Quiz 5/23
A 55-year-old man is being considered for living kidney donation. Which of the following would constitute an absolute contraindication to proceeding with donation?
B. Diabetes mellitus
Which of the following is least likely to be a cause of infection four months after transplant?
D. E.coli wound infection
Eight weeks after undergoing liver transplantation, a 58-year-old man presents for routine follow-up. His postoperative course has been uncomplicated, and he has been maintained on tacrolimus, mycophenolate, and a tapering prednisone regimen for maintenance immunosuppression. In clinic he complains of fatigue, "low-grade" fever, and myalgias, which have been present for the past week. On laboratory evaluation, he has leukopenia and mild elevation in transaminases. What is the most likely diagnosis?
A. Cytomegalovirus Infection
A patient undergoes a kidney transplant. The cold ischemic time of the kidney is 36 hours. What postoperative clinical finding in this patient may be related to the prolonged cold ischemic time?
A. Dialysis required on postoperative day 3 (delayed graft function)
A 44-year-old man with a long-standing history of congestive heart failure and type 1 diabetes mellitus undergoes simultaneous kidney and pancreas transplantation. Four hours after the operation, he has a decrease in urine output. His heart rate is 140 beats/min and his blood pressure is 90/40 mm Hg. His abdomen is distended, tender, and ecchymotic. Hemoglobin is 6.5 g/dL and hematocrit is 18%. What is the next best course of action?
A. Emergent surgical reexploration
A 75-year-old woman is diagnosed with a 1.8-cm right breast invasive ductal carcinoma. In terms of biomarkers, the carcinoma is estrogen receptor (ER)-positive, progesterone receptor (PR)-positive, and human epidermal growth factor 2 (HER2)-negative. She is an appropriate candidate for breast conservation, which is what she requests. Which of the following would allow consideration of omission of adjuvant radiation?
A. Estrogen receptor-positive status
A 66-year-old man with a history of hepatitis C virus cirrhosis underwent a living donor liver transplant from his son 6 months ago. He presents to the clinic with recurrent fevers, and laboratory tests demonstrate abnormal liver function. An ultrasound of his liver graft shows multiple bile duct strictures, the most prominent one being 5 cm from the anastomosis. What is the most likely cause of this complication?
A. Hepatic artery stenosis or thrombosis
A young patient with a strong family history of malignancy presents with what might be a primary colon cancer. For which familial cancer syndrome would you recommend that the patient starts cancer screening with colonoscopy at age 20 to 25 years (repeated every 1-3 years) and transvaginal ultrasound or endometrial aspiration beginning at age 20 to 25 years (repeated annually)?
A. Hereditary nonpolyposis colon cancer
A 28-year-old woman with no previous medical history presents to the emergency department for evaluation of bilateral lower quadrant abdominal pain. She recently had a positive pregnancy test at home and estimates she is about 7 weeks pregnant based on the date of her last period. This is her first pregnancy. A transvaginal ultrasound fails to demonstrate a intrauterine gestation. There is a mass visualized adjacent to the right ovary. There is no free fluid visualized in her pelvis. Her serum human chorionic gonadotropin level is 2260 mIU/mL. She is diagnosed with an unruptured ectopic pregnancy. Which is the most appropriate treatment?
A. Intramuscular methotrexate
A 40-year-old woman is deemed to need hysterectomy for endometriosis. In counseling her regarding surgical techniques, you inform her that a laparoscopic hysterectomy is best for what reason?
A. It allows for intra-abdominal assessment of extrauterine endometriosis deposits.
A 23-year-old woman at 25 weeks of pregnancy presents with anorexia, nausea, vomiting, diffuse abdominal pain, and rebound tenderness to the emergency department. An abdominal ultrasound is suspicious for appendicitis. What do you recommend?
A. Laparoscopic appendectomy
A 5-year-old female presents to your office referred by her primary physician for a thyroid mass. Her father had a thyroidectomy at the age of 25 for a "tumor". She is noted to have an elevated serum calcitonin level. In addition to surgical resection, what also must be done in the screening of this patient?
A. Measurement of serum calcium levels
A gain-of-function mutation of the RET proto-oncogene predisposes an individual to develop which of the following malignancies?
A. Medullary thyroid cancer
The procurement team anticipates they will arrive with the donor liver for your patient at 2:00 a.m., and you schedule the liver transplant for that time. The operating room scheduling team asks if you can schedule the liver transplant instead for 3:00 p.m. so that elective cases can be completed. Which of these considerations is most important in providing a response?
A. Minimizing cold ischemic time improves graft outcomes.
A 25-year-old female presents to your office referred by her primary physician for unexplained hypertension refractory to multiple pharmacotherapeutic agents. She had a full metabolic workup including a CT scan of her abdomen and pelvis, which showed a 4-cm mass in her right adrenal gland. She asks you about the possibility of genetic syndromes she read about online. Which of the following would make you suspicious in her family history regarding a genetic syndrome?
A. Ocular vascular lesions in her maternal grandmother
A 65-year-old woman is undergoing staging surgery for endometrial cancer. Preoperative imaging showed disease limited to the uterus. A total hysterectomy and bilateral salpingo-oophorectomy is performed, and the specimen is sent for frozen section. On frozen section, the tumor is found to be poorly differentiated endometrioid type, with deep myometrial invasion. What additional procedures are needed to complete the staging surgery?
A. Pelvic and para-aortic lymphadenectomy
Which of the following is recommended for the establishment of donation after cardiac death?
A. Period of 5 minutes of asystole following cardiac arrest as established by EKG or pulse oximetry
A 62-year-old man with end-stage renal disease is undergoing a kidney transplant. After en bloc organ retrieval, what is a core component of back-table preparation of the kidney?
A. Preservation of periureteric tissue is crucial, because this will limit the rate of urine leaks and ischemic complications, given that the periureteric fat is crucial in maintain perfusion after transplantation.
A 29-year-old woman presents to the emergency department with 6 hours of worsening right lower quadrant abdominal pain and nausea. She denies any other symptoms. She has an intrauterine device and does not know when her last period was. She has a history of gonorrhea. Her white blood count on arrival to the emergency department is 9000/µL. Which of the following is the next step in management?
A. Serum beta-human chorionic gonadotropin
A 28-year-old woman with a history of type 1 diabetes recently underwent an uneventful pancreas transplant 21 days ago. She has since developed progressive pain and hyperglycemia. Amylase and lipase are found to be elevated. She subsequently develops fever, tachycardia, and hypotension. Ultrasound demonstrates complete pancreatic graft venous thrombosis. What is the most appropriate next step in management?
A. Transplant graft pancreatectomy
A 32-year-old woman presents to the emergency department with vaginal bleeding. She has a quantitative human chorionic gonadotropin (hCG) drawn; it is 6152 mIU/mL. A pelvic ultrasound is performed and shows no intrauterine pregnancy. There is evidence of a tubal ectopic pregnancy, which measures 3 cm, and fetal cardiac activity is noted. The patient reports she recently delivered a baby (3 months ago) and is breastfeeding. Because the woman is hemodynamically stable and wants to avoid surgery, you are considering methotrexate. What is the absolute contraindication to methotrexate therapy in this scenario?
B. Breastfeeding
A 59-year-old woman is diagnosed with a pT2N2M0, a triple-positive ductal carcinoma in the left breast. Neoadjuvant chemotherapy and trastuzumab are started. Which side effect is associated with the administration of trastuzumab?
B. Cardiomyopathy
A 45-year-old male is sent to your clinic for evaluation of anemia and abdominal pain. You perform a colonoscopy and find a splenic flexure adenocarcinoma. He undergoes left colectomy with excellent recovery. Six months later, he is noted to have a rising CEA level and liver lesions on abdominal CT. CT-guided biopsy is positive for metastatic adenocarcinoma. He has marginal response to his initial chemotherapy regimen and cetuximab is added. By which mechanism does this targeted agent work?
B. Decreases production of EGFR
An 18-year-old woman is undergoing a diagnostic laparoscopy for suspected ovarian torsion. She presented with pelvic pain and abnormal Doppler flow of the left ovary along with a 5-cm left simple ovarian cyst seen on pelvic ultrasound. You visualize the left ovary and notice that it is torsed. The left ovary appears bluish-black in color. The right ovary appears normal. What is the most appropriate next step?
B. Detorsion of left ovary and ovarian conservation
A 43-year-old man with type 1 diabetes recently underwent successful pancreas-alone transplantation with enteric drainage. His hospital course was unremarkable and on postoperative day 4, he was discharged home. On postoperative day 30, he presents to the emergency department with fever and abdominal pain. On examination, his heart rate is in the 120s (beats/min) with blood pressure in the 90s/50s (mm Hg). His abdomen is tense with rebound tenderness in all four quadrants. What is the next best step?
B. Exploratory laparotomy
A 32-year-old woman is 34 weeks pregnant. What are the normal cardiovascular changes during pregnancy?
B. Heart rate increased, stroke volume increased, mean arterial pressure decreased, and vascular resistance decreased
You are the surgeon on call at a community hospital where a 28-year-old woman at 39 weeks' gestation presents to the pregnancy assessment center with contractions every 3 minutes after having rupture of membranes. On cervical examination, she is noted to be 5 cm dilated. She has no drug allergies. In preparing for repeat cesarean delivery, what is your preferred choice for antibiotics for infection prophylaxis?
B. Intravenous cefazolin and intravenous azithromycin
A young patient presenting with osteosarcoma is found to have a germline p53 mutation. Which syndrome and pattern of malignancies are associated with mutations in this gene?
B. Li-Fraumeni syndrome
You are performing a cesarean delivery on a 32-year-old woman with a twin pregnancy and recently diagnosed severe preeclampsia. On delivery of the second fetus and placenta, you note that the uterus is boggy with poor tone and significant hemorrhage from the hysterotomy. Which uterotonic agent is contraindicated in this patient?
B. Methergine
What are the risks associated with performing a pancreas transplant on an obese recipient (BMI >35)?
B. Surgical site infection and fascial dehiscence
An 85-year-old woman presents with shortness of breath, early satiety, and abdominal distension. She has a history of diabetes mellitus, coronary artery disease with stent placement, and moderate persistent asthma. A computed tomography scan shows a 10-cm bilateral adnexal mass, large-volume ascites, omental caking, para-aortic lymphadenopathy, four intraparenchymal liver metastases, and a moderate right pleural effusion. Her cancer antigen 125, or CA-125, is 15,000 U/mL. Thoracentesis is performed and reveals a serous carcinoma of mullerian origin. The most appropriate initial treatment plan in this patient is which of the following?
B. Neoadjuvant intravenous chemotherapy
A 47-year-old man receives a renal transplant for end-stage renal disease secondary to diabetes mellitus. He is counseled regarding the toxic effects of the tacrolimus he takes. This medication may be associated with which of the following?
B. Nephrotoxicity and neurotoxicity
A 30-year-old woman presents to the emergency department with complaints of acute onset of left lower quadrant pain. It is associated with nausea and vomiting. She has no vaginal bleeding. Transvaginal ultrasound identifies an adnexal mass. The most likely diagnosis is which of the following?
B. Ovarian torsion
A 14-year-old girl presents with severe right lower quadrant pain. A pelvic ultrasound shows a 10-cm mass involving the right ovary and no blood flow to that side. The girl is taken to the operating room for an urgent laparoscopy for suspected ovarian torsion. The right ovary appears to be completely replaced by a large abnormal-appearing mass, and a right salpingo-oophorectomy is performed and the specimen sent for frozen section. The uterus and left adnexa appear normal. The frozen section of the right fallopian tube and ovary show an immature teratoma. What additional procedures are required to complete a fertility-sparing staging surgery?
B. Pelvic and para-aortic lymphadenectomy, omentectomy, peritoneal biopsies, and pelvic washings
You are performing a risk-reducing bilateral salpingo-oophorectomy on a 40-year-old woman who has a deleterious BRCA1 mutation. Pathology results return as no evidence of occult malignancy in the ovary or fallopian tube. You inform the patient that despite having this procedure performed, she still has a risk of which cancer listed below?
B. Peritoneal cancer
A 12-year-old boy underwent successful small bowel transplantation 9 months ago. He has suffered no signs of rejection but recently has developed fever and cervical lymphadenopathy. Abdominal imaging reveals numerous enlarged mesenteric lymph nodes. What is the most likely diagnosis?
B. Posttransplant lymphoproliferative disorder (PTLD)
A 45-year-old female presents with a 2.6 cm high-grade triple-negative (ER/PR/HER2 negative) breast cancer with a biopsy-proven axillary lymph node metastasis. She wears a C-cup bra and the lesion is located near the nipple. No skin changes are present. She is scheduled to receive neoadjuvant chemotherapy. Which of the following applies to this patient?
B. She may have a higher chance of breast conservation by receiving neoadjuvant therapy compared to postoperative adjuvant chemotherapy.
A 65-year-old man undergoes a radical resection of a retroperitoneal dedifferentiated liposarcoma. Margins are grossly positive along the aorta, so he undergoes adjuvant radiation therapy with 60 Gy. Two years later, there is no evidence of recurrence. However, he has worsening diarrhea refractory to antimotility agents. A colonoscopy with biopsy shows patchy thickening of the basement membrane with infiltration of lymphocytes in the lamina propria of the transverse colon. The next best step in management is which of the following?
B. Steroids
What is the primary mechanism of infection in pelvic inflammatory disease?
C. Disruption of the cervical mucus barrier
After completing the appropriate exposure during a deceased donor kidney transplant, the operating surgeon is ready to anastomose the donor kidney to the native vessels. The surgeon decides to place the donor kidney in the retroperitoneum and anastomose to the iliac vessels. What is an advantage of this strategy?
B. The kidney is close to the bladder.
An asymptomatic 38-year-old woman with a family history of breast cancer was recently found to have a BRCA1 mutation. She presents to the clinic to discuss prophylactic surgical treatment options. How do you counsel her?
B. The lifetime risk of developing ovarian cancer is 40% to 60% for carriers of a BRCA1 mutation, and prophylactic salpingo-oophorectomy should be offered.
A 40-year-old female presents to your clinic for evaluation for a palpable 4-cm left breast mass. Diagnostic mammogram shows a spiculated mass in the upper outer quadrant. She undergoes US-guided core needle biopsy which reveals a ductal carcinoma, ER/PR negative, Her-2-neu positive. To add a 50% reduction in the risk of recurrence, which chemotherapy agent should be added her to treatment?
B. Trastuzumab
A kidney is being retrieved from a living donor, a 44-year-old healthy man. The period of time from the clamping and dividing of the renal artery to the flushing of the organ with cold preservation solution is known as which of the following?
B. Warm ischemia time
A 45-year-old woman is undergoing a total abdominal hysterectomy for a fibroid uterus the size of a 20-week pregnancy. She has a history of four prior cesarean sections. During the surgery, you encounter dense scar tissue and decide to attempt to trace the ureters' course in order to avoid injury. When is ureteral injury most likely to occur during hysterectomy?
B. When the uterine vessels are ligated
A 45-year-old man wants to donate a kidney to his brother. During the course of the evaluation, he is determined to be ABO blood group A; his brother is ABO blood group O. Which of the following is the best option?
C. Enroll the donor and recipient in a kidney paired exchange program.
A 53-year-old female undergoes a diagnostic mammogram for a palpable left breast mass followed by an US-guided core needle biopsy which reveals a ductal carcinoma, ER/PR negative, Her-2-neu positive. Over-expression of the Her-2-neu oncogene is a ________ prognostic factor and allows treatment targeted at the _______ receptors. Fill in the blanks.
C. Negative Tyrosine kinase
A 28-year-old woman presented to the emergency department 3 days ago in hemorrhagic shock from a ruptured ectopic pregnancy. She is now postoperative day 3 status post-unilateral salpingectomy and ready for discharge. Her last beta-human chorionic gonadotropin this morning was unmeasurable. Which of the following is important in her postoperative management?
C. Administer anti-D immunoglobulin for an Rh-negative blood type
Which of the following is not a part of maintenance immunosuppression?
C. Basiliximab
A 61-year-old man comes to the clinic complaining of 3 months of fatigue and a 12-pound weight loss. A colonoscopy is performed, and an ulcerated polyp is found and biopsied. The diagnosis of colon adenocarcinoma is made. Computed tomography of the abdomen and chest reveals multiple hepatic nodules. Which of the following would be the most appropriate therapy regimen for this patient?
C. Bevacizumab, fluorouracil, and oxaliplatin
A 61-year-old woman is started on pembrolizumab for melanoma metastatic to the liver and small bowel. What is the mechanism of action of pembrolizumab?
C. Blockade of the PD1-PDL1 interaction
Which tumor marker is used primarily in screening for ovarian cancer?
C. Cancer antigen 125 (CA-125)
A 36-year-old woman presents for a follow-up appointment with her transplant hepatologist. She underwent a deceased donor liver transplant 2 years ago and is without symptoms. What finding is most likely to be seen in this patient?
C. Decreased immunosuppression regimen
A 70-year-old woman undergoes a laparoscopic cholecystectomy for biliary colic. Pathology notes an incidental gallbladder carcinoma invading the perimuscular connective tissue. She is referred to a hepatobiliary surgeon, who performs a resection of segment 4b/5 with a portal lymphadenectomy. Margins are negative, and of the five lymph nodes removed, none is positive. The most appropriate adjuvant therapy recommendation is which of the following?
C. Gemcitabine with cisplatin
Four hours after a renal transplant, a man's urine output abruptly decreases. In 1 hour, it drops from 100 to 5 mL. In addition, it is frankly sanguineous. He also complains of increased pain at the surgical site. What should the next course of action be?
C. Immediate renal ultrasound
You are called to assist in the delivery of a 26-year-old pregnant woman (39 weeks) who has elected to proceed with cesarean delivery for a macrosomic infant (> 99th percentile in size) and a prior history of a cesarean section. When attempting delivery through the low transverse incision, you experience difficulty with delivery of the fetal head. What incision type would help with successful delivery of the fetus?
C. J-shaped or inverted T-shaped incision
A 45-year-old male is sent to your outpatient clinic for evaluation of anemia and abdominal pain. In obtaining his medical history, you learn that he has a strong family history of cancer. His mother had ovarian and colon cancer, diagnosed in her 40s. His maternal uncle and grandfather also had colon cancer. He undergoes a colonoscopy and is found to have a mass in the ascending colon. Biopsy during colonoscopy reveals adenocarcinoma. Given the patient's history, what pathologic finding is most likely to be positive in this patient?
C. Microsatellite instability
A 58-year-old man undergoes a left hemicolectomy for colon cancer. How would the patient's prognosis be affected by the presence of an APC gene mutation found in the tumor cells?
C. Mutations in APC are seen in more than 80% of sporadic colon cancers and do not confer significant additional cancer risk.
A 51-year-old woman with cirrhosis of the liver secondary to hepatitis C virus needs a liver transplant. She is receiving a liver from a donor who has been declared brain dead. During the transplant surgery, the donor liver is noted to have rounded edges and visual steatosis. What is the next most appropriate step?
C. Perform a biopsy, and proceed with the procurement if the pathology results return as microvesicular steatosis.
A 26-year-old woman was recently found to have the BRCA1 gene mutation following her mother's ovarian cancer diagnosis. She has no children and strongly desires future fertility. You counsel the patient regarding her risk-reducing options. The most appropriate strategy to reduce this patient's risk of developing ovarian cancer is which of the following?
C. Risk-reducing bilateral salpingo-oophorectomy at the completion of childbearing or by the age of 35 to 40 years.
A 30-year-old woman with type 2 diabetes mellitus presents to your office to discuss pancreas transplantation. She has had very labile blood glucose and admissions for diabetic ketoacidosis. Her renal function is normal. Review of her laboratory results shows a glomerular filtration rate of 60 mL/min per 1.73 m2 and an absence of proteinuria. Which of the following best applies to the management of this woman?
C. She should be considered for pancreas transplantation alone.
Which of the following statements applies to monoclonal antibodies?
C. The HAMA response is due to the production of human antimouse antibodies.
Following kidney transplantation, a 31-year-old man is ready to be discharged home with normal graft function. He underwent nondepleting induction therapy and will be taking tacrolimus, mycophenolate mofetil, and prednisone for maintenance therapy. Which medication (on his discharge list) prevents Pneumocystis jiroveci pneumonia, a posttransplant fungal infection?
C. Trimethoprim-sulfamethoxazole (TMP-SMZ)
A 27-year-old woman is found down in a park and brought to the emergency department. She is found to be in hemorrhagic shock and has significant intraperitoneal bleeding identified on focused assessment with sonography for trauma (FAST). She is taken to the operating room for exploratory laparotomy. The source of bleeding is identified as a ruptured ectopic pregnancy with significant damage to the associated fallopian tube. Which of the following is the correct surgical procedure?
C. Unilateral salpingectomy
A 31-year-old woman has type 1 diabetes and end-stage renal disease. She has previously received a successful renal allograft and is now undergoing pancreas transplantation. What intraoperative assessments does the surgical team need to make to determine the quality of the donor pancreas?
C. Visual examination of the pancreas, with attention to the texture, nodularity, and peripancreatic fat content, aids the surgeon in assessing the quality of a donor pancreas.
A 55-year-old Caucasian woman is undergoing staging surgery for grade 3 endometrioid endometrial cancer. You perform a hysterectomy, bilateral salpingo-oophorectomy, and pelvic washings. The tumor in the endometrial cavity, when you bivalve the uterus, is noted to be less than 2 cm in diameter. You are about to perform a pelvic and para-aortic lymphadenectomy. What factor would make you MOST likely to perform lymphadenectomy?
D. Tumor grade
A 55-year-old postmenopausal woman undergoes a pelvic ultrasound for pelvic pain. The ultrasound shows a right adnexal mass. For which of the following findings would you recommend ultrasound surveillance over surgical exploration?
D. Anechoic unilocular cyst
You are the surgeon on call at a rural hospital where a 28-year-old pregnant woman (25 weeks) presents to triage with contractions every 2 minutes after rupture of membranes. On cervical examination, she is noted to be 8 cm dilated with a palpable fetal foot as the presenting part, and the fetus is confirmed to be in footling breech presentation on ultrasound. You take her to the operating room for emergent cesarean delivery. What is the most likely incision you will use?
D. Classical incision
A 42-year-old, otherwise healthy man has anemia and occult blood in his stool. His family history is significant for the death of his father at age 45 and the death of his paternal grandmother at age 50 with colon cancer. At colonoscopy, a 4-cm mucinous carcinoma of the cecum and three adenomatous polyps of the ascending colon are found. The most likely genetic defect is a mutation of:
D. DNA mismatch repair gene
A 50-year-old female undergoes a partial mastectomy for a 1 cm ER+ PR+ HER2 negative invasive ductal carcinoma. Axillary staging with sentinel lymph node biopsy was negative. Her medical oncologist plans to use a 21-gene assay to estimate her risk of relapse and benefits of systemic therapy. Use of this assay may impact this patient in which of the following ways?
D. Decreases the use of chemotherapy
You are evaluating whether an 18-year-old man who died by isolated head trauma can become an organ donor via donation after cardiac death (DCD). The patient weighed approximately 185 lbs and was 6 feet 2 inches tall when he died. The possible organ recipient is in the same hospital as the deceased patient. Which factor in the deceased patient's history increases his Liver Donor Risk Index (LDRI) score?
D. Donation after cardiac death
A 57-year-old man with a longstanding history of alcohol abuse presents to the hepatology clinic for evaluation. He was recently hospitalized for a first episode of large-volume hematemesis. On examination, he is cachectic with obvious muscle wasting of his extremities. His abdominal examination notes distension and varicose veins around an umbilical hernia, but he is nontender. His laboratory tests are notable for creatinine 2.1 mg/dL, hemoglobin 7.6 g/dL, and platelets 49 ×10³/µL. Which factor in this patient's history and physical is most linked to his ability to get an offer for a liver transplant?
D. Elevated creatinine
A 49-year-old woman is newly diagnosed with colorectal cancer. After assessing her family history, you deem that she is at high risk for Lynch syndrome and refer her for genetic counseling and testing. What is the most common extracolonic tumor in patients with Lynch syndrome?
D. Endometrial cancer
You are seeing a patient with a newly diagnosed colon cancer. Which of the following patient characteristics would prompt you to consider testing for microsatellite instability?
D. Family history of father with colon cancer and paternal aunt with endometrial cancer
A 30-year-old woman is brought to the emergency department by her husband. Abdominal pain of acute onset, which began about 4 hours ago, has subsequently worsened. On arrival, her blood pressure is 85/47 mm Hg and her heart rate is 120 beats/min. Her extremities are cool, and she is poorly responsive. Her last menstrual period was 6 weeks ago, and she had a positive pregnancy test at home last week. Which of the following is the first step in management of this patient?
D. Focused assessment with sonography for trauma (FAST)
A 19-year-old woman presents to the emergency department with right lower quadrant pain and vaginal bleeding. Her medical history is significant for two prior episodes of chlamydia, and she received treatment for pelvic inflammatory disease last year. She has been pregnant once before; the pregnancy ended in a first-trimester miscarriage. She is currently a smoker and takes oral contraceptive pills, although she believes she missed a few pills last month. After a human chorionic gonadotropin determination and transvaginal ultrasound, she is found to have an ectopic pregnancy. Which of the following is the most likely contributing factor for ectopic pregnancy?
D. History of pelvic inflammatory disease
A 54-year-old man with a long-standing history of hepatitis C virus (HCV) cirrhosis has a standard 6-month surveillance ultrasound, which reveals a new liver mass. He subsequently undergoes an MRI of the abdomen, which demonstrates a 2.8-cm mass in segment IV. Which liver mass would most likely exclude this patient from transplantation?
D. Intrahepatic cholangiocarcinoma
You are performing a liver transplant on a 23-year-old recipient and find a replaced right hepatic artery. How often is this anatomy found, and what is its origin?
D. It occurs in 20% of patients and originates from the superior mesenteric artery.
You are operating on a 26-year-old woman with a suspected malignant germ cell tumor—immature teratoma. Preoperative counseling confirmed that the patient desires fertility preservation if possible. You perform a salpingo-oophorectomy of the affected adnexa. Which of the following is also required for appropriate staging when fertility preservation is desired?
D. Lymph node dissection
A 34-year-old woman wishes to donate one of her kidneys to her sister. During the medical evaluation of the woman as a potential living kidney donor, which of these is adequate for establishing her glomerular filtration rate?
D. MAG-3 renal scan
For 2 hours after a renal transplant, a man's urine output has been 15 mL/h. He has received 2 liters of crystalloid as boluses and appears volume resuscitated. His blood pressure is 140/80 mm Hg. A renal ultrasound shows good perfusion to the kidney with normal waveforms in the arteries and veins, and there are no signs of bleeding. What should the next step in management be?
D. Maintenance fluids, with reassurance given to the patient and staff
A 65-year-old man undergoes a low anterior resection for a stage II T4N0 (eight lymph nodes removed and none positive) invasive adenocarcinoma of the colon. Final pathology shows a high-grade tumor with lymphovascular and perineural invasion. Margins are negative. He inquires if he needs any additional therapy. You decide to offer adjuvant FOLFOX (leucovorin, fluorouracil, oxaliplatin) because he has several risk factors. Of the following risk factors, which is considered a low-risk factor in this patient?
D. Negative margins
A 45-year-old man with chronic liver disease is undergoing a liver transplant. In the donor liver, you find variants of the classic hepatic anatomy. When approaching the hepatic dissection, what intraoperative findings would suggest the presence of a replaced right hepatic artery?
D. Palpation of a distinct pulse most lateral at the porta hepatis, with the vessel tracing back to the superior mesenteric artery
You are planning to perform a laparoscopic appendectomy on a 30-year-old woman who is 20 weeks pregnant and has acute appendicitis. What fetal monitoring should be requested for this case?
D. Preoperative and postoperative fetal heart rate documentation
A 21-year-old woman presents to the emergency department with 6 hours of crampy right lower quadrant abdominal pain. She denies fever, nausea, vomiting, or other symptoms. Her last period was 6 weeks ago, but she reports some minor vaginal bleeding today. She has no other medical history and is sexually active with a new partner. Abdominal examination reveals a tender lower abdomen without guarding or rebound. Her blood pressure is 110/70 mm Hg and her heart rate is 80 beats/min. Which of the following is the most appropriate diagnostic test to perform first?
D. Serum human chorionic gonadotropin level
A 38-year-old African American woman presents for management of an enlarged fibroid and abnormal uterine bleeding. She is interested in definitive therapy but does not want hormone replacement. You offer hysterectomy. When she asks if any other procedure is indicated if she has a leiomyosarcoma, you comment:
D. Should a leiomyosarcoma be discovered on final pathology, no other surgery would be required.
You are seeing a 26-year-old man with a family history of familial adenomatous polyposis in the general surgery clinic to discuss the results of his recent colonoscopy. He is noted to have florid polyposis throughout the entire colon on endoscopic examination. He is hesitant about surgery and specifically wishes to avoid having a permanent ostomy. Which of the following would be an appropriate treatment option for the patient?
D. Total proctocolectomy with ileal pouch-anal anastomosis followed by endoscopic surveillance every 2 years
An otherwise healthy 29-year-old woman presents with a palpable 2.5-cm thyroid nodule in the left lobe. Biopsy results are consistent with a differentiated thyroid carcinoma. In considering options for surgery in this case, which of the following is an appropriate reason to consider total thyroidectomy rather than lobectomy?
D. Total thyroidectomy allows for use of thyroglobulin as a biomarker of disease recurrence in the future.
According to the Kidney Profile Index (KDPI) system, which potential donor will have the highest KDPI?
E. A 60-year-old female DCD donor who had insulin-dependent diabetes, poorly controlled hypertension, hepatitis C virus, obesity, and a terminal creatinine level of 5 mg/dL
The Organ Procurement and Transplantation (OPTN) mandates that an independent living donor advocate (ILDA) be assigned to each potential living donor who undergoes the evaluation process. An ILDA must be which of the following?
E. A person who is not involved in the donor's evaluation
A patient with abnormal uterine bleeding has opted for definitive management with a laparoscopic hysterectomy. When you see her in the preoperative area, she asks what is the most common complication following a hysterectomy. What do you tell her?
E. Bladder injury
A woman with end-stage renal disease presents to the clinic. She inquires about a kidney transplant and the advantages of using a kidney from a living donor kidney versus one from a deceased donor. What do you tell her is the best reason to use a living donor (as opposed to a deceased donor)?
E. Graft survival is improved over the long term.
A 57-year-old man underwent kidney transplantation 18 months ago and is taking sirolimus, mycophenolate mofetil, and prednisone. He has developed a 6-cm incisional hernia at an old midline laparotomy incision. What is the best management of his immunosuppression in the perioperative period?
E. Hold the sirolimus and start tacrolimus for 2 weeks following surgery.
A 29-year-old woman presents with right upper and lower quadrant abdominal pain and fever. Her history is remarkable for an ectopic pregnancy, infertility, and hypertension. After failure of conservative management with antibiotics and a nondiagnostic computed tomography scan, she undergoes diagnostic laparoscopy where multicystic ovaries and adhesions between the liver capsule and the peritoneum are noted. Which of following processes is responsible for this finding?
E. Pelvic inflammatory disease
A 22-year-old woman with primary sclerosing cholangitis and ulcerative colitis is being referred to you for transplant. She has a Model for End-stage Liver Disease (MELD) score of 15 with no history of hepatic decompensation at this time. During the informed consent process, you discuss potential sources of donated organs and the risks and benefits of accepting each type of graft. Which graft may provide her the greatest benefit?
E. Right lobectomy from a 40-year-old unrelated living donor
A 56-year-old man with type 1 diabetes presents to your office for evaluation for pancreas transplantation. He works full time in a warehouse and is active in his job but does no dedicated exercise. He has no history of peripheral vascular disease or coronary artery disease. He has easily palpable femoral and pedal pulses. Which of the following should be included in his workup?
E. Stress echocardiogram
A 51-year-old man is diagnosed with non-Hodgkin lymphoma. The patient is started on cyclophosphamide, doxorubicin, vincristine, prednisolone, and rituximab. Regarding rituximab, which of the following is accurate?
E. The drug is a chimeric anti-CD20 monoclonal antibody.
A 35-year-old woman presents to an urgent care facility with right lower quadrant abdominal pain and vaginal bleeding that have been steadily worsening over the past 1 day. Her beta-human chorionic gonadotropin is 4000 mIU/mL. A transvaginal ultrasound is unable to confirm an intrauterine pregnancy but detects a mass in the left adnexa. Vital signs are currently stable. She has a history of significant renal insufficiency but is not currently on dialysis. Which of the following is an appropriate next step in management?
Laparoscopic salpingectomy
