Surgery ABS Exam Question Bank

60 CME Credits


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Surgery Sample Questions:

Question 1

A 72-­year­-old is s/p open abdominal aortic aneurysm repair, in septic shock with a white count of 42 × 10^3/microL and a temperature of 38.4◦C. He is on empiric antibiotics and has no bowel function. He is Clostridium difficile positive by PCR. The appropriate antibiotic regimen is:

A) Oral metronidazole only
B) ​Oral vancomycin only
C) Oral metronidazole and oral vancomycin
D) ​V metronidazole and rectal vancomycin
E) V vancomycin and oral vancomycin

Answer
D) ​V metronidazole and rectal vancomycin


Explanation
Correct: (D) V metronidazole and rectal vancomycin. Explanation: There are risk factors for infectious C. difficile diarrhea including previous antibiotic use, hospitalization, and increased age. Fever and very high white counts may accompany the abdominal pain. Rarely, diarrhea may be absent due to paralytic ileus. C. difficile diarrhea varies in severity (mild, moderate, and severe) and treatment depends on severity. Two or more of the following indicates severe disease: age greater than 60, temperature greater than 38.3◦C, white count greater than 15000 cells/mm3, and albumin less than 2.5mg/dL. This patient has a severe infection based on his increased age, WBC, and fever. The optimal treatment for severe infection is oral vancomycin. Since this patient does not have bowel function, IV metronidazole will provide appropriate concentration in the colonocytes for treatment of C. difficile diarrhea. Addition of oral vancomycin or metronidazole could benefit if the drug would reach the site of infection—the colon. Some data exists regarding the use of rectal administration of vancomycin (intraluminal). Thus the answer is D.

References
Bartlett JG, Gerding DN (2008) Clinical recognition and diagnosis of clostridium difficile infection. Clinical Infectious Diseases 46, S12-18. Gerding DN, Muto CA, Owens RC Jr., et al. (2008) Treatment of clostridium difficile infection. Clinical Infectious Diseases 46, S32-42. Reference Copyright 2012 Surgical Critical Care and Emergency Surgery: Clinical Questions and Answers This question was taken from BoardVitals Surgery CME Question Bank


Question 2

A 69­ year ­old man with history of COPD presents with 24­hour history of abdominal distension and emesis. Physical examination reveals abdominal distension with hypoactive bowel sounds and a tender mass in the left groin below the inguinal ligament. During groin exploration, an incarcerated femoral hernia is found. Bowel is not viable and required resection. The preferred repair of the hernia would be

A) ​Bassini repair
B) ​Lichenstein repair
C) Shouldice repair
D) ​Cooper's ligament repair
E) ​Mesh plug in femoral canal

Answer
D) ​Cooper's ligament repair


Explanation
Correct: (D) ​Cooper's ligament repair. Explanation: A Bassini repair involves reconstruction of the floor by suturing the transversalis fascia, the transverses abdominis, and the internal oblique muscle to the inguinal ligament. The Shouldice, which used to be the standard repair, is similar but is done in multiple layers. Both are tension repair. The Lichenstein repair uses mesh and is considered a tension­free repair, which is viewed as a gold standard. These repairs, however, do not address the femoral canal defect. The mesh plug technique was developed by Gilbert and then modified by Rutkow and Robbins, Milikan, and others. The technique involves a premade mesh shaped like a mushroom or self­made rolled up mesh that was placed in the defect like internal ring for indirect hernia, or the neck of the defect for direct hernia, or into the femoral canal in femoral hernia and secured in place by stitches. However, it is not recommended in this case because of the contamination and a possible mesh infection. A Cooper ligament repair is similar to Bassini repair, except that Cooper's ligament instead of the inguinal ligament is used for the medial portion of the repair. This addresses the femoral defect and is indicated for this patient.

References
Deveney KE (2006) Hernias and other lesions of abdominal wall. In Doherty GM (ed.) Current Surgical Diagnosis and Treatment, 12th edn, New York, McGraw­Hill, pp. 765-78. Reference Copyright 2012 Surgical Critical Care and Emergency Surgery: Clinical Questions and Answers This question was taken from BoardVitals Surgery CME Question Bank

Questions taken from the Surgery ABS Exam Question Bank.

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