Mcq Salad 009

Front 1

With a perforation of a duodenal ulcer which occurred 6hago, what features are likely to be present?

Back 1

a .generalised abdominal tenderness and guarding

c .percussion over the liver may demonstrate resonance

d. the respiration is shallow and the abdominal muscles are held rigid

e. plain radiograph shows free gas under the diaphragm

Front 2

Which of the following factors is MOST likely to be associated with a significant risk of rebleeding from a duodenal ulcer?

Back 2

a visible vessel with adherent clot seen on endoscopy

Front 3

The treatment of choice for a perforated duodenal ulcer in a 56–year–old man with a strong history of ulcer disease and signs of peritonitis after 12 hours is

Back 3

omental patch repair and peritoneal lavage

Front 4

Following a gastric resection for a stage III gastric cancer the patient asks whether any further therapy will improve their prognosis. What is true of chemo?

Back 4

chemoradiotherapy may improve outcome

Front 5

A 67 year old man is found to have a submucosal 5 cm tumour in the body of his stomach. The treating physician considers that this may be a gastrointestinal stromal tumour. How does it grow?

Back 5

it is difficult to predict how this tumour will behave

Front 6

Following gastric resection a patient is told that they have a T2 N1 (stage II) cancer of the stomach. They ask about 5–year survival, how many patients from 100 with such a tumour would be alive at 5 years?

Back 6

60

Front 7

Endoscopic ultrasound is used in the staging of gastric cancer. What is it good for in particular?

Back 7

EUS is better than CT in assessing T stage

Front 8

An 80–year–old woman presents with biliary pain and stones are seen in the gall bladder on ultrasound. The probability of the pain being due to a stone in the common bile duct is approximately:

Back 8

30%

Front 9

A 73–year–old man presents with cholangitis. He has had no previous abdominal operation. The definitive treatment should be:

Back 9

ERCP, sphincterotomy with stone extraction and later consideration of cholecystectomy

Front 10

Which of the following is the appropriate investigation in a patient presenting with a recent episode of right upper quadrant pain and a normal physical examination?

Back 10

upper abdominal ultrasound

Front 11

The following investigation should always be performed when investigating obstructive jaundice:

Back 11

liver US

Front 12

A14–year–old boy is seen by a pediatric cardi– ologistbecause of increasing shortness of breath. Studies reveal increased pulmonaryvascular resistance, left axis deviation on Electrocardiogram (ECG), and mitralregur– gitation murmur.What is the most likely diagnosis?

(A) Ostium primumdefect

(B) Tetralogy of Fallot

(C) Right aortic arch

(D) Ostium secundum defect

(E)Atrioventricular canal

Back 12

(A)

Ostium primum. Typically ostium primum in an adolescent would be diagnosed by increasing symptoms, increased pulmonary resistance, left axis on ECG, and a mitral regur– gitation murmur due to a cleft mitral valve. Ostium secundum would cause increased pul– monary resistance later in life, not at age 14. AV canal is seen most commonly in Down syn– drome. Right aortic arch and tetralogy of Fallot do not have this symptom complex.\n

Front 13

Acyanotic female neonate is born with trans– position of the great arteries. Metabolic acido– sis and hypoxemia are present and are life threatening. Which of the following is the best initial treatment?

(A) Urgent Mustard operation

(B) Prostaglandin E1

(C) Atrial septotomy

(D) Pulmonary artery banding

(E) Prostaglandin E1 and atrial septotomy

Back 13

(E)

Prostaglandin E1 and Aterial septotomy. Prostaglandin E1 is used to keep the ductus arteriousus open in transposition. Desaturated “systemic” blood can pass through the pul– monary circulation to be oxygenated. The ate– rial septotomy creates an ASD, which aids in saturated blood being pumped peripherally, decreasing the cyanosis. The mustard opera– tion is not commonly done as the arterial switch operation is most common in this era, and in this acutely ill neonate definitive oper– ation would not be the best initial treatment. Pulmonary artery banding does not apply.

Front 14

A 65–year–old man undergoes cardiac surgery for triple vessel coronary artery disease. What can he anticipate?

(A)95% chance his grafts will occlude after 12 months.

(B)5% chance of living for 5 years.

(C)If the internal mammary artery is used as a conduit, patency is increased.

(D)Mortality if 10–20% in most centers.

(E) Functional improvement with the saphenous vein graft is better than internal memory artery.

Back 14

(C)

Internal thoracic artery. The internal tho– racic artery is the conduit of choice especially for grafting the left anterior descending (LAD) artery. Arterial and venous grafts 95% of the time do not occlude after 12. Seventy–five per– cent of patients under coronary artery bypass graft (CABG) survive 5 years. Mortality is 2% or lower in most centers.

Front 15

Three months after aortic valve replacement with a mechanical prosthesis, a 60–year–old man describes malaise, and increasing short– ness of breath. Examination reveals pulsus paradoxus. ECG shows low voltage precor– dially. What test is most useful for making the diagnosis?

(A) Stress thallium exam

(B) Computer Tomography (CT) examination of chest

(C) Coronary angiography

(D) Echocardiography

(E) Serum creatinine phosphokinase (CPK)

Back 15

(D)

Echocardiography. This patient has a peri– cardial effusion. Echocardiography is the most useful in making the diagnosis. CAT scan of thechest can be used but is not the best exam. The other choices do not apply.

Front 16

In the patient described above urine output decreases to 20 cc/h. Studies reveal paradoxi– cal septal motion. What is the next course of therapy?

(A) Expectant medical therapy

(B) Redo aortic valve surgery

(C) Left chest tube

(D) Ontra–aortic balloon

(E) Pericardial window

Back 16

(E)

Pericardial window. The patient developed decreased cardiac output (decreasing urine output,)and cardiac tamponade. Emergent pericardial window is the treatment of choice. Medical therapy will result in the patient’s death. The other choices do not apply.

Front 17

A58–year–old man is in cardiogenic shock in the emergency department after sustaining an acute myocardial infarction (MI). An intra– aortic balloon pump (IABP) is inserted. Which statement is TRUE about IABP?

(A) The balloon increases coronary perfusion during diastole.

(B) The balloon increases coronary perfusion during systole.

(C) The balloon increases peripheral resistance.(D)The balloon is inflated in systole and diastole.

(E)The pump must be removed after 24 hours.

Back 17

(A)

IABP increases coronary perfusion during distole. The IABP inflates during diastole and propels blood into the coronary circulation. IABP decreases peripheral resistance and decreases afterload on the heart. The IABPcan stay in the patient for longer than 24 hours.\n

Front 18

A66–year–old female has had two MIs in the past. She is admitted to the emergency depart– ment in congestive heart failure. After admis– sion and appropriate therapy her Holter monitor shows frequent PVCs and her ejection fraction is found to be 35%. Appropriate treat– ment would include which of the following?

(A) Single chamber pacemaker

(B) Cardioversion

(C) Dual chamber pacemaker

(D) Internal cardiac defibrillator (ICD)

(E) Greenfield filter

Back 18

(D)

ICD. In a patient with history of MI, con– gestive heart failure, and decreased ejection fraction coupled with frequent premature ven– tricular beats studies have shown that this subset of patient benefits from internal cardiac defibrillators, as the most frequent cause of death in these patients is sudden cardiac death from ventricular fibrillation. Single and dual chamber pacemakers are used for bradyarry– thmias. The other choices do not apply.

Front 19

During a routine examination of a 30–year–old female actuary seeking life insurance, she is found to have a ventricular septal defect (VSD). She undergoes subsequent studies including ECG, chest x–ray, echocardiography, and Doppler ultrasound. What is the major deter– minant of operability in VSD?

(A) Age of patient

(B) Pulmonary vascular resistance

(C)Size of the VSD

(D)Location of the VSD

(E) Presence of cyanosis

Back 19

(B)

Increase in pulmonary vascular resistance causes an increased cardiac output. Small shunts (with a pulmonary/systemic flow ratio >1.5) do not require surgery but must be treated with prophylactic antibiotics. Larger shunts should be repaired, because the mortality rate exceeds 50% when severe pulmonary pressure (>85 mm Hg) occurs. Closure of the VSD in the presence of cyanosis withestablishedreversalofthe direction\nof flow (right to left) would be detrimental, car– rying a very high mortality.

Front 20

At the age of 3 years, a child with a VSD becomes progressively short of breath and requires urgent surgery. What is the most common type of VSD (Fig. 4–1)?Pulmonary valveSupracristal defectCrista supraven– tricularisMuscular defectSeptal leaflet defectMembranous defectTricuspid valveFigure 4–1.Anatomical locations of various ventricular septal defects. The wall of the right ventricle has been excised to expose the ventricular septum. (Reproduced, with permission, from Doherty GM: Current Surgical Diagnosis and Treatment, 12th ed. 433. McGraw–Hill, 2006.)

(A) Defect anterior to the crista supraventricular

(B) Membranous septal defect

(C) Posterior septal defect

(D) Low muscular defect

(E) Right–to–left shunt

Back 20

(B)

VSD is the most common cardiac congeni– tal abnormality and results from failure of fusion of the uppermost part of the interven– tricular septum with the aortic septum. Membranous septal defects account for 90% of VSDs. There is usually a left–to–right shunt and cyanosis does not occur until pulmonary hypertension is severe enough to reverse flow across the VSD. Surgery is indicated in large shunts only when symptoms occur and pul– monary hypertension is evident. Forty percent will close spontaneously in childhood.

Front 21

A1–year–old girl is found to have a posterior membranous VSD. Peripheral resistance of the pulmonary system is 40% that of the systemic. How should you proceed?

(A)Observe the child, because most VSDs close spontaneously.

(B)Band the pulmonary artery and fix the defect at age 6.

(C)Repair electively at age 14.

(D)Repair electively between ages 4 and 6 years.

(E) Repair immediately as an emergency.

Back 21

(D)

Increase in pulmonary resistance would require more urgent intervention. Because nearly half the cases of VSD in childhood will close spontaneously, elective surgery is deferred to late childhood. Banding procedures are used less frequently today because of the high mor– tality rate. If symptoms increase in severity and pulmonary pressure is high, more urgent inter– vention is indicated. If the pulmonary systolic pressure is over 85 mm Hg and the left–to–right shunt is small, surgical mortality exceeds 50%.

Front 22

When is bile duct injury during laparoscopic cholecystectomyis\nmore common:

Back 22

a in the presence of cholecystitis

b when the surgeon is inexperienced

c if the biliary anatomy is unusual

d when the operation is complicated by haemorrhage

Front 23

Cholangiocarcinoma is most commonly found:

Back 23

at the biliary confluence

Front 24

Primary sclerosing cholangitis is associated with:

Back 24

a inflammatory bowel disease

b carcinoma of the bile duct\n

c gallstones

d multifocal biliary strictures

it is not associated with hepatocellular carcinoma

Front 25

Primary hepato–cellular carcinoma may be caused by

Back 25

alcohol

haemochromatosis

hepatitis B virus\ngallstones

not caused by steroids

Front 26

Liver metastases may be treated by

Back 26

arterial embolisation

cryotherapy

laparoscopic resection

regional chemotherapy

not treated with open lobectomy

Front 27

Regarding pyogenic liver abscess, what does therapy entail

Back 27

drainage of the abscess and appropriate antibiotic therapy are the mainstay of management

Front 28

Regarding amoebic liver absesses, what are some facts about it

Back 28

a it is an uncommon disease in Australia and is endemic\nin South and Southeast Asia

b intestinal amoebiasis, which leads to liver abscess, is\ntransmitted by the faeco–oral route

c amoebic serology is usually positive in these patients

d mainstay of treatment is antimicrobial therapy

e amoebic liver abscess can be drained by percutaneous technique

Front 29

Regarding hydatid disease, what are some facts ng organs

Back 29

a the human is an end host, which breaks the development cycle of the parasite

b initial infection occurs through the alimentary tract and is asymptomatic

c the natural history of a hydatid cyst in the human is one of slow progressive growth

d rupture of a hydatid cyst is not a common event

e most symptoms are related to pressure effects on the liver and surroundi

Front 30

Tell me more about hydatid disease, I am intruiged

Back 30

a extremely small cysts may be managed conservatively provided they are followed up to monitor growth

b medical management is unsuccessful in the majority of cases

c medical therapy is usually used to supplement surgical intervention

d the most common surgical technique is that of evacuation of the content and de–roofing of the cyst and the placement of an omental patch in the cavity

e prevention of spillage of the contents into the peritoneal cavity is of critical importance

Front 31

The following are true of liver infestations:

Back 31

a the liver fluke Fasciola hepatica is acquired from sheep and cattle and infests the biliary tree

b the flat worm Clonorchis sinensis is usually ingested by eating raw fish

c Clonorchis sinensis infestation leads to recurrent\ncholangitis and a high incidence of cholangiocarcinoma

d biliary ascariasis is caused by the migration of the common intestinal roundworm into the biliary tree

Front 32

What are causes of pancreatitis?

Back 32

a gallstones

b alcohol

c mumps

d ampulla of Vater tumours

Front 33

At birth, the 6 weeks premature infant is noted to haveprogressive dyspnea. There is a continuous murmur in the pulmonic area (secondleft intercostal space), and cyanosis is absent. ECG findings are normal. Anx–ray of the heart shows cardiomegaly, and the pulse is bounding. Patent ductusarteriosus (PDA) is diagnosed. What does treatment include?

(A) Immediatesurgical correction

(B) Administration of indomethacin

(C) Administration ofcortisone

(D) Renal dialysis

(E) Endotracheal intubation in all cases

Back 33

(B)

Management of compromised respiratory status in the premature infant with PDA includes fluid restriction, adequate oxygena– tion, attempted closure by medication with indomethacin, and surgical ligation (under– taken when indomethacin is contraindicated). Good results can be anticipated in the absence of other serious complications.

Front 34

During a routine preschool physical examina– tion, the physician notes that a 3–year–old girl has a machinery–type murmur on auscultation of the chest. The pulse is bounding and palpa– ble in the femoral and radial region of both sides of her body. There were no symptoms, and she has excellent exercise performance. Persistent PDA is confirmed on subsequent examination. The parents should be advised that the girl requires which of the following:

(A) Surgical correction and closure of the PDA

(B) Indomethacin

(C) Coronary angiography

(D) No treatment unless symptoms occur

(E)CT scan of the heart

Back 34

(A)

In full–term infants born with persistent PDA, the anomaly must be closed or excised between 6 months and 3 years of age to avoid cardiac complications, including endocarditis. In PDA, persistence of the communication between the pulmonary trunk and aorta increases pulmonary blood flow, left atrial flow, left ventricular flow, and ascending aorta flow. PDAaccounts for 15% of all congenital cardiac abnormalities. Cyanosis does not occur initially, because oxygenated blood is shunted from the aorta to the pulmonary trunk. Themurmur is continuous (sounds like machinery) and has harsh features. Its intensity is maxi– mum over the left second intercostal space but radiates to the chest wall and the neck.

Front 35

At the age of 34 years, a female long–distance runner notes increasing dyspnea after running more than 10 mi. On inspection and palpation, a prominent right ventricular heave is noted. There is a loud systolic murmur in the left third interspace. The ECG shows right–axis devia– tion with right bundle branch block. An x–ray of the chest shows a small aortic knob. What sign or test will most likely reveal the cause of the congenital heart abnormality thought to be atrial septal defect?

(A)Beading (scalloping) of the ribs on x–ray

(B) Decreased carotid pulse

(C) Left ventricular hypertrophy on ECG

(D) Elevated sedimentation rate

(E) Increased oxygen saturation gradient between the superior vena cava and the right ventricleQuestions: 6–16 81

Back 35

(E)

Cardiac catheterization is the definitive test for confirming the diagnosis of ASD. It quanti– fies the size of the shunt and confirms the increase in oxygen saturation between the right ventricle and the superior vena cava. Beading of the ribs is seen in coarctation, and a decreased carotid pulse is found in aortic steno– sis. An elevated sedimentation rate occurs in the presence of infection such as bacterial endocarditis.

Front 36

The only son of a physiology instructor dies suddenly at the age of 12 years following wors– ening symptoms of tetralogy of Fallot. What would an autopsy reveal?

(A) Dextroposition of the appendix

(B) Brachiocephalic vein draining into the right renal vein

(C)Inferior vena cava (IVC) draining to the superior mesenteric vein

(D) Atrial Septal Defect (ASD)

(E) Decreased vascularity of the lung field.

Back 36

x–ray. .(E)

There is decreased vascularity of the lungs seen on chest Tetralogy of Fallot includes VSD, right ventricular outflow obstruction, dextroposition of the aorta, and right ventricu– lar hypertrophy. Tetralogy of Fallot accounts for over one–half the cases of congenital cyan– otic heart disease.\n

Front 37

After suffering a streptococcal throat infection, a 12–year–old immigrant boy develops cardiac symptoms that are attributed to rheumatic fever. Years later, at the age of 34 he is admitted to the hospital with pulmonary edema. Further examination reveals a diastolic murmur at the apex and mitral stenosis is diagnosed. Before surgical evaluation, which of the following findings can be attributed to mitral stenosis?

(A) Large left ventricle

(B)Indentation of the middle third of the esophagus by an enlarged left atrium

(C)Notching of the ribs

(D) Bounding, full pulse

(E) Angina pectoris

Back 37

(B)

Dilation of the left atrium is the obvious com– plication following long–standing mitral stenosis. Echocardiography is the simplest and most pre– cise method of showing enlargement of the left atrium. Frequently, there is a latency period of 15–20 years before symptoms become evident. Important complications of mitral stenosis include exertional dyspnea caused by an increase in left atrial pressure and backup of blood with possible pulmonary edema, decreased cardiac output, atrial fibrillation, emboli (15%), and pres– sure in the intermediate third of the esophagus as seen on an esophogram after barium swallow. The pulse in mitral or aortic stenosis is reduced.

Front 38

A 23–year–old ballet dancer is concerned about the recent sudden death of a young famous Russian dancer on a New York stage. The patient seeks advice about his own risk for developing cardiac disease. His father died suddenly from ischemic heart disease at the age of 40. What is the most important risk factor that would further indicate the possibil– ity of coronary artery heart disease?

(A) Diabetes mellitus

(B) Personality type

(C) Elevated high–density lipoprotein

(D) Elevation of total cholesterol/ high–density lipoprotein ratio

(E) Obesity

Back 38

(D)

Elevation of total cholesterol/high–density lipoprotein is a useful predictor of coronary artery disease (CAD). Other known main risk factors include genetic predisposition, high cholesterol level, arterial hypertension, and cig– arette smoking. Obesity, diabetes mellitus, and personality type are of probable importance as independent risk factors. The presence of elevated high–density lipoprotein is a favor– able factor.

Front 39

In evaluating the risk factors involved in advis– ing elective cholecystectomy in a 52–year–old man with heart disease, which of the following conditions should alert the surgeon to avoid an elective procedure?

(A)MI 9 months earlier

(B) Persistent nonspecific changes on ECG

(C) Increased frequency and severity of attacks of angina

(D) Elevated alkaline phosphatase levels

(E) Hypertension controlled with diuretics

Back 39

.(C)

Changes in the nature of angina should alert the physician to the possible progression of the underlying cardiac status. The pain may become more severe and more frequent, may last longer, and may occur with a lesser degree of exertion. Nocturnal pain should likewise signal concern. In the face of unstable angina, 30% of patients are likely to develop MI within a 3–month period.

Front 40

After his first heart attack 3 years ago, a 63– year–old painter complained of central chest pains that radiated to the left arm after exercise. The pain was alleviated by nitroglycerin. Recently, he fell on a steel object and severed the median nerve and flexor tendons at the wrist. The skin was sutured but he is now scheduled to have a second operation that will require anesthesia. What is the best method to diagnose angina pectoris?(A) Cholesterol/high–density lipid ratio

(B) Isoenzymes

(C) Stress electrocardiography

(D) Echocardiography(E) Chest x–ray

Back 40

(C) In about one–quarter of patients with angina pectoris, the ECG findings will be normal. Exercise electrocardiography will reveal ST– segment depression and possibly precipitate symptoms if angina pectoris is present. There is a risk of myocardial death in patients tested, and patients with symptoms after minimal exertion and/or unstable angina are at particular risk with this procedure. If hypotension, ventricular arrhythmia, and supraventricular arrhythmia occur or if the ECG shows a fall in segment ST of over 3 mm, the test should be discontinued. In these cases, 201Tl scintigraphy would be used to detect cardiac ischemia or infarction. Echocardiography during supine exercise may be a helpful test in selected circumstances.

Front 41

Eight days after undergoing a hysterectomy, a 64–year–old woman complains of chest pain. After 12 hours, the internist orders tests to exclude MI. Which test will most likely support this diagnosis?

(A) Serum glutamic oxaloacetic transaminase (SGOT) elevation

(B) Increased sedimentation rate

(C) 99mTc pyrophosphate scintigraphy showing a “hot spot”

(D) Thallium 201 (201Tl) scintigraphy showing a (“hot spot”)

(E) Dimethyliminodiacetic acid (HIDA) scan

Back 41

(C)

99mTc pyrophosphate scintigraphy showing a “hot spot.” Following injection of 99mTc pyrophos– phate, scintigraphy may show a hot spot in the infarcted area. The hot spot is developed as the radiotracer forms a complex with calcium in necrotic tissue. The test should be requested within the first 18 hours following the onset of acute MI. It is not sensitive enough to detect small infarctions. Following 201Tl scintigraphy, a “cold spot” occurs because of hypoperfusion. The test is performed where exercise or dipyri– damole (Persantine) injection can be given. SGOT levels are elevated in liver disease. The HIDAscan is used to exclude gallbladder dis– ease. Cardiac enzyme levels and ECG findings are useful to establish a diagnosis of MI.

Front 42

After undergoing repair of a left indirect inguinal hernia, a 72–year–old obese man is admitted to the emergency department with severe retrosternal pain of 1–hours duration. The pain radiates to the medial aspect of the lefthand. The ECG shows Q waves and an ele– vated ST–segment. Adiagnosis of acute MI is established 1 hour after admission. Immediate management should include which of the following?

(A) Thrombolytic therapy with tissue plasminogen activator (tPA)

(B) Vitamin K

(C)Ampicillin, 2 mg tid PO

(D) Hydrochlorthiazide, 50 mg/d

(E) Sodium, nitroprusside 0.5 mg/kg/min

Back 42

(A)

Thrombolytic therapy intravenously with streptokinase, urokinase, or tPA is indicated in most patients with MI presenting early for treatment. This therapy, however, is effective only if initiated within 6 hours after the onset of pain in patients with acute MI. These drugsAnswers: 9–22 91are fibrinogenolytic, and aspirin and heparin are frequently included in the anticoagulant protocol. Reperfusion rates of 60% can be anticipated; reocclusion rates of 15% usually occur. Vitamin K is not indicated, because it would increase the coagulability of blood. If a diuretic, such as hydrochlorothiazide, 25–50 mg/d is indicated to treat milder hyperten– sion, hypokalemia must be avoided.

Front 43

The pancreas is protected from autodigestion by:

Back 43

secreting enzymes in an inactivated form Severity of acute

Front 44

pancreatitis is determined by:

Back 44

clinical scoring systems (Ranson/Imrie)

Front 45

Which features regarding antibiotic use in acute pancreatitis which are important

Back 45

a antibiotic uptake by pancreatic necrotic tissue

b therapeutic level in serum

d broad–spectrum cover, including anaerobes

Front 46

Patients who suffer from chronic pancreatitis are totally\ncured of their disease by:

Back 46

None of these cure chronic pancreatitis

a surgical removal of the pancreas

b endoscopic drainage of the pancreatic duct via a stent

c total abstinence from alcohol

Front 47

Gimme some facts about pancreatic carcinoma:

Back 47

a most pancreatic cancers are incurable

b palliation can be achieved with a biliary stent

c palliation can be achieved by surgical bypass of the tumour

d ampullary cancer has a worse prognosis than carcinoma of the body of the pancreas

Front 48

Which of the following investigations are useful in determining the curability of pancreatic carcinoma:

Back 48

a Ultrasound

b ERCP

d Serum markers

e Pancreatic biopsy

CT is apparently shithouse

Front 49

Regarding the portal circulation in the normal healthy adult, where does the portal vein form?

Back 49

the portal vein is formed by the confluence of the superior mesenteric vein and the splenic vein behind the neck of the pancreas

Front 50

Which one of following physical signs are seen in a patient with portal hypertension?

Back 50

a caput medusaeb hepatomegalyc ascites\nd splenomegaly would not expect to see lower limb varicose veins