Surgery Review

CEBU INSTITUTE OF MEDICINE BLUEPRINT FOR QUESTIONS CONTENT AREA WEIGHT GENERAL SURGERY (53%) Abdominal Stomach Small intestine Colon/Rectum Appendix Liver Biliary tree Breast Head and Neck SURGICAL SPECIALTIES (47%) Pedia Surg TCVS Urology Neurosurgery Plastic reconstructive Orthopedics TOTAL

SURGERY SPECIFICATIONS RECALL COMPREHENS ION

APPLICATION

6 6 9 6 4 9 1 9 53

0 4 8 4 0 5 3 7 31

3 2 1 2 2 2 1 2 15

3 0 0 0 2 2 0 0 7

4 10 10 10 3

3 10 9 7 2

1 0 1 3 1

-

10 47

10 41

0 6

0

MEAN MPL FOR THE EXAM = 60.45

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CEBU INSTITUTE OF MEDICINE Department of Surgery DIRECTION: Each question below is followed by four possible answers. Select the one best response and mark the appropriate spaces on the answer sheet provided for. 1. The most common and most life threatening surgical abdominal emergency in a 3 to 10 month old infant is: A. Necrotizing enterocolitis B. Ascaris bolus causing intestinal obstruction C. Ileocolic intussusception D. Midgut volvulus 2. In acute appendicitis among children: A. Diagnosis is straightforward and easy among infants B. “Dance sign” C. Abdominal films are useful in most cases D. A palpable right lower quadrant mass in the abdomen will indicate a localized abscess 3. Known predisposing factors for necrotizing enterocolitis: A. Premature contractions B. Breech extraction C. Maternal intake of drugs D. Maternal viral infections 4. Therapeutic management of unilateral Wilm’s tumor in a 3 year old child with a favorable histology: A. Radical nephrectomy for stages I to III B. If stage II, adjuvant methotrexate C. Irradiation for all stages D. Renal transplantation 5. An easily compressible blind ending tubular structure measuring 5 mm or less on graded sonography means: A. Acute appendicitis B. Ruptured appendendictis C. Normal appendix D. Caecal carcinoma 6. In some patients, an ill defined mass on the right lower quadrant will be detected on physical examination. In a patient over the age of 50 years old, this mass is most likely due to: A. Phlegmon B. Periappendiceal abscess C. Ruptured appendix D. Perforated cecal carcinoma 7. Pneumatosis cystoides intestinalis develops after one of the following events in a patient with small bowel tumor: A. Bleeding B. Obstruction C. Perforation D. Fistula formation 8. Which of the following is the LEAST likely reason why the diagnosis of small bowel carcinoma is often delayed and far advanced at the time of operation? A. Because of the rarity of the lesion B. Vagueness of the symptoms C. Absence of the physical findings D. Lack of available diagnostic studies 9. Diverticula associated with the ampulla of Vater have significant relationship to: A. Diabetes mellitus B. Non-specific symptoms C. Cholangitis, pancreatitis, stone disease D. Obstruction, perforation, bleeding 10. Radiation enteritis may cause malnutrition syndrome and this is brought about by: A. Decrease in the effective length of the small bowel B. Decreased digestive activity

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C. Changes in microorganism population D. Changes in the mucosal epithelial cells 11. Psudo-obstruction, post-vagotomy syndrome, and small bowel diverticula create intestinal stasis and will eventually cause malnutrition syndrome due to: A. Decrease in the effective length of the small bowel B. Decreased digestive activity C. Changes in microorganism population D. Changes in the mucosal epithelial cells 12. The diagnosis of appendicitis should be questioned if it is not accompanied by which of the following? A. Pain B. Anorexia C. Vomiting D. Obstipation or diarrhea /Ref. pp 1383 13. The passive internal rotation of the flexed right thigh with the patient supine producing hypogastric pain is termed as the: A. Psoas sign B. Obturator sign C. Rovsing’s sign D. Fothergill sign 14. The inflammatory process that involves the serosa of the appendix and in turn the parietal peritoneum produces a shift: A. To the left in white blood cell count B. Of the somatic phase to the visceral phase C. Of the pain to the right lower quadrant D. Of the innervating nerve fibers 15. This is a rapid method of taking fresh tissue in the operating room and staining it for microscopic study so that the slides can be examined in a short period of time. It is a highly accurate method of diagnosis with the main purpose of making a therapeutic decision. It is ideal for thyroid, breast and other soft tissue tumors: A. Open biopsy B. Frozen section biopsy C. Fine needle aspiration biopsy D. Exfoliative cytology 16. Masses in the upper cervical region may be related to metastatic lesions coming from the: A. Stomach B. Pancreas C. Lungs D. Nasophayrnx 17. All of these symptoms/complaints for malignancies such as nasal, auricular, neuroophthalmic, and tumoral symptom are exhibited by malignancies affecting the: A. Nasopharynx B. Hypopharynx C. Larynx D. Cervical esophagous 18. An immediate neck exploration should be done with penetrating injuries involving which zone of the neck? A. I B. II C. III D. All of the above 19. The immediate cause of death from untreatable asphyxiation in thermal airway injury is: A. Mucosal and sub-mucosal edema B. Erythema C. Hemorrhage D. Ulceration 20. The small bowel segment most susceptible to primary disease is: A. Jejunum B. Duodenal bulb C. Ileum

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D. Jejuno-ileal junction 21. Among young patients with hereditary descending colon cancer, the accepted most radical surgical option would be: A. Left hemicolectomy B. Extended left hemicolectomy C. Total proctocolectomy D. Total abdominal colectomy 22. For CEA (carcino embryonic antigen) to be useful in the postoperative monitoring for cancer recurrence, at what value must it be preoperatively? A. More than 1.0 ng/ml B. More than 2.1 ng/ml C. More than 4.6 ng/ml D. More than 6.0 ng/ml /Ref. pp 1265 23. The cecum is the most common site of colonic rupture as explained by the Laplace’s law which states that tension is directly proportional to the ___ of a sphere. A. Diameter B. Wall thickness C. Radius D. Circumference (Answer C/MPL – 0.6/Ref. pp 1265) 24. Cancerous lesions of the anal verge usually drain to the: A. Inguinal nodes B. Nodes at origin of sigmoid artery branches C. Sacral nodes D. Internal iliac nodes 25. When colonic pseudo-obstruction is suspected and the cecal diameter is greater than 12 cm, the initial approach should be: A. Colonoscopic decompression B. Barium enema C. Transverse loop colostomy D. Cecostomy 26. Bird’s beak deformity in volvulus points to the: A. Obstruction B. Gangrenous segment C. Cause D. Potential point of rupture 27. Full rectal prolapse patients with normal sphincteric function should be treated with: A. Thiersch procedure B. Perineal proctectomy C. Low anterior resection D. Abdomino-perineal resection 28. Hemorrhoids that bleed, prolapse and require manual reduction are classified as: A. 1st degree B. 2nd degree C. 3rd degree D. 4th degree 29. The most common complication after an excisional hemorrhoidectomy is: A. Bleeding B. Infection C. Fecal impaction D. Urinary retention (Answer C/ MPL – 0.3/Ref. pp 1265) 30. Sistrunk procedure is done in: A. Papillary carcinoma of thyroid B. Thyroid adenoma C. Thyroglossal duct cyst D. Lingual thyroid (Answer C/ MPL – 0.6/Ref. pp 1661) 31. Most clinicians believe that the single most sensitive test of thyroid function is:

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A. T4 B. T3 C. TSH D. Free thyroxine index 32. When doing thyroidectomy for diffuse toxic goiter with severe ophthalmopathy, the extent should ideally be: A. Total B. Near total C. Subtotal, bilateral D. Subtotal one lobe, total in the other 33. When a thyroid cyst is more than 4 cm in diameter or has solid and cystic components, thyroid lobectomy is recommended because: A. Repeated aspiration may cause hemorrhage B. Repeated aspiration will not totally eradicate the cyst C. Of high potential for malignancy D. Of high incidence of thyrotoxicity 34. The most commonly performed operation for stage II breast cancer is: A. Total mastectomy B. Modified radical mastectomy C. Classical radical mastectomy D. Quadrantectomy 35. The most common cause of valvular dysfunction in the Philippines: A. Infective endocarditis B. Rheumatic heart disease C. Papillary muscle rupture secondary to myocardial infarction D. Congenital in origin 36. The best option for valvular surgery: A. Replacement with a bioprosthetic valve B. Replacement with a mechanical valve C. Replacement with an allograft or autograft D. Preservation of existing valve if repairable 37. Definite indications for Coronary artery bypass graft (CABG): A. Left main stenosis > 50% B. Proximal LAD stenosis > 90% C. Double valve disease > 50% D. Acute myocardial infarction > 6 hrs in CHF 38. Patients who had valvular replacement with mechanical valves would require anticoagulation for: A. 4 weeks B. 3 months C. 6 months D. life 39. The three major coronary supply to the heart: A. Left anterior descending, right posterior descending, circumflex artery B. Diagonal, right posterolateral artery, circumflex artery C. Left anterior descending, right coronary artery, circumflex artery D. Ramus intermedius, right coronary artery, circumflex artery 40. The best method of preserving the heart during bypass: A. Moderate hypothermic arrest at 32oC B. Profound hypothermic arrest at 12oC C. Fibrillatory arrest D. Cardioplegic arrest 41. Cardiac tamponade arising from massive pericardial effusion can present as a classical syndrome of Beck’s triad. The following are components of the triad, EXCEPT: A. Elevation of systemic venous pressure B. Systemic arterial hypertension C. Distant heart sounds D. Engorged neck veins 42. The most common tumor in the anterior mediastinum: A. Thymoma B. Foregut cyst

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C. Pericardial cyst D. Neurofibroma 43. The following congenital heart disease presents with decreased pulmonary blood flow EXCEPT: A. Tetralogy of Falot B. Tricuspid atresia C. Aortopulmonary window D. Hypoplastic left heart syndrome 44. Blalock-Tausig shunt, a palliative systemic-to-pulmonary artery shunt is indicated in the following, EXCEPT: A. Tetralogy of Falot B. Tricuspid atresia C. Pulmonary atresia D. Truncus arteriosus 45. The most radioopaque stone among the following is A. Uric acid stone B. Cystine stone C. Struvite stone D. Calcium phosphate stone 46. The following may be manifestations of renal tumors EXCEPT A. Pain B. Mass C. Hematuria D. None of the above 47. The most common presentation of Urinary Bladder tumors is: A. Suprapubic mass B. Gross or microscopic hematuria C. Urinary frequency D. Fever 48. The most common testicular tumor of childhood is: A. Seminoma B. Teratoma C. Embryonal carcinoma D. Choriocarcinoma 49. The histology of ureteral cancers are generally: A. Adenocarcinoma B. Squamous cell carcinoma C. Transitional cell carcinoma D. Choriocarcinoma 50. Benign prostatic hypertrophy (BPH) arises in the : A. Peripheral zone B. Transition zone C. Central zone D. Anterior fibromuscular stroma 51. The following statements are true regarding renal trauma, EXCEPT: A. Urinalysis is the most important laboratory test in the evaluation of renal trauma B. The degree of hematuria predicts the severity of renal injury C. Hematuria is present in greater than 95% of renal trauma D. Gross hematuria is associated with more severe renal trauma than is microscopic hematuria 52. The most common histologic type of penile malignancies is: A. Mucoid adenocarcinoma B. Clear cell adenocarcinoma C. Squamous cell carcinoma D. Rhabdomyosarcoma 53. The following are the organisms implicated in non specific urethritis EXCEPT: A. Chlamydia trachomatis B. Ureaplasma urealyticum C. Nisseria gonnorhea D. Trichomonas vaginalis 54. The normal capacity of the human urinary bladder:

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A. 150 – 250 cc B. 350 – 500 cc C. 800 – 1000 cc D. 50 – 150 cc 55. The most common location of hypertensive intracerebral bleed: A. Frontal lobe B. Thalamus C. Putamen D. Cerebellum 56. Transient disturbance of neurologic function without gross pathologic changes due to trauma is called: A. Cerebral contusion B. Cerebral concussion C. Diffuse axonal injury D. Hemorrhagic contusion 57. How does a 10cc volume pineal gland tumor cause increased intracranial pressure? A. Adding volume intracranially B. Increase in production of CSF C. Increased cerebral edema D. Obstruction of the aqueduct of Sylvius 58. Ocular sign of uncal herniation: A. Anisocria B. Papilledema C. Conjunctival injection/congestion D. Medial deviation of eyeball 59. Most common cause of spontaneous subarachnoid hemorrhage: A. Hypertension B. Ruptured AV malformation C. Ruptured aneurysm D. Blood dyscrasia 60. A patient with gradually decreasing visual acuity and frequent urination with ophthalmologic finding of bilateral optic nerve atrophy would most likely have a: A. Sphenoid wing meningioma B. Occipital lobe astrocytoma C. Cerebellar tumor (medulloblastoma) D. Pituitary tumor 61. When the mean arterial blood pressure decreases, the cerebral arteries A. Vasoconstrict B. Vasodilate C. Remain the same D. Develop obstruction due to thrombosis 62. Common location of otogenic brain abscess is: A. Frontal B. Parietal C. Temporal D. Occipital 63. Cardiac or carotid plaque embolism usually lodges in which branch of the internal carotid artery? A. Anterior cerebral artery B. Ophthalmic artery C. Middle cerebral artery D. Posterior cerebral artery 64. Definitive diagnostic procedure for intracranial vascular anomaly such as aneurysm or AV malformation is: A. CT Scan B. MRI C. Cerebral angiogram D. CSF analysis for evidence of hemorrhage For question numbers 65 – 67 please refer to the case below.

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A 45 year old male complaining of sudden onset of epigastric pain started about 5 hours ago was seen at the emergency room. Vital signs includes BP=125/80 mmHg PR= 95/min RR= 25/min Temp = 37.8 o C. Significant physical examination include direct and rebound tenderness with guarding all over the abdomen, hypoactive bowel sounds. 65. Your initial clinical impression would most likely be: A. Acute appendicitis B. Acute pancreatitis C. Perforated peptic ulcer D. Intestinal obstruction 66. The single most important X ray procedure should include: A. Chest PA B. Flat plate of the abdomen C. Upright film of the abdomen D. Chest AP 67. Your impression would be confirmed by the presence of what findings in the above X-ray? A. Presence of air-fluid level B. Presence of pneumoperitoneum C. Presence of soft tissue density at the right lower quadrant D. Presence of gallbladder shadow For question numbers 68 – 70 please refer to the case below. A 55 year old female complaining of recurrent right upper quadrant tenderness specially after a fatty meal. The pain usually disappears after a while. 68. What is the most likely condition that the patient may have? A. Hydrops gallbladder B. Empyema gallbladder C. Cholecystolithiasis D. Acute cholecystitis 69. The single most important laboratory examination to document the problem is: A. Ultrasound B. Serum bilirubin (direct type) C. CBC D. Chest X-ray 70. The pain persisted for more than 24 hours and is getting more severe. The patient was seen in the emergency room. In your PE, you were able to elicit direct tenderness on the right subcostal area on deep inspiration. This maneuver is known as: A. Murphy’s punch sign B. Murphy’s sign C. McMurphy’s punch sign D. McMurphy’s sign 71. Conditions to consider in a 25 year old male patient presenting with right lower quadrant pain: A. Acute appendicitis B. Ruptured ovarian cyst C. Tubo-ovarian abscess D. Ectopic pregnancy 72. Which of the following conditions may present with pneumoperitoneum? A. Ruptured appendicitis B. Perforated peptic ulcer C. Ruptured gallbladder D. All of the above 73. Primary peritonitis may occur in association with: A. Chronic renal failure B. Perforated peptic ulcer C. Acute appendicitis

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D. Cholecystolithiasis 74. A 28 year old female, single presents with sudden onset of generalized abdominal tenderness. Patient has a pulse rate of 110/min and BP of 80/60 mmHg. Direct and rebound tenderness of the abdomen. A single most important laboratory examination to confirm your diagnosis is: A. Chest PA X-ray B. CBC C. Pregnancy test D. Ultrasound of the biliary tree 75. The risk for development of invasive breast cancer is 8-10 times higher compared to the base population if the histologic findings show: A. Atypical lobular hyperplasia B. Florid hyperplasia C. Sclerosing adenosis D. Sever ductal hyperplasia 76. With invasion of cancer cells in the surrounding breast parenchyma, the accompanying fibrosis shorten the suspensory ligament of Cooper producing: A. Nipple retraction B. Peau d orange C. Ulceration D. Satellite nodule 77. The most important risk variable for recurrence of breast cancer is? A. Tumor histology B. Tumor grade C. Tumor Estrogen receptor status D. Tumor size For question numbers 78 – 79 please refer to the case below. A 56 year old married male from Mandaue City was seen at the emergency room because of hematemesis and melena. He is a known heavy alcoholic drinker for the past 20 years and often times skip meals. PE: BP= 80/50 mmHg PR = 120/min RR = 24/min Skin: pale Sclerae: non icteric; Abdomen: globular, slightly distended, soft, palpable liver edge and spleen, positive shifting wave. 78. The probable cause of bleeding in this patient is: A. Esophageal tear from vomiting B. Acute gastritis C. Peptic ulcer D. Gastro-esophageal varices 79. The probable source of bleeding can be best identified with: A. Insertion of nasogastric tube B. Upper gastrointestinal series C. Endoscopy D. Ultrasonography 80. Which of the following is the most common acid-base disturbance in patients with liver cirrhosis and portal hypertension? A. Metabolic alkalosis B. Metabolic acidosis C. Respiratory alkalosis D. Respiratory acidosis 81. Which of the following statements most accurately describes the current therapy of pyogenic hepatic abscess? A. Antibiotics alone are adequate for the treatment in most cases B. All patients require open surgical drainage for optimal management C. Optimal treatment involves treatment of not only the abscess but the underlying source as well D. Percutaneous drainage is more successful in multiple rather than in solitary lesions For question numbers 82 – 86 please refer to the case below. A 36 year old female 5’5” in height, 100 lbs with history of passing out ascaris per stool in her childhood comes to you with complaints of colicky epigastric pain, intermittent jaundice, and

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intermittent acholic stools. Pertinent physical examination: Temp= 39.8 o C BP = 80/50 mmHg PR= 120/min; Skin: cold, clammy perspiration; sclerae: (+) jaundice; Abdomen: Flat, soft, (+) tenderness at the epigastric and right subcostal area, no palpable mass appreciated; Total serum bilirubin: 6 mg % 82. The most probable diagnosis is: A. Carcinoma of the common bile duct B. Sclerosing cholangitis C. Choledocholithiasis D. Choledochal cyst 83. The clinical manifestations of shock is most probably due to: A. Hemorrhage B. Perforation of the gallbladder C. Cholangitis D. Generalized peritonitis 84. If your diagnosis is a choledochal cyst, what is the most pertinent PE finding in the abdomen? A. Board like rigidity B. Mass C. Rebound tenderness D. Absent bowel sounds 85. If your diagnosis is sclerosing choalngitis, the pathology involves mainly the: A. Intrahepatic ducts B. Extrahepatic ducts C. Gallbladder D. All of the above 86. If your diagnosis is carcinoma of the distal common bile duct, what is the pathological finding in the gallbladder? A. Inflamed B. Distended C. Contracted D. Normal 87. What is the initial immediate treatment of patients with septic shock? A. Exploratory laparotomy B. Blood transfusion resuscitation C. Isotonic solution resuscitation D. Vasoconstrictor drugs 88. Requisites for cleft lip surgery according to the “Rule of Tens” include: A. Age of at least 10 months B. Body weight of no less than 10 kgs. C. WBC count not more than 10,000/ cumm D. Hemoglobin of 10 gms or less 89. Which of the following statements regarding skin grafts and flaps is NOT VALID? A. Facial defects are best covered by either full thickness grafts or random pattern grafts B. Areas of dense scaring, defects with exposure to vital structures and those where secondary surgical procedures are still planned are ideally covered with full thickness skin graft C. Split thickness skin grafts are usually harvested using a dermatome from the the thigh or anterior abdomen D. Myocutaneous flaps provide viable coverage of composite defects, with good restoration of form, contour and symmetry 90. Clinical signs suggestive of facial bone fractures include all of the following, EXCEPT: A. Subconjunctival hemorrhage B. Malocclusion C. Epistaxis D. Ectropion 91. Most common ligament injured in ankle sprain: A. Posterior talofibular Lig B. Calcaneo-fibular Lig C. Ant Talofibular Lig D. Spring Ligament

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92. Blood clotting noted in veins of Lower Extremities: A. Deep vein thrombosis B. Varicosities C. Pulmonary embolism D. Chronic Venous Insufficiency 93. Pain on calf muscles noted on walking, commonly in diabetics: A. Arthropathy B. Diabetic foot C. Ulcer D. Claudication 94. Splint for fractures in lower extremity: A. Jefferson splint B. Skin Splint C. Thomas splint D. Sling & Swathe 95. Fracture in one side of cortex: A. Torus B. Greenstick C. Compression D. Epiphyseal Fractures 96. Disease entity that features destruction of large joint commonly seen in elderly: A. Osteopetrosis B. Osteoporosis C. Osteoarthritis D. Rheumatoid arthritis 97. Decrease in bone mass with altered bone microarchitecture and fracture risks: A. Osteopenia B. Osteoarthritis C. Osteoporosis D. Osteopetrosis 98. Nerve affected in carpal tunnel syndrome: A. Median Nerve B. Musculocutaneous N. C. Femoral nerve D. Posterior interosseos N. 99. Muscle group that gives stability to the shoulder: A. Scapulothoracic B. Trapezius C. Deltoid D. Rotator cuff 100. 45 year old female post total abdominal hysterectomy & salphingo-ophorectomy. Long term complication includes: A. Osteoporosis B. Osteoarthritis C. Anemia D. Calcium Deficiency Reference: Schwartz, S; Shires, T; Spencer, F. (editors). Principles of Surgery, 7th edition, 1999. New York: McGraw-Hill

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