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MIDYEAR EXAM 2011 1-The most effective method to avoid gas gangrene infection in a contaminated wound after a road

car accident is: SABISTON a) Anti-gas gangrene serum injection. b) Penicillin G injection. c) Wound irrigation and debridement. d) Rapid suturing of the wound. e) Daily dressing with normal saline. 2. The ideal fluid therapy in a patient with pyloric stenosis and repeated vomiting is: a) Isotonic crystalloid containing sodium chloride. b) Hypertonic crystalloid containing dextrose-saline. c) Isotonic solution containing dextrose. d) Large molecular weight colloid containing dextran. e) Plasma protein. 3. The following is correct content of common crystalloid solution: a) NaCl 0.9% contains 154 mmol of sodium/L. b) NaCl 0.9% contains 72 mmol of chloride/L. c) Glucose 5% contains 20 mmol of potassium/L. d) Hartmanns contains 40 mmol potassium /L. e) Hartmanns contains 150 Kcal/L. 4- Definite indication for emergency laparotomy is: a) Stab wound to the back with evidence of injury to the renal parenchyma b) Stab wound to peri-umblical region with protrusion of the omentum c) Stab wound to the periumblical region with negative FAST. d) Haemodynamically stable patient with liver laceration and free intra-abdominal fluid on CT scan. e) Rupture diaphragm. 5. Diagnostic Peritoneal Leavage (DPL): ??MONT REID a) Is more sensitive than CT scan for intraperitonial bleeding. b) Is positive if RBCs more 10,000/mm2. c) Is positive if WBCs more 1000/mm2 d) Should be performed in haemodynimicaly unstable patient with peritonism. e) Its accuracy depends on the person doing it.

6. In catabolic surgical patients, which of the following changes in body composition DO NOT occur? a) Lean body mass increase. b) Total body water increase. c) Adipose tissue decreases. d) Body weight decrease. e) Lean body decreases. 7. Which of the following steatments regarding cytolines is Incorrect? a) Cytokines act directly on target cells and may potentiate the action of one another. b) Interleuckin 1 (IL-1) is a major proinflammatory mediator with multiple effects including regulation of skeletal muscle proteolysis in patient with sepsis. c) Platlet activating factor (PAF) is a major cytokine that results in platlet aggregation, bronchoconstriction, and increase vasculat permiability. d) Tumor necrotic factor alpha (TNF-a) appears to be a principal mediator in the evalution of sepsis and the multiple organ dysfunction syndrome. e) Cytokines are endogeous signals that stimulate the central nervous system to intiate fever. 8. All of the following are true about neurogenic shock EXCEPT: (SCHWARTZ'S 100 TEXT) a) There is decrease in systematic venous resistance and an increase in venous capacity. b) Tachycardia or bradycardia may be observed along with hypotension. c) The use of alpha agonist Phenylephrine is the mainstay of treatment. d) Severe head injury, spinal cord injury and high spinal anesthesia may all cause neurogenic shock. e) Neurogenic shock occurs when severe head injury, spinal cord injury, lead to sympathetic denervation and loss of vasomotor tone. 9. An 18 years old man shot once in the left chest has blood pressure of 80/50mm.Hg, a heart rate of 130 /min and distended neck veins, immediate treatment will include: a) Administration of one liter of albumin solution. b) Xiphoid pericardiotomy. c) Needle decompression of the left chest in the second intercostal space. d) Emergency thoracotomy to cross clamp the aorta e) Chest X ray.

10. which of the following statement about head injury and concomitant hyponatremia is TRUE? a) There are no primary alteration in cardiovascular signs. b) Signs of increased intracranial pressure may be masked by the hyponatremia. c) Oliguric renal failure is an unlikely complication. d) Rapid correction of the hyponatremia may prevent central pontine injury. e) This patient is best treated by restriction of water intake. ?? 11. Which of the following statement about extracellular fluid is true? (RUSH 12) a) The total extracellular fluid volume represents 40% of the body weight. b) The plasma volume constutes one fourth of the total extracellular fluid volume. c) Potassium is the principle cation in extracellular fluid. d) The protein content plasma produces a lower concentration of cation than in the interstitial fluid. e) The interstitial fluid equilibrates slowly with the other body compartments.

12. Which of the following statements about respiratory acidosis is true? a) Compensation occurs by a shift of chloride out of the red blood cells. b) Renal compensation occurs rapidly. c) Retention of bicarbonate and increase ammonia formation is normal compensatory mechanisms. d) Narcotic administration is an unusual cause of respiratory acidosis. e) The ratio of bicarbonate to carbonic acid is less than 5:1. 13. Which of the following is true of loss of gastrointestinal secretion? a) Gastric losses are best replaced with a balanced salt solution. b) Potassium supplementation is unnecessary in replacement of gastric secretions. c) Bicarbonate wasting is an unusual complication of a high volume pancreatic fistula. d) Balance salt solution is a reasonable replacement fluid for a small bowel fistula e) Patient with persistent vomiting usually requires hypochlorec ( 45% saline ) replacement fluids 14. Which of the following is NOT associated with increased likelihood of infection after major elective surgery? a) Age over 70 years. b) Chronic malnutrition. c) Controlled diabetes mellitus.

d) Long term steroid use. e) Infection at a remote body site. 15. In patients receiving massive blood transfusion for acute blood loss, which of the following is correct? a) Packed red blood cells & crystalloid solution be infused to restore oxygen carrying capacity & intravascular volume b) 2unit of FFP should be given with every 5 units of packed RBC in most case. c) 6 packs of platelets should be administered with every10 units of PRBC in most cases. d) One of two ampoules of sodium bicarbonate should be administered with 5 units of PRBCs to avoid acidosis. e) One ampoule of calcium chloride should be administered with every units of PRBCs to avoid hypocalcemia. 16. Which of the following statements about presence of gallstone in diabetic pt. is correct? a) Gallstones occur with the same freqency in DM pt and the healthy population. b) The presence of gallstones, regardless of the presence of symptoms, is an indication for cholecystectomy in a DM pt. c) Diabetic pt with gallstones & chronic billiary pain should be managed nonoperatively with chemical dissolution and/or lithotripsy because of sever complicating medical condition with operative risk. d) Presence of DM and gallstones place pt at risk of pancreatic cancer. e) Diabetic pt. with symptomatic gallstones should have elective cholecystectomy, to avoid the complications of acute cholecystitis and gallbladder necrosis. 17. Which of the following statements is true concerning gram negative bacterial sepsis? a) Mortality due to this condition has almost been eliminated due to therapeutic intervention with antibiotic, aggressive hemodynamic monitoring & fluid resuscitation. b) Recent series have noted a decrease in the incidence of this condition. c) Predisposing factors include old age, malnutrition, and immunosuppression. d) Pseudomonas bacteremia is the most common cause of gram negative sepsis e) Single organism sepsis is generally considered a more serious problem than sepsis due to a polymicrobial.

18. A 70 year old lady was given 7 mg of midazolam prior to an upper GI Endoscopy. During the procedure she was noted to be heavily sedated with a subsequent drop in her oxygen saturation from 96% to 82%. This lady should be managed now by: a) Immediate intubation & mechanical ventilation. b) Administration of 10 L oxygen through a ventura mask. c) Administration of Naloxone. d) Administration of Flumazenil. e) Discontinuation of the procedure, insertion of NGT & placed in recovery position. 19. A 55 year old patient with a long history of a gastro-esophageal reflux disease had an endoscopic examination and biopsy of the lower esophagus. The histopathology report as suggestive of Barretts esophagus is: a) The presence of granuloma with transmural involvement. b) Polymorphic infiltration with evidence of extensive cell necrosis. c) Evidence of metaplasia from squamous to columner epithelium . d) Caseous ?? necrosis with esenophilic inflammatory reaction??? e) Multineucleated giant cells with large lymphocytic infiltration. 20. A 15 year old boy presented with 2 hours history of sever right lower abdominal pain, tenderness, guarding. His T=38 c, pulse 100 beats with BP 120/70. his leukocytic count is 18 K with neutrophilic shift the best line of management is : a) Obtain an abdominal US. b) Obtain erect chest X ray. c) Obtain erect and supine abdominal X-ray. d) Obtain abdominal CT with water soluble rectal contrast. e) Perform appendectomy with no radiological assessment.??

21. The commonest cause of intussusceptions in infant is: a) Acute Meckles diverticulitis. b) Carcinoid tumor. c) Payers patches lymphadenitis d) Lymphoma. e) Mesenteric lymphadenitis.

22. At abdominal exploration a patient is found to have a non obstructing carcinoma of the transverse colon and apparent metastases. Which of the following is the best treatment? a) Taking a biopsy of the liver nodules, and then closing the abdomen. b) Closing the abdomen. c) Resecting the colon lesion only. d) Resecting the colon and taking a biopsy of the liver lesion. e) Performing a colostomy. 23. A clear contraindication for hemarrhoidectomy is: a) Previous hemarrhoidectomy. b) Anorectal Crohns.?? c) HIV pt d) Anal warts. e) Thrombosed hemorrhoid. 24. The most common complication after a big inguinoscrotal hernia repair in a 32 year old man is: a) Reactionary hemorrhage. b) Wound infection. c) DVT. d) Scrotal hematoma. e) Impotence. 25. The floor of a tuberculosis ulcer will be seen to contain: a) Apple jelly granulation. b) A wash leather slough. c) A strawberry nevus. d) Fat. e) A pyogenic granuloma. 26. Failure of penile erection following an abdominoperineal resection (APR) is due to injury of: (2009) a) Pudendal nerve. b) Sympathetic hypogastric nerve. c) Parasympathetic nervi eregentis. d) Parasympathetic hypogasteric nerve. e) Obturator nerve.

27. A 13 year old boy presented with acute scrotal pain following football match. Examination revealed a swollen tender right side with some discoloration of the scrotum. The left testicle appears ?normal. The next plan of action is: (2009) a) Schedule the patient for immediate exploration of right ?testes with consent for orchidectomy. b) Admit the pt & start IV gentamycin. c) Admit and schedule the pt for right inguinal hernia --d) Admit and consent for laparoscopic orchidectomy. e) Obtain an US guided testicular biopsy. 28 29 28. A 65 year old lady developed acute severe hematemesis with melena. She was scoped and was found to have a large duodenal ulcer on the posterior wall of D1 with a visible bleeding vessel. Attempts to stop bleeding endoscopically failed. The vessel involved is: a) Right gastric artery. b) Rt gasteroepiploic artery. c) Gasterodoudenal artery. d) Left gastric artery. e) Rt hepatic artery. 29. In the same pt, the bleeding should be trated now by: a) Over sewing the vessel, vagotomy, and pyloroplsty. b) Vasopressin infusion with repeated blood transfusion. c) Referral to specialized center for selective angiographic embolization. d) Ligation of the celiac axis. e) Excision of the ulcer & omental patch 30. Which of the following is not the early clinical feature of compartment syndrome? a) Absent dorsalis pedis pulse. b) Pain disproportionate to the degree of injury. c) Unrelenting pain after a pain free interval. d) Pain on dorsifexion. e) Swollen & tense extensor compartment.

31-33 (2009) 31. A 35-year-old patient underwent a segmental jejunal resection as result of a perforation due to intraperitoneal TB. On the 3rd post operative day, the patient develops a brown -greenish discharge from the wound. This continues with a daily volume of 400-600 ml. The patient remains stable with no signs of peritonitis. The likely complication described is: a) Wound dehiscence b) Enterocutanous fistula c) Wound abscess d) Stitch sinus e) Wound seroma 32. The likely metabolic changes associated with this condition is : a) Hypokalemic metabolic alkalosis b) Hpokalemic metabolic acidosis c) Hypernatremic meta bolic acidosis d) Hypocalcemic metabolic alkalosis e) Normal findings 33. The treatment of choice for this complication is: a) Keep the patient NPO and maintain him on Ringer's lactate b) Keep the patient NPO and start TPN c) Open the whole wound and perform a bed side debridement d) Insert a gauze at the site of discharge and continue IV antibiotics e) Immediate exploratory laparotomy 34. A pt was brought to the emergency room with a history of Burn. The features most suggestive of inhalation injury is: a) Deep burn to the hands & arms. b) Singing of the eyebrows and nasal vibrissae. c) History of a fire burn in a farm. d) Burn in chronic smoker. e) Bluish discoloration of the finger nail. 35. at surgery for Rt. Inguinal hernia repair in 23 year-old man the hernia sac was adherent to the cecum and found to form part of the wall of the sac. Such hernia is referred to as: a) Incarcerated. b) Irreducible.

c) Sliding. d) Richters. e) Interstitial. 36. The term Fourniers gangrene indicates: a) A gangrene of the great toe. b) A gangrene of the hand. c) A gangrene of the back and the gluteal region. d) A gangrene of the scrotum and perineum. e) A stump gangrene following below knee amputation. 37. with regard to surgical treatment of Crohns disease of the small intestine: a) Extensive resection is the rule. b) Limited resection of the diseased bowel is the aim. c) Surgery is indicated in early stages of the disease. d) Surgery is the only treatment modality. e) Surgery is usually curative. 38. Which of the following is an essential condition for proper matching for renal transplant? a) HLA compatibility. b) ABO compatibility. c) DNA compatibility. d) Same sex. e) Relatives. 39. Which of the following is associated with high risk for surgery? (2009) a) AF since one month. b) Mild renal insufficiency. c) DM. d) Subendocardial infarction since one month. e) Uncontrolled hypothyroidism 40. A patient with breast cancer treated by radiotherapy after mastectomy. Which of the following symptoms suggest recurrence rather than radiation effect? a) Skin atrophy b) Skin erythema c) Breast pain d) Dermatitis

e) Skin contraction 41. You are liable to court order of patient care negligence if: a) You performed a procedure which is not done by the standard care b) You performed a procedure not done by staff known c) Patient develops a complication related to treatment d) Patient develops a complication to adhesions e) Poor medical records 42. The earliest manifestation of hypomagnesaemia is: a) tremor b) Hypotension c) Decreased tendon reflexes d) Renal failure e) convulsion Questions 43-44 A 63 year- old man presented with right lower quadrant abdominal pain. He is hemodynamically normal. WBC 16000/mm. abdominal exam confirms localized right lower quadrant abdominal tenderness and no peritonitis. CT abdomen & pelvis showed a complex phlegmon in the Rt lower quadrant, the appendix is not visualized. (SESAP 13-82) 43. The most likely diagnosis is: a) Cecal diverticulitis b) Meckel's diverticulum c) Perforated appendicitis d) Cecal carcinoma e) Appendicial carcinoma 44. The preferred management of this patient would include: a) Emergency laparotomy b) Emergency diagnostic laparoscopy c) Intravenous antibiotics, bowel rest d) Diagnostic colonoscopy e) Upper gastrointestinal series with small bowel follow-through

45. Which of the following is the most effective treatment for chronic anal fissure? (SESAP 13-52) a) Glycoglycerine ointment b) Fissurectomy c) Lateral anal sphincterotomy d) Botulinum toxin injection e) Ointment 46. A 47 year-old woman has acid reflux that has not respond to PPI. (BMI) is 43 and she is hypertensive and diabetic. Upper endoscopy reveals grade I esophagitis. Esophageal manometry is normal. The procedure MOST likely to help her would be: (SESAP 13-56) a) b) c) d) e) Total fundoplication. Partial fundoplication. Gastric bypass. Endoscopic anti reflux procedure. Vertical band gastroplasty.

47. a 37 year-old obese man has a 1-day dihrea, fever and Lt. lower quadrant pain. His WBC is 11.000/mm3. Abdominal CT scan shows thickened sigmoid colon with stranding of surrounding fat, but no intraperitoneal air or fluid collection. He is NPO and is receiving IV antibiotics. After 4 days in the hospital he is clinically improved without fever. Which of the following is recommended for him? (SESAP 13-56) a) b) c) d) e) Elective sigmoidectomy before discharge. Elective sigmoidectomy in 6 weeks. Colonoscopy in 6 weeks. Repeat CT scan in 6 weeks. Dietary counseling.

48. a 22 year-old patient has multiple injuries after RTA. 10 days after injury he develops an acute abdomen with pneumoperetonum. At laparatomy a 2-cm gastric perforation along the greater curveture of the body is discovered. The best management would be: (SESAP 13-59) a) Closure with graham patch. b) Excision of the perforations and primary closure. c) Clouser of the ulcer, truncal vagotomy and antrectomy.

d) Closure of the ulcer, and highly selective vagotomy. e) Subtotal gastrectomy. 49. A 23 year-old woman underwent gastric bypass and was discharged on postoperative day 2, she presents 6 months later with persistent emesis and bilateral symmetric thigh numbness and difficulty walking. Work up has revealed no anatomic cause for her condition. The most likely cause of her neurologic symptoms is a deficiency of: (SESAP 13-60) a) Iron. b) Folate. c) Vit. B1. d) Vit. B6 e) Vit. B12. 50. Which of the following is NOT a risk factor for Clastridium difficle-associated diarrhea? (SESAP 13-61) a) Advanced age. b) Pervious Clastridium difficle colitis. c) Immunosuppresive agents. d) Asymptomatic carrier status. e) Nasogastric intubation. 51. A hemodynamically normal 70 year-old man presents with a 3-days Hx of melena. Upper endoscopy and rigid proctoscopy to 20cm dont identify the source of bleeding. Proctoscopy shows melena. The next diagnostic study should be: (SESAP 13-63) a) Colonoscopy. b) Radionuclide imaging. c) Catheter angiography d) CT angiography. e) Capsule endoscopy. 52. A non immune surgical resident is struck by a contaminated needle from an HBs-Ag-Positive source. Which of the following is the correct initial treatment? (RUSH 211) a) Interferon. b) Vaccination against HBV. c) Hepatitis B immunoglobulin. d) Vaccination plus HB immunoglobulin.

e) Conservation. 53. A 50 year-old man recovering from major operation, who has been on TPN for 2 weeks, developed multiple bruises. There was no evidence of GI bleeding, and the patient was stable. The most likely cause is: (SESAP 13a) Disseminated intravascular coagulopathy (DIC) b) Sepsis. c) Platelet deficiency. d) Vit. K deficiency. e) Calcium deficiency. 54. US report of a 15-mm polypoid lesion in the gall bladder of an asymptomatic 60year-old patient. Which of the following test describes the recommended treatment? (RUSH 479) a) Observation with repeat US studies in 6 months. b) Cholecystectomy if the patient is female. c) Cholecystectomy. d) Cholecystectomy only if symptoms developed. e) Cholecystectomy only if the patient also has gallstones. 55. Which of the following infectious complication of an implanted Hickman central venous catheter requires catheter removal? (2009). a) Exit site infection. b) Subcutaneous tunnel infection. c) Bacterimia without local sign of catheter infection. d) Septic thrombophilebitis. e) Temp. 38.5 56. A 67-year-old man presented with alternating bowel habits, bleeding PR. Colonoscopy showed a stenotic lesion in the descending colon. The most acceptable line of management is: (2008) a) Repeated enemas to clear his bowel. b) Regular pneumatic dilatation of the colon. c) Emergency laparotomy and Lt hemicolectomy. d) Laser fulguration of stricture. e) Elective Lt hemicolectomy with primary anastemosis.

57. Which of the following pulmonary changes would not be anticipated during laparoscopic surgery? (Please check RUSH 236) a) Decreased air way pressure. b) Decreased pulmonary capillary wedge pressure. c) Decreased functional residual capacity. d) Increased thoracic compliance. e) Increased respiratory rate. 58. Which of the following statement about squamous cell carcinoma of the anal canal is TRUE? (Please check RUSH 434) a) The sensitivity of CT scan and clinical examination for involved lymph nodes is only 50% b) The tumor size initial diagnosis is the most reliable predictor of survival after medical or surgical treatment. c) Inguinal lymph nodes dissection is indicated for patient with clinical lymphadenopathy or positive sentinel lymph node biopsy at initial presentation. d) Combined chemo radiotherapy is associated similar local control!! And improved survival compared with radiation alone. e) Liver and bone are the most common sites of metastases. 59. Which of the following is the primary determinant of the feasibility of avoiding permanent colostomy in patient with colon cancer? (SESAP 13-72) a) Distance of the tumor from proximal anal canal. b) Presence of enlarged lymph nodes on CT scan. c) Distance of the tumor from dentate line. d) Distance of tumor from anal verge. e) Extention of tumor into posterior vaginal wall or bladder . 60. Controlled clinical trials comparing laparoscopic and open colectomy demonstrate that: (SESAP 13-76) a) Time to recovery is not significant. b) Intestinal !!! metastasis are more common with laparoscopic resection. c) Complication occurs with equal frequency. d) Significant fewer LN are retrieved with laparoscopic resection. e) Overall survival is more favorable with open resection.

61. A 24 year-old woman with autoimmune hemolytic anemia that has not responded to medical therapy is scheduled for laparoscopic spleenectomy. The most likely location for an accessory spleen would be the: (SESAP 13- 154) a) Splenic hilum. b) Small bowel mesentery. c) Splenocolic ligament. d) Tail of the pancreas. e) Greater omentum. 62. The preferred repair of incarcerated femoral hernia which was reduced during groin exploration and the bowel is viable? (SESAP 13- 157) a) Bassini. b) Coopers ligament. c) Lichtenstein Repair d) Mesh plug in femoral canal. e) Marry repair. 63. Trans jugular intrahepatic portosystemic shunt (TIPS) is indicated for: (SESAP 13- 159) a) Refractory variceal bleeding. b) Caroli's disease. c) Primary prophylaxis of variceal hemorrhage. d) Prehepatic portal hypertension. e) Correction of hypersplenism and thrombocytopenia. 64. Randomized trials comparing laparoscopic versus open inguinal hernia repair suggest all of the following EXCEPT: (SESAP 13-169) a) Increased incidence of intra operative complication. b) Similar incidence of the life threatening complication. c) Similar rate of long term complication. d) Improved pain in short term follow up. e) Increased recurrence rates at 2 years for surgeons with 250 cases. 65. The standard for location of mesh implantation for open venteral hernia repair is: (SESAP 13-171) a) Superficial to the posterior rectus sheath with at least 4 cm overlap. b) Between the anterior rectus sheath and the anterior rectus muscle with at least 4 cm overlap. c) Sutured to the fascial edge of the defect.

d) Deep to the posterior rectus sheath with at least 4 cm overlap. e) Mesh reinforcement of facial margins with linear closure. 66. An obese 54-year-old woman presents acutely with nausea, vomiting and abdominal distention. On examination she appears quite ill with tender mass in Rt groin inferior to the inguinal ligament, WBC 16,000/mm3 and Temp 38C. the best treatment would be: (SESAP 13-173) a) A transverse incision above the typical herniorrhaphy incision. b) Incision & drainage. c) An attempt of manual reduction after generous sedation. d) Total extra peritoneal patch (TEPP) hernia repair. e) Laparoscopic transabdominal ore-peritonial (TAPP) hernia repair. 67. A 20-year-old woman has had increasingly bothersome Lt upper quadrent discomfort over the last several months. CT scan shows a large splenic cyst. The single best treatment would be: (SESAP 13-175) a) Non steroidal anti inflammatory agents. b) Percutanous aspiration c) Angiographic embolization. d) Partial spleenectomy. e) Total spleenectomy. 68. A 28-year-old lady body builder has acute onset of a swollen Rt arm, which of the following statement about her condition is TRUE: (SESAP 13-229) a) Higher incidence in female. b) Often accompained by neurologic symptoms. c) Not successfully treated with anticoagulants. d) Difintely treated with catheter directed thrombolysis. e) Associated with venous gangrene of the upper extremities. 69. Which of the following statements about management of abdominal aortic aneurysm (AAA) is TRUE: (SESAP 13-223) a) Elective operation should be considered for patients with symptomatic AAA in the absence of significant co-morbidities. b) The risk of rupture is higher in women than men for small aneurysm. c) In healthy 75-year-old man a 4.5cm aneurysm should be repaired. d) An unreliable patient who is unlikely to comply with lifelong surveillance should be preferentially offered endograft versus open repair. e) Mortality is not related to the hospitals volume of AAA repairs performed.

70. Which of the following statement about A-V fistulas for hemodialysis access is TRUE? (SESAP 13-236) a) AVFs should be placed immediately after patient has started dialysis. b) Over 50% of Pts are being dialysed through AVf. c) The radio fistula can be done in over 50% of all patients. d) If an AVf fails to mature properly secondary operations are rarely successful. e) For a Pt with small vessels, a prosthatic graft will provide a higher patancy rate than a radiocephalic fistula. 71. A 10-week-prergnant, 25-year-old woman referred to OPD because her obstetrician felt a new breast mass. Mammography was not done, and an US examination failed to show an abnormality. The surgeon can feel 1.5 cm firm non tender discrete mass just lateral to the areola. Which of the following options is appropriate? (RUSH 284) a) Perform a biopsy if the mass is still present 1 month after delivary. b) Perform a stereotactic core biopsy. c) Locally excise the mass and if cancer recommend axillary dissection and irradiation. d) Locally excise the mass and if cancer recommend termination of the pregnancy and mastectomy. e) Perform a palpation guided needle core biopsy and if cancer recommend mastectomy. 72. a 6-year-old boy has a large intra abdominal mass in the mid line just above the symphysis pubis. During surgery, a cystic mass is found attached to the umbilicus and to the apex of the bladder. The most likely diagnosis is: (2009) a) Hydrocele. b) Meckels cyst. c) Meckels diverticulum. d) Omphalocele. e) Urachal cyst. 73. A 35-year-old air line pilot has acute shortness of breath; on physical examination he has decreased breath sounds on the Rt side. CXR reveals pneumothorax and chest tube is placed. The most appropriate management now would be: (SESAP 13-468) a) Serial CXR. b) Chemical pleurodesis. c) Axillary thoracotomy.

d) Vedio-assisted thoracic surgery (VAST). e) Poster lateral thoracotomy. 74. A 27-year-old patient has a 12x10x8 cm mass in her Lt breast. It has been present for 7 years and has slowly grown to its present size. It is firm, non tender, rubbery, and completely movable. There are no palpable axillary nodes. Which of the following is the most likely diagnosis? (2008) a) Breast cancer. b) Chronic cystic mastitis. c) Cystosarcoma phylloids. d) Intraductal papilloma. e) Mammary dysplasia. 75. a 56-year-old man had a history of appendectomy and calf DVT, presented to ER with severe abdominal pain, gaseous abdominal distention, and absence of tenderness. Serum amylase is elevated. The most likely diagnosis is: (2008) a) Acute pancreatitis. b) Intestinal obstruction. c) Perforated peptic ulcer. d) Acute mesenteric vascular occlusion. e) Acute cholecystitis. 76- Following a modified radical mastectomy a women developed "winged" shoulder. The deformity is due to paralysis of the nerve to: (2008) a) Latissmus dorsi b) Pectoralis major c) Terres major d) Serratous anterior e) Subscapularis

77. a 75-year-old male patient had abdominal aortic aneurysm repaired 5-days ago developed bloody diarrhea in past 2 days, now complaining of severe abdominal pain. What is the most likely diagnosis? (2008) a) Exacerbation of chronic ulcerative collitis. b) Small bowel ischemia. c) Ischemia of the cecum. d) Ischemia of ascending colon. e) Ischemia of descending colon.

78. A 33-year-old pt on mechanical ventilation following a motor vehicle accident with multiple injuries, including a femur # and severe head injury is noted to heart rate of 44/min, and his BP has decreased to 70/40 mm Hg. Which one of the following is the most appropriate step in his management? (2008) a) Admenister vasoactive agents to increase the BP and evaluate for tension pneumothorax. b) Check the ventolator to see if it is malfunctioning while obtaining a 12 leads ECG. c) Disconnect the pt from the ventilator and initiate bag-mask valve ventilation with 100% oxygen. d) Suction the air way and adminster 1L of normal saline. e) Bronchoscopy and take sputum for culture. 79. A pt in shock has pulmonary artery catheter placed and is found to have low cardiac output, a low pulmonary artery occlusion pressure, and a high systemic vascular resistance. The initial treatment for this type of shock is: (2008) a) Dopamine infusion. b) Adrenaline infusion. c) After load reduction. d) IVF bolus. e) Pericardiocentesis.

80. a 75-year-old male presents with severe chest pain and is found to have dissecting aortic aneurysm. In addition to controlling BP, he will also require which of the following? (2008) a) Inotropic support to maintain cardiac output. b) Anticoagulation with heparin. c) Nitroglycerine to decrease chest pain from myocardial ischemia. d) Beta blocker to control the rise of the BP. e) Valium to make him sleep all the time. 81. The 1st step in management of acute hypercalcemia is: (SCHWARTIZ'S 8-13) a) Correction of deficit of extracellular fluid volume. b) Hemodialysis. c) Admenstration of frusamide. d) Admenstration of methramycin. e) Parathyroidectomy.

82. A 23 year-old man presents with a firm 2 cm mass in Rt thyroid lobe and epislateral lower deep jugular LN 1.5 cm in diameter. FNA from both lesions revealed papillary cancer. Which of the following therapy is the most appropriate? (RUSH 326) a) Thyroid loubectomy with external beam radiotherapy to the involved part of the neck. b) Total thyroidectomy and ipsilateral neck dissection. c) Total thyroidectomy and ipsilateral modified radical neck dissection. d) Total thyroidectomy and bilateral modified radical neck dissection e) Rt loubectomy and isthmectomy with ipsilateral modified radical neck dissection. 83. a 45-year-old woman whose mother had breast cancer under goes stereotactic Rt breast core biopsy. Pathologic examination demonstrates lobular carcinoma in situ. Next step should be: (SESAP 13-20) a) Re-excision to obtain clear margins. b) Lumpectomy and sentinel LN biopsy. c) Lumpectomy, sentinel LN biopsy, and radiation therapy. d) Observation, examination and mammography in 6 months. e) Radiation therapy for Rt breast. 84. a 77-year-old patient had operative embolectomy for cold left hand. What is the next step in evaluation of this pt? (SESAP 13-246) a) MRA of subclavian artery. b) Duplex examination of the carotid artries. c) Echocardiogram. d) Cardiac cathetrisation. e) CXR. 85. a 50-year-old woman has a 3 cm Rt adrenal mass discovered incidentally during an abdominal CT scan for epigastric pain. The next step should be: (SESAP 13-276) a) Measurment of 24h urinary cortisol. b) Measurment of 24h catecholamines and metabolites. c) CT guided FNA of the mass. d) Determination of plasma aldosterone concentration to plasma reinin activity ratio. e) Operative excision.

86. gastro-osephegeal reflux disease (GERD): a) Is a neurovascular disorder caused by failed esophageal peristalsis. b) Relapse after stopping medical therapy occurs in 100% of cases. c) Is the failure of the antireflux barrier, allowing abnormal reflux of gastric contents into the esophagus. d) Laparoscopic nissens fundoplication is totally free of complications. e) Baretts esophagus contraindicates operating on GERD pt. 87. On introducing the primary trocar at a lap cholecystectomy the pt suddenly collapsed. What you will do? (2008) a) Quickly pull the trocar and perform an urgent laparotomy. b) Ask for immediate help of a vascular surgeon. c) The trocar should be left in place and adequate resuscitative measures should be taken before any intervention. d) Rule out CO2 embolization due to direct entry of gas into the vessels by requesting immediate echocardiogram. e) Call the cardiac arrest team. 88. which of the following is TRUE about the treatment and management of Graves disease? (RUSH 321) a) Subtotal thyroidectomy is the treatment of choice. b) Irradiation is a much better treatment option than subtotal thyroidectomy. c) Subtotal thyroidectomy results in improvement in exophthalmus. d) Recurrence rates for anti thyroid drugs are comparable to that for subtotal thyroidectomy. e) Radioactive iodine is the treatment of choice other than in children and women of childbearing age. 89. Which of the following is appropriate management of an open pelvic # with a perineal wound? (RUSH 179) a) Diverting colostomy and wound irrigation b) Diverting colostomy and primary closure of the perineal wound. c) Bowel rest and TPN d) Laparatomy and peritonial and pelvic irrigation. e) Primary closure of the perineal wound after debridement.

90. a 77-year-old woman presents with cold Lt hand. After operative embolectomy, the next step in the patient evaluation should be: a) MRI angiogram of the subclavian arteries. b) Duplex examination of the carotid artieries. c) Echocardiogram. d) Cardiac catheterization. e) Adesons maneuver. 91. Which of the following statements about Hashimoto's thyroiditis is NOT true? (SESAP 13-277) a) b) c) d) e) 24 hour uptake of radioactive iodine 123 confirms the diagnosis Is associated with hyperlipidemia ESR is normal Ultrasound examination is hypo echoic Lymphocytic infiltration is seen in pathological examination

92- Which of the following is the main stimulus for gall bladder contraction? a) Cholecystokinin b) Acetylcholine c) Secretin d) Epinephrine e) Gastrin 93. Clinically a saphena varix is most likely to be confused with: (SURGICAL RECALL) a) b) c) d) e) Baker's cyst Femoral hernia Spermatocele Inguinal hernia Varicocele

94- The Brodie Trendlingburg is used to detect: a) b) c) d) e) Presence of femoral vein thrombosis Integrity of the long saphenous nerve Acute limb ischemia due to superficial femoral artery occlusion Presence of arteriovenous fistula Site if incompetent perforator vein

95. A 60 year-old man has a 4-cm left thyroid nodule. FNA of the nodule is interpreted as papillary cancer. No lymph nodes are palpable. Management of this patient should include all of the following EXCEPT: (SESAP 13-279) a) b) c) d) e) Total thyroidectomy Radioactive iodine ablation Suppressive thyroxin Modified left neck dissection Serum thyroglobulin monitoring

96. A 27 year- old refinery worker is brought to the ER after natural gas explosion at the plant. The best screening test for diagnosing a primary blast injury is: (SESAP 13-300) a) b) c) d) e) Chest X-ray Otoscopic examination Fundoscopic examination Focused assessment with sonography for trauma Chest auscultation

97- The most rapid method of reversing the anticoagulation with warfarin in trauma patient would be: (SESAP 13-305) a) Recombinant factor VIIa b) Fresh frozen plasma c) Vitamin K d) Cryoprecipitate e) Thrombin concentration 98. In the management of penetrating colon injuries, which of the following factors would NOT influence the development of intra-abdominal abscess? (SESAP 13306) a) Fecal contamination b) Use of diverting colostomy c) Blood transfusion >4 units/24 hours d) Shock at admission e) Delay in therapy >6 hours

99. A 29-year-old man is brought to ER with a gunshot in the Rt anterior axillary line 2cm above the nipple and a 2nd wound in the Lt back 2cm lateral to and 2cm above the tip of scapula.CXR shows Rt pleural effusion. He had mild chest pain; pulse is 88, BP 130/70. The next step should be: (SESAP 13-308) a) Angiography b) Chest CT scan c) Thoracoscopy d) Bronchoscopy e) Observation and repeat CXR in 6 hours 100- Which of the following is NOT a sign of brain death? (SESAP 13-313) a) Loss of response to painful stimulus b) Absence of brainstem reflexes c) Apnea d) Temperature > 36 C e) Study confirming absence of cerebral flow