Senior & Junior Quiz ANSWER SHEET 12/13/11

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Question 1 A 31-year-old woman presents to the emergency department with lower abdominal cramping and vaginal bleeding. A serum -human chorionic gonadotropin -hCG) test is positive. While awaiting transvaginal ultrasonography, she develops a rigid abdomen and her blood pressure decreases to 75/40 mm Hg. What is the most appropriate next step in management? A) B) C) D) E) A) B) C) D) E) Emergent transvaginal ultrasonography Emergent transabdominal ultrasonography Admission to the intensive care unit for resuscitation and serial abdominal examinations Computed tomography (CT) of the abdomen and pelvis Surgical exploration Emergent transvaginal ultrasonography Emergent transabdominal ultrasonography Admission to the intensive care unit for resuscitation and serial abdominal examinations Computed tomography (CT) of the abdomen and pelvis Surgical exploration

Question 2 A 30-year-old female experiences 14 hours of right lower quadrant pain and is taken to the operating room with the preoperative diagnosis of appendicitis. Exploratory laparoscopy reveals a 4 cm simple right ovarian cyst, torsion of the right adnexa, and an injected, edematous right ovary. What is the most appropriate next step in management? A) B) C) D) E) A) B) C) D) E) Right ovarian cystectomy Right ovarian cystectomy and detorsion of the right adnexa Right ovarian oopherectomy Right ovarian salpingo-oopherectomy Detorsion of the right adnexa Right ovarian cystectomy Right ovarian cystectomy and detorsion of the right adnexa Right ovarian oopherectomy Right ovarian salpingo-oopherectomy Detorsion of the right adnexa

Question 3 A 68-year-old active female is found to have repeated episodes of low-volume vaginal bleeding. A focused history is negative for an obvious cause, and her physical and pelvic examinations are unremarkable. A pelvic sonogram is also unrevealing for pathology. What is the next most appropriate step in management? A) B) C) D) E) A) B) C) D) E) CT scan of the pelvis with intravenous and enteral contrast. Endometrial biopsy Dilatation and curettage Hysterectomy Hormone replacement therapy CT scan of the pelvis with intravenous and enteral contrast. Endometrial biopsy Dilatation and curettage Hysterectomy Hormone replacement therapy

Question 4 A 22-year-old sexually active female is seen in the emergency department with 1 day of acute lower abdominal pain. On examination, her temperature is 38.7C (101.8F) and she has diffuse tenderness of the bilateral lower quadrants with rebound tenderness on the left lower quadrant. A pelvic examination reveals purulent endocervical discharge with cervical motion tenderness. A CT scan reveals a 3.5 cm left tubo-ovarian abscess. What is the most appropriate treatment strategy? A) B) C) D) E) A) B) C) D) E) 14- to 21-day course of oral antibiotics and outpatient follow-up IV antibiotics and hospital admission Percutaneous drainage Laparoscopy and drainage Laparoscopy and unilateral ovarian cystectomy 14- to 21-day course of oral antibiotics and outpatient follow-up IV antibiotics and hospital admission Percutaneous drainage Laparoscopy and drainage Laparoscopy and unilateral ovarian cystectomy

Question 5 A 62-year-old male recently diagnosed with paroxysmal atrial fibrillation presents to the emergency department complaining of severe abdominal pain out of proportion to the physical examination. Mesenteric ischemia is considered in the differential diagnosis, and a CT angiogram is ordered. Which of the following is correct with regard to superior mesenteric artery (SMA) occlusion in thromboembolic mesenteric ischemia?

A) There is no preference for SMA involvement relative to the celiac or inferior mesenteric arteries (IMAs). B) The SMA is the least likely mesenteric vessel to be involved in mesenteric ischemia. C) Emboli typically lodge at the origin of the SMA. D) Thrombi typically lodge distal to the middle colic branch of the SMA. E) Thrombi typically form at the origin of the SMA. A) There is no preference for SMA involvement relative to the celiac or inferior mesenteric arteries (IMAs). B) The SMA is the least likely mesenteric vessel to be involved in mesenteric ischemia. C) Emboli typically lodge at the origin of the SMA. D) Thrombi typically lodge distal to the middle colic branch of the SMA. E) Thrombi typically form at the origin of the SMA. Question 6 A 72-year-old female with coronary artery disease, severe heart failure, hypertension, and peripheral arterial disease presents with abdominal pain to the emergency department. The history and physical examination reveal a cachectic woman with evidence of an upper respiratory infection and dry mucous membranes. Although her abdomen is soft and nondistended, she complains of constant, severe abdominal pain, which began several hours prior to presentation. A diagnosis of nonocclusive mesenteric ischemia (NOMI) is made following a diagnostic angiogram. Which of the following statements regarding NOMI is false? A) B) C) D) E) A) B) C) D) E) Management of NOMI largely consists of medical optimization. Despite the etiology, laparotomy is required when peritonitis is present. Angiography typically reveals absence of SMA filling. Vasopressors should be avoided during the resuscitative period. Intra-arterial infusion of papavarine may be of benefit. Management of NOMI largely consists of medical optimization. Despite the etiology, laparotomy is required when peritonitis is present. Angiography typically reveals absence of SMA filling. Vasopressors should be avoided during the resuscitative period. Intra-arterial infusion of papavarine may be of benefit.

Question 7 An 18-year-old male presents to his pediatrician following soccer practice complaining of severe right calf pain after being kicked in the leg earlier in the day. His past medical history is unremarkable, and on physical examination, a tense calf is appreciated with numbness identified in the first web space of the right foot. If left untreated, tissue ischemia and necrosis will be caused by which of the following? A) B) C) D) E) Cell membrane destruction by elevated pressure Arterial inflow obstruction Venous outflow obstruction Activation of apoptotic pathways Elevated lactate level

A) B) C) D) E)

Cell membrane destruction by elevated pressure Arterial inflow obstruction Venous outflow obstruction Activation of apoptotic pathways Elevated lactate level

Question 8 A 68-year-old male lifelong smoker with hypertension relates to his primary care physician that he has not been able to walk more than one block without cramping in his legs. In addition to a complete physical examination, the physician obtains an ankle-brachial index (ABI) for each leg in the office. Which of the following is false regarding the measurement obtained? A) An ABI < 0.6 is consistent with occlusive arterial disease. B) In a claudicant, an ABI of 0.8 rules out arterial insufficiency; other causes should be investigated. C) Doppler ultrasonography is used to listen to the dorsalis pedis and posterior tibial arteries to identify the systolic pressure. D) The ABI is calculated as the ratio of the ankle to brachial artery systolic pressure. E) ABIs should be calculated in all vasculopaths. A) An ABI < 0.6 is consistent with occlusive arterial disease. B) In a claudicant, an ABI of 0.8 rules out arterial insufficiency; other causes should be investigated. C) Doppler ultrasonography is used to listen to the dorsalis pedis and posterior tibial arteries to identify the systolic pressure. D) The ABI is calculated as the ratio of the ankle to brachial artery systolic pressure. E) ABIs should be calculated in all vasculopaths. Question 9 A 44-year-old male type 1 diabetic patient presents with an erythematous, draining wound on the medial aspect of the first metatarsophalangeal joint of the right foot. Wound cultures are sent prior to the initiation of antibiotic therapy. Which of the following organisms might be identified in the culture from this wound? A) B) C) D) E) A) B) C) D) E) Escherichia coli Klebsiella Bacteroides Pseudomonas All of the above Escherichia coli Klebsiella Bacteroides Pseudomonas All of the above

Question 10 A 72-year-old bed-bound nursing home patient presents with a gangrenous left foot. He has previously undergone a left femoropopliteal bypass, which has occluded. No further revascularization options remain, and amputation is being considered. Which of the following is true regarding lower extremity amputation in this patient? Transcutaneous oxygen tension can be used to determine that an amputation will not heal A below-the-knee amputation is ideal for this patient. In this patient, a transmetatarsal amputation has a high likelihood of success. Guillotine amputation above the ankle followed by definitive above-the-knee amputation is a treatment option. E) Mortality from a lower extremity amputation has a mortality of less than 5%. A) B) C) D) Transcutaneous oxygen tension can be used to determine that an amputation will not heal A below-the-knee amputation is ideal for this patient. In this patient, a transmetatarsal amputation has a high likelihood of success. Guillotine amputation above the ankle followed by definitive above-the-knee amputation is a treatment option. E) Mortality from a lower extremity amputation has a mortality of less than 5%. A) B) C) D)

Question 11 A 63-year-old man with chronic renal failure and diabetes has a chronic ulcer of the right heel that has not healed after multiple revascularization attempts. Amputation is being considered. Which of the following is false regarding below-the-knee amputation? A) Flexure contracture at the knee is easily corrected with a prosthetic limb. B) The tibia should be divided no more than 1 cm proximal to the anterior skin incision. C) A below-the-knee amputation is likely to heal if the patient has a palpable femoral pulse and a patent deep femoral artery. D) The length of the posterior flap should equal one third of the circumference of the leg measured 10 cm distal to the tibial tuberosity. E) The fibula should be divided cephalad to the division of the tibia. A) Flexure contracture at the knee is easily corrected with a prosthetic limb. B) The tibia should be divided no more than 1 cm proximal to the anterior skin incision. C) A below-the-knee amputation is likely to heal if the patient has a palpable femoral pulse and a patent deep femoral artery. D) The length of the posterior flap should equal one third of the circumference of the leg measured 10 cm distal to the tibial tuberosity. E) The fibula should be divided cephalad to the division of the tibia. Question 12 A 24-year-old man is transported to the emergency department (ED) after being stabbed in the chest two times. He was intoxicated and hemodynamically stable at the scene, but on arrival at the ED, a pulse cannot be found. Examination reveals two 3 cm lacerations over the left chest at the level of the

nipple in the anterior and midaxillary line. After securing an airway and while resuscitation is being performed, an emergency department resuscitative thoracotomy (EDRT) is performed. Which of the following is not one of the six therapeutic goals of EDRT? A) B) C) D) E) A) B) C) D) E) Relief of cardiac tamponade Cross-clamping the pulmonary hilum to control hemorrhage Repairing an injury to the left pulmonary artery Cross-clamping the descending aorta for lower extremity hemorrhage Confirming endotracheal intubation Relief of cardiac tamponade Cross-clamping the pulmonary hilum to control hemorrhage Repairing an injury to the left pulmonary artery Cross-clamping the descending aorta for lower extremity hemorrhage Confirming endotracheal intubation

Question 13 An 18-year-old ejected driver of a high-speed rollover motor vehicle accident presents with stridor and subcutaneous emphysema of the neck. What is the preferred method of securing an airway in this patient? A) B) C) D) E) A) B) C) D) E) Intubation over a flexible bronchoscope Blind intubation ED cricothyrotomy ED tracheostomy OR tracheostomy Intubation over a flexible bronchoscope Blind intubation ED cricothyrotomy ED tracheostomy OR tracheostomy

Question 14 A 42-year-old man is the unrestrained driver in a motor vehicle collision. Reports from the accident scene include significant damage to the steering wheel, and cardiac injury is suspected. Which of the following statements is false regarding cardiac trauma? A) Patients who make it to the hospital with vital signs have greater than 50% chance of survival B) Cardiac tamponade is preferably treated by performing a pericardial window in the OR C) Cardiac tamponade is accurately diagnosed by pericardiocentesis D) Pump failure from cardiac contusion is usually attributable to right heart failure E) Right atrial perforation is the most common injury in patients with cardiac disruption who make it to the hospital alive

A) Patients who make it to the hospital with vital signs have greater than 50% chance of survival B) Cardiac tamponade is preferably treated by performing a pericardial window in the OR C) Cardiac tamponade is accurately diagnosed by pericardiocentesis D) Pump failure from cardiac contusion is usually attributable to right heart failure E) Right atrial perforation is the most common injury in patients with cardiac disruption who make it to the hospital alive Question 15 A 38-year-old woman was the victim of domestic abuse when she was stabbed in the right mid- and upper neck. She is transported by the emergency medical service to the ED and rapidly moved to the operating room after examination demonstrated findings consistent with a vascular injury. During an internal carotid artery exploration for bleeding, which of the following structures should not be sacrificed? A) B) C) D) E) A) B) C) D) E) Mastoid process Occipital artery Ascending ramus of the mandible Hypoglossal nerve Ansa cervicalis Mastoid process Occipital artery Ascending ramus of the mandible Hypoglossal nerve Ansa cervicalis

Question 16 A 45-year-old man sustained multiple stab wounds to his neck, chest, and abdomen in an altercation. On arrival at the trauma bay, he is hemodynamically unstable. Emergency release blood is called for, and he is being intubated. On examination, he has pulsatile blood spurting from a zone II neck wound when the paramedic removes his hand. In addition, he does not have left-sided breath sounds and his abdomen is tensely distended. Which is the proper management of a left common carotid laceration in this situation? A) Exploration through a supraclavicular incision and ligation of the common carotid artery at its takeoff from the brachiocephalic artery B) Exploration through an incision along the anterior border of the sternocleidomastoid (SCM) muscle and ligation of the common carotid artery C) Exploration through an incision along the anterior border of the SCM muscle and repair of the laceration D) Exploration through an incision along the anterior border of the SCM muscle and repair using a saphenous vein patch angioplasty E) None of the above A) Exploration through a supraclavicular incision and ligation of the common carotid artery at its takeoff from the brachiocephalic artery B) Exploration through an incision along the anterior border of the sternocleidomastoid (SCM)

muscle and ligation of the common carotid artery C) Exploration through an incision along the anterior border of the SCM muscle and repair of the laceration D) Exploration through an incision along the anterior border of the SCM muscle and repair using a saphenous vein patch angioplasty E) None of the above Question 17 A 59-year-old woman is brought to the ED after being the victim of a mugging. She is hemodynamically stable but confused. On examination, she has a large hematoma over her left frontal skull and linear ecchymoses over the left neck. Which of the following statements is true regarding blunt injuries to the vasculature of the neck? A) B) C) D) E) A) B) C) D) E) Most injuries are the result of direct trauma to the neck Traditional angiography should be used as a method of screening for vascular injury All high-grade injuries need surgical intervention Complications of such injuries include pseudoaneurysm, dissection, and emboli All patients with such injures should receive antiplatelet or anticoagulation agents Most injuries are the result of direct trauma to the neck Traditional angiography should be used as a method of screening for vascular injury All high-grade injuries need surgical intervention Complications of such injuries include pseudoaneurysm, dissection, and emboli All patients with such injures should receive antiplatelet or anticoagulation agents

Question 18 A 29-year-old professional pianist is brought to the emergency department after suffering a rollover motor vehicle accident while driving at high speed. He is alert, oriented, and hemodynamically stable. On examination, his only injury is a 4 cm longitudinal laceration to his distal left forearm over the radial artery. Blood spurts from the wound when direct pressure is not held, and the distal radial pulse at the wrist is not palpable. Motor and sensory examinations of the left hand are normal. What is the appropriate management of this patient? A) B) C) D) Apply a pressure dressing and perform serial examinations Explore the wound in the OR and ligate the injured radial artery Explore the wound in the OR and perform a primary repair of the radial artery Explore the wound in the OR, perform a primary repair of the radial artery, and place the patient on a heparin drip E) Explore the wound in the OR and perform a repair of the artery using a vein patch angioplasty A) B) C) D) Apply a pressure dressing and perform serial examinations Explore the wound in the OR and ligate the injured radial artery Explore the wound in the OR and perform a primary repair of the radial artery Explore the wound in the OR, perform a primary repair of the radial artery, and place the patient on a heparin drip E) Explore the wound in the OR and perform a repair of the artery using a vein patch angioplasty

Question 19 A 20-year-old man is brought to the ED with a single gunshot wound to his central abdomen between the xiphoid and the umbilicus. Examination demonstrates a distended and tender abdomen. He is taken to the OR for exploration while being resuscitated with blood and plasma. On exploration, hemoperitoneum is encountered and a zone I retroperitoneal hematoma is noted. Medial visceral rotation is performed, and an injury to the pancreas and superior mesenteric artery (SMA) is identified. Which of the following is the best management of the SMA injury in a relatively stable patient with this combination of injuries? A) B) C) D) Ligate the artery Perform primary repair of the artery Use a great saphenous vein (GSV) patch to repair the artery Ligate the artery at its origin and use a polytetrafluoroethylene (PTFE) graft or GSV patch to reconstruct the SMA takeoff from the distal abdominal aorta away from the site of injury E) Use a PTFE interposition graft to reconstruct the artery A) B) C) D) Ligate the artery Perform primary repair of the artery Use a great saphenous vein (GSV) patch to repair the artery Ligate the artery at its origin and use a polytetrafluoroethylene (PTFE) graft or GSV patch to reconstruct the SMA takeoff from the distal abdominal aorta away from the site of injury E) Use a PTFE interposition graft to reconstruct the artery

Question 20 A 24-year-old male is brought to the ED after a single gunshot wound to his left lower abdomen. He is severely hypotensive with a distended abdomen and a pulseless left lower extremity. On exploration in the OR, an injury to the left common iliac artery and vein is identified. During the case, the patient receives one round of advanced cardiac life support after developing pulseless electrical activity; he regains a carotid pulse, and with massive resuscitation, his blood pressure has stabilized. What is the most appropriate management of this patient? A) Ligate both the left common iliac artery and vein and resuscitate in the ICU B) Ligate the left common iliac vein, place a Pruitt shunt in the artery, resuscitate in the ICU, and perform definitive operation at a later date C) Perform primary repair of the vein and then subsequent primary repair of the artery D) Perform primary repair of the vein and then subsequent interposition PTFE graft repair of the artery E) Perform primary repair of the vein and then subsequent repair of the artery using the ipsilateral internal iliac artery A) Ligate both the left common iliac artery and vein and resuscitate in the ICU B) Ligate the left common iliac vein, place a Pruitt shunt in the artery, resuscitate in the ICU, and perform definitive operation at a later date C) Perform primary repair of the vein and then subsequent primary repair of the artery D) Perform primary repair of the vein and then subsequent interposition PTFE graft repair of the artery

E) Perform primary repair of the vein and then subsequent repair of the artery using the ipsilateral internal iliac artery Question 21 A 52-year-old man was involved in a motorcycle accident and suffered a femur fracture. In patients with long bone fractures of the lower extremity, what measure has been shown to decrease the incidence of developing fat embolism syndrome? A) B) C) D) E) A) B) C) D) E) Volume replacement Administration of corticosteroids Early stabilization of the fracture Administration of appropriate analgesics Respiratory support Volume replacement Administration of corticosteroids Early stabilization of the fracture Administration of appropriate analgesics Respiratory support

Question 22 A 27-year-old helmeted male fell from his motorcycle while traveling on a roadway partially covered with sand and gravel. He did not lose consciousness and was awake at the scene complaining of pain in his right hip. He was taken to the emergency department, where he underwent a trauma evaluation. He was speaking and had bilateral breath sounds and a strong carotid pulse. His heart rate was in the 90s, his blood pressure was 143/87 mm Hg, and he had a normal oxygen saturation. During the evaluation, gentle rocking of his pelvis evoked tenderness. A sheet wrap was placed. He then underwent chest and cervical films that did not demonstrate an injury. An anteroposterior pelvis film demonstrated an injury pattern consistent with an anteroposterior compression injury. A contrastenhanced computed tomographic (CT) scan of the abdomen and pelvis showed the aforementioned pelvic fracture as well as extravasation of contrast from a branch of the right internal iliac artery. What is the most appropriate next step in the management of this patient? A) Immediate transfer to the intensive care unit for further resuscitation B) Immediate transfer to the operating room for an exploratory laparotomy C) Immediate transfer to the operating room for open reduction and internal fixation of the pelvic fracture D) Immediate transfer to the interventional radiology suite for angiographic embolization E) Perform the FAST examination (focused assessment for sonographic evaluation of the trauma patient) A) Immediate transfer to the intensive care unit for further resuscitation B) Immediate transfer to the operating room for an exploratory laparotomy C) Immediate transfer to the operating room for open reduction and internal fixation of the pelvic fracture D) Immediate transfer to the interventional radiology suite for angiographic embolization E) Perform the FAST examination (focused assessment for sonographic evaluation of the trauma patient)

Question 23 A 19-year-old female involved in a motor vehicle collision is found to have a left tibial fracture and soft tissue injury requiring operative repair. In the postanesthesia care unit, she complains of pain that is unable to be relieved with narcotic analgesics. On palpation, she has a tense and swollen left leg. Passive flexion and extension of her foot increase her pain. Her dorsalis pedis and posterior tibial pulses are intact. She is subsequently taken back to the operating room for a decompressive fasciotomy. In a patient who is not awake or alert enough to complain of symptoms, what is the most accurate method of diagnosing compartment syndrome? A) B) C) D) E) A) B) C) D) E) Measurement of a compartment pressure of 10 mm Hg in the affected extremity Motor nerve stimulation to evaluate for muscle paralysis in the affected extremity Handheld Doppler ultrasonography to evaluate for pulselessness in the affected extremity Measurement of a compartment pressure of 15 mm Hg in the affected extremity A difference of less than 30 mm Hg between arterial diastolic pressure and compartment pressure in the affected extremity Measurement of a compartment pressure of 10 mm Hg in the affected extremity Motor nerve stimulation to evaluate for muscle paralysis in the affected extremity Handheld Doppler ultrasonography to evaluate for pulselessness in the affected extremity Measurement of a compartment pressure of 15 mm Hg in the affected extremity A difference of less than 30 mm Hg between arterial diastolic pressure and compartment pressure in the affected extremity

Question 24 A 34-year-old woman 20 weeks pregnant presents to the hospital as a victim of blunt trauma sustained in a motor vehicle collision. Shortly after arrival at the trauma bay, the patient becomes hypotensive and tachycardic, and you are concerned about intra-abdominal injury. Which of the following is least likely to be injured in a pregnant patient? A) B) C) D) E) A) B) C) D) E) Liver Spleen Gastrointestinal tract Uterus Bladder Liver Spleen Gastrointestinal tract Uterus Bladder

Question 25 A 43-year-old woman presents with progressive dysphagia to solids and liquids along with regurgitation of food particles and chest pain. A barium swallow demonstrates a dilated and atonic esophagus with "bird's beak" narrowing of the gastroesophageal junction.

What is the most appropriate next step in the diagnostic workup for this patient? A) B) C) D) E) A) B) C) D) E) Upper endoscopy Endoscopic ultrasonography Esophageal manometry Computed tomography (CT) Fluorodeoxyglucose positron emission tomography Upper endoscopy Endoscopic ultrasonography Esophageal manometry Computed tomography (CT) Fluorodeoxyglucose positron emission tomography

Question 26 A 34-year-old male has a history of chest pain and has undergone a thorough cardiac workup, which is unrevealing. His primary care physician suspects an esophageal motility disorder and refers him for esophageal manometry. The manometry shows a normal peristaltic pattern with occasional prolonged, multipeaked, high-amplitude contractions. What is the next most appropriate step in management? A) B) C) D) E) A) B) C) D) E) Medical management with beta blockers Medical management with calcium channel blockers Endoscopic injection of botulinum toxin Laparoscopic Heller myotomy with Dor fundoplication Laparoscopic Nissen fundoplication Medical management with beta blockers Medical management with calcium channel blockers Endoscopic injection of botulinum toxin Laparoscopic Heller myotomy with Dor fundoplication Laparoscopic Nissen fundoplication

Question 27 A 57-year-old man with dysphagia undergoes a barium swallow. A stricture is seen. Which of these features observed on barium swallow are suggestive of a malignant esophageal stricture as opposed to a peptic stricture? A) B) C) D) E) A) B) C) D) Short segment Mucosal irregularity Location at the squamocolumnar junction Circumferential Narrow caliber Short segment Mucosal irregularity Location at the squamocolumnar junction Circumferential

E) Narrow caliber Question 28 A patient presents to the surgeon with a presumed diagnosis of GERD, which is confirmed by preoperative testing. A laparoscopic Nissen fundoplication is considered. What patient factor predicts a high failure rate for this operation? A) B) C) D) E) A) B) C) D) E) The patient has endoscopy-documented grade III esophagitis The patient shows good response to proton pump inhibitors (PPIs) preoperatively The patient complains of heartburn The patient's 24-hour pH score is abnormal The patient's body mass index (BMI) is greater than 35 kg/m2 The patient has endoscopy-documented grade III esophagitis The patient shows good response to proton pump inhibitors (PPIs) preoperatively The patient complains of heartburn The patient's 24-hour pH score is abnormal The patient's body mass index (BMI) is greater than 35 kg/m2

Question 29 A 47-year-old woman with achalasia is undergoing laparoscopic Heller myotomy. The esophagogastric junction has been exposed. Which is not a technical step in creating the myotomy itself? A) B) C) D) E) A) B) C) D) E) The esophagus is pulled downward and to the left The myotomy is started 3 cm below the esophagogastric junction The submucosal plane is entered at a single point Muscle fibers are separated from the mucosa for transection The myotomy is extended 2 cm distally and 6 cm proximally The esophagus is pulled downward and to the left The myotomy is started 3 cm below the esophagogastric junction The submucosal plane is entered at a single point Muscle fibers are separated from the mucosa for transection The myotomy is extended 2 cm distally and 6 cm proximally

Question 30 A 79-year-old man undergoes chest radiography because of a persistent cough. The chest x-ray shows a solitary pulmonary nodule, and this is confirmed on a chest CT scan. Which of the following features is most predictive of malignancy for a solitary pulmonary nodule? A) B) C) D) E) Age over 70 years Lesion size 2.1 to 3 cm Doubling time less than 465 days History of smoking Spiculated margins on a CT scan

A) B) C) D) E)

Age over 70 years Lesion size 2.1 to 3 cm Doubling time less than 465 days History of smoking Spiculated margins on a CT scan

Question 31 A patient with a solitary pulmonary nodule on a chest x-ray undergoes CT scanning to better characterize the lesion. What feature seen on a CT scan is most suggestive that the lesion is benign? A) B) C) D) E) A) B) C) D) E) Solid attenuation within areas of ground-glass opacity Lesion wall thinner than 4 mm Enhancement by 25 Hounsfield units (HU) after intravenous contrast injection Absence of intranodular fat Air bronchograms Solid attenuation within areas of ground-glass opacity Lesion wall thinner than 4 mm Enhancement by 25 Hounsfield units (HU) after intravenous contrast injection Absence of intranodular fat Air bronchograms

Question 32 A 53-year-old woman presents with a chest wall mass. Biopsy confirms a chest wall sarcoma. Which of the following is the strongest predictor of disease-free survival after resection? A) B) C) D) E) A) B) C) D) E) Patient age Preoperative symptoms Chest wall size Histologic grade of the tumor Patient gender Patient age Preoperative symptoms Chest wall size Histologic grade of the tumor Patient gender

Question 33 A 58-year-old woman presents with a chest wall mass. Pathologic examination shows that her mass is a desmoid tumor. Which of the following is true about desmoid tumors? A) They are histologically malignant B) They are managed with radical surgical excision C) They arise from bone

D) They do not affect surrounding structures E) They tend not to recur A) B) C) D) E) They are histologically malignant They are managed with radical surgical excision They arise from bone They do not affect surrounding structures They tend not to recur

Question 34 A 78-year-old man with metastatic lung cancer develops a symptomatic pericardial effusion. In a patient with a pericardial effusion resulting in cardiac tamponade, which of the following treatment modalities is considered the safest and carries an acceptably low rate of recurrence? A) B) C) D) E) A) B) C) D) E) Image-guided pericardiocentesis Subxiphoid pericardiostomy Left thoracoscopic pericardiostomy Right thoracoscopic pericardiostomy Pericardiectomy Image-guided pericardiocentesis Subxiphoid pericardiostomy Left thoracoscopic pericardiostomy Right thoracoscopic pericardiostomy Pericardiectomy

Question 35 A 62-year-old man developed an empyema after a severe pneumonia. Decortication is planned. In a patient requiring a decortication, which clinical factor is most predictive of the procedure's success or failure? A) B) C) D) E) A) B) C) D) E) Infectious etiology Operative approach (video-assisted thoracoscopic surgery [VATS] versus open) Duration of antibiotic therapy Ability or inability of the lung to reexpand Calculated predictive postoperative forced expiratory volume in 1 second (ppoFEV1) Infectious etiology Operative approach (video-assisted thoracoscopic surgery [VATS] versus open) Duration of antibiotic therapy Ability or inability of the lung to reexpand Calculated predictive postoperative forced expiratory volume in 1 second (ppoFEV1)

Question 36 Patients with pancreatic or biliary adenocarcinoma may have an elevated serum concentration of the tumor marker CA 19-9.

Which of the following is true regarding CA 19-9 levels in patients with pancreatic or biliary adenocarcinoma? A) B) C) D) E) A) B) C) D) E) CA 19-9 is higher in patients with biliary than with pancreatic adenocarcinoma CA 19-9 levels always remain elevated even after tumor resection Concentrations higher than 10 U/mL are highly suggestive of malignancy Serum levels reflect the extent of the tumor CA 19-9 levels are rarely associated with pancreatic or biliary adenocarcinoma CA 19-9 is higher in patients with biliary than with pancreatic adenocarcinoma CA 19-9 levels always remain elevated even after tumor resection Concentrations higher than 10 U/mL are highly suggestive of malignancy Serum levels reflect the extent of the tumor CA 19-9 levels are rarely associated with pancreatic or biliary adenocarcinoma

Question 37 A 48-year-old man undergoes CT after a motor vehicle accident. This reveals a cystic pancreatic mass. Further workup confirms an intraductal papillary mucinous neoplasm (IPMN). Which of the following IPMNs does not require resection? A) B) C) D) E) A) B) C) D) E) Symptomatic large duct IPMN Asymptomatic small duct IPMN with a 4 cm cyst Symptomatic small duct IPMN with a 2 cm cyst Asymptomatic large duct IPMN Asymptomatic small duct IPMN with a 2 cm cyst Symptomatic large duct IPMN Asymptomatic small duct IPMN with a 4 cm cyst Symptomatic small duct IPMN with a 2 cm cyst Asymptomatic large duct IPMN Asymptomatic small duct IPMN with a 2 cm cyst

Question 38 A 62-year-old woman underwent laparoscopic cholecystectomy for presumed chronic cholecystitis. Pathology revealed adenocarcinoma of the gallbladder with tumor invading through the lamina propria. What is the most appropriate next step in management? A) B) C) D) E) A) B) C) D) No further surgical therapy is required Reoperation to complete an extraserosal resection (removal of the fibrous liver plate) Resection of segments 4b/5 of the liver Resection of segments 4b/5 of the liver along with portal/celiac lymph nodes Resection of segments 4 to 8 of the liver No further surgical therapy is required Reoperation to complete an extraserosal resection (removal of the fibrous liver plate) Resection of segments 4b/5 of the liver Resection of segments 4b/5 of the liver along with portal/celiac lymph nodes

E) Resection of segments 4 to 8 of the liver Question 39 A cholecystectomy for cholecystitis is complicated by a lateral injury to the common bile duct. This biliary injury is classified as: A) B) C) D) E) A) B) C) D) E) Strasberg type A Strasberg type B Strasberg type C Strasberg type D Strasberg type E Strasberg type A Strasberg type B Strasberg type C Strasberg type D Strasberg type E

Question 40 For the patient in the above question, the injury appears to be from a cautery burn and involves 50% of the circumference of the duct. What is the most appropriate next step in management? A) Ligation of the duct B) Wide drainage and observation C) Primary repair D) Repair of the duct with a cholodochojejunostomy E) Primary repair over a T tube with a cholangiogram in 6 weeks A) Ligation of the duct B) Wide drainage and observation C) Primary repair D) Repair of the duct with a cholodochojejunostomy E) Primary repair over a T tube with a cholangiogram in 6 weeks Question 41 A 54-year-old man presents to the emergency department with 8 hours of acute abdominal pain. During your physical examination, you perform several maneuvers to help define your differential diagnosis. Which of the following signs are not matched with their appropriate definition? A) Rovsing sign: pain in the right lower quadrant when the left lower quadrant is palpated deeply B) Murphy sign: arrest of inspiration when the right upper quadrant is deeply palpated C) Carnett test: patient elevates his or her head off the bed, thus tensing the abdominal muscles; with intraperitoneal conditions, the pain worsens

D) Obturator sign: pain elicited by raising the flexed right leg and rotating the thigh internally E) Kehr sign: after placing the patient in the Trendelenburg position, pain in the shoulder indicates irritation of the diaphragm by a noxious intraperitoneal fluid A) Rovsing sign: pain in the right lower quadrant when the left lower quadrant is palpated deeply B) Murphy sign: arrest of inspiration when the right upper quadrant is deeply palpated C) Carnett test: patient elevates his or her head off the bed, thus tensing the abdominal muscles; with intraperitoneal conditions, the pain worsens D) Obturator sign: pain elicited by raising the flexed right leg and rotating the thigh internally E) Kehr sign: after placing the patient in the Trendelenburg position, pain in the shoulder indicates irritation of the diaphragm by a noxious intraperitoneal fluid Question 42 A 78-year-old man with a past medical history notable for a 4.3 cm AAA presents to the emergency department via ambulance. He is obtunded, hypotensive, and tachycardic, and a physical examination is notable for a pulsatile abdominal mass. The appropriate next steps in management of this patient include all of the following except A) B) C) D) E) A) B) C) D) E) Abdominopelvic CT scan with oral and IV contrast Initiation of appropriate IV fluid resuscitation Targeted laboratory analysis including chemistry panel and complete blood count Clarification of his clinical history Expeditious workup completed within 1 hour of arrival at the emergency department and transfer to the operating room for emergency surgery Abdominopelvic CT scan with oral and IV contrast Initiation of appropriate IV fluid resuscitation Targeted laboratory analysis including chemistry panel and complete blood count Clarification of his clinical history Expeditious workup completed within 1 hour of arrival at the emergency department and transfer to the operating room for emergency surgery

Question 43 You are consulted on a 64-year-old woman who is an inpatient on the oncology service. She is being treated for advanced metastatic ovarian cancer and now has symptoms of an acute complete small bowel obstruction. CT is notable for diffuse carcinomatosis. Which of the following therapeutic interventions is not appropriate in this scenario? A) B) C) D) E) An urgent exploratory laparotomy and diverting end-colostomy Antisecretory drugs such as octreotide IV analgesic pain medication Antiemetic medication such as odansetron Gastrostomy decompression

A) An urgent exploratory laparotomy and diverting end-colostomy B) Antisecretory drugs such as octreotide C) IV analgesic pain medication

D) Antiemetic medication such as odansetron E) Gastrostomy decompression Question 44 You are consulted on an inpatient on the cardiology service recovering from a myocardial infarction. The primary team has noted that the patient is nauseous and has not passed gas or had a bowel movement for several days. Imaging is notable for a markedly dilated colon with the cecum larger than the distal bowel. You diagnose Ogilvie syndrome. Which of the following interventions is the least appropriate? A) B) C) D) E) A) B) C) D) E) Nasogastric decompression Placement of a rectal tube Neostigmine administration Correction of underlying metabolic disturbances Avoidance of narcotic analgesia for pain management Nasogastric decompression Placement of a rectal tube Neostigmine administration Correction of underlying metabolic disturbances Avoidance of narcotic analgesia for pain management

Question 45 A 76-year-old man is brought to the emergency department with massive abdominal distention, fever, lethargy, and bloody rectal discharge. On physical examination, you note peritoneal signs, and a plain abdominal radiograph is diagnostic of sigmoid volvulus. Which of his presenting characteristics is not an indication for immediate laparotomy in a patient with sigmoid volvulus? A) B) C) D) E) A) B) C) D) E) Signs of systemic toxicity Bloody rectal discharge Peritoneal irritation Fever Abdominal distention Signs of systemic toxicity Bloody rectal discharge Peritoneal irritation Fever Abdominal distention

Question 46 An 18-year-old male presents to the emergency department with anorexia and periumbilical pain that subsequently localized to his right lower quadrant. He has a leukocytosis, and a physical examination is consistent with acute appendicitis. You take him to the operating room for an open appendectomy. When considering your incision, which of the following inaccurately describes the exposure?

A) The skin incision is made in an oblique direction, crossing a line drawn between the anterior superior iliac spine and the umbilicus at a right angle B) The McBurney point is approximately one third of the way from the iliac spine to the umbilicus C) A slightly shorter incision should be made in the aponeurosis of the external oblique, first using a scalpel and then extending the incision with scissors in the direction of the fibers of the muscle and tendon D) Fibers of the internal oblique and transversus abdominis should be separated with a blunt instrument at a right angle to the external oblique aponeurosis E) If greater exposure is needed, the medial edge of the serratus anterior is incised and retracted laterally A) The skin incision is made in an oblique direction, crossing a line drawn between the anterior superior iliac spine and the umbilicus at a right angle B) The McBurney point is approximately one third of the way from the iliac spine to the umbilicus C) A slightly shorter incision should be made in the aponeurosis of the external oblique, first using a scalpel and then extending the incision with scissors in the direction of the fibers of the muscle and tendon D) Fibers of the internal oblique and transversus abdominis should be separated with a blunt instrument at a right angle to the external oblique aponeurosis E) If greater exposure is needed, the medial edge of the serratus anterior is incised and retracted laterally Question 47 An 85-year-old otherwise healthy man sustains lower GI bleeding. Eventually, he undergoes angiography, which reveals a colonic arteriovenous malformation (AVM). Which of the following is an incorrect statement about AVMs? A) B) C) D) E) A) B) C) D) E) The incidence of AVMs increases with age AVMs are degenerative lesions of the GI tract AVMs are most commonly found in the sigmoid colon Colonic AVMs are derived from chronic colonic wall muscle contraction AVMs are associated with several systemic diseases, including von Willebrand disease The incidence of AVMs increases with age AVMs are degenerative lesions of the GI tract AVMs are most commonly found in the sigmoid colon Colonic AVMs are derived from chronic colonic wall muscle contraction AVMs are associated with several systemic diseases, including von Willebrand disease

Question 48 A 63-year old woman presents with a hematochezia. She is hemodynamically unstable and admitted to the intensive care unit for aggressive resuscitation; however, she continues to bleed despite maximal supportive efforts. The decision is made to take her to the operating room for surgical intervention. Which of the following would not be an appropriate intervention in the operating room?

A) Colonoscopy to aid in localizing the bleeding B) Esophagogastroduodenoscopy (EGD) to aid in localizing the bleeding C) Transoral passage of a pediatric colonoscope for enteroscopy with simultaneous assistance for small bowel manipulation to aid in localizing the bleeding D) Blind segmental colectomy E) Subtotal colectomy A) Colonoscopy to aid in localizing the bleeding B) Esophagogastroduodenoscopy (EGD) to aid in localizing the bleeding C) Transoral passage of a pediatric colonoscope for enteroscopy with simultaneous assistance for small bowel manipulation to aid in localizing the bleeding D) Blind segmental colectomy E) Subtotal colectomy Question 49 A 56-year-old man with a history of weekend alcohol consumption is admitted with acute pancreatitis. Which of the following factors is least likely to help determine if he should be admitted to the intensive care unit (ICU)? A) B) C) D) E) A) B) C) D) E) Oliguria Lipase of 1,500 U/L More than 8 APACHE II points C-reactive protein greater than 150 mg/L Contrast-enhanced computed tomography (CT) of the abdomen demonstrating peripancreatic fat stranding and decreased attenuation within the head of the pancreas Oliguria Lipase of 1,500 U/L More than 8 APACHE II points C-reactive protein greater than 150 mg/L Contrast-enhanced computed tomography (CT) of the abdomen demonstrating peripancreatic fat stranding and decreased attenuation within the head of the pancreas

Question 50 The patient from the previous question is admitted to the ICU with severe acute pancreatitis and CT evidence of pancreatic necrosis. Fifteen days into his hospitalization, he develops fever and hypotension, for which he requires fluid resuscitation and initiation of vasopressors to be stabilized. Blood, urine, and sputum cultures return negative. Right upper quadrant ultrasonography is not concerning for cholecystitis. Fine-needle aspiration of the pancreatic necrosis grows enterococci, and broad-spectrum antibiotics are started. Which of the following methods of treatment is not adequate treatment for infected pancreatic necrosis? A) B) C) D) E) Intravenous antibiotics only Endoscopic transgastric drainage followed by laparoscopic intracavity necrosectomy Laparoscopic transperitoneal necrosectomy and drainage Retroperitoneoscopic necrosectomy and drainage Open necrosectomy and drainage

A) B) C) D) E)

Intravenous antibiotics only Endoscopic transgastric drainage followed by laparoscopic intracavity necrosectomy Laparoscopic transperitoneal necrosectomy and drainage Retroperitoneoscopic necrosectomy and drainage Open necrosectomy and drainage

Question 51 A 60-year-old man with abdominal pain and chronic pancreatitis from alcohol abuse is referred for evaluation to determine if he is a surgical candidate. On examination, he is thin, without jaundice or caput medusa. He has no prior surgical history. Contrast-enhanced CT demonstrates a highly calcified pancreas with a main duct that is greater than 8 mm throughout its entire course. Hemoglobin A1c is elevated. It is determined that he is an appropriate candidate for surgery and wishes to proceed. Which procedure is most appropriate for this patient? A) B) C) D) E) A) B) C) D) E) Pancreaticoduodenectomy Frey procedure Puestow procedure Distal pancreatectomy Total pancreatectomy with islet cell transplantation Pancreaticoduodenectomy Frey procedure Puestow procedure Distal pancreatectomy Total pancreatectomy with islet cell transplantation

Question 52 You are consenting a patient to undergo EGD. When you advise her of the risks of the procedure, you mention that there is a small risk of damage to the gastrointestinal tract during the procedure, specifically, perforation. The patient wants to know where perforation is most likely to occur. Which of the following is the most common site of perforation during EGD? A) B) C) D) E) A) B) C) D) E) Stomach Duodenum Midesophagus Distal esophagus Proximal esophagus Stomach Duodenum Midesophagus Distal esophagus Proximal esophagus

Question 53 A 62-year-old man with a 2-week history of jaundice presents from an outside institution with computed tomography (CT) of the abdomen demonstrating mild dilation of the intra- and extrahepatic bile ducts but no mass in the pancreas. What is the most appropriate next step in his workup? A) B) C) D) E) A) B) C) D) E) Endoscopic retrograde cholangiopancreatography (ERCP) ERCP with endoscopic ultrasonography (EUS) and biopsy Magnetic resonance cholangiopancreatography (MRCP) Contrast-enhanced CT of the abdomen, pancreas protocol with 3 mm axial cuts Diagnostic laparoscopy with intraoperative ultrasonography Endoscopic retrograde cholangiopancreatography (ERCP) ERCP with endoscopic ultrasonography (EUS) and biopsy Magnetic resonance cholangiopancreatography (MRCP) Contrast-enhanced CT of the abdomen, pancreas protocol with 3 mm axial cuts Diagnostic laparoscopy with intraoperative ultrasonography

Question 54 A 72-year-old woman is referred for evaluation of an incidentally found 4 cm cystic lesion in the tail of the pancreas. The patient denies a history of prior abdominal pain. CT-guided aspiration reveals mucinous fluid and high levels of carcinoembryonic antigen. What is the most appropriate next step in management? A) B) C) D) E) A) B) C) D) E) Laparoscopic distal pancreatectomy without splenectomy Radical antegrade modular pancreaticosplenectomy Laparoscopic pancreatic enucleation Observation with serial CT every 3 months Laparoscopic percutaneous drainage of the cyst Laparoscopic distal pancreatectomy without splenectomy Radical antegrade modular pancreaticosplenectomy Laparoscopic pancreatic enucleation Observation with serial CT every 3 months Laparoscopic percutaneous drainage of the cyst

Question 55 A 72-year-old woman is being evaluated for pancreatic resection of a somatostatinoma in the head of the pancreas. Which of the following statements is incorrect? A) B) C) D) E) Enucleation is a surgical option Gallstones and anemia are common signs of somatostatinoma Nearly half of all cases are associated with multiple endocrine neoplasia type I (MEN I) Somatostatinomas are malignant in 75% of cases Pancreaticoduodenectomy is the most common procedure for surgical excision

A) B) C) D) E)

Enucleation is a surgical option Gallstones and anemia are common signs of somatostatinoma Nearly half of all cases are associated with multiple endocrine neoplasia type I (MEN I) Somatostatinomas are malignant in 75% of cases Pancreaticoduodenectomy is the most common procedure for surgical excision

Question 56 A 25-year-old man with MEN I, diagnosed after his parathyroidectomy, is concerned about the possibility of a tumor arising in his pancreas. MRI performed at age 20 did not demonstrate any pancreatic mass at that time. Which of the following pancreatic tumors is unlikely to affect this patient? A) B) C) D) E) A) B) C) D) E) Insulinoma Gastrinoma Glucagonoma VIPoma Mucinous cystic neoplasm Insulinoma Gastrinoma Glucagonoma VIPoma Mucinous cystic neoplasm

Question 57 You are consulted for a patient who presented to the emergency department after a screening colonoscopy, during which time a polyp was removed. You are immediately concerned about postpolypectomy syndrome. Which of the following correctly describes postpolypectomy syndrome? A) The risk of postpolypectomy syndrome increases with polyps found in the left colon when they are greater than 1 cm in diameter B) The risk of postpolypectomy syndrome increases with polyps found in the right colon when they are greater than 2 cm in diameter C) Postpolypectomy syndrome occurs in up to 5% of patients undergoing polypectomy D) Postpolypectomy syndrome is the result of a transmural thermal injury with subsequent serosal inflammation E) Most patients require operative management with diverting colostomy A) The risk of postpolypectomy syndrome increases with polyps found in the left colon when they are greater than 1 cm in diameter B) The risk of postpolypectomy syndrome increases with polyps found in the right colon when they are greater than 2 cm in diameter C) Postpolypectomy syndrome occurs in up to 5% of patients undergoing polypectomy D) Postpolypectomy syndrome is the result of a transmural thermal injury with subsequent serosal inflammation E) Most patients require operative management with diverting colostomy

Question 58 A 72-year-old woman is taken to the operating room for pancreaticoduodenectomy after preoperative imaging demonstrates a resectable tumor of the pancreatic head. In which of the following cases is the tumor resectable? A) B) C) D) E) A) B) C) D) E) Tumor invading the superior mesentericportal venous confluence Tumor invading the superior mesenteric artery (SMA) Carcinomatosis and malignant ascites Single hepatic metastasis, measuring 2 cm in diameter Tumor abutting the inferior vena cava Tumor invading the superior mesentericportal venous confluence Tumor invading the superior mesenteric artery (SMA) Carcinomatosis and malignant ascites Single hepatic metastasis, measuring 2 cm in diameter Tumor abutting the inferior vena cava

Question 59 A 46-year-old man with autoimmune pancreatitis presents for surgical evaluation of his disease. His primary complaint is of chronic abdominal pain. His diabetes is well controlled at this time. He has no prior surgical history. Contrast-enhanced CT of his abdomen demonstrates an enlarged, calcified pancreatic head and a pancreatic duct that is 11 mm in diameter throughout its entire course. What is the most appropriate surgical procedure to relieve his pain from chronic pancreatitis? A) B) C) D) E) A) B) C) D) E) Laparoscopic spleen-preserving distal pancreatectomy Open distal pancreatectomy Puestow procedure Frey procedure Beger procedure Laparoscopic spleen-preserving distal pancreatectomy Open distal pancreatectomy Puestow procedure Frey procedure Beger procedure

Question 60 A 42-year-old woman presents with an incidentally found hepatic mass on CT to evaluate right upper quadrant abdominal pain. MRI is performed to further evaluate the lesion. Which of the following statements about radiographic features of benign hepatic tumors is true? A) Hemangioma is a well-defined lesion with homogeneous enhancement and scar uptake on delayed CT images B) Hepatic adenoma is hypodense with peripheral nodular enhancement on delayed CT images C) Focal nodular hyperplasia (FNH) is a well-defined, hypointense lesion with enhanced scar

uptake on delayed CT images D) MRI characteristics of hemangioma include T1 and T2 hypointensity A) Hemangioma is a well-defined lesion with homogeneous enhancement and scar uptake on delayed CT images B) Hepatic adenoma is hypodense with peripheral nodular enhancement on delayed CT images C) Focal nodular hyperplasia (FNH) is a well-defined, hypointense lesion with enhanced scar uptake on delayed CT images D) MRI characteristics of hemangioma include T1 and T2 hypointensity E) MRI accuracy in diagnosing hemangioma is only 70 to 80% E) MRI accuracy in diagnosing hemangioma is only 70 to 80% Question 61 A 46-year-old man with a history of T3N0 colon cancer status post right colectomy 1 year ago presents for follow-up with an elevated carcinoembryonic antigen level. Abdominopelvic CT demonstrates a single 3 cm FDG-avid lesion of segment 4. Which of the following would make metastasectomy unindicated? A) B) C) D) E) A) B) C) D) E) A 1cm margin cannot be obtained due to the proximity of the portal vein on CT A single peripheral pulmonary metastasis is identified on chest CT A second metastasis is identified in segment 7 at the time of surgery CT demonstrates local recurrence of tumor at the ileocolic anastomosis CT demonstrates large celiac axis lymphadenopathy, and biopsy confirms adenocarcinoma A 1cm margin cannot be obtained due to the proximity of the portal vein on CT A single peripheral pulmonary metastasis is identified on chest CT A second metastasis is identified in segment 7 at the time of surgery CT demonstrates local recurrence of tumor at the ileocolic anastomosis CT demonstrates large celiac axis lymphadenopathy, and biopsy confirms adenocarcinoma