Absite Review Questions

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Absite Review Questions
2014-01-23 01:37:38

Absite review questions
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  1. Regarding contrast study for intestinal obstruction:
    Gastrografin can cause serious fluid shift
  2. An absolute contraindication to breast-conserving surgery for breast cancer is:
    Early pregnancy
  3. The most common indication for surgery in chronic pancreatitis is:
  4. The most common cause of spontaneous intestinal fistula is:
    Crohn's disease
  5. Gastrointestinal stromal tumors (GIST):
    are often radioresistant
  6. Rightward shift of oxyhemoglobin dissociation curve occurs with:
  7. The most common site of gastrointestinal lymphoma is:
  8. Meckel's diverticulum:
    is asymptomatic in most cases
  9. Biliary-enteric fistula most commonly connects:
    gallbladder and duodenum
  10. Spontaneous closure is least likely in fistulae originating from:
  11. Gastrointestinal diverticula do not occur in:
  12. The hepatic caudate lobe:
    drains directly into the inferior vena cava
  13. von Willebrand's disease:
    is an autosomal dominant disorder
  14. Which of the following is consistent with syndrome of inappropriate antidiuretic hormone (SIADH)?
    Increased urine sodium
  15. Normal anion gap acidosis is associated with:
    severe diarrhea
  16. Benign small bowel tumors most commonly present as:
    small bowel obstruction
  17. The diagnostic test of choice for suspected acute sigmoid diverticulitis is:
    computed tomography scan of the abdomen and pelvis
  18. Malignant small bowel neoplasms most commonly present with:
    weight loss
  19. Small bowel obstruction in an elderly female without external hernia or previous surgery is most likely caused by:
    gallstone ileus
  20. During cell cycle, DNA replication occurs in:
    S phase
  21. Li-Fraumeni syndrome shows increased incidence of:
    breast cancer
  22. The best operative approach to choledochal cyst is:
    cyst excision and hepaticojejunostomy
  23. Leiomyoma of the esophagus:
    is usually located in the lower one-third of the esophagus
  24. Hemangioma of the liver:
    is the most common benign hepatic tumor
  25. Phosphorus:
    deficiency may result in insulin resistance
  26. Hypermagnesemia is a complication of:
    oliguric renal failure
  27. The optimal management of traumatic duodenal hematoma is:
  28. Hairy cell leukemia:
    death is usually related to infectious complications
  29. Overwhelming postsplenectomy sepsis:
    can be fatal within hours of onset
  30. The development of thrombocytopenia and arterial thrombosis with heparin requires:
    discontinuation of heparin
  31. A trauma patient has a GCS 13, BP 80/40, widened mediastinum on CXR, and bloody peritoneal tap.  The next step in management is:
    perform laparotomy
  32. Insulinomas:
    are mostly benign
  33. Intussusception in adults:
    usually requires resection
  34. Optimal treatment for an ileosigmoid fistula in Crohn's disease is:
    Ileocecectomy and closure of the sigmoid defect
  35. Obturator hernia:
    is most common in older women with cachexia
  36. Gastrointestinal bleeding in the Mallor-Weiss syndrome:
    stops with nonoperative management in most cases
  37. The risk of overwhelming postsplenectomy sepsis is highest for patients requiring splenectomy for:
  38. After mastectomy, winging of the scapula results from injury to:
    the long thoracic nerve
  39. vonWillebrand's disease:
    is the most common congenital bleeding disorder
  40. Disc lesion between L4 & L5 will lead to:
    weakness of foot dorsiflexion
  41. Kidney transplant recipients are at increased risk for:
    epidermoid skin cancer
  42. The optimum management of medullary thyroid carcinoma in multiple endocrine neoplasia type 2 (MEN 2) is:
    total thyroidectomy +/- radical neck dissection
  43. Optimum management for a 2cm mass in the head of the pancreas with hypoglycemia and high insulin levels is:
    local excision
  44. Which of the following is not a risk factor for wound infection?
    surgeon's hand scrub for 5 instead of 10 minutes
  45. On the second day after abdominal aortic aneurysm repair, the patient passes grossly bloody stool.  The next step is:
  46. Spontaneous pneumothorax:
    is recurrent in at least 30% of cases
  47. The most common cause of hypercalcemic crisis is:
  48. A sudden onset of glucose intolerance in patients receiving TPN often indicates:
  49. Pectus excavatum:
    cosmesis is usually the indication for surgery
  50. Sacrococcygeal teratoma:
    requires complete excision of the coccyx
  51. Dry, scaly, pruritic rash on the trunk and extremities of a patient receiving TPN is caused by:
    free fatty acid deficiency
  52. The main cause of postoperative death in children with chronic diaphragmatic hernia is:
    abnormal pulmonary microvasculature
  53. A neonate has bilious vomiting and a double-bubble sign on plain X-ray.  The most appropriate operation is:
  54. The most common source of bacteria in wound infection after groin hernia repair is:
    the patient's skin
  55. Enterocytes' energy requirements are provided by:
  56. In critical illness, immune function can be enhanced by:
  57. Intra-aortic balloon pump:
    increases diastolic pressure
  58. Popliteal artery aneurysms:
    are often bilateral
  59. The most common cause of pneumaturia is:
    diverticular disease
  60. The most common benign hepatic lesion is:
  61. The most common etiologic factor for hepatocellular carcinoma worldwide is:
    Hepatitis B virus
  62. Pulmonary hilar adenopathy with noncaseating granuloma is consistent with:
  63. A solitary lung nodule with a popcorn pattern of calcification is most likely:
  64. The most common presentation of gastric lymphoma is:
    abdominal pain
  65. The protective immune function of immunoglobulin A is mediated through:
    inhibition of bacterial adherence to epithelial cells
  66. The most potent stimulus for antidiuretic hormone secretion is:
  67. Which of the following distinguishes adrenal insufficiency from sepsis?
  68. For penetrating chest injury, thoracotomy is indicated if:
    initial chest tube output is 1500cc
  69. Which cell type is essential for wound healing?
  70. The treatment for osteosarcoma of the distal femur is:
    chemotherapy and limb-sparing surgery
  71. Abnormal bleeding with normal prothrombin time occurs with:
  72. The most important prognostic factor for soft tissue sarcoma is:
    histologic grade
  73. After reduction of posterior knee dislocation, the patient should undergo:
  74. Metabolic acidosis is a complication of topical application of:
    sodium mafenide
  75. Stored blood is deficient in:
    factor VIII
  76. Post-transplant lymphoproliferative disorders are related to:
    Epstein-Barr virus
  77. Which of the following requires surgical drainage?
    pancreatic abscess
  78. The main complication of topical silver nitrate is:
  79. The adverse effects of steroids on wound healing can be reversed with:
    vitamin A
  80. The most common source of infection in burn patients is:
  81. The most common cause of death after kidney transplantation is:
  82. Which of the following is least appropriate when evaluating a 14yo girl with a breast lump?
  83. An absolute contraindication to renal transplantation is:
    chronic osteomyelitis
  84. Changes occurring in stored blood include:
    increased H+
  85. The most effective method of treating hyperkalemia is:
  86. The most common cause of hypercalcemia in hospitalized patients is:
    metastatic carcinoma
  87. Smoke inhalation is most reliably excluded by:
    normal flexible bronchoscopy
  88. Which of the following ligands bind to cell surface receptors?
  89. vonWillebrand's disease:
    is autosomal dominant
  90. Coumadin-induced skin necrosis is due to:
    protein C deficiency
  91. A patient receiving 1800cal/day in TPN will require:
    125g protein/day
  92. Apoptosis:
    is an energy-dependent cell death
  93. Splenic artery aneurysm:
    is usually asymptomatic
  94. The site of action of aldosterone is:
    the distal renal tubules
  95. The site of action of antidiuretic hormone is:
    the collecting ducts
  96. The common bile duct:
    lies to the right of the hepatic artery
  97. A respiratory quotient (RQ) of 1 indicates the main source of fuel is:
  98. Magnesium:
    hypomagnesemia is associated with neuromuscular excitability
  99. The management of pancreatic pleural fistula is:
    tube thoracostomy
  100. 48 hrs after coronary artery bypass grafting, nausea with epigastric pain and tenderness are most likely due to:
    acute pancreatitis
  101. Hypotension develops after pneumoperitoneum and trocar placement for laparoscopic cholecystectomy.  The next action is to:
    deflate the abdomen
  102. Delayed primary wound closure:
    results in increased angiogenesis
  103. The most common cause of esophageal perforation is:
  104. Multicentricity is characteristic of:
    bronchoalveolar carcinoma
  105. DNA alkylation is the chemotherapeutic action of:
  106. Spontaneous perforation of the esophagus:
    typically presents with sudden onset
  107. Fentanyl:
    is 100 times more potent than morphine
  108. Popliteal artery aneurysms:
    are bilateral in more than 50% of cases
  109. The lower esophageal sphincter (LES) tone:
    is increased by gastrin
  110. Tachycardia is the main side effect of:
  111. Intralobar pulmonary sequestration often presents with:
    recurrent pneumonia
  112. Doxorubicin:
    is an anthracycline antibiotic
  113. A 45yo M has an 8x4cm soft tissue mass on his right thigh.  The most appropriate method to confirm the diagnosis of sarcoma is:
    incisional biopsy
  114. Appropriate treatment of malignant hyperthemia is IV:
  115. Volkmann's contracture is a complication of:
    supracondylar humeral fracture
  116. Decreasing glucose and increasing fat in TPN will:
    decrease minute ventilation
  117. Acute appendicitis in pregnancy:
    is least common in the third trimester
  118. Eight hours after EGD a patient complains of severe substernal pain.  CXR shows left pleural effusion.  The next test is:
  119. The initial site of distant metastasis in breast cancer is:
  120. Arrest of the cell cycle in metaphase is the action of:
  121. After acute MI, elective operation should be postponed for at least:
    6 months
  122. Succinylcholine is contraindicated for:
    celiotomy 2 weeks after spinal cord injury
  123. Splenic artery aneurysm:
    can present with double-rupture phenomenon
  124. One week after coumadin therapy, a patient develops severe pain in the right leg with areas of skin necrosis.  Appropriate action is:
    stopping coumadin and starting heparin
  125. Mixed venous saturation is increased in:
    septic shock
  126. Paraneoplastic syndrome is most commonly associated with:
    small cell lung cancer
  127. The endothelial cells are the source of:
    factor VIII
  128. Which of the following is likely to be multiple?
  129. The mechanism of action of heparin is:
    potentiation of antithrombin III action
  130. Which of the following is an aminoester?
  131. Vitamin K:
    requires bile salts for absorption
  132. Hyponatremia is a complication of topical application of:
    silver nitrate
  133. Which of the following is an etiologic factor in occlusive vascular disease?
  134. Cardiomyopathy is a complication of:
  135. Spontaneous antitumor activity is a function of:
    natural killer cells
  136. Pulmonary fibrosis is a complication of:
  137. The best indicator of adequate resuscitation in shock is:
    improved mental status
  138. Adrenal incidentalomas:
    require endocrine evaluation
  139. Peaked T-wave on electrocardiogram is a feature of:
  140. Distinction between prerenal and renal azotemia is best made by:
    urine sodium level
  141. During prolonged starvation, the brain's main fuel is:
  142. Dobutamine:
    decreases cardiac filling pressure
  143. Epidermal growth factor stimulates:
  144. Magnesium:
    is an intracellular ion
  145. The most commonly injured organ in a patient with seatbelt sign is:
    the small intestine
  146. The development of necrolytic erythematous rash in a diabetic patient requires assessment of the serum level of:
  147. Appearance of a U-wave on electrocardiogram occurs in:
  148. Seizures can be associated with the use of:
  149. Nasotracheal intubation:
    is contraindicated for apneic patients
  150. The most important initial management of suspected blunt myocardial injury is:
    electroencephalographic monitoring
  151. Headache, vomiting, and seizure may develop with rapid correction of:

    (not hypernatremia???)
  152. The most common microbial agent transmitted by blood transfusion is:
  153. The most frequent major complication of blood transfusion is:
    hepatitis C
  154. Adenosine diphosphate-induced platelet aggregation is inhibited by:
  155. Malignant hyperthermia:
    is an autosomal dominant disorder
  156. Colonic perforation in a patient with acquired immunodeficiency syndrome is most likely due to:
  157. Which of the following results of thyroid fine-needle aspiration indicates surgical treatment?
    clumps of follicular cells
  158. Somatostatin:
    inhibits gastric motility
  159. The most common site for accessory splenic tissue is:
    splenic hilum
  160. The most sensitive indicator of increased hemolysis with hypersplenism is:
    reticulocyte count
  161. Howship-Romberg sign is characteristic of:
    obturator hernia
  162. Which of the following is least indicated for evaluating adrenal incidentaloma?
    fine-needle aspiration
  163. Lobular carcinoma in situ:
    is mostly found in premenopausal women
  164. Sequence of return of gastrointestinal motility after surgery is:
    intestine, stomach, colon
  165. The treatment of choice for Barrett's esophagus with severe dysplasia is:
  166. Esophageal diverticula:
    myotomy is always indicated for pulsion diverticula
  167. The primary fuel source for enterocytes is:
  168. Infection caused by dog and cat bites is due to:
    Pasteurella species
  169. Which of the following is preserved in radical neck dissection?
    spinal accessory nerve
  170. The organ most commonly involved in graft-versus-host reaction is:
  171. The most characteristic of malignancy in a cystic pancreatic neoplasm is:
    wall calcification
  172. Which of the following is contraindicated for a paraplegic undergoing laparotomy?
  173. Which of the following is consistent with pleural transudate?
    red blood cells count of 1000/mm3
  174. Appropriate management of renal cell carcinoma extending into the inferior vena cava is:
    radical nephrectomy and caval tumor extraction
  175. The gastroduodenal artery is a branch of the:
    common hepatic artery
  176. Inflammatory aortic aneurysm:
    may present with abdominal pain in the absence of rupture
  177. The initial management of a diabetic patient with fever, plantar ulcer, and food edema is:
    exploration and ulcer debridement
  178. Male breast cancer is associated with:
    BRCA-2 gene
  179. The diagnosis of inflammatory breast cancer is confirmed by:
    skin biopsy
  180. The most common retroperitoneal sarcoma is:
  181. Platelet dysfunction in uremia can be corrected with:
    desmopressin (DDVAP)
  182. Gynecomastia is a side effect of:
  183. Optimum approach to inflammatory breast carcinoma is:
    chemotherapy, modified radical mastectomy, and radiotherapy
  184. A potent inhibitor of T cell proliferation is:
    transforming growth factor-β
  185. THe most reliable indicator of successful endotracheal intubation is:
    end-tidal CO2
  186. The layer responsible for the strength of an intestinal anastamosis is the:
  187. Healing of the donor site for a split thickness skin graft is accelerated by:
    epidermal growth factor
  188. Prevention of empyema in a patient with residual hemothorax and a chest tube in place is best achieved by:
    placement of a second chest tube
  189. Popliteal artery entrapment:
    results from compression by the medial head of the gastrocnemius
  190. Cervical anastomosis after esophagectomy for cancer:
    leak is likely to heal spontaneously
  191. Appropriate management of 3cm squamous cell carcinoma of the anal canal is:
    chemotherapy + radiation
  192. Idiopathic thrombocytopenia purpura:
    is caused by anti platelet immunoglobulin G originating in the spleen
  193. The most common cause of death related to a central venous catheter is:
    central vein perforation
  194. Postoperative morbidity after splenectomy for hematologic diseases is highest for:
    myeloid dysplasia
  195. The respiratory quotient in prolonged starvation is:
  196. The most abundant amino acid in the body is:
  197. Maximum efficiency of glucose use in TPN occurs at infusion rate of:
  198. Refeeding syndrome is most commonly related to:
  199. Eczematoid rash at intertriginious areas with prolonged TPN is caused by:
    zinc deficiency
  200. The volume of air moved with maximum exhalation after deep inhalation measures:
    vital capacity
  201. Bleeding after adequate heparin reversal with protamine is usually caused by:
    heparin rebound
  202. Ileocolic intussusception in children:
    is the most common cause of intestinal obstruction before the age of 3yo
  203. Alopecia with prolonged TPN may be caused by:
    essential fatty acids deficiency
  204. A 1cm carcinoid found in the midappendix after appendectomy requires:
    no further action
  205. The most common complication of heparin reversal with protamine is:
  206. The most common side effect of pancuronium is:
  207. THe most common cause of massive lower gastrointestinal bleeding in children is:
    Meckel's diverticulum
  208. Fine-needle aspiration of bilateral upper cervical lymphadenopathy shows squamous cell carcinoma.  No primary lesion is found on clinical exam.  The most likely source is:
  209. Analysis of pleural effusion shows RBC count of 500/mm3, WBC 600/mm3, protein level 1.5g/dL, and specific gravity of 1.010.  The most likely diagnosis is:
    congestive heart failure
  210. Pulmonary sequestration:
    extralobar sequestration is supplied by the aorta
  211. The most important diagnostic test for a thyroid nodule is:
  212. Pleomorphic parotid adenoma:
    is the most common parotid neoplasm
  213. The mean arterial pressure is:
    diastolic pressure + 1/3 pulse pressure
  214. A contraindication to breast-conserving therapy is:
    collagen vascular disease
  215. Death from tension pneumothorax is caused by:
    decreased venous return
  216. The most important element in the history of an infant with vomiting is:
    if vomit is bile stained
  217. The substrate for nitric oxide synthetase is:
  218. The most frequent complication of giant gastric ulcer is:
  219. Mucosal defense is provided by immunoglobulin:
  220. The most common cause of nipple discharge is:
    intraductal papilloma
  221. The most common agent transmitted by blood transfusion is:

  222. Advantage of full thickness over split thickness skin graft is:
    less wound contraction
  223. Cyclosporin A inhibits the production of:
  224. The main component of urinary stones complicating resection of terminal ileum is:
  225. A characteristic feature of toxic shock syndrome in children with burns is:
  226. The rate of axonal regeneration after nerve injury is:
  227. The optimal treatment for bleeding gastric varicose in chronic pancreatitis is:
  228. Electrical burn injury:
    requires close cardiac monitoring
  229. The highest rate of metastasis occurs in carcinoid arising from:
  230. The most common presentation of ductal carcinoma in situ is:
  231. The main source of fuel in sepsis is:
    amino acids
  232. A patient with electrical burn of the leg complains of pain on passive movement of the foot.  The pedal pulses are diminished.  The next step is:
  233. The most common complication of blood transfusion is:
    allergic reaction
  234. The highest concentration of immunoglobulin A producing cells is in:
    small intestine
  235. In the treatment of coagulopathy:
    desmopressin (DDVAP) stimulates the release of factor VIII
  236. The most common source of metastatic small bowel tumor is:
  237. Meyloid metaplasia:
    results in extramedullary hematopoiesis
  238. Which of the following is contraindicated in managing corrosive esophagitis?
    gastric lavage
  239. Which of the following is effective in treating refractory Crohn's fistula?
  240. Hypothermic coagulopathy:
    is a complication of massive transfusion
  241. Secretin:
    inhibits intestinal motility
  242. The use of inverse ration ventilation will:
    improve alveolar ventilation
  243. The optimal management of esophageal leimyoma is:
    esophagomyotomy and enucleation
  244. Hand infection caused by a human bite is due to:
    Eikenella corrodens
  245. Gastric intrinsic factor is secreted from:
    parietal cells
  246. Which of the following directly induces coagulation?
    microfibrillar collagen (Avitene)
  247. Which of the following inhibits gastric bicarbonate secretion?
  248. A characteristic of prerenal azotemia is:
    fractional excretion of sodium value <1%
  249. At an operation for small bowel obstruction, cecal volvulus is diagnosed.  The cecum is viable.  The procedure of choice is:
    right hemicolectomy
  250. For a patient with a serum potassium level of 7mEq/dL and an absent P-wave on EKG, the initial management is:
    IV calcium gluconate
  251. Optimal management of mucosa-associated lymphoid tissue (MALT) is:
  252. Positive end-expiratory pressure therapy will result in:
    decrease in atrial natriuretic peptide
  253. At the initiation of swallowing, the pressure at the lower esophageal sphincter:
    decreases and then increases
  254. The serum sodium level in a 60yo man who weighs 70kg is 125mEq/L.  His sodium deficit is:

  255. A colorectal tumor that invades through the muscularis mucosa into the subserosa is a:
    T3 lesion
  256. Glutamine:
    increases intestinal cellularity
  257. Which of the following is a defect in the hemoglobin chain that responds to splenectomy?
  258. A central scar in a hepatic lesion is characteristic of:
    focal nodular hyperplasia
  259. The initial step in management of a hypercalcemic crisis is intravenous:
  260. Hepatic focal nodular hyperplasia:
    usually occurs in women of reproductive age
  261. The most accurate measure of adequacy of nutritial support is:
    serum prealbumin level
  262. Refractory hypokalemia can be caused by:
  263. A respiratory quotient of 1.2 indicates:
  264. Mallory-Weiss tear is located:
    on the lesser curve of the cardia
  265. The blood supply of the thoracic stomach used for esophageal replacement depends on:
    the right gastroepiploic artery
  266. The most serious complication of gastric bypass procedure is:
    anastomotic leak
  267. Helicobacter pylori:
    is isolated in up to 90% of duodenal ulcer cases
  268. L5-S1 disc lesion will result in:
    weak plantar flexion
  269. A patient with head injury opens his eyes and withdraws his arm to pain.  He is making incomprehensible sounds.  His GCS is:
  270. Perianal Crohn's disease:
    fistulas are usually multiple
  271. Appropriate management of chronic pancreatitis with pancreatic duct ectasia is:
    longitudinal pancreaticojejunostomy
  272. The most common cause of massive bleeding in chronic pancreatitis is:
  273. Colonic distention in toxic megacolon is most prominent in the:
    transverse colon
  274. At the lung functional residual capacity:
    lungs and chest wall exert equal and opposing recoil
  275. Which of the following inhibits intestinal motility?
  276. The most common site of ectopic pheochromocytoma is:
    para-aortic tissue
  277. Which of the following is poorly absorbed in achlorhydria?
    vitamin B12
  278. The most common cause of hypophosphatemia in hospitalized patients is:
    glucose overload
  279. The main fuel for colonocytes is:
    short-chain fatty acids

  280. Pulmonary fibrosis is a complication of:
  281. The most useful serum marker for cancer screening is:
    prostate-specific antigen
  282. The inferior parathyroid gland originates from the:
    third pharyngeal pouch
  283. Hypotension and decreased end-tital CO2 during laparoscopy are likely due to:
    CO2 embolism
  284. The main fuel for most cancer cells is:
  285. Which of the following is an inhibitor of wound contraction?
  286. Fetal wound healing is characterized by:
    increased hyaluronic acid synthesis
  287. Death from postoperative renal failure is most commonly due to:
  288. Regarding graft rejection:
    hyperacute rejection is antibody mediated
  289. The most important prognostic variable for melanoma:
    Breslow's thickness
  290. Follicular thyroid carcinoma:
    spreads via hematogenous route
  291. Multiple endocrine neoplasia is associated with germline mutation in:
    RET proto-oncogene
  292. Optimal treatment of cloacogenic carcinoma of anal canal is:
  293. The most common hernia in women is:
    inguinal hernia
  294. Gastroschisis:
    repair is followed by prolonged ileus
  295. The most common visceral aneurysm is:
  296. Gastroschisis is associated with an increased risk of:
    intestinal atresia
  297. The cremaster muscle is derived from:
    the internal oblique muscle
  298. The time for platelet transfusion during splenectomy for idiopathic thrombocytopenic purpura is:
    after ligation of the splenic artery
  299. The most common congenital cardiac defect is:
    ventricular septal defect
  300. The most appropriate method to diagnose small bowel injury in a conscious trauma patient with seatbelt injury is:
    serial abdominal exam
  301. On POD1 a patient develops a temperature of 104F and foul-smelling wound drainage.  The most likely isolate is:
    gram-positive rods
  302. A hemolytic consequence of carbon dioxide pneumoperitoneum is:
    decrease in cardiac index
  303. In the diabetic foot:
    foot sepsis is often polymicrobial
  304. Decreased hemoglobin affinity to oxygen at the tissue level is caused by:
    increased body temperature
  305. A patient with pelvic fracture is hypotensive and has grossly positive diagnostic peritoneal lavage.  The next step is:
  306. Heparin:
    potentiates the action of antithrombin III
  307. Cholecystokinin:
    stimulates pancreatic enzyme secretion
  308. The earliest and most specific sign of malignant hyperthermia is:
    increase in end tidal CO2
  309. The most frequent manifestation of blunt myocardial contusion is:
    premature ventricular contractions
  310. The most commonly injured nerve under general anesthesia is:
    ulnar nerve
  311. Respiratory distress associated with goiter is most commonly caused by:
    retrosternal goitrous extension
  312. Malignant hyperthermia:
    is more common in children than adults
  313. The most common cardiac anomaly found in adults is:
    atrial septal defect
  314. The most common complication of epidural analgesia is:
    respiratory depression
  315. The lateral boundary of a femoral hernia is:
    the femoral vein
  316. A characteristic of primary hyperaldosteronism is:
  317. Regarding the adrenal gland:
    the adrenal cortex does not have nerve supply
  318. At an operation for appendicitis, the appendix is found to be normal and the fallopian tube is found to be thickened with surrounding purulent exudate.  Operative management should be:
  319. In the preoperative preparation of pheochromocytoma, medications are given in the following order:
    alpha-blockers, then beta-blockers
  320. Hyperinsulinism in a newborn is most likely caused by:
  321. A patient with abdominal wall desmoid tumor should be screened for:
    colon polyps
  322. Which of the following is a vasoconstrictor?
  323. Paralytic ileus is a complication of:
    vinca alkaloids
  324. Neutropenic enterocolitis is a complication of:
  325. Severe peripheral neuropathy is a complication of:
  326. Watery diarrhea, hypokalemia, hypochloremia, and acidosis are features of:
    vasoactive intestinal peptide-producing tumor
  327. Characterists of somatostatinoma are:
    mild diabetes, diarrhea, gallstones
  328. An inhibitor of platelet aggregation is:
    prostacyclin I
  329. Regarding gastrointestinal bleeding in children:
    anal fissure is the leading cause
  330. The colon secretes:
  331. Mild diabetes, skin rash, and glossitis are features of:
  332. The most common intra-abdominal solid tumor in children is:
  333. Distinction between toxic epidermal necrolysis and staphylococcal scalding skin syndrome is based on:
    level of exfoliation
  334. An indication for laparotomy in neonatal necrotizing enterocolitis is:
    abdominal wall erythema
  335. Regarding congenital diaphragmatic hernia:
    foramen of Bochdalek hernia is the most common type
  336. Regarding neonatal Hirschsprung's disease:
    enterocolitis  is the leading cause of death
  337. Prosthetic graft infection is most commonly due to:
    Staphylococcus epidermidis
  338. Sinistral portal hypertension is most commonly due to:
    chronic pancreatitis
  339. Cervical sympathectomy is least likely to improve:
  340. Management of deep vein thrombosis during pregnancy is:
    10-day IV heparin and then therapeutic subcutaneous heparin until term
  341. A pleural fluid pH > 6.5 =
    indicates esophageal perforation
  342. The most accurate method to diagnose traumatic aortic arch injury is:
    transesophageal echocardiogram
  343. Lung resection is contraindicated if:
    preoperative PCO2 = 50
  344. Immediately after IV injection of 5,000U of heparin, the effect can be reversed with IV:
    50mg protamine sulfate
  345. The most common cause of small bowel obstruction during pregnancy is:
  346. Which of the following is an analgesic?
  347. A contraindication to the use of ketamine is:
    head injury
  348. The cytokine directly responsible for hepatic acute phase response is:
  349. In multiple endocrine neoplasia type 1:
    almost all patients have parathyroid hyperplasia
  350. Post operative cardiac events are most likely if preoperative electrocardiogram shows:
  351. An indication for preoperative angiography for elective abdominal aortic aneurysm surgery is:
    history of claudication
  352. An early feature of lidocaine toxicity is:
    muscle twitching
  353. The superior pancreaticoduodenal artery is a branch of:
    the gastroduodenal artery
  354. Which of the following pancreatic enzymes is secreted in an active form?
  355. A tracheostomy-related tracheoinnominate fistula is best managed by:
    division of the innominate artery and ligation of both ends
  356. Optimum calorie/nitrogen ratio for protein synthesis is:
  357. Aldosterone:
    stimulates sodium resorption in distal renal tubules
  358. Hypertension in cases of extra-adrenal pheochromocytoma is caused by:
    pure norepinephrine
  359. The highest bicarbonate concentration is found in:
    pancreatic secretion
  360. A 70kg male with 50% body surface area second-degree burn requires:
    7,000mL LR over the first 8hrs.
  361. A complication that enteral and parenteral feeding have in common is:
    hyperosmolar nonketotic coma
  362. The most common organism isolated from bile is:
    Escherichia coli
  363. The protein loss equivalent to 100g of negative nitrogen balance is:
  364. The most common cause of cancer-related death in females is:
    lung cancer
  365. The highest potassium concentration is found in:
  366. The risk of regional node metastases in 0.7mm thick melanoma is:
    < 5%
  367. The initial fluid bolus for an injured child is:
    20mL/kg of LR
  368. Elevation of urinary 5-hydroxyindole acetic acid is diagnostic of:
    carcinoid syndrome
  369. Regarding hypertrophic pyloric stenosis:
    more common in males
  370. A colon polyp with the highest malignant potential is:
    2cm villous adenoma
  371. Gastric smooth muscle tumors present most commonly as:
    incidental finding on EGD
  372. The desired minimum distal margin of resected rectal cancer is:
  373. Regarding gastric adenocarcinoma:
    the intestinal type is often distal in location
  374. In the TNM staging, stage II colorectal cancer is:
    T4, N0, M0
  375. Postoperative radiation without chemotherapy:
    improves local recurrence in stage III rectal cancer
  376. Risk of irreversible tissue damage in pressure sores is highest with:
    constant pressure of 70mmHg for 2 hours
  377. In caustic esophageal injury:
    acids cause severe gastric rather than esophageal injury
  378. Toxic epidermal necrolysis in children is most commonly related to:
    Staphylococcus aureus
  379. The most essential step in management of esophageal reflux and Barrett's change is:
    close endoscopic surveillance
  380. A prominent "v" wave in the right atrial venous waveform indicates:
    tricuspid valve regurgitation
  381. The mainstay of treatment of blunt carotid artery injuries is:
  382. Regarding the anatomy of the esophagus:
    the cervical esophagus is supplied by the inferior thyroid artery
  383. The most common cause of early postoperative death in elective abdominal aortic aneurysm repair is:
    acute MI
  384. The initial test in cases of suspected gastroesophageal reflux should be:
    upper endoscopy
  385. Which of the following organisms is slime-producing?
    Staphylococcus epidermidis
  386. An increased incidence of adenocarcinoma of the esophagus is associated with:
    Barrett's esophagus
  387. Insulinomas:
    are usually benign
  388. The initial step in management of a 25yo male with a painless scrotal mass is:
    scrotal ultrasound
  389. The most common anterior mediastinal tumor is:
  390. The hallmark of multiple endocrine neoplasia type 2 syndromes is:
    medullary thyroid carcinoma
  391. The cranial nerve most commonly injured during carotid endarterectomy is:
  392. Inadvertent tissue extravasation of intravenous dopamine is best managed with:
    local infiltration of phentolamine
  393. Hurthle cell thyroid carcinoma:
    often metastasizes to the cervical lymph nodes
  394. Which of the following contributes to the arterial supply of the thoracic esophagus?
    bronchial artery
  395. Regarding postoperative MI:
    ischemic injury is more common postoperatively rather than intraoperatively
  396. The least appropriate test in the initial evaluation of adrenal incidentaloma is:
    FNA biopsy
  397. A 58yo F with a tubo-ovarian abscess should be treated with:
    antibiotics with hysterectomy and bilateral salpingo-oophorectomy
  398. Cannon "a" waves on a right atrial waveform tracing indicate:
    atrioventricular block
  399. Intralobar pulmonary sequestration:
    is supplied by the aorta
  400. Specific therapy for heparin-induced thrombocytopenia is:
  401. Hurthle cell thyroid carcinoma:
    is more aggressive than follicular thyroid carcinoma
  402. Burn-associated inhalation injury can be excluded if:
    There is no abnormal finding on flexible bronchoscopy
  403. The lateral boundary of a left paraduodenal hernia is:
    the inferior mesenteric vein
  404. The carotid body is:
    is located in the adventia
  405. Barrett's esophagus:
    is an indication for life-long endoscopic surveillance
  406. The most common causative agent in nosocomial sinusitis in the ICU is:
    Pseudomonas aeruginosa
  407. The treatment of hyper acute kidney transplant rejection is:
    immediate transplant nephrectomy
  408. Blunt cardiac injury:
    should be suspected if admission EKG is abnormal
  409. A characteristic of Buerger's disease is:
    superficial migratory thrombophlebitis
  410. Recurrence of thyroid carcinoma after definitive treatment is best detected by:
    thyroglobin serum measurement
  411. The primary regulator of aldosterone secretion is:
    angiotensin II
  412. The optimum management of a T4 breast cancer is:
    chemotherapy followed by mastectomy and radiation
  413. The diagnosis of esophageal achalasia is confirmed by:
    failure of lower esophageal sphincter relaxation on manometry
  414. Factor VIII-related antigen is a marker of:
    postmastectomy angiosarcoma
  415. The indication for FNA biopsy of an adrenal incidentaloma is:
    suspected adrenal metastases
  416. Male breast cancer:
    is typically hormonally dependent
  417. A non-anion gap metabolic acidosis is associated with:
    excessive sodium chloride administration
  418. Inverse ratio ventilation:
    increases mean airway pressure and increases intrathoracic pressure
  419. Duodenal atresia:
    commonly exhibits normal muscular wall with a mucosal web
  420. Angiotensin-converting enzyme is produced by:
    vascular endothelial cells
  421. Hereditary nonpolyposis colorectal cancer:
    is associated with higher incidence of endometrial cancer
  422. Auto-positive end-expiratory pressure in mechanical ventilation is most likely to develop with:
    high rates and prolonged I:E ratio
  423. Initial management of T4 invasive lobular breast carcinoma:
    neoadjuvant chemotherapy
  424. The fluid of chylothorax is composed of:
    fat and lymphocytes
  425. The most common cause of renovascular hypertension is:
    renal artery atheroma
  426. Merkel cell carcinoma:
    is highly radiosensitive
  427. A complication of tacrolimus therapy is:
    new-onset diabetes
  428. Extralobar pulmonary sequestration:
    is supplied by the aorta
  429. Appropriate management of radiation mastitis is:
    pentoxifylline therapy
  430. Optimum therapy for effort thrombosis of the axillary vein is:
    Thrombolysis, anticoagulation, and possible first rib resection
  431. Drooling from the corner of the mouth after submandibular gland excision is due to:
    injury of the marginal mandibular nerve
  432. The component of blood transfusion responsible for immunosuppression is:
  433. In therapeutic immunosuppression, rapamycin:
    blocks interleukin-2 action
  434. Gallstones diagnosed during pregnancy:
    may resolve spontaneously after delivery
  435. Trauma cesarean section is indicated if the fetus is viable and:
    5 minutes of CPR were unsuccessful
  436. The single most common abdominal operation for the elderly is:
  437. An age-related change in respiratory functions is:
    increased residual volume
  438. Fetal death during pregnancy is most commonly due to:
    maternal demise
  439. A physiologic change of aging is:
    decreased aldosterone secretion
  440. Which of the following is contraindicated during pregnancy for treating breast cancer?
  441. In the elderly:
    there is increased antidiuretic hormone response
  442. During pregnancy:
    intestinal obstruction is most commonly caused by adhesions
  443. An 80yo male is confused, lethargic, and has tonic spasms.  He has been receiving IV D5,1/2NS for 3 days after right hemicolectomy. The most likely cause is:
  444. A physiologic change in pregnancy is:
    elevated alkaline phosphatase
  445. In the elderly:
    diastolic function is more impaired than systolic function
  446. A Crohn's disease-related internal fistula:
    most commonly involves small bowel to small bowel fistulation
  447. In inflammation, early "rolling" of neutrophils on endothelium is a function of:
  448. A paraesophageal hernia:
    may present with chronic anemia
  449. The most common cause of large bowel obstruction is:
    colorectal cancer
  450. Hypophosphatemia is associated with:
    decreased hemoglobin p50, hemolysis, and respiratory failure
  451. Preoperative radiotherapy for rectal adenocarcinoma:
    increases postoperative morbidity
  452. The principal side effect of gangciclovir therapy is:
    bone marrow suppression
  453. In contrast to ulcerative colitis, Crohn's disease:
    may spare the rectum
  454. The negative predictive value of a test is:
    the proportion of patients with negative test who do NOT have the disease
  455. Radiation enteritis of the large bowel most commonly affects:
    the rectum
  456. Eight hours after treatment for a scald injury, an infant has a temperature of 40C and a WBC of 5,000/mm3.  The burn wound is clean.  The most likely diagnosis is:
    toxic shock syndrome
  457. The medial boundary of the femoral canal is:
    the lacunar ligament
  458. Hemorrhagic dermal bullae are characteristic of wound infection caused by:
    Streptococcus pyogenes
  459. A marker with prognostic significance in cases of seminoma is:
    serum lactate dehydrogenase
  460. Collagen synthesis in the actively healing wound is best assessed by:
    hydroxyproline content
  461. The main motor nerve supply to the urinary bladder is:
    the pelvic nerve
  462. Compared with hepatitis B virus, hepatitis C virus:
    is an RNA virus
  463. The positive predictive value of a test is:
    the proportion of persons with a positive test who have the disease
  464. The circulating level of which cytokine can be used as a prognostic marker in sepsis?
  465. Nitric oxide:
    prevents platelet aggregation
  466. The most common cause of facial nerve paralysis is:
    Bells' palsy
  467. Most renal absorption of sodium takes place in:
    the proximal tubules
  468. Distinction between hemorrhagic and cardiogenic shock can be based on
    ventricular filling pressures
  469. Renin-angiotensin system is activated by:
  470. The thoracodorsal nerve:
    is purely motor
  471. Hypocalcemia is a complication of chemotherapy with:
  472. Male breast cancer most commonly presents with:
    breast mass only
  473. Which of the following is a clear indication of surgery for necrotizing enterocolitis?
  474. An infected dog bite is most readily treated with:
  475. During CO2 pneumoperitoneum:
    the systemic vascular resistance increases
  476. In diabetic foot ulcers:
    motor neuropathy mostly affects toe flexors
  477. A sign of early sepsis is:
    respiratory acidosis
  478. In contrast to a keloid, a hypertrophic scar:
    may subside spontaneously
  479. In transplant recipients, there is an increased incidence of:
    anal cancer
  480. The most common cause of small bowel bleeding in adults is:
    arteriovenous malformation
  481. A type IV hiatal hernia is:
    a hernia that contains parts of the intestine and colon
  482. Isosulfan blue injection for sentinel node biopsy may result in:
    inaccurate pulse oximetry
  483. The most common complication of gastric ulcer is:
  484. The preferred neuromuscular-blocking agent in a liver failure patient is:
  485. The most common fatal infection in burn victims is:
  486. The cardiac ejection fraction:
    is increased in ventricular septal defect
  487. After 3 years, vein graft failure in the lower extremities is mostly caused by:
    atherosclerosis of the graft
  488. The predominant parathyroid pathology in MEN is:
    parathyroid hyperplasia
  489. In renal artery stenosis, angiotensin-converting enzyme inhibitors will:
    decrease glomerular filtration rate
  490. The appropriate agent for prophylaxis in elective colectomy is:
  491. Which of the following is a dopamine antagonist?
  492. Peripheral neuropathy is the main side effect of:
  493. In liver transplantation, biliary complications are most commonly related to:
    adequacy of hepatic arterial flow
  494. The optimum management of aspiration pneumonitits is:
    endotracheal intubation and mechanical ventilation
  495. Malignant hyperthermia:
    is associated with intraoperative rise of end tidal CO2
  496. The long thoracic nerve:
    is purely motor
  497. The likelihood of malignancy in cystic pancreatic neoplasm is related to:
    mucin content
  498. Colovesical fistula:
    most commonly presents with pneumaturia
  499. The optimum management for stage II thyroid lymphoma is:
    cervical radiation
  500. The most reliable indicator of successful ventilatory weaning is:
    f/Vt < 100
  501. Chronic allograft rejection:
    is more common with kidney than liver transplantation
  502. The most accurate test to determine the need for neoadjuvant therapy in esophageal carcinoma is:
    endoluminal ultrasound
  503. The most characteristic metabolic abnormality in glucagonoma is:
  504. A local anesthetic that can be safely administered with tetracaine allergy is:
  505. Clonidine is:
    an alpha2-agonist
  506. A definitive diagnosis of inflammatory breast cancer is provided by:
    finding extensive inflammatory cell infiltration of the tumor
  507. Tissue loss almost always results from ligation of the:
    popliteal artery
  508. Male breast cancer:
    can only be of ductal origin
  509. Keloid formation has been associated with an increased amount of:
    transforming growth factor-β
  510. The anteroposterior anatomic relationship at the renal hilum is:
    vein - artery - ureter
  511. Endophthalmitis is characteristic of:
    systemic candidiasis
  512. The most important determinant of survival of retroperitoneal sarcoma is:
    complete surgical resection
  513. A pulmonary embolus is associated with:
    decrease in pulmonary capillary wedge pressure
  514. Pyoderma gangrenosum is typically associated with:
    ulcerative colitis
  515. Popliteal artery aneurysms:
    are the most common peripheral arterial aneurysms
  516. After vigorous exercise, an athlete develops pain on dorsiflexion of the foot and decreased sensation in the first web space.  Appropriate action should be:
    immediate fasciotomy
  517. The most common presentation of testicular cancer is:
    painless scrotal mass
  518. Which of the following is most likely to cause a false-positive fecal occult blood test?
    dietary peroxidases
  519. Aldosteronoma is associated with:
    • Hypertension
    • Hypokalemia
    • High aldosterone
    • Low renin
  520. A PO2 of 90 torr, PCO2 of 28 torr, and pH of 7.16 on room air are indicative of:
    hypovolemic shock
  521. Idiopathic thrombocytopenic purpura is most likely to respond to splenectomy if:
    the disease responded to steroids
  522. A marker that would distinguish nonseminoma from seminoma is:
  523. Positive end-expiratory pressure:
    decreases alveolar-arterial oxygen gradient
  524. Estrogen therapy for post menopausal women is associated with:
    increased incidence of endometrial cancer
  525. A 10yo boy comes from a family of "bleeders." His coagulation profile shows: prolonged bleeding time, PTT, & normal PT.  Platelet count is 150,000/mm3.  The most likely diagnosis is:
    von Willebrand's disease
  526. A single organism is usually the causative agent in:
    primary peritonitis
  527. Neurogenic bladder dysfunction with intact bladder sensation is associated with:
    cerebrovascular accident
  528. Tumor necrosis factor-α antagonist is useful in treating:
    Crohn's disease
  529. An 83yo female presents with vomiting and abdominal distention.  She complains of pain in the medial aspect of right thigh, and a palpable lump can be felt on the right side on rectal exam.  The appropriate action is:
    urgent laparotomy
  530. A normal-sized spleen is found in:
    idiopathic thrombocytopenic purpura
  531. Neurogenic bladder after extensive pelvic surgery is characterized by:
    large bladder capacity with overflow incontinence
  532. Regarding cytokines:
    serum level is not related to the severity of illness
  533. Hypothermic coagulopathy is characterized by:
    normal PT & PTT
  534. A patient with diagnosed pseudomembranous colitis is developing a worsening clinical picture and is taken for urgent laparotomy.  The appropriate surgical procedure should include:
    total abdominal colectomy
  535. The specificity of a test is:
    the proportion of patients without the disease who have a negative test
  536. A 45yo M complains of severe chest pain after a diagnostic upper endoscopy.  He has crepitus on palpation of his neck.  The next step in management should be:
    gastrografin swallow
  537. Familial adenomatous polyposis:
    is caused by inactivation of a tumor suppressor gene
  538. The most common posterior mediastinal mass in children is:
  539. In the absence of sepsis, glucose intolerance with total parenteral nutrition may indicate:
    chromium deficiency
  540. The most common presentation of gastric cancer is:
    vague abdominal pain and weight loss
  541. In burn victims, the finding most indicative of inhalation injury is:
    carbonaceous sputum
  542. A child with anaphylactoid purpura develops an acute colicky abdominal pain and bleeding per rectum.  The most likely diagnosis is:
  543. The most reliable means of preoperative nutritional assessment is:
    clinical history of weight loss 

  544. In contrast to adults, fetal wound healing:
    has a higher content of type III collagen
  545. The greatest amount of maintenance IV fluids is required for:
    21yo male athlete
  546. The most accurate test to detect subclinical hypothyroidism is:
    TSH level
  547. A 28yo M has a closed head injury, pulmonary contusion, grade III splenic injury, and closed femoral shaft fracture.  The ideal management of this fracture is:
    intramedullary nailing within 24hrs of injury
  548. Accessory spleens are most commonly found in:
    hereditary spherocytosis
  549. The effectiveness of prophylactic antibiotics in surgery is mostly related to the:
    timing of initial administration
  550. A 6yo boy has a right undescended testicle.  His parents should be advised that:
    orchiopexy is performed but with no effect on spermatogenesis or cancer prevention
  551. The sensitivity of a test is:
    the proportion of patients with the disease who have a positive test
  552. Regarding an amebic liver abscess:
    it is treated with metronidazole
  553. An infant has been having episodic coughing for 48hrs.  On exam, he is wheezing with decreased aeration on the left chest.  A CXR shows an overinflated left lung.  The next step in management should be:
    rigid bronchoscopy
  554. A 40yo female has a 4cm hemangioma in the right lobe of the liver on CT.  She is asymptomatic.  Appropriate action should be:
    No further action
  555. A non-anion gap metabolic acidosis is associated with:
    large amount of saline resuscitation
  556. The gold standard for the diagnosis of pelvic inflammatory disease is:
  557. A 60yo alcoholic male presents with severe chest pain after repeated vomiting.  A CXR shows a small left pleural effusion.  The next step in management is:
    administer gastrografin swallow test
  558. Mediastinal granulomas may be associated with:
    esophageal traction diverticulum
  559. What is the patency rate for patients who undergo angioplasty for iliac occlusive disease?
    60% at 5 years
  560. Hereditary Nonpolyposis Colorectal Cancer is associated with mutation of what gene?

    The hallmark of HNPCC is defective DNA mismatch repair, which leads to microsatellite instability.  Microsatellites are repeated sequences of DNA. These sequences can be made of repeating units of 1-6 base pairs in length.

    Carriers of potentially pathogenic mutations in the hMLH1/hMSH2 genes have consistently been shown to be at a greatly increased risk of developing colorectal cancer compared with the general population. When considered together, the available evidence shows a strong, consistent, and biologically plausible association between mismatch repair gene mutations and colorectal cancer. The penetrance of mutations in hMLH1/hMSH2 is incomplete and is significantly higher in males (approximately 80%) than in females (approximately 40%)
  561. Familial Adenomatous Polyposis is associated with mutation of what gene?
    APC (adenomatous polyposis coli)

    The APC gene is a tumor suppressor gene located on the long arm of chromosome 5 in band q22.2.  It codes for a protein that helps control how often a cell divides, how it attaches to other cells within a tissue, or whether a cell moves within or away from a tissue. This protein also helps ensure that the chromosome number in cells produced through cell division is correct. The APC protein accomplishes these tasks mainly through association with other proteins, especially those that are involved in cell attachment and signaling.
  562. A 68yo M presents with pain in his left leg.  Exam and workup confirms diagnosis of a popliteal aneurysm.  What is the most common complication that would result in the patient's leg pain?
    Thromboembolic events associated with the popliteal aneurysm

    occurs in up to 35% of untreated aneurysms
  563. Most common thyroid cancer:
    Papillary (70-80%)
  564. A 60yo M with chronic alcoholism presents with acute pancreatitis.  He has suffered similar episodes that resolved without complications.  He is found to have a 4cm pancreatic pseudocyst on CT scan.  What would be the best treatment?
    Observation & serial CT scans
  565. A 70yo M with ascites 2/2 cirrhosis presents for elective umbilical hernia repair.  Should he be offered repair?
    Yes if he is leaking ascites from the hernia

    • Pts leaking ascites are at higher risk of peritonitis
    • Must minimize ascites preoperatively to avoid 73% recurrence rate.  Control with salt restriction, diuretics, paracentesis, TIPS procedure
  566. A 68yo M with atrial fibrillation presents to the ER with a cool, pulseless right foot.  Sensation is intact.  Duplex US of the right leg reveals multiple femoral stenoses and tibioperoneal thrombosis with poor tibial flow.  What is the most appropriate management?
    Intra-arterial site-directed thrombolysis
  567. A 55yo F presents to your clinic with new diagnosis of tertiary hyperparathyroidism.  What operation has she most likely previously undergone?
    Renal transplantation
  568. What is the most helpful in diagnosing Helicobacter pylori infection?
    Histologic examination of endoscopic antral biopsies

    Biopsy specimens from EGD, stained with Giemsa stain, usually demonstrate a variable number of H pylori organisms adhering to the gastric epithelium, both coating the gastric wall and lining the gastric glands. The mucous film appears decreased. A large inflammatory infiltrate is present, with lymphocytes, neutrophils, and a variable number of mast cells that seem to play an important role in the pathogenesis of the gastric injury of persons infected with H pylori
  569. A 73yo M has developed a pulseless left lower leg 8 days after experiencing a MI requiring CPR.  On exam, he has diminished sensation in his left foot.  What is the most appropriate definitive treatment?
    Percutaneous embolectomy under local anesthesia

    embolectomy (instead of thrombolysis) is indicated in patients with sensorimotor deficits
  570. 38yo F referred to your clinic after an elevated 24hr urine cortisol measurement.  She is not on any steroids.  What is the most likely cause of this patient's disease?
    Pituitary adenoma
  571. 36yo F underwent hemorrhoidal banding, 6 days later she notices  a small amount of blood on the toilet paper after defecation but denies increasing pain and fever.  What do you tell her?
    This is normal, start taking fiber supplements and sitz baths.
  572. Which nerve is most commonly injured during fasciotomy of the lower leg?
    Superficial peroneal nerve

  573. 18mo after undergoing an aortobifemoral artery bypass, a 69yo F presents with a draining, cellulite wound in her right-side groin, with exposed polytetrafluoroethylene graft.  What is the most likely pathogen infecting this graft?
    Staph. epidermidis
  574. A 56yo M 2y s/p left colectomy for stage IIA colon cancer is now found to have rising CEA and 2 new lesions in the liver on follow-up CT scan.  There is no evidence of extrahepatic disease.  How do you manage this patient?
    Extended left hepatectomy
  575. A 56yo M presents to your clinic with a 5mm wide lesion confined to the middle of his lower lip.  You suspect SCC.  What is the most appropriate management?
    Surgical resection with 1cm margin and primary repair.
  576. After perioral tingling, what is the next symptom expected in the progression of lidocaine toxicity?

    Progression of signs = perioral paresthesias, visual & auditory hallucinations, sedation, unconsciousness, seizures, respiratory depression, cardiac arrythmias, cardiovascular collapse.  Treatment is supportive

    • Max dose of Lidocaine is 5mg/kg (7mg/kg with dpi)
    • Max dose of Bupivicaine is 2.5mg/kg

    Progression of action of local anesthetics on nerve function: blockade of autonomic transmission, sensory transmission, motor transmission
  577. 64yo postmenopausal F with ER+, stage IIB breast cancer presents following lumpectomy, radiation therapy, and tamoxifen therapy.  She asks about the risks of tamoxifen therapy.  You tell her:
    Tamoxifen has been linked to an increased risk of developing endometrial adenocarcinoma and uterine sarcoma
  578. Workup for vomiting in a 46yo F with Crohn disease reveals a stricture in the second portion of the duodenum.  Best surgical management is:
    Heineke-Mikulicz strictureplasty
  579. Humeral head displaced medial to the glenoid fossa --> which nerve is most likely injured in this type of dislocation?
    Axillary nerve
  580. What is the most common cause of late death after heart transplant?
    Accelerated atherosclerosis
  581. Regarding split-thickness skin grafts, the rate of healing of the donor site is related to:
    epithelial appendages and thickness of graft
  582. 21yo M brought to the trauma bay after sustaining a superficial stab wound to the left shoulder.  He received last tetanus booster when he was 15.  What tetanus ppx should he receive?
    Tetanus toxoid 0.5ml IM and tetanus immune globulin 250units IM

    • Guidelines:
    • - Pts who have been fully immunized & received booster within 5 years do not need pix
    • - Pts who have been fully immunized & received booster between 5-10y ago should get tetanus toxoid booster
    • - Pts who have been fully immunized & received booster >10y ago should receive tetanus toxoid booster & TIG
    • - Pts who have not been fully immunized should receive booster & TIG
    • - Pts with tetanus-prone wounds should receive a tetanus booster & TIG
    • - Pts with immunodeficiency should receive tetanus booster & TIG
  583. A 28yo professional violinist woman presents with headaches, neck pain, and hand clumsiness in her right hand.  She also reports occasional numbness in the hand and right-sided chest pain.  Diagnosis =
    Thoracic outlet syndrome
  584. 22 week pregnant, 31yo F received 7 days of ampicillin for UTI, then developed diarrhea on day 5 of therapy, stool +Cdiff.  Treatment =
    Metronidazole 500mg orally QID x 10days
  585. 47yo F undergoes core needle bx of a lesion found on mammography in the lower outer quadrant of her right breast.  Pathology is read as atypical ductal hyperplasia of the breast.  What is the most appropriate next step in this patient's care?
    Excisional biopsy with wire localization
  586. 22yo 65kg M seen in the ED after motorcycle accident that resulted in significant head and maxillofacial trauma.  Following initial evaluation and stabilization, he is admitted to the ICU and given LR @ 125/hr.  During the first 60hrs of his stay, his UOP gradually declines to 25ml/hr and his serum Na drops from 136 to 127.  VSS.  Urine osmolarity = 548mOsm/L.  Which of the following is the next best intervention?
    Convert his IVF to 3% NS
  587. 45yo F with hx of gallstones admitted to the ICU after dx with acute pancreatitis w/ hemodynamic instability.  Her admission laboratory values were remarkable for hyponatremia, hyperamylasemia, hyperlipasemia, and hyperlipidemia.  What is the etiology of hyponatremia in pancreatitis?

    In pancreatitis with hyperlipidemia, circulating lipids draw water into the intravascular compartment, leading to relative hyponatremia
  588. 54yo alcoholic man presents to ED with severe substernal and epigastric pain after vomiting.  Gastrografin esophagogram shows perforation of distal esophagus with drainage into the mediastinum.  What is the most appropriate treatment?
    Emergent primary repair
  589. 42yo F in ICU immediately following removal of a left adrenal pheochromocytoma.  Her BP is 80/40.  The most appropriate treatment of the patient's hypotension is:
    IV bolus of LR solution
  590. What clinical signs are suggestive of 30-40% blood volume loss?
    • HR>120
    • decreased BP
    • very decreased pulse pressure
    • RR 30-40
    • UOP 5-15ml/hr
  591. For a 4mm oral cavity epidermoid cancer without palpable lymph nodes, the appropriate surgical treatment entails:
    supraomohyoid dissection
  592. A 45yo F is in the surgical ICU 2 days after an orthotopic liver transplant for primary biliary cirrhosis.  The patient's condition has rapidly deteriorated, with signs consistent with fulminant hepatic failure.  Ultrasound of the graft is most likely to reveal?
    hepatic artery thrombosis
  593. A 34yo F is brought to the ED after a high-speed MVC.  She is unresponsive, breathing spontaneously, and has absent breath sounds on the left chest.  A thoracostomy tube is placed and fails to yield any fluid.  She continues to have absent breath sounds on the left part of her chest, and she appears to have an air leak.  What is the next step in management?
    Flexible bronchoscopy

  594. POD2 after right lower pulmonary lobectomy for lung cancer, 57yo M becomes tachypneic, tachycardic, O2 sat 85%, req increased inspired O2 concentration to 50%.  ABG reveals PaO2 68, CXR shows diffuse bilateral infiltrates.  The patients pulmonary artery wedge pressure is 8mmHg.  What is the underlying pathophysiologic mechanism?
    Inflammatory-mediated vascular permeability
  595. What margin do you need to take around a 0.6mm thickness (level III) melanoma?
  596. The conduit with the best patency for a CABG is:
    left internal thoracic artery
  597. Surgical treatment of adenocarcinoma in the duodenum, just proximal to the ligament of Treitz =
    surgical resection with duodenojejunostomy
  598. 67yo M with COPD now POD3 after right lower lobe lung resection for adenocarcinoma complicated by bronchopleural fistula with a rising PaCO2.  What is the optimal mode of mechanical ventilation to reduce his bronchopleural fistula?
    High-frequency jet ventilation
  599. An opera singer who recently underwent total thyroidectomy returns for her postoperative visit reporting voice fatigue and an inability to sing high notes.  Her total calcium level is 9.1 (nl 9.0-10.5).  This complication could have been prevented by:
    ligating individual branches of the superior thyroid artery at the level of the thyroid capsule
  600. While eating breakfast on the morning after undergoing resection of the RML of her lung, a 65yo F has acute abdominal pain.  Her stomach is distended and tympanic, she is bradycardic, hypotensive, tachypneic, and sweating profusely.  What is the most appropriate course of action?
    Place NGT
  601. Broken ribs causing rapid shallow breaths and gradual hypoxia, most effective method of treatment =
    bupivacaine thoracic paravertebral block
  602. 48yo alcoholic man with painless jaundice, multiple prior admissions for pancreatitis, found to have intrahepatic biliary ductal dilation on CT scan and bilirubin 12.6 with other LFTs normal. No obstructing mass seen on CT, MRCP demonstrates no stones in biliary tree & dilation extending to the pancreas.  The most likely cause of his ductal dilation is:
    benign common bile duct stricture
  603. 45yo M with solitary 3cm insulinoma in the head of the pancreas adjacent to the pancreatic duct.  Which procedure should be used to remove the tumor?
    Laparotomy with pancreatoduodenectomy
  604. A previously healthy 57yo F had increased SOB & CP while undergoing a root canal.  After stopping the procedure, the pt's symptoms resolved and the oral surgeon resumed drilling. She began experiencing right-side facial pain and periorbital & neck swelling and subsequently complained of severe dyspnea.  The patient lost consciousness and her BP was undetectable.  An emergent EKG showed nonspecific ST wave changes.  Her O2sat was 89-90% throughout the procedure.  Immediate action should be:
    Positioning of the patient in Trendelenberg and left lateral decubitus position.
  605. 68yo F who underwent barium enema for ileocolic intussesception with XR showing that the intussesception has only been partly reduced.  What is the next step?
    Laparotomy for manual reduction.
  606. Approximate incidence of DVT in "high risk" patients, (i.e. those undergoing hip arthroplasty, with major trauma/spinal cord injury, and those with prior VTE) =
  607. 56yo M 6mo s/p redo lap Nissen ℅ bloated feeling after meals, dysphagia, inability to vomit, and dyspepsia. Cause of these symptoms =
    the esophagus is shortened
  608. 76yo M, 6 weeks s/p vagotomy & antrectomy with Billroth II recon for peptic ulcer dz, now with nausea, abd pain, & low-grade fever concerning for afferent limb obstruction.  Which one test will best confirm this diagnosis?
    CT scan

  609. What is the most common indication for internal iliac artery revascularization during aortic aneurysm repair?
    absence of retrograde flow in the internal iliac artery
  610. Greatest risk of postsplenectomy sepsis in:
    3yo M who underwent splenectomy for thalassemia major
  611. 35yo M with burns to 75% of TBSA, more than 50% deep dermal burn.  Resuscitation initiated with crystalloids and dry sterile dressings placed over his wounds.  Within 12hrs of hospital admission, he developed severe respiratory distress, a high-grade temp, and pressor requirement.  Subsequent management should include:
    Wound biopsy

  612. 33yo M with 2nd degree burns to trunk & extremities on 35% of TBSA, singed nasal vibrissae & soot in oropharynx but clear, unlabored breathing & O2sat 94% on RA.  Development of hypoxia on POD1 most likely due to:
    upper airway obstruction and asphyxia

    ARDS develops within 1 week of insult
  613. The modified maze procedure for afib refractory to antiarrhythmics, cardioversions, and endocardial catheter ablation:
    can be performed off cardiopulmonary bypass
  614. What margin do you need to take around a 1.7mm thickness (level IV) non-ulcerative melanoma?
  615. Regarding the scalenus muscle:
    The anterior body inserts into the first rib posterior to the subclavian vein
  616. Greatest increase in the calculated resting energy expenditure as determined by the Fick equation =
    Blood transfusion to increase hemoglobin by 2g/dL
  617. Characteristics of unresectable pancreatic cancer:
    • encasement of the SMA
    • ...
  618. Most common site of lung abscesses:
    RUL, posterior segment
  619. 45yo M with 20y hx of alcohol dependence presents to gen surf clinic with concerns of fatty, foul-smelling stools & chronic intractable pain recalcitrant to narcotic therapy.  Routine blood work is significant for megaloblastic anemia, slightly elevated LFTs, and high blood glucose.  Abd CT scan shows small pancreas with several calcifications & pancreatic duct dilated to 10mm.  What is the appropriate therapy?
    longitudinal pancreatojejunostomy
  620. Intraoperatively a transplanted kidney becomes grossly mottled and cyanotic.  The surgeon notes capsular bulging due to marked edema, followed by graft rupture.  What is the pathophysiology behind this graft failure?
    Presence of antibodies directed toward donor ABO blood group antigens
  621. Post-splenectomy patients at risk for infection with:
    • beta-hemolytic streptococcus
    • H. influenzae
    • Nisseria meningitidis
    • Strep pneumoniae
    • S. aureus
    • E. coli
    • Pseudomonas
  622. Most abundant bacteria in poo:
    B. vulgatus
  623. Low anterior resection appropriate for lesions:
    Tumors located between 8-12 cm from the anal verge are in the middle third of the rectum and considered candidates for LAR or APR

    Patients with tumors located 2 cm above the puborectal muscle by digital examination can undergo low anterior resection. Distal surgical margins should be at least 1 cm from the tumor in cases of differentiated cancer and localized tumors of stage T2 or less and more than 2 cm in poorly differentiated cancer and tumors of stage T3 or greater with total mesorectal excision (TME). Longer distal surgical margins should be provided in patients with unlocalized tumors and extensive node metastasis
  624. Most common symptom of reaction to iodine contrast:
  625. What test is the most prognostic of liver function reserve?
    Aminopyrine breath test

    C14-labeled aminopyrine is administered to a patient orally and CO2 (including C14-labeled CO2) in the breath is measured over the following 2 hours --> reflects the efficiency of cytochrome P-450, which reflects the residual viable hepatic tissue

    • Can also use:
    • - Inject Lidocaine --> measure metabolite monoethylglycinexylidide
    • - galactose elimination capacity

    • Measurement of liver function:
    • liver transaminaes, alkaline phosphatase, gamma-glutamyl transpeptidase, leucine aminopeptidase, 5'-nucleotidase, albumin, transferrin
  626. What is the most potent stimulant of pancreatic acinar cells?
  627. 72yo alcoholic M with ascites undergoes emergent colectomy for lower GI bleed.  Post-operatively, UOP is consistently low (350-475cc/day), serum creatinine rises progressively, but central venous pressure remains normal.  24hr UA on POD4 is as follows:
    volume - 374cc
    color: yellow
    micro: renal epithelial cells
    urine [Na] <10mEq/L
    Urine sp grav: 1.030
    serum sp grav: 1.004
    pH 5.0
    What is the most likely diagnosis?
    Hepatorenal syndrome
  628. Most likely side effect of pancuronium:
  629. Erythromycin can act as a secretagogue for:
  630. 48yo former alcoholic 10 weeks s/p liver transplant with episodic fevers, leukocytosis, malaise, FTT, found to have multiple liver abscesses on CT.  Most likely causative organism:
    Klebsiella pneumoniae
  631. How to prepare a uremic pt for surgery:
    give desmopressin, or DDVAP
  632. 39yo F with watery diarrhea and upper abdominal pain x 2 weeks. On CT found to have small mass in body of pancreas.  Lab abnormalities include Hb 8.7, WBC 10.1, hypokalemia, and metabolic acidosis.  She undergoes ex lap to remove the mass and multiple small nodules are found in the liver.  Best treatment option =
    5-fluorouracil & interferon alpha

    Dx: ??
  633. How to differentiate appendicitis from acute ileitis in a pt with acute RLQ pain:
    thickened mesenteric lymph nodes on radiographic imaging
  634. Why is type II DM a contraindication for live-donor nephrectomy?

    And what is a unilateral duplicated collecting system?
    i don't know...

    i don't know...
  635. Merkel cell carcinoma characteristic =
    early distant metastases
  636. Which of the following is a characteristic of a cutaneous lymphatic malformation?
    cystic mass with overlying vesicles
  637. The fundamental goal of the ACS National Surgical Quality Improvement Program (NSQIP) is:
    to collect outcomes data to measure and improve surgical care outcomes
  638. Appropriate management of phyllodes tumor diagnosed on core biopsy =
    tumor excision with 1cm margin
  639. During resection of a pelvic tumor, the left ureter is inadvertently transected below the level of the pelvic brim.  What is the best immediate treatment?
  640. Lymphocele formation after renal transplant can cause:
  641. 18mo after aortobifemoral artery bypass, a 74yo M presents with painful leg swelling in his left groin.  US demonstrates a pseudo aneurysm at the site of the distal anastamosis with surrounding fluid.  What is the underlying cause of this condition?
    graft infection
  642. 40yo F s/p excision fibroadenoma found on final path to have a small are of lobular carcinoma in situ in the surrounding breast tissue, focally extending to one margin.  Next best step in management is:
    counsel the patient about future breast cancer risk and screening options
  643. Best imaging modality for evaluating vascular graft for blood flow and to rule out stenosis/false aneurysm:
    color-flow duplex US
  644. Obese woman s/p transabdominal hysterectomy who developed a ventral hernia s/p laparoscopic repair now with recurrent bulge.  Most common reason for recurrence after lap ventral hernia repair:
    separation of the mesh from the abdominal wall
  645. Positive secretin stimulation test in a patient with persistent peptic ulcers refractory to PPI's indicates _____ tumor which is:
    • ______
    • likely to be sporadic
  646. Erythematous, edematous esophageal mucosa with partially circumferential white ulcerations is a grade _____ lesion:
    Grade IIA

    • Degrees of esophageal burns:
    • Grade I - superficial mucosal injury characterized by erythema and mucosal edema
    • Grade IIA - as above, plus partial-thickness non circumferential ulceration characterized by white, patchy ulcers, mucosal sloughing, & pseudomembranes
    • Grade IIB - as above, plus partial-thickness circumferential ulceration (70-100% form strictures)
    • Grade III - as above, plus transmural injury characterized by full thickness necrosis, dark ulcers with eschar formation (100% form strictures)
  647. Long term outcomes of synthetic graft use in femoral-tibial artery bypass for vascular insufficiency could be improved by:
    daily use of 81mg aspirin indefinitely
  648. When should surgery for repair of left lateral cutaneous nerve of the thigh occur?
    2-3 months
  649. Advantage of full-thickness skin grafts over split-thickness skin grafts =
    lower incidence of contractures
  650. Characteristics of ARDS vs. ventilator-associated pneumonia:
    • Temp 38.5
    • WBC 16
    • no pleural effusions
    • increased protein on BAL
  651. 2yo inconsolable & refusing feeds for last 24hrs, vomited twice, no BM.  On exam abd is diffusely tender, esp in inguinal area.  What is first step?
    Elevation of the child's lower extremities with a pillow

  652. 82yo M with COPD presents with claudication, found to have occlusive disease localized to the left common iliac artery.  What procedure is most appropriate for management?
    percutaneous transluminal angioplasty under local anesthesia
  653. Appropriate treatment of completely displaced supracondylar fracture of the humerus (Garland type III) in an 8yo:
    closed reduction and internal fixation
  654. 42yo F 8 weeks postpartum with presumed dx of inflammatory carcinoma of her left breast.  Appropriate management =
    If the tumor responds to high-dose chemotherapy, continue with mastectomy, postoperative radiation, and then possible further adjuvant therapy
  655. On initial assessment using the GCS, the most important predictor of return of function in a patient with a severe head injury is:
    motor-score component of the GCS
  656. 7 week old with 3 day hx of projectile non-bilious vomiting appears dehydrated with olive shaped epigastric mass.  Most appropriate initial IV fluid regimen for resuscitation is:
    normal saline
  657. 65yo F with weakness, fatigue, easy bruising found to have guarding & distention of upper abdomen.  Reports hx of taking prednisone & weekly epoetin alfa.  Symptoms have become worse in the last year.  What procedure is needed for definitive management of this condition?
    Laparoscopic splenectomy

    Diagnosis: ITP???
  658. Treatment of gallstone ileus:
    surgical exploration
  659. The cerebral perfusion pressure in a patient with head injury should ideally be greater than:
  660. A 42yo M with marked ascites is being treated for hepatic encephalopathy 2/2 alcoholic cirrhosis.  What is the most likely acid-base abnormality found in this patient?
    normal anion-gap metabolic acidosis
  661. Treatment for squamous cell carcinoma of the anal verge:
    Chemoradiation therapy with 5-fluorouracil and mytomycin C
  662. Management of pleomorphic adenoma in the deep parotid lobe:
    Total parotidecomy with preservation of the facial nerve
  663. 2mo boy born to mother with marfanoid habitus and hx of pheochromocytoma undergoes genetic testing & found to have RET oncogene.  Initial goal in management =
    total thyroidectomy with central lymph node dissection before 6mo of age
  664. Most common etiology of common bile duct injury during laparoscopic cholecystectomy:
    excess cephalad retraction of the gallbladder
  665. 57yo F with biopsy-proven 4.5cm buccal squamous cell carcinoma of right cheek with no palpable lymph nodes.  What is the most appropriate management?
    wide resection with supraomohyoid neck dissection
  666. After removal of a suspected parathyroid adenoma, a decrease in PTH to which level within the specified time frame would signify that the only the hyperfunctioning gland had been removed?
    99pg per ml in 10 minutes
  667. What do you use to rapidly correct Coumadin coagulopathy?
    fresh frozen plasma
  668. 58yo F is experiencing bright red rectal bleeding after undergoing a lumbar laminectomy 3 days ago.  She has been stable, post op course uncomplicated.  What is the most likely etiology?
  669. Most effective way to maintain a patient's core body temperature intraoperatively:
    using forced-air warming devices
  670. 24yo M stabbed in the right flank, urine grossly positive for blood, CT shows extravasation from the superior pole of the right kidney.  Operative exploration confirms cortical injury but no injury to hilum or pelvis.  Management:
    debride devitalized tissue and repair it primarily
  671. What technique has the most favorable results for inhibiting keloid formation?
    intralesional steroid injection following keloid excision
  672. The benefits of liver transplantation outweigh the risks at a MELD score of:
    MELD 15
  673. Pain in distal extremities worse with laying flat, better with sitting in chair and purple/red feet while seated that are white while elevated indicates an ABI in the range of:
    ABI 0.3 to 0.4
  674. 62yo F with parathyroid adenoma, 3 normal parathyroid glands found (2 right, 1 superior gland identified posterior to the superior pole of the left thyroid lobe) thymus and left neck explored but no abnormal masses found.  Next step =
    left-sided thyroid lobectomy
  675. 50yo F s/p lap chole found on final path to have adenocarcinoma of the gallbladder wall limited to the muscular layer of the gall bladder, cystic duct margin negative.  Recommended treatment plan =
    resection of the gallbladder fossa and portal lymphadenectomy
  676. The preferred location for central venous access is:
    left subclavian vein
  677. Respiratory quotient consistent with overfeeding syndrome:

    Respiratory quotient = ratio of CO2 produced to O2 consumed during oxidation of a given energy substrate (glucose, protein, fat)

    • RQ >1 indicates lipogenesis c/w overfeeding
    • RQ = 1 indicates pure carbohydrate metabolism
    • RQ = 0.8 indicates protein metabolism
    • RQ = 0.7 indicates fat metabolism
    • RQ <0.7 indciates ketogenesis c/w starvation

    Overfeeding leads to overproduction of CO2 --> increased ventilatory demand & increased work of breathing
  678. 62yo F undergoes lap splenectomy for ITP.  After recovery from the operation she continues to have a platelet count of 20,000.  What is the next step in her treatment?
    Administer IV immunoglobulin
  679. Indications for sentinel lymph node biopsy in non-ulcerated melanoma:
    1.5mm thick with no clinical nodal metastases
  680. Highest temperature of IV fluids that is safe to administer to patients?
    65 degrees C
  681. 30yo M underwent pelvic fixation, has been vomiting episodically for past 24hrs, had high NGT output, & RR 8.  To correct his acid-base status of his electrolytes, you should give:
    1L NS + 20 mEq KCl
  682. 65yo M with hx of severe atherosclerosis, HTN, and bicuspid aortic valve presents to the ED in acute distress after a sudden onset of tearing chest pain directly below his sternum.  The pt is hypertensive (196/110) and appears very anxious with an overwhelming sense of doom.  Which of the following tests or interventions is contraindicated in this patient?
    Thrombolytic treatment of an MI
  683. A 51yo M with diabetes and a 5.8cm AAA undergoes preop eval.  He has the following lab results:

    Na - 144
    K - 5.7
    Cl - 117
    bicarb - 18
    Cr - 1.6
    Plasma renin activity - 1.3 (nl 1.9-3.7)
    urine pH 5.0

    These lab tests are consistent with:
    type 4 RTA
  684. 68yo F with hx of weight loss and nausea, denies vomiting or early satiety.  Workup ultimately leads to biopsy proven B-cell mucosa-associated lymphoid tissue lymphoma confined to the stomach.  Most appropriate treatment =
  685. Right renal artery lies ________ to the IVC.
  686. 27yo M with GSW & massive hemorrhage, ABG shows:

    pH 7.5
    PaO2 140
    PaCO2 50
    HCO3- 28

    Most likely etiology of acid-base disturbance:
    contraction alkalosis
  687. Regarding the distribution of insulinomas:
    insulinomas are evenly distributed throughout the pancreas
  688. Treatment for focal nodular hyperplasia of the liver:
  689. A negative side effect of delayed primary wound closure compared with healing by secondary intention =
    risk of formation of delayed abscess or wound infection
  690. 40yo M unrestrained driver is involved in high-speed MVC with a 5 minute extrication time.  First responders find him breathing shallowly with a HR 113, BP 110/70.  He has a scalp laceration but no obvious extremity fractures.  He is given a large volume of IV fluids en route to the hospital.  Upon arrival, his GCS is 8, and he is intubated & placed on a vent.  Shortly thereafter, he becomes markedly hypotensive and is found to be in PEA, CPR is started.  Next best step =
    bilateral needle decompression
  691. 52yo M reports intermittent episodes of tachycardia, nausea, diaphoresis that improve with snacks.  He's gained 10lbs in the past 3 months and has become increasingly irritable.  He is diagnosed with insulinoma but a CT scan with IV contrast fails to localize the tumor.  The next step is:
    perform endoscopic US
  692. What physiologic alteration is caused by truncal vagotomy?
    increased intragastric pressure
  693. T3 colon cancer =
    lesion invading through the muscular is propria into the serosa
  694. A 23yo M with type 1 choledochal cyst found on ERCP should undergo:
    complete excision with Roux-en-Y hepaticojejunostomy
  695. Earliest indicator of compartment syndrome:
  696. 40yo M with Crohns, develops coloureteral fistula with pericolic abscess, administered Levofloxacin upon which pt goes into cardiopulmonary arrest.  The fatal arrhythmia is caused by:

    Quinolones (widely used for UTIs) can cause QT prolongation which is can lead to TdP.  So can hypokalemia & this patient has both.

    QT interval = length of time between the first depolarization and end of repolarization of the ventricles.  QT prolongation >500msec is a known risk factor for torsade de pointes.

    Torsade de pointes arises from early after-depolarization initiated by a premature ventricular beat or salvo of ventricular beats, followed by a pause, then a supraventricular beat.  Another premature ventricular beat arrives at a short coupling interval and falls on the preceding T wave, precipitating the rhythm.
  697. Anatomically, which is the most likely origin of an anomalous takeoff of the right hepatic artery?
    Superior mesenteric artery
  698. 67yo F with hx of multiple left hemispheric ischemic attacks found to have "string of beads" appearance in the distal left internal carotid artery, proximal to the carotid canal at the base of the skull.  There is no further evidence of narrowing at the bifurcation on the left side, or of any disease of the right internal carotid artery.  What is the most appropriate management?
    Percutaneous transluminal balloon dilation

    Diagnosis: fibromuscular dysplasia
  699. 27yo with mult abd GSW, POD 3 extensive bowel resection with open abdomen develops hyperdynamic shock as evidenced by:
    • increased/decreased CVP/PCWP
    • increased CO
    • decreased SVR
    • increased SvO2
  700. 58yo F with severe refractory peptic ulcer dz that has failed conventional treatment, found to have 1.8cm duodenal mass on EUS & octreotide scan.  No liver mets.  Elevated serum gastrin level.  Appropriate surgical management =
    duodenotomy and resection of the mass
  701. Complications of hepatic adenoma include:
    50-65% risk of spontaneous rupture and intraperitoneal hemorrhage
  702. Best method for assessing venous valvular competency =
    duplex doppler US
  703. 40yo F with long standing Crohn's dz found to have perianal fistula above the dentate line involving sphincter muscles.  The fistula is well drained and there is no sign of pelvic sepsis.  Best option for treatment =
    Anti-TNF antibody
  704. Cultures of a human bite wound are most likely to reveal:
    Staphylococcus aureus
  705. 4 years after GSW to right thigh a 26yo M is referred to your clinic because of a thrill over his right thigh.  What other finding is likely?
    left ventricular hypertrophy
  706. As part of her workup for anemia, a 60yo F undergoes EGD which reveals a 5cm mass along the greater curvature of the stomach.  Biopsy reveals spindle cells and a CT scan shows no other abnormalities.  The most appropriate next step is:
    wedge resection of the gastric mass
  707. Finding suggestive of an MI in the LAD distribution:
    • decreased SBP
    • decreased CO
    • increased HR
    • decreased SV
    • increased SVR
    • increased CVP
    • increased PCWP
  708. A 50yo M with carcinoid tumor metastatic to both lobes of his liver.  The GI site with the highest metastatic potential is:
  709. 62yo F s/p sigmoid resection for stage IIIA moderately differentiated adenocarcionma.  What adjuvant therapy should this patient receive postoperatively?
    5-FU + leucovorin + oxaliplatin
  710. Adenocarcinoma of the lung indications for lobectomy + mediastinal lymphadenectomy vs. pneumonectomy + mediastinal lymphadenectomy:
    2.8 - lobectomy
  711. Risk of development of parastomal hernia after end-colostomy:
  712. Why use DDAVP in von Willebrand dz?
    to reverse platelet dysfunction

    VWF is a complex multimeric glycoprotein with two important roles in haemostasis: it binds to platelet receptors, bridging them to other platelets and subendothelial tissue that is exposed after vascular injury, and also acts as a carrier protein for the coagulation factor VIII (FVIII), thus preventing its proteolytic inactivation in the plasma.

    VWF is released into plasma as a large multimer, which is instantaneously broken down by a protease into several molecules of varying molecular sizes: multimers with high, intermediate and low molecular weight.

    The high‐molecular‐weight multimers, by virtue of their strong affinity to platelet receptors, are considered more potent than the other multimers. The absence of these multimers leads to a defect in platelet adhesion, prolonging the bleeding time. Ristocetin is an antibiotic that enhances the interaction between the VWF and the platelet receptors. On the basis of this effect, ristocetin cofactor activity test is used as a surrogate marker of the functional activity of the VWF

    Vasopressin is a secretagogue of VWF. This hormone functions through two receptors, termed V1 and V2, which activate different intracellular second messengers.7 Agonist activity at V2 receptors leads to a rise in intracellular concentrations of cyclic adenosine monophosphate, which in turn induces exocytosis of VWF from its storage sites.

    Desmopressin (1‐desamino‐8‐d‐arginine vasopressin, also abbreviated DDAVP) is a synthetic analogue of vasopressin, which activates only V2 receptors and thus lacks its vasoconstrictor and uterotonic properties. Intravenous or intranasal administration of desmopressin to healthy individuals is followed by a rise in levels of both VWF and its precious cargo, FVIII.2 Individuals who lack V2 receptors—that is, patients with nephrogenic diabetes insipidus—expectedly do not show this increase in VWF and FVIII levels.
  713. Why is hand washing so important around neonates?
    neonatal neutrophils have impaired chemotaxis
  714. Effect of the inspiration phase of positive-pressure mechanical ventilation:
    decreased cardiac output
  715. A duodenal diverticulum is seen in a 58yo M with recurrent episodes of acute pancreatitis.  On endoscopic evaluation, the ampulla of Vater is found to be located just distal to the border of the diverticular opening.  Most appropriate interventional management of this patient's duodenal diverticulum:
    endoscopic sphincterotomy and stent placement
  716. Carotid endarterectomy for asymptomatic patients is indicated for stenoses defined by diameter reduction on angiography of:
    > 60%
  717. What is the most serious complication of treatment of Crohn's with infliximab?
    Tuberculosis pneumonia

    50% of patients experience infectious complications during & following treatment with infliximab, likely due to the anti-TNF antibodies blocking intracellular immune mechanisms.  Specifically, multiple cases of TB have been reported.
  718. Creating a tumor vaccine would take advantage of what aspect of the immune system?
    Adaptive immunity

    • Adaptive immune system composed of T & B cells.
    • Adaptive immunity is regulated by dendritic cells.
  719. Staging of HCC:
    • T1 - tumors of any size without vascular invasion
    • T2 - tumors <5cm with vascular invasion or multiple tumors <5cm
    • T3 - multiple tumors >5cm or solitary tumor involving a major branch of a hepatic/portal vein
    • T4 - invasion of adjacent organs (except gallbladder) or spread to visceral peritoneum

    • Stage I-IIIB - no evidence of lymphatic spread, based on size
    • Stage IIIC - regional lymph node metastases
    • Stage IV - evidence of distant mets
  720. In a normally distributed population, the value that best describes the population =
  721. What do you give a pt with hemophilia A who needs an operation?
    Factor VIII

    During surgery, factor level should be monitored.

    • Deficient factors in various hemophillias:
    • A - factor VIII
    • B - factor IX (christmas dz)
    • C - factor XII
  722. Possible effect of rapid resuscitation with blood products:
    Jaundice and fever seen 1 week later

    Delayed hemolytic transfusion reaction occurs once in every 2500 units of PRBCs.  The reaction typically occurs 2-14 days after transfusion and results in fever, jaundice, and anemia.  Results from the clearance of the antibody-coated erythrocyte by the reticuloendothelial system.
  723. Treatment of bleeding after administration of urokinase for saddle PE:
    transfusion of whole blood or FFP which restores plasma fibrin
  724. 62yo F s/p hemorrhoidectomy complains of inability to urinate.  What do you tell her?
    Return to the ED for foley catheter placement

    • UR is a common complication after surgery for anorectal disease.
    • Occurs in 20% of patients after hemorrhoidectomy
    • Etiology likely due to reflex spasm of the pelvic musculature due to postoperative pain.
    • Independent RF: female, resection of >3 hemorrhoids, DM, need for postoperative pain meds, preoperative urinary symptoms.
  725. What is the mechanism of action of gastrin?
    It is secreted by the gastrin cells of the stomach in response to protein (especially tryptophan or phenylalanine) and stimulates parietal cells
  726. 50yo F presents with 4 week history of RUQ pain.  RUQ US does not show any evidence of cholelithiasis or cholecystitis.  Next step should be:
    cholecystokinin cholescintigraphy
  727. 2yo boy presents with 1mo hx of episodic painless rectal bleeding, exam findings unremarkable.  Most useful imaging study =
    99mTc-pertechnate scan

    aka Meckel scan, relies on selective uptake of isotope by eutopic and ectopic gastric mucosa
  728. Gastric outlet obstruction can cause the following metabolic abnormalities:
    hypovolemia, hypokalemia, metabolic alkalosis, hypochloremia

    • Vomiting causes loss of fluid & HCl leading to hypochloremic metabolic alkalosis & dehydration
    • Loss of gastric contents & hypovolemia promote renal K+ secretion, which is augmented by aldosterone release
  729. What characteristic is specific to primary hyperaldosteronism?
    Adrenal tumor

    Conn syndrome is caused by an aldosterone-producing adrenal adenoma and accounts for 60-70% of cases of primary hyperaldosteronism

    Other causes: idiopathic bilateral adrenal hyperplasia, adrenocortical carcinoma, glucocorticoid-suppressible hyperaldosteronism