2009 Exam

DEPARTMENT OF SURGERY

PRINCIPLES OF SURGERY EXAM

February 17, 2009

7:30 a.m. to 9:30 a.m.

EXAMINATION INSTRUCTIONS

1. Please write and code your name on the Computer Answer Sheet – left side.

2. This examination is multiple-choice. Choose the single best answer.

3. This examination is two hours in length.

4. Examination results will be sent from the Department of Surgery

5. Questions marked with an asterisk are optional for residents in the ENT and OB-GYN programs.

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1. Which of the following is NOT a major clinical predictor of post-operative cardiac morbidity and mortality?

1) unstable coronary syndrome

2) coronary artery bypass surgery in the last three months

3) significant arrhythmias

4) severe valvular heart disease

2. A 50 year old man suffers from acute respiratory distress syndrome following treatment for an obstructed left ureter. He is orally intubated with ventilator settings of AC 16, TV 800 cc’s, FIO2 0.7, PEEP of 15 cm H2O. The ventilator high pressure alert signals and the RT has great difficulty bagging the patient. The arterial blood pressure and 02 saturation drop precipitously. You should immediately?

1) extubate and re-intubate the patient suspecting a mucous plug in the endotracheal tube

2) obtain a stat chest x-ray

3) paralyze the patient to achieve increased chest wall compliance

4) insert bilateral 14 gauge angiocaths in the anterior 2nd interspace to R/O tension pneumothorax

3) A 45 year old woman undergoes an abdominal hysterectomy because of uterine cancer. The following morning she is found obtunded with a temperature of 394, heart rate 130, blood pressure 100/70, respiratory rate 25. The skin around her incision is noted to be gray in colour. In addition to resuscitation, the next steps in her management include all of the following, EXCEPT?

1) broad spectrum antibiotics

2) high dose intravenous immunoglobulin infusion

3) exploration of the wound and peritoneal cavity in the operating room

4) administration of hyperbaric oxygen

Principles of Surgery Exam February 2009

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* 4) A 29 year old unbelted male driver crashes head first into a bridge while driving under the influence of alcohol. He is hemodynamically stable and a complete body CT scan reveals the following injuries; a 2 cm thick subdural hematoma, an aortic aneurysm at the take off of the left subclavian artery, a ruptured spleen with active extravacation of blood, an open left fracture of the tibia and fibula. This patient should undergo immediate?

1) craniotomy

2) thoracotomy and repair aneurysm

3) laparotomy and splenectomy

4) open reduction and internal fixation of left open fracture of the tibia and fibula

* 5) Which of the following statements concerning the resuscitation of trauma patients is TRUE?

1) treatment should be terminated if the patient requires continuing resuscitation after receiving 50 units of packed RBCs

2) hypotensive patients with blunt abdominal trauma should not be resuscitated until they are able to receive definitive care

3) hypothermia affects platelet function

4) hypertonic saline improves survival

6) The most important prognostic factor in patients with advanced cancer is?

1) progression of disease during chemotherapy

2) metastatic spread

3) Karnofsky score

4) clinical judgement

7) Which of the following statements concerning heat-shock proteins is NOT true?

1) they are expressed under conditions of compromised oxygen delivery

2) they are both constituitively and inducibly expressed

3) they are both pro and anti inflammatory

4) they play no role in cellular apoptosis


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8) A post-operative surgical patient is receiving NG tube feeds. Three days after feeding is initiated, he begins to have diarrhea. All the following steps are appropriate management of his diarrhea, EXCEPT?

1) stop the tube feeds immediately to ensure the patient does not become dehydrated

2) check the patient’s medications to determine if any are contributing to his diarrhea

3) slow the rate of feedings or consider antidiarrheal medication when clostridium difficile is ruled out as a cause of the diarrhea

4) follow the patient’s fluid and electrolyte status carefully until the diarrhea subsides

9) Hypovolemic shock secondary to blood loss occurs commonly in surgical patients. Which of the following statements accurately characterizes the fluid shifts that occur during hemorrhagic shock?

1) the loss of intravascular volume is usually fully compensated by movement of extra vascular interstitial fluid into the vascular space

2) intracellular fluid volume decreases as fluid shifts from the intracellular to the extra cellular fluid compartment to compensate for the intravascular loss

3) the extracellular and intravascular fluid volume is best restored using packed red blood cell transfusion and fresh frozen plasma

4) there is a decrease in the transmembrane potential resulting in increased sodium permeability and an influx of sodium into the cell

10) A surgical resident sustains a needle-stick injury from a patient who is hepatitis B antigen positive. The resident completed a series of three hepatitis B vaccines one year ago but her antibody response has not been checked. How should this injury be treated?

1) there is no need to do anything since the source does not have active hepatitis B infection

2) the resident should receive hepatitis B immunoglobulin immediately

3) the resident should receive hepatitis B immunoglobulin and a Hepatitis B vaccine booster immediately

4) the resident should be tested for anti-hepatitis B antibody immediately. If the test result is negative, she requires further therapy


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11. A 65 year old man is brought to the Emergency Room with an open fracture of the left tibia and fibula. He is taking aspirin and plavix for known coronary artery disease. The orthopedic surgeon wants to do an open reduction and internal fixation operation in the next six hours, but is concerned about post-operative bleeding causing a compartment syndrome. The best way to reverse the action of aspirin and plavix for immediate surgery is?

1) administer von Willebrands factor

2) administer 5 units of platelets

3) administer activated factor 7A

4) dialyze the patient for four hours pre-operatively

12. A 37 year old man has a tracheostomy for two months following treatment for a severe closed head injury. He is on the Neurosurgery Ward receiving FI02 0.28 via trach mask. You are called to see him because of acute respiratory distress with central cyanosis. You should immediately?

1) change the inspired oxygen to 100%

2) remove the inner tube of the tracheostomy

3) intubate the patient orally

4) obtain a STAT portable chest x-ray

13. An anesthetized patient is erroneously transfused with a unit of ABO incompatible blood. This may cause all of the following, EXCEPT?

1) unexplained hypotension

2) ventricular arrhythmias

3) diffuse bleeding

4) hemoglobinuria


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14. The oxyhemoglobin dissociation curve relates the partial pressure of O2 in the blood (PO2) to the % saturation of hemoglobin with oxygen (SO2). For a given SO2, the PO2 depends on all of the following, EXCEPT?

1) temperature

2) serum potassium

3) pH

4) RBC content of 2,3-DPG

15. A 31 year old woman with poorly controlled hyperthyroidism has a prolonged and difficult delivery of her first child. Immediately following delivery, her heart rate is 148 per minute, temperature is 39.4° C and O2 SAT 94%. She is agitated and restless. Which of the following statements about the initial treatment of her condition is NOT true?

1) the patient should be hydrated with balanced salt solution containing glucose

2) intravenous propranolol should be given

3) salicylates should be used to cool the patient

4) intravenous hydrocortisone should be given

16) Eicosanoids are potent mediators of shock. Which of the following statements concerning eicosanoids is NOT correct?

1) eicosanoids are lipids

2) eicosanoids are derived from arachadonic acid

3) eicosanoids are stored in hepatic Kupfer cells

4) eicosanoids include thromboxanes and leukotrienes


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17) Hemolytic transfusion reactions are rare. Which of the following statements concerning such reactions is true?

1) they are caused by ABO incompatibility of the transfused blood

2) urticaria and pruritis are the commonest initial symptoms in the unanesthesized patient.

3) initial treatment should include solumedrol 1 gram IV bolus

4) shock may be produced by antigen-antibody complexes stimulating helper T-Cells to release cytokines

18) Which of the following is unlikely be a cause of the adult respiratory distress syndrome (ARDS)?

1) gram negative sepsis

2) pulmonary aspiration

3) pancreatitis

4) congestive heart failure

19) A diabetic patient has been recently discharged from hospital after undergoing a craniotomy for a subdural hematoma. He is readmitted to the medical service because of aspiration pneumonia two weeks later. His condition deteriorates rapidly and he is transferred to the Intensive Care Unit because of hypotension and multiorgan dysfunction. Which of the following treatments is CONTRAINDICATED?

1) activated protein C

2) intensive insulin therapy for hyperglycemia

3) low dose hydrocortisone

4) ventilatory support with high (>15 cm H2O) PEEP


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20) A 47 year old diabetic male is brought to the emergency room with a 12 hour history of rapidly progressive cellulitis of the right leg. He is confused and agitated, hypotensive (90/60) and has a heart rate of 160. All the following antibiotics should be administered immediately, EXCEPT?

1) 3rd generation cephalosporin

2) clindamycin

3) gentamycin

4) penicillin

* 21) A 19 year old woman is involved in a severe motor vehicle crash. At the scene of the accident she has a GCS of 3 and is intubated. Upon arrival of the emergency room, she has no obtainable blood pressure, good bilateral air entry to her lungs and fixed and dilated pupils. Her end-tidal PCO2 is 2. The next step in her management should be?

1) extubate and reintubate the patient as the endotracheal tube is likely in the esophagus

2) insert bilateral chest tubes

3) begin CPR

4) declare the patient dead

22) More than half of pulmonary infections in the post-operative period are caused by gram negative bacilli. The most common source of these gram negative bacteria is?

1) translocation from the gut to the lymphatics

2) colonization of the oral pharynx with hospital acquired organisms

3) overgrowth of gram negative bacteria in the stomach with secondary aspiration

4) hospital air contaminated with aerosolized bacteria


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23) A 27 year old man suffers a severe facial crush injury in a motor vehicle crash. On arrival in the emergency room, vitals are:

heart rate 100

blood pressure 130/80

respiratory rate 30

O2 saturation 80% on an FIO2 of 0.4 by face mask

The anesthetist is unable to intubate the patient with a laryngoscope. He cannot be bagged and the O2 saturation is dropping. The best way to gain control of the airway in this patient is:

1) fiber optic intubation

2) call for a more experienced anesthetist

3) use a glidescope

4) emergency surgical airway

24) There are three basic kinds of rejection reaction to kidney transplants: hyperacute, acute, and chronic. Which of the following statements concerning chronic rejection is true:

1) chronic rejection is mediated by CD8 positive T-cells

2) chronic rejection is diagnosed with Doppler ultrasound showing decreasedrenal artery blood flow

3) chronic rejection is treated with OKT-3 monochlonal antibodies

4) chronic rejection always results in eventual graft loss

25) A 45 year old woman is undergoing laparoscopic ovarian cystectomy. Shortly after abdominal insufflation and Trandelenberg positioning, an increase in peak airway pressure and decrease in oxygen saturation is noted. On examination, decreased breath sounds are noted on the left side. The most likely cause is?

1) mucous plug

2) right mainstem intubation

3) CO2 embolus

4) left pneumothorax


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26) Metabolic effects of the neuro-endocrine response to injury include all of the following, EXCEPT:

1) gluconeogenesis

2) glycogen synthesis

3) lipolysis

4) proteolysis

27) Patients are frequently prescribed aspirin because of coronary artery disease. Aspirin decreases platelet function by inhibiting prostaglandin synthesis. Which of the following treatments will return a patients risk of surgical bleeding to normal?

1) administer 100u of Von Willibrands factor at the beginning of the operation

2) administer DDAVP IV at the beginning of the operation

3) administer two units of platelets at the beginning of the operation

4) stop aspirin 10 days prior to the operation

28) Which of the following factors is primarily responsible for increasing the cardiac output of patients with acute mild to moderate normalvolemic anemia?

1) tachycardia

2) increased myocardial contractility

3) decreased sympathetic nervous activity

4) decreased blood viscosity


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29) A 37 year old patient undergoes a trauma laparotomy and splenectomy following a high speed motor vehicle crash. He also suffers from a significant closed head injury. Regarding post-operative nutrition, which of the following statements is correct?

1) because of the likelihood of post-operative ileus, TPN should be administered for seven days before enteral feeding is attempted

2) enteral feeding should be begun on post-operative day number one via a fluoroscopically placed nasal-jejunal feeding tube

3) enteral feeding should be begun on post-operative day number one via a nasogastric tube

4) nutritional support is not needed during the first seven days following surgery

* 30) A 30 year old woman while crossing a street, slips and falls striking her head against the curb. The ambulance attendant notes that she is unconscious at the scene. On arrival in the Emergency Department, she has a generalized seizure. Immediate management of her head injury should include all of the following EXCEPT?

1) intubation and mechanical ventilation

2) keep pCO2 less than 30

3) sedation with propothol

4) administer 1 gram Dilantin IV over 30 minutes

31) A 63 year old man is found to have a partially obstructing adenocarcinoma of the ascending colon, without metastatic disease. He weighs 75 kgs, having lost 4 kgs of weight in the preceding three months. His albumin is 32gm/l. With regards to nutrition, the most appropriate pre-operative preparation would be?

1) expeditious surgery with resection of the tumour

2) liquid food supplements for at least one week prior to the surgery

3) admit the patient to hospital one week in advance of the surgery for pre-operative total parenteral nutrition

4) expedite surgery, with placement of a feeding jejunostomy tube for immediate post-operative nutritional supplementation


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32) A 55 year old man undergoes pre-operative neo-adjuvant radiotherapy for carcinoma of the rectum. Radiotherapy is known to affect wound healing. When is the optimal time to carry out surgical resection of this tumor?

1) within two weeks of the completion of radiotherapy

2) within 2 -12 weeks of the completion of radiotherapy

3) more than three months after completing radiotherapy

4) the effects of radiotherapy on wound healing are independent of time

33) A 65 year old woman undergoes right hemicolectomy for carcinoma of the cecum. On post-operative day five, she develops an anastomotic leak and has an emergency laparotomy to take down the anastomosis and create an ileostomy. The following day her vitals are:

Heart rate 120 Respiratory Rate 25

Temperature 395 O2 Saturation 80% on FIO2 0.8 by face mask

Blood Pressure 110/80

Chest x-ray shows pulmonary edema. The initial management of her respiratory failure should be:

1) increase FIO2 to 1.0

2) Lasix 40 mgs IV stat

3) start broad-spectrum antibiotics for aspiration pneumonia

4) intubate and ventilate patient

34) Mr. Smith is awaiting a kidney transplant. Which of the following donor requirements are necessary to allow successful kidney transplantation?

1) Complete HLA match

2) Class I HLA match only

3) ABO blood group compatibility

4) no restriction on donors


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35) Which of the following statements about central venous catheters is TRUE?

1) a positive blood culture drawn through the catheter is diagnostic of catheter related sepsis

2) the maximum sterile barrier technique (cap, gown, hat, mask, sterile gloves and barrier sheet) is required only for long-term (>10 days) central venous access

3) the source of most catheter related bacteremia is injection or infusion of contaminated solutions

4) specialized central venous access teams can reduce the incidence of line complication

36) The neurohumeral response to acute injury includes elevation of the serum level of all of the following, EXCEPT?

1) glucagon

2) glucocorticoids

3) thyroid-stimulation hormone (TSH)

4) catecholamines

37) Regarding urinary retention after ambulatory surgery, which of the following statements is NOT correct?

1) urinary retention is most frequently associated with herniorrhaphy and anal- rectal procedures

2) spinal anaesthesia, but not general anaesthesia, is a predisposing factorfor post-operative urinary retention

3) post-operative urinary retention frequently can be asymptomatic

4) over zealous administration of intravenous fluids (>1200 mls) can cause urinary retention


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38) Which of the following mechanisms is an important defense in states of severe oxygen transport deficiency?

1) hyperventilation

2) reduction of oxygen consumption

3) varying of the organ distribution of cardiac output

4) shift of the oxygen dissociation curve

* 39) A 44 year old man suffers a gunshot wound to the left thigh which results in arterial injury to his superficial femoral artery. His arterial injury is repaired surgically with a saphenous vein interposition graft four hours after injury. At the end of the operation he has good distal pulses and the leg is neurologically intact. Six hours later, he is noted to have increasing leg pain, pain with passive flexion and extension of the calf muscles, and numbness of the left foot. The distal pulses are palpable but diminished. The next step in the care of this patient should be?

1) angiogram

2) heparin bolus followed by infusion to maintain a PTT >50

3) return to the operating room for revision of the arterial repair

4) four-compartment fasciotomy

40) While you are in the Emergency Department, the local ambulance supervisor calls to ask your advice. A middle aged man has been run over by a truck and has severely crushed legs. What should the ambulance attendants (trained paramedics) do?

1) bring the patient to the nearest Emergency Room immediately

2) start an intravenous and give a 500 cc bolus of 3% normal saline while transporting the patient to the nearest Emergency Room

3) intubate the patient, start intravenous with normal saline 2,000 cc bolus, apply tourniquet to both legs, and transport the patient to the nearest Emergency Room

4) apply MAST pants to the patient and bring him to the nearest Emergency Room


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41) You have carried out a successful left total hip replacement on a wealthy 60 year old businessman. In conversation on the first post-operative visit, you mention to him that you want to buy a cottage in Muscoka but cannot afford it at present. The patient offers an interest free loan of $50,000. You should?

1) gratefully accept the offer

2) gratefully accept the offer but insist on paying appropriate interest charges

3) politely refuse the offer

4) gratefully accept the offer but ask that the cheque be made out to your husband

42) Non-steroidal anti-inflammatory drugs (NSAIDS) such as torodol are often used to reduce the requirement for narcotic analgesic following major surgery. Which of the following medical conditions is a contra-indication to the use of NSAIDS?

1) renal transplantation

2) known coronary artery disease

3) hypertension

4) increased intra-cranial pressure

43) A 60 year old man undergoes prostatectomy for prostate carcinoma. On the third post-operative day he is found to be diaphoretic with vitals of:

Heart rate 125

Blood pressure 90/50

O2 Saturation 94.

The electrocardiogram shows marked ST segment depression in the anterior leads. The next step in the management of this patient should be:

1) administration of oxygen by face mask with FIO2 0.6

2) administraton of 1,000 N/S bolus

3) give heparin 10,000 units IV bolus, following by a high dose infusion

4) transfer to Intensive Care Unit and start Dopamine infusion


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44) A 65 year old woman presents with a two month history of pain and swelling in the left thigh. You can palpate a roughly 6 cm mass in the vastus lateralis muscle. You are suspicious of soft tissue sarcoma. The best way for you to make a diagnosis is?

1) fine needle aspiration cytology of the mass

2) incisional biopsy of the mass

3) CT scan leg

4) MRI leg

45) A 30 year old man suffers a 70% body surface area flame burn as a result of an industrial propane explosion. Following massive fluid infusion in the first 48 hours, his abdomen becomes distended and tense. Findings consistent with the diagnosis of abdominal compartment syndrome include all of the following EXCEPT?

1) bladder pressure > 25 mmHg

2) peak inspiratory pressure > 40 cm H2O

3) oliguria in the presence an adequate cardiac output

4) hyperbilirubinemia

46) A 60 year old man is admitted to the Intensive Care Unit following endoscopic control of a massive upper GI bleed. His vitals are Heart rate 130, Blood pressure 110/70, respiratory rate 25, O2 SAT 96. His laboratory findings are:

Hgb 102 Platelets 67 Creatinine 100 HCO3 11

pH 7.19 pCO2 30 pO2 85

His metabolic acidosis is best treated with?

1) 2 amp Na bicarb IV

2) 1,000 cc normal saline bolus

3) dopamine infusion to increase renal blood flow

4) Lasix 40 mgs IV x 1 dose


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47) Evidence based strategies for perioperative renal protection in elective patients with moderate to severe renal impairment include which of the following?

1) dopamine 0.01 mgs/kg/min IV

2) mannitol 0.5 – 1 gram/kg IV

3) Lasix 20-40 mgs IV

4) none of the above

48) Which of the following statements regarding the complement cascade is NOT correct?

1) complement may be activated by immune complexes

2) the component C3a inhibits mast-cell release of granules

3) the components C5b 6,7,8,9 form a complex that causes cell lysis

4) the components C5a is chemotactic for macrophages and neutrophils

* 49) A 47 year old woman is brought to the Emergency Room following a motor vehicle crash. She is alert but confused. Her eyes open on command and she moves all four extremities on command. She complains of headache, neck and back pain. Her vitals are normal. As she is being investigated 30 minutes later, she becomes much less responsive, moving only to painful stimuli. Which of the following pathologic conditions is likely to be present?

1) subdural hematoma

2) epidural hematoma

3) cerebral contusion

4) diffuse axonal injury


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50) An 80 year old woman undergoes laparotomy because of bowel obstruction and is found to have untreatable peritoneal carcinomatosis. After the surgery, the patient and her family request palliative care only. Three weeks later the patient is near death and requests that the surgeon “make sure” that she dies in the next week so that her children can all participate fully in her eldest grandchild’s wedding. The surgeon should?

1) slowly increase the rate of morphine infusion over the next few days

2) order diazepam 20 mgs intravenously q4h prn so that the patient may have control over the time of her death

3) meet with the patient and her family to reassure the patient that her condition will not affect the granddaughters wedding

4) ask the chaplin to see the patient to reconsider the timing of her death

51. Most bacterial abscesses require treatment with drainage and antibiotics however, all of the following abscesses can be treated with antibiotics alone, EXCEPT?

1) lung abscess

2) amebic liver abscess

3) tubo ovarian abscess

4) empyema of the gallbladder

52. A 22 year old woman was shot in the chest and abdomen and underwent a right thoracotomy and laparotomy with bowel resection and abdominal packing. In the Intensive Care Unit, her first post operative blood work shows:

pH 7.19 Na 140

pCO2 25 K 7.3

p02 230 Cl 115 Bicarb 12

Her electrocardiogram shows peaked T waves. The core temperature is 33.2°. The immediate treatment of her hyperkalemia should be?

1) rewarm patient with a warm air device (BAIR hugger)

2) administer 40 mgs of Lasix IV stat

3) administer 2 amps sodium sodium bicarbonate IV

4) administer 1 amp calcium glucagon


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* 53. A 36 year old woman is brought to the Emergency Room with a stab wound in the 6th left intercostal space just lateral to the sternum. Heart rate is 120, blood pressure 90/60. Portable chest x-ray is negative. An ultrasound shows no abdominal fluid but pericardial fluid is detected. The next step in her management should be?

1) pericardial aspiration under ultrasound guidance

2) subxiphoid pericardial window to look for blood

3) medial sternotomy

4) insertion of a Swan-Ganz catheter and close observation in the ICU

54. The theoretical advantage in combining surgery and radiotherapy in the treatment of malignancies is based on the mechanism by which they fail to achieve their purpose. Surgical failures occur at the margins of tumour, while radiation therapy fails in the center of tumours. The reason for this relative failure of radiotherapy in the centre of large solid tumours is?

1) peripheral tumour cells shield central tumour cells from ionizing radiation

2) central tumour cells are relatively hypoxic, thus decreasing the rate of cellular mitoses

3) central tumour cells are relatively hypoxic, thus decreasing the generation of oxygen free radicals by ionizing radiation

4) the central portions of solid tumours contain a higher fraction of radio-resistant tumour stem cells

55. A 38 year old woman has partial and full thickness burn to 60% of her total body surface after the car she was driving crashed into a tree and caught fire. She was extricated from the wreckage and brought to the Emergency Room. For the first 24 hours, fluid resuscitation should include infusion of?

1) 2 mls of 25% albumin/kg body wt/% burn

2) 4 mls of ringers lactate/kg/%burn

3) fluids at the rate needed to obtain a urine output of 80 mls/hr

4) 3 mls of 3% hypertonic saline/kg/%burn


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56. Which of the following is NOT a complication of severe hypocalcemia?

1) seizures in children

2) painful muscle spasm

3) perioral or fingertip tingling

4) cardiac dysfunction with shortening of the ST segments

57. Following a laparotomy for small bowel obstruction with lysis of adhesions, a 75 year old man becomes agitated and calls out for his deceased wife. Which of the following statements concerning post-operative delirium is NOT correct?

1) post-op delirium may occur in up to 15% of patients 70 years of age and older

2) pre-operative assessment of cognitive function should be routine in patients over 75 years of age prior to elective surgery

3) post-operative delirium increases the risk of other complications

4) in geriatric patients, regional anaesthetic is associated with a lower incidence of post-operative delirium that is general aneasthesia

58. Phagocytosis is the process where by the immune system engulfs and (usually) destroys pathogenic bacteria. Which one of the following statements concerning phagocytosis is correct?

1) neutrophils compromise the majority of phagocytic cells

2) lysosomal granules require oxygen to destroy foreign particles

3. chronic granulomatus disease is a genetic defect of macrophages causing ineffective phagocytosis

4) once a monocyte migrates to tissue to become a macrophage, its ability to generate oxygen free radicals is severely curtailed


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* 59. A 22 year old man is brought to the Emergency Room following a motor vehicle crash. He is combative, pale and bleeding profusely from the nose and mouth. He has an obvious deformity of his right thigh. His vital signs are heart rate 130, blood pressure 80/40, respiratory rate 40. Which one of the following management plans for his airway is optimal?

1) immediate endotracheal intubation with cervical spinal control

2) oxygen by face mask, FIO2 1.0

3) cricothyroidectomy

4) open airway with jaw thrust maneuver and apply face mask FIO2 1.0

60. A 60 year old woman has significant left carotid stenosis. In discussion with the patient concerning whether to carry out carotid endarterectomy, the surgeon must disclose:

1) all risks associated with the anaesthetic and operation

2) all information that a reasonable person in the patients’ position would need to make an informed decision

3) all information that the surgeon feels is important in making in an informed decision

4) the morbidity and mortality rate for this procedure at the surgeon’s institution

61. A 65 year old diabetic male undergoes distal gastrectomy for an antral adeno-carcinoma. On post-operative day one, the patient was found to have mottled discolouration of the skin about the midline incision for a distance of 10 cms on either side of the wound. The patient’s vitals are: heart rate 130, blood pressure 100/60, respiratory rate 25, temperature 38.7°C. His wound infection is most likely caused by?

1) clostridium septicum

2) methacillin resistant staph aureus

3) group A streptococcus

4) pseudomonas aruginosa


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62. A 65 year old man is in the Surgical Step Down Unit three days after undergoing pelvic exenteration for a locally advanced rectal cancer. While you are in the unit seeing another patient, he suddenly suffers a cardiac arrest. An ECG monitor shows ventricular fibrillation. He has no palpable carotid pulse and no response to a precordial thump. Your next step should be?

1) intubate the patient

2) begin chest compressions

3) administer 1 mg 1:10,000 epinephrine and defibrillate the patient

4) defibrillate immediately with 200 J

63. The initial treatment for hypotension secondary to septic shock is?

1) 2000 cc normal saline bolus

2) 500 cc pentaspan (starch solution) bolus

3) 500 cc 5% albumin in saline bolus

4) epinephrine infusion

64. Treatment of malignancies with adjuvant (post operative) chemotherapy is associated with many side effects. Which of the following is NOT a side effect of chemotherapy?

1) bone marrow suppression

2) alopecia

3) gastrointestinal mucosal damage

4) transverse myelitis (spinal core damage)


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65. A 23 year old man undergoes distal pancreatectomy, splenectomy, and repair of colon and small bowel injuries, as treatment for a gun shot wound to the abdomen. Four hours following completion of his surgery, his vitals are: heart rate 116, blood pressure 112/90, urine output 20 mls/h, CVP 5 mmHg. His hemoglobin is 103 g/l and his blood gasses are: pH 7.23, PO2 95, pC02 27, bicarb 15 mg/l. The next step in his management should be?

1) vasopressin infusion at 0.04 units/min

2) renal dose dopamine

3) 1,000 cc normal saline bolus

4) sodium bicarbonate 2 amps IV bolus

66. Which of the following ECG findings is NOT associated with hyperkalemia?

1) peak T waves

2) prolonged PR intervals

3) loss of P wave

4) narrowing of QRS complex

67. A 60 year old man undergoes elective hemicolectomy for adenocarcinoma of the colon. In the post-anaesthetic unit, he is in no distress. However, he is noted to have a heart rate of 128 that is irregularly irregular with no P waves. Which of the following treatment options would NOT be appropriate?

1) metoprolol

2) diltiazem

3) digoxin

4) adenosine


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68. The endothelial cells which line a blood vessels luminal surface are indispensable in the maintenance of a patent vasculature. Endothelial cells contain all of the following thromboregulators, EXCEPT?

1) nitric oxide

2) prostacycline

3) ectonucleotidase CD 39

4) glycoprotein VI

* 69. A patient involved in a motor vehicle crash is found to have a thoracic spine fracture at T6 and paraplegia. The patient is hypotensive with a systolic blood pressure of 70 mmHg and is bradycardic. The patient is breathing comfortably. Which of the following would be appropriate initial treatment?

1) fluid administration

2) steroid administration within 24 hours of injury

3) immediate intubation

4) alpha-agonist administration to increase blood pressure

* 70. A 19 year old man is shot in the thigh, transecting the superficial femoral artery. The patient undergoes reconstruction of the artery. The intact bullet is recovered in the surgery and placed in a labeled container. After the surgery, the bullet should?

1) be sent to the pathology department

2) be given to a police officer who is guarding the patient

3) be given to the patient when he recovers from the anaesthetic

4) be kept by the surgeon until a judge decides its disposition


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71. All of the following are risk factors for post-operative agitation, confusion and delirium, EXCEPT:

1) elderly patient

2) CNS disease

3) elevated serum creatinine

4) drug or alcohol dependence

72. A 60 year old man undergoes right upper lobectomy for carcinoma of the lung through a right postero-lateral thoracotomy. On post operative day two, he develops superventricular tachyarrhythmia of 160. The systolic blood pressure drops from 130 to 90. He complains of retrosternal chest pain. The appropriate immediate management of this arrhythmia is?

1) begin diltiazem infusion and titrate to keep heart rate <120

2) metoprolol 5 mgs IV bolus and repeat every 10 minutes until rate controlled

3) start amiodarone infusion

4) immediate cardioversion

73. The most common cause of preventable death in patients hospitalized for surgical procedures is?

1) myocardial infarction

2) pulmonary embolus

3) surgical site infection

4) pneumonia


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* 74. A 52 year old man is brought to the emergency room after a motor vehicle crash. His GCS is 6. He is intubated and an IV inserted. A CT scan of the head reveals a right frontal contusion with a compressed basal cistern. The next step in his management should be?

1) placement of an intracranial pressure monitor

2) hyperventilation to a PaCO2 of <25

3) methylprednisolone (30 mgs/kg bolus followed by 5 mg/kg/h infusion for 24 hours)

4) phenytoin (Dilantin) administration

75. A 70 year old man undergoes laparotomy for perforated sigmoid diverticulitis four days following elective right total hip replacement. He has known significant coronary artery disease. 12 hours post-operatively in the ICU his vitals are: Heart rate 100, blood pressure 140/80, respiratory rate 15 (ventilated), O2 saturation 96. Laboratory values are hemoglobin 72, albumin 19 g/L, creatinine 140. His urine output is 20 ml/hr. What would be the optimal fluid management at this time?

1) 1,000 ccs normal saline bolus

2) 100 ccs 25% albumin bolus

3) 2 units packed red blood cells over 2 hours each

4) Lasix 20 mgs IV x1 dose

76. In morbidly obese patients (BMI >40), obstructive sleep apnea often results in all but which of the following conditions?

1) hypoxemia

2) hypercapnia

3) right heart failure

4) left heart failure


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77) Which of the following is least likely to occur in conjunction with a surgically induced stress response?

1) increased metabolic rate

2) hypercoagulability

3) immune response suppression

4) increased secretion of thyroid stimulating hormone (TSH)

78) With regard to the pathophysiology of multiple organ failure in ICU patients, which of the following statements is FALSE?

1) sepsis is a major risk factor

2) injury to the microvascular endothelium is uniformly present

3) neutrophil-mediated injuries depend on adherence to the microvascular endothelium

4) the high concentration of xanthene oxidize in ischemic endothelial cells prevents the generation of toxic oxygen radicals

79) A 45 year old man is brought to the emergency room following a motor vehicle crash. His GCS is 6. He is intubated. His blood pressure is 90/60 and an abdominal ultrasound shows free fluid in the abdomen. The ambulance attendant states that in the patient’s wallet there is an unsigned undated Jehovah Witness Card forbidding blood transfusion. You should?

1) continue treatment (immediate laparotomy) but not transfuse any blood products

2) ask the police to find any relatives and bring them to the emergency room to find out if the patient is really a Jehovah Witness believer

3) consult the hospital chaplain about further management

4) continue treatment (immediate laparotomy) and administer blood products as needed


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80) A 58 year old single unemployed woman on social assistance, is admitted to hospital with an upper GI blood. She has a long history of alcohol abuse. Investigation reveals a malignant appearing gastric ulcer as the source of her ongoing bleeding. Her physician believes she would die in the next few days without surgery, but the patient refuses surgical intervention. You, the surgeon, should?

1) declare her incompetent, and then operate on her

2) ask the hospital chaplain to see her

3) consult psychiatry

4) transfer her to a palliative care unit

81) A 75 year old man is in the Intensive Care Unit on a ventilator seven days after undergoing a repair of a ruptured abdominal aortic aneurysm. For the last few days, his urine output has decreased to 10-20 cc’s per hour. Creatinine has increased from 100 two days ago to 150 at present. He has remained hypertensive (180/90) with a CVP >15 throughout. With regards to his renal function, the next step in his management should be?

1) examine the urine sediment and check urine sodium

2) obtain renal ultrasound

3) consult nephrology

4) change the foley catheter

82) Patients being treated for malignancy are frequently malnourished. Enteral or parental nutritional support in these patients, versus no supplementation, has been shown in clinical trials to?:

1) increase length of survival by 15%

2) decrease tumour recurrence rate by 10% following surgical excision

3) allow significantly more successful completions of aggressive chemotherapy regimes in patients with GI malignancies

4) has not shown any convincing evidence of improvement in overall survival


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83) Nonsteroidal anti-inflammatory drugs are commonly used for post-operative pain relief. All of the following are potentially complications of non-steroidal use, EXCEPT?

1) colonic ileus

2) gastric ulceration

3) platelet inhibition

4) renal damage

* 84) A 60 year old man was involved in a motor vehicle crash and ejected from the car. On arrival in the emergency room, his pulse is 120, blood pressure 80/60, respiratory rate 21, GCS 8. He is intubated and 2 liters of normal saline are infused rapidly. He remains tachycardiac and hypotensive. Primary survey reveals a non-bleeding scalp laceration and hematoma, a distended abdomen, and shortening with external rotation of the left leg. Chest x-ray was normal. Pelvic x-rays shows a left femoral neck fracture. The next step in his management should be?

1) switching to colloid resuscitation

2) CT scan head and abdomen

3) application of a traction splint

4) laparotomy

85) Furosemide (Lasix) is commonly used to treat fluid overload. All of the following are mechanisms of action of Furosemide, EXCEPT?

1) inhibition of active sodium absorption in the ascending loop of Henle

2) increased blood flow to the kidney

3) augmented catecholamaine susceptibility to alpha-adrenergic receptors

4) increased venous capacitance


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86) A 25 year old asthmatic is scheduled for elective right inguinal hernia repair. In the holding area he has severe wheezing bilaterally. The optimal management for this patient is?

1) carry out the procedure under local anaesthesia with IV sedation to avoid airway manipulation

2) administer ventolin and atrovent nebulizer treatment in the holding area and proceed with surgery when the patient stops wheezing

3) administer corticosteroids and carry out the procedure under spinal anaesthesia

4) postpone surgery until the patient’s asthma is under control

87) Which of the following opiods, when given in high dosages, may cause hyperflexia, myocolonus, seizures and anticholinergic effects?

1) morphine

2) demerol

3) codeine

4) fentanyl

88) With regard to the use of vasopressors in the management of hemorrhage shock, which of the following statements is NOT correct?

1) vasopressors usually result in an elevation of the blood pressure

2) vasopressors achieve their goal of blood pressure support primarily through inotropic effects

3) dopamine given in low to moderate dosages may provide inotropic and chronotropic support to the heart as well as enhance renal blood flow

4) in general, the use of vasopressos in hemorrhagic shock is discouraged


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89) The most common clinical symptom of a post-operative myocardial infarction is?

1) none

2) retrosternal chest pain

3) dyspnea

4) sudden post-operative death

90) A 40 year old woman spikes a fever to 40° following percutaneous drainage of a pelvic appendiceal abscess. She is noted to be tachypnic and an arterial blood gas is sent. The earliest change in arterial blood gasses associated with sepsis is?

1) increased PCO2

2) decreased PO2

3) respiratory alkalosis

4) metabolic acidosis

91) During acute starvation, the liver maintains serum glucose levels by synthesizing glucose from all the following substrates, EXCEPT?

1) lactate

2) alanine and glutamine

3) branch-chain amino acids

40 glycogen

92) A patients basal energy requirements are often estimated using the Harris-Benedict formula. This formula uses which of the following sets of variables to determine basal energy requirements?

1) height, weight, gender, age

2) body mass index, age

3) weight, height, age, serum albumin level

4) body mass index, gender, triceps skin fold thickness


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93) A 50 year old workman suffers 40% body surface area burn including secondary burns to his face when paint catches fire in an underground storage locker. Upon arrival at the emergency room, he is not in respiratory distress. What should be the management of this man’s respiratory system?

1) bronchoscope to look for airway injury

2) administer oxygen by face mask to keep oxygen saturation > 92%

3) administer 100% oxygen by face mask if carboxyhemoglobin levels are above 5%

4) intubate and ventilate the patient

94) Following a cellular injury, cells die by a process of necrosis or apoptosis. Which of the following statements is concerning apoptosis is NOT CORRECT?

1) it begins under the precise control of diverse intracellular and extracelluar signals

2) it acts mainly through its effects on the mitochondria

3) its progression is regulated by a single gene

4) it follows a fixed sequence of events

95) A 45 year old woman is scheduled for an elective abdominal hysterectomy because of fibroids. Pre-operative evaluation shows the presence of mild to moderate hypothyroidism. The optimal management of this patient is?

1) proceed with surgery and consult endocrinology if any post-operative complications

2) proceed with surgery only if TSH is less than twice the maximal normal value

3) proceed with surgery while beginning treatment with l-thyroxin

4) postpone surgery until euthyroid state is achieved


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96) Which of the following is NOT associated with morbid obesity?

1) coronary artery disease

2) Type I diabetes mellitus

3) sleep apnea

4) reduction in life expectancy

97) Which of the following is NOT commonly seen as a clinical manifestation of shock?

1) restlessness

2) apathy

3) vomiting

4) diarrhea

98) A 60 year old man undergoes appendectomy for perforated appendicitis. One week later, he complains of fever, abdominal cramps, and watery diarrhea. A stool assay for C. difficile cytotoxin is positive. Which of the following isolation precautions is appropriate?

1) anyone examining the patient should wear disposable gown and gloves

2) all visitors should wear gowns, glove, and a surgical mask

3) the patient should be placed in isolation with no visitors

4) if a stethoscope is used when examining the patient, it should be gas sterilized

99) Concerning the use of electrosurgical units during surgical incision, which of the following statements is NOT correct?

1) coagulation current entails a higher risk of infection than does use of a scalpel

2) coagulation current causes greater necrosis than does cutting current

3) burns at the return electrode (grounding) site do not occur because of the direction of the electrocautery current

4) bipolar cautery limits tissue destruction to the area between the electrodes


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100) Concerning the cardiopulmonary effects of pneumoperitoneum during laparoscopy, which of the following statements is NOT correct?

1) cardiopulmonary dysfunction occurs when the intraabdominal pressure (IAP) reaches 20 mmHg or more in normovolemic patients

2) positive end-expiratory pressure (PEEP) offsets the hemodynamics effect of pneumoperitoneum

3) hypovolemia lowers the level of intra-abdominal pressure that will cause adverse hemodynamic effects

4) laparoscopic surgery does not prevent diaphragmatic dysfunction during the post-operative period for patients with chronic obstructive pulmonary disease (COPD)


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2009 Exam