Rosh Surgery Questions with 100%
Correct Answers
What sign is characterized by ecchymosis in the periumbilical region associated
with acute necrotizing pancreatitis? Correct Answer: Pancreatitis is
characterized by acute inflammation of the pancreas that can be classified by
severity. Patients will have a sudden onset of epigastric pain that radiates to the
back. The pain is often alleviated by leaning forward or sitting straight up.
Aggravating factors will include food intake. Associated symptoms may include
nausea and vomiting. Physical exam findings may vary but include epigastric
tenderness upon palpation. Patients may have abdominal distention or
hypoactive bowel sounds if there is an associated ileus from the adjacent
inflammatory process. If the pancreatitis is caused by biliary obstruction,
jaundice may be present. If there is retroperitoneal bleeding in the setting of
pancreatic necrosis, then bruising may be seen in the periumbilical region
(Cullen sign). Amylase may be elevated. Lipase is more specific to pancreatic
inflammation and damage and is more sensitive for pancreatitis caused by
alcoholism. Abdominal ultrasound will reveal a diffusely enlarged and
hypoechoic pancreas. Gallstones may be visualized if these are contributing to
the pathology. Contrast-enhanced abdominal CT scan is the modality of
choice for imaging and can rule out necrosis or mass. Initial management
consists of fluid replacement and pain and nausea control.Cullen sign
Which of the following terms describes a thermal injury that involves the
epidermis, dermis, and subcutaneous tissues? Correct Answer: Full-thickness burn
Burns are classified by depth of injury and the layers of tissue involved.
Traditionally, burns were described as first, second, third, or fourth degree.
Current nomenclature describes the depth of the injury and is more useful for
determining treatment, but the former terms are still often used. Superficial or
,first-degree burns involve only the epidermis. The skin appears red and blanches
with pressure. Treatment involves cooling the area and pain relief, and these
burns heal without scarring. Superficial partial-thickness or superficial second-
degree burns involve the epidermis and superficial dermis. They form blisters
within 24 hours and are painful. Treatment is cooling the skin and debriding
necrotic tissue if the blisters rupture. These burns typically heal within one to
three weeks and do not result in scarring, but may produce mild changes in
pigmentation. Deep partial-thickness or deep second-degree burns involve the
epidermis and deep dermis and damage hair follicles and glandular tissue. They
cause blisters and may have a mottled appearance. They take significantly
longer (three to nine weeks) to heal than superficial partial thickness burns, and
cause scarring. Full-thickness or third-degree burns involve the epidermis, dermis,
and subcutaneous tissues. They are minimally painful because of injury to the
cutaneous nerves. The skin may appear white, gray, or black and does not
blanch with pressure. Blisters do not develop, and the necrotic tissue forms
eschar, which impairs healing and can act as a nidus for infection. Burn eschar
must be debrided, ideally within 72 hours of injury. Granulation tissue forms deep
to the eschar, and the wound will heal by epithelialization from the edges and
result in scarring and contractures.
Which of the following upper endoscopy findings is consistent with a benign
peptic ulcer?
A Clubbed folds surrounding the ulcer crater
B Irregular, thickened ulcer margins
C Smooth ulcer base filled with exudate
D Ulcerated mass protruding into the lumen Correct Answer: Smooth ulcer base
filled with exudate
,Peptic ulcer disease forms characteristic ulcerative lesions within the stomach
and the duodenum that are most commonly due to nonsteroidal anti-
inflammatory drug use and Helicobacter pylori infection. Peptic ulcers can be
asymptomatic or present with symptoms such as epigastric pain and food-
provoked epigastric discomfort and fullness, early satiety, or nausea. Alarm
features that should raise clinical suspicion for underlying malignancy include
unintentional weight loss, progressive dysphagia, odynophagia, unexplained
iron deficiency anemia, persistent vomiting, palpable mass or
lymphadenopathy, and a family history of upper gastrointestinal cancer.
Definitive diagnosis is accomplished via upper endoscopy with direct
visualization of the ulcer, however, patients with no alarm features and benign-
appearing duodenal ulcers identified on radiologic imaging do not require this
diagnostic test. Benign peptic ulcers have smooth, regular, rounded edges with
a flat, smooth ulcer base that is often filled with exudate. Biopsies can be
obtained to rule out malignancy in suspicious lesions and for tissue urease
testing to rule out H. pylori infection. A urea breath test can be used to diagnose
H. pylori infection in patients with acute gastrointestinal bleeding once the
bleeding has been controlled. The stool antigen test is an alternative testing
method but is not appropriate for patients with gastrointestinal bleeding.
Treatment for identified H. pylori infection initially involves triple therapy with a
proton pump inhibitor (omeprazole), amoxicillin, and clarithromycin. Alternative
therapies are warranted for patients with risk factors for macrolide resistance.
Patients who receive treatment for H. pylori infection should have repeat testing
performed four or more weeks after therapy completion to ensure eradication
of infection. All offending agents (e.g., nonsteroidal anti-inflammatory drugs,
aspirin) should be removed, and patients who smoke should be advised to quit.
Patients should also limit alcohol intake to one alcoholic beverage daily.
Correct Answer: Antisecretory therapy is a mainstay of treatment for peptic
ulcer disease and typically involves the use of a proton pump inhibitor given for
four to eight weeks for duodenal ulcers and eight to twelve weeks for gastric
ulcers. Repeat endoscopy is warranted after 12 weeks of antisecretory therapy
in patients with gastric ulcers who have symptoms despite medical therapy, an
, unclear etiology, a giant gastric ulcer (> 2 cm), or risk factors for gastric cancer.
Additionally, patients with gastric ulcers who have suspicious biopsy results, or in
whom biopsies were not performed or were inadequate for follow-up testing,
should receive repeat upper endoscopy. Complications of peptic ulcer disease
include bleeding, gastric outlet obstruction, penetration into a solid organ or
fistulization into a hollow viscus, and free perforation. The first indication of a
developing complication may be new ulcer symptoms or a sudden change in
symptoms.
A 12-year-old boy presents to the clinic with concerns for swelling in his neck. His
father states that they initially thought it was a swollen lymph node since he had
just been sick with mild cold symptoms for the previous few days. When it got
larger, he thought it should be evaluated. On exam, a soft, cystic structure
adjacent to the hyoid bone that seems deep to palpation is noted. Which of
the following is the most likely diagnosis?
A Branchial cleft cyst
B Dermoid cyst
C Lipoma
D Thyroglossal duct cyst Correct Answer: Thyroglossal duct cyst
Thyroglossal duct cysts consist of epithelial remnants of the thyroglossal tract.
Typically, children and adolescents present with a cystic midline mass of the
neck, which sometimes occurs after an upper respiratory tract infection. In most
cases, the mass is close in proximity to the hyoid bone. CT scan of the neck with
contrast should be completed to confirm the diagnosis and to rule out infection
Correct Answers
What sign is characterized by ecchymosis in the periumbilical region associated
with acute necrotizing pancreatitis? Correct Answer: Pancreatitis is
characterized by acute inflammation of the pancreas that can be classified by
severity. Patients will have a sudden onset of epigastric pain that radiates to the
back. The pain is often alleviated by leaning forward or sitting straight up.
Aggravating factors will include food intake. Associated symptoms may include
nausea and vomiting. Physical exam findings may vary but include epigastric
tenderness upon palpation. Patients may have abdominal distention or
hypoactive bowel sounds if there is an associated ileus from the adjacent
inflammatory process. If the pancreatitis is caused by biliary obstruction,
jaundice may be present. If there is retroperitoneal bleeding in the setting of
pancreatic necrosis, then bruising may be seen in the periumbilical region
(Cullen sign). Amylase may be elevated. Lipase is more specific to pancreatic
inflammation and damage and is more sensitive for pancreatitis caused by
alcoholism. Abdominal ultrasound will reveal a diffusely enlarged and
hypoechoic pancreas. Gallstones may be visualized if these are contributing to
the pathology. Contrast-enhanced abdominal CT scan is the modality of
choice for imaging and can rule out necrosis or mass. Initial management
consists of fluid replacement and pain and nausea control.Cullen sign
Which of the following terms describes a thermal injury that involves the
epidermis, dermis, and subcutaneous tissues? Correct Answer: Full-thickness burn
Burns are classified by depth of injury and the layers of tissue involved.
Traditionally, burns were described as first, second, third, or fourth degree.
Current nomenclature describes the depth of the injury and is more useful for
determining treatment, but the former terms are still often used. Superficial or
,first-degree burns involve only the epidermis. The skin appears red and blanches
with pressure. Treatment involves cooling the area and pain relief, and these
burns heal without scarring. Superficial partial-thickness or superficial second-
degree burns involve the epidermis and superficial dermis. They form blisters
within 24 hours and are painful. Treatment is cooling the skin and debriding
necrotic tissue if the blisters rupture. These burns typically heal within one to
three weeks and do not result in scarring, but may produce mild changes in
pigmentation. Deep partial-thickness or deep second-degree burns involve the
epidermis and deep dermis and damage hair follicles and glandular tissue. They
cause blisters and may have a mottled appearance. They take significantly
longer (three to nine weeks) to heal than superficial partial thickness burns, and
cause scarring. Full-thickness or third-degree burns involve the epidermis, dermis,
and subcutaneous tissues. They are minimally painful because of injury to the
cutaneous nerves. The skin may appear white, gray, or black and does not
blanch with pressure. Blisters do not develop, and the necrotic tissue forms
eschar, which impairs healing and can act as a nidus for infection. Burn eschar
must be debrided, ideally within 72 hours of injury. Granulation tissue forms deep
to the eschar, and the wound will heal by epithelialization from the edges and
result in scarring and contractures.
Which of the following upper endoscopy findings is consistent with a benign
peptic ulcer?
A Clubbed folds surrounding the ulcer crater
B Irregular, thickened ulcer margins
C Smooth ulcer base filled with exudate
D Ulcerated mass protruding into the lumen Correct Answer: Smooth ulcer base
filled with exudate
,Peptic ulcer disease forms characteristic ulcerative lesions within the stomach
and the duodenum that are most commonly due to nonsteroidal anti-
inflammatory drug use and Helicobacter pylori infection. Peptic ulcers can be
asymptomatic or present with symptoms such as epigastric pain and food-
provoked epigastric discomfort and fullness, early satiety, or nausea. Alarm
features that should raise clinical suspicion for underlying malignancy include
unintentional weight loss, progressive dysphagia, odynophagia, unexplained
iron deficiency anemia, persistent vomiting, palpable mass or
lymphadenopathy, and a family history of upper gastrointestinal cancer.
Definitive diagnosis is accomplished via upper endoscopy with direct
visualization of the ulcer, however, patients with no alarm features and benign-
appearing duodenal ulcers identified on radiologic imaging do not require this
diagnostic test. Benign peptic ulcers have smooth, regular, rounded edges with
a flat, smooth ulcer base that is often filled with exudate. Biopsies can be
obtained to rule out malignancy in suspicious lesions and for tissue urease
testing to rule out H. pylori infection. A urea breath test can be used to diagnose
H. pylori infection in patients with acute gastrointestinal bleeding once the
bleeding has been controlled. The stool antigen test is an alternative testing
method but is not appropriate for patients with gastrointestinal bleeding.
Treatment for identified H. pylori infection initially involves triple therapy with a
proton pump inhibitor (omeprazole), amoxicillin, and clarithromycin. Alternative
therapies are warranted for patients with risk factors for macrolide resistance.
Patients who receive treatment for H. pylori infection should have repeat testing
performed four or more weeks after therapy completion to ensure eradication
of infection. All offending agents (e.g., nonsteroidal anti-inflammatory drugs,
aspirin) should be removed, and patients who smoke should be advised to quit.
Patients should also limit alcohol intake to one alcoholic beverage daily.
Correct Answer: Antisecretory therapy is a mainstay of treatment for peptic
ulcer disease and typically involves the use of a proton pump inhibitor given for
four to eight weeks for duodenal ulcers and eight to twelve weeks for gastric
ulcers. Repeat endoscopy is warranted after 12 weeks of antisecretory therapy
in patients with gastric ulcers who have symptoms despite medical therapy, an
, unclear etiology, a giant gastric ulcer (> 2 cm), or risk factors for gastric cancer.
Additionally, patients with gastric ulcers who have suspicious biopsy results, or in
whom biopsies were not performed or were inadequate for follow-up testing,
should receive repeat upper endoscopy. Complications of peptic ulcer disease
include bleeding, gastric outlet obstruction, penetration into a solid organ or
fistulization into a hollow viscus, and free perforation. The first indication of a
developing complication may be new ulcer symptoms or a sudden change in
symptoms.
A 12-year-old boy presents to the clinic with concerns for swelling in his neck. His
father states that they initially thought it was a swollen lymph node since he had
just been sick with mild cold symptoms for the previous few days. When it got
larger, he thought it should be evaluated. On exam, a soft, cystic structure
adjacent to the hyoid bone that seems deep to palpation is noted. Which of
the following is the most likely diagnosis?
A Branchial cleft cyst
B Dermoid cyst
C Lipoma
D Thyroglossal duct cyst Correct Answer: Thyroglossal duct cyst
Thyroglossal duct cysts consist of epithelial remnants of the thyroglossal tract.
Typically, children and adolescents present with a cystic midline mass of the
neck, which sometimes occurs after an upper respiratory tract infection. In most
cases, the mass is close in proximity to the hyoid bone. CT scan of the neck with
contrast should be completed to confirm the diagnosis and to rule out infection
