Surgery exam 1 Access Med

A 74-year-old 100-kg man with rectal cancer underwent a laparoscopic low anterior resection with diverting loop ileostomy. Preoperatively, he received a regional block per ERAS protocol. Intraoperatively, he received 2-L of IV crystalloid for a 5-hour case and received multimodal pain control with Toradol and Tylenol. On postoperative day 1, 200 mL of urine was collected from his Foley catheter over 12 hours, accompanied by an elevation from his baseline creatinine. He was given 40 mL/h of crystalloid over the same time period. What is the most likely cause of his oliguria? A Inadequate fluid resuscitation. B High ileostomy output. C Urinary tract obstruction. D Low cardiac output. E Bladder dysfunction.

A

Acute cholecystitis can be commonly confused with each of the following, except A Diverticulitis B Pancreatitis C Peptic ulcer disease D Acute appendicitis E Fitz-Hugh-Curtis syndrome

A

Carotid endarterectomy A Should not be performed when the carotid artery is completely occluded B Has not been shown to be beneficial for any patients in prevention of ipsilateral stroke C Is performed through a catheter placed in the ipsilateral femoral artery D Carries a 30% risk of transient cranial nerve injury E Has a restenosis rate of 35% at 5 years

A

Pancreatic adenocarcinoma A Is unresectable at the time of diagnosis in most people B Is smaller at diagnosis, on average, for tumors in the tail of the pancreas than those in the head C Can be resected by pancreaticoduodenectomy for those tumors limited to the tail D Has a similar prognosis as malignant pancreatic neuroendocrine tumor E Should generally be managed by operative enucleation

A

Rectal prolapse A Can be distinguished from prolapsed hemorrhoids based on exam showing concentric folds of the mucosa B Is more common in males C Cannot involve the muscular layers of the rectum due to fixation to the pelvic sidewalls D Is best evaluated by magnetic resonance imaging E Is more common in men than women

A

Squamous cell tumors of the anal canal A Are typically treated with a regimen of chemotherapy and radiation therapy after diagnosis B Are about as common as rectal cancers C Have a 25% response rate to initial therapy regimens D Typically require abdominoperineal resection for complete treatment E Rarely metastasize to regional lymph nodes

A

The American Society of Anesthesiologists patient classification system: A Is an approach to preoperatively categorizing patients to assess their risk for an operation. B Requires specific measures of certain laboratory values in order to complete the scoring system. C Can be used to decide upon whom not to operate. For example, no ASA 5 patients should undergo operations. D Includes categories ASA1 through ASA5. E Both A and C are true.

A

The most common cause of small bowel obstruction is A Intra-abdominal adhesions B Neoplasms C Intussusception D Crohn disease

A

What route of antibiotics should be given for catheter-associated peritonitis? A Intraperitoneal B Intraperitoneal and intravenous C Intravenous D Intramuscular

A

Which of the following is the most common intestinal fistula in patients with Crohn disease (CD)? A Ileosigmoid B Ileovesical C Ileocutaneous D Ileovaginal

A

According to the STOP-IT trial, for intra-abdominal infection causing peritonitis, how long should antibiotics be continued after adequate source control? A 2 days B 4 days C 8 days D 14 days

B

Acute lower limb ischemia A Usually is caused by increased muscular demand for blood flow in the distribution of an occluded artery B Can be caused by a major arterial dissection C Causes the five Ps: pain, petechiae, pulselessness, paresthesias, paralysis D Is generally best managed by initial observation to allow recruitment of collaterals E Threatens skin loss before muscle or nerve damage

B

Acute pancreatitis A Is usually caused by acute cholecystitis B Can be complicated by pancreatic necrosis C Causes inflammation of the pancreas that is usually not discernible by computed tomography scan D Is associated with common bile duct stones in > 80% of patients E Progresses to chronic pancreatitis in about 40% of those affected

B

Gallstones A. Are symptomatic in > 50% of people B. Are nearly always present in people with chronic cholecystitis C. Are not detected in the gallbladder by ultrasound in about 50% of cases (false negative) D. Are usually detectable by ultrasound if present in the common bile duct E. Are composed of bile pigment in the majority of cases in the United States

B

Laparoscopic adrenalectomy is usually not indicated for A An aldosteronoma B A feminizing tumor C A pheochromocytoma D A metastasis from melanoma E A symptomatic myelolipoma

B

Postsplenectomy sepsis A Only occurs within 1 year of operation B Is at greatest risk in young children C Is associated with residual accessory splenules D Is more often lethal in adults than children E Is more common after splenectomy for trauma than for other indications

B

What is the best radiologic imaging study for diagnosis of an intra-abdominal abscess? A. Computed tomography (CT) scan of the abdomen without contrast B. CT scan of the abdomen with intravenous contrast C. Abdominal ultrasound D. Magnetic resonance imaging (MRI) of the abdomen

B

Which of the following symptoms should prompt suspicion of spontaneous bacterial peritonitis in a patient with ascites? A Headache B Fever over 37.8°C (100.0°F) C Weakness D Obstipation

B

A 56-year-old woman is being prepared for an elective ventral hernia repair in the preoperative care unit. She is overweight, with a history of non-insulin-dependent diabetes, hypertension, and smoking. Her fingerstick glucose is 326, and you note that her most recent HgA1c was 8.4%. She wants to proceed with the operation, and has traveled a long distance to see you and has taken the day off from work. The most appropriate choice of management is to: A Proceed with the operation and plan for an intraoperative insulin drip. B Repeat the fingerstick after insulin administration and proceed with the operation if the glucose is improved, with the plan for consultation of the diabetes team postoperatively for management. C Cancel the operation with the plan for improved preoperative preparation. D Admit the patient for preoperative glucose management and reschedule the operation for several days from now.

C

A 60-year-old man presents with abdominal pain, fevers, and nausea. He is febrile, focally tender in the left lower quadrant, and has a white blood cell count of 18,000/µL. Computed tomography (CT) shows sigmoid diverticulitis with a 4-cm pericolonic abscess. What is the optimal management strategy for this patient? A Bowel rest and intravenous fluids B Bowel rest, intravenous fluids, and broad-spectrum antibiotics C Bowel rest, intravenous fluids, broad-spectrum antibiotics, and percutaneous drainage D Urgent exploratory laparotomy

C

A 90-year-old man, currently living in a skilled nursing facility, presents to the emergency department with a 2-day history of progressively worse nausea, vomiting, abdominal distention, and pain. His nurse indicates that his last bowel movement was 5 days ago. His past medical history is significant for hypertension, hyperlipidemia, senile dementia, and chronic constipation. Upon physical examination, he is afebrile with stable vital signs and is in visible discomfort due to the abdominal pain. His abdomen is distended, with lower quadrant tenderness and no peritoneal signs. His rectal examination shows a hypotonic sphincter with no feces on the rectal vault. His white blood cell (WBC) count is 10,000/µL. A plain film of the abdomen is done and shows a dilated sigmoid with a coffee bean shape. Which one of the following steps is the most appropriate next step in the management of this patient? A Admission to hospital, bowel rest, intravenous (IV) fluids, barium enema B Observation in the emergency department C Admission to hospital, bowel rest, IV fluids, colonoscopy D Admission to hospital, bowel rest, IV fluids, IV antibiotics E Admission to hospital, bowel rest, IV fluids, exploratory laparotomy

C

All the following are true of surgical site infections except: A Antiseptic technique helps prevent surgical site infections. B Development of an intra-abdominal phlegmon is indicative of poor wound healing. C Surgical technique does not play a role in leading to infection. D Wound dehiscence is a consequence of surgical site infection.

C

An 82-year-old woman with dementia who is otherwise healthy presented to the emergency department with a strangulated umbilical hernia. Her initial vital signs were a temperature of 102.1°F, heart rate of 112 beats/min, blood pressure of 102/46 mm Hg, and respiratory rate of 22 breaths/min on 2 L nasal cannula. On exam, she had a large, nonreducible bulge that was erythematous and tender to palpation. Lab work showed leukocytosis to 23 with a lactic acid of 3.1. She was emergently taken for exploratory laparotomy and hernia repair, with subsequent normalization of her labs and vital signs. On postoperative day 3, she became confused and combative, requiring restraints. She reported new low abdominal pain and was found to have a low-grade fever. What is the most likely cause? A Atelectasis. B Postoperative delirium. C Urinary tract infection. D Abdominal abscess. E Nosocomial pneumonia.

C

Arterial aneurysm A Management requires operative or catheter-based intervention in nearly all patients B Management should include urgent operation in most patients C Is defined as a localized dilation of an artery to at least 1.5 times its normal diameter D Is caused by a disruption of the artery wall and does not include all layers of the wall E Is most commonly a mycotic aneurysm

C

Condyloma acuminata A Are unlikely to recur after treatment B Are often treated with antiviral therapy as first-line treatment C Can be managed by palliation of macroscopic lesions by operation D Do not carry any risk of dysplasia E Are always asymptomatic

C

Geriatric patients: A Are a limited portion of a general surgery practice now and in the near future. B Can have perioperative risks closely estimated by chronological age. C Can have frailty measured by a variety of means that predict the risk of complications. D Require limited special assessment other than modification of drug dosages. E Both A and C are true.

C

In a patient with nonocclusive mesenteric ischemia, what is the best management strategy? A Operative revascularization B Systemic heparinization C Reversal of low-flow state D Endovascular revascularization

C

Management of acute cholangitis A Typically requires emergent operation B Should not include antibiotics until bile cultures are pending C Should usually include draining the biliary tree D Is commonly required in the management of chronic pancreatitis E Should reserve invasive procedures for patients who have required more than 3 days of antibiotics

C

Management of insulinoma A Typically requires emergent operation B Should not include preoperative imaging C May be treated by enucleation of the pancreatic lesion D Is commonly required in the management of chronic pancreatitis E Is a palliative approach to an incurable problem for most people

C

The workup of an adrenal incidentaloma includes all of the following, except A Measurement of 24-hour urinary fractionated metanephrines B Measurement of 24-hour urinary cortisol and creatinine C Fine-needle biopsy of the adrenal tumor D Plasma aldosterone level and renin activity E Obtaining family history of adrenal disease

C

Venous thromboembolism risk: A Has no relationship to the family history. B Is assessed using the RCRI score. C Can be modified by risk-based interventions. D Has few long-term consequences as long as a pulmonary embolus is not fatal. E Frequently should be modified by placement of an inferior vena cava filter preoperatively.

C

What is the most common symptom patients experience after removal of the colon? A Vitamin K deficiency B Renal stones C Dehydration D Hyponatremia E Short-chain fatty acid deficiency

C

Which of the following is true regarding small bowel obstruction (SBO)? A The most common worldwide etiology is adhesions from prior surgery. B It is more frequent with upper intestinal than lower intestinal surgeries. C In a complete closed-loop obstruction, serum lactate can be normal. D Partial SBO symptoms typically improve within 24 hours of nonoperative management. E Abdominal pain disproportionate to exam findings occurs early in the setting of obstruction.

C

Which of the following statements about acute mesenteric ischemia is incorrect? A The most common cause is the arterial embolism. B Thrombosis of mesenteric veins is often associated with portal hypertension. C Deep venous thrombosis can be a cause. D Abdominal pain is the main clinical finding.

C

A 25-year-old man is 6 hours postoperative from emergent laparotomy after blunt abdominal trauma from a motor vehicle accident. His spleen was removed, and the hepatic laceration was repaired primarily with sutures and packed with topical procoagulants. There was tearing in his mesentery leading to a small partial bowel resection and a notable retroperitoneal hematoma. The duration of the operation was 5 hours, and he received 3 L of crystalloid, 15 U of blood, 15 U of fresh frozen plasma, and 10 U of platelets. His abdominal wall was lax enough to be closed primarily. He remained intubated and was transferred to the ICU postoperatively for further resuscitation. His urine output dropped from 50 mL/h to 15 mL/h over the past 3 hours. His abdomen appears distended and his breaths appear more labored on the ventilator with increased peak pressures and decreased tidal volumes. Further steps in his management should include: A Paralyzing the patient for better ventilation. B Trial of diuresis to improve renal function. C Additional fluid resuscitation, given the large-volume blood loss. D Bladder pressure measurement to assess for increased abdominal pressures. E Obtain CT of the chest/abdomen/pelvis to evaluate for further bleeding.

D

A 43-year-old man with a distant history of intravenous drug use is now status post right inguinal hernia repair and is complaining of severe groin pain on the side of the operation. All of the following are appropriate actions except: A Evaluate the patient for necrotizing fasciitis. B Reassure the patient that his use of preoperative Suboxone that morning may have blocked his postoperative response to narcotics. C Allow the nurse to administer a postoperative parenteral nonopioid analgesic. D Discharge the patient with a prescription for pain medication and a plan for follow-up in 2 weeks. E Perform a nerve block with local anesthetics.

D

A 50-year-old white woman presents to the emergency department with a 24-hour history of right upper quadrant abdominal pain, fever, and a white blood cell count of 14,000/µL. What is the initial imaging study of choice? A 99m-Tc hepatobiliary scintigraphy (hepatic iminodiacetic acid [HIDA]) scan B Computed tomography (CT) scan of the abdomen C Kidney, ureter, and bladder radiograph D Abdominal ultrasound E Magnetic resonance cholangiopancreatography

D

A 65-year-old, asymptomatic woman is found to have a 3-cm sessile polyp in the ascending colon on screening colonoscopy. It was biopsied but could not be resected. Pathology shows tubulovillous adenoma. What is the next step in management? A Colonoscopy in 1 year B Colonoscopy in 3 years C Local excision D Right hemicolectomy

D

A 72-year-old man underwent resection of hepatic segments 5/6 for a hepatoma in the setting of hepatocellular carcinoma 2 days ago and was recently discharged to the floor. Perioperatively, he required a large volume of fluid resuscitation. He now has bloody output from his two Jackson-Pratt drains that are seated in the liver bed, his hematocrit has fallen 7 points to 23, his INR is 2.7, he is febrile to 102.8°F, and he is confused. Which of the following is the most appropriate order and choice of management? A Evaluation of the patient, transfer to higher level of care, transfusion with 2 units of unmatched packed red blood cells, return to the operating room for surgical control of bleeding. B Evaluation of the patient, transfusion with two packs of fresh frozen plasma and 2 units of matched packed red blood cells, computed tomography with angiography for possible embolization. C Evaluation of the patient, intubation for protection of airway, transfer to higher level of care, transfusion with cryoprecipitate, antibiotic administration, return to the operating room for surgical control of bleeding. D Evaluation of the patient, intubation for protection of airway, transfer to a higher level of care, transfusion with 2 units of fresh frozen plasma and 2 units of matched packed red blood cells, antibiotic administration, and computed tomography of the abdomen.

D

A 75-year-old man has a right hemicolectomy performed for cecal polyps. The patient has return of bowel function. On postoperative day 10, the patient complains of worsening abdominal pain and a low-grade fever. A CT scan is performed that shows evidence of a high-grade small bowel obstruction. A nasogastric (NG) tube is placed. The patient is observed over the next 2 days, and he has no return of bowel function. The next step in management is to A Start Reglan and encourage ambulation B Diagnostic laparoscopy C Exploratory laparotomy D NG tube decompression and continued observation E Repeat CT scan

D

After the decision to operate has been made, the evaluation regarding safety to proceed: A Is the sole province of the anesthesiologist. B Should not take into account the planned operation. C Is best performed by specialists not directly invested in the planned operation. D Should include a pain assessment to aid in the management of postoperative pain. E Both A and C are true.

D

All of the following are current useful imaging modalities for the biliary tree and gallbladder, except A Abdominal ultrasound B Endoscopic retrograde cholangiopancreatography C Abdominal computed tomography scan D Oral cholecystography E Transhepatic cholangiography

D

All of the following are sites of perirectal fistulas, except A Suprasphincteric B Transsphincteric C Intersphincteric D Infralevator E Submucosal

D

All of the following are true about the anatomy of the pancreas, except A The head is adherent to the medial duodenum. B The body is in contact posteriorly with the left crus of the diaphragm and the left adrenal gland. C The common bile duct passes through a groove in the posterior aspect of the head. D The uncinate process lies anterior to the superior mesenteric artery. E The main pancreatic duct is also known as the duct of Wirsung.

D

All of the following are true about the perioperative care of a patient undergoing unilateral adrenalectomy for pheochromocytoma, except A. α-Adrenergic blockade is indicated preoperatively to prevent intraoperative hemodynamic instability B. An arterial line should be placed for real-time blood pressure monitoring C. Nitroprusside should be available to manage severe hypertension D. Stress dose steroids and subsequent steroid taper are needed in all patients postoperatively E. Glucose should be checked hourly until tolerating a diet to identify hypoglycemia

D

An otherwise healthy 60-year-old man presents with abdominal pain. His CT shows an obstructing mass in the sigmoid colon with dilation of the cecum to 13 cm. After fluid resuscitation, what is the next step in management? A Nasogastric decompression and observation B NPO (nothing by mouth), antibiotics, and observation C Flexible sigmoidoscopy with biopsies to further evaluate the mass D Exploratory laparotomy

D

Anal bleeding can be commonly caused by A Diverticulitis B Anal condyloma C Anorectal abscess (undrained) D Anal fissure E Thrombosed external hemorrhoids

D

Arterial occlusive disease A Occurs predominantly due to congenital abnormalities or anatomical anomalies B Includes disease caused by atherosclerotic plaques, which typically develop at arterial branch points of high shear stress C Is masked by collateral arterial circulation that typically has a lower resistance than the original unobstructed artery D Typically occurs with at least a 50% reduction in arterial diameter, which correlates with a 75% narrowing of cross-sectional area E Causes symptoms due to high pressure proximal to stenosis

D

Indications for splenectomy can include A Vascular disease B Splenomegaly associated with infection C Hereditary spherocytosis D Both A and C E A, B, and C

D

Intermittent claudication characteristics include all of the following except A "Cramping" in a muscle B Deep-seated ache in the calf C Can be associated with walking D Pain occurring at rest E Has a low rate of major limb loss

D

Proctectomy requires pelvic dissection and has the potential to cause injury to the nerves that supply the rectum, pelvic floor muscles, and bladder, as well as the prostate and seminal vesicles in men. Which of the following associations is incorrect regarding the nerves at risk at different points in the operation? A Superior hypogastric plexus near root of inferior mesenteric artery B Hypogastric nerves in the retrorectal space C Nervi erigentes near lateral stalks D Inferior hypogastric plexus near Denonvilliers fascia

D

Serum alkaline phosphatase can come from A Lung B Muscle C Skin D Intestin E Red blood cells

D

Serum amylase can come from A Lung B Muscle C Skin D Parotid gland E Red blood cells

D

The most sensitive and specific test for diagnosis of pheochromocytoma is A Plasma free catecholamines B 24-hour urinary vanillylmandelic acid (VMA) C 24-hour urinary catecholamines D Plasma free metanephrines E Plasma free VMA

D

The treatment of small bowel obstruction includes A Nasogastric suction B Fluid and electrolyte resuscitation C Laparoscopic adhesiolysis in highly selected cases D All of above

D

Which of the following is true about the spleen? A The red pulp of the spleen is normally a significant contributor to red blood cell hematopoiesis. B The spleen's venous drainage is evenly divided between the splenic vein and direct branches of the left renal vein. C The outer capsule of the spleen is a continuous sheet of smooth muscle. D The gastrosplenic ligament carries the short gastric vessels. E Normally, 80% of the platelet cell mass is sequestered in the spleen.

D

Which of the following statements about small bowel tumors is correct? A Adenomas are more common in the distal ileum. B The most common neoplasm is gastrointestinal stromal tumor (GIST). C Peutz-Jeghers syndrome has a very high malignant potential. D Carcinoid syndrome develops in presence of liver metastases.

D

A 45-year-old woman developed fever, chills, and worsening abdominal pain 7 days after a small-bowel resection for Crohn disease. She complained of persistent nausea and vomiting. Her abdomen was distended and diffusely firm with peritonitis on examination. Her vital signs are a temperature of 102.3oF, heart rate of 117 beats/min, blood pressure of 98/56 mm Hg, and respiratory rate of 23 breaths/min on 2L nasal cannula. CT of the abdomen/pelvis showed anastomotic stranding with trace free fluid. What is the next best step? A Take her back to the operating room. B Consult interventional radiology for drain placement. C Initial management requires a nasogastric tube placement, IV fluids, and supportive management. D Start empiric antibiotics. E Both A and D. F Both B and C. G None of the above.

E

A 65-year-old woman undergoes a thyroid lobectomy for a follicular neoplasm. She has a history of coronary artery disease, hypertension, insulin-dependent diabetes, and stroke. The procedure lasted 2 hours, during which the patient required occasional neosynephrine for brief intraoperative hypotension. Two hours after the procedure, the nurse called from the post anesthesia care unit to report that the patient is agitated and hypertensive. Which of the following is not likely to be the cause for her agitation? A. Hypoxia B. Stroke C. "Unmasking" of cognitive dysfunction D. Hyperglycemia E. Hypocalcemia

E

Adrenal tumor can secrete all of the following, except A Normetanephrine B Aldosterone C Cortisol D DHEAS E 5-HIAA

E

An 89-year-old man who is currently a resident in a senior assisted living facility comes to the emergency department with an 8-day history of nausea, vomiting, abdominal pain, and profound abdominal distention. The patient states that his last bowel movement was 9 days ago. He is afebrile with stable vital signs. His physical examination is consistent with a distended and tender abdomen without evidence of peritoneal signs. A CT of the abdomen and pelvis with intravenous contrast only shows a diffusely dilated colon, without evidence of perforation. Which one of the following steps is the most appropriate next step in the management of this patient? A Colonoscopy B Barium enema C Watchful waiting D Docusate E Cholinesterase inhibitor

E

Diabetes mellitus patients require more operations than patients without diabetes, and if not carefully controlled have increased risks of: A Surgical site infection. B Perioperative adrenal insufficiency. C Perioperative hypoglycemia. D A, B, and C are all true. E Both A and C are true.

E

Which of the following are routine components of an ERAS protocol in patients who have undergone colon resection? A Vital signs including heart rate, blood pressure, oxygen saturation. B Wound evaluation including assessment of drain output and content. C Assessment of the adequacy of pain management. D Plan for removal of the nasogastric tube, Foley catheter, and advancement of diet. E All of the above.

E