Study Questions for Part I(Introduction)

Directions: Each of the numbered items in this section is followed by several possible answers. Select the ONE lettered answer that is BEST in each case.

1. A healthy adult presents for a pre-employment physical. What will be the largest component of his or her body by mass?

A Protein

B Water

C Calcium

D Sodium

E Potassium

View Answer

B

2. An 80-year-old man with a history of ischemic cardiomyopathy is hypotensive and oliguric after major abdominal surgery. Initial fluid resuscitation produces only transient improvements. He is transferred to the intensive care unit for further management. A pulmonary artery catheter could be used to measure all of the following except:

A Left atrial filling pressure

B Cardiac output

C Ejection fraction

D Mixed venous oxygen saturation

E Systemic vascular resisitance

View Answer

C

3. A 25-year-old man is injured in the arm with a knife. What is the first mechanism responsible for hemostasis?

A Extrinsic clotting system

B Vessel constriction

C Intrinsic clotting system

D Platelet activation

E Fibrinolytic system

View Answer

B

4. A 27-year-old woman is experiencing perioral and extremity numbness the morning after a neck operation. What is the cause of her symptoms?

A Hypokalemia

B Hypercalcemia

C Hypocalcemia

D Hypochloremia

E Hyperkalemia

View Answer

C

5. A 55-year-old woman undergoes laparotomy for small bowel obstruction. During lysis of adhesions, an enterotomy is made in the obstructed, but viable, bowel, and a large amount of fecal-looking bowel contents are spilled into the abdomen. The incision would now be considered what kind of wound?

A Clean contaminated

B Secondary

C Infected

D Contaminated

E Clean

View Answer

D

6. A critically ill 55-year-old man is in septic shock in the intensive care unit after removal of a nonviable small bowel. What is the most reliable measurement of arterial blood pressure?

A Arterial line diastolic

B Noninvasive systolic

C Arterial line mean

D Arterial line systolic

E Noninvasive mean

View Answer

C

7. Delayed primary closure would be the most appropriate wound closure technique for which of the following procedures?

A Removal of perforated appendix

B Repair of wound dehiscence 1 week after elective left colectomy

C Emergency drainage of a diverticular abscess with sigmoid resection and end colostomy

D Vagotomy and pyloroplasty for bleeding duodenal ulcer

E Repair of an incisional hernia 12 weeks after an elective left colectomy complicated by a wound infection and a resultant incisional hernia.

View Answer

A

8. A 55-year-old man with insulin-dependent diabetes presents to the emergency department with acute abdominal pain. His heart rate is 130 beats per minute, his blood pressure is 90/60 mm Hg, and his oral temperature is 101.8°F. His respiratory rate is 28 breaths per minute. The abdominal examination demonstrates diffuse peritonitis. What should be the first step in the evaluation and management of this patient?

A Volume resuscitation

B Abdominal radiograph

C Intravenous antibiotics

D Computed tomography (CT) scan

E Immediate laparotomy

View Answer

A

9. A 57-year-old man underwent a laparoscopic splenectomy for idiopathic thrombocytopenic purpura (ITP). He subsequently develops a persistent output of 100 cc daily of amylase-rich fluid from a drain placed at the time of surgery. All of the following would be expected to prevent spontaneous resolution of this problem except:

A Octreotide administration

B Pancreatic duct stricture

C Infection

D Nonabsorbable suture in distal pancreatic duct

E Epithelialization of the tract

View Answer

A

10. For appropriate procedures, antibiotic prophylaxis for bacterial endocarditis should be administered in patients with a history of which of the following?

A Mitral valve prolapse without regurgitation

B Automatic implantable cardiac defibrillator placement

C Aortic valve replacement

D Coronary artery bypass graft

E Surgically repaired ventricular septal defect

View Answer

C

11. Which of the following procedures would be expected to have the greatest impact on postoperative pulmonary function?

A Low anterior resection

B Femoropopliteal bypass

C Subtotal gastrectomy

D Open cholecystectomy

E Total abdominal hysterectomy

View Answer

C

12. Which of the following is a criteria for emergent preoperative dialysis?

A Potassium (K⁺) 5.0, without arrhythmia

B Arterial pH 7.30, anion gap 8

C Pericardial friction rub

D Blood urea nitrogen 105

E Creatinine 5.5

View Answer

C

13. Preoperative coagulation studies should be obtained on which of the following patients?

A A 35-year-old woman on aspirin, prior to varicose vein surgery

B A 65-year-old diabetic man, prior to inguinal hernia repair

C A 70-year-old jaundiced woman, prior to choledochojejunostomy

D A 45-year-old woman prior to bilateral prophylactic mastectomy with transverse rectus abdominus myocutaneous flap reconstructions

E A 50-year-old man with stable angina, prior to coronary artery bypass

View Answer

C

Directions: The group of items in this section consists of lettered options followed by a set of numbered items. For each item, select the lettered option(s) that is(are) most closely associated with it. Each lettered option may be selected once, more than once, or not at all.

Questions 14–17

Match the clinical situation with the appropriate type of drain.

14. Nasogastric decompression

A Jackson-Pratt closed drain

B No drain

C Underwater-seal drain

D Sump drain

View Answer

D

15. Spontaneous pneumothorax

A Jackson-Pratt closed drain

B No drain

C Underwater-seal drain

D Sump drain

View Answer

C

16. Diffuse peritonitis from perforated duodenal ulcer

A Jackson-Pratt closed drain

B No drain

C Underwater-seal drain

D Sump drain

View Answer

B

17. Splenectomy for ruptured spleen

A Jackson-Pratt closed drain

B No drain

C Underwater-seal drain

D Sump drain

View Answer

A

Answers and Explanations

• 1. The answer is B (Chapter 1, I A 1). The normal adult human body is made up of 50%–70% water. The water is contained in three primary compartments of the body: intracellular, extracellular, and intravascular. On average, two thirds of the body is made of water; in the hypothetical 70-kg man, this is 46 L. Of this 46 L, two thirds is intracellular (30 L), and one third is extracellular (16 L). Of the extracellular portion, two thirds is extravascular (10.5 L), and one third is intravascular (5.5 L). This approximation gives a good starting point when beginning to estimate fluid resuscitation, replacement, and maintenance.

• 2. The answer is C (Chapter 1, VII D). A pulmonary artery catheter can be useful in distinguishing cardiac dysfunction from other causes of shock in certain patients. It will allow the treating physician to measure left atrial filling pressure from the port in the tip via back pressure through the lungs. Cardiac output is measured via thermal dilution. Mixed venous oxygen saturation can be measured by drawing a sample from the catheter. Systemic vascular resistance can be calculated from the cardiac output, mean arterial pressure, and central venous pressure.

• 3. The answer is B (Chapter 1, III A). The first mechanism activated when there is damage to a vessel is constriction, which is an effort to stop blood flow. This is followed by platelet activation, which produces a platelet plug. The intrinsic and extrinsic pathways are then activated to form a fibrin clot. The fibrinolytic system is the body's mechanism to dissolve established clots.

• 4. The answer is C (Chapter 1, II B). Hypocalcemia can induce neuromuscular irritability, including perioral and extremity numbness. This can progress to carpopedal spasm and tetany. The most common cause of hypocalcemia is parathyroid surgery to treat hypercalcemia, resulting in rebound hypocalcemia.

• 5. The answer is D (Chapter 1, V C). The wound described is a contaminated wound due to the gross spill of contaminated material. A clean wound is one made through normal, antiseptically prepared skin and encounters no infected or colonized areas. A clean-contaminated wound is similar to a clean wound except that a contaminated or potentially contaminated area (e.g., bowel, bronchus, urinary tract), which has been prepared to the best of one's ability and presents minimal contamination, has been opened. An infected wound is one that already has an established infection present. Secondary is a type of wound closure and not a classification of a wound.

• 6. The answer is C (Chapter 1, VII D 2 b). The arterial line mean pressure is the most accurate and is the most physiologically useful measurement of blood pressure. It may be very accurate but often has limited clinical usefulness and must be used cautiously. Noninvasive blood pressures are not very accurate in critically ill patients. Noninvasive blood pressure measurements are notoriously high in hypotensive patients and low in hypertensive patients.

• 7. The answer is A (Chapter 1, V C, D 3; Chapter 2, I A 3). Delayed primary closure is appropriate for contaminated wounds, such as a ruptured appendix without abscess formation. Wound dehiscences are closed with retention sutures that include all layers, including the skin, because the fascial strength has been compromised. Infected wounds are packed open to heal by secondary intention, as with drainage of a diverticular abscess. Clean and clean-contaminated wounds can be closed primarily, as with incisional hernia repair (clean) and vagotomy/pyloroplasty (clean contaminated).

• 8. The answer is A (Chapter 3, VI C a). Intra-abdominal sepsis in a diabetic patient may be complicated by the development of ketoacidosis and dehydration. The patient presents with a condition that will likely require emergent surgical intervention. Initial management should be directed at restoration of the patient's circulating blood volume and optimization of his physiologic status prior to possible laparotomy. The serum glucose, electrolytes, and pH should be determined and abnormalities corrected. Measurement of hourly urine output will allow assessment of the adequacy of resuscitation. Abdominal radiographs should be obtained to look for free intraperitoneal air, and broad spectrum intravenous antibiotics should be administered, but fluid resuscitation takes top priority. A computed tomography scan may not be indicated in the patient who, on physical examination and history, clearly has peritonitis.

• 9. The answer is A (Chapter 2, VII D). Enterocutaneous fistulas typically respond to conservative management and spontaneously close when conditions are favorable. Octreotide has been shown to decrease pancreatic fistula output and clearly does not inhibit resolution. Distal obstruction (pancreatic duct stricture), infection, foreign body (nonabsorbable suture), and epithelialization all inhibit resolution.

• 10. The answer is C (Chapter, 3 II D; Table 3-5). In 1997, the American Heart Association updated guidelines to clarify recommendations for antibiotic prophylaxis for the prevention of bacterial endocarditis. In general, appropriate prophylaxis should be given to patients with underlying structural cardiac defects (e.g., prosthetic cardiac valves, significant valvular disease, hypertrophic cardiomyopathy, complex congenital heart disease, surgically constructed systemic-pulmonary shunts) who undergo procedures leading to bacteremia with organisms likely to cause endocarditis (e.g., major dental work or invasive procedures of the respiratory, gastrointestinal, or genitourinary tracts).

• 11. The answer is C (Chapter 3, III C). Major upper abdominal surgery performed via a vertical midline incision would be expected to have the greatest impact on postoperative pulmonary function. Other operative factors would include thoracotomy, residual intraperitoneal sepsis, age greater than 59 years, prolonged preoperative hospitalization, colorectal or gastroduodenal surgery, procedure longer than 3.5 hours, and higher body mass index. Lower abdominal and extremity surgery are associated with fewer pulmonary complications when compared with thoracic and upper abdominal surgery.

• 12. The answer is C (Chapter 3, C 1 b). Indications for emergent dialysis include life-threatening hyperkalemia, severe metabolic acidosis secondary to retained organic acids, uremic pericarditis, and volume overload. The serum creatinine and blood urea nitrogen levels reflect the underlying renal dysfunction but will not necessarily mandate emergent preoperative dialysis.

• 13. The answer is C (Chapter 3, I C; Table 3-1). Preoperative evaluation with routine coagulation studies is neither cost effective nor routinely indicated. Patients with a history of postsurgical bleeding or ongoing acute hemorrhage, patients on oral anticoagulation, patients with liver disease or hepatobiliary obstruction, malnourished patients, and patients unable to give an adequate history should have prothrombin time, partial thromboplastin time, and platelet counts checked preoperatively.

• 14–17. The answers are 14-D, 15-C, 16-B, and 17-A (Chapter 2, II A; II A 1 b). Sump drains are needed to adequately decompress the stomach. When the pleural space requires drainage, a chest tube is placed and connected to an underwater seal so that air and fluid cannot reflux into the chest. This is needed because of the negative intrathoracic pressure generated with each inspiration. Diffuse peritonitis cannot be drained, as the peritoneal contents quickly “wall off” foreign bodies such as drains; discrete intraperitoneal collections can be drained. Splenectomy jeopardizes the pancreatic tail, which is in close proximity to the splenic hilum. When the area is obscured, as with the hematoma accompanying splenic rupture, the integrity of the pancreas cannot be assured, and the potential pancreatic fluid leak is drained with a closed-suction drain such as a Jackson-Pratt drain.

Study Questions for Part II(Thorcic)

Directions: Each of the numbered items in this section is followed by several possible answers. Select the ONE lettered answer that is BEST in each case.

1. A 50-year-old man is brought to the emergency room after falling 20 feet from a roof. He is complaining of dyspnea, and his blood pressure is 70/50 mm Hg. Breath sounds are diminished on the left, and there is tracheal deviation to the right. What is the best initial treatment for this patient?

A Chest radiograph

B Close observation

C Needle decompression of the left chest

D Computed tomography (CT) scan of the thorax

E Emergent surgical exploration