surgery 2006

1. General monitoring of shock

 ①Consciousness
 ②Colour and temperature of extremities:
 ③Blood pressure
 ④Pulse
 ⑤Urine output
2. Definition and motivation of MODS
Two or more organs dysfunction or failure happen during the process of severe acute illness
simultaneously or consecutively
 severe trauma, burn
 severe infection
 shock
 cardiac arrest
 acute hemorrhagic necrotizing pancreatitis and strangulating intestinal
obstruction
 others : lapsus of transfusion or medication
3. What is the indication of blood transfusion
 Acute massive blood lose
 anaemia and hypoalbuminemia
 Overwhelming infection
 dysfunction of coagulation
4. What is the indication of EN (external nutrition)?
 partial nutrition supports used to supplement diet if oral intake is inadequate
(condition such as swallowing impairment due to e.g: stroke , parkinson’s disease
,motor m euron disease, severe weight lose ,anorexia and nausea.
 total nutritional support in eating .swallowing disorders and in unconscious
/sedated/ventilated patient.
5. Show me the complication of trauma?
 Infection
 Shock
 Fat embolized syndrome
 Stress ulcer
 Cruor obstacle---DIC
 Organ obstacle---MODS
6. What methods are used for sterilization? What method is Commonly used for
operative instruments sterilization?
 1 Heat sterilization Eg steam sterilization utensile
 2-Chemical sterilization :Ethyleno-oxide, Ozone And Hydrogen peroxide Dry
sterilization process
 3- Radiation sterilization : Electron Beams ,x-ray and Gamma rays of gas atomic
particle
Surgery
1. What is the manifestation of epidural hematoma?
 history of trauma. Local injuries or scalp hematoma
 brief posttraumatic loss of consciousness followed by a “lucid interval” for several
hours
 pupil change. Cerebellar tentorium hernia induced early oculomotor nerve
involvement.
  pyramidal signs. Early strength diminishes, ankylosis after cerebral hernia.
 vital signs change. High blood pressure, breathing deep, slow heart rate.
 CT scan confirmed. Double-convex mirror or bow-shaped density increased.
2. Classification of cervical spondyosis
degeneration of cervical intervertebral disc, the space between the vertebra become narrower.
calcification
A. cervican sponelytic rediculopathy
B. cevical spondilic mayopathy
C. vertebral artery type of cervical spondylosi
3. Early complication of fracture
Local
A. Vascular injury cousing haemorrhage ,internal or external visceral injury cousing
damage to structures such as brain ,lung or bladder ,damage to the surrounding
tissue,nerves or skin.
B. Haemerthrosis
C. Compertment syndrom(or volk mann’s ischemia).wound infection
Systemic
a) fat embolism
b) Shock
c) thromboembolism (pulmonary or venous)
d) Exacerbation of under layin desease such as diabetes or cronary artery disease
(CAD),pneumonia.
4. Describe the garden I-IV of the fracture of the femoral neck?
Garden [1961]
 I incomplete or Valgus impacted
 II Complete Non-displaced
 III Complete Partial displacement
 IV Complete Full displacement** Portends risk of AVN and Nonunion
5. What is the operative indication of renal injury after conservative treatment
fails?
The failure of conservative treatment is also the indication for operation:
 shock is persistent although routine measures are given which represents a persistent
retroperitoneal bleeding;
 The hemoturia becomes more severe and hemotocrit decreases;
 The mass in loin and abdominal area becomes larger than initial;
 The injuries of the abdominal viscera are suspected.
Operations for the injured kidney include renal repair, partial nephrectomy, nephrectomy,
adequate drainage of extravasated urine and blood is required
6. Describe symptoms of renal and ureteral calculi?
A. Pain: Upper-tract urinary stones usually cause pain.
B. Hematuria
 Patients frequently admit to intermittent gross hematuria or occasional tea-colored
urine (old blood). Most patients will have at least microhematuria.
 Rarely (in 10-15% of cases), complete ureteral obstruction presents without
microhematuria.
C. Infection: All stones, may be associated with infections secondary to obstruction and
stasis proximal to the offending calculus
D. Associated Fever The association of urinary stones with fever is a relative medical
emergency. Signs of clinical sepsis are variable and include fever, tachycardia, hypotension
Fever associated with urinary tract obstructionrequires prompt decompression
E. Nausea and Vomiting Upper-tract obstruction is frequently associated with nausea and
vomiting.
7. What is seddon classification in peripheral nerve injury?
Anatomically the various degrees represent injury to:
i. Myelin
ii. Axon
iii. The endoneurial tube and its contents
iv. Perineurium
v. The entire nerve trunk
8. Risk factors of the breast cancer?
 ① Family history of breast cancer:
 ② Early menarche is less than 12 years old or late menopause more than 50
years old:
 ③ Late first pregnancy more than 35 years old or no pregnancy:
 ④ Bloody discharge of the breast
 ⑤ Breast cancer in one side:
 ⑥ Mammary dysplasia accompanied with proliferative changes, papillomatosis,
or atypical epithelial hyperplasia
 ⑦ Personal history such as dietary factors, administration of estrogens, alcohol
consumption
9. What are the pathological effect of peritonitis
1, widespread absorption of toxins from the large, inflamed surface.
2, The associated paralytic ileus with:
i. loss of fluid
ii. loss of electrolytes
iii. loss of protein
iv. sepsis or septic shock
3, Gross abdominal distension with elevation of the diaphragm, which produces a liability to
lung collapse and pneumonia.
4, SIRS and MODS or MOF
10. Medical treatment on acute pancreatics?
The goals of medical therapy are reduction of pancreatic secretory stimuli and correction of
fluid and electrolyte derangements
 Gastric decompression and Diet Control
 Fluid Replacement and Preventing Shock.
 Spasmolytic and Painkiller
 Pancreatic Exocrine Secretion Suppression
 Nutrition
 Antibiotics
 Elimination of Toxic Intraperitoneal Contents
 TCM
11. Characteristics of gastrointestinal haemorrhage
 Acute Gastrointestinal Hemorrhage:
– Hematemesis: vomit bright red blood/ coffee-like materials.
– Melena: black, tarry,foul-smelling stools, >50~100ml blood.
– Hematochezia: passage of bright red blood/maroon stools.
 Chronic Gastrointestinal Hemorrhage
– Self-limited, no overt evidence of blood loss.
– Usually present as melena/hematochezia, and persistent anemia.
– Difficult to identify the bleeding source, especially from small intestine.
 12. According to the time limits how to categorize the osteomyelitis what kind of
systemic finding could be associated with the acute osteomyelitis?

13. What are the 4 pathological types of lung cancer?

 Patho1-Squamous cell carcinoma the most common kind 45％ of lung cancer. 2/3 are
central type . smoking
 Patho 2 - Adenocarcinoma The incidence is Increasing 3/4 are peripheral type
.young female > male
 Patho3- Large cell carcinoma Rare : 3-5% of all cases Most are central type .Low
differentiated Metastases early to the BRAIN
 Patho 4- Small cell carcinoma Highly malignant ! 4/5 are central type Worst
prognosis
14. What’s the typical clinical finding of acute appendicitis ?
Abdominal examination reveals the following signs:
a- Localized rebound (tenderness)
b- Rigidity
c- Rovsing’s sign
d- Anterior tenderness on rectal examination
e- Fever between 37.3 – 38.50c
f- Psoas sign

SURGERY 2007:
1. What are the basic principles to treat surgical fluid and electrolyte imbalance?
 To make the diagnosis clear
 Remove causes
 Replenish the blood volume
 Correct the anoxia
 Correct acid base imbalance
 Manage the hyperkalemia
2. What are the definition and treatment of hypokalemia?
Definition: Serum potassium is less than 3.5mmol/L.
Causes: not enough intake of potassium for a long time; diuretics make kidney excrete
potassium; patient having infusion without potassium for a long time; intravenous nutrition
without enough potassium; vomiting; persistent gastrointestinal suction; bowel fistula.
Clinical manifestation
Muscle weakness from extremities to trunk, dyspnea, even choke and cough at eating and
drinking, negative or decreasing of tendon reflexes and paralysis.
Bowel paralysis, nausea and vomiting
Impaired heart, ECG may have changes
Diuresis because of decreasing of ADH
Alkalosis
Unusual acid urine
Diagnosis
History
Clinical manifestation
Decreased serum potassium<3.5mmol/L
ECG
Treatment
Remove causes
Give K+
• 1.when urine is more than 40ml/L, give potassium.
• 2.KCl<3.0g/1000ml fluid
• 3.oral intake
3. The complication of trauma?
 Infection
 Shock
 Fat embolized syndrome
 Stress ulcer
 Cruor obstacle---DIC
 Organ obstacle---MODS
4. What is the classification of surgical infection by duration?
Duration of ill
a) Acute infection: course of disease within 3 weeks.
b) Subacute infection: 3w~2month.
c) Chronic infection: course of infection lasted more than 2m.
5. Clinical manifestation of acute pancreatitis:
 Abdominal Pain
 Nausea and Vomiting
 Abdominal Distention
 Peritoneal Irritation
 Systemic Symptoms
 Bleeding: Turner's sign and Cullen's sign
6. What are the indication of parenteral nutrition?
 Patients with an inability to absorb nutrients via the gastrointestinal tract.
 Patients whose nutrient needs cannot be met with enteral feedings within 7 to 10 days.
 Patients with severe malnutrition or catabolism where the GI tract is not usable within 3-5
days.
7. What are the main symptoms for colorectal cancer?
 Blood in the stool
 A change in bowel habit
 Diarrhea, constipation or feeling that the bowel did not empty completely
 Abdominal discomfort(frequent gas paints bloating and cramps)
 Stools narrower then usual
 Weight loss for no reason
 Constant fatigue
8. What are the indications of exploratory laparotomy?

9. What are Pathology and clinical types of acute appendicitis?

Acute simple appendicitis
Acute supurative appendicitis
Gangrenous or perforative
Periappendicular abcess
When doing epidural anesthesia which tissue does the needle pass through?
①Entering root subarachnoid space by passing through arachnoid villi,drug act on spinal
nerve roots;
②Exuding intervertebral foramina, drug block spinal nerve at lateral side of spine;
③Entering subarachoid space by penetrating dura mater and arachnoid directly, drug act on
spinal cord and spinal nerve roots.
 10. Kinds of drugs for pain management and give one name of representative drugs?
 Non-steroidal anti-inflammation drugs slight to medium non-cancer pain
-aspirin
 Opioids post operation pain and cancer pain -fentanyl, morphine
 Anti-epileptic drugs neurogenic pain -phenytoin sodium,carbamazepine
 Antidepressant depression -fluoxetine
 Sedative & hypnotics -dizepam
11. Please Describe symptom of renal and urethral calculi?
A. Pain: Upper-tract urinary stones usually cause pain.
B. Hematuria
 Patients frequently admit to intermittent gross hematuria or occasional tea-colored
urine (old blood). Most patients will have at least microhematuria.
 Rarely (in 10-15% of cases), complete ureteral obstruction presents without
microhematuria.
C. Infection: All stones, may be associated with infections secondary to obstruction and
stasis proximal to the offending calculus
D. Associated Fever The association of urinary stones with fever is a relative medical
emergency. Signs of clinical sepsis are variable and include fever, tachycardia, hypotension
Fever associated with urinary tract obstructionrequires prompt decompression
E. Nausea and Vomiting Upper-tract obstruction is frequently associated with nausea and
vomiting.
12. What are the reasons for Reasons anterior urethral injury and posterior urethral
injury what is the Difference fields of urine extravasations b/w anterior and
posterior urethral injuries
Reasons anterior urethral injury
The anterior urethra is the portion distal to the urogenital diaphragm, which is fixed in the
perineum. Straddle injury may cause laceration, contusion, or complete disruption of the
urethra. Iatrogenic instrumentation may cause partial disruption. Urethral contusion may
result in edema and hemorrhage and heals spontaneously. Urethral laceration leads to
periurethral hematoma and urine extravasations, which result in subsequent urethral stricture.
Complete disruption may cause urinary retention, large hematoma, and urine extravasations.
Reasons of posterior urethral injury
The membranous urethra passes through the urogenital diaphragm and is the portion of the
posterior urethra most likely to be injured. When pelvic fractures occur from blunt trauma,
the membranous urethra is sheared from the prostatic apex at the prostatomembranous
junction. The prostate is displaced superiorly when the laceration of puboprostatic ligament
occurs. Pelvic fracture and vascular injuries may lead to a large hematoma around the
prostate and bladder. Urinary extravasation may occur in the retropubic space and the space
surrounding the bladder and prostate.
Difference fields of urine extravasations b/w anterior and posterior urethral injuries
The anterior extravasations of urine and blood may extend into the scrotum and perineum,
along the penile shaft, and up to the abdominal wall. It is limited only by Colles’ fascia.
Urethral injury with urinary extravasations may result in necrosis of the skin and
subcutaneous tissue, infection, and even sepsis.
posterior Urine extravasation -urinary extravasations occur in the periprostatic and
perivesical space. Urinary extravasation and hematoma may occur in the perineum and
scrotum when laceration of the urogenital diaphragm present
13. please describe the diagnosis and manifestation of epidural hematoma
 1, history of trauma. Local injuries or scalp hematoma
 2, brief posttraumatic loss of consciousness
  followed by a “lucid interval” for several hours
 3, pupil change. Cerebellar tentorium hernia induced early oculomotor nerve
involvement.
 4, pyramidal signs. Early strength diminishes, ankylosis after cerebral hernia.
 5, vital signs change. High blood pressure, breathing deep, slow heart rate.
 6, CT scan confirmed. Double-convex mirror or bow-shaped density increased.
14. What are the treatment principles of hand injury?
 Thorough debridement at earlier period
 Recover anatomical continuity: Unless severely contaminated or crushed, important
tissue in the depth of the wound should be repaired primarily (bone&joint, nerve and
tendon). Bony architecture should always be reestablished primarily.
 Close wound: Unless severely contaminated or crushed, every wound of hand should
be closed primarily by means of direct suture, skin graft or skin flap.
 Correct bandaging and splinting: vessels (2w), tendon (4-6w) or nerve (4-6w) should
be immobilized to be of no tension; fractured bone (4-6w)and dislocated joint (3w)
should be fixed firmly.
 Immediate exercise after healing of tissue
15. What is flail chest and how to diagnose it?
Flail chest is (occurs )When there are multiple-fractured ribs, bilateral rib fractures, several
ribs fractured at two or more points, or an associated fracture of the sternum, the respiratory
exchange may be inadequate
Diagnoses:
 Sharp knife-like pain by motion of the rib cage.
 Deep respiration causes severe pain.
 The breathing is apt to rapid and shallow.
 Direct tenderness and indirect tenderness.
 Fractured sound and the paradoxical movement of the chest wall
 Subcutaneous emphysema, pneumothorax and hemothorax
 Chest film MAY show the fracture line or displacement of the ends of fractured ribs,
pneumothorax and hemothorax can be found.
16. Describe the differential diagnoses of Mediastinal Tumors?
 Lung cancer
 Tuberculosis
 Leiomyoma of esophagus
 Aortic aneurysm and dissection
17. What are the early complication of fracture?
 Shock
 Infection
 Visceral injuries： spleen lung bladder rectum
 Injury of peripheral tissue： arteries nerves spinal cord
 Fat embolism compartment syndrome
18. What are the late complication of fracture?
 Hypostatic pneumonia
 Bed sores
 Deep venous thrombus of lower extremity
 myositis ossificans
 Traumatic arthritis
 Anchylosis(Joint stiffness)
 Acute bone atrophy(Sudeck atrophy)
  Ischemic bone necrosis
 Ischemic muscle contracture
 Malformation of the bone
 Infection
19. Please describe the three Colum concept of the spine?
The anterior column includes the anterior longitudinal ligament, the anterior 2/3 of the
vertebral body, and the anterior portion of the annulus fibrosus and disc.
The middle column consists of the posterior longitudinal ligament, the posterior 1/3 of the
vertebral body, and the posterior aspect of the annulus fibrosus and disc.
The posterior column includes the neural arch, the ligamentum flavum, the facet capsules,
and the interspinous ligaments
20. The definition of monteggia fracture-dislocation and galeazzi fracture –
dislocation.
Definition:
 Monteggia fracture: The fracture of the proximal 1/3 of the ulna with associated
dislocation of the radial head
 Galeazzi fracture: The fracture of the radius in the distal third associated with
dislocation of the radioulnar joint
SURGERY 2008
1. What are principles of the first aid of trauma?
 1.locale emergence cure
 2.effective resuscitation
 3.transport immediately.
LOCALE FIRST AID
A. 1.Basic measure
B. 2.airway
C. 3.breathing
D. 4circulation
E. 5,precedence salvage.
2. What are the basic principles to treat surgical fluid and electrolyte imbalance?
to make the diagnosis clear remove causes replenish the blood volume correct anoxia
carrect acid base imbalance manage the hyperkalemia
3. What are the complication of liver cancer?
Hepatic coma
Upper gastrointestinal hemorrhage
Rupture and hemorrhage of carcinoma
Secondary infection
4. What are the complications of trauma?
Infection
Shock
Fat embolized syndrome
Stress ulcer
Cruor obstacle---DIC
Organ obstacle---MODS
5. What are the indication of exploratory laparotomy

6. How many common complications after operation?

a) Postoperative bleeding:
Incomplete homeostasis during operation, spasm of the small artery stratum and
uncontrolling of extravasation.
 b) Wound infection
• Clean incision and probably contaminated incision.
• Symptoms: pain, swelling, red , fever, increment of WBC.
• treatment: culture the discharge to find the bacteria.take off the suture.
C) Wound dehiscence
• Reasons: Malnutrition, healing ability of patient is poor. Tension of the abdominal
wall increase, such as severe cough.Poor techniques: such as knot is not tight,
laceration of the peritoneum when suturing it.
7. According to the degree of the urgency, operations are classified into three
categories what are they and make examples respectively?
 Selective surgery, (subtotal gastrectomy…)
 Date limited surgery, (malignant tumors resection…)
 Emergency surgery, (spleen rupture…)
8. What is the classification of surgical infection by duration
Acute infection: course of disease within 3 weeks.
Subacute infection: 3w~2month.
Chronic infection: course of infection lasted more than 2m.
9. What are the six ingredients of nutrition?
I. Dextrose
II. lipid
III. animo acid
IV. Electrolytes and minerals
V. Vitamins
VI. Trace elements

10. Please describe the three-column theory of spine

a) The anterior column include the anterior longitudinal ligament,the anterior 2/3 of
the vertebral body,and anterior portion of the annulus fibrous and disc.
b) The middle column consistsof the posterior longitudinal ligament,the posterior
longitudinal of the vertebral body ,and the posterior aspect of the annulus fibrous
and disc
c) C).The posterior column includes the neural arh the ligamentum flavum,the facet
capsules and interspinous ligaments.
11. What are the three characteristic signs of fracture, and what are the three
principles in fracture treatment?
Characteristic signs of fracture,
 Deformity
 Abnormal movement
 Crepitus
The three principles in fracture treatment,
 Reduction
 Immobilization
 Exercises
12. What are the characteristics of the adolescent idiopathic scoliosis
 The most common type: 80%
 Young girls
 Right thoracic curve
 Hypokyphosis of thoracic spine
13. What is CPCR and describe the resuscitation order from AtoE
CPCR--cardiopulmonary cerebral resuscitation
 C: circulation
A: airway, head- chin lift
B: breathing -mouth to mouth breathing.
D: disability, careful neurologic examination.
E: exposure, examine all skin surfaces
14. What are three steps of treatment of cancer pain
Three-step therapy recommended by WHO
 Step 1. Non-opioids aspirin
 Step 2. Weak opioids codeine
 Step 3. Superactive opioids morphine
15. What is the operative indication of renal injury after conservative treatment fails
 1.shock is persistent although routine measures are given which represents a
persistent retroperitoneal bleeding
 2.the hematuria becomes more severe and hemotocrit decreases
 3.the mass in loin and abdominal area becomes larger than initial .
 4. the injuries of the abdominal viscera are suspected
16. Please describe the symptoms of renal and ureteral calculi
A. Pain: Upper-tract urinary stones usually cause pain.
B. Hematuria
 Patients frequently admit to intermittent gross hematuria or occasional tea-colored urine
(old blood). Most patients will have at least microhematuria.
 Rarely (in 10-15% of cases), complete ureteral obstruction presents without
microhematuria.
C. Infection: All stones, may be associated with infections secondary to obstruction and stasis
proximal to the offending calculus
D. Associated Fever The association of urinary stones with fever is a relative medical emergency.
Signs of clinical sepsis are variable and include fever, tachycardia, hypotension Fever associated with
urinary tract obstructionrequires prompt decompression
E. Nausea and Vomiting Upper-tract obstruction is frequently associated with nausea and vomiting.
17. Describe the differential diagnosis of mediastinal tumor
 Lung cancer
 Tuberculosis
 Leiomyoma of esophagus
 Aortic aneurysm and dissection
18. What are the four abnormalities of tetralogy of fallot
 malalignment vsd
 2.overriding aorta .
 3.pulmonary stenosis .
 4.right ventricular hypertrophy (RVH).
19. Please describe the manifestation of epidural hematoma
 history of trauma. Local injuries or scalp hematoma
 brief posttraumatic loss of consciousness followed by a “lucid interval” for several
hours
 pupil change. Cerebellar tentorium hernia induced early oculomotor nerve
involvement.
 pyramidal signs. Early strength diminishes, ankylosis after cerebral hernia.
 vital signs change. High blood pressure, breathing deep, slow heart rate.
 CT scan confirmed. Double-convex mirror or bow-shaped density increased.
20. what are the treatment of principles of hand injuries
 Early and complete debridement Within post-injured 6-8 hours
 Correctly repair injured tendons, nerves and vessels
 Primary closure of wound: Directly or Flap transfer
 Correct postoperative treatment
 （1）Expose the finger tip
 （2）Functional immobilization
 （3）Injection of TAT、using antibiotics, changing dressing every other day
 （4）Remove sutures after 14 days