Surgery - END (Part 2) Flashcards
Water constitutes what percentage of total body weight? *
A. 30-40%.
B. 40-50%
C. 50-60%
D. 60-70%.
C. 50-60%
Rationale: Water typically makes up about 50-60% of an adult’s total body weight. This proportion can vary based on factors such as age, gender, and body fat percentage, but for a healthy adult, around 50-60% is a standard reference range.
Closure of an appendectomy wound in a patient with perforated appendicitis who is receiving appropriate antibiotics will result in a wound infection in what percentage of patients? *
A. 3-4%
B. 8-12%
C. 15-18%
D. 22-25%
A. 3-4%
A 35-year-old unrestrained driver was involved in a motor-vehicle crash. A computed tomography (CT) of the abdomen revealed a large hematoma in the second portion of duodenum. The rest of the abdomen is normal. The initial management of this duodenal hematoma should be: *
A. Operative evacuation
B. Nasogastric decompression, intravenous fluids, and gradual resumption of oral diet
C. Endoscopic retrograde cholangiopancreatogram (ERCP)
D. Laparotomy, pyloric exclusion, and gastrojejunostomy
E. Octretide
B. Nasogastric decompression, intravenous fluids, and gradual resumption of oral diet
Rationale: The initial management of a duodenal hematoma, especially in the absence of other abdominal injuries, is conservative. This includes nasogastric decompression to relieve gastric distension and prevent vomiting, intravenous fluids to maintain hydration, and a gradual resumption of an oral diet as tolerated. Surgery or other invasive procedures are considered if there is no improvement with conservative management.
38-year-old woman is brought to the emergency department after she stepped on a rusty nail and sustained a puncture wound to the foot. The patient has been on a therapeutic dose of steroids for the past 5 years for ulcerative colitis. Her last tetanus toxoid booster was 8 years ago. What should the patient receive? *
A. Tetanus toxoid booster
B. Human immunoglobulin
C. Antibiotics with anaerobic coverage
D. Tetanus toxoid plus human immunoglobulin
E. Tetanus toxoid plus human immunoglobulin and antibiotics with aerobic and anaerobic coverage
E. Tetanus toxoid plus human immunoglobulin and antibiotics with aerobic and anaerobic coverage
A 27-year-old man is brought to the emergency room after a house fire. He has burns around his mouth and his voice is hoarse, but breathing is unlabored. What most appropriate next step in management? *
A. Immediate endotracheal intubation
B. Examination of oral cavity and pharynx, with fiberoptic laryngoscope if available
C. Place on supplemental oxygen
D. Placement of two large-bore intravenous (IV) catheters with fluid resuscitation
B. Examination of oral cavity and pharynx, with fiberoptic laryngoscope if available
Rationale: The patient’s burns around the mouth and hoarseness suggest possible inhalation injury or airway burns. However, since his breathing is unlabored, immediate endotracheal intubation may not be necessary. A thorough examination of the oral cavity, pharynx, and if possible, the larynx using a fiberoptic laryngoscope is appropriate to assess the extent of injury and determine the need for airway management.
Which of the following is NOT one of the four major physiologic events of hemostasis? *
A. Fibrinolysis
B. Vasodilatation
C. Platelet plug formation
D. Fibrin production
B. Vasodilatation
Rationale: Hemostasis involves the arrest of bleeding and includes four main steps: vasoconstriction, platelet plug formation, fibrin production, and finally fibrinolysis. Vasodilatation is not a part of the hemostasis process; in fact, vasoconstriction occurs initially to help reduce blood flow to the injured area.
What percentage burn does a patient have who has suffered burns to one leg (circumferential), one arm (circumferential), and the anterior trunk? *
A. 18%
B. 27%
C. 36%
D. 45%.
D. 45%.
According to the Rule of Nines used in calculating body surface area affected by burns, each arm is approximately 9% of the body’s surface area, each leg is approximately 18%, and the entire trunk is approximately 36%. Therefore, burns to one entire leg (18%), one entire arm (9%), and the anterior trunk (half of 36%, so 18%) would total 45%.
What is the risk of Hepatitis C and HIV-1 transmission with blood transfusion? *
A. 1:10,000,000
B. 1:1,000,000
C. 1:500,000
D. 1:100,000
B. 1:1,000,000
Rationale: The risk of transmission of Hepatitis C and HIV-1 through blood transfusion has greatly decreased due to rigorous screening processes. While the exact risk can vary, it is generally considered to be around 1 in 1,000,000 for each virus, reflecting the effectiveness of current blood screening methods.
A patient who has spasms in the hand when a blood pressure cuff is blown up most likely has *
A. Hypercalcemia
B. Hypocalcemia
C. Hypermagnesemia
D. Hypomagnesemia
B. Hypocalcemia
Rationale: The description is indicative of Trousseau’s sign, a medical phenomenon where inflation of a blood pressure cuff to a level above systolic pressure leads to spasms of the hand and wrist. This sign is commonly associated with hypocalcemia, as low calcium levels increase nerve excitability.
Allergic reactions do not occur with *
A. Packed RBC’s
B. FFP.
C. Cyroprecipitate
D. None of the above
D. None of the above
Rationale: Allergic reactions can potentially occur with any blood product, including packed red blood cells (RBCs), fresh frozen plasma (FFP), and cryoprecipitate. Therefore, it’s incorrect to say that allergic reactions do not occur with any specific one of these products; all can potentially trigger an allergic response in susceptible individuals.
A 53-year-old woman involved in a bus accident suffered a severe blow to the middle upper abdomen. Physical examination revealed diffuse tenderness, but there was no evidence of rebound tenderness or guarding. What test would be performed to rule out traumatic pancreatitis? *
A. Peritoneal lavage
B. Serum amylase
C. CT scan with oral and intravenous contrast
D. Upper GI study
E. ERCP
C. CT scan with oral and intravenous contrast
Rationale: A CT scan with oral and intravenous contrast is the best choice for assessing abdominal trauma and can provide detailed images of the pancreas and surrounding structures to rule out traumatic pancreatitis. It can identify pancreatic injuries, hematomas, and other complications like fluid collections.
Patients with a penicillin allergy are LEAST likely to have a cross-reaction with *
A. Synthetic penicillins
B. Carbapenems
C. Cephalosporins
D. Monobactams
D. Monobactams
Rationale: Monobactams, such as aztreonam, have a different chemical structure from penicillins and are less likely to cause cross-reactivity in patients with a penicillin allergy. Unlike penicillins, cephalosporins, and carbapenems, monobactams do not have the beta-lactam ring structure similar to penicillins, making them a safer option for patients with known penicillin allergies
A 46-year-old man is struck by a motor vehicle while crossing the street; he arrives in the ED hypotensive, bradycardic, and unable to move his extremities.
What is the most likely cause of his hypotension? *
A. Hypovolemic shock
B. Obstructive shock
C. Neurogenic shock
D. Vasodilatory shock.
C. Neurogenic shock
Rationale: Neurogenic shock can occur following a severe spinal cord injury, which may be inferred from the inability to move extremities and the presence of bradycardia combined with hypotension. This type of shock results from the loss of sympathetic tone, leading to vasodilation and decreased cardiac output.
A 68-year-old woman is hit by a car and injures her midabdomen. The best way to rule out a rupture of the second part of the duodenum is by which mode? *
A. Repeated physical examinations
B. Ultrasound
C. Repeated amylase levels
D. CT with oral and intravenous contrast
E. Peritoneal lavage
D. CT with oral and intravenous contrast
Rationale: A CT scan with oral and intravenous contrast is the most effective method to evaluate for injuries such as a rupture of the duodenum. It provides detailed images of the abdominal organs, allowing for the identification of any ruptures, hematomas, or other injuries.
Which factor does NOT influence the development of surgical site infections (SSls)? *
A. Duration of procedure
B. Degree of microbial contamination of the wound
C. Malnutrition
D. General anesthesia
D. General anesthesia
Rationale: While factors like the duration of the procedure, the degree of microbial contamination of the wound, and the nutritional status of the patient (malnutrition) can influence the risk of SSIs, general anesthesia itself does not directly affect the development of surgical site infections.
A 55-year-old male with a known history of alcoholism is admitted with acute pancreatitis. His serum calcium is 7 mg/dL. Management is based upon which of the following *
A. One-fourth of calcium in serum is ionized
B. Alkalosis increases the ionized calcium component
C. Hypocalcemia may cause polyuria and polydipsia
D. Determination of serum albumin is necessary
E. Treatment should involve intravenous administration of calcium chloride
D. Determination of serum albumin is necessary
Rationale: In the context of hypocalcemia and acute pancreatitis, it is important to determine the serum albumin level because calcium is often bound to albumin in the blood. Hypoalbuminemia, which can occur in the setting of alcoholism and acute illness, may cause a decrease in total serum calcium while the ionized (biologically active) calcium may be normal. Therefore, it’s crucial to assess the albumin level to correctly interpret the calcium level and guide management.
A 46-year-old man has multiple intra-abdominal injuries after a gunshot wound.
Celiotomy reveals multiple injuries to small and large bowel and major bleeding from the liver. After repair of the bowel injuries, the abdomen is closed with towel clips, leaving a large pack in the injured liver. Within 12 hours, there is massive abdominal swelling with edema fluid, and intra-abdominal pressure exceeds 35 mm Hg. The immediate step in managing this problem is to *
A. Administer albumin intercavernously
B. Give an IV diuretic.
C. Limit IV fluid administration
D. Open the incision to decompress the abdomen
D. Open the incision to decompress the abdomen
Rationale: This scenario describes abdominal compartment syndrome, where intra-abdominal pressure is critically high, threatening organ function. The immediate treatment is to relieve the pressure, typically by opening the abdominal incision to decompress the abdomen. This can prevent further organ damage and improve blood flow.
All the following treatments for hyperkalemia reduce serum potassium EXCEPT *
A. Bicarbonate
B. Kayexalate
C. Glucose infusion with insulin
D. Calcium
D. Calcium
Rationale: Calcium is used in the treatment of hyperkalemia to stabilize the heart muscle cells’ membranes, reducing the risk of arrhythmias. However, it does not lower the serum potassium level; it merely protects against its cardiac effects. Bicarbonate, Kayexalate, and glucose infusion with insulin help to actually lower the potassium levels in the blood.
The most abundant amino acid in the human body is *
A. Carnitine.
B. Arginine
C. Glutamine
D. Methionine
C. Glutamine
Rationale: Glutamine is the most abundant amino acid in the human body and plays a key role in many biological processes, including protein synthesis, energy production, and as a nitrogen transporter.
A 65-year-old man is brought into the emergency department following his injury as a passenger in a car crash. He complains of right side chest pain.
Physical examination reveals a respiratory rate of 42 breaths per minute and multiple broken ribs of a segment of the chest wall that moves paradoxically with respiration. What should the next step be? *
A. Tube thoracostomy
B. Tracheostomy
C. Thoracentesis
D. Endotracheal intubation
E. Intercostal nerve blocks
C. Thoracentesis
Successful antibiotic penetration of a burn eschar can be achieved with *
A. Mafenide acetate
B. Neomycin
C. Silver nitrate
D. Silver sulfadiazine
A. Mafenide acetate
Rationale: Mafenide acetate is known for its ability to penetrate burn eschar effectively. It has broad-spectrum antimicrobial activity and is used topically to prevent and treat infections in burn wounds. Unlike other agents, which may have limited penetration through eschar, mafenide acetate can reach deeper tissues.
A 22-year-old man is shot with a handgun and found to have a through-and-through injury to the right transverse colon. There is little fecal contamination and no bowel devascularization. At operation, what does he require? *
A. Right hemicolectomy with ileotransverse colon anastomosis
B. Right hemicolectomy with ileostomy and mucous fistula
C. Debridement and closure of wounds with exteriorization of colon
D. Debridement and closure of wounds
E. Segmental resection with primary anastomosis
D. Debridement and closure of wounds
A 54-year-old man underwent major abdominal surgery to remove a ruptured aortic aneurysm. Four days after the operation, an attempt was made to wean him off the ventilator. ABG analysis reveals pH, 7.54; PCO2, 30 mm Hg; PO2, 110 mm Hg; HCO3,30 mEq/L; and Sa02, 99%. Blood gas analysis reveals which of the following? *
A. Respiratory acidosis
B. Metabolic alkalosis
C. Respiratory alkalosis
D. Compensated respiratory acidosis
E. Combined respiratory and metabolic alkalosis
B. Metabolic alkalosis
A 35-year-old woman presents to the emergency department with a stab wound to the neck above the angle of the mandible. The patient’s blood pressure is 110/80 mm Hg, pulse rate is 100 bpm, and respiration rate is 24 breaths per minute. Between initial presentation and insertion of intravenous lines, the hematoma in the upper neck enlarges significantly. What should be the next step in the patient’s management? *
A. Barium swallow
B. Flexible endoscopy
C. Operative exploration
D. Doppler ultrasound
E. Angiography
E. Angiography
A 55 year-old restrained driver was involved in a motor-vehicle crash. He is hemodynamically stable and has a large seat belt sign on the abdomen. His abdomen is tender to palpation. In this patient one should be most concerned about: *
A. Liver and spleen injury
B. Transection of the head of the pancreas
C. Renal pedicle avulsion
D. Hollow-viscus injuries
E. Pelvic fracture
D. Hollow-viscus injuries
Rationale: The presence of a seat belt sign (ecchymosis across the abdomen from the seat belt) and abdominal tenderness in a patient involved in a motor-vehicle crash is particularly concerning for hollow-viscus injuries (injury to the bowel or other hollow abdominal organs). These injuries may not be immediately apparent but can lead to significant morbidity if not promptly identified and treated.
The proliferative phase of wound healing occurs how long after the injury? *
A. 1 day
B. 2 days
C. 7 days.
D. 14 days
C. 7 days.
A 16-year-old girl had an injury to the right retroperitoneum with duodenal contusion. What is the test required to exclude a rupture of the duodenum? *
A. Serum amylase
B. Dimethyliminodiacetic acid (HIDA) scan
C. Gastrografin study
D. Upper Gl with barium
E. ERCP
C. Gastrografin study
Rationale: A Gastrografin (or water-soluble contrast) study is the preferred initial test to evaluate for duodenal rupture. Gastrografin is a contrast agent that can be used in imaging to highlight the gastrointestinal tract and identify leaks or ruptures, particularly in the duodenum.
A 18-year-old girl presents to the emergency department with a stab wound to the abdomen and a blow to the head that left her groggy. Her blood pressure is 80/0 mm Hg, pulse is120 bpm, and respiration rate is 28 breaths per minute. Her abdomen has a stab wound in the anterior axillary line at the right costal margin.
Two large-bore intravenous lines, a nasogastric tube, and a Foley catheter are inserted. The blood pressure rises to 85 mm Hg after 2 L of Ringer’s lactate. The appropriate management is which of the following? *
A. Peritoneal lavage
B. Ultrasound of the abdomen
C. Laparoscopic assessment of the peritoneal cavity
D. Exploratory laparotomy
E. CT of the head
D. Exploratory laparotomy
Rationale: Given the patient’s stab wound in a critical area, hemodynamic instability despite fluid resuscitation, and the potential for significant intra-abdominal injuries, immediate exploratory laparotomy is indicated. This allows for direct visualization and treatment of any internal injuries. The urgency of the abdominal findings supersedes the need for head imaging at this critical juncture.
Which is required for platelet adherence to injured endothelium? *
A. Thromboxane A2.
B. Glycoprotein (GP) IIb/Illa
C. Adenosine diphosphate (ADP)
D. Von Willebrand factor (vWF)
D. Von Willebrand factor (vWF)
Rationale: Von Willebrand factor (vWF) plays a crucial role in the initial stages of blood clot formation by mediating the adhesion of platelets to the site of endothelial injury. vWF binds to specific receptors on the platelet surface (like glycoprotein Ib), anchoring the platelets to the damaged vessel wall.
A 63-year-old man sustains numerous injuries involving the abdomen and lower extremities. During the intra- and postoperative periods, he is resuscitated with 10 L of Ringer’s lactate and 2 U of packed red blood cells (RBC). After initial improvement, he has severe dyspnea on the second postoperative day. The most useful initial diagnostic test is which of the following? *
A. Electrocardiogram
B. Analysis of arterial blood gas
C. Insertion of a central venous line
D. Ventilation-perfusion scan
E. Computed tomography (CT) scan of abdomen
B. Analysis of arterial blood gas (ABG)
Rationale: Given the sudden onset of severe dyspnea postoperatively, especially after significant fluid resuscitation, an ABG analysis would be very informative. It can help assess the oxygenation status, ventilation, and acid-base balance, providing crucial information to diagnose potential issues such as acute respiratory distress syndrome (ARDS), fluid overload, or pulmonary embolism.
Hypocalcemia may cause which of the following? *
A. Congestive heart failure
B. Atrial fibrillation
C. Pancreatitis
D. Hypoparathyroidism
A. Congestive heart failure
Which of the following is true about antidiuretic hormone (ADH) production in injured patients? *
A. ADH acts as a potent mesenteric vasoconstrictor.
B. ADH levels all to normal within 2 to 3 days o the initial insult
C. ADH decreases hepatic gluconeogenesis.
D. ADH secretion is mediated by the renin-angiotensin system.
A. ADH acts as a potent mesenteric vasoconstrictor.
Fluid resuscitation using albumin *
A. Is associated with coagulopathy
B. Is available as 1% or 5% solutions
C. Can lead to pulmonary edema
D. Decreased factor XIII
C. Can lead to pulmonary edema
Rationale: Albumin is used in fluid resuscitation to expand blood volume. However, if administered excessively or in patients with compromised cardiac or renal function, it can lead to fluid overload and pulmonary edema, where fluid accumulates in the lungs, making it difficult to breathe.
A 54-year-old man skidded from the road at high speed and hit a tree. Examples of deceleration injuries in this patient include: *
A. Aortic valve rupture
B. Kidney injury
C. Posterior dislocation of shoulder
D. Mesenteric avulsion
E. Stomach rupture
D. Mesenteric avulsion
D. Mesenteric avulsion is the most prototypical example of a deceleration injury among the options provided. This type of injury aligns with the mechanics of deceleration where the fixed point (attachment of the mesentery to the posterior abdominal wall) and the moving organ (small intestine) are subjected to forces that lead to avulsion injuries. This selection best fits the described injury mechanisms in deceleration scenarios detailed in surgical literature and textbooks such as “Schwartz’s Principles of Surgery”.
A trauma patient arrives following a stab wound to the left chest with systolic blood pressure (SBP) 85 mm Hg, which improves slightly with intravenous (IV) fluid resuscitation. Chest X-ray demonstrates clear lung fields. What is the most appropriate next step? *
A. Computed tomography (CT) scan of the chest
B. Pelvic X-ray
C. Focused abdominal sonography for trauma (FAST) examination
D. Tube thoracostomy of the left chest
C. Focused abdominal sonography for trauma (FAST) examination
Which is NOT a component of systemic inflammatory response syndrome (SIRS)?
A. Temperature
B. White blood cell (WBC) count
C. Blood pressure
D. Heart rate
C. Blood pressure
Rationale: SIRS criteria include body temperature abnormalities, heart rate, respiratory rate, and white blood cell count. While blood pressure changes can be a consequence of severe SIRS leading to shock, it is not one of the primary diagnostic criteria for defining SIRS.
Less than 0.5% of transfusions result in a serious transfusion-related complication. What is the leading cause of transfusion-related deaths? *
A. Transfusion-related acute lung injury
B. ABO hemolytic transfusion reactions
C. Bacterial contamination of platelets
D. latrogenic hepatitis C infection
A. Transfusion-related acute lung injury (TRALI)
Rationale: TRALI has become one of the leading causes of transfusion-related mortality. It typically occurs within hours of transfusion, leading to acute respiratory distress and pulmonary edema not related to cardiac overload or volume excess.
Normal saline is *
A. 135 mEq NaCI/L
B. 145 mEq NaCl/L
C. 148 mEq NaCI/L
D. 154 mEq NaCI/L
D. 154 mEq NaCl/L
Rationale: Normal saline (0.9% sodium chloride) contains 154 mEq of sodium and 154 mEq of chloride per liter.
A 50-year-old man who weighs 65 kg is being observed in the ICU. Twenty-four hours postoperatively, he develops convulsions. His serum sodium is 118 mEq/L.
Appropriate management includes which of the following? *
A. Administration of normal saline (0.9%)
B. Administration of hypertonic saline (3%)
C. Emergency hemodialysis
D. Administration of vasopressin
E. Administration of Lasix, 40 mg intravenously (IV)
B. Administration of hypertonic saline (3%)
Rationale: Convulsions due to severe hyponatremia (serum sodium 118 mEq/L) require prompt treatment with hypertonic saline (3%) to raise the serum sodium concentration quickly and safely to prevent further neurological complications.
Cardiogenic shock*
A. Is most commonly caused by exacerbation of congestive heart failure
B. Cardiogenic shock following an acute myocardial infarction is typically present on admission.
C. Cardiogenic shock occurs in 5 to 10% of acute MIs.
D. Is characterized by hypotension, reduced cardiac index, and reduced pulmonary artery wedge pressure.
C. Cardiogenic shock occurs in 5 to 10% of acute MIs.
Rationale: Cardiogenic shock is a serious condition that occurs in 5 to 10% of patients with acute myocardial infarction (MI) and is characterized by reduced cardiac output leading to inadequate tissue perfusion. It is associated with high mortality and typically presents with hypotension, a reduced cardiac index, and increased pulmonary artery wedge pressure (not reduced).
A 70-year-old man, who weighs 70 kg, is admitted with acute cholecystitis. His calculated daily fluid requirement for maintenance is approximately which of the following?*
A. 1 L
B. 2L
C. 2.5 L
D. 3 L
E. 4 L
C. 2.5 L
C. 2.5 L is the most appropriate choice for the daily fluid requirement of a 70-year-old man weighing 70 kg with acute cholecystitis. This volume meets the calculated needs based on standard fluid management principles, ensuring adequate hydration while avoiding the risks associated with both underhydration and fluid overload in a patient without specific complicating factors.
A 69-year-old man has undergone anterior resection for carcinoma of the rectum. He is extubated in the operating room (OR). In the recovery room, he is found to be restless with an HR of 136 bpm and a BP of 144/80 mm Hg. ABG analysis on room air reveals pH, 7.24; PCO2, 60 mm Hg; PO2, 54 mm Hg;
HCO3,25 mEq/L; and SaO2, 90%. The physiologic status can best be described as which of the following? *
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic acidosis
D. Metabolic alkalosis
E. Combined respiratory and metabolic acidosis
B. Respiratory acidosis
Rationale: The ABG values show a decreased pH (7.24), indicating acidosis. The elevated PCO2 (60 mm Hg) suggests that this is due to respiratory causes, hence respiratory acidosis. The normal HCO3 level (25 mEq/L) suggests there is no significant metabolic compensation or contribution.
An 7-year-old boy is brought to the emergency room after accidentally touching a hot iron with his forearm. On examination, the burned area has weeping blisters and is very tender to the touch. What is the burn depth? *
A. First degree
B. Second degree
C. Third degree
D. Fourth degree
B. Second degree
Rationale: Second-degree burns (partial-thickness burns) are characterized by the presence of blisters, moist appearance, and tenderness, fitting the description provided.
