FINAL COACHING – SURGERY 2022 complaint of worsening fatigue and malaise over the

past several weeks. He has noted an improvement in

1. A 40-year-old man with epiglottitis is intubated at an his appetite and denies any increase in bowel habits.
outside hospital and sent to the emergency room for On examination, he appears pale but without muscle
evaluation. The transport team states that the patient wasting or other signs of weight loss. His laboratory
became combative during the trip and was given results: K+ × 4.5, Cl- = 110, blood urea nitrogen = 14,
more “sedative” and strapped more securely to the creatinine = 1.2, Mg2+ = 2.5, PO4- = 5.0, and Ca2+ =
stretcher. During your examination you notice that the 8.5. His hematocrit is 25%, white blood cell count is
patient can blink his eyes to command but is unable 5,000, platelets are 150,000, and mean red cell
to move any extremities nor make respiratory effort. volume is 125. Which of the following would be the
He blinks affirmatively to your query if he is in pain. most appropriate therapy in the definitive
You administer a narcotic and a benzodiazapine. management of this patient's current condition?
What is the most likely cause of paralysis? Select one:
Select one: a. Vitamin B12 supplementation
a. A C2 cord lesion b. Folate supplementation
b. Muscle relaxant c. Iron supplementation
c. Guillain-Barré syndrome  d. Administration of 2 U packed red blood cells
d. Subarachnoid hemorrhage
5. For wound infections presenting in the early
2. A 25-year-old man sustains a 45% full-thickness burn postoperative period (< 48 hours), which of the
injury to his lower extremities and torso. After following statements is true?
adequate initial fluid resuscitation and local wound Select one:
care he is awake and alert. On hospital day 3, his a. Clostridium and streptococcus species are frequent
heart rate is 130, blood pressure is 130/80, and pathogens
respiration rate is 24. He is also noted to have a blood b. The bacterial contamination leading to wound infection typically
glucose of 300 despite administration of 12 units of occurs in the postoperative period
regular insulin. His blood urea nitrogen is 45 and his c. The rate of wound healing is unaffected by wound infections
creatinine is 1.8. Which of the following statements is occurring in the early postoperative period 
appropriate with regard to this patient's metabolic d. Débridement of an infected wound should be performed if
state? antibiotic therapy fails
Select one:
a. The major source of glucose for the burn wound is probably via 6. A 22-year-old man underwent percutaneous pin
glycogenolysis. fixation of a right ankle fracture as an outpatient.
b. Protein requirements are 1 g/kg/day to avoid excessive azotemia Three days later he presents at the emergency
with associated renal insufficiency. department complaining of vomiting and mild
c. Insulin stimulation of lipolysis plays a critical role in providing shortness of breath, but denies any pain. The wound
glucose for peripheral tissues.  is without obvious drainage or erythema. His
d. Catecholamines and glucagon play a critical role in temperature is 39°C (102.2°F), his heart rate is 140
stimulating glucose production via hepatic beats/min, and his blood pressure is 90/40 mm Hg.
gluconeogenesis. His chest radiograph is clear and his creatinine is 3.4.
Which of the following statements is true regarding
3. A 65-year-old man undergoes pancreatic débridement this patient?
for alcohol-induced necrotizing pancreatitis. He is Select one:
noted to be malnourished on admission to the a. The causative organism is most likely a clostridial species
intensive care unit. He is initially alert but unable to b. An intra-abdominal source of infection is likely 
wean from the ventilator postoperatively. He is started c. Outpatient antibiotic therapy is indicated
on parenteral nutritional therapy with 35 kcal/kg/ day d. A desquamating erythematous rash is characteristic
with 60% as carbohydrates, 30% as lipids, and 10%
kcal as protein. His prealbumin slowly improves over 7. After a routine right inguinal hernia repair, a 42-year-
the next several days and his glucose levels remain old man develops erythema over the incision. A
relatively stable (130–190). Over a 10-day period the wound infection is diagnosed and the patient is
patient fails to wean from the ventilator and becomes discharged to home on 10 days of ciprofloxacin.
more confused and lethargic. He also gradually Three weeks later he returns with complaints of
develops a worsening picture of cardiogenic shock. persistent watery diarrhea with a low-grade fever. His
For definitive management of this patient's underlying temperature is 38.3°C (101°F), his heart rate is 80
problem, which of the following is most appropriate to beats/min, and his blood pressure is 125/65 mm Hg.
be administered? Which of the following is the most appropriate next
Select one: step in the management of this patient?
a. Thiamine Select one:
b. KPO4-  a. Intravenous (IV) vancomycin therapy
c. Niacin b. Colonoscopy
d. Insulin c. No treatment, because the cause is probably viral 
d. Oral clindamycin
4. A 65-year-old man underwent resection of the distal
150 cm of his small bowel for severe mesenteric 8. Which of the following statements is correct regarding
ischemia 3 months ago. He has since recovered and wound healing and persistent local tissue hypoxia?
is receiving supplemental enteral nutritional support Select one:
through a gastrostomy tube in addition to eating small a. Fibroblasts are stimulated by low oxygen tension
amounts of food each day. He now presents with the
b. High lactate levels inhibit macrophage production of
angiogenesis factor  13. During cardiac transplantation, a recipient requires
c. Low oxygen tension is the most common cause of poor multiple blood transfusions from blood loss during
wound healing surgery. During the operation, the patient develops
d. Collagen synthesis is stimulated by hypoxia sudden hypotension, bleeding from intravenous sites
and wound edges, along with severe tachycardia.
9. During the first 4 days after an injury, which of the Which of the following is the most likely cause of
following cells are most critical to wound healing? these findings?
Select one: Select one:
a. Fibroblast a. Type I immediate hypersensitivity 
b. Lymphocyte b. Type II cytotoxic hypersensitivity
c. Myofibroblast c. Previous aspirin therapy
d. Macrophage  d. Type IV delayed hypersensitivity
Macrophages play a critical role in the inflammatory phase of
wound healing and in the modulation of collagen production. 14. After an uncomplicated renal transplantation, a patient
These cells affect wound healing through multiple secretory inadvertently removes his Foley catheter on the first
factors and receptors. Studies of the role of macrophages have postoperative day. Why should the Foley catheter be
shown a marked inhibition in the process of wound reinserted?
débridement and collagen production with administration of Select one:
antimacrophage serum early in wound healing. Although a. Hourly urine output monitoring is necessary.
lymphocytes also modulate wound healing by secreting b. Foley catheters decrease the risk of urinary tract infections (UTI).
interleukin-2, transforming growth factor-β, and other c. Foley catheters decompress the bladder. 
lymphokines, these substances do not appear until After ureteroneocystostomy, decompression of the bladder for
inflammation has resolved, approximately 3 days after injury. several days using a Foley catheter allows healing of the
anastomosis. Urine output monitoring aids in detection of renal
10. A 45-year-old, obese man develops a wound infection hypoperfusion and graft rejection but can be accurately
on postoperative day 10. The patient undergoes measured in this setting without the use of a Foley catheter.
wound débridement, followed by dressing changes to Foley catheters are associated with an increased rate of
the open wound and systemic antibiotics. Allowing urinary tract infections. Overdistension of the bladder can lead
this wound to heal by wound contraction and to breakdown of the anastomosis of the ureter to the bladder.
epithelialization (i.e., secondary intention) means that Although ureter strictures are not uncommon after renal
the wound will spend a prolonged period of time in transplantation, urethral strictures are rare. Foley catheters do
which of the following phases? not prevent rejection.
Select one: d. Urethral strictures occur more commonly after kidney
a. Inflammatory transplantation.
b. Proliferative 
c. Fibroblastic 15. A 49-year-old woman develops markedly increased
d. Remodeling liver enzymes on the ninth postoperative day after
11. Which of the following is the most appropriate option liver transplantation for hepatitis C. Further evaluation
for closing a large wound once the wound appears includes a Doppler ultrasound demonstrating
“clean”? adequate hepatic blood flow, and liver biopsy
Select one: demonstrating endothelialitis and bile duct damage.
a. Split-thickness skin graft Which of the following therapies is most likely to be
b. Full-thickness skin graft  effective?
c. Local skin flap Select one:
d. Myocutaneous flap a. Interferon therapy for recurrent hepatitis C
b. Steroid bolus therapy for rejection 
12. A 65-year-old man underwent an uneventful open The pathologic findings and time course described are
inguinal herniorrhaphy, but during overnight consistent with acute cellular rejection. M ore than half of liver
observation was found to have vomited while he slept. transplant recipients will develop acute rejection, most within
He received aggressive suctioning but later that day the first 4 weeks. Initial therapy often includes steroid boluses.
he displayed a fever of 39.0°C. Other vital signs were Hepatitis C, like many other indications for transplantation, may
a blood pressure of 140/70 mm Hg, pulse of 90 recur 3–6 months after transplantation. Adequate hepatic blood
beats/min, and respiration of 24/min. Oxygen flow on Doppler ultrasound decreases the likelihood of portal
saturations were 92% with a 40% face tent. There vein thrombosis. Bile duct strictures are often associated with
were thick crackles on auscultation of the lungs. jaundice and characteristic pathologic findings. Observation
Chest radiograph was significant for bilateral alone may lead to graft loss due to rejection.
infiltrates. Which of the following statements most c. Reoperation for portal vein thrombosis
accurately reflects the patient's current clinical d. Reoperation for bile duct stricture
condition?
Select one: 16. A 53-year-old woman is undergoing an elective
a. Cefazolin is the antibiotic of choice for treatment of this condition sigmoid resection for recurrent diverticulitis.
because of its activity against oral flora Intraoperatively, the patient requires transfusion of 2
b. Pneumonias resulting from this condition are associated with units of packed red blood cells (PRBCs) for significant
minimal morbidity and mortality blood loss early in the case. After starting the
c. The left upper lobe is the most frequently involved pulmonary transfusion, the anesthesiologist notes that the
segment  patient's blood pressure is now 70/40 mm Hg, having
d. Nasogastric suction tubes and endotracheal tubes do not dropped from 120/80 mm Hg. There is no
uniformly prevent this complication intraabdominal bleeding noted, however her urine has
 suddenly become very dark. Electrocardiogram c. Administer naloxone and control the airway
(ECG) reveals sinus tachycardia without evidence of d. Administer sodium bicarbonate
myocardial ischemia. Which of the following is the
most frequent cause of this patient's current 20. A 55-year-old woman underwent a Whipple procedure
condition? for pancreatic adenocarcinoma. Postoperatively, she
Select one: develops a pancreaticocutaneous fistula, which drains
a. Primary bacterial contamination of donor blood approximately 400 mL/day. On evaluation, the patient
b. Clerical errors in matching donor blood to recipient is noted to be tachycardic with a heart rate of 115
c. Inadequate screening of donor blood for leukocytes  beats/min and a blood pressure of 100/80 mm Hg.
d. Recipient antibody formation to minor antigens on donor blood Her skin is noted to be dry, and her urine output has
cells decreased significantly over the past 2–3 days. Labs
reveal a Na+ of 140 mEq/L, Cl- of 120 mEq/L, and
17. A 62-year-old, 90-kg woman undergoes exploratory HCO3- of 15 mEq/L. To resuscitate this patient, which
laparotomy and resection of an obstructing sigmoid of the following is the most appropriate fluid?
colon cancer. Postoperatively, the patient is Select one:
transferred to the surgical floor where she receives a. 5% dextrose in normal saline (0.9%)
normal saline at 100 mL/hr. The next morning she is b. 5% dextrose in ½ normal saline (0.45%) 
tachycardic with a heart rate of 120 beats/min and a c. 5% albumin solution
blood pressure of 95/60 mm Hg. Her urine output is d. Lactated Ringer's solution
diminished to 20 mL/hr. Her physical examination is
remarkable for a distended abdomen without bowel 21. A 16-year-old man is brought to the emergency room
sounds and with mild tenderness. Her hematocrit is after his clothes caught on fire. He has severe burns
now 36% (it was 33% the night before). Abdominal to both his upper extremities. What signs would
radiograph shows a gasless abdomen, and a chest indicate the need for an escharotomy?
radiograph is read as “normal.” Which of the following Select one:
is the most likely source for her hypotension in the a. Circumferential burns with severe blistering and erythema
intensive care unit the day after surgery? b. Circumferential burns with severe pain over the affected area 
Select one: c. Circumferential partial-thickness burns over the elbow joint
a. Renewed bleeding within the abdominal cavity d. Circumferential burns with an absence of the left radial
b. Gastrointestinal bleeding from stress ulceration  pulse
c. Acute gastric dilation with a vasovagal response
d. Third space losses within the peritoneum 22. An 18-year-old man is admitted to the hospital after
sustaining a burn injury from a gasoline fire. His entire
18. A 32-year-old man sustained a left femur fracture anterior trunk, left upper extremity, and both complete
after a steel beam fell on his legs and trapped him anterior thighs are affected. All areas appear to be at
underneath. It was approximately 2 hours before least partial-thickness burns. What is the estimated
coworkers were able to locate him and remove the total body surface area of burn injury involvement?
beam. On admission, the patient received 2 units of Select one:
packed red blood cells (PRBCs) for hypotension and a. 18%
had significant blood loss from the femur fracture. On b. 27%
hospital day 2, the patient is noted to have frequent c. 36% 
runs of ectopy on the electrocardiogram (ECG) Total body surface area (TBSA) estimates used to quantify the
monitor. Widened QRS complexes are also noted. His extent of burn injuries in adults is based on the “rule of nines.”
urine is dark red, but microscopic examination of the The anterior trunk is equal to 18%. The left upper extremity is
urine reveals no red blood cells (RBCs). Which of the equal to 9%. Each lower extremity is equal to 18%, thus each
following events is most likely responsible for this anterior thigh is approximately 4.5%, and making a total of 9%
patient's current findings? TBSA involved in the lower extremity. Therefore 18 + 9 +
Select one: 2(4.5) = 36%.
a. Rhabdomyolysis d. 55%
b. Acute tubular necrosis secondary to hypovolemia 
c. An unrecognized kidney laceration 23. During a routine postoperative check, a 67-year-old
d. Fat embolus syndrome woman who had undergone resection of an infrarenal,
abdominal aortic aneurysm complained of peri-
19. A 65-year-old man with non–insulin-dependent incisional tenderness and some light-headedness.
diabetes mellitus (NIDDM) is postoperative day 2 after Her vital signs were a blood pressure of 110/40 mm
undergoing an elective colon resection for Hg, pulse of 130 beats/min, respiration of 24/min, and
adenocarcinoma. The patient is poorly responsive. On temperature of 37.9°C. She had 25 mL urine output
examination, the patient is obtunded, his pupils are for the last 2 hours. On examination, she had dry
pinpoint, his heart rate is 130 beats/min, and his blood mucus membranes, there were faint bibasilar crackles
pressure is 70/50 mm Hg. A patient care assistant on pulmonary auscultation, her abdomen was mildly
states that the patient was awake 1 hour before, but distended, the incisional dressing was clean and dry,
somewhat confused. Arterial blood gas reveals a pH and her feet were cool to the touch. Hematocrit
of 7.29, PaCO2 of 75 mm Hg, PaO2 of 70 mm Hg, dropped from 43% to 27%. Which of the following
and a HCO3+ of 23 mEq/L. Which of the following is statements is true of her condition?
the most appropriate initial step in the management of Select one:
this patient? a. These findings are suggestive of acute myocardial infarction with
Select one: congestive heart failure
a. Administer an insulin bolus immediately b. Plain radiographs are the most sensitive imaging modality for
b. Obtain a chest radiograph immediately  determining the cause of abdominal pathology
c. More potent narcotic analgesics may be helpful because her
examination suggests a sympathetic nervous system response 27. An elderly male is involved in a motor vehicle
to poor postoperative pain control accident. He states he was going approximately 45
d. Operative exploration may be necessary if nonoperative mph when his car struck a car that stopped abruptly in
measures fail to correct this condition  front of him. His blood pressure is 110/74 mm Hg,
Hemoperitoneum is the most common cause of hypovolemic with a heart rate of 87 beats per minute. After
shock in the first 24 hours after abdominal surgery. Signs thorough examination his only injuries include a
include lowgrade fever, tachycardia, hypotension, oliguria, and nondisplaced right femur fracture with intact
peripheral vasoconstriction. The diagnosis is confirmed by peripheral pulses and some minor abrasions. Which
demonstrating increasing anemia on routine hematologic tests. of the following would be appropriate to confirm the
A computed tomography (CT) scan showing fluid in the absence of a cervical spine injury in this patient?
abdomen consistent with blood may also be used if the clinical Select one:
picture is questionable. Treatment consists of volume a. A normal lateral neck film with no cervical tenderness or pain
resuscitation, possible blood transfusion, correction of during examination
coagulopathy (if one exists), and re-operation with meticulous b. A normal anterior posterior film with no cervical tenderness or
hemostasis if other measures fail. Although tachycardia is pain during examination
sometimes an indication of poor pain control, or infection and c. A normal computed tomography (CT) scan of the cervical spine
sepsis, there are enough other signs to quickly rule these out with pain upon lateral neck motion
as the source of the current problem. d. Lateral, anterior-posterior, and odontoid views with no
cervical tenderness or pain during examination 
24. After being hit on the left side, a 24-year-old football To adequately confirm the absence of a cervical spine injury in
player becomes unconscious. He regains a patient at a potential risk for such injury (i.e., high-speed
consciousness and is brought emergently to the motor vehicle accident) radiographs must be performed. To
hospital. After initial resuscitation, performance of an rely on the physical examination alone, the patient must be
abdominal computed tomography (CT) scan reveals a alert and oriented and have no distracting injuries (e.g., femur
splenic injury involving the vessels within the hilum fracture) or be under the influence of drugs. Radiographs
with significant intraperitoneal bleeding. Which of the needed to evaluate the cervical spine are a lateral, anterior-
following statements is true regarding the posterior, and open mouth odontoid views. It is important to
management of this patient? visualize all seven cervical vertebrae. If a physical examination
Select one: is reliable and negative for tenderness or pain with full range of
a. Nonoperative management with bedrest is indicated for this motion, no further evaluation needs to be performed. Even with
splenic injury. a normal computed tomography (CT) scan, however, the
b. This patient will need to be immunized with vaccines against presence of pain during range of motion testing should prompt
Haemophilus, Pneumococcus, and Neisseria. an evaluation for a potential ligamentous injury.
c. If a splenectomy is performed, this patient will require lifelong
antibiotic therapy.  28. A 4-year-old girl is brought in by her parents after she
d. This injury is a grade 1 splenic injury because of the involvement apparently was burned during her bath. Her feet,
of the hilum. buttocks, and perineum are badly scalded with
blistering skin. Her legs have no blistering, but are
25. A 46-year-old woman suffered a full-thickness burn to mildly red and somewhat tender to the touch. Which
10% of her body, a partial-thickness burn to 30% of of the following is true regarding admission criteria for
her body, and first degree burns to an additional 20% burn injured victims?
of her body. She weighs 50 kg and the burn occurred Select one:
just before admission. What is the estimated amount a. Children with deep partial-thickness burns on ≤ 30% total body
of fluids she will need for the first 24 hours? surface area (TBSA) can be managed as outpatients with
Select one: close follow-up.
a. 2 liters  b. Patients with full-thickness burns to the perineum only can be
b. 3.6 liters managed as outpatients with close follow-up. 
c. 8.0 liters c. Children with full-thickness burns to the feet only can be
d. 12.4 liters managed as outpatients with close follow-up.
d. All children with burn injuries and a concern of possible
26. A 19-year-old cross country runner presents to the abuse should be admitted for inpatient treatment.
emergency room after falling off a 9-foot ridge and
landing on his right side. He is complaining of some 29. A patient is complaining of shortness of breath after
tenderness over his right lower ribs with no abdominal falling off his tractor and getting run over by the rear
tenderness to palpation. His blood pressure is 128/74 wheel. Physical examination reveals a blood pressure
mm Hg with a pulse of 96 beats per minute. An of 82/40 mm Hg, a heart rate of 122 beats per minute,
abdominal computed tomography (CT) scan is short shallow respirations, breath sounds louder on
performed, which reveals a grade III liver injury with the left than on the right, and tracheal shifting toward
intra-abdominal bleeding. Which statement is true the patient's left. What is the most likely diagnosis?
regarding this patient? Select one:
Select one: a. Right tension pneumothorax
a. Hypotension and tachycardia are often late findings of b. Left tension pneumothorax 
shock in young athletes. c. Cardiac tamponade
b. Hepatic arteriography is the preferred examination in the d. Severe tracheal injury
evaluation of liver injuries. 
c. A 9-foot fall is not sufficient enough to cause a severe liver injury. 30. A 49-year-old man presents to the emergency room
d. The lack of abdominal tenderness is inconsistent with intra- after being hit by a car while walking down the road.
abdominal bleeding. Minimal history is available from the emergency
 medical technicians. He is conscious upon arrival and show stones but is not as sensitive as ultrasound or IVP. The
moving all 4 extremities. The most appropriate initial patient's clinical presentation, in addition to the urinalysis
step in the evaluation of this patient is to findings of no white blood cells, nitrates, leukocyte esterase, or
Select one: bacteria, makes infection possible, but less likely. Immediate
a. Remove all clothing and inspect for injuries.  orchiopexy would be appropriate if testicular torsion were
b. Ask the patient his name. suspected. This generally presents with acute abdominal pain
c. Place a Foley catheter after a rectal examination. and extreme tenderness in the affected testicle.
d. Evaluate the patient's pupils. d. Computed tomography (CT) scan of the abdomen

31. A 17-year-old woman is seen in the emergency room 34. A 45-year-old, obese man was involved in a high-
with severe burns to both of her hands. She seems speed motor vehicle accident. He was hypotensive at
very responsible, and is with her parents who are very the scene and was noted to have a distended
willing to help take care of her at home. She is not abdomen upon presentation. He was quickly
complaining of any pain and wonders if she can be evaluated and taken to the operating room for an
treated as an outpatient. Which of the following exploratory laparotomy. Which of the following is true
statements is true regarding the management of this with regard to adequate closure of the abdomen after
patient? this procedure?
Select one: Select one:
a. This patient can be adequately managed as an outpatient with a. Permanent suture materials should not be used for closing the
close follow-up.  fascial layers because of the increased risk of local
b. Skin grafting should be performed in 1–2 months to provide the inflammation
best outcome. b. The instability of wound closure is decreased by the
c. Her burns are likely to be superficial partial-thickness burns. removal of devitalized tissue
d. Early skin grafting (within days) will decrease contracture Inadequate closure of fascial layers is the most important
formation. factor in determining the likelihood of dehiscence. Other
important factors contributing to dehiscence events include
32. A 44-year-old, obese woman presents to the increased intra-abdominal pressure (e.g., obesity, severe
emergency department with a history of acute onset pulmonary disease, excess postoperative coughing, bowel
of severe epigastric pain radiating toward the back. obstruction, and cirrhosis with ascites formation) and deficient
The pain began several hours after dinner. The wound healing (e.g., infection, seroma or hematoma formation,
patient has no significant past medical history and drain placement, chronic disease, malnutrition, or chronic
denies any previous surgery. She takes no steroid use). Suture material for fascial closure should not be
medications. On examination, the patient has marked rapidly dissolvable because these layers are so important to
epigastric tenderness with guarding and hypoactive wound integrity. Devitalized tissue predisposes to wound
bowel sounds. Her vital signs are: heart rate, 110 infection and should be eliminated. Dehiscence is a partial or
beats/min; blood pressure, 120/50 mm Hg; total disruption of anatomic layers after surgical closure.
respiration, 28/min; temperature, 38.0°C. Amylase Evisceration is wound dehiscence with the extrusion of
level is 2500 units. Which of the following is the most abdominal contents. This is a highly morbid event, however not
likely cause of this patient's pain? uniformly fatal. Treatment would consist of rapid wound
Select one: coverage with sterile, moist towels, and emergent surgical
a. Gallstones exploration and repair.
b. Alcohol abuse c. Body habitus and nutritional status are not important factors
c. Hyperparathyroidism  influencing wound stability
d. Hyperlipidemia d. Wound dehiscence is uncommon, although when it does occur it
is usually during the first or second postoperative day
33. A 40-year-old man presents with significant right flank
pain radiating down to his testicle. The pain is 35. A 50-year-old woman presents to the emergency
intermittent and severe in nature. Microscopic department with abdominal pain and jaundice. Her
hematuria is present on urinalysis, but there are no vital signs are: heart rate, 80 beats/min; blood
white blood cells. Leukocyte esterase and nitrates are pressure, 130/72 mm Hg; respiration, 18/min;
negative. His vital signs are: heart rate, 88 beats/min; temperature, 37.0°C. Examination reveals tenderness
blood pressure, 130/60 mm Hg; respiration, 20/min; in the right upper quadrant (RUQ) and a positive
temperature, 37.2°C. Which of the following is the Murphy's sign. Which of the following statements
most appropriate next step in the management of this regarding this patient is true?
patient? Select one:
Select one: a. Referred pain would likely be to the right shoulder or
a. Intravenous antibiotics scapula. 
b. Immediate laparotomy Cholecystitis is caused when a gallstone is impacted in the
c. Intravenous fluids and pain medication  cystic duct. Referred pain is to the right shoulder and scapula.
Urinary tract calculi classically present with flank pain that is Jaundice may be present, despite the fact that there is no
colicky in nature with radiation to the ipsilateral testicle and red obstruction of the common bile duct. Charcot's triad is
blood cells and stones in the urine. Appropriate treatment of an associated with ascending cholangitis, which results from
initial episode of this disease generally involves administering bacterial infection of the biliary tree after a gallstone is
intravenous fluids to assure appropriate hydration and to impacted in the common bile duct. Only 15% of gallstones are
provide adequate pain control [e.g., nonsteroidal anti- radio-opaque, thus an abdominal film is not likely to show the
inflammatory drugs (NSAIDs)] during passage of the stone. etiology of the pain. M orphine should probably be avoided in
Ultrasound and intravenous pyelogram (IVP) are the tests of patients with cholecystitis as it theoretically contracts the
choice in diagnosing patients with recurrent or complicated sphincter of Oddi, which will prevent stone passage and
urinary tract stones. A computed tomography scan could also
 possibly increase the risk of complications such as c. This type of diverticulum is most common in the third and fourth
pancreatitis. decades of life
b. This disease is characterized by Charcot's triad. d. The procedure of choice in this patient would be a
c. Jaundice is rarely present in these patients. cricopharyngeal myotomy and diverticulectomy
d. Etiology of the pain would likely be present on abdominal film.
40. A 42-year-old woman with scleroderma presents with
36. A 65-year-old man with no previous abdominal symptoms of gastroesophageal reflux disease
surgery presents with severe abdominal pain over the (GERD) that have persisted despite 6 months of
right lower quadrant (RLQ). His past medical history is adequate medical therapy. Which of the following
significant for a previous aortic valve repair and the statements best describes her condition?
patient is on chronic coumarin (Coumadin) Select one:
anticoagulant therapy. On physical examination there a. Further medical therapy is warranted before surgical intervention
is an exquisitely tender mass noted in the RLQ just is considered
lateral to the umbilicus. When the patient attempts to b. Therapy is generally aimed at controlling gastroesophageal
sit up the mass remains palpable and the pain reflux
associated with the mass increases. Of the following, c. Because this disease affects primarily the distal esophagus,
which is most appropriate in the management of this resection of this segment is curative 
patient? d. The risk of esophageal cancer is higher in these patients
Select one:
a. Incision and drainage with wound packing 41. A 47-year-old man presents with a 6-month history of
b. Immediate exploratory laparotomy intermittent chest pain and dysphagia for both solids
c. Local exploration and biopsy of the mass  and liquids. Cardiac work-up is negative and standard
d. Performance of an abdominal computed tomography (CT) barium esophagram was unremarkable. Esophageal
scan manometry reveals high amplitude contractions and
intermittent normal peristalsis with simultaneous
37. A 59-year-old, obese woman presents to the contractions 40% of the time. Which of the following
emergency room with a painful right groin mass below statements is true regarding this patient's condition?
the inguinal ligament. Aggressive attempts to reduce Select one:
the mass are unsuccessful. Intraoperatively, the a. Surgery is the treatment of choice 
patient is confirmed to have an incarcerated femoral b. Medical therapy includes nitrates and H2-blockers
hernia although the viability of the bowel appears c. In patients with incapacitating dysphagia, 80%–90% report
intact. Attempted intraoperative reduction of the palliation of their symptoms with surgical intervention
hernia sac is unsuccessful as well. Which of the d. Esophagram is the gold standard for identification of this disorder
following is the most appropriate next step in the
management of this patient? 42. A 42-year-old woman presents to the office with a 2-
Select one: month history of increasing nausea and nonbilious
a. Resection of the herniated bowel and primary reanastomosis vomiting associated with a 15-lb weight loss. Upon
b. Division of the inguinal ligament with reduction of the hernia upper gastrointestinal endoscopy, biopsy reveals
contents Helicobacter pylori and a low-grade lymphoma. Which
c. Performance of an enterotomy and decompression of the of the following is the most appropriate statement
herniated bowel regarding the management of gastric lymphoma?
d. Performance of a laparotomy with traction of the herniated bowel Select one:
intraperitoneally  a. Treatment is limited to radiation therapy alone 
38. After a routine left inguinal hernia repair, a 45-year-old b. Treatment consists of surgery alone
man presents to the office complaining of numbness c. Some lymphomas may regress with treatment of H. pylori
over a portion of the left side of his scrotum and over d. Overall 5-year survival is less than 20%
the anteromedial portion of his left thigh. Very anxious
about these findings, the patient also asks if this is 43. A 62-year-old man with a history of alcoholic cirrhosis
associated with sexual dysfunction. Which of the presents to the emergency room with a 4-hour history
following is an appropriate explanation with regards to of hematemesis. His abdomen is soft. He is
the patient's inquiry? tachycardic with a heart rate of 121 beats/min and
Select one: has a blood pressure of 98/58 mm Hg. Which of the
a. There is a significant risk of erectile dysfunction associated with following is the most appropriate step in the
this complication immediate management of this patient?
b. Erectile function remains unaffected although the patient may be Select one:
sterile  a. Airway control and resuscitation 
c. The hernia has probably recurred and will require reoperation Whatever the cause of bleeding in this patient, the first and
d. This probably represents an inadvertent injury to the foremost important step in his management is securing a
ilioinguinal nerve functional airway (e.g., endotracheal intubation) and adequate
volume resuscitation (e.g., crystalloid and blood products when
39. A 70-year-old man presents with dysphagia, necessary). Administering intravenous vasopressin or placing
occasional regurgitation of undigested food, and a Sengstaken-Blakemore tube are appropriate in the
chronic halitosis. Manometric studies are normal but a management of esophageal varices but should not precede
barium esophagram reveals a 4-cm Zenker's initial resuscitative measures. Although a chest radiograph
diverticulum. Which of the following statements is should be performed early in the course of management to rule
true? out potential pulmonary pathology and to identify a pulmonary
Select one: source of hemorrhage, it should not precede resuscitation. A
a. This is the least common diverticulum of the esophagus barium swallow is not indicated in this situation.
b. A Zenker's diverticulum is a true diverticulum  b. Intravenous vasopressin infusion
c. Placement of a Sengstaken-Blakemore tube a. Catheterization alone with continued observation 
d. Performance of a barium swallow Postoperative urinary retention is a common problem
especially after pelvic and perineal procedures or after spinal
44. A 68-year-old man presents to the emergency room anesthesia. The causes in those cases appear to be
complaining of severe intense abdominal pain that interference with the normal autonomically mediated bladder
came on suddenly and quickly reached peak intensity. emptying and overdistention of the bladder that inhibits
Upon evaluation, the patient is lying completely still, is contraction of the smooth muscle. Prevention of this includes
tachycardic, and has an ashen-gray appearance. catheterization of the bladder for long cases or for those where
Upon further questioning he reveals that the pain large volumes of intravenous fluids are used. Removing the
began in his epigastric region and then moved down bladder catheter and encouraging early postoperative voiding
to the right quadrants. His abdomen is rigid and is also useful. If this is unsuccessful, in and out catheterization
extremely tender. Laboratory investigation reveals a to decompress the bladder is used. The catheter should be left
white blood cell count of 30,000 and a hematocrit of in place if the volume obtained is over 1000 mL. An indwelling
44%. Which of the following is the most likely cause of catheter left for 4–5 days should be used if prior insertions
this patient's clinical presentation? were traumatic or if there is a continued inability to void.
Select one: Formal urologic follow-up may be necessary.
a. Mallory-Weiss tear b. Catheterization and antibiotic administration
b. Bleeding duodenal ulcer  c. Catheterization and administration of furosemide
c. Acute gastritis d. Catheterization and administration of mannitol
d. Perforated peptic ulcer
48. A 65-year-old woman with an open tibia/fibula fracture
45. A 53-year-old, obese woman with a history of Type II of her left lower extremity underwent uneventful
diabetes and chronic obstructive pulmonary disease débridement and external fixation. Her initial
(COPD) underwent mesh closure of an abdominal postoperative course was uneventful. On
incisional hernia. She tolerated the procedure well postoperative day 4, she was noted to have mild
and was discharged from the hospital the following swelling of her left ankle and a fever of 38.6°C. Her
morning. Which of the following factors would LEAST wounds were without signs of infection and there
likely contribute to the incidence of postoperative were no palpable cords. Which of the following is the
complications in this patient? most likely cause of this patient's findings?
Select one: Select one:
a. A small enterotomy made while dissecting the fascial layers was a. Fat emboli
closed with dissolvable suture after minimal spillage of b. Iatrogenic lymphatic disruption 
intestinal contents c. Thrombophlebitis
b. Her last hemoglobin A1C was 11.7 and she has a history of an d. Deep venous thrombosis
anaphylactic reaction to penicillin
c. She had previously smoked 2 packs of cigarettes per day for 40 49. A 72-year-old man has recently undergone extensive
years, but has not smoked for the last 5 years  resection of a primary squamous cell carcinoma of the
d. She has end-stage COPD and her medications include tongue with radical neck dissection. Postoperatively
prednisone 20 mg per day he is found to have extensive esophageal candidiasis
with severe diffuse ulceration. His past medical
46. A 45-year-old woman presented to the emergency history is significant for a previous sigmoid resection
room with right upper quadrant (RUQ) abdominal pain for diverticular disease and he has had intermittent
and fever. The patient states that she had a symptoms of nausea and vomiting over the past
cholecystectomy 2 years earlier. Computed several months which seem to resolve on their own.
tomography (CT) scan reveals a 6-cm, fluid-filled Which of the following would be the most appropriate
mass in the right lobe of the liver that was not noted to reason for parenteral versus enteral nutritional
be present by ultrasound 2 years ago. Which of the support?
following is the appropriate definitive treatment for the Select one:
potential cause of this patient's condition? a. Severe esophageal ulceration
Select one: b. Extensive oropharyngeal resection
a. “Triple” antibiotics alone for a large pyogenic liver abscess c. Severe sepsis 
b. Antibiotics alone for uncomplicated amebic liver abscess d. Small bowel obstruction secondary to adhesions
c. Percutaneous drainage of fluid from echinococcal cyst
d. Antibiotics alone for a ruptured amebic liver abscess  50. A 68-year-old woman is transferred to a tertiary care
hospital after a recent extensive small bowel resection
47. After an uneventful laparoscopic inguinal at an outside hospital. She has been diagnosed with
herniorrhaphy, a 58-year-old man had the urinary short bowel syndrome following the surgery and has
catheter removed and began to ambulate. During received parenteral nutritional support for
routine vital sign checks, he was noted to have had approximately 3 months. The patient cannot
no urine output over the previous 8 hours. An remember exactly what she is taking but she states
intravenous bolus of saline (500 mL) did not stimulate that she hangs 1 large bag of clearyellow fluid 3 times
voiding. Straight catheterization revealed 1000 mL of a day at home administered through a central venous
urine. Urinalysis showed a specific gravity of 1.018, a catheter. She presents with complaints of worsening
pH of 6, moderate blood, and negative leukocyte fatigue and hair loss. Her hematocrit is 34%, white
esterase and nitrites. There were 23 red blood blood cell count 6,000, and platelets 45,000. For
cells/high power field (hpf) and 2 white blood cells/hpf. managing this patient it would be most appropriate to
What is the most appropriate treatment for his failure administer
to void? Select one:
Select one: a. Niacin
b. Vitamin C 
c. Zinc
d. Lipids