Syrgery Mock 10

Breast
1. Which of the following statement(s) is/are correct concerning prognostic
factors for breast carcinoma?
a. Prognosis is improved with estrogen or progesterone receptor positivity
b. Increased thymidine labeling index, a measure of the proportion of cells in
the DNA synthetic phase (S-phase), is associated with improved survival
c. High tumor levels of cathepsin D are associated with an improved
prognosis
d. Immunohistochemical demonstration of active angiogenesis correlates
with increased metastatic potential and poor prognosis
Answer: a, d

2. A 42-year-old woman undergoes her first mammogram. Clustered

microcalcifications are seen but there is no mass palpable. Which of the
following statement(s) is/are true concerning this patient’s diagnosis and
management?
a. A needle localization and excision of the mass is necessary to establish
the diagnosis
b. Frozen-section examination is particularly useful in the diagnosis of this
lesion
c. Intense interlobular fibrosis and proliferation of small ductules with loss of
orientation of lobules and epithelial cells may suggest carcinoma
d. This finding is associated with an increased risk of cancer
Answer: a, c

3. Which of the following conclusion(s) can be drawn from the results of the
NSABP prospective randomized trials completed in the 1970’s and 1980’s?
a. Delay of axillary node dissection until there is clinical evidence of disease
does not influence overall survival
b. Removal of clinically negative nodes has no therapeutic benefit
c. Breast irradiation reduces both local recurrence and overall survival
d. Modified radical mastectomy offers no advantage of lumpectomy with
axillary node dissection
Answer: a, b, d

4. A 41-year-old patient presents to your office with a biopsy proven

invasive ductal cancer in the upper outer aspect of her left breast, a
suspicious palpable left axillary lymph node, and diffuse calcifications
throughout the rest of the breast proven to be DCIS on stereotactic biopsy.
The best surgical option is:
(A) Modified radical mastectomy
(B) Simple mastectomy
(C) Lumpectomy with sentinel lymph node biopsy
(D) Radical mastectomy
(E) Total mastectomy with sentinel lymph node biopsy
Answer: (A) This patient has a palpable axillary lymph node making
sentinel node biopsy contraindicated. The multicentricity of the disease also
makes the use of sentinel lymph node biopsy relatively contraindicated.
Radical mastectomies are no longer performed unless gross tumor invasion
into the pectoralis muscle is found.

Endocrine
5. Preparation for surgical removal of a pheochromocytoma includes:
A. Beta-adrenergic blockade followed by alpha-adrenergic blockade.
B. Hydration.
C. Alpha-adrenergic blockade, with or without beta-adrenergic blockade.
D. Preoperative Swan-Ganz monitoring in all patients.
E. Planning removal through an anterior, posterior, or laparoscopic approach
based upon tumor localization with CT, magnetic resonance imaging (MRI),
and/or 131I-MIBG.
Answer: BCE

6. Indications for surgical adrenalectomy include:

A. An adrenal mass larger than 6 cm.
B. Hypertensive patients with aldosteronism that is ACTH insensitive and
posture sensitive and who also have multiple adrenal nodules on CT.
C. Cushing's syndrome secondary to adrenal neoplasms or to persistent
ectopic ACTH syndrome when the primary tumor is inoperable.
D. Pheochromocytoma in adults and children. E. Congenital adrenal
hyperplasia secondary to 21-hydroxylase deficiency.
Answer: ACD

7. Incidental adrenal masses:

A. May be seen in as many as 10% of abdominal CT studies.
B. Most commonly represent pheochromocytoma; adrenocortical adenoma,
adrenocortical carcinoma, and metastases from other primary cancers occur
less frequently.
C. May represent adrenocortical carcinoma if greater than 6 cm. in diameter.
D. Should be routinely evaluated by measurement of 24-hour urine levels of
catecholamines and their metabolites, cortisol, and aldosterone plus fine-
needle aspiration.
E. Should be resected if biochemically active, if greater than 6 cm., or if they
grow over six months' follow-up.
Answer: CE
8. The chest x-ray of a 62-year-old woman who complains of weakness,
dyspnea, and hemoptysis
shows multiple nodules in the right lung. She states that the dyspnea is
worse in the supine position (platypnea) and improves on sitting up. On
examination, the physician notes multiple hemorrhagic telangiectasia in the
mouth and in the skin of the upper chest wall. There is a mild increase in the
erythrocyte count, and the PO2 is 90. An angiogram shows multiple
pulmonary arteriovenous (AV) fistula in both lungs. What should be the next
step in treatment?
(A) Needle biopsy of lesion
(B) Irradiation
(C) Therapeutic embolization
(D) Endobronchial biopsy
(E) Sympathomimetic inhalation therapy
Answer: (C) The presence of multiple masses on a chest x-ray should alert
the physician to the possible diagnosis of pulmonary AV fistula. Needle
biopsy and endobronchial biopsy of the lesion
should not be attempted, because severe hemorrhage may be precipitated.
Paradoxical emboli,
brain abscess, and hemothorax are recognized complications. If the fistula is
localized, resection is undertaken; in multiple lesions therapeutic
embolization is done. In addition to AV malformation, multiple masses on a
chest xray could be due to metastasis, granulomatous infection, or sarcoid
or rheumatoid arthritis. therapeutic embolization is done. In addition to AV
malformation, multiple masses on a chest x-ray could be due to metastasis,
granulomatous infection, or sarcoid or rheumatoid arthritis.
Abdumin

9. The following statement(s) is/are true concerning incarceration of an

inguinal hernia.
a. All incarcerated hernias are surgical emergencies and require prompt
surgical intervention
b. Attempt at reduction of an incarcerated symptomatic hernia is generally
considered safe
c. Vigorous attempts at reduction of an incarcerated hernia may result in
reduction en masse with continued entrapment and possible progression to
obstruction or strangulation
d. Incarcerated hernias frequently cause both small and large bowel
obstruction
Answer: b, c

10. A careful history is necessary in all patients being considered for inguinal
hernia repair. Symptoms which deserve investigation and appropriate
treatment prior to proceeding with inguinal hernia repair include:
a. Chronic cough
b. Urinary hesitancy and straining
c. Change in bowel habit
d. A specific episode of muscular straining with associated discomfort
Answer: a, b, c

11. Which of the following structures are derived from the external oblique
muscle and its aponeurosis?
a. The inguinal or Poupart’s ligament
b. The lacunar ligament
c. The superficial inguinal ring
d. The conjoined tendon
Answer: a, b, c
OD
12. Which of the following statements about the anatomic basis for the
syndrome of vascular compression of the duodenum are true?
A. The duodenum is obstructed in its distal third as it crosses over the
lumbar vertebral column.
B. Structures crossing beneath the superior mesenteric artery include the
duodenum, the uncinate process of the pancreas, and the left renal vein.
C. Hyperextension of the back allows the angle of origin of the superior
mesenteric artery to widen, lessening the obstruction of the duodenum.
D. Patients are at significant risk for vascular compression of the duodenum
if the angle between the takeoff of the superior mesenteric artery and the
aorta is less than 45 degrees.
E. Arteriographic studies show a typical area of extrinsic compression and
narrowing of the arterial lumen due to duodenal pressure.
Answer: AB

13. Which of the following statements concerning the pathology of gastric

cancer is true?
A. Distal gastric cancers are becoming more common.
B. Intestinal-type gastric tumors resemble colon carcinomas and have a
better prognosis than diffuse type.
C. Early gastric cancers are confined to the mucosa and are lymph node
negative.
D. Broders' histologic grading system correlates well with survival: patients
with grade IV tumors have 5-year survival rates around 65%.
Answer: B
14. An 80% distal gastrectomy is performed for a 6-cm. antral cancer with
extension to the muscularis propria and three positive lymph nodes less than
3 cm. from the tumor. The stage of this tumor was:
A. Stage I.
B. Stage II.
C. Stage III A.
D. Stage III B.
Answer: B

Small Intestine
15. The most obvious function of the GI tract is digestion and absorption of
food for continued growth and survival of the organism. Which of the
following statement(s) is/are true concerning small bowel absorption?
a. The jejunum is the site of maximum absorption for most ingested
materials with almost all jejunal absorption performed via active transfer
mechanisms
b. Eighty percent of water presented to the gastrointestinal system is
reabsorbed by the small bowel
c. The absorption of carbohydrates requires digestion of large starch
molecules by salivary and pancreatic amylase, therefore presenting smaller
oligosaccharides to the brush border of the jejunum to complete the
digestion and absorptive process
d. Dietary fiber represents poorly digestible carbohydrates which can absorb
organic materials such as bile salts and lipids
Answer: b, c, d
16. A 45-year-old man with a history of previous right hemicolectomy for
colon cancer presents with colicky abdominal pain which has become
constant over the last few hours. He has marked abdominal distension and
has had only minimal vomiting of a feculent material. His abdomen is
diffusely tender. Abdominal x-ray shows multiple air fluid levels with
dilatation of some loops to greater than 3 cm in diameter. The most likely
diagnosis is:
a. Proximal small bowel obstruction
b. Distal small bowel obstruction
c. Acute appendicitis
d. Closed-loop small bowel obstruction
Answer: b

17. In the patient described above, the following statement(s) is/are true
concerning the possible etiology of bowel obstruction.
a. Simple obstruction secondary to an adhesion is most likely to resolve
nonoperatively
b. It is most likely that the patient’s obstruction is secondary to recurrent
malignancy
c. A history of colon cancer makes carcinomatosis the most likely diagnosis
d. Lower abdominal procedures are more likely to result in obstructive
adhesions than are upper abdominal procedures
Answer: a, d
Liver
18. A 45-year-old woman undergoes an ultrasound because of vague right
upper quadrant pain and epigastric fullness. A 7 cm cystic lesion is detected.
Which of the following statement(s) is/are true concerning the patient’s
diagnosis and management?
a. Simple aspiration is indicated for treatment and diagnosis
b. Bile stained fluid suggests underlying biliary pathology
c. The cyst is likely lined by cuboidal epithelium
d. Laparoscopic unroofing of the cyst can provide satisfactory treatment
Answer: c, d

19. A 38-year-old woman with a 17 year history of oral contraceptive use

presents with right upper quadrant pain. A CT scan demonstrates a 4 cm
lesion in the right lobe of the liver. Which of the following statement(s)
is/are true concerning the patient’s diagnosis and management?
a. The lesion is likely premalignant
b. A 99mTc sulfur colloid scan will distinguish this benign lesion from a
malignant hepatoma
c. The lesion, although benign, may be associated with life-threatening
hemorrhage
d. The lesion would be expected to be hypervascular on angiographic study
Answer: c, d
Spleen
20. Useful methods for detection of splenic injury, in descending order of
sensitivity, are:
A. Diagnostic peritoneal lavage.
B. CT. C. Ultrasonography.
D. Isotope scan.
E. Magnetic resonance imaging (MRI).
Answer: B

21. A 40-year-old man has had recurrent symptoms suggestive of peptic

ulcer disease for 4 years. Endoscopy reveals an ulcer located on the greater
curvature of the stomach. A mucosal biopsy reveals Helicobacter. pylori.
What is TRUE about H. pylori?
(A) Active organisms can be discerned by serology.
(B) It is protective against gastric carcinoma.
(C) It is associated with chronic gastritis.
(D) It causes gastric ulcer but not duodenal ulcer.
(E) It can be detected by the urea breath test in <60% of cases.
Answer: (C) H. pylori (previously called Campylobacter pylori) is associated
with chronic gastritis, duodenal ulcers, gastric ulcers, and gastric cancer.
Serology can accurately detect H. pylori but remains positive for up to 1 year
post treatment. The urea breath test is highly sensitive (96%) and specific
(94%). In 2005, Barry Marshall and J. Robbin Warren won the Nobel Prize in
medicine for their work on H. pylori and its role in gastritis and peptic ulcer
disease.

22. Amale neonate develops small-bowel obstruction due to malrotation of

the midgut segment. An x-ray of the abdomen confirms the presence of
small-bowel obstruction (Fig. 6–1). He undergoes an emergency laparotomy,
untwisting of the malrotated intestines, and partial small-bowel resection for
intestinal infarction.Which of the following statements is true of the small
intestine (jejunum and ileum)?
(A) It is derived entirely from the midgut.
(B) In the fetus, it enters the physiologic umbilical hernia in the the fifth
month.
(C) It remains in the physiologic hernia for 4 months.
(D) It is attached to the urachus.
(E) It drains into the lymph nodes around the iliac arteries
Answer: (A) The small intestine arises from the midgut segment. The
midgut segment extends between the ampulla of Vater and the distal
transverse colon. It enters the physiological umbilical hernia at sixth week
and returns to the peritoneal cavity by the tenth week. The vitellointestinal
tract (site from which Meckel’s diverticulum arises) is attached to the
antimesenteric margin of the distal ileum. The urachus is attached to the
bladder. The intestinal lymphatic drainage is directed to the preaortic glands

23. A 62-year-old postal officer develops minimal urinary symptoms. His

PSA level is elevated and continues to increase during a 6-month period of
observation. The next step in evaluation, if transrectal ultrasound (TRUS)
prostate biopsy (Fig. 9–1) were positive for adenocarcinoma of prostate,
would be:
(A) Refer to oncologist for chemotherapy
(B) Metastatic evaluation including CT and bone scans
(C) Repeat PSA and biospy
(D) Evaluation by radiation oncologist
(E) Start hormonal ablation treatment
Answer: (B) Typical workup after a positive TRUS biopsy would be
evaluating the common metastatic sites (pelvic lymph nodes and bone). CT
scan of abdomen and pelvis with and without contrast is performed to also
rule out other GU abnormalities (i.e., renal mass, renal stone, and so forth)
in addition to pelvic lymphadenopathy. Bone scan, however, is typically not
indicated for PSA <20 mg/mL.

24. A 6-month-old boy was born with hypospadias. This condition is due to
failure in the development of which of the following?
(A) Urogenital fold
(B) Müllerian system
(C) Genital tubercle
(D) Urachus
(E) Vitelline duct
Answer: (A) Embryologically, the genital tubercule develops into the penis.
The edge of the cloacal membrane forms the urogenital fold and by the
process of invagination forms the urethral groove and finally the penile
urethera. The severity of hypospadias depends on the location of the
anomalous opening onto the penile urethra. The mildest degree is where the
opening is on the glans and the most severe form at the penoscrotal junction

Genato urenery
25. Which of the following statements are true concerning male infertility?
a. Although 15% of couples in the United States are affected by infertility,
the male rarely contributes to the problem
b. A varicocele can be associated with diminished sperm motility and
abnormal sperm morphology
c. Complete testicular failure will usually respond to systemic testosterone
administration
d. Anti-sperm antibodies are an important cause of infertility which may be
treated successfully with corticosteroid administration
Answer: b, d