ABSITE EXAM QUESTIONS WITH
COMPLETE SOLUTIONS!
Bottom Line: Patients who are NPO (no oral intake) for 5-7 days are primarily relying on
hepatic gluconeogenesis for cellular energy. The primary substrate of hepatic
gluconeogenesis is alanine (derived primarily from skeletal muscle proteins -
ANSWERS
Bottom Line: For cardiac injuries identified during thoracotomy, pericardiotomy is
performed if a tense pericardium is noted, followed by digital control of the injury without
worsening the injury. If digital control is not helping to control the injury, cardiorrhaphy
with pledgeted, permanent horizontal mattress sutures (eg, 3-0 Prolene) should be
performed. - ANSWERS
Gallbladder injuries are treated with cholecystectomy. Drains should be placed in all
high-grade liver injuries. - ANSWERS
Bottom Line: The precursor of niacin (vitamin B3) is tryptophan. Carcinoid tumors can
shift tryptophan to the overproduction of serotonin and cause niacin deficiency
(pellagra), which is associated with diarrhea, dementia, and dermatitis. - ANSWERS
Bottom Line: In penetrating thoracoabdominal trauma, exploratory laparoscopy is
recommended. - ANSWERS
Bottom Line: Postoperative intussusception in children classically occurs after
prolonged laparotomy with significant bowel handling but can occur after non-GI surgery
as well. Diagnosis is by US, and treatment is with operative reduction -
ANSWERSnswer A: Postoperative intussusception is typically ileoileal, in contrast to
primary intussusception, which is usually ileocolonic.
ottom Line: Patients who are mechanically ventilated for more than 24 hours should
have their readiness to wean assessed daily. The rapid shallow breathing index is a
well-studied and popular weaning predictor. - ANSWERSA frequently used test is the
rapid shallow breathing index (RSBI), which is the ratio of respiratory frequency to tidal
volume (f/VT). This patient's RSBI is 100 [(25 breaths/min)/(.25 L) = 100 breaths/min/L].
An RSBI > 105 breaths/min/L is associated with weaning failure, while an RSBI < 105
breaths/min/L predicted weaning success with a sensitivity, specificity, positive
predictive value, and negative predictive value of 97%, 64%, 78%, and 95%,
respectively. Evidence suggests that a negative RSBI (RSBI ≥ 105 breaths/min/L) is
better at identifying patients who will fail to wean than a positive RSBI (RSBI < 105
breaths/min/L) is at identifying patients who can be successfully weaned.
Clinical Criteria Used To Determine Readiness for Trials of Spontaneous Breathing
,Required Criteria
1. The cause of respiratory failure has improved
2. PaO2/FiO2 ≥ 150* OR SpO2 ≥ 90% on FiO2 ≤ 40% and PEEP ≤ 5 cm H2O
3. pH > 7.25
4. Hemodynamic stability (no or low-dose vasopressor medications)
5. Able to initiate an inspiratory effort - ANSWERS
ne: The necessary studies for staging of colon cancer include CT scan of the chest,
abdomen, and pelvis; colonoscopy, CEA, and preoperative laboratory studies -
ANSWERSBottom Line: The main treatment of postoperative atelectasis is alveolar
inflation by instituting deep breathing exercises. The patient should be taught to carry
out a sustained maximal inspiration using incentive spirometr
Type Definition
Superficial Involves skin and subcutaneous tissue only
Deep Involves deeper tissue including fascia and muscle
Organ space Involves body cavities deep to the fascia that were entered during the
surgical procedu - ANSWERSMinor superficial SSI can be managed by opening the
incision and packing the wound. However, in the above scenario, the patient has a
history of poorly controlled diabetes and renal failure; hence this patient has impaired
immunity. He also demonstrates evidence of systemic toxicity with fever, raised
inflammatory markers, and has surrounding cellulitis. Therefore, empirical antibiotics to
cover gram-positive skin commensals and gram-negative anaerobes are indicated. As
with any abscess, source control should be achieved by drainage of the affected part of
the incision by removing the staples and allowing the pus to drain out. A culture swab
should be sent for to de-escalate the antibiotic choice once results are available
Bottom Line: According to the 2014 American College of Cardiology/American Heart
Association (ACC/AHA) guidelines for peri-operative cardiovascular evaluation, a
patient without prior cardiac issues who can perform >4 metabolic equivalents (METs)
does not require any further work-up. - ANSWERSPeri-operative cardiac risk is
increased in patients that are unable to perform 4 metabolic equivalents (METs).
Examples of activities requiring more than 4 METs are climbing a flight of stairs, walking
up a hill, walking on level ground at 4 mph, and performing moderate intensity work
around the house.
Bottom Line: Smoking is an independent risk factor for perioperative complications.
Smoking cessation is a requisite preoperative preparation for safe surgery, ideally 4
weeks prior to surgery. Varenicline is the most effective pharmacologic aid for smoking
cessation. Preoperative pulmonary evaluation including forced expiratory volume in 1
second and diffusing capacity for carbon monoxide are key parts of the preoperative
evaluation prior to major lung resection. - ANSWERSPostoperative surveillance in a
patient with colorectal cancer should include clinical examination, biochemical markers,
endoscopic surveillance, and imaging. Clinical examination is needed every 3-6 months
for 2 years, then every 6 months for a total of 5 years. Carcinoembryonic antigen (CEA)
levels are checked every 3-6 months for 2 years and then every 6 months for 5 years.
, In patients with a high risk of recurrence, such as lymphovascular invasion or poorly
differentiated tumors, a CT scan is done every 6-12 months up to 5 years. Colonoscopy
is performed at 1 year after surgery. If an advanced adenoma is present, then it is
repeated in 1 year. If no advanced adenoma, it can be repeated in 3 years and then
every 5 years.
Bottom Line: Smoking cessation is important for wound healing in all surgical
indications, but especially in those with hernia repair, given the increased risk of
recurrence with smoking. - ANSWERS
Bottom Line: Albumin has a half-life of 21 days, allowing it to serve as an appropriate
estimation of long-term nutritional risk and inflammation in patients without an acute
inflammatory process. Levels are negatively impacted by inflammatory processes that
favor the production of acute-phase reactants by the live - ANSWERSA level < 3.0 g/dL
can identify patients at a heightened risk for postoperative morbidity or mortality
Bottom Line: For patients who undergo major abdominal and/or pelvic surgery for
cancer, chemical thromboprophylaxis should be continued for a period of 4 weeks.
TrueLearn Insight: Although the compliance with this recommendation is, at times, poor,
it remains a recommendation. Postoperative deep vein thrombosis prophylaxis is also a
highly tested subject on surgical exams. - ANSWERSPreoperative hypotension is one
of the leading factors associated with renal dysfunction.
Preoperative hypotension is one of the leading factors associated with renal
dysfunction. - ANSWERSProlonged clamp time, suprarenal clamping, and age are all
predictors for poor outcomes in AAA surgery.
ottom Line: Methemoglobinemia should be suspected in patients with cyanosis and low
oxygen saturation without significant cardiopulmonary dysfunction, especially when
there is a history of recent use of drugs that are known to cause methemoglobinemia.
Basic treatment includes removal of the agent responsible for the disorder,
administration of oxygen, and observation. - ANSWERS
Various risk factors can be identified to assess the risk of anastomotic leakage after
colectomy. Male gender, higher American Society of Anesthesiologists class,
preoperative radiation therapy, and renal disease constitute preoperative risk factors.
Fecal contamination is the most significant overall risk factor - ANSWERSottom Line:
The Caprini score for deep venous thrombosis development assigns 3 points for a
family history of venous thromboembolism (VTE). Family history of VTE should include
first-degree relatives (sibling, son/daughter, parent), second-degree relatives (maternal
half-sibling, paternal half-sibling, niece/nephew), and third-degree relatives (cousin
Patients on dual antiplatelet therapy due to cardiac stents undergoing procedures at a
lower risk of bleeding such as colectomy, hernia repair, or gastrectomy can have
COMPLETE SOLUTIONS!
Bottom Line: Patients who are NPO (no oral intake) for 5-7 days are primarily relying on
hepatic gluconeogenesis for cellular energy. The primary substrate of hepatic
gluconeogenesis is alanine (derived primarily from skeletal muscle proteins -
ANSWERS
Bottom Line: For cardiac injuries identified during thoracotomy, pericardiotomy is
performed if a tense pericardium is noted, followed by digital control of the injury without
worsening the injury. If digital control is not helping to control the injury, cardiorrhaphy
with pledgeted, permanent horizontal mattress sutures (eg, 3-0 Prolene) should be
performed. - ANSWERS
Gallbladder injuries are treated with cholecystectomy. Drains should be placed in all
high-grade liver injuries. - ANSWERS
Bottom Line: The precursor of niacin (vitamin B3) is tryptophan. Carcinoid tumors can
shift tryptophan to the overproduction of serotonin and cause niacin deficiency
(pellagra), which is associated with diarrhea, dementia, and dermatitis. - ANSWERS
Bottom Line: In penetrating thoracoabdominal trauma, exploratory laparoscopy is
recommended. - ANSWERS
Bottom Line: Postoperative intussusception in children classically occurs after
prolonged laparotomy with significant bowel handling but can occur after non-GI surgery
as well. Diagnosis is by US, and treatment is with operative reduction -
ANSWERSnswer A: Postoperative intussusception is typically ileoileal, in contrast to
primary intussusception, which is usually ileocolonic.
ottom Line: Patients who are mechanically ventilated for more than 24 hours should
have their readiness to wean assessed daily. The rapid shallow breathing index is a
well-studied and popular weaning predictor. - ANSWERSA frequently used test is the
rapid shallow breathing index (RSBI), which is the ratio of respiratory frequency to tidal
volume (f/VT). This patient's RSBI is 100 [(25 breaths/min)/(.25 L) = 100 breaths/min/L].
An RSBI > 105 breaths/min/L is associated with weaning failure, while an RSBI < 105
breaths/min/L predicted weaning success with a sensitivity, specificity, positive
predictive value, and negative predictive value of 97%, 64%, 78%, and 95%,
respectively. Evidence suggests that a negative RSBI (RSBI ≥ 105 breaths/min/L) is
better at identifying patients who will fail to wean than a positive RSBI (RSBI < 105
breaths/min/L) is at identifying patients who can be successfully weaned.
Clinical Criteria Used To Determine Readiness for Trials of Spontaneous Breathing
,Required Criteria
1. The cause of respiratory failure has improved
2. PaO2/FiO2 ≥ 150* OR SpO2 ≥ 90% on FiO2 ≤ 40% and PEEP ≤ 5 cm H2O
3. pH > 7.25
4. Hemodynamic stability (no or low-dose vasopressor medications)
5. Able to initiate an inspiratory effort - ANSWERS
ne: The necessary studies for staging of colon cancer include CT scan of the chest,
abdomen, and pelvis; colonoscopy, CEA, and preoperative laboratory studies -
ANSWERSBottom Line: The main treatment of postoperative atelectasis is alveolar
inflation by instituting deep breathing exercises. The patient should be taught to carry
out a sustained maximal inspiration using incentive spirometr
Type Definition
Superficial Involves skin and subcutaneous tissue only
Deep Involves deeper tissue including fascia and muscle
Organ space Involves body cavities deep to the fascia that were entered during the
surgical procedu - ANSWERSMinor superficial SSI can be managed by opening the
incision and packing the wound. However, in the above scenario, the patient has a
history of poorly controlled diabetes and renal failure; hence this patient has impaired
immunity. He also demonstrates evidence of systemic toxicity with fever, raised
inflammatory markers, and has surrounding cellulitis. Therefore, empirical antibiotics to
cover gram-positive skin commensals and gram-negative anaerobes are indicated. As
with any abscess, source control should be achieved by drainage of the affected part of
the incision by removing the staples and allowing the pus to drain out. A culture swab
should be sent for to de-escalate the antibiotic choice once results are available
Bottom Line: According to the 2014 American College of Cardiology/American Heart
Association (ACC/AHA) guidelines for peri-operative cardiovascular evaluation, a
patient without prior cardiac issues who can perform >4 metabolic equivalents (METs)
does not require any further work-up. - ANSWERSPeri-operative cardiac risk is
increased in patients that are unable to perform 4 metabolic equivalents (METs).
Examples of activities requiring more than 4 METs are climbing a flight of stairs, walking
up a hill, walking on level ground at 4 mph, and performing moderate intensity work
around the house.
Bottom Line: Smoking is an independent risk factor for perioperative complications.
Smoking cessation is a requisite preoperative preparation for safe surgery, ideally 4
weeks prior to surgery. Varenicline is the most effective pharmacologic aid for smoking
cessation. Preoperative pulmonary evaluation including forced expiratory volume in 1
second and diffusing capacity for carbon monoxide are key parts of the preoperative
evaluation prior to major lung resection. - ANSWERSPostoperative surveillance in a
patient with colorectal cancer should include clinical examination, biochemical markers,
endoscopic surveillance, and imaging. Clinical examination is needed every 3-6 months
for 2 years, then every 6 months for a total of 5 years. Carcinoembryonic antigen (CEA)
levels are checked every 3-6 months for 2 years and then every 6 months for 5 years.
, In patients with a high risk of recurrence, such as lymphovascular invasion or poorly
differentiated tumors, a CT scan is done every 6-12 months up to 5 years. Colonoscopy
is performed at 1 year after surgery. If an advanced adenoma is present, then it is
repeated in 1 year. If no advanced adenoma, it can be repeated in 3 years and then
every 5 years.
Bottom Line: Smoking cessation is important for wound healing in all surgical
indications, but especially in those with hernia repair, given the increased risk of
recurrence with smoking. - ANSWERS
Bottom Line: Albumin has a half-life of 21 days, allowing it to serve as an appropriate
estimation of long-term nutritional risk and inflammation in patients without an acute
inflammatory process. Levels are negatively impacted by inflammatory processes that
favor the production of acute-phase reactants by the live - ANSWERSA level < 3.0 g/dL
can identify patients at a heightened risk for postoperative morbidity or mortality
Bottom Line: For patients who undergo major abdominal and/or pelvic surgery for
cancer, chemical thromboprophylaxis should be continued for a period of 4 weeks.
TrueLearn Insight: Although the compliance with this recommendation is, at times, poor,
it remains a recommendation. Postoperative deep vein thrombosis prophylaxis is also a
highly tested subject on surgical exams. - ANSWERSPreoperative hypotension is one
of the leading factors associated with renal dysfunction.
Preoperative hypotension is one of the leading factors associated with renal
dysfunction. - ANSWERSProlonged clamp time, suprarenal clamping, and age are all
predictors for poor outcomes in AAA surgery.
ottom Line: Methemoglobinemia should be suspected in patients with cyanosis and low
oxygen saturation without significant cardiopulmonary dysfunction, especially when
there is a history of recent use of drugs that are known to cause methemoglobinemia.
Basic treatment includes removal of the agent responsible for the disorder,
administration of oxygen, and observation. - ANSWERS
Various risk factors can be identified to assess the risk of anastomotic leakage after
colectomy. Male gender, higher American Society of Anesthesiologists class,
preoperative radiation therapy, and renal disease constitute preoperative risk factors.
Fecal contamination is the most significant overall risk factor - ANSWERSottom Line:
The Caprini score for deep venous thrombosis development assigns 3 points for a
family history of venous thromboembolism (VTE). Family history of VTE should include
first-degree relatives (sibling, son/daughter, parent), second-degree relatives (maternal
half-sibling, paternal half-sibling, niece/nephew), and third-degree relatives (cousin
Patients on dual antiplatelet therapy due to cardiac stents undergoing procedures at a
lower risk of bleeding such as colectomy, hernia repair, or gastrectomy can have
