6th Year Surgery Final Exam

1 A 44-year-old man presents with painless rectal bleeding of 1 month's duration. He reports a history of constipation. He works in heavy labor. For this patient, which of the following statements regarding internal hemorrhoids is true? Choose one answer a. Stapled hemorrhoidectomy should be done for grade 1 and 2 hemorrhoids b. All of the above c. Internal hemorrhoids are located proximal to the dentate line and therefore are usually painless d. A grade 1 internal hemorrhoid represents bleeding with prolapse 2 39. A 34-year-old woman presents for evaluation of severe and frequent bloody bowel movements, as well as abdominal pain, dehydration, and anemia. She has had these symptoms for 2 days. She has not had any similar symptoms in the past, and she has been in relatively good health. If the patient has toxic megacolon, under what circumstances emergency surgical management is indicated? Choose one answer. a. There is a perforation b. Any of the above c. The patient's clinical or radiographic status worsens d. There is no improvement in 24 to 36 hours after aggressive medical therapy 3 Complications of untreated pancreatic pseudocysts include all of the following EXCEPT: Choose one answer. a. intracystic hemorrhage b. abscess c. pancreatic necrosis d. free rupture e. gastrointestinal obstruction 4 Platelets in the wound form a hemostatic clot and release clotting factors to produce: Choose one answer. a. thrombin b. Fibrin c. Fibrinogen d. Fibroblasts e. thromboplastin 5 A 43-year-old man presents to the office for evaluation of recent weight loss and frequent loose stools. He is concerned because his father was diagnosed with colon cancer at the age of 50. Besides family history, what are some other risk factors for colorectal cancer?

Choose one answer. a. Hypertension b. Diabetes c. All of the above d. Inflammatory bowel disease

6 A 40-year-old woman presents to the office for evaluation of yellowish skin. She states that over the past few weeks, she has noticed that her eyes and skin have developed a yellow tint. She also reports that she has dark urine and pale-colored stools. Further history elicits periodic bouts of right upper quadrant pain after eating. She is otherwise healthy. She denies using any medications. On physical examination, a yellowish tint is observed on the patient's skin, sclera, and mucous membranes. On the basis of this patient's history and clinical examination, which type of bilirubin would you expect to predominate? Choose one answer. a. Mixed b. c. d.

Conjugated Unconjugated Indirect

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7 39. A 38-year-old man presents with a complaint of a slow-growing mass over his right parotid gland. The lesion is fixed to the underlying structures and has recently become painful. Which of the following features strongly suggests that this patient's lesion is a malignancy? Choose one answer. a. Ipsilateral numbness of the tongue b. .All of the above c. Overlying skin involvement d. Facial nerve paralysis 8 Axillary lymph nodes are classified according to the relationship with the Choose one answer. a. b. c. d. e.

pectoralis minor muscle pectoralis major muscle axillary vein serratus anterior muscle latissimus dorsi muscle

9 39. A 78-year-old man is recovering from abdomino-perineal (A-P) resection for Ca rectum, which was performed 3 days ago. The patient is now complaining of mild shortness of breath and chest pain. On physical examination, the patient's right leg is slightly more swollen than his left. The pulse oximetry reading is 90%. What is the principal method of diagnosing acute pulmonary embolism?

Choose one answer. a. Magnetic resonance imaging b. Chest x-ray c. Ultrasound d.

Spiral computed tomography scanning

10 Compartment syndrome Choose one answer. a. Passive stretch decrease muscle pain b. Due to decrease pressure in muscle compartments c. Pulse is the first thing to disappear d. e.

Cause severe pain in the limb Treatment is by delayed fasciotomy

11 The most significant risk factor for the development of adenocarcinoma of the esophagus is: Choose one answer. a. lye stricture b. alcohol abuse

c.

Barrett's esophagus

d. e.

long-standing achalasia smoking

12 All of the following statements are true about patients with carcinoid tumors EXCEPT: Choose one answer. a. the combination of streptozotocin and 5-fluorouracil (chemotherapy) can often result in objective response. b. tumor growth is often slow c. they often have evidence of serotonin production d. the majority have carcinoid syndrome e. they have a much better prognosis if the tumors are less than 2 cm.

13 39. A 67-year-old man presents with left-lower-quadrant pain and low-grade fever. He has had these symptoms for 1 day. The patient denies experiencing any rectal bleeding, but for the past week, his bowel movements have been irregular. For this patient, which of the following statements is true regarding diverticular disease? Choose one answer.

14

a.

The sigmoid colon is the most common site of diverticula

b. c. d.

All of the above Most diverticula of the colon involve the muscular layer Smoking does not seem to be related to the development of diverticular disease

All of the following are components of the MEN type 2B syndrome except: Choose one answer. a. Multiple neuromas on the lips, tongue, and oral mucosa b. Medullary thyroid carcinoma c. Pheochromocytoma

d.

Hyperparathyroidism.

15 The risk of bilateral breast cancer is HIGHEST if the first breast shows: Choose one answer. a. inflammatory carcinoma b. medullary carcinoma c. infiltrating ductal carcinoma d. paget’s disease

e.

lobular carcinoma

16 The best initial therapy for deep venous thrombosis of the common femoral vein is: Choose one answer. a. warfarin b. streptokinase

c.

Heparin

d. e.

venous thrombectomy placement of a vena caval filter

17 Complications after thyroidectomy include all the following EXCEPT: Choose one answer. a. recurrent laryngeal nerve paralysis b. parathyroid insufficiency c. thyrotoxic crisis(storm) on operating on inadequitly prepared thyrotoxic patient d. tracheomalacia

e.

hypercalcemia

18 A 55-year-old man presents with hematemesis that began 2 hours ago. He is hypotensive and has altered mental status. No medical history is available. For this patient, which of the following statements regarding nasogastric aspiration is true? Choose one answer. a. None of the above b. A clear, nonbilious aspirate rules out the need for EGD c. A clear, bilious aspirate rules out the need for EGD

d. A bloody aspirate is an indication for esophagogastroduodenoscopy (EGD)

19 The major cause of impaired wound healing is: Choose one answer. a. steroid use b. malnutrition c. diabetes mellitus

d.

local tissue infection

e.

anemia

20 Common presenting conditions in patients with pancreatic carcinoma include all of the following EXCEPT: Choose one answer.

a.

esophageal varices.

b. c. d.

palpable gallbladder weight loss. abdominal pain

21 All of the following statements about keloids are true EXCEPT: Choose one answer. a. Keloid tissue contains an abnormally large amount of collagen b. A keloid does not regress spontaneously c. Keloid tissue contains an unusually large amount of soluble collagen d. A keloid extends beyond the boundaries of the original wound e. Keloids or hypertrophic scars are best managed by excision and careful reapproximation of the wound 22 The treatment of choice for a 40-year-old man who is found on endoscopy and biopsy to have a gastric lymphoma would be: Choose one answer. a. wide local excision b. subtotal gastrectomy c. chemotherapy d. subtotal gastrectomy and radiotherapy

e.

Radiotherapy

23 The treatment of an esophageal EXCEPT:

burn with a caustic agent may include all of the following

Choose one answer. a. boogieing. (dilatation) b. induction of vomiting

c.

gastrectomy

d. e.

expeditious administration of an antidote steroids and antibiotics.

24 A 32-year-old man with a family history of familial adenomatous polyposis (FAP) presents with hematochezia. He denies having any diarrhea, abdominal pain, or fever. For this patient, which of the following statements regarding FAP is true? Choose one answer. a. CRC does not occur in patients with FAP if they are given adequate medical treatment b. Total proctocolectomy (TPC) is considered the only option for the surgical management of FAP c. For patients with FAP, there is a 10% risk of CRC by age 40 if prophylactic colectomy is not performed

d. In the setting of FAP, colorectal cancer (CRC) is more commonly located on the left side 25 When stage I breast cancer is treated by partial mastectomy and axillary dissection, further therapy should include: Choose one answer a. antiestrogen agents.

b. radiation of the affected breast. c. oophorectomy if premenopausal. d. nothing e. chemotherapy 26 For the patient in Question 68, which of the following statements is true regarding an esophageal varix as the site of bleeding? Choose one answer. a. I.V. propranolol should be administered first b. Balloon tamponade should be performed first

c.

Rubber banding or intravariceal sclerotherapy should be performed first

d.

I.V. somatostatin should be administered first

27 Drugs which may produce gynecomastia include all of the following EXCEPT: Choose one answer. a. furosemide b. cimetidine c. Verapamil d. Diazepam e. Tamoxifen 28

Splenectomy is commonly indicated for the following EXCEPT: Choose one answer. a. hypersplenism associated with cirrhosis b. hereditary spherocytosis

c.

splenic tumor

d. e.

immune thrombocytopenic purpura grade four splenic injury in trauma

29 An ischiorectal abscess is characterized by all of the following EXCEPT: Choose one answer. a. Requires deroofing

b.

Should be treated entirely by antibiotics

c. d. e.

May be tuberculous in origin Can be followed by anal fistula Is an infective necrosis of the fat of the ischiorectal fossa

30 Marks: 1 The most common presentation of Meckel’s diverticulum in an adult is: Choose one answer. a. intussuception b. Littre’s hernia

c. d.

Gastrointestinal bleeding diverticulitis

31 For the patient in Question 65, which of the following is an indication for immediate surgery? Choose one answer. a. Closed-loop obstruction b. All of the above c. Complete bowel obstruction d. Incarcerated hernia 32 Choledocholithiasis in a patient who previously had cholecystectomy is BEST treated with: Choose one answer.

33

a.

endoscopic sphincterotomy

b. c. d. e.

choledochoduodenostomy choledochojejunostomy. dissolution with mono-octanoin open common bile duct exploration with stone removal

39. A 77-year-old man undergoes endoscopic ultrasonography as part of a workup for jaundice. He is found to have a tumor in the head of the pancreas. For this patient, which of the following findings would indicate that the tumor is unresectable? Choose one answer. a. All of the above b. Peritoneal metastases c. Invasion of the superior mesenteric artery d. Metastases to celiac lymph nodes 34 Regarding polyps of the colon Choose one answer. a. Villous polyps are usually pedunculated b. Villous polyps occur more proximal in colon c. Adenomatous polyps are usually solitary d. Cancer risk is not related to size of polyp

e.

Metaplastic polyps are not precancerous

35 The most likely diagnosis in elderly patient with abdominal pain and colonoscopy finding of patchy mucosal ulceration at the splenic flexure of the colon is : Choose one answer. a. ulcerative colitis b. crohns disease

c.

ischemic colitis

d. diverticulitis e. lymphogranuloma venerum 00000000000000000000000000000000000000000000000000000000000000 36 39. A 54-year-old man presents with a neck mass of 2 weeks' duration. He has no significant medical history. He smokes two packs of cigarettes a day and has been doing so since he was 21 years of age. For this patient, which of the following statements is true? Choose one answer. a. Low cervical nodes are more likely to contain metastases from a primary source other than the head and neck, whereas upper cervical nodes are more likely to contain metastases from the head and neck b. Soft or tender nodes are more likely to derive from an inflammatory or infectious condition, whereas hard, fixed, painless nodes are more likely to represent metastatic cancer c. All of the above d. Enlarged lymph nodes are by far the most common neck masses encountered 37 The first-choice diagnostic study for suspected deep venous thrombosis of the lower extremity is: Choose one answer. a. real-time Doppler imaging b. contrast sonography

c. d. e.

radioactive labeled fibrinogen uptake impedance plethysmography isotope injection with gamma scintillation scanning

38 Decreased PaCO2 levels should be attained in a patient at serious risk for cerebral edema secondary to a head injury in order to : Choose one answer. a. prevent neurogenic pulmonary edema b. prevent increased capillary permeability c. prevent metabolic acidosis d. allow reciprocally high levels of PaO2 in the brain e. prevent cerebral vasodilation 39 Causes of third space loss include all except: Choose one answer. a. Acute pancreatitis b. Pancreatic fistula c. Necrotizing fasciitis d. Site of major surgery e. Crush syndrome 40 Causes of metabolic acidosis include all except: Choose one answer. a. Small bowel fistula b. Shock c. CO poisoning d. severe anemia e. All of the above 41 A 39-year-old man comes in for evaluation of intermittent anal pain and bleeding after bowel movements. He also has hard stools. He has had these symptoms for over 1 year . For this patient, which of the following is included in the classic triad of signs of chronic anal fissures? Choose one answer. a. An anal fissure b. All of the above c. A sentinel skin tag d. Hypertrophy of the anal papilla 42 All the following statements about achalasia are true EXCEPT: Choose one answer. a. it occurs most commonly in persons between the ages of 30 and 50 years

b. in most affected persons, ganglion cells in the body of the esophagus either are absent or have degenerated c. esophageal cancer is seven times as common in affected persons as in the general population d. pressure in the body of the esophagus is lower than normal e. affected persons usually experience more difficulty swallowing cold foods than warm foods 43 A patient with the Zollinger-Ellison syndrome is found to have the multiple endocrine neoplasia type I (MEN-I) syndrome. Appropriate management for the ulcer symptoms should be: Choose one answer. a. Omeprazole b. pancreatic resection c. streptozocin d. cimetidine e. total gastrectomy 44 Fat absorption occurs primarily in the: Choose one answer. a. Ileum b. third portion of the duodenum c. Stomach d. Jejunum e. first portion of the duodenum 45 39. A 56-year-old woman has been experiencing abdominal pain for 4 hours. The pain is in right upper quadrant and radiates into the scapular region. She has had multiple episodes of vomiting. For this patient, which of the following signs on physical examination is associated with acute cholecystitis? Choose one answer. a. Carnett sign b. Kehr sign c. Murphy sign d. Rovsing sign 46 Mammary duct ectasia is characterized by the following EXCEPT : Choose one answer. a. Is treated usually by simple mastectomy b. May present with nipple retraction and Peau d'orange picture c. Anaerobic superinfection cmmmonly occurs in this recurrent periductal plasma cell mastitis d. Is defined as primary dilatation of major ducts of breast in middle aged women e. Iscommonly pre-malignant 47

Regarding veins of lower limbs all are true except: Choose one answer. a. Valves allow flow from deep to superficial system Venous return from lower limbs is aided by respiratory movements b. Superficial veins lie in subcutaneous tissue c. The pressure in veins of the foot while standing is 100mmHg d. a) Stasis of blood is important factor in developing varicose veins 48 Most common complication of central venous access is: Choose one answer. a. major artery damage. b. Catheter problems. c. Thrombosis of central vein d. Catheter related sepsis e. Pleural space damage, pneumothorax 49 Factors associated with increase risk of death in acute pancreatitis include all except: Choose one answer. a. Ranson score more than five b. Obesity c. High APACHE_II score d. Age more than 70 years e. sterile necrosis 50 For the patient in Question 56, which of the following chronic conditions can cause a neck mass? Choose one answer. a. Tuberculosis b. Sarcoidosis c. AIDS d. All of the above 51 For the patient in Question 56, if metastatic cancer is suspected initially, which of the following would be the most appropriate step to take next in the workup? Choose one answer. a. CT scan b. Empirical therapy with antibiotics c. Fine-needle aspiration (FNA) d. Observation only 52 The largest component of intestinal gas is: Choose one answer. a. Nitrogen

b. c. d. e.

carbon dioxide Oxygen ammonia hydrogen

53 A 66-year-old woman presents to the office complaining of a sharp, constant pain in her lower abdomen. She has had this pain for the past 2 weeks. Examination of her abdomen is normal. However, subsequent ultrasound reveals a 4.5 cm Aortic abdominal aneurysm (AAA). Spiral computed tomography confirms the ultrasound findings. Aside from rupture, which of the following is a complication associated with (AAA) ? Choose one answer. a. Aortoenteric fistula b. Lower-extremity atheroemboli c. All of the above d. Thrombosis 54 Diagnosis of esophageal perforation is best established by: Choose one answer. a. transesophageal ultrasound study b. esophagoscopy with a flexible esophagoscope c. contrast esophagograms d. esophagoscopy with a rigid esophagoscope e. upright X-rays of the chest including lateral and oblique films 55 For the patient in Question 68, which of the following is an indication for surgery? Choose one answer. a. Ongoing hemorrhage occurs from a gastric ulcer in a hemodynamically unstable patient b. All of the above c. Bleeding continues from either a duodenal ulcer or a gastric ulcer despite medical and endoscopic therapy d. Substantial bleeding occurs from a duodenal ulcer that is not controlled by EGD 56 Yesterday, a 38-year-old woman underwent a laparoscopic cholecystectomy for cholelithiasis and was discharged home 8 hours after surgery. She returns this morning complaining of worsening abdominal pain. The oral narcotics that the patient was prescribed are ineffective in controlling the pain. The patient's temperature is (38.3 C). Laboratory studies reveal an elevated white blood cell count. Abdominal ultrasonography shows a large subhepatic fluid collection. The fluid is percutaneously aspirated and reveals enteric contents. What step should be taken next in the management of this patient? Choose one answer. a. Immediate laparotomy b. I.V. antibiotics and close observation c. None of the above

d.

Observation in the hospital until pain improves

57 The most common symptom after major pulmonary embolism is: Choose one answer. a. cough b. Dyspnea c. Hemoptysis d. pleural pain e. fear of death 58 Treatment of paralytic ileus includes all of the following EXCEPT : Choose one answer. a. intravenous fluids b. cessation of oral intake c. correction of electrolyte imbalance d. early operation e. nasogastric suction 59 Lymphedema : Choose one answer a. e) None of the above b. b) should be bilateral c. c) may be pitting in early stage d. d) A & C only e. a) may be Congenital 60 The level of consciousness for a head injury patient is BEST evaluated by : Choose one answer. a. CT scan b. visual evoked potentials c. Glasgow coma scale d. papillary responses e. response to pain 61 A 52-year-old male weighing 70 kg, sustained a 65% total body surface area (TBSA) burn. What are his fluid requirements? Choose one answer. a. 18,200 cc in 16 h b. 9100 cc in the first 8 h c. 8000 cc in 24 h

d. 12,800 cc in 24 h 62 Management of cholangitis may include all of the following EXCEPT: Choose one answer. a. decomperession of the common bile duct. b. cholecystostomy c. IV antibiotics. d. correct underlying cause. e. percutaneous transhepatic cholangiography. 63 A 48-year-old woman presents to the emergency department complaining of right upper quadrant pain, which began 4 hours ago. She reports the pain as being spasmodic and sharp and that it radiates to her right shoulder blade. She says that she has had similar episodes over the past few months, especially after eating large meals. Associated with the pain is nausea and vomiting. Her blood pressure is 120/85 mm Hg, and her pulse is 100 beats/min. On physical examination, the patient is found to have a nontender abdomen with no palpable masses. Her chest and cardiovascular examinations are normal. The nurse notices that her sclerae are slightly icteric. On subsequent laboratory studies, her serum bilirubin level is found to be 10 mg/dl. What imaging study should be performed next for this patient with presumed posthepatic jaundice? Choose one answer. a. Percutaneous transhepatic cholangiography (PTC) b. Ultrasonography c. Endoscopic retrograde cholangiopancreatography (ERCP) d. Magnetic resonance imaging 64 39. An HIV-positive man presents for evaluation of new oral cavity lesions he discovered last month. Physical examination reveals purple exophytic masses involving the palate mucosa and gingiva. What is the most likely diagnosis of these oral cavity lesions? Choose one answer. a. Oral hairy leukoplakia b. Non-Hodgkin lymphoma c. Syphilis d. Kaposi sarcoma 65 Brain injury alone Choose one answer. a. causes shock only if the skull is intact b. rarely causes shock c. causes shock that is reversed by very simple measures d. frequently causes shock e. causes shock if hypoxia is superimposed 66

All of the following substances are irritating to the peritoneum EXCEPT: Choose one answer. a. bile. b. blood c. gastric content. d. meconium e. pus 67 Regarding volvulus of the sigmoid colon, each of the following is true except : Choose one answer. a. likely results from redundant sigmoid colon with an elongated narrow mesocolon b. there appears to be a congenital predisposition sigmoid volvulus. c. diagnostic barium enema for sigmoid colon is essential d. diagnostic x-ray for sigmoid volvulus shows a dilated loop of colon which points toward the right upper quadrant. 68 Gallstones are characterized by all the following EXCEPT: Choose one answer. a. cause mucocoele of the gall bladder b. are present in the common bile duct in 40% of patients with stones in the gall bladder c. are becoming common in post-partum primipara who were pre pregnancy ‘Pill’ takers d. are frequently the cause of flatulent dyspepsia e. may be present in the newborn 69 Following a burn, the agent responsible for early increased capillary permeability is Choose one answer. a. thromboxane A2 b. serotonin c. histamine d. prostacyclin PGI2 e. bradykinin 70 Incisonal hernias all are true except: Choose one answer. a. 10 % of all hernias b. Usually easy to reduce c. Multiloculated sac d. Operative technique is most important cause e. Complication is common 71 In the treatment of gastric cancer, all of the following are true EXCEPT:

Choose one answer. a. five-year survival rates in the continue to be between 10% and 25%. b. Palliative resection is frequently helpful with advanced disease. c. Lymph node involvement is associated with a poorer prognosis. d. Finding early disease at the time of operation is associated with a better prognosis. e. total gastrectomy is mandated in most patient. *** 72 of the involved area and : Severe cases of hidradenitis suppurativa in the groin area are best managed by excision Choose one answer. a. transfer of a rectus abdominus muscle flap b. split thickness skin grafting c. primary closure d. delayed primary closure e. closure by secondary intention 73 Patients at increased risk for gastric carcinoma include all the following EXCEPT: Choose one answer. a. those who have undergone gastric bypass for morbid obesity b. those who have undergone gastric resection for duodenal ulcer c. those with pernicious anemia d. those with a high consumption of smoked fish e. those with blood group A 74 A 56-year-old woman presents with symptoms of abdominal pain, weight loss, and rectal bleeding. She is anemic and hypotensive, but she is stable. For this patient, which of the following should be done first if the gastric lavage yields copious amounts of bile? Choose one answer. a. Arteriography b. Emergency laparotomy c. Colonoscopy d. Esophagogastroduodenoscopy 75 A 39-year-old man presents with lower GI bleeding. He has no abdominal discomfort and has experienced no loss of weight. For this patient, which of the following statements regarding the etiology of lower GI bleeding is true? Choose one answer. a. Lower GI bleeding from diverticulosis often requires surgery b. Arteriovenous malformations (AVMs) are the most common cause of lower GI bleeding c. 6% to 10% of patients with ulcerative colitis have lower GI bleeding severe enough to necessitate emergency surgical resection d. None of the above 76

For the patient in Question 65, which of the following statements regarding abdominal radiographic findings is true? Choose one answer. a. In gastric outlet obstruction, no gastric air will be seen, but large amounts of air will be seen in the small bowel and colon b. Mechanical small bowel obstruction usually shows no air-fluid levels, nor will distended bowel loops of similar sizes be seen c. All of the above d. High-grade obstruction of the colon in association with an incompetent ileocecal valve may mimic small bowel obstruction on x-ray 77 A 41-year-old female presents to the emergency department after sustaining a gunshot wound to the abdomen, with injuries to the liver and large bowel. Despite successful resuscitation and operative intervention, the patient dies 2 weeks later of multisystem organ failure in the intensive care unit. Which organ most likely first experienced dysfunction? Choose one answer. a. lung b. heart c. liver d. gastrointestinal tract e. kidney 78 39. A 35-year-old man presents with severe acute abdominal pain of sudden onset. The pain initially began in the upper abdomen and has now settled in the whole abdomen. On examination, the abdomen was rigid. Chest X-Ray showed free gas under diaphragm. Which of the following is the most appropriate course of management for this patient? Choose one answer. a. Observation b. Urgent laparotomy c. Nonurgent laparotomy d. Laparoscopy 79 All are true about the dumping syndrome except: Choose one answer. a. Symptoms can be controlled with a somatostatin analogue. b. Early postoperative dumping after vagotomy often resolves spontaneously. c. Flushing and tachycardia are common features of the syndrome. d. Diarrhea is always part of the dumping syndrome. e. Separating solids and liquids in the patient's oral intake alleviates some of the symptoms of the syndrome. 80 An anal fissure is characterized by the following EXCEPT: Choose one answer. a. Is more common in women.

b. Is an ulcer of the anal mucosa. c. Can be treated coservatively. d. Usually lies anteriorly. 81 All of the following statements are true of esophageal carcinoma EXCEPT Choose one answer. a. squamous cell tumor is the most frequent histology. b. operation is frequently curative. c. patient often require a pyloroplasty with operation. d. patients usually die within one year of diagnosis e. patient can have intestinal continuity reestablished using the stomach after esophageal resection. 82 A serum tumor marker correlated with recurrence after management of colon cancer is: Choose one answer. a. carcinoembryonic antigen (CEA) b. Calcitonin c. 5-hydroxyindoleacetic acid d. CA 15-3 e. Alpha-fetoprotein 83 Conditions associated with gastric cancer include all of the following EXCEPT: Choose one answer. a. adenomatous polyps. b. a high intake of dietary nitrates. c. pernicious anemia. d. higher socioeconomic groups. e. chronic atrophic gastritis. 84 Which of the following is required for addressing any pressure sore? Choose one answer. a. pressure reduction b. hyperbaric oxygen c. antibiotics d. skin flap coverage 85 The most effective treatment of achalasia is: Choose one answer. a. antireflux surgical procedures b. Esophagomyotomy c. dilation of the lower esophageal sphincter d. antispasmodic medication e. resection of the cardioesophageal junction

86 Regarding desmoid tumors all are true except: Choose one answer. a. Treatment is wide local excision with safety margins b. Has high rate of local recurrence c. Is a low grade fibro sarcoma d. More common in females e. Is radio resistant 87 Which of the following variables best predicts prognosis for patients with a recent diagnosis of cutaneous melanoma and no clinical evidence of metastatic disease? Choose one answer. a. Ulceration. b. Clark's level. c. Gender d. Bleeding e. Breslow thickness. 88

In the treatment of acute cholecystitis, most patient are BEST served with: Choose one answer. a. endoscopic sphincterotomy. b. cholecystostomy. c. percutaneous drainage of the gallbladder. d. early cholecystectomy (within 3 days of onset of symptoms). e. IV antibiotics and cholecystectomy in 6 to 8 weeks. 89 Regarding crohn's disease all are true except Choose one answer. a. Cause non caseating granuloma b. commonly affect small bowel c. Causes sub mucosal fibrosis d. It is full thickness inflammation e. Cause depletion of goblet cell mucin 90 Advantages of laparoscopic versus open cholecystectomy include all of the following EXCEPT: Choose one answer. a. decreased pain. b. less risk of bile duct injury. c. reduced hospitalization. d. improved cosmetic. e. reduced ileus. 91

The most common cause of massive hemorrhage in the lower gastrointestinal tract is: Choose one answer. a. carcinoma b. Diverticulosis c. Diverticulitis d. Polyp e. ulcerative colitis 92 Carcinoma of the gallbladder is Choose one answer. a. rarely associated with jaundice. b. associated with a good prognosis. c. usually not diagnosed preoperatively. d. most commonly metastatic to the lung. e. best treated with radiation and chemotherapy 93 All the following statements concerning nipple discharges are true EXCEPT: Choose one answer. a. benign duct papillomas are the most common cause of bloody discharges. b. when bloody , the discharge is due to a malignancy 70% of the time c. a) excision of involved duct may be necessary to determine the etiology d. they may be caused by multiple lesions. e. a milky discharge may be due to a pituitary adenoma . 94 39. A 28-year-old woman presents with a complaint of a growing, painless mass in her neck. Physical examination reveals a firm, fixed nodule measuring 2 cm on the right lobe of her thyroid. The surgeon recommends fine-needle aspiration (FNA) of the lesion instead of excisional biopsy. What are the advantages of FNA over excisional biopsy? Choose one answer. a. FNA is associated with a decreased risk of tumor seeding b. FNA requires only an office visit c. Anesthesia is not necessary d. All of the above 95 For the patient in Question 74, which of the following is a sign of a colovesical fistula associated with diverticulitis, as seen on computed tomography with contrast? Choose one answer. a. Thickening of the bladder and the colon b. Sigmoid diverticula c. All of the above d. Air in the bladder 96

All of the following are true statements concerning paget ’ s disease of the nipple EXCEPT: Choose one answer. a. it is an eczematoid lesion. b. it is very uncommon, accounting for only 2% of all breast cancers. c. it is an in situ squamous cell malignancy of the nipple. d. it can be confused with malignant melanoma histologically e. it has a better prognosis than the majority of other breast cancers. 97 The classical picture of Acute arterial embolism include all the following except: Choose one answer. a. peripheral pulses b. Parasthesia c. All the above d. Pain e. Pallor 98 Extra colonic manifestation of inflammatory bowel disease include all except: Choose one answer. a. Erythema nodosum b. Mixed connective tissue disease c. Primary Sclerosing cholangitis d. Polyarthopathy e. Episcleritis 99 A 45-year-old woman presents with abdominal pain and vomiting of 1 day's duration. The patient underwent an exploratory laparotomy after a motor vehicle accident 8 years ago. Which of the following statements is true for this patient? Choose one answer. a. Pain from mechanical obstruction is usually more severe than pain from ileus b. The severity of pain from mechanical obstruction may decrease over time c. Pain from mechanical obstruction is usually localized in the middle of the abdomen, whereas pain from ileus or pseudo-obstruction is diffuse d. All of the above 100 A 4-year-old girl has been experiencing dyspnea on exertion. Chest x-ray shows a Morgagni hernia. For this patient, which of the following statements is true? Choose one answer. a. Morgagni hernias can be repaired with a subcostal, a paramedian, or a midline incision b. Morgagni hernias are most commonly seen on the right side c. All of the above d. The average age at diagnosis is typically greater for patients with Morgagni hernia than for patients with Bochdalek hernia