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Surgical Principles and Practice: Comprehensive MCQ Review for Medical Students - Prof. s, Exams of Plastic surgery

City University LondonPlastic surgery
Prof. Jones Smithfield

Surgical Principles and Practice: Comprehensive MCQ Review for Medical Students - Prof. s

Typology: Exams

2024/2025

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157
QUESTIONS
1. A 33-year-old male is transported to your facility fol-
lowing a single stab wound to the anterior abdomen
at the umbilicus. Initial vital signs are blood pressure
93/67 mmHg, heart rate 125 bpm, and respiratory rate
28 breaths/min. Intraoperatively, a large midline retro-
peritoneal hematoma is explored, and transection of the
superior mesenteric artery (SMA) is identified posterior
to the pancreas. Appropriate operative management of
the mesenteric artery includes
(A) Ligation only if proximal arterial injury
(B) Ligation only if distal arterial injury
(C) Proximal arterial ligation with bypass graft originat-
ing at the infrarenal aorta
(D) End-to-end anastomosis with polytetrafluoroethyl-
ene (PTFE) graft
(E) End-to-end anastomosis with saphenous vein graft
2. Following a motor vehicle crash, a 23-year-old trauma
patient undergoes a contrast-enhanced computed
tomography (CT) scan of the abdomen that reveals a
large right perinephric hematoma with associated con-
trast extravasation, failure of the right kidney to uptake
contrast, and a normal-appearing left kidney. The patient
is hemodynamically normal and has no other intra-
abdominal injuries. Appropriate management of the
right kidney is
(A) Admit for observation of residual renal function
(B) Retroperitoneal exploration
(C) Exploration through Gerota’s fascia to exclude a
parenchymal injury
(D) Radiologic vascular stent placement
(E) Nephrostomy tube and N-acetylcysteine
3. A 19-year-old male involved in a motor vehicle crash
presents to the emergency department (ED) with hema-
turia. He is hemodynamically normal and undergoes a
contrast-enhanced CT scan of the abdomen. He is found
CHAPTER 8
TRAUMA
KIMBERLY C. ZAMOR AND ANDREW W. HOEL
to have a grade V injury to the left kidney and a normal-
appearing right kidney. Appropriate management of the
injured kidney is
(A) Nephrostomy tube placement
(B) Renal artery bypass or graft
(C) Observation with exploration for hemodynamic
instability
(D) Nephrectomy
(E) Renal artery stent
4. A 20-year-old male presents to the ED with a stab wound
to the right lower abdomen. On exploration, he has a
2-cm cecal laceration with gross contamination as well
as a laceration to the right iliac vein. The best treatment
option with regard to the iliac vein is
(A) Primary repair
(B) Ligation
(C) Repair with PTFE
(D) Extra-anatomic bypass graft
(E) Repair with autogenous vein
5. Which of the following management options for supra-
renal inferior vena cava injury is directly associated with
renal failure?
(A) Ligation
(B) Lateral venorrhaphy
(C) Spiral saphenous vein graft
(D) Extra-anatomic bypass
(E) Panel graft using saphenous vein
6. Following blunt abdominal trauma, mandatory explora-
tion is indicated for a nonexpanding hematoma identi-
fied on CT scan in which of the following areas?
(A) Right perinephric
(B) Midline inframesocolic
(C) Lateral pelvic
(D) Retrohepatic
(E) Left perinephric
McElroy ch08_p0157_0192.indd 157 16/09/16 7:14 PM
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QUESTIONS

  1. A 33-year-old male is transported to your facility fol- lowing a single stab wound to the anterior abdomen at the umbilicus. Initial vital signs are blood pressure 93/67 mmHg, heart rate 125 bpm, and respiratory rate 28 breaths/min. Intraoperatively, a large midline retro- peritoneal hematoma is explored, and transection of the superior mesenteric artery (SMA) is identified posterior to the pancreas. Appropriate operative management of the mesenteric artery includes (A) Ligation only if proximal arterial injury (B) Ligation only if distal arterial injury (C) Proximal arterial ligation with bypass graft originat- ing at the infrarenal aorta (D) End-to-end anastomosis with polytetrafluoroethyl- ene (PTFE) graft (E) End-to-end anastomosis with saphenous vein graft
  2. Following a motor vehicle crash, a 23-year-old trauma patient undergoes a contrast-enhanced computed tomography (CT) scan of the abdomen that reveals a large right perinephric hematoma with associated con- trast extravasation, failure of the right kidney to uptake contrast, and a normal-appearing left kidney. The patient is hemodynamically normal and has no other intra- abdominal injuries. Appropriate management of the right kidney is (A) Admit for observation of residual renal function (B) Retroperitoneal exploration (C) Exploration through Gerota’s fascia to exclude a parenchymal injury (D) Radiologic vascular stent placement (E) Nephrostomy tube and N-acetylcysteine
  3. A 19-year-old male involved in a motor vehicle crash presents to the emergency department (ED) with hema- turia. He is hemodynamically normal and undergoes a contrast-enhanced CT scan of the abdomen. He is found C H A P T E R 8

TRAUMA

KIMBERLY C. ZAMOR AND ANDREW W. HOEL

to have a grade V injury to the left kidney and a normal- appearing right kidney. Appropriate management of the injured kidney is (A) Nephrostomy tube placement (B) Renal artery bypass or graft (C) Observation with exploration for hemodynamic instability (D) Nephrectomy (E) Renal artery stent

  1. A 20-year-old male presents to the ED with a stab wound to the right lower abdomen. On exploration, he has a 2-cm cecal laceration with gross contamination as well as a laceration to the right iliac vein. The best treatment option with regard to the iliac vein is (A) Primary repair (B) Ligation (C) Repair with PTFE (D) Extra-anatomic bypass graft (E) Repair with autogenous vein
  2. Which of the following management options for supra- renal inferior vena cava injury is directly associated with renal failure? (A) Ligation (B) Lateral venorrhaphy (C) Spiral saphenous vein graft (D) Extra-anatomic bypass (E) Panel graft using saphenous vein
  3. Following blunt abdominal trauma, mandatory explora- tion is indicated for a nonexpanding hematoma identi- fied on CT scan in which of the following areas? (A) Right perinephric (B) Midline inframesocolic (C) Lateral pelvic (D) Retrohepatic (E) Left perinephric

158 CHAPTER 8 TRAUMA

  1. Following a gunshot wound to the lower extremity, signs and symptoms that mandate exploration include which of the following? (A) History of significant hemorrhage at the scene, although no longer actively bleeding (B) Deficit in anatomically related nerve (C) Hypotension (D) Small, stable, nonpulsatile hematoma (E) Palpable thrill
  2. The earliest symptoms of compartment syndrome are a result of tissue intolerance to hypoxia. Which of the fol- lowing structures is the most sensitive to hypoxia? (A) Skin (B) Bone (C) Unmyelinated nerve (D) Myelinated nerve (E) Skeletal muscle
  3. One day following fixation of a complex femur fracture sustained in a motor vehicle crash (MVC), a 24-year-old male complains of severe pain along the ipsilateral thigh. On examination, he is hemodynamically normal with a heart rate of 104 breaths/min, oxygen satura- tion of 94%, and blood pressure of 140/78 mmHg. He has no urinary catheter and no recorded urine output. Laboratory studies at that time include hemoglobin of 8.1 (down from 12.3 preoperatively) and potas- sium of 5.8 (up from 3.4 preoperatively). Which of the following would be included in the next steps in management? (A) Placement of a central venous catheter (B) Transfer to the intensive care unit (C) Obtain family history for bleeding disorders (D) Fasciotomy (E) Observation
  4. Which of the following is correct regarding fasciotomy of the lower extremity for compartment syndrome? (A) A four-compartment fasciotomy cannot be per- formed using a single incision. (B) A four-compartment fasciotomy may be performed using anterolateral and posteromedial incisions. (C) Compartment syndrome involving the thigh may be treated by decompression of the quadriceps com- partment or hamstring compartment. (D) The superficial branch of the tibial nerve is espe- cially vulnerable when extending the fascial incision proximally in the superficial posterior compartment. (E) The most common cause of acute compart- ment syndrome in the lower extremity is thromboembolism.
  5. Which of the following veins is most amenable to ligation? (A) Infrarenal vena cava (B) Suprarenal vena cava (C) Common femoral vein (D) Popliteal vein (E) Innominate vein
  6. Which of the following statements is true regarding the incidence of contrast nephropathy (CN)? (A) The incidence in overall healthy patients is 5%. (B) The most important risk factor is dehydration. (C) In patients with a normal serum creatinine, contrast doses in excess of 200 mL of 300 mg/mL solution are considered a significant risk factor. (D) Mannitol has been shown to decrease the risk of CN. (E) The most important prophylactic maneuver is hydration.
  7. Three months following a MVC in which she suffered a grade III liver laceration, a 34-year-old female presents with hematemesis. She has no history of peptic ulcer disease and denies nonsteroidal anti-inflammatory drug use. Following initial stabilization, the next most appro- priate step would be (A) Upper endoscopy (B) Contrast-enhanced CT of the abdomen (C) Abdominal ultrasonography (US) (D) Admission for observation (E) Angiography
  8. Which of the following vessel injuries can be safely ligated in an unstable trauma patient? (A) SMA (B) Internal iliac artery (C) Suprarenal inferior vena cava (IVC) (D) Infrarenal abdominal aorta (E) Simultaneous radial and ulnar arteries
  9. The most appropriate management of an isolated radial artery injury with no clinical evidence of hand ischemia is (A) Primary repair (B) Ligation (C) Repair with vein graft (D) Repair with PTFE graft (E) Shunt
  10. A 20-year-old male suffers a gunshot blast to the right neck. Initial workup reveals stable vital signs, an intact airway, and no active bleeding from the multiple small entrance sites visible along the right neck. As part of his workup, the arteriogram below is obtained (see Fig. 8-1).

160 CHAPTER 8 TRAUMA

FIGURE 8-3. Aortic arch arteriogram. FIGURE 8-4. Aortic arch arteriogram. This study demonstrates (A) Ascending aortic injury (B) Descending aortic injury (C) Normal study; no injury demonstrated (D) Subclavian artery injury (E) Pericardial tamponade

  1. After stabilization and full workup, the patient in Ques- tion 22 is found to have no other significant injuries. The next step in management of this patient is (A) Admit and observe on cardiac monitor (B) Operative repair of the aorta (C) Endovascular repair of the subclavian artery (D) Esophagogastroduodenoscopy (EGD) and bronchoscopy (E) Emergency thoracotomy
  2. A 22-year-old male presents to the ED after sustaining a stab wound to the left chest. The injury is 2 cm left of the sternum at the level of his nipple. Initial vital signs include a heart rate of 88 bpm, Glasgow Coma Scale score of 15, respiratory rate of 12 breaths/min, and blood pressure of 139/74 mmHg. Initial management of this patient should be (A) Chest x-ray (CXR) (B) Pericardiocentesis (C) Left chest tube thoracostomy (D) Esophagram (E) Echocardiogram
  3. An arteriogram is performed on the patient described in Question 24, and an injury to the proximal left sub- clavian artery is identified. The patient remains hemo- dynamically stable. The next step in the management of this patient is The next step in management of this patient is (A) X-ray of the left femur (B) Admit and observe (C) Cervical spine x-ray series (D) Spiral CT scan of the chest (E) Flat and upright abdominal x-ray
  4. The patient described in Question 19 subsequently develops weakness in her right arm and hand. The fol- lowing arteriogram was performed (see Fig. 8-3). This arteriogram demonstrates (A) No injury (B) Cardiac contusion (C) Sternal fracture (D) Aortic tear (E) Innominate artery pseudoaneurysm
  5. After arteriogram, the next step in the management of the patient described in Questions 19 and 20 is (A) Anticoagulation with heparin and blood pressure control (B) Repair of the injury via right anterolateral thoracotomy (C) Repair of the injury via left anterolateral thoracotomy (D) Repair of the injury via median sternotomy (E) Admission and observation
  6. A 62-year-old male is brought to the ED after being involved in a motor vehicle collision. Vital signs include Glasgow Coma Scale score of 15, heart rate of 78 bpm, respiration rate of 12 breaths/min, and blood pressure of 195/110 mmHg. Radiologic workup includes the arterio- gram shown in Fig. 8-4.

CHAPTER 8 TRAUMA 161

(A) Admit and observe (B) Subclavian repair through a median sternotomy (C) Subclavian repair through a supraclavicular incision (D) Subclavian repair through an anterolateral thoracotomy (E) Exploratory laparotomy

  1. A 19-year-old male presents to the ER following a self- inflicted gunshot wound to the left shoulder. His initial vital signs are heart rate of 100 bpm, respiratory rate of 12 breaths/min, blood pressure of 122/83 mmHg, and a Glasgow Coma Scale score of 15. Physical examination reveals absent pulses in the left brachial, radial, and ulnar arteries. Neurologic examination of the left hand and arm reveals no gross motor or sensory deficit. Follow- ing complete examination, an arteriogram is obtained (see Fig. 8-5). FIGURE 8-5. Arteriogram.
  2. A 27-year-old male is transported to the ER following a gunshot wound to the left thigh. Physical examination reveals an entrance wound on the medial aspect of the left thigh and an exit wound on the lateral aspect of the left thigh. There is no pulse or Doppler signal in his left foot. The patient’s arteriogram is shown in Fig. 8-6 and reveals a (A) Normal arteriogram (B) Left common femoral artery injury (C) Left profunda femoris artery injury (D) Left superficial femoral artery injury (E) Left external iliac artery injury
  3. The next step in the management of the vascular injury presented in Question 28 is (A) Admit and heparin anticoagulation (B) Reversed saphenous vein interposition (C) Endovascular stent placement (D) Immediate above knee amputation (E) Reversed saphenous vein bypass graft
  4. A 37-year-old unrestrained driver is involved in an MVC where he is struck on the driver’s side. The patient arrives at the ED hemodynamically normal but complaining of left-sided abdominal pain. An abdominal CT is per- formed. Based on the CT (see Fig. 8-7), what is the most appropriate management of this patient? (A) Observe in the ED overnight and discharge to home in the morning if remains hemodynamically normal (B) Observe in the intensive care unit with serial hema- tocrits and abdominal exams (C) Perform angiography and embolization (D) Perform exploratory laparotomy (E) Discharge to home FIGURE 8-6. Arteriogram. The arteriogram reveals an injury to the (A) Left subclavian artery (B) Left axillary artery (C) Left brachial artery (D) Left carotid artery (E) Left internal mammary artery
  5. Management of the vascular injury described in Question 26 includes (A) Admit for observation and anticoagulation (B) Repair the axillary artery with PTFE (C) Repair the axillary artery with reversed saphenous vein graft (D) Fracture stabilization with intramedullary (IM) rodding (E) Permanent shunting of the vascular injury followed by fracture stabilization

CHAPTER 8 TRAUMA 163

(D) Paracentesis to evaluate the intraperitoneal amylase level (E) Magnetic resonance cholangiopancreatography

  1. A 21-year-old male with a stab wound to the abdomen presents to the ED in stable condition. On local wound exploration, there is evidence of anterior fascia penetra- tion and omental evisceration. The patient is taken to the operating room for an exploratory laparotomy. A com- plete transection of the ascending colon near the hepatic flexure with minimal contamination is identified. The most appropriate surgical management would be (A) Ileostomy with Hartmann’s pouch (B) Colostomy with mucous fistula (C) Debridement and ileocolostomy (D) Debridement and primary anastomosis (E) Right colectomy with primary anastomosis
  2. A 36-year-old female is ejected during an MVC. She is found to have a pelvic fracture and hematuria. Cysto- gram is performed demonstrating the presence of an extraperitoneal bladder rupture. An indwelling bladder catheter is placed. After 14 days, a repeat cystogram identifies a persistent extraperitoneal leak. What is the most appropriate management? (A) Remove the bladder catheter and observe the patient (B) Continue the bladder catheter for 7–10 days longer and repeat cystogram (C) Cystoscopy to evaluate the extent of the rupture (D) Exploratory laparotomy and repair of extraperito- neal rupture
  3. A 29-year-old male restrained passenger is brought to the ED in stable condition following an MVC. He is admitted for observation following an abdominal CT demonstrating a spleen laceration and a moderate amount of free fluid in the pelvis. Within 48 hours, the patient develops worsening abdominal pain and under- goes exploratory laparotomy. A small bowel perforation is identified (see Fig. 8-9). Which of the following state- ments regarding small bowel injuries is correct? (A) They only occur when the bowel is crushed against the spine. (B) They are frequently associated with Chance fractures. (C) There has been a decreased incidence since the mandatory seat belt laws. (D) Ninety percent of patients with blunt intestinal per- foration have no other injuries. (E) Laboratory studies and CT are used to localize the site of bowel injury.
  4. An 18-year-old female unrestrained driver is involved in a head-on collision. Paramedics at the scene note extensive steering wheel and windshield damage. The patient is hemodynamically normal and complaining of head and abdominal pain. Head and abdominal CT are initially read as negative. After observation overnight, the patient is discharged to home. Approximately 72 hours later, the patient presents to the ED complaining of nausea and bilious emesis. Findings on repeat abdominal CT are shown in Fig. 8-10. What is the most appropriate management? (A) Conservative management with nasogastric suction and total parenteral nutrition (B) Esophagogastroduodenoscopy to evaluate severity of duodenal injury (C) Exploratory laparotomy with evacuation of hematoma (D) Angiography and embolization (E) Percutaneous drainage by interventional radiology
  5. A 16-year-old unrestrained driver is involved in a roll- over head-on collision. Extensive damage to the vehicle and prolonged extrication time was noted. The patient was hemodynamically unstable upon extrication and was transported by air to a level I trauma center. While in transport, the patient became severely hypotensive and unresponsive, with impending respiratory distress. Which of the following is considered a life-threat- ening injury in this patient that warrants immediate intervention? (A) Pneumothorax secondary to rib fractures (B) Aortic intimal tear (C) Diaphragm rupture (D) Tension pneumothorax (E) Myocardial contusion FIGURE 8-9. Small bowel perforation following motor vehicle crash.

164 CHAPTER 8 TRAUMA

  1. An unrestrained 23-year-old male drag racer involved in a high-speed motor vehicle crash presents to the ED with intense pain in the right chest. The primary survey demonstrates decreased breath sounds over the right hemithorax with noted paradoxical motion of the right chest wall during respiration (see Fig. 8-11). The major pathologic sequela of this injury is (A) Disruption of ventilation because of paradoxical motion of the chest wall (B) Bleeding from disruption of intercostal vessels FIGURE 8-11. Chest x-ray. From Knoop KJ, Stack LB, Storrow AB, Thurman RJ. The Atlas of Emergency Medicine, 3rd ed. New York, NY: McGraw-Hill; 2009. FIGURE 8-10. Abdominal CT. From Mattox K, Moore E, Feliciano D (eds.). Trauma, 7th ed. New York, NY: McGraw- Hill; 2012. (C) Underlying pulmonary contusion (D) Pneumothorax (E) Splinting from chest wall pain
  2. A 65-year-old male restrained driver involved in a high-speed MVC suffered a severe blow to the epigastrium and presents to the ED with abdominal pain out of proportion to the apparent injury. The patient is intubated, and a nasogastric tube is placed on arrival. The primary survey reveals decreased left- sided breath sounds. After assuring proper endotra- cheal tube placement, a chest tube is placed on the left side. Initial chest tube output is 50 mL of blood; then particulate matter is noted inside the chest tube. The usual mechanism of this injury is (A) Laceration of the esophagus by a portion of a frac- tured rib (B) Inappropriate nasogastric tube placement (C) Sudden deceleration resulting in shear stress to the esophagus (D) Compression of the esophagus against the vertebral column (E) Forceful compression of the stomach
  3. A restrained 52-year-old female presents to the ED fol- lowing a high-speed MVC during which she suffered a side door impact. On arrival, primary survey reveals airway stridor and severe respiratory distress. A pneu- mothorax is suspected. Chest x-ray reveals massive pneumomediastinum. The patient is resuscitated and remains stable. Further evaluation of the chest radio- graph reveals the right lung appearing to fall laterally and posteriorly away from the hilum. The next step in man- agement should be (A) Observation for 48 hours (B) Tube thoracostomy (C) Immediate bronchoscopy (D) Exploratory thoracotomy (E) Place patient on humidified air
  4. A 35-year-old female involved in a restrained MVC presents to your ED. Initial chest radiograph is shown in Fig. 8-12. The next step in management is (A) CT scan of the abdomen (B) Delayed thoracotomy (C) Video-assisted thoracoscopy (D) Barium swallow (E) Nasogastric tube insertion

194 CHAPTER 9 BURNS

  1. A 4-year-old child was brought in with burns. Which of the following would make you suspect the child may have an inhalation injury? (A) A flash burn from a campfire with singed eyebrows and arm burns (B) Splash pattern burns on the nose, chin, and anterior chest from hot beverage spill (C) Cigarette burns on extremities (D) Structural fire in which the patient was found unconscious and rescued by emergency medical services (EMS)
  2. What is the gold standard for diagnosing inhalation injury? (A) Chest x-ray (B) Computed tomography (CT) scan (C) Bronchoscopy (D) Burns to face
  3. In a 45-year-old man with a 25% TBSA full-thickness burn to the trunk, arms, neck, and face, which of the fol- lowing is an indication for escharotomy? (A) Circumferential burns of the forearm with intersti- tial tissue pressure of 35 mmHg (B) Mean airway pressures to 28 mmHg H 2 O (C) Swelling of lips and tongue (D) Loss of radial pulse
  4. Which of the following would make you suspect child abuse? (A) “V” shape scald burns extending from the chin to the umbilicus from pulling hot water off a stove (B) Flame burn to volar forearm from camp fire (C) Burn to chest and underarm from candle setting shirt on fire (D) Stocking distribution to lower legs and feet from bathing self
  5. A 3-year-old child with a 40% TBSA burn to the trunk, arms, and scalp is brought to the operating room in preparation for a tangential excision of approximately 20% TBSA. Which of the following measures is most important in assuring a safe procedure? (A) Placement of a new subclavian vein catheter (B) Measurement of serum lactate level (C) Increasing ambient operating room temperature near or above 108°F (D) Transfusion of platelets and fresh frozen plasma in the preoperative period
  6. A 30-year-old firefighter sustained 55% TBSA burns 6 days ago. Which of the following assessments demon- strates adequate nutritional support? (A) Low serum retinol-binding protein (B) Indirect calorimetry with a calculated respiratory quotient (RQ) of less than 0. (C) Serum albumin of 2. (D) Prealbumin of 20
  7. Which of the following is true regarding burn hypermetabolism? (A) The patient’s homeostatic thermostat remains unchanged. (B) There are decreased levels of circulating catecholamines. (C) Patients prefer to set the ambient room temperature to 65°F. (D) There is protein catabolism in skeletal muscles.
  8. Enteral feeding is preferred to parenteral feeding in the burn patient for which of the following reasons? (A) Provision of carbohydrate calories (B) Avoidance of gastric ileus (C) Replacement of trace minerals (D) Reduced complications compared to total paren- teral nutrition (E) Decreased risk of diarrhea
  9. Deficiency of which of the following results in impaired collagen synthesis secondary to deficient hydroxylation of lysine and proline? (A) Selenium (B) Zinc (C) Ascorbic acid (D) Iron (E) Vitamin E
  10. Anemia in the burn patient is frequently secondary to (A) Idiopathic reaction to silver sulfadiazine (B) Decreased circulating erythropoietin (C) Depletion of bone marrow progenitor cells (D) Increased erythrocyte fragility (E) Microthrombus formation
  11. A 42-year-old man is intubated 1 week after a 53% TBSA burn with inhalation injury. The patient has had two operative excisions with grafting and currently has an increasing white blood cell (WBC) count to 20, tempera- ture spikes to 103°F, oliguria, and hypotension. The most common source of sepsis in this patient is (A) Invasive burn wound infection (B) Urosepsis from indwelling catheters (C) Pneumonia (D) Central line–associated bloodstream infection
  12. A decrease in cardiac output immediately following ther- mal injury is due in part to (A) Decreased systemic vascular resistance (B) Decreased venous return (C) Increased left ventricular distensibility (D) Norepinephrine release

CHAPTER 9 BURNS 195

  1. Match the topical antimicrobial to its side effect. (A) Silver sulfadiazine (a) nephrotoxicity (B) Silver nitrate (b) leukopenia (C) Mafenide (c) metabolic acidosis (D) Bacitracin (d) hyponatremia, hypochloremia
  2. A 40-year-old electrical lineman is injured on an elec- tric pole and is brought to the emergency department unconscious. He has an area on his left hand that is charred, evidence of thermal injury to the arm, and an exit wound on his right knee. Which of the following interventions is the first priority? (A) Escharotomy of the left arm (B) CT scan of the abdomen and pelvis (C) Endotracheal intubation (D) CT scan of the head and neck (E) Measurement of serum creatinine phosphokinase levels
  3. A 24-year-old petroleum worker presents with a burn to his leg approximately 6% TBSA when hydrofluoric acid spilled onto his clothing. In addition to irrigation of the wound with saline, what therapy is indicated? (A) Irrigation with dilute sodium hydroxide (NaOH) solution (B) Application of dimethyl sulfoxide (DMSO) to the wound area (C) Topical application of calcium gluconate solution (D) Systemic infusion of magnesium sulfate
  4. What initial treatment of frostbite has been shown to preserve limb function/viability? (A) Quickly reheating the limb to normal body temperatures (B) Intra-arterial tissue plasminogen activator (tPA) (C) Intravenous administration of warmed fluids (D) Heparin injection
  5. The site of injury in toxic epidermal necrolysis syndrome (TENS) and Stevens-Johnson syndrome (SJS) is (A) The Nikolsky body (B) Superficial to basement membrane (C) The dermoepidermal junction (D) The endoplasmic reticulum
  6. A critical factor in the “take” of a skin autograft is (A) Presence of elastin fibers in the graft (B) Diffusion of metabolites from wound bed to skin graft (C) The patient’s intraoperative body temperature (D) Securing the graft with sutures or staples
  7. Which of the following has a major risk of hypertrophic scar formation? (A) Third-degree burn grafted within a week (B) Partial-thickness burn that heals at 3 weeks (C) Split-thickness donor site that heals within 12 days (D) Partial-thickness wound that heals in 10 days
  8. A 36-year-old man sustained a 20% TBSA hot water scald burn to his abdomen, genitalia, and right leg. One referral criterion that this patient meets for transfer to a burn center is (A) Burn of 20% TBSA or greater (B) Patient age (C) Scald burns (D) Patient sex
  9. A 27-year-old lineman was on duty and came in contact with over 12,000 volts. He was found at the scene to be obtunded with obvious deformities in his hands. He was immediately intubated and then transported to the emergency department. What injury is commonly asso- ciated with this mechanism of burn? (A) Splenic laceration (B) Ruptured bowel (C) Cervical spine injury (D) Ruptured tympanic membrane
  10. Which of the following public health interventions has caused the largest reduction in burn injuries? (A) Educating children on stop, drop, and roll (B) Recommending flame-resistant mattresses for children (C) Discussing burn prevention with mothers of infants prior to their children ambulating (D) Laws requiring smoke detectors in homes
  11. What percentages best represent the TBSA burns of an adult patient with burns to bilateral lower extremi- ties and groin and of an infant with a scald to the entire head? Adult Infant (A) 37% 20% (B) 49% 10% (C) 49% 20% (D) 37% 10%
  12. An electrician exposed to 12,000 volts in a rural area is transferred to your facility 8 hours after initial injury. His urine is red-brown. How would you treat his condition? (A) Do escharotomies of all limbs (B) Increase fluids so that urine output is 100 mL/h (C) Start furosemide drip (D) Do nothing; the damage has already been done

QUESTIONS

  1. Cells of the monocyte-macrophage lineage recognize antigens by which of the following mechanisms? (A) Lipid A (B) Toll-like receptors (TLR) (C) T-cell receptor (D) Immunoglobulin G (E) Interleukin (IL)-
  2. The cell type most characteristic of chronic inflammation is the (A) Macrophage (B) B cell (C) Natural killer cell (D) Neutrophil (E) Eosinophil
  3. The resolution of an acute inflammatory process is medi- ated by which of the following? (A) Apoptosis (B) Anti-inflammatory cytokines (C) Angiogenesis (D) Corticosteroids (E) All of the above
  4. In the alternative pathway of the complement cascade, the stimulus for the production of C3 convertase is pro- vided by which of the following? (A) Antibody-antigen complex (B) Virus-infected cells (C) Mannin-binding lectin (D) IL-
  5. A 35-year-old man develops a fever of 38.9°C 24 hours after being involved in a motor vehicle crash in which he sustained multiple lower extremity fractures. C H A P T E R 1 0

INFLAMMATION

AND SHOCK

ZACHARY ABECASSIS, PETER DORSCHNER, AND STEVEN SCHWULST

This febrile response stems from which of the follow- ing mediators? (A) IL- (B) IL- (C) Interferon (IFN)-α (D) IL- (E) IL-

  1. Which molecule is a precursor of nitric oxide? (A) Citrulline (B) Arginine (C) Tryptophan (D) Alanine (E) Leucine
  2. The severity of hypovolemic shock has been found to correlate with (A) Hematocrit (B) Pulmonary capillary wedge pressure (PCWP) (C) Lactic acid (D) PaO 2 (E) White blood cell count Questions 8 and 9 An 80-year-old male undergoes pancreatic debridement. On postoperative day 6, the patient begins a regular diet, and subsequently, the output from the drains also markedly increases. Two days later, the patient develops hypotension and tachycardia, accompanied by oliguria and confusion.
  3. The first organ affected by the compensatory mecha- nisms of hypovolemic shock is the (A) Heart (B) Kidney (C) Gastrointestinal tract (D) Skin (E) Spleen

220 CHAPTER 10 INFLAMMATION AND SHOCK

  1. The initial compensatory mechanism to hypovolemic shock is the release of (A) Aldosterone (B) Norepinephrine (C) Renin (D) Vasopressin (E) Angiotensinogen
  2. A 22-year-old male presents to the emergency department after sustaining a gunshot wound to the right upper quad- rant of his abdomen. On arrival, the patient is lethargic. His systolic blood pressure is 85 mmHg with a heart rate of 130 bpm. Fluid resuscitation is initiated. Which of the following is the most appropriate resuscitation fluid? (A) 0.9% sodium chloride (B) Albumin (C) Dextran (D) 5% dextrose in 0.45% sodium chloride (E) 3% sodium chloride
  3. A 41-year-old woman presents to the emergency depart- ment after sustaining a gunshot wound to the abdo- men, 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? (A) Liver (B) Gastrointestinal tract (C) Lung (D) Kidney (E) Heart
  4. A 23-year-old man presents to the emergency depart- ment after an altercation in which he sustained trauma to his head and neck. On arrival, the patient is found to have a systolic blood pressure of 65 mmHg with a heart rate of 50 bpm. His Glasgow Coma Scale score is 5. A head computed tomography (CT) reveals a large epidural hematoma, whereas a cervical spine CT demonstrates bilateral vertebral facet dislocations at the level of C4. What is the likely cause of his hypotension? (A) Head trauma (B) Hypovolemia (C) Massive vasodilatation (D) Alcohol intoxication (E) Blunt cardiac injury
  5. The most common mechanism of spinal cord injury is (A) Distraction (B) Transection (C) Impact with persisting compression (D) Impact alone (E) Laceration
  6. In which category of shock is the Trendelenburg position considered a viable treatment option? (A) Cardiogenic (B) Neurogenic (C) Hypovolemic (D) Septic (E) Cardiac compressive
  7. A 74-year-old previously healthy woman is admitted to the hospital and undergoes an uneventful open appendec- tomy for a ruptured appendix. On postoperative day 1, the patient reports crushing substernal chest pain with radia- tion to the left arm. She appears pale, anxious, and dia- phoretic. Her extremities are cold. Initial vital signs reveal a systolic blood pressure of 75 mmHg and a heart rate of 101 bpm. An electrocardiogram (ECG) is consistent with an acute anterior myocardial infarction. What factor pre- dicts the development of cardiogenic shock in the setting of an acute myocardial infarction (MI)? (A) ST elevations on presenting ECG (B) Age less than 75 years old (C) Posterior infarction (D) Pulmonary rales on physical examination (E) Inferior infarction
  8. The patient in Question 15 is transferred to the intensive care unit, and judicious fluid resuscitation and vasopres- sor support are initiated. A pulmonary artery catheter is placed to guide therapy. What readings are characteristic of cardiogenic shock? Cardiac Output Systemic Vascular Resistance PCWP Central Venous Pressure (A) Low High High Normal to high (B) Low High Low Low (C) High Low Low High (D) Low High Low High (E) High Low Low Low
  9. A transthoracic echocardiogram is obtained and dem- onstrates new-onset mitral regurgitation. An angiogram is immediately performed, showing acute left main coronary artery occlusion. What is the next step in management? (A) Thrombolytic therapy (B) Emergent coronary artery bypass graft (CABG) with mitral valve repair (C) Emergent percutaneous coronary intervention (PCI) (angioplasty with stenting)

222 CHAPTER 10 INFLAMMATION AND SHOCK

  1. An example of an anti-inflammatory cytokine is (A) IL- (B) IFN-γ (C) Lymphotoxin-α (LT-α) (D) IL- (E) Tumor necrosis factor-α (TNF-α)
  2. Which of the following is a biological function of TNF-α in inflammation? (A) Initiation of the coagulation cascade (B) Increased insulin sensitivity (C) Inhibition of macrophage phagocytosis (D) Stimulation of muscle growth
  3. Which of the following is true of tissue oxygenation in septic shock? (A) Oxygen delivery is elevated while oxygen extraction is decreased. (B) Oxygen delivery is reduced while oxygen extraction is increased. (C) Arterial-venous oxygen difference is increased. (D) Both oxygen delivery and extraction are increased. (E) Mixed venous oxygen is decreased.
  4. Glucocorticoids influence the inflammatory response by which of the following? (A) Enhanced production of IkB (B) Increased neutrophil aggregation (C) Increased production of cyclooxygenase (COX) (D) Increased IL-2 levels (E) Enhancement of inducible nitric oxide synthase production
  5. A 46-year-old woman develops septic shock following an open cholecystectomy for a gangrenous gallbladder. She remains intubated after surgery but exhibits persistent hypoxia with maximal ventilator support. The diagnosis of acute respiratory distress syndrome (ARDS) is sug- gested. This condition is defined by which of the follow- ing criteria? (A) PaO 2 /FiO 2 < 200 and PCWP < 18 mmHg (B) PaO 2 /FiO 2 > 200 and PCWP < 18 mmHg (C) PaO 2 /FiO 2 < 200 and PCWP > 18 mmHg (D) PaO 2 /FiO 2 > 200 and PCWP > 18 mmHg
  6. Positive end-expiratory pressure (PEEP) is added to the ventilatory support of the patient in Question 30 with an improvement in her oxygenation. Which of the follow- ing describes the mechanism by which PEEP improves oxygenation? (A) Reduction in the rate of pulmonary edema formation (B) Improvement in the reabsorption of edema fluid (C) Inhibition of the opening of collapsed alveoli (D) Prevention of the collapse of alveoli (E) Enhancement of surfactant production
  7. A 75-year-old man with a history of steroid-dependent chronic obstructive pulmonary disease undergoes a left hemicolectomy for treatment of cancer. The operation is complicated by an anastomotic dehis- cence, requiring reexploration and the creation of a colostomy. Following surgery, the patient becomes febrile and exhibits a decline in his systolic blood pressure. The nitric oxide–induced vasodilatation exhibited by this patient is mediated by which intra- cellular messenger? (A) Cyclic adenosine monophosphate (cAMP) (B) Cyclic guanosine monophosphate (cGMP) (C) Inositol 1,4,5-trisphosphate (IP 3 ) (D) Diacylglycerol (DAG) (E) Inosine 5-monophosphate (IMP)
  8. The effects of nitric oxide inhibition include (A) Pulmonary hypertension (B) Decreased neutrophil adhesion (C) Increased peroxynitrite production (D) More pronounced inhibition of mitochondrial respiration (E) Elevated cardiac output
  9. A pulmonary artery catheter measures which of the fol- lowing parameters directly? (A) Cardiac index (B) Systemic vascular resistance (C) Mixed venous oxygen saturation (D) Left ventricular end diastolic pressure (E) Pulmonary vascular resistance index
  10. The variable directly measured by gastric tonometry is the (A) Gastric mucosal pH (B) Gastric mucosal PCO 2 (C) Gastric mucosal PO 2 (D) Gastric mucosal bicarbonate (E) Splanchnic hypoperfusion ANSWERS AND EXPLANATIONS
  11. (B) Phagocytic cells such as macrophages, monocytes, and neutrophils compose the innate immune system. Innate immunity represents a preexisting resistance to antigens, not requiring a prior exposure. This contrasts with acquired immunity, which depends on repeated contact with the antigen to augment the immune response. Although the innate immune system com- mences an inflammatory reaction, its interaction with the T and B cells of acquired immunity propagate and strengthen the response.

QUESTIONS

  1. A 34-year-old woman presents with a large right-sided thyroid nodule seen on ultrasound. What information in her history and workup would make her at higher risk for a differentiated thyroid cancer? (A) She underwent radiation treatment after resection of a left lower extremity sarcoma 2 years ago. (B) Her thyroid-stimulating hormone (TSH) level is suppressed. (C) She grew up in an iodine-deficient area. (D) She had acne as a teenager that was treated with radiation. (E) She had scoliosis as a teenager requiring frequent spinal x-rays.
  2. The patient in Question 2 was found to be hyperthyroid on laboratory evaluation. In which situation would anti- thyroid medication followed by radioactive iodine (RAI) be appropriate? (A) Graves disease (B) Cold nodule on iodine uptake scan, correlating with the ultrasound finding, with increased uptake in the surrounding parenchyma (C) Hot nodule on iodine uptake scan, correlating with ultrasound finding, with suppressed background (D) Hashimoto thyroiditis (E) If thyroglobulin levels are within normal limits
  3. Which of the following ultrasound findings is most sug- gestive of malignancy? (A) Complete halo (B) Hypoechogenicity (C) Hyperechogenicity (D) Wider than tall (E) Anechogenicity C H A P T E R 1 2

THYROID AND

PARATHYROID

AMIT D. TEVAR AND DINESH P. TEVAR

  1. A recommendation of repeat fine-needle aspiration (FNA) in 3 months would be appropriate for which Bethesda category? (A) Atypia of undetermined significance or follicular lesion of undetermined significance (B) Benign (C) Follicular neoplasm or suspicious for follicular neoplasm (D) Suspicious for malignancy
  2. Which of the following is the most accurate statement with regard to FNA of thyroid nodules? (A) The false-positive rate is ~2%. (B) The false-negative rate is ~15%. (C) Ultrasound must be used for a reliable result. (D) FNA findings classified as atypia of undeter- mined significance have a malignancy rate of 15–30%. (E) FNA diagnosis of follicular neoplasm has a malig- nancy rate of 1–4%.
  3. A 35-year-old woman presents with a painless midline mass above the hyoid bone for the past 4 months. She denies any history of neck radiation or previous surgery. The mass is 2 × 2 cm on physical examination and elevates with tongue protrusion. What is the most common malignancy associated with this condition? (A) Follicular (B) Hürthle cell (C) Papillary (D) Medullary (E) Anaplastic

CHAPTER 12 THYROID AND PARATHYROID 277

(C) Total thyroidectomy with central neck dissection (D) Total thyroidectomy with postoperative chemora- diation therapy (E) Measure calcium and plasma fractionated metanephrines

  1. Which of the following is the most common site of ori- gin for isolated metastatic lesions to the thyroid? (A) Kidney (B) Breast (C) Colon (D) Soft tissue (E) Lung
  2. A 31-year-old woman develops sudden onset of neck pain radiating to the jaw with a temperature of 40°C 4 days after being treated for “strep throat.” Thyroid function tests are normal, and the white blood cell count is 24,000. The thyroid is tender, but there are no obvious areas of fluctuance found on physical examination. What is the most appropriate form of treatment? (A) Total thyroidectomy (B) Operative incision and drainage (C) Intravenous antibiotics (D) High-dose immunosuppression (E) FNA
  3. A 42-year-old woman presents with symptoms of hypo- thyroidism with a painless, enlarged, firm, rubbery thy- roid gland on exam. Which diagnosis is most consistent with her condition? (A) Hashimoto thyroiditis (B) Acute suppurative thyroiditis (C) Riedel thyroiditis (D) Painless thyroiditis (E) Subacute de Quervain thyroiditis
  4. A 27-year-old woman with a history of lupus develops symptoms of hyperthyroidism 2 months after delivery of her first child. Three months later, she develops symp- toms of hypothyroidism that persist. A small, nontender goiter is present. What is the best method of treatment for her disease? (A) 131 I treatment (B) Total thyroidectomy (C) FNA (D) Thyroid hormone replacement (E) High-dose steroids
  5. Which of the following statements is true regarding the origin of the parathyroids? (A) The two inferior glands are usually found near the posterior aspect of the thyroid capsule. (B) The two superior glands are usually found near the posterior aspect of the thyroid capsule. (C) Thirty-five percent of normal people have a fifth parathyroid gland. (D) The parathyroid glands arise from the fourth and fifth branchial pouches. (E) The inferior glands arise from the fourth branchial pouch.
  6. Parathyroid hormone (PTH) acts indirectly on which organ to increase calcium levels? (A) Small bowel (B) Kidney (C) Bone (D) Liver (E) Skin
  7. A 58-year-old woman without any significant past medi- cal history presents to her primary care physician for her routine yearly physical. She has had some vague com- plaints of fatigue, but has otherwise been in good health. Her calcium level was noted to be elevated on her blood work. Which of the following is the most likely etiology of her disease? (A) Vitamin D toxicity (B) Malignancy (C) Primary hyperparathyroidism (D) Sarcoidosis (E) Secondary hyperparathyroidism
  8. In patients with primary hyperparathyroidism, which of the following will cause worsening hypercalcemia? (A) Amiodarone (B) Furosemide (C) Hydrochlorothiazide (D) Bisphosphonate (E) Calcitonin
  9. A 33-year-old woman has had elevated serum cal- cium levels since birth. Further evaluation dem- onstrates a normal PTH and hypocalciuria. She denies any symptoms. What is the most appropriate treatment? (A) Subtotal parathyroidectomy (B) Technetium-99m (99mTc)-sestamibi (C) Bisphosphonates (D) Observation (E) Minimally invasive parathyroidectomy

278 CHAPTER 12 THYROID AND PARATHYROID

  1. A 47-year-old woman develops symptomatic hypercal- cemia, and further workup demonstrates primary hyper- parathyroidism. Surgical treatment shows the following gross and permanent histologic sections (see Fig. 12-1). What is the most likely etiology of her disease? (A) Single adenoma (B) Familial hypocalciuric hypercalcemia (C) Hyperplasia (D) Carcinoma (E) Exogenous calcium intake
  2. A 48-year-old woman with primary hyperparathyroid- ism has a T score of less than –1.8 at the left distal radius on her dual-energy x-ray absorptiometry (DEXA) scan but is otherwise asymptomatic. What is the next step in her management? (A) Cystoscopy (B) Serum oxalate measurement (C) Parathyroid localization studies (D) Bilateral neck exploration (E) Observation
  3. A patient with primary hyperparathyroidism undergoes surgical exploration. A single irregularly enlarged para- thyroid gland is found that invades into surrounding tis- sue. The specimen histology is shown in Fig. 12-2. What is the most appropriate surgical resection? (A) Single parathyroidectomy, with visual inspection of the other three glands (B) Subtotal parathyroidectomy (C) En bloc gland resection, with ipsilateral thyroid lobectomy and cervical thymus and central neck dissection (D) Total parathyroidectomy with reimplantation (E) En bloc gland resection, with ipsilateral thyroid lobectomy and cervical thymus and central and lat- eral neck dissections
  4. Surgical exploration for a patient with primary hyper- parathyroidism reveals all four glands to be enlarged. What is the most appropriate treatment? (A) Closure with localization study (B) Biopsy of all glands (C) Subtotal parathyroidectomy (D) Excision of the largest gland (E) Selective venous PTH sampling
  5. In a 65-year-old woman with primary hyperparathyroid- ism, which of the following is a contraindication to mini- mally invasive parathyroidectomy? (A) Calcium >12 μg/dL (B) Large parathyroid adenoma noted in the right par- aesophageal space (C) History of ionizing radiation exposure to the neck (D) Amiodarone-induced hyperparathyroidism (E) Inability to acquire preoperative imaging ANSWERS AND EXPLANATIONS
  6. (D) Although thyroid nodules are common within the general population, thyroid malignancy overall is still relatively rare. Approximately 5% of thyroid nodules are eventually found to harbor malignancy; the overwhelm- ing majority of these will be differentiated thyroid cancer (papillary, follicular). Therapeutic doses of radiation to FIGURE 12-2. Frozen section of parathyroid tissue. FIGURE 12-1. Hematoxylin and eosin stain of parathyroid tissue. From Kemp W, Burns D, Brown T. Pathology: The Big Picture. New York, NY: McGraw-Hill; 2007.