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Surgery EOR Exam PA Questions with
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A 54-year-old man presents to the emergency department with crampy abdominal pain, nausea, and vomiting. The patient has not passed gas or had a bowel movement for at least 10 hours. On examination, the abdomen is distended and there are high-pitched bowel sounds with rushes. A plain radiograph of the abdomen reveals cecal distension to 12 cm. What is the most appropriate definitive management for this patient? A Intravenous fluids B Nasogastric suction C Observation D Surgical exploration - ✔✔The Correct Answer is: D Massive distention of the cecum, as detected on plain radiograph, is typically seen in "closed loop" obstructions where the ileocecal valve is competent. When distention approaches 12 cm, there is an increased risk of perforation and/or gangrene. Expedient surgical intervention is indicated. Although observation with intravenous fluids and nasogastric decompression are important adjuncts to management, surgical exploration is the only way to rapidly address this emergent situation. When a bone is fractured, there are the 3 stages of healing. What is the proper order in which the healing occurs? A Inflammatory, Remodeling, Reparative B Inflammatory, Reparative, Remodeling C Remodeling, Inflammatory, Reparative
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Remodeling, Reparative, Inflammatory E Reparative, Inflammatory, Remodeling - ✔✔The Correct Answer is: B Inflammatory changes happen after fractures and this is followed by a reparative phase and ultimately, a remodeling phase. The healing from acute injuries generally starts with inflammation,. Once the integrity of the bone has been restored on the macro level, bone remodeling continues until full healing has occurred. What is the most common embolic source of acute arterial occlusion in the lower extremities? A Atrial fibrillation B Aortic aneurysm C Myocardial infarction D Prosthetic cardiac valve E Iliac artery thrombus - ✔✔The Correct Answer is: A The heart accounts for 80% of all emboli, with atrial fibrillation making up 70% of that. Aortic aneurysms are frequently lined with thrombus but infrequently embolize; aneurysmal disease only accounts for 6% of all acute arterial occlusion. Acute myocardial infarction (especially those associated with left ventricular thrombus) accounts for 25% of cardioembolism, with peripheral embolization often the first sign of a previously "silent" MI. Prosthetic cardiac valves make up a still small but increasingly prevalent source of emboli. Peripheral arterial thrombi account for only 3% of acute occlusion. Following emergent appendectomy, a 58-year-old obese male develops a temperature of 102.4˚F, 18 hours postoperatively. His respiratory rate is 26 and his pulse is 116bpm. A physical exam reveals scattered fine rales. What is the most likely diagnosis? A Atelectasis
Von Willebrand's disease - ✔✔The Correct Answer is: E Desmopressin is the mainstay of therapy for people with von Willebrand's disease. Hemolytic anemia, iron deficiency anemia, and thalassemia would all have abnormal findings on the CBC. Allo immunization does not require desmopressin therapy. What absolute tissue pressure generally is used as a guideline for diagnosing compartment syndrome? A 10 mm Hg B 20 mm Hg C 30 mm Hg D 40 mm Hg E 50 mm Hg - ✔✔The Correct Answer is: C Many trauma surgery services use an absolute tissue pressure of approximately 30 mm Hg as the threshold for diagnosing compartment syndrome. Based on the entire clinical picture, patients with numbers in that range or higher will likely require surgical decompression with a fasciotomy, while lower numbers will probably be managed with a more conservative approach. What is the most common site of an acute arterial occlusion due to embolic disease? A Iliac artery B Aortic bifurcation C Mesenteric arteries D Femoral artery
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Popliteal artery - ✔✔The Correct Answer is: D The most common site for an acute embolic occlusion is the femoral artery. Other common sites include the axillary, popliteal, and iliac arteries as well as the aortic bifurcation and mesenteric vessels. The majority (80%) of arterial embolic originate in the heart in patients with atrial fibrillation or from mural thrombi in the left ventricle from an akinetic or dyskinetic portion of the myocardium following a myocardial infarction. A 64-year-old man has been experiencing signs and symptoms compatible with diverticular disease for the past 3 weeks. He now presents to the emergency department malnourished with severe left-sided lower abdominal pain. After appropriate workup and hydration, he is taken to the operating room where a perforated sigmoid colon is discovered with gross contamination. What is the most appropriate surgical intervention at this time? A Left colectomy with primary anastomosis B Hartmann procedure C Proctocolectomy D Abdominoperineal resection E Low anterior resection - ✔✔The Correct Answer is: B This vignette is consistent with an emergent resection in an unprepared patient. The most appropriate therapy for an acute perforation is a Hartmann procedure, which includes resection of the affected portion of the bowel, a temporary diverting colostomy, and oversewing of the distal rectal stump; the second stage of the procedure will involve taking down the colostomy with anastomosis to the rectal stump. A colectomy with a primary anastomosis should not be done when the bowel is unprepared due to the significant risk of infection and leakage of the bowel at the site of the anastomosis. Abdominoperineal resection is used in the treatment of malignant disease of the lower rectum. In this procedure, a permanent colostomy is created and the entire rectum, anal canal, and anus are removed. In the management of benign disease of the lower rectum, a proctocolectomy is appropriate to preserve anal function.
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CT scan of the abdomen E Bone scan - ✔✔The Correct Answer is: D Abdominal/pelvic CT scans and chest radiographs should be obtained as part of the preoperative staging of colon carcinoma for the evaluation of distant metastasis. CT scan of the chest is indicated only if the chest radiograph is abnormal. Endorectal ultrasound is useful in further staging rectal carcinoma. Bone scan is not indicated as a routine diagnostic study in the preoperative staging of colon cancer. Although carcinoembryonic antigen levels are performed preoperatively, they are not helpful in staging and are useful only in the postoperative follow-up of patients to monitor for a recurrence. Approximately what percentage of patients with a solid primary tumor elsewhere will end up with metastatic disease of the vertebrae during the clinical course of their cancer? A 10% B 20% C 30% D 40% E 50% - ✔✔The Correct Answer is: E Fifty percent of cancer patients will develop metastatic disease of the vertebrae at some point during the course of their illness. The highest percentages of cancers that lead to such spinal lesions are carcinomas of the breast, lung, prostate, colon, thyroid and kidney. This likely occurs through hematogenous spread. Pain is a common presenting symptom, but it may be found while still asymptomatic if routine screenings are done with bone scans, MRI or CT in patients with a known primary tumor elsewhere in the body. The pain is usually worse with weight bearing activities and better when lying down, but pain that persists through the night and prevents sleep needs to be evaluated for possible neoplasm. Some metastatic disease of the spine may present with neurological symptoms such as sensory or motor deficits following a spinal nerve root distribution or more generalized neurological deficits due to spinal cord compression or cauda equina syndrome.
Which of the following signs and symptoms is associated with the abdominal pain secondary to chronic intestinal ischemia? A Guarding and rigidity B Fear of eating C Nausea and vomiting D Bloody diarrhea E Positive obturator and psoas signs - ✔✔The Correct Answer is: B The clinical symptoms associated with chronic intestinal ischemia include severe epigastric pain following meals, which results in weight loss and fear of eating. Nausea, bloody diarrhea, and vomiting as well as guarding and rigidity are consistent with acute intestinal ischemia. Obturator and psoas signs are indicative of acute appendicitis. A 67-year-old female with a history of oxygen dependent emphysema presents with a 4-hour history of increasing shortness of breath and pleuritic chest pain on the right side. Her resting oxygen saturation rate is 90%, and she is having pain on inspiration. On examination, the patient has decreased lung sounds with wheeze on the left and absent sounds on the right. There is also tympany to percussion on the right. Based on these findings, what is the best therapy for this patient? A Needle insertion to right chest wall B Supportive care C Increased oxygen delivery D Chest tube insertion E
radiation therapy D radioactive iodine therapy E total thyroidectomy - ✔✔The Correct Answer is: E Total or near-total thyroidectomy is indicated for this woman. No chemotherapy (A) is available for thyroid cancer. Lobectomy with isthmectomy is reserved for papillary carcinoma that is less than 1 cm in size in persons with no history of radiation exposure and no evidence of metastasis. Radiation therapy (C) is used to treat bone metastasis and anaplastic carcinoma. Radioactive iodine therapy (D) may be used following thyroidectomy to ablate any remnant of the gland and to treat cancer that has metastasized or is otherwise high risk. A patient is scheduled for a mitral valve replacement. Which of the following pharmacologic agents would be recommended for surgical prophylaxis? There are no known drug allergies. A Cefazolin B Vancomycin C Ciprofloxacin D Nafcillin - ✔✔The Correct Answer is: A Cefazolin is used as prophylaxis for the majority of clean surgical procedures. For cases in which there is an increased likelihood of encountering gram-negative organisms or anaerobic bacteria, a second- generation cephalosporin is recommended to provide broader coverage. Vancomycin is an alternative if the patient has an allergy to cephalosporin antibiotics. What types of connective tissue are injured in a sprain? A Bones and muscles B Fascia and joint capsules
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Ligaments and joint capsules D Muscles and tendons E Tendons and bones - ✔✔The Correct Answer is: C A sprain involves injury to those tissues that give support to joints - ligaments and joint capsules. Injury to muscles, tendons, and fascia would all be classified as a strain. A 5-year-old male is being evaluated for an acute injury to the right ankle. On the x-ray of the ankle there is a distal tibia fracture that involves the separation of the epiphysis, as well as a small non-displaced chip fracture of the metaphysis of the tibia. Based on these findings, what type of Salter-Harris fracture does this child have? A I B II C III D IV E V - ✔✔The Correct Answer is: B The growth plate is the most fragile part of the bone prior to bone maturation and thus is usually the first structure disrupted when force is applied. Statistically, Type II fractures are most common - those that involve both the growth plate and a chip fracture of the metaphysis. A 45-year-old man presents to the office with the complaint of perianal pain and bleeding. Examination reveals an anal/perianal mass complex. Biopsy is taken and the results are positive for epidermoid carcinoma of the anus. Which of the following treatment options would be the most appropriate therapy for this patient? A
A 74-year-old woman presented with the new onset of seizures. An MRI with gadolinium showed a parasagittal mass with homogenous enhancement and a "dural tail." What is the appropriate management of this patient? A Radiation therapy B Chemotherapy C Surgical resection D Surgical resection with chemotherapy - ✔✔The Correct Answer is: C The clinical presentation is consistent with a meningioma. Meningiomas are commonly located in the parasagittal region, the convexity of the brain, sphenoid ridge, or posterior fossa. Radiographic features on MRI include homogenous enhancement and evidence of a "dural tail" indicating the origin of the tumor. Since meningiomas are a benign tumor, the primary treatment is surgical removal. In the event of a subtotal resection or if the meningioma is found to be malignant, surgical resection is followed by radiation therapy. Which peripheral nerve is involved in the most common compression neuropathy in the upper extremity? A Axillary B Median C Radial D
Sciatic nerve E Ulnar - ✔✔The Correct Answer is: B The median nerve is commonly compressed as it passes through the carpal tunnel in the wrist. This syndrome is most often diagnosed in middle aged or pregnant female patients. The axillary nerve passes through the axilla and is often compressed when patients use crutches improperly and bear weight on the axillary area. The ulnar nerve is second only to the median nerve and can be compressed as it passes through the cubital tunnel at the elbow or as it passes through the humeral and ulnar heads of the flexor carpi radialis muscle. Compression of the radial nerve (and its branches) as it passes through the radial tunnel on the lateral side of the elbow is often confused with lateral epicondylitis. The sciatic nerve is associated with the lower extremities and pain is often elicited as a result of a lumbar disk herniation causing nerve root impingement. A 56-year-old insulin dependent diabetic has been under your evaluation for his diabetes for several years. The patient has a 3-year history of diabetic neuropathy to the right foot, and may have suffered an injury to the foot without knowing due to loss of sensation. The patient now presents with a tender, reddened, and swollen right foot for the last 10 days that is also warm to the touch. You suspect that this patient may have an acute case of osteomyelitis. Based on this history, what bacterial organism is most commonly the cause of osteomyelitis? A Group A beta-hemolytic streptococci B Hemophilus influenzae C Mycoplasma D Pseudomonas aeruginosa E Staphylococcus aureus - ✔✔The Correct Answer is: E Osteomyelitis is an infection in a bone and can occur in patients of all ages. The most common organism implicated in osteomyelitis across all age groups is Staphylococcus aureus. It can enter the bone through multiple mechanisms including by direct inoculation during an open fracture or during surgical intervention following a fracture (most common mechanisms for adults) or by hematogenous spread from another source (the usual cause in children). Hemophilus influenzae was a much more common
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Colon cancer C Diverticular disease D Upper gastrointestinal hemorrhage E Meckel diverticulum - ✔✔The Correct Answer is: C Although hemorrhoids are a common cause of lower gastrointestinal hemorrhage, they do not cause massive hemorrhage. Massive lower gastrointestinal hemorrhage is most commonly due to diverticular disease. Upper gastrointestinal hemorrhage may present as massive lower hemorrhage due to the cathartic effect of blood. Colon cancer usually presents with occult bleeding. Meckel diverticulum may also present significant lower gastrointestinal hemorrhage, but it affects only approximately 2% of the population and is therefore not as common. Which type(s) of Salter-Harris fractures can generally be treated with closed reduction and cast immobilization? A Type I B Types I and II C Types I, II, and III
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Types I, II, III, and IV E Types I, II, III, IV, and V - ✔✔The Correct Answer is: C Minimally displaced Salter-Harris types I, II, and III fractures generally can be treated with immobilization only. Types IV and V involve the cartilage of both the articular surface and the growth plate. To ensure proper alignment and a congruous joint surfaces open reduction and internal fixation is usually necessary. A 1 day-old boy develops progressing abdominal distension, bilious vomiting and failure to pass a meconium stool. Abdominal radiographs show dilated loops of small bowel. Which of the following is the most likely diagnosis in this patient? A Cystic Fibrosis B Hypothyroidism C Imperforate anus D Intussusception E Pyloric Stenosis - ✔✔The Correct Answer is: A The patient presents with a meconium ileus consistent with a diagnosis of cystic fibrosis (A). Pyloric stenosis (E) typically presents between 3 and 6 months of age, while intussusception (D) presents later (
D
Annual flexible sigmoidoscopy E Annual colonoscopy - ✔✔The Correct Answer is: E Routine follow-up after surgical resection of a colon cancer includes annual colonoscopy not sigmoidoscopy, which only assesses the distal colon. The tumor marker for colon cancer is carcinoembryonic antigen (CEA) not carbohydrate antigen 19-9 (CA 19-9), which is used for pancreatic cancer. There is no role for annual chest films or fecal occult blood testing to monitor for a recurrence. A 29-year-old female has a long history of supraventricular tachycardia, for which she has been treated with long-term flecanide, as well as prior therapy with verapamil. She continues to have repeated episodes, sometimes two to three times a week, along with shortness of breath and at times hypotension that has been recorded. What is the next best therapy for this patient? A Synchronized cardioversion B Cardiac catheterization C Ablation therapy D Pacemaker insertion E Long-term telemetry monitoring - ✔✔The Correct Answer is: C After exhaustion of non-invasive therapies, ablation therapy can be used to try to negate the aberrant pathway for SVT. Pacemakers will not allow for an override of the pathway, and cardioversion is only a temporary solution to an acute event. Implantable telemetry monitoring is only diagnostic and not therapeutic to treat. A 46-year-old male is evaluated for a fall from approximately 15 feet, landing on his legs. There is intense pain and swelling to the lower extremity, with decreased sensation. What bone is fractured and is most commonly associated with acute compartment syndrome? A
Femur B Patella C Navicular D Talus E Tibia - ✔✔The Correct Answer is: E The tibia is the most common bone fracture that leads to acute compartment syndrome. It can also occur after other long bone fractures of the arms and legs. While it does occur in the hands and feet, it is unlikely that the fracture of a small carpal bone (scaphoid) or tarsal bone (talus) would result in compartment syndrome. Damage to the hyoid bone in the neck and the patella in the knee are not associated with compartment syndrome. A patient presented with intermittent rectal bleeding associated with decreased caliber in the size of his stool. On examination, there were no palpable abdominal masses, but the fecal occult testing was positive. A barium enema was obtained with the results pictured below. What is the most likely diagnosis for this patient? A Diverticular disease B Crohn disease C Colorectal carcinoma D Intussusception - ✔✔The Correct Answer is: C Barium enema finding of carcinoma of the sigmoid colon causing high-grade obstruction shows the classic "apple core" lesion. Crohn's disease is typically associated with the string sign, which is an area of stricture or stenosis that shows up as a narrow line of contrast, giving the appearance of a string associated with the stricture. Diverticular disease is associated with outpouchings from the colon that will be filled with barium.
