2012 Pos Exam

7/18/2019 2012 Pos Exam

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DEPARTMENT OF SURGERY

PRINCIPLES OF SURGERY EXAM

February 28, 2012

7:30 a.m. to 9:30 a.m.

EXAMINATION INSTRUCTIONS

1. Please write and code your name on te !om"uter #nswer $eet % left side.

2. &is e'amination is multi"le(coice. !oose te single best answer.

3. &is e'amination is two ours in lengt.

). *'amination results will be sent from te +e"artment of $urgery

. -uestions igligted in BOLD are o"tional for residents in te *& and /( "rograms.

Princi"les of $urgery *'am

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1. *arly(onset breast cancer, sarcomas, leuemia, and brain and adrenal cortical tumors

would be most consistent wit4

15 6(Fraumeni syndrome

25 Peut(egers syndrome

35 !# 2

)5 ata'ia(telangiectasia

2. ic of te following is often associated wit early se"sis4

15 metabolic alalosis

25 metabolic acidosis

35 res"iratory alalosis

)5 res"iratory acidosis

3. &wel;e ours after an o"en ysterectomy, a ) year old woman de;elo"s a fe;er of

39.< !. /n e'amination, se as foul(smelling =diswater> "us draining from er

wound. # gram stain re;eals gram("ositi;e rods. ic of te following statementsregarding tis condition is true4

15 te causati;e organism is an aerobe

25 emergency o"erati;e debridement of te wound is indicated

35 ig(dose flagyl ?metronidaole5 is te antibiotic of coice

)5 te organism "roduces an endoto'in


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4. In a blunt tau!a "#$t#!% &'(#(t'nt )*&+t'n(#+n ,'(&#t' "#-++u( lu#,

'(u($#tat#+n !a* b' #n,#$at#"' + all + t)' +ll+/#n-% EXCEPT0

15 tension "neumotora'

25 "ericardial tam"onade

35 ongoing intracranial emorrage

)5 myocardial infarction

. A 3 *'a +l, /+!an #( '($u', +! a )+u(' #' at' 2 !#nut'(. In t)'

'!'-'n$* ++! ()' )a( ant'#+ $)'(t /all bun( an, #( /'a% $+nu(',% an,

l't)a-#$. T)' !+(t l#'l* ,#a-n+(#( #(0

15 carbon mono'ide "oisoning

25 inalation lung in@ury

35 y"ercarbic res"iratory failure

)5 u""er airway obstruction

5. &ecnical errors during surgical "rocedures are A/$& liely to occur4

15 during routine "rocedures in com"le' "atients

25 in ig(com"le'ity o"erations

35 due to surgical ine'"erience

)5 due to inadeBuate resident su"er;ision


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6. &ree years after renal trans"lantation, a C) year old man "resents wit a newly

diagnosed colon cancer. &e "atient recei;es immunotera"y wit sirolimus for

immunosu"ression. #n electi;e colon resection is sceduled.

&is "atient as increased ris for4

1. intra(o"erati;e bleeding

2. wound deiscence

3. dee" ;enous trombosis

). "ost(o"erati;e diabetes

. &ree days after uncom"licated gastrectomy for cancer, a 72 year old woman suffers

a large "ulmonary embolism reBuiring mecanical ;entilation. /;er te ne't wee inte D!E se goes on to de;elo" multi(organ system failure including a large middle

cerebral artery emorragic stroe.

Prior to te o"eration, te "atient communicated to te surgeon er clear wis not to be maintained on artificial life su""ort. er usband acnowledges tis, but tere is

no li;ing will and e wises to continue aggressi;e su""ort des"ite te de;astating

neurologic in@ury and a grim "rognosis. &e "atientGs surgeon sould4

15 continue dialysis, isoto"es, and ;entilatory su""ort as directed by te usband

25 res"ect er wises and transition te "atient to "alliati;e care

35 allow te os"ital etics committee to resol;e te issue

)5 continue te current le;el of care only


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7. A 3 *'a +l, !an #( b+u-)t t+ t)' '!'-'n$* ++! +ll+/#n- a )#-) (&'',

!+t+ "')#$l' $a(). 8#( GCS #( 4 an, bl++, &'((u' 7 (*(t+l#$. 8' )a( a

tau!at#$ a!&utat#+n + )#( #-)t a! an, an +b"#+u( #-)t '!u a$tu'.

C)'(t an, &'l"#$ 9:a*( a' n+!al. 8#( FAST ulta(+un, #( &+(#t#"'. T)' n'9t

(t'& #n )#( !ana-'!'nt ;at' #ntubat#+n< ()+ul, b'0

15 go to !& scan to delineate is in@uries

25 resuscitate wit normal saline and "aced red cells in te emergency room

ten go to !& scan

35 go to / for re"air of is orto"edic in@uries

)5 go to / for la"arotomy

1. enal trans"lant "atients a;e an increased incidence of4

15 nonmelanoma sin cancer

25 lobular breast cancer

35 colonic carcinoid

)5 lung cancer

11. #ll of te following are "rinci"les of te management of se;ere frostbite, *H!*P&4

15 ra"id rewarming

25 limb ele;ation

35 early am"utation for fran gangrene

)5 antibiotics

12. ic one of te following findings is most liely to be "resent in a "atient witse;ere magnesium deficiency4

15 res"iratory de"ression

25 bradycardia

35 tetany

)5 loss of "atellar refle'


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13. # C9 year old woman "resents wit abdominal "ain, diarrea, fe;er, and deydration.

$e was os"italied four wees earlier for "neumonia. /n e'amination te

abdomen is diffusely tender wit guarding. &em"erature is 39.1< !, wite blood cellcount 2,000. Plain abdominal '(rays re;eal a distended colon wit gross mucosal

edema. #fter fluid ydration, management sould consist of4

15 oral flagyl

25 oral ;ancomycin

35 oral ;ancomycin and DI flagyl

)5 total colectomy and ileostomy

14. A 26 *'a +l, !an #( #n"+l"', #n a )#-) (&'', !+t+$*$l' $a(). 8' #(

)*&+t'n(#"' ;5 (*(t+l#$< +n a#"al #n t)' '!'-'n$* ++! an, )#( FAST

ulta(+un, #( &+(#t#"'. At la&a+t+!* )' )a( a la-' a!+unt + bl'',#n- +!

b')#n, t)' l#"'. T)#( #( $+nt+ll', /#t) &a$( all+/#n- )'!+,*na!#$(tab#l#=at#+n at' a--'((#"' '(u($#tat#+n. F+ll+/#n- t)#( '(u($#tat#+n )#( &8 #(

6.5 an, )#( $+' t'!&'atu' #( 33> C. T)' n'9t (t'& #n )#( !ana-'!'nt ()+ul,

b'0

15 mobilie li;er to obtain control of te interior ;ena ca;a abo;e and below te

li;er

25 "erform a median sternotomy in order to "lace an DI! sunt

35 gently remo;e "acs to see if te bleeding as sto""ed

)5 carry out tem"orary abdominal closure and transfer te "atient to te D!E


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1. A 16 *'a +l, !an #( b+u-)t t+ t)' '!'-'n$* ++! +ll+/#n- a !+t+ "')#$l'

$a(). T)' &aa!',#$( '&+t t)at )' l+(t )#( "#tal (#-n( 1 !#nut'( &#+ t+

a#"al t+ t)' '!'-'n$* ++! an, t)at CPR /a( #n#t#at',. On a#"al% )' #(

b'#n- ba- !a( "'nt#lat', /#t) b#lat'al a# 'nt*. 8#( &u&#l( a' n+t 'a$t#"'

an, )' #( a&n'#$ /#t) n+ &al&abl' &ul('(. 8#( ECG ()+/( a /#,' $+!&l'9 ?RS

at a at' + 35. T)' !+(t a&&+&#at' !ana-'!'nt /+ul, b'0

15 intubate, resuscitati;e left toracotomy

25 intubate, DI access and massi;e transfusion

35 intubate, DI access, massi;e transfusion and "ericardiocentesis

)5 termination of resuscitation efforts

15. ew onset "ost(o"erati;e atrial fibrillation in non(cardiotoracic surgical "atients4

15 ty"ically resol;es wit correction of te electrolytes and fluid balance

25 is liely to be "ermanent if not cardio;erted to normal sinus rytm witin 2)ours

35 reBuires immediate cardio;ersion to sinus rytm

)5 is best "re;ented wit "erio"erati;e calcium cannel blocers

16. A 4 *'a +l, !an )a( a -a,' I@ l#"' #nu* /#t) !+,'at' )'!+&'#t+n'u!%

!ult#&l' #-)t (#,', #b a$tu'(% an, a &ul!+na* $+ntu(#+n at' a !+t+

"')#$l' $a(). 8' #( #ntubat', an, +b('"', #n t)' ICU. Tan(u(#+n

'u#'!'nt( #n t)' #(t 24 )+u( a' 5 un#t( RBC% 4 un#t( FFP% 5 un#t(&lat'l't(% an, 4 l#t'( + (al#n'.

S'"'nt*:t/+ )+u( at' a,!#((#+n )#( bl++, &'((u' #( 7% &lat'au a#/a*

&'((u' #( 3 !!8-% u#n' +ut&ut 1!l). 8-b 7 !-(,l% $'at#n#n' 3.

C@P 2 !!8-% bla,,' &'((u' 3 !!8-.

T)' n'9t (t'& #n )#( !ana-'!'nt ()+ul, b'0

15 abdominal angiogra"y

25 continuous ;eno;enous emofiltration

35 la"arotomy to "ac abdomen o"en

)5 transfusion of "aced !


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1. # "ysician submits an a""lication to a local institutional re;iew board ?D5 to

conduct a researc study com"aring two surgical "rocedure of te same disease. &e

D re@ects te reBuest on te basis tat te "ro"osed researc study does not a;esufficient eBui"ose. &is means tat4

15 te antici"ated sam"le sie in eac grou" is too small

25 te "ro"osed statistical metods are not a""ro"riate

35 tere is no uncertainty as to wic treatment is o"timal

)5 "otential sub@ects will not be free of undue influence wen consenting to testudy

17. # 39 year old man de;elo"s y"o;olemic soc due to s"lenic ru"ture caused by amotor ;eicle cras. ic of te following treatments will el" treat is

y"o;olemia as e is brougt to te o"erating room4

15 use of te "neumatic anti(soc garment ?A#$& "ants5

25 use of &rendelenburg "osition ?ele;ation of te lower e'tremities abo;e te

le;el of te eart5

35 use of e"ine"rine infusion to raise blood "ressure

)5 ra"id infusion of normal saline


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2. # C0 year old man undergoes radical debridement of a necrotiing soft tissue

infection of te abdominal wall and left flan. Post(o"erati;ely te "atient is

y"otensi;e and oliguric. Pertinent date include:

eart rate120 "er minute

blood "ressure 90JC0

!IP 3 cmJ2/

lactate C meBJl

#t tis "oint management of tis "atient sould include all of te following,

*H!*P&4

1. aggressi;e fluid resuscitation followed by inotro"ic su""ort if reBuired

2. an antibiotic regimen tat includes clindamycin

3. intra;enous immunoglobulin ?DID5

). "enyle"rine

21. A 3 *'a +l, !al' &','(t#an &'('nt( /#t) a &+(t'#+ l't n'' ,#(l+$at#+n

at' b'#n- )#t b* a $a. 8' )a( n+ ,#(tal &ul('( #n )#( l't l'-. T)' !+(t

a&&+&#at' n'9t (t'& #n )#( !ana-'!'nt /+ul, b'0

15 tae te "atient to te o"erating room

25 reduce dislocation in te emergency room

35 obtain an angiogram

)5 start DI e"arin


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22. $eiure and coma de;elo" in a "atient four days after remo;al of a brain tumor. Iital

signs are:

eart rate 112

blood "ressure 110J70

res"iratory rate 1)

tem"erature 37.<!

urine out"ut 3() mlJgJ

6aboratory tests demonstrate:

a 112

K ).1

!l 80

!/3 2C

creatinine

110

urinalysis

normal

urine #170

ic of te following is te most liely diagnosis:

15 diabetes insi"idus

25 syndrome of ina""ro"riate antidiuretic ormone ?$D#+5

35 cerebral salt wasting

)5 ig(out"ut renal failure

23. &e most common organism associated wit o;erwelming "ost(s"lenectomy se"sis

is4

15 aemo"ilus influenae

25 stre"tococcus "neumonia


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35 meningococus

)5 babecia microti

24. A 2 *'a +l, !an (u(ta#n( a -un()+t /+un, u(t ab+"' t)' #-)t $la"#$l'. On

a#"al )#( (*(t+l#$ bl++, &'((u' #( 5 !!8- an, )' #( a-#tat',. )#$) + t)'

+ll+/#n- #( #n,#$at', a( t)' n'9t (t'& t+ )#( !ana-'!'nt0

15 endotracial intubation

25 rigt tube toracostomy

35 normal saline ydration

)5 emergency de"artment toracotomy

2. # )8 year old man sustains bilateral closed femur fracture in a motor ;eicle cras.

e as no oter in@uries. e undergoes bilateral /DF of is fractures. &e mosta""ro"riate "ro"yla'is for +I& in tis "atient would be4

15 low molecular weigt e"arin subcutaneously

25 unfractionated e"arin subcutaneously

35 leg "neumatic com"ression de;ices

)5 DI! filter

25. # C) year old man is sceduled undergo femoral("o"liteal by"ass grafting for

"eri"eral ;ascular disease. e ad one e"isode of congesti;e eart failure two years "re;iously and is now well controlled wit an angiotension(con;erting enyme

?#!*5 inibitor and a diuretic. e gardens and is able to carry on normal acti;itieswitout restrictions. is resting *! is normal. #dditional "re(o"erati;e cardiac

testing sould be include:

15 nuclear medicine cardiac study

25 e'ercise stress testing

35 coronary angiogra"y

)5 no furter testing


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26. #nemia ?gb L 9 gmJdl5 in a "atient wit a traumatic brain in@ury sould be treated

wit red blood cell transfusion:

15 witout e'ce"tion

25 in "atients manifesting "ysiologic indications for transfusion

35 in "atients aged or older

)5 in "atients wit se"sis

2. #fter intubation, te A/$& accurate and e'"editious way to determine weter teendotracial tube is in te tracea is4

15 lung auscultation

25 tube misting

35 end(tidal !/2

)5 cest wall rise

27. # C0 year old man undergoes bowel resection because of infarction caused by

trombosis of is su"erior mesenteric artery. Post(o"erati;ely e does well butreBuires long term ome &P. ic ty"e of central intra;enous line is least liely

to cause se"sis in tis "atient4

15 "oly;inylcloride tri"le lumen cateter in te subcla;ian ;ein

25 single(lumen icman cateter in te subcla;ian ;ein

35 double(lumen PD!! line in te rigt ce"alic ;ein

)5 single(lumen "oly;inylcloride line in te rigt internal @ugular ;ein

3. Dntra(o"erati;e y"otermia ?"atient core tem"erature L3)< !5 is associated wit allof te following, *H!*P&4

15 decreased le;els of fibrinogen

25 decreased "latelet acti;ity

35 increased incidence of surgical site infection

)5 increased blood loss during abdominal surgery


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31. #ll te following are nown com"lications of e"arin administration, *H!*P&4

15 sin necrosis

25 colestatic e"atic in@ury

35 arterial trombosis

)5 osteo"orosis

32. Dn te management of emorragic soc, te best clinical sign of successful fluid

resuscitation is4

15 a increase in blood "ressure

25 an increase in urine out"ut

35 an increase in arterial o'ygenation

)5 a decrease in tacycardia

33. # )C year old woman is about to undergo e"atic resection for metastatic carcinoid

tumor. +uring anaestesia induction, er blood "ressure decreases to 80 mmg

systolic and er eart rate increases to 110. er entire body a""ears flused. ertem"erature is normal as is end(tidal !/2. Aanagement consists of4

15 corticosteroids

25 octreotide

35 abort o"eration

)5 dantrolene

34. #ll te following bacteria are associated wit te "roduction of e'oto'in, *H!*P&4

15 acteroides fragilis

25 !lostridium tetani

35 $ta"ylococcus aureus

)5 $tre"tococcus "yogenes


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3. A 23 *'a +l, /+!an )a( a ('"'' $l+(', )'a, #nu* +ll+/#n- a !+t+ "')#$l'

$a() . S)' )a( n+ #nta$an#al !a(( l'(#+n. 8' GCS #( 4T. Tan($an#al

D+&&l' '(t#!at#+n + )' ICP #( 25 !!8-. 8' PaCO2 #( 3 !!8-% C@P 3 $!

82O% an, CPP &'((u' 5 !!8-. S)' ()+ul, b' t'at', /#t)0

15 y"ertonic saline

25 mannitol

35 y"er;entilation

)5 nore"ine"rine

35. ic of te following statements about transfusion tera"y wit "aced !s is

&E*:

15 o'ygen release in te "eri"ery by baned "aced !s increase in direct

relation to storage time

25 blood transfusion in "atients undergoing resection for colorectal malignanciesis associated wit an increased "erio"erati;e infection rate but as no effect on

year cancer sur;i;al

35 "re(storage leuoreduction of "aced !s eliminates te febrile

nonemolytic transfusion reaction

)5 tere is a dose(res"onse relationsi" between early blood transfusion of

in@ured "atients and subseBuent de;elo"ment of te multi system organ failuresyndrome

36. #ll te following are a""ro"riate indications for traceostomy, *H!*P&4

15 airway security

25 "atient comfort

35 decrease in ;entilator(associated "neumonia rate

)5 decrease wor of breating


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3. Four days after uncom"licated la"arosco"ic a""endectomy, a 38 year old woman tells

er surgeon tat se could ear "eo"le taling during er surgery. $e sould be

informed:

15 to see legal counsel

25 se will be referred for "sycological su""ort and counseling

35 se will need a ead !& scan

)5 it was only a dream

37. # cronic alcoolic "atient may de;elo" delirium tremours following surgery. ic

of te following drugs is E6DK*6 to be el"ful in te management of tis

"roblem4

15 dilantin

25 benodiae"ine

35 ;itamin 1, ?tiamine5

)5 magnesium sulfate

4. # C year old man is now si' days "ost resection of an abdominal aortic aneurysm.

is ;ital signs are normal. e is afebrile. is /2 saturation is 92M. Preo"erati;ely

e wored full time as an accountant and dran one(two glasses of wine "er day.

#t "resent e is not orientated to "lace or time, res"onds in full sentences tat are

nonsensical, and as ;isual allucinations.

ic of te following statements about te "atient is true4

15tis "atient as delirium tremens

25tis condition sould be treated wit lorae"am

35establising normal slee"Jwae cycles will im"ro;e is condition

)5tis "atient as a iger ris of dying com"ared to "atients witout delirium


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41. A 5 *'a +l, /+!an #( b+u-)t t+ t)' '!'-'n$* ++! +ll+/#n- a )#-):(&'',

!+t+ "')#$l' $a(). 8' GCS #( 5 /#t) a ,#lat', #-)t &u&#l. Bl++, &'((u' #(

147. A CT ($an + t)' )'a, '"'al( a #-)t (ub,ual )'!at+!a /#t) !#,l#n'

()#t. A CT ($an + t)' $)'(t% ab,+!'n an, &'l"#( ()+/( a !',#a(t#nal

)'!at+!a /#t) a &+((#bl' #nt#!al la& #n t)' t)+a$#$ a+ta. Mana-'!'nt

()+ul, $+n(#(t +

15simultaneous craniotomy and left toracotomy

25 craniotomy followed by immediate aortic angiogra"y and if "ositi;e for

aortic in@ury, aortic re"air

35craniotomy followed by delayed aortic re"air

)5craniotomy only

42. !ardiac o'ygen deli;ery can be increased by increasing all of te following

*H!*P&4

15emoglobin

25atmos"eric "ressure

35cardiac out"ut

)5ins"ired o'ygen concentration

43. # year old man "resents wit a 12 our istory of e"igastric "ain, nausea, and

;omiting. e as diffuse mild abdominal tenderness on "al"ation. 6aboratory ;alues

are significant for a serum amylase of 800 uJ6, serum glucose of 11.3, ! 12,000,serum sodium 12 mgJ6, and serum triglyceride le;el of 1800 mgJdl. &e most lie

e'"lanation for is y"onatremia is:

15e'cessi;e fluid loss

25"seudoy"onatremia

35ina""ro"riate antidiuretic ormone res"onse

)5adrenal insufficiency


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44. ic of te following agents as been sown clinically to reduce te deleterious

effects of corticosteroids on wound ealing4

15;itamin !

25;itamin #

35inc

)5transforming growt factor N

4. A 23 *'a +l, !an (u(ta#n( a $l+(', #-)t !#,()at t#b#a:#bula a$tu' #n a

!+t+$*$l' $a(). 8' )a( n+ +t)' #nu#'(. 8#( l'- #( ('"''l* &a#nul% '(&'$#all*

/#t) &a((#"' (t't$)#n-. 8' )a( ,'$'a(', (#n ('n(at#+n #n )#( #-)t l+/' l#!b.

D+(al#( &','( an, &+(t'#+ t#b#al &ul('( a' n+n&al&abl' but $an b' +un, /#t)

a D+&&l' ulta(+un, !+n#t+.

&e most a""ro"riate management now would be4

15 angiogra"y

25com"artment "ressure measurement

35s"lint and ele;ate rigt leg and reassess in four ours

)5fasciotomy

45. # C0 year old man undergoes "aratyroidectomy for "rimary y"er"aratyroidism.

Post(o"erati;ely, te "atient de;elo"s "erioral tingling, numbness, and car"o"edel

s"asm. *'"ected *! findings include:

15"rolonged -& inter;al

25"eaed & wa;es

35&orsades de "ointes

)5u wa;es


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46. &e allmar biocemical feature of re(feeding syndrome in se;erely malnourised

"atients tat is associated wit increased mortality is4

15y"oalemia

25y"o"os"atemia

35y"oglycemia

)5y"ocalcemia

4. $igns and sym"toms of to'icity from administration of an amide local anestetic?e.g. lidocaine5 include all of te following, *H!*P&4

15seiures

25"rofound y"otension

35nausea and ;omiting

)5"erioral numbness

47. Ketorolac, a nonsteroidal anti(inflammatory drug, is often used in "ost(o"erati;e

"atients. ic of te following statements concerning Ketorolac is /& correct4

15a 30 mg dose as demonstrated analgesic efficacy rougly eBui;alent to 10 mgsof mor"ine

25Ketorolac in large doses, may de"ress te res"iratory dri;e

35 D and renal com"lications of Ketorolac use are ;ery rare wit sort(term?3days5 "eri(o"erati;e use

)5Ketorolac may im"air blood coagulation


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. Dmmediately following a difficult 3 our o"en total abdominal ysterectomy and

bilateral sal"ingoo"orectomy for o;arian cancer, a 3 year old woman could not

e'tend er left nee. !linical e'amination is consistent wit a femoral ner;e "alsy.

ic of te following statements about tis condition is &E*4

15robotic(assisted la"arosco"ic surgery increases te ris of tis in@ury

25it is associated wit e'ternal com"ression or leg "ositioning

35most "atients are "ermanently disabled

)5and eld retractors can minimie te incidence of tis in@ury

1. A 3 *'a +l, /+!an #( #n"+l"', #n a )#-):(&'', !+t+ "')#$l' $a(). CT ($an +

t)' )'a,% $:(&#n'% t)+a9% ab,+!'n an, &'l"#( ()+/( a T1 (&#n+u( &+$'((

a$tu' an, a (!all l't &n'u!+t)+a9. T)' +ll+/#n- ,a*% ()' )a( a GCS + 1

but #( n+t', t+ )a"' #-)t a! an, #-)t l'- /'an'(( /#t) ,'$'a(', ('n(at#+n.

All + t)' +ll+/#n- a' tu' '-a,#n- t)#( $+n,#t#+n% EXCEPT0

15!& angiogra"y is indicated

25systemic anticoagulation may be of benefit

35if te carotid artery is occluded, urgent surgical inter;ention is indicated

)5te condition is associated wit ornerOs $yndrome

2. ic of te following is an a""ro"riate definition of soc4

15low blood "ressure

25low cardiac out"ut

35low circulating ;olumes

)5inadeBuate tissue "erfusion


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Page 20 of 3)

3. # 70 year old man wit diabetes "resents to te emergency room wit rigt u""er

Buadrant abdominal "ain, y"otension, and leuocytosis. lood tests demonstrate a

"rolonged D of 2., a P&& C0 seconds, a low fibrinogen le;el, and a "latelet count

of 70,000. #bdominal ultrasound sows gallstones and gas in te wall of tegallbladder. is coagulo"aty sould be treated wit4

15administration of fres froen "lasma

25administration of cryo"reci"itate

35emergency colecystectomy

)5administration of "latelets

4. #ll of te following are nown "redictors of an increased ris of "erio"erati;e cardiac

com"lication, *H!*P&4

15istory of coronary artery disease

25istory of smoing

35istory of stroe

)5serum creatinine greater tan 200

. #fter com"leting a full day of electi;e surgery, te surgeon and te entire o"erating

room staff com"lete a Buestionnaire regarding eac team memberOs "erce"tion of te

teamwor during te day. &e "oorest ratings concerning team wor come from4

15oter surgical colleagues

25o"erating room nurses

35scrub tecnologists

)5anestetists


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Page 21 of 3)

5. # C2 year old oterwise ealty woman suffers an iatrogenic in@ury to te iliac ;ein

during an electi;e lumbar s"inal fusion. +uring te si' our o"eration, se recei;es

eigt units of "aced red blood cells, si' units of fres froen "lasma, 2 units of "latelets, recombinant factor IDDa, and 10 liters of saline. &wo ours "ost o"erati;ely,

se is difficult to o'ygenate. it an FD/2 of 0.8 ?re(breating mas5, er blood

gasses are:

" 7.31

"!/2

"/2 8

!est '(ray sows bilateral "ulmonary edema. Iitals are 10, P 130J70, urine

out"ut 120 ccJ, !IP ) cm2/. &e most liely diagnosis is4

15congesti;e eart failure

25acute res"iratory distress syndrome ?#+$5

35atelectasis

)5transfusion(related acute lung in@ury ?&#6D5

6. Pressure sores are *$& "re;ented by4

15routine use of air(flow mattresses

25freBuent re("ositioning

35aggressi;e nutritional su""ort

)5drying "owders to moist sin surfaces


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Page 22 of 3)

. # year old man is found to a;e an osteogenic sarcoma in is left distal femur. #t

te &umor oard, te decision is made to treat im first wit e'ternal beam radiation,

ten radical surgical e'cision, followed by ad@u;ant cemotera"y.

&e orto"edic surgeon is worried about wound ealing. $e sould4

15administer su""lemental enteral nutrition for one wee "rior and two wees

"ost surgery

25administer large doses of ;itamin ! as soon as te radiation tera"y iscom"leted and for si' wees after te surgery

35administer angiogenesis(stimulating factor daily for tree wees after tesurgery

)5a;oid resection margins in radiated tissue as muc as "ossible

7. # ) year old woman wit cirrosis of te li;er secondary to e"atitis ! infectionreBuires a ysterectomy for bleeding fibroids. &e single best "redictor of

"erio"erati;e mortality is4

15!& a""earance of te li;er

25!ilds(Pug classification

35A*6+ score

)5e"atitis ! ;iral load

5. Dn "atients undergoing coronary artery by"ass grafting, all of te following a;e beenidentified as being associated wit an increased o"erati;e ris *H!*P&4

15 ad;anced age

25low e@ection fracture

35male se'

)5diabetes


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Page 23 of 3)

51. #ll of te following are true regarding Pla;i' ?clo"idogrel5, *H!*P&4

15it inibits te binding of adenosine di"os"ate to its "latelet rece"tor

25te ris of bleeding is increased if it is used wit as"irin

35wen discontinued, bleeding time normalies in a""ro'imately 2(3 days

)5it inibits "latelet aggregation witin 2 ours of oral administration

52. A 3 *'a +l, /+!an #( #n"+l"', #n a )#-):(&'', !+t+ "')#$l' $a() an,

(u(ta#n( a '!u a$tu'. P'"'nt#+n + at '!b+lu( #( b'(t a$$+!&l#()', b*0

15subcutaneous e"arin

25DI de'tran

35sort course of DI steroids

)5early o"erati;e reduction and internal fi'ation

53. ic of te following statements concerning te anticoagulant drug argatroban is

correct4

15acti;ates antitrombin

25is re;ersed wit fres froen "lasma

35can be monitored by te acti;ated "artial trombo"lastin time

)5as a 3 our alf(life

54. # C0 year old woman undergoes resection of a retro"eritoneal sarcoma. /n "ost(o"erati;e day er "latelet count decreases to 8,000 ?er baseline is 32,0005. $e

as been recei;ing unfractionated e"arin for I&* "ro"yla'is. $e as no clinical

e;idence of bleeding. #ll of te following are indicated, *H!*P&4

15oral warfarin

25direct trombin inibitor

35discontinuing all e"arin tera"y

)5testing for e"arin(induced trombocyto"enia ?D&5 antibodies


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Page 2) of 3)

5. eliable reduction in te incidence of "ost(o"erati;e com"lications after ma@or

surgery in malnourised "atients can be acie;ed wit4

15"re(o"erati;e enteral nutrition

25"re(o"erati;e "arenteral nutrition

35bot

)5neiter

55. A 6 *'a +l, !an (u(ta#n( &at#al:t)#$n'(( bun( t+ t)' a$' a( /'ll a( ('$+n,

an, t)#, ,'-'' bun( t+ t)' u&&' '9t'!#t#'( #n a )+u(' #'. E9a!#nat#+n

'"'al( '"#,'n$' + $ab+na$'+u( (&utu!. 8' #( a/a' an, al't% /#t)+ut (#-n(

+ '(&#at+* ,#(t'((. T)' )#-)'(t &#+#t* + )#( !ana-'!'nt ()+ul, b'0

15establis a definiti;e airway

25arrange for transfer to a burn unit

35initiate intra;enous resuscitation

)5assess for unrecognied traumatic in@ury

56. # C year old man undergoes a radical "rostatectomy for cancer. Post(o"erati;ely e

is gi;en a regular diet and an DI of normal saline at 0 ccJr. /n "ost(o"erati;e day

tree, is urine out"ut in te "re;ious 2) ours was 1200 ccs and is electrolytes are:

a 131

K 3.

!l 107

!/2 2C

!reatinine 108

is y"onatremia sould be treated wit4

15increase DI J$ to 100 ccJ

25restrict oral fluid intae to 800 cc "er day

35administer 3M a!l at 30 ccJ and sto" J$

)5continue "resent tera"y and re"eat electrolytes in two days


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Page 2 of 3)

5. # 0 year old man undergoes a left inguinal ernia re"air wit "lacement of a mes

"lug. e ad a renal trans"lant fi;e years ago and is recei;ing "rednisone and

tacrolimus for immunosu""ression. is nasal swab "re(o"erati;ely is "ositi;e formeticillin resistant sta"ylococcus aureus ?A$#5.

ic of te following statements about tis "atient is true4

15is wound classification is clean

25e sould recei;e oral antibiotics for )8 ours "ost(o"erati;ely

35mes is contraindicated in tis "atient

)5is wound sould be irrigated wit ;ancomycin

57. ic of te following is true regarding carbon mono'ide ?!/5 "oisoning4

15!/ sifts te o'ygen(emoglobin disassociation cur;e to te rigt

25!/ irretrie;ably binds to te eme(molecules of emoglobin

35 "ulse o'imetry is an accurate measurement of o'ygen saturation after !/

"oisoning

)5 !/ as 200 times more affinity for emoglobin tan o'ygen

6. # 10 year old boy wit a istory of emo"ilia "resents to te emergency room

com"laining of abdominal "ain, nausea and ;omiting. !& scan demonstrates mucosal

fold ticening and a large duodenal ematoma. +efiniti;e management is best

acie;ed by:

15la"arotomy

25factor IDD re"lacement

35++#IP ?desmo"ressin5 infusion

)5recombinant factor IDDa infusion

61. ic of te following is te least liely com"lication of "ost("yloric enteral

feeding4

15as"iration

25diarrea

35electrolyte abnormality

)5mucosal ;illous atro"y


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Page 2C of 3)

62. #ll of te following are true regarding ele;ated serum omocystine le;els, *H!*P&4

15it is associated wit an increased ris of ;enous trombosis

25it is associated wit an increase ris of coronary and cerebral ;ascular e;ents

35ele;ated le;els can be lowered by folic acid and ;itamin 12 su""lementation

)5medically lowering le;els reduces te ris of stroe and cardio;ascular deat

63. &e most common *! finding after a "ulmonary embolus is4

15rigt bundle branc bloc

25non(s"ecific $& and & wa;e canges

35$1, -3, &3 "attern

)5sinus tacycardia

64. Post(o"erati;e nutritional management after a gastrectomy for a &10A0 gastric

cancer sould include4

15allowing ad libitum food intae on day one

25allowing no oral intae until flatus is "assed

35starting total "arenteral nutrition ?&P5 on day one

)5starting enteral feeds ;ia a nasal(@e@unal feeding tube on day one


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Page 27 of 3)

7(775 Esing te following table, wic best describes te action of4

75 Dnsulin

7C5 !orticosteroids

775 6ong(term fasting


February 2012

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Page 28 of 3)

785ic of te following statements about te treatment of necrotiing fasciitis is

&E*4

15te underlying tissue necrosis is reflected by te e'tent of sin necrosis

25 intra;enous immune globulin ?DID5 is te first line of tera"y

35y"erbaric o'ygen as been sown to im"ro;e sur;i;al

)5 e'"loratory incisions o;er normal a""earing sin are effecti;e in

determining te e'tent of te necrosis

79.# 17 year old woman is struc by a truc wile crossing a road. Dn te emergency

room se was intubated because of a decreased le;el of consciousness. !est '(

ray is normal. F#$& ultrasound is "ositi;e. $e as o"en bilateral tibial fibula

fractures. Following ) l of saline resuscitation, er blood wor is:

gb 82

Platelets 1)0,000

!reatinine 8)

D 1.)

" 7.19

"!/2 )

"/2 200 ?FD/2 1.05

!/3 (12

er acid(base disorder sould be treated wit4

15 2 am"s a bicarb DI

25 y"er;entilate "atient to bring down "!/2

35 administer 2 units uncrossed blood $&#&

)5 immediate la"arotomy


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Page 29 of 3)

80.# 0 year old woman wit goiter de;elo"s mental status canges, nausea and

;omiting sortly after undergoing electi;e orto"edic surgery. /n e'amination,

se is e'tremely an'ious, tacycardiac and febrile to 39. !.

Ergent treatment of er condition sould include all of te following, *H!*P&4

15 beta blocage

25anti"yretics

35DI dantrolene

)5fluid resuscitation

81.ic of te following statements is true regarding fluid resuscitation in burn

;ictims4

15normal saline sould be a;oided

25y"ertonic saline sould be used in se;ere burns to reduce edema

35albumin use is associated wit an increased mortality rate

)5abdominal com"artment syndrome from o;er(resuscitation does not occur

82.# com"lication of te use of etastarc colloid solutions DI, wic limits its use insurgical "atients, is te increased ris of4

15 bleeding

25y"ocloremic alalosis

35li;er failure

)5im"aired "ulmonary function


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Page 30 of 3)

83. # "edestrian is "inned against a wall by an automobile and suffers a significant

crus in@ury to er lower legs. &wo day later er urine is noted to be dar brown

in colour. er urine out"ut is 10(20 ccsJ. er serum creatinine inase is 38,000.&reatment of tis condition sould include all of te following *H!*P&4

15management of bilateral lower leg com"artment syndrome

25aggressi;e DI fluid ydration

35M de'trose in water wit 3 am"oules of sodium bicarbonateJ6 infusion

)5cystosco"y and 2) ours urine for creatinine clearance

8). ear te com"letion of a total tyroidectomy, as te tyroid gland is being

cauteried off te anterior surface of te tracea, flame and smoe eru"ts from teo"erati;e field.

&e ne't ste" sould be4

15 "our saline in te fire

25s"ray te field wit a fire e'tinguiser

35e'tubate te "atient

)5remo;e all flammable dra"es

8.ic of te following statements about coagulo"aty in in@ured "atients is &E*4

15 abnormal coagulation ;alues are uncommon immediately after in@ury

25 factor IDDD is ele;ated after in@ury and falsely sortens te D and P&

35 an D ;alue L1. "redicts normal emostatic concentrations of all

coagulation factors and fibrinogen

)5an ele;ated aP&& is a more reliable indicator tat P& of nonemostatic

le;els of coagulation factors

8C.!om"ared wit wet to dry dressing canges, negati;e "ressure wound tera"y is

associated wit all of te following *H!*P&4

15increased local blood flow

25decreased tissue edema

35decreased bacterial count

)5increased rate of wound ealing


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Page 31 of 3)

87.# C) year old man is about to undergo a i""le Procedure for carcinoma of te

duodenum. Following te induction of anaestesia, te surgeon is unable to "ass

a 1C Frenc Foley cateter into te bladder. Following er attem"t, tere is no blood at te meatus. &e most a""ro"riate ne't ste" would be4

15continue te case witout a Foley cateter

25 "lace a su"ra"ubic cateter

35 "lace a small caliber Foley cateter ?12 Frenc5

)5 "lace a large coudQ ti" cateter ?18 or 20 Frenc5

88.# )0 year old man sustains a gunsot wound to te ead and is "ronounced dead

sortly after arri;al in te emergency room. &irty minutes later is moter callsto enBuire about er son. $e li;es 300 miles away and wants to now if se

sould come to te os"ital.

&e best course of action would be4

15gently relate tat e is dead

25contact te local "olice and a;e tem tell er

35e'"lain tat e;eryting is being done and as er to come to te os"ital

)5call te ca"lain to deli;er te bad news

89.adiation tera"y wit eiter ig energy "otons or "articles ?e.g. electrons5

damages biological tissues by:

15destroying inter(atomic bonds in biologic molecules

25causing electrons to be e@ected from atoms to interact wit water to "roducedamaging free radicals

35e'citing nuclei to release gamma radiation resulting in moleculardisintegration

)5causing e'citation of molecular energy le;els resulting in damage to

biological macromolecules


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Page 32 of 3)

90.#ll of te following burn in@uries reBuire a referral to a burn center, *H!*P&4

15a 1M total body surface area ?&$#5 second(degree burn to te cest in a

30 year old man

25a M &$# second degree burn of te face in a )0 year old man

35a 3M &$# second degree burn to te and in a 2 year old woman

)5a )M &$# full(ticness burn of te nee in a 30 year old woman

91.&e most im"ortant "re(o"erati;e test to assess te ris of abnormal intra(o"erati;e bleeding is4

15 bleeding time

25acti;ated "artial trombo"lastin time ?aP&&5

35international normalied ration ?D5

)5istory and "ysical e'amination

92.#fter an electi;e &EP for P, a C9 year old man de;elo"s "al"itations. e as

a istory of congesti;e eart failure. e is awae and con;ersing wit is nurse.is blood "ressure is 130J7. is *! sows ;entricular tacycardia, at a rate of

120 beats "er minute. &e best initial treatment of tis arrytmia would be4

15 amiodarone 10 mgs DI o;er 10 minutes

25 immediate defibrillation wit 3C0

35 bretylium mgsJg DI

)5 diltiaem 1 mgs DI o;er 2 minutes

73.A *'a +l, !an #( b+u-)t t+ t)' '!'-'n$* ++! /#t) a (tab /+un, t+ t)'

l't $)'(t u(t b'l+/ t)' n#&&l'. @#tal( a' 8'at at' 12% Bl++, P'((u'

15% R'(&#at+* Rat' 14. FAST ulta(+un, #( &+(#t#"' + &'#$a,#al

lu#,. T)' n'9t (t'& #n )#( !ana-'!'nt ()+ul, b'0

15endotracial intubation

25left tube toracostomy

35DI fluids

)5median sternotomy


February 2012

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Page 33 of 3)

9).ic of te following infection control strategies as been sown to reduce

meticillin resistant sta"ylococcus aureus ?A$#5 infection in surgical "atients4

15uni;ersal admission screening wit standard cultures

25routine nasal decoloniation

35routine "re(o"erati;e clore'idine sowers

)5routine and wasing

9.#ll of te following contribute to wrong site surgery, *H!*P&4

15administering sedation immediately before induction

25incorrect "ositioning

35anaestetic ner;e blocs "erformed before time(out "rocedure

)5not ;erifying consents

9C.Pysiologic canges secondary to "regnancy include all of te following

*H!*P&4

15increased "lasma ;olume

25increased cardiac out"ut

35decreased Pa!/2

)5decreased fibrinogen le;el

97.# surgeon is engaged by a de;ise manufacturer to e;aluate a new de;ise for a

"articular o"eration. &e de;ise is F+# a""ro;ed. &e surgeon will recei;e

monetary com"ensation from te manufacturer for collection and re"orting of te

data.

&e surgeons bea;ior will be unetical if4

15te relationsi" is disclosed to te os"ital administration against te reBuest

of te manufacturer

25ad;erse e;ents are re"orted only to te manufacturer

35te relationsi" is not disclosed to oter manufacturers

)5te financial relationsi" wit te manufacturer is disclosed to te "atient


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Page 3) of 3)

98.# targeted cancer tera"y is any drug tat s"ecifically acts on a well(defined target

or biological "atway. ic of te following drugs is /& targeted tera"y for

cancer:

15erce"tin

25!is"latin

35#;astin

)5lee;ec

99.#n 80 year old woman undergoes left emicolectomy for a &31A0 $tage DDD

adenocarcinoma of te colon. &ree wees "ost surgery se is li;ing

inde"endently at ome.

ic of te following statements about ad@u;ant cemotera"y in elderly

"atients is &E*4

15systemic cemotera"y is associated wit increased mortality related toto'icity

25 ad@u;ant tera"y is associated wit reduced mortality

35 ad@u;ant tera"y is rarely tolerated

)5 ad@u;ant tera"y is associated wit im"ro;ed sur;i;al but decreasedBuality of life

100.#ll of te following neo"lasms a;e been associated wit #D+$, *H!*P&4

15non(odginOs lym"oma

25Ka"osiOs sarcoma

35gastrointestinal stromal tumor ?D$&5

)5!$ lym"oma

2012 Pos Exam

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