American Board of Surgery Recertification Examination Prep

These questions are similar to those asked on the American Board of Surgery Recertification Examination. Use them to prepare for the examination, fulfill learning requirements for various maintenance of competence programs, or simply improve your surgical knowledge. Answers can be viewed by following the "Read the Answers" link at the end.

1. Breast cancer is identified on screening mammography in 1 in 100 studies 1 in 500 studies 1 in 1,000 studies 1 in 5,000 studies 1 in 10,000 studies

1. Imatinib is effective in treating Medullary carcinomas of the thyroid Gastrointestinal stromal tumors Osteogenic sarcomas Melanomas All of the above tumors

1. Accelerated acute rejection Is mediated by antibodies Occurs within 1 hour Complicates 20% of transplants Has a good prognosis Occurs despite negative crossmatches

1. In adults with cystic fibrosis, spontaneous pneumothorax Occurs more frequently than in the general population Is generally caused by rupture of a bleb in the lower lobe of the lungs Is unrelated to coughing Is always symptomatic Can be prevented by tight control of pulmonary infection

1. Following renal transplantation, renal cell carcinoma Carries the same risk as in patients with normal renal function Should be treated by heminephrectomy and transplant salvage Occurs more frequently than among the general population Is unrelated to acquired renal cystic disease Occurs with normal frequency in native kidneys

1. All of the following statements about morbid obesity are correct, except: Life expectancy is decreased by an average of 6 years Operation is associated with a four-fold increase in the rate of wound breakdown Each increment of 1.0 kg/m² above 40 increases the likelihood of congestive heart failure by 6% Loss of 30% of body weight is necessary to improve associated comorbidities Pulmonary functional residual capacity is decreased by 66%

1. All of the following statements about cryptococcosis are correct, except: Pulmonary involvement is generally self-limited Meningeal involvement causes an acute illness Prostatic involvement is fairly common in male patients When properly treated, disseminated infection carries a 20% to 25% mortality rate The usual human species is Cryptococcus neoformans

1. In pleural effusions, transudates are characterized by High lactic dehydrogenase levels Glucose levels lower than those found in serum pH levels below 7.3 Protein concentrations <3.0 g/dL Leukocyte counts of 10,000 to 50,000/mm³

1. Postoperative hyponatremia to 115 mEq/L Is usually due to SIADH (syndrome of inappropriate antidiuretic hormone secretion) Should be corrected at the rate of 20 mEq/L daily Can result in pontine myelinolysis Should prompt conversion from hypotonic to isotonic saline infusion Should be routinely treated with fluid restriction

1. In the diagnosis of insulinoma Whipple's triad (symptomatic hypoglycemia, low blood sugar measurement, and relief of symptoms after the administration of glucose) is diagnostic The tolbutamide test is indicated Low circulating levels of C-peptide are characteristic Octreotide scintigraphy is effective in localizing tumors Insulin to glucose ratios of >0.4 are specific

1. In familial isolated primary hyperparathyroidism Calcium levels are usually between 10.5 mg/dL and 11.5 mg/dL Minimally invasive parathyroidectomy is not indicated Jaw tumors are common A specific chromosomal abnormality has been documented There is no increased risk of recurrent hyperparathyroidism after routine parathyroidectomy

1. Flexor tendon injuries in the hand Can easily be repaired successfully in Zone III Heal best after delayed primary repair Require multiple interrupted sutures to repair Should not be treated by proximal or distal extension of the skin incision Require interposition tendon grafts if repaired more than 2 weeks after the injury

Correction Statement

In the January issue of Surgical Rounds, Vol. 31, No. 1, the answer to Question 9 of the Recertification Practice Quiz, concerning the Glasgow Coma Scale, was identified incorrectly as b) 10. This was based on the erroneous statement that "Opening the eyes in response to pain counts for 3." The correct answer is c) 9, and the explanation to Question 9 on page 20 should have read as follows:

Opening the eyes in response to pain counts for 2, withdrawal for 4, and uttering inappropriate words for 3, for a total Glasgow score of 9.

We regret the mistake and appreciate all the Surgical Rounds readers who took time to call this to our attention.

Answers

1. c—Breast cancers are identified in 1 in 1,000 studies.
2. b—Imatinib was discovered initially for use in treating chronic myelogenous leukemia. In further testing, it was also noted to be effective against gastrointestinal stromal tumors. Its effectiveness in treating other cancers is being investigated.
3. e—Accelerated acute rejection occurs regularly in patients with negative crossmatches. In fact, it often occurs in patients with low antibody titers and low PRA (panel reactive antibody) scores. This form of rejection is mediated by T lymphocytes and is a form of cellular (not humoral) rejection. It occurs within 12 to 24 hours. Rejection that occurs immediately or within 1 hour of transplantation is hyperacute rejection, which is antibody-mediated and caused by the recipient reacting to donor antigens, to which they have been presensitized. Accelerated acute rejection occurs after 1% to 4% of transplants and carries a terrible prognosis (≥40% organ loss).
4. a—Spontaneous pneumothorax occurs in 20% of cystic fibrosis patients as compared with <1% of otherwise healthy control patients. A bleb in the upper lung lobes (not the lower) is generally responsible. This entity is directly related to intensity of coughing and generally occurs or is recognized 12 hours after a bout of coughing. Only 15% of spontaneous pneumothoraces cause recognizable symptoms; this is because cystic fibrosis patients are always so short of breath that they do not recognize their symptoms worsening or they have well-developed compensatory mechanisms. In cases of total lung collapse, which is rare in this disease, the affected patients develop severe respiratory failure. Spontaneous pneumothoraces continue to occur despite best efforts to control pulmonary infections with long-term antibiotic therapy and chest physical therapy.
5. c—Renal cell carcinoma occurs 15 times as frequently in kidney transplant recipients than in patients with otherwise normal renal function, and the malignancy carries a much worse prognosis (5-year survival, <10%). The best treatment is radical nephrectomy followed by dialysis and, perhaps, subsequent retransplantation if the patient survives and remains disease-free for at least 2 or 3 years after resection. This lesion is directly related to acquired renal cystic disease and is the consequence of this nephropathy. In patients with end-stage renal disease, the frequency of renal cell carcinoma is increased (to 5%) in native kidneys.
6. d—Loss of as little as 5% to 10% of body weight can cause significant improvement in comorbidities, such as diabetes, hypertension, and sleep apnea. The remaining statements are true.
7. b—Meningeal involvement with Cryptococcus is either chronic or subacute. Symptoms generally include change in the level of consciousness, diplopia, and headache; these manifestations are generally present for some time before the diagnosis is made. Pulmonary disease patients usually present with an acute febrile illness associated with mild cough and chest pain. Symptoms last for a short period and then disappear. Prostatic involvement is relatively common, followed by meningeal, pulmonary, myocardial, and chorioretinal infections in frequency. With two-agent antifungal coverage, disseminated disease results in a 20% to 25% mortality rate. In contrast, the mortality rate increases to 35% in the presence of fungemia. Although there are many other species, C neoformans is the offending agent in humans. This disease is relatively common in immunosuppressed (endogenously or exogenously) surgical patients.
8. d—All of the characteristics are incorrect other than the low protein concentration. In transudates, the lactic dehydrogenase levels are low, glucose concentrations in pleural fluid are higher than those in serum, pH levels are >7.3, and leukocyte counts are <1,000/mm³.
9. c—Pontine myelinolysis is a dreaded complication of severe hyponatremia, particularly if corrected too quickly, manifesting spastic quadriplegia, pseudobulbar palsy, and decreased levels of consciousness. SIADH is rare, except in patients with carcinoids, small cell carcinomas of the lung, and intracranial lesions. Correction should not be accomplished any faster than by 8 to 12 mEq/L daily. The means of correction depends on the status of the extracellular fluid volume and total body sodium, both of which need to be assessed to determine whether fluid restriction or administration of additional sodium is indicated.
10. e—The hallmark of insulinomas is a high insulin level despite a low level of circulating glucose, which should normally suppress secretion of insulin. Whipple's triad is not very specific and is also seen in patients with reactive hypoglycemia, factitious hypoglycemia, and other conditions. The tolbutamide test causes such intense hypoglycemia that it is potentially dangerous and should not be routinely used. Insulinomas secrete proinsulin, C-peptide, and insulin; disproportionately low levels of C-peptide should arouse suspicion of surreptitious administration of insulin by the patient. Because insulinomas have low levels of somatostatin receptors, octreotide scintigraphy is ineffective in diagnosing or localizing these tumors.
11. c—Jaw tumors occur in 10% to 15% of patients with familial isolated primary hyperparathyroidism. Serum calcium levels are elevated to >2 mg/dL above normal, higher than observed in the sporatic form of the disease. Minimally invasive parathyroidectomy can be used, assuming localization studies are unequivocal. Unfortunately, the specific molecular abnormality has not yet been identified. Finally, there is an increased risk of persistent and recurrent hypercalcemia in this syndrome because of an increased incidence of both carcinoma and ectopic lesions.
12. a—Zone III is the region between the distal carpal ligament and the distal palmar crease. It includes the lumbrical muscles and is highly vascular, favoring successful repair. The treacherous zone is Zone II, between the distal palmar crease and the distal phalangeal joint, where the tendon pulleys are. Tendon repairs are most successful after primary repair (0 to 24 hours after injury) rather than delaying primary repair (24 hours to 10 days after injury). Rather than using interrupted sutures, the repair is best accomplished with a single "core" suture, which provides strength, followed by a running, very fine suture to oppose the epitenon. Often the tendons retract, and skin extensions must be extended to locate the severed ends. Interposition grafts are needed if repair is delayed by 6 or more weeks, the time required for the tendon units to be irreversibly shortened.