SURGERY

A 65 y/o M, smoker, obese presented at the ER with sudden, severe abdominal pain. The PE of the abdomen was normal. What is the most probable diagnosis? A. Acute mesenteric ischemia B. Acute perforated PUD C. Acute appendicitis D. Acute diverticulitis E. NOTA

45 A. Abdominal pain with severity out of proportion to PE findings is the hallmark of acute mesenteric ischemia.

What is the risk of perforation of acute appendicitis? A. 25% by 24 hours from onset of symptoms B. 50% by 24 hours from onset of symptoms C. 75% by 24 hours from onset of symptoms D. 100% by 24 hours from onset of symptoms E. NOTA

48 A. The risk of perforation of acute appendicits is as follows: 25% by 24 hours rom onset of symptoms, 50% by 36 hours, and 75% by 48 hours

What is the most common appendicial tumor? A. Carcinoid tumor B. Mucinous tumor C. Serous tumor D. Brenner tumor E. Dysplastic tumor

49 A. Carcinoid tumors are the most common appendicial tumor. <5% of which are malignant.

Which of the following maneuvers involve clamping of the portal triad and is used for hemostasis and control of bleeding during hepatic surgery? A. Madison meneuver B. Pringle maneuver C. Henderson’s maneuver D. Koch maneuver E. Rovsing maneuver

5 B. SIMILAR TO PREVIOUS BOARD EXAM CONCEPT/PRINCIPLE Source: Schwartz’s Principles of Surgery 8th ed p 1128

The amount of time kidneys for transplantation can be preserved is: A. 6-8hrs B. 16hrs C. 24hrs D. 36-40hrs E. 48-72hrs

1 D. 6-8hrs - heart and lungs 16hrs - liver 24hrs - pancreas 36-40hrs - kidneys Source: Schwartz's Principles of Surgery 8th ed p 282

A 43 year old male incurred corneal scarring from eye herpes and lost vision of his left eye. A full thickness corneal transplant was done. Examples of full thickness keratoplasty include: A. Penetrating keratoplasty B. Descemet stripping with endothelial keratoplasty C. Descemet membrane keratoplasty D. A and B E. All of the above

10 A. Penetrating keratoplasty â€" full thickness Partial thickness - Deep anterior lamellar keratoplasty - Descemet stripping with endothelial keratoplasty - Descemet membrane keratoplasty SIMILAR TO PREVIOUS BOARD EXAM CONCEPT/PRINCIPLE Source: Corneal Endothelial Transplant DSEAK, DMEK and DLEK By John Thomas (MD.), Thomas John

20. Which of the following types of esophageal hiatal hernia is characterized by upward dislocation of both the cardia and the gastric fundus? a. type II rolling b. type I sliding c. type III sliding-rolling d. type IV e. NOTA

100 C. Schwartz Principles of SUrgery 9th edition p. 842

Which of the following structures are removed in a skin sparing mastectomy? A. All breast tissue B. Nipple areola complex C. Scars from previous biopsy procedures D. A and B E. All of the above

11 E. Breast conservation â€" resection of primary breast cancer + margin of normal appearing breast tissue + assessment of regional lymph node status Radical mastectomy â€" Medial/Lateral pectoral nerves, Long thoracic nerve, Thoracodorsal nerve + Pectoralis Major and minor + All LN + All breast Modified radical mastectomy â€" Same as Radical mastectomy except all nerves are spared, level III LN spared, Pectoralis major spared Source: Schwartz’s Principles of Surgery 8th ed p 460-461 + Topnotch Lecture on Surgery

Which of the following pertains to Osteonecrosis of the proximal femoral epiphysis of the pediatric hip and is thought to be due to vascular compromise? A. Slipped capital femoral epiphysis B. Developmental dysplasia of the hip C. Talipes equinovarus D. Legg-Calve-Perthes disease E. Osgood-Schlatter disease

12 D. Legg-Calve-Perthes disease also known as cox plana is a condition fo the pediatric hip characterized by a flattened misshapen femoral head. The etiology is related to osteonecrosis of the proximal femoral epiphysis and is thought to result from vascular compromise. SIMILAR TO PREVIOUS BOARD EXAM CONCEPT/PRINCIPLE Source: Schwartz’s Principles of Surgery 8th ed p 1605

Which of the following orthopedic conditions describe a form of neuropathic arthropathy that affects some diabetics with peripheral neuropathy? A. Charcot joints B. Osgood Schlatter Disease C. Paget Schroetter Disease D. Kimmel-Steil Wilson Lesions E. None of the above

13 A. It may also occur with several other diseases that affect the sensory nervous system (alcoholism, leprosy, syphilis, Charcot-Marie- Tooth Disease to name a few). In the United States, diabetes is the number-one cause. SIMILAR TO PREVIOUS BOARD EXAM CONCEPT/PRINCIPLE Source: https://www.aofas.org/footcaremd/conditions/ diabetic-foot/Pages/Charcot-Joints-or- Neuropathic-Arthropathy.aspx

A 57 year old male with poorly controlled hypertension presents with acut onset painless loss of vision in the left eye. PE reveals a relative afferent pupillary defect and fundoscopy of the affected eye showed “cherry red spot†over a pale background. What is the diagnosis? A. Rhegmatogenous retinal detachment B. Age related macular degeneration C. Central serous retinopathy D. Central retinal artery occlusion E. Central retinal vein occlusion

14 D. Also called amaurosis fugax. Management options include direct infusion of thrombolytic to the ophthalmic artery or by decreasing IOP (IV acetazolamide or vitreous paracentesis) SIMILAR TO PREVIOUS BOARD EXAM CONCEPT/PRINCIPLE Source: http://www.williamsoneyeinstitute.com/retina- center/retinal-artery-occlusions

Which of the following aortic aneurysms merit/merits operative management? A. Sudden onset lower back pain in a man diagnosed with aortic aneurym 6 months ago. Last CT showed diameter of 4.5cm. B. Asymptomatic ascending thoracic aortic aneurysm of 5.75cm C. Asymptomatic descending thoracic aortic aneurysm of 5.75cm D. A and B only E. All of the above

15 D. Indications for repair of aortic aneurysms in asymptomatic patients without connective tissue disorders - Ascending aortic aneurysm >5.5cm diameter - Descending aortic aneurysm >6.5cm diameter - Abdominal aorta >5.5cm - Rate of dilatation >1cm/yr for thoracic aorta/ >0.5cm for abdominal aorta Normal aortic diameter: 2-3cm Source: Schwartz’s Principles of Surgery 8th ed p 671, 723

Dr. Juan dela Cruz is assisting in a bowel surgery and is about to do an anastomosis. Which of the following is the strongest layer of the of the bowel wall that he has to pay special attention to? A. Mucosa B. Submucosa C. Muscularis Propria D. Serosa E. Adventitia

16 B. Tensile strength Aorta: Tunica media GIT: submucosa Source: Schwartz’s Principles of Surgery 8th ed p 667 + Topnotch handout in surgery

A 42-year-old jaundiced female with pancreatic cancer is admitted at the female ward of the hospital you are on duty in. She has been febrile for 24 hours now and the nurse refers her to you for changes in sensorium. You evaluate her and on PE, her vitals were HR 98 RR 20 BP 80/50 T38.9. What is the next step in management? A. IV antibiotics and fluids B. Laparoscopic cholecystectomy with sphincterotomy C. Emergency exploratory laparotomy D. Whipple’s procedure E. Bowel resection with end to end anastomosis

17 A. This is a case of ascending cholangitis secondary to biliary tract obstruction secondary to a pancreatic mass. The patient presented with Raynaud’s pentad. The initial management in such patients is IV antibiotics and fluid resuscitation. About 15% of patients will not respond to antibiotics and fluid resuscitation and an emergency biliary decompression may be required. Source: Schwartz’s Principles of Surgery 8th ed p 1150

A 15 year old female has a history of intermittent abdominal pain and jaundice. On PE, hepatosplenomegaly was noted. A ultrasound revealed intrahepatic biliary cysts. What is the diagnosis? A. Choledochal cyst type I B. Choledochal cyst type II C. Choledochal cyst type III D. Choledochal cyst type IV E. Choledochal cyst type V

18 E. Choledochal cyst type I â€" saccular/fusiform dilatation Choledochal cyst type II â€" isolated diverticulum Choledochal cyst type III - choledochocele Choledochal cyst type IV â€" dilatations of the intra and extrahepatic/ extrahepatic biliary tree only Choledochal cyst type V â€" dilatation of the intrahepatic biliary tree Source: Schwartz’s Principles of Surgery 8th ed p 1158

The law of Laplace states that as the diameter of the lumen of cavity increases, the wall tension also increases. Which segment of the GIT has the widest luminal diameter and is thus most prone to rupture and least prone to obstruction? A. Cecum B. Appendix C. Sigmoid colon D. Transverse colon E. Duodenum

19 A. Normal cecum has a luminal diameter of 7.5- 8.5cm and becomes at risk at 10cm. Sigmoid colon is the narrowest part and most vulnerable to obstruction and also most mobile and vulnerable to volvulus. Source: Schwartz’s Principles of Surgery 8th ed p 1015

Which of the following treatment used for the management of burn wounds can be absorbed systemically and cause metabolic acidosis? A. Silver nitrate B. Silver sulfadiazine C. Mafenide acetate D. A and B E. All of the above

2 C. Silver sulfadiazine - antimicrobial activity, soothing quality, inexpensive and easily applied, neutropenia Mafenide acetate - antimicrobial activity, painful, metabolic acidosis Silver nitrate - antimicrobial activity, hyponatremia, methemoglobinemia, black staining Source: Schwartz's Principles of Surgery 8th ed p 202

A 42-year old man with gunshot wound to the RUQ and epigastric area arrives in the ER drowsy, pale with a BP = 80/60, HR = 120, RR = 35. Abdomen is distended, tense and with diffuse rebound tenderness. What is the most appropriate procedure? A. Laparotomy B. Stat CT scan of the abdomen C. Stat Diagnostic peritoneal lavage D. Stat FAST E. Observation

20 A. Patient is already unstable hence should be opened for exploratory laparotomy. Source: Topnotch handout on Surgery

Thyroglossal duct cysts are most commonly located A. On the anterior border of the sternocleidomastoid muscle B. In the midline at the level of the hyoid C. Over the medial clavicular head D. In the midline just superior to the thyroid gland E. Behind the base of the tongue near the foramen cecum

21 B. Thyroglossal duct cysts are the most commonly encountered congenital cervical anomalies. During the fifth week of gestation, the thyroglossal duct lumen starts to obliterate, and the duct disappears by the eighth week of gestation. Rarely, the thyroglossal duct may persist in whole, or in part.

A patient with hypertension is diagnosed with hyperaldosteronism. A CT scan shows bilaterally enlarged adrenals without a mass. The most appropriate next intervention is A. Unilateral adrenalectomy B. Bilateral adrenalectomy C. Selective venous catheterization D. Medical management E. Observation

22 C. If an adrenal tumor is not seen or if both adrenals are abnormal on CT scan, selective venous catheterization and adrenal vein sampling for aldosterone can help determine if the aldosteronoma is unilateral, because this can benefit from surgery. Bilateral adrenal tumors or adrenal hyperplasia are best managed medically.

A 70 year old male incurred 20% TBSA burns. If PE revealed normal and stable vital signs, how much fluids should be given to him in the first hour? A. 250cc B. 350cc C. 450cc D. 550cc E. 1 L fast drip

3 B. Parkland formula = 4ml*kg*%burned, given in the first 8hrs then the next half given over the next 16hrs. 70x20x4/2/8 = 350cc Source: Schwartz's Principles of Surgery 8th ed p 200

A 60-year-old woman develops a right-sided colonic adenocarcinoma. She has a history of alleged colonoscopies; however, review of images from her most recent colonoscopy reveals a prominent fold in the region that subsequently developed cancer. Biopsy from this area would have most likely revealed which of the following? A. Tubular adenoma B. Hyperplastic polyp C. Peutz-Jeghers polyp D. Sessile serrated adenoma E. Inflammatory polyp

23 D. Sessile serrated adenomas can be very subtle and are easily missed on endoscopy. Under the microscope, they closely resemble hyperplastic polyps but show more complicated glands, often with “boot-shaped†configurations at the gland bases. Unlike tubular adenomas, they lack the overtly dysplastic epithelium and often do not form polypoid lesions. Hyperplastic polyps, Peutz-Jeghers polyps, and inflammatory polyps are not malignant precursors.

The most common type of hiatal hernia is A. Type I B. Type II C. Type III D. Type IV E. Type V

24 A. SIMILAR TO PREVIOUS BOARD EXAM CONCEPT/PRINCIPLE. There were 3 questions about esophageaWith the advent of clinical radiology, it became evident that a diaphragmatic hernia was a relatively common abnormality and was not always accompanied by symptoms. Three types of esophageal hiatal hernia were identified: (a) the sliding hernia, type I, characterized by an upward dislocation of the cardia in the posterior mediastinum; (b) the rolling or paraesophageal hernia (PEH), type II, characterized by an upward dislocation of the gastric fundus alongside a normally positioned cardia; and (c) the combined sliding-rolling or mixed hernia, type III, characterized by an upward dislocation of both the cardia and the gastric fundus. The end stage of type I and type II hernias occurs when the whole stomach migrates up into the chest by rotating 180° around its longitudinal axis, with the cardia and pylorus as fixed points. In this situation the abnormality is usually referred to as an intrathoracic stomach. In some taxonomies, a type IV hiatal hernia is declared when an additional organ, usually the colon, herniates as well. When radiographic examinations are done in response to GI symptoms, the incidence of a sliding hiatal hernia is seven times higher than that of a PEH. The PEH is also known as the giant hiatal hernia. Over time the pressure gradient between the abdomen and chest enlarges the hiatal hernia. In many cases the Type 1 sliding hernia will evolve into a type II mixed hernia. Type II Hernias are rare.

Which of the following infections have been correlated with nasopharyngeal carcinoma? A. Herpes simplex virus B. Epstein Barr virus C. Cytomegalovirus D. Human immunodeficiency virus E. Human Papilloma Virus

25 B. There are plenty of ENT questions in our Surgery Exam. Risk factors for nasopharyngeal carcinoma include area of habitation, ethnicity, and tobacco use. There is an increased incidence of nasopharyngeal cancer in southern China, Africa, Alaska, and in Greenland Eskimos. A strong correlation exists between nasopharyngeal cancer and the presence of EBV infection, such that EBV titers may be used as a means to follow a patient’s response to treatment.

A classic Le Fort Type I fracture involves the: A. Forehead B. Nose C. Maxilla D. Mandible E. Zygomatic

26 C. Le Fort I fractures occur transversely across the alveolus, above the level of the teeth apices. In a pure Le Fort I fracture, the palatal vault is mobile while the nasal pyramid and orbital rims are stable. The Le Fort II fracture extends through the nasofrontal buttress, medial wall of the orbit, across the infraorbital rim, and through the gomaticomaxillary articulation. The nasal dorsum, palate, and medial part of the infraorbital rim are mobile. The Le Fort III fracture is also known as craniofacial disjunction. The frontozygomaticomaxillary, frontomaxillary, and frontonasal suture lines are disrupted. The entire face is mobile from the cranium.

The yearly mammogram of a 65-year-old postmenopausal woman shows an irregular area of microcalcification that has grown in size compared with her mammogram from 2 years ago. She missed her mammogram last year. Physical examination is unrevealing without lymphadenopathy or nodularity in the breasts. You refer her to a surgeon, and a 2-cm invasive ductal carcinoma is removed from her left breast. Sentinel node biopsy shows two positive lymph nodes, and axillary dissection reveals five additional positive nodes. The tumor expresses the estrogen receptor (ER ). Which of the following interventions would increase her chance of cure? A. Chemotherapy followed by hormonal therapy B. Radiation therapy C. Total mastectomy D. Hormonal therapy alone E. High-dose chemotherapy with stem cell support

27 A. This patient is at high risk of recurrence by virtue of having disease in her lymph nodes. Radiation therapy or surgical excision of the breast cancer usually provides local control and adequate protection against recurrence of disease in the tumor bed. However, micrometastatic disease can only be addressed through the administration of systemic therapy such as cytotoxic chemotherapy. In patients with hormonally sensitive tumors (e.g., estrogen- receptor positive), hormonal therapy has been shown to be very effective in the prevention of disease recurrence after chemotherapy. Randomized clinical trials have shown that lumpectomy and radiation therapy is equal to a total mastectomy in terms of overall survival. For tumors that can be completely removed with adequate margins (10 mm), lumpectomy offers better cosmetic and psychological results, is less invasive, and allows for faster recovery time.

The Norwood procedure is used in the treatment of A. Coarctation of the aorta B. TGA C. Hypoplastic left heart syndrome D. Truncus Arterious E. TAPVC

28 C. Hypoplastic left heart syndrome - Norwood + Glenn + modified Fontan; TGA - palliative: Rastelli, arterial switch: Jenning, atrial switch:Senning/Mustard; TOF - palliative: Blalock-Taussig shunt

An aortic dissection that extends from the left subclavian artery to the aortic bifurcation is a A. DeBakey Type I dissection B. DeBakey Type II dissection C. DeBakey Type IIIa dissection D. DeBakey Type IIIb dissection E. DeBakey Type IV dissection

29 D. Dissections are categorized according to their anatomic location and extent to guide treatment. The two traditional classification schemes that remain in common use are the DeBakey and the Stanford classification systems. In their current forms, both of these schemes describe the segments of aorta that are involved in the dissection, rather than the site of the initial intimal tear. The main drawback of the Stanford classification system is that it does not distinguish between patients with isolated ascending aortic dissection and patients with dissection involving the entire aorta. DeBakey type I: involves ascending and descending aorta (= Stanford A) DeBakey type II: involves ascending aorta only (= Stanford A) DeBakey type III: involves descending aorta only, commencing after the origin of the left subclavian artery (= Stanford B). Type III dissections are further divided into IIIa and IIIb. DeBakey Type IIIa refers to dissections that originate distal to the left subclavian artery but extend proximally and distally, mostly above the diaphragm. DeBakey Type IIIb refers to dissections that originate distal to the left subclavian artery, extend only distally, and may extend below the diaphragm

The treatment of stage II pressure sores is A. Local wound care only B. Extensive débridement and local wound care C. Direct closure D. Skin grafting E. Observation

30 A. Stage I and II ulcers are treated conservatively with dressing changes and basic pressure ulcer prevention strategies as already discussed. Patients with stage III or IV ulcers should be evaluated for surgery.

The most common location for a congenital diaphragmatic hernia is A. Left posterolateral B. Right posterolateral C. Left anteromedial D. Right anteromedial E. Right anterolateral

31 A. SIMILAR TO PREVIOUS BOARD EXAM CONCEPT/PRINCIPLE. The most common variant of a congenital diaphragmatic hernia (CDH) is a posterolateral defect, also known as a Bochdalek’s hernia. This anomaly is encountered more commonly on the left (80 to 90% of cases).

A 60-year-old man with newly diagnosed prostate cancer comes to see you. He underwent transrectal ultrasonography with a needle biopsy showing adenocarcinoma. Except for elevated PSA, he is currently asymptomatic. The fi rst test to order in staging for his prostate cancer is: A. Full-body plain film x-rays B. Bone scan C. CT of head D. CEA level E. Repeat PSA now

32 B. The correct answer is to do a bone scan. This is the first staging test done in the workup of prostate cancer. If abnormalities are found on the bone scan, you then proceed to do plain film x-rays of the areas to exclude other possible causes. Then you would perform surgical staging with removal and examination of the surrounding nodes (often done with prostatectomy).

Patients with symptoms from a Chiari I malformation may complain of: A. Seizures B. Extremity weakness C. Eye pain D. Ataxia E. Dysautonomia

33 B. SIMILAR TO PREVIOUS BOARD EXAM CONCEPT/PRINCIPLE. Chiari I malformation is the caudal displacement of the cerebellar tonsils below the foramen magnum. It may be seen as an incidental finding on MRI scans in asymptomatic patients. Symptomatic patients usually present with headache, neck pain, or symptoms of myelopathy, including numbness or weakness in the extremities. A syrinx may be associated, but the brain stem and lower cranial nerves are normal in Chiari I malformations. Chiari II malformations are more severe and involve caudal displacement of the lower brain stem and stretching of the lower cranial nerves. Symptomatic patients may be treated with suboccipital craniectomy to remove the posterior arch of the foramen magnum, along with removal of the posterior ring of C1. Removal of these bony structures relieves the compression of the cerebellar tonsils and cervicomedullary junction, and may allow reestablishment of normal CSF flow patterns.

A clerk rotating on a radiology elective was presented an x-ray of the abdomen, which showed multiple airâ€"fluid levels with dilated loops of small bowel, paucity of air in the colon, and no air in the rectum. The radiology consultant asked the clerk which of the following clinical features would most likely be found in this patient: A. Hypoactive bowel sounds B. Pain out of proportion to physical examination C. Crampy abdominal pain that waxes and wanes D. Diarrhea E. A flat, rigid abdomen

34 C. The patient has a mechanical intestinal obstruction, as the description of the airâ€"fluid levels indicates a mechanical intestinal obstruction. Mechanical intestinal obstruction may be the result of extrinsic, intramural, or intraluminal causes. Symptoms include crampy abdominal pain that waxes and wanes, obstipation or constipation, nausea and vomiting, and abdominal distention. Physical examination of the abdomen reveals high- pitched bowel sounds and rushes and tinkles, as well as marked abdominal distention and tympany on percussion. Pain out of proportion to the physical examination is most suggestive of acute mesenteric ischemia.

A 51-year-old man with recurrent peptic ulcer disease had a fasting gastrin level of 1000. Which of the following organs is the most common site of origin of the tumor associated with this syndrome? A. Stomach B. Duodenum C. Lymph nodes D. Spleen E. Pancreas

35 E. Zollingerâ€"Ellison syndrome is caused by a nonâ€" islet cell tumor that produces gastrin and is associated with gastric acid hypersecretion and peptic ulcer disease. Tumors are biologically malignant in 60% of cases, and the most common site involved is the pancreas. Most gastrinomas are found in the gastrinoma triangle (Passaro's triangle): this is bound by the junction of cystic and common bile ducts, junction of the second and third parts of the duodenum, and the junction of the neck and body of the pancreas.

Paraphimosis refers to: A. Inability to retract the foreskin B. Inability to reduce the foreskin after it has been retracted C. Infection of the foreskin near the urethral meatus D. Excessive length of foreskin E. Incomplete embryologic formation of the foreskin

36 B. Paraphimosis is a common problem that represents a true medical emergency. When foreskin is retracted for prolonged periods, constriction of the glans penis may ensue. This is particularly likely in hospitalized patients who are confined to bed or who have altered mentation. Edema often forms in the genitals of supine patients due to the dependent position of that area. Patients with diminished consciousness will not be aware of the penile pain from paraphimosis, which may delay recognition of the problem until too late. Delay can be catastrophic as penile necrosis may occur due to ischemia.

Which of the following is NOT part of Cantrell’s pentalogy? A. Omphalocele B. Ectopia cordis C. Posterolateral diaphragmatic hernia D. Cardiac anomalies E. cleft sternum

37 C. Omphalocele has an incidence of approximately 1 in 5000 live births and occurs in association with special syndromes such as exstrophy of the cloaca (vesicointestinal fissure), the Beckwith- Wiedemann constellation of anomalies (macroglossia, macrosomia, hypoglycemia, visceromegaly, and omphalocele) and the Cantrell pentalogy (lower thoracic wall malformations such as cleft sternum, ectopia cordis, epigastric omphalocele, anterior midline diaphragmatic hernia, and cardiac anomalies)

A 10-year-old presents with a painless swelling along her lateral neck. Ultrasound reveals a fluid- filled cyst. What is the most common origin of this anomaly? A. Thyroglossal duct cyst B. First branchial cleft cyst C. Second branchial cleft cyst D. Third branchial cleft cyst E. Fourth branchial cleft cyst

53 C. The second branchial cleft anomaly is the most common and usually presents on the first decade of life. Treatment is by complete excision

A 25-year-old female with protein C deficiency presents with the acute onset RUQ pain and jaundice. Her evaluation reveals occlusion of her hepatic veins at the level of her IVC. What is the immediate first treatment? A. IVC filter B. Systemic anticoagulation C. Systemic fibrinolysis D. Thrombolectomy E. AOTA

54 B. The syndrome described is Budd-Chiari Syndrome. First line therapy is systemic anticoagulation

A 30-year-old man is evaluated for a thyroid nodule. T he patient reports that his father died from thyroid cancer and that a brother had a history of recurrent renal stones. Blood calcitonin concentration is 2000 pg/mL (normal is < 100); serum calcium and phosphate levels are normal. T he patient is referred to a thyroid surgeon. Which of the following studies should also be obtained? A. Obtain a liver scan. B. Measure parathormone level. C. Measure urinary catecholamines. D. Administer suppressive doses of thyroxine and measure levels of thyroid-stimulating hormone. E. Treat the patient with radioactive iodine.

38 C. For the patient described, the markedly increased calcitonin level indicates the diagnosis of medullary carcinoma of the thyroid. In view of the family history, the patient most likely has multiple endocrine neoplasia (MEN) type 2A, which includes medullary carcinoma of the thyroid gland, pheochromocytoma, and parathyroid hyperplasia. Pheochromocytoma may exist without sustained hypertension, as indicated by excessive urinary catecholamines. Before thyroid surgery is performed on this patient, a pheochromocytoma must be ruled out through urinary catecholamine determinations; the presence of such a tumor might expose him to a hypertensive crisis during surgery. T he serum calcium serves as a screening test for hyperparathyroidism. At surgery, the entire thyroid gland must be removed because foci of parafollicular cell hyperplasia, a premalignant lesion, may be scattered throughout the gland. Successful removal of the medullary carcinoma can be monitored with serum calcitonin levels. Medullary carcinoma of the thyroid rarely metastases to the liver, so a liver scan would be unnecessary if liver enzymes are normal. Thyroxine will be needed after surgery, but MEN type 2 is not associated with hypothyroidism. Radioactive iodine can be used to treat malignancies that arise from the follicular cells of the thyroid; parafollicular cells, however, do not take up iodine and do not respond to radioactive iodine. Hyperparathyroidism, while unlikely in this eucalcemic patient, is probably present in his brother.

A 61-year-old man with a history of gastroesophageal reflux disease and Barrett’s esophagus is undergoing a screening endoscopy. The biopsy results show high-grade dysplasia. What is the recommended treatment approach? A Refer the patient to a surgeon for esophagectomy. B Repeat surveillance endoscopy in 6 months. C Repeat surveillance endoscopy in 1 year. D No further endoscopy is indicated unless the patient becomes symptomatic. E Initiate chemotherapy.

39 A. Barrett’s esophagus with high-grade dysplasia requires defi nitive treatment, and referral for esophagectomy is recommended. For patients who are medically unstable or for those who refuse surgery, endoscopic resection or photodynamic therapy are viable alternatives. Surveillance alone is inappropriate, making B and C incorrect. (Surveillance endoscopy at 6 months and 1 year are recommended for patients with Barrett’s esophagus with low- grade dysplasia and no dysplasia, respectively.) Chemotherapy is not indicated unless carcinoma in found.

In which type of hiatal hernia does the fundus of the stomach herniate? A. Type I B. Type II C. Type III D. Type IV E. Type V

4 B. Type I (sliding) â€" cardia Type II (rolling) â€" fundus Type III â€" cardia and fundus Type IV â€" intestines SIMILAR TO PREVIOUS BOARD EXAM CONCEPT/PRINCIPLE Source: Schwartz’s Principles of Surgery 8th ed p 842

A 6-year-old presents with a tibial fracture of the metaphysis extending across the growth plate. This would be a A. Salter-Harris type 1 fracture B. Salter-Harris type 2 fracture C. Salter-Harris type 3 fracture D. Salter-Harris type 4 fracture E. Salter-Harris type 5 fracture

40 B. Classification of growth plate injuries has important implications as doctors communicate about the treatment of a patient. The exact type of physeal injury is important for the prognosis and treatment of the fracture. Salter and Harris described a very useful classification of growth plate injuries. A type I injury is a simple transverse failure of the physis without involvement of the ossified epiphysis or metaphysis. A Salter-Harris type II fracture contains a component of fracture through the growth plate in continuity with a fracture of the metaphysis. Salter-Harris type III fracture occurs partially through the epiphysis and partially through the growth plate. These fractures are essentially always intra-articular. A Salter-Harris type IV injury is one which has a fracture line extending through the physis extending from the metaphysis through into the epiphysis. Finally, a Salter-Harris type V injury is a subtle injury where the physis itself is injured but not displaced.

Absolute contraindications to Breast Conservative Surgery A. Prior RT B. Preganancy C. Positive margins D. Multicentric E. AOTA

41 E. Absolute contraindications to BCS include A. Prior RT B. Preganancy C. Positive margins D. Multicentric E. Diffuse microcalcifications

To confirm a diagnosis of achalasia, the following should be requested A. EGD B. Manometry C. CT scan D. Barium swallow E. 24 hours pH monitoring

42 B. To confirm a diagnosis of achalasia, manometry should be requested.

What is the basal caloric requirement (kcal/Kg/day) of a normal healthy individual? A. 20 B. 25 C. 30 D. 35 E. 40

43 B. basal requirement: 25; mild stress: 25-30; moderate stress: 30; severe stress 35-40

Single most important test in the evaluation of thyroid nodules: A. Core needle biopsy B. Fine needle aspiration biopsy C. Thyroid ultrasound D. Excision biopsy E. Incision biopsy

44 B. FNAB - single most important test in evaluation of thyroid nodules; core needle biopsy - for breast nodules

Most common presentation of Meckel's Diverticulum in adults A. Bleeding B. Perforation C. Intractability D. Obstruction E. NOTA

46 D. Intestinal obstruction is the most common presentation of Meckel's diverticulum in adults.

The most common abnormality of hemostatis in the surgical patients A. Anemia B. Hypovolemia C. Thrombocytopenia D. Leukopenia E. DIC

47 C.

A 67-year-old otherwise healthy male presents with a TAA. What are the indications for repair? A. TAA > 8 cm B. TAA in asymptomatic patient C. TAA growth rate > 0.5 cm/year D. TAA > 5 cm in the setting of a connective tissue disorder E. AOTA

50 D. A. TAA > 6 cm B. TAA in a symptomatic patient (e.g., aortic insufficiency) C. TAA growth rate > 1 cm/year D. TAA > 5 cm in the setting of a connective tissue disorder

What are the six P’s of acute limb ischemia? A. Pain, purple, paralysis, paresthesias, pulselessness, poikilothermia B. Pain, purple, pathologic, paresthesias, pulselessness, poikilothermia C. Pain, pallor, paralysis, paresthesias, pulselessness, poikilothermia D. Pain, pallor, pathologic, paresthesias, pulselessness, poikilothermia E. Pain, pallor, paralysis, paretic, pulselessness, poikilothermia

51 C. Pain, pallor, paralysis, paresthesias, pulselessness, poikilothermia

Charaterized by chronic eczematoid eruption of the nippe A. Tubular carcinoma B. Mucinous carcinoma C. Paget's disease D. Inflammatory carcinoma E. Medullary carcinoma

52 C. Paget's disease is a chronic, eczematous eruption of the nipple. Large pale vacuolated cells in the rete pegs of epithelium (Paget cells) are pathognomonic.

What is the most common location of an insulinoma? A. Pancreatic head B. Pancreatic tail C. Evenly distributed throughout the pancreas D. Gastrinoma triangle E. Pancreatic body

55 C. Insulinoma: Evenly distributed throughout the pancreas Gastrinoma: Gastrinoma triangle Glucagonoma: Pancreatic tail

What is the most common cause of fever in the first 48 hours post-operatively? A. Atelectasis B. Pneumonia C. UTI D. Wound infection E. Seroma

56 A. Atelectasis is the most common cause of in the first 48 hours post-operatively.

What sedative medication has caloric value? A. propofol B. midazolam C. desflurane D. fentanyl E. NOTA

57 A. Propofol delivers 1 kcal/cc in the form of lipid.

Most common origin of masses in the pre-styloid compartment of the parapharyngeal space A. Salivary B. Paraganglioma C. Neurogenic D. Lymph nodes E. Vascular

58 A. 45% of the pre-styloid tumors/masses are pre- styloid in origin.

Most common site of perforation of the colon A. Cecum B. Ascending colon C. Transverse colon D. Descending colon E. Sigmoid colon

59 A. The cecum is the widest portion but has the thinnest wall; thus, it is the most common site of perforation. The sigmoid is the narrowest portion; thus, it is the most common site of obstruction.

Patient is diagnosed with a superior sulcus tumor (a form of lung adenocarcinoma). Invasion of nearby structures results to which clinical findings? A. Hoarseness B. Back pain C. Ptosis, miosis, anhidrosis D. Shoulder pain, hiccups and dyspnea E. Conjunctival edema, swelling of the head and neck, headache

6 C. This is a case of pancoast syndrome. Invasion of the stellate sympathetic ganglion results to the classic Horner’s triad â€" ptosis, miosis, anhidrosis. SIMILAR TO PREVIOUS BOARD EXAM CONCEPT/PRINCIPLE Source: Schwartz’s Principles of Surgery 8th ed p 534

What is the most common indication for intubation? A. Facial trauma B. Hypotension C. Flail chest D. Pulmonary contusion E. Altered mental status

60 E.

Which of the ff is not a component of the SIRS criteria? A. Temp of =/<36 C B. HR of =/>90 bpm C. RR =/> 24 D.WBC =/< 4,000/ul E. Bandemia

61 C. Source of the SIRS criteria wherein RR>20 is in Schwartz. If the question was asked in the IM boards, then the SIRS criteria is RR>24 accdg to Harrisons. I think it depends on the subject and the source book to be used . RR should be equal or more than 20 not 24. All the other parameters are correct.

This interluekin promotes eosinophil proliferation and airway inflammation? A. IL-3 B. IL-5 C. IL-7 D. IL-9 E. IL-11

62 B. IL-5 is secreted by mast cells and basophils in order to promote eosinophil proliferation and airway infllammation

This statement is true of Von Willberand's disease? A. It is the most common congenital bleeding disorder B. It is a pure quantitiative defect of the vWF C. Patients with this disorder have characteristic visceral and joint hemorrhages D. Menorrhagia is also common in men E. Patient also have prolonged PTT due to deficiency of F9

63 A. it is both a qualitative and quantitiave defect char by mucocutaneous bleeding. Menorrhagia is common in women. It is assoc with F8 deficinecy not F9.

The ff statement regarding transfusion therapy is correct except? A. Rh negative blood should ideally be transfused with Rh negstive blood only. B. In emergency situations, type O negative blood may be transfused to all recipients. C. Cross matching shoild always be performed before the administration of dextran because it interferes with the typiong procedure D. Platelet preparations are capable of transmitting infectious infectious diseases and accounts for allergic disease as well. E. FFP is the usual source of the vitamin K dependent factors and is the only source of F8

64 E. FFP is the usual source of the vitamin K dependent factors and is the only source of F5 not F8. All the other statements are correct.

What electrolyte abnormality occurs after a refeeding syndrome? A. Decreased serum sodium B. Increased serum potassium C. Decreased serum magnesium D. Increased serum phosphate E. Increased serum calcium

65 C. In refeeding syndrome, you expect decreased serum potassium, magnesium and phosphate especially when refeeding via TPN or NGT.

How much percentage of blood loss is expected in a patient with normal blood pressure but with orthostatic hypotension? A. 10% B. 20% C. 30% D. 40% E. 50%

66 B. Pateint has Class II hemorrhage with approximately 15-30% blood loss or 750-1500 cc. Although cghoice C could be correct it is borderline Class II and III therefore Choice B is the best answer.

All of the following rpactice guidelines are part of the Surviving Sepsis Campaign Bundle EXCEPT ? A. Measure lactate levels B. Obtain blood cultures prior to the admistration of antibiotics C. Administer 30cc/kg crystalloid for hypotension D. Maintain a mean arterial pressure of >60 mmHg E. Remeasure lactate levels if initial lactate was elevated

67 D. The goal MAP in the Surviving Spesis guidelines is >65 mmHg not 60mmHg

What antiobitic is recommended as prophylactic use for a laparoscopic low risk biliary tract surgery A. Cefazolin B. Cefazolin + Metronidazole C. Cefoxitin D. Ampicilin-sulbactam E. None of the above

68 E. Accdg to Schwartz's 10 ed pg 146 Table 6-5: No antibiotic is needed for a low risk laparasocopic biliary tract surgery.

An extensive introduction of bacteria into a normally sterile are of the body due to major breaks in the sterile technique is identified as what wound classification? A. Clean B. Clean/Contaminated C. Contaminated D. Dirty E. Somewhat dirty

69 C. Contaminated or Class 3 wounds includes open accidental wound encountered early after injury, those with extensive extensive introduction of bacteria into a normally sterile are of the body due to major breaks in the sterile technique penetrating abdominal trauma, large tissue injury and enterotomy during bowel obstruction

A fistula with an external opening located anteriorly 2.75cm from the anal margin will have: A. Short, radial tract to the anterior midline B. Curvilinear tract to the posterior midline C. Curvilenear tract to the anterior midline D. A and C E. All of the above

7 A. Goodsall’s rule dictates that fistulas with an external opening anteriorly connect to the internal opening by a short, radial tract. Fistulas with an external opening posteriorly track in a curvilinear fashion to the posterior midline. However, if the anterior external opening is greater than 3cm from the anal margin, such fistulas tract to the posterior midline. SIMILAR TO PREVIOUS BOARD EXAM CONCEPT/PRINCIPLE Source: Schwartz’s Principles of Surgery 8th ed p 1064

In relation to the previous question, what is the expected infection rate? A. 1.0-2.0% B. 2.1-9.5% C. 3.4-13.2% D. 3.1-12.8% E. None of the above

70 C. Accdg to Schwartz's 10 ed pg 148 Table 6-7; Choice A- Class 1, Choice B- Class 2 and so forth.

All of the ff are criteria for referral to a burn center EXCEPT? A. Partial thickness burns greater than 20% TBSA B. Burns involving the genitalia C. Electrical burns D. Chemical burns E. Burns involving the hands

71 A. Accdg to Schwartz's 10 ed pg 228 Table 8-1; A partial thickness burns of greater than 10% TBSa should already be referred to a burn center. Burns involving the face, hands, feet, genitalia, perineum or major joints are also referred to a burn center.

This is true of Basal Cell Carcinoma? A. Arises from the basal layer of keratinocytes B. It accounts for half of all diagnosed skin cancers C. The natural history is BCC is distant metastasis D. The most common form of BCC is the superficial form accounting for 60% of all forms E. Bleeding, ulceration and itching are often part of the clinical presentation.

72 E. BCC arises from the basal layer of non keratinocytes. IT accounts for 75% of all skin cancers. The natural history is local invasion not distant mets. The msot common form is the nodular form.

It is the treatment of choice for morpheaform, poorly delinated, recurrent and infiltrative BCC, particularly facial lesions. A. Excisional surgery B. Incisional surgery C. Wide local excision D. Cautererization E. Moh's microsurgery

73 E. Moh's microsurgery provides histologic confirmation of excision and maximal conservation of tissue, which is important to keep in mind in cosmetically senstivie areas such as the face.

Among the ff breast conditions, which has the highest relative risk in terms of breast CA? A. Florid hyperplasia B. Sclerosing adenosis C. Intraductal papilloma D. Atypical ductal hyperplasia E. Lobular carcinoma in situ

74 E. Florid hyperplasia- 1.5-2 fold Sclerosing adenosis- No risk Intraductal papilloma- No risk Atypical ductal hyperplasia- 4-fold Lobular carcinoma in situ- 10-fold

Nasopharngeal carcinoma will likely spread to what level of neck lymph nodes? A. Level 2 B. Level 3 C. Level 4 D. Level 5 E. Level 6

75 D. NPCA will classically spread to the Level 5 or posterior triangle lymph nodes.

All of the ff are true regardign the principles of anti-reflux surgery EXCEPT? A. Following a fundoplication, the expected increase is to a level twice the resting pressure B. The operation should place an adequate length of the distal esophageal sphincter of about 2 or more cm in the stomach. C. The operation should allow the recontructed cardia to relax on deglutition for about 10 secs D. The operation should increase the resistance of the relaxed sphincter to a level that exceeds the peristaltic power of the body of the esophagus. E. The operation should ensure that the fundoplication can be placed in the abdomen without undue tnesion and maintained there by approximation the crura of the diaphragm above the repair.

76 D. The operation should NOT increase the resistance of the relaxed sphincter to a level that exceeds the peristaltic power of the body of the esophagus. All other statements are true.

It is known as the upward sliding of the gastric fundus alongside a normally positioned cardia? A. Hiatal hernia type I B. Hiatal hernia type II C. Hiatal hernia type III D. Hiatal hernia type IV E. Sliding hernia

77 B. Type I/Sliding hernia- upward dislocation of the cardia; Type 2/Rolling hernia- upward dislcoation of the fundus; Type 3- upward dislocation of both cardia and fundus; Type 4- in addition to above, an addtl organ such as the colon is dislocated.

Herniation involving a Meckel's diverticulum is also known as? A. Littre's hernia B. Spigelian hernia C. Petersen's hernia D. Pantaloon's hernia E. Richter's hernia

78 A. Spigelian- hernia through the semilunaris; Petersen's- internal henriation of the small bwel through the mesenteric defect from the Roux limb; Pantaloon's- hernia sac exists as both direct and indirect hernia straddling the inferior epigastric vessels; Richter's- incarcerated or strnagulated hernia involving only one sidewall of the bowel

It is the single most important test in the evaluation of thyroid masses and is the first diagnostic step of a solitary thyroid nodule according to the Bethesda criteria? A. TSH B. Thyroid UTZ C. FNAB D. Thyroid scan E. fT4 and fT3

79 C. Please refer to the figure in Schwartz's 10 ed pg 1539 Figure 38-14.

The Poupart’s ligament is derived from which of the following structures? A. External oblique B. Internal oblique C. Trasversus abdominis D. Transversalis fascia E. Peritoneum

8 A. The poupart’s ligament/inguinal ligament forms the inferior margin of the inguinal canal. Inside courses the spermatic cord. Source: Schwartz’s Principles of Surgery 8th ed p 1308

All fo the ff statements are true regarding epidural hematoma EXCEPT? A. Epidural hematomas usually appear convex in shape because their expansion stops at the skull's sutures, B. May present with a lucid period immediately following the trauma and a delay before symptoms become evident C. It is an extra-axial bleed D. Associated with tearing of the bridging veins in the dural venous sinuses E. The most common cause of intracranial epidural hematoma is traumatic

80 D. Choice D refers to subdural hematoma. In epidural hematoma there is tearign of the middle mengineal artery instead

Which of the following giant diaphragmatic hernias refers to an upward dislocation of the gastric fundus alongside a normally positioned cardia? a. type II rolling b. type I sliding c. type III sliding-rolling d. type IV e. NOTA

81 A. Schwartz Principles of SUrgery 9th edition p. 842

2. A 16 year old male stowaway came in for persistent feculent discharge over his underwear. Upon rectal examination, an indurated tract is palpable. Which of the following is TRUE? a. an anterior opening 4cm from the anal margin will have an internal opening through a short radial tract b. goal of treatment is eradication of sepsis c. a posterior opening will track in a long radial route in posterior midline d. intersphincteric fistulas usually result from an ischiorectal abscess and extends to both internal and external sphincters e. Extrasphincteric fistulas are the most common

82 B. fistulas with an external opening anteriorly connect to the internal opening by a short radial tract. Fistulas with an external opening posteriorly tract in a curvilinear fashion to the posterior midline. D - transphinteric fistula; E - extrasphincteric fistula are rare and treatment depends upon both anatomy of fistula and its etiology Schwartz Principles of SUrgery 9th edition p. 1064

3. Which of the following techniques for breast surgery will leave most of the breast skin that will create a pocket to be filled with implants or with patient’s own tissue from another part of her body? a. skin sparing mastectomy b. simple mastectomy c. modified radical mastectomy d. total mastectomy e. radical mastectomy

83 A. http://www.breastpreservationfoundation.org/ nipple-sparing-mastectomy

4. AJ Perez, a young actor, died in a MVA in Moncada, Tarlac. He donated his cornea to a 28 year old and 8 year old. He is the famous face on the Eye Bank of the Philippines posters. Which of the following refers to corneal transplantation wherein the endothelial cells and descemet’s membrane are left in place and the anterior layers of the cornea are removed and replaced with donor tissue? a. penetrating keratoplasty b. superficial anterior lamellar keratoplasty c. deep anterior lamellar keratoplasty d. endothelial keratoplasty e. NOTA

84 C. When the entire cornea is replaced it is known as penetrating keratoplasty and when only part of the cornea is replaced it is known as lamellar keratoplasty. Keratoplasty simply means surgery to the cornea.Endothelial keratoplasty replaces the patient's endothelium with a transplanted disc of posterior stroma/Descemets/endothelium (DSEK) or Descemets/endothelium (DMEK). https://en.wikipedia.org/wiki/Corneal_transpla ntation

5. which of the following refers to an esophageal hiatal hernia characterized by an upward dislocation of the cardia in the posterior mediastinum? a. type II rolling b. type I sliding c. type III sliding-rolling d. type IV e. NOTA

85 B. Schwartz Principles of Surgery 9th edition p. 842

6. Which of the following bones of the orbital wall will be involved in a blowout fracture? a. frontal process of the maxilla b. zygomatic bone c. orbital plate of the maxilla d. orbital process of palatine bone e. ethmoid bone

86 C. Vaughan and Asbury’s General Ophthalmology 17th edition p.1

7. Which of the following maxillary fractures refers to a fracture line which passes through the nasal and lacrimal bones in addition to the maxilla forming the medial orbital floor? a. type I Le Fort b. type II Le Fort c. type III Le Fort d. type IV Le Fort e. type V Le Fort

87B. Type I - below the orbital floor type III - involves the medial and lateral walls and the orbital floor in the presence of separation of the facial skeleton Vaughan and Asbury’s General Ophthalmology 17th edition p.375

8. Which of the following refers to a delayed hypersensitivity reaction to microbial antigens and consists of a perivasculitis with lymphocytic cuffing of a vessel? a. ligneous conjunctivitis b. granulomas c. phlyctenules d. pseudomembrane e. chalazion

88 C. A - recurring membranous conjunctivitis B - most commonly are chalazia D - results from exudative process (coagulum on the surface of the epithelium and when removed, epithelium remains intact) Vaughan and Asbury’s General Ophthalmology 17th edition p.101

9. A 4 year old male came in for proptosis, hyperemia, edema, chemosis, limitation of eye movement and blurring of vision. Patient had a history of recurrent watery nasal discharges and nasal congestion for the past 3 months. Which of the following is the most common cause of proptosis in children? a. preseptal cellulitis b. orbital cellulitis c. rhabdomyosarcoma d. capillary hemangioma e. meningocele

89 B. Vaughan and Asbury’s General Ophthalmology 17th edition p.254

A 26 year victim of a vehicular accident is brought on a stretcher in the ER. On physical examination his blood pressure is 70/40 and heart rate is 65. The extremities are warm and he is noted to have decreased sensorium. Which of the following is the appropriate initial management? A. Fluid resuscitation B. Blood transfusion C. Dopamine/Norepinephrine D. Dobutamine/Digoxin E. Epinephrine/Antihistamine/ Corticosteroids

9 A. This is a case of neurogenic shock. The classic description of neurogenic shock consists of decreased BP associated with bradycardia (absence of reflexive tachycardia due to disrupted sympathetic discharege), warm extremities (loss of peripheral vasoconstriction), motor and sensory deficits indicative of a spinal cord injury, and radiographic evidence of a vertebral column fracture. After the airway is secured and ventilation is adequate, fluid resuscitation and restoration of intravascular volume often will improve perfusion in neurogenic shock. Most patients with neurogenic shock will respond to restoration of intravascular volume alone, with satisfactory improvement in perfusion and resolution of hypotension. Administration of vasoconstrictors will improve peripheral vascular tone, decrease vascular capacitance, and increase venous return, but should only be considered once hypovolemia is excluded as the cause of the hypotension, and the diagnosis of neurogenic shock established. If the patient's blood pressure has not responded to what is felt to be adequate volume resuscitation, dopamine may be used first. **Note: Be careful of doing fluid resuscitation in patients with decreased cardiac function. Always ask for history of MI and auscultate for crackles. Source: Schwartz’s Principles of Surgery 8th ed p 108

10. Which of the following diaphragmatic hernias refers to the herniation of an additional organ such as the colon? a. type II rolling b. type I sliding c. type III sliding-rolling d. type IV e. NOTA

90 D. Schwartz Principles of Surgery 9th edition p. 842

11. JCR 24 years old medical student frequently complaints of throbbing headache which is immediately relieved with paracetamol. Initially he thought it was just tension headache. After taking the bimonthly examination, he went to the ER now with double vision and stiff neck which he attributed to lack of sleep due to excessive studying. On physical examination, JCR was wide awake and nuchal rigidity was noted. Which of the following is NOT true of this case? a. JCR should have a CT scan of the head immediately b. Hunt -Hess clinical grading would be grade 3 c. negative CT and LP rules out SAH d. 4 vessel angiography is the gold standard for diagnosis e. if LP is performed, xanthochromia with high RBC count which do not decrease in the tubes would be present

91 B. it is grade 2. grade 3 would be lethargic with mild focal neurologic deficit (pronator drift) Schwartz Principles of Surgery 9th edition

12. RP a movie actor was involved in a motor vehicular accident in Mandaue City which caused a traffic standstill. RP sustained crushing injuries over his tibia and fibula and upon examination, he is unable to evert his foot. Based on the Seddon classification, which of the following peripheral nerve injury patterns is present when there is disruption of axons and endoneurial tubes? a. wallerian degeneration b. neurapraxia c. axonotmesis d. neurotmesis e. none of the above

92 D. B - temporary failure of nerve function without physical axonal disruption. axonal degeneration does not occur. C - disruption of axons and myelin. endoneurium are intact. axons degenerate proximally and distally from area of injury. A - distal degeneration D - peripheral collagenous components such as perineurium may or may not be intact. Schwartz Principles of Surgery 9th edition

13. In the above scenario, RP’s right foot was noted to be cool, pale, with absent pulses, and a hematoma over the fracture site. Which of the following is NOT true in the management? a. this would require operative exploration as absent pulses is a hard sign b. due to the presence of nerve injury, observation is only warranted c. the fractures should be realigned before definitive vascular examination d. significant hematoma and peroneal nerve injury are soft signs e. acute ischemia and pulsatile hemorrhage are also hard signs

93 B. due to presence of hard signs (absent pulses), operative exploration is warranted. Other soft signs include proximity to vasculature, A-A index of <0.9, thrill or bruit Schwartz Principles of Surgery 9th edition

14. Due to RP’s blood loss through his leg, RP started to feel dizzy and disoriented time and place. Upon physical examination, HR = 128, RR = 38, BP = 80/60. Which of the following is NOT true regarding shock classification and management? a. patient is in class III shock b. fluid resuscitation begins with 2L IV bolus of isotonic crystalloid c. PRBC is given after fluid resuscitation is repeated d. adequate urine output monitoring for RP would be 1ml/kg/hour e. none of the above

94 D. adult: 0.5ml/kg/hr; child: 1ml/kg/hr; infant: 2ml/kg/hr Schwartz Principles of Surgery 9th edition

15. A 16 year old male came in for sudden onset of right scrotal pain and swelling. On PE, the right scrotum is swollen with a tender high riding testicle. Which of the following is not appropriate in management? a. golden period for immediate exploration is 8 hours b. contralateral testes must also be explored and fixed to dartos fascia c. if found necrotic, orchiectomy must be performed d. testes are fixed with a small nonabsorbable suture on medial and lateral aspects of dartos fascia e. none of the above

95 A. more than 80% of testes can be salvaged if surgery is performed within 6 hours, which decreases to 20% or less as time progresses beyond 12 hours Schwartz Principles of Surgery 9th edition

16. A 34 year old drug lord was stabbed in the left flank area by an unknown assailant. Which of the following are ABSOLUTE indications for surgical intervention for renal trauma except? a. renal pedicle avulsion b. expanding pulsatile or uncontained retroperitoneal hematoma c. coexisting bowel injuries d. persistent life threatening hemorrhage e. none of the above

96 C. -other relative indications: large laceration of renal pelvis or avulsion of UPJ, persistent urinary leakage, abnormal intraoperative one shot IV urogram, devitalized parenchymal segment with associated urine leak, complete renal artery thrombosis of both kidneys, renal vascular injuries after failed angiographic management, renovascular hypertension Schwartz Principles of Surgery 9th edition

17. Which of the following is a feature of primary hyperparathyroidism except? a. increased 1,25 dihydroxy vitamin D b. normal 24 hour urinary calcium c. mild hyperchloremic metabolic acidosis d. decreased alkaline phosphatase e. increased chloride

97 D. alkaline phosphatase should be normal or increased (in the presence of high turnover bone disease) Schwartz Principles of Surgery 9th edition

18. A 62 year old male IBV, was admitted at the SICU for flame burns 68% of his body. On the third hospital day, patient extubated himself and started to complain of right upper quadrant pain and recurrent high grade fever. Bedside HBT ultrasound revealed distended gallbladder with thickened wall. Which of the following is not appropriate in the management? a. HIDA scan is less sensitive with high false positive rates b. cholecystectomy is the treatment of choice c. this requires urgent intervention d. patient is usually unfit for surgery e. cholecystostomy can be diagnostic and therapeutic

98 B. percutaneous UTZ or CT guided cholecystostomy is the treatment of choice. Schwartz Principles of Surgery 9th edition

19. IBV burn wounds were dressed appropriately by the interns rotating in the burn unit. Which of the following is NOT TRUE of the management? a. mafenide acetate is not effective in eschar and it can cause metabolic acidosis b. topical application of silver nitrate may cause electrolyte extravasation c. silver sulfadiazine is contraindicated on burns in proximity to newly grafted areas d. bacitracin, neomycin, and polymyxin B are useful for superficial partial thickness facial burns e. neutropenia from silver sulfadiazine may be due to neutrophil margination from inflammatory response

99 A. mafenide acetate is effective and will penetrate eschar Schwartz Principles of Surgery 9th edition