I 11
I I
2'. A~7 - ear-old man i cbcdulod to undoqo
s id colcctomy for diverticular diaeue.
He nies a history of proloapd bleedina
after itlaa the lip or tonaue, bruios with-
out parent h\jury, or prolc,npd bloodina
.after dental extraction. Ho bu bad a c~
lecyatectomy in tho put without bleedlna
complications. Hi preoperative evaluation
of bemo tui hould include
(A) no screenina tets
(B) prothrombin time (Pr) and partial
thromboplutin time (PTT)
(C) . platelet count, blood mcar, and PIT
(D) platelet count, blood smear, bleedina
time, Pl', and PIT
(E) platelet count, Pl', and PIT
1:1. The most practical and reliable measure of
glomerular filtration is provided by
(A) blood urea nitroaen
(B) hourly urinary output
(C) crealiaine c:learaace
(D) serum crealioioe iietermination
(E) urinary specific aravity
21. Each of .the following facton reqURs vi-
tamin K for its production EXCEPT
(A) antibemophilic globulin
(B) factor X
(C) plasma thromboplastin component
(D) proconvertin
(E) prothrombin
29. Laboratory fmdinp in posttranafuaion hc-
,molysis include all the followina EXCEPT
(A) hcmoglobinuria
(B) elevated free beldoglobin
(C) elevated scrum baptoglobin
(D) seroloaic criteria showing anti&en in-
compatibility of donor and recipient
blood
(E) positive Coombs' test
' ~,
30. On her third day or bo pltallz.atlon, a 70-
yeaM>ld woman who 11 belna treated with
antibiotic, for acute cholecystitl1 develop
Inc~ pain and tendemc11 in the riaht
upper quadrant with a palpable maH. Her
temperature rios to WC (104P) and her
blood prc11uro fall to 80/60 mmHa. Hc-
matemc1i1 and melena ensue and petechiac
are noted. Laboratory studlc reveal
thrombocytopcnla, prolonaed prothrombin
time, and a dccroucd fibrinoaen level. The
most important step in the correction of
this patient's coqulopathy i1
(A) admini1tration of heparin
(8) adminiatratJon of freab frozen pluma
(C) admlolatratioo of whole blood
(D) admiaiatratioo c-1 e-aminocaproic acid
(E) exploratory laparotomy
31. A 45-year-old obese man undergoes sub-
total patrectomy for an antral carcinoma.
On the fifth poatopcrative day, non-foul-
smcllioa acroaaoauincou1 drainqe appears
from the wound. All the followina may
have been contributina factors EXCEPT
(A) malnutrition
(B) atelectasis
(C) anemia
(D) poor technique
(E) ascitcs
31. A 55-ycar-old man was discharacd from
the hospital after havina been treated for
an acute myocardial infarction. One week \I
later he presents to the emcraency room
I
with epipatric and riaht upper quadrant '
abdominal discomfort. An ultrasound is \
.obtained and shows cholclithiuia. His pain
subsides and he is dicharaed with a diaa-
nosis of biliary colic. To minimize the
chances of his havina another Ml, what is
the earliest time that this patient could
undera~ elective cholecystectomy?
(A) Any time
(B) 6 weeks after the Ml
(C) 3 months after ~ Ml
(D) -i to S months after the Ml
(E) .More than 6 months after the Ml
- --

33. ~
~ {\
tfill~
\

""''' k ft, \ ~ \\\ - ,_.. A ~ VAa1i'riUl \ltt"lhi lM

1
\ ~1 ~ vrlPI troffl
l ~ ,- lb, ~~ Ml~n,tk\4, CN pUt l\\tlt Uut Of thl Mh poe
"4 ttw '1Y dtvt l"l'I rtvt aild c;oo,plaln of
cl\ \:-~ ""~~ \ "' M1\r.1t1 ~ Min Ill lh 1ttk,'4' of th lt t\ tltl'Otld tland
tL~
(C) ~ ~ ~ ~ ~ -. l. wtth ' At,Uhkll~ IMl-.&\Y' f\lt' lhl. patJ.nt 1houJd
or
bl ~~ '411 whlob tM followln, orpn
\IUl
~ft\
mthe ~'~ ' t ~ ~ l-1
\ . ltnu
(D) :~~ \'l P'~hl~ t\\ '"'"'''
\'R) ~tbl ~~ ~ i\Wi~ -M
3'. Three mafttt-1 II'), , ' ~ mu u.~
derweal l ~ lftlft\\~~ lMt It U
roth t\ 1.na,~1, Thi ll\11\ ft\\W Ml~ JP. "-f\r l da)ll QI 1111iWodo trutmtnl, tlM pa-
" ~tm a.l'ld ~ , ,~, qttw,, lltftt lt 11ilt ttbfll and hu pain ud totm
d l ~ ~ lht n'8.ll, i"M llllll 11 lwt.llh\l about lbt parodd aland, At thl
relitftd wht1' he ~ttl bli\001 nllmill, l)Olnt U11t.mtf1t thould comlat of
whid, b l Mt contlh\ foolt s,art~ ltl, 1\1
most tttety d~l ll (A) I ~hlap rJ anllbk>ticit
Un ~ llauatklCi ol tht orillMI uulbk>tlc
(A) d\lffiP1"8 ~ 'A.ntU ultu"' Uld Nn1ltlvhy re1ultt
lB liftnal ~ ~ - - Mt known
(C) duodeaal itwnp ~ " " ' (C) lmd&ll&on thorap,y
(D) p.,tric cwtlet ubltNC~ ( > lm..sllt1 lnoluon and dnl.11111
(B) none af the 1bo~ ( ~ fl wvm ul1ne compreuet
foul' tlm11 dally -
35. Durlna the caune at an ~
nccromy fur traumatl,c Np(UN, I pllM-1\t ,, A puleo oalmtttr may aiv an lnaccurato
noted to have etttulve ~ bltld- OlYltft ..turatlon nadlna ln tho pnacnce
ina. Dcspte adequate blood replactmeat, rl tlQh of the ro11owtna RXCBl'T
the patient becocMa hypotenalw, t.nd dark
urine it found ln thl coU1ctlna bit, n-. (A) carboqhtfflQllobinemla
most imponant tbenpl\ltio IMUW'I to bl (11) dNpl,y plamenttd akin
taken it ~mlnl1tr1tion at ) h.yperi,lltnabalemla -
(D) rMthlfflOllob!nemla
(A) aterolda (B) opaquo 1\111 Potlth
(B) turonlnltM and bioarbonate
( ) pluma
(D) 5'I deltroM ll\ ttlftllt'I llCllle Ind
potuaium
(Ii) anti~

L
 PMICIPLD OF IURGEIY
4
I
I 23, In the awake, n~~
. -.-.L~9M patient IIIS-
uransfu-
r.-
~
I
A 65-year-old man und:entc:>iea an abdominoperi-
pectcd of bavina a beJDC?l,~~.tic si8nS
aion reaction, ~ most emu-----
ii

ncal resection for id carcinoma with- are

?11' any i n ~ v e com cations. Blood k>U
11 replaced volume for vol , and urine output
is main~ at_20 to~ mti. Postoperatively,
the patient re<:eaves appropriate replacement of
gastrointestinal fluid losses and mainte{Wlce flu-
ids cooaiating of 5% dextrose in 0.45% saline at
150m1Jb.
24. All the following findings would indicate
19. The most likely metabolic abnormality to
be found in this_patient 24 b after surgery
is
(A) hypokalemia
(B). hyponatremia
(C) bypernatremia
(D) bypocbloremia
(E) hypoglycemia
20. The patient's metabolic: abnormality is most
likely to be due to
25.
(A) inadequate provision of dextrose
(B) bypotonic fluid administration
(C) inappropriate antidiuretic hormone
(ADH} secretion
(D) loss of chloride
(E) aldosterone secretion
21. Which of the following factors is labile in
ACD bank blood?
(A) Antihemophilic globulin
(B) Christmas factor
(C) Fibrinogen
(D) Proconvertin
(E) Prothrombin
22. Positive end.;.expiratory pressure (PEEP)
ventilation is widely used in the treatment
of acute puimonary failure. The beneficial
effects of PEEP include all the following
EXCEPT
(A) decreased pulmonary 1huntin1 .
(B) decreued extravucular tuna water
(C) increased restin1 volume of the lung
(D) increased oxyaenation
(E) increased pulmonary compliance
(A) diffuse bleedinl ~ bypotensioo
(B) naUIA and vomitinl
(C) fever and chills
(D) olipria and bcmDllobinuria
(E) cyanosia and dyspnea
C
that a patient requires mechanical ventila-
tory support EXCEPT
)
(A) respiratory rate greater than 30
breaths per minute
(B) vital capacity less than 1.S mL/ka
(C) maximal inapiratory force of - 40
cmH10
(D) alveolar-arterial oxygen gradient
greater than 350 torr
(E) Pacoi greater than 60 torr
A 57-year-old woman who has rheumatic
heart disease presents with a 12-h history
of increasina riaht lower quadrant pain as-
sociated with nausea and vomitina. A di- I
agnosis of appendicitis is made. History re-
veals that she suffered a transient ischemic
attack 3 years ago and since then has been
taking warfarin (Coumadin). Laboratory
data are as follows: white blood cell count,
13,000/mm3; bematocrit, 45 percent; and
protbrombin time, 40 percent of normal. I I
Management of this patient should include I
(A) administration of vitamin K; surgery
in 12 h
(B) administration of vitamin K and fresh
frozen plasma; immediate awpry
(C) administration of vitamin K imJDe..
diate surgery with low-dose heparin
intraoperatively
(D) administration of fresh frozen plate-
' leta; immediate sursery
(E) none of the above
 111

, Ql&Udo,u 153-154 155, When a patient i1 11tlC11\ with ia t11h wound

of the neck that hill h\iured the lr.fi VMto
A 45-ycar-old woman is admitted to a hospital be-
brat ar1ery, the most froquont llnl ill fi1ul
cause of a third-degree bum irtjury to 40 percent
in1 is
of her total body surface area, and her wounds
arc treated with topical silver sulfadiazinc cream (A) hemiparc1i1
(Silvadene). Three days followina admission, (B) hemiploaia
a bum wound biopsy cmiquantitativc culturo (C) homorrhqio 1hook
shows 104 Pst'udomonas orpniams per anun of (D) monocular blinchu.,u
tissue. The patient's condition is stable at this (B) stable hcmatoma
time.
156. For pationts seen within I h ot' " rn1tl11
153. The most appropriate management for this snake bile In which vcmom hh h~11n 111
patient would be to jcctcd, effective Ul:latmcmt may In hhlc, i11l
the followin1 moasurQs RXCHP'l'
(A) repeat the biopsy and culture in 24 h
(B) start subeschar clysis with antibiotics (A) antivenin
(C) administer systemic antibiotics (B) application or a tourniquet
(D) administer anti-Pst>udomonas vac- (C) incision and 1uotlon
cine (D) wide cxoialon
(E) surgically excise the bum wounds (6) cryotherapy

154. Twelve days following her admission to the
hospital, the patient develops a spiking
temperature curve, and blood cultures are
found to be positive for gram-positive or-
ganisms (Staphylococcus) sensitive to
methicillin, vancomycin, and clindamycin.
On physical examination, the only positive
findina is a small amount of pus that can be
expressed above the ankle from the riaht
greater saphenous vein, at the site where a
venous infusion catheter was removed 1
week ago. The best treatment for this com-
plication is to
(A) apply warm compresses to and ele-
vate the affected leg while maintain-
ing the patient on bed rest
(8) elevate the affected lea and adminis-
ter intravenous methicillin in a hiah
dosaae
(C) elevate the affected lea and start a 10-
day coune of intravenous vancomy-
cin
(D) toe.ally excise the offendina vein by
removina at least -4 cm above and be-
low the point of entry and leave the
wound open
(E) completely excise the offcndina vein,
leave the entire wound open, and
cover it only with a porcine hctcro-
graft
157. For most pancreatic lr\lurlo1 tlmt involve,
the area to the let) of the 1u1"'rior maaan
teric vessels and that Jl1ru1ll lho ,tuc1 or'
Wlrsuna, the preferred trcutrnont IM
(A) local debrldcmcnt or the wountl 1uul
draina,e
(8) repair of the duct over
I\ tube, 11tont
and drainaac
(C) distal pancrcatoctomy arnd dralnl\Ja
(D) placement of u Roux en Y .loJu1ml
limb anteriorly over tha if\lmy
(B) complete tnu,1cction of tho l'"nc1t.,ll:t,
implantation or hoth omll of tha lll'U
crcas Into a Roux en Y JoJunnl llmh,
and drainlljc
158. An udult who 1u1nahu a burn lnvolvln1 thci
entire surface 01' the l'lJht u1,1\01' a ti mlty,
one-halt' of the anterior trunk, l\n<l ono
third of the rlaht ll,wor " tromhy lu,a
burned uppmxlmatcly whl\t po1,~nll\KC ,,I'
total body 1mrfucc 1mu,1
(A) 14
(D) 19
( ) 24
(0) 29
(11) )4
52 ,-"1HC~ 0, IWROlfff
IM. h1t 1hc: purpt,~ of uJlm11tln1 thtJ ex rent or
burM, U "nc.u,'-llry lo re;ell1.e th1t1 the di~
uibutiflfl of the body ,urfau i.rett over 1.tn-
au,mic rc&1on, of ~ child 's body diffe r,
from t~I found In aadult,. Which of the ful-
lowin1 -t.atcment, tbout the urfau area of
~h,ldrcn . compared with icldult,, i, true'/
(A) The , urfacc a1ca of their lower t)(
trcmit~ i, relatively areater: and the
,urfau rerc-a of their head, and nech
,, relatively le"
(B) 'Th wrlacc area of their lower e,c.
trem1tit, i, relatively greater, and the
MJr!ac.c area o< their upper cxtrcmi-
tic, 11 relatively lcn
CI Tbe ,u rfac.c area of their lower ex-
trcmitict i, relatively leu, and the
,urlace arcc1 of their head" and necks
i, relatively 11eatcr
rD) The w rface area of their lower ex-
tremities is relatively leu, and the
wrlace area of their up-per cxtrcmi-
tie, i, relatively arcatcr
rE) The ,urfacc area of their lower cx-
Lremitin i, relatively ten, and the
wrface area of their up-per extremi-
tie, is relatively less
160. Wh.cb of the foUowins statements con-
cunina injuric1 of' the extrahepatic biliary
tree i, true 7
, A) Pend rat.ins gallbladder injuries arc
bell treated by primary repair and
tube cbokcy1wstomy
CB, Injured pllbladders treated initiaJly
b,- tube cholec-yuostomy must be re-
mov-ed at a w cr date
(CJ Blunt lransection of the common bile
duct most often occurs just distal to
the cystic dua
, Btum tran~ion of the common bile
duct with Jisruf"lUnt lwue loss is
bnt treated by implantation of the
duct into I.be duodenum or the je-
junum
11 B nt rnnsccuon o( the common bile
due, Wllh Slpufacant fJSJUC lou is
best uuted by pancrcaticoduodenec-
tomy
161. Which of the following measurements best
Indicates the adequacy of pulmonary ven
tlltttion'/
(A) Minute ventilation (tidal volume x
respiratory rate) . .
(8) Partial pressure of oxygen in arterial
blood (Pao,) . . .
(C) Partial pressure of carbon d1ox1de an
arterial blood (Pac0i>
(D) lnspiratory force
(E) Maximal breathing capacity
162. Phy,ical examination of a 35-year-old pa-
tient admitted to a burn center reveals
severe first-dearee injuries involving 20
percent of total body surface area, second
degree injuries involving 18 percent, and
third-degree injuries involving 14 percent.
Por the purpose of planning intravenous
nuid replacement, the effective percentage
of total body surface area burned is
(A) 52
(8) 46
(CJ 32
(D) 23
(E) 14
163. In a patient suspected of having a blunt ab-
dominal injury and in whom there is an ab-
Jenct of any other signs of abdominal in-
jury, any one of the following findings
would be an indication for exploratory lap-
arotomy EXCEPT
(A) bile in the peritoneal lavage fluid
(B) more than 100,000 red blood cells/
mm1 of peritoneal lavage fluid
(C) more than 500 white blood cells/mml
of peritoneal lavage fluid
(D) rctroperitoncal air visualized on plain
abdominal x-ray
(E) an elevated serum amylase level
 - - -- -----
hit. .-\ 1 ~ boy is brousbt to a hospital
3 h ~ sustainiQ& an cJectrical iqjury in-
~ i Q& his lcf\ arm and lq. On cxamina-
tioa of bis left arm, an entry point is noted
~ the ulnar swf111cc of the fifth diait, and
a c i ~ t i a l bum of the forearm is
.p rcscat. Escharotomics arc performed on
both. medial and lateral aspects of his fore-
arm. ..\ftcr a short interval, the patient's
\cf\ band remains cokl, poor capillary refill
is noted, and no Doppkr wtrasouod sian&ls
vc auswltatcd at the wrist or ovcr the pal-
mar an:bcs. 1bc patient is, however, well
resuscitated, his vital sips arc stable, and
bis urine output is adequate. 1bc ocxt step
in the mana;gcmcnt of the patient's left arm
sbou.ld be
CA) artcrioraphy
(Bl cx.ploration of the brachia) artery
lC) fasciotocnics
(D) iajcction of 250 mL of dcxtran into
the brachial artery
(E} iajcction of papavcrine into the bra-
dual artery
1i.., A 55-ycar-oki woman who is undcraoing
cmcrgcncy surgery for a bleeding duodenal
ukcr is gi\'CO five units of blood during the
opcBtion. Postoperatively, her urine out-
put is 10 mlJh, and urinalysis yields the
follo~'ing: specific gravity 1.027; sodium 4
mcqfL; and potassium 38 mcq/L. Which of
the following statements concerning this
situation is true'!
(A) The data support a diagnosis of acute
tubular necrosis
(B) Osmolar clearance is likely to be
unity (I) or less
(C) An intrn-cnous pyclognun should be
obtained
(D) Proper treatment should include a po-
tent diuretic
() Further volume expansion is required
53
166.
Seven days after iqjury, a .S-ycar-old man
who bas sustained a second- and third-
degree bum iitjury t.o 34 percent of his total
body surface develops acute pstric stress
bleedina, which is confirmed by gastros-
copy. Saline lavaae is started, and blood
volume is rapidly restored with intravenous
fluids, but the blccdina is not slowed by
any con~ative measures. Assuming that
the patient is stable and has no previous e:it-
istina diseases, the next stage of manage-
ment should consist of
(A) ligation of the left pstric artery
(B) ljption of bleeding point.s
(C) ligation of bleeding points, followed
by vqotomy and pyloroplasty within
a few weeks
(0 ) ligation ofblcedina points, vagotomy,
and hemipstrcctomy
(E) total pstrcct.o my
167. Three hours followina a burn irtjury that
consisted of circumferential, third-degree
bums at the wri.s t and elbow of the right
arm, a patient loses sensation to light touch
in bis fingers. Motor function of his digits,
however, remains intact. The most appro-
priate treatment for this patient now would
consist of
(A) elevation of the extremity, Doppler
ultrasonoaraphy every 4 h, and if dis-
tal pulses arc absent 8 h later, imme-
diate escharotomy
(B) palpation for distal pulses, and im-
mediate escharotomy if pulses arc ab-
sent
(C) Doppler ultrasonograpby for assess-
ment of peripheral flow, and imme-
diate escharotomy if flow is de-
creased
(D) warming of the fingers with moist
compresses, and immediate escharot-
omy under local anesthesia if there is
no return of sensation
(E) immediate escbarotomy under gen-
eral anesthesia from above the elbow
to below the wrist on both medial and
lateral aspects of the arm
 PRINCIPLES OF SURGERY
DlllECTIONS: Each question below contains five sugested answen. For each of the ftn alternative~
lwcd with every item, you arc to respond either YES (Y) or NO (N). In a given item, all, some, 01" none
ol ~ .~ m a y be con-ect.
liS.. C ~ t statements concerning burns of the
bead include
burns around the eye rarely iqjurc
ocular structures directly
B) bums of the lids may lead to late cor-
Dcal ittjury
C miaostomia may be a late effect
(D) bypcrtrophic: facial scarring should
be treated by early operative correc-
tion
(E) external pressure to minimize hyper-
trophic scarring is particularly impor-
tant with bums involving the external
car
16!. During exploratory laparotomy for a gun-
shot wound of the abdomen in a 24-year-
old man, a through-and-through perfora-
tion of the rectum, approximately 10 cm
from the anal verge, is found. Surgical
management of this injury might correctly
include
N creation of a proximal double-barrel
colostomy.
B prcsacral drainage with Penrose or
sump drains
( C) closure of the perforations if spillage
is minimal
(D) transabdominal drainage of the retro-
rectal area .
E) removal of all feces from the distal
rectum by copious saline irrigation
Qustio,u 170-171
An 18-ycar-old woman is admitted to an _emer-
gency room in hemorrhagic shock following an
automobile accident. After the infusion of 2000
mL of lactated Ringer's solution, her blood prc!l-
sure and pulse remain unstable, and she c~m-
plains of upper abdominal pain. On eununa-
tion, there is tenderness and marked involuntary
guarding in the left upper abdominal quadrant.
Chest x-rays, hematocrit, and urinalysis arc nor
mal.
170. Which of the following procedures would I
be considered tsstntial for proper manage-
ment of this patient?
I
11
(A) Abdominal CT scan
(8)
(C)
Peritoneal lavaae
Abdominal sonoaraphy I:
(D) Selective ccliac arteriography II
(B) Exploratory laparotomy tI
I
171. At surgery, a clean, nonbleeding laceration I 1
of the left lobe of the liver (3 cm long and
l .S cm deep) and a larae stellate fracture of 1
the spleen with near-complete transcction ' 1
in two areas arc found. Surgical manage- I
ment of these injuries would include which
of the following procedures?
(A) Closure of the liver laceration with in-
terlocking chromic catgut sutures
(8) Splencctomy
(C) Drainqe of the liver laceration and
splenic area
(D) Irrigation of the peritoneal cavity
with a dilute antibiotic solution 11
(E) Closure of the peritoneum and fascia
of the abdominal incision with the
skin and subcutaneous layers left
open
 TllAUIIA AND IIURNI
171. True statements concerning duodenal per-
foration after blunt abdominal trauma in-
clude which of the following?
(A) Rctroperitoncal perforation frequent-
ly produces few early signs or symp-
toms
(8) lntrapcritoncal perforation produces
immediate chemical irritation of the
peritoneum due to the highly alkaline
pH of the duodenal content
(C) The absence of free intraperitoncal
a.ir on upright abdominal x-rays rules
out intraperitoncal perforation
(D) Duodenal fistula formation can be
prevented by careful closure of the in-
jury
(E) When retroperitoncal a.ir is found
during celiotomy, a wide Kocher ma-
neuver should be done to locate the
site of irtjury
173. True statements concerning the currently
recommended guidelines for the use of bio-
logic dressings (homografts or hetero-
grafts) in treating burn irtjurics include
which of the following?
(A) They may be applied to granulation
tissue but must be removed every 5
days
(8) When they arc applied to superficial
second-degree bums soon after in-
jury, they must be removed daily
(C) They may be used to test the readi-
ness of a large burn wound for auto-
grafting
(D) They may be applied over exposed
tendons or neurovascular structures
to prevent them from desiccating
(E) They may be applied over reepithc-
lializing, deep, second-degree burns,
once superficial necrotic debris has
been entirely removed
55
174. Which of the following rctroperitoncal he-
matomas resultin& from blunt abdominal
trauma should be explored?
(A) A small, centrally placed, nonex-
panding hematoma superior to the
pelvis
(8) A small, nonexpanding hematoma
over the body of the pancreas with an
intact pancreatic capsule
(C) A large, nonexpanding pelvic hema-
toma
(D) A large, nonexpanding hematoma
over the body and head of the pan-
creas
(E) A large, expanding perirenal hema-
toma
175. A 19-ycar-old woman presents with a non-
bleeding stab wound, I cm long, in the an-
terior triangle of her neck, 3 cm above her
left clavicle. Her blood pressure is 130/90
mmHg, and she has no evidence of respi-
ratory distress. Examination of the neck
reveals that the wound has penetrated the
platysma muscle, and that the left carotid
pulse is normal; there is no hematoma or
bruit. Appropriate management of this pa-
tient might include
(A) immediate tracheostomy
(B) nasogastric intubation
(C) chest x-rays
(D) angiography
(E) formal exploration under general an-
esthesia
 PRINCIPLES OF SURGERY
176. ~c statements concc'i"ing hepatic resec-
tions for the treatment of liver injuries in-
clude which of the folldwing?
(A) When possible, aj sublobar resection
is preferable to a hepatic lobcctomy
(B) A right thoracoabdominal incision is
preferred for major lobar resection
(C) Hepatic artery ligation is an appro-
priate method for controlling major
parcnchymal hemorrhage
(D) The use of hemostatic agents like
Gclfoam is helpful during resection
(E) A T tube should be inserted routinely
into the common duct following re-
section
177. True statements concerning metabolic re-
sponses to a major bum injury include
which of the following?
(A) Preventing all evaporative water loss
from a bum wound can dramatically
decrease the metabolic rate in bum
patients
(B) Manipulation of environmental tem-
perature and humidity can reduce ox-
ygen consumption in bum patients to
near normal levels
(C) Durink the second week after the
bum, cardiac output plateaus at 2 to
2 times the resting state
(D) The metabolic response in bum pa-
tients can be partially blocked by
administration of beta-adrenergic
blocking agents
(E) The metabolic response in bum pa-
tients is associated with elevated skin
temperature but normal rectal tem-
perature
178. True statements concerning tangcn~ ex-
cision of the eschar in burn wounds include
which of the following?
(A) It removes 0.015-inch l~yer:5 of cs-
char until capillary bleeding ,s appar-
ent graft"
(B) Primary closure by skin mg can
be achieved following the procedure
in most cases
(C) It is most applicable to lesions cx- ,
tcndina across joints lI I
(D ) It requires general anesthesia
(E) It has been shown to reduce the hos-
pital stay
179. True statements regarding the diagnosis of
smoke inhalation syndrome include which
of the following?
(A) Lung edema is peribronchiolar and is
derived from the systemic circulation
(B) The finding of carbonaceous sputum
requires hospitalization of the patient
(C) Diagnosis is precluded by the finding
of a normal carboxyhcmoglobin con-
centration
(D) Direct-vision bronchoscopy, per-
formed within 6 to 12 h of injury, is
diagnostic in over 75 percent of cases
(E) A ~ of less than 300 mmHg found
in a suspected patient breathing I 00%
oxygen is diagnostic in over 75 per-
cent of cases
34 PRINCIPLES OF SURGERY

100. ~ patient has a blood pressure of 70/50 104. Following drainage of a subphr~nic ab-
mmHg and a serum lactate level of 30 mg/ scess, a patient who weighs 70 kg ts pla~ed
100 mL (normal: 6 to 16). His cardiac out- on a volume ventilator with the following
put is 1.9 Umin, and his central venous settings: tidal volume, 500 . mL; ~esp!ra-
pressure is 2 cmH 20. The most likely di- tory rate, 12 breaths per !'lm~te; msp1ra-
agnosis is tion:expiration ratio, 1:2; msp1rc~ oxygen
(A) congestive heart failure concentration (F10i), 0.5. Artenal blood
(B) cardiac tamponade gas analysis obtained a half-hour later re-
(C) pulmonary embolus veals pH, 7.48; Pc,, 62 mmHg; Pco2, 33

~
(D) hypovolemic shock mmHg. On the basis of these results, the
(E) septic shock patient's physician should
(A) increase the tidal volume to 1000 mL
101. When military antishock trousers (MAST)
arc fully inflated in a patient following
(8) increase the respiratory rate to 20
breaths per minute ~
acute hemorrhage, the effects include
(A) increased cardiac output
(C) change the inspiration:expiration ra-
tio to I :3
,-
{D) increase the F10i to 1.0 I
(8) increased venous return to the heart
(C) increased peripheral resistance (E) add 10 cmH20 positive end-expira-
(D) increased tissue oxygenation tory pressure
{E) control of shock
105. All the following statements concerning
mycotic and pseudomycotic infections are B
102. Which of the following antibiotics is
LEAST likely to be associated with neph-
rotoxicity?
true EXCEPT
. (A) actinomycosis can be treated sue-
f
(A) Gentamicin cessfully by a prolonged course of
(B) Clindamycin penicillin If
(C) Colistin {polymyxin E) (B) Nocardia stains acid-fast and can be
(D) 8acitracin confused with tuberculous organisms e I
(C) the diagnosis of active coccidioido- 5
(E) Neomycin ..
mycosis can be made on the basis of
103. Which of the following statements con- a positive coccidioidin skin test f
(D) hemoptysis or cavitation constitutes
cerning antibiotics and infection is correct?
the usual indication for surgery in as-
(A) Antibiotics arc most effective when pergillosis
bacteria arc actively dividing (E) Healed histoplasmosis may produce
(8) Antibiotic therapy is more effective multiple small calcific pulmonary
treatment for an abscess than for cel- nodules
lulitis
(C) Necrotic tissue in abscess cavities
protects bacteria from the action of
antibiotics
(D) The inflammatory reaction around an
abscess produces high antibiotic con-
centrations in the abscess cavity
{E) The presence of pus neutralizes anti-
biotic activity
 ,.

IIHOCK AND INRCTION 35

106. A SO-year-old woman undergoes an opera-
tion for a gunshot wound of the chest and
abdomen. Over the next 2 days in the in-
tensive care unit, she develops progres-
sive hypoxemia that is treated with contin-
uous mechanical ventilation and positive
end-expiratory pressure maintained at 12
cmH,O. Twenty-four hours later, she sud-
denly develops hypotcnsion, for which the
most likely cause is
(A) impaired venous return
(B )tension pneumothorax
(C )occult hemorrhage
(D) lobar pneumonia
(E) pulmonary embolus
107. Which of the following antibiotics is most
appropriate for an otherwise healthy young
woman who has swelling and erythcma
of the dorsum of her right hand together
with lymphadcnitis and lymphangitis of her
right arm?
(A) Intravenous clindamycin
( B)Intravenous penicillin G
(C) Intravenous ccphalothin
(D) Intravenous tetracycline
(E) Oral cephalcxin
108, A 76-ycar-old patient who has gram-nega-
tive pneumonia becomes hypotcnsive, and
resuscitative measures arc started. After 4
L of salt solution are administered, the fol-
lowing measurements arc obtained:
Blood pressure: 60/0 mmHg
Pulse: 140 beats per minute
Central venous pressure: 26 cmH20
Pulmonary artery diastolic pressure:
22 mmHg
Pulmonary capillary wedge pressure:
22 mmHg
Arterial blood gases: pH 7 .33; Po, 100
mmHg; Pco, 3S mmHg
A decision is made to commence treatment
with an adrenergic agent. An intravenous
infusion of which of the following drugs
should be started?
109. The P,o value (the P0z at which 50 percent
of hemoglobin is saturated with oxygen) in-
dicates the position of the oxyhcmoglobin
dissociation curve along the horizontal
axis. All the following conditions can pro-
du~e a leftward-shifted curve (decreased
P,o) EXCEPT
(A) carbon monoxide poisoning
(8) transfusion of 2-week-old blood
(C) hypothermia
(D) acidosis
(E) 2,3-diphosphoglycerate deficiency
110. A patient who is undergoing an elective op-
eration under spinal anesthesia develops a
blood pressure of 70/40 mm Ha. There is no
evidence of hemorrhaae or sepsis. Appro-
priate initial therapy should consist of
administration of
(A) 2 L of saline
(B) whole blood
(C) adrenal corticosteroids
(D) a bcta-adrenergic stimulator
(E) an alphamimetic drug
111. Each of the following indicates adequate
pulmonary function in an adult EXCEPT
(A) effective compliance 40 cmJ/cmH2O
(8) minute volume 11 Umin
(C) Paco, 40 mmHg
(D) J>aoi95 mmHg
(E) P8oz!F10z 260
112. The drug of choice for clostridial myone-
crosis is
(A) penicillin G
(B) ampicillin
(C) amikacin
(D) cephalosporin
(E) chloramphenicol
113. The effects of the application and inflation
of military antishock trousers (MAST) arc
similar to those after the intravenous
administration of

(A) Levarterenol {A) dopamine

(B) lsoproterenol (B) steroids
(C) Dopamine (C) whole blood
(D) Metaraminol (D) norcpinephrinc
(B) Phenoxybenzamine (E) digoxin
36 PRINCIPLES OF SURGERY

114. When a patient with adult respiratory dis- 117. In experimental hemorrhagic shock: the
ttcss syndrome (ARDS) is managed by best survival figures have been achieved
ventilatory support with high tidal vol- when the experimental animals received
umes, normal Pac0t should be maintained
by (A) whole blood alone
(B) whole blood plus albumin
(A) increased inspired CO2 concentration (C) whole blood plus Ringer's lactate
(B) increased dead space (D) whole blood plus dopamine
(C) hypoventilation (E) whole blood plus hydroxyethyl starch
(D) increased F10t
(B) decreased respiratory rate 118. The majority of the blood volume at rest is
contained within the
J
11S. The cellular response to hypovolemic
I
shock includes each of the following EX-
(A) arterial system
CEPT (B) capillary bed
(C) portal circulation
(A) depletion of cellular ATP (D) pulmonary circulation
(B) increase in cellular c1- (E) venous system
(C) increase in cellular K +
(D) increase in cellular Na+ 119. An infection with Staphylococcus aureus I
(E) increase in cellular water acquired in an intensive care unit should be
treated initially with
116. All the following statements concerning
(A) aztreonam
the use of steroids in the treatment of sep-
(8) erythromycin
tic shock are true EXCEPT (C) methicillin
(A) steroids may protect cells from endo- (D) penicillin G
toxins by stabilizing cellular and ly- (E) vancomycin
sosomal membranes
(8) large doses of steroids arc known to 120. Appropriate empiric therapy for an in-
produce a modest inotropic effect traabdominal infection acquired in the hos-
(C) pharmacologic doses of steroids are pital by a patient who had received pre-
not indicated vious antibiotic therapy would be
(D) steroids are detrimental in patients (A) aztreonam
with renal insufficiency (8) ccfoxitin
(II steroid therapy must be continued for (C) chloramphenicol
at least 5 days to be effective (D) imipenem/cilastatin
(E) penicillin, gentamicin, and mctroni-
dazole i-
 SHOCK AND INFECTION 37

l?-lRh~'lONS: Ench question below contains five suggested answers. For each of the five alternatives
hstc-J with c,-cry item. you arc to respond either YES (Y) or NO (N). In a given item, all, some, or none
ol UM ~mathfl "'--'' ~ COl'TtCt.

UI. Three- h\lurs after undergoing an incision 123. True statements regarding tetanus include
:lnJ drainnge "'f l\ large pelvic abscess, a which of the following'?
patient is found to be confused, agitated,
amt tachypncic. Her blood pressure is 70/0 j (A) The presence of Clostridium tetani or
its spores in a wound is not necessar-
mmHa. pulse is 160 beats per minute, tem-
pnaturc is 40-C ( l()4 F). and respiratory ily followed by tetanus
rate is ~-- brcZlths per minute. The skin of ~ (B) The averaac incubation period for the
her c.~trcmitics is warm and dry. A Foley disease is 3 to S days afler injury
catheter. central venous catheter, and ~ (C) Generally, the shorter the incubation
Swun-Ganz thcrmodilution catheter have period of tetanus, the worse the prog-
nosis
been inscncd. Findings likely to be asso-
ci:ttcd w ith. this stage of the patient's con-
j (D) Tetanus occurring as a complication
dition include of narcotic addiction has a mortality
of approximately 90 percent
\A (A ) increased cardiac output \\) (E) Recovery from tetanus provides sub-
J tB decreased peripheral resistance sequent immunity
\) (C) increased ancriovcnous oxygen dif-
ference 124. Which of the following therapeutic modal-
J ~) increased scrum lactate level
normal blood volume
ities would be useful in treating a patient
who has tetanus?
(A) Thorough cleansing and debridement
Ul. True statements regarding the administra-
of the wound
tion and cffccts of amphotcricin B include
(B) Administration of muscle relaxants
which of the following?
and sedatives
'j (A ) Its mode of action involves weaken- (C) Administration of antibiotics
ing of the permeability of microbial N (D) Immediate hemodialysis
cell walls j(E) Control of respiratory secretions
lt ma . be effectively administered
~\ (8 either orally or parenterally 125. The usefulness of clinical dextran when it
It is cffccti-.,-c in treating actinomy- is employed as a volume expander in pa-
\~ {C) tients suffering from hypovolemic shock is
co:sis
(D) lt is effective in treating nocardiosis influenced by

J El Its toAic effects can include head-

ac-bc. nausea, vomiting, and eventu-
(A) the interference of dex.tran with co-
agulation and cross-matching
all~ remtl damage (B) the development of transient coagu-
lopathics
(C) the decrease in blood viscosity
caused by dextran
(D) the potent antigenic properties of
dcxtran
~ (E) the deleterious effect of dextran on
liver function
38 PftlNOIPLEI Qfl ll,l"OllAV
126. True statements conccrnina clostrldla in-
clude which of the fallowing?
~ (A) Clostridia ate obligate anaerobes
(8) The lesions produced by pathogenic
clostridia are due to endotoxins
(C) Acute emphysematous cholccystltis
caused by clostridia is believed to re-
sult from an ascending Infection
within the biliary tract
(D) Gas gangrene caused by clostrldia is
a slowly spreading, usually crcpilant
infection of the subcutaneous tissues
(E) Antitoxin is useful in treating either
gas gangrene or established tetanus
12'7. True statements regarding the use of lno-
tropic agents in the treatment of cardlo-
genic shock include which of the follow-
ing?
(A) Dopamine in low doses (2 to R -a/l(g/
min) improves mean arterial prcu urc
and cerebral and coronary blood now
without significantly Increasing pulse
rate
(B) Dopamine in high doses (greater than
10 g/kg/min) increases systemic vas-
cular resistance and dccrcasc!I renal
blood now
(C) Dopamine in high doses has alpha-ad
reneraic effects
(D) Dobutamine has predominantly lno-
lropic effects and Is leu likely than
dopamine lo produce arrhythmia.
(E) lsoproterenol is more useful than do-
pamine for patients whh an ucutc
myocardial infarction
128. Which of the following antibiotics m11y be
efficacious in tho treatment of Clostrldlum
d(/Jlcllt'-relalcd paeudomembranou1 coll
tis?
(A) Clindamycin
(8) Penicillin G
(C) Chlonunphcnlcol
\.,\_ lD) Mctroniduolo
,j (E) Va.neomycin
ll9, Correo, 1rel\t11w111 uf 1mll()jU1nl ~hook
baitUI 01\homo,1v"1unlu m lll'll1 6'11\ ,,,~
lihoulcl lo ludo
(M volume risr1\n~ln11 with h111 11vt111u1111
J Oulll lo th\1 (\1011t1nc10 <,f hvpnl'll11111111
{HHI a low w111I"" nr p11l111onflr 1 111 M V
<li"!il(lliO1'1 Oliillf1'
l\ (R) l11oprott,rt1nnl l\1hnh1l111n,1lou In thf\
N rroscm o of hvooton11lo11 ""'' 1, rul,
monary wcidao ,,n,uur~ of l O1nrnt Iii
~ (C) 11odlum nhroprn11ide 1utmlnl1111,uln11
J with 1uot\1I U1(111hurll\ll In lhct 111011~11
of " li)'litoll ,,,01111111-0 llhove I 10
mmH11," ~"'" rri,111011"\'1 nt' .it mmttta,
and ln1on110 11laan11 of va110001114f1 lu1lo11
rmd lmul~c111111q tl111me oc,rf\1111011
~ (D) l\1m11omlclo a,lmlnl111r1uloo 111 th
r rciion ~ of h)'1'0lo1111ion i.mt ra,lu ~d
~
f'Ulmomuy wodao f'f'(!OIII
(11) lntraaortlc hallonn co11n1cirpuliuttlon
In tho l'fflil'1n ~ or ontlrminll hy
('(lton11lon ""'' "lov"tod 1mlmomo y
W'3llao r1-au1110
lJO. Cor~cl statamont about h1""111 .-h11 00011
In mtrillna mot ho, s 111 luda whl h of cha I ,1.
lowina'l
' ~~~AntlhlolhJ!i t1hm1lll h~ 11lv<'n
lncliilon llml d1 "lnaao lit f\lquit,"I
~(C) Nuralna ilhouhl ba Mhll't'o,t
~ (D) Thoy "ro usu11lly Q"Uilod hy St<111l1 ,.
/c>('(lf'('U:t OUt'tUJ
N<B> Thoy '""' 11su111ly hlhu"rnl
Ill, 'lruo srntomont&cono<1111tn1 tho t,"
101 lol
,,I
oay of ammn l\l'tlvo "o~,1 ""''
M
al'\I
11hO<lk In ho pltlllba(I 1,rulal\t8 In lulla
whl h or tho followln&'l
~I
(A)
Moat u1uc,11 uf itOl'tl 11hock 1\1~ "''IOU
by nwro ttum Ol\o ilffiml\ttltlvo ,w. It
111u1lam ..
(II)
rrm,u.r i.ml Ps,utlommw., "'" tho
nw,t ~""'""-' " 1u1111lvo or1i\11ls11u
,.
(C) Ra ont f'Of)(Wta hi.va 11hOWf\ "" In
raft11ln11 th1,,ucn y l\f l1"hulon 01' ~
Nl,b.rl,11 nnton,~c.1 lo1 hHioA Sflt rtt )
tlo arm,,,
(U) Rm:tt ml,I,.,, I&tho m\lll
atroblo "raul1m l11"\1tod
omm,,n "" \
( ) ltot't,mldH "r-tl\nltm, "'" 1 111)()nalvo
to troitrnont with do\lbla hth,I" tl\m 'C
Qmhlntll)tU f
 Trauma and Burns
DOECTIOSS: Each question below contains th-c s ~lC\.I rcsponsts. Solccl tho one b,,.,t 101111111!1~
to each question.
l.ll. A patient has a gunshot \\'OUnd in \\'hid\ a
bullet has entCT'Cd the left sixth intcn:-ostal
space anteriorly and exited straight poste-
riorly. He is not hypotcnsive and has no
signs of peritoneal irritation. The most
suitable management is
(A) admission to the hospital for close
observation
( B ) local e xploration of both wounds. and
if penetration into the peritoneal ca\'
ity cannot be proved, admission to
the hospital for observation
(C) peritoneal lavage. and if tttis proves
positive, exploratory laparotomy
(D) injection of radiopaque material into
the anterior wound, and if dye enters
the peritoneal cavity, exploratory
laparotomy
(E} exploratory laparotomy
133. Significant vascular injury is likely to occur
with all the following fractures or disloca-
tions EXCEPT
(A) fracture of the midshaft of the hu-
merus
(B) supracondylar fracture of the hu-
merus
(C) fracturc of the femoral shaft
(D) supracondylar fracture of the femur
(E) posterior dislocation of the knee
47
134. A con-eel Sh\lomcnl C()IICl!flllnta 1111111 !i~I\I .
ri,~ is
(A) cnrly use ur c.Hctnnl p1c1111111 c !1l1&11lrl,
\:l\ntly 1>cliucct1 burn calc1111,
(B) the use or I\ p l'Cti!IUI Q llhl 1110111 llV Of
joints nmy 1,111\I to t1litrlu.i11!1 111111 1o
Jm:eu joint t\111ctio11
l ) t\ prcssurc llllfmcnt 1111otl for 1,t l011111 (,
months l'\lJucc:i 11c111 hyr,01lrnrhy hy
cnusint1 bc.illor "lillllll\Olll ol' Clllll\MOO
fibers
(D) burn controcturos 1,mund lho 111dlh1
nrc rcauily prcvo11ll1hlo
(E) ll burn contrncluro 111 tho 1111ld0 pro
Juccs 1m inversion doformlly of lho
foot
135. All the folluwinll stllt0fll0lll!I concornltll,l
early 1111111c11til1I cxchilon ,,r
hum w,)111ul11
urc true EX I.WI'
(A) the procedure 01111111s sl11nlnc1111t hlood
loss
(R) in n pntiont with severe smoke lnhn
lntion tho procedure 11hould ho done
under locl1l 1m011th0sh1
(C) by expediting h1mlin11 In burn!! 11round
joints tho procclh1ro prc11orvo11 joint
function
(D) tho procedure Is cnrrlod 0111 !loqucn
tinily until good cnplll1,ry bleeding in-
dicates vinblo tissue
(E) when tissue llcstructlon 0x10nd11
through the dermis, It 111 dlt'Ocult to
apprcclntc tis5110 vil1bllhy
I
I
48
PRIHCIPlU 0, IUAOl!RY
136. A 55-ycur-old woman IU81ulns clo11ed fruc-
1t1rcs of lhe rlghl llblu nd flbulu In a skiing
occldo~I, nnd id10 h1 noted lo huvc u loss of
scnsn11on over lhc lutcrul aspect of lhc uf-
fecled culf und fool. The fntclure11 ure non-
di11pl11ced . Tho patient's lea is casted, and
lhc fractures hcul without complicnllon.
Six mo~thic uOer the irtjury, the patient de
vclops _intense burning, hyperesthesiu and
cya?os1s of lhe right foot. The trcatme,nt of
choice for her would be
(A) locul cxplorn1ion of lhe peroncnl
nerve
(8) muscle relaxants
(C) narcotics
(D) ganglionic blockade
CE) purnvertebral sympathetic block
137. The majority of deaths in patients who
have pancreatic injuries arc due to
(A) puncrea1ic abscesses
(B) pancreatic pseudocysts
(C) pancreatic fistulas
(0) duodenal fistulas from associated
duodenal irtjury
(E) associaled vascular irtjuries
138. Whether the nutritional needs of a patient
JO days after a major burn arc being met is
best assessed by
(A) calorie counts
(8 ) measurement of daily body wciaht
{C) measurement of red cell mass
(D) measurement of scrum aJbumin levels
(E) nitrogen balance studies
139. All the following problems may be associ-
ated with the use of mafcnide acetate {Sul-
famylon) EXCEPT
(A) pain on application
(B) acid-base deranaements
{C) rapid desiccation of the eschar
(D) emergence of opportunistic organ-
isms
(E) hypersenslrfvfty reactions
140. An 18-year-old man is admiu.ed to ~
emeracncy department shortly after bei~g
Involved in an automobile: ac:cidcnt. He IS
in a coma (Glasa,ow corM sc:.aJc score 7).
His pulse is barely palpable: at a rate of I~
beats per minute and blood p,-c:ssurc: 11
60/0. Brcathina is rapid and shallo~, a.er
atina both Jung fields . His ~men 1s ~ -
erately distended with no audible: pc:~ual-
sis. There arc closed fractures of the n~t
forearm and the left lower leg. After rapid
intravenous administralfon of 2 L of lac-
tated Ringer's solution in lhe upper ex-
tremities, hjs pulse is 130 and blood pres-
sure 70/0. The nut immediate step should
be lo
(A) obtain cross-table lateral x-rays of the
cervical spine
(B) obtain head and abdominal CT scans
(C) obtain supine and lateral decubitus x- x-
rays of the abdomen
(D) obtain an arch aortogram
CB) explore the abdomen
141. A 3.S-year-old man is brought to an emer-
gency department shortly after being re-
moved from a burning, smoke-filled auto-
mobile. The patient is confused, agitated,
and tachypneic. His general color is nor-
mal, his blood pressure is 80/40 mmHg, and
his pulse is 160 beats per minute. No sur-
face bums arc noted. Auscultation of his
chest reveals normal air entry bilaterally,
with minimal coarse expiratory wheezes.
His abdomen is soft, active bowel sounds
arc present, and the remainder of the phys-
ical examination is within normal limits.
Results of the neurologic examination are
normal except for an acute confusional
state. The imm~diat~ treatment for the
most likely cause of this patient's agitation
and confusion is administration of
(A) intravenous morphine, 2 to 3 mg
(B) intravenous Ringer's lactate, I Lover I
Ih r
(C) intramuscular haloperidol, 2 mg, or
chlorpromazine, .SO mg r
(D) 100% oxygen by face mask
(E) intravenous methylprednisolone, 2 g,
and mannitol, .SO g

Qin u IQ-14...1
~ C~-, ~ liffll hlcr "h() 'A'Ciah1 ~ -- ~ tl63
I w ~ a l l u N ~ bum h., tl,4 pcl\..~nl
al , tau.I t'loJ) iur(-...c vca. TlW' patient arn, c
tht t f'l'CtlC) ~me-nl ~,imatcl 30
~r Uw tune al th< ~ ;jJ,cnt.
1he patte"t' intra, Cll\.)U , fluid
R-mcnl cakulatcJ u ma the Part-
Att
~ formula . the initial l.-\f\kn for choice
o( flwd and nale o( infus.ion houlJ be
~ Ruller ' I - ttc. 200 ml;b for 7 h
Rlnacr lai:tatc. ll50 ml.lh for n,; h
, ) Rif\lCr' ~ tatc . 950 ml../h for I I ~ h
tO) RulFr's lact.tc , 600 ml..Jb, and col-
t E)
klild solul,on , lOO mUh, for 7V) h
R.i~, lactate. 800 mUh. and col-
k>td soluhon. 200 ml.Jh. for 7Y: h
IC. waa Lbc Padland formula, the choice of
flu._id and rate of infusion for this patient's
ICCOOd 24-h po5lU\,jw-y period s.bould be
\ 9' de trose in 'IAo-atcr to maintain
Krum sodium concentration at 140
mcq/L and approximately l L of col-
loid solution
t 8 ) SW, dextrose in water to maintain a
mtraJ \"'CtlOUJ prc-s~ of more than
, cmH:O and approximately 500 mL
of ~oUoid solution
(C ) "' dextrose in v.-"at.er to maintain
uriM out.put a.t .SO mlJh and packed
red blood cdh, 100 mL per 10 pcr-
\Xflt total body iurlacc an burned
(D J sdextrose and Rinaer's lactate to
a:wnt.ain urine output at SO mUb and
IPtJf"O>.ilnalc-ly I L of colloid solution
(E) 11, dnlr'OIC in V.-nonnal Aline to
mamt:ain a alraf -.enous ~ssurc of
mor~ than 4 cmH,0 and approxi-
m&ldy SOO mL ol colloid solution
1.a. Tbe most fftqUetlt noobacterial, oppo.--
recc>\~ from bum
(A) J (A)
Ii
) TttUU11Ua
(DJ ,., aa,c~tr
cE) H,,,.,,,,
49
~- A .S- r M>ld m ,u undcr~s nn uncompli-
~tod splcncctom )' following blunt ~hd.o m -
imal tnurnu,. Ourinai 1&nt1 thc,siu , he ,s given
o,)!.icn. nitrous oxide, , n~rc~tic, u~d. n
nm clc rchaxl\nt . No other s,,mfirnnt 1ruu-
rics "re found Jurin suracr)', unJ transfu-
sion of blood products is nut ~quired . In
the re i.Wcry room uftcr cx1ut,11tion. the pu-
re- ti(nt i noted tn hnvc u bl~">d pressure of
l7l\' IOO mmHa. u pulse of 140 be ,1s p~r
minute, amt a respiratory r.ite of R_brefllhs
per minute. Shortly thcrcnOer, his blood
pressure is found to huvc dropped to
1oorti0 mmHg nnd his pulse to 60 bents ~r
minute; he is not orousublc. The diug~ostac
m 11nemrcr most likely to define this J>U
tient's problem is
(A) measurement of central venous pres-
(B)
sure
measurement of pulmonary cnpillary
wedge pressure
(C) spirometry
D) analysis of arterial blood gas
{E) chest x-ray
(111,stioas 146-141
A 25-ycar--old man is brought to the emergency
department after falling 20 feet from a ladder. He
is unconscious. and there is blood-tinged. non-
clottina fluid in his left car canal. He withdraws
from painful stimuli. His eyes arc closed. but they
open in response to pain. He is making unintelli-
gible sounds. His pupils arc equal, and both react
sluaaishly to Hght.
146. His Glasgow coma scale score is
(A) .S
(8) 8
(C) 11
(D) 14
(E) 17
141. After control of this patient's airway is
achieved, the first diagnostic study to ob-
t~n is
x-rays of the skull
(8) CT scan of the head
(C) ,i.-rays of the cervical spine
(D) carotid anaioaraphy
(E) fumbar puncture
 =-
60

1411.
I\ Pllllonl who develnp1 acvoro aymplom
shortly 11ncr beln1 hillcn by hunc ~ lJI. In 1ti. l1w"C'Y ul .__..,~
hould he, rrc11lc'1 wllh y bc'tt c:t,oec.t ,,.,, ot ~ - -
,11 ..ie>ft "
CA) dopamine
CH ) epinephrine
CC) prcdnl1onc
fAI II.fl 111CJQIC I O ~ ,:WW-
R .,, IM"fR. . . . Uf'fM
( J .,, tncrov _ , . ,
"'o-.y.....-
,..
er>) pr-op,anolol
lPJ lkerffilif aft lllanJ
IH) rn1chco1romy
f PJ a dcctca.M !fl I.kt,

1 9, A 25-ycar-old woman 1, Ken be<au\C or ... --
vcrc mu1cular pain, nauaea, vomhtna. and
hc11d11ohc (ollowln1 bile or a black "'ldow
11pldcr. flcr man11cme111 hoold Include
U2. A tnafl . , . ,

........... .,..,,...,... .....

?0 '-1 ' I lldllalnJ
1,a,,.J.md to I ...,,. . - . . 4 '#A- fliftct
..,~
l,uu,y 10 " ' ~ d -..,.
(A) cxcl11lon of 1hc area of 1,uury t.ecc a,u Ptw llt UIII Cldlnll IJlw ,-..
(f)) lntnavcnoua ponrcllltn
(C ) ln1ra vcnou1 dlaupam
~- ~- ...__., n. _,
(l)J lntravcnou1 calcium
(t ) lnrr1mu1cular anrlvcnln

150, A l-yaar-old airl au, raln, 11 11vim burn

mcu urln1 6 by 7 lnchc, over rhc ul111r .,.
pee l o( her riahr forearm. Bllsrcn devlop
over rhc cnrlrc 11rcaa of lhCI burn wound , and
by Iha rime the parlcnt 1, accn 6 h 10 11 rtw
lruury, some of the blf aten have rupeurcd
spontancoualy. In addition to dcbfldcmcnl
of the necrotic epithelium, aJI the foUowlna
therapeutic rcalmcn, mlahc be con11dcre_d
approprl1tc for this pat lent EXCe PT
(A) oppllcarlon of silver sulfldlulnc c~am
(Sllvadcnc) and daily w11he1, but no
drculna

(D) application o( polyvlnylpyrroUdonc
(Dctadinc) foam, dally wuhe1, and 1
liaht occlu1lvc dro11ln1 chan,cd daily
(C) Mppllcarlon of mafcnldc accwc cram
(Sulfamylon), but no daJly wuhc1 or
drc11ln1 i
(D) hofllOll"lll appllcatlon wllhoul 1uture1
lo aecun, Ir In place, bur no da.lly
washes or drculna
( fl) hetero1mn (pla,kln) appllcarion wilh
suiurcs ro 11ccurc lr In place ind dally
wa1hcs, bur no dreulna
 Shock and Infection

DIRECTIONS: Each question below contains five suggested responses. Select the one best response i:
to each question.

89. An exotoxin plays an important part in the 91. A 70-year-old patient is operated on for fi
pathogenicity of infection with each of the acutely bleeding esophageal variccs. Dur- ll
following EXCEPT ing the operative procedure, two hypotcn- !I
(A) Clostridium botulinum sive episodes occur and arc treated by b
administration of six units of blood. ln the ta
(8) Clostridium tetani
recovery room, urine output is noted to be b
(C) Escherichia coli
15 mUh (over 2 h), and the central venous ti
(D) Staphylococcus aureus
pressure (CVP) is 14 cmH2O. The correct :c
(E) Streptococcus pyogenes
therapeutic measure at this point would be t,.
to
90. A 30-year-old, otherwise healthy woman
undergoes an appendectomy with primary (A) administer an intravenous loop di-
rfi
closure of the wound for a perforated ap- uretic
pendix. No antibiotics are administered. (8) administer an inotropic agent
Should this patient develop an.intraabdom- (C) insert a pulmonary artery catheter
inal abscess. which of the following organ- (D) infuse intravenous fluid until the CVP
fP
isms would most likely be responsible? reaches 20 cmH2O
(E) decrease the infusion rate of intrave-
(A) Escherichia coli nous fluid e-
( 8 ) Bacuroldes
(C) Streptococcus f aeca/is 92. Prompt correction of fluid deficits is cssen-
(D) Proteus n-
t!al in treating patients suffering from sep-
(E) Serratia marcescens p-
tic shock, and the preferred intravenous
fluid to be used is JS

(A) a balanced salt solution

(B) a colloid solution
(C) one-half normal saline
(D) dextrose in water
(E) whole blood or packed cells

32

. .
 IHOCK AND INnCTION
93, The most effective level of positive end-ex-
piratory pressure (optimum PEEP) is best
determined by measurement of the
(A) partial pressure of carbon dioxide in
arterial blood
(8) partial pressure of oxygen in arterial
blood
(C) pulmonary. capillary wcdae pressure
(D) alvoolar-artorlal oxyaon dlft'oronce
( ) cffoctive compliance
94. The earliest man Ifcstations of serious
gram-negative infection may consist of a
triad of signs that Includes
(A) tachypnea, hypotension, and an al-
tered senaorium
(B) tachypnea, hypotension, and lactic
acidosis
(C) thrombocytopenia, hypotension, and
lactic acidosis
( D) mild hyperventilation, respiratory al-
kalosis, and an altered sensorium
(E) neutropenia, hyperventilation, and met-
abolic acidosis
95. After the infusion of 2000 mL of intrave-
nous nuid following trauma, a patient's
blood pressure is I1ono mmHg. Which of
the following findings would be the best
clinical 1uide to adequate fluid resuscita-
tion of this patient'!
(A) A urine output greater than 30 mUh
(B) A decrease in pulse to less than 100
beats per minute
(C) A return of normal sltin temperature
(D) A return of normal sensorium
(E) The disappearance of orthostatic hy-
potension
96, Neuroaenic shock is characterized by the
presence of
(A) cool, moist skin
(B) increased cardiac output
(C) decreased peripheral vascular resis-
tance
(D) decreased blood volume
(E) increased pulse rate
33
97. The most common source of gram-negative
infection In a patient with septic shock is
the
(A) biliary tract
(B) tracheobronchial tree
(C) small bowel
(D) colon
(E) urinary tract
98. Following drainage of a pelvic abscess, a
45-year-old patient receiving 70% oxygen
is found to have the following arterial
blood gases: pH, 7.48; P0i, SS mmHg; Pc0i,
30 mmHg. These results arc most consis-
tent with the diagnosis of
(A) chronic obstructive pulmonary dis-
ease
(B) postoperative pain and anxiety
(C) adult respiratory distress syndrome
(D) postoperative atelectasis
(E) pulmonary embolism
99. All the following statements concerning
the use of vasoactive drugs to treat septic
shock are true EXCEPT
(A) vasopressor drugs that have primar-
ily alpha-adrcncrgic cffects are of lim-
ited value
(B) dobutamine has predominately i.no-
tropic effects
(C) the major side effect of isoproterenol
is tachyarrhythmias, particularly in
digitalized patients
(D ) dopamine decreases renal blood flow
when infused at a dose of S 1,1,g/kg/min
(E) metaraminol can be useful in patients
who have an elevated cardiac output
and pronounced hypotension due to
very low peripheral resistance