have a 6.8-cm infrarenal AAA and bilateral common iliac occlusive disease. He is taken to the operating room for elective repair by aortobifemoral grafting. What is the most common indication for internal iliac artery revascularization dur¬ing aortic aneurysm repair?
A. Absence of retrograde flow in the internal iliac artery
B. Absence of anterograde flow in the internal iliac artery
C. Unilateral aneurysmal dilation of the internal iliac artery origin
D. Postoperative rest pain due to buttock ischemia
A. Absence of retrograde flow in the internal iliac artery
The following patients have all undergone splenectomy, and none have received vaccinations for S. pneumoniae, H. influenzae, or N. meningitiaes. Who is at greatest risk of postsplenectomy sepsis?
A. A 20-year-old man with HIV who underwent splenectomy for trauma
B. A 73-year-old woman who underwent splenectomy for ITP
C. A three year old boy who underwent splenectomy for thalassemia major
D. A 45yo man who underwent splenectomy for Hodgkin disease
C. A three year old boy who underwent splenectomy for thalassemia major
A 60-year-old woman comes to you describing progressive dysphagia. She denies pain while swallowoing, but says she feels that some food become stuck on a "lump in my throat" She has not lost any weight from these symptoms, has no smoking history, and does not use alcohol. You suspect a benign process. How would you go about confirming your suspicion of an esophageal leiomyoma?
A. CT scan showing a circumferential narrowing along the proximal third of the esophagus
B. esophagoscopy showing a submucosal lesion in the distal third of the esophagus
C. Barium swallow showing a bird-beak pattern in
the distal third of the esophagus
D. Plain radiographs of the lateral neck demonstrat¬ing a pedunculated lesion arising from the poste¬rior wall of the esophagus
B. esophagoscopy showing a submucosal lesion in the distal third of the esophagus
A 35-year-old man received thermal burns from the explosion of a gas cylinder at his factory. The man suffered burns to 75% of his total body surface area. Including to his face, neck, chest, abdomen, back, arms, hands, and legs. More than 50% of his bum area was deep dermal in nature. Resuscitation was initiated with crystalloids, and dry sterile dressings were placed over his wounds. Within 12 hours of hospital admission, he developed respiratory distress, a high-grade tempera¬ture, and a pressor requirement. Subsequent manage¬ment should include which of the following?
A. Allow burn wounds to demarcate
B. Stop all enteral feeds
C. Obtain a wound biopsy
D. Initiate antibiotics on the basis of WBC count and fever
C. Obtain a wound biopsy
A 33 yo man was extricated from a house fire and at the scene was found to have second-degree burns to his trunk and extremitires totaling 35% of total body surface area. Primary survey showed singed nasal vibrissae and soot in the oropharynx, but unlabored breathing. He did not have rales, rhonchi, or wheezing, and his o2 saturation was 94% on room air. In this patient, development of hypoxia on hospital day 1 is most likely due to which of the following?
A. Upper airway obstruction and asphyxia
B. bronchospasm
C. ARDS
D. Pulmonary edema
A. Upper airway obstruction and asphyxia
A 54 yo man with atrial fibrillation refractory to multiple cardioversions and antiarrhythims underwent attempted endocardial catheter ablation by a cardiac electrophysiologist. After unsuccessful catheter ablation, he is referred to a cardiac surgeon for evaluation. Which of the following is true regarding the modified maze procedure?
A. It is possible to perform the modified maze procedure off cardiopulmonary bypass.
B. The modified maze procedure is not indicated in patients at risk for stroke.
C. Success In restoring sinus rhythm ranges from - 40% to 50% with the modified maze procedure.
D. The myocardium around the tricuspid valve is cut and then sewn back together to interrupt aberrant circuits in the modified maze procedure.
A. It is possible to perform the modified maze procedure off cardiopulmonary bypass.
A 52-year-old man with no prior medical problems reports intermittent episodes of tachycardia, nausea, and diaphoresis that improve with snacks. He has gained 10 lbs in the past 3 months and has become increasingly irritable. The patient's internist orders a monitored fast and makes the diagnosis of an insulinoma, A CT scan with IV contrast fails to localize the tumor. The next step in the patient's management is to:
A. perform somatostatin receptor scintigraphy
B. perform exploratory laparotomy and employ intraoperative ultrasonography
C. perform endoscopic ultrasonography
D. perform selective arterial calcium stimulation
with hepatic venous insulin sampling
E. recornmend judicious carbohydrate intake and a trial of octreotide
C. perform endoscopic ultrasonography
A 52-year-old man undergoes truncal vagotomy and antrectomy for peptic ulcer disease. Postoperatively, he experiences diarrhea. Which of the following physio¬logic alterations is due to the truncal vagotomy alone?
A. Accelerated emptying of solids
B. Increase in gastric acid secretion
C. Increased intragastric pressure
D. Decreased gallbladder distention
E. Decrease in gastrin production
C. Increased intragastric pressure
A 63-year-old woman is referred to your clinic for management of a biopsy proven, 1.7-mm-thick, levcl IV non¬ulcerative melanoma on the center of her back. Lymph nodes are normal to palpation. What is an appropriate surgical margin to take during excision to minimize local recurrance
A. >2cm
B. 2cm
C. lcm
D. None
B. 2cm
On routine annual examination a 78-year-old man has a 2-cm circular peripheral density in his right upper lobe on chest radiograph. To help establish a diagnosis, what should come next in the workup of this finding?
A. Sputum analysis
B. Lactate dehydrogenase level
C. Contrast-enhanced thoracic CT
D. 18F-2-fluoro-2-deoxy-D -glucose- positron emission tomography
E. Fiberoptic bronchoscopy
C. Contrast-enhanced thoracic CT
Which of the following statements regarding the scalenus
muscle is true?
A. The anterior body inserts into the first rib posterior to the subclavian vein.
B. The middle body inserts into the first rib anterior
to the brachial plexus.
C. The phrenic nerve crosses the anterior body from the medial to lateral aspects.
D. The muscle originates from the transverse processes of CI through C6.
A. The anterior body inserts into the first rib posterior to the subclavian vein
Which of the following is a characteristic of T3 colon cancer?
A. Lesion not penetrating the submucosa
B. Lesion invading through the muscularis propria into the serosa
C. Lesion invading through the submucosa into the muscularis propria
D. Lesion invading through the serosa into adjacent organs
E. Lesion invading through the serosa into the free peritoneal cavity
B. Lesion invading through the muscularis propria into the serosa
A 23-year-old man is referred to the surgical oncology clinic after an ERCP shows a type I choledochal cyst. What is the preferred method of surgical management?
A. Complete excision with Roux-en-Y hepaticojejunostomy
B. Cyst gastrostomy
C. Cyst jejunostomy
D. Cholecystectomy
E. Complete excision, partial hepatectomy, and
Roux-en-Y hepaticojejunostomy
A. Complete excision with Roux-en-Y hepaticojejunostomy
A 54-year-old woman with a low rectal cancer under¬goes an abdominoperineal resection in what proves to be a challenging procedure that lasts 9 hours. Which of the following would be the earliest indicator of compartment syndrome in the lower extremities?
A. Paresis
B. Pallor
C. pain
D. Pulselessness E. Paralysis
C. pain
In clinic, a 40-year-old man states that for the past 2 days he has had air passing through his urethra, cramping abdominal pain, distension, and loose bowel movements. He was diagnosed with Crohn disease of the terminal ileum 6 months ago and has not adhered to his medication regimens. Physical exam is notable for oral temperature 38.9"C, HR 120 beats per minute, and blood pressure 100/86 mm Hg. His skin is dry and he is tremulous. The patient has leukocyte count of 19,000 per cubic millimeter, serum Na+ of 128 mEq per deciliter, and K+ of 3.0 m£q per deciliter, and CT scan shows fistulous communication with the right ureter and a pericolic abscess. He is administered a dose of levofloxacin intravenously, upon which the patient goes Into cardiopulmonary arrest. The fatal arrhythmia is caused by which of the following?
A. Premature repolarization
B. After-depolarization
C. Re-entrant rhythm
D. Enhanced automaticity
E. Accessory conduction pathway
B. After-depolarization
A 24-year-old man has suffered 60% total body surface area burns. You estimate he needs to receive transfu¬sion of 4 L fluid over the next 2 hours. Which of the following would have the greatest increase in the cal¬culated resting energy expenditure, as determined by the Fick equation?
A. Blood transfusion to increase hemoglobin by 2 g per deciliter
B. Decreased FI02
C. Use of an epinephrine drip to increase cardiac output by 1L per minute
D. Administration of the correct amount of resuscitative fluid
A. Blood transfusion to increase hemoglobin by 2 g per deciliter
Among the examples given, which patient with pancreatic cancer would most likely be deemed unresectable on the basis of his or her abdominal CT scan and laboratory findings?
A. 75yo man with a 5 cm mass in the tail of the pancreas, CA 19-9 200 U per milliliter, and no vessel invasion
B. 54-year-old woman with a 3-cm mass in the head of the pancreas, CA 19-9 150 U per milliliter, and encasement of the superior mesenteric vein
C. 67-year-old man with a 5-cm mass in the head of the pancreas, CA 19-9 50 U per ml and encasement of the superior mesenteric artery
D. 58-year-old woman with a central pancreatic mass, CA 19-9 200 U per milliliter, and adhesion to the ventral surface of the IVC
C. 67-year-old man with a 5-cm mass in the head of the pancreas, CA 19-9 50 U per ml and encasement of the superior mesenteric artery
A 75-year-old woman falls while getting up from an unlocked wheelchair and subsequently experiences numbness in her index finger and thumb as well as difficulty in moving her thumb. Further questioning reveals a history of rheumatoid arthritis. She has tenderness on the dorsal aspect of her wrist and at the base of her thumb. She also has a noticeable 'dinner fork" deformity. Her findings are suggestive of which of the following diagnoses?
A. Scaphoid fracture
B. Lunate dislocation
C. Bennet fracture
D. Colles fracture
E. Smith fracture
D. Colles fracture
While performing an open cholecystectomy, you find a short cystic artery off the right hepatic artery and further note that the right hepatic artery does not originate from the proper hepatic artery. Anatomically, which is the most likely origin of the anomalous takeoff of the right hepatic artery?
A. Superior mesenteric artery
B. Left gastric artery
C. GastroduodenaJ artery
D. Left hepatic artery
E. Common hepatic artery
A. Superior mesenteric artery
A 67-year-old, otherwise healthy woman referred to you after arteriographic workup for multiple left hemispheric ischemic attacks reveals a "string of beads" appearance in the distal left Internal carotid artery, proximal to the carotid canal at the base of the skull. There is no further evidence of narrowing at the bifurcation on the left side, or of any disease of the right Internal carotid artery. What is the most appropriate management of this patient?
A. High, Internal CEA
B. Carotid artery Interposition graft
C. Percutaneous transluminal balloon dilation
D. chronic anticoagulation with regular observation
E. Open transluminal balloon dilation with stent placement
C. Percutaneous transluminal balloon dilation
A 60-year-old otherwise healthy man presents with symptoms of reflux disease and undergoes an endoscopic evaluation. The biopsies in the distal esophagus are consistent with high-grade dysplasia associated with Barrett esophagus. What is the appropriate treatment for this patient?
A. Proton pump inhibitor therapy
B. Esophagectomy
C. Anti-reflux surgery
D. Observation with annual endoscopic gastroduodenoscopy
B. Esophagectomy
You are caring for a 27 yo man in the ICU who was shot through the abdomen four times. He is postoperative day 3 from extensive bowel resection, and he has an open abdomen following the heavily contaminated procedure. He has a pulmonary artery catheter and has developed a depressed systemic blood pressure despite resuscitation to 10 kg above his baseline weight. Which pulmonary artery findings would support your suspicion of hyperdynamic septic shock?
A. decreased CVP/PCWP, dec CO, inc SVR, dec SVO2
B. inc CVP/PCWP, dec CO, inc SVR, dec, SVO2
C. inc or dec CVP/PCWP, inc CO, dec SVR, inc SVO2
D. inc or dec CVP/PCWP, dec CO, inc SVR, inc or dec SVO2
E. dec CVP/PCWP, dec CO, dec SVR, dec SVO2
C. inc or dec CVP/PCWP, inc CO, dec SVR, inc SVO2
Which of the following is the most common site of lung
abscesses?
A. Right middle lobe, lateral segment
B. Right upper lobe, posterior segment
C. Lingula.
D. Left lower lobe, posterior basal segment
B. Right upper lobe, posterior segment
A 58-yeat-old woman presents with severe refractory peptic ulcer disease that has failed to respond to con¬ventional treatment. Her workup includes an endoscopic ultrasound and octreotide scan that localize a 1.8-cm duodenal mass. There are no liver metastases. Laboratory evaluation reveals an elevated serum gastrin level What is the appropriate surgical management?
A. Pancreaticoduodenectomy
B. Total gastrectomy
C. Endoscopic mucosal resection
D. Duodenotomy and resection of the mass
E. Subtotal gastrectomy with truncal vagotomy
D. Duodenotomy and resection of the mass
One night after undergoing an open gastric bypass procedure, a 45 year.old 105 kg man had an isolated tem¬perature spike to 38.0 C Over the following 3 days, he was afebrile. This morning, on post-operative day 4, his pulse rate is 100 per minute and blood pressure is 95/60 mm Hg, which is lower than his normal 120/70. His wound appears slightly erythematous and is more ten¬der to palpation than yesterday. He admits to feeling slightly unwell. How might this complication have been avoided?
A. By shaving his abdomen before surgery
B. By washing the abdominal cavity with antibiotic solution before closure during surgery
C. By continuing prophylactic antibiotics for 48 hours postoperatively
D. By removing his Foley catheter on post-operative day 1
E. By maintaining tight glucose control following surgery
E. By maintaining tight glucose control following surgery
A 72-year-old man with a history of hypertension, hyperlipidemia, diabetes mellitus, and an irregular heart rhythm presents in the emergency department with the acute on¬set of unremitting right leg pain below the knee. He de¬nies trauma and states that he regularly walks a block to the grocery store without difficulty. On physical exami¬nation, the leg appears white and cool to touch and is no¬ticeably painful to palpation. In addition, no dorsalis pedis or posterior tibialis pulse can be palpated nor can a signal be identified with use of the Doppler probe. The most likely etiology for this patient's peripheral ischemia is
A. acute thrombosis
B. embolic disease
C. chronic atherosclerotic disease
D. drug-induced ischemia
E. vasculitis
B. embolic disease
A 35 yo woman who has been on oral contraceptive for 10yrs presents with a 6 month h/o RUQ discomfort. After a negative workup for cholelithiasis, CT reveals a 6.5cm tumor of hepatic segment IV. Complications of this tumor include which of the following?
A. 90% risk of malignant transformation
B. 50% to 65% risk of spontaneous rupture and intraperitoneal hemorrhage
C. 30% risk of spontaneous thrombosis
D. compression of the portal vein, leading to portal hypertension
E. Compression of the common hepatic duct, leading to obstructive jaundice
B. 50% to 65% risk of spontaneous rupture and intraperitoneal hemorrhage
The chest x-ray of a 68-year-old intubated man in the surgical ICU reveals an infiltrate in his right lower lobe. Concurrent with this finding, the patient has an elevated leukocyte count and increased endotracheal secretions. Which of the following procedures would have been most effective in preventing ventilator-associated pneumonia?
A. Initiation of ranitidine
B. elevation of the head of the bed at an angle >30 degrees
C. Selective decontamination of the digestive tract
D. Replacement of nasogastric tube with nasoduode-nal tube for post-pyloric enteral feeding
E. Use of prophylactic topical antibiotics (intratracheal or oral)
B. elevation of the head of the bed at an angle >30 degrees
A 62-year-old woman presents to your clinic with a de¬scription of progressive leg swelling throughout the day. Which of the following is the best method for assessing venous valvular competency?
A. Venography
B. Arteriography
C. Impedance plethysmography
D. Duplex Doppler ultrasonography
E. Venography with direct venous cannulation
D. Duplex Doppler ultrasonography
A 45 year-old man with 20 yr history of alcohol dependence presents to a general surgery clinic with concerns of fatty, foul-smelling stools and chronic intractable pain recalcitrant to narcotic therapy. Routine blood work is significant for a megaloblastic anemia, slightly elevated liver function tests, and high blood glucose level. CT scan of the abd is notable for a small pancreas containing several calcifications and a pancreatic duct dilated to 10mm. What is the appropriate therapy for this patient?
A. Longitudinal pancreatojejunostomy
B. Analgesics and oral pancreatic enzymes
C. Pancreatoduodenectomy
D. Distal pancreatectomy
A. Longitudinal pancreatojejunostomy
A 68-year-old retired construction worker is admitted to the ICU with severe acute pancreatitis. From discussions with his family it is learned that he drinks several glasses of beer and other alcoholic beverages daily. In the course of his resuscitation, he receives 20 L of IV fluid. By hospital day 6 he has regained hemodynamic stability and begins to mobilize volume with the aid of furosemide. After a brisk diuresis of 6 L the covering ICU physician is called to the patient's room because he has developed a substantial tremor, hyperreflexia, and mental status changes. A serum electrolyte panel demonstrates low potassium. What additional electrolyte is likely to be decreased in this patient?
A. Calcium
B. Magnesium
C. Phosphorus
D. Sodium
E. Chloride
B. Magnesium
A 70 yo man with a 60 pack per year smoking history undergoes a Whipple operation for pancreatic adenocarcinoma. Intubated overnight in the surgical ICU, his serial arterial blood gases show marked hypoxemia. The positive end-expiratory pressure is increased from 5 cm H,0 to 10 an H,0. The patient's urine output starts to decline thereafter and he receives several boluses of fluid throughout the night The next morning, he is edematous and still intubated. What ac¬counts for his falling urine output?
A. Decrease in intra-abdominal pressure
B. Increase in intrathoracic pressure
C. reduced renal blood flow
D. Kinked urinary catheter
C. reduced renal blood flow
A 40-year-old woman with a long-standing history of Crohn disease is found to have a perianal fistula above the dentate line involving the sphincter muscles. The fistula is well drained and there is no sign of pelvic sep¬sis. What is the best option for treatment?
A. Seton placement
B. Anti-TNF antibody
C. Treatment with ciprofloxacin and metronidazole
D. Fistulotomy
E. Diverting colostomy
B. Anti-TNF antibody
A 4-year-old girl is brought to the emergency department from preschool after being bitten by a classmate. The bite is on her forearm and is clean with no signs of devitalized tissue. The wound is copiously irrigated and primarily closed. Cultures of the wound taken before ir¬rigation are most likely to reveal which bacteria?
A. Staphylococcus aureus
B. Eikenella corrodens
C. Fusobacterium species
D. Prevotella species
E. Pasteurella multocida
A. Staphylococcus aureus
Four years after surgery for a gunshot injury to the right thigh, a 26-year-old man with no other significant past medical history is referred to your clinic because of a thrill and bruit over his right thigh discovered during a routine physical examination. Which of the following findings might you find in this patient?
A. Cardiac output of 3.2 L per minute
B. HR 55 beats per minute
C. SvO2 55%
D. Blood pressure 160/90 mm Hg
E. Left ventricular hypertrophy
E. Left ventricular hypertrophy
As part of her workup for anemia, a 60-year-old woman undergoes esophagogastroduodenoscopy, which reveals a 5-cm mass along the greater curvature of the stomach. Biopsy of the mass reveals spindle cells, and a CT scan shows no other abnormalities. The most appropriate next step for treatment is which of the following?
A. Endoscopic submucosal resection
B. Total gastrectomy with lymph node resection
C. Wedge resection of the gastric mass
D. Wedge resection of gastric mass followed by treatment with imatinib
E. Treatment with imatinib followed by total gastrectomy
C. Wedge resection of the gastric mass
A 43-year-old man with end-stage renal disease second¬ary to type II diabetes underwent a cadaveric renal trans¬plant. Intraoperatively, the transplanted kidney became grossly mottled and cyanotic. The surgeon noted capsular bulging due to marked edema, followed by graft rupture. What is the pathophysiology behind this graft failure?
A. Acute thrombosis of the renal vein
B. presence of antibodies directed toward donor ABO blood group antigens
C. Presence of recipient human leukocyte antigen class I antigens
D Stenosis or kinking of the renal artery
B. presence of antibodies directed toward donor ABO blood group antigens
You are caring for a 75yo man in the surgical ICU who is post-operative day 3 from an open cholecystectomy for a necrotic gallbladder. Since surgery, he has demonstrated a prolonged inflammatory response. The patient is 10L fluid positive since surgery and is producing only 10 cc urine per hr. After ordering an IV bolus of 1L crystalloid, you decide to insert a PA catheter. What findings would suggest that the patient has suffered an acute MI in the left anterior descending coronary artery distribution?
A. inc SBP, dec CO, inc HR, inc SV, inc SVR, dec CVP, dec PCWP B. dec SBP, dec CO, dec HR, dec SV, inc SVR, nl CVP, inc PCWP C. dec SBP, dec CO, dec HR, dec SV, inc SVR, inc CVP, inc PCWP D. dec SBP, nl CO, dec HR, inc SV, inc SVR, dec CVP, inc PCWP E. dec SBP, dec CO, inc HR, dec SV, inc SVR, inc CVP, inc PCWP
E. dec SBP, dec CO, inc HR, dec SV, inc SVR, inc CVP, inc PCWP
A 50-year-old man presents with a history of episodic facial flushing, diarrhea, and palpitations. His examina¬tion is notable for hepatomegaly. A workup reveals el¬evated 24-hour urine 5-hydroxyindoleacetic acid. He is diagnosed with carcinoid syndrome, and undergoes a CT scan to evaluate the extent of his disease. The radi¬ologist reports metastatic tumor to both lobes of his liver. The GI site with the highest metastatic potential is which of the following?
A. Stomach
B. Duodenum
C. jejunum
D. Ileum
E. Rectum
D. Ileum
After being struck by a truck, a 23yo woman undergoes splenectomy during diagnostic lapartotomy. She leaves the hospital against medical advice on postoperative day 4, after refusing vaccination. Infectionwith which of the following organisms is most likely to result in her developing sepsis?
A. Escherichia coli
B. Beta-hemolytic Streptococcus
C. Clostridium difficile
D. Pseudomonas aeruginosa
B. Beta-hemolytic Streptococcus
A 64 yo man with new diagnosis of lung cancer is scheduled for preoperative pulmonary function tests to determine if he is a candidate for surgical pneumonectomy. Which of the following results would confirm him as a good candidate for the proposed surgical procedure?
A. Predicted postoperative FEV1 of .7L B. VO2 max of 10ml per kg per min
C. Diffusing lung capacity for carbon monoxide of 85% the predicted value
D. Preoperative Pao2 of 48mm Hg on room air
E. Preoperative PaCO2 of 48 mm Hg on room air
C. Diffusing lung capacity for carbon monoxide of 85% the predicted value
A 62-year-old healthy female patient on your service has just undergone successful sigmoid resection. Final pathology reveals the tumor to be a stage IIIA moderately differentiated adenocarcinoma. What adjuvant therapy should this patient receive postoperatively?
A. Adjuvant therapy has not been proved beneficial in colorectal cancer
B. 5-Fluorouracil (5-FU) + leucovorin
C. 5-FU + leucovorin + oxaliplatin
D. 5-FU + leucovorin + bevacizumab
E. 5-FU + leucovorin + irinotecan
C. 5-FU + leucovorin + oxaliplatin
After sustaining a gunshot wound to the abd, a 24 yo man is brought to the operating room. During exploratory lap, you find gross contamination of the peritoneum by feces resulting from multiple sigmoid colonic enterotomies. Which of the following species of bacteria is the most abundant in feces?
A. Klebsiella pneumoniae
B. E. coli
C. Enterococcus faecalis
D. B. vulgatus
D. B. vulgatus
A 63 yo woman with a 60 pack year history of smoking presents to her primary care provider with a persistent cough and a 10lb weight loss. Chest CT demonstrates a solitary, speculated 2.8cm mass in the periphery of the right upper lobe without evidence of spread to mediastinal lymph nodes or the contralateral lung. FNA returns adenocarcinoma of the lung. She is referred to you for further management. What would be the preferred therapy for this tumor?
A. Chemotherapy alone
B. Chemotherapy plus radiation therapy
C. Pulmonary wedge resection
D. Lobectomy and mediastinal lymphadenectomy
E. Pneumonectomy and mediastinal lymphadenectomy
D. Lobectomy and mediastinal lymphadenectomy
A 50-year-old man with acute diverticulitis requires a colectomy. During the operation, gross contamination of the peritoneal cavity with fecal material is noted. The decision is made to perform a Hartmann procedure and leave the patient with an end-colostomy. Over the next 5 years, the subsequent risk of development of a parastomal hernia in this patient is which of the following?
A. 10%
B. 20%
C. 40%
D. 50%
E. 85%
D. 50%
A 40yo woman with von Willebrand disease presents for an elective cholecystectomy. What precautions should the surgical and anesthesia team take, and why? A. Ensure adequate FFP is ordered for the anticipated elevated INR B. Administer a dose of IV vitamin K the night before surgery for the anticipated elevated INR C. Have recombinant factor VIII available for a deficiency in this clotting factor D. Type and cross 4 units of PRBCs for the congenital anemia E. Have DDAVP available to reverse the platelet dysfunction
E. Have DDAVP available to reverse the platelet dysfunction
A 6-year-old boy referred to your clinic after workup for recurrent pneumonia reveals extralobar pulmonary sequestration. Which of the following characteristics is most commonly associated with the patients diagnosis
A. Venous drainage via the Inferior pulmonary
ligament
B. Usually occurs in upper lobes
C. Ebstein anomaly
D. Arterial supply from the abdominal aorta
E. Abnormal tissue surrounded by normal lung
parenchyma
D. Arterial supply from the abdominal aorta
A 64-year-old man presents to a clinic describing a recent history of bright red blood per rectum with associated constipation and decreased stool caliber. A digital rectal examination is performed and a mass is palpated in the proximal rectal vault. Endorectal ultrasound with biopsy reveals a stage IIA (T3, N0, M0) rectal adenocarcinoma approximately 8 cm from the anal verge. What is the appropriate surgical management of this tumor?
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A. Transanal excision
B. Low anterior resection
C. Abdominosacral resection
D. No surgery; primary chemotherapy and radiation therapy only
B. Low anterior resection
You are called to the neonatal ICU to see a full-term neonate with suspected malrotation. The baby's nurse reminds you of the importance of washing your hands thoroughly before touching the child. Why is this of particular importance?
A. Newborns have immature immune systems because their T cells have not fully differentiated and remain within their thymus
B. Neonates have weak coughs and are unable to clear their secretions
C. It is unknown whether the child has HIV and he may be immunosuppresed
D. Newborn lung lack IgA in the mucosal barrier to protect against airborne pathogens.
E. Neonatal neutrophils have impaired chemotaxis
E. Neonatal neutrophils have impaired chemotaxis
You are caring for an intubated patient in the ICU who is hypovolemic but has normal left ventricular function. Which of the following is an effect of the inspiration phase of positive-pressure mechanical ventilation?
A. Increased ventricular distensibility
B. Increased cardiac output
C. Reversed pulsus paradoxus
D. Decreased cardiac output
E. decreased intrathoracic pressure
D. Decreased cardiac output
A duodenal diverticulum is seen in a 58-year-old man with recurrent episodes of acute pancreatitis. On en¬doscopic evaluation, the ampulla of Vater is found to be located just distal to the border of the diverticular opening. What is the most appropriate interventional management of this patient's duodenal diverticulum?
A. Resection with choledochoduodenostomy
B. Resection with two-layer transverse closure
C. inversion and oversewing of the diverticulum
D. Pancreatoduodenectomy
E. Endoscopic sphincterotomy and stent placement
E. Endoscopic sphincterotomy and stent placement
A 54yo woman visited her primary care physician for a routine check-up. On physical exam the doctor noted a right-side carotid bruit. A subsequent contrast angiogram revealed 50% stenosis of her right-side carotid artery. Carotid endarterectomy for asymptomatic patients is indicated for stenosis defined by diameter reduction on angiography of which of the following
A. >90%
B. >80%
C. >70 %
D. >60%
E. >50%
D. >60%
What is the anatomical origin of the replaced right hepatic artery?
A. Proper hepatic artery
B. Common hepatic artery
C. Right hepatic artery
D. Superior mesenteric artery
E. Gastroduodenai artery
D. Superior mesenteric artery
A 37-year-old man is seen in the emergency department with abdominal pain. He has no known allergies. He undergoes CT scan with oral and IV contrast. Should he develop a reaction to the iodine contrast, which is most likely?
A. Itching
B. Dyspnea
C. Nausea
D. Cardiac arrest
C. Nausea
Which of the following tests is the most prognostic of liver function reserve?
A. Gamma-glutamyl transpeptidase measurement
B. Bromsulphalein clearance test
C. Transferrin measurement
D. Aminopyrine breath test
D. Aminopyrine breath test
You are treating a 56yo woman with Crohn disease for recurrent perianal fistulas. Metronidazole therapy has been abandoned because of limited results and patient intolerance of the medication. Before starting the patient on infliximab, you warned her that she may be at increased risk of several complications. Which of the following is considered the most serious complication attributable to treatment of Crohn disease with infliximab?
A. Urticaria
B. Perianal abscess
C. Perianal abscess
D. Lymphoma
E. Hypercoagulability
A. Urticaria
Pancreatic acini secrete enzymes that play an important role in the digestion of proteins. What is the most potent stimulant of pancreatic acinar cells?
A. trypsinogen
B. Secretin
C. Cholecystokinin
D. Acetylcholine
C. Cholecystokinin
You are a tumor researcher aiming to find novel cancer treatments. One of your projects involves constructing a tumor vaccine for breast cancer. Such a vaccine would take advantage of which of the following aspects of the immune system to prevent cancer?
A. Activation of latent T cells in the thymus
B. Adaptive immunity
C. Innate Immunity
D. Type IV hypersensitivity reaction
E. Cytokine activation
B. Adaptive immunity
A 72yo alcoholic man with ascites undergoes emergent colectomy for a lower GI bleed. During his postoperative recovery, urine output is consistently low (250 to 475 ml per day), serum creatinine rises progressively, but central venous pressure remains normal. Twenty-four-hour urinalysis on postoperative day 4 is as follows:
Volume: 374cc
Color: yellow
Micro: renal epithelial cells
Urine (Na): <10meq per liter
Urine specific gravity: 1.030
Serum specific gravity: 1.004
pH: 5.0
What is the most likely diagnosis accounting for this?
A. Acute tubular necrosis
B. Hepatorenal syndrome
C. Type 1 RTA
D. Prerenal azotemia
B. Hepatorenal syndrome
A 37-year-old woman with Crohn disease who has been managed on TPN for 6 months complains of nonhealing ulcers on her lower extremities. On physical exam, she has bilateral pretibial erythematous areas with blisters, pustules, and superficial ulcerations. Which of the following elemental deficiencies would be most consistent with this clinical picture?
A. Iron
B. Copper
C. Chromium
D. Zinc
E. selenium
D. Zinc
You are about to divide a short gastric artery during a total gastrectomy when the attending surgeon asks you. "What is the mechanism of action of gastrin?" You answer that it Is:
A. secreted by the chief cells of the stomach and it stimulates the release of cholecystokinin
B. secreted by the parietal cells of the stomach and stimulates the release of insulin from the pancreas
C. secreted by the parietal cells of the stomach and
promotes mucus release
D. secreted by the G cells of the stomach and pro¬motes peristalsis
E. secreted by the gastrin cells of the stomach and stimulates parietal cells
E. secreted by the gastrin cells of the stomach and stimulates parietal cells
A 62yo white man has developed ARDs 1wk after AAA repair. Multiple efforts to control his high peak airway pressures have been unsuccessful, and you have decided to use muscle relaxants to facilitate ventilation. While preparing pancuronium for administration, the nurse asks what the most likely side effect of this paralytic is. You answer:
A. Central nervous system toxicity
B. Residual motor weakness
C. Histamine release
D. tachycardia
D. tachycardia
Erythromcyin can act as a secretagogoue for which of the following?
A. Somatostatin |
B. Secretin
C. Motolin
D. Gastrin
C. Motolin
A 43 yo woman with hepatitis C and hepatocellular carcinoma undergoes orthotopic liver transplantation. Her explanted liver demonstrates a solitary, 4.9-cm hepatocellular carcinoma with evidence of vascular invasion but without spread to regional lymph nodes. The stage of her hepatocellular carcinoma is which of the following?
A. Stage I
B. Stage II
C. Stage IIIA
D. Stage IIIB
E. Stage IIIC
B. Stage II
A 64 yo man in the ICU has hemetemesis and melena. The patient has undergone unsuccessful endoscopic attempts to stop the bleeding of an ulcer in the duodenal bulb. He is now hemodynamically unstable and intubated. The ligation of which artery during surgery is most likely to stop the bleeding?
A. Gastroduodenal artery
B. Supraduodenal artery
C. Right gastroepiploic artery
D. Posterior superior pancreatoduodenal artery
E. Right gastric artery
A. Gastroduodenal artery
The policy makers at your institution would like to implement a new coumarin protocol for patients with aor¬tic valve replacements. They would like you to provide them with the INR value that best describes the current population of aortic valve replacement patients with stable INR levels. Assume the INR levels are normally distributed among your patient population. What test statistic would be best to provide them? A. Median
B. Standard error
C. Mean
D. Z statistic E. Mode
C. Mean
A 50-year-old woman presents to your outpatient clinic with a 4-week history of right upper quadrant pain. A. right upper quadrant ultrasound does not show any ev¬idence of cholelithiasis or cholecystitis. You should next do which of the following?
A. Obtain upper endoscopy
B. Admit her for hydration and pain control and schedule a laparoscopic cholecystectomy for the following day
C. Arrange for an ERCP
D. Obtain a noncontrast CT scan
E. Obtain cholecystokinin cholescintigraphy
E. Obtain cholecystokinin cholescintigraphy
Medicare is considering whether to continue funding gastric bypass procedures. A key concern of Medicare officials is the average weight loss among gastric bypass patients. Your institiuion has been asked to provide them with evidence demonstrating the associated probability of weight loss reported by your center. What information should you provide to the Medicare officials?
A. Mean difference between preoperative and postoperative weights
B. Median difference between preoperative and postoperative weights
C. Mode of the difference between preoperative and postoperative weights
D. 95% confidence interval of the median difference between preoperative and postoperative weights
E. 95% confidence interval of the mean difference between preoperative and postoperative weights
E. 95% confidence interval of the mean difference between preoperative and postoperative weights
Which of the following statements regarding lipid metabolism is correct?
A. Fatty acids are used to synthesize glucose in times of starvation.
B. Insulin induces release of fatty acids from adipocytes
C. Lipid oxidation occurs in the cytoplasm.
D. Fatty acids enter the tricarboxylic acid cycle as either acetyl-CoA or succinyl-CoA.
E. Glucagon and epinephrine act to promote fatty acid synthesis
D. Fatty acids enter the tricarboxylic acid cycle as either acetyl-CoA or succinyl-CoA.
A 10-year-old boy develops right lower quadrant pain, nausea, vomiting, and a fever. You suspect appendicitis and plan for an emergent appendectomy. As you are preparing to transport him to the operating room, his parents mention that he has hemophilia A. What should you administer for this condition?
A. Vitamin K
B. FFP
C. Factor VIII
D. Cryoprecipitate
E. Factor VII
C. Factor VIII
A 52 yo woman is referred to you after a several year history of progressive dysphagia that began with liquids and then progressed to include solid foods. She describes a sensation of her food sticking and passing into her stomach. Barium swallow evaluation demonstrates diffuse dilation and a narrow tapering of the distal esophagus. Esophageal manometry reveals LES pressures that remain constant throughout a swallow test. You make the diagnosis of achalasia and discuss treatment options with her. Which of the following is true regarding the LES in a healthy patient?
A. The LES is a specific anatomical sphincter
B. Gastric distension causes decreased LES tone.
C. LES pressure decreases during the initiation of a swallow
D. the LES serves to prevent air from entering the stomach during a swallow
E. The LES can be visualized by upper endoscopy
C. LES pressure decreases during the initiation of a swallow
A 35 year-old man is referred to you with an asymptomatic, 12-cm mass In his left thigh. MRI of the thigh and CT of the chest demonstrate no evidence of nodal or dis¬tant metastases. A core needle biopsy is interpreted as fi¬brosarcoma. You perform a radical soft part resection and the final pathology returns as a moderately differentiated fibrosarcoma. The most important prognostic factor in soft tissue sarcomas is which of the following'
A. Location of the primary tumor
B. Histologic grade of the tumor
C. Size of the primary tumor
D. presence of nodal metastases
E. Presence of distant metastases
B. Histologic grade of the tumor
A 2-year-old boy with no significant past medical history presents with a 1-month history of episodic painless rec¬tal bleeding. Findings on physical examination, including rectal examination, are unremarkable. The most useful imaging study in this situation is which of the following
A. Abdominal ultrasound scanning
B. Barium enema
C. Abdominal CT scan
D. 99mTc-pertechnate scan
E. Selective mesenteric angiography
D. 99mTc-pertechnate scan
A 25yo man is brought to the trauma bay after two GSWs to the left chest and mid back. His HR is 130 BPM, his BP is 80/40 mm Hg, and he has a GCS score of 9. It is estimated that he lost approximately 3L of blood in the field and that he has lost another 2 L within the trauma bay during the initial assessment. Which of the following effects would be most likely due to rapid resuscitation with blood products in this patient?
A. Jaundice and fever seen a week later
B. Myoglobinuria
C. Massive lower extremity swelling
D. Temporary blindness
E. Cerebral hemorrhage
A. Jaundice and fever seen a week later
A 48yo former alcoholic is now 10 wks post liver transplantation. He continues to have episodic fevers with leukocytosis, overall malaise, and failure to thrive. Additionally, his liver enzymes have increased over the past several days. His blood cultures have come back positive but he has no central venous lines. His urine culture is negative for pathogens. CT of his ab¬domen reveals multiple liver abscesses. Which of the fol¬lowing organisms is most likely causing this condition?
A. Ecitnococcus
B. Schistosoma mansoni
C. Klebsiella pneumoniae
D. Entamoeba histolytica
C. Klebsiella pneumoniae
On post-operative day 4 after a Whipple procedure, a patient develops symptoms consistent with massive pulmonary embolism. CT confirms a saddle embolus. After emergent lytic therapy with urokinase, the patient is bleeding from the surgical site. Which of the following options is the best choice to treat the bleeding?
A. Cryoprecipitate
B. FFP
C. Dextran
D. PRBCs
E. Aminocaproic acid
B. FFP
A 65 yo woman is referred by her primary care provider for a 2 month history of progressive nausea, vomiting, palpitations, anorexia, and lethargy. A CT scan reveals a mass in the first portion of the duodenum. The diagnosis of gastric outlet obstruction secondary to pancreatic cancer is made. She is admitted to the hospital for further preoperative evaluation. What metabolic abnormalitites require monitoring in this patient?
A. Hypovolemia, hypokalemia, metabolic alkalosis, hypochloremia
B. Hypervolemia, hyperkalemia, metabolic acidosis, hyperchloremia
C. Euvolemic, normokalemia, respiratory acidosis, normochloremia
D. Hypovolemia, hyperkalemia, metabolic acidosis, normochloremia
E. Hypovolemia, normokalemia, metabolic alkalosis normochloremia
A. Hypovolemia, hypokalemia, metabolic alkalosis, hypochloremia
You receive a phone call from a 62-year-old woman complaining of inability to urinate. Ten hours prior, she underwent a hemorrhoidectomy. How should you manage this problem?
A. Tell the patient not to worry, that she will urinate eventually
B. Tell the patient to drink more liquids
C. Tell the patient to return to the emergency department for placement of a Foley catheter
D. Tell the patient to phone the urologist on call
E. Tell the patient to contact you again if she does not urinate within 24 hours of the surgery
C. Tell the patient to return to the emergency department for placement of a Foley catheter
Which of the following characteristics is specific to the diagnosis of primary hyperaldosteronism?
A. Aldosterone excess
B. Hypertension
C. Adrenal tumor
D. Hypokalemia
E. Edema
C. Adrenal tumor
During afternoon rounds, a patient who underwent right-hemicolectomy 3 days ago complains of right arm pain. You note that the arm has a peripheral IV catheter in it with surrounding warmth and erythema. What is the best course of action?
A. Elevate the affected arm and alternate warm compresses and ice packs
B. Begin a 3 day course of IV cephalosporin antibiotics
C. Remove the peripheral IV catheter
D. Order a STAT right UE venous duplex
E. Draw two sets of peripheral blood cultures
C. Remove the peripheral IV catheter
Pancreatic enzymes are secreted as zymogens to prevent inappropriate activation within the pancreas. Which of the following enzymes can autoactivate to produce the active form of the enzyme?
A. Chymotrypsin
B. Elastase
C. Carboxypeptidase A
D. Trypsin
E. Enterokinase
D. Trypsin
A 68-year-old man presents with progressive onset of Painless jaundice due to an adenocarcinoma located in the pancreatic head. He undergoes a pylorus-preserving pancreatoduodenectomy without intraoperative compli¬cations. A peripancreatic drain is placed intraoperatively. Postoperative course is unremarkable, and on postoper¬ative day 4, he is advanced to a regular diet. Upon re¬suming this regular diet, the patient's peripancreatic drain begins to produce moderate volumes of murky fluid. The amylase level of this fluid is 2,000 units per liter (normal 23 to 85 units per liter). The patient is kept in the hospital and the drain output over the next 3 days is 85 mL per 24 hours, 73 ml per 24 hours, and 65 mL per 24 hours. During this time, the patient looks and feels fine, is able to tolerate a regular diet, and has no fever or elevation of WBC count. Which of the following is the most appropriate way to manage this problem?
A. Removal of pancreatic drain and patient discharge
B. Continued hospitalization with continued drainage C. Slow removal of drain over course of weeks with continuation of diet
D. TPN with continued drainage
E. Reoperative exploration
C. Slow removal of drain over course of weeks with continuation of diet
A 58yo man has constipation, nausea, loss of appetite, right-sided flank pain, and postural dizziness. A complete blood count is drawn and reveals hemoglobin of 6.8g per deciliter and slightly elevated white blood count of 12,000. Colonoscopy reveals a circumferential narrowing at the hepatic flexure that bleeds easily when biopsied. CT scan shows some enlarged mesenteric lymph nodes and a normal liver. The patient is referred for surgery. Which procedure would best benefit this patients
A. Right hemi colectomy
B. Extended right hemicolectomy
C. Subtotal colectomy with primary anastamosis
D. Total proctocolectomy with ileal-pouch anal anastamosis
E. Total colectomy with ileorectal anastamosis
B. Extended right hemicolectomy
Which of the following risk factors predicts the highest risk of developing breast cancer
A. Mother with breast cancer
B. Nulliparity
C. BRCA-1 or BRCA-2 mutation
D. Age>55
E. Biopsy-proven lobular carcinoma in situ
C. BRCA-1 or BRCA-2 mutation