Download 2008 Exam - Department of Surgery University of Toronto

DEPARTMENT OF SURGERY
PRINCIPLES OF SURGERY EXAM
March 25, 2008
7:30 a.m. to 9:30 a.m.
EXAMINATION INSTRUCTIONS
1.
Please write and code your name on the Computer Answer Sheet – left side.
2.
This examination is multiple-choice. Choose the single best answer.
3.
This examination is two hours in length.
4.
Examination results will be sent from the Department of Surgery
5.
Questions marked with an asterisk are optional for residents in the ENT and OBGYN programs.
Page 2 of 31
1.*
2.
3.
4.
A 37 year old man is involved in a high speed motor vehicle collision. He is
hemodynamically stable. A supine chest x-rays shows a pulmonary contusion and
possible widened mediastinum. The most appropriate study to diagnosis the
presence of a traumatic injury to the aorta is?
A)
transesophageal echocardiogram
B)
helical thin-cut CT angiography
C)
thoracic aortogram
D)
MR scan of the thorax
Which of the following statements about the use of intravenous fat emulsions in
the nutritionally depleted surgical patient is NOT true?
A)
daily infusion is associated with a higher incidence of infection
B)
critically ill patients achieve nitrogen balance more easily with a mixture
of glucose and lipid compounds than with glucose alone
C)
the requirements for essential fatty acids can be met with 1500 ml of 10%
lipid per week
D)
a 500 ml bottle of 20% lipid contains about 900 kilocalories
In the acute-phase response to injury or infection, levels of which of the following
serum proteins is decreased?
A)
C-reactive protein
B)
fibrinogen
C)
ceruloplasmin
D)
albumin
A 50 year old man develops severe septic shock following manipulation of an
impacted ureteric stone. He is treated with aggressive volume resuscitation,
vasopressor therapy, and mechanical ventilation. Which of the following therapies
may further help him to survive his shock?
A)
infusion of IL-1 receptor antagonist
B)
high dose steroid administration
C)
infusion of antiendotoxin antibodies
D)
infusion of activated protein C
Principles of Surgery Exam
March 2008
Page 3 of 31
5.
6.
7.
A 46 year old woman who has been on long-term prednisone therapy for
rheumatoid arthritis needs an abdominal hysterectomy for fibroids. Which of the
following complications may be expected to occur in this patient with greater than
average frequency?
A)
poor wound healing
B)
pulmonary embolus
C)
ileus
D)
renal failure
The incidence of post-operative venous thromboembolism is increased in patients
with genetically determined procoagulant states. The following are all
procoagulant states, EXCEPT:
A)
antithrombin-III deficiency
B)
resistance to activated protein C (Factor V Leiden)
C)
antiphospholipid antibodies (lupus anticoagulant)
D)
hypohomocystinemia
A 30 year old woman is being evaluated for abdominal pain in the Emergency
Room when she suddenly develops a grand mal seizure with tonic clonic
movements. The initial pharmacologic management of her seizure should be?
A)
phenytoin (dilantin) 1 gram IV (loading dose)
B)
lorazepam 0.1 mg/kg IV
C)
proprofol 40 mgs bolus IV
D)
Phenobarbital 10 mgs/kg IV over 1 hour
Principles of Surgery Exam
March 2008
Page 4 of 31
8.
9.
10.*
A 65 year old woman presents to the Emergency Room with a right hip fracture.
She is scheduled for open reduction and internal fixation the following day. The
orthopedic resident notices that the patient is tachycardic and hyper-reflexic.
Blood tests confirm that the patient has hyperthyroidism. The appropriate perioperative management of this condition is?
A)
close observation in the ICU post-operatively
B)
begin propylthiouracil and proceed with surgery
C)
begin beta blockage with propranolol and proceed with surgery
D)
arrange urgent radio-iodine ablation and proceed with surgery
Resuscitation from hypovolemic shock requires large quantities of fluids. Which
of the following parameters are NOT helpful in assessing the adequacy of fluid
resuscitation?
A)
serum lactate
B)
base deficit calculated from arterial blood gases
C)
near infrared spectroscopy
D)
central venous pressure
A 27 year old man is brought to the Emergency Room after being thrown from a
motorcycle at high speed. His systolic blood pressure is 60. A chest x-ray shows
a widened mediastinum. In addition to appropriate resuscitation, the next step in
his management should be:
A)
immediate left thoracotomy
B)
CT thorax
C)
aortic ach angiogram and possible stenting
D)
abdominal ultrasound (FAST)
Principles of Surgery Exam
March 2008
Page 5 of 31
11.
12.
13.*
A 70 year old man with a history of ischemic heart disease, two prior myocardial
infarctions, and prior coronary artery bypass grafting, is scheduled to undergo
right total hip replacement. Echocardiography confirms a decreased ejection
fraction of 40% and no significant valvular disease. Stress thallium scan confirms
a fixed perfusion defect inferiorly and no evidence of reversible ischemia. Preoperative medical therapy to reduce cardiac morbidity and mortality in this patient
should include?
A)
an ACE inhibitor
B)
beta-adenergic blockade
C)
hydralazine afterload reduction
D)
digoxin
Regarding tight control of serum glucose levels in diabetic patients undergoing
cardiac surgery, which of the following statements is correct?:
A)
it has no affect on the incidence of post-op complications
B)
it significantly reduces the incidence of deep sternal wound infections
C)
it enhances neurtophil phagocytosis
D)
it increases urine output
A 50 year old trauma patient is admitted to the ICU with a GCS of 8, unilateral
posturing, an intracranial pressure (ICP) of 25, and a mean arterial pressure of 90.
All of the following treatments will help to prevent secondary brain injury,
EXCEPT?:
A)
sedation and muscle paralysis
B)
CSF fluid drainage for persistent elevated ICP
C)
administration of the calcium-channel blocker nimodipine
D)
mild hyperventilation to a pCO2 of 35 mm/Hg
Principles of Surgery Exam
March 2008
Page 6 of 31
14.
15.
16.
17.
During fasting, the liver produces energy substraits by all of the following
mechanisms, EXCEPT?
A)
glycogenolysis
B)
glycolysis
C)
gluconeogenesis from alanine
D)
formation of ketone bodies from fatty acids
Apoptosis (programmed cell death) is an important regulatory mechanism that
limits inflammatory tissue injury. Inducers of apoptosis include all of the
following, EXCEPT?
A)
hyperglycemia
B)
oxidant stress
C)
radiation
D)
cytokines
A 50 year old grossly malnourished alcoholic undergoes surgery for perforated
gastric ulcer. Post-operatively, he is started on total parental nutrition because of
sepsis and prolonged ileus. He is at risk of developing severe hypophosphatemia
secondary to refeeding syndrome. Symptoms of severe hypophosphatemia
include all of the following EXCEPT?
A)
myocardial depression
B)
atrial and ventricular arrhythmias
C)
muscle weakness leading to respiratory failure
D)
confusion, stupor, coma, seizures
The syndrome of inappropriate secretion of anti-diuretic hormone (SIADH) may
be caused by all of the following, EXCEPT?
A)
lung tumours
B)
congestive heart failure
C)
closed head injury
D)
alcohol withdrawal
Principles of Surgery Exam
March 2008
Page 7 of 31
18.
19.*
20.
The proliferative phase of wound healing is characterized by collagen deposition
and remodeling as well as wound contraction. The cell most responsible for this
is?
A)
the myocyte
B)
the fibroblast
C)
the macrophage
D)
the endothelial cell
A 20 year old man sustained severe left thoracic trauma after a fall of 20 feet. He
is awake, alert, and neurologically intact. Pulse oximetry demonstrates a 90%
oxygen saturation on nasal prong O2 at 4l/min. Chest x-ray shows a left
pneumothorax and a chest tube is placed which drains 500 mls of blood. An
abdominal CT scan is normal. Over the next 4 hours the chest tube drains 250
mls/hr and the patient has intermittent hypotension. The next step in management
should be?
A)
placement of a second chest tube
B)
CT angio of thorax
C)
vasopressor therapy
D)
emergency thoracotomy
A 37 year old farmer rolls his tractor and is trapped underneath for four hours. He
has a crush injury to both legs including bilateral femur fractures. Twenty-four
hours after admission, he was found to have the following blood work:
Na
140
K
5.7
Cl
100
HCO3 10
Cr
220
CPK
15,000
Principles of Surgery Exam
March 2008
Page 8 of 31
The first step in preventing renal failure in this patient is?
A)
loop diuretic administration
B)
mannitol administration
C)
restoring adequate circulating volume
D)
alkalinization of urine with sodium bicarbonate
For each of the following three (3) questions, select the one answer that is closely
associated with the question stem.
A)
case control study
B)
cohort study
C)
both
D)
neither
21.
Prospective design
22.
Reasonable design when outcome is rare
23.
Strength of association (conclusions) similar to randomized trials
24.
Which of the following statements concerning the metabolic response to simple
starvation is NOT true?
A)
starvation results in a respiratory quotient of 0.6-0.7, indicative of fat as a
primary fuel source.
B)
The Cori and Alanine cycles provide carbon for gluconeogenesis in the
liver
C)
Resting energy expenditure decreases in simple starvation
D)
Lipogenesis ensures maintenance of fat reserves
Principles of Surgery Exam
March 2008
Page 9 of 31
26.
27.
25.
A patient who develops angioedema after the administration of penicillin
is scheduled for a craniotomy to ablate a seizure focus. Which of the
following options is most appropriate with respect to antibiotic
prophylaxis?
A)
no antibiotic prophylaxis
B)
Cefazolin 1 gram IV at the time of induction
C)
Vancomycin 1 gram IV at the time of induction
D)
Vancomycin 1 gram and Gentamyacin 160 mgs IV at the time of induction
Hepatocellular carcinoma is epidemiologically associated with all of the
following, EXCEPT?
A)
Hepatitis A
B)
Hepatitis B
C)
Hepatitis C
D)
alcoholic cirrhosis
A 75 year old woman undergoes bilateral total knee replacement. On the third
post-operative day, she developed hypotension with a blood pressure of 90/60,
heart rate 120. An electrocardiogram shows marked ST segment depression in
the lateral leads. The initial management of this hypotension should be?
A)
IV fluid bolus
B)
Initiate inotropic support
C)
emergency cardiac catheterization to attempt coronary revascularization
D)
support cardiac function with intra-aortic balloon pump
Principles of Surgery Exam
March 2008
Page 10 of 31
28.
29.
30.
A 25 year old man driving a motorcycle strikes a guard rail and is taken to the
nearest Emergency Room. He is found to have multiple left rib fractures and a
small pneumothorax on chest x-ray. A CT scan shows a subcapsulsar hematoma
of the spleen. A chest tube is inserted but unfortunately entered the abdomen and
ruptures the subcapsular hematoma necessitating laparotomy and splenectomy.
Post-operatively the patient is doing well in the Intensive Care Unit. What should
the surgeon tell the patients wife?
A)
“He is doing well”
B)
“His spleen was injured and we had to take it out”
C)
“Unfortunately, we caused his spleen to bleed while treating his lung
injury and we had to take the spleen out”
D)
“I am sorry, we almost killed your husband with a chest tube, but
fortunately we were able to rescue him”
Metabolic acidosis with a high anion gap maybe be produced by all of the
following, EXCEPT?
A)
hypovolemic shock
B)
acute renal failure
C)
acetylsalicylic acid intoxication
D)
chronic diarrhea
Radiation therapy for malignancy primarily depends on DNA damage. The extent
of DNA damage following radiotherapy is dependent on all of the following,
EXCEPT?
A)
cellular oxygen level
B)
the phase of the cell cycle
C)
use of radiation sensitizers such as 5-flouoroucil
D)
tissue intracellular pH
Principles of Surgery Exam
March 2008
Page 11 of 31
31.
32.
33.
A 45 year old man who was involved in a motor vehicle accident remains
hypotensive despite attempted resuscitation with crystalloids. Abdominal
sonography reveals a large amount of fluid in the abdomen. The patient states
that he will not accept blood transfusions for religious reasons. The next step in
his management should be?
A)
angiography and embolization of bleeding sites
B)
secure an emergency court order for blood transfusion
C)
exploratory laparotomy without blood products
D)
administration of vasopressor
Which of the following statements about post-operative infections is NOT true?
A)
increases in patients with diabetes mellitus
B)
can be reduced with clipping versus dry shaving
C)
can be reduced by perioperative delivery of 80% oxygen
D)
can be reduced by maintaining mild (35%) intra-operative hypothermia
Which of the following statements concerning post-operative hyponatremia is
NOT true?
A)
hyperglycemia may be a cause of hyponatremia
B)
following craniotomy, hyponatremia despite adequate salt administration
is usually caused by occult renal dysfunction
C)
hyponatremia may occur when water is used to replace sodium-containing
fluids
D)
in oliguric patients, cellular catabolism with resultant metabolic acidosis
increases cellular release of water and can contribute to hyponatremia
Principles of Surgery Exam
March 2008
Page 12 of 31
34.
35.
36.
Which of following statements concerning reperfusion injury is correct?
A)
reperfusion injury is initiated by the formation of oxygen-derived free
radicals
B)
free radicals cause membrane lipid peroxidation rendering capillary
vessels more permeable
C)
the deleterious effects of free radicals is worsened by superoxide
dismutase
D)
neutrophils play no role in reperfusion injury
During an emergency appendectomy, a surgical resident sustains an injury from a
contaminated hollow-bore needle with spontaneous bleeding. Which of the
following blood-borne diseases is most like to be transmitted, assuming the
patient was infected with all of these?
A)
HIV
B)
Hepatitis B
C)
Hepatitis C
D)
Malaria
A five week old boy had a five day history of vomiting and resultant weight loss
of 0.4 kgs (4.0 kgs to 3.6 kgs). Examination finds his anterior fontanels flattened
and his mucous membranes dry. Laboratory data are as follows:
Na
132
K
3.2
Cl
91
CO2
28
Capillary pH 7.
This patient is suffering from which of the following acid-base disorders?
A)
none
B)
metabolic alkalosis
C)
respiratory alkalosis
D)
compensated metabolic acidosis
Principles of Surgery Exam
March 2008
Page 13 of 31
37.
38.
39.
A 47 year old man undergoes resection of a large retroperitoneal liposarcoma.
Post-operatively he develops acute renal failure requiring intermittent
hemodialysis. A dietitian estimates that he requires 70 grams of protein and 2500
kilocalories per day for optimal wound healing. Since he is in acute renal failure,
his nutritional goal should be adjusted to:
A)
same – 70 grams protein, 2500 kilocalories
B)
low protein diet – 35 grams protein, 2500 kilocalories
C)
adjusted low protein diet – 35 grams protein, 1500 kilocalories
D)
hyperalimentation – 100 grams protein, 3500 kilocalories
An 85 year old man undergoes open reduction and internal fixation for a right hip
fracture. On post-operative day three he suffers a massive myocardial infarction
and is transferred to the Intensive Care Unit where he is ventilated. In the ICU, he
develops pneumonia, acute renal failure, and a large left middle cerebral artery
stroke. All physicians caring for the patient agree that the situation is hopeless,
but the patient’s family demands continuation of all care, including ventilation
and haemodialysis, because of religious beliefs. What should his treating
physician do at this time?
A)
Refuse to provide futile care and extubate the patient
B)
Ask the hospital lawyer to obtain a court order to allow the patient to be
extubated
C)
Negotiate with the family with the help of an appropriate religious leader
D)
Continue all treatment and hope the patient dies soon, thus freeing up the
ICU bed
You are reviewing a study comparing medical vs. surgical treatment of
inflammatory bowel disease. You notice that the patients referred for surgery
tended to be younger and fitter than those treated medically. The validity of this
study is therefore compromised because of:
A)
selection bias
B)
measurement bias
C)
confounding variables
D)
external validity (generalizeability)
Principles of Surgery Exam
March 2008
Page 14 of 31
40.
41.*
Patients requiring massive blood transfusion often become cooagulopathic.
Which of the following factors is NOT a significant cause of such coagulopathy?
A)
dilution of coagulation factors
B)
metabolic acidosis
C)
hypocalcaemia
D)
hypothermia
A 78 year old woman falls in her nursing home and sustains a scalp laceration.
She is unconscious for four minutes. She has a history of chronic atrial
fibrillation for which she takes coumadin.
In the Emergency room she has a normal neurological exam and normal CT head.
Her INR is 2.2. After the laceration is sutured, management should consist of?
42.
A)
transfer back to nursing home
B)
admission to hospital, reversal of anticoagulation
C)
MR imaging of head
D)
Admit to ICU for observation overnight
A 60 year old woman suffers an isolated liver injury in a motor vehicle accident.
Three months earlier, she was treated with prednisone and plasmaphoresis for
idiopathic thrombocytopenic purpura. Her platelet counts have remained normal
since therapy was discontinued two months earlier.
Twelve hours after admission her blood pressure is 80/40, heart rate 120, CVP 3
mm/hg, Hgb 105. The next step in her management should be?
A)
laparotomy
B)
transfuse of two units packed red blood cells
C)
hydrocortisone 100 mgs IV bolus
D)
levophed infusion
Principles of Surgery Exam
March 2008
Page 15 of 31
43.
44.
45.
46
Which one of the following clinical signs or symptoms is NOT associated with a
serum sodium concentration below 125 mEq/l?
A)
headache
B)
bradycardia
C)
hypoventilation
D)
hyperthermia
A patient requires re-operation one month after a vertical midline abdominal
incision has been made. Which of the following procedures will promote the
most rapid gain in strength of the new incision?
A)
use a separate transverse incision
B)
excise the midline scar with a l cm margin
C)
reopen the midline incision without scar excision
D)
the rate of strength gained is not affected by the incision technique
What is the fundamental tissue property measured by a CT scan?
A)
atomic number
B)
density
C)
relative x-ray attenuation
D)
hydrogen content
Which of the following is the best screening test for significant carotid stenosis in
a patient with an asymptomatic carotid bruit?
A)
MR angiography
B)
four-vessel cerebral angiography
C)
CT angiography
D)
duplex ultrasound scanning
Principles of Surgery Exam
March 2008
Page 16 of 31
47.
48.
49.
50.
All of the following are clinical features of acute hypocalcemia,
EXCEPT?
A)
Chvosteks sign – facial muscle spasm on stimulation of the facial nerve
B)
Trousseaus sign –carpal spasms following inflation of a blood pressure
cuff
C)
hypertension
D)
prolonged QT interval
All the following patients require intubation and mechanical ventilation. In which
ONE of these patients is the use of succinylcholine contraindicated?
A)
patient with cardiogenic shock
B)
patient with 70% 3rd degree burns
C)
trauma patient with Lefort III facial fracture
D)
patient with severe hypokalemia
A patient wants your advice about recovery after an attack of acute low back pain.
The best available study of this question describes time-to-time recover for a
cohort of patients with low back pain. The study found that several variables
were related to prognosis: severity of pain at onset, presence of lumbar disc
disease, neurological deficit such as weakness and numbness, activity following
the attack and spinal manipulation. Which approach would provide the most
information in tailoring prognosis to your particular patient?
A)
stratified analysis
B)
matching
C)
multivariate analysis
D)
sensitivity analysis
A 70 year old man is about to undergo a left total hip replacement. He has a
history of significant penicillin allergy. Which of the following drugs would
NOT be appropriate for use as a prophylactic agent for this patient?
A)
cefazolin
B)
clindamycin
C)
erythromycin
D)
Vancomycin
Principles of Surgery Exam
March 2008
Page 17 of 31
51.*
A 22 year old man is brought to the Emergency Room after a motor vehicle
collision. His blood pressure is 80/40 and his heart rate is 140 after 2000-ccs
bolus of normal saline. His GCS is 7 (eyes closed, no verbalization, purposeful
movement of all four extremities). He has crepitus and palpable rib fractures on
the left with equal breath sounds bilaterally. He has an obvious femur fracture
also on the left.
The most likely explanation for this hemodynamic picture is?
52.
53.
54.
A)
intracranial hemorrhage
B)
left tension pneumothorax
C)
inter-abdominal hemorrhage
D)
blood loss associated with femur fracture
Which of the following is the most important stimulus for triggering the endocrine
response after injury?
A)
afferent nerve stimuli from the injured area
B)
hypovolemia
C)
tissue acidosis
D)
local wound factors
Many drugs used in surgical practice are bound to plasma proteins. Which of the
following statements is correct?
A)
albumin is the plasma protein largely responsible for binding drugs
B)
binding is usually irreversible
C)
binding to plasma proteins is highly specific, that is, the binding locus is
specific for a given drug
D)
bound drug has enhanced glomerular filtration
Which of the following can cause spuriously elevated pulse oximeter readings?
A)
methemoglobinemia
B)
finger nail polish
C)
hyperbilirubinemia
D)
IV methylene blue
Principles of Surgery Exam
March 2008
Page 18 of 31
55.
56.*
57.
A 53 year old woman who underwent brain tumour resection four days ago
develops left lower extremity pain and swelling. An ultrasound examination
demonstrates clot in the femoral popliteal veins on the left. The most appropriate
treatment for this is?
A)
begin ambulation and discontinue bed rest
B)
begin intravenous heparin administration
C)
use intermittent leg compression and graduated-compression stockings.
D)
place an IVC filter
A 19 year old man is shot in the abdomen. When EMS arrives his vitals are heart
rate 130, blood pressure 90/60, respiratory rate 20. EMS calls you at the base
hospital to ask for advice. You should ask the EMS team to?
A)
bring the patient to the Emergency Room ASAP
B)
administer 1,000 cc 10% dextran solution on route to the ER
C)
intubate the patient in the field and administer fluid on route to the ER
D)
administer fluid bolus in the field over 10 minutes and then transport
patient to the ER
A 57 year old man requires mechanical ventilation because of respiratory failure
secondary to a blood transfusion (TRALI). Despite an FI0 2 of 0.5, his PO2 is
noted to be only 60. The cause of this man’s hypoxemia is?
A)
right to left shunt
B)
V/Q mismatch
C)
increased diffusion barrier
D)
decreased mixed venous O2 saturation
Principles of Surgery Exam
March 2008
Page 19 of 31
58.*
59.
A 30 year old man is involved in a motor vehicle accident. He requires
emergency splenectomy and open reduction and internal fixation of a left femur
fracture. On post-operative day two in the Intensive Care Unit, he develops a
decreasing level of consciousness (GCS 14) and severe hypoxemia, necessitating
intubation and mechanical ventilation. He was noted to have petechiae on his
chest. The cause of his respiratory failure is likely?:
A)
aspiration
B)
fat embolism syndrome
C)
adult respiratory distress syndrome (ARDS)
D)
nosocomial pneumonia
An 85 year old man develops septic shock following attempted removal of an
obstructing right ureteric stone. He is transferred to the ICU and resuscitation is
begun with fluids and pressors. Which of the following antibiotics would NOT be
appropriate for use in this patient while awaiting blood and urine culture results?
A)
ceftriaxone
B)
ciprofloxacin
C)
gentamycin
D)
imipenem
Principles of Surgery Exam
March 2008
Page 20 of 31
60.*
61.
62.
A 31 year old man was a belted driver involved in a high-speed motor vehicle
collision. His air bag deployed. He was found apparently uninjured at the scene.
In the Emergency Room, he has right sided weakness despite a normal CT head.
The next step in is management should be?
A)
close observation with serial neurological examination
B)
neck immobilization and C-spine x-ray
C)
CT angiogram of neck
D)
EEG
In a septic patient, cytokine-mediated effects on trace element metabolism include
which of the following?
A)
decreased serum iron level
B)
increased serum zinc level
C)
increased serum copper level
D)
decreased serum manganese level
Pre-operative non-invasive testing for the presence of inducible myocardial
ischemia would be most appropriate for which of the following patients?
A)
a healthy 60 year old man without historical cardiac risk factors scheduled
for a gastrectomy for gastric adenocarcinoma
B)
a patient with a history of myocardial infarction one year ago and good
exercise tolerance undergoing a laparoscopic cholecystectomy
C)
a patient with diabetes and renal insufficiency undergoing an inquinal
hernia repair
D)
a patient with limited exercise tolerance and diabetes undergoing a right
hemi colectomy
Principles of Surgery Exam
March 2008
Page 21 of 31
63.
64.
65.*
With regard to the spread of neoplasm, which of the following statements is
FALSE?
A)
metastatic cells enter the lymph node via the subcapsular space and later
permeate the sinusoids of the node
B)
carcinoma-in-situ is a lesion with histopathological characteristics of
malignancy without detectable invasion beyond the basement membrane
C)
lymphatic involvement is common with epithelial neoplasms, whereas
most sarcomas metastasize hematogenously
D)
the metastatic process is highly efficient, as evidenced by the fact that the
number of circulating tumour cells correlates with the metastatic burden
A 67 year old man is admitted to hospital for treatment of bilateral pulmonary
emboli with a heparin infusion. The patient’s platelet count on admission was
250,000 and three days later, it is noted to be 75,000. On physical examination,
the patient is noted to have ischemic changes in the right upper and lower
extremities. Which of the following statements concerning this situation is
correct?
A)
low molecular heparin can be safely used as a substitute for unfractionated
heparin
B)
venous thrombosis is the most like cause of this man’s recent physical
findings
C)
subcutaneous administration of heparin is not associated with this problem
D)
direct thrombin-inhibitors are used as the first line of treatment
A 25 year old woman is involved in a motor vehicle accident. On arrival in the
Emergency Room, the GCS is 7. CSF is seen in her left ear. There are obvious
extremity fractures in both legs. The patient is intubated. With regards to her
head injury, what is the most important treatment prior to getting a CT scan of the
head?
A)
maintain normal blood pressure and oxygenation
B)
hyperventilate patient to a pCO2 level of 25
C)
administer 250 cc’s 10% mannitol over 30 minutes
D)
administer Ancef 1 gram IV
Principles of Surgery Exam
March 2008
Page 22 of 31
66.
67.
68.
69.
Which of the following statements about packed red blood cells after three weeks
of storage is TRUE?
A)
affinity for oxygen decreases
B)
they must be used within one week
C)
24 hour post-transfusion red cell survival is less that 50%
D)
potassium concentration increases
Which of the following conditions is NOT a risk factor for post-operative cardiac
morbidity?
A)
S3 gallop rhythm on auscultation
B)
more than five pvcs/minute on an ECG
C)
coronary artery stenting in the past six months
D)
significant aortic stenosis
A 37 year old homeless man presents in the Emergency Room with left leg pain.
He has numerous bruises and abrasions on both legs. He has an area of erythema,
tenderness, and induration starting on the medial aspect of the left ankle and
extending up the leg to the knee. The left inquinal lymph nodes are enlarged and
tender. The microorganism most likely responsible for this clinical scenario is?
A)
actinomycoses
B)
enterococcus
C)
staphylococcus aureus
D)
streptococcus pyogenes
A 65 year old diabetic man is scheduled for arteriography using non-ionic
contract. His serum creatinine is 200. In addition to hydration, which of the
following is indicated to reduce the risk of contrast-induced nephropathy?
A)
low dose dopamine infusion
B)
mannitol infusion
C)
hydrocortisone IV
D)
acetylcysteine IV
Principles of Surgery Exam
March 2008
Page 23 of 31
For each of the following three questions, select the one answer that is most
closely associated with the question stem.
A)
corticosteroids
B)
cyclosporine
C)
mycophenolate mofetil
D)
sirolimus
70.
Blocks the calcineuron pathway
71.
Inhibitor of nuclear factor of activated T-cells
72.
Inhibits calcium-independent pathways for T and B cell activation
73.
Which of the following statements concerning glucagon is correct?
74.
A)
major stimulants for the secretion of glucagon include hypoglycemia
and exercise
B)
the effects of glucagon are inhibited by cortisol
C)
glucagon plays a major role in the development of post-injury
hyperglycemia
D)
somatostatin potentiates glucagon release from islet cells
Which of the following statements concerning the cytokine interleukin-1 (IL-1) is
NOT correct?
A)
the cells most responsible for IL-1 production are monocytes and
macrophages
B)
IL-1 may induce fever
C)
T-lymphocyte production of IL-2 is inhibited by IL-1
D)
IL-1 may augment wound healing by increasing fibroblast proliferation
and collagen synthesis
Principles of Surgery Exam
March 2008
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75.
76.
77.
Planned primary multimodality therapy results in improved survival or reduced
morbidity of treatment in all of the following tumours, EXCEPT?
A)
infiltrating carcinoma of the breast
B)
Wilms tumour
C)
melanoma
D)
sarcoma of the extremities
A 60 year old trauma patient undergoes tracheostomy because of prolonged
respiratory failure. Five days following the procedure, large quantities of bright
red blood are noted to be coming from within and around the tracheostomy tube.
The presumed diagnosis is?
A)
pulmonary embolus
B)
necrotizing pneumonia
C)
tracheitis
D)
tracheo-innominate artery fistula
A 75 year old woman is scheduled to undergo a right total hip replacement. She
takes coumadin for chronic atrial fibrillation. Which is the most appropriate
management of her anticoagulation pre-operatively?
A)
stop coumadin five days pre-operatively and check the INR on the day of
surgery
B)
stop coumadin five days pre-operatively, initiate low molecular weight
heparin subcutaneously twice a day and hold heparin for 12 hours prior to
surgery
C)
stop coumadin five days pre-operatively, admit patient to hospital and start
IV unfractionated heparin infusion. Stop heparin infusion 6 hours preoperatively
D)
stop coumadin one day pre-operatively and administer vitamin K1 10 mgs
subcutaneously. Check INR on day of surgery
Principles of Surgery Exam
March 2008
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78.
79.
80.
A 35 year old man suffers a significant closed head injury and ruptured spleen in
a motor vehicle accident. He undergoes emergency laparotomy and splenectomy
and is transferred to the Intensive Care Unit post-operatively. He has a history of
deep venous thrombosis due to antithrombin-III deficiency. The preferred VTE
prophylaxis for this patient is?
A)
antithrombin III concentrate to maintain levels at 80 to 120% of normal
B)
enoxaparin 30 mgs subcutaneously bid
C)
heparin 5000 units subcutaneously bid
D)
heparin infusion to keep PTT >60
Clostridium difficile colitis is becoming increasingly common. Which of the
following statements about this disease is correct?
A)
not all antibiotics can cause Clostridium difficile colitis
B)
Clostridium difficile colitis always induces severe diarrhea
C)
the mainstay of treatment is oral Vancomycin
D)
emergency colectomy may be required
Endocarditis prophylaxis is recommended for which of the following patients?
A)
a patient with mitral valve prolapse without murmur undergoing rigid
bronchoscopy
B)
a patient with a history of rheumatic fever with normal cardiac valves
undergoing prostatic biopsy
C)
a patient with a prosthetic aortic valve undergoing endoscopic retrograde
cholangiography for biliary obstruction
D)
a patient with hypertrophic cardiomyopathy undergoing tympanoplasty
tube insertion
Principles of Surgery Exam
March 2008
Page 26 of 31
81.
82.
83.
A 45 year old man develops hyperglycemia despite adequate levels of circulating
insulin during his recovery from a laparotomy for trauma with splenectomy. Post
traumatic insulin resistance is primarily due to?
A)
cortisol
B)
insulin antibodies
C)
reduced insulin receptors
D)
increased insulin clearance
A 65 year old man is injured in a motor vehicle collision. He suffers a chest wall
injury consisting of a flail segment ((5-9th ribs) and an underlying pulmonary
contusion without hemo or pneumothorax. After resuscitation, he is receiving 4 l
O2 per minute by nasal canula. He rates his pain as 8/10 and cannot take a deep
breath or cough. His respiratory rate is 24 and he has mild respiratory acidosis.
Urine output is 40 ml/h. Spinal injury has been ruled out. Which of the following
is the most appropriate next step?
A)
endotracheal intubation and mechanical ventilatory support
B)
continuous epidural analgesia
C)
fluid resuscitation
D)
non-invasive ventilatory support with bi-PAP
Which of the following statements regarding the transcription factor NFKB is
correct?
A)
it is anti-inflammatory
B)
it inhibits TNF and IL1 transcription
C)
its activation increases iNOS expression
D)
its primary site of action is the cytoplasm
Principles of Surgery Exam
March 2008
Page 27 of 31
84.
85.
86.
Regarding indexes of tissue perfusion, which of the following statements is
correct?
A)
normal cardiac index precludes tissue hypoxia
B)
normal or high mixed venous oxygen saturation (Sv 02) precludes tissue
hypoxia
C)
high plasma lactate levels always reflect tissue hypoxia
D)
there is a supply dependence of oxygen consumption on oxygen delivery
in some circumstances
Which part of the cell is thought to be the target of radiation damage?
A)
mitochondria
B)
nucleus
C)
nucleolus
D)
cell membrane
A 50 year old woman is found to have an adenocarcinoma of the cecum. Consent
is obtained for “right hemicolectomy”. At surgery a right hemicolectomy is
carried out without difficulty. No evidence of metastatic disease is found except
for a very bulky right ovary, highly suggestive of metastatic disease (Krukenberg
tumour). In this situation, the surgeon should?
A)
close the abdomen and obtain informed consent for future right
oophorectomy post operatively from the patient
B)
consult a gynecologist about the appropriate action to take in the
Operating Room
C)
scrub out of the case and obtain consent for right oophorectomy from the
patient’s husband
D)
carry out right oophorectomy and inform the patient post-operatively
Principles of Surgery Exam
March 2008
Page 28 of 31
87.
88.
89.
A 50 year old man is admitted to the day surgery unit prior to craniotomy for
meningioma. He is noted to be hypertensive and tremulous. He admits to daily
heavy alcohol use including the night prior to surgery. The optimal management
of this patient is?
A)
cancel surgery, rebook when the patient has abstained from alcohol for
one month
B)
transfer the patient to a detoxification centre and reschedule surgery in one
week
C)
admit the patient to the Neurosurgery Ward, sedate with benzodiazepine,
reschedule surgery when the patient is free of withdrawal symptoms
D)
carry on with surgery and observe patient in the Intensive Care Unit postoperatively
Nephrotoxicity from IV contrast agents is:
A)
caused by contract precipitation in the distal tubule
B)
reduced by oral acetylcystine
C)
increased by iso-osmolar contrast mediums
D)
independent of baseline renal function
A 50 year old homeless alcoholic is admitted to hospital for treatment of left leg
cellulitis. You are concerned that this patient may be very malnourished and
require special dietary therapy. The best method of determining the nutritional
status of this patient is?
A)
history and physical examination (subjective global assessment)
B)
calculate the creatinine-height index
C)
test for delayed hypersensitivity reaction to common recall antigens
D)
measure serum albumin and transferrin
Principles of Surgery Exam
March 2008
Page 29 of 31
90.
91.
92.
93.
Which of the following statements regarding methacillin resistent staph aureus
(MRSA) is NOT correct?
A)
MSRA is a common nosocomial pathogen, but it can also be detected in
the community
B)
the treatment of choice is vancomycin
C)
MRSA is more virulent than methacillin sensitive staph aureus
D)
hospitalized patients colonize with MRSA require contact isolation
The most accurate test for the diagnosis of adrenal insufficiency is critically ill
patients is?
A)
morning serum cortisol level
B)
morning serum ACTH level
C)
corticotrophin (ACTH) stimulation test
D)
metapyrone overnight test
The key components of informed consent, or the process by which physicians and
patients make decisions together, include each of the following, EXCEPT?
A)
disclosure
B)
competency
C)
comprehension
D)
compliance
Significant protein loss after severe injury is common. Which of the following
statements concerning this situation is correct?
A)
it results from impaired protein synthesis
B)
it occurs primarily from skeletal muscle
C)
it occurs primarily at the site of injury
D)
it can be prevented by enteral but not parenteral feeding
Principles of Surgery Exam
March 2008
Page 30 of 31
94.
95.
96.
Regarding renal function during states of hemorrhagic shock, which of the
following statements is correct?
A)
the blood flow to the kidney, like that to the brain, is maintained until late
in the course of hemorrhagic shock
B)
renal ischemia longer than 10 minutes produces irreversible renal damage
in most patients
C)
fractional excretion of Na is less than 1-2% in most patients with
hemorrhagic shock
D)
alteration in the serum BUN level is as sensitive a measurement of renal
function as is serum creatinine
Which of the following treatments is used for the preoperative preparation of
patients with a known pheochromocytoma?
A)
fluids, blood, or both
B)
diuretics
C)
alpha antagonists
D)
beta agonists
A 60 year old man undergoes total gastrectomy for carcinoma of the stomach.
Post-operatively he develops an anastomotic leak at the esophageal anastomoses
and undergoes further surgery and percutaneous drainage of multiple abscesses.
Over the course of his hospital stay, he is noted to have marked wasting of his
skeletal muscles. This is primarily caused by:
A)
disease atrophy
B)
malnutrition
C)
elevated levels of counter-regulatory hormones (cortisol, glycogen,
epinephrine)
D)
elevated levels of cytokines such as interlukin-2 and tumour necrosis
factor
Principles of Surgery Exam
March 2008
Page 31 of 31
97.
98.
99.
100.
A 75 year old woman is recovering from total abdominal hysterectomy. On postoperative day five, as she is being helped out of bed, she suffers sudden cardiac
arrest. You are the first doctor to arrive at the bedside, 60 seconds later. ECG
monitor shows slow ventricular fibrillation. Your first action should be?
A)
intubate patient
B)
initiate chest compressions
C)
defibrillate patient
D)
administer 1 mg epinephrine IV and recheck rhythm
Which of the following statements concerning post-operative ulnar neuropathy is
correct?
A)
it is more common in females
B)
it can be prevented by padding the arms during anesthesia
C)
it is the least common perioperative nerve injury
D)
it may have delayed onset of symptoms
Rapid sequence induction of anaesthesia is commonly used for emergency
surgery in patients who may have significant quantities of fluid in the stomach.
Which of the following statements about rapid sequence induction is correct?
A)
pre-oxygenation is not necessary
B)
only a depolarizing muscle relaxant can be used
C)
cricothyroid pressure has been shown to decrease the incidence of
aspiration pneumonitis
D)
hypotension may result in hypovolemic patients
Which of the following is NOT an adverse event associated with the use of
quinoline antibiotics (such as ciprofloxacin)?
A)
tendonitis and possible tendon rupture
B)
seizures
C)
clostridium difficile colitis
D)
narrowing of QT interval
Principles of Surgery Exam
March 2008