ITE QUESTION CHOICES ANSWER RATIONALE SOURCE

1 Calculating the appropriate A. Early enteral feeding is C. Oxandrolone, an Early enteral feeding​ for patients with ​burns larger than 20% Schwartz’s
caloric needs of the burn safe when burns are anabolic steroid, TBSA is safe​ and may reduce loss of lean body mass, slow the Principles of
patient can be challenging. less than 20% TBSA, can improve lean hypermetabolic response, and result in more efficient protein Surgery 10th
Which of the following is true otherwise enteral body mass but can metabolism. If the enteral feeds are started within the first few edition pp.
regarding nutritional needs of feeding should await be associated with hours after admission, gastric ileus can be avoided. 232-233
burn patients? return of bowel hyperglycemia and
function to avoid clinically significant A commonly used formula in nonburned patients is the
feeding a patient with rise in hepatic Harris-Benedict equation, which calculates
gastric ileus. transaminitis. caloric needs using factors such as gender, age, height, and
B. For patients with weight. This formula uses an activity factor for specific injuries,
greater than 40% and for burns, the basal energy expenditure is multiplied by two.
TBSA, caloric needs The Harris-Benedict equation may be inaccurate in ​burns of
are estimated to be less than 40% TBSA​, and in these patients, the Curreri formula
25kcal/kg/day plus may be more appropriate. This formula estimates caloric needs
40% kcal/%TBSA/day. to be ​25 kcal/kg/d plus 40 kcal/%TBSA/d​.
C. Oxandrolone, an
anabolic steroid, can The anabolic steroid ​oxandrolone​ has been extensively studied
improve lean body in pediatric patients as well, and has demonstrated
mass but can be improvements in lean body mass and bone density​ in
associated with severely burned children. The weight gain and functional
hyperglycemia and improvements seen with oxandrolone may persist even after
clinically significant rise stopping administration of the drug. A recent double-blind,
in hepatic randomized study of oxandrolone showed decreased length of
transaminitis. stay, improved hepatic protein synthesis, and no adverse effects
D. The hypermetabolic on endocrine function, although the authors noted a ​rise in
response to burn
 wounds typically raises transaminases​ with unclear clinical significance. ​Intensive
the basic metabolic insulin
rate by 120%. therapy​ in critically ill patients has shown benefit, presumably
from ​avoidance of hyperglycemia​.

The hypermetabolic response in burn injury

may ​raise baseline metabolic rates​ by as much as ​200%​. This
can lead to catabolism of muscle proteins and decreased lean
body mass that may delay functional recovery.

2 Patients with acute A. Induction of B. Correct deficit of Treatment is required when hypercalcemia is Schwartz’s
hypercalcemia usually have mithramycin extracellular fluid symptomatic, which usually occurs when the serum level Principles of
either acute B. Correct deficit of volume exceeds 12 mg/dL. The critical level for serum calcium is 15 Surgery 10th
hyperparathyroidism or extracellular fluid mg/dL, when symptoms noted earlier may rapidly progress to edition p.78
metastatic breast carcinoma volume death. The ​initial treatment is aimed at repleting the
with no metastases. These C. Administration of associated volume deficit​ and then inducing a brisk diuresis
patients develop severe furosemide with normal saline.
headache, bone pain, thirst, D. Subject patient to
emesis and polyuria. What is hemodialysis
the FIRST step in the
management of acute
hypercalcemia?

3 A patient with necrotizing A. Endoscopic retrograde B. Sterile necrosis based on negative FNA and/or stable clinical Clinical
pancreatitis undergoes cholangiopancreatogra Culture-appropriate picture should be managed nonoperatively, and antibiotics are Practice
computed phy antibiotic therapy not indicated. For unstable patients in whom sepsis is suspected Guideline:
tomography-guided B. Culture-appropriate but no source has been identified, treatment with broad spectrum Management
of Acute
aspiration which results in antibiotic therapy antibiotics on speculation may be indicated while an appropriate
Pancreatitis
growth of ​Escherichia coli​ on C. CT-guided placement work up (bacterial and fungal cultures, CT scan) is carried out.
culture. Which is the MOST of drain
 appropriate treatment for D. Exploratory laparotomy In patients with ​FNA-confirmed infections​, a s ​ tep-up https://www.nc
this? approach of antibiotics, image-guided drainage, followed by bi.nlm.nih.gov/
surgical intervention​, if necessary, is indicated. pmc/articles/P
MC4814287/

4 Tumor necrosis factor-alpha A. Induces pre-coagulant A. Induces TNF mediates coagulation activation, cell migration, and Schwartz’s
is one of the earliest activity and peripheral pre-coagula macrophage phagocytosis, and Principles of
cytokines to be described. vasoconstriction nt activity enhances the expression of adhesion molecules, prostaglandin Surgery 10th
Which of the following is B. Can be released as a and E2, platelet-activating factor, glucocorticoids, and eicosanoids. edition p.26
TRUE about TNF-A? response to bacteria or peripheral
endotoxin vasoconstric
C. Increased more in tion
trauma than septic
patients
D. Contributes to anemia
of chronic illness

5 Frozen plasma prepared A. Christmas factor B. Antihemophilic Clotting Factor - Ideal Agent for Replacing Deficit Schwartz’s
from freshly donated blood is B. Antihemophilic factor factor Principles of
necessary when a patient C. Prothrombin IX (​Christmas factor​, plasma thromboplastin component) - Surgery 10th
requires which of the D. Fibrinogen Fresh-frozen plasma; bank edition p.99
following? blood​; concentrated preparation

VIII (​antihemophilic factor​, antihemophilic globulin) - ​Fresh

frozen plasma​; concentrated antihemophilic
factor;cryoprecipitate

II (​prothrombin​) - ​Bank blood​; concentrated

preparation
 I (​fibrinogen​) - ​Bank blood​; concentrated fibrinogen

6 A patient with penetrating A. more than 200 mL/h of A. more than The majority of thoracic trauma can be managed non-operatively. Penetrating
injury to the chest should blood for 3 hours from 200 mL/h of However, 15% of patients require operative management and Chest Trauma.
undergo thoracotomy if there the chest tube. blood for 3 surgery should not be delayed when appropriate.
is B. documented lung injury hours from https://www.nc
on CT scan. the chest Operative exploration​ of thoracic injuries should be considered bi.nlm.nih.gov/
C. more than 500 mL of tube. if ​tube thoracostomy drainage exceeds 1000 to 1500 mL books/NBK535
blood which drains ​ 00 mL per hour for 444/
immediately​, or there is an output of about 2
from the chest tube 2 to 4 hours or ongoing resuscitation​ (blood transfusion,
when placed. persistent hypotension) with no other discernable cause.
D. an air leak that persists
for >48 hours.

7 The relationship between A. 40-50% D. 50-60% In an average​ young adult male, Total Body water (TBW) Schwartz’s
total body weight and total B. 60-70% accounts for 60% of total body weight​, Principles of
body water is relatively C. 30-40% whereas in an ​average young adult female, it is 50%​. The Surgery 10th
constant for an individual. D. 50-60% lower percentage of TBW in females correlates with a higher edition p.65
What percentage of the total percentage of adipose tissue and lower percentage of muscle
body weight constitutes mass
water? in most. Estimates of percentage of TBW should be adjusted
downward approximately 10% to 20% for obese individuals and
upward by 10% for malnourished individuals.

8 Early excision and grafting in A. Tangential excision D. Human Once the initial resuscitation is complete and the Schwartz’s
burned patients consists of tangential cadaveric allograft patient is hemodynamically stable, attention should be turned to Principles of
revolutionized survival slices of burn tissue is a permanent excising the burn wound. Surgery 10th
outcomes in burn care. until bleeding tissue is alternative to edition
Which is NOT TRUE encountered. Thus, split-thickness skin Burn excision and wound coverage should ideally start within the p.233-234
excision can be grafts when there first several days, and in larger
concerning surgical associated with are insufficient burns, serial excisions can be performed as patient condition
treatment of burn wounds? potentially significant donor sites. allows.
blood loss.
B. Meshed split thickness Excision​ is performed with r​ epeated tangential slices using a
skin grafts allow Watson or Goulian blade until viable, diffusely bleeding
serosanguinous tissue remains​. It is appropriate to leave healthy dermis, which
drainage to prevent will appear white with punctate areas of bleeding. Excision to fat
graft loss and provide or fascia may be necessary in deeper burns. The ​downside​ of
a greater area of tangential excision is a ​high blood loss​, though this may be
wound coverage. ameliorated ​using techniques such as ​instillation of an
C. Bleeding from epinephrine
tangential excision can tumescence solution​ underneath the burn. ​Pneumatic
be helped with tourniquets ​are helpful in extremity burns, and ​compresses
injection of epinephrine soaked in a
tumescence solution, dilute epinephrine solution​ are necessary adjuncts after
pneumatic tourniquets, excision. ​A fibrinogen and thrombin spray sealant​ (Tisseel
epinephrine soaked Fibrin Sealant;
compresses, and Baxter, Deerfield, IL) also has beneficial effects on both
fibrinogen and hemostasis and graft adherence to the wound bed.
thrombin spray sealant
D. Human cadaveric In larger burns,​ meshed autografted skin​ provides a​ larger
allograft is a area of wound coverage​.
permanent alternative This also ​allows drainage of blood and serous fluid​ to prevent
to split-thickness skin accumulation under the skin graft with subsequent graft loss.
grafts when there are
insufficient donor sites. Options for ​temporary wound coverage​ include ​human
cadaveric allograft​, which is incorporated into the wound but is
rejected by the immune system and ​must be eventually
replaced​. This allows temporary biologic wound coverage until
donor sites heal enough so that they may be reharvested.
9 Neurogenic shock is caused A. Decreased blood C. Decreased Neurogenic shock refers to diminished tissue perfusion as ​a Schwartz’
by loss of arteriolar and volume peripheral vascular result of loss of vasomotor tone to peripheral arterial beds. Principles of
venular tone in response to B. Increased cardiac resistance Loss of vasoconstrictor impulses results in increased vascular Surgery, 11th
paralysis, acute gastric output capacitance, decreased venous return, and decreased cardiac Edition, page
dilatation or sudden pain or C. Decreased peripheral output. 151
even unpleasant sight. Which vascular resistance
of the following characterizes D. Cool, moist skin The classic description of neurogenic shock consists of
this type of shock? decreased blood pressure associated with bradycardia (absence
of reflexive tachycardia due to disrupted sympathetic discharge),
warm extremities (loss of peripheral vasoconstriction), motor and
sensory deficits indicative of a spinal cord injury, and
radiographic evidence of a vertebral column fracture.

10 A 70-kg male patient A. 5% C. 35% Schwartz’

presents to the ER following B. 55% Principles of
a stab wound to the C. 35% Surgery, 11th
abdomen. He is hypotensive, D. 15% Edition, page
markedly tachycardic, and 142
appears confused. What
percent of blood volume has
he lost?

11 Patients at risk for cardiac A. Hypotension, wide D. Hypotension, Beck's triad​ is a collection of three medical signs associated
tamponade require additional pulse pressure, jugular muffled heart with acute cardiac tamponade, an emergency condition wherein
maneuvers to confirm venous distension fluid accumulates around the heart and impairs its ability to pump
 cardiac injury. Which B. Hypotension, wide sounds, jugular blood. The signs are ​low arterial blood pressure, distended
constellation of clinical pulse pressure, venous distension neck veins, and distant, muffled heart sounds.
findings is suggestive of tachycardia
cardiac tamponade? C. Tachycardia,
hypotension, jugular
venous distension
D. Hypotension, muffled
heart sounds, jugular
venous distension

12 Duodenal hematomas are A. Exploratory laparotomy D. Observation is The majority of duodenal hematomas are managed Schwartz’
caused by direct blow to the and bypass of the the primary nonoperatively with nasogastric suction and parenteral nutrition. Principles of
abdomen and occur more duodenum management Patients with suspected associated perforation, suggested by Surgery, 11th
often in children. What is the B. Exploratory laparotomy clinical deterioration or imaging with retroperitoneal free air or Edition, page
most appropriate treatment and evacuation of the contrast extravasation, should undergo operative exploration. A 229
for a duodenal hematoma hematoma marked drop in nasogastric tube output heralds resolution of the
that occurs from blunt C. Exploratory laparotomy hematoma, which typically occurs within 2 weeks; repeat imaging
trauma? to rule out associated to confirm these clinical findings is optional. If the patient shows
injuries no clinical or radiographic improvement within 3 weeks, operative
D. Observation is the evaluation is warranted.
primary management

13 Which finding is not A. Schistocytes on C. Splenomegaly TTP is classically characterized by ​thrombocytopenia, Schwartz’
consistent with thrombotic peripheral blood smear microangiopathic hemolytic anemia, fever, and renal and Principles of
thrombocytopenic purpura? B. Microangiopathic neurologic signs or symptoms​. The finding of ​schistocytes Surgery, 11th
hemolytic anemia on a peripheral blood smear​ aids in the diagnosis. Edition, page
C. Splenomegaly 109
D. Fever
14 A 23 year-old is brought to A. Placement of two C. Immediate Smoke inhalation causes injury in two ways: by direct heat injury Schwartz’
the ER after a house fire. He large-bore intravenous endotracheal to the upper airways and inhalation of combustion products into Principles of
has burns around his mouth catheters with fluid intubation the lower airways. ​Direct injury to the upper airway causes Surgery, 11th
and his voice is hoarse, but resuscitation airway swelling that typically leads to maximal edema in the Edition, page
breathing is unlabored. What B. Place on supplemental first 24 to 48 hours after injury and often requires a short 256
is the MOST appropriate next oxygen course of endotracheal intubation for airway protection.
step in management? C. Immediate Treatment of inhalation injury consists primarily of supportive
endotracheal care. Aggressive pulmonary toilet and routine use of nebulized
intubation bronchodilators such as albuterol are recommended. Nebulized
D. Examination of oral N​-acetylcysteine is an antioxidant free radical scavenger
cavity and pharynx, designed to decrease the toxicity of high oxygen concentrations.
with fiberoptic Aerosolized heparin aims to prevent formation of fibrin plugs and
laryngoscope decrease the formation of airway casts and has been associated
with increased number of ventilator-free days.

15 Surgical wounds are A. Class II (Clean/ C. Class III (Contaminated) Schwartz’

classified based on the Contaminated) Clean/contaminated wounds ​(class II) include those in which a hollow viscus such as Principles of
presumed magnitude of the B. Class I (Clean) the respiratory, alimentary, or genitourinary tracts with indigenous bacterial flora is Surgery, 11th
bacterial load at the time of C. Class III opened under controlled circumstances without significant spillage of contents. Edition, page
surgery. During a (Contaminated) Contaminated wounds ​(class III) include open accidental wounds encountered early 169-170
laparoscopic appendectomy, D. Class IV (Dirty) after injury, those with extensive introduction of bacteria into a normally sterile area of
a large bowel injury was the body due to major breaks in sterile technique (e.g., open cardiac massage), ​gross
caused during trochar spillage of viscus contents such as from the intestine​, or incision through inflamed,
placement with spillage of albeit nonpurulent tissue.
bowel contents into the
abdomen. What class of
surgical wound is this?
16 This interleukin is considered A. IL-6 A. IL-6 Following burn or traumatic injury, damage-associated molecular Schwartz’
an anti-inflammatory cytokine B. IL-1 patterns (DAMPs) from dam- aged or dying cells stimulate TLRs Principles of
that may have C. IL-2 to produce IL-6, a proinflammatory cytokine that plays a central Surgery, 11th
immunosuppressive D. IL-10 role in host defense. IL-6 levels in the circulation are detectable Edition, page
properties. Which cytokine by 60 minutes post injury, peak between 4 and 6 hours, and can 45
increases after shock and persist for as long as 10 days.
trauma?
IL-1
 Two forms (IL-1 α and IL-1 β); similar physiologic effects as TNF;
induces fevers through prostaglandin activity in anterior
hypothalamus; promotes β-endorphin release from pituitary;
half-life <6 min

IL-2
Promotes lymphocyte proliferation, immunoglobulin production,
gut barrier integrity; half-life <10 min; attenuated production after
major blood loss leads to immunocompromise; regulates
lymphocyte apoptosis. IL-2 is not readily detectable after acute
injury.

IL-6
Elicited by virtually all immunogenic cells; long half-life;
circulating levels proportional to injury severity; prolongs
activated neutrophil survival

IL-10
Prominent anti-inflammatory cytokine; reduces mortality in animal
sepsis and ARDS models.

17 Treatment of metabolic A. Salicylate C. Bicarbonate Metabolic acidosis results from an increased intake of acids, an Schwartz’s
acidosis depends on the B. Ethanol increased generation of acids, or an increased loss of Principles of
cause and severity. Given C. Bicarbonate bicarbonate. In evaluating a patient with a low serum bicarbonate Surgery 10E,
the following lab results of D. Magnesium level and metabolic acidosis, first measure the AG, an index of page 74
patient A, pH of 7.1, PCO2 of unmeasured anions.
40, Sodium of 132, Protein of
4.2 and Chloride of 105, the AG = [Na] – [Cl + HCO3]
next MOST appropriate test
 to order in this patient is Metabolic acidosis with an increased AG occurs from either
serum ______. exogenous acid ingestion (ethylene glycol, salicylate, or
methanol) or endogenous acid production, β-hydroxybutyrate
and acetoacetate in ketoacidosis, lactate in lactic acidosis, or
organic acids in renal insufficiency.

18 The goal of resuscitation and A. Equals the Systolic D. Can be In addition to operative intervention, postinjury care directed at Schwartz’s
management in patients with Blood Pressure minus increased by limiting secondary injury to the brain is critical. The goal of Principles of
head injuries is to avoid ICP lowering ICP and resuscitation and management in patients with head injuries is to Surgery 11E,
hypotension and hypoxia. B. Is lowered with avoiding avoid hypotension (SBP of <100 mmHg) and hypoxia (partial pages 217-218
Which of the following should sedation, osmotic hypotension pressure of arterial oxygen of <60 or arterial oxygen saturation of
be the target for cerebral diuresis, and <90%).
perfusion pressure? barbiturate coma
C. Should be targeted to Attention, therefore, is focused on maintaining cerebral perfusion
be greater than rather than merely lowering ICP. Resuscitation efforts aim for a
100mmHg euvolemic state and a SBP of >100 mmHg. ​Cerebral perfusion
D. Can be increased by pressure (CPP)​ is ​equal to the mean arterial pressure minus
lowering ICP and the ICP​, with a ​target range of >60 mmHg​. CPP can be
avoiding hypotension increased by either ​lowering ICP or raising mean arterial
pressure​. ​Sedation, osmotic diuresis, paralysis, ventricular
drainage, and barbiturate coma ​are used in sequence, with
coma induction being the last resort.

19 What metabolic derangement A. Respiratory acidosis B. Metabolic Sodium chloride is mildly hypertonic, containing 154 mEq of Schwartz’s
will result if excessive normal B. Metabolic acidosis acidosis sodium that is balanced by 154 mEq of chloride. ​The high Principles of
saline is administered during C. Metabolic alkalosis chloride concentration imposes a significant chloride load Surgery 11E,
fluid resuscitation? D. Respiratory alkalosis on the kidneys and may lead to a hyperchloremic metabolic page 93
acidosis.
 Sodium chloride is an ideal solution, however, for correcting
volume deficits associated with hyponatremia, hypochloremia,
and metabolic alkalosis.

20 Hyperglycemia and insulin A. Requires insulin to B. Decreases Hyperglycemia and insulin resistance are typical in critically ill Schwartz
resistance are typical in keep serum glucose length of antibiotic and septic patients, including patients without underlying Principles of
critically ill patients. What is <140 therapy diabetes mellitus. A recent study reported significant positive Surgery 10th
the outcome as a result of B. Decreases length of impact on tight glucose management on outcome in critically ill ed., p. 125
tight glucose management in antibiotic therapy patients. The two treatment groups in this randomized,
critically ill and septic C. Has no effect on prospective study were assigned to receive intensive insulin
patients? ventilator support therapy (maintenance of blood glucose between 80 and 110
D. Has no effect on mg/dL) or
mortality conventional treatment (infusion of insulin only if the blood
glucose level exceeded 215 mg/dL, with a goal between 180 and
200 mg/dL). The mean morning glucose level was significantly
higher in the conventional treatment as compared with the
intensive insulin therapy group (153 vs 103 mg/dL).

Mortality in the intensive insulin treatment group (4.6%) was

significantly lower than in the conventional treatment group
(8.0%), representing a 42% reduction in mortality. This reduction
in mortality was most notable in the patients requiring longer than
5 days in the ICU. Furthermore, intensive insulin therapy reduced
episodes of septicemia by 46%, reduced duration of antibiotic
therapy, and decreased the need or
prolonged ventilatory support and renal replacement therapy.

21 Prolonged mechanical A. Obtain Chest CT B. Obtain Prolonged mechanical ventilation is associated with nosocomial Schwartz
ventilation is associated with bronchoalveolar pneumonia. These patients present with more severe disease, Principles of
nosocomial pneumonia. A lavage are more likely to be infected with drug-resistant pathogens, and
 patient in the ICU has been B. Obtain suffer increased mortality compared to patients who develop Surgery 11th
on ventilator support for 3 bronchoalveolar community-acquired pneumonia. The diagnosis of pneumonia is ed., p. 174
weeks. He has new onset lavage established by presence of purulent sputum, elevated leukocyte
elevated WBC count, fever, C. Exchange count, fever, and new chest X-ray abnormalities, such as
and consolidation seen on endotracheal tube and consolidation. The presence of two of the clinical findings, plus
chest Xray. What is an change respiratory chest X-ray findings, significantly increases the likelihood of
appropriate next step? circuit pneumonia.Consideration should be given to
D. Start treatment with performing bronchoalveolar lavage to obtain samples for Gram
empiric penicillin G stain and culture. Some authors advocate quantitative cultures
as a means to identify a threshold for diagnosis. Surgical patients
should be weaned from mechanical ventilation as soon as
feasible, based on oxygenation and inspiratory effort, as risk of
pneumonia increases with increased time on mechanical
ventilation.

22 Surgical management of the A. 8-12% ​C. 3-4% Surgical management of the wound is also a critical determinant Schwartz
wound is also a critical B. 15-18% of the propensity to develop an SSI. In healthy individuals, class I Principles of
determinant of the propensity C. 3-4% and II wounds may be closed primarily, while skin closure of Surgery 10th
to develop a surgical D. 22-25% class III and IV wounds is associated with high rates of incisional ed., p. 149
infection. Closure of an SSIs (~25–50%). The superficial aspects of these latter types of
appendectomy wound in a wounds should be packed open and allowed to heal by
patient with perforated secondary intention, although selective use of delayed primary
appendicitis who is receiving closure has been associated with a reduction in incisional SSI
appropriate antibiotics will rates. It remains to be determined whether National Nosocomial
result in a wound infection in In ections Surveillance (NNIS) system type stratification
what percentage of patients? schemes can be employed prospectively in order to target
specific subgroups of patients who will benefit from the use of
prophylactic antibiotic and/or specific wound management
techniques. One clear example based on cogent data from
clinical trials is that class III wounds in healthy patients
 undergoing appendectomy for perforated or gangrenous
appendicitis can be primarily closed as long as antibiotic therapy
directed against aerobes and anaerobes is administered. This
practice leads to SSI rates of approximately 3 to 4%.

23 The avoidance of prolonged A. Improves patient D. Usually The avoidance of prolonged orotracheal and nasotracheal Schwartz
orotracheal and nasotracheal discomfort as spontaneously intubation decreases the risk of laryngeal and subglottic injury Principles of
intubation decreases the risk compared to long term closes within 2 and potential stenosis, facilitates oral and pulmonary Surgery,10th
of laryngeal and subglottic oropharyngeal months of removal suctioning, and decreases patient’s discomfort. When the ed., p. 602.
injury and potential stenosis. intubation tracheostomy is no longer needed, the tube is removed and
Which of the following is B. Should be performed closure of the opening usually occurs spontaneously over a
NOT true about in patients anticipated 2-week period. Placement of tracheostomy does not obligate a
tracheostomy? to be intubated more patient to loss of speech. When a large cuffed tracheostomy tube
than 2 weeks is in place, expecting a patient to be capable of normal speech is
C. Does not obligate impractical. However, after a patient is downsized to an uncuffed
patient to loss of tracheostomy tube, intermittent finger occlusion or Passy-Muir
speech valve placement will allow a patient to communicate while still
D. Usually using the tracheostomy to bypass the upper
spontaneously airway.
closes within 2
months of removal

24 Which factor is NOT A. Ultraviolet light ​ . Reflux

C Human papillomavirus (HPV) is an epitheliotropic virus that has Schwartz
associated with increased exposure esophagitis been detected to various degrees within samples of oral cavity Principles of
incidence of head and neck B. Human papillomavirus squamous cell carcinoma. Infection alone is not considered Surgery, 10th
cancers? exposure sufficient or malignant conversion; however, results of multiple ed., p. 579
C. Reflux esophagitis studies suggest a role of HPV in a subset of head and neck
D. Plummer - vinson squamous cell carcinoma.
syndrome
 Multiple reports reflect that up to 40 to 60% of current diagnoses
of tonsillar carcinoma demonstrate evidence of HPV types 16 or
18. Environmental ultraviolet light exposure has been associated
with the development of lip cancer. The projection of the lower
lip, as it relates to this solar exposure, has been used to explain
why the majority of squamous cell carcinomas arise along the
vermilion border of the lower lip. In addition, pipe smoking also
has been associated with the development of lip carcinoma.

Factors such as mechanical irritation, thermal injury, and

chemical exposure have been described as an explanation or
this finding. Other entities associated with oral malignancy
include Plummer-Vinson syndrome (achlorhydria, iron deficiency
anemia, mucosal atrophy of mouth, pharynx, and esophagus),
chronic infection with syphilis, and immunocompromised status
(30-fold increase with renal transplant).

25 You were assigned to A. Bacteria with gram B. ​Many patients Many patients who develop intravascular catheter infections Schwartz
monitor post-operative negative bacteria or with intravascular are asymptomatic, often exhibiting solely an elevation in the Principle of
patients on catheter. Which fungi should prompt catheter infections blood WBC count.​ Blood cultures obtained from a peripheral Surgery
of the following is NOT TRUE catheter removal are asymptomatic site and drawn through the catheter that reveals the presence of 11E.p174
regarding intravascular B. Many patients with the same organism increase the index of suspicion for the
catheter infection? intravascular catheter presence of a catheter infection. Obvious purulence at the exit
infections are site of the skin tunnel, severe sepsis syndrome due to any type
asymptomatic of organism when other potential causes have been excluded, or
C. In high-risk patients, bacteremia due to gram-negative aerobes or fungi should lead to
prophylactic antibiotics catheter removal. Selected catheter infections due to low
infused through the virulence microbes such as S epidermidis can be effectively
catheter can reduce treated in approximately 50% to 60% of patients with a 14- to
21-day course of an antibiotic, which should be considered when
 rate of catheter no other vascular access site exists. The use of antibiotic-
infections bonded catheters and chlorhexidine sponges at the insertion site
D. Selected low-virulence has been associated with lower rates of colonization. Use of
infections can be ethanol or antimicrobial catheter “locks” have shown promise in
treated with a reducing incidence of infection in dialysis catheters. The surgeon
prolonged course of should carefully consider the need for any type of vascular
antibiotics. access devices, rigorously attend to their maintenance to prevent
infection, and remove them as quickly as possible. Use of
systemic antibacterial or antifungal agents to prevent catheter
infection is of no utility and is contraindicated.

26 A 62 year-old man is A. CO laser useful for A. CO laser The initial lesion appears as painless erythematous macules or ​ ssentials of
E
diagnosed with carcinoma of excision of small early useful for nodules or fissured areas over the tongue. There may be some Oral
the tongue. Which of the tumors excision of cases of nonhealing ulcers on the lateral border. Pathology.p84
following is NOT a feature of B. Can be result in small early The advanced lesions often produce fast enlarging, painful, Sabiston
this condition? contralateral tumors exophytic and large, extensively indurated ulcers with elevated Textbook of
paresthesias and everted margin. surgery,
C. May involve Paresthesia of the tongue frequently occurs due to invasion of 19E.p800
submandibular and the lingual nerve by tumor cells.
upper cervical lymph Tumor cells of the anterior two-third of the tongue often spread
nodes via lymphatics to submandibular, mid-anterior jugular and
D. Presentation as digastric lymph nodes.
ulcerated exophytic ● Small tumors may be removed by wide local excision and
mass primary closure or closure by secondary intention.
Excision of larger tumors requires partial glossectomy or
hemiglossectomy. Extirpation may result in significant
dysfunction in terms of disarticulation and dysphagia from
an inability to contact the palate, sense oral contents, or
manipulate the tongue against the alveolus or lips.
Reconstructive efforts should focus on maintaining
 tongue mobility without excess bulk. Split-thickness skin
grafts, primary closure, or healing by secondary intention
of larger tongue defects often results in tongue tethering.
Thin, pliable fasciocutaneous flaps (e.g., the radial
forearm free flap) are the preferred reconstructive
technique for such defects. A palatal augmentation
prosthesis may assist in maintaining palatal contact,
important for speech and posterior propulsion of food
boluses.

27 Lina, 47 year-old presented A. Empiric cefuroxime B. ​Empiric ● Infected pancreatic necrosis should be suspected in Sabiston
with severe, necrotizing plus gentamicin carbapenems or patients with prolonged fever, elevated WBC count, or Textbook of
pancreatitis. Which treatment B. Empiric carbapenems fluoroquinolones progressive clinical deterioration. Evidence of air within surgery,
should she receive? or fluoroquinolones the pancreatic necrosis seen on a CT scan confirms the 19E.p1524
C. Empiric cefoxitin or diagnosis but is a rare finding. If infected necrosis is
cefotetan suspected, fine-needle aspiration (FNA) should be Harrison’s
D. No antibiotics unless performed. A positive Gram stain and/or culture establish Principles of
CT-guided aspirate the diagnosis. Although positive cultures are confirmatory, Internal
yields positive culture a recent review has demonstrated that despite negative Medicine,
preoperative cultures, 42% of patients with so-called 20E.p2443
persistent unwellness will have infected necrosis.
● Once infection has been demonstrated, IV antibiotics
should be given. Because of their penetration into the
pancreas and spectrum coverage, carbapenems are the
first option of treatment. Alternative therapy includes
quinolones, metronidazole, third-generation
cephalosporins, and piperacillin. Definitive treatment for
infected pancreatic necrosis is surgical débridement with
necrosectomy, closed continuous irrigation, and open
packaging.
 ● The management of necrosis requires a multidisciplinary
team approach. The benefits of percutaneous aspiration
of necrosis with Gram stain and culture should be
considered or discussed if there are ongoing signs of
possible pancreatic infection such as sustained
leukocytosis, fever, or organ failure. There is currently no
role for prophylactic antibiotics in necrotizing pancreatitis.
It is reasonable to start broad-spectrum antibiotics in a
patient who appears septic while awaiting the results of
Gram stain and cultures

28 Which of the body is NOT A. Nares D. ​Main https://www.nc

Oral and Upper Respiratory Tract Flora
likely to contain resident B. Terminal ileum pancreatic duct bi.nlm.nih.gov/
microorganisms? C. Oropharynx A varied microbial flora is found in the oral cavity, and books/NBK761
D. Main pancreatic duct streptococcal anaerobes inhabit the gingival crevice. The 7/
pharynx can be a point of entry and initial colonization for
Neisseria,​ ​Bordetella​, ​Corynebacterium,​ and ​Streptococcus​ spp.

Gastrointestinal Tract Flora

Organisms in the stomach are usually transient, and their

populations are kept low (103 to 106/g of contents) by acidity.
Helicobacter pylori​ is a potential stomach pathogen that
apparently plays a role in the formation of certain ulcer types. In
normal hosts the duodenal flora is sparse (0 to 103/g of
contents). The ileum contains a moderately mixed flora (106 to
108/g of contents). The flora of the large bowel is dense (109 to
1011/g of contents) and is composed predominantly of
anaerobes. These organisms participate in bile acid conversion
 and in vitamin K and ammonia production in the large bowel.
They can also cause intestinal abscesses and peritonitis.

29 Which of the following is the A. There is no effective C. ​Two- or three- People can be accidentally exposed to HIV though healthcare
MOST effective treatment known drug therapy work or due to exposures outside healthcare setting, for https://www.wh
post-exposure prophylaxis B. Single drug therapy started within example, through unprotected sex or sexual assault. o.int/hiv/topics/
for a surgeon stuck with a started within 24 hours hours of exposure ● Antiretrovirals (ARVs) have been used to prevent prophylaxis/inf
needle while operating on an of exposure infection in case of accidental exposures for many o/en/
HIV-positive patient? C. Two- or three- drug years. This intervention is called post-exposure
therapy started within prophylaxis (PEP) and involves taking a 28-day course
hours of exposure of ARVs.
D. Triple drug therapy ● PEP should be offered, and initiated as early as
started within 24 hours possible, for all individuals with an exposure that has
of exposure the potential for HIV transmission, and ideally within
72 hours.
● If started soon after exposure, PEP can reduce the
risk of HIV infection by over 80%. Adherence to a full
28-day course of ARVs is critical to the effectiveness
of the intervention.
The recommended PEP regimens are:
○ For adults​: Tenofovir combined with either
lamivudine (3TC) or emtricitabine (FTC) as
preferred backbone drugs and these are also
the preferred drugs for treating HIV. The
recommended third drug is ritonavir-boosted
lopinavir (LPV/r), which is also recommended
by WHO as a preferred drug for HIV treatment.
○ For children​: Zidovidune (AZT) and
lamivudine (3TC) backbone drugs for children
aged 10 or below, with ritonavir-boosted
 lopinavir (LPV/r) recommended as the third
drug choice. This is also in alignment with
preferred drugs for treating HIV in children.

30 What is the etiology A. Crescendo-decrescend B. ​Flow between ● Holosystolic murmurs begin with S1 and continue through ● Harrison’s
associated with a o, occurs as blood is chambers that systole to S2. They are usually indicative of chronic mitral or Principles of
holosystolic murmur that is ejected into left and have widely tricuspid valve regurgitation or a VSD and warrant TTE for Internal
accompanied by ventricular right ventricular outflow different further characterization. The holosystolic murmur of a VSD is Medicine,
septal defect? tracts. pressures loudest at the mid- to lower-left sternal border and radiates 20E.p244
B. Flow between throughout widely. A thrill is present at the site of maximal intensity in the ● Bates’s
chambers that have systole majority of patients. There is no change in the intensity of the Guide to
widely different murmur with inspiration. The intensity of the murmur varies as Physical
pressures throughout a function of the anatomic size of the defect. Small, restrictive Examination
systole VSDs, as exemplified by the maladie de Roger, create a very and History
C. Ventricular filling that loud murmur due to the significant and sustained systolic taking 10E.
follows atrial pressure gradient between the left and right ventricles. With p383
contraction large defects, the ventricular pressures tend to equalize, shunt
D. A relative disproportion flow is balanced, and a murmur is not appreciated. The
between valve orifice distinction between post-MI ventricular septal rupture and MR
size and has been reviewed previously
diastolic-blood flow ● A ventricular septal defect is a congenital abnormality in which
volume blood flows from the relatively high-pressure left ventricle into
the low-pressure right ventricle through a hole.

31 Which compartment is the A. Deep posterior C. ​Anterior ​ ​The ​anterior compartment of the leg​ is the most https://www.nc
MOST commonly affected in B. Lateral common location for compartment syndrome. This bi.nlm.nih.gov/
a lower leg compartment C. Anterior compartment contains the extensor muscles of the toes, the books/NBK448
syndrome? D. Superficial posterior tibialis anterior muscle, the deep peroneal nerve, and the 124/
tibial artery.
32 There is an increasing A. >0.6 D. <0.9 Calculation of the ankle-brachial index (ABI) is a relatively simple UpToDate
interest in the use of B. >0.9 and inexpensive method to confirm the clinical suspicion of lower
ankle-brachial index (ABI) to C. <0.6 extremity arterial occlusive disease.
evaluate patients at risk for D. <0.9
cardiovascular events. Which The highest resting systolic blood pressure at the ankle is
ABI suggests increased risk compared with the highest systolic brachial pressure, and the
of myocardial infarction? ratio of the two pressures defines the ankle-brachial index.

A low ABI is associated with a higher risk of coronary heart

disease, stroke, transient ischemic attack, progressive renal
insufficiency, and all-cause mortality.

The normal ABI is >0.91 to as high as 1.3.

An ABI >1.3 suggests the presence of calcified vessels and the

need for additional vascular studies, such as pulse volume
recordings, measurement of the toe pressures and toe-brachial
index, transcutaneous oxygen measurements, or arterial duplex
studies.

An ABI ≤0.9 is diagnostic of occlusive arterial disease in patients

with symptoms of claudication or other signs of ischemia and has
95 percent sensitivity (and 100 percent specificity) for detecting
arteriogram-positive occlusive lesions associated with ≥50
percent stenosis in one or more major vessels.

An ABI of 0.4 to 0.9 suggests a degree of arterial obstruction

often associated with claudication.
 An ABI below 0.4 represents multilevel disease (any combination
of iliac, femoral, or tibial vessel disease) and may be associated
with nonhealing ulcerations, ischemic rest pain, or pedal
gangrene.

33 The most important criterion A. Internal thoracic artery A. Internal Thoracic Arterial grafts into the coronary circulation are much more Various
in conduit selection is graft B. Greater saphenous vein Artery durable than venous grafts and have been associated with better Researches
patency. Which bypass C. Radial artery patient survival in some studies.
conduit has the highest D. Radial artery
patency rate? In patients undergoing coronary artery bypass graft surgery
* Double entry of Radial Artery (CABG), long-term graft patency is excellent with internal
on actual exam. thoracic artery and radial artery bypass grafts. Rates exceeding
90 percent at 5 to 10 years are common.

When one arterial graft is placed, it is usually the left internal

thoracic artery (ITA), which is also referred to as the internal
mammary artery. Long-term graft patency is much higher with left
ITA than venous grafts.

Saphenous vein graft patency declines significantly starting at

the time of surgery. Rates below 90 percent are common at one
year. Failure is often in the form of vein graft stenosis.

34 Ischemic strokes are due to A. Cardiogenic emboli C. Carotid artery Ischemic stroke can be due to embolic occlusion of large Harrison's
hypoperfusion from arterial B. Idiopathic disease cerebral vessels; source of emboli may be heart, aortic arch, or Manual of
occlusion or to decreased C. Carotid artery disease other arteries such as the internal carotids. Small, deep ischemic Medicine, 20th
flow resulting from proximal D. Lacunar lesions are most often related to intrinsic small-vessel disease Edition
arterial stenosis and poor (lacunar strokes).
collateral network. Which of
the following is the most
 common cause of ischemic
stroke?

35 Angina pectoris is the pain or A. "Typical" angina occurs in B. Angina is Angina pectoris, the most common clinical manifestation of Harrison's
discomfort caused by approximately 50% of patients typically substernal coronary artery disease (CAD), results from an imbalance Manual of
myocardial ischemia. Which with coronary disease. and may radiate to between myocardial O2 supply and demand, most often due to Medicine, 20th
of the following BEST B. Angina is typically the left upper atherosclerotic coronary artery obstruction. Edition /
describes angina pectoris? substernal and may radiate to extremity. UpToDate
the left upper extremity. Angina is usually characterized more as a discomfort rather than
C. "Atypical" angina occurs pain. Terms frequently used by patients include squeezing,
more commonly in men. tightness, pressure, constriction, strangling, burning, heart burn,
D. Angina is a typical fullness in the chest, band-like sensation, knot in the center of
symptom for mitral stenosis. the chest, lump in throat, ache, heavy weight on chest (elephant
sitting on chest), like a bra too tight, and toothache (when there is
radiation to the lower jaw.

Angina is referred to the corresponding dermatomes (C5-6 and

T1-T6) that supply afferent nerves to the same segments of the
spinal cord as the heart. Thus, angina often radiates to other
parts of the body, including the upper abdomen (epigastric),
shoulders, arms (upper and forearm), wrist, fingers, neck and
throat, lower jaw and teeth (but not upper jaw), and rarely to the
back (specifically the interscapular region).

Atypical angina is more common in women than in men.

36 What valvular lesion is most A. Aortic stenosis D. Mitral Ehlers-Danlos syndrome (EDS) is the term used for a group of UpToDate /
commonly found in a patient B. Mitral stenosis insufficiency relatively rare genetic disorders of connective tissue that are Various
with Ehlers-Danlos C. Aortic insufficiency characterized by one or another of several features, including Researches
syndrome? D. Mitral insufficiency skin hyperextensibility, joint hypermobility, and tissue fragility.
 Mitral valve prolapse has been reported as a feature of several
forms of EDS.

In hypermobile EDS, problems that can occur are mild dilation of

the aortic root and postural tachycardia syndrome.

37 Which is the MOST accurate A. Computed tomography C. Fasting Serum Initial evaluation in a patient with suspected ZES is with UpToDate
diagnostic test for (CT) scan Gastrin measurement of fasting serum gastrin concentration and
Zollinger-Ellison Syndrome B. Endoscopy measurement of gastric pH. In patients with elevated gastrin
(ZES)? C. Fasting serum gastrin levels/low gastric pH that are not diagnostic for ZES, we perform
D. Secretin stimulation test a secretin stimulation test.

38 Which of the following A. Chemotherapy+Radiation D. H. pylori Most patients with primary gastric lymphoma can be treated Schwartz's
options is the best Therapy eradication without gastric resection. Principles of
management of a low-grade B. Antrectomy Surgery, 10th
gastric lymphoma of the C Wedge Resection For individuals with early stage MALT gastric lymphoma confined Edition;
gastric antrum? D. H. pylori eradication to the stomach, antibiotics alone may be prescribed. Many Various
studies have shown that curing MALT gastric lymphoma is Researches
possible with just antibiotics in many patients. The eradication of
H. pylori with antibiotics is considered by many physicians to be
a reasonable initial therapy for individuals with early stage MALT
gastric lymphoma.

39 ​ hich cranial nerve is NOT

W ​A. X ​C. VIII ​ he ​vestibulocochlear nerve (auditory vestibular nerve), known
T
involved in the swallowing as the eighth ​cranial nerve​, transmits sound and equilibrium
mechanism? B. V (balance) information from the ​inner ear​ to the ​brain​.

C. VIII

D. VII
40 ​ subtotal gastrectomy with
A ​A. Billroth II reconstruction ​ . More than 15
B
D2 dissection performed for lymph nodes
stage 3 gastric B. More than 15 lymph nodes removed
adenocarcinoma in the removed
antrum includes______
C. Grossly negative marginsof
2cm

D. Splenectomy

41 ​ elief from respiratory

R ​A. 50% B. 25%
symptoms can be expected
approximately in what B. 25%
percent of patients with reflux
C. <10%
associated asthma with
medical therapy? D. 75%

42 ​ here does the cervical

W ​A. Superior thyroid artery ​ . Inferior thyroid
B ​The blood supply of the esophagus is segmental.
esophagus receive its blood artery
B. Inferior thyroid artery The inferior thyroid artery supplies the cervical
supply primarily?
esophagus. Branches of the bronchial arteries and
C. Internal carotid artery
branches directly off of the aorta supply the proximal
 D. Inferior cervical artery and distal thoracic esophagus, respectively. Finally,
branches of the left gastric and inferior phrenic artery
supply the abdominal esophagus. A relatively
constant branch connects the left gastric and inferior
phrenic arteries, called the Belsey artery

43 ​ Toupet fundoplication
A ​A. A 180 posterior wrap ​ . A 270 posterior
D ​The Toupet posterior partial fundoplication consists a 270​° ​gastric fundoplication S​CHWARTZ
involves_____ wrap around the distal 4 cm of esophagus. It is usually stabilized by anchoring the wrap 10​TH​ Ed p.976
B. A 90 posterior wrap posteriorly to the hiatal rim.

C. A 180 anterior wrap

D. A 270 posterior wrap

44 ​Which of these is NOT a ​A. Efficient esophageal ​C. Mucus secreting ​If the pharyngeal swallow does not initiate a peristaltic contraction, then the ​Schwartz 10th
part of the human antireflux clearance cells of the distal coincident relaxation of the LES is unguarded ed., p. 949
mechanism? esophagus
B. Adequate gastric reservoir and reflux of gastric juice can occur. This may be an explanation for the
observation of spontaneous lower esophageal relaxation, thought by some to be a
C. Mucus secreting cells of the causative factor in gastroesophageal reflux disease (GERD). The power of the
worm-drive pump of the esophageal body is insufficient to force open a valve that
distal esophagus
does not relax. In dogs, a bilateral cervical parasympathetic blockade abolishes the
relaxation of the LES that occurs with pharyngeal swallowing or distention of the
D. Mechanically functioning
esophagus. Consequently, vagal function appears to be important in coordinating
lower esophageal sphincter the relaxation of the LES with esophageal contraction. The antireflux mechanism
(LES) in human beings is composed of three components: a mechanically effective LES,
efficient esophageal clearance, and an adequately functioning gastric reservoir. A
defect of any one of these three components can lead to increased esophageal
exposure to gastric juice and the development of mucosal injury.
45 ​A pancreatic cystic ​A. A repeat CT scan in 3-6 ​D. resection SCHWARTZ
neoplasms that is <3cm, has mos 10​TH​ ED 1409
atypical cells present and
has a solid component B. A repeat CT scan in 1 year
requires_____
C. Continued observation

D. resection

46 Relaxation of the sphincter A. Secretin B. Cholecystokinin Schwartz

of Oddi in response to a meal B. Cholecystokinin Principles of
is largely under the control of C. Gastrin Surgery 10th
which hormone? D. Motilin ed chapter 28

47 Acute inflammation of the A. Severe burns B. Relational stress Acute inflammation of the gallbladder can occur without Schwartz
gallbladder can occur without B. Relational stress gallstones. Acalculous cholecystitis typically develops in critically Principles of
gallstones. One of these is C. Sepsis ill patients in the intensive care unit. Patients on parenteral Surgery 10th
NOT a risk factor for D. Multiple trauma nutrition with extensive burns, sepsis, major operations, multiple ed chapter 32
acalculous cholecystitis. trauma, or prolonged illness with multiple organ system failure
are at risk for developing acalculous cholecystitis. The cause is
unknown, but gallbladder distention with bile stasis and ischemia
has been implicated as causative factors.
48 Initial management of a A. Surgical drainage A. Surgical The current cornerstones of treatment include correction of the Schwartz
pyogenic liver does NOT and/or resection drainage underlying cause and IV antibiotic therapy. Empiric antibiotic Principles of
include ____. B. Percutaneous and/or therapy should cover gram-negative and anaerobic Surgery 10th
fine-needle aspiration resection organisms; percutaneous needle aspiration and culture of the ed chapter 31
and culture aspirate may be useful in guiding subsequent antibiotic therapy.
C. Treatment of the IV antibiotic therapy should be continued for at least 8 weeks
underlying cause and can be expected to be effective in 80% to 90% of patients.
D. Broad-spectrum Placement of a percutaneous drainage catheter is beneficial only
intravenous antibiotics for a minority of patients, as most pyogenic abscesses are quite
viscous and catheter drainage is often ineffective.
Surgical drainage either via the laparoscopic or open approach
may become necessary if initial therapies fail.

49 Variations in the anatomy of A. 25% D. 50% Anomalies of the hepatic artery and the cystic artery are quite Schwartz
the cystic and hepatic B. 15% common, occurring in as many as 50% of cases. Principles of
arteries are exceedingly C. 35% Surgery 10th
common. Anomalies in these D. 50% ed chapter 31
arteries are present in what
percent of individuals?
50 Which factor does NOT A. History of cholelithiasis C. Smoking Cancer of the gallbladder is a rare malignancy that occurs Schwartz
increase the risk for the B. Female gender predominantly in the elderly. It is two to three times more Principles of
development of gallbladder C. Smoking common in females than males, and the peak incidence is in the Surgery 10th
cancer? D. Gallbladder polyp seventh decade of life. Cholelithiasis is the most important risk ed chapter 32
factor for gallbladder carcinoma, and up to 95% of patients with
carcinoma of the gallbladder have gallstones. Polypoid lesions of Risk factors for
the gallbladder are associated with increased risk of cancer, Gallbladder
particularly in polyps >10 mm. The calcified “porcelain” cancer from
gallbladder is associated with >20% incidence of gallbladder American
carcinoma. Patients with choledochal cysts have an increased Cancer Society
risk of developing cancer anywhere in the biliary tree, but the
incidence is highest in the gallbladder. Sclerosing cholangitis, Image:
anomalous pancreaticobiliary duct junction, and exposure to Gallbladder
carcinogens (azotoluene, nitrosamines) also are associated with cancer:
cancer of the gallbladder. epidemiology
and genetic
risk
associations
from Chinese
Clinical
Oncology
 Studies have found other factors that might increase the risk of
gallbladder cancer, but the links are not as clear. These include:

● Smoking
● Exposure to chemicals used in the rubber and textile
industries
● Exposure to nitrosamines

51 With respect to the A. Duodenum D. Terminal ileum The bile salts, however, remain in the bowel Schwartz
enterohepatic circulation of B. Colon lumen and travel to the terminal ileum, where they are actively Principles of
bile, where are the majority C. Proximal jejunum resorbed. They enter the portal circulation and are resecreted Surgery 10th
of bile salts reabsorbed? D. Terminal ileum into bile, thus completing the enterohepatic circulation. ed chapter 28
and 32
The primary bile salts, cholate and chenodeoxycholate, are
synthesized in the liver from cholesterol. They are conjugated
there with taurine and glycine and act within the bile as anions
(bile acids) that are balanced by sodium. Bile salts are excreted
into the bile by the hepatocyte and aid in the digestion and
absorption of fats in the intestines. In the intestines, about 80% of
the conjugated bile acids are absorbed in the terminal ileum. The
remainder is dehydroxylated (deconjugated) by gut bacteria,
forming secondary bile acids deoxycholate and lithocholate.
These are absorbed in the colon, transported to the liver,
conjugated, and secreted into the bile.

52 The most common cause of A. Cardiogenic shock B. Acute viral Acute liver failure (ALF) occurs when the rate and extent of Schwartz
acute liver failure is ____. B. Acute viral hepatitis hepatitis hepatocyte death exceeds the liver’s regenerative capabilities. Principles of
C. Autoimmune hepatitis
 D. Drug/toxin-induced In the East and developing portions of the world, the most Surgery 10th
common causes of ALF are viral infections, primarily hepatitis B, ed chapter 31
A, and E.20
In these areas, there are a relatively small number of drug
induced cases. In contrast, 65% of cases of ALF in the West are
thought to be due to drugs and toxins, with acetaminophen
(paracetamol) being the most common etiologic agent. The U.S.
Acute Liver Failure Study Group identified several other causes
of ALF, including autoimmune hepatitis, hypoperfusion of the
liver (in cardiomyopathy or cardiogenic shock),
pregnancy-related conditions, and Wilson’s disease. Even with
exhaustive efforts to identify a cause, approximately 20% of all
cases of ALF remain indeterminate in origin.

53 Short bowel syndrome has A. 300 cm D. 200cm Although the best definition of short bowel syndrome is likely a Schwartz’s
been arbitrary defined in B. 50 cm functional one, reflecting a state of significant malabsorption of 11th ed pg
adults as having a small C. 100 cm both macronutrients and micronutrients, some have used a more 1254
intestine of less than what D. 200 cm anatomical definition with it being arbitrarily defined as the
length? presence of less than 200cm of residual small bowel in adult
patients

54 How much fluid normally A. 6L D. 8L 8-9L of fluid enters the small intestine daily. Schwartz’s
enters adult small intestine B. 2L 11th ed pg
each day? C. 4L 1222
D. 8L

55 A closed-loop obstruction is A. The obstructive B. Intraluminal If the intramural pressure becomes high enough, intestinal micro Schwartz’s
particularly dangerous segment is not pressure rises high vascular perfusion is impaired, leading to intestinal ischemia and, 10th ed pg
because apparent on imaging enough to cause ultimately, necrosis. This condition is termed strangulated bowel 1147
studies ischemia and obstruction.
necrosis
 B. Intraluminal pressure
rises high enough to
cause ischemia and
necrosis
C. The obstruction is
painless
D. Bacterial overgrowth
results in sepsis

56 An 8-year old boy presents A. Ulcerative colitis

to the emergency department B. Clostridium difficile
complaining of generalized C. Carcinoid
abdominal pain for the past D. Crohn colitis
24 hours. Laboratory tests
reveal a leukocytosis of
13,000 and has tenderness
in the RLQ on physical
examination. He is taken to
the operating room of
laparoscopic appendectomy.
Removal of the appendix has
been associated with a
protective effect of which of
the following?

57 What imaging finding would A. An ultrasound study

exclude appendicitis? with a compressible
appendix that is <5mm
in diameter
 B. A barium enema where
a short (2 cm)
appendix was clearly
identified
C. A CT scan showing an
edematous but
retrocecal appendix
D. A computed
tomographic scan with
a non visualized
appendix

58 What ectopic tissue is A. Ovarian follicles C. Gastric mucosa Approximately 60% of Meckel’s diverticula contain heterotopic Schwartz’s
commonly found in meckel’s B. Ectopic pancreas mucosa, of which over 60% consist of gastric mucosa. 10th ed pg
diverticulum? C. Gastric mucosa Pancreatic acini are the next most common; others include 1164
D. Splenic Follicles Brunner’s glands, pancreatic islets, colonic mucosa,
endometriosis, and hepatobiliary tissues.

A useful, although crude, mnemonic describing Meckel’s

diverticula is the “rule of two’s”: 2% prevalence, 2:1 male
predominance, location 2 feet proximal to the ileocecal valve in
adults, and half of those who are symptomatic are under 2 years
of age.

59 A patient with recent onset A. Low-fat diet

of ascites after an episode of B. Total parenteral
acute pancreatitis undergoes nutrition (TPN) and
paracentesis, which reveals octreotide
cloudy white fluid. What C. Octreotide and weekly
therapy is indicated? paracentesis
 D. Surgical exploration

60 Schwartz’s
A previously healthy 44 year a. No examination is needed B. The timing of ileostomy closure should take into account Principles of
old woman with a history of as this was a simple diversion anastomotic healing as well as the patient’s overall condition. A Surgery, 11​th
rectal adenocarcinoma and check for patency flexible endoscopy exam and a contrast enema (Gastrografin) Edition. Page
discovered on colonoscopy 1 are recommended prior to closure to ensure that the 1277
year ago underwent low b. A flexible sigmoidoscopy or anastomosis has not leaked and is patent. A patient’s nutritional
anterior resection with contrast enema to check for status should be optimized. Because the timing of adjuvant
diverting loop ileostomy. She patency chemotherapy effects survival, cancer patients receiving adjuvant
followed for pre-operative chemotherapy usually should defer ileostomy closure until
c. A digital rectal examination
appointment to undergo completion of treatment.
to palpate the anastomoses
ileostomy reversal. Over the
and check for patency
past 3 months she had good
ileostomy output with
d. A colonoscopy to evaluate
occasional loose stools.
for polyps not previously seen
What work up does she need
on previous colonoscopy
before ileostomy reversal?

61 Schwartz’s
According to Nyhus a. Recurrent hernia D. Nyhus classification system Principles of
classification system that Surgery, 11​th
characterizes hernia, defecta b. Indirect hernia Type I Indirect hernia; internal abdominal ring normal; typically in
Edition. Page
by location, size and type, infants, children, small adults
1602
c. Direct hernia
Type IIIC represents which of
the following?
d. Femoral hernia
Type II Indirect hernia; internal ring enlarged withoutimpingement
on the floor of the inguinal

canal; does not extend to the scrotum

 Type IIIA Direct hernia; size is not taken into account

Type IIIB Indirect hernia that has enlarged enough to encroach

upon the posterior inguinal wall;

indirect sliding or scrotal hernias are usually placed in this

category because they are

commonly associated with extension to the

direct space; also includes pantaloon hernias

Type IIIC Femoral hernia

Type IV Recurrent hernia; modifiers A–D are sometimes added,

which correspond to indirect, direct, femoral, and mixed,
respectively

62 Schwartz’s
With pregnancy, the breast a. Accumulation of secretory D. With pregnancy, the breast undergoes proliferative and Principles of
undergoes proliferative and products in minor duct lumina developmental maturation. As the breast enlarges in response Surgery, 11​th
developmental maturation. Edition. Page
Which of the following to hormonal stimulation, lymphocytes, plasma cells, and
545
eosinophils accumulate within the connective tissues. The minor
 changes in the breast is NOT ducts branch and alveoli develop. Development of the alveoli is
associated with pregnancy? b. Accumulation of asymmetric, and variations in the degree of development may
lymphocytes, plasma cells and occur within a single lobule. With parturition, enlargement of the
eosinophils breasts occurs via hypertrophy of alveolar epithelium and
accumulation of secretory products in the lumina of the minor
c. Enlargement of breast
ducts. Alveolar epithelium contains abundant endoplasmic
alveoli
reticulum, large mitochondria, Golgi complexes, and dense
lysosomes. Two distinct substances are produced by the alveolar
d. Release of colostrum
epithelium: (a) the protein component of milk, which is
synthesized in the endoplasmic reticulum (merocrine secretion);
and (b) the lipid component of milk (apocrine secretion), which
forms as free lipid droplets in the cytoplasm. Milk released in the
​ nd has low
first few days after parturition is called ​colostrum a
lipid content but contains considerable quantities of antibodies

63 Schwartz’s
Exposure of the skin to a. Zone of coagulation B. The zone of coagulation is the most severely burned portion and Principles of
thermal extremes disrupts its is typically in the center of the wound. As the name implies, the Surgery, 11​th
primary function as a barrier b. Zone of stasis affected tissue is coagulated and sometimes frankly necrotic, Edition. Page
to heat loss, evaporation and much like a full thickness burn, and will need excision and 253
c. Zone of hyperemia
microbial invasion. Which are grafting. Peripheral to that is a zone of stasis, with variable
is MOST amenable to degrees of vasoconstriction and resultant ischemia, much like a
d. Zone of scalding
salvage by resuscitative and second degree burn. Appropriate resuscitation and wound care
wound management may prevent conversion to a deeper wound, but infection or
techniques following thermal suboptimal perfusion may result in an increase in burn depth.
injury? This is clinically relevant because many superficial
partial-thickness burns will heal with nonoperative management,
and the majority of deep partial-thickness burns benefit from
excision and skin grafting. The outermost area of a burn is called
the zone of hyperemia, which will heal with minimal or no
 scarring and is most like a superficial partial thickness burn or
first-degree burn

64 Schwartz’s
64. The clinician observes a. Neutralizing agent C. Treatment for acidic or alkaline chemical burns is first and Principles of
and treats injury to the skin foremost centered around dilution of the offending agent, Surgery, 11​th
based on degree of b. Running water or saline for typically using distilled water or saline for 30 minutes for acidic Edition. Page
presentation. Following 30 minutes burns and 2 hours for alkaline injuries. 521
caustic injury to the skin with
c. Running water or saline for
an alkaline agent, the
2 hours
affected area should be
initially be treated with a __.
d. Topical emollients and oral
analgesics

65 Schwartz’s
Hemorrhage from the a. Unexplained anemia C. Hemorrhage from the network of collateralizing vessels within the Principles of
network of collateralizing rectus sheath and muscles can result in a rectus sheath Surgery​ 10​th
vessels within the rectus b. Abdominal wall bulge hematoma. Although a history of trauma may be present, a Edition. Page
sheath and muscles can rectus sheath hematoma can follow vigorous coughing, 1453.)
c. Sudden Abdominal pain
result in a rectus sheath sneezing, or extreme exertion. It typically occurs in elderly
hematoma. The usual patients or those on anticoagulant therapy. Patients usually
d. Inability to stand erect
presentation in this condition report the sudden onset of unilateral abdominal pain and have
is __. localized tenderness which is not accompanied by peritoneal
signs.

66 Schwartz’s
To which lymphatic basin will a. Inguinal C Above the umbilicus, the lymphatics of the abdominal wall drain Principles of
a cutaneous malignancy of into the superficial axillary nodes. Surgery, 11​th
the anterior abdominal wall 2 b. Umbilical
Edition. Page
inches above the umbilicus 1550
c. Axillary
drain?
 d. Retroperitoneal Below the umbilicus, these drain into the inguinal nodes.
Lymphatics near the umbilicus can drain along the falciform
ligament toward the hepatic nodes.

67 Of the following, which is not A. Raloxifene ​B. Aspirin The P-2 trial, the Study of Tamoxifen and Raloxifene (known as Schwartz
useful in the prevention of B. Aspirin the STAR trial), randomly assigned 19,747 postmenopausal Principle of
breast cancer? C. Aromatase inhibitors women at high risk or breast cancer to receive either tamoxien or Surgery 10th
D. Tamoxifen raloxifene. The initial report on the P-2 trial showed the two ed. P 514
agents were nearly identical in their ability to reduce breast
cancer risk, but raloxifene was associated with a more favorable
adverse event profile. An updated analysis revealed that
raloxifene maintained 76% of the efficacy of tamoxifen in
prevention of invasive breast cancer with a more favorable
side-effect profile. Aromatase inhibitors (AIs) have been shown to
be more effective than tamoxifen in reducing the incidence of
contralateral breast cancers in postmenopausal women receiving
AIs or adjuvant treatment of invasive breast cancer.

68 Epidemiologic studies have A. Types II and III ​D. Types I and III Epidemiologic studies have identified risk factors that may Schwartz
identified risk factors that B. Types I and II predispose to a hernia. Microscopic examination of skin of Principle of
may predispose to a hernia. C. Types III and VI inguinal hernia patients demonstrated significantly decreased Surgery 10th
Which two types of collagen D. Types I and III ratios of type I to type III collagen. Type III collagen does not ed. P 1502
are found in a decreased contribute to wound tensile strength as significantly as type I
ratio of the skin of inguinal collagen. Additional analyses revealed disaggregated collagen
hernia patients? tracts with decreased collagen fiber density in hernia patients’
skin. Collagen disorders, such as Ehlers-Danlos syndrome, are
also associated with an increased incidence of hernia formation.
Recent studies have found an association between
concentrations of extracellular matrix elements and hernia
formation. Although a significant amount of work remains to
 elucidate the biologic nature of hernias, current evidence
suggests they have a multifactorial etiology with both
environmental and hereditary influences.

69 Children exposed to the A. Follicular thyroid D. Papillary Papillary thyroid cancer accounts for 80% of all thyroid Schwartz
Chernobyl disaster in 1986 cancer thyroid cancer malignancies and is the predominant thyroid cancer in children Principle of
subsequently demonstrated B. Anaplastic thyroid and individuals exposed to external radiation. Surgery 10th
an increased incidence of cancer ed. P 1542
which thyroid cancer? C. Medullary thyroid
cancer
D. Papillary thyroid
cancer

70 In North America, A. Thyroid stimulating C. Diffuse toxic Graves disease, named after Robert Graves, the Irish physician Schwartz
hyperthyroidism is most often hormone-secreting goiter (Graves who described the disorder in three patients in 1835, is the most Principle of
caused by? pituitary adenoma disease) common cause of hyperthyroidism in North America, and Surgery 10th
B. Thyroid cancer accounts for 60 to 80% of cases. ed. P 1531
C. Diffuse toxic goiter
(Grave’s Disease)
D. Toxic multinodular
goiter

71 A trauma patient arrives A. Tube thoracostomy of C.​ ​Focused During the circulation section of the primary survey, our life Schwartz
following a stab wound to the the left chest abdominal threatening injuries must be identified promptly: (1) massive Principle of
left chest with systolic blood B. Computed tomography sonography for hemothorax, (2) cardiac tamponade, (3) massive Surgery 10th
pressure 85 mmHg, which scan of the chest trauma hemoperitoneum, and (4) mechanically unstable pelvic fractures ed. P 166
improves slightly with IV fluid C. Focused abdominal examination with bleeding.
resuscitation. Chest Xray sonography for
demonstrates clear lung trauma examination In this patient hemothorax is unlikely given normal chest X-ray;
fields. What is the most D. Pelvic Xray thus, hemoperitoneum and cardiac tamponade should be
appropriate next step? suspected. Cardiac tamponade occurs most commonly after
 penetrating thoracic wounds, although occasionally blunt rupture
of the heart, particularly the atrial appendage, is seen. Acutely,
<100 mL o pericardial blood may cause pericardial tamponade.
he classic Beck’s triad—dilated neck
veins, mu led heart tones, and a decline in arterial pressure— is
usually not appreciated in the trauma bay because of the noisy
environment and associated hypovolemia. Diagnosis is best
achieved by bedside ultrasound of the pericardium, which is one
of the our views of the FAST examination.

72 Which surgeon was A. Harvey CUshing C. Emil Kocher The Nobel Prize in Physiology or Medicine was awarded to Emil Schwartz
awarded the Nobel prize in B. John Bunter Kocher in 1909. In addition to his research on the physiology of Principle of
Physiology or Medicine for C. Emil Kocher the thyroid, Kocher’s operative methods greatly reduced the Surgery 10th
his work on the “physiology, D. Theodore Billroth mortality risk of thyroidectomy. The Kocher clamp was designed ed. P 1521
pathology, and surgery of the to prevent hemorrhage from the hypervascular gland during
thyroid gland”? thyroidectomy.

73 The most common A. Ganglioglioma B.​ ​Astrocytoma Astrocytoma is the most common primary central nervous Schwartz
malignant tumor of the brain B. Astrocytoma system (CNS) neoplasm. The term glioma o ten is used to refer Principle of
is _____ C. Ependymoma to astrocytomas speci ically, excluding other glial tumors. Surgery 10th
D. Teratoma Astrocytomas are graded from I to IV. Grades I and II are ed. P 1733 -
referred to as low-grade astrocytoma, grade III as anaplastic 1734
astrocytoma, and grade IV as glioblastoma multiforme (GBM).
Prognosis varies significantly between grades I/II, III, and IV, but
not between I and II. Median survival is 8 years a ter diagnosis
with a low grade tumor, 2 to 3 years with an anaplastic
astrocytoma, and roughly 1 year with a GBM. GBMs account for
almost two thirds of all astrocytomas, anaplastic astrocytomas
 account for two-thirds of the rest, and low-grade astrocytomas
the remainder.

74 Which of the following is true a. Study of choice or D. Most common Urolithiasis, or urinary calculus disease, may affect up to 10% of Schwartz
concerning urolithiasis? diagnosis is contrast type is calcium the population over the course of a lifetime.Calculi are crystalline
computed tomography oxalate lithiasis aggregates of one or more components, most commonly calcium
scanning oxalate. They also may contain calcium phosphate, magnesium
b. May affect up to 20% ammonium phosphate (struvite), uric acid, or cystine. Calcium-
of the population over and struvite-containing stones often are visible on plain
the course of a lifetime radiographs, but CT scans will demonstrate
c. Most patients will all calculi except those composed of crystalline-excreted
benefit from chronic indinavir, an antiretroviral medication.​ ​For this reason,
urinary acidification noncontrast CT scans have become the study of choice to
program evaluate for urolithiasis. Risk factors for stone formation include
d. Most common type is dietary habits, family history, white race, geographical location or
calcium oxalate occupational exposure to heat.dehydration, intestinal disease,
lithiasis and male gender, although the gender gap is decreasing. It has
also been associated with obesity, metabolic syndrome and
diabetes. Definitive treatment of renal or ureteral calculi
(lithotripsy) is through ureteroscopy, percutaneous
nephrostolithotomy (PCNL), or extracorporeal shock wave
lithotripsy (ESWL).

75 What is NOT an early goal in a. Serum lactate a. Serum Sepsis​ is defined as systemic inflammatory response syndrome with Schwartz
treatment of severe sepsis? <2mmol/L lactate suspected infection. Uptodate
b. Central venous <2mmol/L Severe sepsis​ is characterized as sepsis (defined previously)
combined with the presence of new-onset organ failure.
pressure 8 to 12mmHg
c. Urine output >0.5 Septic shock ​is a state of acute circulatory failure identified by the
cc/kg/h presence of persistent arterial hypotension (systolic blood pressure <90
d. Mean arterial pressure mm Hg) despite adequate fluid resuscitation, without other identifiable
causes.
>65mmHg
Patients presenting with severe sepsis should receive resuscitation
fluids to achieve a central venous pressure target of 8-12 mm Hg, with
a goal of mean arterial pressure of ≥ 65 mHg and urine output of ≥ 0.5
mL/kg/h. Delaying this resuscitative step for as little as 3 hours until
arrival in the ICU has been shown to result in poor outcome.Typically
this goal necessitates early placement of central venous catheter.
Serum lactate is not a direct measure of tissue perfusion.

Increases in the serum lactate level may represent tissue hypoxia,

accelerated aerobic glycolysis driven by excess beta-adrenergic
stimulation, or other causes (e.g., liver failure). Regardless of the
source, increased
lactate levels are associated with worse outcomes. ​Serum lactate – An
elevated serum lactate (eg, >2 mmol/L or greater than the laboratory
upper limit of normal) may indicate the severity of sepsis and is used to
follow the therapeutic response
76 A patient in the ICU has a. Obtain chest CT Ventilator-associated pneumonia is defined as pneumonia
been on ventilator support for b. Exchange occurring more than 48 h after patients have been intubated and
3 weeks. He has new onset endotracheal tube and received mechanical ventilation.
of elevated WBC count, change respiratory
fever, and consolidation seen circuit
on chest X-ray. What is an c. Start treatment with
appropriate next step? empiric penicillin G
d. Obtain bronchoalveolar
lavage
77 Possible exposure to a. Collistin B. Anthrax is a serious infectious disease caused by gram-positive, Schwartz
anthrax should be initially b. Ciprofloxacin Ciprofloxaci rod-shaped bacteria known as Bacillus anthracis. Anthrax can be found
naturally in soil and commonly affects domestic and wild animals
treated with __________ c. Amoxicillin n around the world. Domestic and wild animals such as cattle, sheep,
d. observation goats, antelope, and deer can become infected when they breathe in or
ingest spores in contaminated soil, plants, or water. In areas where
domestic animals have had anthrax in the past, routine vaccination can
help prevent outbreaks.

Inhalational anthrax develops after a 1- to 6-day incubation period, with

nonspecific symptoms, including malaise, myalgia, and fever. Over a
short period of time, these symptoms worsen, with development of
respiratory distress, chest pain, and diaphoresis. Characteristic chest
roentgenographic findings include
a widened mediastinum and pleural effusions.

Postexposure prophylaxis consists of administration of either

ciprofloxacin or doxycycline.93 If an isolate is demonstrated to be
penicillin-sensitive, the patient should be switched to amoxicillin.
Inhalational exposure followed by the development of symptoms is
associated with a high mortality rate. Treatment options include
combination therapy with ciprofloxacin, clindamycin, and rifampin;
clindamycin added to block production of toxin, while rifampin
penetrates into the central nervous system and intracellular locations.
78 What is the MOST common a. Astrocytoma a. Astrocytomas are the most common intramedullary tumors in Absite
intradural extramedullary b. Ependymoma Astrocytoma children, although they also occur in adults. They may occur at Schwartz
tumor in children? c. Dermoid all levels, although more often in the cervical cord. The tumor
d. Teratoma may interfere with the CSF-containing central canal of the spinal
cord, leading to a dilated central canal, referred to as
syringomyelia (syrinx).

Ependymomas are the most common intramedullary tumors in

adults.

Teratomas are germ cell tumors commonly composed of multiple cell

types derived from one or more of the 3 germ layers. Teratomas range
from benign, well-differentiated (mature) cystic lesions to those that are
solid and malignant (immature)

79 Advantages of laparoscopic a. Operative time a. Operative The advantages of laparoscopic adrenalectomy over open https://pubmed
adrenalectomy compared b. Incidence of wound time adrenalectomy are well documented and include ​a shorter hospital .ncbi.nlm.nih.g
with open adrenalectomy infection stay, a decrease in postoperative pain, shorter interval between ov/12537946/
surgery and return to preoperative activity level, and improved
include all of the following c. Narcotic analgesic use
cosmesis.
EXCEPT decreased d. Length of hospital stay
________

80 All of the following are true a. Treatment may require D. Etiologic factors Priapism is a persistent erection for greater than 4 hours unrelated
concerning priapism injection of include sickle cell to sexual stimulation.​ Priapism is divided into two types. The most
EXCEPT _______ phenylephrine disease, common
type—low-flow/ischemic priapism—is a medical emergency. On
b. Priapism is defined as malignancy, total
examination, the penis is very tender, and both cavernosal bodies will
persistent erection or parenteral nutrition,
 >4 hours unrelated to penile shaft be rigid while the glans will be flaccid. Decreased venous outflow with
sexual stimulation fractures. persistent inflow results in increased intracorporeal pressure and
c. Low flow priapism can tumescence, which is the normal process of erection. Risk factors
include sickle cell disease or trait, malignancy, medications, cocaine
be confirmed with a
abuse, certain antidepressants, and total
penile blood gas
parenteral nutrition. If a cause is not identified, a hematologic workup is
determination necessary to rule out malignancy or blood dyscrasias. The
d. Etiologic factors management of priapism is rapid detumescence with the goal of
include sickle cell preservation of future erectile function. The ability to achieve normal
disease, malignancy, erections is directly related to length of
total parenteral the episode of priapism.​ Low-flow priapism can be confirmed with a
nutrition, penile shaft penile blood gas of the cavernosal bodies demonstrating hypoxic,
fractures. acidotic blood.​ Initial management can include oral agents such as
peudoephedrine or baclofen, but more aggressive measures usually
are necessary to achieve rapid detumescence. Insertion of a
large-gauge needle (18-gauge) into the lateral aspect of one corporal
body allows thorough aspiration and irrigation of both corporal bodies
because of widely communicating channels.​ Injection of
phenylephrine (up to 200 mg in 20 mL normal saline) into the
corporal bodies may be required. ​For those with sickle cell disease,
hydration and oxygen administration should be performed first,
because these are sometimes successful in this group. A surgical shunt
is sometimes necessary to resolve the episode. Distal shunts should be
performed first, because they can be done quickly in the emergency
room with a True-Cut needle (Winter shunt).

81 Thyroid hormones (T3 and A. Visual acuity in Thyroid hormones affect almost every system in the body. They Schwartz 11e
T4) have regulatory roles in low-light conditions are important for fetal brain development and skeletal maturation.
all of the following EXCEPT (“night vision”) T3 increases oxygen consumption, basal metabolic rate, and
heat production. It has also positive inotropic and chronotropic
effects on the heart. Thyroid hormones are responsible for
 B. The speed of muscle maintaining the normal hypoxic and hypercapnic drive in the
contraction and respiratory center of the brain​. They also​ increase GI motility​,
relaxation leading to diarrhea in hyperthyroidism and constipation in
C. The hypoxia and hypothyroidism. Thyroid hormones also increase bone and
hypercapnia drives of protein turnover and the ​speed of muscle contraction and
the respiratory center relaxation​. That also increases glycogenolysis, hepatic
in the brain gluconeogenesis, intestinal glucose absorption, and cholesterol
D. Gastrointestinal motility synthesis and degradation.

82 The intentional dilution of A. Acute hypovolemic B Acute ​ he intentional dilution of blood volume is often referred to as
T Schwartz
blood volume often is normodilution (ahn) normovolemic acute normovolemic hemodilution (ANH) anemia. ANH is a
referred to as ______. anemia hemodilution (anh) technique in which whole blood is removed from a patient, while
B. Acute normovolemic anemi the circulating blood volume is maintained with acellular fluid.
hemodilution (anh) Blood is collected via central lines with simultaneous infusion of
anemia crystalloid or colloid solutions. Collected blood is reinfused after
C. Hypercoagulable major blood loss has ceased, or sooner, if indicated. Blood units
hemodilution (hh) are reinfused in the reverse order of collection. Under conditions
anemia of ANH, the increased plasma compartment becomes an
D. None of these important source of O2, which is delivered to tissues.

83 Which of the following A. Colloid solutions may C. Extracellular Because of a higher osmotic pressure, colloid solutions draw Schwartz
statements is NOT TRUE bind to the ionized fluid volume deficit extracellular fluid into the vascular space, increasing the
when a patient with fraction of serum is restored extracellular deficit. In addition, the ionized fraction of serum
hemorrhagic shock is calcium calcium is decreased, circulating levels of immunoglobulin drop,
resuscitated using an B. Circulating levels of and reaction to tetanus toxoid given to the patient suffering from
intravenous colloid solution immunoglobulins are major trauma is decreased. Endogenous production of albumin
rather than lactated ringer decreased production also decreases. Colloid resuscitation is no more
solution? effective than crystalloid resuscitation, and it is more expensive
 C. Extracellular fluid
volume deficit is
restored
D. Endogenous
production of albumin
is decreased

84 Which of the following occur A. Lipogenesis D. Hepatic ​ atecholamine release almost immediately prepares the body
C Schwartz 11e
as a result of epinephrine B. Hypoglycemia glycogenolysis for the “fight or flight” response with well-described effects on the
and norepinephrine? C. Insulin sensitivity cardiovascular and pulmonary systems, and on metabolism.
D. Hepatic glycogenolysis These include heart rate, myocardial contractility, conduction
velocity, and blood pressure; the redirection of blood flow to
skeletal muscle; increased cellular metabolism throughout the
body; and mobilization of glucose from the liver via
glycogenolysis​, gluconeogenesis, lipolysis, and ketogenesis. To
compound the resulting hyperglycemia, insulin release is
decreased maimly through the stimulation of a-adrenergic
pancreatic receptors.

85 Which factor does NOT A. Duration of procedure D. General ​The development of SSIs is related to three factors: Schwartz 11e
influence the development of B. Degree of microbial anesthesia 1. The degree of microbial contamination of the wound during
surgical site infections? contamination surgery
C. Malnutrition 2. The duration of the procedure; and
D. General anesthesia 3. Host factors such as diabetes, malnutrition, obesity, immune
suppression; and a number of other underlying disease states.

86 Which of the following is A. Decreases hepatic B. Acts as a potent The pituitary also releases vasopressin or antidiuretic hormone Schwartz
TRUE about antidiuretic gluconeogenesis mesenteric (ADH) in response to hypovolemia, changes in circulating blood
hormone production in B. Acts as a potent vasoconstrictor volume sensed by baroreceptors and left atrial stretch receptors,
injured patients? mesenteric and increased plasma osmolality detected by hypothalamic
vasoconstrictor osmoreceptors. Epinephrine, angiotensin II, pain, and
 C. Levels fall to normal hyperglycemia increase production of ADH. ADH levels remain
within 2 to 3 days of elevated for about 1 week after the initial insult, depending on the
the initial insult severity and persistence of the hemodynamic abnormalities.
D. Mediates secretion by ADH acts on the distal tubule and collecting duct of the nephron
the renin-angiotensin to increase water permeability, decrease water and sodium
system losses, and preserve intravascular volume. Also known as
arginine vasopressin, ADH acts as a ​potent mesenteric
vasoconstrictor, shunting circulating blood away from the
splanchnic organs during hypovolemia. ​This may contribute
to intestinal ischemia and predispose to intestinal mucosal barrier
dysfunction in shock states. Vasopressin also increases hepatic
gluconeogenesis and increases hepatic glycolysis.

87 Which constellation of A. Hypotension, wide D. Hypotension, ​ he classic Beck’s triad – dilated neck veins, muffled heart
T Schwartz 11e
clinical findings is suggestive pulse pressure, muffled heart tones, tones, and a decline in arterial pressure.​ Cardiac tamponade
of cardiac tamponade? tachycardia jugular venous occurs when sufficient fluid has accumulated in the pericardial
B. Hypotension, wide distension sac to obstruct blood flow to the ventricles. The hemodynamic
pulse pressure, jugular abnormalities in pericardial tamponade are due to elevation of
venous distension intracardiac pressures with limitation of ventricular filling in
C. Tachycardia, diastole with resultant decrease in cardiac output. Acutely, the
hypotension, jugular pericardium does not distend; thus a small amount may produce
venous distension cardiac tamponade.
D. Hypotension, muffled
heart tones, jugular
venous distension

88 Which of the following a. Free flap: flaps that are D. Flap contiguity: The composition of a flap describes its tissue components. The SCHWARTZ
definitions is INCORRECT? completely detached the position of a flap contiguity of a flap describes its position related to its source. 10TH ED
from the body prior to relative to its Distant flaps are transferred from a different anatomic region to P.1833
their reimplantation recipient bed the defect. They may remain attached to the source anatomic
 with microvascular region (pedicled flaps) or may be transferred as free flaps by
anastomoses microsurgery. These are completely detached from the body, and
b. Flap composition: their blood supply is reinstated by microvascular anastomoses to
Description of the recipient vessels close to the defect. The term pedicle was
tissue components originally used to describe a bridge of tissue that remains
within flap between a flap and its source, similar to how a peninsula remains
c. Pedicle: Bridge of attached to its mainland. However, as knowledge of flap blood
tissue that remains supply and (micro)vascular anatomy has improved over the
between a flap and its years, the term pedicle has increasingly become reserved for
source; blood vessels describing the blood vessels that nourish the flap.
that nourish a flap
d. Flap contiguity: the
position of a flap
relative to its recipient
bed

89 Regional anesthesia may be a. Renal disease Z

useful in patients with which b. Colorectal cancer
of the following conditions? c. Diabetes mellitus
d. Advanced liver disease

90 During a preoperative a. Cervical spine mobility; C. auscultation of Schwartz

physical examination, visualize uvula, lungs; wheezes; Principles of
specific areas to investigate artificial teeth; rales Surgery, 10th
for the respiratory system thyromental distance Ed
include b. Consciousness;
neurocognition;
peripheral sensory
c. Auscultation of lungs;
wheezes; rales
 d. Blood pressure;
standing and sitting,
bilateral; peripheral
pulses; heart
auscultation

91 Which is the most common a. Schwannoma C. ganglion cyst Ganglion cyst is the most common soft tissue tumor of the hand Schwartz
soft tissue tumor of the wrist? b. Lipoma and wrist, comprising 50% to 70% of all soft tissue tumors in this Principles of
c. Ganglion cyst region. They can occur at any age but are most common in the Surgery, 10th
d. Mucous cyst second to fourth decades with slight predilection toward females. Ed

92 All hand infections EXCEPT a. Osteomyelitis D. cellulitis All hand infections other than cellulitis will require surgical Schwartz
which of the following require b. Felon management. Clinical examination, particularly noting the area of Principles of
surgical management? c. Paronychia greatest tenderness and/or inflammation, is the single most Surgery, 10th
d. Cellulitis useful diagnostic tool to localize any purulence requiring Ed
drainage.

93 Which of the following is a. Displacement D. Prompt Pelvic fractures are indicative of high energy trauma and are Schwartz
NOT associated with pelvic associated with two or operative associated with head, chest, abdominal, and urogenital injuries. Principles of
fracture? more fractures in the intervention for Hemorrhage from pelvic trauma can be life threatening and Surgery, 10th
pelvic ring pubic rami fractures patients can present with hemodynamic instability, requiring Ed
b. Associated significant fluid resuscitation and blood transfusions.
genitourinary injury other associated injuries are bladder and urethral injuries that
c. Life - threatening manifest with bleeding from the urethral meatus or blood in the
hemorrhage catheter and need to be assessed with a retrograde urethrogram.
d. Prompt operative Because it is a ring, displacement can only occur if the ring is
intervention for pubic disrupted in two places. This may occur either from fractures of
rami fractures the bones or tears of the ligaments.
displaced sacral fractures and iliac wing fractures are treated with
screws or plates, while pubic rami fractures can usually be managed
nonoperatively.
94 The most common form of a. Esophageal atresia C. esophageal The most commonly seen variety is EA with distal TEF (type C), Schwartz
esophageal atresia (EA) is with proximal atresia with distal which occurs in approximately 85% of the cases in most series. Principles of
tracheoesophageal tracheoesophageal The next most frequent type is pure EA (type A), occurring in 8% Surgery, 10th
fistula fistula to 10% of patients, followed by TEF without EA (type E). Ed
b. Pure esophageal
atresia (no fistula)
c. Esophageal atresia
with distal
tracheoesophageal
fistula
d. Pure esophageal
fistula (no atresia)

95 A.​ A
​ pproximately 20% of
Which of the following cases are diagnosed C.Decompressive In approximately 20% of cases, the diagnosis of Hirschsprung’s disease Schwartz-
statements regarding ostomy should is made beyond the newborn period. Principles of
beyond the newborn
Hirschsprung disease is NOT period involve distal, surgery 10​th​ ed
These children have severe constipation, which has usually been
CORRECT? B.​ C ​ onstipation and nondilated bowel
treated with laxatives and enemas. Abdominal distention and
p. 1624-1626
abdominal distention
are classic symptoms failure to thrive may also be present at diagnosis.
C.​ ​Decompressive
Hirschsprung’s disease, described this condition as follows: “Congenital
ostomy should involve
megacolon
distal, nondilated
bowel is caused by a malformation in the pelvic parasympathetic system
D.​ ​The underlying which results in the absence of ganglion cells in Auerbach’s
pathology is
characterized by an plexus of a segment of distal colon. The classic surgical approach
absence of ganglion consisted of
cells in Auerbach
a multiple-stage procedure. This included a colostomy in the newborn
plexus period, followed by a definitive pull-through operation
 after the child was over 10 kg. There are three viable options for the
definitive pull-through procedure that are currently used. Although
individual surgeons may advocate

one procedure over another, studies have demonstrated that the

outcome after each type of operation is similar. For each

of the operations that is performed, the principles of treatment include

confirming the location in the bowel where the transition zone between
ganglionic and aganglionic bowel exists, resecting the aganglionic
segment of bowel, and performing an anastomosis of ganglionated
bowel to either the anus or a cuff of rectal mucosa (Fig. 39-23).

96 A.​ P
​ atients exposed to
Which of the following patient inorganic arsenic C. Patients with Exposure to herbicides such as phenoxyacetic acids and to wood Schwartz-
groups has a 1000 times xeroderm preservatives containing chlorophenols has been linked to an increased Principles of
B.​ T ​ ransplant patients on
increased risk of developing pigmentosa risk of soft tissue sarcoma.12 Several chemical carcinogens, including surgery 10​th​ ed
immunosuppression
thorium oxide (Thorotrast), vinyl chloride, and arsenic, have been
squamous cell carcinoma C.​ ​Patients with associated with hepatic angiosarcomas.(p.1466) p. 1817
(SCC)? xeroderm pigmentosa
D.​ ​Patients with actinic Actinic keratosis is a commonly detected abnormal proliferation of
keratosis intraepidermal keratinocytes primarily found in fair-skinned individuals.
The general behavior of this premalignant lesion is regression,
progression, or persistence, and their calculated 10-year potential to
transform into SCC

is between 6.1% and 10%. In fact, 60% to 65% of SCCs are believed to
originate from these precursor lesions.(p.486)

Transplant patients on immunosuppression

have a four-fold increased risk and patients

 with xeroderma pigmentosa have a 1000-fold increased risk of
developing an SCC. (P.1817)

97
The initial treatment for a A. Gastrostomy alone C. Repair of the Primary EA (type A) represents a challenging problem, Schwartz-
pure esophageal atresia (no esophageal atresia Principles of
B. Repair of the esophageal particularly if the upper and lower ends are too far apart for an
fistula) is ___ with placement of a surgery 10​th​ ed
atresia, Nissen fundoplication, anastomosis to be created. Under these circumstances, treatment
gastrostomy
strategies include placement of a gastrostomy tube and performing
and placement of a p.1608-1612
serial bougienage to increase the length of the upper pouch. This
gastrostomy
occasionally allows for primary anastomosis to be performed.
Occasionally, when the two ends cannot be brought
C. Repair of the esophageal
atresia with placement of a safely together, esophageal replacement is required using a gastric
gastrostomy pull-up, reverse gastric tube, or colon interposition.

D. Repair of the esophageal (p.1612)

atresia

98 A.​ 1
​ %
What is the estimated risk of B.​ 5​ % D. <0.5% The estimated risk of transmission from a needlestick from a source Schwartz-
transmission of human with HIV-infected blood is estimated at 0.3%. Transmission of HIV (and Principles of
C.​ ​10%
immunodeficiency virus (HIV) other infections spread by blood and body fluid) from patient to health surgery 10​th​ ed
D.​ ​<0.5%
care worker can be minimized by observation of universal precautions,
from a Source of
which include the following: (a) routine p.154
HIV-infected blood?
use of barriers (such as gloves and/or goggles) when anticipating
contact with blood or body fluids, (b) washing of hands and other skin
surfaces immediately after contact with blood or body fluids, and (c)
careful handling and disposal of sharp instruments during and after use.
(p.154)
99
A predicted 4 year survival A. 24 D. 97 Essentially, patients who have disease confined to one kidney that is Schwartz-
rate of a child with Wilm’s completely excised surgically receive a short course of chemotherapy Principles of
tumor that is confined to one B. 38 and can expect a 97% 4-year survival, with tumor relapse rare after that surgery 10​th​ ed
time.
kidney and is grossly excised
C. 68 P.1639
is _____%
D. 97

100 A.​ L
​ aparotomy, reduction
A premature infant boy has of the volvulus, division D. Nasogastric In all infants suspected of having NEC, feedings are Absite 9​th​ ed
been started on enteral feeds of adhesions, decompression, discontinued, a nasogastric tube is placed, and broad-spectrum
shortly after birth, but parenteral nutrition, parenteral antibiotics are given. The infant is resuscitated, and Chap.39
appendectomy
develops feeding intolerance B.​ W ​ ater-soluble broad-spectrum inotropes are administered to maintain perfusion as needed.
2 weeks postnatally. He contrast enema antibiotics. Intubation and mechanical ventilation may be required to
displays abdominal C.​ ​Laparotomy, excision maintain oxygenation. TPN is started. Subsequent treatment may
tenderness, distention, and of the affected bowel be influenced by the particular stage of NEC that is present.
bloody stools. An abdominal with ostomy Patients with Bell stage I disease are closely monitored and
radiograph is obtained. What D.​ ​Nasogastric generally remain on nil per os (NPO) status and are given IV
should be the next step in decompression, antibiotics for 7 to 10 days before enteral nutrition is resumed.
management? parenteral nutrition, After this time, provided the infant fully recovers, feedings may
broad-spectrum be reinitiated. Patients with Bell II disease merit close
antibiotics. observation. Serial physical examinations are performed to look
for the development of diffuse peritonitis, a fixed mass,
progressive abdominal wall cellulitis, or systemic sepsis. If the
infant fails to improve after several days of treatment,
consideration should be given to exploratory laparotomy.