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Home , Hyperplastic polyp, Juvenile polyp, Obturator hernia

174 Surgery Review Questions

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

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

11. Gastrointestinal diverticula do not occur in: 18. Malignant small bowel most commonly (a) cecum present with: (b) duodenum (a) weight loss (c) (b) abdominal pain (d) jejunum (c) gastrointestinal bleeding (e) ileum (d) jaundice (e) intestinal perforation

12. The hepatic caudate lobe: 19. Small in an elderly female (a) drains directly into the inferior vena cava without external or previous surgery is most (b) represents segment IV likely caused by: (c) is supplied by the left portal vein only (a) small bowel (d) is supplied by the right portal vein only (b) (e) lies to the right of the inferior vena cava (c) (d) abdominal abscess 13. von Willebrand’s disease: (e) obturator hernia (a) is an autosomal dominant disorder (b) results in prolonged prothrombin time 20. During cell cycle, DNA replication occurs in: (c) is associated with normal bleeding time (a) G1 phase (d) is due to decreased hepatic synthesis of von (b) G2 phase Willebrand’s factor (c) S phase (e) is typically associated with joint bleeding (d) M phase 21. Li-Fraumeni syndrome shows increased incidence 14. Which of the following is consistent with syndrome of: of inappropriate antidiuretic hormone (SIADH)? (a) colon cancer (a) hypovolemia (b) ovarian cancer (b) increased urine sodium (c) lung cancer (c) hypernatremia (d) breast cancer (d) plasma hyperosmolarity (e) (e) excessive diuresis 22. The best operative approach to choledochal is: (a) cystoduodenostomy 15. Normal anion gap acidosis is associated with: (b) cystojejunostomy (a) ketoacidosis (c) Roux-en-Y cystojejunostomy (b) lactic acidosis (d) Cyst excision and hepaticojejunostomy (c) salicylate poisoning (d) severe 23. Leiomyoma of the esophagus: (e) uremic acidosis (a) commonly presents with dysphagia (b) is more common in females 16. Benign small bowel tumors most commonly present (c) is usually multiple as: (d) is usually diagnosed with endoscopic biopsy (a) small bowel obstruction (e) is usually located in the lower one-third of the (b) gastrointestinal bleeding esophagus (c) weight loss (d) incidental finding on laparotomy 24. Hemangioma of the liver: (e) intestinal perforation (a) is the most common benign hepatic tumor (b) is diagnosed with percutaneous needle biopsy (c) is associated with α-fetoprotein level 17. The diagnostic test of choice for suspected acute (d) should be resected as soon as diagnosed sigmoid is: (a) barium enema 25. Phosphorus: (b) Gastrografin enema (a) is a major extracellular anion (c) computed tomography scan of the abdomen (b) is passively absorbed from the gastrointestinal and pelvis tract (d) abdominal ultrasound (c) deficiency may result in insulin resistance (e) (d) deficiency is rare in hospitalized patients 174. Surgery Review Questions 407

26. Hypermagnesemia is a complication of: 33. Intussusception in adults: (a) extensive burns (a) is idiopathic in most cases (b) (b) usually requires resection (c) oliguric renal failure (c) is often successfully treated with hydrostatic (d) resection of the terminal ileum reduction (e) diuretic therapy (d) is seldom recurrent

27. The optimal management of traumatic duodenal 34. Optimal treatment for an ileosigmoid fistula in hematoma is: Crohn’s disease is: (a) angiography and embolization (a) closure of the fistula (b) laparotomy and evacuation (b) proximal ileostomy (c) laparotomy and gastrojejunostomy (c) proximal ileostomy and closure of fistula (d) observation (d) ileocecectomy and sigmoid colectomy (e) ileocecectomy and closure of the sigmoid 28. Hairy cell leukemia: defect (a) can be cured with splenectomy (b) is an aggressive form of leukemia 35. Obturator hernia: (c) death is usually related to infectious com- (a) is most common in older women with plications cachexia (d) is a T-cell leukemia (b) is associated with pain in the sciatic nerve distribution 29. Overwhelming postsplenectomy sepsis: (c) is repaired through a transverse incision in the (a) commonly occurs after splenectomy for trauma upper medial thigh (b) does not occur if accessory spleens are present (d) is rarely strangulated (c) can be fatal within hours of onset 36. Gastrointestinal bleeding in Mallory-Weiss (d) is most common in elderly patients syndrome: (e) most fatal cases occur 10 to 15 years after (a) is occult in the vast majority of cases splenectomy (b) can be controlled with balloon tamponade (c) stops with nonoperative management in most 30. The development of thrombocytopenia and arterial cases thrombosis with heparin requires: (d) is caused by mucosal tear in the lower one-third (a) continuation of heparin and platelet trans- of the esophagus fusion (b) continuation of heparin and thrombolysis 37. The risk of overwhelming postsplenectomy sepsis is (c) doubling the heparin dosage highest for patients requiring splenectomy for: (d) changing the route of heparin administration (a) thalassemia (e) discontinuation of heparin (b) trauma (c) immune thrombocytopenic purpura 31. A trauma patient has a Glasgow Coma Scale score (d) hereditary spherocytosis of 13, blood pressure 80/40; widened mediastinum (e) acquired hemolytic anemia on chest x-ray, and bloody peritoneal tap. The next step in management is: 38. After mastectomy, winging of the scapula results (a) obtain head computed tomography scan from injury to: (b) perform thoracotomy (a) the medial pectoral nerve (c) perform arch angiography (b) the lateral pectoral nerve (d) monitor intracranial pressure (c) the long thoracic nerve (e) perform laparotomy (d) the thoracodorsal nerve (e) the intercostal-brachial nerve 32. Insulinomas: (a) are often multiple 39. von Willebrand’s disease: (b) are mostly benign (a) is the most common congenital bleeding (c) are a common component of multiple endo- disorder crine neoplasia type 1 (MEN 1) (b) commonly results in hemarthrosis (d) are commonly located in the head of the (c) affects males only pancreas (d) results in prolonged prothrombin time 408 Part XVI. Surgery Review Questions and Answers

40. Disc lesion between L4 and L5 will lead to: 47. The most common cause of hypercalcemic crisis is: (a) reduced knee jerk (a) sarcoidosis (b) reduced ankle jerk (b) primary hyperparathyroidism (c) weakness of foot dorsiflexion (c) secondary hyperparathyroidism (d) reduced sensation on the small toe (d) malignancy (e) renal failure 41. Kidney transplant recipients are at increased risk for: (a) epidermoid skin cancer 48. A sudden onset of glucose intolerance in patients (b) lung cancer receiving total parenteral nutrition often indicates: (c) colon cancer (a) diabetes mellitus (d) breast cancer (b) sepsis (e) uterine cancer (c) hypophosphatemia (d) adrenal insufficiency 42. The optimum management of medullary thyroid (e) zinc insufficiency carcinoma in multiple endocrine neoplasia type 2 (MEN 2) is: (a) thyroid lobectomy 49. Pectus excavatum: (b) thyroid lobectomy and cervical lymphadenec- (a) is usually associated with respiratory dysfunc- tomy tion (c) radioactive iodine (b) is usually associated with dysphagia (d) radiotherapy (c) is often associated with cardiac dysfunction (e) total thyroidectomy ± radical neck dissection (d) cosmesis is usually the indication for surgery 43. Optimum management for a 2-cm mass in the head of the pancreas with hypoglycemia and high insulin 50. Sacrococcygeal teratoma: levels is: (a) is usually malignant (a) total pancreatectomy (b) is more common in males (b) Whipple resection (c) requires complete excision of the coccyx (c) local excision (d) diagnosis is ruled out if calcification is absent on (d) streptozotocin administration radiography 44. Which of the following is not a risk factor for wound infection? 51. Dry, scaly, pruritic rash on the trunk and extremities (a) prolonged operative time of a patient receiving total parenteral nutrition is (b) prolonged preoperative hospitalization caused by: (c) shaving the skin the night before surgery (a) zinc deficiency (d) patient’s having upper respiratory tract infec- (b) vitamin A deficiency tion (c) vitamin C deficiency (e) surgeon’s hand scrub for 5 instead of 10 minutes (d) free fatty acid deficiency

45. On the second day after abdominal aortic aneurysm repair, the patient passes grossly bloody stool. The 52. The main cause of postoperative death in children next step is: with chronic is: (a) immediate exploratory laparotomy (a) increased intra-abdominal pressure (b) (b) persistent lung collapse (c) computed tomography scan of the abdomen (c) patent ductus arteriosus with intravenous contrast (d) abnormal pulmonary microvasculature (d) barium enema (e) aortogram 53. A neonate has bilious vomiting and a double- 46. Spontaneous pneumothorax: bubble sign on plain x-ray. The most appropriate (a) is more common in young females operation is: (b) is typically postexertional (a) division of annular pancreas (c) is recurrent in at least 30% of cases (b) gastroenterostomy (d) often requires thoracotomy in the first episode (c) duodenoduodenostomy (e) is often associated with severe persistent pain (d) duodenal resection 174. Surgery Review Questions 409

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

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

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

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

83. An absolute contraindication to renal trans- 90. Coumadin-induced skin necrosis is due to: plantation is: (a) protein S deficiency (a) chronic osteomyelitis (b) protein C deficiency (b) diabetes mellitus (c) antithrombin III deficiency (c) age >55 years (d) disseminated intravascular coagulation (d) lung cancer treated 10 years ago (e) exertional angina 91. A patient receiving 1,800cal/day in total parenteral nutrition will require: (a) 125g protein/day 84. Changes occurring in stored blood include: + (b) 150g protein/day (a) increased H (c) 200g protein/day (b) increased 2,3-diphosphoglycerate (d) 250g protein/day (c) decreased red cell fragility + (e) 300g protein/day (d) decreased K (e) increased Ca2+ 92. Apoptosis: (a) is an energy-dependent cell death 85. The most effective method of treating hyperkalemia (b) results in cell swelling is: (c) is associated with an inflammatory response (a) intravenous calcium gluconate (d) is usually toxin induced (b) intravenous sodium bicarbonate (e) is indistinguishable from necrosis (c) hemodialysis (d) cation-exchange resin 93. Splenic artery aneurysm: (e) intravenous glucose-insulin (a) is usually asymptomatic (b) is usually a pseudoaneurysm (c) is more common in young males 86. The most common cause of hypercalcemia in hos- (d) rupture is seldom fatal pitalized patients is: (a) primary hyperparathyroidism 94. The site of action of aldosterone is: (b) metastatic carcinoma (a) proximal renal tubules (c) sarcoidosis (b) distal renal tubules (d) immobility (c) collecting ducts (e) milk alkali syndrome (d) glomeruli (e) loop of Henle 87. Smoke inhalation is most reliably excluded by: (a) absence of carbonaceous sputum 95. The site of action of antidiuretic hormone is: (b) normal carboxyhemoglobin level (a) collecting ducts (c) normal xenon-133 inhalation scan (b) glomeruli (d) normal chest x-ray (c) proximal tubules (e) normal flexible bronchoscopy (d) distal tubules (e) loop of Henle 88. Which of the following ligands bind to cell surface 96. The common bile duct: receptors? (a) lies to the right of the hepatic artery (a) steroids (b) is posterior to the hepatic artery (b) catecholamines (c) lies to the right of the portal vein (c) retinoids (d) is posterior to the portal vein (d) thyroid hormones (e) lies to the left of the hepatic artery (e) vitamin D 97. A respiratory quotient (RQ) of 1 indicates that the 89. von Willebrand’s disease: main source of fuel is: (a) is autosomal dominant (a) fatty acid (b) results in prolonged prothrombin time (b) protein (c) results in thrombocytopenia (c) carbohydrate (d) is associated with normal bleeding time (d) ketone (e) is corrected by factor VIII therapy (e) glycerol 412 Part XVI. Surgery Review Questions and Answers

98. Magnesium: 105. DNA alkylation is the chemotherapeutic action of: (a) deficiency can be accurately diagnosed with (a) cyclophosphamide serum level measurement (b) vincristine (b) hypomagnesemia is associated with hyper- (c) methotrexate kalemia (d) doxorubicin (c) hypomagnesemia is associated with neuromus- cular excitability 106. Spontaneous perforation of the esophagus: (d) hypomagnesemia is a complication of renal (a) is usually seen in elderly females failure (b) is the most common cause of esophageal perfo- (e) is a major extracellular cation ration 99. The management of pancreatic pleural fistula is: (c) is usually located in the midesophagus (a) distal pancreatectomy (d) is usually preceded by history of dysphagia (b) pancreaticojejunostomy (e) typically presents with sudden onset (c) cystogastrostomy (d) tube thoracostomy 107. Fentanyl: (e) thoracotomy and decortication (a) is normally found in the body (b) is 100 times more potent than morphine 100. 48 hours after coronary artery bypass grafting, (c) has twice as long a duration of action as mor- nausea with epigastric pain and tenderness are most phine likely due to: (d) results in hypotension because of histamine (a) perforated peptic ulcer release (b) acute (c) acute pancreatitis (d) acute myocardial infarction 108. Popliteal artery aneurysms: (e) mesenteric ischemia (a) are commonly complicated by rupture (b) occur equally in both sexes 101. Hypotension develops after (c) are not surgically treated unless size is >4cm and trocar placement for laparoscopic cholecystec- (d) are bilateral in more than 50% of cases tomy. The next action is to: (a) convert to open cholecystectomy 109. The lower esophageal sphincter (LES) tone: (b) deflate the abdomen (a) is increased by gastrin (c) give intravenous fluids (b) is decreased by metoclopramide (d) place the patient in head down position (c) is increased by nicotine (e) check for bowel injury (d) is increased by chocolate 102. Delayed primary wound closure: (a) results in increased angiogenesis 110. Tachycardia is the main side effect of: (b) results in decreased wound strength (a) fentanyl (c) results in lower collagen content (b) succinylcholine (d) results in a wider scar (c) morphine (d) pancuronium 103. The most common cause of esophageal perforation is: 111. Intralobar pulmonary sequestration often presents (a) penetrating neck injury with: (b) iatrogenic (a) chest pain (c) spontaneous (b) dyspnea (d) foreign body (c) recurrent pneumonia (e) malignancy (d) hemoptysis 104. Multicentricity is characteristic of: (a) of the lung 112. Doxorubicin: (b) small cell lung cancer (a) is an alkylating agent (c) bronchoalveolar carcinoma (b) is an antimetabolite (d) bronchial (c) is an alkaloid (e) bronchial (d) is an anthracycline antibiotic 174. Surgery Review Questions 413

113. A 45-year-old man has an 8 × 4cm soft tissue mass 120. Arrest of cell cycle in the metaphase is the action in his right thigh. The most appropriate method to of: confirm the diagnosis of sarcoma is: (a) cyclophosphamide (a) fine-needle aspiration (b) methotrexate (b) core biopsy (c) doxorubicin (c) local excision (d) vincristine (d) incisional biopsy (e) enucleation 121. After an acute myocardial infarction, elective oper- ation should be postponed for at least: 114. Appropriate treatment of malignant hypothermia is (a) 1 month intravenous: (b) 3 months (a) morphine sulfate (c) 6 months (b) dantrolene (d) 1 year (c) benzodiazepines (e) 2 years (d) KCl 122. Succinylcholine is contraindicated for: (e) calcium gluconate (a) patients with hepatitis (b) emergency intubation of burn victims 115. Volkmann’s contracture is a complication of: (c) celiotomy 2 weeks after spinal cord injury (a) humeral head fracture (d) parotidectomy (b) femoral neck fracture (e) thyroidectomy (c) posterior dislocation of the knee (d) supracondylar humeral fracture 123. Splenic artery aneurysm: (e) Colles’ fracture (a) can present with double-rupture phenomenon (b) is more common in males 116. Decreasing glucose and increasing fat in total par- (c) is seldom multiple enteral nutrition will: (d) will continue to enlarge if left untreated (a) increase respiratory quotient

(b) increase C02 production 124. One week after Coumadin therapy, a patient devel- (c) decrease minute ventilation ops severe pain in the right leg with areas of skin (d) delay weaning from mechanical ventilation necrosis. Appropriate action is: (a) transfusion of fresh-frozen plasma 117. Acute in pregnancy: (b) intravenous vitamin K therapy (a) has a higher incidence of wound infection (c) wound debridement and antibiotics (b) is least common in the third trimester (d) stopping Coumadin and starting heparin (c) leukocytosis is important in making the (e) lumbar sympathectomy diagnosis 125. Mixed venous saturation is increased in: (d) initial observation is recommended when diag- (a) hypovolemic shock nosis is suspected (b) septic shock (c) cardiogenic shock 118. Eight hours after esophagogastroduodenoscopy (d) neurogenic shock (EGD), a patient complains of severe substernal (e) anaphylactic shock pain. Chest x-ray film shows left pleural effusion. The next test is: 126. Paraneoplastic syndrome is most commonly associ- (a) repeated EGD ated with: (b) celiotomy (a) bronchial adenocarcinoma (c) computed tomography scan of the chest (b) small cell lung cancer (d) water-soluble esophagogram (c) bronchoalveolar carcinoma (e) thoracotomy (d) bronchial carcinoid

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

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

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

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

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

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

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

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

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

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

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

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

186. The layer responsible for the strength of an intes- 178. Male breast cancer is associated with: tinal anastomosis is the: (a) BRCA-1 gene (a) mucosa (b) BRCA-2 gene (b) submucosa (c) APC gene (c) muscularis propria (d) p53 gene (d) serosa

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

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

203. Alopecia with prolonged total parenteral nutrition 210. Pulmonary sequestration: may be caused by: (a) commonly occurs on the right side (a) zinc deficiency (b) intralobar sequestration is supplied by the pul- (b) magnesium deficiency monary artery (c) vitamin A intoxication (c) extralobar sequestration is supplied by the (d) essential fatty acids deficiency aorta (e) selenium deficiency (d) intralobar sequestration drains into systemic veins 204. A 1-cm carcinoid found in the midappendix after (e) extralobar sequestration drains into pulmonary appendectomy requires: veins (a) octreotide therapy (b) right hemicolectomy 211. The most important diagnostic test for a thyroid (c) streptozotocin therapy nodule is: (d) no further action (a) ultrasound (b) radioactive isotope scan 205. The most common complication of heparin reversal (c) thyroid function test with protamine is: (d) fine-needle aspiration (a) bradycardia (e) computed tomography scan (b) hypotension 212. Pleomorphic parotid adenoma: (c) thrombotic crisis (a) requires core biopsy before resection (d) thrombocytopenia (b) is adequately treated with enucleation (e) leukopenia (c) commonly undergoes malignant transformation (d) commonly results in facial palsy 206. The most common side effect of pancuronium is: (e) is the most common parotid neoplasm (a) tachycardia (b) hypotension 213. The mean arterial pressure is: (c) hyperkalemia (a) diastolic pressure + 1/2 pulse pressure (d) hyperthermia (b) systolic pressure + pulse pressure (e) renal insufficiency (c) systolic pressure + 1/3 pulse pressure (d) diastolic pressure + 1/3 pulse pressure 207. The most common cause of massive lower gastrointestinal bleeding in children is: 214. A contraindication to breast-conserving therapy is: (a) anal fissure (a) age more than 70 years (b) intussusception (b) coronary artery disease (c) Meckel’s diverticulum (c) family history of breast cancer (e) (d) collagen 215. Death from tension pneumothorax is caused by: 208. Fine-needle aspiration of bilateral upper cervical (a) decreased venous return lymphadenopathy shows squamous cell carcinoma. (b) cardiac arrhythmia No primary lesion is found on clinical examination. (c) acute hypoxia The most likely source is: (d) acute hypercapnia (a) lungs (b) esophagus 216. The most important element in the history of an (c) tongue infant with vomiting is: (d) tonsils (a) the frequency of vomiting (e) nasopharynx (b) the amount of vomiting (c) the presence of fever 209. Analysis of pleural effusion shows red blood cell (d) if vomiting is projectile 3 count of 500/mm , white blood cell count of (e) if vomiting is bile stained 600/mm3, protein level of 1.5g/dL, and specific gravity of 1.010. The most likely diagnosis is: 217. The substrate for nitric oxide synthetase is: (a) congestive heart failure (a) glutamine (b) parapneumonic effusion (b) alanine (c) hemothorax (c) L-arginine (d) bronchogenic carcinoma (d) valine 420 Part XVI. Surgery Review Questions and Answers

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

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

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

234. The highest concentration of immunoglobulin A– 241. Secretin: producing cells is in: (a) stimulates gastrin secretion (a) bloodstream (b) stimulates pancreatic enzyme secretion (b) oral cavity (c) inhibits intestinal motility (c) bronchial tree (d) stimulates gastric acid secretion (d) small intestine (e) urogenital tract 242. The use of inverse ratio ventilation will: (a) decrease auto-positive end-expiratory pressure 235. In the treatment of coagulopathy: (b) improve alveolar ventilation (a) calcium should be routinely infused with (c) increase incidence of pneumonia massive transfusion (d) decrease mean airway pressure (b) desmopressin (DDAVP) stimulates the release of factor VIII 243. The optimal management of esophageal leiomyoma (c) von Willebrand’s disease can be treated with is: factor VIII concentrate (a) Ivor-Lewis esophageal resection (d) the effect of aspirin can be reversed by fresh- (b) transhiatal esophageal resection frozen plasma (c) segmental esophageal resection (d) esophagomyotomy and enucleation (e) endoscopic resection 236. The most common source of metastatic small bowel tumor is: 244. Hand infection caused by a human bite is due to: (a) lungs (a) Staphylococcus aureus (b) melanoma (b) Clostridium difficile (c) breast (c) Herpes simplex (d) soft tissue sarcoma (d) Eikenella corrodens (e) Candida species 237. Myeloid metaplasia: (a) is a disease of young females 245. Gastric intrinsic factor is secreted from: (b) is rarely associated with splenomegaly (a) parietal cells (c) results in extramedullary hematopoiesis (b) chief cells (d) results in increased bone marrow megakary- (c) antral G cells ocytes (d) D cells

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

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

248. A characteristic of prerenal azotemia is: 255. A colorectal tumor that invades through the mus- (a) abnormal urine sediment cularis propria into the subserosa is a: (b) fractional excretion of sodium value <1% (a) T1 lesion (c) urine sodium level <40mEq/L (b) T2 lesion (d) blood urea nitrogen/serum creatinine level >10 (c) T3 lesion (d) T4 lesion

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

263. A respiratory quotient of 1.2 indicates: 270. Perianal Crohn’s disease: (a) lipogenesis (a) typically occurs late in the course of the disease (b) ketogenesis (b) fistulas are usually multiple (c) pure fat utilization (c) fecal diversion is usually curative (d) carbohydrates are the source of fuel (d) lesions are typically located posteriorly (e) proteins are the source of fuel (e) granulomas are seldom found on biopsy

264. Mallory-Weiss tear is located: 271. Appropriate management of chronic pancreatitis (a) in the distal esophagus with pancreatic duct ectasia is: (b) anteriorly across the gastroesophageal junction (a) pancreaticoduodenectomy (c) posteriorly across the gastroesophageal junc- (b) distal pancreaticojejunostomy tion (c) longitudinal pancreaticojejunostomy (d) on the lesser curve of the cardia (d) near total pancreatectomy (e) on the greater curve of the cardia (e) sphincteroplasty

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

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

267. Helicobacter pylori: 274. At the lung functional residual capacity: (a) colonization is highest in childhood (a) chest wall exerts inward elastic recoil (b) eradication does not influence ulcer recurrence (b) lungs exert outward elastic recoil (c) is isolated in up to 90% of duodenal ulcer cases (c) alveolar pressure equals pleural pressure (d) metronidazole achieves eradication as a single (d) lungs and chest wall exert equal and opposing agent recoil

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

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

277. Which of the following is poorly absorbed in 285. Which of the following is an inhibitor of wound ? contraction? (a) proteins (a) glucocorticoids (b) fats (b) d-penicillamine (c) bile salts (c) colchicine (d) vitamin D (d) aspirin

(e) vitamin B12 286. Fetal wound healing is characterized by: 278. The most common cause of hypophosphatemia in (a) increased angiogenesis hospitalized patients is: (b) increased hyaluronic acid synthesis (a) renal failure (c) increased inflammatory response (b) sepsis (d) decreased collagen (c) glucose overload (d) diarrhea 287. Death from postoperative renal failure is most com- monly due to: 279. The main fuel for colonocytes is: (a) myocardial infarction (a) glutamine (b) bleeding (b) short-chain fatty acids (c) sepsis (c) alanine (d) (d) glucose (e) ketones 288. Regarding graft rejection: (a) hyperacute rejection is antibody mediated 280. Pulmonary fibrosis is a complication of: (b) hyperacute rejection is reversed with steroids (a) doxorubicin (c) acute rejection is B cell mediated (b) methotrexate (d) acute rejection occurs over month (c) bleomycin (d) cyclophosphamide 289. The most important prognostic variable for (e) vincristine melanoma is: (a) gender 281. The most useful serum marker for cancer screening (b) age is: (c) Clark’s level (a) prostate-specific antigen (d) Breslow’s thickness (b) CA 19.9 (e) complexion (c) α-fetoprotein (d) carcinoembryonic antigen 290. Follicular thyroid carcinoma: 282. The inferior parathyroid gland originates from (a) is the most common thyroid cancer the: (b) is readily diagnosed with fine-needle aspira- (a) first pharyngeal pouch tion (b) second pharyngeal pouch (c) spreads via hematogenous route (c) third pharyngeal pouch (d) is commonly multifocal (d) fourth pharyngeal pouch 291. Multiple endocrine neoplasia is associated with

283. Hypotension and decreased end-tidal CO2 during germline mutation in: laparoscopy are likely due to: (a) p53 gene (a) tension pneumothorax (b) RET proto-oncogene (b) inferior vena cava compression (c) N-myc gene

(c) CO2 embolism (d) APC gene (d) anesthetic overdose 292. Optimal treatment of cloacogenic carcinoma of anal 284. The main fuel for most cancer cells is: canal is: (a) butyrate (a) local excision (b) glutamine (b) abdominoperineal resection (c) L-arginine (c) chemotherapy alone (d) glucose (d) radiotherapy alone (e) ketones (e) chemoradiation 174. Surgery Review Questions 425

293. The most common hernia in women is: 301. On postoperative day 1, a patient develops a (a) femoral hernia temperature of 104°F and foul-smelling wound (b) obturator hernia drainage. The most likely isolate is: (c) (a) Gram-negative rods (d) (b) Gram-positive rods (e) spigelian hernia (c) Gram-negative cocci (d) Gram-positive cocci 294. Gastroschisis: (a) is usually associated with other anomalies 302. A hemodynamic consequence of carbon dioxide (b) is usually associated with chromosomal dis- pneumoperitoneum is: orders (a) decrease in cardiac index (c) is located on the left of the umbilical cord (b) decrease in systemic vascular resistance (d) repair is followed by prolonged ileus (c) decrease in mean arterial pressure (d) increase in cardiac preload 295. The most common visceral aneurysm is: (a) celiac (b) superior mesenteric artery 303. In the diabetic foot: (c) splenic (a) atherosclerosis often involves the pedal arteries (d) hepatic (b) foot sepsis is often polymicrobial (c) ankle–brachial index accurately measures the degree of ischemia 296. Gastroschisis is associated with an increased risk of: (d) diabetic neuropathy involves only sensory (a) hepatomegaly nerves (b) intestinal atresia (c) microcephaly (d) cardiac anomalies 304. Decreased hemoglobin affinity to oxygen at the tissue level is caused by: 297. The cremaster muscle is derived from: (a) increased body temperature (a) the external oblique muscle (b) decreased 2,3-diphosphoglycerate (b) the internal oblique muscle (c) decreased pCO2 (c) the transversus abdominis muscle (d) increased pH (d) the transversalis fascia 305. A patient with pelvic fracture is hypotensive and has 298. The time for platelet transfusion during splenec- grossly positive diagnostic peritoneal lavage. The tomy for idiopathic thrombocytopenic purpura is: next step is: (a) on making the incision (a) angiography and embolization (b) after ligation of the splenic artery (b) computed tomography of the abdomen and (c) on induction of anesthesia pelvis (d) after removal of the spleen (c) celiotomy (d) application of C-clamp 299. The most common congenital cardiac defect is: (e) application of pneumatic antishock garment (a) atrial septal defect (b) ventricular septal defect (c) transposition of great vessels 306. Heparin: (d) aortic coarticulation (a) prevents platelet aggregation (b) prevents factor VII synthesis (c) is a cyclo-oxygenase inhibitor 300. The most appropriate method to diagnose small (d) potentiates the action of antithrombin III bowel injury in a conscious trauma patient with seatbelt injury is: (a) diagnostic peritoneal lavage 307. Cholecystokinin: (b) ultrasound (a) stimulates the sphincter of Oddi (c) computed tomography scan (b) is secreted by the antral mucosa (d) serial abdominal examination (c) stimulates pancreatic enzyme secretion (e) plain abdominal film (d) stimulates gastric emptying 426 Part XVI. Surgery Review Questions and Answers

308. The earliest and most specific sign of malignant 315. The lateral boundary of a femoral hernia is: hyperthermia is: (a) the femoral nerve (a) high fever (b) the femoral artery (b) hypotension (c) the femoral vein

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

312. Malignant hyperthermia: 319. In the preoperative preparation of pheochromocy- (a) can be induced by local anesthetics toma, medications are given in the following order: α (b) can be induced by nondepolarizing muscle (a) diuretics and then -blockers α β relaxants (b) -blockers and then -blockers β α (c) can be induced by nitrous oxide (c) -blockers and then -blockers β (d) is related to disordered K+ metabolism (d) diuretics and then -blockers (e) is more common in children than adults 320. Hyperinsulinism in a newborn is most likely caused 313. The most common cardiac anomaly found in adults by: is: (a) nesidioblastosis (a) atrial septal defect (b) glycogen storage disease (b) ventricular septal defect (c) benign insulinoma (c) transposition of great vessels (d) malignant insulinoma (d) coarctation of the aorta 321. A patient with abdominal wall desmoid tumor 314. The most common complication of epidural anal- should be screened for: gesia is: (a) lung cancer (a) hypotension (b) colon polyps (d) nausea (c) breast cancer (c) respiratory depression (d) medullary thyroid carcinoma (d) deep vein thrombosis (e) pancreatic cancer 174. Surgery Review Questions 427

322. Which of the following is a vasoconstrictor? 330. The colon secretes: (a) procaine (a) water (b) bupivacaine (b) sodium (c) lidocaine (c) chloride (d) cocaine (d) potassium

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

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

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

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

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

353. The superior pancreaticoduodenal artery is a 360. A 70-kg male with 50% body surface area second- branch of: degree burn requires:358 (a) the celiac axis (a) 7,000mL of lactated Ringer’s solution over the (b) the superior mesenteric artery first 6 hours (c) the hepatic artery (b) 7,000mL of lactated Ringer’s solution over the (d) the right gastric artery first 8 hours (e) the gastroduodenal artery (c) 8,000mL of lactated Ringer’s solution over the first 8 hours 354. Which of the following pancreatic enzymes is se- (d) 10,000mL of lactated Ringer’s solution over the creted in an active form? first 8 hours (a) lipase (b) phospholipase A 361. A complication that enteral and parenteral feeding (c) trypsin have in common is: (d) elastase (a) increased incidence of sepsis (b) intestinal villous atrophy (c) elevated liver transaminases 355. A tracheostomy-related tracheoinnominate fistula (d) hyperosmolar nonketotic coma is best managed by: (e) diarrhea (a) division of innominate artery and ligation of both ends 362. The most common organism isolated from bile is: (b) division of innominate artery and vein graft (a) Escherichia coli (c) division of innominate artery and polytetraflu- (b) Klebsiella oroethylene graft (c) Staphylococcus aureus (d) primary repair of the innominate artery (d) Bacteroides (e) Proteus 356. Optimum calorie/nitrogen ratio for protein synthe- sis is: 363. The protein loss equivalent to 100g of negative (a) 25–50:1 nitrogen balance is: (b) 50–75:1 (a) 75g (c) 75–100:1 (b) 150g (d) 100–150:1 (c) 375g (d) 525g 357. Aldosterone: (e) 625g (a) stimulates sodium resorption in proximal renal tubules 364. The most common cause of cancer-related death in (b) stimulates sodium resorption in distal renal females is: tubules (a) breast cancer (c) stimulates potassium resorption in proximal (b) colon cancer renal tubules (c) ovarian cancer (d) stimulates potassium resorption in distal renal (d) pancreatic cancer tubules (e) lung cancer 365. The highest potassium concentration is found in: 358. Hypertension in cases of extra-adrenal pheochro- (a) saliva mocytoma is caused by: (b) gastric secretion (a) combined epinephrine and norepinephrine (c) bile (b) pure epinephrine (d) small intestine (c) pure norepinephrine (e) pancreatic secretion (d) rennin, epinephrine, and norepinephrine 366. The risk of regional node metastases in 0.70mm 359. The highest bicarbonate concentration is found in: thick melanoma is: (a) saliva (a) <5% (b) gastric secretions (b) 10% (c) biliary secretion (c) 20% (d) pancreatic secretion (d) 30% (e) small intestine (e) 50% 430 Part XVI. Surgery Review Questions and Answers

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

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

395. Regarding postoperative myocardial infarction: 401. Hürthle cell thyroid carcinoma: (a) it is often associated with chest pain (a) can be readily diagnosed with fine-needle (b) ischemic injury is more common postopera- aspiration tively rather than intraoperatively (b) is often associated with previous neck radiation (c) T-wave changes are the most specific finding for (c) is more aggressive than follicular thyroid carci- acute myocardial infarction noma (d) it occurs most commonly within the first 48 (d) typically shows avid 131I uptake hours after surgery 402. Burn-associated inhalation injury can be ex- 396. The least appropriate test in the initial evaluation of cluded if: adrenal incidentaloma is: (a) the chest x-ray on admission is normal (a) magnetic resonance imaging of the abdomen (b) there is no abnormal finding on flexible bron- (b) fine-needle aspiration biopsy choscopy (c) follow-up computed tomography of the abdo- (c) the arterial oxygen saturation is over 90% men in 6 months (d) the FEV1/FVC is normal (d) 24-hour urinary vanillylmandelic acid (VMA) level 403. The lateral boundary of a left paraduodenal hernia (e) serum potassium level is: (a) the splenic artery 397. A 58-year-old female with a tubo-ovarian abscess (b) the left renal vein should be treated with: (c) the superior mesenteric vein (a) antibiotics and laparoscopic drainage (d) the inferior mesenteric artery (b) antibiotics with hysterectomy and bilateral (e) the inferior mesenteric vein salpingo-oophorectomy (c) antibiotics and unilateral salpingo- 404. The carotid body: oophorectomy (a) is a pressure receptor (d) antibiotics and computed tomography–guided (b) is an osmoreceptor drainage (c) is a subintimal structure (e) antibiotics and observation (d) is located in the adventia (e) is located in the media 398. Cannon “a” waves on a right atrial waveform tracing indicate: 405. Barrett’s esophagus: (a) atrial flutter (a) is commonly congenital in origin (b) atrial fibrillation (b) is associated with epidermoid carcinoma of the (c) tricuspid regurgitation esophagus (d) pulmonary embolism (c) is reversed by a successful antireflux surgery (e) atrioventricular block (d) is an indication for life-long endoscopic surveillance 399. Intralobar pulmonary sequestration: (a) is supplied by the aorta 406. The most common causative agent in nosocomial (b) is drained by the azygos venous system sinusitis in the ICU is: (c) is commonly associated with diaphragmatic de- (a) Pseudomonas aeruginosa fect (b) Staphylococcus aureus (d) has a separate pleural covering (c) Staphylococcus epidermidis (d) Streptococcus pneumoniae 400. Specific therapy for heparin-induced thrombocy- topenia is: 407. The treatment of hyperacute kidney transplant (a) low-molecular-weight heparin rejection is: (b) Coumadin (a) administration of OKT-3 (c) dextran-60 (b) administration of massive doses of steroids (d) aspirin (c) immediate transplant nephrectomy (e) lepirudin (d) observation and dialysis 174. Surgery Review Questions 433

408. Blunt cardiac injury: 415. The indication for fine-needle aspiration biopsy of (a) most commonly affects the left ventricle an adrenal incidentaloma is: (b) most commonly results in ventricular arrhyth- (a) suspected pheochromocytoma mias (b) suspected aldosteronoma (c) can be reliably excluded if cardiac enzymes are (c) suspected adrenal carcinoma normal (d) suspected adrenal metastases (d) should be suspected if admission electrocardio- gram is abnormal 416. Male breast cancer: (a) has a peak incidence at the age of 40 years 409. A characteristic of Buerger’s disease is: (b) is typically hormonally dependent (a) superficial migratory thrombophlebitis (c) typically presents with bloody nipple discharge (b) female predominance (d) is seldom an indication for tamoxifen therapy (c) severe involvement of the aortoiliac segment (d) the disease is restricted to the lower extremities 417. A non-anion gap metabolic acidosis is associated with: 410. Recurrence of thyroid carcinoma after definitive (a) diabetic ketoacidosis treatment is best detected by: (b) hemorrhagic shock (a) ultrasound of the neck (c) excessive sodium chloride administration (b) thyroid-stimulating hormone level measure- (d) uremia ment (e) ingestion of ethylene glycol (c) thyroglobin serum measurement (d) computed tomography scan of the neck 418. Inverse ratio ventilation: (e) triiodothyronine/thyroxine measurement (a) decreases mean airway pressure and increases intrathoracic pressure (b) decreases mean airway pressure and decreases 411. The primary regulator of aldosterone secretion is: intrathoracic pressure (a) angiotensin II (c) increases mean airway pressure and increases (b) serum K level intrathoracic pressure (c) adrenocorticotropic hormone (d) increases mean airway pressure and decreases (d) prostaglandins intrathoracic pressure

412. The optimum management of a T4 breast cancer is: 419. Duodenal atresia: (a) modified radical mastectomy and radiation (a) is caused by intrauterine mesenteric vascular (b) chemoradiation only accident (c) simple mastectomy and radiation (b) commonly exhibits normal muscular wall with (d) chemotherapy followed by mastectomy and a mucosal web radiation (c) is seldom associated with normal passage of (e) radiation therapy only meconium at birth (d) is rarely associated with other congenital 413. The diagnosis of is confirmed anomalies by: (a) bird’s beak appearance on barium swallow 420. Angiotensin-converting enzyme is produced by: (b) subatmospheric intraluminal esophageal pres- (a) type I pneumocytes sure on manometry (b) type II pneumocytes (c) endoscopic evidence of distal esophagitis (c) hepatocytes (d) failure of lower esophageal sphincter relaxation (d) juxtaglomerular cells on manometry (e) vascular endothelial cells (e) hyperperistalsis of the body of the esophagus 421. Hereditary nonpolyposis colorectal cancer: 414. Factor VIII–related antigen is a marker of: (a) is an autosomal recessive disorder (a) Kaposi’s sarcoma (b) is associated with higher incidence of ovarian (b) melanoma cancer (c) postmastectomy angiosarcoma (c) is associated with higher incidence of endome- (d) desmoid tumors trial cancer (e) Merkel cell carcinoma (d) is mostly left-side colon cancer 434 Part XVI. Surgery Review Questions and Answers

422. Auto-positive end-expiratory pressure in mechani- 429. Appropriate management of radiation mastitis is: cal ventilation is most likely to develop with: (a) local heat application (a) high rates and prolonged I:E ratio (b) danazol therapy (b) high rates and decreased I:E ratio (c) therapeutic breast massage (c) decreased rate and decreased I:E ratio (d) simple mastectomy (d) decreased rate and prolonged I:E ratio (e) pentoxifylline therapy 430. Optimum therapy for effort thrombosis of the axil- 423. Initial management of T4 invasive lobular breast lary vein is: carcinoma is: (a) therapeutic heparin followed by Coumadin for (a) tamoxifen therapy 3 months (b) modified radical mastectomy (b) therapeutic heparin followed by Coumadin for (c) radiation therapy to the breast and ipsilateral 6 months axilla (c) thrombolysis, anticoagulation, and possible first (d) neoadjuvant chemotherapy rib resection (d) thrombolysis, anticoagulation, and balloon an- gioplasty 424. The fluid of chylothorax is composed of: (e) thrombectomy,anticoagulation, and stent place- (a) pure fat ment (b) fat and neutrophils 431. Drooling from the corner of the mouth after sub- (c) fat and lymphocytes mandibular gland excision is due to: (d) fat and macrophages (a) injury of the lingual nerve (b) injury of the ansa cervicalis (c) injury of the hypoglossal nerve 425. The most common cause of renovascular hyperten- (d) injury of the marginal mandibular nerve sion is: (a) aneurysm of the renal artery 432. The component of blood transfusion responsible for (b) fibromuscular hyperplasia immunosuppression is: (c) renal artery calcinosis (a) red cells (d) renal artery atheroma (b) immunoglobulins (c) white blood cells (d) platelets 426. Merkel cell carcinoma: (a) is highly radiosensitive 433. In therapeutic immunosuppression, rapamycin: (b) has the best prognosis when it occurs on the (a) blocks interleukin-1 production trunk (b) blocks interleukin-1 action (c) seldom spreads to regional lymph nodes (c) blocks interleukin-2 production (d) is less likely than melanoma to recur after local (d) blocks interleukin-2 action excision 434. Gallstones diagnosed during pregnancy: (a) may resolve spontaneously after delivery (b) are the most common cause of jaundice during 427. A complication of tacrolimus therapy is: pregnancy (a) new-onset diabetes (c) are seldom the cause of recurrent acute chole- (b) upper gastrointestinal bleeding cystitis during the same pregnancy (c) thrombocytopenia (d) are most commonly pigment stones (d) cardiac arrhythmia (e) bronchospasm 435. Trauma cesarean section is indicated if the fetus is viable and: (a) the mother is unstable and cardiac arrest is anti- 428. Extralobar pulmonary sequestration: cipated (a) typical presents with repeated pulmonary infec- (b) 5 minutes of cardiopulmonary resuscitation were tions successful (b) is drained by the pulmonary veins (c) 5 minutes of cardiopulmonary resuscitation were (c) is supplied by the aorta unsuccessful (d) is more common on the right side (d) cardiopulmonary resuscitation has just been (e) is commonly connected with the bronchial tree initiated 174. Surgery Review Questions 435

436. The single most common abdominal operation for 443. An 80-year-old male is confused, lethargic, and has the elderly is: tonic spasms. He has been receiving intravenous 5% (a) adhesiolysis for small bowel obstruction dextrose in water in one-half normal saline for 3 (b) closure of perforated duodenal ulcer days after right hemicolectomy. The most likely (c) resection of colon cancer cause is: (d) cholecystectomy (a) hypokalemia (e) appendectomy (b) hyperkalemia (c) hypocalcemia 437. An age-related change in respiratory functions is: (d) hypernatremia (a) increased total lung capacity (TLC) (e) hyponatremia (b) decreased total lung capacity (TLC) (c) decreased functional residual capacity (FRC) 444. A physiologic change in pregnancy is: (d) increased residual volume (RV) (a) increased gallbladder contractility (e) increased vital capacity (VC) (b) elevated alkaline phosphatase (c) elevated alanine aminotransferase (AST)/ 438. Fetal death during pregnancy is most commonly due aspartate aminotransferase (ALT) to: (d) direct hyperbilirubinemia (a) abruptio placentae (e) indirect hyperbilirubinemia (b) subarachnoid hemorrhage (c) penetrating fetal injury 445. In the elderly: (d) maternal demise (a) the myocardium is oversensitive to the effect of catecholamines 439. A physiologic change of aging is: (b) systolic function is more impaired than diastolic (a) increased total body water function (b) decreased antidiuretic hormone secretion (c) diastolic function is more impaired than systolic (ADH) function (c) decreased aldosterone secretion (d) systolic and diastolic functions are equally (d) exaggerated thirst response impaired (e) decreased atrial natriuretic peptide (ANP)

440. Which of the following is contraindicated during 446. A Crohn’s disease–related internal fistula: pregnancy for treating breast cancer? (a) most commonly presents with florid sepsis (a) methotrexate (b) most commonly presents with Crohn’s disease (b) 5-fluorouracil flare–up (c) doxorubicin (c) requires excision of both organs involved for (d) cyclophosphamide surgical treatment (d) most commonly involves small bowel to small 441. In the elderly: bowel fistulation (a) there is decreased insensible water loss (e) requires surgical intervention as soon as the (b) there is increased antidiuretic hormone re- diagnosis is made sponse (c) there is increased volume of distribution of 447. In inflammation, early “rolling” of neutrophils on water-soluble medications endothelium is a function of: (d) there is decreased volume of distribution of (a) selectins lipid-soluble medications (b) N-cahedrins (c) immunoglobulin superfamily 442. During pregnancy: (d) integrins (a) acute appendicitis is more common than in the (e) complement activation nonpregnant state (b) intestinal obstruction is most commonly caused 448. A paraesophageal hernia: by adhesions (a) is a type I (c) laparoscopic cholecystectomy is contraindi- (b) is most common in men <50 years of age cated (c) may present with chronic anemia (d) leukocytosis is often indicative of a surgical (d) is often associated with reflux abdominal pathology (e) requires surgery only if symptomatic 436 Part XVI. Surgery Review Questions and Answers

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

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

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

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

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

478. In contrast to a keloid, a hypertrophic scar: 486. The cardiac ejection fraction: (a) is more likely to be familial (a) is normally 45% (b) may subside spontaneously (b) is an accurate indicator of cardiac dysfunction (c) may develop in delayed fashion years after in the elderly initial injury (c) is increased in mitral stenosis (d) often extends beyond the limits of the original (d) is decreased in mitral incompetence wound (e) is increased in ventricular septal defect

479. In transplant recipients, there is an increased inci- 487. After 3 years, vein graft failure in the lower extrem- dence of: ities is mostly caused by: (a) colon cancer (a) technical complications (b) (b) anastomotic aneurysm (c) lung cancer (c) atherosclerosis of the graft (d) breast cancer (d) intimal thickening (e) prostate cancer 488. The predominant parathyroid pathology in multiple 480. The most common cause of small bowel bleeding in endocrine neoplasia is: adults is: (a) a single parathyroid adenoma (a) Crohn’s disease (b) multiple parathyroid adenomas (b) arteriovenous malformation (c) parathyroid hyperplasia (c) leiomyosarcoma (d) parathyroid carcinoma (d) Meckel’s diverticulum (e) carcinoid neoplasms 489. In renal artery stenosis, angiotensin-converting enzyme inhibitors will: 481. A type IV hiatal hernia: (a) decrease glomerular filtration rate (a) is a sliding hiatus hernia (b) increase glomerular filtration rate (b) is a traumatic diaphragmatic hernia (c) result in dilation of the afferent arterioles (c) is a hernia that contains the stomach (d) result in constriction of the afferent arterioles (d) is a hernia that contains parts of the intestine (e) result in constriction of the efferent arterioles and colon

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

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

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

493. In liver transplantation, biliary complications are 499. The optimum management for stage II thyroid lym- most commonly related to: phoma is: (a) adequacy of hepatic venous outflow (a) total thyroidectomy (b) adequacy of portal venous flow (b) total thyroidectomy and radical neck dissection (c) adequacy of hepatic arterial flow (c) total thyroidectomy and chemotherapy (d) length of the donor’s common bile duct (d) chemoradiation (e) cervical radiation 494. The optimum management of aspiration pneu- monitis is: 500. The most reliable indicator of successful ventilatory (a) endotracheal intubation and mechanical ven- weaning is:

tilation (a) PO2 >100 with FiO2 of 40% (b) endotracheal intubation, mechanical ventila- (b) PCO2 <40mmHg tion, and bronchial lavage (c) negative inspiratory force less (more negative)

(c) endotracheal intubation, ventilation, bronchial than −30cm HO2 lavage, and steroids (d) f/Vt <100 (d) endotracheal intubation, ventilation, bronchial lavage, and antibiotics 501. Chronic allograft rejection: (a) can be prevented with adequate immun- 495. Malignant hyperthermia: osuppression (a) is triggered by the stress of surgery or anesthe- (b) is the main cause of death after liver trans- sia only plantation (b) is a contraindication to future general anesthe- (c) is more common with liver than heart trans- sia plantation (c) can be prevented by perioperative calcium (d) is more common with kidney than liver trans- channel blockers plantation (d) is associated with intraoperative rise of end tidal CO 2 502. The most accurate test to determine the need for neoadjuvant therapy in esophageal carcinoma is: 496. The long thoracic nerve: (a) endoluminal ultrasound (a) is purely motor (b) chest computed tomography scan (b) provides sensation to the medial wall of the (c) bronchoscopy axilla (d) barium swallow (c) provides sensation to the medial aspect of the (e) esophagogastroduodenoscopy upper arm (d) supplies motor innervation to the latissimus dorsi muscle 503. The most characteristic metabolic abnormality in (e) its injury results in weakness of arm abduc- glucagonoma is: tion (a) hypoglycemia (b) hypoaminoacidemia 497. The likelihood of malignancy in cystic pancreatic (c) hypocholesterolemia neoplasm is related to: (d) hypercholesterolemia (a) high glycogen content (b) mucin content 504. A local anesthetic that can be safely administered (c) sunburst appearance on computed tomography with tetracaine allergy is: scan (a) lidocaine (d) previous history of pancreatitis (b) cocaine (c) procaine 498. Colovesical fistula: (d) chloroprocaine (a) is most commonly caused by colon cancer (b) is more common in females than in males 505. Clonidine is:

(c) is readily diagnosed with barium enema in most (a) an α1-agonist cases (b) an α1-antagonist (d) requires segmental colectomy and partial cys- (c) an α2-agonist tectomy for treatment (d) a β1-agonist (e) most commonly presents with pneumaturia (e) a β2-agonist 440 Part XVI. Surgery Review Questions and Answers

506. A definitive diagnosis of inflammatory breast cancer 513. A pulmonary embolus is associated with: is provided by: (a) decrease in pulmonary capillary wedge pressure (a) unique mammographic appearance (b) decrease in mean pulmonary artery pressure (b) finding tumor emboli in dermal lymphatics (c) decrease in central venous pressure (c) finding extensive inflammatory cell infiltration (d) decrease in dead space/tidal volume ratio of the tumor (d) elevated white cell count, fever, axillary 514. Pyoderma gangrenosum is typically associated with: lymphadenopathy (a) advanced colonic adenocarcinoma (e) ultrasound appearance of cavitation (b) rectal carcinoid (c) ulcerative colitis (d) villous adenoma of the colon 507. Tissue loss almost always results from ligation of the: 515. Popliteal artery aneurysms: (a) popliteal artery (a) commonly present with rupture (b) common femoral artery (b) seldom result in limb ischemia (c) superficial femoral artery (c) are the most common peripheral arterial aneu- (d) brachial artery rysms (e) portal vein (d) require operation only if they result in em- bolization 508. Male breast cancer: (e) are most commonly false aneurysms (a) is associated with the BRCA-1 gene mutation (b) can only be of ductal origin 516. After vigorous exercise, an athlete develops pain on (c) is seldom hormone receptor positive dorsiflexion of the foot and decreased sensation in (d) develops at a much younger age than female the first web space. Appropriate action should be: breast cancer (a) color duplex scan and immediate hepariniza- tion (b) leg elevation, ice packs, and nonsteroidal anti- 509. Keloid formation has been associated with an inflammatory medications increased amount of: (c) immediate fasciotomy (a) transforming growth factor-β (d) immediate femoral arteriogram (b) platelet-derived growth factor (c) epidermal growth factor 517. The most common presentation of testicular cancer (d) basic fibroblast growth factor is: α (e) tumor necrosis factor- (a) a painless scrotal mass (b) acute testicular pain 510. The anteroposterior anatomic relationship at the (c) a secondary hydrocele renal hilum is: (d) gynecomastia (a) vein—artery—ureter (e) retroperitoneal lymphadenopathy (b) artery—vein—ureter (c) ureter—artery—vein 518. Which of the following is most likely to cause a (d) ureter—vein—artery false-positive fecal occult blood test? (a) oral iron therapy (b) Coumadin therapy 511. Endophthalmitis is characteristic of: (c) aspirin therapy (a) Escherichia coli sepsis (d) nonsteroidal anti-inflammatory medications (b) toxic shock syndrome (e) dietary peroxidases (c) systemic candidiasis (d) facial necrotizing fasciitis 519. Aldosteronoma is associated with: (a) hypertension, hypokalemia, high aldosterone 512. The most important determinant of survival of and high renin levels retroperitoneal sarcoma is: (b) hypertension, hyperkalemia, high aldosterone (a) the use of adjuvant chemotherapy and low renin levels (b) the size of the primary tumor (c) hypertension, hyperkalemia, high aldosterone (c) the histologic type of the primary and high renin levels (d) the use of intraoperative radiotherapy (d) hypertension, hypokalemia, high aldosterone (e) complete surgical resection and low renin levels 174. Surgery Review Questions 441

520. A PO2 of 90 torr, PCO2 of 28 torr, and pH of 7.16 527. Neurogenic bladder dysfunction with intact bladder on room air are indicative of: sensation is associated with: (a) hypovolemic shock (a) nerve injury with abdominoperineal resection (b) alveolar hypoventilation (b) cauda equina lesion (c) prolonged nasogastric suctioning (c) myelomeningocele (d) hyperventilation (d) paraplegia (e) cerebrovascular accident

521. Idiopathic thrombocytopenic purpura is most likely 528. Tumor necrosis factor-α antagonist is useful in to respond to splenectomy if: treating: (a) the spleen is enlarged (a) disseminated intravascular coagulopathy (b) the patient is a female (b) septic shock (c) the disease is chronic (c) Crohn’s disease (d) the disease responded to steroids (d) metastatic melanoma

522. A marker that would distinguish nonseminoma 529. An 83-year-old female presents with vomiting and from seminoma is: abdominal distension. She complains of pain in the (a) lactate dehydrogenase medial aspect of the right thigh, and a palpable lump (b) alkaline phosphatases can be felt on the right side on rectal examination. (c) human chorionic gonadotropin The appropriate action is: (d) α-fetoprotein (a) nasogastric tube, intravenous fluids, and observation (b) flexible sigmoidoscopy and drainage of the 523. Positive end-expiratory pressure: rectal mass (a) increases cardiac output (c) urgent laparotomy (b) decreases functional residual capacity (d) Gastrografin study with small bowel follow- (c) increases right to left shunting through (d) lowers PCO2 (e) right groin exploration and hernia repair (e) decreases alveolar–arterial oxygen gradient 530. A normal-sized spleen is found in: (a) idiopathic thrombocytopenic purpura 524. Estrogen therapy for postmenopausal women is (b) myelodysplasia associated with: (c) Gaucher’s disease (a) increased incidence of thrombophlebitis (d) thalassemia (b) increased incidence of hepatic adenoma (e) schistosomiasis (c) increased incidence of endometrial cancer (d) increased incidence of breast cancer 531. Neurogenic bladder after extensive pelvic surgery is characterized by: 525. A 10-year-old boy comes from a family of “bleed- (a) painful urine retention ers.” His coagulation profile shows: prolonged (b) large bladder capacity with overflow inconti- bleeding time, normal prothrombin time, and pro- nence longed partial thromboplastin time. His platelet (c) small residual volume and uninhibited bladder count is 150,000/mm3. The most likely diagnosis is: contractions (a) idiopathic thrombocytopenic purpura (d) autonomic dysreflexia (b) thrombotic thrombocytopenic purpura 532. Regarding cytokines: (c) hemophilia (a) serum level is not related to the severity of (d) Christmas disease illness (e) von Willebrand’s disease (b) are stored intracellularly as preformed mole- cules 526. A single organism is usually the causative agent in: (c) are produced by a limited number of specific (a) pelvic inflammatory disease cells (b) perforated diverticulitis (d) most commonly function in an endocrine (c) acute cholecystitis fashion (d) primary (e) low serum levels are normally detected in heal- (e) diabetic foot infections thy individuals 442 Part XVI. Surgery Review Questions and Answers

533. Hypothermic coagulopathy is characterized by: 538. The most common posterior mediastinal mass in (a) normal prothrombin time and normal partial children is: thromboplastin time (a) neuroblastoma (b) normal prothrombin time and prolonged partial (b) teratoma thromboplastin time (c) lymphoma (c) prolonged prothrombin time and normal partial (d) pheochromocytoma thromboplastin time (d) depletion of factor VII (e) depletion of factor VIII 539. In the absence of sepsis, glucose intolerance with total parenteral nutrition may indicate: (a) copper deficiency 534. A patient with diagnosed pseudomembranous (b) zinc deficiency colitis is developing a worsening clinical picture and (c) magnesium deficiency is taken for urgent laparotomy.The appropriate sur- (d) chromium deficiency gical procedure should include: (a) segmental colectomy and exteriorization of the ends 540. The most common presentation of gastric cancer is: (b) total abdominal colectomy (a) and (c) diverting proximal colostomy (b) acute abdominal pain due to perforation (d) segmental colectomy and primary anastomosis (c) vague abdominal pain and weight loss (e) segmental colectomy, primary anastomosis, and (d) an epigastric mass diverting colostomy

535. The specificity of a test is: 541. In burn victims, the finding most indicative of (a) the proportion of patients with the disease who inhalation injury is: have a positive test (a) singed nasal hair (b) the proportion of patients without the disease (b) soot around the mouth who have a negative test (c) dyspnea (c) the proportion of patients with a positive test (d) carbonaceous sputum who have the disease (d) the proportion of patients with a negative test who do not have the disease 542. A child with anaphylactoid purpura develops an acute colicky abdominal pain and bleeding per rectum. The most likely diagnosis is: 536. A 45-year-old-male complains of severe chest pain (a) perforated duodenal ulcer after a diagnostic upper endoscopy. He has crepitus (b) bleeding Meckel’s diverticulum on palpation of his neck. The next step in manage- (c) enterocolitis with perforation ment should be: (d) intussusception (a) repeated upper endoscopy (b) immediate endotracheal intubation (c) Gastrografin swallow 543. The most reliable means of preoperative nutritional (d) administration of aspirin and sublingual assessment is: nitrite (a) clinical history of weight loss (e) admission to ICU, administration of intra- (b) serum albumin level venous narcotics, and observation (c) impaired cell-mediated immunity (d) triceps skinfold measurement 537. Familial adenomatous polyposis: (a) is caused by inactivation of a tumor suppressor gene 544. In contrast to adults, fetal wound healing: (b) has normal life expectancy after prophylactic (a) has a higher content of type III collagen colectomy (b) has a higher level of transforming growth (c) is associated with increased risk of right-side factor-β colon cancer (c) has an exaggerated inflammatory phase (d) is inherited as an autosomal recessive trait (d) has much less hyaluronic acid content 174. Surgery Review Questions 443

545. The greatest amount of maintenance intravenous 551. The sensitivity of the test is: fluids is required for: (a) the proportion of patients with the disease who (a) 21-year-old male athlete have a positive test (b) 55-year-old obese male office worker (b) the proportion of patients without the disease (c) 21-year-old housewife who have a negative test (d) 75-year-old female with recent weight loss (c) the proportion of patients with a positive test who have the disease (d) the proportion of patients with a negative test 546. The most accurate test to detect subclinical who do not have the disease hypothyroidism is: (a) radioactive iodine uptake 552. Regarding an amebic liver abscess: (b) thyroid-stimulating hormone level (a) surgical drainage is usually required (c) total thyroxine level (b) negative stool testing for amebiasis rules out the (d) free thyroxine level disease (c) it should be drained percutaneously under com- puted tomography guidance 547. A 28-year-old male has a closed head injury, pul- (d) it is treated with metronidazole monary contusion, grade III splenic injury, and closed femoral shaft fracture. The ideal manage- 553. An infant has been having episodic coughing for 48 ment of his fracture is: hours. On examination, he is wheezing with (a) external fixation decreased aeration of the left chest. A chest x-ray (b) skeletal traction shows an overinflated left lung. The next step in (c) intramedullary nailing within 24 hours of injury management should be: (d) intramedullary nailing 1 week after the injury (a) insertion of left-side chest tube (e) use of metal plates and screws (b) insertion of right-side chest tube (c) endotracheal intubation (d) administration of steroid inhaler and observa- 548. Accessory spleens are most commonly found in: tion (a) idiopathic thrombocytopenic purpura (e) rigid bronchoscopy (b) thrombotic thrombocytopenic purpura (c) schistosomiasis 554. A 40-year-old female has a 4-cm hemangioma in the (d) hereditary spherocytosis right lobe of the liver on computed tomography scan. She is asymptomatic. Appropriate action should be: 549. The effectiveness of prophylactic antibiotics in (a) fine-needle biopsy surgery is mostly related to the: (b) arrangement for elective resection (a) use of broad-spectrum agents (c) no further action (b) continuation of antibiotics for 24 hours after (d) angiographic embolization surgery (c) timing of initial administration 555. A non-anion gap metabolic acidosis is associated (d) use of two synergistic agents with: (e) use of bactericidal agents (a) methane intoxication (b) large amount of saline resuscitation (c) diabetic ketoacidosis 550. A 6-year-old boy has a right undescended testicle. (d) cardiogenic shock His parents should be advised that: (e) hemorrhagic shock (a) right orchiectomy should be performed (b) a course of endocrine treatment is advisable 556. The gold standard for the diagnosis of pelvic inflam- (c) orchiopexy is performed to improve spermato- matory disease is: genesis and prevent cancer (a) vaginal microbiology swab (d) orchiopexy is performed but with no effect on (b) pelvic ultrasound spermatogenesis or cancer prevention (c) laparoscopy (e) the right testicle is probably atrophic and can be (d) pelvic computed tomography scan left undisturbed (e) endometrial biopsy 444 Part XVI. Surgery Review Questions and Answers

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