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8. A patient shown to have wasting at the interdigital web
spaces, experiences numbness of the ring finger and
exhibits Wartenberg sign on physical examination most
likely is suffering from:
A. Cubital tunnel syndrome.
B. Carpal tunnel syndrome.
C. Compartment syndrome.
D. Rheumatoid arthritis.
CHAPTER 44
Surgery of the Hand and Wrist
Answer: A
The ulnar nerve also innervates the dorsal surface of the
small finger and ulnar side of the ring finger, so numbness in
these areas can be explained by cubital tunnel syndrome. The
patient may also report weakness in grip due to effects on the
flexor digitorum profundus (FDP) tendons to the ring and
small fingers and the intrinsic hand muscles. Patients with
advanced disease may complain of inability to fully extend
the ring and small finger interphalangeal (IP) joints.
Physical examination for cubital tunnel syndrome begins
with inspection. Look for wasting in the hypothenar eminence and the interdigital web spaces. When the hand rests
flat on the table, the small finger may rest in abduction with
respect to the other fingers; this is called Wartenberg sign.
Tinel sign is often present at the cubital tunnel. Elbow flexion
test will often be positive. Grip strength and finger abduction
strength should be compared to the unaffected side. Froment
sign can be tested by placing a sheet of paper between the
thumb and index finger and instructing the patient to hold on
to the paper while the examiner pulls it away without flexing
the finger or thumb (this tests the strength of the adductor
pollicis and first dorsal interosseous muscles). If the patient
must flex the index finger and/ or thumb (FDP-index and
flexor pollicis longus [FPL], both median nerve supplied) to
maintain traction on the paper, this is a positive response.
(See Schwartz 11th ed., p. 1944.)
9. Necrotizing infections:
A. Often present with pain out of proportion to findings.
B. Often have discharge present.
C. Debridement should begin following confirmation
by way of radiograph findings.
D. Oral antibiotics should begin immediately.
Answer: A
Bacteria spread along the fascial layer, resulting in the death
of soft tissues, which is in part due to the extensive blood vessel thrombosis that occurs. An inciting event is not always
identified. Immunocompromised patients and those who
abuse drugs or alcohol are at greater risk, with intravenous
drug users having the highest increased risk. The infection
can by mono- or polymicrobial, with group A β-hemolytic
Streptococcus being the most common pathogen, followed by
α-hemolytic Streptococcus, S. aureus, and anaerobes. Prompt
clinical diagnosis and treatment are the most important factors for salvaging limbs and saving life. Patients will present with pain out of proportion with findings. Appearance
of skin may range from normal to erythematous or maroon
with edema, induration, and blistering. Crepitus may occur if
a gas-forming organism is involved. “Dirty dishwater fluid”
may be encountered as a scant grayish fluid, but often there
is little to no discharge. There may be no appreciable leukocytosis. The infection can progress rapidly and can lead to
septic shock and disseminated intravascular coagulation.
Radiographs may reveal gas formation, but they must not
delay emergent debridement once the diagnosis is suspected.
Intravenous antibiotics should be started immediately to
cover gram-positive, gram-negative, and anaerobic bacteria.
Patients will require multiple debridements, and the spread
of infection is normally wider than expected based on initial
assessment. Necrotizing myositis, or myonecrosis, is usually
caused by Clostridium perfringens due to heavily contami-
nated wounds. Unlike necrotizing fasciitis, muscle is universally involved and found to be necrotic. Treatment includes
emergent debridement of all necrotic tissue along with empirical intravenous antibiotics. (See Schwartz 11th ed., p. 1949.)
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10. The majority of acute cases of infections flexor tenosynovitis (FTS) are due to:
A. Systemic lupus erythematosus.
B. Chronic inflammation as a result of diabetes.
C. Rheumatoid arthritis (RA).
D. Purulent infection after penetrating trauma.
11. All of the following are TRUE about felon EXCEPT:
A. Abscess of the fingertip that is caused by penetrating
trauma.
B. Staphylococcus aureus is the most common infectious
agent.
C. Incision and drainage should be through a longitudi-
nal incision.
D. The infection extends to the nail bed, and may require
removal of the nail.
Answer: D
FTS is a severe pathophysiologic state causing disruption of
normal flexor tendon function in the hand. A variety of etiologies are responsible for this process. Most acute cases of
FTS are due to purulent infection. FTS also can occur secondary to chronic inflammation as a result of diabetes, RA, crystalline deposition, overuse syndromes, amyloidosis, psoriatic
arthritis, systemic lupus erythematosus, and sarcoidosis. (See
Schwartz 11th ed., p. 1950.)
Answer: D
A felon is a subcutaneous abscess of the fingertip and is most
commonly caused by penetrating trauma. S. aureus is the
most common pathogen. The fingertip contains multiple
septa connecting the distal phalanx to the skin. These septa
are poorly compliant, and presence of an abscess will increase
pressure and lead to severe pain and tissue death. Patients will
experience erythema, swelling, and tenderness of the volar
digital pad. Oral antibiotics may resolve the infection if diagnosed very early, but incision and drainage is indicated when
fluctuance is identified. A digital block should be performed,
followed by a longitudinal incision over the point of maximal
fluctuance (Fig. 44-2). (See Schwartz 11th ed., p. 1951.)
CHAPTER 44
Surgery of the Hand and Wrist
FIG. 44-2. Felon. A. Lateral view of the digit
showing fluctuance between the skin of the pad
and the underlying distal phalanx bone. B. The
authors prefer to drain felons with a longitudinal
incision (dashed line) directly over the area of
maximal fluctuance.
12. All hand infections EXCEPT the following require surgical management.
A. Paronychia.
B. Felon.
C. Cellulitis.
D. Osteomyelitis.
BA
Answer: C
All hand infections other than cellulitis will require surgical
management. Clinical examination, particularly noting the
area of greatest tenderness and/or inflammation, is the single
most useful diagnostic tool to localize any purulence requiring drainage. Specific recommendations for differentiating
among the possible locations of hand infection are included
in the diagnostic algorithm shown in Fig. 44-3. (See Schwartz
11th ed., pp. 1947–1948.)
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Hand inflammation
Plain X-rays
CHAPTER 44
Surgery of the Hand and Wrist
Cellulitis
admit, IV Abx
serial exam
No improvement
in 48 hours
MRI if no
fluctuance
Localized fluctuance
Entire finger
Kanavel’s
signs present
Pyogenic FTS
Nondiagnostic
Site of fluctuance
Dorsal
Subcutaneous
abscess
seYoN
Partial finger
Centered
on joint
Pain with
axial loading
of joint
Pyogenic vs.
crystalline
arthritis
Consider
arthrocentesis
Fracture
Palm
Distal
Between
digits
Web space
abscess
Foreign body
Ulnar to
SF MC
Loss of
palmar
concavity
Radial to
IF MC
Hypothenar
abscess
Midpalm
abscess
Thenar
abscess
FIG. 44-3. Diagnostic algorithm. Diagnostic workup for a patient with hand inflammation to evaluate for
infection. See text for details about particular infectious diagnoses. Abx = antibiotics; FTS = flexor tenosynovitis;
IF MC = index finger metacarpal; MRI = magnetic resonance imaging; SF MC = small finger metacarpal.
13. Treatment of ganglion cyst consists all of the following
EXCEPT:
A. Splinting and pressure.
B. Aspiration.
C. Surgical excision.
D. Observation.
14. The most common primary malignant tumor of the
hand is:
A. Melanoma.
B. Basal cell carcinoma.
C. Squamous cell carcinoma (SCC).
D. Epithelioid sarcoma.
Answer: A
Treatment consists of observation if asymptomatic. If
symptoms exist or the patient desires removal for cosmetic
appearance, aspiration of the cyst may be performed with a
successful cure rate ranging from 15% to 89%. The benefit of
injected steroids is inconclusive. Aspiration of a volar wrist
ganglion cyst can be dangerous due to the potential of injuring neurovascular structures. Open excision and arthroscopic
excision of the cyst stalk are surgical options for cysts that are
not amendable to aspiration. A recent meta-analysis reported
recurrence rates after either needle aspiration, open excision,
and arthroscopic excision as 59%, 21%, and 6%, respectively.
(See Schwartz 11th ed., p. 1953.)
Answer: C
Squamous cell carcinoma (SCC) is the most common primary
malignant tumor of the hand, accounting for 75% to 90% of
all malignancies of the hand. Eleven percent of all cutaneous
SCC occur in the hand. It is the most common malignancy
of the nail bed. Risk factors include sun exposure, radiation
exposure, chronic ulcers, immunosuppression, xeroderma
pigmentosa, and actinic keratosis. (See Schwartz 11th ed.,
p. 1955.)
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Plastic and Reconstructive Surgery
1. All of the following are TRUE about split-thickness skin
grafts EXCEPT:
A. Degree of contraction dependent on amount of
dermis in graft.
B. High reliability of take.
C. Healing with abnormal pigmentation more common
in thin than thick grafts.
D. Meshing grafts improves their ultimate cosmetic
appearance.
2. Which of the following definitions is incorrect?
A. Flap composition: description of the tissue compo-
nents within the flap
B. Flap contiguity: the position of a flap relative to its
recipient bed
C. Pedicle: bridge of tissue that remains between a flap
and its source; blood vessels that nourish a flap
D. Free flap: flaps that are completely detached from the
body prior to their preimplantation with microvascular anastomoses
Answer: D
Many of the characteristics of a split-thickness graft are determined by the amount of dermis present. Less dermis translates into less primary contraction (the degree to which a graft
shrinks in surface area after harvesting and before grafting),
more secondary contraction (the degree to which a graft
shrinks during healing), and better chance of graft survival.
Thin split grafts have low primary contraction, high secondary contraction, and high reliability of graft take, often even
in imperfect recipient beds. Thin grafts, however, tend to heal
with abnormal pigmentation and poor durability compared
with thick split grafts and full-thickness grafts. Split grafts
may be meshed to expand the surface area that can be covered. (See Schwartz 11th ed., pp. 1975–1976.)
Answer: B
The composition of a flap describes its tissue components.
The contiguity of a flap describes its position related to its
source. Distant flaps are transferred from a different anatomic
region to the defect. They may remain attached to the source
anatomic region (pedicle flaps) or may be transferred as free
flaps by microsurgery. These are completely detached from
the body, and their blood supply is reinstated by microvascular anastomoses to recipient vessels close to the defect. The
term pedicle was originally used to describe a bridge of tissue
that remained between a flap and its source, similar to how
a peninsula remains attached to its mainland. However, as
knowledge of flap blood supply and (micro)vascular anatomy
has improved over the years, the term pedicle has increasingly
become reserved for describing the blood vessels that nourish
the flap. (See Schwartz 11th ed., pp. 1977–1980.)
3. Phases of wound healing include all of the following
EXCEPT:
A. Hemostasis.
B. Proliferation.
C. Contraction.
D. Remodeling.
Answer: C
There are different processes that characterize healing in several types of tissue, such as skin, muscle, or bone, and there
is a strong underlying mechanism that is best understood in
terms of a simple skin injury. The process of wound healing is comprised of four integrated processes that overlap:
(a) bleeding and hemostasis, (b) inflammation, (c) proliferation, and (d) tissue modeling or resolution. (See Schwartz
11th ed., p. 1971.)
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4. Which of the following is TRUE about vascular
anomalies?
A. Hemangiomas affect 5% of premature infants.
B. Oral propranolol is the treatment of choice for high-
risk infantile hemangiomas.
C. Spontaneously involving hemangiomas was result in
visible sequellae in 10% of patients.
D. Sturge-Weber syndrome present with capillary mal-
CHAPTER 45
formations involving only superficial cutaneous
tissues.
Plastic and Reconstructive Surgery
Answer: B
Hemangiomas are the most common vascular tumor in children, presenting in up to 20% of premature infants. Oral
propranolol therapy has emerged as the first-line treatment
for complicated or high-risk infantile hemangiomas. While
hemangioma involution may result in no visible sequelae, up
to 50% of patients are left with a residual fibrofatty mass with
antrophic, hypopigmented, and/or telangiectatic overlying
skin. Sturge-Weber syndrome may be accompanied by vascular malformations of the underlying leptomeninges or globe.
(See Schwartz 11th ed., pp. 1996–1997.)
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Anesthesia for the Surgical Patient
1. Malignant hyperthermia (MH) can develop after receiving general anesthesia. Which of the following represents
a triggering agent?
A. Nitrous Oxide
B. Isoflurane
C. Cisatracurium
D. Rocuronium
2. ASA Physical Status III of the American Society of Anesthesiologists physical status classification system denotes
which of the following classes of patients?
A. A normal healthy patient
B. A moribund patient who is not expected to survive
without operation
C. A patient with severe systemic disease that is a con-
stant threat to life
D. A patient with severe systemic disease
Answer: B
MH is a hereditary, life-threatening, hypermetabolic acute
disorder, developing during or after receiving general anesthesia. The clinical incidence of MH is about 1:12,000 in
children and 1:40,000 in adults. A genetic predisposition and
one or more triggering agents are necessary to evoke MH. Tr iggering agents include all volatile anesthetics (eg, halothane,
enflurane, isoflurane, sevoflurane, and desflurane) and the
depolarizing muscle relaxant succinylcholine. Volatile anesthetics and/or succinylcholine can cause a rise in the myoplasmic calcium concentration in susceptible patients, resulting
in persistent muscle contraction. (See Schwartz 11th ed.,
p. 2040.)
Answer: D
American Society of Anesthesiologists physical status classification system:
P1 A normal healthy patient
P2 A patient with mild systemic disease
P3 A patient with severe systemic disease
P4 A patient with severe systemic disease that is a constant
threat to life
P5 A moribund patient who is not expected to survive without the operation
P6 A declared braindead patient whose organs are being
removed for donor purposes
3. A sudden rise in end-tidal CO2 concentration from 11 to
37 mm Hg during cardiopulmonary resuscitation most
likely represents which of the following?
A. Adequate chest compressions
B. Adequate respirations
C. Return of spontaneous circulation
D. Measurement artifact
(See Schwartz 11th ed., p. 2034.)
Answer: C
End tidal CO2 (etCO2) concentration monitoring during cardiopulmonary resuscitation (CPR) is becoming increasingly
common. And etCO2 value of ≥10 represents adequate chest
compressions. A sudden rise in etCO2 during CPR most likely
represents return of spontaneous circulation. (See Schwartz
11th ed., p. 2033.)
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4. A patient presents for elective laparoscopic cholecystectomy. The patient reports a history of cardiac disease
including a non-ST elevation MI 4 years prior that was
treated with a drug-eluting stent. The patient reports
being able to climb two flights of stairs. Which of the following BEST represents workup needed prior to induction of anesthesia?
A. Electrocardiogram (EKG).
CHAPTER 46
Anesthesia for the Surgical Patient
B. Transthoracic echocardiography.
C. Stress nuclear perfusion imaging.
D. No further workup is needed.
5. A 34-year-old woman presents for elective hernia repair.
According to American Society of Anesthesiologists
(ASA) guidelines, after what interval from consumption
of black coffee can anesthesia be induced in this patient?
A. 2 hours
B. 4 hours
C. 6 hours
D. 8 hours
6. In patients who cannot be mask ventilated or intubated
via direct laryngoscopy after induction of anesthesia,
which of the following represents the best next step?
A. Videolaryngosocpy
B. Laryngeal mask airway insertion
C. Fiberoptic intubation
D. Surgical airway
Answer: D
Patients who are able to perform 4 METs of exercise or more
can typically proceed to surgery without additional evaluation. The patient presents with a history of stable coronary
disease and good exercise tolerance; no further workup
is needed prior to proceeding. (See Schwartz 11th ed.,
pp. 2034–2035.)
Answer: A
NPO guidelines for preoperative fasting safe intervals after
intake of food and drink when anesthesia can be induced.
The suggested interval after intake of clear liquids is 2 hours,
after breast milk is 4 hours, after a light meal (small amount
of easily digestible food such as toast or crackers) or infant
formula is 6 hours, and after more food intake is 8 hours. In
this patient, anesthesia can be induced 2 hours after intake of
clear liquids. (See Schwartz 11th ed., p. 2036.)
Answer: B
The American Society of Anesthesiologists (ASA) difficult
airway algorithm covers strategies to deal with difficult intubation and difficult mask ventilation scenarios. For patients
in whom anesthesia has been induced, if initial intubation
attempts are unsuccessful and face mask ventilation is inadequate, supraglottic airway insertion should be considered.
(See Schwartz 11th ed., pp. 2037–2039.)
7. According to ACC/AHA guidelines, how long after bare
metal coronary stent placement should elective surgery
be delayed?
A. 30 days
B. 3 months
C. 6 months
D. 1 year
8. Local anesthetic systemic toxicity can be treated by
administration of which of the following?
A. Sugammadex
B. Neostigmine
C. Flumazenil
D. Lipid emulsion
Answer: A
The ACC/AHA guidelines recommend delaying elective surgery for 30 days after bare metal stent placement and for 1 year
after drug-eluting stent placement. Dual antiplatelet therapy
should be continued for urgent or emergent procedures
that take place before the minimum recommended waiting
period. For semi-elective surgeries in patients with drugeluting stents, where the risk of delaying surgery is greater
than the risk of in-stent thrombosis, ACC/AHA guidelines
recommend surgery be delayed for 180 days. Observational
data suggest that the risk of in-stent thrombosis is increased
for 180 days after stent implantation, regardless of whether a
bare metal stent or drug eluting stent is used. (See Schwartz
11th ed., p. 2035.)
Answer: D
In addition to treating symptomatology, local anesthetic systemic toxicity can be treated with intravenous administration
of lipid emulsion. (See Schwartz 11th ed., p. 2031.)
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Surgical Considerations in the Elderly
1. Which of the following conditions are considered components of “geriatric syndromes”?
A. Frailty
B. Urinary incontinence
C. Malnutrition
D. All of the above
2. Criteria to define frailty include all of the following
EXCEPT:
A. Weight loss.
B. Physical activity quantified as kcal/week.
C. Grip strength.
D. Orientation to time and location.
3. Risks for postoperative delirium include which of the
following?
A. Age > 70 years
B. History of alcohol abuse
C. Intraoperative blood loss
D. All of the above
Answer: D
Geriatric syndromes are clinical syndromes that do not fit
into discreet categories but which can negatively impact quality of life, result in disability, and contribute to morbidity and
mortality in elderly surgical patients. They include frailty,
falls, dementia, malnutrition, and urinary incontinence, and
each should be evaluated carefully preoperatively in surgical
patients. (See Schwartz 11th ed., p. 2045.)
Answer: D
Unintentional weight loss of >5% from that of the previous
year is considered a criterion of frailty. A standard algorithm
is used to calculate physical activity and is corrected for gender. Men who expend <383 kcal/wk or women who expend
<270 kcal/wk may be frail. Grip strength is stratified by body
mass index and by gender and is also used as a criterion.
Orientation to time and place may or may not indicate dementia
and is not a specific criterion of frailty. (See Schwartz 11th ed.,
p. 2046.)
Answer: D
In addition to management of fluid and electrolyte imbalance
and optimization of preoperative hematocrit and intraoperative blood loss, other risk factors include undertreatment of
pain and a history of antecedent alcohol abuse. (See Schwartz
11th ed., p. 2047.)
4. The preoperative assessment and counseling should
include which of the following?
A. Confirm patient treatment goals including advance
directives
B. Confirm the patient’s health care proxy or surrogate
decision maker
C. Discuss the specific risks of the procedure and
alternative treatments based on patient’s expressed
preferences
D. All of the above
Answer: D
Preoperative assessment and counseling establishes the
patient’s choices and the identity of a proxy or surrogate decision maker if the patient is unable to assess postoperative
complications. A detailed discussion of the risks and likely
resumption of full function will inform decisions regarding
whether to proceed with the recommended procedure or an
alternative treatment. (See Schwartz 11th ed., p. 2049.)
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5. Risks for postoperative delirium include which of the
following?
A. Untreated or inadequately controlled pain
B. Renal insufficiency
C. Dehydration
D. All of the above
CHAPTER 47
6. Best practice guidelines for the assessment of nutritional
status include which of the following?
A. Document height, weight, and body mass index
(BMI)
B. Measure baseline serum albumin and prealbumin
levels
Surgical Considerations in the Elderly
C. Document unintentional weight loss during the
preceding year
D. All of the above
7. Factors which adversely affect the cardiac function
of older adults postoperatively include which of the
following?
A. Depletion of intravascular volume
B. Age-related impairment in the response to
catecholamines
C. Increased myocardial relaxation time
D. All of the above
Answer: D
The American College of Surgeons and the American Geriatrics Society compiled a list of risk factors for postoperative
delirium that include untreated or undertreated pain; sleep
deprivation; renal insufficiency; anemia; dehydration; immobilization; and the use of psychotropic medications such as
benzodiazepines, anticholinergics, and antihistamines. (See
Schwartz 11th ed., p. 2050.)
Answer: D
A BMI < 18.5 kg/m2 increases the risk of complications due
to nutritional impairment and may indicate a period of preoperative nutritional support. A serum albumin of <3.0 g/dL
should also prompt a referral for a detailed nutritional assessment. Unintentional weight loss of >5% compared to the
previous year and weight loss of >10%–15% in the preceding
6 months may also be an indication for preoperative nutritional restoration. (See Schwartz 11th ed., p. 2051.)
Answer: D
Aging has been shown to cause a 1% decrease in cardiac output per year, even in the absence of arrhythmias and cardiac
ischemia. The inability to increase cardiac output during
stress is dependent on ventricular dilatation and volume status. Incomplete emptying of the ventricle at end systole and
reduced ejection fraction leads to impaired coronary perfusion and ischemia. (See Schwartz 11th ed., p. 2051.)
8. Medications which should be discontinued or avoided
in the elderly postoperative patient include which of the
following?
A. Meperidine (Demerol)
B. Diphenhydramine (Benadryl)
C. Antihistamines
D. All of the above
9. Which forms of oral intake may be allowed up until 2
hours before general anesthesia?
A. Clear liquids
B. Light food and full liquids
C. Fried and fatty foods
D. Cooked meat
10. Prophylaxis against deep venous thrombosis has been
shown to reduce the incidence of postoperative venous
thromboembolism. For older adults undergoing nonorthopedic procedures which of the following regimens is
recommended?
A. Full-dose heparization
B. Low molecular weight heparin and lower extremity
compression devices
C. Low molecular weight heparin only
D. Intracaval filter placement
Answer: D
Medications with psychotropic effects such as meperidine,
diphenhydramine and anticholinergics may contribute to
postoperative delirium and should be avoided. (See Schwartz
11th ed., p. 2052.)
Answer: A
The American Society of Anesthesiologists issued new guidelines in 2011 that reduced the fasting period prior to general anesthesia. Clear liquids were judged permissible until
2 hours before anesthesia, and light foods and full liquids
were permissible until 6 hours before anesthesia. Fried and
fatty foods and meats continue to be restricted for 8 hours
before anesthesia, but other factors which can affect gastric
emptying such as diabetes may require longer periods of preoperative fasting. (See Schwartz 11 ed., p. 2053.)
Answer: B
Low molecular weight heparin (LMWH) together with lower
extremity compression devices are recommended. Full-dose
heparin and intracaval filter placement are accompanied by
unnecessary risks and costs. (See Schwartz 11th ed., p. 2053.)
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11. Preoperative prehabilitation programs have been
shown to reduce complications in elderly compromised
patients. What are the components of such a prehabilitation program?
A. An at home-based walking program with daily
follow up
B. Incentive spirometry training beginning one week
prior to surgery
C. Education on stress management
D. All of the above
12. What is the role of surgical palliative care?
A. To avoid high-risk operations
B. To minimize intervention in patients at high risk of
immanent mortality
C. To improve symptoms, reduce anxiety, and improve
quality of life
D. To support patient’s family members and caregivers
13. In frail nursing home residents, what percent of patients
are alive 1 year after colon cancer resection?
A. 70%
B. 50%
C. 30%
D. 10%
Answer: D
The Michigan Surgical Home and Optimization Program has
included preoperative home-based walking; incentive spirometry; and education about nutrition, stress management,
and care planning, The program has been found to reduce
postoperative complications, length of hospital stay and costs.
(See Schwartz 11 ed., p. 2053.)
Answer: C
The role of surgical palliative care is to offer the treatment
which will most likely improve symptoms and reduce anxiety. Quality of life issues are paramount, even if for limited
periods of time. The purpose of surgical palliative care is to
provide the best care for the patient who is compromised by
age, disease, or diminished function. (See Schwartz 11th ed.,
p. 2053.)
Answer: B
Among frail older adults, functional decline after surgery is
substantial and sustained. In one study of frail nursing home
patients only 53% were alive 1 year after colon resection for
malignancy. The same was true for patients who underwent
lower extremity bypass. Hip replacement was associated with
a 1 year mortality rate of more than one-third of patients. (See
Schwartz 11 ed., p. 2054.)
CHAPTER 47
Surgical Considerations in the Elderly
14. Cancer surgery in elderly patients is:
A. Always less successful.
B. Complicated by the fact that clinical trials usually do
not include elderly subjects.
C. Recommended equally as in younger patients.
D. Does not change overall life expectancy.
15. Elderly patients with acute peritonitis may not present
with typical symptoms of acute abdominal pain, fever,
or leukocytosis due to an impaired immune response. A
high index of suspicion is needed as the initial clinical
diagnosis in elderly patients with acute appendicitis is
correct in what percent of cases?
A. Less than 50%
B. 70%–80%
C. 90%–95%
D. 100%
16. In elderly patients undergoing heart valve replacement,
bioprosthetic valves are preferred over synthetic valves
because:
A. There is less need for anticoagulation which is
hazardous in the elderly.
B. The operative time is shorter which reduces the risk
of pulmonary complications.
C. Synthetic valves have a higher incidence of manufac-
turing defects.
D. The extent of hemolysis is less with bioprosthetic valves.
Answer: B
The frequency of referrals for surgical treatment of equivalent stage cancer is decreased in the elderly for virtually all
tumors. Despite this, survival after surgery is nearly equivalent for same stage malignancy as in younger patients. The
data derived from clinical trials of adjuvant and neoadjuvant
therapy are less helpful for decision making in elderly patients
because elderly subjects are usually not included in clinical
studies. (See Schwartz 11 ed., p. 2055.)
Answer: A
In elderly patients with acute appendicitis or acute cholecystitis, one-third lack symptoms of abdominal pain, one-third
are afebrile, and one-third have a normal white blood cell
count. Therefore an “unimpressive” abdominal examination
is irrelevant in the evaluation of the elderly patient whose tolerance for food has suddenly changed. (See Schwartz 11th ed.,
p. 2055.)
Answer: A
Prolonged anticoagulation is more hazardous in the elderly
where the risk of falls is increased. Even a fall from the
standing position can result in a fatal intracranial bleed in
an anticoagulated patient. (See Schwartz 11th ed., p. 2056.)
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