Asef Belal Qadomi

‫هاي عباره عن اسئله مجمعه مهمه جدا وكل سنه بيجي منها‬
‫ احفظوها حفظ‬.. ‫مو‬
‫مع تحيات عاصف قدومي‬

Study Questions for Part II

Directions: Each of the numbered items in this section is followed by several possible answers.
Select the ONE lettered answer that is BEST in each case.

1. A 50-year-old man is brought to the emergency room after falling 20 feet from a roof. He is
complaining of dyspnea, and his blood pressure is 70/50 mm Hg. Breath sounds are diminished
on the left, and there is tracheal deviation to the right. What is the best initial treatment for this
patient?
A Chest radiograph
B Close observation
C Needle decompression of the left chest
D Computed tomography (CT) scan of the thorax
E Emergent surgical exploration.

• 1. The answer is C [Chapter 4, II A 2]. Hypotension, diminished breath sounds, and

tracheal deviation are clinical signs of tension pneumothorax. This represents a surgical
emergency and without treatment may rapidly become fatal. In this scenario, prompt
needle decompression of the left chest is indicated, prior to chest x-ray or other
diagnostic studies that could delay treatment.

2. A patient undergoes a left scalene node biopsy to rule out carcinoma of the lung. One hour
later, the patient is cyanotic and dyspneic; a marked tachycardia is accompanied by decreased
breath sounds on the left. Which step is most likely to improve the patient's condition?
A Blood transfusion
B Insertion of a right subclavian catheter and administration of intravenous fluids
C Endotracheal intubation
D Insertion of a left chest tube
E Re-exploration of the wound

• 2. The answer is D [Chapter 4, I B 3 c]. Insertion of a left chest tube will most likely
improve the patient's condition. The pleura of the lung lies immediately adjacent to the
scalene fat pad. If the pleura is injured during scalene node biopsy, a resultant
pneumothorax can cause the symptoms that developed in the patient described. Scalene
node biopsy can also injure other nearby structures; for example, lymph duct structures,
the brachial plexus, the vagus and phrenic nerves, and the subclavian vessels, resulting in
corresponding symptoms.

A large wound hematoma could cause tracheal compression and airway compromise, but
this is not described. Intubation with positive pressure ventilation will make the
pneumothorax worse without a chest tube. While injury to the subclavian vessels could
cause a hemothorax, a chest tube still needs to be inserted for evaluation. A
pneumothorax is the more likely injury. With a suspected left-sided pneumothorax, a
subclavian line should be inserted on the left because of the risk of producing a second
right-sided pneumothorax.

3. A patient is brought to the emergency department with a stab wound to the right chest in the
fourth intercostal space in the midaxillary line. The patient is hypotensive, complains of
shortness of breath, and is found to have absent breath sounds on the right side of the chest.
Which step should come next in the management of this patient?
A Chest radiograph
B Chest tube insertion
C Needle thoracentesis
D Local wound exploration
E Pericardiocentesis

• 3. The answer is C [Chapter 4, II A 2 b–c]. The patient has signs and symptoms
consistent with a tension pneumothorax. This life-threatening situation should be treated
immediately by needle thoracentesis. A chest tube insertion should follow this maneuver.
A chest radiograph is not necessary to confirm the diagnosis and will only delay
treatment. Local wound exploration has no role in the management of stab wounds of the
chest. Pericardiocentesis is the choice when evidence indicates pericardial tamponade.

4. A tall, thin 19-year-old male presents to the emergency department with sudden onset of chest
pain, cough, and shortness of breath. Breath sounds are absent in the left chest. Which of the
following is an indication for surgery?
A Family history of recurrent spontaneous pneumothorax
B Persistent air leak after 3 days of chest tube drainage
C Identification of an apical bleb on chest CT
D Evidence of life-threatening respiratory compromise on initial presentation
E History of one prior episode successfully treated with conservative management on the
contralateral side

• 4. The answer is E [Chapter 5, II B]. Indications for definitive surgical management of

spontaneous pneumothorax include recurrence (ipsilateral or contralateral), persistent air
leak greater than 7–10 days, and incomplete expansion of lung.

Questions 5–6
A chest radiograph of a 55-year-old man involved in a high-speed motor vehicle accident shows
a widened mediastinum and pneumomediastinum. Electrocardiogram shows sinus tachycardia
with frequent premature ventricular contractions.
5. All of the following maneuvers are appropriate at this time except
A Aortogram
B Bronchoscopy
P.135

C Continuous cardiac monitoring

D Left thoracotomy
E Endotracheal intubation

6. Expected physiologic changes due to blunt chest trauma include all but which of the
following?
A Elevated PCO2
B Increased compliance
C Elevated A-a gradient
D Decreased ventricular contractions
E Elevated shunt fractions.

• 5–6. The answers are 5-D [Chapter 4, II A 5, 6; B 1, 2, 5, 6] and 6-B [Chapter 4, II A

6]. Causes for the chest radiograph and electrocardiographic findings are multiple and
include aortic rupture, cardiac tamponade, tracheobronchial disruption, hypoxia, and
cardiac contusion. A more precise diagnosis would be mandatory before undertaking
thoracotomy because operative strategy would depend on which injury is present.

Blunt thoracic trauma with or without flail chest results in chest wall muscle damage and
pain, with resultant splinting and loss of chest wall elasticity. Intra-alveolar hemorrhage
and interstitial edema reduce pulmonary parenchymal elasticity. Therefore, both lung and
chest wall compliance decrease. PCO2, A-a gradient, and shunt fractions would probably
be elevated, and ventricular contractions would probably be decreased.

Questions 7–8
A 70-year-old patient on antibiotic therapy for necrotizing bacterial pneumonia is found to have
a large pleural effusion.
7. In addition to continued antibiotics, what should be the next step in management of this
patient?
A Sputum culture and sensitivity
B Chest tube insertion
C Thoracentesis
D Thoracotomy and decortication
E Rib resection and open drainage

8. A sample of pleural fluid is cloudy and thick, with a pH of 7.2. What should be the next
therapeutic step?
A Video-assisted thorascopic surgery with talc pleurodesis
B Chest tube drainage
C Repeat thoracentesis
D Thoracotomy and decortication
E Rib resection drainage

• 7–8. The answers are 7-C [Chapter 5, II B 2] and 8-B [Chapter 5, II C 2–3]. The
patient developing a pleural effusion in the setting of an underlying pneumonia requires
thoracentesis for diagnosis. The character of the fluid described is consistent with that
present in an empyema. Initial treatment of an empyema should involve closed chest tube
drainage. Thoracotomy and decortication or rib resection may be required when the
empyema is not adequately drained by the chest tube or is otherwise not amenable to
closed drainage. Video-assisted thorascopic surgery pleurodesis is not standard treatment
for an empyema.

9. A routine chest radiograph for a 55-year-old man with a 50 pack-year smoking history shows
a peripherally located 1.5-cm, noncalcified lesion of the upper lobe of the left lung. No evidence
of this lesion appeared on a chest radiograph 5 years earlier. What should be the next step in this
patient's management?
A Observation with serial chest radiographs
B Thoracotomy
C Bronchoscopy
D Biopsy
E Sputum cytology

• 9. The answer is D [Chapter 5, IV B 5]. The patient has a solitary pulmonary nodule. He
is older than age 40, and the characteristics do not favor a benign lesion, such as
concentric calcification. In addition, the lesion was not present on the chest radiograph 5
years earlier. Diagnosis is mandatory for determining whether the lesion is malignant.
This can be done by needle biopsy or thoracoscopic biopsy.
10. A 35-year-old man is involved in a high-speed motor vehicle collision. He arrives in the
emergency room in respiratory distress. Radiographs taken during the initial evaluation reveal an
air-fluid level in the left chest. Management includes all of the following except
A Establishment of a secure airway
B Immediate placement of a nasogastric tube
C Urgent thoracotomy to repair the injury
D Placement of adequate peripheral vascular access
E Urgent laparotomy to repair injury

• 10. The answer is C [Chapter 4, II B]. This patient is presenting with a diaphragmatic
disruption, as evidenced by the identification of the stomach in the chest. Treatment
involves standard resuscitation principles, (Airway, Breathing, Circulation), placement of
a nasogastric tube to prevent acute gastric dilitation (which can produce severe, life-
threatening respiratory distress), and urgent transabdominal repair of the diaphragmatic
defect. If diagnosis is delayed by 7–10 days, transthoracic repair is preferred to
facilitate the freeing of any adhesions to the lung.

11. Which of the following forms of congenital heart disease is most common?
A Transposition of the great vessels
B Tetralogy of Fallot
C Atrial septal defect
D Patent ductus arteriosus
E Ventricular septal defect

• 11. The answer is E [Chapter 6, II A]. The most common forms of congenital heart
disease are, in decreasing order: ventral septal defect, transposition of the great vessels,
tetralogy of Fallot, hypoplastic left heart syndrome, atrial septal defect, and patent ductus
arteriosus.

12. A 32-year-old man is referred for a 1.0-cm lesion of the right upper lobe of the lung. The
lesion appears calcified. Previous chest radiograph taken 1 year prior demonstrates the lesion to
be present at the same size. Further workup and treatment would include which of the following?
A CT scan–guided biopsy
B Radiation therapy
C Surgical excision
D Antibiotics
E Observation with repeat chest x-ray

• 12. The answer is E [Chapter 5, IV B]. Isolated lung nodules less than 1.0 cm are known
as coin lesions. Workup should include a detailed history, noting any use of tobacco
products or previous malignancy. Any prior chest radiographs should be obtained. A
calcified lesion that has not enlarged over a 2-year period suggests a benign process. In
 this patient, observation with follow-up x-ray is indicated. Any change in the lesion is an
indication for biopsy.

13. A 57-year-old male patient with a 60 pack-year smoking history is referred for a 1.5-cm
solitary mass in the right upper lobe. CT scan demonstrates no evidence of lymph node
involvement. What should further workup or treatment include?
A Radiation therapy
B Open lung biopsy
C Chemotherapy
D Right upper lobectomy
E Repeat chest x-ray in 6 months

• 13. The answer is D [Chapter 5, V F]. The appropriate treatment is surgical lobectomy.
Observation with repeat chest x-ray is not warranted with a smoking history.

This patient is in clinical stage I, based on tumor size and nodal status. There is no clear
benefit in biopsying the lesion. Chemotherapy and radiation may be indicated in certain
stage IIIa lesions or in locally advanced disease.

14. A 22-year-old female is referred for evaluation of a 2-cm posterior mediastinal mass
discovered on routine chest radiograph. What is the most likely diagnosis?
A Bronchogenic cyst
B Lymphoma
C Neurogenic tumor
D Thymoma
E Adenocarcinoma

• 14. The answer is C [Chapter 5, X C]. The most common posterior mediastinal mass is a
neurogenic tumor. Seventy-five percent of neurogenic tumors occur in children under 4
years of age. Childhood tumors are more likely to be malignant. Lymphoma, thymoma,
and germ cell tumors are commonly located in the anterior mediastimun. Middle
mediastinal lesions include bronchogenic and pericardial cysts. Metastatic
adenocarcinoma may involve the pleural surfaces; however, lesions are often small and
multiple.

15. A 78-year-old previously healthy man is admitted to the emergency department complaining
of angina, dyspnea, and near syncope. Electrocardiogram is normal, and a loud systolic murmur
is heard in the second right interspace with radiation to the carotids. What is the most likely
diagnosis in this patient?
A Myocardial infarction
B Pericarditis
C Mitral regurgitation
D Aortic stenosis
E Aortic insufficiency
 • 15. The answer is D [Chapter 6, I B]. Angina, syncope, and dyspnea are the classic
symptoms of aortic stenosis. Physical examination generally reveals a systolic ejection
murmur in the second right intercostal space. An electrocardiogram and serial cardiac
enzymes should be obtained to rule out cardiac ischemia. The murmur of aortic
insufficiency is diastolic with a clinical picture of heart failure.

16. Which of the following is not a risk factor for coronary artery disease?
A Hypertension
B Smoking
C Diabetes
D Renal failure
E Hypercholesterolemia

• 16. The answer is D [Chapter 6, I E]. Risk factors for coronary artery disease are the
same as those for vascular disease in general––smoking, diabetes, obesity,
hypertension, and hypercholesterolemia. While renal failure is often associated with
coronary artery disease, this is because of the frequent association with other risk factors,
such as hypertension and diabetes.

17. A 72-year-old female patient is admitted with unstable angina. Cardiac catheterization
reveals severe triple-vessel coronary artery disease. The optimal treatment of this patient would
include which of the following?
A Coronary artery bypass surgery
B Observation
C Medical management (nitrates, β-blockers)
D Coronary angioplasty
E Tissue plasminogen activator

• 17. The answer is A [Chapter 6, I E]. This patient has severe triple-vessel coronary
disease. Studies have shown a significant survival advantage for patients in this category
who are treated with surgical revascularization, rather than with medical management or
angioplasty. Additional benefit may be realized in patients with compromised ventricular
function.

18. A 72-year-old patient with a history of syncope and dyspnea presents for evaluation for
peripheral vascular surgery. Physical examination reveals a systolic crescendo–decrescendo
murmur that radiates to the carotid arteries. As he is symptomatic, his diseased valve would
typically have an area of less than which of the following?
A 1 cm2
B 1.5 cm2
C 2 cm2
D 3 cm2
E 4 cm2

• 18. The answer is A [Chapter 6, I B]. This patient has aortic stenosis. Symptoms usually
begin when the valve area is less than 1 cm2.

19. A 29-year-old man is evaluated for a cerebral vascular accident. Physical examination
reveals a systolic ejection murmur at the left second interspace and a fixed split second heart
sound. What is the most likely diagnosis?
A Ventricular septal defect
B Atrial septal defect
C Mitral stenosis
D Aortic insufficiency
E Ventricular aneurysm

• 19. The answer is B [Chapter 6, II D]. Echocardiogram searching for thrombus or septal
defect should be obtained in a younger patient who suffers from a cerebral vascular
accident. A second interspace murmur and fixed splitting of the second heart sound are
classic findings in atrial septal defect. Anticoagulation for 4–6 weeks with elective
repair of the atrial septal defect is the indicated treatment.
‫هاض كمان امتحان مهم جدا االجوبه تحت‬

‫مع تحيات القدومي‬

1) The mammary artery

1. Is a direct branch of the aorta.

2. Most commonly used for grafting the inferior wall coronary arteries.
3. Carry very low ten years patency.
4. Should be used as a skeletonized graft only.
5. Is affected by the flow through the subclavian artery.

2) Associated with anomalous partial pulmonary venous return

1. The ASD sinus venosus

2. The unroofed coronary sinus type ASD
3. The ASD osteum secundum
4. The ASD osteum primum
5. None of the above.

3) The most commonly operated VSD is

1. The supracrystal type

2. The perimembranous VSD
3. The muscular one that might be multiple.
4. The AV canal type
5. None of the above.

4) Tetralogy of Fallot

1. Pulmonary hypertension is what brings the babies for surgery.

2. Is most frequently met in Down babies.
3. ASD is mandatory for their survival
4. Can be met in non-cyanotic patients.
5. Early closure of PDA is desired in the cyanotic babies.
5) A 63-year-old woman has the sudden onset of "knife-like" pain in the chest radiating
to the back. She has been previously healthy except for a history of poorly controlled
hypertension. She is transported to the hospital and on arrival she has a heart rate of
90/minute, respirations 20/minute, temperature 36.8°C, and blood pressure 150/100
mm Hg. No murmurs, rubs, or gallops are audible. A chest radiograph reveals a
widened mediastinum. Laboratory findings include a total serum creatine kinase of 1.
U/L, creatinine 0.9 mg/dL, and glucose 123 mg/dL. Which of the following is the most
likely diagnosis?

1. Fibrinous pericarditis
2. Aortic dissection
3. Infective endocarditis
4. Dilated cardiomyopathy
5. Myocardial infarction.

6) The coronary sinus (CS) all are correct except

1. It is used for cardioplegia infusion for cardiac muscle preservation.

2. It is a continuation of the great cardiac vein.
3. The small cardiac and the middle cardiac veins are tributaries of the CS.
4. Mostly it drains into the right ventricle
5. If unroofed it is behind interatrial shunt.

7) Atrioventriocular canal defect ( A-V canal) which is incorrect

1. Is associated with Down syndrome.

2. Can be partial or complete
3. Defect of the cushion formation is behind this pathology.
4. It is unlikely to cause pulmonary hypertension.
5. Better repaired within the first year of life.

8) A 27-year-old G2 P1 woman has a screening ultrasound performed at 18 weeks

gestation. The fetus is appropriate in size for 18 weeks. The fetal kidneys, liver, head,
and extremities appear normal. However, the fetus has a heart with a membranous
ventricular septal defect, overriding aorta, and marked pulmonic atresia. If the baby
were to be live born, which of the following characteristics on physical examination
would most likely result from these cardiac defects?

1. Cyanosis
2. Systematic hypertension
 3. Weak lower extremities pulses
4. Clubbing of the digits
5. Telangiectasia.

9) A 65-year-old man has sudden onset of severe abdominal pain that has persisted for
3 hours. Physical examination reveals his temperature is 37°C, heart rate 110/minute,
respirations 25/minute, and blood pressure 145/100 mmHg. He has diminished pulses
in the lower extremities. There is a pulsatile abdominal mass. His serum creatine kinase
is not elevated. He has had fasting blood glucose measurements in the range of 140 to
180 mg/dL for over 20 years. Which of the following conditions is he most likely to
have?

1. Superior mesenteric artery thrombosis

2. Atherosclerotic aortic aneurysm
3. Polyarteritis nodosa
4. Acute coronary syndrome
5. Monckeberg’s
6. midial clinic sclerosis.

10) A 17-year-old girl is short in stature for her age. She has not yet shown any changes
of puberty. On physical examination her vital signs include T 37°C, RR 18/minute, P
75/minute, and BP 165/85 mm Hg. She has a continuous murmur heard over both the
front of the chest as well as her back. Her lower extremities are cool with diminished
pulses and poor capillary filling. She has a webbed neck. A chest radiograph reveals a
prominent left heart border, no oedema or effusions, and rib notching. Which of the
following cardiovascular abnormalities is she most likely to have?

1. Shortening and thickening of the chordae tendineae of the mitral valve

2. Narrowing of the aortic isthmus
3. Supravalvular aortic root stenosis.
4. Simgle large AV valve
5. Lack of development of the spiral septum and partial absence of conus
muscular tissue.

11) Lt dominant coronary circulation is when

1. The posterior descending artery is a branch of the Circumflex artery.

2. The posterior descending artery is a branch of the Rt coronary artery (RCA)
3. The Circumflex artery takes off from the RCA
4. Its frequency is about 85%
5. None of the above.
12) A 45-year-old woman has had worsening shortness of breath for 3 years. She now
has to sleep sitting up on two pillows. She has had difficulty swallowing for the past
year. She has no history of chest pain. A month ago, she had a "stroke" with resultant
inability to move her left arm. She is afebrile. A chest radiograph reveals a near-normal
left ventricular size with a prominent left atrial border. Which of the following conditions
is most likely to account for her findings?

1. Essential hypertension
2. Cardiomyopathy
3. Mitral valve stenosis
4. Aortic coarctation
5. Patent foramen ovale.

13) A 16-year-old healthy adolescent is involved in a schoolyard gang fight and is

stabbed in the chest with a knife in the left midclavicular line. He is taken to the
emergency department and on arrival his blood pressure is barely obtainable. His lungs
are clear to auscultation. His heart sounds are barely audible. His jugular veins look
engorged. Which of the following is the most useful therapeutic approach for this boy?

1. Coronary angioplasty
2. Pericardiocentesis
3. Start antibiotics immediately
4. Start antiarrhythmic drugs
5. Aortic repair.

14) A 72-year-old woman has had no major illnesses throughout her life. She has had 3
syncopal episodes during the past 2 weeks. Over the past 2 days she has developed
shortness of breath and a cough with production of frothy white sputum. On physical
examination she is afebrile. Her blood pressure is 135/90 mm Hg. She has no
peripheral edema. A chest radiograph reveals a prominent left heart border in the region
of the left ventricle, but the other chambers do not appear to be prominent. There is
marked pulmonary edema. Laboratory studies show total serum cholesterol of 170
mg/dL. Which of the following is the most likely diagnosis?

1. Acute rheumatic fever

2. Calcific aortic stenosis
3. Mitral insufficiency
4. Infective endocarditis of the AV valve
5. Atehrosclerotic aortic aneurysm.
The Key

Question 1 2 3 4 5 6 7
Number
Answers 5 1 2 4 2 4 4
Question 8 9 10 11 12 13 14
No
Answers 1 2 2 1 3 2 2

Complications reported to occur with transcatheter closure include

1) air embolism (1–3 percent);
2) thromboembolism from the device (1–2 percent);
3) disturbed atrioventricular valve function (1–2 percent);
4) systemic/pulmonary venous obstruction (1 percent);
5) perforation of the atrium or aorta with hemopericardium (1–2 percent);
6) atrial arrhythmias (1–3 percent);
7) and malpositioning/embolization of the device requiring ntervention (2–15 percent).
the most common associated anomaly with coarctation is that of a bicuspid aortic valve, which
can be demonstrated in 25–42 percent of cases.

In coarctation it has been shown thatearly surgical correction may prevent the development of
long-term hypertension,which undoubtedly contributes to many of the adverse sequelae of COA:
1) the development of circle ofWillis aneurysms,
2) aortic dissection andrupture,
3) an increased incidence of coronary arteriopathy with resulting myocardial infarction.
Angina is the most frequent symptom, but MI may appear without prior warning.

QP:QS of 0.7: 1 is compatible with one of the following pathologies

Truncus artreiosus
TOF
Aortopulmonary window
VSD
ASD osteum primum.

A 9 yr old underwent PDA surgical closure through Lt thoracotomy, on the 2nd post op day he is
complaining of hoarseness of voice. The most likely underlying cause is:

Lt vocal cord paralysis

Phrenic nerve injury.
Tracheal irritation
Aspiration.
Temporary subglottic injury

On the day of surgery after an MVR, a 54 yr old male patient stopped to drain blood through his
chest tubes, he developed hypotension that responded fairly to fluid replacement and poorly to
the inotropic support. Engorged neck veins is clear. He went into anuria and acidocis.
Proper action is:

Start Adrenaline in high dose.

Give antic
oagulant
Pericardiocentesis
Reopen the chest without delay.

All the following are tributaries of the coronary sinus except:

The anterior cardiac veins

The middle cardiac vein
The great cardiac vein
The oblique vein .
The small cardiac vein.

The Coronary sinus, all correct except

Can be used for cardiopledia infusion.

It drains the biggest part of the myocardium
It drains into the Rt atrium.
It goes parallel with the circumflex artery
It courses around the Tricuspid valve into the Rt AV groove.