surgery

Question 1

All these methods are used to prevent thromboembolic complications in the perioperative period, except one:

A) Na-heparin
B) Colfarit (acidum acetylsalicylicum)
C) Ca-heparin
D) compression stockings

Answer 1

B) Colfarit (acidum acetylsalicylicum)

EXPLANATIONOne of the most frequent complications after a surgical intervention is thromboembolization (with an average risk of around 20-30% after abdominal surgeries, and 50-60% after major orthopedic and trauma surgeries). Thromboembolic prophylaxis should be carried out in patients at a high risk (e.g. history of thrombosis or myocardial infarction, elderly people, obesity, undergoing long surgery). Methods include medical therapy: conventional and low-molecular-weight heparin administered subcutaneously (started before the surgery!), and physical modalities: early mobilization, use of compression stockings, pillowing up the lower extremities. Acetylsalicylic acid (e.g. Colfarit) decreases the risk of thromboembolism by inhibiting platelet aggregation. Its effect starts around 15 minutes after administration and lasts for 3-7 days. Its side effects (e.g. bleeding complications) cannot be suspended and the patient may require platelet transfusion, thus these drugs are not suitable for preoperative prophylaxis.

Question 2

All those means, methods and interventions with which we try to prevent the contamination of the pathogens are collectively called as:
A)  	disinfection
B)  	asepsis
C)  	antisepsis
D)  	sterilization

Answer 2

B) asepsis

EXPLANATION
All those interventions, actions and methods with which we try to prevent the contamination of the pathogens are collectively called asepsis. To reach this goal, all the instruments and materials we use during an intervention must be made free of germs (sterilization). Antisepsis means all the actions taken against the already present contamination, which can be most effectively achieved by disinfection. (See also SEB-1.65.)

Question 3

The most frequent type of surgery of the repair of an inguinal hernia is:
A)  	Fabricius surgery
B)  	Kocher surgery
C)  	Nissen–Rosetti surgery
D)  	Lichtenstein surgery
E)  	Bassini-Kirschner surgery

Answer 3

D) Lichtenstein surgery

EXPLANATION
Today the most widely accepted inguinal hernia repair is the tension-free Lichtenstein surgery which comes with the lowest recurrence rate. Previously the standard technique was the Bassini surgery, which was not tension-free, and the rate of recurrence could be as high as 10-15%.

Question 4

Which of the following statements is true?

A) Hernia repairs are categorized as clean-contaminated surgeries
B) The average suppuration rate after clean-contaminated surgeries is around 5-15%
C) The average suppuration rate after clean-contaminated surgeries is <8-22%.
D) The average suppuration rate after clean-contaminated surgeries is >2-8%.

Answer 4

D) The average suppuration rate after clean-contaminated surgeries is >2-8%.

EXPLANATION
We consider a surgery clean-contaminated if the gastrointestinal, genitourinary and/or respiratory tracts are opened under controlled conditions without significant. After such surgeries the risk of infection is inevitably increased, regardless of how careful the surgical manipulation or isolation of the operating field was.

Question 5

Relatives of a 63-year-old male patient discover jaundice on him. All of the following presumed diagnoses are reasonable, except one:

A)  	infective hepatitis
B)  	pancreatic cancer
C)  	chronic pancreatitis
D)  	Crigler–Najjar syndrome
E)  	choledocholithiasis

Answer 5

D) Crigler–Najjar syndrome

EXPLANATION

Based on the clinical data and etiology (alcohol abuse), the patient can have liver cirrhosis, some form of chronic hepatitis or chronic pancreatitis. Painless jaundice is often caused by a head of the pancreas cancer (see also SEB-1.29.). Similarly, an acquired infective hepatitis or even choledocholithiasis cannot be ruled out. Crigler-Najjar syndrome, however, is a fetal metabolic disorder leading to hyperbilirubinemia (see also SEB-1.169. - 1.180.).

Question 6

The most common pathway of metastatic spreading in colonic cancer is:

A) via the inferior mesenteric vein
B) via the portal vein
C) lymphogenic spreading
D) intraluminar spreading

Answer 6

C) lymphogenic spreading

EXPLANATION
Colorectal cancer has the potential to give hematogenous metastases when penetrating the vessels of the bowel-wall as they grow. The major supplying vessels of the colon – e.g. both the superior and inferior mesenteric veins – both reach the liver via the portal vein. In colorectal cancer, however, the most common means of spreading is through the lymphatics. If the cancer infiltrates all layers of the colonic wall, lymphatic spreading is present in 90% of the cases.

Question 7

Proper treatment of a furuncle on the face:
A)  	incision, excochleation
B)  	expression of the pus
C)  	moist packing and antibiotics
D)  	excision

Answer 7

C) moist packing and antibiotics

EXPLANATION
The venous system of the face has a direct connection with the basilar plexus in the head. Thus, any facial infection has to be treated with special care. Incision and excision are often unfavorable due to cosmetic reasons. The popular ‘self-made popping’ is strictly contraindicated.

Question 8

Which histologic type of the thyroid cancer has generally the best prognosis?
A)  	medullary cancer
B)  	papillary cancer
C)  	follicular cancer
D)  	anaplastic cancer

Answer 8

B) papillary cancer

EXPLANATION
From the thyroid cancers the papillary type grows very slowly and is rare to give metastases. Thus, the papillary type is considered the most ‘benign’ of the malignant cancers.

Question 9

The Perthes test:

A) assesses the condition of the valves in the greater saphenous vein
B) assesses the rate of blood flow towards the deep veins
C) is a sign of deep-vein thrombosis when dorsalflexion of the foot induces calf pain
D) if negative, phlebography has to be performed next

Answer 9

B) assesses the rate of blood flow towards the deep veins

EXPLANATION

The Perthes test is a clinical test for assessing the patency of the deep femoral vein. After placing a rubber compression band on the leg of the standing patient (under the knee or sometimes also unto the thighs -, he/she is asked to walk for some time. Emptying (collapse) of the superficial veins means a good flow towards the deep veins – this we call a negative Perthes test. If the test is positive, further evaluation tests (e.g. venous Doppler US, phlebography) are needed when planning a varicectomy. (Other references in the question A: Trendelenburg test, C: Homan’s sign).

Question 10

In which disease is it most common to find an enlarged, palpable gallbladder?

A) Klatskin tumor
B) papilla of Vater carcinoma
C) cancer in the head of the pancreas
D) hepaticolithiasis

Answer 10

B) papilla of Vater carcinoma

EXPLANATION
In the case of a hilar or intrahepatic Klatskin tumor or biliary tract stone, the obstruction is proximal to the gallbladder, thus the gallbladder can empty freely. If the cancer is in the body of the pancreas, the distal bile duct is usually not compressed, and the gallbladder is cannot be palpated. The characteristic „Courvoisier sign” is most often present in head of the pancreas or papilla of Vater malignancies.

Question 11

Select the examples of an absolute indication of surgery:

1) an injury that is so severe that the life of the patient can only be saved with a surgical intervention
2) deepening jaundice
3) intestinal obstruction
4) certain cases of gallstone disease
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 11

C) 2nd and 4th answers are correct

EXPLANATION
Answer 1 and 3: Vital (immediate) indication of surgery usually refers to perforation of a hollow viscera with consequent peritonitis, major acute bleeding, bowel incarceration, or any other medical condition where the life of the patient can only be saved with an immediate surgery. In such cases delaying the surgical intervention can lead to irreversible organ damage, development of sepsis and eventually death. Answer 2 and 4: Absolute surgical indication means that the disease is to be treated surgically – although not necessarily immediately -, otherwise permanent organ damage may develop, and the process may lead to the death of the patient. Cholelithiasis in itself is not an absolute indication, but it may lead to pancreatitis, cholangitis, cholecystitis and perforation and as such, a symptomatic cholelithiasis is considered an absolute surgical indication (see also SEB-1.42. and SEB-1.81., 1.82., 1.83., 1.84.).

Question 12

Possible causes of a complete postoperative abdominal wound disruption:

1) protein deficiency
2) improper surgical technique
3) postoperative abdominal distension
4) early mobilization
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 12

A) 1st, 2nd and 3rd answers are correct

EXPLANATION
Wound dehiscence is the consequence of several predisposing factors and usually develops on the 5-8. postoperative day. It happens most often in cachectic patients, but adiposity, protein loss, the presence of ascites or sudden postoperative intra-abdominal pressure changes (e.g. coughing) or improper surgical technique is also a risk factor. Often wound suppuration lay in the background. Early mobilization is, however, not a predisposing factor. Dehiscence is often preceded by clear-bloody discharge from the wound. In the case of a total disruption, abdominal viscera may prolapse. Treatment is urgent reoperation. After suppuration and dehiscence, closure of the abdominal cavity can be challenging.

Question 13

Characteristics of the lateral/indirect inguinal hernia:

1) it is less prone to incarceration
2) can cause intermittent groin pain
3) it never extends into the scrotum
4) it is often congenital
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 13

C) 2nd and 4th answers are correct

Lateral (indirect) inguinal hernias are especially prone to incarceration since the hernia has to pass through the long, curvy and relatively narrow inguinal canal. Medial (direct) hernias, on the other hand, has only a short hernial sac – if any -, and their orifice is usually wide. The characteristic intermittent pain or discomfort associated with inguinal hernias is caused by the stretching of the mesentery of the trapped bowel loop. Lateral hernias often develop in the persisting tunica vaginalis (congenital hernia) and thus the hernia sac can reach the scrotum itself (inguinoscrotal hernia) (see also SEB-1.23.).

Question 14

What are those areas where the laparoscopic surgical approach has the most obvious benefits?
1) gallstone disease
2) inguinal hernia
3) gastroesophageal reflux disease (GERD)
4) adrenal adenoma
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 14

E) all of the answers are correct

Question 15

When diabetes mellitus is diagnosed, the further investigations has to be carried out:
1) quantitative glucose assessment from collected urine
2) sugar profile assessment
3) glucose acetone assessment from fragmented urine using test strips
4) glucose tolerance test
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

Answer 15

A) 1st, 2nd and 3rd answers are correct

Question 16

In case of lacerated wound which involves the gluteal muscle
1) wound edges should be excised
2) prophylactic antibiotics (in this case Sulfaguanidine) should be administered
3) wound cavity should be rinsed with H2O2-solution
4) the wound should only be closed if a drain tube is left in the cavity
5) wound closure should be done with running intracutaneous suture
A) 1, 2, 4 and 5 answers are correct
B) all of the answers are correct
C) 2 and 4 answers are correct
D) 1, 3 and 4 answers are correct

Answer 16

D) 1, 3 and 4 answers are correct

Question 17

Tetanus prophylaxis is mandatory:
1)  	erysipelas
2)  	congelation
3)  	gunshot wound
4)  	bite wound
5)  	hydradenitis
A)  	1, 2 and 3 answers are correct
B)  	1, 3 and 4 answers are correct
C)  	2, 3 and 4 answers are correct
D)  	3, 4 and 5 answers are correct

Answer 17

C) 2, 3 and 4 answers are correct

EXPLANATIONTetanus prophylaxis is mandatory in every type of lacerated, bitten or gunshot wounds. In these cases the skin is damaged and soft tissues are contaminated (see also SEB-1.11). Tetanus prophylaxis is also necessary in case of congelation because of the extensive soft tissue damage. Antibiotics are notable for treating inflamed skin lesions

Question 18

What could be the main sources of bleeding in patients with liver cirrhosis except esophageal varices?
1)  	gastritis
2)  	duodenal ulcer
3)  	gastric ulcer
4)  	Mallory–Weiss-syndrome
5)  	Barret's esophagus
A)  	1, 2 and 3 answers are correct
B)  	1, 3 and 4 answers are correct
C)  	1, 4 and 5 answers are correct
D)  	1, 3 and 5 answers are correct
E)  	2, 3 and 4 answers are correct

Answer 18

A) 1, 2 and 3 answers are correct

EXPLANATION
Gastroduodenal ulcers are the most common cause of massive gastrointestinal bleeding. Ulcer bleeding also must be excluded in known cirrhotic patients. Other important causes of bleeding can be alcoholic or erosive gastritis. Mallory-Weiss syndrome and Barrett-esophagus are less common causes of gastrointestinal bleeding, which are rare in patients with cirrhosis.

Question 19

Clinical significance of basal cell cancer

1) its histological structure is not malignant
2) recurrence is frequent
3) metastases are uncommon
4) frequently develops in elderly patients
5) its only therapy is surgical
A) 1, 3 and 4 answers are correct
B) 2, 3 and 4 answers are correct
C) 1, 3 and 5 answers are correct
D) 3 and 4 answers are correct
E) all of the answers are correct

Answer 19

D) 3 and 4 answers are correct

EXPLANATION
Malignant skin tumor originated from the basal cells of the skin typically occurs in elderly patients. Its clinical significance is that it is unlikely to disseminate, grows slowly and rarely recurs after excision.

Question 20

A physical examination by the family doctor on the right side reveals basal bruises, the patient should immediately be sent to the following tests:

A heavy smoker and known alcoholic patient arrives to the family doctor visibly having lost weight and in a weakened state, saying he has severe cough attacks, especially after drinking. After eating solid food, he vomits frequently.

1) Chest X-ray
2) abdominal ultrasound examination
3) Swallowing X-ray
4) Laboratory test
A) Answers 1, 2 and 4 are correct
B) Answers 2, 3 and 4 are correct
C) Answers 1 and 3 are correct
D) All of the answers are correct
E) None of the answers are correct

Answer 20

C) Answers 1 and 3 are correct

EXPLANATION
The patient has coughing attacks after drinking liquids which should raise the suspicion for an esophago-bronchial fistula or dysphagia. His smoking and alcohol abuse history, and his poor general condition can be a sign that malignancy lies in the background of the esophago-bronchial fistula. Diagnosis is possible by swallowing X-ray examination with water-soluble contrast media. In esophago-bronchial fistulas aspiration pneumonia is common, therefore chest radiography should be always performed. (Blood tests and abdominal ultrasound is also important since spontaneous esophago-bronchial fistula, periodic dysphagia, vomiting and desquamation are associated with esophageal tumors, but these tests do not affect the patient’s immediate care.) The patient has dysphagia, so he is unable to feed, he has pneumonia, and he needs hospitalization because of his respiratory complaints. (Antibiotics, mucolytic and other adjuvant therapies as well as oral or parenteral nutrition should be carried out hospital settings.) Swallowing X-ray revealed an occlusion. Although we know that is most often occurs in esophageal cancer, we still have to confirm the suspicion as the next step. Biopsy is usually taken during endoscopy. (Chest, mediastinal CT scan can provide further information on extent of the malignancy; bronchoscopy may reveal tracheal involvement the presence/location of the suspected fistulae, while an abdominal ultrasound can detect distant metastases – dominantly liver metastases. Bacteriological culture is relevant if the patient’s pneumonia is not responding to the administered antibiotics, and targeted antibiotic therapy is planned. These latter investigations are only secondary to endoscopy.) The patient has a stenosing cancer in the esophagus, infiltrating the trachea and leading to the development of an esophago-bronchial fistula. As such, this cancer is inoperable, and the esophagus can only be removed together with the trachea. Of the palliative solutions, the endoscopic tube implantation is the best choice since the tube covers the fistula eliminating the possibility of aspiration, ensures the patency of the esophagus and thus making oral feeding possible. (A feeding tube does not eliminate the possibility of aspiration, antibiotic, mucolytic and analgesic drugs are only adjuvant therapy for the development of esophago-bronchial fistula.)

Question 21

In the patient, chest X-ray confirmed right sided pneumonia, swallowing could not be performed due to patient dysphagia, so the most important thing to do is:A heavy smoker and known alcoholic patient arrives to the family doctor visibly having lost weight and in a weakened state, saying he has severe cough attacks, especially after drinking. After eating solid food, he vomits frequently.

1) Antibiotic and mucolytic treatment should be applied for pneumonia
2) The patient should be treated with some minor neuroleptic agent to deal with the consequences of alcoholism
3) Because of respiratory and swallowing complaints the patient is to be hospitalized
4) The patient should be instructed to apply a feeding tube
A) Answers 1, 2 and 4 are correct
B) Answers 2, 3 and 4 are correct
C) Answer 1 is correct
D) Answer 3 is correct
E) All of the answers are correct

Answer 21

D) Answer 3 is correct

Question 22

The swallowing test confirmed the existence of an oesophagobronchial fistula, for which the following options should be considered:A heavy smoker and known alcoholic patient arrives to the family doctor visibly having lost weight and in a weakened state, saying he has severe cough attacks, especially after drinking. After eating solid food, he vomits frequently.

1) esophageal resection by removal of the tumor
2) Endoscopic tube implantation to close the fistula and ensure nutrition
3) apply a feeding tube
4) antibiotic, mucolytic and analgesic treatment
A) Answers 1, 2 and 3 are correct
B) Answers 2 and 3 are correct
C) Answer 2 is correct
D) Answer 1 is correct
E) Answer 4 is correct

Answer 22

C) Answer 2 is correct

Question 23

One correct answer is possible based on the key.After two years of uneventful period in the central operating room of the well-known surgical unit, the operations of nosocomial category A and B are facing infections. The cause was discovered by the surgeon and the hygienist and then reported. As a result of the report, the air ducts of the air conditioning unit were disinfected, and the bacterial filters were replaced. After the final disinfection, surgeries restarted, and the rate of wound infections reduced to an acceptable level.
1) For nosocomial category A, after sterile or clean surgery, no pathogen is expected in the surgical area.
2) For nosocomial category A, the prevalence of wound healing is 4–8%.
3) In the case of nosocomial category A, antibiotic prophylaxis is not required from a surgical aspect.
4) In the case of a blocked bacterial filter, the over pressure in the operating room is eliminated.
5) The condensation fluid of the air ducts in the air conditioner may become colonized by bacteria.
A) Answers 1, 2 and 4 are correct
B) Answers 1, 3, 4 and 5 are correct
C) Answers 2, 3 and 5 are correct
D) Answers 2, 3 and 4 are correct
E) All of the answers are correct

Answer 23

B) Answers 1, 3, 4 and 5 are correct

EXPLANATION
In nosocomial category A (e.g. sterile or clean surgery) no pathogen is to be expected in the surgical area. This group includes surgeries where no hollow organs are opened and there is no inflammation present. (Without this exception even an abscess surgery could fall into this category!) Moreover, in clean surgeries there cannot be thread granuloma, or other foreign substances in the surgery area. Examples of these surgeries are hernia repairs, vascular and endocrine surgeries, diagnostic laparoscopic or open interventions. In the case of nosocomial category ‘A’ the rate of wound suppuration is <1%. From a surgical point of view, only categories C and D justify the administration of prophylactic antibiotics. In the case of a blocked bacterial filter, the required overpressure in the operating room is reduced – the inflow of air is significantly less - while the outflow stays unchanged. Fluid condensation from the air in the ducts of air conditioners can lead to the proliferation of bacteria. Condense fluid is mainly produced in significant quantities when the air conditioner is operated periodically. Final disinfection should be carried out after every nosocomial epidemic and its efficacy must be confirmed with multiple cultures. The causes of the epidemic should be identified during and after the nosocomial epidemic. In addition to human factors, contamination often has technical reasons. During the epidemic and the consequent investigations, the significant medical facilities (operating rooms, outpatient offices, etc.) and patient rooms, as well as service areas are contaminated. After a thorough cleaning, disinfection of all the surfaces, mechanical equipment, airspace and devices is required to restore the aseptic conditions. Tissues dissected during a surgery themselves cannot defend against infections. The infection can come from the air of the operating room, from the hands or clothes of the surgical team, from instruments and materials used during the surgery, or from the bloodstream of the patient (endogenous infection). During the operation of an infected area, proper surgical technique should be used to avoid the direct or indirect contamination of the surgical site with pathogens. Since none of the above factors can be completely eliminated, wound infection is always a part of the surgical risk. The frequency of wound infection is one of the oldest quality indicators used beside surgical mortality and effectiveness (resectability, total healing rate). It represents the training and attention of the staff at the department, the functionality of the devices, the adequacy of the cleaning, sterilizing, surgical, and wound care processes. It affects the department’s antibiotics strategies and the internal quality control methods. Because of its complex nature, if wound infection rate starts to rise a thorough investigation of the possible causes must be carried out. The lack of monitoring of this indicator is a fundamental deficiency.

Question 24

Choose the right answer!After two years of uneventful period in the central operating room of the well-known surgical unit, the operations of nosocomial category A and B are facing infections. The cause was discovered by the surgeon and the hygienist and then reported. As a result of the report, the air ducts of the air conditioning unit were disinfected, and the bacterial filters were replaced. After the final disinfection, surgeries restarted, and the rate of wound infections reduced to an acceptable level.
A) Closing disinfection should be performed daily after the final surgery.
B) Closing disinfection can be performed with a 12.5% hypochlorite solution.
C) The final disinfection can only be supervised by the head of the department.
D) Closing disinfection should be performed after each nosocomial infection and the result should be checked by bacteriological examination.
E) Final disinfection can only be ordered by the ÁNTSZ.

Answer 24

D) Closing disinfection should be performed after each nosocomial infection and the result should be checked by bacteriological examination.

ANSWER (sur.1.145)

E) Wound infection is part of the surgical risk.

SNWER (sur 1.146)
B) The frequency of wound infection is a quality indicator.

Question 25

Diseases in differential diagnosis except: There is no significant illness in the 63-year-old male patient. His relatives noticed the yellow color of his scleras, so he attended his family doctor who carried out a laboratory test. The family doctor received the following laboratory results: accelerated erythrocyte sedimentation rate, moderate anemia, significant serum bilirubin elevation, which was mainly direct, elevated AST and ALT, significantly elevated ALP, slightly elevated serum creatinine, elevated blood glucose, normal amylase and lipase, bilirubinuria, glucosuria. ``` A) infective hepatitis B) pancreatic cancer C) chronic pancreatitis D) Crigler-Najjar syndrome E) choledocholithiasis ```

Answer 25

ANSWER D) Crigler-Najjar syndrome In a 63-year-old patient, Crigler-Najjar syndrome is not plausible, since it is a fetal bilirubin metabolism disorder due to the lack of glucuronyl transferase (see also SEB-1.30). A significantly increased conjugated bilirubin level, usually together with increased ALP levels, is characteristic to occlusive jaundice.

Question 26

Knowing the laboratory results, the family doctor referred the patient to the hospital: There is no significant illness in the 63-year-old male patient. His relatives noticed the yellow color of his scleras, so he attended his family doctor who carried out a laboratory test. The family doctor received the following laboratory results: accelerated erythrocyte sedimentation rate, moderate anemia, significant serum bilirubin elevation, which was mainly direct, elevated AST and ALT, significantly elevated ALP, slightly elevated serum creatinine, elevated blood glucose, normal amylase and lipase, bilirubinuria, glucosuria. A) diagnosis: acute septic cholangitis - internal medicine B) diagnosis: infective hepatitis - infectology C) diagnosis: obstructive icterus, chronic pancreatitis - internal medicine D) diagnosis: obstructive icterus, pancreatic tumor? - internal medicine E) diagnosis: obstructive icterus, choledocholithiasis - internal medicine

Answer 26

D) diagnosis: obstructive icterus, pancreatic tumor? - internal medicine

Question 27

Based on the medical history and laboratory results the following additional laboratory tests should be carried out for differential diagnosis in the ward: There is no significant illness in the 63-year-old male patient. His relatives noticed the yellow color of his scleras, so he attended his family doctor who carried out a laboratory test. The family doctor received the following laboratory results: accelerated erythrocyte sedimentation rate, moderate anemia, significant serum bilirubin elevation, which was mainly direct, elevated AST and ALT, significantly elevated ALP, slightly elevated serum creatinine, elevated blood glucose, normal amylase and lipase, bilirubinuria, glucosuria. 1) pancreatic function tests (Lundh test, secretion test, starch load, etc.) 2) virus-serological tests (anti-HAV IgM, HbsAG, anti-HBs, anti-HBc, etc.) 3) serum iron, iron binding capacity, stool benzidine tests 4) tumor marker tests (CEA, CA19-9, etc.) A) Answer 1, 2 and 3 are correct B) Answer 2 and 3 are correct C) Answer 2 and 4 are correct D) Only the 4th answer is correct E) all 4 answers are correct

Answer 27

D) Only the 4th answer is correct

Question 28

For diabetes mellitus, the following tests are required: There is no significant illness in the 63-year-old male patient. His relatives noticed the yellow color of his scleras, so he attended his family doctor who carried out a laboratory test. The family doctor received the following laboratory results: accelerated erythrocyte sedimentation rate, moderate anemia, significant serum bilirubin elevation, which was mainly direct, elevated AST and ALT, significantly elevated ALP, slightly elevated serum creatinine, elevated blood glucose, normal amylase and lipase, bilirubinuria, glucosuria. 1) blood glucose test 2) hemoglobin A1C test 3) urine sugar depletion test 4) glucose tolerance test A) Answer 1, 2 and 3 are correct B) Answer 2 and 3 are correct C) Answer 2 and 4 are correct D) Only the 4th answer is correct E) all 4 answers are correct

Answer 28

A) Answer 1, 2 and 3 are correct

Question 29

Additional imaging studies needed for diagnosis: There is no significant illness in the 63-year-old male patient. His relatives noticed the yellow color of his scleras, so he attended his family doctor who carried out a laboratory test. The family doctor received the following laboratory results: accelerated erythrocyte sedimentation rate, moderate anemia, significant serum bilirubin elevation, which was mainly direct, elevated AST and ALT, significantly elevated ALP, slightly elevated serum creatinine, elevated blood glucose, normal amylase and lipase, bilirubinuria, glucosuria. 1) pancreas scintigraphy 2) CT 3) ERCP 4) intravenous cholecystography A) Answer 1, 2 and 3 are correct B) Answer 2 and 3 are correct C) Answer 2 and 4 are correct D) Only the 4th answer is correct E) all 4 answers are correct

Answer 29

B) Answer 2 and 3 are correct

Question 30

If the patient's cytological examination cannot confirm malignancy, the following should be done: There is no significant illness in the 63-year-old male patient. His relatives noticed the yellow color of his scleras, so he attended his family doctor who carried out a laboratory test. The family doctor received the following laboratory results: accelerated erythrocyte sedimentation rate, moderate anemia, significant serum bilirubin elevation, which was mainly direct, elevated AST and ALT, significantly elevated ALP, slightly elevated serum creatinine, elevated blood glucose, normal amylase and lipase, bilirubinuria, glucosuria. A) consider surgical exploration due to a suspected cancer B) observe of the patient until healing of chronic pancreatitis C) consider endoscopic sampling D) antibiotic treatment 'ex juvantibus'

Answer 30

A) consider surgical exploration due to a suspected cancer

Question 31

If the cytology test is positive for malignancy, do the following: There is no significant illness in the 63-year-old male patient. His relatives noticed the yellow color of his scleras, so he attended his family doctor who carried out a laboratory test. The family doctor received the following laboratory results: accelerated erythrocyte sedimentation rate, moderate anemia, significant serum bilirubin elevation, which was mainly direct, elevated AST and ALT, significantly elevated ALP, slightly elevated serum creatinine, elevated blood glucose, normal amylase and lipase, bilirubinuria, glucosuria. A) radiation and cytostatic treatment, followed by surgery depending on their effectiveness B) starting cytostatic treatment C) surgical exploration and the evaluation of tumor resectability D) percutaneous transhepatic drainage for palliative purposes

Answer 31

C) surgical exploration and the evaluation of tumor resectability

Question 32

``` Radiological studies that play a key role in breast cancer diagnosis (3 responses possible) 1) breast ultrasound examination 2) mammography 3) PET 4) MR 5) CT A) Answers 1, 2 and 4 are correct B) Answers 1, 3, 4 and 5 are correct C) Answers 2, 3 and 5 are correct D) Answers 2, 3 and 4 are correct E) All of the answers are correct ```

Answer 32

A) Answers 1, 2 and 4 are correct

Question 33

The breast cyst (one answer wrong) A) the most common benign breast lesion B) often gets superinfected C) rarely needs surgical treatment D) pneumocystography is the best diagnostic and therapeutic method

Answer 33

B) often gets super infected EXPLANATION Breast cysts are the most common benign breast disorders, their size can reach several centimeters. In previous decades, symptomatic cysts have always been surgically removed. Nowadays pneumocystography is the most accepted diagnostic and therapeutic method. The rate of recurrence after draining the cyst content and the filling the cyst with air is around 10%. Cysts should only be treated surgically if there is an intracystic growth (papilloma) or they recur. Superinfection of the cysts is very rare.

Question 34

Recommended surgical treatment for a non-palpable invasive breast cancer (one answer is correct) A) excision with guide-wire localization + axillary block dissection B) excision with isotope localization + sentinel lymph node biopsy C) mastectomy D) quadrant resection + axillary block dissection

Answer 34

B) excision with isotope localization + sentinel lymph node biopsy

Question 35

What tests would you carry out?A 48-year-old female patient was presented at the clinic with an enlarged goiter. Despite having good appetite, she complained of weight loss, being tense and nervous. Occasionally there was a feeling of palpitation, drowsiness and difficulty in swallowing. 1) neck US 2) basic metabolic tests 3) thyroid scintigraphy 4) thyroid hormone levels assessment 5) swallowing X-Ray, native trachea X-Ray ``` A) Answers 1, 2 and 4 are correct B) Answers 1, 3, 4 and 5 are correct C) Answers 2, 3 and 5 are correct D) Answers 2, 3 and 4 are correct E) All of the answers are correct ```

Answer 35

B) Answers 1, 3, 4 and 5 are correct D) thyreostatics and surgery (sur1.164) B) lobectomy on the affected side (Su1.1.65) EXPLANATION Based on the case history, this is probably a hyperthyroid goiter with signs of compression. The studies are aimed to clarify the stage of hyperfunction (hormone test), the reason (scintigraphy, ultrasonography) and the signs of compression (esophagus-, trachea compression, dislocation). Hot nodule refers to an autonomous adenoma. The patient should be treated to reach euthyroid status and the adenoma needs to be removed. We need to perform surgery after thyrostatic therapy. Since this is a benign tumor, there is no need for extended resection, enucleation is sufficient (radioiodine treatment is an alternative). The recurrent laryngeal nerve runs and enters the larynx behind the thyroid gland, innervating the vocal cords. In case of thyroid resection, nerve damage is a well-known surgical complication, resulting in unilateral vocal cord paralysis and symptomatic hoarseness.

Question 36

What conservative treatment had been probably used to treat the limb disorders 5 years ago?A 45-year-old woman was admitted with a history of large bowel resection 5 years ago due to colonic cancer. At that time on postoperative day 4 the left lower limb got swollen, the skin tightened, shiny, warm, slightly cyanotic and pain occurred. The symptoms disappeared for conservative treatment. Three years ago, repeated left lower limb complaints began. Currently the limb is swollen again, with visible varices and ulcers on the lower extremity. 1) bed rest for 5-7 days 2) elevation of the limb 3) wearing elastic bandage or compression stockings 4) anticoagulation for 5 to 7 days with heparin followed by long-term treatment with Warfarin 5) fibrinolysis (depending on indication) A) Answers 1, 2 and 4 are correct B) Answers 1, 3, 4 and 5 are correct C) Answers 2, 3 and 5 are correct D) Answers 1, 2, 3 and 4 are correct E) All of the answers are correct

Answer 36

E) All of the answers are correct

Question 37

What kind of surgery would you choose in this case?A 45-year-old woman was admitted with a history of large bowel resection 5 years ago due to colonic cancer. At that time on postoperative day 4 the left lower limb got swollen, the skin tightened, shiny, warm, slightly cyanotic and pain occurred. The symptoms disappeared for conservative treatment. Three years ago, repeated left lower limb complaints began. Currently the limb is swollen again, with visible varices and ulcers on the lower extremity. A) arterial thrombectomy B) arterial embolectomy C) venous thrombectomy D) crossectomy, stripping, subfascial ligature of perforator veins E) reconstructive arterial surgery

Answer 37

D) crossectomy, stripping, subfascial ligature of perforator veins

Question 38

What treatment plan would you choose based on the previous diagnosis?A 78-year-old diabetic woman is admitted to the hospital due to right subcostal cramping pain, nausea, vomiting. Two days later she developed jaundice. A) open surgery after the inflammation was gone B) laparoscopic surgery after the inflammation was gone C) pancreatic head resection D) referring the patient to an Infectology Ward E) ERCP, stone extraction and laparoscopic cholecystectomy performed next day

Answer 38

E) ERCP, stone extraction and laparoscopic cholecystectomy performed next day

Question 39

``` If no source of bleeding was found with gastroscopy, what shall be the next diagnostic option?An elderly female patient is referred to an inpatient ward due to repeated episodes of melena. The patient's laboratory examination shows anemia (Ht: 25). The patient is known to have confirmed liver cirrhosis and previous upper gastrointestinal bleeding episodes, treated conservatively (endoscopy, sclerotherapy). A) rectoscopy or colonoscopy B) angiography C) ultrasound examination D) CT E) none of the above ```

Answer 39

A) rectoscopy or colonoscopy (first done is gastroscopy) The source of melena causing anemia - because it is digested blood - can be usually found in the upper gastrointestinal tract. This is also supported by the patient's history. Therefore, the first investigation should be urgent gastroscopy, and other diagnostic modalities should come only if endoscopy turns out to be negative. The next step is to confirm or rule out if the bleeding source was in the large bowels. Angiography can be useful in the diagnosis of rare, small bowel or endoscopically undetectable bleeding sources. During the endoscopic management of bleeding peptic ulcers, urgent hemostatic methods (sclerotherapy and/or clipping) should be tried first to minimize the blood loss. If, however, despite every endoscopic effort re-bleeding occurs, immediate surgery becomes necessary. Therefore, such cases should be observed and treated in a surgical ward or more so in a surgical intensive care unit.

Question 40

``` Gastroscopy revealed an acutely bleeding ulcer. What is the proper endoscopic treatment approach?An elderly female patient is referred to an inpatient ward due to repeated episodes of melena. The patient's laboratory examination shows anemia (Ht: 25). The patient is known to have confirmed liver cirrhosis and previous upper gastrointestinal bleeding episodes, treated conservatively (endoscopy, sclerotherapy). 1) notify the surgeon 2) order for blood transfusions 3) perform endoscopic sclerotherapy 4) hemostasis with endoscopic electrocoagulation 5) start steroid treatment A) Answers 1, 2 and 4 are correct B) Answers 1, 3, 4 and 5 are correct C) Answers 1 and 3 are correct D) Answers 2, 3 and 4 are correct E) All of the answers are correct ```

Answer 40

C) Answers 1 and 3 are correct

Question 41

36 hours after the successful endoscopic hemostasis, the patient vomited blood again at night. Next step to do:An elderly female patient is referred to an inpatient ward due to repeated episodes of melena. The patient's laboratory examination shows anemia (Ht: 25). The patient is known to have confirmed liver cirrhosis and previous upper gastrointestinal bleeding episodes, treated conservatively (endoscopy, sclerotherapy). A) urgent gastroscopy B) urgent gastroscopy and repeated endoscopic hemostasis C) urgent colonoscopy D) urgent surgery E) maintaining the patient's circulation by repeated transfusions until morning

Answer 41

D) urgent surgery

Question 42

``` Method used for taking biopsy and exposure of paratracheal and praetracheal lymph nodes: A) Stemmer (Chamberlain)-biopsy B) Klassen-biopsy C) Carlens-biopsy D) Scalenus lymph node biopsy ```

Answer 42

C) Carlens-biopsy

Question 43

Usually effective treatment of the pleural empyema: A) bed rest, antibiotics and pain killers B) early thoracotomy, decortication C) thoracic drainage, suction therapy D) fenestration E) VATS suctions and drainage

Answer 43

C) thoracic drainage, suction therapy

Question 44

``` Which type of the primary lung cancer is the most suitable for lung resection? A) squamocellular cancer B) adenocarcinoma C) small cell lung cancer D) large cell lung cancer E) bronchioloalveolar ```

Answer 44

A) squamocellular cancer

Question 45

Left upper lobe adenocarcinoma with ipsilateral mediastinal lymph node metastasis. How would you proceed? A) This tumor is inoperable, because not only the lung but the mediastinum is also affected. Primery radio-chemotherapy is recommended. B) Left upper lobectomy with radical mediastinal lymphadenectomy is recommended. C) Induction (neoadjuvant) chemo (-radio) therapy is recommended with lobectomy and radical mediastinal lymphadenectomy later on. D) Lobectomy, lympahedenectomy followed by adjuvant oncological therapy is recommended.

Answer 45

C) Induction (neoadjuvant) chemo (-radio) therapy is recommended with lobectomy and radical mediastinal lymphadenectomy later on.

Question 46

In spite of the improving living conditions what is the most frequent type of operation of TB patients? A) thoracoplasty B) extrapleural pneumolysis C) adhaesiolysis (Jacobeus’ s operation) D) lung resection E) decortication

Answer 46

D) lung resection

Question 47

``` Find the examination what is not included in the normal preoperative examinations list of the lung cancer patients. A) chest X-ray B) chest CT and MRI C) bronchoscopy D) pulmonary angiography E) sputum cytology F) spirometry, blood gas analysis ```

Answer 47

D) pulmonary angiography

Question 48

``` Which parameter shows decompensated respiratory insufficiency? A) pH B) PCO2 C) PO2 D) BE E) standard HCO3 ```

Answer 48

A) pH

Question 49

``` Which is the best dynamic lung function parameter for examining the obstructive lung diseases? A) FEV1 B) Tiff% C) MEF50 D) flow-volume loop ```

Answer 49

D) flow-volume loop

Question 50

``` The most common malignant tumor of the chest wall bones: A) single bone metastasis B) osteosarcoma C) multiple myeloma D) Ewing-sarcoma E) chondrosarcoma ```

Answer 50

E) chondrosarcoma

Question 51

Cardio-vascular mortality in Hungary: A) is not significant B) significant, but is comparable to current european trends C) statistic data is not available D) is second following mortality of malignancies E) is on top of the mortality list

Answer 51

E) is on top of the mortality list EXPLANATION 50-55% of overall mortality in Hungary is due to cardiovasular diseases. That puts Hungary in the 3rd worst position in Europe.

Question 52

What is the exact location of the coarctation of the aorta? A) between the right subclavian and the right carotid arteries B) between the right and the left carotid arteries C) between the left carotid and the left subclavian arteries D) between the left subclavian artery and the duct of Botallo

Answer 52

D) between the left subclavian artery and the duct of Botallo EXPLANATION The morphological stenosis in coarctation of the aorta is on the border of the aortic arch and the descending aorta, between the left subclavian artery and the duct of Botallo.

Question 53

Symptoms of pericardial tamponade, except for: A) elevated central venous pressure B) decreased cardiac output C) low blood pressure D) elevated left ventricular filling pressure

Answer 53

D) elevated left ventricular filling pressure EXPLANATION Pericardial tamponade is caused by fluid collection in the pericardial cavity. Compression of heart chambers in the localised pericardial space results in reduction of diastolic filling capacity.

Question 54

``` The following congenital cardiac defects depend on ductal circulation, except for: A) pulmonary atresia B) hypoplastic left heart syndrome C) interruption of the aortic arch D) ventricular septal defect ```

Answer 54

D) ventricular septal defect EXPLANATION A patent ductus areriosus is mandatory in pulmonary atresia and hypoplastic left heart syndrome because it is the only connection between left and right sided circulation, as pulmonary and systemic circulations are provided by the same single ventricle. In patients with interrupted aortic arch lower body is perfused throught the patent ductus arteriosus by the right ventricle, so ductus closure results lower body ischaemia. In cases of ventricular septal defect ductus Botalli closure is preferable to aviod pulmonary congestion.

Question 55

Coronary angiography is necessary prior to surgery, except for: 1) patients older than 60 years of age with with degenerative aortic valve stenosis 2) patients with angina pectoris 3) patients with persisting ischaemic symptoms following myocardial infarction 4) patients with mitral stenosis younger than 40 years of age A) the 1st, 2nd and 3rd answers are correct B) the 1st and 3rd answers are correct C) the 2nd and 4th answers are correct D) only the 4th answer is correct E) all of the answers are correct

Answer 55

D) only the 4th answer is correct EXPLANATION Coronary angiography is indicated before any cardiac surgical intervention in patients above 40 years of age. If the medical history of a patient contains data suggesting myocardial ischaemia under 40 years of age angiography is obviously necessary as well.

Question 56

Surgical procedures for correcting mitral stenosis are the following, except for 1) commissurotomy 2) implantation of artificial chordae 3) prosthesis implantation 4) implantation of an annuloplastic ring A) the 1st, 2nd and 3rd answers are correct B) the 1st and 3rd answers are correct C) the 2nd and 4th answers are correct D) only the 4th answer is correct E) all of the answers are correct

Answer 56

C) the 2nd and 4th answers are correct EXPLANATION Mitral commissurotomy and prosthetic heart valve implantation are procedures to correct mitral stenosis. Implantation of artificial chordae and the use of annuloplasty rings (and sometimes prosthetic heart valve implantation) are surgical methods of treating mitral regurgitation.

Question 57

A patient after aortobifemoral bypass presents with succulent fistula of the right groin. Management is the following: 1) waiting, these type of fistulas usually heal spontaneously 2) wound management, ambulantory care 3) looking for suture granuloma in the wound 4) admission to vascular surgical department, fistulography, CT angiography, surgery A) the 1st, 2nd and 3rd answers are correct B) the 1st and 3rd answers are correct C) the 2nd and 4th answers are correct D) only the 4th answer is correct E) all of the answers are correct

Answer 57

D) only the 4th answer is correct EXPLANATIONThese symptoms are signs of potential vascular graft suppuration. It is a dangerous complication due to the risk of bleeding, propagation, sepsis. Waiting is not the right option. Searching for suture granulome in the wound can result bleeding. Until precise diagnosis we have to presume the infection of the graft.

Question 58

``` A 65 year old male patient presents with the history of aortobifemoral bypass 6 years ago. He noticed melaena and diarrhea lately and had no other complains than general weakness until admission to the hospital. Which diagnosis is likely for this patient? 1) aorto-duodenal fistula 2) stress ulcer 3) aortojejunal fistula 4) colitis ulcerosa A) the 1st, 2nd and 3rd answers are correct B) the 1st and 3rd answers are correct C) the 2nd and 4th answers are correct D) only the 4th answer is correct E) all of the answers are correct ```

Answer 58

B) the 1st and 3rd answers are correct EXPLANATION Melaena due to aortoenteric fistula is a possible late complication of aorto-bifemoral bypass with prosthetic graft. A patient with colitis ulcerosa would not have been asymptomatic for 6 years. Stress ulcer does not occur without previous damage.

Question 59

Possibilities in the treatment of deep vein thrombosis: 1) angio VAC/Jet therapy 2) selective thrombolysis 3) per os medical treatment, which do not need monitoring 4) phlebography A) the 1st, 2nd and 3rd answers are correct B) the 1st and 3rd answers are correct C) the 2nd and 4th answers are correct D) only the 4th answer is correct E) all of the answers are correctx

Answer 59

A) the 1st, 2nd and 3rd answers are correct EXPLANATIONPhlebography is a diagnostic modality, it is not used for therapy. The other answers are right.

Question 60

A patient with poor general condition (ASA III) presents with critical ischemia of the right lower limb. DSA demonstrates right ilio-femoral occlusion, significant stenosis of the left common iliac artery with the outflow of deep femoral artery on both sides. What is the right therapeutic choice? 1) right femoral amputation 2) Aorto-bifemoral bypass. 3) We try to improve the patient’s condition by conservative treatment 4) stenting of the left iliac artery, crossover bypass surgery from left to right A) the 1st, 2nd and 3rd answers are correct B) the 1st and 3rd answers are correct C) the 2nd and 4th answers are correct D) only the 4th answer is correct E) all of the answers are correct

Answer 60

D) only the 4th answer is correct EXPLANATION If a patient with poor general condition presents with critical lower limb ischaemia, there is no time for improving the general condition. In this case the least ivasive procedures should be performed like extraanatomic bypasses. One requirement for crossover bypass is the good inflow, so stenting of the contralateral side is needed.

Question 61

What are the right steps in the case of an acute Stanford type B aortic dissection causing chest pain? 1) exclusion of acute myocardial infarction 2) performing CT angiography to verify the dissection 3) admission to intensive care unit, hypotensive therapy by using beta-blockers 4) if the symptoms are persisting, or new symptoms (visceral) evolve, TEVAR is recommended A) the 1st, 2nd and 3rd answers are correct B) the 1st and 3rd answers are correct C) the 2nd and 4th answers are correct D) only the 4th answer is correct E) all of the answers are correct

Answer 61

E) all of the answers are correct EXPLANATION The symptoms of myocardial infarction are similar to acute Stanford type B dissection, so it must be excluded. The diagnosis of dissection can be verifyed by CT angiography. The patient must recieve controlled hypotensive therapy. Surgery should be performed when symptoms would not resolve, or new symptoms occur.

Question 62

An open fracture can be treated in the same way as a closed fracture if A) it is a type 1 open fracture B) has only minimal lateral dislocation C) it is a type 2 open fracture D) in any type of open fracture, after proper treatment of the wound

Answer 62

A) it is a type 1 open fracture EXPLANATIONOnly type 1 open fractures can be treated in the same manner as closed fractures because type 1 open fractures are a result of low energy trauma, the fractured bone ruptures the skin and soft tissue from inside out, therefor the incidence of bacterial infection is low. This is why this type of fracture is considered and treated in a similar way as closed fractures.

Question 63

Which classification system is best for prognosis of proximal humerus fractures? A) The Neer classification based on the number of fractured fragments B) Garden classification C) Böhler classification D) Pauwels classification

Answer 63

A) The Neer classification based on the number of fractured fragments EXPLANATION The Neer classification pertains to the treatment of proximal humerus fractures.

Question 64

Which is the most frequently missed shoulder dislocation?A) Luxatio erecta – inferior dislocation B) Posterior dislocation C) Axillary dislocation D) Anterior dislocation

Answer 64

B) Posterior dislocation EXPLANATIONThe posterior shoulder dislocation is missed most often; we must think of this if the contour of the humerus head and glenoid contour overlap each other.

Question 65

In a Monteggia fracture, where is the location of the radius head dislocation? A) In the proximal radioulnar joint B) In the distal radioulnar joint C) There is no dislocation, it follows the fracture line D) The elbow joint is dislocated

Answer 65

A) In the proximal radioulnar joint EXPLANATIONIn a Monteggia fracture, the dislocation of the radius head is located in the proximal radioulnar joint by definition. (MUGR; Montiega - Ulnar fx, Radius prox dislocation. Galeazzi - Radius fx, Ulnar distal dislocation)

Question 66

In an anterior cruciate ligament rupture, the anterior drawer sign, the Lachman test and the pivot shift test are all positive. A) Only the first two tests are positive B) All three tests are positive C) Only the last two tests are positive D) Only the first and last tests are positive

Answer 66

B) All three tests are positive EXPLANATIONThe anterior drawer sign, Lachmann test and the pivot shift test are all positive in an anterior cruciate ligament tear of the knee.

Question 67

Which of the following have a high risk in a traumatic hip joint dislocation? 1) Femoral head necrosis 2) Extensive cartilage damage/early arthritis 3) Sciatic (ischiadic) nerve injury 4) Infection A) only the 1st and 2nd answers are correct B) only the 1st, 2nd and 3rd answers are correct C) only the 1st, 2nd, 3rd and 4th answers are correct D) only the 4th answer is correct

Answer 67

B) only the 1st, 2nd and 3rd answers are correct EXPLANATION The risk of joint infection in a traumatic hip dislocation is minimal.

Question 68

In a medial femoral neck fracture, the affected lower limb is shortened, in external rotation, and the patient cannot actively elevate his leg. 1) This is true for all types of femoral neck fractures 2) This is not true for laterobasal femoral neck fractures 3) This is not true for valgus type impacted femoral neck fractures 4) This is not true for non-dislocated Garden type II femoral neck fractures A) only the 1st answer is correct B) only the 2nd answer is correct C) only the 3rd answer is correct D) only the 3rd and 4th answers are correct

Answer 68

D) only the 3rd and 4th answers are correct EXPLANATION In Garden type III and IV medial femoral neck fractures, the affected lower limb is shortened, in external rotation, and the patient cannot actively elevate his leg. In impacted, non-dislocated femoral neck fractures (Garden type II) and in valgus impacted fractures (Garden type I), the patient can frequently even elevate the leg.

Question 69

Which of the following are associated injuries of shoulder dislocations, which lead to recurrent shoulder dislocation? 1) Bankart-lesion 2) Hill–Sachs-lesion 3) Rotator cuff injury 4) Axillary nerve paresis A) only the 1st answer is correct B) only the 2nd answer is correct C) only the 1st, 2nd, 3rd and 4th answers are correct D) only the 1st and 2nd answers are correct

Answer 69

D) only the 1st and 2nd answers are correct EXPLANATION Recurrent shoulder dislocations can occur due to all associated injuries, which lead to the instability of the joint. In Bankart lesions, the capsule and part of the labrum are torn off the glenoid. In a Hill-Sachs lesion, the depressed fracture of the humerus head leads to incongruence of the joint, which may cause luxation when the rotational position of the depressed humeral head allows it to dislocate from the glenoid cavity.

Question 70

Which of the following is NOT true regarding perilunate dislocations? A) Perilunate dislocations result from high energy trauma. B) On the AP view, the displaced lunate has a triangular profile, rather than its normal quadrilateral image. C) The head of the capitate does not sit within the distal articular cup of the lunate. D) Osteoporosis plays a major role in the cause of the injury E) It can be associated with a scaphoid fracture.

Answer 70

D) Osteoporosis plays a major role in the cause of the injury EXPLANATION Perilunate dislocations most often occur in younger (usually male) patients. Osteoporosis does not play a role in the occurrence of the injury. Injury to an osteoporotic wrist results in a distal radius fracture.

Question 71

What do we have to be most aware of when treating metacarpal fractures? A) Prevention of shortening. B) Any palmar displacement requires reduction. C) It is important to perfectly reduce the small wedge fragment. D) To decrease lateral displacement. E) To completely eliminate any rotational malalignment

Answer 71

E) To completely eliminate any rotational malalignment EXPLANATION It is most important to eliminate any rotational malalignment when treating metacarpal fractures, because if the metacarpus has healed in rotational malalignment, the neighboring fingers’ functions are also decreased during flexion of the fingers.

Question 72

Which of the following statements is NOT TRUE concerning pyogenic (suppurative) tenosynovitis? A) The entire length of the tendon sheath is swollen and tender. B) The involved finger is in a flexed posture. C) The tendon sheath must be opened in at least 2 places, irrigated and drained. D) Delayed treatment of pyogenic tenosynovitis leads to damage and/or necrosis of the flexor tendon. E) V-shaped phlegmon is not a tenosynovitis..

Answer 72

E) V-shaped phlegmon is not a tenosynovitis. EXPLANATION The type of pyogenic tenosynovitis extending between the thumb and the little finger is called a V-shaped phlegmon, because the tendon sheaths reach the level of the wrist, but on the 2nd-4th fingers, they extend only to the distal palmar crease

Question 73

Which of the following are characteristic of scaphoid fractures? 1) tenderness of the snuff box 2) there are no characteristic clinical symptoms 3) hematoma and deformity on the radial side of the wrist 4) painful wrist extension 5) due to the mild symptoms, patients often do not go to a doctor A) only the 1st, 2nd and 3rd answers are correct B) only the 1st, 2nd and 5th answers are correct C) only the 1st, 3rd, 4th and 5th answers are correct D) only the 1st, 2nd, 4th and 5th answers are correct E) only the 2nd, 3rd, 4th and 5th answers are correct

Answer 73

D) only the 1st, 2nd, 4th and 5th answers are correct EXPLANATION It is typical that there are no characteristic symptoms (no hematoma or deformity, etc.) of scaphoid fractures.

Question 74

Which are symptoms of cubital tunnel syndrome (sulcus ulnaris syndrome)? 1) hypoesthesia on the ulnar half of the ring finger and on the pinky 2) Positive Froment’s sign: the patient cannot grip a piece of paper between their thumb and index finger. 3) the ring finger and pinky are in a flexed pose, the patient cannot fully extend the PIP and DIP joints 4) The patient cannot close the pinky to the extended ring finger due to the impaired motor function of the intrinsic muscles 5) The patient cannot flex the thumb A) only the 1st, 2nd, 3rd and 4th answers are correct B) only the 1st, 3rd, 4th and 5th answers are correct C) only the 2nd, 3rd, 4th and 5th answers are correct D) only the 1st, 4th and 5th answers are correct E) only the 2nd, 3rd and 5th answers are correct

Answer 74

A) only the 1st, 2nd, 3rd and 4th answers are correct EXPLANATION In cubital tunnel syndrome, the area of sensory innervation and muscles of motor innervation by the ulnar nerve are affected; the median nerve is responsible for flexion of the thumb. opposition of thumb: median+ulnar nerve. Ulnar nerve: ADduction of thumb

Question 75

Which of the following are correct regarding Dupuytren’s contracture? 1) Among many other risk factors, Dupuytren’s contracture is likely to be hereditary. 2) Most often occurs in middle-aged males. 3) The disease progresses and worsens over time and causes the flexion contractures of the fingers. 4) Dupuytren’s contracture can be treated with splinting, cast fixation and dynamic redressing bandaging 5) The surgical treatment involves complete removal of the thickened, degenerated tissue as well as the intact aponeurosis. A) only the 1st, 2nd, 3rd and 4th answers are correct B) only the 1st, 2nd, 3rd and 5th answers are correct C) only the 1st, 2nd, 4th and 5th answers are correct D) only the 2nd, 3rd, 4th and 5th answers are correct E) all of the answers are correct

Answer 75

B) only the 1st, 2nd, 3rd and 5th answers are correct Dupuytren’s contracture cannot be treated with conservative methods (splinting, cast fixation and redressing bandaging techniques); it requires surgery (recently, collagenase injection methods have been introduced)

Question 76

The optimal time for surgery for gastroduodenal ulcer perforation: A) within 48 hours after the onset complaints B) within 24 hours after the onset of complaints C) within 6 hours after the onset of complaints D) scheduled in advance after the investigation is completed

Answer 76

C) within 6 hours after the onset of complaints EXPLANATION As explained in the note SEB-3.1. surgical treatment of gastroduodenal peptic ulcer perforation is one of the most urgent surgical intervention. Symptoms of the disease meets the criteria of an acute abdominal disaster, and if the correct surgical intervention (see SEB-3.1) is not performed within 6 hours, the rapidly progressing peritonitis can cause sepsis, septic shock, and death of the patient. If the surgical therapy is missed, the chances of survival after 24 hours of perforation will dramatically decrease. There is no effective conservative treatment of perforation of gastroduodenal ulcer.

Question 77

Which statement is correct? A) The stomach of patients with peptic ulcers contains a large amount of pathogen bacteria B) The use of non-steroid anti-inflammatory drugs (NSAIDs) predisposes to gastric carcinoma C) Anterior wall ulcers of the duodenum tend to perforation, posterior wall ulcers tend to bleed D) Malignancy is a dangerous and frequent complication of duodenal ulcers

Answer 77

C) Anterior wall ulcers of the duodenum tend to perforation, posterior wall ulcers tend to bleed EXPLANATION Explanation of the correct answer has already been given in SEB-3.2.. The content of stomach of patients with ulcers do not contain pathogen bacteria, NSAID does not predispose to carcinoma and transformation of duodenal ulcers to cancers are literary rarities. Digestion of gastroduodenal peptic ulcer is the most often a complication of ulcers on the anterior wall of the duodenum. One of the reasons for this phenomenon is that peptic ulcers occur most frequently in the first 1-2 cm part of the duodenum bulb following pylori. The other reason is that the front wall of the duodenum is connected to the abdominal cavity in contrast to the posterior wall that is situated in the retroperitoneum. Posterior wall ulcers can adhere or penetrate to the underlying retroperitoneal organs ie. to the the pancreas or head of the pancreas, so here the destruction caused by the ulcer does not pass into the free abdominal cavity. Howevere the penetration to pancreas can be resulted in the erosion of the pancreaticoduodenal artery. This anatomic situation is the explanation of the most common complication of duodenal ulcers occurs in free abdominal perforation, while bleeding is a typical complication of posterior wall ulcers.

Question 78

``` Necrotising pancreatitis may be associated with peritonitis except: A) Localised peritonitis B) Secunder peritonitis C) Fibrinopurulent peritonitis D) Primary peritonitis ```

Answer 78

D) Primary peritonitis EXPLANATION As explained in SEB-3.9. peritonitis associated with necrotizing pancreatitis is always a consequential process, and therefore the primary peritonitis cannot be used for this purpose. Primary peritonitis refers to the inflammatory process on the peritoneal surfaces, without prior or concurrent disease of an other abdominal organ. This disease is also called "spontaneous" peritonitis. Pathomechanism is the inflammation of the peritoneum by hematogen spread or direct translocation (“migration) of bacterias from the large bowel, but can develop from urinary tract, female genitalia etc. as an ascending infection. Special forms include pneumococcus-, Streptococcus-, gonococcus- peritonitis and tuberculous peritonitis.

Question 79

Which statement is true? A) The fecal peritonitis is a banal complication of colon surgery. B) The fecal peritonitis an extremely dangerous complication of colon surgery. C) The peritonitis caused by diverticulitic perforation is milder than the peritonitis caused by appendicitis. D) After rich meal evolved foreign body colon-perforation's treatment is the suture of the opening.

Answer 79

B) The fecal peritonitis an extremely dangerous complication of colon surgery. EXPLANATION Due to the presence of pathogen bacterias in the colon safe sutures can only be made after mechanical preparation and antibiotic profilaxis. In the case of colon perforation caused by any etiology after eating, treating the opening primere suture is a wrong procedure, which means the patient's endangerment. The colon contains the most dangerous pathogenic aerobic and anaerobic bacteria (fecalflora) of the human body. In any case where the abdominal cavity is contaminated by colon content, severe septic peritonitis (fecalperitonitis) occurs, followed by a septic shock. The bacterial flora of the appendix is similar to the colon, therefore appendicitis and diverticulitis caused peritonitis is equally dangerous.

Question 80

Which statement is correct? A) The Hartmann’s procedure is the most common elective large bowel surgery. B) The Hartmann’s procedure advantage is, that there is no need of an anus preternaturalis to assure the emptying of stool. C) The essence of Hartmann’s procedure is the resection of the tumorous part of the colon, with closure of the aboral blind-ended colonic stump and formation of an end colostomy with the oral colonic stump. D) The Hartmann’s procedure is a palliative operation, and it leaves the colontumor on its place till the definitive treatment. E) By the Hartmann’s procedure we restore the continuity of the bowel with an anastomosis.

Answer 80

C) The essence of Hartmann’s procedure is the resection of the tumorous part of the colon, with closure of the aboral blind-ended colonic stump and formation of an end colostomy with the oral colonic stump.

Question 81

Large bowel ileus typical symptom of... Which one is true?A) progressively evolving abdominal distension B) seizures with enormous pain C) seizure like occurring fecal vomiting D) sudden complete stop of bowel sounds E) diffuse firm abdominal muscle guarding

Answer 81

A) progressively evolving abdominal distension EXPLANATION Large bowel ileus is sneeking, presented with slowly progressing symptoms, characterized by gradually developing abdominal bloating. The large area of the gastrointestinal tract over blockage can compensate for long time the colon stenosis and obstruction caused by bowel content congestion. In the case of colon obstruction the symptoms like pain, seizures and vomiting only appear after several days of complete blockage. Stormy symptoms are characteristic of small bowel ileus. Fecal vomiting is also a result of progressed small bowel ileus, which does not occur in colon obstruction. The full outage of bowel sounds can be a sign of diffuse peritonitis and extensive bowel necrosis. The diffuse plank hard abdomen is a characteristic symptom of gastroduodenal ulcer perforation.

Question 82

``` It can cause pelveoperitonitis and life-threatening sepsis: A) ruptured tubal pregnancy B) ruptured ovarian chocolate cyst C) gonorrhea D) for more years uncontrolled IUD ```

Answer 82

D) for more years uncontrolled IUD EXPLANATION The intrauterine contraceptive device (IUD or "spiral"), which has been uncontrolled for several years, especially in women with promiscuity, as a result of chronic endimetritis superinfection and the foreign body induced sepsis causes pyometros. Later the abdominal cavity will be infected, in the more severe cases pyometric rupture, fierce flow of pelveoperitonitis, or septic shock may occur. Ruptured extrauterine pregnancy may cause abdominal hemorrhage and bleeding shock, but not peritonitis. Gonococcal peritonitis is a mild, rare, pelvic-localized, circumscribed process that is a complication of ascending gonorrhea adnexitis. The rupture of "Chocolate" –cyst can cause acute abdominal symptoms without inflammatory signs and does not lead to peritonitis.

Question 83

Diagnostic methods for gastroduodenal ulcer perforation: 1) abdominal x-ray with barium based contrast material 2) native abdominal fluoroscopy 3) gastrodoudenoscopy 4) by swallowing water souble contrast material to prove leakage A) the 1st, 2nd and 3rd answers are correct B) the 1st and 3rd answers are correct C) the 2nd and 4th answers are correct D) only the 4th answer is correct E) all of the answers are correct

Answer 83

C) the 2nd and 4th answers are correct EXPLANATION In the case of suspected perforation of the gastroduodenal ulcer, the use of barium as a contrast agent is a mistake because when entering the abdominal cavity it causes peritonitis or aggravates the existing peritonitis. This rule is valid for all the X-ray examinations of the digestive tract susceptible to perforation. It is not appropriate to perform gastroduodenoscopy because the air supplied to the bowel lumen for evolving the field of vision by the examination may cause distension of the wall, further rupture, or progression of the perforation. The abdominal native x-ray is a nececcery sorce of information wich can detect the free abdominal air as the evidence of the perforation. Water-soluble (hydrosoluble) contrast agents can be used without risk to radiological visualization the site of exit.

Question 84

Adequate treatment of mechanical ileus: 1) conservative intestinal movement triggering 2) laxatives, enema 3) sympatholytic treatment 4) treat the obstruction with surgery if possible ``` A) the 1st, 2nd and 3rd answers are correct B) the 1st and 3rd answers are correct C) the 2nd and 4th answers are correct D) only the 4th answer is correct E) all of the answers are correct ```

Answer 84

D) only the 4th answer is correct

Question 85

``` Two most common complications of Meckel’s diverticulum: 1) bleeding 2) invagination 3) inflammation 4) perforation A) the 1st, 2nd and 3rd answers are correct B) the 1st and 3rd answers are correct C) the 2nd and 4th answers are correct D) only the 4th answer is correct E) all of the answers are correct ```

Answer 85

B) the 1st and 3rd answers are correct EXPLANATION All four complication can happen in Meckel’s diverticulum but bleeding and inflammation is more frequent than invagination and perforation.

Question 86

``` Typical symptom of appendicitis, except: 1) Lumbar pain 2) Right lower abdominal quadrant pain 3) Odorous eructation 4) Nausea, vomiting A) the 1st, 2nd and 3rd answers are correct B) the 1st and 3rd answers are correct C) the 2nd and 4th answers are correct D) only the 4th answer is correct E) all of the answers are correct ```

Answer 86

B) the 1st and 3rd answers are correct

Question 87

The diagnosis is most likely appendicitis if 1) irregular menstruation is present 2) painful urination is present with pain radiating to the thigh 3) extreme leukocytosis is present 4) odorous vaginal discharge is present 5) high fever is present 6) watery diarrhea is present 7) ascites is present 8) empty rectal ampulla is present A) none of the answers are correct B) all of the answers are correct C) the 3rd, 5th and 7th answers are correct D) the 3rd and 8th answers are correct E) the 4th, 6th and 7th answers are correct

Answer 87

A) none of the answers are correct

Question 88

These large bowel diseases can cause peritonitis, except: 1) irritable bowel disease 2) ulcerative colitis 3) Crohn’s disease 4) diverticulitis 5) polyposis 6) tumorous obstruction 7) carcinoid 8) villous adenoma A) the 1st, 2nd, 3rd and 4th answers are correct B) the 3rd, 4th, 5th and 6th answers are correct C) the 1st, 5th, 7th and 8th answers are correct D) the 4th, 5th, 6th and 7th answers are correct E) the 5th, 6th, 7th and 8th answers are correct

Answer 88

C) the 1st, 5th, 7th and 8th answers are correct

Question 89

The bacterial flora of large bowel content: 1) is not rich in pathogenic bacteria 2) is very rich in dangerous pathogenic bacteria species 3) is almost only contains anaerobe bacteria 4) aerobe and anaerobe species are equally present 5) enema can completely clear the bowel from bacteria 6) mechanical bowel preparation is not needed if antibiotic prophylaxis is given (enema, laxatives etc.) A) the 1st and 3rd answers are correct B) the 1st and 5th answers are correct C) the 2nd and 4th answers are correct D) the 3rd and 6th answers are correct

Answer 89

C) the 2nd and 4th answers are correct

Question 90

If there is no inguinal metastasis, the appropriate primary treatment of squamous cell carcinoma of the anus is: A) radio-chemotherapy B) supervoltage irradiation C) cytostatic treatment D) local excision with inguinal lymph node dissection E) abdominoperineal resection with bilateral inguinal dissection

Answer 90

A) radio-chemotherapy

Question 91

``` All of the following treatment options are appropriate for the treatment of second-degree haemorrhoids, EXCEPT: A) suppositories, ointments B) radical excision C) sclerotization D) rubber band ligation E) sitz bath ```

Answer 91

B) radical excision far too invasive at such an early stage.

Question 92

In the case of colorectal cancer causing no occlusion and solitary liver metastasis, the action that needs to be taken is: A) radiotherapy of colorectal cancer B) resection of colorectal carcinoma C) local electrocoagulation D) resection of the rectum and the removal of liver metastasis E) creation of ileostomy

Answer 92

D) resection of the rectum and the removal of liver metastasis EXPLANATION In the case of a tumour that does not cause an obstruction and, therefore, is probably less extensive, only the radical removal results in recovery. This includes the removal of solitary liver metastasis even at the same time, which significantly increases survival chances. Radiotherapy alone serves only as palliation, and can possibly be considered as an adjuvant of surgical treatment. Either the disruption of the surface of the tumour or the local disruption of the tumour can serve no purpose. Ileostomy alone is only performed locally in the case of unresectable tumours.

Question 93

The following procedures are surgical procedures performed due to portal hypertension in order to reduce direct bleeding. EXCEPT: A) sclerotization of oesophageal varices B) splenorenal shunt C) oesophageal transection D) endoscopic ligature

Answer 93

B) splenorenal shunt EXPLANATION The answers are the treatment options of acute bleeding; whereas, splenorenal shunt is not a surgical procedure that can reduce direct bleeding, but an indirect treatment option of portal hypertension.

Question 94

``` The following factors influence the prognosis of oesophageal cancer. EXCEPT: A) tumour stage B) feasibility of R0 resection C) type of therapy D) age of the patient ```

Answer 94

D) age of the patient

Question 95

Which of the following interventions would you recommend to a patient with combined gallstones as the least invasive and the lowest-risk intervention? A) first step is the removal of the gall bladder and, in case of jaundice, choledochus exploration B) LC after successful EST C) open cholecystectomy and choledochus exploration with Kehr’s drainage D) open cholecystectomy and drainage surgery (eg choledochoduodenostomy or choledochojejunostomy).

Answer 95

B) LC after successful EST A significant proportion of choledochus stones spontaneously passes after EST. If the choledochus stone passes after the less invasive EST, then LC (Laparoscopic cholecystectomy), which is also less invasive, can be performed. In benign bile duct disorders, such as choledochus stones, drainage surgery is not to be performed because regular, ascending infections cause complications over the years.

Question 96

When is PTC contraindicated? 1) if the patient suffers from coagulopathy which is not corrected 2) if intrahepatic stones are also formed 3) if the intrahepatic bile ducts are narrowed 4) if only biliary draining is planned A) 1st, 2nd and 3rd answers are correct B) 1st and 3rd answers are correct C) 2nd and 4th answers are correct D) only 4th answer is correct E) all of the answers are correct

Answer 96

B) 1st and 3rd answers are correct EXPLANATION Percutaneous transhepatic cholangiography, as the name suggests, is performed by penetrating an intrahepatic bile duct through the skin. If a patient who needs PTC has coagulopathy, the puncture of the liver and the abdominal wall may result in severe bleeding complications. If the patient does not have sufficiently dilated bile ducts, there is little chance that the physician can manage to hit a normal diameter bile duct with the needle. If we are planning biliary drainage, the thin cannula used for drainage is to be inserted using the needle used for the PTC. Intrahepatic stone formation is one of the diseases that can be diagnosed with PTC

Question 97

``` Resection of the terminal ileum results in: 1) anaemia 2) loss of biliary acids 3) loss of Vitamin B12 4) low levels of serum Fe A) 1st, 2nd and 3rd answers are correct B) 1st and 3rd answers are correct C) 2nd and 4th answers are correct D) only 4th answer is correct E) all of the answers are correct ```

Answer 97

A) 1st, 2nd and 3rd answers are correct

Question 98

``` Risk for colorectal cancer is increased in the following conditions: 1) familial polyposis 2) pseudomembranous colitis 3) Gardner syndrome 4) juvenile polyposis A) 1st, 2nd and 3rd answers are correct B) 1st and 3rd answers are correct C) 2nd and 4th answers are correct D) only 4th answer is correct E) all of the answers are correct ```

Answer 98

B) 1st and 3rd answers are correct EXPLANATION Familial polyposis and Gardner's syndrome are congenital, genetically-determined obligatory precancerous conditions; the development of cancer can be expected in young adulthood. Pseudomembranous colitis is a bacterial inflammation, which can be completely treated using the appropriate therapy. In the case of juvenile polyposis, the polyps have a histological profile similar to that observed in hamartomas and, as usually in the case of hamartomas, there is no malignant transformation potential.

Question 99

``` In acute pancreatitis, the following may refer to unfavourable prognosis: 1) extended necrosis 2) high levels of serum amylase 3) infection 4) meteorismA) 1st, 2nd and 3rd answers are correct B) 1st and 3rd answers are correct C) 2nd and 4th answers are correct D) only 4th answer is correct E) all of the answers are correct ```

Answer 99

B) 1st and 3rd answers are correct amylase level does not correlate with severity.

Question 100

``` The following may mimic the manifestations of acute appendicitis: 1) mesenteric lymphadenitis 2) acute cholecystitis 3) perforated duodenal ulcer 4) right-sided ureterolithiasis A) 1st, 2nd and 3rd answers are correct B) 1st and 3rd answers are correct C) 2nd and 4th answers are correct D) only 4th answer is correct E) all of the answers are correct ```

Answer 100

E) all of the answers are correct

Question 101

``` Symptoms of diffuse peritonitis are: 1) tachycardia 2) oliguria 3) muscular defense 4) diarrhoea involving hyperperistaltics A) 1st, 2nd and 3rd answers are correct B) 1st and 3rd answers are correct C) 2nd and 4th answers are correct D) only 4th answer is correct E) all of the answers are correct ```

Answer 101

A) 1st, 2nd and 3rd answers are correct EXPLANATION In diffuse peritonitis, several litres of fluid may accumulate in the peritoneal cavity either through the peritoneum which becomes permeable due to the inflammation, or due to the perforation of a cavity organ which leaks. Due to hypovolaemia, tachycardia associated with centralized circulation and oliguria due to reduced renal perfusion are accompanying symptoms. Due to parietal peritoneal anxiety, muscular defense develops which involves the development of reflex paralysis in the intestines causing no passage of gas or stools.

Question 102

``` The following are common complications of acute pancreatitis, except: 1) pseudocyst formation 2) ARDS 3) diabetes mellitus 4) bleeding varix of the oesophagus A) 1st, 2nd and 3rd answers are correct B) 1st and 3rd answers are correct C) 2nd and 4th answers are correct D) only 4th answer is correct E) all of the answers are correct ```

Answer 102

D) only 4th answer is correct

Question 103

Colonic diverticulitis complications are: 1) ileus in the large intestine 2) malignant abnormality 3) life-threatening bleeding 4) pelvic abscess 5) perforation of the large intestine A) 1st, 2nd and 3rd answers are correct B) 1st, 3 and 4th answers are correct C) 1st, 3 and 5th answers are correct D) 1st, 4th and 5th answers are correct E) 2nd, 4th and 5t answers are correct F) 3rd, 4th and 5th answers are correct

Answer 103

D) 1st, 4th and 5th answers are correct EXPLANATION Thickening of the diverticular intestinal portion will cause narrowing of the lumen and may lead to ileus development. Due to the microscopic perforations, bacteria may invade the peritoneum causing abscess formation, but occasionally microscopic and macroscopic perforation may also occur. Severe bleeding is more characteristic of diverticulosis than of diverticulitis, when malignant abnormalities are not likely.

Question 104

Gastric cancer is incurable if: 1) carcinosis peritonei is present 2) multiple liver metastases are present 3) the tumour affects the left adrenal gland and hilus of the spleen 4) the tumour affects the body and tail of the pancreas A) 1st, 2nd and 3rd answers are correct B) 1st, 2nd and 4th answers are correct C) 1st and 2nd answers are correct D) 1st, 3rd and 4th answers are correct E) 1st, 2nd, 3rd and 4th answers are correct

Answer 104

C) 1st and 2nd answers are correct EXPLANATION A T4 stage tumour, despite the fact that it affects one or more of the surrounding organs, is not unresectable, therefore the stomach and the spleen may be removed. The body and tail of the pancreas is also resectable, as well as the left adrenal gland, a section of the transverse colon, the left lobe of the liver, a part of the esophagus and of the diaphragm, and a few inches from the duodenum. If there is a solitaire metastasis in the liver, its removal may be indicated when all the tumours are removed within the abdominal cavity, although its role in improving survival rates is still not fully understood. If there are multiple metastases in the liver, extended liverresection or removal of multiple metastases are not considered. The tumour is also inoperable if there is metastasis in a distal lymph nodes or if peritoneal carcinosis is present in the abdominal cavity

Question 105

``` The main pathologies causing trigeminal pain: A) Intracranial tumors B) Sclerotic plaque C) Vascular compression of the nerve D) Idiopathic ```

Answer 105

C) Vascular compression of the nerve EXPLANATION The leading cause of trigeminal neuralgia 90% of the cases is vascular compression. The remaining 10% is idiopathic, but there is 2% in sclerosis multiplex caused by sclerotic plaque localized in the pons. In some cases brainstem tumors, or skull base tumors can also cause trigeminal compression.

Question 106

``` The specific symptoms in case of elderly normal pressure hydrocephalus are the following, except for: A) gait disturbance B) blurred vision C) incontinence D) memory loss ```

Answer 106

B) blurred vision

Question 107

Acute epidural hematoma is half as dangerous as subdural hematoma considering mortality: A) true B) false

Answer 107

A) true EXPLANATION The statement is indeed true, because according to great international statistics, mortality of acute subdural hematomas is between 36-74%, while mortality of epidural hemorrhage is nowadays 9-36%. The difference is partly due to the fact that in the case of epidural hemorrhage, with modern imaging early diagnosis and rapid surgical intervention can provide a favorable outcome, partly because it doesn’t always involve severe and extensive brain damage. The development of acute subdural hematoma is a consequence of high force (speed) and in all cases involves severe brain contusion (in many cases the outcome is determined by the latter). This statement is intended to correct an earlier belief.

Question 108

Parinaud’s syndrome characterized by: A) orbital tumor B) incomplete superior orbital fissure syndrome C) optic tract injury D) compression of the site of quadrigeminal lamina

Answer 108

D) compression of the site of quadrigeminal lamina

Question 109

In case of so-called silent carotid stenosis, no surgical solution is recommended because the results of medication treatment are better than the surgical solution: A) true B) false

Answer 109

B) false EXPLANATION Today it is a fact has been proven by international studies that in case of certain carotid stenosis (significant, higher than 75%) endarterectomy results in better outcome with lower risk of stroke than only drug therapy. It should be considered separately if the silent but narrowed carotid artery has a serious collateral role in the blood supply of the opposing hemisphere (e.g., contralateral carotid occlusion). In case of such so-called tandem lesions endarterectomy is also recommended. Therefore, the 15-year-old professional opinion that "in the case of mute carotid stenosis, no surgical solution is to be considered" is to be changed.

Question 110

If the patient is in deep coma, their pupils are dilated and they do not respond to light, there isn’t spontaneous breathing and any response to painful stimuli, brain death can be stated. A) true B) false

Answer 110

B) false EXPLANATION The listed symptoms and test findings actually meet the criteria for brain death according to physical examination. Nevertheless, in this form, the statement is considered false, caused by ignoring an important consideration. In all case of symptoms correspond to brain death; the key phrase must also be that "findings can’t be related to drug effects". However, the findings listed correspond to the clinical condition of deep barbiturate coma, which we sometimes need to use as a therapeutic solution.

Question 111

What is your treatment recommendation if your patient suddenly experiences a lumbar pain that radiates into the lower limb on its outer surface towards the old finger? A) pain relief and bed rest B) pain relief and acupuncture treatment C) pain relief and neurosurgical consultation D) Medication and orthopedic examination E) Pain relief and physiotherapy

Answer 111

A) pain relief and bed rest EXPLANATION The decision has to be made based on an important consideration in the statement that is the sudden emergence of a symptom, a radiating pain, without paresis. Because of the latter, we do not have to necessarily suppose such lesion that may warrant deliberation of an urgent surgical solution. The first and most important task is pain relief and bed rest (A) to reduce acute, tortuous complaints. Only if this treatment does not produce results (within a few days) it is advisable to turn to other methods or tests.

Question 112

``` Cerebral vasopasm is a condition that takes after subarachnoid hemorrhage A) 12-24 hours B) 1-3 days C) 3-14 days D) 0-48 hours ```

Answer 112

C) 3-14 days Starts on day 3 after bleeding. Peak on day 10. Ceases after 14 days.

Question 113

Mortality of acute subdural haemorrhage is at least two-times higher than diffuse axonal injury: A) true B) false

Answer 113

A) true

Question 114

The patient has regular events like TIA and the ultrasound and angiography certified an ulcerous and sclerotic plaque causing a stenosis of 50%. In this case is it preferred to do endarterectomy? A) yes B) no

Answer 114

B) no EXPLANATION - Only operation if stenosis is >75%!!! - If stenosis is 50% or less --> medication. (if medication does not help --> consider surgery. ) - Ulcerated plaque --> try first medication, then consider surgery. Today, based on large international studies, it is considered acceptable that the symptom causing carotid artery stenoses are operated only when the rate of the stenosis is significant (above 75%) from the haemodynamic point of view. In the case of a stenosis of 50% or less, medication is certainly more beneficial, and this has been confirmed by the aforementioned studies. In case of an ulcerated plaque, which does not cause hemodynamic disorders, it is not advisable to think about surgical solution until antiaggregation treatment has not been applied. If symptoms persist beside the embolism preventing anticoagulant therapy, then the surgical solution is only to be discussed (the more favorable effect of which is not yet demonstrated in international studies).

Question 115

Choose the correct statements. 1) Each and every head trauma patient has to be transported to a trauma surgery department. 2) In the case of a posttraumatic pupillary inequality(/anisocosia/ unequal pupils) an immidiate transport to neurosurgery is required. 3) By a suspected impression fracture of the skull, the patient has to be transported to the nearest trauma clinic. 4) A polytraumtic patient with skull injury needs an immidiate transport to neurosurgery. 5) A prompt transport to neurosurgery in a case of a severe (traumatic) skull injury is mandatory A) only 1st and 2nd answers are correct B) only 3rd answer is correct C) only 4th and 5th answers are correct D) all of the answers are correct

Answer 115

C) only 4th and 5th answers are correct EXPLANATION It is not correct to state that each and every head trauma patient has to be transported to a trauma surgery department because some minor head injuries do not even require any treatment, but some severe ones should be treated in neurosurgery. Posttraumatic pupillary inequality can be a consequence of direct eye-ball (bulbus) or orbit (orbita) injury, which is primarily a subject of an ophthalmological treatment. Thus, neurosurgical intervention is not always part of the cure. By a suspected impression fracture of the skull, the patient has to be transported not to the nearest trauma clinic, but to a neurosurgery. Polytrauma patients with skull injury or patients with severe (traumatic) skull injury indeed have to be transported to neurosurgery. Considering these, the correct answer is „C’.

Question 116

``` In distinguishing hydrocele and inguinal hernia, the following(s) may be useful: 1) Anamnestic data 2) Physical examination 3) Ultrasound scan 4) X-ray A) 1st, 2nd and 3rd answers are correct B) 1st and 3rd answers are correct C) 2nd and 4th answers are correct D) only 4th answer is correct E) all of the answers are correct ```

Answer 116

E) all of the answers are correct

Question 117

When does scrotal pain in an infant or child mean an imminent indication for operation? 1) If there is parenchymal bleeding in the testis because of blunt trauma 2) If scrotal pain is accompanied by abdominal pain 3) In case of orchido-epididymitis 4) If a testicular torsion cannot be ruled out based on the clinical symptoms, physical examination and/or Doppler sonography scan A) 1st, 2nd and 3rd answers are correct B) 1st and 3rd answers are correct C) 2nd and 4th answers are correct D) only 4th answer is correct E) all of the answers are correct

Answer 117

D) only 4th answer is in complete torsion (360 degrees) - testicle may necrotize within 4-6 hours.

Question 118

In case of infantile intussusception, which treatment(s) option(s) should be taken? 1) Hydrostatic desinvagination attempt (with ultrasound control) 2) In case of an unsuccessful desinvagination attempt operative treatment 3) In case of peritoneal symptoms, guarding, perforation immediate laparotomy 4) In case of bloody stool laparotomy is always needed A) 1st, 2nd and 3rd answers are correct B) 1st and 3rd answers are correct C) 2nd and 4th answers are correct D) only 4th answer is correct E) all of the answers are correct

Answer 118

A) 1st, 2nd and 3rd answers are correct

Question 119

Choose which of the following the most common cause of mechanical icterus is in the early postoperative period after laparoscopic cholecystectomy. A) halothane induced hepatitis B) not recognised Vater papilla tumor in the preoperative period C) postoperative pancreatitis D) clip placed on the common bile duct

Answer 119

D) clip placed on the common bile duct

Question 120

Consequence of persistent loss of gastric juice: 1) decreased plasma hydrogen ion concentration 2) hypokalaemia 3) hypochloraemia 4) increased plasma bicarbonate level ``` A) 1st, 2nd and 3rd answers are correct B) 1st and 3rd answers are correct C) 2nd and 4th answers are correct D) only 4th answer is correct E) all of the answers are correct ```

Answer 120

E) all of the answers are correct EXPLANATION The gastric juice is rich in hydrochloric acid, therefore, in the event of loss of gastric acid, the loss of hydrogen ion and chloride ion is common along with the loss of water. Sodium ion concentration does not change significantly, however significant hypokalaemia will develop. This is secondary in nature, due to metabolic alkalosis. Compensatory hypoventilation may be characteristic, breathing becomes slow and superficial.

Question 121

``` Parameters used for management of patient controlled analgesia: 1) rate of continuous administration 2) bolus dose 3) lockout time 4) bolus delivery time A) 1st, 2nd and 3rd answers are correct B) 1st and 3rd answers are correct C) 2nd and 4th answers are correct D) only 4th answer is correct E) all of the answers are correct ```

Answer 121

A) 1st, 2nd and 3rd answers are correct EXPLANATION When using Patient Controlled Analgesia (PCA), 3 main parameters can be set on the syringe pump. The rate of continuous "background" administration, the amount of bolus medication given by the patient, and the duration between boluses during which the patient is in vain pressing the button, the pump does not carry out the patient's new demand (lockout time e.g. 10 or 15 minutes) to avoid patient-induced overdose. Generally, the administration time of boluses can’t be set on the pump.

Question 122

Proper definition for sepsis: 1) Sepsis is a life-threatening condition which is caused by the dysregulated response to infection. 2) Sepsis is suspected if the qSOFA score is >= 2. 3) In septic shock, vasopressor support is required for maintaining mean arterial blood pressure of at least 65 mmHg, and despite adequate fluid resuscitation serum lactate level is > 2.0 mmol/l. 4) Multiple organ failure is the simultaneous altered function of 3 or more organ systems. ``` A) 1st, 2nd and 3rd answers are correct B) 1st and 3rd answers are correct C) 2nd and 4th answers are correct D) only 4th answer is correct E) all of the answers are correct ```

Answer 122

A) 1st, 2nd and 3rd answers are correct MOF= failure of 2 or more organs....