core surgical principals

Question 1

A 47-year-old woman is evaluated because of an asymptomatic left lower eyelid lesion that has been present for 8 months. She underwent incision and curettage of the lesion 5 months ago, but she developed a recurrence soon after. Which of the following is the most appropriate next step in management?
A) Biopsy of the lesion
B) Corticosteroid injection in conjunction with repeat incision and curettage
C) Mohs micrographic surgery
D) Scrub with baby shampoo and warm compresses
E) Observation

Answer 1

A. biopsy of the lesion

sebaceous carcinoma

can do Mohs after dx made

Question 2

A 70-year-old woman is evaluated in the office for delayed breast reconstruction. The modified 5-Item Frailty Index is used to estimate her perioperative risk. A history of which of the following is considered in the calculation of this index?
A) Cerebrovascular accident
B) Congestive heart failure
C) Coronary artery disease
D) Peripheral vascular disease
E) Pulmonary hypertension

Answer 2

B. CHF

• Functional status before surgery
• Diabetes mellitus
• Chronic obstructive pulmonary disease * Congestive heart failure
• Hypertension requiring medication

Question 3

A plastic surgery residency program director is developing criteria for allowing postgraduate year 1 and 2 residents to perform laceration repairs in the emergency department without direct supervision by a more senior resident. In addition to at least 2 months on a plastic surgery rotation and 10 repairs observed and coached directly by a senior practitioner, the program director decides that the resident must submit a video of the resident repairing a standard laceration on a facial laceration model, which will be graded against a published rubric. In this scenario, which of the following is the purpose of the simulation of a facial laceration repair?
A) Certification to practice
B) Deliberate practice
C) Technique training
D) Verification of proficiency

Answer 3

D. verification of proficiency

Question 4

A 55-year-old woman with lipodystrophy after massive weight loss is scheduled to undergo mastopexy and brachioplasty. She underwent Roux-en-Y gastric bypass 10 years ago. Preoperative complete blood count demonstrates macrocytic anemia. This condition is most likely associated with deficiency of which of the following?
A) Iron
B ) Vitamin A
C) Vitamin B12 (cobalamin)
D ) Vitamin C
E) Vitamin D
F) Vitamin E

Answer 4

B. vitamin B12

Question 5

A 68-year-old man who underwent thoracic fusion is evaluated because of exposed spinal hardware. Physical examination shows a loss of soft tissue and an exposed hardware cage at the T2 level. There is no sign of infection. Coverage with a paraspinous muscle flap is planned. Which of the following is the Mathes and Nahai classification for this flap?
A) I B) II C) III D) IV E) V

Answer 5

D. IV

The paraspinal muscles are classified as Type IV flaps with multiple segmental pedicles. The dominant pedicle of the paraspinous muscle flap consists of segmental perforating vessels arising from the posterior intercostal vessels. The minor pedicle includes lateral row perforators arising from the posterior intercostal arteries.

Question 6

Which of the following healthcare reform laws guarantees the transferability of a patient’s health insurance coverage from one employer to another?
A) 21st Century Cures Act
B) Health Information Technology for Economic and Clinical Health Act
C) Health Insurance Portability and Accountability Act
D) Patient Safety and Quality Improvement Act
E) Women’s Health and Cancer Rights Act

Answer 6

C) Health Insurance Portability and Accountability Act

Question 7

Which of the following methods of achieving osteosynthesis is most likely to result in relative stability?
A) Compression plate
B) Intramedullary nail
C) Lag screws
D) Tension band

Answer 7

B. intramedually nail

Forms of this osteosynthesis include lag screws, compression plates, and tension banding

Types of relative stability include intramedullary nailing, bridge plating, external fixation, and splinting/casting.

Question 8

A 38-year-old man is brought to the emergency department after a snowboarding accident that resulted in his being trapped under snow for 5 hours. He has no medical comorbidities and does not smoke cigarettes. Physical examination shows edema, erythema, and blistering of the left foot extending proximally to the distal third of the lower leg. X-ray study shows no fracture. Which of the following actions is CONTRAINDICATED given the patient’s injury?
A) Administration of aspirin 75 mg orally
B) Administration of ibuprofen 400 mg orally twice daily
C) Infusion of warm intravenous fluids
D) Rubbing of the affected limb
E) Technetium-99 triple-phase bone scanning

Answer 8

D. rubbing of the affected limb

Question 9

A 3-year-old boy is brought to the clinic for evaluation of severe unilateral ptosis of the upper eyelid that has been present since birth. The boy’s parents are very concerned, and he has been referred for surgical correction. The surgeon recommends a frontalis sling procedure. The sling portion of this procedure is most likely to use which of the following materials?
A) Chromic gut
B) Poliglecaprone
C) Polydioxanone
D) Polyglactin
E) Silicone elastomer

Answer 9

E. silicone elastomer

options:many synthetic materials such as silicone, polytetrafluoroethylene, autologous tissue such as fascia lata and palmaris tendon, and nonabsorbable sutures.

Question 10

A 63-year-old woman undergoes sternal reconstruction. On postoperative day 1, she goes into cardiac arrest, advanced cardiac life support protocols are initiated, and pulse resumes. Four days later, the patient remains ventilator-dependent, unresponsive, and in a comatose state. Which of the following physical examination findings provides the strongest support of brain death/death by neurologic criteria in this patient?
A) Absent pupillary response to light
B) Loss of bicep reflexes
C) Positive Babinski reflex
D) Positive Hoffman sign
E) Urinary incontinence

Answer 10

A. absent pupillary response to light

Question 11

A 31-year-old woman is evaluated for augmentation mammaplasty and mastopexy. She sees a local primary care physician who specializes in medical weight loss. In addition to diet modifications and a rigorous exercise regimen, she was also prescribed phentermine. Which of the following is the most common perioperative complication associated with administration of this drug?
A) Cardiac dysrhythmia
B) Hypotension
C) Metabolic acidosis
D) Metabolic alkalosis
E) Seizures

Answer 11

B hypotension

question removed
Phentermine is a centrally acting sympathomimetic that is structurally related to amphetamines. It stimulates the hypothalamus to release norepinephrine, causing appetite suppression.Perioperatively, phentermine is associated with refractory hypotension on the induction of general anesthesia, hypothetically stemming from catecholamine depletion and subsequent autonomic dysfunction. In this situation, hypotension may not respond to vasopressors that stimulate catecholamine release (eg, ephedrine), and direct sympathetic agonists (eg, phenylephrine) may be needed.

Question 12

A 21-year-old man is brought to the emergency department after being assaulted with a baseball bat. Physical examination shows bilateral periorbital ecchymosis and extensive facial edema, with fluid draining from the nostrils bilaterally. Filter test of the fluid demonstrates a halo sign. CT scan of the head and neck shows a moderately displaced naso-orbital-ethmoid (NOE) fracture. Which of the following is the most appropriate next step in management?
A) Bed rest and head-of-bed elevation
B) Endoscopic repair
C) Initiation of prophylactic intravenous vancomycin
D) Placement of a lumbar drain
E) Urgent operative reduction of the NOE fracture

Answer 12

A. bed rest and HOB elevation

majority of CSF leaks stop spontaneously in 10 days

Question 13

An increase in which of the following is the strongest contributor to impaired cutaneous wound healing in older adults?
A) Cellular turnover
B) Collagen production
C) Cutaneous blood flow
D) Matrix metalloproteinase
E) Nutrient exchange between skin layers

Answer 13

D. matrix metalloproteinase

Question 14

A 31-year-old nulliparous woman undergoes bilateral reduction mammaplasty with a vertical-pattern technique for symptomatic macromastia. Which of the following pathologic findings is most likely to prompt referral to an oncologic surgeon for breast cancer risk stratification?
A) Apocrine metaplasia
B) Atypical ductal hyperplasia
C) Fibrocystic breast changes
D) Flat epithelial atypia
E) Sclerosing adenosis

Answer 14

B. ADH

Question 15

A 15-year-old boy is brought to the office by his mother because of new pink-red stretch marks that she noticed on his lower back when she saw him in swim trunks at the pool. The patient is 5 ft 7 in (167 cm) tall, and BMI is 21 kg/m2. Physical examination shows a Fitzpatrick Type III complexion with typical tan lines. Over the lumbar area, he has a handful of medium pink-red parallel striae. Which of the following underlying processes is the most likely cause of the striae?
A) Addison disease
B) Cushing disease
C) Exogenous steroid use
D) Rapid growth
E) Weight loss

Answer 15

D. rapid growth

Question 16

A 25-year-old woman presents to a plastic surgeon to discuss breast reconstruction. She is a carrier of the BRCA1 mutation and has decided to undergo risk-reducing mastectomies. Which of the following is the approximate average risk for this patient developing breast cancer by the age of 70 years if she does not undergo bilateral mastectomies?
A) 20% B) 40% C) 60% D) 90%

Answer 16

C. 60%

the risk for developing breast cancer by age 70 years is 57% in BRCA1 mutation carriers and approximately 49% in BRCA2 mutation carriers

Question 17

A 40-year-old woman who underwent surgery of the chest is evaluated because she is dissatisfied with the raised, thick, widened scars. She is offered intralesional 5-fluorouracil injection as a treatment. Which of the following best describes the mechanism of action of 5-fluorouracil?
A) Coagulation in microthermal zones and preservation of the integrity of the epidermis
B) Decrease in fibroblast proliferation and decrease in collagen synthesis
C) Decrease in leukocyte and monocyte migration and phagocytosis
D) Localized hypoxia and increase in collagenase activity
E) Protein denaturation and tissue coagulation

Answer 17

B) Decrease in fibroblast proliferation and decrease in collagen synthesis

Intralesional steroid injections decrease leukocyte and monocyte migration and phagocytosis, and laser therapy acts by protein denaturation and tissue coagulation, as well as by coagulation in microthermal zones and preserving the integrity of the epidermis. Localized hypoxia and increased collagenase activity is associated with pressure therapy

Question 18

A 37-year-old woman undergoes left breast reconstruction with a deep inferior epigastric artery perforator flap. During dissection of the internal mammary vessels, a small tear is inadvertently made in the left parietal pleura. The decision is made to repair the tear primarily, using a single figure-of-eight suture. Which of the following ventilatory maneuvers is most appropriate immediately prior to cinching the stitch for pleural closure?
A) Decreasing positive end-expiratory pressure
B) Disconnecting the endotracheal tube
C) Pausing at end-expiration
D) Sustaining maximal inspiration
E) Switching to volume-controlled ventilation mode

Answer 18

D. sustaining maximal inspiration

modified valsalva
The maneuver is probably most commonly performed manually by the anesthesiologist (using the ventilator’s built-in bag valve mask), but it can also be done by holding ventilation at the end of an inspiratory cycle or by significantly increasing the positive-end-expiratory pressure (PEEP).

Question 19

A 33-year-old woman presents with a drug-resistant gram-positive bacterial infection of an implant after undergoing implant-based breast reconstruction. Which of the following mechanisms is most likely responsible for this bacterial drug resistance?
A) Increased carotenoid content in cell membrane
B) Increased esterification of cell membrane lipoteichoic acid
C) Inhibition of protease expression
D) Reduction of biofilm
E) Suppression of binding ligands against host defense peptides

Answer 19

B) Increased esterification of cell membrane lipoteichoic acid

Common resistance mechanisms used by bacteria against host defense peptides include: 1) decreased carotenoid content in cell membranes (not increased)
2) increased protease expression (not inhibition)
3) biofilm production (not reduction)
4) increased expression of binding ligands to host defense peptides (not suppression)

Question 20

A 24-year-old woman presents to the clinic for follow-up 2 days after undergoing bilateral subpectoral augmentation mammaplasty using 450-cc silicone-filled breast implants. The patient formerly wore an A-cup brassiere and now wears a D cup. On examination, the patient reports feeling tightness of the chest and shortness of breath since the procedure. Which of the following is the most appropriate next step?
A) Chest tube placement in the fourth intercostal space in the mid-axillary line
B) Chest x-ray study
C) Needle aspiration at the second intercostal space
D) Re-evaluation in 3 days
E) Routine 2-week follow-up examination

Answer 20

B. chest xray

Question 21

Data collection is complete in a study examining Patient-Reported Outcomes Measurement Information System Upper Extremity (PROMIS UE) scores following intramedullary screw placement in the treatment of an isolated proximal phalanx fracture. Which of the following is the most appropriate statistical test to compare the mean PROMIS UE scores at 2 weeks with those at 12 weeks?
A) Independent samples t-test
B) One-sample t-test
C) One-way analysis of variance
D) Paired samples t-test

Answer 21

B. paired sample t-test

An independent samples t-test is a comparison of the mean for two different data sets that are independent from each other. For example, an independent samples t-test might be used to compare PROMIS UE scores at the end of healing between male and female patients, where male versus female is the independent variable.
A paired samples t-test is a comparison of two measurements on the same subject at two different time points. The paired sample t-test is appropriate in this scenario because researchers are looking for differences in PROMIS UE scores at two discrete times after surgery.
A one-sample t-test is used when a mean is compared with a specified constant, such as comparing PROMIS UE scores at one time point with the expected PROMIS UE score in the general adult population.
One-way analysis of variance is used to compare the means in more than two groups.

Question 22

In the design of a proper randomized clinical trial, concerns about a selection bias confounder are best addressed at which of the following stages?
A) Data analysis
B) Data collection
C) Data publication
D) Initial literature search
E) Study design

Answer 22

E. study design

Question 23

A 28-year-old woman presents with a 4-cm mass of the left breast. Examination of a specimen obtained on biopsy discloses a benign phyllodes tumor. Which of the following is the most appropriate treatment for this lesion?
A) Intensity-modulated radiation therapy
B) Mastectomy with sentinel lymph node biopsy
C) Neoadjuvant chemotherapy
D) Wide local excision
E) Observation

Answer 23

D. wide local excision

Question 24

A pregnant woman in the second trimester undergoes ultrasonography for anatomic screening. The screening discloses that the fetus has an omphalocele without liver involvement. Which of the following chromosomal findings is most likely in this fetus?
A) 5p monosomy
B) 22q11 microdeletion
C) Trisomy 13
D) 47,XXY

Answer 24

C. trisomy 13

22q11 microdeletion has many syndromic names, including velocardiofacial syndrome or DiGeorge syndrome, and is related to cleft palate.
47,XXY is Klinefelter syndrome and is not associated with omphalocele. Plastic surgeons may see these patients in adolescence with reports of gynecomastia.
5p monosomy is cri du chat syndrome and is also not associated with omphalocele. Plastic surgeons may be asked to evaluate facial differences, including small jaw and hypertelorism.

Question 25

A 2-year-old boy is brought to the emergency department because of a scald burn sustained after he pulled a pot of boiling water off the counter. Examination demonstrates deep partial thickness burns over the anterior and posterior trunk, equaling 22% total body surface area. Oxandrolone is administered on admission and continued in the weeks following resuscitation and reconstruction. Administration of this drug is most likely to result in which of the following?
A) Decreased bone mineral content
B) Decreased mortality
C) Increased cardiac output
D) Increased serum concentrations of alanine aminotransferase (ALT) and aspartate aminotransferase (AST)
E) Loss of lean body mass

Answer 25

D) Increased serum concentrations of alanine aminotransferase (ALT) and aspartate aminotransferase (AST)

Oxandrolone is a synthetic testosterone derivative that is administered orally. During the catabolic phase, it counteracts the hypermetabolic response, leading to improved clinical outcomes including an increase in lean body mass and bone mineral content, as well as decreased length of stay in the inpatient setting. It does not have an impact on mortality. In the short-term, oxandrolone has been known to cause an increase in the liver enzymes alanine aminotransferase and aspartate aminotransferase, but it is not associated with long-term hepatotoxicity. The favorable effects of increased muscle mass extend to the myocardium, and patients treated may display decreased cardiac output and resting heart rate.

Question 26

A 56-year-old woman is evaluated after falling from a ladder onto her outstretched and extended right wrist. Three-view wrist x-ray study demonstrates a displaced, extra-articular fracture of the right distal radius with approximately 20 degrees of apex volar angulation. After reduction, repeat x-ray studies re-demonstrate the fracture, and the bony relationships are near anatomic. Which of the following treatment modalities is most appropriate for this patient?
A) Closed reduction and percutaneous pinning
B) Long-arm cast for 4 weeks followed by short-arm cast for 2 weeks
C) Open reduction and internal fixation with volar locking plate
D) Short-arm cast for 6 weeks
E) Sugar-tong splint for 4 weeks

Answer 26

D. short arm cast for 6 weeks

question removed

Question 27

Which of the following laboratory values is most likely to be abnormal in a patient who takes daily aspirin?
A) Activated partial thromboplastin time
B) Bleeding time
C) D-dimer concentration
D) Platelet count
E) Prothrombin time/International Normalized Ratio

Answer 27

B. bleeding time

Question 28

A 72-year-old man undergoes wide local excision of a T2 N0 squamous cell carcinoma in the left lateral border of the tongue, along with left cervical lymphadenectomy including sublevels IB and IIA and levels III and IV. The left internal jugular vein, sternocleidomastoid muscle, and spinal accessory nerve are preserved. Which of the following is the most appropriate classification of this neck dissection?
A) Extended
B) Modified radical
C ) Radical
D) Selective

Answer 28

D. selective
selective neck dissection refers to a cervical lymphadenectomy that preserves at least one of the lymph node levels that are routinely removed in a radical neck dissection (I through V)radical = removal of cervical lymph nodes from levels I through V, along with the ipsilateral internal jugular vein, sternocleidomastoid muscle, and spinal accessory nerve.
Modified radical neck dissection refers to the removal of all cervical lymph nodes routinely included in a radical neck dissection (levels I through V), while preserving at least one of the nonlymphatic structures (internal jugular vein, sternocleidomastoid muscle, or spinal accessory nerve).

Question 29

A 30-year-old woman undergoes tumescent liposuction with fat transfer to the buttocks (Brazilian butt lift). History includes anxiety, for which she takes sertraline. Twelve hours after the patient is discharged from the recovery room, she presents to the emergency department with nausea, vomiting, and anxiety. Which of the following is the most appropriate next step in management?
A) Administer benzodiazepine
B) Administer supplemental oxygen, and measure plasma lidocaine concentration
C) Obtain blood cultures and complete blood count, and administer broad-spectrum antibiotics D) Order electrocardiography
E) Order ultrasonography of the lower extremities

Answer 29

B) Administer supplemental oxygen, and measure plasma lidocaine concentration

GI effects (commonly nausea and vomiting), central nervous system effects (such as anxiety, confusion, or light-headedness), and more severe and life-threatening effects (such as respiratory depression, seizures, and cardiovascular collapse). Selective serotonin reuptake inhibitors (such as sertraline) are competitive inhibitors of CYP3A4, which is the same enzyme that metabolizes lidocaine.

Question 30

A 45-year-old woman with newly diagnosed invasive lobular carcinoma of the right breast comes to the clinic to discuss immediate breast reconstruction following bilateral mastectomy. History includes a sulfonamide allergy; otherwise, she has no medical comorbidities and does not smoke cigarettes. Staged implant-based breast reconstruction is planned. Which of the following prophylactic antibiotic regimens is most appropriate for this patient?
A) Intravenous cefazolin for less than 24 hours perioperatively followed by no oral antibiotic
B) Intravenous clindamycin for less than 24 hours perioperatively, followed by a 5-day course of oral trimethoprim-sulfamethoxazole
C) Intravenous clindamycin for less than 24 hours perioperatively, followed by no oral antibiotic
D) Intravenous piperacillin/tazobactam for less than 24 hours perioperatively, followed by a 5-day course of oral ciprofloxacin
E) Intravenous vancomycin for less than 24 hours perioperatively, followed by a 5-day course of cephalexin

Answer 30

A) Intravenous cefazolin for less than 24 hours perioperatively followed by no oral antibiotic

Question 31

A 28-year-old man who underwent transplantation of an upper extremity at the mid humeral level 6 hours ago is evaluated in the intensive care unit because his urine output is decreasing. On examination, the patient’s urine is red-amber in color. Electrocardiography (ECG) shows T waves that are almost as tall as the QRS complex on the rhythm strip. In addition to fluid management and obtaining formal 12-lead ECG, the most appropriate next step is to order measurement of which of the following blood electrolytes?
A ) Calcium
B) Magnesium
C) Phosphate
D) Potassium
E) Sodium

Answer 31

D. potassium

Question 32

A pair of conjoined twins is evaluated to determine the surgical plan for soft-tissue coverage after their separation. The twins face one another and are conjoined from the sternum to the umbilical area. Which of the following terms best describes this type of conjoined twins?
A) Cephalopagus
B) Craniopagus
C) Omphalopagus
D) Parapagus
E) Thoracopagus

Answer 32

E. thoracopagus

• Craniopagus – dorsal conjoined at the cranium – 5%
• Cephalopagus – ventral fusion from vertex to umbilicus – 3.4%
• Thoracopagus – ventral fusion of chest and thorax to umbilicus – 42%
• Omphalopagus – ventral fusion of lower chest to umbilicus – 5.5%
• Parapagus – lateral fusion of lower abdomen and pelvis – 14.5%

Question 33

A 57-year-old woman comes to the office to discuss breast reconstruction after mastectomy. When considering the dimensions of access to healthcare, the distance between the patient’s geographic location and her reconstructive surgeon’s location most significantly affects which of the following?
A) Accessibility
B) Accommodation
C) Affordability
D) Availability
E) Awareness

Answer 33

A. accessibility

Question 34

A plastic surgeon evaluates an 18-year-old woman for potential gluteal augmentation with high-volume fat grafting. The patient has seen the surgeon’s posts on social media, and she states that she wants the same results but is unable to afford the cosmetic fees. The surgeon offers a discount on her procedure if she allows him to livestream the operation. She agrees, and the operation is performed the following week. Which of the following best describes the ethical violation in this interaction?
A) Age criterion not met for surgical consent
B) Discount offered by the plastic surgeon
C) Patient’s lack of control over the posted video D) Sexual harassment
E) None; both parties consented to the agreement

Answer 34

B. discount offered by surgeon

The American Society of Plastic Surgeons Code of Ethics states that there can be no coercion (such as financial coercion) on the part of a plastic surgeon to get a patient to participate in online marketing.

Question 35

A 71-year-old man presents with a 6-month history of a lesion on the left cheek. The patient underwent resection of a basal cell carcinoma of the left cheek 16 months ago. Medical history includes type 2 diabetes and hypertension. Physical examination shows a lesion with indistinct borders. Examination of a specimen obtained on biopsy confirms a diagnosis of recurrent basal cell carcinoma. Which of the following is the most appropriate treatment for this patient?
A) Cryotherapy
B) Marginal excision
C) Mohs micrographic surgery
D) Radiation therapy
E) Topical 5-fluorouracil

Answer 35

C) Mohs micrographic surgery

since the lesion represents tumor recurrence with indistinct borders in a cosmetically sensitive area.

Question 36

A male newborn with a large lumbar bulge receives a diagnosis of myelomeningocele. Which of the following findings supports the diagnosis of myelomeningocele over meningocele?
A) Absence of neural structure involvement
B) Alpha-fetoprotein concentration within the normal range
C) Minimal neurological symptoms
D) Presence of hydrocephalus

Answer 36

D. hydrocephalus

Both are forms of spina bifida, with myelomeningocele being more severe due to the protrusion and underdevelopment of neural structures and meningocele only involving the meninges, commonly referred to as spina bifida occulta.

Question 37

A 62-year-old woman with invasive ductal carcinoma of the left breast is scheduled to undergo a left-sided mastectomy with immediate reconstruction using a free deep inferior epigastric perforator flap. BMI is 30.2 kg/m2. Preoperative examination shows bilateral lower extremity varicose veins. She has a right chest port that has been used for neoadjuvant chemotherapy. Chemoprophylaxis using a weight-based dose adjustment of which of the following drugs is most appropriate to decrease this patient’s risk for postoperative venous thromboembolism?
A) Intravenous heparin
B) Oral apixaban
C) Oral rivaroxaban
D) Subcutaneous enoxaparin
E) No chemoprophylaxis is indicated

Answer 37

D. subcutaneous enoxaparin

Question 38

A 72-year-old man diagnosed with an oral squamous cell carcinoma undergoes segmental mandibulectomy and reconstruction with free fibula flap. The surgery is uneventful, and the patient is transferred to the floor on postoperative day 3. Two days later, he suddenly becomes unresponsive while mobilizing out of bed. A pulse cannot be palpated. Cardiopulmonary resuscitation is promptly started, and a cardiac monitor is attached. The electrocardiography tracing is consistent with pulseless electrical activity. Administration of which of the following drugs is the most appropriate next step in management?
A) Adenosine
B) Atropine
C) Diltiazem
D) Dopamine
E) Epinephrine

Answer 38

E. epinephrine

Question 39

A 45-year-old woman is admitted to the hospital because of multiple fluid collections in bilateral gluteal regions. She underwent abdominoplasty and gluteal fat grafting 2 weeks ago while traveling out of the country. She has obstructive sleep apnea, for which she uses a continuous positive airway pressure (CPAP) device at night. She is obese with a BMI of 42 kg/m2. Vital signs are within normal limits. Surgical exploration of the gluteal collections is planned in the next 48 hours. The use of a CPAP device for this patient’s obstructive sleep apnea is most appropriate during which of the following perioperative periods?
A) Immediate postoperative only
B) Neither preoperative nor immediate postoperative
C) Preoperative and immediate postoperative
D) Preoperative only

Answer 39

C. pre-op and immediate post op

Question 40

Which of the following best describes the type and level of evidence in a Plastic and Reconstructive Surgery paper evaluating a retrospective series of surgical outcomes in 13 patients over 8 months?
A) Diagnostic, Level II
B) Diagnostic, Level III
C) Diagnostic, Level IV
D) Therapeutic, Level II
E) Therapeutic, Level III
F) Therapeutic, Level IV

Answer 40

F) Therapeutic, Level IV

Level I studies are high-quality, multicenter or single-center, randomized controlled trials with adequate power or systematic reviews of these trials. Level II are lesser-quality randomized controlled trials or systematic reviews of these studies. Level III are retrospective cohort or case-controlled studies. Level IV are case studies with pre/post-test or only post-test outcomes. Level V studies encompass expert opinion developed by consensus, case reports, and clinical examples.

Question 41

A 45-year-old woman is brought to the emergency department after sustaining a crush injury to the left upper extremity when a heavy bookshelf fell on her. She reports no injury to any other part of her body. She has severe pain in the forearm. Which of the following findings would be the strongest indication to proceed with fasciotomy of the injured extremity in this patient?
A) Fracture of the distal radius and ulna demonstrated on x-ray study
B) History of trauma due to fall of heavy object
C) Intracompartmental pressure of the forearm at 35 mmHg
D) Pain relieved by morphine
E) Swelling of the left upper extremity

Answer 41

C) Intracompartmental pressure of the forearm at 35 mmHg

Question 42

A 59-year-old woman comes to the office because of a 24-hour history of a painful index finger. Physical examination demonstrates tenderness and erythema over the metacarpal head of the index finger of the right hand. Small white nodules are visible underneath the skin. Serum urate concentration is 11.0 mg/dL (N 4.0-8.5 mg/dL). Pathologic examination of joint aspiration demonstrates monosodium urate crystals. Which of the following findings in this patient is most helpful in confirming the suspected diagnosis?
A) Joint aspirate examination results
B) Monoarticular location
C) Onset of symptoms
D) Serum urate concentration
E) Subcutaneous nodules

Answer 42

A. joint aspirate results

Question 43

A 35-year-old woman is scheduled to undergo wide local excision of a 3-mm–thick melanoma. General endotracheal anesthesia is induced, and a dual tracing approach is implemented with technetium 99m and isosulfan blue dye. Lidocaine 1% with epinephrine is injected intradermally for local bleeding control. Within moments, the patient becomes hypotensive, develops global urticaria, and desaturates. She progresses to cardiac arrest. Which of the following is the most likely cause of these symptoms?
A) Anaphylaxis to isosulfan blue dye
B) Anaphylaxis to lidocaine
C) Anaphylaxis to skin preparation agent
D) Histamine release from general anesthesia induction with depolarizing agent
E) Malignant hyperthermia

Answer 43

A) Anaphylaxis to isosulfan blue dye

Question 44

A 23-year-old man is brought to the trauma bay with a stab wound to the neck. Physical examination shows a 3-cm laceration deep to the platysma, just lateral to the thyroid cartilage. Blood pressure is 125/80 mmHg, heart rate is 80 bpm, and respiratory rate is 16/min. Pulse oximetry shows oxygen saturation is 95%. There is no focal neurologic deficit. Which of the following is the most appropriate next step in management?
A) Cervical collar stabilization
B) CT angiography of the neck
C) Endoscopy of the upper aerodigestive tract
D) Laceration repair
E) Surgical exploration in the operating room

Answer 44

B. CTA neck

Question 45

A 29-year-old woman who weighs 176 lb (80 kg) undergoes fleur-de-lis abdominoplasty after a weight loss of 65 lb. During abdominal wall plication, 266 mg of liposomal bupivacaine combined with 40 mL of 0.25% bupivacaine hydrochloride is injected along the plication line. During skin closure, 40 mL of 1% lidocaine hydrochloride with 1:100,000 epinephrine is injected along the incisions. Which of the following is most accurate regarding the dose of liposomal bupivacaine in this patient?
A) It is reserved for patients undergoing regional analgesia (eg, brachial plexus blocks)
B) It is reserved for patients weighing over 220 lb (100 kg)
C) It may be safely combined with both 0.25% bupivacaine hydrochloride and 1% lidocaine hydrochloride
D) It may be safely combined with 0.25% bupivacaine hydrochloride only
E) It may be safely combined with 1% lidocaine only

Answer 45

D) It may be safely combined with 0.25% bupivacaine hydrochloride only

Liposomal bupivacaine is available in two doses, 266 mg (20 mL) and 133 mg (10 mL).

Question 46

A 56-year-old man is brought to the emergency department after sustaining an isolated Gustilo Type IIIB fracture when he fell from a roof. He undergoes definitive orthopedic fixation and is left with a 10 × 15-cm wound in the distal third of the leg with exposed hardware. Free tissue transfer is successfully performed for wound closure at the time of fracture fixation. One week after closure, the patient is classified as weight-bearing as tolerated and is ready to be discharged from the hospital. Which of the following is the most appropriate prophylaxis for venous thromboembolism on discharge of this patient?
A) Aspirin 325 mg daily for 2 weeks
B) Aspirin 325 mg daily for 4 weeks
C) Low-molecular-weight heparin 40 mg daily for 2 weeks
D) Low-molecular-weight heparin 40 mg daily for 4 weeks
E) No prophylaxis is indicated

Answer 46

D) Low-molecular-weight heparin 40 mg daily for 4 weeks

Question 47

A 54-year-old man is brought to the emergency department (ED) 3 hours after sustaining superficial burns to the entire left upper extremity and deep partial- thickness burns to the entire right upper extremity and half of the right lower extremity during a house fire. He did not receive any resuscitation before arriving at the ED. He appears otherwise healthy, and he weighs 176 lbs (80 kg). According to the Parkland formula, which of the following is the starting rate of fluid resuscitation in this patient?
A) 360 mL/hr
B) 540 mL/hr
C) 576 mL/hr
D) 624 mL/hr
E) 864 mL/hr

Answer 47

C) 576 mL/hr

total fluid needed in 24 hours = (total body surface area) × (4 mL/kg) × (body weight in kg).

For this scenario, the patient will need 5760 mL in 24 hours ([9% for right upper + 9% for right lower] × 4 mL/kg × 80 kg). Half of this fluid (2880 mL) should be given in the first 8 hours, and since the patient arrived 3 hours after the accident, the 2880 mL should be given over the next 5 hours (2880 mL/5 hr = 576 mL/hr).

Question 48

A 42-year-old woman undergoes a circumferential body lift following a 110-lb (49.9-kg) massive weight loss due to a gastric sleeve. Eighteen hours after surgery, she begins vomiting and is noted to have disordered eye movements, ataxia, and mental status changes. Administration of which of the following is most appropriate to treat the symptoms in this patient?
A ) Calcium
B) Folate
C) Iron
D) Vitamin B1 (thiamine)
E) Vitamin B12 (cyanocobalamin)

Answer 48

D. Vitamin B1 thiamine

Question 49

A 54-year-old woman undergoes lipoabdominoplasty under general anesthesia. She is positioned supine with arms abducted for 4 hours. Compression neuropathy of which of the following nerves is most likely in this patient?
A) Long thoracic
B) Median
C) Musculocutaneous
D) Radial
E) Ulnar

Answer 49

E. Ulnar

Question 50

According to the American Board of Plastic Surgery, the certification of a diplomate who fails to maintain the required ethical or professionalism standards may be classified under which of the following statuses?
A ) Expired
B ) Probation
C ) Retired
D ) Revoked
E) Suspended

Answer 50

D. revoked

• Expired – Certification has lapsed; the diplomate has not met the requirements to renew certification.
• Retired – No longer in active practice of plastic surgery.
• Revoked – Certification is no longer valid due to a failure to maintain required ethical
  or professionalism standards.
• Suspended – Certification is suspended due to action on a medical license by a state
  medical board.
• Probation – Certification is placed on probation due to action on a medical license by
  a state medical board.