Surgery Quiz

6. A 35-year-old man is admitted for a sigmoid colectomy due to repeated episodes of acute diverticulitis. He weighs 140 kg, but his ideal body weight is 80 kg. Which of the following body compositions should be used as a basis for calculating basic maintenance fl uids for this patient?

D. TBW 54, IW 32, EW 22, BV 5.4

39. A 30 yo man is in the hospital recovering from splenectomy for a ruptured spleen sustained in a motor vehicle collision. He has otherwise been healthy and was not taking medications prior to the injury. A temperature of 102F is noted on the second postoperative day. Vital signs are BP 130/80, pulse 100/min, and respirations 18/min. His pain is moderately controlled with morphine using patient-controlled analgesia (PCA). Breath sounds are diminished at both bases, more so on the left. His abdomen is mildly distended, soft and tender near the incision. The incision appears to be healing without a problem. What is the most likely cause for his fever? a. Atelectasis and pulmonary infection b. Peritonitis c. Urinary Tract Infection d. Suppurative thrombophlebitis e. Cardiac contusion

a. Atelectasis and pulmonary infection

41. A 22-year-old man is in the emergency department after a high- speed motor vehicle collision. He complains of back pain. He is alert and oriented and is breathing normally. His oxygen saturation is normal and hemodynamically stable. There are ecchymoses on the left chest. Chest x-ray shows fractures of the left first and second ribs. The aortic knob is not clearly visible, and the mediastinum measures 10 cm. Further evaluation should include which of the following? a. Contrast-enhanced chest CT b. Repeat chest x-ray c. Diagnostic thoracoscopy d. Pericardial window e. Diagnostic mediastinoscopy

a. Contrast-enhanced chest CT

18. A 50-year-old man is started on IV heparin for a peripheral arterial thrombosis. Three days later, it is noted that his platelet count has dropped from 200 to 35. What is the next best step in management? a. Discontinue heparin and administer lepirudin b. Continue heparin and administer argatroban c. Discontinue heparin and administer aspirin d. Discontinue heparin and administer Coumadin e. Continue heparin and administer a platelet transfusion

a. Discontinue heparin and administer lepirudin

5. A 28-year-old man is undergoing an operation for right inguinal hernia. The anesthesiologist notices that his end-tidal CO2 value rises abruptly, and the patient's jaw is stiff. The patient's temperature is 41°C, his heart rate is 130 beats/minute, and his blood pressure (BP) is 130/75 mm Hg. Which of the following abnormalities would be expected if a sample of his blood were tested at this point in the operation? a. Hyperkalemia b. Hypocalcemia c. Alkalosis d. Anemia e. Hypoalbuminemia

a. Hyperkalemia

21. 65yo man, severely injured in dump truck rollover. Femur fx bil, pelvic fx, pulm contusion. Pulm artery catheter placed. Correction of which current value will have most dramatic impact on his O2 delivery: a. Measured CO of 2L/min (normal 5L/min) CO x CaO2 x 10 b. Serum Hgb 12mg/dL c. Arterial PO2 82mmHg d. Arterial O2 sat 93% e. Pulm capillary occlusive Pressure 10mmHg

a. Measured CO of 2L/min (normal 5L/min) CO x CaO2 x 10

8. A 65-year-old man is seen in the emergency department with a 5-day history of nausea and vomiting. He has been drinking only water for the last 2 days. His BP is 100/75 mm Hg with a heart rate of 105/ minute. He has a distended abdomen with no bowel sounds but no signs of peritonitis. A diagnosis of a bowel obstruction is made after x-rays of the abdomen reveal distended loops of small bowel. Which of the following abnormalities would you expect to fi nd in this patient? a. Na+—110 mEq/L, Cl−—90 mEq/L, K+—2.8 mEq/L, CO2—20 mEq/L b. Na+—150 mEq/L, Cl−—120mEq/L, K+—5.5 mEq/L, CO2—20 mEq/L c. Na+—140 mEq/L, Cl−—110 mEq/L, K+—4.0 mEq/L, CO2—26 mEq/L d. Na+—120 mEq/L, Cl−—120 mEq/L, K+—5.5 mEq/L, CO2—18 mEq/L e. Na+—135 mEq/L, Cl−—105 mEq/L, K+—3.5 mEq/L, CO2—24 mEq/L

a. Na+—110 mEq/L, Cl−—90 mEq/L, K+—2.8 mEq/L, CO2—20 mEq/L

10. A 40-year-old woman is admitted with a 3-day history of diarrhea. She has a history of chronic renal insuffi ciency due to diabetic nephropathy. She is mildly acidotic. Serum potassium is 6.8 mEq/L. An ECG shows peaked T waves. Which of the following is the most appropriate initial treatment of the hyperkalemia? a. Subcutaneous administration of 10 units of insulin plus 25 g of glucose over 5 minutes b. Administration of a bicarbonate infusion or by injecting 45 mEq sodium bicarbonate intravenously over 5 minutes c. Intravenous administration of sodium polystyrene sulfonate, a cation-exchange resin, to bind extracellular potassium d. Transferring the patient to a center with hemodialysis and peritoneal dialysis capability e. Rapid intravenous infusion of 50 mL of 10% calcium gluconate under continuous ECG monitoring

a. Subcutaneous administration of 10 units of insulin plus 25 g of glucose over 5 minutes

30. A 42-year-old woman with a history of alcohol abuse is admitted to the intensive care unit with active bleeding from esophageal varices. The medication most useful for decreasing the risk of rebleeding, with the least side effects, is a. octreotide b. proton pump inhibitor C. beta-blocker c. vasopressin d. nitroglycerin

a. octreotide

43. A 53-year-old man sustains a severe traumatic brain injury after an assault. His GCS score is 6, and an intracranial pressure monitor is inserted. Vital signs are heart rate—92 beats/minute, blood pressure (BP)—152/88 mm Hg, mean arterial pressure—109 mm Hg, and respiratory rate—16/minute. His intracranial pressure is 32 mm Hg. The patient's cerebral perfusion pressure is a. 120 mm Hg. b. 77 mm Hg. c. 60 mm Hg. d. 56 mm Hg. e. 32 mm Hg.

b. 77 mm Hg.

28. A 52-year-old man was admitted to the hospital with bilateral femur fractures and rib fractures following a motor vehicle crash. He developed a deep vein thrombosis involving the left femoral vein and was started on intravenous heparin 4 days after admission. His platelet count decreased and concern was raised for heparin- induced thrombocytopenia. Which of the following would be the best alternative anticoagulant? a. Clopidogrel b. Argatroban c. Warfarin d. Enoxaparin e. Aspirin

b. Argatroban

40. A 25 yo man is seen in the emergency department because of a painful swollen forearm. Two days ago, he sustained a small laceration to his left forearm while clearing brush. It caused only minor discomfort until about 12 hours ago when the area around the laceration became more red and swollen. He has otherwise been healthy. He takes no medications. His temperature is 38C. This is a 2-cm superficial laceration on the dorsum of his left forearm with 15-cm diameter surrounding erythema that is quite tender. The edges of the erythema were marked and 20 minutes later the erythema has extended another cm beyond the mark. The most likely causative organism is: a. Methicillian-resistant Staphylococcus aureus b. B-hemolytic Streptococcus A. c. Escherichia Coli d. Streptococcus faecalis e. Candida albicans

b. B-hemolytic Streptococcus A.

17. A 55-year-old woman is scheduled for a craniotomy to remove a brain tumor. She has a history of hypertension and hypercholesterolemia, and she underwent coronary artery angioplasty with a stent placed 6 months ago. Current medications include enalapril, pravastatin, and clopidogrel. Which one of the following would most likely be prolonged? a. Activated partial thromboplastin time (APTT) b. Bleeding time c. Prothrombin time (PT) d. Thrombin time e. Activated clotting time (ACT)

b. Bleeding time

2. A 60-year-old woman is being evaluated for surgery to repair an abdominal aortic aneurysm under general anesthesia. She smoked a pack of cigarettes daily for 35 years, but quit 5 years ago when she had a myocardial infarction (MI) complicated by congestive heart failure. She still has occasional orthopnea. She also has hypercholesterolemia and hypertension. Which one of the following factors suggests the greatest risk for a cardiac complication following her surgery? a. History of cigarette smoking b. Congestive heart failure with orthopnea c. General anesthesia d. Hypertension e. Hypercholesterolemia

b. Congestive heart failure with orthopnea

7. A 46-year-old man is in the intensive care unit following surgery for multiple gunshot wounds to the chest and abdomen sustained 2 days ago. He has bilateral chest tubes inserted for hemopneumothoraces. Damage control surgery including packing his liver and performing an ileostomy was done at that time. His urine output has decreased to 90 mL over the past 4 hours. His temperature is 38°C, blood pressure (BP) 110/85 mm Hg, and pulse 100/minute. What is the most likely cause for the drop in urine output? a. Congestive heart failure b. Hypovolemia c. Acute renal failure d. Diabetes insipidus e. Sepsis

b. Hypovolemia

36. A 32 yo man is seen in the emergency department 45 minutes after a motor vehicle collision. His only injury is a long linear laceration beginning on the left temporal forehead at the hairline and extending posteriorly for 10 cm. The edges are still bleeding briskly and the EMTs described a large amount of blood at the scene. He did not lose consciousness. His last tetanus booster was 4 years ago. Which of the following is required for tetanus prophylaxis in this patient? a. Tetanus immune globulin only b. Nothing further at this time c. Tetanus toxoid only d. Tetanus immune globulin followed by a single tetanus toxoid booster e. Tetanus immune globulin followed by three tetanus boosters

b. Nothing further at this time

14. A 48-year-old woman is in the hospital because of nausea, vomiting, and abdominal pain. She has a history of multiple abdominal surgeries for small bowel obstruction. On admission, she was quite thin with temporal and thenar muscle wasting. Her albumin level was 1.7 g/dL. A nasogastric tube was inserted and she has been receiving TPN for 2 days. You are now called by her nurse because, in addition to nausea and abdominal pain, she's begun to feel short of breath and have tingling in her fi ngers. She suddenly goes into cardiac arrest. Laboratory values now show potassium—2.4 mEq/L, magnesium—1.3 mEq/L, phosphorus—1 mg/dL, and glucose—350 mg/dL. What nutritional complication may have resulted in this patient's condition? a. Marasmus b. Refeeding syndrome c. Overfeeding d. Underfeeding e. Kwashiorkor

b. Refeeding syndrome

24. Two weeks following a severe motorcycle crash, a 25 y/o woman remains intubated in the surgical ICU.You are called to the bedside to evaluate a change in her condition. On evaluation, her vital signs include temperature of 39 C, HR 110, RR 22, BP 88/50, and O2 sat 96%. Her urine output has been 20 mL over the past 8 hours. On exam, she is in moderate distress and appears confused. She has crackles posteriorly in her left lung fields and her extremities are warm. A bronchoalveolar lavage is performed revealing Gram-negative rods. What is your diagnosis? a. Atelectasis b. Septic Shock c. Systemic inflammatory response syndrome d. Allergic reaction to penicillin e. Pulmonary embolus

b. Septic Shock

3. A 45-year-old man with a 25-year history of hepatitis C and cirrhosis is found to have a small hepatocellular carcinoma of the right lobe of the liver. In order to assess his risk for surgical therapy, an estimate of liver dysfunction given by the model for end stage liver disease (MELD) score is needed. Which one of the f ollowing laboratory studies is needed to calculate a MELD score for this patient? a. Alkaline phosphatase b. Serum creatinine c. Serum ammonia d. Serum albumin e. Serum gamma glutamyl transpeptidase (γ GT)

b. Serum creatinine

1. A 52-year-old man is in the clinic to discuss treatment of a newly diagnosed pancreatic cancer. He has no signifi cant past medical history. He takes no medications. There is no evidence of metastatic disease, and the tumor is small and appears to be resectable by pancreaticoduodenectomy (Whipple procedure). Optimal treatment would also include adjuvant radiation therapy and chemotherapy. Informed consent for this patient is best defined as a. a form that can be used as a legal defense should a complication occur during the treatment of the patient's problem. b. a process in which the physician and patient discuss the risks and benefi ts of different approaches to the patient's problem. c. a process in which every possible complication of treatment is enumerated. d. a theoretical construct with little practical utility. e. a philosophical principle that applies to surgical procedures but not medication administration.

b. a process in which the physician and patient discuss the risks and benefi ts of different approaches to the patient's problem.

19. A patient is scheduled to undergo open abdominal aortic aneurysm repair. During preoperative testing, it is determined that his blood type is B negative. This means a. he has circulating antibodies to Rh antigens. b. he has circulating antibodies to A antigens. c. he has circulating antibodies to B antigens. d. he has no circulating antibodies to ABO antigens. e. his red blood cells have A antigens.

b. he has circulating antibodies to A antigens.

38. A 42 yo woman is seen in the infectious disease clinic because of a small laceration. She is a surgeon and was assisting a surgical resident with a colon resection when she was accidentally cut with a scalpel blade during the procedure. She has received all required immunizations. Antibodies against which virus could be measured in order to assess the effectiveness of the only vaccine to prevent infection potentially transmitted from the patient to the surgeon during the operative procedure? a. Human immunodeficiency virus b. Hepatitis C c. Hepatitis B d. Cytomegalovirus e. Tuberculosis

c. Hepatitis B

15. A 46-year-old man with an enterocutaneous fi stula has been maintained on TPN for several weeks. The fi stula has healed and prior to removing the central line, the patient is given a unit of packed red blood cells through his central line for his chronic anemia. Two hours into his red cell infusion, a rapid response is called when the nurse discovers the patient comatose and hypotensive. What is the most likely cause of the patient's condition? a. Hypokalemia b. Transfusion reaction c. Hypoglycemia d. Air embolus e. Catheter-related sepsis

c. Hypoglycemia

37. A 48 yo man is being evaluated in the emergency department with fevers, chills, and abdominal pain for the past 24 hours. He has a history of hepatitis C infection following a blood transfusion 14 years ago for a large scalp laceration and orthopedic injuries sustained in a motor vehicle collision. He has not been to a physician for 5 year. He does not smoke or drink alcohol. He takes no medication. His temperature is 39C and vital signs are: BP 90/50, Pulse 110/min, and respirations 26/min. A CT scan shows a single stone in the gallbladder that does not appear to be obstructing. The bile ducts are normal caliber and the gallbladder wall is not thickened. There is a moderate amount of fluid, mild small bowel distention, and stranding around the sigmoid colon as well as a small amount of free intraperitoneal gas around the liver. An aspirate of the peritoneal fluid shows leukocytes and mixed gram positives and negatives on gram stain. Lab values show a WBC of 19,000, total bilirubin 1.2, and alkaline phosphatase 40. In addition to fluid resuscitation and broad spectrum antibiotics, what is the best step in management? a. Laparoscopic cholecystectomy b. Long-term antibiotics only c. Laparotomy d. Magnetic resonance cholangiopancreatography (MRCP) e. Endoscopic retrograde cholangiopancreatography (ERCP)

c. Laparotomy

26. A 68-year-old woman in the surgical intensive care unit is coma- tose 10 days after a motor vehicle crash during which she sustained a fractured right femur treated with an intramedullary rod within 24 hours of the injury. There were no other injuries noted on admission. She remains intubated due to hypoventilation. Vital signs are blood pressure (BP)—100/60 mmHg and pulse—52 beats/minute. Her temperature is 35.4°C. Her chest is clear. There are no heart murmurs. Her abdomen is mildly distended but soft. There are no bowel sounds. The surgical site is healing well with no signs of infection. An electrocardiogram shows sinus rhythm with low-voltage QRS. Computed tomographic scan of her head is normal for her age. Laboratory studies show: Hemoglobin—8.2 g/dL Sodium—138 mEq/L Potassium—3.7 mEq/L Thyroid-stimulating hormone (TSH)—16.4 μU/mL (ref—0.5 to 5.0 μU/mL) T4—0.5 μg/dL (ref—5 to 12 μg/dL) What is the most likely diagnosis for her condition? a. Sick euthyroid syndrome b. Thyroid storm c. Myxedema coma d. Adrenal insufficiency of critical illness e. Graves' disease

c. Myxedema coma

23. A 22 y/o man is transported emergently to the hospital after sustaining a stab wound to the left chest. On initial survey, his airway is patent and he is breathing spontaneously, but he appears to be in shock. Which of the following findings best supports your working diagnosis of pericardial tamponade? a. Central venous pressure of 8 mm Hg b. Crisp S1S2 on cardiac auscultation c. Paradoxical pulse of 18 mm Hg d. Left atrial distention e. Increased QRS voltage on ECG

c. Paradoxical pulse of 18 mm Hg

34. A 55-year-old man is seen in clinic prior to undergoing elective repair of a large umbilical hernia. He is otherwise healthy and has had no previous surgery. He takes no medications. He does not smoke and does not drink alcohol. Except for a large reducible umbilical hernia, his physical exam is normal. Which micronutrient supplementation would not be beneficial to this patient to improve wound healing? a. Vitamin C b. Vitamin E c. Vitamin K d. Vitamin A

c. Vitamin K

20. A 65-year-old woman with severe symptomatic anemia secondary to chronic renal disease is being transfused with packed red blood cells. A couple of minutes into the transfusion, she complains of back pain, chest pain, and shortness of breath. The most likely diagnosis is a. transfusion-related acute lung injury (TRALI). b. delayed hemolytic transfusion reaction. c. acute hemolytic transfusion reaction. d. transfusion-related volume overload. e. transfusion-related hyperkalemia.

c. acute hemolytic transfusion reaction.

35. A 25-year-old man is in the hospital recovering from open surgery for perforated appendicitis performed 5 days ago. Postoperatively his wound was left open with daily debridement and local dressing changes. Today, local anesthesia is applied and the wound is closed with a nylon suture at the bedside. This represents an example of a. primary closure. b. composite graft closure. c. delayed primary closure. d. healing by secondary intent. e. local fl ap closure.

c. delayed primary closure.

44. A 25-year-old woman is brought to the emergency department after involvement in a low-speed motor vehicle collision. She com- plains of feeling light-headed and states that she is 33 weeks pregnant. Vital signs are heart rate—90 beats/minute and BP—82/44 mm Hg. Abdominal examination reveals a gravid uterus but no tenderness. Chest x-ray is unremarkable, and FAST reveals no intra- peritoneal fluid. A viable intrauterine pregnancy is noted, and fetal heart tones are observed. The next step in management should be a. cesarean section. b. induction of labor with vaginal delivery. c. left lateral tilt positioning. d. diagnostic peritoneal lavage. e. MRI of the abdomen and pelvis.

c. left lateral tilt positioning.

33. A 52-year-old man is in the operating room undergoing an emergent laparotomy because of a perforated ulcer. There is free intraperitoneal perforation and approximately 2 L of murky green fluid with obvious vegetable matter is suctioned from the peritoneal cavity. A Graham patch is performed to close the perforation. The abdomen is irrigated with normal saline and suctioned until all return is clear of green fluid and vegetable matter. After closing the fascia the next most appropriate step would be a. interrupted skin closure. b. closure of skin with a skin closure polymer (i.e., Dermabond). c. wound left open and wound care until clean and granulating and then delayed closure. d. closure of skin with staples. e. subcuticular suture skin closure.

c. wound left open and wound care until clean and granulating and then delayed closure.

25. A 34-year-old woman is thrown from a horse during a trail ride and brought to the emergency department 60 minutes after the accident. She is awake but appears to be mildly confused. She complains of left chest pain that is worsened with inspiration as well as generalized abdominal pain. On exam, her airway is patent and breathing unlabored. Her pulse is 110 beats/minute. Her blood pressure is 85/62. Her breath sounds are equal bilaterally. Her neck veins are fl at and her skin is cool. She is tender over her left lower ribs and left upper quadrant. You suspect that she has sustained an injury to her spleen with resultant hemorrhage. Approximately what percentage of intravascular volume loss has she experienced? a. 0% b. 10% c. 20% d. 30% e. 50%

d. 30%

27. A 70-year-old woman is transferred from the surgery ward to the surgical intensive care unit because of hypotension 2 days after undergoing an open low anterior resection for a sigmoid cancer. The surgery went well with minimal blood loss. The tumor was found on routine colonoscopy, and she had no symptoms and was quite healthy and active prior to surgery. Her preoperative medications were multiple vitamins and calcium supplements. Since surgery she has been receiving maintenance intravenous fluids and was stable until a few hours ago when she became hypotensive. Despite receiving boluses of normal saline and starting pressors (norepinephrine and vasopressin), she remains hypotensive. She is intubated because of lethargy and tachypnea. Her temperature is 37.4°C. Pupils are equal and reactive. Her chest is clear bilaterally. There are no heart murmurs. Her abdomen is soft and tender only near the lower midline incision. There are no localizing neurological findings. There is minimal urine output from a Foley catheter. Laboratory studies show: Hematocrit—33% (36% the day before) Sodium—129 mEq/L Potassium—5.1 mEq/L Glucose—108 mg/dL Arterial blood gases (ABGs) on 40% FiO2-pH—7.39 PCO2—38 mm Hg PO2—130 mm Hg U/A—no bacteria, negative leukocyte esterase What is the most likely diagnosis? a. Hemorrhage b. Anastomotic leak c. Pulmonary embolism d. Acute adrenal insufficiency e. Urosepsis

d. Acute adrenal insufficiency

11. A 27-year-old man is in the intensive care unit 24 hours after an automobile collision. He has a left pneumothorax, multiple broken ribs, a ruptured spleen requiring splenectomy, a pelvic fracture, and bilateral femur fractures. He is intubated. He has received 6 units of PRBCs and is currently receiving IV fluids. Which one of the following best describes his metabolic response? a. Insulin is the major mediator of the stress response. b. Glycogen stores can be used for 7 days. c. Energy expenditure is decreased by 30%. d. Hepatic reprioritization of protein synthesis favors acute-phase proteins. e. Epinephrine and adrenocorticotropic hormone (ACTH) production are reduced.

d. Hepatic reprioritization of protein synthesis favors acute-phase proteins.

31. A 42-year-old woman is seen in clinic 2 weeks after undergoing left partial mastectomy and sentinel lymph node biopsy for stage 1 breast cancer. Whole breast radiation is recommended. She is concerned about the effects of radiation on her incision. Which of the following statements is least accurate regarding radiation effects and wound healing? a. Rapidly dividing cells are the least affected by radiation therapy. b. Radiation effects on fibroblasts should be negligible. c. Radiation causes increased amounts of collagen deposition. d. Long-term effects of radiation are often reversible after 24 months. e. Wound healing is impaired postradiation secondary to venous injury.

d. Long-term effects of radiation are often reversible after 24 months.

9. A 30-year-old man is in the intensive care unit where he is being treated for injuries sustained in a motor vehicle crash. He sustains multiple orthopedic injuries and a severe head injury. On hospital day 4, vital signs are BP—120/70 mm Hg, pulse—76/minute, and respiratory rate on a ventilator of 12/minute. His urine output is 20 mL/hour. Serum sodium is 120 mEq/L, BUN is 18 mg/dL, and creatinine is 1 mg/dL. What is the most likely diagnosis? a. Water intoxication due to inappropriate fl uid infusion b. Central diabetes insipidus c. Lab error d. SIADH e. Increased aldosterone secretion due to hypovolemia

d. SIADH

12. A 66-year-old man is in the intensive care unit 10 days following colon resection for perforated diverticulitis. He has a history of chronic obstructive pulmonary disease (COPD) and is unable to wean from the ventilator. He has been maintained on total parenteral nutrition (TPN) and has started tube feeding. The most likely nutritional cause for failure to wean from the ventilator would be a. too much protein. b. refeeding syndrome. c. underfeeding. d. overfeeding. e. hyperphosphatemia.

d. overfeeding.

42. A 30-year-old man is brought to the emergency department after crashing his motorcycle at high speed into a concrete divider. He sustains severe trauma to the midface and mandible and is lethargic upon arrival. He has copious amounts of bloody airway secretions and pulse oximetry reveals oxygen saturation levels of 82% to 85%. Two unsuccessful attempts have been made to place an orotracheal tube. The next step should be a. bag-valve mask ventilation b. nasotracheal intubation c. resuscitative thoracotomy d. surgical cricothyroidotomy e. bronchoscopy

d. surgical cricothyroidotomy

32. A 28-year-old ultimate fighter is seen in clinic 2 weeks after undergoing splenectomy for a ruptured spleen sustained during a prize fight. He is feeling well with minimal incisional pain. There is a midline laparotomy incision that appears to be healing well without evidence of infection or other problems. He wants to know when his incision will be healed enough for him to return to professional fighting. Regarding the tensile strength of his wound, a. it will increase steadily over the first 6 weeks and achieve maximal strength by 12 weeks. b. it will achieve maximal tensile strength at the point of maximal collagen deposition. c. it will take a full year for the wound to regain the same tensile strength as preoperatively. d. wound tensile strength reaches 90% at 26 weeks and this is its plateau. e. collagen deposition reaches a maximum level in the first 6 weeks and is quickly degraded thereafter.

d. wound tensile strength reaches 90% at 26 weeks and this is its plateau.

4. Which of the following patients is at the lowest risk for postoperative deep vein thrombosis? a. An 18-year-old male with femur and lumbar fractures b. A 55-year-old morbidly obese female undergoing total knee replacement c. A 62-year-old man undergoing prostatectomy for cancer d. A 45-year-old woman undergoing hysterectomy and bilateral salpingo-oophorectomy and debulking for ovarian carcinoma e. A 38-year-old woman undergoing carpal tunnel release

e. A 38-year-old woman undergoing carpal tunnel release

13. A 45-year-old man was admitted to the hospital 3 days ago with nausea and vomiting due to a gastric outlet obstruction. Further studies have confi rmed a gastric cancer involving the antrum of the stomach. He has a history of alcohol abuse and being homeless. The patient is thin and has temporal wasting and exposed ribs. He has an albumin of 1.9 g/dL. A nasogastric tube was placed on admission, and he was started on TPN. What is his surgical risk for perioperative complications? a. Moderate risk for developing surgical complications b. Moderate risk for developing wound complications only c. Low risk for developing surgical complications d. Cannot assess risk for surgical complications e. High risk for developing surgical complications

e. High risk for developing surgical complications

22. A 75 y/o woman with a history of CHF underwent elective sigmoid resection for severe recurrent diverticulitis. Postoperatively, she experiences shortness of breath. Physical exam and chest radiography suggest the presence of pulmonary edema. Which of the following parameters is the most accurate determinant of her left ventricular preload? a. Central venous pressure b. Pulmonary artery occlusive pressure c. Systemic vascular resistance d. Pulmonary venous pressure e. Left ventricular end-diastolic volume.

e. Left ventricular end-diastolic volume.

29. A 71-year-old man is admitted to the intensive care unit in septic shock secondary to pneumonia. His BP is 85/40 mm Hg and heart rate 95 beats/minute. Which of the following medications would be the most appropriate to use to treat his hypotension? a. Epinephrine b. Dobutamine c. Milrinone d. Dopamine e. Norepinephrine

e. Norepinephrine

16. A 26 y/o man is brought to the ED after being stabbed in the left arm in a fight. Brisk bleeding from the wound was controlled by the EMTs with a pressure bandage. 15 minutes later in the ED the bandage is removed and only slight oozing is noted. The most likely mechanism for decreased bleeding at this time is a. platelet activation and aggregation. b. activation of the extrinsic coagulation cascade pathway. c. activation of prothrombin to thrombin. d. activation of the intrinsic coagulation cascade pathway. e. local peripheral vascular vasoconstriction.

e. local peripheral vascular vasoconstriction

45. A 22-year-old man is brought to the emergency department after falling from a 10-foot ladder, landing on his left side. He has multiple left-sided rib fractures and a pneumothorax requiring a chest tube. Physical examination of the abdomen is unremarkable. He remains hemodynamically stable throughout the primary and secondary surveys and undergoes contrast-enhanced CT scanning of the abdomen and pelvis. CT scan reveals a grade II laceration of the spleen, with no evidence of active contrast extravasation. The next appropriate step in management is a. exploratory laparotomy with splenectomy. b. exploratory laparotomy with splenorrhaphy. c. splenic angioembolization. d. video-assisted thoracoscopy with evacuation of hemothorax. e. observation with serial abdominal examinations.

e. observation with serial abdominal examinations.