Full-Length Practice Examination 1

Full-Length Practice Examination 1
This is the beginning of the first full-length practice examination.
To most closely simulate the actual examination, take this during an uninterrupted 5-hour block of time.
The answer key is located at the end of the examination.
QUESTION 1-1
A 76-year-old dialysis-dependent woman with a history of multiple prior abdominal operations presents to the emergency room with worsening abdominal pain. Workup raises your suspicions for ischemic bowel. She last underwent hemodialysis 3 days prior, and is currently uremic. How will you best prepare the patient for emergent celiotomy?
image Administer conjugated estrogens
image Administer cryoprecipitate
image Administer desmopressin
image Arrange for dialysis
image Transfuse the patient with packed red blood cells (PRBC)
QUESTION 1-2
A 76-year-old man with aortoiliac occlusive disease undergoes percutaneous transluminal angioplasty of his left common iliac artery. What is the patency rate for patients who undergo angioplasty for iliac occlusive disease?
image 10% at 5 years
image 20% at 5 years
image 30% at 5 years
image 60% at 5 years
image 80% at 5 years
QUESTION 1-3
A 39-year-old female presents to the emergency department with complaints of watery diarrhea and upper abdominal pain for the past 2 weeks. On workup, she is found to have a small mass in the body of the pancreas on computed tomography scanning. Laboratory abnormalities include a hemoglobin of 8.7 mg/dL, white blood cell count of 10.1, hypokalemia, and a metabolic acidosis. She is subsequently scheduled to have an exploratory laparotomy. Intraoperatively, the mass is removed from her pancreas and multiple small nodules are found in her liver. Considering the most likely diagnosis, what are her best treatment options?
image 5-fluorouracil and interferon-alpha
image Intravenous steroids alone
image No further treatment is indicated
image Octreotide and glucocorticoids
image Repetitive embolization of the hepatic artery
QUESTION 1-4
A 46-year-old woman comes to the emergency department complaining of acute right lower quadrant pain. How could appendicitis be differentiated from acute ileitis?
image Colonoscopic biopsy
image Development of acute or subacute pain in the right lower quadrant
image Elevated white blood cell count
image Presence of diarrhea
image Thickened mesenteric lymph nodes on radiographic imaging
QUESTION 1-5
A 27-year-old male with idiopathic renal failure on hemodialysis is awaiting a kidney transplant. Multiple family members and friends have presented to the transplant center for evaluation of possible live donor transplantation. The recipient’s brother volunteers to donate his kidney and is found to have a favorable human leukocyte antigen (HLA) match. Which of the following conditions is least likely to be considered a contraindication for live kidney donation?
image Current cocaine usage
image HIV infection
image Type II diabetes mellitus
image Uncontrollable hypertension
image Unilateral duplicated collecting system
QUESTION 1-6
A 39-year-old male is referred to your clinic for treatment of a cecal mass diagnosed by surveillance colonoscopy. His father, paternal grandmother, and paternal uncle all developed colon cancer by their fifth decade. Mutation of which of the following genes is associated with this man’s disease?
image APC
image BRCA1
image BRCA2
image hMSH2
image K-Ras
QUESTION 1-7
A 68-year-old man presents with pain in his left leg. Examination and workup confirm diagnosis of a popliteal aneurysm. What is the most common complication that would result in the patient’s leg pain?
image Aortic aneurysm rupture
image Nerve impingement by the popliteal aneurysm
image Popliteal aneurysm rupture
image Thromboembolic events associated with the popliteal aneurysm
image Venous obstruction by the popliteal aneurysm
QUESTION 1-8
A 52-year-old woman presents to your clinic with a palpable thyroid nodule. Ultrasound shows a 3-cm lesion in the right thyroid lobe with solid and cystic components. Ultrasound-guided fine-needle aspiration (FNA) reveals a thyroid cancer. Which of the following is the most likely diagnosis?
image Anaplastic carcinoma
image Follicular carcinoma
image Medullary carcinoma
image Papillary carcinoma
image Parathyroid adenocarcinoma
QUESTION 1-9
A 60-year-old man who suffers from chronic alcoholism is admitted to the hospital with an episode of acute pancreatitis. He suffered similar episodes in the past—all of which have resolved without complications. On laboratory studies, he is found to have an elevated serum amylase level. A computed tomography (CT) scan is performed which demonstrates a 4-cm pancreatic pseudocyst. What would be the best subsequent treatment?
image Esophagogastroduodenoscopy
image Observation and serial CT scans
image Percutaneous drainage
image Puestow procedure
image Simple aspiration
QUESTION 1-10
Which of the following is a characteristic of Merkel cell carcinoma?
image Early distant metastases
image Frequently cured with wide local excision alone
image Histologically similar to squamous cell carcinoma
image Locally aggressive tumor with low chance of distant spread
image Slow growing, well-defined cutaneous lesion
QUESTION 1-11
A 70-year-old man with ascites secondary to cirrhosis presents for elective umbilical hernia repair. Should he be offered repair of his hernia?
image No, he should not be offered repair
image Yes, if he had a recent myocardial infarction
image Yes, if he is leaking ascites from the hernia
image Yes, if he is listed for liver transplant
image Yes, if it is significantly affecting his lifestyle
QUESTION 1-12
A 68-year-old man with atrial fibrillation presents to the emergency room with a cool, pulseless right foot. Sensation is intact. Duplex ultrasound of the right leg reveals multiple femoral stenoses and tibioperoneal thrombosis with poor tibial flow. What is the most appropriate management?
image Amputation
image Diagnostic angiography
image Intra-arterial site-directed thrombolysis
image Percutaneous embolectomy under local anesthesia
image Systemic anticoagulation only
QUESTION 1-13
A 55-year-old woman presents to your clinic with the new diagnosis of tertiary hyperparathyroidism. Which of the following operations has she most likely previously undergone?
image Colectomy with resection of terminal ileum
image Parathyroidectomy
image Renal transplantation
image Right middle lung lobectomy
image Thyroidectomy
QUESTION 1-14
A 63-year-old man presents with a “gnawing” upper abdominal pain. He reports that he was diagnosed with a gastric ulcer years ago. Which of the following tests is most sensitive in diagnosing the patient with infection with Helicobacter pylori?
image Histologic examination of endoscopic antral biopsies
image Serum antibodies to H. pylori
image Upper GI radiographic series
image Urea breath test
image Urease test of endoscopic antral biopsies
QUESTION 1-15
Which of the following is a characteristic of a cutaneous lymphatic malformation?
image Bluish mass with overlying telangiectasias
image Cystic mass with overlying vesicles
image Firm, nodular mass
image Irregular mass fixed to the underlying tissues
image Pulsatile ballotable mass
QUESTION 1-16
The fundamental goal of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) is:
image To collect outcome data to measure and improve surgical care outcomes
image To identify those surgeons who deliver excellent surgical care
image To improve health care in underserved US populations
image To model systems for improved use of health care resources
image To monitor surgical costs in order to allocate health care
QUESTION 1-17
A 73-year-old man has developed a pulseless left lower leg 8 days after experiencing a myocardial infarction (MI) requiring cardiopulmonary resuscitation. On examination, he has diminished sensation in his left foot. What is the most appropriate definitive treatment?
image Amputation
image Anticoagulation using intravenous heparin
image Intra-arterial site-directed thrombolysis
image Percutaneous embolectomy under local anesthesia
image Surgical bypass
QUESTION 1-18
A 47-year-old woman presents with a rapidly enlarging 5-cm right breast mass without palpable axillary nodes. Fine-needle aspiration (FNA) is nondiagnostic. Core biopsy is performed and results are reported as equivocal, but suggestive of a phyllodes neoplasm. The appropriate next step in management is:
image Close follow-up
image Simple mastectomy
image Tumor enucleation
image Tumor excision with a 1-cm margin
image Tumor excision with a 2-cm margin and sentinel node biopsy
QUESTION 1-19
A 72-year-old man undergoes percutaneous transhepatic cholangiography (PTC) and percutaneous biliary drainage (PBD) for obstructive jaundice secondary to pancreatic cancer. Following the PTC/PBD, he develops melena and bright red blood is seen in the biliary drain. Laboratory work reveals a drop in hematocrit and increase in his liver function tests. What is the definitive treatment for this change in his condition?
image Biliary stent placement
image Endoscopic epinephrine injection at the site of the bleeding vessel
image Hepatic resection
image Transarterial embolization
image Whipple procedure
QUESTION 1-20
During resection of a pelvic tumor, the left ureter is inadvertently transected below the level of the pelvic brim. The immediate treatment of this problem is:
image Delayed repair and percutaneous drainage of urinoma
image Diversion with ureteroenterostomy
image Primary repair
image Primary repair with ureteral stent
image Ureterocystostomy
QUESTION 1-21
Four weeks after a deceased donor kidney transplant, the recipient returns to the emergency department with bilateral lower-extremity edema. In spite of normal fluid intake, he reports that he has had minimal urine output over the past 18 hours. Serum creatinine is now elevated to 1.4 mg/dL from 1.0 mg/dL postoperatively. After failure to respond to a fluid challenge, an ultrasound is obtained. This reveals good perfusion, minimal hydronephrosis and, a 3- × 4- × 6-cm hypoechoic mass adjacent to the renal pelvis of the allograft. What is the most likely cause of the patient’s oliguria?
image Compressive hematoma
image Lymphocele formation
image Renal artery stenosis
image Renal artery thrombosis
image Ureteroneocystostomy stenosis
QUESTION 1-22
Eighteen months after undergoing an aortobifemoral artery bypass, a 74-year-old man presents with a painful swelling in his left groin. Ultrasound demonstrates a pseudoaneurysm at the site of the distal anastomosis with surrounding fluid. What is the likely underlying cause of this finding?
image Atheroembolism
image Graft failure
image Graft infection
image Graft thrombosis
image Suture failure
QUESTION 1-23
A 38-year-old woman is referred to your clinic after an elevated 24-hour urine cortisol measurement. She is not on any steroids. What is the most likely cause of this patient’s disease?
image Adrenal adenoma
image Adrenal carcinoma
image Factitious insulin use
image Ovarian cancer
image Pituitary adenoma
QUESTION 1-24
A 36-year-old woman underwent banding for an internal hemorrhoid 1 week ago. She contacts your office complaining of a small amount of blood on toilet paper after defecation, but denies pain or fever. The next step in her management is:
image Direct the patient to the emergency room
image Instruct the patient to apply cold compresses to the perineum
image Instruct the patient to take fiber supplementation and increase fluid intake
image Prescribe nifedipine ointment BID to the perianal region
image Tell the patient there is nothing to do
QUESTION 1-25
A 32-year-old male is brought to the emergency department after his left leg was pinned between two cars. Upon examination, his left leg is swollen and tense below the knee and you suspect compartment syndrome. Which nerve is most commonly injured during fasciotomy of the lower leg?
image Deep peroneal nerve
image Lateral femoral cutaneous nerve
image Saphenous nerve
image Superficial peroneal nerve
image Tibial nerve
QUESTION 1-26
While visualizing the gallbladder during an elective laparoscopic cholecystectomy, the anesthesiologist informs you that the patient has a heart rate of 130, and a dropping blood pressure. What is the FIRST step in management?
image Decrease insufflation pressure
image Give inotropes for blood pressure
image Give IV fluids
image Position the patient in the left lateral decubitus position
image Stop insufflation
QUESTION 1-27
Eighteen months after undergoing an aortobifemoral artery bypass, a 69-year-old woman presents with a draining, cellulitic wound in her right groin, with exposed polytetrafluoroethylene (PTFE) graft. What is the most likely pathogen infecting this graft?
image Enterobacter cloacae
image Klebsiella pneumoniae
image Pseudomonas aeruginosa
image Staphylococcus aureus
image Staphylococcus epidermidis
QUESTION 1-28
A 40-year-old premenopausal woman is seen by her physician for evaluation of a breast nodule. Physical examination confirms the presence of a 1-cm movable mass; mammogram and ultrasound evaluation are both found to be consistent with a fibroadenoma. A core biopsy confirms this diagnosis. The lesion is excised at the patient’s request. Pathology results reveal a fibroadenoma with a small area of lobular carcinoma in situ (LCIS) in the surrounding breast tissue, focally extending to one margin. The next step in management is:
image A partial mastectomy with sentinel lymph node biopsy
image Counsel the patient about their future breast cancer risk and screening options
image Remove further tissue from the positive margin side
image Remove further tissue from the positive margin side with axillary node dissection
image Sentinel lymph node biopsy alone
QUESTION 1-29
A 56-year-old man 2 years status post left colectomy for stage IIA colon cancer is now found to have rising carcinoembryonic antigen (CEA) and two new lesions in the liver on follow-up CT scan (see scans below). There is no evidence of extrahepatic disease. How do you manage this patient?

image

image Extended left hepatectomy
image Orthotopic liver transplantation
image Palliative chemotherapy
image Radiofrequency ablation of the two tumors
image Y-90 intra-arterial therapy
QUESTION 1-30
A 56-year-old man presents to your clinic with a 5-mm wide lesion confined to the middle of his lower lip. Biopsy confirms squamous cell carcinoma. What is the most appropriate management?
image Radiation therapy alone
image Radiation therapy followed by surgical resection with 5-mm margin and primary repair
image Surgical resection with 1-cm margin and primary repair
image Surgical resection with 1-cm margin and primary repair, followed by radiation therapy
image Surgical resection with 5-mm margin and primary repair
QUESTION 1-31
A 26-year-old male is undergoing a nerve block for an outpatient orthopedic procedure on his left ankle. During injection of the superficial fibular nerve with lidocaine, he complains of tingling around his mouth and lips. What other symptom would be consistent with lidocaine toxicity?
image Hallucinations
image High fever
image Muscle rigidity
image Peripheral paralysis
image Skin ischemia
QUESTION 1-32
A 64-year-old man undergoes endovascular repair of a 5.9-cm infrarenal abdominal aortic aneurysm with bilateral iliac artery involvement. The patient does well postprocedurally and is discharged home 4 days later. A 6-month follow-up CT reveals contrast extravasation into the aneurysm sac at the proximal aspect of the aneurysm and an interval increase in the aneurysm size to 6.3 cm. What type of endoleak is described, and what is the best management?
image Type I endoleak; observation
image Type I endoleak; urgent endovascular repair
image Type II endoleak; urgent open surgical repair
image Type III endoleak; observation
image Type III endoleak; urgent endovascular repair
QUESTION 1-33
A 64-year-old postmenopausal woman with Estrogen Receptor Positive (ER+), stage I breast cancer presents following lumpectomy, and radiation therapy, now on therapy with tamoxifen. She asks about the risks of tamoxifen therapy. You tell her that:
image Tamoxifen decreases the likelihood of developing all types of cancer
image Tamoxifen has been linked to an increased risk of developing endometrial adenocarcinoma and uterine sarcoma
image Tamoxifen increases bone resorption, increasing risk of long bone and pelvic fractures due to osteoporosis
image Tamoxifen increases the likelihood of developing breast cancer in the contralateral breast
image Tamoxifen is associated with a modest, but significant increase in the risk of cardiovascular events seen in postmenopausal women with coronary artery disease
QUESTION 1-34
Workup for vomiting in a 46-year-old woman with Crohn disease reveals a stricture in the second portion of the duodenum. What is the best surgical management of this problem?
image Heineke-Mikulicz strictureplasty
image Pylorus-preserving pancreaticoduodenectomy (Whipple procedure)
image Resection of the affected segment with primary anastomosis
image Roux-en-Y duodenojejunostomy
image Side-to-side retrocolic gastrojejunostomy
QUESTION 1-35
A 17-year-old male presents to the emergency department after a right shoulder injury sustained while playing football. Plain radiographs reveal the humeral head displaced medial to the glenoid fossa. Which nerve is most likely injured in this type of dislocation?
image Axillary nerve
image Median nerve
image Radial nerve
image Suprascapular nerve
image Sural nerve
QUESTION 1-36
An obese woman who underwent a transabdominal hysterectomy 10 years ago presents for an elective ventral hernia repair. She undergoes hernia repair via a laparoscopic approach, to which she responds well initially. However, she develops a recurrent bulge 2 months later and presents to your office for counseling. What is the most common reason for recurrence after laparoscopic ventral hernia repair?
image Failure of suture material or tacks
image Inadequate dissection of the fascial defect
image Separation of the mesh from the abdominal wall
image Seroma formation
image Unrecognized defect
QUESTION 1-37
What is the most common cause of late death after heart transplant?
image Acute graft rejection
image Accelerated atherosclerosis
image Cytomegalovirus (CMV) infection
image Fungal infection
image Ventilator-associated pneumonia
QUESTION 1-38
A 48-year-old male presents with persistent peptic ulcers that have been refractory to proton-pump inhibitors. His workup includes a positive secretin stimulation test. His underlying tumor is:
image Associated with hypoglycemia
image Associated with MEN 2A
image Associated with Whipple triad
image Frequently located in the tail of the pancreas
image Likely to be sporadic
QUESTION 1-39
A 38-year-old male presents to the emergency department after attempted suicide via ingestion of oven cleaner. Upon rigid esophagoscopy, you observe erythematous, friable, mucosa with superficial, noncircumferential white ulcerations in the mid-esophagus. What degree of injury is this lesion?
image Grade I
image Grade IIA
image Grade IIB
image Grade III
image Grade IV
QUESTION 1-40
A 32-year-old female requires a split-thickness skin graft after being involved in a car accident. A 12- × 6-cm site is harvested from her lateral thigh and is implanted on her scalp without complications. The healing rate at the donor site is most related to:
image Amount of moisture kept on the donor site
image Epithelial appendages and thickness of graft
image Epithelial appendages and width of the site
image Quality of semi-occlusive dressing
image Thickness of graft and moisture on donor site
QUESTION 1-41
A 21-year-old male is brought to the trauma bay after sustaining a superficial stab-wound to the left shoulder. He reports that he received his full series of shots as a child, and received his last tetanus booster shot when he was 15. What should he receive for his tetanus prophylaxis?
image Amoxicillin 500-mg PO TID
image Nothing
image Tetanus immune globulin (TIG) 250-units IM
image Tetanus toxoid (dT) 0.5-mL IM
image Tetanus toxoid (dT) 0.5-mL IM and TIG 250-units IM
QUESTION 1-42
A 72-year-old man is seen in clinic preoperatively to prepare for his upcoming femoral-tibial artery bypass for vascular insufficiency. The duplex scan demonstrates poor candidates for venous conduits, so the use of synthetic graft is anticipated. The long-term outcome for this patient could be improved by:
image Clopidogrel use for the first 3 months after surgery
image Daily use of 81-mg aspirin indefinitely
image Low-molecular-weight heparin injections for the first 6 weeks after surgery
image The use of support stockings
image Warfarin use with a goal International Normalization Ratio (INR) of 1.5
QUESTION 1-43
A 25-year-old male sustains a superficial gunshot wound to his left proximal, lateral thigh, near the anterior superior iliac spine. His initial neurologic examination in the emergency department reveals no motor deficits but numbness in the region of the left lateral cutaneous nerve of the thigh. When should surgery for repair of the suspected nerve injury be performed?
image 1 to 2 weeks
image 2 to 3 months
image 6 months to 1 year
image Immediately
image Never
QUESTION 1-44
A 40-year-old male former Australian lifeguard with a history of melanoma presents to the emergency department with a month-long history of abdominal pain, nausea, and vomiting. What is the most likely cause for his symptoms?
image Colonic obstruction
image Diverticulitis
image Duodenal adenocarcinoma
image Gastroenteritis
image Intussusception of the small bowel
QUESTION 1-45
Which of the following characteristics is an advantage of full-thickness skin grafts (FTSGs) over split-thickness skin grafts (STSGs)?
image Appropriate for larger defects
image Better for contaminated tissue beds
image Better resistance to infection
image Less nutritional demand
image Lower incidence of contractures
QUESTION 1-46
A 56-year-old male is ventilator dependent due to an open abdomen secondary to trauma. On the third day following his injury, he develops hypoxemia and tachypnea requiring an increase of the fraction of inspired oxygen (FiO2) and positive end-expiratory pressure (PEEP). His partial pressure of oxygen in arterial blood (PaO2) increases minimally with these changes. Plain chest radiograph shows bilateral infiltrates and pulmonary artery occlusion pressure is 16 mm Hg. Which combination of features would support a diagnosis of acute respiratory distress syndrome (ARDS) over ventilator-associated pneumonia (VAP)?
image PaO2/FiO2 ratio <200 mm Hg
image Pulmonary artery occlusion pressure ≥18 mm Hg
image Temperature 38.3°C, WBC = 12, minimal pleural effusion, increased protein on bronchoalveolar lavage (BAL), infiltrates not seen on chest radiograph
image Temperature 38.5°C, WBC = 16, no effusions, increased protein on BAL
image Temperature 38.7°C, WBC = 14, pleural effusions, increased protein on BAL
QUESTION 1-47
A 28-year-old female professional violinist presents with headaches, neck pain, and hand clumsiness in her right hand. She also reports occasional numbness in the hand and right-sided chest pain. Which of the following is the likely cause of her symptoms?
image Carpal tunnel syndrome
image Coronary artery disease
image Osteoarthritis
image Paget-Schroetter syndrome
image Thoracic outlet syndrome (TOS)
QUESTION 1-48
A 72-year-old man with a history of diabetes and smoking presents with a 2-day history of excruciating pain in the right lower extremity. The patient states that the pain started while he was sitting in a chair, and that, unlike other pains he has had in the leg before, it was not relieved by elevation of the extremity. Physical examination shows a pale, cool, pulseless, and numb right foot and the calf is quite tender. No pedal Doppler signal is obtainable. The patient is taken to the operating room where on-table angiogram reveals occlusion of the superficial femoral artery. A right femoral below knee popliteal bypass is performed with restoration of the pulses. Postoperatively in the surgical intensive care unit, the resident notices severe swelling of the right lower extremity and loss of the dorsalis pedis pulse. The most likely etiology of the edema is:
image Acute bleed from anastomotic leak
image Acute popliteal venous occlusion
image Acute reperfusion injury
image Chronic venous occlusive disease
image Lymphocele
QUESTION 1-49
A 22-week pregnant, 31-year-old woman received 7 days of ampicillin for a urinary tract infection. The patient developed diarrhea on day 5 of therapy, and stool is positive for Clostridium difficile toxin. How would you treat the patient?
image Clindamycin 300-mg PO QID for 10 days
image Do nothing, this is usually self-limiting
image Metronidazole 500-mg PO QID for 10 days
image Vancomycin 500-mg PO QID for 10 days
image Vancomycin 500-mg PR QID for 10 to 14 days
QUESTION 1-50
You are performing a laparoscopic cholecystectomy on a 64-year-old woman with a history of cholelithiasis and vague abdominal pain. As you insert the camera through the supraumbilical trocar, you are surprised to find white cake-like tumor spreading from the left pelvis across much of the large intestine. You should:
image Perform a biopsy, convert to an open procedure, and perform complete surgical staging
image Perform a biopsy, convert to an open procedure, and remove all involved organs
image Perform a left oophorectomy
image Take a biopsy of the tumor, close, and await the pathology report to plan open surgery
image Take a biopsy of the tumor, remove the gallbladder, and finish the case
QUESTION 1-51
A 2-year-old boy is brought to the emergency department by his mother. She reports that he has been inconsolable for the past 24 hours and has refused his feeds. Upon further questioning, the physician finds that the child has vomited twice and has not had a bowel movement. Examination reveals a slightly distended and diffusely tender abdomen, especially in the inguinal area, without signs of peritonitis. What should be your first step?
image Arrange for immediate groin exploration in the operating room without attempting manual reduction
image Elevation of the child’s lower extremities with a pillow, followed by an attempt at manual reduction
image Emergent exploratory laparotomy
image Apply ice pack to the affected area
image Overnight inpatient observation
QUESTION 1-52
An 82-year-old man with a history of severe chronic obstructive pulmonary disease (COPD) presents with claudication and is found to have occlusive disease localized to the left common iliac artery. Which of the following procedures is the most appropriate for management of this patient’s disease?
image Anticoagulation using intravenous heparin
image Aortobifemoral artery bypass with synthetic graft
image Conservative treatment
image Femoral to femoral artery bypass with venous autograft
image Percutaneous transluminal angioplasty (PTA) under local anesthesia
QUESTION 1-53
A 47-year-old woman undergoes core-needle biopsy of a lesion found on routine mammography in the lower, outer quadrant of her right breast. Pathology is read as atypical ductal hyperplasia (ADH) of the breast. What is the most appropriate next step in this patient’s management?
image Axillary lymph node dissection
image Excisional biopsy with wire localization
image Follow-up mammography in 6 months
image Modified radical mastectomy
image Partial mastectomy with sentinel lymph node biopsy
QUESTION 1-54
A 43-year-old man presents to your clinic complaining of intermittent blood spotting on toilet paper for 2 weeks. Anoscopy reveals a 1-cm split in the anoderm posteriorly on the midline distal to the dentate line, lacking any hypertrophy or visible muscle fibers. What is the optimal management?
image Bisacodyl suppositories
image Initiate stool softeners
image Lateral internal anal sphincterotomy
image Observation only
image Resection of affected tissue
QUESTION 1-55
A 22-year-old male (65 kg) is seen in the emergency department after a motorcycle accident that resulted in significant head and maxillofacial trauma. Following initial evaluation and stabilization, he is admitted to the intensive care unit with lactated Ringer (LR) solution running at 125 mL/hr. During the first 60 hours of his stay, his urine output gradually declines to 25 mL/hr and his serum sodium drops from 136 to 127 mEq/L. His vital signs remain stable. Urine osmolarity is found to be 548 mOsm/L. Which of the following is the next best intervention?
image Add demeclocycline 600 mg BID
image Convert his fluids from LR to 3% normal saline
image Increase his fluids to maintain urine output >0.5 mL/kg/hr
image Start fludrocortisone 0.1 mg QDay
image Stop his fluids entirely
QUESTION 1-56
A 45-year-old woman with a history of gallstones is admitted to the intensive care unit after diagnosis with acute pancreatitis with hemodynamic instability. Her admission laboratory values were remarkable for a number of abnormalities, including hyponatremia, hyperamylasemia, hyperlipasemia, and hyperlipidemia. What is the etiology of hyponatremia in pancreatitis?
image Hypoalbuminemia
image Pseudohyponatremia
image Renal failure
image Salt wasting
image Syndrome of inappropriate anti-diuretic hormone (SIADH)
QUESTION 1-57
A previously healthy 63-year-old woman began to complain of increased shortness of breath and chest pain while undergoing a root canal. After stopping the procedure, her symptoms resolved, and the oral surgeon resumed drilling. She began experiencing right facial pain and periorbital and neck swelling and subsequently complained of severe dyspnea. The patient’s blood pressure then became undetectable. An emergent ECG showed nonspecific ST wave changes. Her pulse oximeter revealed an oxygen saturation of 89% to 90% throughout the procedure. Immediate action should be?
image Administration of intravenous fluids
image Bilateral tube thoracostomy placement
image Initiation of intravenous antibiotics
image Intravenous heparin therapy and/or thrombolytic therapy
image Position the patient in left lateral decubitus Trendelenburg position
QUESTION 1-58
A 34-year-old male Ukrainian immigrant is seen in clinic for a right-sided thyroid nodule, which shows no uptake on technetium scan. In 1986, he was living near the Chernobyl nuclear reactor during its melt-down. Given this history and probable etiology, what is the most likely diagnosis of his thyroid nodule?
image Anaplastic carcinoma
image Follicular carcinoma
image Hürthle cell carcinoma
image Medullary carcinoma
image Papillary carcinoma
QUESTION 1-59
A 54-year-old alcoholic man presents to the emergency department with severe substernal and epigastric pain after vomiting while drinking earlier that evening. Gastrografin esophagogram shows perforation of the distal esophagus with drainage into the left pleural space. What is the most appropriate treatment?
image Emergent primary repair via left thoracotomy
image Esophageal stent placement
image Esophagectomy and delayed reconstruction with interposition graft
image Esophagostomy and placement of a feeding jejunostomy tube
image Nonoperative management with total parenteral nutrition and nasogastric decompression
QUESTION 1-60
The appropriate treatment for an 8-year-old with a completely displaced supracondylar fracture of the humerus (Gartland type III) is:
image Closed reduction and immobilization
image Closed reduction and internal fixation
image Elbow replacement
image Intramedullary rod placement
image Splinting and immobilization
QUESTION 1-61
A 42-year-old woman is in the intensive care unit immediately following removal of a left adrenal pheochromocytoma. Her blood pressure is 80/40 mm Hg. The most appropriate treatment of the patient’s hypotension is:
image Epinephrine
image IV bolus of lactated Ringer solution
image Methylprednisolone
image Phenoxybenzamine
image Phenylephrine
QUESTION 1-62
A 24-year-old man presents to the emergency department after sustaining two gunshots through his chest. Which of the following would suggest that he has lost 30% to 40% of his blood volume?
image HR 90, normal blood pressure, normal or increased pulse pressure, urine output >30 mL/hr
image HR 110, normal blood pressure, increased pulse pressure, urine output >30 mL/hr
image HR 110, normal blood pressure, narrowed pulse pressure, urine output 20 to 30 mL/hr
image HR >120, decreased blood pressure, very decreased pulse pressure, respiratory rate 30 to 40, urine output 5 to 15 mL/hr
image HR >140, very decreased blood pressure, respiratory rate >35, negligible urine output
QUESTION 1-63
A 42-year-old woman presents with the presumed diagnosis of inflammatory carcinoma of her left breast. She is 8 weeks postpartum. What is the appropriate management?
image If the tumor does not respond to neoadjuvant chemotherapy, proceed to mastectomy
image If the tumor responds to an extended course of antibiotics, continue with local resection
image If the tumor responds to high-dose chemotherapy, continue with mastectomy, postoperative radiation, then possible further adjuvant therapy
image If the tumor responds to high-dose chemotherapy, continue with radiation therapy, followed by surgical resection, then chemotherapy
image If the tumor responds to neoadjuvant chemotherapy, proceed to local excision
QUESTION 1-64
A 60-year-old man with a long history of smoking and heavy alcohol use undergoes a transhiatal esophagectomy for esophageal cancer. He does well and is discharged from the intensive care unit on the second postoperative day. However on the third day he develops a fever and malaise. A chest and neck CT scan demonstrates severe inflammation as indicated by stranding around, and wall thickening of, the gastric conduit but no intramural air. Which vascular supply to the stomach may have been compromised during the transhiatal esophagectomy?
image Gastroduodenal artery
image Left gastric artery
image Left gastroepiploic artery
image Right gastroepiploic artery
image Short gastric arteries
QUESTION 1-65
On initial assessment the most important predictor of return of function in a patient with a severe head injury is:
image Intracranial pressure greater than 15 mm Hg
image Overall Glasgow Coma Scale (GCS) score
image Poor eye opening score component of the GCS
image Poor motor score component of the GCS
image Poor verbal score component of the GCS
QUESTION 1-66
A 7-week-old boy is referred with a 3-day history of projectile nonbilious vomiting. He appears dehydrated and, on abdominal examination, an olive-shaped epigastric mass is palpable. The most appropriate initial IV fluid regimen for resuscitation is:
image 2% sodium chloride
image 5% dextrose
image Lactated Ringer
image Normal saline
image Normal saline + 20-mmol/L potassium chloride
QUESTION 1-67
A 67-year-old woman with long-standing diabetes presents to clinic stating that she has noticed some breakdown of the skin on the bottom of her right foot. Examination of the foot reveals a shallow ulcer overlying the area of the metatarsal heads with surrounding erythema. Radiograph of the foot reveals no bony involvement. How should you counsel her?
image She should be admitted to the hospital for aggressive wound care
image She should clean the wound with warm soaks and then put on clean socks
image She should obtain well-fitting shoes
image She will likely need a distal arterial bypass
image She will need a transmetatarsal amputation
QUESTION 1-68
A 65-year-old female complaining of weakness, fatigue, and easy bruising, is found to have guarding and distention of her upper abdomen. She reports a history of taking prednisone and weekly epoetin-α. She feels her symptoms have become worse in the past year. What procedure would this patient need for definitive management of this condition?
image Bone marrow biopsy
image Gastrectomy
image Laparoscopic adrenalectomy
image Laparoscopic splenectomy
image Patient requires no surgical management
QUESTION 1-69
You are called by the Intensive Care Unit (ICU) regarding a 45-year-old man intubated for ARDS for the past 3 weeks. Over the past 48 hours, he has developed increased abdominal distension. His last bowel movement was 4 days ago, and the ICU staff has attempted multiple enemas without result. An abdominal plain film has revealed diffuse dilation of the colon consistent with ileus, without an identifiable transition point. Your physical examination demonstrates a critically ill man with a rotund abdomen. There is no fluid wave or shifting dullness, just diffuse tympany. There is no stool in the rectal vault. How should you proceed with treatment?
image Endoscopic decompression
image Manual disimpaction
image Nasogastric-tube decompression and serial examinations
image Neostigmine
image Therapeutic enteroclysis
QUESTION 1-70
For an oral squamous cell carcinoma with 4-mm depth of invasion without palpable lymph nodes, the appropriate surgical treatment entails:
image Excision plus supraomohyoid neck dissection
image Local excision alone
image Radiation therapy
image Radical neck dissection
image Sentinel lymph node biopsy using blue dye
QUESTION 1-71
A 45-year-old female is in the SICU 2 days postoperative from an orthotopic liver transplant for primary biliary cirrhosis. The patient’s condition has rapidly deteriorated, with signs consistent with fulminant hepatic failure. Ultrasound of the graft is most likely to reveal which of the following?
image Hepatic artery thrombosis
image Hepatic vein thrombosis
image Inferior vena cava stenosis
image Portal vein stenosis
image Portal vein thrombosis
QUESTION 1-72
A 30-year-old man presents with facial swelling, engorged neck veins, and complaints of dizziness for the prior 3 months. Two years previously, he was diagnosed with unresectable malignant thymoma, but completed only two rounds of radiotherapy. How should you proceed with treatment?
image Balloon angioplasty and endovascular stenting of the superior vena cava (SVC)
image Exploratory thoracotomy
image Extra-anatomic bypass from the internal jugular to the femoral vein
image Inpatient heparinization until therapeutic on warfarin
image Internal jugular to right atrial bypass
QUESTION 1-73
A 42-year-old man presents with progressive fullness and abdominal cramping increasing in severity over the past 4 weeks. Computed tomography (CT) reveals a large intra-abdominal mass with multiple enlarged inguinal and cervical lymph nodes visible. Which of the following tests is diagnostic of this patient’s possible intra-abdominal lymphoma?
image CT scan
image CT-guided needle biopsy
image Open biopsy
image Positron emission tomography (PET) scan
image T2-weighted Magnetic Resonance Imaging (MRI)
QUESTION 1-74
An 88-year-old woman presents from a nursing home with altered mental status and abdominal distension. She has a history of gallstones and has never had abdominal surgery. On examination, she is febrile and tachycardic and has a distended, tender abdomen that is tympanitic to percussion. A plain abdominal film demonstrates dilated loops of small bowel with air in the biliary tree. What is your proposed management?
image A trial of nasogastric tube decompression, IV fluids, bowel rest
image ERCP and stent placement
image Exploratory laparotomy
image Family meeting and likely comfort care measures only given extremely poor prognosis
image Laparoscopic cholecystectomy
QUESTION 1-75
The cerebral perfusion pressure (CPP) in a patient with head injury should ideally be greater than:
image 30 mm Hg
image 50 mm Hg
image 70 mm Hg
image 90 mm Hg
image 110 mm Hg
QUESTION 1-76
A 55-year-old man presents with a firm mass on his left thigh, which he noticed recently after bumping into a chair. The mass is painless, not discolored, and 5 cm in diameter. What is the next diagnostic test you should perform?
image Excisional biopsy
image Fine-needle aspiration
image Incisional biopsy
image Magnetic resonance imaging (MRI) scan
image Wide excision with 2-cm margins
QUESTION 1-77
A 45-year-old woman was found on physical examination to have a right thyroid nodule. Ultrasound of the thyroid demonstrated a 2.5-cm hypoechoic nodule, which was identified as papillary thyroid cancer on fineneedle aspiration (FNA). What is the best next step in the management of this patient?
image Obtain Computed Tomography (CT) scan of the neck
image Obtain Integrated Positron Emission Tomography and Computed Tomography (PET-CT) scan for complete staging
image Obtain ultrasound of the neck to evaluate for lymphadenopathy
image Proceed to surgery without other studies
image Repeat the FNA to confirm the diagnosis
QUESTION 1-78
A 35-year-old woman presents with complaint of a bloody discharge from the left nipple. Clinical breast examination confirms inducible discharge from a single duct in the left nipple and a small palpable mass near the inferior areolar margin. Bilateral mammogram and left ultrasound show a small density that appears to correspond to the palpable mass, which measures 8 mm by ultrasound and is solid. The lesion is amenable to ultrasound-guided core biopsy. Which of the following is correct?
image If a core biopsy confirms a benign papilloma, no further intervention is needed
image If core-needle biopsy confirms intraductal papilloma, then proceed to local excision with postoperative routine breast screening examination
image If local excision shows DCIS, the patient can return to routine breast screening with no further intervention needed
image This is most likely a benign process, does not need to be biopsied, and should be followed with clinical breast examination and mammogram every 6 months
image Unilateral bloody discharge is usually associated with a history of breast trauma
QUESTION 1-79
A 54-year-old woman comes to clinic 3 weeks after undergoing a common bile duct exploration for biliary stones refractory to endoscopic management. She was left with a T-tube in place, which has been reliably draining bile until 2 days ago. Over the past 48 hours, she has noted increased right upper quadrant pain that is similar to her preoperative pain. You order a tube cholangiogram, which demonstrates a retained stone lodged in the common bile duct. How should you proceed?
image Admit to the hospital, make NPO with IVF, provide analgesia and observe
image Endoscopic retrograde cholangiopancreatography (ERCP)
image Laparoscopic stone extraction
image Remove the T-tube and perform immediate choledochoscopy
image Repeat open common bile duct exploration
QUESTION 1-80
A 78-year-old African American female with hypertension and diabetes mellitus falls in her kitchen and lacerates her right great toe. Three hours later, her family brings her to the emergency department because she has developed severe erythema migrating up her leg, fever to 40°C (104°F) and a marked change in her mental status. Examination of the wound reveals severe edema of the surrounding skin, marked erythema proceeding up the leg and crepitus to palpation. Her laboratory values show a lactate of 6.7 mmol/L. What is the most appropriate course of treatment?
image Gram-negative antibiotic coverage, IV fluid resuscitation, surgical debridement
image Gram-positive antibiotic coverage, IV fluid resuscitation, surgical debridement
image Immediate surgical debridement, IV fluid resuscitation, broad-spectrum antibiotics

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Oct 7, 2016 | Posted by in GENERAL SURGERY | Comments Off on Full-Length Practice Examination 1

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