2006_ all reviewed Flashcards
- A patient was placed in a left lateral decubitus position for total hip arthroplasty, which lasts over 4 hours. The upper arm was not padded properly. What is the MOST likely abnormality?
A. Weak finger flexion
B. Weak wrist extension
C. Weak finger adduction
D. Weak finger abduction
B. Weak wrist extension
That’s what has been written, but my understanding had been that ulnar is most common
- Which properties of a suture material will incite the LEAST amount of inflammatory reaction?
A. Monofilament, absorbable
B. Monofilament, non absorbable
C. Polyfilament
D. Braided
B. Monofilament, non absorbable
nylon
prolene
- With regards to post heart transplant allograft vasculopathy, all of the following are true EXCEPT:
A. It is associated with CMV
B. It is the #1 cause of late death in heart transplant patients
C. It is characterized by proximal, discrete coronary lesions
D. It is associated with immune-related endothelial injury
C. It is characterized by discrete coronary lesions
- development of rapidly progressing coronary artery disease in the arteries of the transplanted heart (called allograft vasculopathy), becomes the most common cause of death by five years (UptoDate)
- Transplant vasculopathy remains the most daunting long-term complication of heart transplantation, with an annual incidence rate of 5 to 10%. After the first postoperative year, cardiac allograft vasculopathy becomes increasingly important as a cause of death.
- The risk of transplant vasculopathy increases as the number of HLA mismatches and the number and duration of rejection episodes increase. CMV infection and ischemia-reperfusion injury also increase the risk, as do classic risk factors for atherosclerotic disease. Transplant vasculopathy can develop as early as 3 months after transplantation and is detected angiographically in 20% of grafts at 1 year and in 40 to 50% at 5 years. (Cecil)
- In contrast to eccentric lesions seen in atheromatous disease, cardiac allograft vasculopathy produces concentric narrowing from neointimal proliferation of vascular smooth muscle cells and affects the entire length of the coronary tree, from the epicardial to the intramyocardial segments, leading to rapid tapering, pruning, and obliteration of third-order branch vessels.
-The majority of patients will not experience anginal symptoms because of denervation of coronary arteries, so the first clinical manifestation may be myocardial infarction, heart failure, ventricular arrhythmia, or sudden death.
- Which of the following is indicative of a blood test post splenectomy?
A. Thrombocytosis
B. Neutropenia
C. Spherocytosis
D. Leukocytosis
A. Thrombocytosis
Postsplenectomy reactive thrombocytosis has an incidence of about 75% to 82%.
- Toxic shock syndrome is caused by:
A. Staph aureus septiciemia
B. Staph aureus toxin
C. Streptococcus septicemia
D. Streptococcus toxin
B. Staph aureus toxin
-Toxic shock syndrome is an acute febrile illness caused by toxin-producing strains of S. aureus or, less commonly, Streptococcus (toxic shock–like syndrome.
- Malignant hyperthermia is characterized by:
A. Early hyperthermia
B. Autosomal dominant transmission
C. Late increased end-tidal CO2
D. Hypokalemia
B. Autosomal dominant transmission
- The classic MH crisis entails a hypermetabolic state, tachycardia, and the elevation of end-tidal CO2 in the face of constant minute ventilation. Respiratory and metabolic acidosis and muscle rigidity follow, as well as rhabdomyolysis, arrhythmias, hyperkalemia, and sudden cardiac arrest. A rise in temperature is often a late sign of MH. (Schwartz)
- The syndrome is genetically transmitted as an autosomal dominant trait. (Crit Care –access surg)
- A post-op patient is in respiratory distress. Upon exam, he has a Grade IV view and bag-valve mask ineffective. What is the MOST appropriate next step?
A. Perform a tracheostomy
B. Perform a cricothyroidotomy
C. Insert an LMA
D. Attempt nasopharyngeal intubation
C. Insert an LMA
FC. LMA. first step of difficult airway algorithm. if you can’t intubate and you can’t ventilate. you go to LMA
- Which of the following mechanisms BEST explains the coagulopathy associated with severe hemorrhagic shock?
A. Decreased circulating coagulation factors
B. Decreased circulating platelets
C. Acidosis and hypothermia
D. Increased fibrinolysis
C. Acidosis and hypothermia
- Hypothermia is one of the most common and least well recognized causes of altered coagulation in surgical patients, especially those receiving massive transfusion. Body temperatures as low as 30°C to 34°C can be associated with coagulopathy, even if levels of factors and platelets are normal. Nonmechanical bleeding can occur and be uncontrollable and lethal. The best course is to terminate the surgical procedure as expeditiously as possible, pack the bleeding areas as needed, close the surgical incision, and attempt to rewarm the patient as rapidly as possible in the intensive care unit. Damage control celiotomy for trauma, which includes an abbreviated celiotomy with control of gross bleeding, overt enteric contamination, packing and staged delayed definitive repair of injuries, and abdominal closure, has become key in preventing the triangle of death: hypothermia, acidosis, and coagulopathy.
- A young male is involved in an MVC. He sustains a closed head injury + pelvic # and on presentation has a decreased GCS, BP 90/50, HR = 105, RR = 20 and an increased ICP at 22mmHg. All of the following are acceptable courses of action, EXCEPT:
A. Propofol and intubation
B. Lasix, 40mg IV
C. Mannitol, 20mg/kg IV
D. IV morphine for pain control
B. Lasix, 40mg IV
I don’t think this needs an explanation
- Regarding branched chain amino acids, which of the following is TRUE?
A. Alanine is the major type B. Increase protein synthesis by muscle C. Metabolized by liver D. Contraindicated in renal failure E. Increase caloric density
B. Increase protein synthesis by muscle
1- The 3 BCAAs are leucine, isoleucine and valine
2- Branched chain amino acids are essential amino acids that cannot be synthesized in the body.
3- The three branched chain amino acids are unique among amino acids in that their first catabolic step cannot occur in the liver.
4- They don’t seem to be contrindicated in renal patients, but adjusted doses may be required
5- They don’t have increased caloric density
- A 30 yo male fell 15m. He sustained a T8 burst fracture and a complete spinal cord lesion. He is alert and oriented with a BP of 90/50, HR 50 and no change after 2 L Ringer’s. A FAST is negative. What is the MOST likely cause of his hypotension?
A. Unrecognized thoracic injury
B. Unrecognized abdominal injury
C. Inadequate fluid resuscitation
D. Neurogenic shock
D. Neurogenic Shock
Neurogenic shock is a distributive type of shock resulting in low blood pressure, occasionally with a slowed heart rate, that is attributed to the disruption of the autonomic pathways within the spinal cord.
Also warm extremities.
- A young patient sustains a clean laceration to the volar forearm. There is no significant soft tissue injury and he presents to your ER in the periphery. Clinically, you detect a deficit in the ulnar nerve distribution, and suspect ulnar nerve injury from laceration. What is the NEXT most appropriate action?
A. Irrigate, close, and send urgently to appropriate surgical specialist
B. Irrigate, close, splint wrist, and arrange for F/U in 4/52
C. Explore wound to confirm clinical suspicion
D. Leave open, pack with saline-soaked gauze, refer to appropriate surgical specialist
E. Immediately consult appropriate surgical specialist
A. Irrigate, close, and send urgently to appropriate surgical specialist
- What is the BEST predictor of requirement for post-operative ventilation?
A. FEV1
A. FEV1 50
vd/vt>0.6
paO2 300mmHg on 100
- The least toxic radiation to skin is:
A. Linear accelerator.
B. Brachytherapy.
C. Cobalt.
B. Brachytherapy
15. Commonest thyroid carcinoma is: A. Papillary. B. Follicular. C. Medullary. D. Anaplastic
A. Papillary
Follicular is scond
16. Causes of polyuria with high specific gravity : A. DM. B. DI. C. Diuretic Rx. D. Renal tubular acidosis
A. DM
INCREASED:
Volume depletion, CHF, adrenal insufficiency, DM, SIADH, increased proteins (nephrosis), newborn state; if markedly increased (1.040–1.050), artifact or recent administration of radiographic contrast media
DECREASED:
Diabetes insipidus, pyelonephritis, glomerulonephritis, water load with normal renal function (note effective management in kidney stone patients, hydrate to keep SG very low)
17. After debridement of devitalized bone. The best way to close dead space is: A. Myocutaneous flap. B. FTSG C. Primary closure D. Closure with a drain
A. Myocutaneous flap
- In Sunderland classification of nerve injury. In grade 2:
A. Recovery is expected in days to weeks.
B. Partial recovery.
C. Complete recovery is expected
C. Complete recovery
In 1951, Sunderland expanded Seddon’s classification to five degrees of peripheral nerve injury:
1- First-degree (Class I)
Seddon’s neurapraxia and first-degree are the same.
It is a temporary interruption of conduction without loss of axonal continuity.[3]In neurapraxia, there is a physiologic block of nerve conduction in the affected axons.
It is the mildest type of peripheral nerve injury. There are sensory-motor problems distal to the site of injury. The endoneurium, perineurium, and the epineurium are intact.
There is no wallerian degeneration.
Conduction is intact in the distal segment and proximal segment, but no conduction occurs across the area of injury.[4]
Recovery of nerve conduction deficit is full,and requires days to weeks.
EMG shows lack of fibrillation potentials (FP) and positive sharp waves.
2- Second-degree (Class II)
Seddon’s axonotmesis and second-degree are the same.
It involves loss of the relative continuity of the axon and its covering of myelin, but preservation of the connective tissue framework of the nerve ( the encapsulating tissue, the epineurium and perineurium, are preserved ).[5]
Wallerian degeneration occurs distal to the site of injury.
There are sensory and motor deficits distal to the site of lesion.
There is no nerve conduction distal to the site of injury (3 to 4 days after injury).
EMG shows fibrillation potentials (FP),and positive sharp waves (2 to 3 weeks postinjury).
Axonal regeneration occurs and recovery is possible without surgical treatment. Sometimes surgical intervention because of scar tissue formation is required.
Third-degree (Class II)
Sunderland’s third-degree is a nerve fiber interruption. In third-degree injury, there is a lesion of the endoneurium, but the epineurium and perineurium remain intact. Recovery from a third-degree injury is possible, but surgical intervention may be required.
Fourth-degree (Class II)
In fourth-degree injury, only the epineurium remain intact. In this case, surgical repair is required.
Fifth-degree (Class III)
Fifth-degree lesion is a complete transection of the nerve. Recovery is not possible without an appropriate surgical treatment.
19. Patients with Hepatitis C are more liable to have all the following EXCEPT: A. Cryoglobulinemia. B. Lymphoma. C. Chronic infection. D. Hepatoma.
D. Hepatoma
Cryoglobulinemia, B-Cell NHL are both associated with Hep C, and chronic Infection seems like a reasonable.
HCV is associated with HCC, but can’t find association to hepatoma
20. All are true regarding obtaining consent EXCEPT: A. Disclosure. B. Voluntary. C. Capacity. D. Autonomy
D. Autonomy
Elements of valid consent: (Toronto notes)
- voluntary
- capacity
- informed
- All the following are acute effects of radiation therapy EXCEPT:
A. Blood vessel sclerosis and stenosis.
B. Hair loss.
C. Desquamation of skin
A. Blood vessel sclerosis
Hair loss and desquamation are acute effects. Vessel sclerosis is late effect
- Cause of increased bleeding in Obstructive jaundice is :
A. Decreased fibrinogen
B. Decreased absorbtion of Vit K
C. Decreased platelet function
B. Decreased absorption of Vit K
Parenteral vitamin K replacement corrects coagulopathy related to biliary obstruction, bacterial overgrowth, or malnutrition. Vitamin K is less effective for coagulopathy caused by severe parenchymal liver injury.
23. Most commonly reported side effects of electrocautery is : A. Cutaneous burns B. Explosional flame C. Interference with monitoring devices D. arrhythmia
A. Cutaneous burns
-1st in the list of s/e in Schwartz
- Effects of NO include all except:
A. Selective vasodilatation of pulmonary circulation with less effect on systemic circulation
B. Decrease reperfusion injury in transplanted lung
C. May have beneficial effect in ARDS
D. Increase Cyclic GMP
B. Decrease reperfussion injury in transplanted lung
- (Schwartz): NO is derived from endothelial surfaces in response to acetylcholine stimulation, hypoxia, endotoxin, cellular injury, or mechanical shear stress from circulating blood. Normal vascular smooth muscle relaxation is maintained by a constant output of NO. NO also can reduce microthrombosis by reducing platelet adhesion and aggregation. NO also mediates protein synthesis in hepatocytes and electron transport in hepatocyte mitochondria. It is a readily diffusible substance with a half-life of a few seconds. NO spontaneously decomposes into nitrate and nitrite. NO is formed from oxidation of L-arginine, a process catalyzed by nitric oxide synthase (NOS). Cofactors of NOS activity include calmodulin, ionized calcium, and reduced nicotinamide adenine di-nucleotide phosphate (NADPH). In addition to the endothelium, NO formation also occurs in neutrophils, monocytes, renal cells, Kupffer cells, and cerebellar neurons.
- (Critical Care): Since Roissant and colleagues published their initial experience using inhaled nitric oxide as a therapy for ARDS, there has been a rapid expansion of interest and literature in this field.273–278 Given via inhalation, NO has several potentially salutary effects in ARDS. It selectively vasodilates pulmonary capillaries and arterioles that subserve ventilated alveoli, diverting blood flow to these alveoli (and away from areas of shunting). The vasodilating effect, signaled by a fall in pulmonary artery pressure and pulmonary vascular resistance, appears maximal at very low concentrations (0.1 ppm) in patients with ARDS.
- (Google): It also diffuses into the vascular smooth muscle cells adjacent to the endothelium where it binds to and activates guanylyl cyclase. This enzyme catalyzes the dephosphorylation of GTP to cGMP, which serves as a second messenger for many important cellular functions, particularly for signalling smooth muscle relaxation.
- (Annals of Phramacotherapy): Five published studies evaluated iNO therapy in patients after lung transplantation. Variable results, including inconsistent findings of improvement in hemodynamic parameters and decreased incidence of rejection, have been reported. A large, well-designed trial showed no benefit of iNO on hemodynamic parameters, mechanical ventilation duration, ICU and hospital length of stay, or mortality.8
- A 65Y old gentleman with BPH and bilateral hydronephrosis, Foley inserted then started to pass 300cc/hr, mechanism of diuresis include all except :
A. Excretion of retained extra fluid
B. Nephrogenic DI
C. Increased ANP
D. Vasodilatation of afferent arteriole and vasoconstriction of efferent venule
Ans: D
The natriuresis is due in part to the excretion of retained urea (osmotic diuresis). The increase in intratubular pressure very likely also contributes to the impairment in net sodium chloride reabsorption, especially in the terminal nephron segments. Source: Harrison.
26. Which cell is radio resistance A. lymphocyte B. epidemocyte C. gut enterocyte D. neuronal cell E. spermatocyte
D. Neuronal Cell
1- High Radiosensitivity
Lymphoid organs, bone marrow, blood, testes, ovaries, intestines
2- Fairly High Radiosensitivity
Skin and other organs with epithelial cell lining (cornea, oral cavity, esophagus, rectum, bladder, vagina, uterine cervix, ureters)
3- Moderate Radiosensitivity
Optic lens, stomach, growing cartilage, fine vasculature, growing bone
4- Fairly Low Radiosensitivity
Mature cartilage or bones, salivary glands, respiratory organs, kidneys, liver, pancreas, thyroid, adrenal and pituitary glands
5- Low Radiosensitivity
Muscle, brain, spinal cord
Reference: Rubin, P. and Casarett. G. W.: Clinical Radiation Pathology (Philadelphia: W. B. Saunders. 1968).
27. In pregnancy all except A. increase red cell mass B. hemodilution C. increase eosoniphils D. increase plasma protein
C. increased eosinophils
The plasma volume increases by 50% and the red blood cell volume increases only by 20–30%.[13] Consequently, the hematocrit decreases on lab value; this is not a true decrease in hematocrit, however, but rather due to the dilution. The white blood cell count increases and may peak at over 20 mg/mL in stressful conditions. Conversely, there is a decrease in platelet concentration to a minimal normal values of 100-150 mil/mL.
- Most common cause of death in children
A. trauma
B. congenital
C. child abuse
A. Trauma
29. What is the most common cause of SVC syndrome? A. Lymphoma B. Lung cancer C. Teratoma D. Thrombosis from IJ cath
B. Lung CA
- Man waterskiing, run over by his boat resulting in massive chest laceration. Presents to peripheral ER BP 100/60, HR 100. Chest tube inserted, 1200 cc blood returned immediately. Transferred to tertiary care centre, drained 700 cc over the next hour. BP 80/60, HR 130 now. What is the next step?
A. CT chest
B. Insert another chest tube
C. Irrigate, debride and repair chest wound
D. Emergent thoracotomy
D. Emergent Thoracotomy
- Man with tibial plateau fracture, ORIF performed. 4 hours post op developed a red, swollen, painful leg. What is the most sensitive sign to his condition?
A. Pain with passive toe extension
B. Absence of pedal pulses
- Man with tibial plateau fracture, ORIF performed. 4 hours post op developed a red, swollen, painful leg. What is the most sensitive sign to his condition?
A. Pain with passive toe extension
32. Shown an x-ray of an anterior column fracture of the pelvis. What is the source of bleeding from this fracture? A. Pelvic venous plexus B. Bleeding bone ends C. Superior gluteal artery D. External iliac artery
B. Bleeding Bone ends
- type of acetabular #: Anterior Column Fracture - This fracture extends from the middle of the pubic ramus through to any point exiting the anterior segment of the iliac crest. The iliac oblique view reveals disruption of the iliopectineal line and the weight-bearing dome of the acetabulum. CT scan can be useful in evaluating this fracture.
- if # involves greater sciatic notch the sup gluteal artery can bleed
- Which of the following conditions is MOST frequently associated with duodenal atresia?
A. Trisomy 21
B. Aortic coarctation
C. Colonic atresia
- Which of the following conditions is MOST frequently associated with duodenal atresia?
A. Trisomy 21
-Down syndrome occurs in 20–30% of patients with duodenal atresia. Other congenital anomalies that are associated with duodenal atresia include malrotation (20%), esophageal atresia (10–20%), congenital heart disease (10–15%), and anorectal and renal anomalies (5%). (Nelson’s Pediatrics)
34. How to decrease hypermetabolic response after intraabdominal surgery A. preop NSAID B. PCA C. epidural D. periop enteral/parenteral nutrition
C. Epidural
Answer was in the document but I can’t find why.
35. Most important factor in renal transplant for success A. ABO compatability B. Rh comp C. HLA comp D. Low level preformed Antibodies E. Same race
A. ABO compatibility
(( couldn’t find a good source - this was in the document already)
- Registry data demonstrate that, even with current immunosuppression regimens, better HLA-matched allografts have better survival. This benefit applies both to living and deceased donor kidneys. The better outcomes are presumably related to fewer immunologic failures. Recent evidence suggests that the benefits of HLA matching are diminishing and are much less pronounced in living donor recipients (although a large survival advantage is still seen in those with two haplotype matches). (MD consult – Brennar’s The Kidney chap65)
- During neck surgery, the IJ is cut, what is the first step to be done:
A. ask anesthesia to decrease the ventilation rate
B. pressure
C. put patient in the trendelenburg position
D. repair with 6-0 nylon
B. Pressure
- Your working with your staff in the OR and he is struggling and you think that he is under the influence of ETOH, what should you do:
A. help him complete the case and talk to him in private later.
B. call another resident to complete the case
C. call the surgeon chief
C. Call the surgeon chief
- Nephrotoxins affect the kidney by:
A. causing deposition of protein casts then lead to afferent arteriole constriction
A.
- In general, nephrotoxins cause renal injury by inducing a varying combination of intrarenal vasoconstriction, direct tubule toxicity, and intratubular obstruction. (MD consult – Brennar’s The Kidney)
- Renal failure + bleeding
There wasn’t a questions
abnormal plt function
- What is the Indication for thrombolytic therapy in PE ?
Ans: Hypotension/unstable patient
Most clinicians and society guidelines accept that thrombolysis in acute PE with hypotension is likely beneficial and therefore is an accepted indication [1]. Most societal guidelines also suggest catheter-directed thrombolysis as rescue therapy following failed systemic thrombolysis in centers with appropriate expertise [1].
Few trials have evaluated the effects of systemic thrombolytic therapy in hemodynamically unstable patients, but those that did found a consistent trend toward improved mortality [2-6]. A meta-analysis that included those trials did a subgroup analysis of 154 patients with massive PE and found that systemic thrombolytic therapy decreased the composite endpoint of death and recurrent thromboembolism (9.4 versus 19 percent, odds ratio 0.45, 95% CI 0.22-0.92)
41. Hyperacute rejection : A. IgG mediated B. IgM mediated C. B cell mediated D. T cell mediated
Ans: A
Hyperacute rejection occurs usually within the first 24 hours after transplantation. This response occurs so quickly that the tissue never becomes vascularized. It is characterized by thrombotic occlusions and hemorrhage of the graft vasculature that begins minutes to hours after the graft is placed. Hyperacute rejection is caused by preexisting host antibodies that bind to antigens present in the graft endothelium. Antigen recognition activates the complement system. There is also an influx of neutrophils.The resulting inflammation prevents vascularization of the graft. The graft then suffers irreversible damage from ischemia.
- Both IgM and IgG alloantibodies can be detected in the serum and in the allografts (of animals and humans) that are being rejected. Preformed anti-HLA class I antibodies, and occasionally, antiendothelial antibodies, play an important role in hyperacute rejection and accelerated vascular rejection observed in previously sensitized transplant recipients. (MD consult – Brenner’s The Kidney_
42. Appropriate Abx for treatment of G-ve, G+ve, aerobic and anaerobic infections: A. Pen B. Ceftriaxone C. Clinda and Flagyl D. Vanco and Flagyl
B. Ceftriaxone (3rd Gen cephalosporin)
The answer listed was B and Heather (Pharmacist - confirmed that this would likely be the best answer). However, we discussed it, and none are perfect options. Here’s some info I found:
Like other third-generation cephalosporins, it has broad-spectrum activity against Gram-positive bacteria and expanded Gram-negative coverage compared to second-generation agents.
- Penicillin: covers gram +ve and clostridium and Actinomyces, and anaerobic Streptococcus species
- Ceftriaxone: coverage (proteus, E coli, klebsiella, H flu, moraxella) but does not cover pseudomonas.
-Clinda + flagyl: Clindamycin is used primarily to treat anaerobic infections caused by susceptible anaerobic bacteria. It also covers Aerobic Gram-positive cocci, including some members of the Staphylococcus and Streptococcus (e.g. pneumococcus) genera, but not enterococci. It however does not cover gram negative aerobic bacteria (pseudomonas).
Flagyl covers Gram-negative and Gram-positive anaerobic bacteria
-vanco and flagyl: Vanco covers Gram-positive bacteria
43. All of the following influence the risk of transmission of HIV except: A. hollow vs solid needle B. depth of the needle stick C. degree of contamination D. strain of virus
D. strain of virus
FACTORS CONTRIBUTING TO THE RISK FOR OCCUPATIONAL HIV INFECTION
Exposure factors
1. Route of exposure (e.g. percutaneous, * mucous membrane, cutaneous)
MD Consult
2. Inoculum size
• Size of the device producing injury
• For needlestick exposures, type of needle (i.e. hollow-bore * vs solid)
• Extent of contamination (e.g. visible blood on device, † whether or not device had been placed in an artery or vein †)
• ‘Depth/severity’ of exposure * †
• Type of contamination (e.g. blood, * pleural fluid, etc.)
Source/’donor’ factors
1. Extent of viremia (e.g. by polymerase chain reaction or branch-chain DNA assay)
2. Stage of illness (as a presumed surrogate for extent of viremia † )
3. Circulating free (as opposed to cell-associated) virus
4. Antiretroviral chemotherapy (presumably reducing level of viremia)
44. When a test detects what it is intended to detect, this is called: A. sensitivity B. specificity C. validity D. positive predictive value
C. Validity
The validity of a measurement tool (for example, a test in education) is considered to be the degree to which the tool measures what it claims to measure; in this case, the validity is an equivalent to accuracy.
- Most common site for ganglion in the hand is:
A. flexor surface of the wrist.
B. extensor surface of the DIP
C. radial side of the extensor surface of the wrist
C. Radial Side of the Extensor surface of the wrist
-The most frequent site of origin is the dorsal scapholunate ligament. Ganglions frequently are palpable between the second and fourth extensor tendon compartments. The second most frequent site is volar just radial to the flexor carpi radialis tendon. Ganglions on the dorsum of the wrist usually are firm, smooth, fluctuant, and round. Ganglions extending proximally along the extensor tendons are likely to be less firm, multilocular, and irregular, but still contain the slightly yellow, gelatinous, stringy fluid common to all ganglions. The most common site in a flex or tendon is at the level of the metacarpophalangeal joint flexor skin crease(Campbell’s Orthopedics).
- Pt. with a history of fall while climbing, prolonged time to transfer. She has peri-orbital and post auricular bruising. What # is she most likely to have:
A. basal skull #
B. leforte I
C. leforte II
Ans: A
-racoon eyes and battle sign = basal skull #
47. America College of…experts meet in their annual meeting and at the end reach a consensus and publish guidelines for managing a certain disease. What level of evidence would that be: A. level I B. level II C. level III D. level IV
D. IV
Based on the following explanation, I think it’s actually level V, but that isn’t an option
1a: Systematic reviews (with homogeneity) of randomized controlled trials
1b: Individual randomized controlled trials (with narrow confidence interval)
1c: All or none randomized controlled trials
2a: Systematic reviews (with homogeneity) of cohort studies
2b: Individual cohort study or low quality randomized controlled trials (e.g.
- Which of the following markers is most specific for the matched cancer:
A. PSA prostate
B. BHG choriocarcinoma)
C. CA 19-9 pancreatic Ca
B. BHCG
-All choriocarcinomas produce beta HCG.!! CA 19-9 is detected with an immunoassay, and the upper limit of normal for a healthy adult is 37 U/mL. Sensitivities of CA 19-9 in the diagnosis of pancreatic cancer range from 67% to 92%, with specificities ranging from 68% to 92%. The utility of CA 19-9 as a diagnostic marker is limited in a number of ways. First, patients with negative Lewis-A blood group antigen cannot synthesize CA 19-9, and therefore it is not used as a serologic marker in these individuals, who make up about 10% of the population. Second, patients with benign biliary tract disease can have levels up to 400 U/mL, with 87% having concentrations higher than 70 U/mL. Significant numbers of patients with pancreatitis, either acute or chronic, also have elevated levels. Third, besides pancreatic cancer, CA 19-9 levels are also elevated in patients with other cancers, including those of the biliary tree (95%), stomach (5%), colon (15%), liver (HCC, 7%) and lung (13%). For colorectal cancer, CA 19-9 levels add little clinically useful information to determination of CEA levels. (Sabiston)
- Which of the following sutures with be the last to degrade :
A. POLYGLYCOLIC (DEXON)
B. POLYGLACTIC (VICRYL)
C. POLYDIAXONE (PDS, BIOSIN)
Ans: C. recall that PDS is technically an abosorbable suture. Even though it lasts quite long and can be used in presence of infection.
- polyglycolic (Dexon) 60-90days
- polyglactic (Vicryl) 60-90days
- polydiaxone (PDS) 180days
50. 1 L of RL would increase the plasma volume by: A. 1 L B. 500 ml C. 250 ml D. 100 ml
C. 250ml
RL is considered equivalent to NS for water distribution. In these solutions, there is no free water for distribution across the whole TBW. Usually free water will spread equally across the ECF (1/3 of TBW) and ICF (2/3). With RL and NS, all goes to the ECF and then spreads according to 1/3 (or 1/4 I’ve seen both written) to the intravascular space, and 2/3 (or /4) to the extravascular space.
So using 1/4 to the intravascular space, we Multiply 1000cc x 1/4 = 250cc to the intravascular space
- What is the chemical substance in snake venom that permits it to spread via lymphatics:
A. hirudin
B. papain
C. hylarudinase
Ans: C
Most venoms contain hyaluronidase, which enhances the rapid spread of venom by way of the superficial lymphatics. (Schwartz).
Hirudin is found in leeches that helps prevent continued venous congestion.
Papain (papaya proteinase I) is an enzyme in papayas
52. What is the half life of factor VIII in FFP? A. 3-6 hours B. 8-12 hours C. 1-2 days D. 4-7 days
Ans: B
Factor VIII has a half-life of 8 to 12 hours (Hoffman: Hematology)
Factor 8, so 8 hours
- 59 year old diabetic women with claudication. Angiogram reveals atherosclerosis of the superior femoral artery. According to Poiseuille’s law, an artery with a 4 cm segment of 80% atherosclerotic narrowing would have a decrease in blood flow:
A. directly proportional to the radius and inversely proportional to the length
B. indirectly proportional to the radius to the fourth and directly proportional to the length
C. indirectly proportional to the radius and directly proportional to the length
D. directly proportional to the radius to the fourth and directly proportional to the length
Ans: B (previously “D if Length said indirectly, no good answer”)
-Poiseuille’s law: The volume of a homogeneous fluid passing per unit of time through a tube is directly proportional to the pressure difference between its ends and to the fourth power of its internal radius, and is inversely proportional to its length and to the viscosity of the fluid.
They are asking about the DECREASE in blood flow so the decrease is greater if the length is greater (directly), and the radius is less (indirectly)
54. If you were planning a clinical trial to test the efficacy and the morbidity of a new drug compared to the standard chemotherapeutic agent, what type of clinical trial would that be? A. Phase I trial B. Phase II trial C. Phase III trial D. Cohort study
Ans: C
- Phase 0 is a recent designation for exploratory, first-in-human trials.
- Phase I trials are the first stage of testing in human subjects. Normally, a small (20-80) group of healthy volunteers will be selected. This phase includes trials designed to assess the safety, tolerability, pharmacokinetics, and pharmacodynamics of a drug.
- Phase II trials are performed on larger groups (20-300) and are designed to assess how well the drug works, as well as to continue Phase I safety assessments in a larger group of volunteers and patients.
- Phase III studies are randomized controlled multicenter trials on large patient groups (300–3,000 or more depending upon the disease/medical condition studied) and are aimed at being the definitive assessment of how effective the drug is, in comparison with current ‘gold standard’ treatment
- Phase IV trial is also known as Post Marketing Surveillance Trial. Phase IV trials involve the safety surveillance and ongoing technical support of a drug after it receives permission to be sold.
55. In an otherwise healthy looking 3 week old infant who has been vomiting for the last 24 hours and has a palpable “olive” on abdominal exam, you would expect the electrolyte profile to look like: A. Na 132, Cl 78, K 3.2, HCO3 28 B. Na 145, Cl 99, K 3.6, HCO3 24 C. Na 154, Cl 101, K 4.5, HCO3 20 D. Na 128, Cl 79, K 2.9, HCO3 30
Ans: D
-The classic physiologic derangement seen with HPS is hyponatremic, hypochloremic, hypokalemic met alkalosis. Early, the loss of gastric secretions from vomiting leads to dehydration and aldosterone-stimulated potassium excretion in the urine in an attempt to conserve sodium. As potassium depletion worsens, hydrogen ion is exchanged for sodium across the renal tubule, resulting in the “paradoxical aciduria” characteristic of pts with dehydration and met alkalosis from protracted vomiting. (Google books – Mastery of surgery)
- The mechanism of action of Warfarin is:
A. Interferes with thrombin and thus the fibrinogen to fibrin conversion
B. Interferes with the absorption of Vitamin K
C. Decreases formation of factors II, V, VII, IX
D. Decreases formation of factors II, VII, IX, X
Ans: D
-inhibits vit K-dependent coagulation factor synthesis (II, VII, IX, X, proteins C and S)
1972 Canada vs. Soviet union
57. A 23 year old male is stabbed in the neck and sustains a carotid artery injury. He has been in a coma for two hours. What is the best intervention to prevent permanent sequelae? A. carotid artery B. Repair carotid artery C. Observe D. Heparinize
Ans: C vs. B. No clear answer from sources
According to MORRELL notes, guy in a coma, you observe. No ligation, no repair.
- The need to reconstruct the carotid artery of a patient with a clear preoperative hemispheric neurologic deficit has long been a subject of controversy. Current evidence supports revascularization regardless of the patient’s neurologic status, accepting that prognosis is poor in the presence of a profound neurologic deficit (i.e., coma) with or without revascularization. (Sabiston)
- While it would seem obvious that all penetrating carotid injuries should be repaired, this may not be the case. During the 1960s surgeons attempted to revascularize patients who suffered acute strokes due to atherosclerotic carotid artery disease. It quickly became apparent that these patients fared worse than those who were treated nonoperatively. This unfortunate outcome was believed to be due to the conversion of an ischemic infarct to a hemorrhagic infarct that was associated with a higher mortality rate. The same phenomenon is believed by some to occur in patients with carotid injuries. In fact, subsequent studies have rarely identified this complication. This has led to a more aggressive approach of repairing all penetrating carotid injuries regardless of the patient’s neurologic status, or repairing all except those in comatose patients. (Schwartz)
When the patient is truly comatose with a Glasgow Coma Scale score
- Low molecular weight heparin
A. should be stopped 24 hours prior to surgery
B. should be stopped 12 hours prior to surgery
C. increases risk of epidural hematoma following epidural
D. should be monitored by increase PTT level
E. B + C
Ans: A
- stop heparin 12 hours before for bid dosing
- stop heparin 24 hours before for daily dosing
10-40% renal clearance
LMW heparin – We discontinue LMW heparin 24 hours before the planned surgery or procedure, based on a biologic half-life of most subcutaneous LMW heparins of approximately three to five hours [7,59,63]. If a twice-daily LMW heparin regimen is given, the evening dose the night before surgery is omitted, whereas if a once-daily regimen is given (eg, dalteparin 200 international units/kg), one-half of the total daily dose is given on the morning of the day before surgery. This ensures that no significant residual anticoagulant will be present at the time of surgery, based on studies that have shown a residual anticoagulant effect at 24 hours after stopping therapeutic-dose LMW heparin, and it is consistent with the 2012 ACCP Guidelines [7,11,64,65]. (uptodate)
- 45 year old man sustains a laceration to his forearm while using a lawnmower. His tetanus status is uncertain. Do you administer:
A. tetanus vaccine only
B. tetanus immunoglobulins only
C. tetanus toxoid and immunoglobulins
D. inject immunoglobulins into the would directly
Ans: C
Clean and minor wound:
• Tetanus vaccine if =3 doses but last dose >=10 years ago
• No immune globulin
Other wounds (like this one): • Tetanus vaccine if =3 doses but last dose >=10 years ago • Immune globulin if =3 doses in lifetime) Uptodate
60. 78 year old woman with breast cancer presents with hypercalemia, normal lytes and BUN. What is your treatment: A. NS infusion followed by lasix B. Bisphosphonates C. Calcitonin D. Radiation treatment for bony mets
answer A
Basically hydrate with NS + diurese is first line. Add calcitonin + bisphosphonates for severe hypercalcemia
□ intravenous isotonic saline should be given to expand ECF, increase urine flow, enhance calcium excretion, and reduce the serum level
□ Furosemide and intravenous sodium sulfate are other methods of increasing renal calcium excretion
□ Plicamycin is particularly useful for hypercalcemia associated with metastatic cancer
□ Adrenal corticosteroids are useful for hypercalcemia associated with sarcoidosis, vitamin D intoxication, and Addison’s disease
□ Calcitonin is indicated in patients with impaired renal and cardiovascular function. When renal failure is present, hemodialysis may be required.
SALINE HYDRATION — Initial therapy of severe hypercalcemia includes the simultaneous administration of saline, calcitonin, and a bisphosphonate (see ‘Severe hypercalcemia’ above). Isotonic saline corrects possible volume depletion due to hypercalcemia-induced urinary salt wasting and, in some cases, vomiting. Hypovolemia exacerbates hypercalcemia by impairing the renal clearance of calcium (table 1) (uptodate)
61. 56 year old woman with recurrence of breast cancer in a radiated bed. Your treatment of choice is: A. tissue expander B. free flap C. STSG D. Local flap
Answer D?
- Which is most important factor for early success of live donor kidney transplant
A. cold ischemic time
B. warm ischemic time
C. pre harvest urine output
Answer C.
This questions basically is to see if you know that ischemia time is not the most important factor - more important to have the suitable donor kidney for the suitable patient
“Best predictor of LRD - living related donor- kidney function: donor kidney u/o just prior to nephrectomy.”
When organ allocation is based upon HLA typing, one concern is the effect of cold ischemia time upon long-term survival. The beneficial effect of HLA matching appears to generally outweigh the detrimental effect of prolonging the cold ischemia time in transported kidneys. The current registry data indicate that the five-year graft survival of six-antigen-matched cadaver kidneys is the same regardless of whether the kidneys undergo 3 or 36 hours of cold ischemia. A stepwise reduction of 1 to 2 percent in survival has been observed in association with incremental 12-hour increases in cold ischemia time.
- 40 yo female patient history of low dose radiation for acne as a teen presents with left thyroid mass
A. open biopsy
B. total thyroidectomy
C. left hemithyroidectomy
□ Answer B. Most authors agree that patients with high-risk tumors (judged by any of the classification systems discussed above) or bilateral tumors should undergo total or near-total thyroidectomy. Uptodate: We recommend total thyroidectomy for most patients with thyroid cancer.
□ The only instance I could find with an indication for a hemithyroidectomy with a cancer is if the surgeon is inexperienced and wants to avoid bilateral nerve damage…
- Skin graft warm boggy pricked blue blood
A. leeches
B. surgical exploration with re-anastamosis
C. heparin
D. observe
E. answer a
□ Answer: A. Leeches to decrease venous congestion
Another common question about leeches is that they secrete hirudin (anticoagulant)
65. Most common cause of primary hyperaldosteronism A. solitary adenoma B. unilateral adrenal hyperplasia C. bilateral adrenal hyperplasia D. pituitary CA
Answer a
□ Primary hyperaldosteronism results from autonomous aldosterone secretion, which, in turn, leads to suppression of renin secretion.
□ ages of 30 and 50 years, accounts for 1% of cases of hypertension
□ Primary hyperaldosteronism is usually associated with hypokalemia; however, more patients with Conn’s syndrome are being diagnosed with normal potassium levels.
□ Most cases result from a solitary functioning adrenal adenoma (approximately 70%) and idiopathic bilateral hyperplasia (30%).
□ Secondary: stimulation of the renin–angiotensin system from renal artery stenosis and low-flow states (CHF, cirrhosis)
- Postop colectomy. massive MI in cardiogenic shock with hypotension
A. decrease preload, afterload and add inotropes
B. IABP
C. angioplasty
D. maximize oxygenation
Answer: C
□ ABC (judicious volume, inotropes)
□ Patients whose cardiac dysfunction is refractory to cardiotonics may require mechanical circulatory support with an intra-aortic balloon pump (IABP). 9-22% survival at 1 year is used in isolation
□ thrombolytic therapy reduces mortality in patients with acute myocardial infarction, its role in cardiogenic shock is less clear.
□ Current guidelines of the American Heart Association recommend percutaneous transluminal coronary angiography for patients with cardiogenic shock, ST elevation, left bundle-branch block, and age less than 75 years. Early definition of coronary anatomy and revascularization is the pivotal step in treatment of patients with cardiogenic shock from acute MI.When feasible, PTCA (generally with stent placement) is the treatment of choice.
67. TPN in renal failure should have calorie: nitrogen ratio A. 80:1 B. 150:1 C. 200:1 D. 300:1
Answer A. Usual ratio of nonprotein energy to grams of nitrogen: 125:1. Renal failure (serum creatinine greater than 2 mg/dL) who cannot be dialyzed: low-nitrogen TPN. Renal failure who can undergo dialysis may receive the standard or high-nitrogen TPN formulations, with special attention directed toward minimizing potassium and phosphate intake
68. ORIF. bone then heals by A. primary B. secondary C. tertiary D. callus
□ Answer A. primary bone healing occurs without callus formation. Direct attempt by the cortex to re-establish itself after interruption. Need anatomic restoration of the fracture fragments (rigid internal fixation) and stability of fracture reduction
- MVA. T7 vertebra exploded – paraplegic. numerous litres of volume infused, still hypotensive. abd US no hemoperitoneum. closed pelvis fracture. likely cause of hypotension?
A. undiagnosed abd injury
B. head injury
C. neurogenic shock
□ Answer C: decr perfusion d/t loss of vasomotor tone to peripheral arterial beds. loss of VC impulses: increased vascular capacitance, decreased venous return, and decreased cardiac output. usually spinal cord injuries from vertebral body fractures of the cervical or high thoracic region that disrupt sympathetic regulation of peripheral vascular tone. bradycardia, hypotension, cardiac dysrhythmias, reduced cardiac output, and decreased peripheral vascular resistance
- Internal jugular vein lacerated during case. optimal next step:
A. suture with 4-0 vicryl
B. trendelenburg positioning
C. ask anesthesia to decrease RR
B.
Makes sense, decrease your JVP and therefore quantity of bleeding
- Diarrhea gives you what metabolic defect
A. metabolic alkalosis
B. metabolic acidosis, non AG
C. metabolic acidosis, AG
□ Answer B Also hyperchloremic (normal physiological response) to balance anions since there is a decrease in plasma bicarb Anion gap = = ([Na+] + [K+]) − ([Cl-] + [HCO3−]) therefore need to increase chloride to keep non AG true
72. Which suture will you use to close after debriding an infected wound A. pds B. vicryl C. silk D. some other multifilament
□ Answer a: Absorbable monofilament
polydiaxanone
73. What drug don’t you use post cardiac transplant A. azathioprine B. fk-506 (tacrolimus) C. mmf D. cyclosporine
□ Answer A (previous answer here was B).
previous exams: don’t use methotrexate
Most modern immunosuppressive regimens consist of a two- or three-drug regimen, including a calcineurin-inhibitor (either cyclosporine or tacrolimus), an antimetabolite agent (typically mycophenolate mofetil), and tapering doses of corticosteroids over the first year.
MMF (mycophenolate mofetil) has replaced azathioprine as preferred antimetabolite agent - some trial showed that the ones treated with MMF had lower mortality and rejection at 1 year
Although tacrolimus and cyclosporine are both highly effective agents, evidence from clinical trials suggests that tacrolimus-based immunosuppression may offer an advantage over cyclosporine-based regimens with respect to decreased rates of acute rejection and an overall more favorable metabolic derangement profile (decreased incidence of hypertension and hyperlipidemia but higher incidence of post-transplant diabetes).
- late cardiac transplant failure presents as
A. proximal discrete coronary lesions
B. chf +/- arrythmia
□ Chronic rejection in the cardiac allograft typically manifests as aggressive and premature coronary artery disease
o develops months to years after the procedure
o transplant-associated coronary artery disease is generally more diffuse, involving all the vessels of the heart including the arteries, veins, and great vessels
- Side effects of vincristine all except:
A. ileus
B. thrombocytopenia
C. leukopenia
□ Answer: all of these are side effects of vincristine
- 2 months postop cemented THR. Pus aspirated.
A. observe, await cultures
B. 6 weeks IV abx then 6 weeks PO abs
C. operative removal of all THR components
D. operative thorough debridement then 6 weeks IV abx
□ Answer C
- worst prognosis of breast lesions:
A. ductal metaplasia
B. papillary metaplasia
C. ductal metaplasia with atypical cells
□ Answer C
78. most common breast lesion A. fibrocystic change B. DCIS C. fibroadenoma D. Paget’s disease
□ Answer A
□ After fibrocystic changes, fibroadenoma is most common benign breast lesion
79. Most sensitive CXR sign of aortic tear: A. apical cap B. sail sign C. wide mediastinum D. deep sulcus sign E. loss of paraspinal shadow
□ Answer C
80. cerebral autoregulation attempts to maintain cerebral perfusion pressure of A. 30 mmHg B. 70 mmHg C. 30 cm h2o D. 70 cm H2O
answer b (see Q253 2007): CPP is equal to the mean arterial pressure (MAP) minus the ICP, and 60 mm Hg is the lowest acceptable pressure
81. 63 y o female non-insulin diabetic with coronary disease and an MI 18 months ago. ASA score: A. 2 B. 3 C. 4 D. 5
□ answer B ASA 3
ASA grade Description Examples
1 A healthy, fit patient
Ex: Caleb
2 A pats with mild systemic disease
Ex: Controlled DM2, Controlled essential HTN, Obesity, Smoker.
3 Pt. with severe systemic disease that limits activity
Ex: Angina, Prior MI, COPD, uncontrolled DM, obesity
4 Pt. with incapacitiating disease that is a constant threat to life
Ex: CHF, Renal Failure, ARF
5 A moribund pt. not expected to survive 24 hr. with/wihtout surgery
Ex: Ruptured AAA, Head trauma (high ICP)
82. Patient with a smoking history. What is their ASA score? A. 1 B. 2 C. 3 D. B
□ answer B ASA 2
- Lacerated the dura during a routine back dissection, sewed it up fine, no apparent CSF leak. do you
A. not tell patient / family
B. tell them about need to watch for CSF leak but don’t explain why
C. tell them about complication, need to watch for CSF, possibility for reoperation
D. tell only hospital risk assessment team
C
- re epithelialization
A. only occurs from wound edges
B. bacteria and foreign bodies inhibit it
□ answers A and B are true
□ Mitoses appear in epithelium a few cells away from the wound edge. The new cells migrate over the cells at the edge and into the unhealed area and anchor to the first unepithelialized place that they encounter
85. Concerning oxygen in septic shock A. increased delivery increased uptake B. decreased delivery decreased uptake C. increased delivery decreased uptake D. decreased delivery increased uptake
□ answer C
86. C.diff treatment, first choice A. po vanco B. po flagyl C. iv vanco D. iv flagyl
□ answer B
First-line therapy for mild to moderate CDI : PO flagyl
Severe: vancomycin PO 10-14 days
Critically ill: PO vanco + IV flagyl
uptodate
87. Resistant c. diff treatment, all EXCEPT: A. po vanco B. po flagyl C. iv vanco D. iv flagyl
□ answer C
Intravenous vancomycin has no effect on C. difficile colitis since the antibiotic is not excreted appreciably into the colon
88. what colour is fat on MRI A. dark on T1 and T2 B. light on T1 and T2 C. dark T1 light T2 D. light T1 dark T2
□ answer D
□ T1: realignment of nuclear spins with magnetic field T1-weighted images show fluid black, fat white; contrast improvement with gadolinium-enhancement (ie, vascularity) and fat suppression: abdominal MRI.
□ T2: dephasing of nuclear spins with transverse field T2-weighted images show fluid white, fat dark; pelvic MRI.
89. Treatment A reduces death from 26% to 16%. Calculate the NNT. A. 1 B. 10 C. 100 D. 1000
answer B
□ NNT = 1/ARR
□ ARR = |CER - EER| CER = control group event rate EER = experimental group event rate
□ ARR=.26-.16=.1 NNT=1/0.1=10
10% absolute risk reduction
1/10% = 10 NNT
90. MVA. Forearm laceration bled profusely requiring 2 u transfusion but stopped with pressure in ER. What is an appropriate strategy for DVT prophylaxis? A. Wait 48 hours B. SC UFH C. IV UFH via PTT adjusted nomogram D. SCD
Answer D vs A
Logically it would depend on the patient’s activity level (comatose in ICU vs. walking around)
91. Which cranial nerve is injured most? A. II B. III C. V D. VII
D
Depends on what the mechanism is… but I found this:
CN I most affected.
Cranial nerve injury after minor head trauma:
Posttraumatic single nerve palsy was observed in 38 patients (77.6%), and multiple nerve injuries were observed in 11 (22.4%). Cranial nerves were affected in 62 cases. The most affected CN was the olfactory nerve (CN I), followed by the facial nerve (CN VII) and the oculomotor nerves (CNs III, IV, and VI).
92. Pt sustains 50% BSA burn. What fluid? A. RL B. 5% albumin C. D5/0.45 D. D5W
□ Answer A
Parkland formula: 4ml per kg body weight X %Total body surface area in 24h, with half in first 8h and other half in the next 16h
□ Most patients can be resuscitated with crystalloid, specifically lactated Ringer’s solution. NS should be avoided, as the volumes required for resuscitation invariably lead to a complicating hyperchloremic metabolic acidosis.
- Which of the following contraindicates flexion / extension views of C spine post MVA?
A. Previous C3-4 fusion
B. Pain on palpation of spinous process
C. documented unstable injuries
Answer: C
Flexion/extension views are absolutely contraindicated in documented unstable injuries
- Pt has documented real allergy to Lidocaine. What do you use?
A. bupivicaine
B. procaine
C. mepivicaine
□ Answer B (ester)
□ true allergy to amides (eg, lidocaine, bupivacaine) is exceedingly rare
- Post motorcycle accident, pt found to have open book pelvis fracture. After bedsheet fixation he remains hypotensive despite aggressive resuscitation. Next step
A. Re-apply pelvis fixation
B. laparotomy
C. angio for coil embolization
Answer: B??
Preperitoneal packing + ex-fix. Angio if CTA shows active arterial bleed
Previous answer C.
Uptodate:
Hemodynamic instability likely due to retroperitoneal bleeding from the pelvic fracture, we suggest operative control of hemorrhage using external fracture fixation plus preperitoneal pelvic packing to tamponade bleeding, rather than external pelvic fracture fixation plus arteriography and angioembolization (Grade 2C).
The majority of severe bleeding due to pelvic fractures is venous in origin and only a small percentage of patients will have a bleeding site that is amenable to embolization. Fracture fixation decreases pelvic volume, promotes tamponade of venous bleeding, and prevents shifting of the bony elements limiting secondary hemorrhage. Preperitoneal pelvic packing involves the placement of laparotomy sponges into the preperitoneal space via an incision, which reduces the available volume of the retroperitoneal space and tamponades pelvic bleeding.
- Which is true about neonate pharmacokinetics as compared with adults
A. decreased hepatic metabolism
B. increased GFR
C. increased fat distribution
answer A
relative immaturity of neonatal hepatic function prolongs the duration of action for drugs that depend primarily on hepatic metabolism
- On post operative day 3, wound strength that has been closed by primary closure is determined primarily by:
A. fibroblasts
B. collagen
C. re-epithelialization from wound surface edges
D. sutures
answer D
- In first 3 weeks, wound strength and collagen content correlate.
- After 21 days, strength increase with no increase in collagen content, reflecting scar remodelling.
- Collagen turnover causes hydroxy-proline spillage in urine.
- Diabetic foot ulcers display inferior wound healing due to:
A. diminished microcirculation
B. Collagen type I to III ratio alteration
C. balance of macrophages to other cell types in ECM
D. altered cell membrane transport due to glycosylation
A
Peripheral artery disease in combination with diabetic neuropathy contributes to higher rates of non-healing ulcers and limb loss in diabetic patients compared with those without diabetes
99. Elderly African-American lady presents with a new, persisting dark streak in the nail bed. You suspect melanoma. The most likely diagnosis is: A. lentigo maligna B. acrolentigious melanoma C. superficial spreading melanoma D. nodular melanoma.
Answer B
superficial spreading: most common, flat, anywhere on the skin except the hands and feet, long radial growth phase before vertical growth begins
nodular: darker and raised, lack of radial growth peripheral to the area of vertical growth
lentigo maligna: mostly on the neck, the face, and the back of the hands of elderly people
Acral lentiginous
o least-common subtype, 2 to 8% of melanoma in whites
o palms and soles and in the subungual regions
o acral lentiginous type accounts for 29 to 72% of all melanomas in dark-skinned people (Bob Marley)
o subungual lesions appear as blue-black discolorations of the posterior nail fold and are most common on the great toe or thumb. The additional presence of pigmentation in the proximal or lateral nail folds (Hutchinson’s sign) is diagnostic of subungual melanoma
100. Middle aged male patient presents with parathyroid adenoma. The most likely findings in the serum are: A. increased PO4 B. decreased Ca2+ C. decreased PO4 D. increased Ca2+
answer D
The most common clinical presentation of primary hyperparathyroidism (PHPT) is asymptomatic hypercalcemia.
□ elevated serum calcium and intact PTH (iPTH) establishes the diagnosis of PHPT with virtual certainty
□ 50%: decreased serum phosphate
□ 60%: elevated 24-hour urinary calcium concentrations
□ 80%: mild hyperchloremic metabolic acidosis, w an elevated chloride:phosphate ratio (>33)
251. All of the following are indications for laparotomy in a trauma patient, EXCEPT: A. Intra-peritoneal bladder rupture B. Fractured kidney C. Ruptured diaphragm D. Penetrating abdominal gunshot injury
Answer: B.
The only absolute indication for surgical renal exploration is a patient with external trauma and persistent renal bleeding. Signs of continued renal bleeding are a pulsatile, expanding, or uncontained retroperitoneal hematoma. Another sign is avulsion of the main renal artery or vein as noted by CT or arteriography.
emedicine-Renal Trauma
252. Patient involved in ski accident, with displaced tibial plateau injury. That evening, patient develops severe pain in leg, not relieved with elevation or analgesics. The most sensitive clinical finding to diagnose the patient’s problem is: A. Pulselessness B. Paresthesia C. Pain on passive dorsiflexion of toe
Answer: C.
253.
In attempting to practice medicine that pays attention to minimizing economic burden/appropriate resource use, you should do all of the following, EXCEPT:
A. Avoid inappropriate tests
B. If choice exists, use less costly materials
C. Give your patients advantages
D. Treat patients on first-come first-serve basis
Answer: C.
implies lack of justice
- The most important investigation of a solitary thyroid nodule is:
A. CT scan
B. Ultrasound
C. FNA
C. FNA
Fine-needle aspiration biopsy
FNAB has emerged as the most important step in the diagnostic evaluation of thyroid nodules.[11] Data from numerous studies have established FNAB as highly accurate, with mean sensitivity higher than 80% and mean specificity higher than 90%. The accuracy of FNAB in diagnosing thyroid conditions highly depends on the cytopathologist’s expertise and experience and the technical skill of the physician performing the biopsy. In addition, FNAB is highly cost-effective compared with traditional workups that heavily depended on nuclear imaging and ultrasonography. Routine use of FNAB in the evaluation of thyroid nodules can reduce the need for diagnostic thyroidectomy by 20-50% while increasing the yield of cancer diagnoses in thyroid specimens by 15-45%.
emedicine- Thyroid Nodule
- In severe injury to lower leg, which of the following play a role in decision to salvage limb vs. amputation:
A. Presence of vascular injury
B. Severe underlying fractures, with missing bone
C. Intact posterior tibial nerve
D. Large soft tissue defect
C. Intact posterior tibial nerve.
I think this answer is old (1996). Now something called Mangled Extremity Salvage Score
but as per test answer:
Answer: C. Absolute indications to amputate primarily. 1. Tibial nerve transection. 2. Crush injury with warm ischemia time >6 hrs. The most important decision is can the remaining limb be somewhat functional – without nerve function it is not. Posterior tibial nerve innervates the plantar aspect of the foot and is a major determinant in salvaging a limb.
- Regarding nephrotoxicity with IV contrast, which is TRUE:
A. Hyperosmolarity of contrast does not play a role
b. Pre-scan hydration status does not matter
c. Direct toxic effect to renal cells
d. Reduced cortical flow, causing medullary ischemia
c. Direct toxic effect to renal cells
Risk factors: 1. Diabetes; 2. Age >75; 3. Pre-procedural volume depletion; 4. Heart failure; 5. Cirrhosis; 6. NSAIDs. Pathogenesis: direct toxic injury to renal tubule cells and ischemic injury mediated by ROS. The osmolarity of the contrast medium DOES play a role.
Source: NEJM. Prevention of Contrast induced nephropathy. 2006.
- OR with greatest risk of DVT
a. Hip replacement
b. Vein stripping
c. APR
d. C-section
Answer: A. hip replacement. Orthopaedic surgery on hip and knee replacement have the highest risk of DVT.
Go ortho!
- Authorship on a paper could be acceptable to all of the following, EXCEPT:
a. Person who did majority of research/work
b. Person who did major revisions
c. Person who approved final version for publication
d. Person who lent their lab space for experiments to be carried out in
d. Person who lent their lab space for experiments to be carried out in
- Which of the following is appropriate when providing nutritional support to a patient in renal failure?
a. Increased TFI
b. High fat to calorie ratio
c. Increase calorie to nitrogen ratio
c. Increase calorie to nitrogen ratio
Just think that too much protein is hard on the kidneys.
Ivan take note.
- Which of the following contraindicates flexion / extension views of C spine post MVA?
a. previous C3-4 fusion
b. pain on palpation of spinous process
Answer: B.
- Person has difficulty chewing, vision problems, lower extremity weakness and a 7cm mass in the anterior thorax. What is the test that will definitively tell you the diagnosis:
a) alpha-fetoprotein
b) tensilon test
c) CT scan
d) muscle biopsy
Answer: B. Patient has a thymoma and associated Myasthenia Gravis. Tensilon test is diagnostic.
Edrophonium (by the so-called Tensilon test) is used to differentiate myasthenia gravis from cholinergic crisis and Lambert-Eaton myasthenic syndrome. In myasthenia gravis, the body produces autoantibodies which block, inhibit or destroy nicotinic acetylcholine receptors in the neuromuscular junction.
wiki
- Why hypertrophic scar - which of the following works to decrease the effects EXCEPT
a. place pressure overtop of the scar to cause b. some cellular degeneration
c. collagen will re-align itself in line
fibroblasts will align themselves properly
Answer: C. Hypertrophic scars rx include. 1. Pressure garments; 2. Topical silicone; 3. Excision and reclosure. The pressure garments cause the COLLAGEN to re-align.
Source: Current Surgical Treatment. P1223.
- Child is bitten by a dog. Dog appears OK. What is the most appropriate management?
a. local wound care and observe the dog for 10 days
b. contact public health officer
c. sacrifice dog and send brain for pathologic exam
d. vaccinate the child against rabies and administer anti-rabies immunoglobulin only if dog manifests symptoms of rabies
e. reassurance as attack most likely provoked by child
Answer: A. You need to ensure that the dog does not have rabies – so you observe. You do not prophylactically give the child a rabies vaccine as these are toxic.
- Which of these is a contaminated wound?
a. traumatic and open
b. bacteria and pus
c. perforated viscus
d. GI case that is open, but without fecal spillage
Answer: C. as per test answer
I disagree. open trauma considered contaminated.
Dirty wound: traumatic and opened, bacteria and pus. Definition: Perforated viscus is a dirty wound, while an acute traumatic and open wound is considered traumatic. acute inflammation, traumatic, GI tract spillage, or major break in sterile technique. Bacteria and pus = infected wound. GI case that is opened without spillage = “clean contaminated”
Source: Surgery Recall, Essentials of Surgery, Lawrence.
- Major intracellular cations are:
a. Na + Ca
b. K + Mg
c. PO and protein
d. Cl and HCO3
Answer: B. K+ and Mg2+
I remember by potassium and magnesium are good for you, so you want them in the cell.
- ALL of the following carry high mortality rate except:
a. Gallop 3
b. MI 18 months
c. Valve disease
d. CAGB 3 years ago
Answer: D. Once treated with CABG, the disease coronary vessels are removed, therefore the mortality rate should theoretically be eliminated.
- CO poisoning, which is correct:
a. N or high PaO2, Sat O2 is low, low Pulse oxymetry
b. Low PaO2, low SatO2, N P.oxymetry
c. High PaO2, high SatO2, high Pulse oxymetry
Answer: B.
Source: NEJM. CO poisoning. 2002.
Not sure if PaO2 is necessarily low.
- PA catheter, all are correct except:
a. Reduce mortality
b. Can guide resuscitation
c. Can measure LV pressure
Answer: A. It does not reduce mortality.
Source: NEJM. PAC: Peace at Last. 2006.
- 60 year old male patient with bilateral painless parotid swelling:
a. Pleomorphic adenoma
b. Mixed tumor
c. Warthin tumor
d. Cystoadenosarcoma
Answer: C Warthin tumor. The most common bilateral parotid tumor.
Pleomorphic adenoma…….. 70 % if Unilateral , high recurrence , only 10% bil
Mixed tumor
Warthin tumor…….Bilateral.
Cystoadenosarcoma……..MC malignat
