Surgery - END (Part 1) Flashcards
- When is open surgical drainage indicated for intraabdominal abscess? *
A. Good window for percutaneous puncture
B. Ongoing contamination is identified
C. Multiple abscesses less than 1 cm
D. Large solitary abscess
B. Ongoing contamination is identified
This option is the most appropriate for open surgical drainage because it addresses situations where the contamination or infection cannot be controlled adequately by less invasive means. In cases of ongoing contamination, such as from a gastrointestinal tract perforation or complex abscesses that cannot be resolved with percutaneous drainage alone, open surgery allows for direct access to thoroughly manage and eliminate the source of infection, clear the abscess, and potentially repair any associated anatomical defects. This approach helps prevent further spread of infection and facilitates more effective treatment of the underlying condition.
- What is the risk of Hepatitis C and HIV-1 transmission with blood transfusion? *
A. 1:1,000,000
B. 1:10,000,000
C. 1:500,000
D. 1:100,000
A. 1:1,000,000
Transmission of hepatitis C and HIV-1 has been dramatically minimized by the introduction of better antibody and nucleic acid screening for these pathogens. The residual risk among allogeneic donations is now estimated to be less than 1 per 1,000,000 donations and hepatitis B approximately 1 per
300,000 donations. (See Schwartz 10th ed., p. 102.)
- During inspiration the inflamed gallbladder touches the examiners fingers resulting in the sudden cessation of inspiration *
A. Charcot sign
B. Rovsing’s sign
C. Obturator sign
D. Murphy’s sign
D. Murphy’s sign
Rationalization: Murphy’s sign is a clinical sign where palpation of the inflamed gallbladder during inspiration causes pain and a sudden stop in inspiratory effort. This is typically indicative of acute cholecystitis.
- Which of the following is commonly seen in Ehlers-Danlos syndrome (EDS)? *
A. Spontaneous thrombosis.
B. Small bowel obstructions.
C. Abnormal scarring of the hands with contractures.
D. Direct or recurrent hernias in children.
D. Direct or recurrent hernias in children.
Ehlers-Danlos syndrome (EDS) is a group of 10 disorders that present as a defect in collagen formation. Over half of the affected patients manifest genetic defects encoding alpha chains of collagen type V, causing it to be either quantitatively or structurally defective. These changes lead to “classic” EDS with phenotypic findings that include thin, friable skin with prominent veins, easy bruising, poor wound healing, atrophic scar forma-tion, recurrent hernias, and hyperextensible joints. Gastrointestinal (GI) problems include bleeding, hiatal hernia, intestinal diverticula, and rectal prolapse. Small blood vessels are fragile, making suturing difficult during surgery. Large vessels may develop aneurysms, varicosities, arteriovenous fistulas, or may spontaneously rupture. (See Schwartz 10th ed., p. 246.)
- A chronically debilitated patient with spinal cord injury develops a 3 cm diameter non healing ulcer over the greater trochanter and malleolus is best managed by *
A. Wound debridement
B. Frequent turning
C. Adequate nutrition
D. All of the above
D. All of the above
All of the above
Rationalization: Management of pressure ulcers in patients with spinal cord injury includes a multifaceted approach: wound debridement to remove necrotic tissue, frequent turning to relieve pressure, and adequate nutrition to support healing and tissue repair.
- Which of the following statement/s is/are TRUE *
A. The initial insult, whether hemorrhage, injury or infection, initiates both neuroendocrine and inflammatory mediator response
B. Magnitude of the physiologic response is not proportional to the degree and duration of the shock
C. Etiology of shock varies, qualitative nature of response to shock is similar, with common pathways in all types
D. A and C
E. All of the above
D. A and C
Rationalization:
* (A) The initial insult (be it hemorrhage, injury, or infection) does initiate both a neuroendocrine and inflammatory mediator response, which is crucial in the body’s adaptive mechanism to stress.
* (B) The magnitude of the physiological response is indeed proportional to the degree and duration of the shock, indicating that more severe or prolonged insults result in a more intense response.
* (C) While the etiology of shock can vary (hypovolemic, cardiogenic, distributive, etc.), the qualitative nature of the body’s response involves common pathways, including the activation of stress and inflammatory responses.
- A 74 year old woman with a history of coronary artery bypass surgery and myocardial infarction is brought to the hospital because of severe abdominal excruciating pain that suddenly began 8 hours ago. She is confused and disoriented. The patient appears gravely ill with unstable vital signs. Abdomen is distended without muscle guarding and tenderness is difficult to evaluate. What do you think is happening to the patient with regards to her abdomen? *
A. Inflammation
B. Perforation
C. Obstruction
D. Ischemia or infarction
Ischemia or infarction
Rationalization: Given the patient’s history of cardiovascular disease and the sudden onset of severe abdominal pain accompanied by confusion, disorientation, and unstable vital signs, the most likely diagnosis is mesenteric ischemia or infarction. This condition can present with abdominal distension and pain out of proportion to physical findings, often making it a challenging diagnosis.
- The key to the correction of metabolic alkalosis will be the replacement of *
A. Chloride
B. Bicarbonate
C. Carbonic acid
D. None of the above
Chloride
Rationalization: Metabolic alkalosis often results from a chloride-deficient state, which can occur with conditions like vomiting or diuretic use. Replacing chloride, typically with saline solutions, helps restore the balance of electrolytes and correct the alkalosis.
- The 1st line formula for stable patient with intact GI tract. *
A. High protein formula
B. Isotonic formula with fiber
C. Low residue isotonic formula
D. Calorie Dense formula
Isotonic formula with fiber
Rationalization: For a stable patient with an intact gastrointestinal tract, an isotonic formula with fiber is generally recommended. This type of formula supports normal bowel function and prevents complications related to feeding, such as diarrhea or constipation.
- The infection involves apocrine glands in axilla, inguinal and perineal regions *
A. Cellulitis
B. Hidradenitis suppurativa
C. Furuncle
D. Carbuncle
Hidradenitis suppurativa
Rationalization: Hidradenitis suppurativa is a chronic inflammatory condition affecting the apocrine sweat glands, especially in areas like the axilla, groin, and perineal regions. It is characterized by recurrent abscesses, nodules, and scarring.
- Supplementation of which of the following micronutrients improves wound healing in patients without micronutrient deficiency? *
A. Vitamin A
B. Selenium
C. Zinc
D. Vitamin C
A. Vitamin A
Rationalization:
* Vitamin A: The supplementation of vitamin A is beneficial in wound healing even in non-deficient individuals. It enhances collagen synthesis, increases the inflammatory response necessary for healing, and improves the function of macrophages at the wound site. Vitamin A has been shown to overcome the negative effects on wound healing caused by conditions like corticosteroid use, diabetes, tumor formation, cyclophosphamide, and radiation exposure. In severely injured or stressed patients, increased doses of vitamin A are recommended, and supplementation can significantly improve wound healing outcomes.
* Vitamin C: Although vitamin C is crucial for collagen formation and immune function, which are vital for wound healing, there is no evidence that supplementation in non-deficient patients offers additional benefits in wound healing.
* Zinc: Zinc is critical for wound healing, but the benefits of supplementation have only been demonstrated in zinc-deficient patients. There is no evidence to support improved wound healing with zinc supplementation in patients who are not deficient.
* Selenium: There is no specific evidence suggesting that selenium supplementation improves wound healing in non-deficient individuals.
- What is FALSE about peritoneal adhesions? *
A. Intra-abdominal adhesions are the most common cause of small bowel obstruction.
B. Operations in the upper abdomen have a higher chance of causing adhesions that cause small bowel obstruction, especially involving the jejunum.
C. Most peritoneal adhesions are a result of intra-abdominal surgery.
D. Adhesions are a leading cause of secondary infertility in women.
Operations in the upper abdomen have a higher chance of causing adhesions that cause small bowel obstruction, especially involving the jejunum.
Rationalization: This statement is false because operations in the lower abdomen, particularly involving gynecological and colorectal surgeries, are more likely to cause adhesions that lead to small bowel obstructions. Upper abdominal surgeries typically have a lower incidence of causing obstructive adhesions.
- Which of the following in NOT commonly seen in healing of cartilage? *
A. Slow to heal
B. Often heal without structural defects
C. Hyaline cartilage restores functional and structural integrity
D. Synthesis of collagen dependent on chondrocyte
Often heal without structural defects
Rationalization: Cartilage is known to be slow to heal due to its avascular nature. When it does heal, it often does so with structural defects; typically, hyaline cartilage does not restore functional and structural integrity fully and forms fibrocartilage instead, which is structurally and functionally different.
- Who is the physician who reduced mortality of puerperal fever by requiring caregivers to rinse their hands with chlorine water prior to examination of patients? *
A. Joseph Lister
B. Louis Pasteur
C. William Osler
D. Ignaz Semmelweis
Ignaz Semmelweis
Rationalization: Ignaz Semmelweis, a Hungarian physician, is famous for dramatically reducing the incidence of puerperal fever by introducing hand disinfection with chlorine water for doctors who performed autopsies before examining patients in maternity wards.
- Which enteral formula has glutamine, arginine omega 3 fatty acid. *
A. Elemental formula
B. Isotonic formula with fiber
C. Immune enhancing formula
D. Calorie Dense formula
Immune enhancing formula
Rationalization: Immune-enhancing formulas contain specific nutrients such as glutamine, arginine, and omega-3 fatty acids, which are known to support the immune system and are beneficial in critical care and surgical patients to help reduce complications and promote healing.
- What type of cell peak at about a week post injury and bridge the transition from inflammatory to the proliferative phase of healing? *
A. Fibroblast
B. Polymorphonuclears
C. Lymphocytes
D. Macrophage
Macrophage
Rationalization: Macrophages play a crucial role in wound healing, peaking in number about a week after injury. They help in transitioning from the inflammatory phase to the proliferative phase by removing debris, releasing growth factors, and attracting fibroblasts that synthesize new tissue.
- A 38 y/o male seafarer developed abdominal pain that localized to the right lower quadrant 3 days ago. Physical examination showed a BP of 130/ 80, PR 105, Temperature of 39 C, his abdomen is tender on Right lower quadrant with hypoactive bowel sounds. White blood cell count is 25,000 with predominance of neutrophils. What is the body’s response to limit progression of disease? *
A. Diaphragmatic pumping mechanism
B. Phagocytosis and mucus trapping of microbes
C. Containment by omentum
D. Presence of resident microflora
Containment by omentum
Rationalization: The omentum plays a critical role in containing intra-abdominal infections by adhering to and walling off areas of inflammation or infection, such as an inflamed appendix, thereby limiting the spread of infection within the abdominal cavity.
- What polypeptides are named from cells from which they first derived and produced to stimulate cellular migration and proliferation? *
A. Growth factors and cytokines
B. G proteins
C. Ion channels
D. Enzyme linked receptors
Growth factors and cytokines
Rationalization: Growth factors and cytokines are polypeptides produced by various cells in the body. They are crucial in signaling during cellular processes, particularly in stimulating migration and proliferation of cells during processes such as wound healing and tissue regeneration.
- Which growth factor has been formulated and approved for treatment of diabetic foot ulcers? *
A. Keritinocyte growth factor
B. IGF-1
C. Laminin-5
D. IL-8
E. PDGF
PDGF (Platelet-Derived Growth Factor)
Rationalization: PDGF is approved for use in the treatment of diabetic foot ulcers. It promotes the growth of new blood vessels and granulation tissue, which can help in healing chronic, non-healing ulcers.
- Tensile strength of wound reaches normal levels after how many days? *
A. Never
B. 7 days
C. 30 days
D. 1 year
1 year
Rationalization: While wounds can gain significant tensile strength in the first few months after injury, it typically takes up to a year for a wound’s tensile strength to approximate normal levels, usually reaching about 70-80% of the strength of uninjured skin.
- The early integrity of anastomosis is dependent on what factors? *
A. Mucosal repair
B. Fibrin seal on the serosa
C. Both of the above
D. None of the above
Both of the above
Rationalization: The early integrity of an anastomosis relies on mucosal repair to restore continuity of the gastrointestinal tract and on fibrin seal formation on the serosa to provide immediate stability and prevent leakage.
- When a long bone fracture is repaired by internal fixation with plates and screws *
A. Callus at the fracture site forms more rapidly.
B. Direct bone-to-bone healing occurs without soft callus formation.
C. Endochondral ossification is more complete.
D. Delayed union is prevented.
Direct bone-to-bone healing occurs without soft callus formation.
Rationalization:
Precise racture reduction and fixation allows the racture to heal bone-to-bone without the soft callus formation and endochondral ossification, which are characteristic of closed fracture management. However, internal reduction does not prevent delayed union, especially when infection for poor blood supply are present. (See Schwartz 10th ed., p. 249.)
- Which of the following is FALSE regarding healing of full-thickness injuries of the GI tract? *
A. Extraperitoneal segments of bowel that lack serosa have higher rates of anastomotic failure.
B. Serosal healing is essential to form a water-tight barrier to the lumen of the bowel.
C. The greatest tensile strength of the Gl tract is provided by the serosa.
D. Collagen synthesis is done by fibroblast and smooth muscle cells.
E. There is an early decrease in marginal strength due to an imbalance of greater collagenolysis versus collagen synthesis.
The greatest tensile strength of the GI tract is provided by the serosa.
Rationalization: This statement is false. The greatest tensile strength of the gastrointestinal tract is provided by the muscularis layer, not the serosa. The serosa contributes to sealing and isolating the injury but does not provide significant tensile strength.
- The minimum volume of urine to expel body waste is *
A. one liter
B. 500 cc
C. 800 cc
D. 600 cc
500 cc
Rationalization: The minimum volume of urine required to expel waste from the body in a day is approximately 500 cc. This amount is necessary to eliminate waste products and maintain a stable internal environment effectively.
- A 55 year old woman comes to the emergency room complaining of severe, crampy periumbilical pain that began 3 days ago. This was accompanied by nausea, episodes of vomiting dark, thick, greenish fluid. Her last bowel movement was 3 days ago and has not passed flatus for the past 36 hours. Her temperature is 38.5 degrees centigrade and abdomen is distended, symmetrical and tympanitic with minimal tenderness. Her bowel sounds are hyperactive. There is a well healed midline abdominal scar from an exploratory laparotomy secondary to ruptured appendicitis 10 years ago. What do you think is happening to the patient? *
A. Bleeding or rupture of vessels
B. Obstruction
C. Ischemia or perforation
D. Perforation
Obstruction
Rationalization: The patient’s symptoms of crampy pain, nausea, vomiting of dark, thick, greenish fluid, absence of bowel movements and flatus, fever, abdominal distention, and hyperactive bowel sounds, along with a history of prior abdominal surgery (which increases the likelihood of adhesions), suggest a bowel obstruction.
- A 45 year old female came in with persistent vomiting of previously ingested food 2 days prior to consultation. Her ABG will show *
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Metabolic alkalosis
Rationalization: Persistent vomiting can lead to the loss of gastric acid which contains hydrochloric acid, resulting in a decrease in hydrogen ions. This typically causes metabolic alkalosis, characterized by an elevated blood pH and bicarbonate concentration.
- Which of the ff: is true of interleukin 6*
A. Level is not proportional to extent of injury
B. Short half-life
C. Inhibited by TNF and IL-1
D. Detected in the serum w/in 6 hours after injury
D. Detected in the serum w/in 6 hours after injury
Rationalization: Interleukin 6 (IL-6) is a pro-inflammatory cytokine that is typically detected in the serum within hours after an injury, helping to mediate the acute phase response.
- The catecholamine release result to the following effects EXCEPT. *
A. Increase in muscle glycogenolysis
B. Increase of insulin release
C. Increase glucagon release
D. Hepatic glycogenolysis and gluconeogenesis
Increase of insulin release
Rationalization: Catecholamines typically inhibit insulin release, promoting hyperglycemia during stress responses. They stimulate muscle glycogenolysis, increase glucagon release, and enhance hepatic glycogenolysis and gluconeogenesis.
- Which of the following clotting factors is the first factor common to both intrinsic and extrinsic pathways? *
A. Factor I (fibrinogen)
B. Factor X (Stuart-Prower factor)
C. Factor IX (Christmas factor)
D. Factor XI (plasma thromboplasma antecedent)
Factor X (Stuart-Prower factor)
Rationalization: Factor X, also known as the Stuart-Prower factor, is the first clotting factor that is activated and common to both the intrinsic and extrinsic coagulation pathways. Activation of Factor X leads to the conversion of prothrombin to thrombin, which is critical for clot formation.
- Less than 0.5% of transfusions result in a serious transfusion-related complication.
What is the leading cause of transfusion-related deaths? *
A. Bacterial contamination of platelets
B. ABO hemolytic transfusion reactions
C. Transfusion-related acute lung injury
D. Iatrogenic hepatitis C infection
Transfusion-related acute lung injury
Rationalization: Transfusion-related acute lung injury (TRALI) is one of the leading causes of transfusion-related deaths. It involves an acute respiratory distress occurring during or shortly after a blood transfusion and is characterized by non-cardiogenic pulmonary edema.
- A 16 year old female came in to the ER because of sweating after a break-up with her boyfriend. Her respiratory rate was noted to be 140/min. Her ABG will reveal *
A. Metabolic alkalosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Respiratory acidosis
Respiratory alkalosis
Rationalization: A respiratory rate of 140/min is extremely high and likely indicates hyperventilation, which is a common response to emotional stress. Hyperventilation leads to excessive exhalation of CO2, resulting in a decrease in blood CO2 levels (hypocapnia), which causes respiratory alkalosis.
- Which is required for platelet adherence to injure endothelium? *
A. Adenosine diphosphate (ADP)
B. Glycoprotein (GP) lib/Illa
C. Von Willebrand factor (vwf)
D. Thromboxane A2
Von Willebrand factor (vWF)
Rationalization: Von Willebrand factor is critical for the initial adhesion of platelets to the site of endothelial injury under conditions of high shear stress. vWF acts as a bridge between the platelets’ surface receptor complex, glycoprotein Ib (GPIb), and exposed collagen of the damaged vessel wall.
- What is the most likely diagnosis of a patient with hyperextensible joints with friable skin, prominent veins and poor wound healing. Patient was also noted to have rectal prolapse and inguinal hernia. *
A. Ehlers Danlos syndrome
B. Marfans syndrome
C. Acrodermatis enteropathica
D. Osteogenesis imperfecta
Ehlers-Danlos syndrome
Rationalization: Ehlers-Danlos syndrome (EDS) is a group of disorders characterized by skin hyperextensibility, joint hypermobility, and tissue fragility, which fits the description of the patient’s symptoms, including poor wound healing and hernias.
- What is true about coagulopathy related to trauma? *
A. Coagulopathy can develop in trauma patients following acidosis, hypothermia, and dilution of coagulation factors, though coagulation is normal upon admission.
B. Acute coagulopathy of trauma is mechanistically similar to DIC.
C. Acute coagulopathy of trauma is caused by shock and tissue injury.
D. Acute coagulopathy of trauma is mainly a dilution coagulopathy.
Acute coagulopathy of trauma is caused by shock and tissue injury.
Rationalization: Acute coagulopathy of trauma (ACT) can occur immediately following severe injury and is primarily driven by shock and the associated tissue injury. This coagulopathy results from a combination of factors including activation of anticoagulant pathways, consumption of clotting factors, and hyperfibrinolysis.
- Aldosterone exerts it’s action of sodium conservation at the *
A. Proximal convoluted tubules
B. Distal convoluted tubules
C. Loop of henle
D. Renal medulla
Distal convoluted tubules
Rationalization: Aldosterone plays a crucial role in sodium balance and exerts its action mainly in the distal convoluted tubules and the collecting ducts of the nephron, where it promotes sodium reabsorption and potassium excretion.
- A 25 yr old (40kg) male came in because of vomiting and LBM. His estimated intracellular volume will be *
A. 8 liters
B. 16 liters
C. 20 liters
D. 2 liters
16 liters
Rationalization: Generally, about 60% of the human body is water. Of this, two-thirds (approximately 40%) is intracellular. For a 40 kg male, 60% of his body weight is 24 liters (water content), and two-thirds of this is around 16 liters (intracellular volume).
- What type of peritonitis rarely require surgical intervention and with monomicrobial bacterial culture isolates? *
A. Quaternary
B. Tertiary
C. Secondary
D. Primary
Primary
Rationalization: Primary peritonitis, also known as spontaneous bacterial peritonitis (SBP), typically involves a monomicrobial infection and often occurs in patients with chronic liver disease and ascites. It generally does not require surgical intervention and is treated with antibiotics.
- A phase in bone healing characterized by the end of pain and inflammatory signs? *
A. Hard callus
B. Remodeling
C. Hematoma
D. Soft callus
Remodeling
Rationalization: The remodeling phase is the final stage of bone healing where the healed bone gradually returns to its normal shape and strength. This phase follows the hard callus stage and is characterized by a decrease in pain and inflammation as the bone structure normalizes.
- The treatment of choice for keloids is *
A. Pressure treatment
B. Excision alone
C. Excision with adjuvant therapy (eg, radiation)
D. Intralesional injection of steroids
C. Excision with adjuvant therapy (eg, radiation)
Excision alone of keloids is subject to a high recurrence rate, ranging from 45 to 100%. There are fewer recurrences when surgical excision is combined with other modalities such as intralesional corticosteroid injection, topical application of silicone sheets, or the use of radiation or pressure. Surgery is recommended for debulking large lesions or as second-line therapy when other modalities have failed. Silicone application is relatively painless and should be maintained for 24 hours a day for about 3 months to prevent rebound hyper-trophy. It may be secured with tape or worn beneath a pressure garment. The mechanism of action is not understood, but increased hydration of the skin, which decreases capillary activity, inflammation, hyperemia, and collagen deposition, may be involved. Silicone is more effective than other occlusive dressings and is an especially good treatment for children and others who cannot tolerate the pain involved in other modalities. (See Schwartz 10th ed., p. 262.)
- Patients with Marfan syndrome are associated with what genetic defect? *
A. FBN-1 gene mutation
B. COL7A1 gene mutation
C. Type I collagen gene mutation
D. MFN-1 gene deletion
FBN-1 gene mutation
Rationalization: Marfan syndrome is most commonly associated with mutations in the FBN-1 gene, which encodes fibrillin-1, a glycoprotein that is crucial for the formation of elastic fibers in connective tissue. This mutation affects the connective tissue throughout the body.
- A chronic carrier state occurs with hepatitis C infection in what percentage of patients? *
A. 50-60%
B. 75-80%
C. 90-99%
D. 10-30%
75-80%
Rationalization: Hepatitis C infection leads to a chronic carrier state in approximately 75-80% of infected individuals. This high rate of chronic infection underscores the virus’s ability to evade the immune system and persist in the host.
- The most common cause for a transfusion reaction is *
A. Air embolism
B. Contaminated blood
C. Unusual circulating antibodies
D. Human error
Human error
Rationalization: The most common cause of transfusion reactions is human error, including improper blood type matching and identification mistakes. This leads to issues such as ABO incompatibility reactions, which are preventable with careful checks and protocols.
- The concentration of calcium in the extracellular space is controlled by *
A. Parathormone
B. Catecholamine
C. Thyroxine
D. Aldosterone
Parathormone
Rationalization: Parathormone, also known as parathyroid hormone (PTH), plays a key role in regulating serum calcium levels. It increases blood calcium by stimulating the release of calcium from bone, increasing calcium absorption in the intestines, and increasing calcium reabsorption in the kidneys.
- WHICH OF THE FOLLOWING IS TRUE OF C –REACTIVE PROTEIN IS
A. Has a diurnal pattern
B. Produced by lymphocytes
C. Produced by hepatocytes
D. Affected by feeding
Produced by hepatocytes
Rationalization: C-reactive protein (CRP) is primarily produced by hepatocytes in the liver as a part of the acute phase response to inflammation or infection. It is not affected by diurnal variations or feeding and is not produced by lymphocytes.
- In a previously unexposed patient, when does the platelet count fall in heparin-induced thrombocytopenia (HIT)? *
A. <24 hours
B. 5-7 days
C. 3-4 days
D. 24-28 hours
5-7 days
Rationalization: In heparin-induced thrombocytopenia (HIT), typically, the platelet count begins to fall 5-7 days after starting heparin therapy in a patient who has not been previously exposed. This timing reflects the time needed for the immune system to develop antibodies against heparin-platelet factor 4 complexes.
- Signs of malignant transformation in a chronic wound include *
A. Overturned wound edges
B. Persistent granulation tissue with bleeding
C. Nonhealing after 2 weeks of therapy
D. Distal edema
A. Overturned wound edges
Malignant transformation of chronic ulcers can occur in any long-standing wound (Marjolin ulcer). Any wound that does not heal for a prolonged period of time is prone to malignant transformation. Malignant wounds are differentiated clinically from nonmalignant wounds by the presence of overturned wound edges. In patients with suspected malignant transformations, biopsy of the wound edges must be performed to rule out malignancy. Cancers arising de novo in chronic wounds include both squamous and basal cell carci-nomas. (See Schwartz 10th ed., p. 259.)
- Which of the following micronutrient/s is/are avoided in patient in renal failure patients. *
A. Omega 3 fatty acid
B. Vit C
C. Vit A
D. Vitamins A & C
Vitamins A & C
Rationalization: In patients with renal failure, it is often recommended to avoid excessive intake of vitamins A and C. These vitamins can accumulate to toxic levels in patients with impaired kidney function because the kidneys are unable to efficiently excrete excess amounts.
- What is the most common cause of surgical site infection? *
A. Aerobic skin commensals
B. Aerobic gram negative
C. Anaerobic gram positive
D. Enteric microorganism
Aerobic skin commensals
Rationalization: The most common cause of surgical site infections (SSI) is contamination by aerobic skin commensals, such as Staphylococcus aureus, including MRSA. These bacteria are part of the normal skin flora but can cause infections if they enter the body through surgical incisions.
- A 58 year old woman presented with lower abdominal pain, fever and difficulty walking. The patient has noted change in bowel habits over the past 3 months. Physical exam exhibits temperature of 39.5 degrees centigrade. She is lying supine with left leg flexed at the hospital. No scars in the abdomen but with tenderness in the left lower quadrant. What do you think is happening to the patient? *
A. Obstruction
B. Ischemia or rupture of vessels
C. Bleeding or rupture of vessels
D. Inflammation
Inflammation
Rationalization: The patient’s symptoms of lower abdominal pain, fever, change in bowel habits, and the physical exam finding of tenderness in the left lower quadrant with her leg flexed (likely for comfort) suggest a likely diagnosis of diverticulitis, an inflammation of the diverticula in the colon, particularly common in the left lower quadrant.
- Following a recent abdominal surgery, your patient is in the ICU with septic shock.
Below what level of hemoglobin would a blood transfusion be indicated? *
A. <8g/dL
B. <10g/dL
C. <7g/dL
D. <12g/dL
<7g/dL
Rationalization: In the setting of septic shock and critical illness, current guidelines generally recommend maintaining a lower threshold for transfusion, typically around a hemoglobin level of 7 g/dL, to optimize oxygen delivery while avoiding unnecessary transfusions.
- WHICH OF THE FF: IS TRUE OF INTERLEUKIN 4*
A. PRODUCED BY ACTIVATED TYPE 2 T-LYMPHOCYTES
B. POTENT ANTI-INFLAMMATORY ACTIVITY AGAINST ACTIVATED MACROPHAGES
C. IMPORTANT IN ANTIBODY ACTIVATED IMMUNITY
D. ALL OF THE ABOVE
ALL OF THE ABOVE
Rationalization: Interleukin 4 (IL-4) is produced by activated type 2 T-lymphocytes and plays a crucial role in promoting antibody-mediated immunity. It also has potent anti-inflammatory activities, particularly in modulating macrophage activation, which is key in allergic responses.
- What is the estimated risk of transmission of human immunodeficiency virus (HIV) from a needlestick from a source with HIV-infected blood? *
A. 10%
B. <0.5%
C. 1%
D. 5%
<0.5%
Rationalization: The risk of HIV transmission from a needlestick injury where the source is known to be HIV-positive is very low, typically less than 0.5%. This low risk reflects the effectiveness of the skin as a barrier and the relatively low concentration of virus in blood.
- Which of the following statement is TRUE regarding enteral feeding. *
A. Malnourished patient expected to be unable to eat adequately for > 5-7 days
B. Adequately nourished patient expected to be unable to eat > 7-9 days
C. Following severe trauma or burns
D. All of the above
All of the above
Rationalization: All the statements are true regarding indications for enteral feeding. Enteral feeding is recommended if a malnourished patient is expected to be unable to eat adequately for more than 5-7 days, an adequately nourished patient cannot eat for more than 7-9 days, or in cases of severe trauma or burns where nutritional needs cannot be met by oral intake alone.
- What organ is the presence of resident microorganism an important part of host defense? *
A. Urogenital tract
B. Biliary tract
C. Lungs
D. Colon
Colon
Rationalization: The colon contains a significant number of resident microorganisms, collectively known as the gut microbiota. These microorganisms play a crucial role in host defense by competing with pathogenic bacteria for nutrients and space, producing antimicrobial substances, and stimulating the immune system.
- What is the expected infection rate for patients undergoing elective cholecystectomy? *
A. 5%
B. 15%
C. 20%
D. 10%
5%
Rationalization: The infection rate for patients undergoing an elective cholecystectomy is relatively low, generally around 5%. This procedure, often performed laparoscopically, tends to have a lower risk of postoperative infections compared to more invasive surgeries.
- What type of cell is responsible for regulating cell proliferation, matrix synthesis and angiogenesis? *
A. Lymphocyte
B. Neutrophils
C. Macrophage
D. Platelets
Macrophage
Rationalization: Macrophages play a key role in wound healing and tissue repair by regulating cell proliferation, matrix synthesis, and angiogenesis. They secrete growth factors and cytokines that promote these processes, crucial for proper healing.
- Abdominal Examination Signs. Abdominal wall mass that does not cross the midline and remains palpable when rectus is contracted is most likely a Rectus muscle hematoma. *
A. Courvoisier sign
B. Rovsing sign
C. Fothergill sign
D. Charcot sign
Fothergill sign
Rationalization: Fothergill sign is indicative of a rectus sheath hematoma. It is characterized by a mass in the abdominal wall that does not cross the midline and remains palpable and unchanged when the rectus muscle is tensed.
- Exotoxins play in the pathogenicity of *
A. Clostridium species
B. Staphlococcus aureus
C. Streptococcus pyogenes
D. All of the above
All of the above
Rationalization: Exotoxins are potent toxins released by bacteria such as Clostridium species, Staphylococcus aureus, and Streptococcus pyogenes. These toxins can cause a variety of severe symptoms and are major factors in the pathogenicity of these bacteria.
- A patient has a chronic leg ulcer with associated dryness of skin, pallor and absence of hair, What is most likely diagnosis? *
A. Pressure ulcer
B. Decubitus ulcer
C. Ischemic arterial ulcer
D. Venous stasis ulcer
Ischemic arterial ulcer
Rationalization: The symptoms of dryness of skin, pallor, and absence of hair around a chronic leg ulcer are indicative of an ischemic arterial ulcer. These symptoms suggest poor arterial blood supply, typically seen in arterial insufficiency, where the lack of adequate blood flow leads to tissue ischemia and ulceration.
- Inflammation of the dermal and subcutaneous tissues secondary to non suppurative bacterial invasion, producing redness, edema and localized tenderness. *
A. Carbuncle
B. Furuncle
C. Cellulitis
D. Hidradenitis suppurativa
Cellulitis
Rationalization: Cellulitis is a common, potentially serious bacterial skin infection characterized by redness, swelling, and tenderness, typically involving the dermal and subdermal layers of the skin. Unlike furuncles and carbuncles, which involve purulent infections around hair follicles, cellulitis is usually non-suppurative and spreads more diffusely.
- Pressure sores mostly heal by *
A. Secondary intention
B. Surgical excision
C. Primary intention
D. Tertiary intention
Secondary intention
Rationalization: Pressure sores, or decubitus ulcers, typically heal by secondary intention, where the wound heals from the base up without surgical closure. This process involves granulation tissue formation, contraction, and epithelialization, especially because these wounds often have significant tissue loss and contamination.
- Which type of collagen is most important in wound healing? *
A. Type V
B. Type III
C. Type VII
D. Type XI
Type III
Rationalization: Type III collagen is crucial in the early phases of wound healing. It forms the initial scaffold on which further tissue rebuilding occurs. Later in the healing process, it is often replaced by Type I collagen, which provides greater tensile strength to the healed tissue.
- What type of peritonitis is commonly seen in patients with ascites and undergoing peritoneal dialysis? *
A. Secondary
B. Primary
C. Tertiary
D. Quaternary
Primary
Rationalization: Primary peritonitis, also known as spontaneous bacterial peritonitis, is commonly seen in patients with ascites, particularly those undergoing peritoneal dialysis. This type of peritonitis occurs without an apparent intra-abdominal source of infection and is typically monomicrobial.
- Which areas likely do NOT contain resident microorganisms? *
A. Terminal ileum
B. Oropharynx
C. Main pancreatic duct
D. Nares
Main pancreatic duct
Rationalization: The main pancreatic duct typically does not harbor resident microorganisms under normal conditions, unlike areas such as the oropharynx, nares, and even the terminal ileum, which have their own normal microbial flora.
- The sign is positive when pressure applied to the left lower quadrant results in right lower quadrant pain or tenderness *
A. Rovsing’s sign
B. Murphy’s sign
C. Psoas sign
D. Obturator sign
Rovsing’s sign
Rationalization: Rovsing’s sign is a classic clinical indicator used to help diagnose appendicitis. It is positive when palpation of the left lower quadrant of the abdomen elicits pain in the right lower quadrant, suggesting the presence of an inflamed appendix.
- The most effective post exposure prophylaxis for a surgeon stuck with a needle while operating on an HIV-positive patient is *
A. Triple drug therapy started within 24 hours of exposure.
B. Single drug therapy started within 24 hours of exposure.
C. None (no effective treatment is known).
D. Two-or three-drug therapy started within hours of exposure.
Two- or three-drug therapy started within hours of exposure.
Rationalization: Post-exposure prophylaxis (PEP) following exposure to HIV should ideally start as soon as possible, ideally within hours and no later than 72 hours after exposure. The current recommendation is to initiate a combination of two or three antiretroviral medications to minimize the risk of seroconversion. The regimen typically lasts for 28 days.
- In patients over 50 years old, with acute abdominal pain, the most common diagnosis is: *
A. Nonspecific abdominal pain
B. Acute appendicitis
C. Small bowel obstruction
D. Acute cholecystitis
Acute cholecystitis
Rationalization: In individuals over 50, acute cholecystitis, or inflammation of the gallbladder, is a common cause of acute abdominal pain. This condition is often due to gallstones and presents with right upper quadrant pain, fever, and leukocytosis.
- Which of the following is FALSE regarding hypertonic saline? *
A. Increases cerebral perfusion
B. Is an arteriolar vasodilator and may increase bleeding
C. Should not be used for initial resuscitation
D. Should be avoided in closed head injury
Should be avoided in closed head injury
Rationalization: This statement is false. Hypertonic saline is often used in the management of patients with closed head injuries as it helps reduce intracranial pressure by drawing fluid out of swollen brain tissues into the bloodstream.
- A 25 year old female was brought to ER after ingesting 100 tablets of INH. What is the expected ABG findings *
A. Metabolic alkalosis
B. Respiratory acidosis
C. Metabolic acidosis
D. Respiratory alkalosis
Metabolic acidosis
Rationalization: Ingestion of a high dose of isoniazid (INH), especially in an overdose scenario, can lead to metabolic acidosis. INH overdose typically causes a high anion gap metabolic acidosis due to the production of metabolites that increase acid load.
- Which hormone/s promote/s sodium reabsorption and preservation. *
A. Cortisol
B. ADH
C. Aldosterone
D. All of the above
C. Aldosterone
Rationalization: Cortisol, antidiuretic hormone (ADH), and aldosterone all play roles in promoting sodium reabsorption and preservation in the body. Aldosterone directly increases sodium reabsorption in the renal tubules, ADH indirectly affects sodium balance by managing water retention, and cortisol has glucocorticoid activity that also influences sodium retention.
- The surgeon should include this layer of intestinal wall considered as the layer with the greatest tensile strength and suture holding capacity to prevent dehiscence, anastomotic leaks and fistula formation. *
A. Serosa
B. Submucosa
C. Mucosa
D. Muscularis
Submucosa
Rationalization: The submucosa is the strongest layer of the intestinal wall and has the greatest suture-holding capacity. This layer is crucial in preventing dehiscence and leaks when creating bowel anastomoses because it provides the structural strength needed for healing.
- Which of the following is the most common intrinsic platelet defect? *
A. Storage pool disease
B. Thrombasthenia
C. Cyclooxygenase deficiency
D. Bernard-Soulier syndrome
A. Storage pool disease
- Featured Symptoms in Modified Alvarado Scoring System for Appendicitis except *
A. Nausea/vomiting
B. Anorexia
C. Right iliac fossa pain
D. Loose stools(diarrhea)
Loose stools (diarrhea)
Rationalization: The Modified Alvarado Scoring System for diagnosing appendicitis includes symptoms like anorexia, nausea, vomiting, and right iliac fossa pain but does not typically include loose stools or diarrhea as a criterion. Diarrhea is more likely to be associated with other gastrointestinal conditions.
- A 60 yr old patient came into the ER with difficulty of breathing. On auscultation there was decrease breath sound on the right lung field with audible wheezing. His ABG will reveal *
A. Respiratory acidosis
B. Metabolic acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis
Respiratory acidosis
Rationalization: Given the symptoms of difficulty breathing and decreased breath sounds, which suggest poor ventilation, along with wheezing, it’s likely the patient might be experiencing an obstructive pulmonary issue like COPD exacerbation or asthma. This often leads to CO2 retention, causing respiratory acidosis.
- What is the recommended prophylactic antibiotic for modified radical mastectomy?*
A. Ceftazidime
B. Amoxicillin
C. Cefazolin
D. Ampicillin
Cefazolin
Rationalization: Cefazolin is commonly recommended for prophylaxis in clean surgical procedures including breast surgery like modified radical mastectomy. It is effective against the skin flora that are most likely to cause postoperative infections.
- Who proposed that patients die not from infection but from the body’s response to infection? *
A. William Osler
B. Joseph Lister
C. Ignaz Semmelweis
D. Louis Pasteur
William Osler
Rationalization: William Osler noted that it is not necessarily the infection that kills patients but rather the body’s response to the infection, highlighting the role of what we now understand as the inflammatory response and systemic immune processes.
- Which of the following is/are the most active in enhancing wound fibroplasia and significantly increase wound collagen deposition? *
A. Arginine
B. Vitamin A
C. Vitamin C
D. All of the above
A. Arginine
Rationalization: Arginine, Vitamin A, and Vitamin C all play significant roles in wound healing. Arginine promotes collagen synthesis and increases nitric oxide which helps in wound healing; Vitamin A stimulates fibroblast activity and collagen synthesis; Vitamin C is essential for hydroxylation of collagen molecules, crucial for their stabilization and function.
- What is the cornerstone of treatment of venous ulcers? *
A. Vasodilators
B. Control of blood sugar
C. Compression therapy
D. Use of growth factors
Compression therapy
Rationalization: Compression therapy is the cornerstone of treating venous ulcers, as it helps reduce edema, improves venous return, and decreases venous hypertension, which are critical factors in the pathophysiology of venous ulcers.
- A 76 year old diabetic patient receiving steroids developed aggressive soft tissue infection as manifested by erythema, tenderness ,blebs, crepitus and dishwater pus. What is the likely diagnosis? *
A. Lymphangitis
B. Necrotizing fasciitis
C. Carbuncle
D. Cellulitis
Necrotizing fasciitis
Rationalization: The presentation of erythema, tenderness, blebs, crepitus (suggesting gas production by bacteria), and dishwater pus (a sign of a “dirty” looking discharge) are classic signs of necrotizing fasciitis, a severe, life-threatening soft tissue infection requiring urgent surgical and medical intervention.
- Muscle guarding *
A. Detection of increased abdominal muscle tone during palpation
B. Passively extending the hip or actively flexing the hip against resistance causes pain
C. Internal or external rotation of the flexed hip causes pain
D. Sudden withdrawal of the hand after pressing the abdomen may cause increase in the abdominal tenderness
Detection of increased abdominal muscle tone during palpation
Rationalization: Muscle guarding is a reflex contraction of the abdominal muscles that occurs during palpation of the abdomen. It is a protective mechanism that occurs in response to painful stimuli from underlying organs, indicating possible inflammation or irritation.
- The main determinant/s of body osmolality is/are *
A. Na
B. BUN
C. Glucose
D. All of the above
All of the above
Rationalization: Body osmolality, which is a measure of solute concentration in body fluids, is primarily determined by sodium (Na), blood urea nitrogen (BUN), and glucose levels. These solutes have significant osmotic activity and their concentrations greatly influence the osmolality.
- Which of the following biochemical test will provide the latest protein status of a surgical patient *
A. Transferrin
B. Albumin
C. Prealbumin
D. Absolute lymphocytic count
Prealbumin
Rationalization: Prealbumin (transthyretin) is a more sensitive and rapid indicator of nutritional status compared to albumin because of its shorter half-life (about 2 days). It reflects recent changes in protein intake and nutritional status, making it useful for monitoring the nutritional therapy of hospitalized patients.
- All are possible causes of postoperative hyponatremia EXCEPT *
A. Transient decrease in antidiuretic hormone (ADH) secretion.
B. Administration of antipsychotic medication.
C. Excess infusion of normal saline intraoperatively.
D. Excess oral water intake.
A. Transient decrease in antidiuretic hormone (ADH) secretion.
- Which of the following statements is/are true of eicosanoids *
A. Secreted by all nucleated cells except the monocytes
B. Stored in the liver hepatocytes and rapidly synthesized
C. Derivative of membrane phopsholipid arachidonic acid
D. All of the above
C. Derivative of membrane phospholipid arachidonic acid
Eicosanoids are a group of biologically active compounds derived from arachidonic acid, a type of phospholipid found in the cell membranes. They include prostaglandins, thromboxanes, and leukotrienes, which play crucial roles in inflammation, immunity, and other vital physiological functions. Eicosanoids are synthesized in response to cellular stimuli rather than stored pre-formed; thus, they are rapidly produced and released by cells as needed.
- Which afferent signals is sensitive to changes in oxygen tension, H ion concentration and CO2 levels. *
A. Chemoreceptors in the aorta and carotid bodies
B. Protein and non protein mediators
C. Baroreceptors with in the atria, aortic arch and carotid bodies
D. All of the above
A. Chemoreceptors in the aorta and carotid bodies
Rationalization: Chemoreceptors located in the carotid bodies (near the bifurcation of the carotid artery) and the aorta are primarily responsible for detecting changes in oxygen tension (partial pressure), carbon dioxide levels, and hydrogen ion concentration in the blood. These receptors then send signals to the brain to adjust breathing to maintain homeostasis.
- The goal of neuroendocrine response in shock is to maintain perfusion in which of the following vital organs. *
A. Brains
B. Lungs
C. Heart
D. A and B
E. A and C
A and C (brains and heart)
Rationalization: The primary goal of the neuroendocrine response in shock is to preserve perfusion to critical organs such as the brain and heart. These organs are highly sensitive to hypoxia, and maintaining their function is crucial for survival. The lungs, while important, have a dual blood supply and are less likely to suffer from immediate hypoxic damage compared to the brain and heart.
- Which of the following type of wound dressing is recommended to create a warm moist environment that promote debridement and healing? *
A. Gauze
B. Tulle like sofratulle
C. Hydrocolloid
D. Semipermeable film like tegaderm
Hydrocolloid
Rationalization: Hydrocolloid dressings are ideal for creating a moist and warm environment that supports both debridement and healing. These dressings are occlusive or semi-occlusive, which helps maintain wound hydration, facilitates autolytic debridement, and promotes faster healing.
- During evaluation of a male patient with right lower quadrant pain the following are included in the differential diagnosis. *
A. Acute mesenteric adenitis, torsion of the fallopian tube, acute appendicitis
B. Acute appendicitis, ovarian cyst, acute gastroenteritis
C. Acute mesenteric adenitis, gastroenteritis and acute appendicitis
D. Gastroenteritis, ovarian cyst acute appendicitis
C. Acute mesenteric adenitis, gastroenteritis and acute appendicitis
Rationalization: For a male patient, appropriate differential diagnoses for right lower quadrant pain would include conditions like acute mesenteric adenitis, gastroenteritis, and acute appendicitis. Torsion of the fallopian tube and ovarian cyst would not be relevant in a male patient.
- A fully heparinized patient develops a condition requiring emergency surgery. After stopping the heparin, what else should be done to prepare the patient? *
A. Immediate administration of FFP.
B. Transfusion of 10 units of platelets.
C. Immediate administration of protamine 5mg for every 100 units of heparin most recently administered.
D. Nothing, if the surgery can be delayed for 2 to 3 hours.
C. Immediate administration of protamine 5mg for every 100 units of heparin most recently administered.
Rationalization: In cases where a patient must undergo emergency surgery and has been fully anticoagulated with heparin, immediate reversal of heparin’s effects is necessary. Protamine sulfate is administered to neutralize heparin, with the typical dose being 1 mg of protamine for every 100 units of heparin given within the last 2-3 hours.
- A patient in the ICU has been on ventilator support for 3 weeks. He has new onset elevated WBC count, fever, and consolidation seen on chest X-ray. What is an appropriate next step? *
A. Obtain bronchoalveolar lavage.
B. Obtain chest CT.
C. Exchange endotracheal tube and change respiratory circuit.
D. Start treatment with empiric penicillin G.
Obtain bronchoalveolar lavage.
Rationalization: In a ventilated ICU patient who develops signs of a respiratory infection, such as elevated WBCs, fever, and pulmonary consolidation, the next appropriate step is to obtain a bronchoalveolar lavage (BAL). This procedure allows for direct sampling of the lower respiratory tract, providing valuable diagnostic material to identify the causative organism and guide appropriate antibiotic therapy.
A 45 year old female underwent Subtotal Gastrectomy due Stage 2 antral Gastric cancer with Jejunostomy tube inserted in the proximal jejunum. On the 2nd post operative the surgeon started nutrition support. There is bowel movement and flatus. Hgb- 110, WBC-8 Pertinent: Afebrile HR-76 RR-22 Wt:58 kg Ht:5’5* Conscious, coherent Albumin= 27 (35-45) Creatinine- 78 (Normal)
- What will be the patient’s protein caloric requirement base on the actual weight. *
A. 456 kcal/day
B. 783 kcal/day
C. 474.4 kcal/day
D. 348 kcal/day
D. 348 kcal/day
- Compute for the IBW.
A. 57 kg
B. 61.5 kg
C. 63.8 kg
D. 59.3 kg
A. 57 kg
- What will be her fat requirement in grams per day.*
A. 119.9 g
B. 126.6 g
C. 150.8 g
D. 100.5 g
C. 150.8 g
- What will be the patient’s protein caloric requirement base on the actual weight. *
A. 456 kcal/day B. 783 kcal/day
C. 474.4 kcal/day
D. 348 kcal/day
D. 348 kcal/day
- Compute for the IBW. *
A. 57 kg
B. 61.5 kg
C. 63.8 kg
D. 59.3 kg
A. 57 kg
- What will be her carbohydrate requirements in grams per day. *
A. 360 g
B. 339.3 g
C. 380.5 g
D. 226.2 g
D. 226.2 g
- What will be the most appropriate route of nutritional support. *
A. Feeding jejunostomy
B. Central venous access
C. Oral
D. Peripheral venous access
E. NGT
C. Oral
Oral (C) is always preferred if the patient is capable of oral intake and has a functioning gastrointestinal tract. It is the most natural, least invasive, and typically the safest method.
- Compute for the AjBW.
A. 59.82 kg
B. 57.04 kg
C. 58.2 kg
D. 62.9. kg
B. 57.04 kg
- Compute for the BMI. *
A. 22.3
B. 23.1
C. 21.4
D. 21.8
E. 24
C. 21.4
- What will be the patient’s non protein caloric requirement *
A. 2262 kcal/day
B. 1349 kcal/day
C. 2697 kcal/day
D. 3120 kcal/day
B. 1349 kcal/day
- Which of the following will be the most appropriate frequency and duration of feeding. *
A. bolus every 6 hours
B. drip for 24 hours
C. bolus at least every 4 hours
D. drip for 4 hours every 6hrs
B. drip for 24 hours
Drip for 24 hours (B) generally refers to continuous enteral feeding, which is beneficial for patients who need a steady supply of nutrients and for those who might not tolerate large volumes at once (e.g., critically ill patients or those with compromised GI function). This method is often easier on the GI tract and can help manage glucose levels more steadily.
