OTHER SURGERY (BREAST + CARDIO + VASCULAR + PEDS)

Question 1

Method used for taking biopsy and exposure of paratracheal and praetracheal lymph nodes:
A)  	Stemmer (Chamberlain)-biopsy
B)  	Klassen-biopsy
C)  	Carlens-biopsy
D)  	Scalenus lymph node biopsy

Answer 1

C) Carlens-biopsy

Question 2

Most frequently used treatment method of the spontaneous, primary pneumothorax:
A) bed rest
B) emergency thoracotomy and surgery
C) needle aspiration
D) thoracic drainage and suction therapy

Answer 2

D) thoracic drainage and suction therapy

Question 3

Usually effective treatment of the pleural empyema:
A) bed rest, antibiotics and pain killers
B) early thoracotomy, decortication
C) thoracic drainage, suction therapy
D) fenestration
E) VATS suctions and drainage

Answer 3

C) thoracic drainage, suction therapy

Question 4

How much percent of the newly discovered (incidence) primary lung cancer patients are suitable for surgical resection per year in Hungary?
A) 80%
B) 50%
C) 20-25%

Answer 4

C) 20-25%

Question 5

Which type of the primary lung cancer is the most suitable for lung resection?
A)  	squamocellular cancer
B)  	adenocarcinoma
C)  	small cell lung cancer
D)  	large cell lung cancer
E)  	bronchioloalveolar

Answer 5

A) squamocellular cancer

Question 6

Which type of the primary lung cancer is the „worst” from early dissemination point of view, thinking of not suitable for surgical treatment by many experts?
A)  	squamocellular cancer
B)  	adenocarcinoma
C)  	small cell lung cancer
D)  	large cell lung cancer
E)  	bronchioloalveolar carcinoma

Answer 6

C) small cell lung cancer

Question 7

Which one is an important factor in the development of the mesotehlioma according to our knowledge?
A) specific (TB) pleurisy in the younghood
B) smoking
C) asbestos inhalation
D) repetiting chest wall traumas
E) inhalation of tetra-chlore-ethilene

Answer 7

C) asbestos inhalation

Question 8

Left upper lobe adenocarcinoma with ipsilateral mediastinal lymph node metastasis. How would you proceed?
A) This tumor is inoperable, because not only the lung but the mediastinum is also affected. Primery radio-chemotherapy is recommended.
B) Left upper lobectomy with radical mediastinal lymphadenectomy is recommended.
C) Induction (neoadjuvant) chemo (-radio) therapy is recommended with lobectomy and radical mediastinal lymphadenectomy later on.
D) Lobectomy, lympahedenectomy followed by adjuvant oncological therapy is recommended.

Answer 8

C) Induction (neoadjuvant) chemo (-radio) therapy is recommended with lobectomy and radical mediastinal lymphadenectomy later on.

Question 9

When are most of the chest deformity cases (excavated and carinated pectus) discovered?
A)  	at birth
B)  	in babyhood
C)  	in the teenagers
D)  	in adulthood

Answer 9

C) in the teenagers

Question 10

In spite of the improving living conditions what is the most frequent type of operation of TB patients?
A) thoracoplasty
B) extrapleural pneumolysis
C) adhaesiolysis (Jacobeus’s operation)
D) lung resection
E) decortication

Answer 10

D) lung resection

Question 11

Find the examination what is not included in the normal preoperative examinations list of the lung cancer patients.
A)  	chest X-ray
B)  	chest CT and MRI
C)  	bronchoscopy
D)  	pulmonary angiography
E)  	sputum cytology
F)  	spirometry, blood gas analysis

Answer 11

D) pulmonary angiography

Question 12

Which parameter shows decompensated respiratory insufficiency?
A)  	pH
B)  	PCO2
C)  	PO2
D)  	BE
E)  	standard HCO3

Answer 12

A) pH

Question 13

Which is the best dynamic lung function parameter for examining the obstructive lung diseases?
A)  	FEV1
B)  	Tiff%
C)  	MEF50
D)  	flow-volume loop

Answer 13

D) flow-volume loop

Question 14

True for lung cancer, except:
A) never symptom-free
B) can be solitary pulmonary nodule
C) haemoptysis is very common
D) dry, improductive cough can be the only one symptom
E) the endobronchial spread of the tumor can lead to secondary inflammation

Answer 14

A) never symptom-free

Question 15

The most common malignant tumor of the chest wall bones:
A)  	single bone metastasis
B)  	osteosarcoma
C)  	multiple myeloma
D)  	Ewing-sarcoma
E)  	chondrosarcoma

Answer 15

E) chondrosarcoma

Question 16

Haemoptysis can be caused by the followings, except:
A)  	malignant bronchial tumor
B)  	asthma bronchiale
C)  	bronchiectasis
D)  	pulmonary infarction
E)  	tuberculosis

Answer 16

B) asthma bronchiale

Question 17

The most common cause of vena cava superior syndrome is:
A) advanced cancer of the right upper lobe
B) thymic tumor
C) thyroid cancer
D) mediastinal fibrosis
E) goiter

Answer 17

A) advanced cancer of the right upper lobe

Question 18

Thoracic outlet synrome can be caused by the followings, except:
A)  	cervical rib
B)  	scalene anterior syndrome
C)  	costoclavicular compression
D)  	Raynaud-disease
E)  	hyperabduction syndrome

Answer 18

D) Raynaud-disease

Question 19

Symptoms of the thoracic outlet syndrome are the followings, except:
A) paraesthesia of the ulnar side of the arm
B) atrophy of thenar muscles
C) pain in the neck and the shoulder
D) weakening pulsation of the radial artery during abduction of the arm
E) ischaemic gangraena of the fingers

Answer 19

B) atrophy of thenar muscles

Question 20

A 48-year-old lady had total abdominoperineal rectal resection for adenocarcinoma 2 years ago. The patient is symptom-free, has elevated tumor marker levels and the check up revealed a round laesion 2cm in size on the right side peripherally and an other one on the left side in the same size. The tranthoracal needle biopsy makes adenocarcinoma likely. What would you recommend?
A) The patient obviously has biletarel lung metastasis and urgent oncological treatment (at least 6 cycles of chemotherapy) is recommended.
B) Both metastasis must be resected via median sternotomy and the adjuvant radiotherapy of the affected area may improve the outcome.
C) After excluding other distant metastasis and a negative colonoscopy single stage (sternotomy) or 2 staged (axillary thoracotomy) and metastasectomy is indicated. If histology is positive, adjuvant chemotherapy is indicated.
D) Urgent bilateral thoracotomy is recommended, because the laesions are very likely resectable. Even these are metastastic or primary lung cancers, chemotherapy is indicated.

Answer 20

C) After excluding other distant metastasis and a negative colonoscopy single stage (sternotomy) or 2 staged (axillary thoracotomy) and metastasectomy is indicated. If histology is positive, adjuvant chemotherapy is indicated.

Question 21

What are the most common symptoms of the spontaneous primary pneumothorax?

1) fever
2) sputum
3) dyspnoe
4) high red blood cell sedimentation
5) sharp chest pain
6) dullness during percussion
7) tympanic percussion

A) the 1st and 4th answers are correct
B) the 2nd and 6th answers are correct
C) the 4th and 6th answers are correct
D) the 3rd, 5th and 7th answers are correct
E) the 2nd, 5th and 6th answers are correct

Answer 21

D) the 3rd, 5th and 7th answers are correct

Question 22

The most important steps of the treatment of simple rib fracture:

1) fixation with adhesive plaster
2) pain control with local methods at the level of the affected intercostal nerve and pain killers iv. and/or orally
3) urgent operation, fixation of the fractured ends
4) breathing exercises to avoid respiratory complications

A)  	the 1st and 4th answers are correct
B)  	the 2nd and 4th answers are correct
C)  	the 3rd and 4th answers are correct
D)  	the 1st and 2nd answers are correct
E)  	all of the answers are correct

Answer 22

B) the 2nd and 4th answers are correct

Question 23

The rib fracture patient has pneumothorax on the chest X-ray. Recommended treatment:

1) bed rest, fixation with adhesive plasters
2) pain control, breathing exercises
3) aspiration of the pneumothorax with aspiration syringe
4) chest drainage and suction

A)  	the 1st and 4th answers are correct
B)  	the 1st and 3rd answers are correct
C)  	the 2nd and 3rd answers are correct
D)  	the 2nd and 4th answers are correct
E)  	all of the answers are correct

Answer 23

D) the 2nd and 4th answers are correct

Question 24

You can see haemothorax on the chest X-ray in a blunt chest trauma, rib fracture patient. What would you do?
A) thoracotomy, evacuation of the blood
B) needle aspiration
C) wait and see policy
D) thoracic drainage, suction

Answer 24

D) thoracic drainage, suction

Question 25

Methods intended for direct myocardial oxygenation, except for: A) Aorto-coronary bypass grafting (ACBG) B) Coronary thromboendarterectomy C) PTCA (percutaneous transluminal coronary angioplasty) D) IABP (intra-aortic balloon pump) E) Pacemaker implantation

Answer 25

E) Pacemaker implantation Surgical bypass grafting bypasses the coronary narrowing or blockage, thrombendarterectomy removes the narrowed segment (except for the adventitia layer), PTCA dilates it, IABP improves coronary filling and circulation. Pacemakers are used to treat bradyarrythmias, and so that answer is the exception.

Question 26

Surgical access methods for cardiac procedures, except for: A) median sternotomy B) left sided standard, antero-lateral thoracotomy C) parasternal mediastinotomy D) subcostal mediastinotomy E) right sided postero-lateral subscapulary thoracotomy

Answer 26

E) right sided postero-lateral subscapulary thoracotomy Access methods listed as A, B, C and D are used to expose the heart for surgical procedures (A is the commonmost, D is the least frequent). Procedures carried out in extracorporeal circulation are usually performed through a standard median sterntomy. Left sided antero-lateral thoracotomy is suitable for establishing atrio-femoral bypass, treating diseases of the pericardium or for closed mitral commissurotomy. Parasternal mediastinotomy is used in minimally invasive cardiac surgery, and subcostal incisions provide good access to treat pericardial effusion or tamponade. Right sided postero-lateral thoracotomy is not suitable for cardiac surgery, it is used in thoracic surgery (e.g.: pulmonary procedures).

Question 27

Your patient has fever following mechanical heart valve surgrey. Suggested methods of investigation are necessary, except for: A) echocardiography B) blood cultures C) antibiotic therapy D) diagnostic pericardial fluid sampling E) redo valve surgery in presence of vegetations

Answer 27

D) diagnostic pericardial fluid sampling Multiple methods of examination are necessary in investigation of fever following heart valve implantation. CT, repeated blood tests etc. can be useful as well, but diagnostic pericadiocentesis is not reasonable in this scenario.

Question 28

Cardio-vascular mortality in Hungary: A) is not significant B) significant, but is comparable to current european trends C) statistic data is not available D) is second following mortality of malignancies E) is on top of the mortality list

Answer 28

E) is on top of the mortality list 50-55% of overall mortality in Hungary is due to cardiovasular diseases. That puts Hungary in the 3rd worst position in Europe.

Question 29

``` Haemoptysis can be a sign of the following cardio-pulmonary disorders, except for: A) mitral regurgitation B) mitral stenosis C) aortic stenosis D) pulmonary embolism ```

Answer 29

C) aortic stenosis Haemopysis is the classical symptom of pulmonary embolism. Pulmonary congestion seen both in mitral stenosis and regurgitation may present haemoptysis, but not in isolated aortic stenosis.

Question 30

What is the exact location of the coarctation of the aorta? A) between the right subclavian and the right carotid arteries B) between the right and the left carotid arteries C) between the left carotid and the left subclavian arteries D) between the left subclavian artery and the duct of Botallo

Answer 30

D) between the left subclavian artery and the duct of Botallo

Question 31

Symptoms of pericardial tamponade, except for: A) elevated central venous pressure B) decreased cardiac output C) low blood pressure D) elevated left ventricular filling pressure

Answer 31

D) elevated left ventricular filling pressure Pericardial tamponade is caused by fluid collection in the pericardial cavity. Compression of heart chambers in the localised pericardial space results in reduction of diastolic filling capacity.

Question 32

Which of the following devices is capable of supporting circulation and providing oxygenisation at the same time following cardiac surgery? A) intra-aortic balloon pump (IABP) B) single or biventricular circulatory assist device (VAD) C) extracorporeal membrane oxygenisator (ECMO)

Answer 32

C) extracorporeal membrane oxygenisator (ECMO) Intra aortic ballon pump improves coronary perfusion in diastole. Ventricular assist devices provide patients with the necessary cardiac output themselves. Oxygenisation is only provided by ECMO.

Question 33

``` The following congenital cardiac defects depend on ductal circulation, except for: A) pulmonary atresia B) hypoplastic left heart syndrome C) interruption of the aortic arch D) ventricular septal defect ```

Answer 33

D) ventricular septal defect A patent ductus areriosus is mandatory in pulmonary atresia and hypoplastic left heart syndrome because it is the only connection between left and right sided circulation, as pulmonary and systemic circulations are provided by the same single ventricle. In patients with interrupted aortic arch lower body is perfused throught the patent ductus arteriosus by the right ventricle, so ductus closure results lower body ischaemia. In cases of ventricular septal defect ductus Botalli closure is preferable to aviod pulmonary congestion.

Question 34

Which procedure is palliative heart surgery? A) aortic valve replacement B) closure of ventricular septal defect C) Blalock-Taussig shunt D) coarctectomy

Answer 34

C) Blalock-Taussig shunt Aortic valve replacement, closure of ventricular septal defects and coarctectomy provide anatomical restoration of the effected regions. Blalock-Taussig shunts improve pulmonary circulation (e.g. in tertalogy of Fallott) but do not eliminate the primary pathological disorder.

Question 35

Surgical correction procedure of the transposition of the great arteries: A) arterial switch B) closure of atrial septal defects C) coarctectomy

Answer 35

A) arterial switch

Question 36

Lifelong anticoagulation is necessary following the implantation of: A) a stentless biological (tissue) heart valve B) a mechanical heart valve C) a homograft D) a stented biological (tissue) heart valve

Answer 36

B) a mechanical heart valve Patients following mechanical heart valve implantation surgery need to be put on lifelong anticoagulant therapy despite good left ventricular function and stabile sinus rythm. Patients who received bioprosthetic heart valves (tissue valves) need to take anticoagulants for three months only, if their left ventricular function is good and they maintain stabile sinus rythm. Anticogulants are not necessary following homograft implantation (in patients who would not require anticoagulation for other reasons).

Question 37

In which case is the implantation of a mechanical heart valve contraindicated? A) poor left ventricular function B) there is a contraindication for chronic anticoagulant therapy C) chronic atrial fibrillation

Answer 37

B) there is a contraindication for chronic anticoagulant therapy In cases where chronic anticoagulation is contraindicated implantation of a mechanical heart valve is not recommended (e.g.: hemophylia, gastric ulcer, colorectal polyposis, female patients who wish to get pregnant in the future).

Question 38

Emergency surgery is NOT indicated in acute myocardial infarction with the following mechanical complications: A) left ventricular aneurysm B) acut mitral regurgitation caused by papillary muscle rupture C) rupture of the ventricular free wall D) postinfarct ventricular septal defect

Answer 38

A) left ventricular aneurysm Postinfarct papillary muscle rupture, verticular septal rupture, left ventricular free wall rupture all require emergency surgery. Left ventricular aneurysms are deformities which may be subjects for surgical correction, but not in an emergency setting.

Question 39

Coronary angiography is necessary prior to surgery, except for: 1) patients older than 60 years of age with degenerative aortic valve stenosis 2) patients with angina pectoris 3) patients with persisting ischaemic symptoms following myocardial infarction 4) patients with mitral stenosis younger than 40 years of age ``` A) the 1st, 2nd and 3rd answers are correct B) the 1st and 3rd answers are correct C) the 2nd and 4th answers are correct D) only the 4th answer is correct E) all of the answers are correct ```

Answer 39

D) only the 4th answer is correct Coronary angiography is indicated before any cardiac surgical intervention in patients above 40 years of age. If the medical history of a patient contains data suggesting myocardial ischaemia under 40 years of age angiography is obviously necessary as well.

Question 40

Surgical procedures for correcting mitral stenosis are the following, except for 1) commissurotomy 2) implantation of artificial chordae 3) prosthesis implantation 4) implantation of an annuloplastic ring ``` A) the 1st, 2nd and 3rd answers are correct B) the 1st and 3rd answers are correct C) the 2nd and 4th answers are correct D) only the 4th answer is correct E) all of the answers are correct ```

Answer 40

C) the 2nd and 4th answers are correct Mitral commissurotomy and prosthetic heart valve implantation are procedures to correct mitral stenosis. Implantation of artificial chordae and the use of annuloplasty rings (and sometimes prosthetic heart valve implantation) are surgical methods of treating mitral regurgitation.

Question 41

Mandatory elements of cardio-pulmonary bypass circuits: 1) oxygenator 2) arterial pump 3) set of tubes 4) heparin ``` A) the 1st, 2nd and 3rd answers are correct B) the 1st and 3rd answers are correct C) the 2nd and 4th answers are correct D) only the 4th answer is correct E) all of the answers are correct ```

Answer 41

E) all of the answers are correct

Question 42

Sewing rings of stented bioprosthesis (tissue valves) are thrombogenous, so patients receiving them need life-long anticoagulation therapy. A) both the statement and the explanation are true and a causal relationship exists between them; B) both the statement and the explanation are true but there is no causal relationship between them; C) the statement is true, but the explanation is false; D) the statement is false, but the explanation itself is true E) both the statement and the explanation are false

Answer 42

C) the statement is true, but the explanation is false; Sewing ring of a stented bioprosthesis (tissue valve) is in fact thrombogenous, but only needs to be anticoagulated for three months following implantation in case of stabile sinus rythm and good left ventricular function (that is how long it takes the endocardium to cover the sewing ring).

Question 43

Endothel functions of in situ used internal thoracic (mammary) arteries are preserved, that is why patency rates at ten years are the best of all coronary bypass conduits. A) both the statement and the explanation are true and a causal relationship exists between them; B) both the statement and the explanation are true but there is no causal relationship between them; C) the statement is true, but the explanation is false; D) the statement is false, but the explanation itself is true E) both the statement and the explanation are false

Answer 43

A) both the statement and the explanation are true and a causal relationship exists between them; Internal thoracic (mammary) arteries used in an in situ manner keep perfect endothel function, with nitric oxide (NO) production remaining in tact. That possesses coronary dilatory and platelet anti-aggregation effect. That is the reason of the excellent patency rate even long after surgery.