438 - Comprehensive Review of General Surgery Quiz

S.No. Questions

1. Antimicrobial prophylaxis will IDEALLY do which of the following?

A. Prevent surgical site (SSI) infections

B. Prevent SSI-related morbidity and mortality
C. Reduce the duration and cost of healthcare
D. Produce no adverse effects
E. Have no adverse consequences for the microbial flora of the patient or the hospital
F. All of the above

2. A 32-year-old male arrives in the trauma bay after a high-speed motor vehicle collision. He undergoes damage
control laparotomy and is transferred to the ICU with tenuous hemodynamics and an open abdomen. He is
manually ventilated en route from the OR to the ICU. On arrival, the following laboratory data were obtained:

Which of the following most accurately describes his acid-base disorder?

A. Primary respiratory acidosis with secondary anion gap metabolic acidosis

B. Primary non-anion gap metabolic acidosis with secondary respiratory acidosis
C. Primary anion gap metabolic acidosis with secondary respiratory alkalosis
D. Primary respiratory acidosis with secondary non-anion gap metabolic acidosis

3. A 58-year-old man presents to the emergency department with diarrhea with bright red blood. He is known to have
diverticulosis based on screening colonoscopies and was recently started in apixaban 5 mg daily for new onset
atrial fibrillation. The last dose of apixaban was 6 hours ago. He is hemodynamically stable, with hemoglobin that is
just 1 gm/dL lower than baseline. Treatment should involve which of the following?

A. Transfusions with 4 bags of fresh frozen plasma (FFP)

B. Idarucizumab 5 gm IV bolus
C. IV vitamin K
D. Aggressive supportive care with IV fluids and red cell transfusions if necessary
E. Andexanet alfa according to package insert

4. A general anesthetic is defined by which of the following?

A. The lack of response to a noxious stimulus

B. The presence of a formal breathing tube
C. The use of a volatile agent
D. The need for ventilatory support

5. All of the following are components of the Revised Cardiac Risk Index (RCRI) EXCEPT:

A. Prior transient ischemic attack

B. History of congestive heart failure
C. History of ischemic heart disease
D. Age
E. Diabetes mellitus requiring insulin

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5. All of the following are components of the Revised Cardiac Risk Index (RCRI) EXCEPT:

A. Prior transient ischemic attack

B. History of congestive heart failure
C. History of ischemic heart disease
D. Age
E. Diabetes mellitus requiring insulin

6. Which of the following is the best diagnostic option for the initial pathologic work-up of a neck mass?

A. Core needle biopsy

B. Excisional biopsy
C. Fine-needle aspiration biopsy
D. Neck dissection

7. A 60-year-old patient presents with a 50 pack-year smoking history. He quit 10 years ago. He presents with a
cough but is otherwise well. A screening CT was obtained and a 1.5-cm dense lesion was seen in the right upper
lobe. Which of the following is best for this patient?

A. Patient should obtain a PET/CT

B. Patient should proceed to surgical resection
C. Patient should get a repeat CT scan in 3 months
D. A and B
E. A and C

8. Rank the necrotizing pancreatitis debridement procedures from LEAST morbid to MOST morbid.

A. Percutaneous drainage; video-assisted retroperitoneal debridement (VARD); open necrosectomy; transgastric

debridement
B. Video-assisted retroperitoneal debridement (VARD); percutaneous drainage; transgastric debridement; open
necrosectomy
C. Video-assisted retroperitoneal debridement (VARD); percutaneous drainage; open necrosectomy; transgastric
debridement
D. Percutaneous drainage; video-assisted retroperitoneal debridement (VARD); transgastric debridement; open
necrosectomy
E. Percutaneous drainage; transgastric debridement; video-assisted retroperitoneal debridement (VARD); open
necrosectomy

9. The MOST sensitive diagnostic marker for necrotizing soft tissue infection (NSTI) is which of the following?

A. Presence of hemorrhagic bullae

B. LRINEC Score of ≥ 8
C. Hypotension
D. WBC > 15.4 and Na+ < 135
E. CT revealing fascial edema, fascial enhancement, or fascial gas

10. According to the Society of Colon and Rectal Surgeons, which of the following is NOT a protective factor against
the development of left-sided colonic diverticulitis?

A. 2 hours of exercise a week

B. Red meat consumption < 100 gm/day

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10. According to the Society of Colon and Rectal Surgeons, which of the following is NOT a protective factor against
the development of left-sided colonic diverticulitis?

A. 2 hours of exercise a week

B. Red meat consumption < 100 gm/day
C. Fiber consumption > 23 gm/day
D. Normal BMI

11. Which of the following is TRUE about Do Not Resuscitate (DNR) orders?

A. DNR orders can only be changed annually.

B. DNR orders must be placed if the patient’s family insists and even if the medical team does not think they will
benefit the patient.
C. DNR orders should be entered based on the order from the patient’s most recent hospital admission.
D. DNR orders should be revisited during every hospital admission, and are an opportunity to explore the patient’s
health goals and priorities, which can inform medical care.

12. A 45-year-old man underwent kidney transplantation for ESRD secondary to IgA nephropathy 4 months ago. He
presents to the transplant clinic with low-grade fever, general malaise, and flank pain. He notes that he has been
urinating less than usual and laboratory work-up reveals increased serum creatinine from a baseline of 1.5 mg/dL
to 3.2 mg/dL. Which of the following options is part of his diagnostic work-up?

A. You perform a detailed history and physical examination

B. You draw blood and measure the patient’s calcineurin inhibitor level
C. You hydrate the patient
D. You perform a renal ultrasound
E. You do all of the above before moving forward with a renal biopsy to exclude a rejection

13. Which of the following therapeutic agents should be instilled in the esophagus during removal of a button battery?

A. Sodium bicarbonate
B. Acetic acid
C. Hydrochloric acid
D. Methylene blue

14. Risk factors for the development of peripheral arterial disease (PAD) include which of the following?

A. Diabetes
B. Hyperlipidemia
C. Smoking
D. Hypertension
E. All of the above

15. Which of the following statements is FALSE?

A. Venous thromboembolism (VTE) is the top preventable cause of death in hospitals

B. Three risk factors for VTE are vessel injury, stasis, and hypercoagulability
C. Deep vein thrombosis (DVT) prophylaxis options include graduated compression stockings, intermittent
pneumatic compression, and anticoagulation
D. After appropriate anticoagulation, there are no long-term sequelae of DVT

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15. Which of the following statements is FALSE?

A. Venous thromboembolism (VTE) is the top preventable cause of death in hospitals

B. Three risk factors for VTE are vessel injury, stasis, and hypercoagulability
C. Deep vein thrombosis (DVT) prophylaxis options include graduated compression stockings, intermittent
pneumatic compression, and anticoagulation
D. After appropriate anticoagulation, there are no long-term sequelae of DVT

16. Which of the following is the ideal time for arteriovenous fistula creation for hemodialysis?

A. Pre-dialysis when eGFR is < 60 ml/min/1.73 m²

B. Pre-dialysis when eGFR is 15 – 20 ml/min/1.73 m²
C. Pre-dialysis when eGFR is < 10 ml/min/1.73 m²
D. After dialysis initiation and central venous catheter insertion
E. Only if there are recurrent issues with a central venous catheter

17. The philosophical framework for approaching wound closure options based on increasing technical complexity is
known as which of the following?

A. Reconstructive buffet
B. Reconstructive ladder
C. Reconstructive universe
D. Reconstructive pallet

18. A 26-year-old female G1P0 presents with a positive pregnancy test, a likely left tubal ectopic pregnancy, and a
large amount of free fluid consistent with blood. She is hemodynamically stable. The best plan for this patient would
be which of the following?

A. Single-dose methotrexate 50 mg/m²

B. Laparoscopic removal of the fallopian tube with the ectopic pregnancy (salpingectomy) or removal of the ectopic
pregnancy but keeping the fallopian tube in-situ (salpingotomy)
C. Laparotomy with removal of the fallopian tube with the ectopic pregnancy
D. Laparoscopic removal of BOTH fallopian tubes

19. A 25-year-old male presents with a left testicular mass. Scrotal ultrasound confirms the presence of a
heterogeneous mass. Alpha fetoprotein (AFP) is 45 ng/ml (N1 10 – 20 ng/ml). The patient undergoes an uneventful
left radical orchiectomy. Final pathology could include all of the following EXCEPT:

A. Embryonal cell carcinoma

B. Yolk sac carcinoma
C. Seminoma

20. A 20-year-old man presents with intermittent rectal bleeding. On physical exam, the patient appears to have
several firm, fixed soft tissue nodules on the torso and extremities. He reports that many of his family members on
his mother’s side have cancer in their abdomens. The appropriate next step is which of the following?

A. Observation
B. Colonoscopy and genetic testing
C. PET CT
D. Biopsy soft tissue nodules

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S.No. Questions

20. A 20-year-old man presents with intermittent rectal bleeding. On physical exam, the patient appears to have
several firm, fixed soft tissue nodules on the torso and extremities. He reports that many of his family members on
his mother’s side have cancer in their abdomens. The appropriate next step is which of the following?

A. Observation
B. Colonoscopy and genetic testing
C. PET CT
D. Biopsy soft tissue nodules

21. Colonoscopy of the previous patient shows numerous colonic adenomas, several with evidence of recent bleeding.
Biopsies do not show adenocarcinoma. Genetic testing reveals APC mutation. The appropriate next step is which
of the following?

A. Observation with colonoscopy

B. Total proctocolectomy with end ileostomy
C. Colectomy with ileorectal anastomosis
D. Immune therapy

22. Which of the following statements is FALSE?

A. In patients undergoing surgery for primary, localized gastrointestinal stromal tumor (GIST), 3 years of adjuvant
imatinib improves recurrence-free and overall survival rates compared to 1 year of adjuvant therapy.
B. Radiation therapy and limb-sparing surgery has similar disease-free and overall survival rates to amputation for
extremity sarcoma.
C. Preoperative radiation is associated with higher rates of wound complications but lower rates of late toxicities
such as joint stiffness and worse long-term function.
D. Preoperative radiation therapy reduces rates of abdominal local recurrence in patients undergoing surgery for
primary retroperitoneal sarcoma.
E. Front-line watchful waiting is an appropriate option for patients with asymptomatic desmoid tumors.

23. A 45-year-old woman presents with a lump in her right axilla that she has noticed for 3 months. She has no
constitutional symptoms and no recent infections. Mammogram is normal. Complete physical exam reveals no
other suspicious lesions. The mass is ~ 2 cm is diameter, firm, and non-tender. There is no surrounding erythema.
The most appropriate next step is which of the following?

A. Antibiotics
B. Core needle biopsy
C. Excisional biopsy
D. Sentinel node biopsy

24. The core needle biopsy of the right axilla in the previous patient shows that it is a lymph node involved with
metastatic melanoma. There are no skin lesions on the patient’s body. PET CT shows FDG-uptake in the right
axilla but there are no other signs of abnormal metabolic activity. The most appropriate next step is which of the
following?

A. Formal lymph node dissection

B. Immune therapy only
C. Mastectomy
D. Chemotherapy + radiation therapy only

25. A 56-year-old man was incidentally found to have a 4-cm right-sided adrenal mass on a CT done for abdominal
pain. The next best step in the evaluation of the mass is which of the following?

A. Laparoscopic
B.
C.
D. Biopsy
Follow-up imaging
Biochemical work-up
right in
adrenalectomy
3to–rule
6 months
out functional adrenal mass
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25. A 56-year-old man was incidentally found to have a 4-cm right-sided adrenal mass on a CT done for abdominal
pain. The next best step in the evaluation of the mass is which of the following?

A. Biopsy
B. Laparoscopic right adrenalectomy
C. Follow-up imaging in 3 – 6 months
D. Biochemical work-up to rule out functional adrenal mass

26. A lobectomy is performed for a 2.2-cm thyroid nodule with atypical FNA cytology. Final pathology returns as
“noninvasive follicular thyroid neoplasm with papillary-like nuclear features.” The patient should be counseled
regarding next steps with which of the following?

A. Complete thyroidectomy
B. Complete thyroidectomy followed by radioactive iodine ablation
C. No further surgery indicated
D. Ipsilateral central neck dissection followed by surveillance ultrasounds

27. At what measurement (cm) do the National Comprehensive Cancer Network (NCCN) guidelines recommend
excisional or core biopsy of asymptomatic fibroadenomas?

A. 2 cm
B. 3 cm
C. 4 cm
D. 5 cm

28. Which of the following patients should be recommended for an axillary lymph node dissection?

A. Clinical T3N0 invasive ductal cancer ER+ HER2- having upfront mastectomy
B. Clinical T2N0 invasive ductal cancer ER- HER2- having breast conservation following preoperative
chemotherapy
C. Pathologic T2N1 invasive ductal cancer ER+ HER2- following upfront lumpectomy and sentinel node biopsy
(2.5-cm tumor, 1 of 3 nodes with macrometastasis)
D. Clinical T4dN1 invasive ductal cancer ER- HER2+ with complete clinical response following preoperative
chemotherapy

29. Which of the following statements in TRUE regarding Paget’s disease?

A. In 90% of cases, there is no underlying parenchymal carcinoma.

B. Patients with Paget’s disease tend to be younger than breast cancer patients presenting without it.
C. Patients with Paget’s disease are more likely to have hormone receptor positive breast cancer.
D. When the underlying parenchymal disease is present, over 50% of these patients with Paget’s disease have
only ductal carcinoma in situ (DCIS).
E. Population-based data have shown that axillary nodal staging trends in patients with and without Paget’s
disease are similar.

30. Which of the following statements is FALSE regarding male breast cancer?

A. Gynecomastia is not associated with an increased risk of male breast cancer, while obesity and excess estrogen
exposure as well as radiation exposure are.
B. The use of breast conservation for patients with male breast cancer has increased over time.
C. Male breast cancer tends to be treated similarly to female breast cancer.

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30. Which of the following statements is FALSE regarding male breast cancer?

A. Gynecomastia is not associated with an increased risk of male breast cancer, while obesity and excess estrogen
exposure as well as radiation exposure are.
B. The use of breast conservation for patients with male breast cancer has increased over time.
C. Male breast cancer tends to be treated similarly to female breast cancer.
D. When matched for stage and treatment, male breast cancer has a similar prognosis to that of female breast
cancer.
E. Triple-negative breast cancer is more common among male breast cancer patients compared to female breast
cancer patients.

31. You are performing a laparoscopic appendectomy for a 34-year-old female patient with a BMI of 36 kg/m². All
equipment has been passed off. You lose the image on the screen. Which of the following is the most likely cause
and how do you solve the problem?

A. Gas tubing not connected to the insufflator – Connect gas tubing to the insufflator
B. Obese patient – Increase insufflation pressure
C. Loss of light source – Check and tighten loose light cable connections
D. Fogged laparoscope lens – Clean laparoscope lens

32. Laparoscopic inguinal hernia repair expertise is achieved after having performed which of the following?

A. 40 cases
B. 250 cases
C. 75 cases
D. 100 cases

33. When performing a retrorectus hernia repair, the mesh is placed between the rectus muscle anteriorly and which of
the following structures posteriorly?

A. Anterior rectus sheath

B. Posterior rectus sheath
C. Peritoneum
D. Bowel

34. Patients with acute cholecystitis and compared to open cholecystectomy, fenestrating subtotal cholecystectomy is
reported to result in all of the following EXCEPT:

A. Lower common bile duct injury

B. Lower postoperative complications
C. Lower reoperation rates
D. Lower mortality
E. Lower postoperative bile leakage

35. Which of the following is the long-term rate of bile duct stone recurrence in patients undergoing endoscopic
retrograde cholangiopancreatography (ERCP)?

A. Greater than 80%

B. 50%
C. 10%
D. 5%

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35. Which of the following is the long-term rate of bile duct stone recurrence in patients undergoing endoscopic
retrograde cholangiopancreatography (ERCP)?

A. Greater than 80%

B. 50%
C. 10%
D. 5%

36. A 52-year-old man with known Child-Pugh B cirrhosis with hepatitis C is found to have a 4.5-cm mass in the left
lateral liver and a second 2-cm mass in the left medial liver. AFP is 120 ng/ml. Both lesions have arterial
enhancement and venous washout on multi-phase CT. The next step for diagnosis or management is which of the
following?

A. CT-guided biopsy of one tumor

B. Left hepatectomy
C. Referral for transplant evaluation
D. Liver ablation
E. MRI of the abdomen

37. A 75-year-old gentleman presents to clinic, after a recent hospitalization, with painless jaundice. Workup
demonstrated a localized pancreatic head mass. He had an endoscopy performed where a biliary stent was placed
and a biopsy was performed that confirmed pancreatic adenocarcinoma. Contrast-enhanced CT imaging
demonstrates a 2.4-cm ill-defined mass in the head of the pancreas, abutting approximately 180 degrees of the
superior mesenteric vein. Which of the following is the next best step in the management of this patient?

A. Pancreaticoduodenectomy
B. Pancreaticoduodenectomy followed by adjuvant chemotherapy
C. Palliative chemotherapy
D. Neoadjuvant chemotherapy followed by pancreaticoduodenectomy
E. External beam radiation followed by pancreaticoduodenectomy

38. A 69-year-old man is admitted with severe biliary pancreatitis and evidence of evolving necrosis on CT scan. He
develops evidence of systemic inflammatory response syndrome (SIRS) and is on a ventilator in the ICU. On
hospital day 7, he develops a fever to 101.5° and a white blood count of 18K. The next step in management is
which of the following?

A. Percutaneous aspiration of the necrosis for gram stain and culture

B. Interventional radiology placement of multiple drains in the collection
C. Transgastric endoscopic debridement
D. Open surgical debridement

39. Compared to an open approach, a laparoscopic splenectomy leads to which of the following?

A. Shorter surgery time

B. Shorter length of stay
C. Reduced rate of identifying an accessory spleen
D. Better outcomes when done for massive splenomegaly

40. In the management of benign and malignant tumors of the esophagus, which of the following statements is TRUE?

A. Radiofrequency ablation is used to treat squamous papilloma.

D. Endoscopic
E. The CROSSmanagement
regimen consists
is reserved
of sequential
for up to
neoadjuvant
T2 lesions.chemotherapy followed by radiation therapy.
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40. In the management of benign and malignant tumors of the esophagus, which of the following statements is TRUE?

A. Radiofrequency ablation is used to treat squamous papilloma.

B. Circumferential leiomyomas can be resected with a minimally invasive approach consisting of enucleation.
C. Endoscopic mucosal resection is the best approach for benign duplication cysts.
D. The CROSS regimen consists of sequential neoadjuvant chemotherapy followed by radiation therapy.
E. Endoscopic management is reserved for up to T2 lesions.

41. Which of the following is the operation of choice for a systematic type III hiatal hernia with a BMI of 41?

A. Hiatal hernia repair + Nissen fundoplication

B. Hiatal hernia repair + Toupet fundoplication
C. Hiatal hernia repair + gastric bypass
D. Hiatal hernia repair + gastropexy + G-tube

42. Which of the following is TRUE about a perioperative chemotherapy regimen of epirubicin, cisplatin, and infused
fluorouracil (ECF) for patients with operable gastric or lower esophageal adenocarcinoma?

A. Perioperative ECF does not show improvement over surgery alone

B. ECF only decreases the tumor size
C. ECF only decreases the tumor stage
D. ECF decreases tumor size and stage and significantly improved progression-free and overall survival

43. The Roux-en-Y gastric bypass has been shown to be as effective as medical treatment for several obesity-related
conditions EXCEPT:

A. Type 2 diabetes mellitus

B. Hypertension
C. Gastroesophageal reflux
D. Iron deficiency anemia
E. Nonalcoholic fatty liver disease (NAFLD)

44. A 60-year-old man with a history of smoking and alcohol abuse presents to the ED with severe abdominal pain,
nausea, vomiting, tachycardia to 120 bpm, hypotension 90/60 mm Hg, and tenderness throughout the abdominal
region. A small amount of free air is seen on an abdominal CT scan. Which of the following is the best treatment for
his condition?

A. Nasogastric tube placement, IV resuscitation, antibiotics, proton pump inhibitors

B. Open subtotal gastrectomy, truncal vagotomy, and BII reconstruction
C. Endoscopy with epinephrine injection
D. Send the patient to the interventional radiology suite for embolization of the left gastric artery
E. Laparoscopic washout and closure by Graham patch technique

45. Which of the following is the amount of time one should wait before attempting definitive closure of an
enterocutaneous or enteroatmospheric fistula?

A. Time to operation is not associated with surgical outcomes

B. 2 weeks after fistula onset
C. 1 month after fistula onset
D. At least 3 – 6 months after fistula onset

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45. Which of the following is the amount of time one should wait before attempting definitive closure of an
enterocutaneous or enteroatmospheric fistula?

A. Time to operation is not associated with surgical outcomes

B. 2 weeks after fistula onset
C. 1 month after fistula onset
D. At least 3 – 6 months after fistula onset

46. A 48-year-old female with a 20-year history of ulcerative colitis has a colonoscopy. There is multifocal dysplasia in
the right and left colon. The rectum is spared. She has been maintained on 5-ASA agents for the entire time. The
most appropriate treatment is which of the following?

A. Start biologic therapy with infliximab

B. Total abdominal colectomy with ileorectal anastomosis
C. Three-stage proctocolectomy with IPAA
D. Proctocolectomy with IPSS and loop ileostomy

47. A reasonable indication for elective surgery for diverticulitis would be which of the following?

48. A 62-year-old male with no significant past medical history undergoes a right colectomy for colon cancer.
Preoperative CT scan – chest/abdomen/pelvis – did not show any signs of distant metastatic disease. Pathology
reveals moderately differentiated adenocarcinoma, T2, with 2/20 lymph nodes positive. Which of the following is the
next best step in management?

A. Radiation therapy
B. Active surveillance
C. Chemotherapy
D. Subtotal colectomy

49. The Stockholm III clinical trial suggests which of the following regarding radiotherapy and surgery for rectal cancer
as a useful alternative?

A. Short-course radiotherapy with delay in surgery

B. Short-course radiotherapy with immediate surgery
C. Long-course radiotherapy with delay in surgery
D. Long-course radiotherapy with immediate surgery

50. Which of the following is FALSE about the use of nifedipine 0.3% compounded with lidocaine 2% topically QID in
the medical management of anal fissure?

A. It decreases blood flow

B. It relaxes smooth muscle
C. It produced fewer headaches
D. It has better compliance

51. Treatment of intracranial pressure (ICP) elevations in the ICU includes all of the following EXCEPT:

A. CSF drainage
C. Head
D.
E. Mannitol
Hypertonic
of bedstate
flat
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51. Treatment of intracranial pressure (ICP) elevations in the ICU includes all of the following EXCEPT:

A. CSF drainage
B. Sedation
C. Mannitol
D. Hypertonic state
E. Head of bed flat

52. Which of the following is a DISADVANTAGE of the median sternotomy incision?

A. Higher pulmonary complications when compared to thoracotomy

B. Poor approach for access to the heart
C. Difficult to access the descending thoracic aorta for cross clamp
D. Poor approach for access to the distal trachea

53. A 24-year-old male is in the trauma bay after a high-speed motor vehicle collision. His heart rate is 130. His blood
pressure is 92/62. His oxygen saturation is 98% on nasal cannula. Primary and secondary surveys reveal GCS of
14 and he is protecting his airway. There is tenderness and bruising to his left chest and abdomen. Chest x-ray and
pelvic x-ray are unremarkable, and FAST exam is positive in the left upper quadrant. IV access is obtained and
blood transfusion is initiated. His vital signs and clinical presentation remain unchanged. The most appropriate next
step in management would be which of the following?

A. Admission to the intensive care unit for serial hemoglobin monitoring

B. Emergent intubation in the trauma bay to secure airway
C. CT scan to evaluate for injuries to head, neck, chest, abdomen, or pelvis
D. OR for exploratory laparotomy

54. When calculating the total body surface area (TBSA) burn for patients, you should include which of the following?

A. All degrees of burn injury: first degree, partial thickness burns, and full thickness burns
B. Only partial thickness burns and full thickness burns
C. Only full thickness burns
D. The TBSA should be calculated during the primary survey for a patient undergoing ATLS or ABLS resuscitation

55. A 42-year-old female is admitted to the SICU after a fall from 30 feet, sustaining a subdural hematoma, multiple
spinal fractures, and a grade III splenic laceration managed nonoperatively. Since admission, she has received 10
L crystalloids and 2 units pRBC. She is sedated and mechanically ventilated on AC mode. You are called by the
SICU team for slowly rising peak airway pressures without any other changes in ventilatory parameters. The patient
is suctioned with scant amount of bloody secretions. Her urine output has also decreased from 70 cc/hr to 15 cc/hr.
Which of the following is the next most appropriate step in management?

A. Neuromuscular blockade
B. Bladder pressure measurement
C. Fluid bolus with 1 L crystalloid
D. Change to PC ventilation

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