Page of 34

DEPARTMENT OF SURGERY
PRINCIPLES OF SURGERY EXAM

February 16, 2010

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

EXAMINATION INSTRUCTIONS
1.

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

2.

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

3.

This examination is two hours in length.

4.

Examination results will be sent from the Department of Surgery

5.

Questions marked with an asterisk are optional for residents in the ENT and OBGYN programs.

Principles of Surgery Exam

February 2010

Page 2 of 34
*1.

A 19 year old man suffers a stab wound to the mid-abdomen. On arrival in the
Emergency Room his blood pressure is 80/50. Following rapid infusion of 4 liters
of normal saline, his blood pressure is 110/80. Blood gasses taken at this time are:
ph

7.20

pO2

95

PCO2 25
HCO3 15
This patients metabolic acidosis would be best treated with?

2.

3.

a)

1 amp sodium bicarbonate IV

b)

2 units packed RBC stat

c)

hyperventilation

d)

immediate laparotomy

An elderly diabetic man is admitted to hospital for treatment of an infected foot

ulcer. He is found to have a serum sodium of 119 and a blood glucose level of 33.
His hyponatremic state should be treated with?
a)

insulin infusion to reduce blood glucose level to normal

b)

normal saline 150 cc/h until the serum sodium returns to normal

c)

3% NaCl at 400 cc/h until the serum sodium returns to normal

d)

1000 cc/day water restricted diet

A 77 year old man undergoes percutaneous nephrostomy because of an infected and

obstructed left ureter. The patient develops a gram negative bacteremia immediately
following the procedure. The earliest manifestation of sepsis syndrome in this
patient is likely to be:
a)

hypotension

b)

lactic acidosis

c)

elevated serum creatinine

d)

hyperventilation with respiratory alkalosis

Principles of Surgery Exam

February 2010

Page 3 of 34
4.

5.

6.

7.

The following four factors affect the rate of flow of blood through a stenotic artery.
Which is the most important?
a)

diameter of stenosis

b)

length of stenosis

c)

blood viscosity

d)

systolic blood pressure

What is the most common cause of an acquired hypercoagulable state?

a)

cigarette smoking

b)

heparin-induced thrombocytopenia (HIT)

c)

antiphospholipid antibody (eg lupus anticoagulant)

d)

oral contraceptives

Which of the following clinical conditions are indicated by the presence of serum
antibodies against hepatitis B surface antigen (anti-HBs) and hepatitis B core
antigen (anti-HBc) in the absence of HBs AG?
a)

active acute infection with the hepatitis B virus

b)

normal response to vaccination with hepatitis B vaccine

c)

chronic active hepatitis due to the hepatitis B virus

d)

recovery with subsequent immunity following acute hepatitis B infection

A 70 year old man has known cirrhosis of the liver complicated by portal
hypertension and ascites. He is admitted to hospital because of increasing
encephalopathy and low grade fever. Which of the follow statements about this
situation is correct?
a)

a diagnosis should be made clinically and the patient immediately started

on antibiotics

b)

infection, if present, is often polymicrobial

c)

antibiotic therapy is reserved with patients with positive acidic fluid

cultures

d)

gram-negative enteric bacteria are often present in infected ascidic fluid

Principles of Surgery Exam

February 2010

Page 4 of 34
8.

9.

*10.

All the following proteins are primarily synthesized in the liver, EXCEPT?
a)

albumin

b)

fibrinogen

c)

Factor VII

d)

von Willebrand Factor

Regarding the progression of cells from normal to cancerous, which of the

following statements is NOT true?
a)

dysplasia describes cells with altered size, shape, and organization

b)

in the absence of atypia or dysplasia, hyperplasia confirms only a modest,

if any, risk of cancer in a given tissue

c)

all dysplastic tissues eventually progress to frank carcinoma

d)

metaplastic changes may be reversible

Primary blast injury is caused by the blast pressure wave as it propagates through
air or water. Common injuries of this type include all of the following EXCEPT?
a)

myocardial contusion

b)

pulmonary contusion

c)

hollow-viscous perforation

d)

perforated eardrum

11. A 34 year old woman, know to use crack cocaine, is brought to the Emergency Room
following a fall of approximately 20 feet. She has an obvious left tibia-fibula
fracture and an open left humeral fracture. She is extremely agitated and
uncooperative. Blood pressure is 180/120 and the heart rate is 130. Further
investigation and management of this patient will require sedation. This is best
accomplished by?
a)

IM Haloperidol 5 mgs

b)

IV Midazolam 2 mgs, repeated every 5 minutes as required

c)

IV Fentanyl 50 micrograms, repeated every 5 minutes as required

d)

IV Propofol 10 mgs/kg, followed by endotracheal intubation

Principles of Surgery Exam

February 2010

Page 5 of 34
12. A 35 year old man is injured in a high speed motor vehicle crash. When he is brought
to the Emergency Room, his blood pressure is 90/50, heart rate 120, GSC 3. The
anaesthesia resident can mask-bag the patient achieving an O2 saturation of 95, but
cannot intubate the patient with a laryngoscope. The next step in management of
the airway should be?
a)

attempt intubation with a glide-scope

b)

attempt fibroptic intubation

c)

surgical airway

d)

call for a staff anesthetist

13. Immunosuppression to facilitate organ transplant may result in many complications.

Malignant lymphoma may occur years after the transplant. Which of the following
statements about transplantation associated lymphomas is NOT true?
a)

they are usually non-Hodgkins B-cell lymphomas

b)

the malignant transformation may be caused by the Epstein-Barr virus

c)

the incidence of lymphoma is directly related to the amount of

immunosuppression received over time

d)

upon diagnosis of the lymphoma, withdrawn of immunosuppression is

rarely successful in eradicating the tumour

14. A 55 year old man underwent successful kidney transplantation two years ago. He is
taking Mycophenolate, prednisone, and tacrolimus to prevent rejection. He presents
in the Emergency Room with generalized peritonitis secondary to a perforated
viscus and undergoes emergency surgery. In order to prevent organ rejection in the
perioperative period, the surgeon should?
a)

only provide stress-steroid coverage until the patient can resume oral
intake

b)

ask the pharmacist to convert his oral dosages to equivalent IV dosages

until the patient can resume oral intake

c)

continue oral intake with his usual meds in the expectation that his GI tract
will be able to absorb most of the medication

d)

supplement IV steroid stress coverage with IV antithymocyte globulin

until the patient can resume oral intake

Principles of Surgery Exam

February 2010

Page 6 of 34
15. A 70 year old man is found to have a bulky mid-rectal adenocarcinoma without
metastatic disease. He undergoes neoadjuvant chemo-radio therapy. On flexible
sigmoidoscopy six weeks after completion of therapy, he is seen to have only a 2
cm residual tumour, 12 cms from the anal verge. At this point, the surgeon should?

*16.

*17.

18.

a)

continue to follow the patient to see if the tumour will regress completely

b)

resume chemotherapy in the hope of totally irradiating the tumour

c)

proceed to surgery to remove only the portion of the rectum containing the
residual tumour

d)

proceed with surgery to remove almost all of the rectum as if the patient
had not had any adjuvant therapy

Which of the following arteries cannot be ligated to stop uncontrolled bleeding

because of the risk of distal ischemic damage?
a)

common carotid artery

b)

superior mesenteric artery

c)

common femoral artery

d)

descending thoracic artery

The following treatments for hypotension due to acute blood loss are
contraindicated, EXCEPT?
a)

albumin-containing IV solutions

b)

vasopressors

c)

Trendelenburg positioning

d)

tourniquet to acutely bleeding extremity

Peripheral nerve damage is the second most common anesthetic

complication leading to malpractice suits. All of the following nerves may be
injured, EXCEPT?
a)

ulnar nerve

b)

femoral nerve

c)

brachial plexus

d)

sciatic nerve

Principles of Surgery Exam

February 2010

Page 7 of 34
19. A 79 year old man undergoes left hemicolectomy for an obstructing colon cancer. On
post-operative day five he developed peritonitis and undergoes relaparotomy and
exteriorization of his anastomotic leak. Following this procedure, he develops acute
renal failure despite aggressive treatment in the ICU. NG feeds are initiated. His
physician should aim for a protein intake of?
a)

0.3 grams/protein/kg/day

b)

0.8 grams/protein/kg/day

c)

1.4 grams/protein/kg/day

d)

feed only with glucose and lipids because of his acute renal failure

20. A 45 year old man is severely injured in a motor vehicle crash. He undergoes
laparotomy with splenectomy, repair liver laceration, and bowel resection. The
abdomen is closed primarily. An open fracture of the left tibia is treated with an
external fixator. The following morning, his vitals are:
heart rate

120

BP 88/50
CVP 11 mm/Hg
His urine output is 5 cc/h. Peek airway pressures have increased from 32 to
50 cc/H2O. His abdomen is distended and firm. Bladder pressure is 30 mmHg.
The next step in his treatment should be?
a)

increase rate of fluid resuscitation

b)

change the ventilator mode to pressure-control ventilation

c)

inotropic therapy

d)

immediate laparotomy

Principles of Surgery Exam

February 2010

Page 8 of 34
*21.

A 25 year old woman was an unbelted passenger in a high speed vehicle crash. She
is intubated and a C spine collar is in place. Her GCS is 3T. She has a right
pulmonary contusion and multiple lower extremity fractures. The diagnostic
procedure of choice for radiologic clearance of her cervical spine is?
a)

3 view cervical spine x-rays

b)

flexion extension cervical spine x-rays

c)

CT cervical spine

d)

MR cervical spine

22. A 68 year old man sustains multiple injuries in a motor vehicle crash including a
closed head injury with small frontal contusions, and interparenchymal hemorrhage
on CT scan. He has been on coumadin 4 mgs a day for chronic atrial fibrillation for
three years. His admission INR is 2.8. The most rapid method of reversing the
anticoagulant effect of coumadin is?
a)

recombinant factor VIIa

b)

fresh frozen plasma

c)

vitamin K1

d)

octoplex

Principles of Surgery Exam

February 2010

Page 9 of 34
*23.

A 45 year old man is brought to the Emergency room after a high speed motor
vehicle crash. There was no loss of consciousness. He received 2000 ccs of normal
saline en route to hospital. On arrival in the Emergency Room, his vitals are:
Heart Rate

140

Blood pressure

60 systolic

Respiratory Rate

24

GCS

14

On examination, he has no neck tenderness, good breath sounds bilaterally, and a

distended tender abdomen. There is no pelvic tenderness or instability and no
obvious extremity fractures. A portable chest x-ray shows a left 1st rib fracture
only. The next step in his evaluation and treatment should be?
a)

focused assessment with sonography for trauma (FAST ultrasound)

b)

CT abdomen and pelvis

c)

diagnostic laparoscopy

d)

laparotomy

24. A 66 year old woman with long-standing rheumatoid arthritis requires emergency
surgery for perforated sigmoid colon diverticulitis. She has been receiving
prednisone 10 mgs a day for at least the last five years. The recommended
management of perioperative parenteral corticosteroids for this patient should be?
a)

no systemic corticosteroids unless she demonstrates signs of adrenal

insufficiency (eg hemodynamic instability)

b)

a 100 mg bolus of hydrocortisone with induction of anaesthesia, then

hydrocortisone 150 mgs/day, in divided doses until oral intake resumes

c)

a 100 mgs bolus of hydrocortisone at induction of anaesthesia,

hydrocortisone 300 mgs/day in divided doses until oral intake resumes

d)

a 100 mg bolus of hydrocortisone at induction of anaesthesia, 300 mgs/day

of hydrocortisone in divided doses on post operative day one followed by
a taper of 50% per day over the next three days until oral intake resumes

Principles of Surgery Exam

February 2010

Page 10 of 34
25. Three days after knee arthroscopy, a 35 year old man presents with mild dyspnea on
exertion. His temperature is 38 degrees centigrade. His chest is clear to
auscultation except for right lower lobe rales. Minimal knee swelling is noted at the
arthroscopy site. His white blood cell count is 12,400 and D-dimer level is normal.
A chest x-ray shows that the right hemi-diaphragm is obscured. The next diagnostic
test should be?
a)

bilateral lower extremity Doppler ultrasound examination

b)

ventilation/perfusion lung scan

c)

CT chest with PE protocol

d)

sputum culture

26. Which of the following statements about antithrombotic treatments is TRUE?

a)

in the absence of antithrombin III, unfractionated heparin has no

significant anticoagulant affect

b)

low molecular weight heparins share the ability to accelerate the activity
of factor 10a

c)

warfarin inhibits the absorption of vitamin K from the intestinal track

d)

Hirudin, a synthetic thrombin inhibitor, is dependent on antithrombin III

for anti-coagulant activity

27. A 70 year old diabetic man with Childs C cirrhosis undergoes operative repair of an
incarcerated umbilical hernia. On post-operative day one, the patient develops upper
GI bleeding and requires four units of packed red cells. On the fifth post-operative
day, the wound is noted to be painful and erythematous. All of the following are
risk factors for developing a surgical site infection in this patient, EXCEPT?
a)

intra-operative hyperglycemia

b)

post-operative transfusion

c)

cirrhosis

d)

age

Principles of Surgery Exam

February 2010

Page 11 of 34
28. Risk factors for clostridium difficile associated diarrhea include all of the
following EXCEPT?
a)

advanced age

b)

immunosuppressive agents

c)

asymptomatic carrier status

d)

naso-gastric intubation

29. A 60 year old woman with a 40 year history of smoking presents with a painless 2
cm nodule just anterior to the sternomastoid muscle and inferior to the angle of the
mandible. The most appropriate means to obtaining a tissue diagnosis is?
a)

fine-needle aspiration for cytology

b)

ultrasound-guided core needle biopsy for histopathology

c)

incisional surgical biopsy

d)

excisional surgical biopsy

30. Bupivacaine (marcaine) injection for local analgesia may be associated with all of
the following adverse affects, EXCEPT?
a)

seizure

b)

hypotension

c)

heart block

d)

methemoglobinemia

31. The intravenous anesthetic induction agent with the LEAST effect on the
cardiovascular system is?
a)

propofol

b)

ketamine

c)

etomidate

d)

thiopental

Principles of Surgery Exam

February 2010

Page 12 of 34
32. During an elective laparoscopic cholecystectomy, a 35 year old woman develops a
sudden onset of hypotension, tachycardia, cyanosis, flushed warm skin and
increasing end-tidal CO2 levels. Which of the following statements about this
condition is NOT true?
a)

the diagnosis is confirmed by an in vitro muscle test

b)

informing family members of this reaction is critical

c)

treatment includes administration of dantrolene sodium

d)

local anesthetics can also trigger the reaction

33. Prior to making the incision for an emergency open appendectomy, administering
0.5% bupivacaine without epinephrine into the area of the wound (including deep
tissues) will?
a)

increase the risk of wound complications

b)

increase the use of non-steroidal anti-inflammatory medication

c)

decrease post-operative pain as measured by pain scales

d)

increase narcotic analgesic consumption

34. Treatment of wounds with negative-pressure wound dressing (VAC dressings) may
result in all of the following, EXCEPT?
a)

increased apoptosis

b)

increased granulation tissue

c)

improved microvascular blood flow to wound edges

d)

removal of excess fluid and debris

35. A physician punctures her finger with a suture needle while securing a drain tube in
a patient with AIDS. The most appropriate therapy for the physician will be?
a)

Zidovudine

b)

Zidovudine and Lamivudine

c)

Zidovudine, Lamivudine and Nelfinavir

d)

Indinavir and Nelfinavir

Principles of Surgery Exam

February 2010

Page 13 of 34
36. Which of the following statements about the use of antibiotics for the prevention of
surgical site infection is NOT true?
a)

antibiotics should be administered within 60 minutes of incision

b)

the therapeutic dose of the antibiotic should be administered intravenously

c)

adequate tissue concentration should be maintained during the operation

by re-dosing as necessary

d)

antibiotics should be continued for 24 hours after operation

37. The detection of microscopic sulfur granules in a specimen of pus is pathoneumonic

for infection with?
a)

actinomycosis

b)

mucormycosis

c)

stenotrophomonas maltophilia

d)

nocardia asteroides

38. A 50 year old man requires amputation of his left arm for necrotizing fasciitis.
Wound cultures grew clostridium septicum. Which of the following should be
recommended after the patient recovers from the amputation?
a)

upper GI endoscopy

b)

colonoscopy

c)

positron emission tomography (PET Scan)

d)

tagged WBC scan

39. A 55 year old alcoholic male is admitted to hospital with cellulitis of the lower left
leg. Despite appropriate antibiotic therapy, the cellulitis progresses and the patient
becomes febrile and hypotenisve. Incision of the skin under local anaesthesia
reveals necrotic subcutaneous fat. The next step should be?
a)

gram-stain to determine further therapy

b)

hyperbaric oxygen therapy

c)

above-knee amputation

d)

wide debridement of all necrotic tissues

Principles of Surgery Exam

February 2010

Page 14 of 34
40. A 30 year old woman undergoes emergency Caesarian section for fetal distress. On
post-operative day four, her wound dehisces and she is taken back to the operating
room for resuturing of her wound. The following day, her abdomen is not distended
but no bowel sounds are heard. Her physician is concerned about her nutritional
state. The preferred route for nutritional intake in this patient is?
a)

regular oral diet

b)

NG tube feeding

c)

Fluoroscopic placement of an NJ feeding tube

d)

TPN via a PICC line

41. During starvation, the liver maintains serum glucose levels near normal by
synthesizing glucose from all the following molecules EXCEPT?
a)

lactate

b)

glycerol

c)

alanine

d)

arginine

Principles of Surgery Exam

February 2010

Page 15 of 34
42. A 70 year old man undergoes emergency aortic grafting because of a ruptured
abdominal aortic aneurysm. In the ICU immediately post-operatively he is on a
ventilator and his IV is normal saline at 150 ccs/hr. His vitals and initial blood work
are:
Blood pressure

140/80

pH

7.2

Heart rate

95

pCO2

59

Urine output

120 mls/hr

pO2

110

Hgb

85

HCO3

15

WBC

14.9

Platelets

79,000

His acidosis should be treated with?

a)

2 amps sodium bicarb over 30 minutes

b)

1,000 ccs normal saline bolus

c)

1 unit packed red blood cells

d)

increase minute ventilation

Principles of Surgery Exam

February 2010

Page 16 of 34
43. An 80 year old woman undergoes laparotomy and ileostomy because of an
obstructing unresectable carcinoma of her colon. Post-operatively she does well.
Because of excessive ileostomy output she is kept on clear fluids by mouth. She
receives IV 2/3-1/3 saline of 20 mol/l HCL/l at 100 cc/h. On post-operative day
four, her electrolytes are:
Na

122

4.8

HCO2

22

Cr

140

Bun

2.5

Her hyponatremia should be treated with?

a) change IV to normal saline 75 ccs/h and replace ileostomy losses with
normal saline
b) infuse 3% NaCl 30 ccs/h
c) make patient NPO and follow lytes carefully
d) give lasix 20 mgs IV stat
44. Which of the following is NOT a risk factor for surgical site infection?
a)

patient colonized with vancomycin-resistent enterococcus (VRE)

b)

cigarette smoking

c)

diabetes mellitus

d)

intra-operative hypothermia

Principles of Surgery Exam

February 2010

Page 17 of 34
45. An 85 year old woman with a bleeding gastric ulcer receives 2 units of packed cells
over two hours. One hour after her transfusion, she becomes severely dyspnic and
is transferred to the ICU. Her physician suspects transfusion-related acute lung
injury (TRALI) is responsible for her dyspnea. Which of the following data,
obtained in the ICU, rules OUT TRALI?
a)

chest x-rays shows bilateral pulmonary edema

b)

core temperature is 36.8 degrees Centigrade

c)

no history of prior blood transfusions

d)

pulmonary artery wedge-pressure (PAWP) is 28 mm/Hg

46. A 65 year diabetic man presents to the Emergency room with septic shock
secondary to infected necrosis of his left foot and lower leg. Blood work
demonstrates coagulopathy:
INR

1.7

(n<1.2)

PTT

50

(n<30)

Platelet Count

30,000

(n>75,000)

D-dimer

770

(n<230mg/ml)

This coagulopathy is best treated with:

a)

four units fresh plasma

b)

8 units cryoprecipitate

c)

infusion of activated factor VIIa

d)

left leg amputation

47. A 72 year old man with chronic renal failure on hemodialysis requires surgery to
remove an infected hip prosthesis. The surgeon is worried about abnormal bleeding
due to the patients uremia. All the following treatments will improve platelet
functioning in uremic patients, EXCEPT:
a)

intensive dialysis pre-operatively

b)

intraoperative platelet transfusion

c)

intraoperative administration of DDAVP

d)

interaoperative administration of cryoprecipitate

Principles of Surgery Exam

February 2010

Page 18 of 34
48. A 58 year old woman undergoes total hysterectomy, bilateral salpingoophorectomy
and omentectomy for ovarian carcinoma. Post-operatively she receives an
intravenous of 2/3-1/3 of 20 mmol of KCL/l at 100 ccs/h. On post operative day
two, routine blood work records:
Hg

98

Na

127

6.3

Cl

115

(previously 125)

Glucose 23.2
Creatinine 75
She has no history of diabetes or renal disease. The next step in her management
should be?
a)

transfuse 2 units packed red blood cells

b)

give 10 units regular insulin subcutaneously

c)

give oral sodium polystyrene solution (potassium exchange agent)

d)

repeat blood work

49. A 65 year old man is scheduled to have a left total knee replacement. He has a
mechanical aortic valve and is permanently anticoagulated with coumadin. The
most appropriate management of his anticoagulation pre-operatively is?
a)

continue coumadin until the day prior to surgery. Administer two units of
fresh frozen plasma at the beginning of the surgery

b)

continue coumadin until the day prior to the surgery. Administer 10 units
of Factor VIIa at the beginning of the surgery

c)

hold coumadin 5 days prior to surgery, give Fragmin subcutaneous daily,

hold Fragmin on the day of the surgery

d)

hold coumadin 5 days prior to surgery, admit the patient to hospital and
treat with IV unfractionated heparin. Hold the heparin two hours prior to
the surgery

Principles of Surgery Exam

February 2010

Page 19 of 34
50. A 64 year old man has shortness of breath and documented hypoxemia 2 days after
right hemicolectomy for cancer. His chest x-ray is unremarkable. His ECG and
serum troponin are normal. The next diagnostic test should be?
a)

thoracic CT scan

b)

ventilation-perfusion scan

c)

D-dimer assay

d)

Doppler ultrasound study of the lower extremity

51. A 45 year old woman has right sided chest pain and a nonproductive cough seven
days after modified radical mastectomy for breast cancer. Her vitals are:
Heart rate

110

Blood pressure

120/70

Respiratory rate

24

Her ECG is normal. A thoracic CT scan shows a saddle embolus to the main
pulmonary artery extending into both left and right main pulmonary arteries.
Blood flow is not completely obstructed to either lung. The most appropriate
treatment would be?
a)

systemic heparin therapy

b)

system thrombolytic therapy

c)

percutaneous mechanical thrombectomy

d)

placement of IVC filter

52. A 70 year old man develops a 2 cm nodule in the right lung two years after right
hemicolectomy for colon cancer. Which of the following is the BEST predictor of
the risk of pulmonary complications after lung resection for this patient?
a)

age >60 years

b)

predicted post-operative FeV1 <40%

c)

pre-operative PaCO2 >45 torr

d)

pre-operative PaO2 <60 torr

Principles of Surgery Exam

February 2010

Page 20 of 34
53. Which of the following statements about acute rejection of a transplanted kidney is
NOT true?
a)

it is T-cell mediated

b)

it is related to organ-host human leukocyte antigen disparity

c)

treatment can save the grafted organ in 90-95% of cases

d)

it does not occur with living related donors

54. Which of the following is an absolute contraindication for liver transplantation?

a)

hepatitis C

b)

synchronous extra hepatic malignancy

c)

alcohol-induced cirrhosis

d)

fulminant hepatic failure

55-57. For each of the three statements below, fill in the most appropriate answer.
a)

enteral nutrition

b)

parenteral nutrition

c)

both

d)

neither

55.

Pre-operative use decreases mortality in severely malnourished patients

56.

Decreases infectious complications in critically ill patients

57.

Routine post-operative use of after major cancer resection decreases mortality

Principles of Surgery Exam

February 2010

Page 21 of 34
58.

59.

A 58 year old man has chronic duodenal ulcer disease because of noncompliance
with medications. Over the past two weeks he has had increasing nausea and
vomiting with weight loss. In the Emergency room he appears dehydrated with a
serum creatinine of 170. All of the following metabolic abnormalities are expected,
EXCEPT?
a)

elevated pH

b)

low serum sodium

c)

low serum chloride

d)

low serum potassium

Initial fluid resuscitation of the above patient should consist of?

a)

Ringers lactate solution

b)

normal saline with 20 mmol K Cl/l

c)

half-normal saline with 20 mmol K Cl/l

d)

3% hypertonic saline

60. Severe closed head injury often results in increased intra-cranial pressure. Which of
the following treatments would NOT help relieve intracranial hypertension?
a)

pulse steroid therapy with decadron

b)

sedation with propofol and muscle paralysis with short-acting agents

c)

hypertonic saline bolus IV

d)

mannitol bolus IV

Principles of Surgery Exam

February 2010

Page 22 of 34
61.

A 24 year old woman comes to the Emergency Room because of left leg pain.
Twelve hours previously she noticed a small puncture wound on the sole of her
foot. Over the last six hours, her foot and lower leg have become erythematous,
swollen and very tender. She also complains of feeling febrile, with chills and
malaise. On examination, her lower leg is edematous and the skin erythematous.
No areas of fluctuance are noted. The leg below the knee is extremely tender.
Blood work demonstrates a WBC of 25,000. A plain x-ray of the leg does not show
any subcutaneous emphysema. The most appropriate treatment of this would be?
a)

oral Keflex and pain meds and return to the Emergency Room in am for
reassessment

b)

admit the patient to hospital. Administer Cefazolin IV and elevate leg

c)

admit to hospital. Treat with broad spectrum antibiotics and explore under
general anaesthestia if she develops signs or symptoms of compartment
syndrome

d)

admit to hospital. Start broad spectrum antibiotics, explore leg under

general anaesthesia in OR

62. The greatest risk of death due to a blood transfusion is from?

*63.

a)

HIV transmission

b)

Hepatitis C

c)

ABO incompatibility

d)

Bacterial contamination

A 17 year old man driving a snowmobile runs into a tree at high speed. There is no
loss of consciousness. He is taken to the local hospital. On clinical examination he
has multiple right rib fractures. Abdominal examination is unremarkable. The
blood pressure was 130/80 on admission to the Emergency Room and 30 minutes
later drops suddenly to 80/40. The most likely cause of this hypotension is?
a)

myocardial contusion

b)

right tension pneumothorax

c)

intraabdominal bleed

d)

thoracic aortic injury

Principles of Surgery Exam

February 2010

Page 23 of 34
*64.

65.

A 60 year old male unbelted driver is involved in a high speed motor crash. When
evaluated in the Trauma Centre, he is found to be suffering from a significant left
epidural hematoma, a false aneurysm in his thoracic aorta, severe lung contusions, a
grade II liver laceration, and an open fracture of the left tibia and fibula. Which
operation should be carried out first?
a)

craniotomy for epidural hematoma

b)

repair of thoracic aortic aneurysm

c)

laparotomy for hepatic injury

d)

ORIF left tib-fib fracture

Which of the following urinary findings is NOT consistent with the diagnosis of
acute renal failure secondary to tubular necrosis?
a)

presence of heme-granular casts

b)

urine sodium concentration >50

c)

urine osmolality <350 mmol/l

d)

creatinine clearance >50 ml/min/m2

66. A patient with acute adrenal insufficiency would be expected to show each of the
following, EXCEPT?

67.

a)

hypotension

b)

hyperglycemia

c)

hyperkalemia

d)

hyponatremia

A 75 year old man suffers a pulmonary embolus after a bowel resection for cancer.
He is treated with an IV infusion of unfractionated heparin. Two weeks later he is
still on his heparin infusion and his platelets drop from 350,000 to 75,000 in two
days. Which of the following is a risk factor for the development of heparin
induced thrombocytopenia?
a)

heparin given for over ten days

b)

patient over 65 year of age

c)

use of unfractionated heparin

d)

none of the above

Principles of Surgery Exam
February 2010

Page 24 of 34
*68.

A 26 year old man was involved in a motor vehicle crash and suffers a closed
fracture of his left femur. This is treated surgically with an IM nail. The following
day he is found to be confused. His vitals are:
Temperature

39.2

Heart rate

130

Blood pressure

130/80

Respiratory rate

32

Which of the following investigations is most likely to be diagnostic?

69.

70.

a)

blood culture

b)

MR head

c)

CT thorax with PE protocol

d)

Doppler ultrasound of both legs

A 64 year old woman presents with sudden onset of a painful swollen left leg two
days after stepping on a nail in a farm yard. She is hypotenisve (90/50) and febrile
with a temperature of 395. Crepitus is noted in the lower left leg. This infection
could be caused by all of the following organisms, EXCEPT
a)

bacteroides fragilis

b)

streptococcus A

c)

clostridium perfringens

d)

staphylococcus aureus

Which of the following treatments has been shown to reduce mortality for patients
with severe sepsis?
a)

activated protein C

b)

high-dose corticosteroids

c)

anti-endotoxin antibody

d)

Erythropoietin

Principles of Surgery Exam

February 2010

Page 25 of 34
71.

72.

73.

A 62 year old man has hypokalemia refractory to potassium supplementation after

laryngectomy for cancer. The most likely etiology is?
a)

hypomagnesemia

b)

hypochloremia

c)

hypoglycemia

d)

hyperphosphatemia

A 23 year old man has a subdural hematoma after a motor vehicle crash. This
requires craniotomy shortly after his admission to hospital. He remains intubated
and comatose in the ICU. On the fourth post-operative day, he develops an
increased oxygen requirement and a CT thorax shows a pulmonary embolus. This
should be treated with?
a)

infusion of unfractionated heparin

b)

infusion of a direct thrombin inhibitor (argartroban)

c)

sequential compression device on both legs

d)

place an IVC filter

A 60 year old man is scheduled for a low anterior resection of rectal cancer. He has
hypertension controlled with an angiotension-coverting enzyme inhibitor. He does
not smoke and is able to walk up two flights of stairs without difficulty. Preoperative evaluation and management should include?
a)

dobutamine stress echocardiography

b)

myocardial perfusion scan

c)

perioperative beta blockers

d)

none of the above

Principles of Surgery Exam

February 2010

Page 26 of 34
74.

A 60 year old man is admitted to the ICU following an open aorta-iliac

reconstruction. On admission, his vitals are:
heart rate

130

blood pressure

80/40

CVP

2 mm/Hg

urine output

10 ccs in the past hour

His abdomen is soft and nondistended. His last haematocrit in the OR was 35%. His
low blood pressure should be treated with?

75.

a)

Levophed infusion

b)

blood transfusion

c)

Hydroxyethyl starch solution

d)

Isotonic crystalloid (N/S, R/L)

Which of the following statements about alcohol withdrawal syndrome in an

acutely ill patient with multiple injuries is TRUE?
a)

dilantin (phenytoin) should be administered prior to benzodiazepines to

reduce the risk of seizures

b)

IV alcohol is superior to benzodiazepines for prevention of the syndrome

c)

proprofol may be used as an alternative to benzodiazepines for the

treatment of established delirium tremens

d)

prophylactic regimes that include clonidine in addition to benzodiazepine

reduce the incidences of cardiac complications

Principles of Surgery Exam

February 2010

Page 27 of 34
76.

77.

*78.

A 55 year old woman undergoes mitral valve replacement with a St. Jude
mechanical prosthesis. Coumadin therapy is started post-operatively. On post-op
day 5, she develops signs and symptoms of DVT and is started on a unfractionated
heparin infusion. On post-operative day nine she has an acute onset of shortness of
breath and hypoxemia. CT thorax demonstrates multi pulmonary emboli. Her
platelet count is found to have fallen from 300,000 to 50,000. Definitive
management of this problem should be?
a)

discontinue unfractionated heparin and start low molecular heparin

b)

discontinue unfractionated heparin and begin argatroban infusion

c)

continue unfractionated heparin and place an IVC filter

d)

continue unfractionated heparin and give a platelet transfusion

A 60 year old man receiving total parenteral nutrition via a right arm PICC line,
suddenly develops fever and malaise. The PICC line is removed and the tip is sent
for culture. Peripheral blood cultures are obtained and the patient is started on
cefazolin 1 gram IV tid. The tip grows >15 colony forming units of staph aureus at
24 hours and peripheral blood cultures are also positive for methicillin sensitive
staph aureus at 48 hours. The patient is currently afebrile. The most appropriate
treatment now would be?
a)

stop antibiotic, reculture if the patient again develops a fever

b)

continue cefazolin for seven days

c)

change antibiotic to vancomycin for seven days

d)

continue cefazolin for 14 days.

Following crush injury and rhabdomyolysis the most important component of

treatment to avoid renal failure is?
a)

mannitol

b)

furosemide

c)

bicarbonate

d)

volume replacement

Principles of Surgery Exam

February 2010

Page 28 of 34
*79.

80.

81.

A 20 year old woman was an unrestrained passenger in a high speed motor vehicle
crash. She was found on the road 20 feet ahead of the car. She has no signs of life
when the paramedics arrive but develops a pulseless rhythm during CPR on route to
the Emergency Room. On arrival in the Emergency Room, she again loses her
cardiac rhythm. The best course best of action now should be?
a)

immediate Emergency Department thoracotomy through the left chest

b)

immediate Emergency room thoracotomy through the right chest

c)

continue external CPR, resuscitate with IV fluids

d)

declaration of death

A 75 year old man is brought to the Emergency room because of severe abdominal
pain. Plain films of the abdomen demonstrate free air under both hemidiaphrams.
At laparotomy a perforated duodenal ulcer is repaired with an omental patch. At the
end of the operation, the anesthetist notes that despite fluid resuscitation, the
patients blood pressure is 80/40, core temperature is 33.5, and he is unable to be
extubated because of CO2 retention. This state could be due to any of the following
conditions, EXCEPT?
a)

severe hypothyroidism

b)

acute adrenal insufficiency

c)

diabetic ketoacidosis

d)

severe malnutrition

A 45 year old woman with type I diabetes mellitus is admitted to hospital and
undergoes emergency cholecystectomy for gangrenous cholecystitis. Postoperatively, her serum glucose is difficult to control with an insulin infusion.
Which of the following hormones is NOT a cause of her elevated blood sugar?
a)

epinephrine

b)

cortisol

c)

glucogen

d)

triodothyronine (T3)

Principles of Surgery Exam

February 2010

Page 29 of 34
82.

83.

84.

A 32 year old man presents to the Emergency Room in septic shock. He was well
until two days ago when he developed a flu like illness. He has rapidly deteriorated
since then. His past medical history is unremarkable except for a splenectomy at
the age of two years. Which of the following organisms is likely to be the cause of
his sepsis?
a)

staphylococcus aureus

a)

escherichia coli

c)

streptococcus pneumoniae

d)

pseudomouas aeruginosa

A 65 year old man is admitted to hospital to undergo right total hip replacement
because of osteoarthritis. In the pre-op hold area an intravenous is started and he is
given 1 gram of cefazolin IV. Two minutes after starting the infusion he developes
hypotension, bronchospasm, cyanosis, and an urticarial skin rash. All of the
following drugs will be useful in treating this condition EXCEPT?
a)

epinephrine

b)

dopamine

c)

solucortef

d)

benadryl

A 60 year old woman is found to have ovarian cancer and requires total
hysterectomy and bilateral salpingo-oophorectomy. She also has severe aortic
stenosis with an aortic valve area of 1 cm2 and a pressure gradient of 60 mm/Hg
across the valve. Which of the following statements about the management of this
patient is TRUE?
a)

she would benefit from pre-operative balloon dilatation of the valve

b)

she would benefit from after load reduction to maintain cardiac output

c)

she should be fluid restricted peri-operatively to avoid problems with

pulmonary edema

d)

epidural analgesia may be risky because of induced hypotension

Principles of Surgery Exam

February 2010

Page 30 of 34

85.

86.

87.

A 60 year old woman develops oliguria one day after total abdominal hysterectomy
and bilateral salpingo-oophorectomy for uterine cancer. She is known to have
systemic lupus eythrematosis with renal involvement. The diagnostic test that most
accurately distinguishes pre-renal versus renal etiology of the oliguria is?
a)

fractional excretion of sodium

b)

microscopic sediment analysis

c)

two hour creatinine clearance test

d)

urine specific gravity

An 86 year old man with colon cancer with widespread hepatic metastases is
admitted to hospital because of dehydration. He has been receiving feedings
through a previously placed jejunal tube. He has an advanced directive stating that
feeding and intravenous fluids should be discontinued if his condition worsens. The
day after admission, he becomes comatose. Which of the following statements is
TRUE?
a)

a metabolic work up is necessary and will likely discover a cause for the
patients coma

b)

intravenous fluids and J-tube feeds should be withheld

c)

central venous access should be carried out if needed for comfort

measures

d)

the patients son may override the patients wishes and have the J-tube
feedings increased

Which of the following statements is an example of communication promoting

improved team functioning in the Operating Room?
a)

hello, my name is Dr. Doe, and I am in charge

b)

weve got a lot to do, so lets be sure were all on the same page

c)

that is totally wrong!! No wonder youre still a resident

d)

quiet! Ive got a problem here

Principles of Surgery Exam

February 2010

Page 31 of 34

88.

89.

90.

Which of the following statements about the use of opioid analgesics in surgical
patients is TRUE?
a)

meperidine is preferred to morphine sulfate in critical care patients with

renal failure

b)

morphine is advantageous for patients with congestive heart failure due to

its effects on venous capacitance

c)

morphine has a direct effect on myocardial contractility

d)

Fentanyl should not be used in patients with reactive airway disease

Many cancers are now known to be caused by genetic defects. Which of the
following statements concerning genetic testing for hereditary nonpolyposis
colorectal cancer is TRUE?
a)

seeks to identify the responsible oncogene

b)

can predict the risk of desmoid tumour development

c)

is useful for at-risk family members when no mutation is detected in the

proband

d)

can be preformed on peripheral white blood cells

Solid organ transplantation has been made possible by the use of

immunosuppressant drugs. Originally, all kidney transplant recipients had been
treated with azothyoprine along with other drugs. Which of the following drugs has
now replaced azothyoprine because of lower toxicity?
a)

cyclosporine

b)

tacrolimus

c)

mycophenolate mofetil

d)

daclizumab

Principles of Surgery Exam

February 2010

Page 32 of 34

91.

92.

93.

94.

An 80 year old woman with advanced Alzheimers disease has been ill for four days
and is transferred from the nursing home with fever, hypotension, and abdominal
distention. CT scan reveals a superior mesenteric artery thrombosis and bowel
ischemia with pneumatosis of the small bowel wall. She is acidotic and in acute
renal failure. Which of the following statements about this patients care is TRUE?
a)

she is dying and palliative care is indicated

b)

the decision for future care should be left solely with the family

c)

operation is the only chance for cure of the bowel ischemia and should be
performed

d)

aggressive ICU resuscitation is warranted and operation should be

performed if the patient stabilizes

The use of positive end-expiratory pressure in a ventilated ICU patient:

a)

primarily affects PaO2

b)

primarily affects PaCO2

c)

both

d)

neither

Adjustments of tidal volumes in a ventilated ICU patient:

a)

primarily affects PaO2

b)

primarily affects PaCO2

c)

both

d)

neither

A 57 year old hypertensive man develops torsades de pointes arrhythmia four days
after 4-vessel coronary artery bypass grafting for severe coronary artery disease
associated with a recent anterior myocardial infarction. Which of the following
electrolytes disturbances is likely contributing to the etiology of his arrhythmia?
a)

hyperkalemia

b)

hypermagnesium

c)

hypomagnesium

Principles of Surgery Exam

February 2010

Page 33 of 34
d)
95.

96.

97.

hypocalcemia

All of the following are involved in the control of aldosterone secretion, EXCEPT?
a)

angiotensin

b)

cortisol

c)

serum potassium

d)

serum sodium

An 86 year old hypertensive man has left calf intermittent claudication after waking
two blocks. His physician ordered an arteriogram. The patients creatinine is 240.
Which of the following statements concerning contrast-induced nephropathy is
TRUE?
a)

pre-procedure hydration with IV normal saline is contra-indicated because

of the risk of congestive heart failure

b)

pre-procedure hydration with IV sodium bicarbonate is more effective at

preventing contrast-induced nephropathy than IV hydration with normal
saline

c)

an increase in serum creatinine of 25% is expected and generally not

clinically significant after contrast arteriography

d)

the risk of renal failure from intra-arterial contrast is too high in this
patient and alternative imaging should be considered

Which of the following practices help promote a culture of safety in the Operating
Room environment?
a)

maintaining strict accountability for mistakes

b)

emphasizing timely completion of procedures

c)

reporting problems face-to-face

d)

stressing role flexibility in crisis situations

Principles of Surgery Exam

February 2010

Page 34 of 34
98.

*99.

100.

Post-operative patients often develop hypoxemia and pulmonary embolus is

suspected. Which of the following statements concerning the diagnosis of
pulmonary embolus is TRUE?
a)

chest CT has excellent sensitivity for isolated peripheral pulmonary

emboli

b)

the negative predictive value of chest CT for ruling out clinically

significant pulmonary exceeds 99%

c)

elevation in D-dimer blood levels require empiric anticoagulation

d)

the best initial screening test is ventilation-perfusion radionuclide scanning

A 25 year old male falls 15 feet from a ladder and is brought to the Emergency
room. He has a GSC of 3 with reactive pupils. There are no other injuries. CT head
shows evidence of diffuse axonal injury. He is taken to the Operating Room for
placement of a ventriculostomy. In the ICU post-operatively he has a mean arterial
blood pressure of 65 mm/Hg and and ICP of 32 mm/Hg. He is ventilated and his
pupils are still reactive. Appropriate management of this situation includes all of
the following, EXCEPT?
a)

chemical paralysis

b)

hyperventilation to PCO2 of 25 tor

c)

processors to maintain mean arterial pressure

d)

administration of mannitol

An 87 year old male pedestrian is struck by a car while crossing a street. He is

brought to the Emergency Room and found to have a heart rate of 80, blood
pressure 80/40, O2 saturation of 92. There was no history of loss of consciousness.
Chest x-ray is normal but the FAST ultrasound is positive. The surgeon tells the
patient that he requires immediate laparotomy but the patient states that he does not
want surgery and wishes only to be made comfortable. The surgeon should then?
a)

take the patient to the Operating Room, declaring him to be incompetent

to make this decision

b)

attempt to contact family members to discuss the situation

c)

call the chaplain to discuss the situation with the patient

d)

transfer the patient to a ward bed with an appropriate analgesic orders and
a DNR on the chart

Principles of Surgery Exam

February 2010