MedCosmos Surgery
Surgery Lecture Notes, Books, MCQ and Good Articles
Saturday, September 6, 2008
Vascular Surgery MCQ
1. A 55-year-old woman gives a history of tiredness, aching, and a
feeling of heaviness in the left lower leg for the past 3 months. These
symptoms are relieved by leg elevation. She is also awakened
frequently by calf and foot cramping, which is relieved by leg
elevation, walking, or massage. On physical examination there are
superficial varicosities, nonpitting edema, and a slightly painful, 2 cm.
diameter superficial ulcer 5 cm. above and behind the left medial
malleolus. What is the most appropriate diagnosis?
A. Isolated symptomatic varicose veins.
B. Superficial lymphatic obstruction.
C. Deep venous insufficiency.
D. Arterial insufficiency.
E. Incompetent perforating veins.
Answer: C
DISCUSSION: The most common symptoms associated with venous
insufficiency are aching, swelling, and night cramps of the involved
leg, which often occur after periods of sitting or inactive standing. Leg
elevation frequently provides relief of symptoms due to venous
insufficiency, while it increases pain due to arterial insufficiency.
Although edema can occur with varicose veins alone, usually it is
associated with deep venous abnormalities and incompetent
perforators. In such cases, ulcers usually are located above and
posterior to the malleoli, reinforcing their relationship with perforator
abnormalities. The ulcers associated with arterial insufficiency may
occur anywhere on the lower leg, eventually penetrate the fascia, and
are more painful than venous ulcers.
2. The best treatment plan for the patient described in the preceding
question should include:
A. Varicose vein ligation and stripping as soon as possible.
B. Ulcer débridement, vein stripping, and skin grafting.
C. Ligation of the medial perforating veins.
,D. Transposition of saphenous vein valve.
E. Leg elevation, external Unna boot support, and ambulation without
standing.
Answer: E
DISCUSSION: Operative treatment of venous insufficiency is in most
instances an adjunct after failure of aggressive conservative
management. Leg elevation, active exercise, and elastic compression
form the cornerstones of nonoperative management. The goals of
compression are to relieve symptoms and reduce swelling. The
indications for superficial vein ligation and stripping are moderate to
severe symptoms without other signs of deep venous insufficiency. If
ulceration persists despite appropriate conservative management,
ligation of the underlying incompetent perforators helps ulcer
recurrence, and split-thickness skin grafting provides immediate
coverage and healing of the ulcer. The patient must, however, comply
with a program of external stocking support and prevention of leg
edema since the underlying venous pathophysiology remains and
ulcers tend to recur.
3. In patients who develop a documented episode of deep venous
thrombosis (DVT) the most significant long-term sequela is:
A. Claudication.
B. Recurrent foot infections.
C. Development of stasis ulcer.
D. Pulmonary embolization.
E. Diminished arterial perfusion.
Answer: C
DISCUSSION: The increased hydrostatic pressure from incompetent
venous valves following DVT predisposes to erythrocyte extravasation,
hemosiderin deposition, and brown pigmentation around the ankle.
Although the edema that occurs with deep venous insufficiency can
predispose to skin infections, these usually are located about the
ankle and resolve with adequate short-term care. When patients with
a history of DVT are followed beyond 10 years, as many as 80%
ultimately develop venous stasis ulcers. While there may be
recurrence of DVT in a minority of patients, the incidence of
pulmonary embolization is no greater than with the initial episode.
Even in a leg severely affected by venous stasis changes, the arterial
circulation is unimpaired unless there is concomitant arterial
obstructive disease.
4. A 28-year-old woman developed a painful thrombosis of a
superficial varix in the left upper calf 2 days previously. After spending
,the 2 days in bed with her leg elevated, she felt better and the
tenderness resolved; however, when out of bed she developed a
twinge of right-sided chest pain when walking and a feeling of
heaviness in the calf. Which treatment is most appropriate?
A. Check for leg swelling, tenderness, and Homan's sign, and obtain a
Doppler ultrasound study.
B. Begin antibiotics for a probable secondary bacterial infection.
C. Order emergency venography, and if it is abnormal, begin heparin
administration.
D. Begin ambulation and discontinue bed rest that probably caused
muscle pain by hyperextension of the knee.
E. If there is no pain on dorsiflexion of the left foot reassure her, since
a negative Homan's sign precludes the diagnosis of DVT.
Answer: C
DISCUSSION: Associated DVT may occur during treatment of
superficial venous thrombosis, especially if the process is near the
groin or popliteal fossa. Although a positive Homan's sign or calf,
popliteal, or groin pain is suggestive of DVT, clinical examination alone
may be incorrect in more than 50% of cases. Noninvasive tests,
including Doppler ultrasonography, are accurate for diagnosing DVT
in the thigh but are less dependable in the calf. Emergency
venography performed on an outpatient basis remains the most
accurate and cost-effective technique for diagnosing DVT of the calf
veins. Because 85% of pulmonary emboli arise from the lower
extremity, early diagnosis and aggressive treatment are important.
5. In a 55-year-old grocery store cashier with an 8-month history of leg
edema increasing over the course of a work day, associated with
moderate to severe lower leg bursting pain, the most appropriate
investigative study or studies are:
A. Doppler duplex ultrasound.
B. Brodie-Trendelenburg test.
C. Ascending and descending phlebography.
D. Measurement of ambulatory and resting foot venous pressure.
E. Venous reflux plethysmography.
Answer: A
DISCUSSION: While the Brodie-Trendelenburg test was an early
attempt to clinically evaluate valve competence and function, it is
neither quantitative nor precise. The development of phlebography
allowed anatomic delineation of normal and abnormal veins and,
when used in combination with invasive measurement of venous
pressures in the foot at rest and on ambulation, helped correlate the
venous hypertensive state with postphlebitic changes. Noninvasive
plethysmography to quantitate the degree of venous valvular
, incompetence was more easily accepted; however the combination of
B-mode duplex ultrasound (to accurately locate the vein of interest)
plus pulsed Doppler flow signal is now the “gold standard” for venous
assessment.
6. Which of the following statements are true of pulmonary
embolism?
A. Most cases occur postoperatively.
B. In the majority of patients pulmonary emboli are ultimately lysed in
situ without the administration of pharmacologic agents.
C. The preferred therapy for most patients is intravenous heparin.
D. It is generally safe to give thrombolytic agents as early as 48 hours
postoperatively.
Answer: BC
DISCUSSION: Although many patients develop pulmonary embolism
postoperatively, the majority of such lesions reported in most series
do not follow operation. These patients develop thromboembolism as
a complication of an underlying condition such as congestive heart
failure, cerebrovascular accident, malignancy, chronic infection, and a
variety of other debilitating diseases. Generally, postoperative
patients comprise approximately one third of those with pulmonary
embolism. Serial pulmonary scans following pulmonary embolism
generally show gradual clearing of the emboli with re-establishment
of perfusion in the occluded vessels. Depending on the magnitude of
the embolism, most patients show the clearing at the end of a month
to 6 weeks. The presence of persistent congestive heart failure,
chronic infection, and atelectasis retard thrombolysis. This dissolution
of emboli is generally agreed to be caused by naturally circulating
thrombolysins. In fewer than 1% of cases the emboli persist and often
increase with the passage of time, with the development of chronic
pulmonary embolism leading to severe respiratory insufficiency,
chronic cor pulmonale, pulmonary hypertension, right ventricular
failure, and death. The majority of patients with pulmonary embolism
are managed by continuous intravenous heparin. Thrombolytic
agents are generally reserved for the management of extensive
thromboembolism in patients with a stable cardiovascular system.
Thrombolytic agents are generally withheld from postoperative
patients until at least the fifth postoperative day, or preferably later.
Earlier administration of these agents is apt to produce bleeding at
the operative site. While it may occasionally be indicated to proceed
earlier, it is generally best to wait until the thrombi in the vessels
divided at the time of the surgical procedure have become organized.
7. Which of the following can cause a radioactive pulmonary perfusion
Surgery Lecture Notes, Books, MCQ and Good Articles
Saturday, September 6, 2008
Vascular Surgery MCQ
1. A 55-year-old woman gives a history of tiredness, aching, and a
feeling of heaviness in the left lower leg for the past 3 months. These
symptoms are relieved by leg elevation. She is also awakened
frequently by calf and foot cramping, which is relieved by leg
elevation, walking, or massage. On physical examination there are
superficial varicosities, nonpitting edema, and a slightly painful, 2 cm.
diameter superficial ulcer 5 cm. above and behind the left medial
malleolus. What is the most appropriate diagnosis?
A. Isolated symptomatic varicose veins.
B. Superficial lymphatic obstruction.
C. Deep venous insufficiency.
D. Arterial insufficiency.
E. Incompetent perforating veins.
Answer: C
DISCUSSION: The most common symptoms associated with venous
insufficiency are aching, swelling, and night cramps of the involved
leg, which often occur after periods of sitting or inactive standing. Leg
elevation frequently provides relief of symptoms due to venous
insufficiency, while it increases pain due to arterial insufficiency.
Although edema can occur with varicose veins alone, usually it is
associated with deep venous abnormalities and incompetent
perforators. In such cases, ulcers usually are located above and
posterior to the malleoli, reinforcing their relationship with perforator
abnormalities. The ulcers associated with arterial insufficiency may
occur anywhere on the lower leg, eventually penetrate the fascia, and
are more painful than venous ulcers.
2. The best treatment plan for the patient described in the preceding
question should include:
A. Varicose vein ligation and stripping as soon as possible.
B. Ulcer débridement, vein stripping, and skin grafting.
C. Ligation of the medial perforating veins.
,D. Transposition of saphenous vein valve.
E. Leg elevation, external Unna boot support, and ambulation without
standing.
Answer: E
DISCUSSION: Operative treatment of venous insufficiency is in most
instances an adjunct after failure of aggressive conservative
management. Leg elevation, active exercise, and elastic compression
form the cornerstones of nonoperative management. The goals of
compression are to relieve symptoms and reduce swelling. The
indications for superficial vein ligation and stripping are moderate to
severe symptoms without other signs of deep venous insufficiency. If
ulceration persists despite appropriate conservative management,
ligation of the underlying incompetent perforators helps ulcer
recurrence, and split-thickness skin grafting provides immediate
coverage and healing of the ulcer. The patient must, however, comply
with a program of external stocking support and prevention of leg
edema since the underlying venous pathophysiology remains and
ulcers tend to recur.
3. In patients who develop a documented episode of deep venous
thrombosis (DVT) the most significant long-term sequela is:
A. Claudication.
B. Recurrent foot infections.
C. Development of stasis ulcer.
D. Pulmonary embolization.
E. Diminished arterial perfusion.
Answer: C
DISCUSSION: The increased hydrostatic pressure from incompetent
venous valves following DVT predisposes to erythrocyte extravasation,
hemosiderin deposition, and brown pigmentation around the ankle.
Although the edema that occurs with deep venous insufficiency can
predispose to skin infections, these usually are located about the
ankle and resolve with adequate short-term care. When patients with
a history of DVT are followed beyond 10 years, as many as 80%
ultimately develop venous stasis ulcers. While there may be
recurrence of DVT in a minority of patients, the incidence of
pulmonary embolization is no greater than with the initial episode.
Even in a leg severely affected by venous stasis changes, the arterial
circulation is unimpaired unless there is concomitant arterial
obstructive disease.
4. A 28-year-old woman developed a painful thrombosis of a
superficial varix in the left upper calf 2 days previously. After spending
,the 2 days in bed with her leg elevated, she felt better and the
tenderness resolved; however, when out of bed she developed a
twinge of right-sided chest pain when walking and a feeling of
heaviness in the calf. Which treatment is most appropriate?
A. Check for leg swelling, tenderness, and Homan's sign, and obtain a
Doppler ultrasound study.
B. Begin antibiotics for a probable secondary bacterial infection.
C. Order emergency venography, and if it is abnormal, begin heparin
administration.
D. Begin ambulation and discontinue bed rest that probably caused
muscle pain by hyperextension of the knee.
E. If there is no pain on dorsiflexion of the left foot reassure her, since
a negative Homan's sign precludes the diagnosis of DVT.
Answer: C
DISCUSSION: Associated DVT may occur during treatment of
superficial venous thrombosis, especially if the process is near the
groin or popliteal fossa. Although a positive Homan's sign or calf,
popliteal, or groin pain is suggestive of DVT, clinical examination alone
may be incorrect in more than 50% of cases. Noninvasive tests,
including Doppler ultrasonography, are accurate for diagnosing DVT
in the thigh but are less dependable in the calf. Emergency
venography performed on an outpatient basis remains the most
accurate and cost-effective technique for diagnosing DVT of the calf
veins. Because 85% of pulmonary emboli arise from the lower
extremity, early diagnosis and aggressive treatment are important.
5. In a 55-year-old grocery store cashier with an 8-month history of leg
edema increasing over the course of a work day, associated with
moderate to severe lower leg bursting pain, the most appropriate
investigative study or studies are:
A. Doppler duplex ultrasound.
B. Brodie-Trendelenburg test.
C. Ascending and descending phlebography.
D. Measurement of ambulatory and resting foot venous pressure.
E. Venous reflux plethysmography.
Answer: A
DISCUSSION: While the Brodie-Trendelenburg test was an early
attempt to clinically evaluate valve competence and function, it is
neither quantitative nor precise. The development of phlebography
allowed anatomic delineation of normal and abnormal veins and,
when used in combination with invasive measurement of venous
pressures in the foot at rest and on ambulation, helped correlate the
venous hypertensive state with postphlebitic changes. Noninvasive
plethysmography to quantitate the degree of venous valvular
, incompetence was more easily accepted; however the combination of
B-mode duplex ultrasound (to accurately locate the vein of interest)
plus pulsed Doppler flow signal is now the “gold standard” for venous
assessment.
6. Which of the following statements are true of pulmonary
embolism?
A. Most cases occur postoperatively.
B. In the majority of patients pulmonary emboli are ultimately lysed in
situ without the administration of pharmacologic agents.
C. The preferred therapy for most patients is intravenous heparin.
D. It is generally safe to give thrombolytic agents as early as 48 hours
postoperatively.
Answer: BC
DISCUSSION: Although many patients develop pulmonary embolism
postoperatively, the majority of such lesions reported in most series
do not follow operation. These patients develop thromboembolism as
a complication of an underlying condition such as congestive heart
failure, cerebrovascular accident, malignancy, chronic infection, and a
variety of other debilitating diseases. Generally, postoperative
patients comprise approximately one third of those with pulmonary
embolism. Serial pulmonary scans following pulmonary embolism
generally show gradual clearing of the emboli with re-establishment
of perfusion in the occluded vessels. Depending on the magnitude of
the embolism, most patients show the clearing at the end of a month
to 6 weeks. The presence of persistent congestive heart failure,
chronic infection, and atelectasis retard thrombolysis. This dissolution
of emboli is generally agreed to be caused by naturally circulating
thrombolysins. In fewer than 1% of cases the emboli persist and often
increase with the passage of time, with the development of chronic
pulmonary embolism leading to severe respiratory insufficiency,
chronic cor pulmonale, pulmonary hypertension, right ventricular
failure, and death. The majority of patients with pulmonary embolism
are managed by continuous intravenous heparin. Thrombolytic
agents are generally reserved for the management of extensive
thromboembolism in patients with a stable cardiovascular system.
Thrombolytic agents are generally withheld from postoperative
patients until at least the fifth postoperative day, or preferably later.
Earlier administration of these agents is apt to produce bleeding at
the operative site. While it may occasionally be indicated to proceed
earlier, it is generally best to wait until the thrombi in the vessels
divided at the time of the surgical procedure have become organized.
7. Which of the following can cause a radioactive pulmonary perfusion
