Surgery CURRENT Questions

A 54-year-old alcoholic man is discovered to have a new gastric cancer. He reports 15 lb weight loss over the past month. Laboratory data includes an albumin of 2.4 g/dL, indicating significant longstanding malnutrition. Postoperatively, which of the following electrolyte derangements would be of initial concern, especially when he starts to eat or receive some other form of nutrition? A Hypophosphatemia B Hyperphosphatemia C Hypermagnesemia D Hyponatremia E Hyperkalemia

A

All of the following are true about surgical site infection, except A Classified by the Centers for Disease Control into: (1) wound only, (2) organ space, and (3) involving organ parenchyma B Risk varies based upon degree of wound contamination by bacteria C Risk is modified by patient factors such as diabetes and ongoing immunosuppression D May have reduced risk by the use of appropriately chosen and timed antibiotics E Treatment emphasizes primary source control

A

All of the following are true of respiratory complications, except A They are common after chest procedures, but rare after abdominal operations B They are the most common single cause of morbidity after major surgical procedures C They occur more commonly in the elderly, smokers, and obese patients D Predisposing factors can be moderated by preoperative and postoperative activities E They include atelectasis, pneumonia, aspiration, and pulmonary emboli

A

The clinical findings at breast cancer presentation most commonly include A A painless mass identified by the patient B A new mass discovered during a clinician physical examination (60% of cases) C Nipple discharge (60% of cases) D An axillary mass due to metastatic lymph nodes (40% of cases) E None of the above

A

The four sources of mediastinal infection include the following, except A Spontaneous bacterial mediastinitis of sarcoidosis B Direct contamination C Hematogenous or lymphatic spread D Extension of infection from the neck or retroperitoneum E Extension from the lung or pleura

A

A 61-year-old woman undergoes a sigmoid colectomy for perforated sigmoid diverticulitis. Postoperatively she is transferred to the surgical intensive care unit, still intubated and mechanically ventilated. On postoperative day 3 she develops an ileus, and her orogastric tube is put to low wall suction. On postoperative day 8 she develops hypotension and tachycardia to 140 beats/min, and requires a norepinephrine infusion to maintain adequate mean arterial blood pressure. Laboratory data includes Image not available. ABG 7.32/40/154/20 What is the most likely explanation for her acid-base disorder? A AG metabolic acidosis with adequate respiratory compensation B Mixed metabolic alkalosis and AG metabolic acidosis C Metabolic alkalosis with respiratory compensation D Mixed metabolic alkalosis and respiratory acidosis E Mixed AG metabolic acidosis and respiratory alkalosis

B

All of the following are true about electrosurgery, except A In monopolar electrosurgery, the current flows through the patient from the active electrode to the return electrode B In bipolar electrosurgery, the current flows from the handpiece to the return electrode C The cutting mode of monopolar electrosurgery utilizes a continuous sine wave of current D The coagulation mode of monopolar electrosurgery relies on spikes of electric wave activity E The resistance of the tissue influences the effect of the electrosurgery

B

Breast cancer screening in asymptomatic women A Identifies about 2 cancers per 1000 women over age 50 years B Identifies cancer without node involvement in about 80% of detected cases C Includes a history, physical examination, bilateral mammogram, and ultrasound for women between ages 40 and 50 years D Is followed by a 5-year survival of 95% for women diagnosed through screening E Should include all women yearly after the age of 30 years

B

Pleural effusion, the presence of fluid within the pleural space, can collect through all of the following mechanisms except A Increase in the pulmonary vascular hydrostatic pressure (congestive heart failure and mitral stenosis) B Ureteral obstruction with transdiaphragmatic urine leak C Decrease in the vascular colloid oncotic pressure (hypoproteinemia) D Increase in the capillary permeability due to inflammation (pneumonia, pancreatitis, and sepsis) E Pancreatic pseudocyst rupture with transdiaphragmatic movement of abdominal fluid

B

Regarding the timing of the preoperative anesthesia workup for patients scheduled for a surgical procedure A The initial assessment can be done the day of surgery for healthy patients undergoing procedures of high surgical invasiveness. B The initial assessment should be done at a minimum the day before surgery for patients undergoing procedures of high surgical invasiveness. C The preoperative assessment for healthy patients by an anesthesiologist is not required. D A note from the patient's primary care physician stating that the patient is "cleared for anesthesia and surgery" will suffice as the preoperative assessment.

B

Which phase of acute wound healing is prolonged during progression to a chronic wound? A Coagulation B Inflammation C Fibroplasia D Angiogenesis E Remodeling

B

28-year-old man with history of depression is found down and brought to the emergency department. He responds to voice, moves his extremities spontaneously, and opens his eyes to pain only. Initial vital signs: T 98.0°F, P 72, BP 118/65 mm Hg, RR 28 breaths/min, O2 saturation 99% on a non-rebreather mask. Primary survey is within normal limits, secondary survey reveals only superficial abrasions. Initial laboratory data include ABG: pH 7.36, Pco2 38 mm Hg, Pao2 173 mm Hg, HCO3− 20 mmol/L CPK 125 Serum salicylate 824 mg/L (normal 30-300 mg/L) Based on this patient's history, examination findings and laboratory data, what is this patient's acid-base derangement? A No disorder B Respiratory acidosis with appropriate renal compensation C Anion gap metabolic acidosis with appropriate respiratory compensation D Nonanion gap metabolic acidosis with appropriate respiratory compensation E Mixed metabolic acidosis and metabolic alkalosis

C

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 is 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 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 64-year-old woman is 12 days after total abdominal hysterectomy for benign disease. She returns to the emergency room with nausea and vomiting, and has an abdominal examination that is distended, but not very tender, and her wound is clean. An abdominal series shows some dilated loops of small bowel but no free air. A She should return to the operating room as soon as is practical for lysis of adhesions. B The abdominal focus of her symptoms rules out chest problems such as pneumonia. C Her initial management can include intravenous hydration and nasogastric suction. D The presence of dilated loops of bowel on radiographs rules out the possibility of a benign ileus. E Both A and C are true.

C

A 82-year-old woman underwent a laparoscopic hand-assisted sigmoid colectomy with diverting loop ileostomy 5 days ago for a rectal cancer after neoadjuvant radiation therapy. She is tolerating a regular diet and her ileostomy is healthy and functional. The nurses report that she is somewhat somnolent, and has not urinated during the past two shifts. Which is the most likely cause of her anuria? A Acute renal failure B Inadequate fluid resuscitation in the operating room C High ileostomy output with inadequate postoperative replacement D Low cardiac output E Urinary retention

C

Chest wall masses A Are nearly always benign B Are common in postmenopausal women C Mostly arise from bone or cartilage D Most commonly arise from muscle, nerve, or fascia E Are rarely resectable

C

Fibrocystic condition of the breast is A Communicable disease B Common in postmenopausal women C Caused at least in part by estrogen stimulation of breast tissue D Carries a threefold increased risk of breast cancer E Does not actually include any cysts on histology

C

Geriatric patients A Are a limited portion of a general surgery practice now and in the future B Can have their perioperative risk very closely estimated by their 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

The preoperative assessment by an anesthesiologist includes an assessment of a patient's risk for an intraoperative cardiac event. The RCRI factors include all of the following except A A history of ischemic heart disease B Diabetes mellitus C Obesity D Renal insufficiency E High-risk surgery F Heart failure

C

Venous thromboembolism (VTE) 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

Which cell is most important for signaling wound healing? A Platelet B PMN C Macrophage D Fibroblast E Endothelial cell

C

Which of the following is not a clinical impediment to wound healing? A Repeated trauma B Wound infection C A moist wound environment D Foreign bodies E Obesity

C

A 70-year-old man undergoes a laparoscopic cholecystectomy for acute cholecystitis. On postoperative day 1 he complains of light-headedness while attempting to transfer from his bed to a chair. His vital signs include T 99.1°F, P 82, BP 109/63 mm Hg, RR 14 breaths/min, O2 saturation 99% on room air. The nurse informs you that he has had poor enteral intake since the operation, and his urine output has diminished to 10 mL/h. She also informs you that his intravenous access was lost soon after his surgery and was never reestablished. His BUN and Cr preoperatively were 16 mg/dL and 0.8 mg/dL, respectively. Laboratory data include Urine Na 153 mmol/L Urine Cr 284 mg/dL You suspect the cause of his orthostasis and oliguria is hypovolemia. Which of the following findings would most strongly confirm your hypothesis? Image not available. A BUN:Cr ratio < 20 B Fractional excretion of sodium (FENa) > 1% C FENa < 1% D Renal ultrasonography demonstrating normal kidney parenchyma and vasculature E Fractional excretion of urea nitrogen (FEUN) > 35%

C. FENa < 1%. In oliguric patients, FENa < 1% is indicative of pre-renal azotemia and intravascular volume depletion. BUN:Cr ratio > 20 is indicative of hypovolemia. FENa > 1% is indicative of intrinsic renal causes of oliguria, and should prompt workup including microscopic urine analysis and renal ultrasonography. Post-renal obstruction should be investigated if clinically suspected (eg, caused by benign prostatic hypertrophy in this 70-year-old male). FENa is unreliable in patients taking diuretics. In such cases, FEUN should be calculated: Image not available. where U: urine, P: plasma, UN: urea nitrogen, BUN: blood urea nitrogen, Cr: creatinine.

A 19-year-old woman arrives in the trauma bay after a helmeted motorcycle crash. She is hemodynamically unstable, and immediately taken to the operating room. Exploratory laparotomy reveals 3 L of hemoperitoneum, a grade 5 splenic laceration, and a grade 3 liver laceration. A splenectomy is performed and the liver laceration is packed. Inspection of the rest of the abdomen reveals no additional injuries. Two hours into the case anesthesia alerts you that her temperature is 93°F and her pH is 7.2; thus you decide to suspend the operation, leave her abdomen open, and admit her to the surgical intensive care unit (SICU) for resuscitation before returning to the operating room. Despite aggressive resuscitation with packed red blood cells (PRBCs) and other blood products, she remains hemodynamically unstable. Pelvic angiography reveals a bleeding right inferior gluteal artery, which is embolized. She is returned to the SICU for further resuscitation. You take over her care at this point, and notice that she has received 21 units of PRBCs, 19 units of fresh frozen plasma, and 20 units of platelets, but has not had her serum electrolytes checked in 5 hours. Which of the following electrolyte disorders is she most at risk for? A Hypocalcemia B Hypomagnesemia C Hyperkalemia D All of the above E None of the above

D

A 30-year-old man is 16 hours s/p emergency laparotomy for blunt abdominal trauma from a motor vehicle accident. His spleen was removed, a liver laceration was managed with sutures and topical procoagulants, and a segment of damaged jejunum was resected. His operation took 3 hours, and he received 12 units of crystalloid, 6 units of blood, 4 units of fresh frozen plasma, and 5 units of platelets. His abdominal wall was closed primarily. He remains intubated and ventilated in the SICU. His urine output was 55 mL over the last 6 hours. Further steps in his management should include the following: A Early extubation is preferable to limit the risk of pneumonia, even if his mental status is not yet clear. B Aggressive early diuresis can promote continued renal function. C Further fluid resuscitation is rarely necessary after the bleeding is controlled. D Bladder pressure measurement may be useful to determine the likelihood of abdominal compartment syndrome. E A and C.

D

A 43-year-old man with a distant history of intravenous drug use is now status post a right inguinal hernia repair and is complaining of severe groin pain on the side of the operation. All of the following are appropriate maneuvers 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 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 and his INR is 2.7, and he is febrile to 102.8°F and 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 RBCs, return to the operating room for surgical control of bleeding B Evaluation of the patient, transfusion with two packs of FFP and 2 units of matched packed RBCs, 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 forprotection of airway, transfer to a higher level of care, transfusion with 2 units of FFP and 2 units of matched packed RBCs, antibiotic administration, and computed tomography of the abdomen.

D

Axillary lymph node metastases from breast cancer A Are not important for predicting patient survival in women with breast cancer B Are generally palpable if present C Can be reliably detected by sestamibi scintigraphy D Can be reliably detected by sentinel lymph node biopsy in women with clinically uninvolved axillary lymph nodes E Are frequently present in residual lymph nodes when sentinel lymph node biopsy shows no evidence of disease

D

Early childbearing B Iodine deficiency C BRCA1 mutation only in families of Ashkenazi Jewish descent D A personal history of breast cancer E None of the above

D

Many patients take over-the-counter herbal remedies. In the perioperative period patients should be advised To continue taking their usual herbal remedies B Stop only those remedies that have been approved by their physician C Continue taking only those remedies that have been approved by the FDA D Stop all over-the-counter herbal remedies

D

Risk factors for lung cancer include all of the following except A Exposure to asbestos B Tobacco smoking C Vitamin A deficiency D Iodine deficiency E Exposure to arsenic

D

The fundamental mechanism for incisional hernia formation is A Long-term fascial scar failure B Suture failure C Suture pulling through the fascia D Early fascial dehiscence and wound failure E Poor technique

D

The perioperative process, including the workup regarding safety for anesthetic, after the decision to operate has been made A Is the sole province of the anesthesiology specialists 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

Strategies to prevent intraoperative awareness include A Strict monitoring of intraoperative vital signs by the anesthesiologist will always detect intraoperative awareness B Informing patients during the preoperative workup of the possibility of awareness C Monitoring brain electrical activity with the BIS monitor D None of the above

D. None of the above. There is no way to be 100% of preventing intraoperative awareness. Anesthesiologists performing strict equipment check before beginning an anesthetic to ensure that vaporizers have sufficient agent levels, that there is an agent concentration monitor as part of the anesthesia monitoring system, and frequent observation that IV lines are patent and intact when intravenous medications are used is one way to eliminate the preventable components. Stable vital signs throughout a case are not always a reliable sign that a patient may not suffer from intraoperative awareness. Finally the processed EEG BIS monitor has been shown to be no more effective in preventing awareness than careful monitoring of end-tidal agent concentration.

Regarding patients who have had a recent drug-eluting stent placed and scheduled for an elective surgical procedure with a high risk of bleeding A Surgery may be performed within 4 weeks of stent placement as long as the patient continues taking aspirin and clopidogrel. B Surgery may be performed within 4 weeks of stent placement with the patient stopping the clopidogrel and continuing on low-dose aspirin. C Should have the surgical procedure delayed until the procedure can be performed with the patient only taking low-dose aspirin. D Surgery should be delayed for up to 1 year.

D. Surgery should be delayed for up to 1 year. The risk of stent thrombosis makes it necessary to place patients who have had a drug-eluting stent placed on antiplatelet agents such as clopidogrel and aspirin. Stopping these drugs prematurely to allow for the performance of an elective surgical procedure requires careful consideration of the risk of bleeding as well as the risk of stent thrombosis if the antiplatelet agents are both stopped. At a minimum aspirin should be continued. Emergent procedures that involve a high risk of bleeding require that the clopidogrel be stopped, but continuing the low-dose aspirin is recommended.

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 Neo-Synephrine for brief interoperative hypotension. Two hours after the procedure, the nurse calls from the PACU to report that the patient is agitated and hypertensive. Which of the following is unlikely to be the cause for her agitation? Hypoxia B Stroke C "Unmasking" of cognitive dysfunction D Hyperglycemia E Hypocalcemia

E

Patients with diabetes mellitus require more operations than their nonaffected counterparts, and if diabetes mellitus is not carefully controlled, they have increased risk of A Surgical site infection (SSI) 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 the first 24-hour postoperative check 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 except for D

E

Which is the most predictive direct measure of impaired or delayed wound healing? A Vitamin C deficiency B Low serum albumin C Irradiated tissue D Smoking E TcO2 less than 30 mm Hg

E, TcO2 less than 30 mm Hg. Wounds will not heal when the tissue concentration of oxygen falls below 30 mm Hg. It is the most powerful predictive measure of delayed or impaired wound healing. Vitamin C deficiency may result in impaired collagen cross linking (scurvy) and weak scars. Low serum albumin predicts increased wound complications, like wound infection. The microangiopathy of radiated tissue indirectly reduces perfusion and therefore, TcO2 levels. Finally, smoking impairs wound healing through the vasoconstrictive effects of chronic nicotine and relative hypoxia as well.