1. 
   
   vessel radius
2. 
   
   vessel length
3. 
   
   fluid viscosity
4. 
   
   vessel length to the second power
5. 
   
   vessel radius to the fourth power

1. 
   
   capillaries
2. 
   
   arteries
3. 
   
   arterioles
4. 
   
   venules
5. 
   
   aorta

A 40-year-old, moderately obese man presents with a persistent productive cough. The cough has been present for several weeks, but recently the man noted that his sputum has assumed a greenish color. Further questioning elicits a history of productive cough , usually in the winter months, over the past several years. He has smoked two packs of cigarettes per day since he was 16 years old. On examination, the man is febrile (100° F), and coarse rhonchi and wheezes can be appreciated bilaterally. Which of the following is the most likely diagnosis?

A. Bronchogenic carcinoma
B. Chronic bronchitis with superimposed infection
C. Cystic fibrosis
D. Emphysema
E. Pulmonary tuberculosis

Answer

A 7- year-old girl develops behavioral changes, and her performance in school begins to deteriorate. Several months later she develops a seizure disorder, ataxia, and focal neurologic symptoms. She is eventually quadriparetic, spastic, and unresponsive. Death occurs within a year. This patient may have had which of the following viral diseases at 1 year of age?
A. Chickenpox
B. German measles
C. Measles
D. Mumps
E. Parvovirus B19

Answer

A healthy, 37-year-old, recently divorced woman loses her job at the auto factory. She picks up her three young children from the factory day care center and gets into an automobile accident on the
way home. Her 5-year-old son, who was not wearing a seat belt, sustains a severe head injury. The woman was not hurt in the accident, but is hyperventilating as she sits in the waiting room at the
hospital. She complains of feeling faint and has blurred vision. Which of the following is decreased in this woman?
A. Arterial oxygen content
B. Arterial oxygen tension (PO2)
C. Arterial pH
D. Cerebral blood flow
E. Cerebrovascular resistance

Answer

A 37-year-old female presents to the emergency room with a fever. Chest x-ray shows multiple patchy infiltrates in both lungs. Echocardiography and blood cultures suggest a diagnosis of acute bacterial endocarditis limited to the tricuspid valve. Which of the following is the most probable etiology?
A. Congenital heart disease
B. Illicit drug use
C. Rheumatic fever
D. Rheumatoid arthritis
E. Systemic lupus erythematosus

Answer

A. CT of the abdomen.

B. Contrast study of the intestine.

C. Supine and erect x-rays of the abdomen.

D. Ultrasonography of the abdomen.

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A. CT of the abdomen.

B. Ultrasonography of the gallbladder.

C. Oral cholecystogram.

D. Radionuclide (HIDA) scan of the gallbladder.

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A. Proximal jejunum.

B. Distal jejunum.

C. Proximal ileum.

D. Distal ileum.

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A. Persons aged 60 and older.

B. Women aged 18 to 35.

C. Infants younger than 1 year.

D. Pregnant women.

A. Prophylactic antibiotics should be administered.

B. Prophylactic antibitics are not necessary unless there is evidence of perforation.

C. If the appendix is not ruptured and not gangrenous, antibiotics may be discontinued after 24 hours.

D. Multiple antibiotics are in all cases preferable to a single agent.

A. After menopause.

B. In patients with unilateral lower abdominal pain.

C. During the menstrual cycle.

D. In patients with cervical tenderness and vaginal discharge.

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A. Temperature above 104؛ F.

B. Frequent loose stools.

C. Anorexia, abdominal pain, and right lower quadrant tenderness.

D. White blood cell count greater than 20,000 per cu. mm.

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A. A viral infection.

B. Acute gastroenteritis.

C. Obstruction of the appendiceal lumen.

D. A primary clostridial infection.

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A. Mesenteric cysts are most often due to congenital lymphatic spaces that gradually fill with lymph.

B. Mesenteric cysts usually present as abdominal masses accompanied by pain, nausea, or vomiting.

C. Mesenteric cysts are best treated by marsupialization.

D. Omental cysts are frequently asymptomatic unless they undergo torsion.

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A. The disease rarely occurs after menopause.

B. Gonococcal infection is most common.

C. There is minimal cervical tenderness to palpation.

D. Vaginal discharge occurs rarely.

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29. Which of the following statements concerning intraperitoneal fluid collections are correct?

A. Ascites occurs when either the peritoneal fluid secretion rate increases or the absorption rate decreases.

B. Accumulation of lymph within the peritoneal cavity usually results from trauma as tumor involving the intra-abdominal lymphatic structures.

C. Choleperitoneum (intraperitoneal bile) generally occurs following biliary surgery, but spontaneous perforation of the bile duct has been reported.

D. The most common cause of hemoperitoneum is trauma to the liver or spleen.

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30. The following statement about peritonitis are all true except:

A. Peritonitis is defined as inflammation of the peritoneum.

B. Most surgical peritonitis is secondary to bacterial contamination.

C. Primary peritonitis has no documented source of contamination and is more common in adults than in children and in men than in women.

D. Tuberculous peritonitis can present with or without ascites.

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The following statement(s) is/are true concerning abdominal incisional hernias.

1. Large incisional hernias are associated with a high recurrence rate when closed primarily

2. A large potential space remains anterior to the abdominal wall closure in most patients indicating a need for postoperative wound drainage

3. The use of prosthetic mesh can often be avoided by employing relaxing incisions in the anterior fascia parallel to the midline

4. Incisional hernias are frequently associated with a tissue deficit either due to chronic retraction and scarring or the result of tissue necrosis from either infection or tension at the initial closure

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Which of the following structures are derived from the external oblique muscle and its aponeurosis?

1. The inguinal or Poupart’s ligament

2. The lacunar ligament

3. The superficial inguinal ring

4. The conjoined tendon

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A number of special circumstances exist in the repair of inguinal hernias. The following statement(s) is/are correct.

1. Simultaneous repair of bilateral direct inguinal hernias can be performed with no significant increased risk of recurrence

2. The preperitoneal approach may be appropriate for repair of a multiple recurrent hernia

3. A femoral hernia repair can best be accomplished using a Bassini or Shouldice repair

4. Management of an incarcerated inguinal hernia with obstruction is best approached via laparotomy incision

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

1. All incarcerated hernias are surgical emergencies and require prompt surgical intervention

2. Attempt at reduction of an incarcerated symptomatic hernia is generally considered safe

3. Vigorous attempts at reduction of an incarcerated hernia may result in reduction en masse with continued entrapment and possible progression to obstruction or strangulation

4. Incarcerated hernias frequently cause both small and large bowel obstruction

1. Chronic cough

2. Urinary hesitancy and straining

3. Change in bowel habit

4. A specific episode of muscular straining with associated discomfort

The following statement(s) is/are true concerning the anterior abdominal wall musculature.

1. The lateral musculature of the abdominal wall consists of three muscle layers. These are, from external to internal, the external oblique, the transversus abdominis, and the internal oblique muscles

2. The transversalis fascia lies on the deep side of the transversus muscle and extends to form an essentially complete fascial envelope of the abdominal cavity

3. Above the semicircular line, the internal oblique aponeurosis splits into posterior and anterior laminae

4. The rectus abdominis muscles originate on the ribs superiorly and on the pubis inferiorly and are clearly distinct throughout their entire length

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A 48-year-old woman maintained on Warfarin for a history of cardiac valvular replacement and a history of recent upper respiratory infection presents with severe abdominal pain exacerbated by movement. Her physical examination shows tenderness in the right paramedian area with voluntary guarding but no peritoneal signs. The following statement(s) is/are true concerning the diagnosis and management of this patient.

1. Urgent laparotomy should be performed because of concern for arterial mesenteric embolus

2. The correct diagnosis could likely be made by CT scan and operation avoided

3. The status of her anticoagulation should be checked and if her prothrombin time is excessively prolonged, correction is necessary

4. If untreated, hemodynamic instability is common

True statements concerning the diagnosis and management of retroperitoneal fibrosis include:

1. Most patients present with dull, non-colicky back, flank, or abdominal pain

2. Evidence of impaired renal function with an elevated blood urea nitrogen is common

3. The diagnosis is most commonly suggested by intravenous pyelography although contrast studies with CT scan or MRI are useful in further defining the disease

4. Most patients can be managed nonoperatively

5. The prognosis for nonmalignant retroperitoneal fibrosis is grim with progression of disease until death occurring in most patients

Retroperitoneal fibrosis is a fibrosing condition of retroperitoneum, which is of significance as it generally encompasses the ureters and eventually causes hydronephrosis and kidney damage. Which of the following statement(s) is/are true concerning this condition?

1. The majority of cases are idiopathic in nature

2. A history of use of methysergide for treatment of migraine headaches would be significant

3. There is no known association of malignancy with retroperitoneal fibrosis

4. The disease occurs more commonly in women than in men

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A 77-year-old multiparous female presents with a bowel obstruction. She has no previous abdominal operations and no abdominal wall hernias can be detected. In addition to her abdominal symptoms, she reports pain in her right medial thigh. The following statement(s) is/are true concerning her diagnosis and management.

1. Expectant management with nasogastric suction and IV fluid replacement is indicated

2. A right groin approach is indicated for exploration and repair of the presumed hernia

3. The use of a polypropylene mesh will likely be necessary for repair

4. A correct diagnosis can usually be made by visualizing an external mass in the upper, medial thigh

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The following statement(s) is/are true concerning umbilical hernias in adults.

1. Most umbilical hernias in adults are the result of a congenital defect carried into adulthood

2. A paraumbilical hernia typically occurs in multiparous females

3. The presence of ascites is a contraindication to elective umbilical hernia repair.

4. Incarceration is uncommon with umbilical hernias

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A 28-year-old woman with a history of an appendectomy presents with a nontender palpable mass in the right lower quadrant abdominal incision. The following statement(s) is/are true concerning the diagnosis and management of this patient.

1. The best diagnostic test involves imaging of the abdominal wall by either CT or MRI

2. Resection of the mass with a 2 cm margin is usually adequate

3. Low dose radiation is a suitable alternative to surgery for primary treatment

4. Re-resection for recurrence will likely have a higher rate of recurrence than for primary resection

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Which of the following statement(s) is/are true concerning repair of inguinal hernias?

1. The Bassini repair approximates the transversus abdominis aponeurosis and transversalis fascia and the shelving edge of the inguinal ligament.

2. The Bassini repair is an adequate repair for a femoral hernia

3. A relaxing incision is important for repairs of direct and large indirect inguinal hernias to prevent excessive tension in the closure

4. An advantage to the use of prosthetic material is the mesh incites formation of scar tissue to further increase tensile strength provided by the mesh alone

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The following statement(s) is/are true concerning the epidemiology of inguinal hernias.

1. Inguinal hernias occur with a male-to-female ratio of about 7:1

2. Femoral and umbilical hernias are more common in women, with a female-to-male ratio of 4:1

3. The frequency of inguinal hernias increases with age

4. Almost all umbilical hernias occur in the pediatric age group

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Chylous ascites is the accumulation of chyle within the peritoneal cavity. Which of the following statement(s) is/are true concerning chylous ascites?

1. The cisterna chyli lies at the anterior surface of the first and second lumbar vertebrae and receives lymphatic fluid from the mesenteric lymphatics

2. Chylous ascites is most commonly associated with abdominal lymphoma

3. Paracentesis and analysis of chylous fluid typically reveals elevated triglycerides, protein, and leukocyte levels with cytologic analysis reflecting the underlying presence of malignancy

4. Treatment of chylous ascites with dietary manipulation will be successful in most cases

5. The mortality rate in adults with chylous ascites is in excess of 50%

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Which of the statement(s) is/are true concerning laparoscopic hernia repair?

1. General anesthesia is required

2. Either an abdominal or preperitoneal approach is possible

3. The use of prosthetic mesh is required in all variations

4. Long-term results suggest that the laparoscopic approach is equal or better than traditional repairs

In advising a patient preoperatively of potential complications of operative treatment of an inguinal hernia, which of the following statement(s) is/are true?

1. Severe symptoms due to sensory nerve entrapment or injury can occur

2. The most common vascular structure injured during the course of a groin hernia repair is the femoral artery

3. Recurrent hernia after primary groin repair should occur in less than 10% of cases

4. Wound infection increases the risk of recurrent hernia

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The following statement(s) is/are true concerning neurovascular structures in the inguinal region.

1. The inferior epigastric artery and vein run upward in the preperitoneal fat posterior to the transversalis fascia close to the lateral margin of the internal inguinal ring

2. The iliohypogastric and ilioinguinal are motor and sensory nerves in the inguinal region which lie beneath the external oblique aponeurosis

3. The ilioinguinal nerve runs anterior to the spermatic cord in the inguinal canal and at the superficial inguinal ring, branches into the sensory supply to the pubic region and the upper scrotum or labium majoris

4. The genital branch of the genitofemoral nerve is a sensory nerve only to the upper thigh and genital area

In addition to its absorptive and digestive roles, the small bowel also plays a significant role in the body’s immune system. Gut-associated lymphoid tissue (GALT) represents a major division of the immune system. Which of the following statement(s) is/are true concerning the immunologic functions of the small intestine?

1. 
   
   The B lymphocytes of the small intestine do not produce immunoglobulin A (IgA)
2. 
   
   Peyer’s patches, an example of an aggregated cellular portion of the gut-associated lymphoid system tissue, are large collections of lymphoid follicles found on the antimesenteric border of the ileum
3. 
   
   The major immunoglobulin of the intestinal immune system is IgM
4. 
   
   IgA produced by the intestinal immune system produces the classic Fc-mediated inflammatory reactions to antigen stimulus

During the fasting state, a well-defined pattern of small bowel electrical activity occurs which is known as the interdigestive myoelectric complex or the migrating motor complex (MMC). Which of the following statement(s) is/are true concerning the MMC?

1. 
   
   This complex consists of a cyclic pattern of spike bursts and muscular contractions that migrate from the duodenum to the terminal ileum and can be divided into four phases
2. 
   
   The major activity during the MMC occurs during phase I
3. 
   
   In humans the MMC usually lasts less than one hour
4. 
   
   Blood levels of the GI peptide, motilin, correlate closely with MMC activity and exogenous motilin can induce the MMC front

1. 
   
   The second (descending), third (transverse) and fourth (ascending) portions of the duodenum lie in the retroperitoneum and are mobilized for surgical procedures via the Kocher maneuver
2. 
   
   The identification of the superior mesenteric vein and artery can be facilitated by an extensive Kocher maneuver mobilizing the transverse portion of the duodenum and exposing the vessels as they course over the duodenum and under the neck of the pancreas
3. 
   
   In only the minority of patients can the accessory pancreatic duct (the duct of Santorini) be seen on endoscopic exam entering the duodenum
4. 
   
   The ileum is the widest portion of the small intestine, with the diameter of the small bowel progressively increasing as the ileocecal valve is approached

A. Halstead-Reitan Battery
B. Stanford Binet Intelligence Test
C. Vineland Adaptive Behavior Scale
D. Wechsler Adult Intelligence Scale
E. Wide Range Achievement Test

Answer

A. ampicillin
B. cefaclor
C. ciprofloxacin
D. sulfamethoxazole/trimethoprim
E. tetracycline

Answer

A patient develops an acute febrile illness with shivers, nonproductive cough, and pleuritic chest pain. Five days later, he presents to the emergency room after abruptly having "coughed up" nearly a cup of
blood-stained sputum. Which of the following is most likely to be seen on chest x-ray?
A. A cavity with a fluid level
B. Blunting of diaphragmatic costal angles
C. Complete opacification of one lobe with no additional findings
D. Patchy consolidation centered on bronchi
E. Prominent bronchi that can be followed far out into the lung fields

Answer

1. 
   
   Cholecystokinin (CCK) is produced from cells in the mucosa of the duodenum and jejunum and is released in response to luminal fats and proteins
2. 
   
   Secretin is released in response to rising intraduodenal pH, resulting in inhibition of pancreatic secretion
3. 
   
   Motilin is a 22-amino acid peptide released during the fasting state with increased levels corresponding with the onset of the migrating motor complex (MMC)
4. 
   
   Neurotensin is produced primarily in the duodenal mucosa and its release is stimulated primarily by carbohydrates and proteins

1. The enterohepatic circulation is highly efficient with 80% to 90% of secreted bile salts reabsorbed and returned to the liver through the portal circulation
2. The reabsorption of bile is entirely an active process
3. The small amount of bile escaping in the colon is deconjugated by bacteria, promoting lipid solubility and passive colonic absorption
4. Ileal resection results in presenting high concentrations of bile salts to the colon which promotes diarrhea by bacterial overgrowth

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?

1. 
   
   The jejunum is the site of maximum absorption for most ingested materials with almost all jejunal absorption performed via active transfer mechanisms
2. 
   
   Eighty percent of water presented to the gastrointestinal system is reabsorbed by the small bowel
3. 
   
   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
4. 
   
   Dietary fiber represents poorly digestible carbohydrates which can absorb organic materials such as bile salts and lipids

1. 
   
   Most of gas seen on plane abdominal radiographs is produced by gas forming microorganisms
2. 
   
   Elevation of luminal pressure contributes to fluid accumulation in the small bowel in closed loop but not open loop small bowel obstructions
3. 
   
   Intestinal blood flow initially increases to the bowel wall in early bowel obstruction
4. 
   
   In the face of obstruction, myoelectrical activity of the bowel is consistently increased

1. 
   
   Proximal small bowel obstruction
2. 
   
   Distal small bowel obstruction
3. 
   
   Acute appendicitis
4. 
   
   Closed-loop small bowel obstruction

1. 
   
   Simple obstruction secondary to an adhesion is most likely to resolve nonoperatively
2. 
   
   It is most likely that the patient’s obstruction is secondary to recurrent malignancy
3. 
   
   A history of colon cancer makes carcinomatosis the most likely diagnosis
4. 
   
   Lower abdominal procedures are more likely to result in obstructive adhesions than are upper abdominal procedures

1. 
   
   The presence of a white blood cell count > 15,000 would be highly suggestive of a closed-loop obstruction
2. 
   
   Metabolic acidosis mandates emergency exploration
3. 
   
   An elevation of BUN would suggest underlying renal dysfunction
4. 
   
   There is no rapidly available test to distinguish tissue necrosis from simple bowel obstruction

1. 
   
   Contrast enema
2. 
   
   Enteroclysis study with dilute barium
3. 
   
   CT scan with dilute barium oral contrast
4. 
   
   None of the above

1. 
   
   Colon distension with a cecal diameter in excess of 12 cm should indicate the need for urgent operation
2. 
   
   Endoscopic decompression may be attempted but seldom is successful
3. 
   
   After successful colonoscopic decompression, recurrence is unlikely
4. 
   
   A rectal tube as the primary treatment is generally not successful

1. 
   
   In the United States, peritoneal adhesions account for over half of the cases of small bowel obstruction
2. 
   
   A leading cause of bowel obstruction is early postoperative adhesions
3. 
   
   Bowel obstruction cannot occur with a Richter’s hernia
4. 
   
   Ninety percent of adult cases of intussusception are associated with a pathologic process, most commonly a tumor

Which of the following statement(s) is/are true concerning postoperative ileus?

1. 
   
   The use of intravenous patient-controlled analgesia has no effect on return of small bowel motor activity
2. 
   
   The presence of peritonitis at the time of the original operation delays the return of normal bowel function
3. 
   
   The routine use of metoclopramide will hasten the return of small intestinal motor activity
4. 
   
   Contrast radiographic studies have no role in distinguishing early postoperative bowel obstruction from normal ileus

The initial management of this patient should consist of:

1. 
   
   Fluid resuscitation with D5 half normal saline with 40 mEq of potassium chloride/liter
2. 
   
   Placement of an indwelling urinary catheter
3. 
   
   Nasogastric decompression with a nasogastric tube
4. 
   
   Immediate surgery
5. 
   
   The patient should be begun on broad spectrum antibiotics at the time of admission