2007 with explanations (entire exam reviewed 2007)

Question 1

1- 55 year-old man presents with induration and erythema in the submandibular region, crossing midline. Patient complains of sore throat and increasing dysphagia but is otherwise sating well and not in any respiratory distress. Examination of oral cavity reveals induration and swelling at the floor of mouth, pushing the base of tongue posteriorly. What is the most appropriate next step.

1. incision and drainage of submandibular region in the OR.
2. transfer patient to ICU and perform rapid sequence intubation.
3. transfer patient to OR for flexible bronchoscopic intubation and possible tracheostomy.
4. send patient home.

Answer 1

Answer #3. The patient has Ludwig’s angina. A form of submandibular space infection. It is always bilateral, both submandibular and sublingual spaces are involved, rapidly spreading cellulitis without abscess formation – “woody” or brawny cellulitis. Clinically – dysphagia, drooling, leaning forward – can lead to rapid airway obstruction. Current treatments – 1. Flexible bronchoscopy in the OR – eventual tracheostomy is the best means of definitive airway control.
Source: Up To Date

Question 2

2- 62 year old man presents with a scaly, ulcerated lesion at the tip of left pinna. Biospy was done in suspicion of malignancy. Biospy results come back as a benign tumor. What is the likely diagnosis?

1. Merkel’s tumor
2. Keratoacanthoma
3. fibrodermosarcoma
4. squamous cell carcinoma

Answer 2

Answer: #2. Keratoacanthoma mimics squamous cell ca. but its benign. Frequently the diagnosis is made on biopsy.
The relationship between Keratoacanthoma and scc is controversial. Currently dermatologist think that they should be classified differently as they usually involute and do not go on to malignancy.
Source: Am J Dermatopath. 2008

Question 3

3- Which of the following is not associated with a patient who has a Pancoast tumor?

1. Horner’s syndrome
2. Adrenal hyperplasia

Answer 3

Answer: #2. A Pancoast tumor is a lung cancer that is located at the apex of the lung. If large enough it can cause compression to adjacent structures. I.e. brachiocephalic vein, subclavian artery, phrenic nerve, recurrent laryngeal nerve, vagus nerve, or characteristically, the sympathetic ganglion producing miosis, anhidrosis and ptosis = Horner’s syndrome.

Question 4

4- 75 year old man presents with a pathologic fracture of left femur. Blood work shows hypercalcemia. X-rays show multiple lytic lesions. What is the likely diagnosis?

1. osteosarcoma
2. multiple myeloma
3. osteoporosis

Answer 4

Answer #2.

Question 5

5- Patient presents with hoarseness post extubation. History is consistent with a traumatic intubation. What is the most likely cause?

1. cricoarytenoid dislocation
2. compression injury to the superior laryngeal nerve
3. endotracheal tube was too large

Answer 5

Answer #1. Pt presents with hoarseness, coughing. Most common cause is traumatic intubation – 80%.
Source: J. Voice 2005

Question 6

6- Pregnant women presents with DVT in the left iliofemoral vein. What is the most appropriate treatment?

1. warfarin
2. heparin
3. ASA
4. none of the above

Answer 6

Answer #2. Warfarin is contraindicated in pregnancy and heparin is safe.

Question 7

7- Patient intubated in the ICU and on mechanical ventilation. He is on FiO2 of 75% with the following blood gas: PaO2 50, PCO2 38, pH 7.25. What would be your next step?

1. increase FiO2 to 90%
2. administer IV bicarb
3. hyperventilate
4. increase respiratory rate.

Answer 7

Answer #1. His blood gas shows that he is hypoxemic. He is mechanically ventilated so you can increase is RR or increase in inspired oxygen, but you realize that his pCO2 is normal-low, so the best choice would be to increase his inspired oxygen level.

Question 8

8- 13 year old boy presents with unilateral gynecomastia. What is the next appropriate step?

1. anti-estrogen therapy
2. unilateral mastectomy
3. observe

Answer 8

Answer: #3

Question 9

9- All of the following are true about heterotropic ossification except:

1. occurs more commonly in head injury patients
2. commonly associated with prolonged immobilization
3. NSAIDS can be given as prophylaxis
4. calcification on x-ray can appear prior to development of symptoms

Answer 9

Answer: #2: It is commonly associated after traumatic brain injuries (up to half and occurs at 12 weeks) and radiographic signs may not correlate with symptoms. NSAIDs and bisphonates have been used as prophylaxis (and external beam radiation)
Source: Dr. Paul Martineau – immbolization does not necessarily lead to increased risk of HO. YES, calcification can appear prior to symptoms

Question 10

10- Which of the following is the site of calcium and iron absorption in the gastrointestinal tract?

1. duodenum
2. distal ileum
3. proximal ileum
4. jejunem

Answer 10

Answer: #1 Most minerals are absorbed from the proximal half of the intestine. The exception is magnesium and vitamin B12, which are absorbed from the ileum.

Question 11

11- 56 year-old lady with malignant hyperthermia, which one you don’t give?
a- Diltiazem
b- cooling blankets
c- oxygen

Answer 11

Answer: #a – Dantrolene is the only known antidote. Dantrolene will block Ca release. Other treatments are supportive. (i.e. cooling blankets and oxygen are universal and can only help).

Question 12

12 - which one is not premalignant?

A - Dysplastic Nevus

Answer 12

Answer: #A. Patients with dysplastic nevus (atypical mole) syndrome are prone to cutaneous melanoma. The incidence of this syndrome is increased in patients with uveal melanoma and may predispose to the development of ocular melanocytic tumors. However, a patient who has ONE dysplastic nevus is not necessarily at increased risk of developing cancer (specifically melanoma)

Question 13

13-Which one you don’t see in SIADH?

a- Hypernatremia

Answer 13

Answer: #A.

Question 14

14 - a young lady with pelvic pain, mass close to the pelvis the diagnosis:
a - chondroma
b - soft tissue sarcoma
c - rectal cancer

Answer 14

Answer: #A
Chondromas – 5% of all primary bone tumours RARE. Every bone is suscepltible, mostly in smalls bones of hands and feet. They are labeled according to site of origin. Example, meduallary canal origin – ENCHONDROMA; cortical surface – PERIOSTEAL CHONDROMA. Usually complain of local tenderness, palpable mass. Treatment is surgical.
Source: Neurosurg Clin N America 2008.

Question 15

16. All are true of soft tissue necrotizing infection except:

1) anaerobic environment
2) bacterial synergy
3) thrombosis of nutrient vessel that supplies the skin and fascia
4) streptococcal exotoxins

Answer 15

Answer: #3.
Not directly related to the question, but useful to know:
Clindamycin may be more effective because it is not affected by inoculum size or the stage of growth, it suppresses toxin production, it facilitates phagocytosis of S. pyogenes by inhibiting M-protein synthesis, it suppresses production of regulatory elements controlling cell wall synthesis and it has a long postantibiotic effect. Recently, a retrospective analysis of cases demonstrated a greater efficacy for clindamycin compared to beta-lactam antibiotics in patients with invasive infections . Although there are no data from clinical trials establishing the benefit of combined therapy, we recommend the administration of penicillin G (4 million units intravenously every four hours in adults >60 kg in weight and with normal renal function) in combination with clindamycin (600 to 900 mg intravenously every eight hours) . This recommendation is based upon the observation that clindamycin resistance has been rarely described in GAS.

Question 16

17. Patient is transfused blood that has been matched for ABO and Rh factor. What is the likelihood of an acute transfusion reaction in this patient?
18. 0.1%
19. 2%
20. 5%
21. 10%

Answer 16

Answer: #4

Adverse reactions occur in 1 to 6 percent of all blood transfusions and are more frequent (10 percent) in patients with hematologic and oncologic diseases. Uptodate
Psychrophilic organisms (ie, those capable of multiplication at cold temperatures), especially Yersinia enterocolitica and some Pseudomonas species (eg, Pseudomonas fluorescens), can survive and multiply in cold stored bank blood and have been said to account for up to 80 percent of red blood cell-associated bacterial infections.
In Western countries, however, whole blood is rarely used because within a few hours or days, some coagulation factors (especially factors V and VIII) and platelets decrease in quantity or lose viability. After a 7-day hold at 4° C, factor VIII levels will have fallen to 0.32 ± 0.09 IU/mL, and there is a lesser fall in factor V levels to 0.78 ± 0.15 IU/mL. At 4° C, platelets undergo a shape change from discoid to spherical that is irreversible after 8 hours, and their in vivo survival is reduced to 2 days.

Administrative error leading to ABO incompatibility, bacterial contamination, and transfusion-related lung injury are the three leading causes of fatality after blood transfusion.
The agents most often implicated in packed RBC bacteremia were Serratia and Yersinia. For platelets, S. aureus, Escherichia coli, Enterobacter, and Serratia species were more frequently identified. Sabiston
Transfusion-related adverse events can occur with 10% of transfusions, and serious adverse events have been estimated to less than 0.5% of transfusions. Hematology/Oncology Clinics of North America - Volume 21, Issue 1 (February 2007)

Question 17

18. Propofol is a useful inductive agent frequently used in anesthesia. Which pharmacologic property is true of propofol:
19. it causes post-operative nausea and vomiting
20. it acts as an ionotropic agent
21. causes bronchoconstriction
22. decreases cerebral perfusion pressure

Answer 17

Answer: #4.

From Schwarz:

With a short duration, rapid recovery, and low incidence of nausea and vomiting, it has emerged as the agent of choice for ambulatory and minor general surgery. Additionally, propofol has bronchodilatory properties that make its use attractive in asthmatic patients and smokers. Propofol may cause hypotension and should be used cautiously in patients with suspected hypovolemia
and/or coronary artery disease (CAD), the latter of which
may not tolerate a sudden drop in blood pressure. It can be used as a continuous infusion for sedation in the intensive care unit setting.

It is often used in the ICU for that purpose specifically, because it lowers MAP. It DOES NOT CAUSE 1. Bronchoconstriction, 2. Nausea and vomiting 3. Increase BP

Question 18

19. A study has been designed to assess the wear properties of two different metal interfaces for total hip arthroplasty. There are 11 patients in one group and 13 in the other. Which test would best determine if a difference exists between these two groups?
20. t-test
21. Fischer exact test
22. Chi-square test
23. Linear regression

Answer 18

Answer: #1

Question 19

20. A patient arrives in the trauma suite hypotensive, and identified as having a pelvic fracture. Sheeting (bedsheet fixation) is done to stabilize the pelvic fracture. For which type of pelvic fracture would this be most helpful for:
21. A/P compression type injury (open-book)
22. Anterior superior iliac spine avulsion
23. High velocity axial load
24. Vertical sheer fracture

Answer 19

Answer: #1. Important to realize, pelvic wrapping helps “close-down” the pelvis. This works only for injuries that have cause the pelvis to “open”. Secondly, wrapping the pelvis is thought to help control hemorrhage. Vertical shear and AP compression pelvic injuries both have high association with vascular injury; however, wrapping a vertical shear pelvic injury will likely not decrease the pelvic volume as much as it would be done in an AP compression injury.

Question 20

21. A patient undergoes surgery and a complication arises. Surrounding the issue of disclosure, which of the following is correct:
22. the patient doesn’t need to know of any medical errors which took place if there are no immediate consequences
23. the patient should be informed of all medical errors as is their right for autonomy
24. disclosure of medical errors often leads to lawsuits
25. every attempt should be made to prevent the patient from learning about the medical error

Answer 20

Answer #2.

Question 21

22. Regarding Carbon monoxide, which of the following is true:
23. carboxyhemoglobin binds to hemoglobin with less affinity than oxygen
24. the half-life of carboxyhemoglobin is 45-60 minutes in room air
25. carbon monoxide binds to the Fe in the RBC
26. irreversibly binds to hemoglobin

Answer 21

Answer: #3.
CO binds to hemoglobin with much greater affinity than oxygen, forming carboxyhemoglobin (COHb) and resulting in impaired oxygen transport and utilization. CO can also precipitate an inflammatory cascade that results in CNS lipid peroxidation and delayed neurologic sequelae. Carbon monoxide (CO) diffuses rapidly across the pulmonary capillary membrane and binds to the iron moiety of heme (and other porphyrins) with approximately 240 times the affinity of oxygen .
Nonsmokers may have up to 3 percent carboxyhemoglobin at baseline; smokers may have levels of 10 to 15 percent.
The half-life of CO while a patient is breathing room air is approximately 300 minutes, while breathing high-flow oxygen via a non-rebreathing facemask is about 90 minutes, and with 100 percent hyperbaric oxygen is approximately 30 minutes.
The diagnosis of CO poisoning is based upon a compatible history and physical exam in conjunction with an elevated carboxyhemoglobin level measured by cooximetry of a blood gas sample.
Carbon monoxide (CO) is removed almost exclusively via the pulmonary circulation through competitive binding of hemoglobin by oxygen.
We suggest treatment with HBO in the following circumstances (Grade 2B):
- CO level >25 percent - CO level >20 percent in pregnant patient - Loss of consciousness - Severe metabolic acidosis (pH

Question 22

23. Warm ischemic tolerance is best for which of the following:
24. gut
25. muscle
26. bone
27. skin

Answer 22

Answer: #4. Warm ischemic time is time between absence of adequate blood perfusion but the tissue is at physiologic temperature. Skin has 9 hr. Bowel can tolerate a substantial amount of decreased blood flow (20-25% normal) – Cecile’s internal medicine).

should be bone actually

Question 23

24. A 30 y old lady is involved in a motor vehicle accident and sustains multiple facial fractures. 5 days later, she presents to the ER with bilateral anosmia, fever, and delirium. What is the most likely diagnosis:
25. bacterial meningitis
26. infected subdural hematoma
27. superior sagittal sinus thrombosis
28. cavernous sinus thrombosis

Answer 23

Answer: #1. Anterior floor fracture with CSF fistula. Cavernous sinus thrombosis causes CN III,IV, V palsy. The only choice that makes sense is bacterial meningitis post-trauma. Classic findings, fever, delirium.
Source: E.Galven, M.D. neurosurgeon.

Question 24

25. A patient is admitted for the administration of doxorubicin. During treatment, it is evident that some of the infusion went interstitial. What is the most appropriate action:
26. Proceed to the OR for immediate debridement
27. Topical anti-inflammatories
28. Stop the I.V. infusion, elevate the arm, and apply cold compresses and observe
29. Inject the arm with leucovorin antidote

Answer 24

Answer: #3.
Skin irritation/extravasation: I.V. use only. Doxorubicin is a potent vesicant; if extravasation occurs, severe tissue damage leading to ulceration and necrosis, and pain may occur.
Extravasation of a vesicant drug has the potential to cause tissue necrosis with a more severe and/or lasting injury. Vesicant extravasation may result in loss of the full thickness of the skin and, if severe, underlying structures.

Initial management — When extravasation of an irritant or vesicant drug is suspected, the following initial management is recommended:
- Stop the infusion immediately. Do not flush the line, and avoid applying pressure to the extravasated site.
- Elevate the affected extremity
- The catheter/needle should not be removed immediately. Instead, it should be left in place to attempt to aspirate fluid from the extravasated area, and to facilitate the administration of an antidote to the local area, if appropriate.
- If an antidote will not be injected into the extravasation site, the catheter/needle can be removed after attempted aspiration of the subcutaneous tissues.
Surgical intervention — Nonhealing ulcers resulting from an extravasation injury often require debridement and skin grafting. However, the optimal timing of surgical intervention is controversial.
Although some clinicians suggest early surgical intervention to prevent ulceration, a conservative approach is more often recommended, particularly since fewer than one-third of vesicant extravasations ultimately result in ulceration. Failure of initial conservative management with continued erythema, swelling and pain, or the presence of large areas of tissue necrosis or skin ulceration are indications for surgery.
Early debridement has been recommended for anthracycline (eg.doxurubicin), extravasations, since these agents bind to fat . This recommendation was based upon a series of three cases in which delayed surgical care resulted in a poor functional outcome.
Uptodate

Question 25

26. Patient involve in a high speed MVC. Fracture dislocation at C7. Despite 2L of fluid
    rescussitation, the BP is still 80/55, with the HR of 110 bpm. The reason for the difficulty raising
    the BP is:
27. undiagnosed intra-abdominal trauma
28. neurogenic shock
29. spinal shock

Answer 25

Answer: #1. Hypovolemic shock. Need to r/o bleeding sites in chest abdomen and pelvis. Once certain and a patient has bradycardia with hypotension, the diagnosis of neurogenic shock can be considered.
Source. M.Bernstein, M.D.

Question 26

27. year old male, high speed MVC with multiple injuries. Knee has a positive anterior and posterior drawer, with substantial varus laxity with the knee at 30 degrees. The most immediate next step would be:
28. immediately to the OR to repair the ligamentous damage
29. place the patient in a below knee cast
30. arteriogram

Answer 26

Answer: #3. High speed mechanism with obvious knee instability = knee discloation. WORRY ABOUT POPLITEAL ARTERY DAMAGE. Confirm with ABI and/or arteriogram. Best to splint patient before, in above knee SPLINT. Not a CAST.
Source: Mitchell Bernstein, M.D.

Question 27

28- Chronic diarrhea, which of the following would present:

1. metabolic alkolosis
2. metabolic acidosis with normal anion gap
3. metabolic acidosis with increased anion gap
4. increased [HCO3]

Answer 27

Answer: #2

Question 28

29. Laryngeal mask Vs. endotracheal tube, which of the following is true:
30. the laryngeal mask has less incidence of reflux/aspiration
31. the endotracheal tube is technically easy to insert and therefore, can be done by all personnel
32. the endotracheal tube, although technically demanding to insert, offers the advantage of delivering medications through the endotracheal tube if needed

Answer 28

Answer: #3. Note, LMA does not protect the patient against aspiration.
Source: Up to date

Question 29

30. A 75 year old man presents with pain in the left flank. He is assessed as having an obstructing stone in the ureter. Which of the following would require immediate attention:
31. Temperature of 38.9
32. a stone measuring 10mm on CT scan
33. hydronephrosis
34. uncontrolled pain

Answer 29

Answer: #1
Urgent urologic consultation is warranted in patients with urosepsis, acute renal failure, anuria, and/or unyielding pain, nausea, or vomiting . Outpatient urology referral is indicated in patients with a stone >10 mm in diameter, and in patients who fail to pass the stone after a trial of conservative management, particularly if the stone is >5 mm in diameter and/or there is uncontrolled pain.
Patients with calcium stones can be treated with a thiazide diuretic and low sodium diet for hypercalciuria, allopurinol for hyperuricosuria, and potassium citrate for hypocitraturia.

Question 30

31. year old diabetic arrives to ER, febrile, confused. Left leg is Red, and blotches of dusky skin throughout. The ER physician said the he made a small incision and was easily able to insert a hemostat along the fascia of the lower leg. You are the senior resident responsible for this patient. Your next step would involve:
32. I.V. antibiotics after blood culture done
33. Immediately to the OR for debridement and possible amputation of the limb

Answer 30

Answer: #2

Question 31

32. What colour is fat on MRI:
33. dark on T1 and T2
34. light on T1 and T2
35. dark on T1 and light on T2
36. light on T1 and dark on T2

Answer 31

Answer: #4.
In general, tissues with short T1 values (e.g., fat) will be bright on a T1-weighted image. On the contrary, tissues with long T2 values (e.g., water) will be bright on a T2-weighted image. Many pathologic areas have a longer T1 and T2 than surrounding normal tissue.
Gadolinium-enhanced tissues and fluids appear extremely bright on T1-weighted images. This provides high sensitivity for detection of vascular tissues (e.g., tumors) and permits assessment of brain perfusion (e.g., in stroke).

Hounsfield units for CT:
Tissue 
 HN range 
  Air 
 -1,000 
  Lungs 
 -900 to -300 
  Fat 
 -120 to -80 
  Water 
 0 
  Muscle 
 10 to 30 
  Soft tissue 
 10 to 30 
  Cortical bone 
 50 to 100 
  Trabecular bone 
 500 to 1,000 
  HN, Hounsfeld number.

Question 32

33. The least toxic type of radiation to the skin is:
34. cobalt therapy
35. brachytherapy
36. linear accelerator

Answer 32

Answer: #2

Question 33

34. All the following are absolute indications for thoracotomy tube except:
35. open pneumothorax
36. spontaneous pneumothorax
37. empyema
38. chylothorax

Answer 33

Answer: #2. Chylothorax needs CT drainage, so does empyema. (it’s and abscess). Open pneumothorax needs to be converted to a closed PTX before a tension occurs.
Source: Morell notes.

Question 34

35. When you administer 1L of normal saline you:
36. distribute equally the volume between all compartments
37. pull fluid from the extravascular space intravascularly
38. increase intravascular volume
39. increase intracellular volume

Answer 34

Answer: #3.

Question 35

36. Injury of the ulnar nerve at the level of the wrist will lead to the inability to:
37. Abduct the thumb
38. Cross the index and second fingers
39. Flex the middle finger at the carpometacarpal joint
40. Extend the fingers

Answer 35

Answer: #2. Ulnar nerve controls the intrinsic muscles of the hand. Therefore, Abduction and Adduction of the fingers will be affected. Middle finger flexion (D3) is median nerve. Extending the fingers is P.I.N. (post interosseous nerve, a branch of the radial nerve). Abducting the thumb is median nerve.
Source: M.Bernstein M.D.

Question 36

37. All of the following can be seen in cardiac tamponade EXCEPT:
38. narrow pulse pressure
39. Wide pulse pressure
40. Muffled heart sounds
41. Distended neck veins

Answer 36

Answer: #2. Elevated JVP, sinus tachycardia, pulsus paradoxus (abnormally larger decreased in systolic BP > 10 mmHg on inpiration. Muffled heart sounds occurs due to fluid in pericardial space. Because of diastolic dysfunction the DBP approaches SBP and pulse pressure is narrowed. Therefore, there is no increased pulse pressure.
Source: Up To Date

Question 37

38. When comparing subcapital vs. intertrochanteric hip fractures, subcapital type fractures are
    more susceptible to:
39. Avascular necrosis
40. Nonunion
41. Infection
42. DVT’s

Answer 37

Answer: #1. Subcapital = femoral neck fracture. = non-union and Avascular necrosis because the blood supply to the femoral head enters at the the femoral neck. You need blood to heal a fracture and for the bone to live. Intertrochanteric fractures are not near the femoral neck and have wonderful blood supply. Non-union after IT# is 2%. AVN is rare. (Rockwood and Green.) FN non-union occurs in 0-30%, depending on fracture displacement. AVN can occur 50% of cases depending on fracture displacement. I think the better answer is #1.
Source: M.Bernstein, M.D. Asim Al-Daheri, M.D. PGY-5 Ortho. JAAOS. 2008. Rockwood and Green.

Question 38

39. A 70 y old lady is set to undergo elective surgery for bilateral carpal tunnel release. She has rheumatoid arthritis and a history of mitral regurgitation, as well as intermittent atrial fibrillation. What would be your plan for coagulation management of this patient leading up to surgery:
40. Stop coumadin 5 days before the surgery
41. Stop the coumadin 5 days prior to surgery and administer LMWH 3 days prior to surgery
42. Stop the coumadin the day of the surgery and administer vitamin K
43. Stop the coumadin the day of the surgery and administer fresh frozen plasma

Answer 38

Answer: #2 Patients with mitral regurg and a-fib need Coumadin. It takes 4-5 days for INR to be safe. So hold Coumadin for 4-5 days pre-op. Because when stopping Coumadin you get a transient increase in INR, adding a LMWH (short half life) pre-op will decrease their risk of embolic phenomena. (because patient has A-fib with mechanical heart problem.)
Source: 2006 ACC/AHA guidelines. Circulation. Up to Date.

Question 39

40. Carbon dioxide is transported in the blood primarily as:
41. dissolved CO2
42. carbonic acid
43. carboxyhemoglobin
44. bicarbonate salt (HCO3)

Answer 39

Answer: #4. 70% of carbon dioxide is transported in the blood as HCO3-.
Source: Perfusion.com

Question 40

41. A 22 y old male is to undergo elective surgery on the knee. In order to get the goal factor VIII of 60-80% normal, what can you do regarding perioperative planning:
42. give replacement factor before the surgery and for 10 days following
43. administer factor VIII immediately after the surgery
44. administer Factor VIII for 2 doses pre-operatively, and one dose post-op
45. give Factor VIII for 5 days following surgery

Answer 40

Answer: #1. Factor VIII deficiency is Hemophilia A. You can give high purity factor VIII concentrates, or porcine factor VIII. You give the replacement before surgery and for a total of 10 days following.
Source: Up to Date

Question 41

42. The commonest infectious agent post transplant is:
43. HIV
44. HBV
45. HCV
46. CMV

Answer 41

Answer: #4
Source: Up to Date. Morell notes

Question 42

43. Which drug has the longest action:
44. mepivacaine
45. bupivocaine
46. lidocaine
47. procaine

Answer 42

Answer: #2
bupivicaine= 360-720 min
Mepivacaine= 180-300 min
Lidocaine= 120-240
Procaine= ester
Tetracaine= 360-720 min

Question 43

44. Which of the following is the prophylactic antibiotic of choice (if only one could be chosen), for a patient set to undergo abdominal surgery and who has a penicillin allergy and has an artificial valve:
45. vancomycin
46. clindamycin
47. metronidazole
48. cipro

Answer 43

Answer: #1

Genitourinary or gastrointestinal procedures — For those high risk patients who undergo gastrointestinal or genitourinary procedures at a time of ongoing gastrointestinal or genitourinary infection, antibiotic coverage for enterococcal bacteremia should be provided with amoxicillin or ampicillin or, in the patient unable to tolerate these drugs, vancomycin. For dental and upper resp. tract procedures give amoxicillin or ampicillin and if allergic give clinda., azithro. Or cephalexin.
The AHA guideline no longer considers any GI (including diagnostic colonoscopy or esophagogastroduodenoscopy ) or GU procedures high risk and therefore do not recommend routine use of IE prophylaxis even in patients with the highest risk cardiac conditions.

The following are the highest risk conditions according to 2007 guidelines:
· Prosthetic heart valves, including bioprosthetic and homograft valves.
· A prior history of IE.
· Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits.
· Completely repaired congenital heart defects with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure.
· Repaired congenital heart disease with residual defects at the site or adjacent to the site of the prosthetic device.
· Cardiac valvulopathy in a transplanted heart.
The following are the highest risk procedures:
· All dental procedures that involve manipulation of either gingival tissue or the periapical region of teeth or perforation of the oral mucosa.
· Procedures of the respiratory tract that involve incision or biopsy of the respiratory mucosa.
· Procedures in patients with ongoing GI or GU tract infection.
· Procedures on infected skin, skin structure or musculoskeletal tissue.
· Surgery to place prosthetic heart valves or prosthetic intravascular or intracardiac materials.

No longer indicated — Common valvular lesions for which antimicrobial prophylaxis is no longer recommended in the 2007 AHA guidelines include bicuspid aortic valve, acquired aortic or mitral valve disease (including mitral valve prolapse with regurgitation and those who have undergone prior valve repair), and hypertrophic cardiomyopathy with latent or resting obstruction
Up to Date

Question 44

45. Which of the following is true when comparing an animal vs. human bite:
46. animal bites have more anaerobic organisms
47. human bites have greater beta-lactamase bacteria
48. Iekenella is in higher concentration in animal bites
49. Pasturalla multiceda is in higher concentration in human bites

Answer 44

Answer: #2
Aerobic gram-positive cocci and anaerobes are found more frequently in bites from humans than from those from animals. Pasteurella species were the most common bacteria from dog and cat bites (50 and 75 percent respectively. Eikenella corrodens, a gram-negative anaerobe, is a common constituent of normal human mouth flora and is recovered from seven to 29 percent of human bite wounds but rarely from animal bites.
Source: Up to Date

Question 45

46. What is the most common infectious agent responsible for a would infection POD#2
47. staph aureus
48. E-coli
49. Enterococcus
50. Pseudomonas

Answer 45

Answer: #1.
Source: M.Bernstein, M.D. Up to date.

Question 46

47. What are the fluid requirements for a 15 kg child:
48. 900 cc/d
49. 1000 cc/d
50. 1200 cc/d
51. 1500 cc/d

Answer 46

Answer: #3. Use 4:2:1: rule.First 10 kg, multiply by 4. And then the next 10 kg, multiply by two. 10x4 + 5 x2 = 40 + 10 = 50 cc/hr. 50 cc/hr x 24 hr = 1200 cc/d
Source: M.Bernstein M.D.

Question 47

48. What rate should you bolus a child:
49. 10 ml / h
50. 20 ml / h
51. 30 ml / h
52. 40 ml / h

Answer 47

Answer: #2 You bolus at 20cc per Kg/Hour
Source: D.Schonfeld, NYU peds resident.

Question 48

49. 1 week post-op from surgery involving GA (endotracheal intubation), and the patient develops hoarseness with no associated pain. The most likely cause is:
50. laceration of the laryngeal artery
51. dislocation of the tracheolaryngeal junction
52. neuropraxia of the recurrent laryngeal nerve
53. collapse of the voice box

Answer 48

Answer: #3. Collapse of the voice box would cause airway compression, and the patient would have more symptoms. Neuropraxia to RLN (1st degree nerve injury). Can occur within a couple of days after surgery. Confirmed on fiberoptic laryngoscopy.
Source: Acta Anesth. Scand 2005.

Question 49

50. Which of the following is most determinant for renal transplant success:
51. HLA
52. Cold ischemia time
53. Warm ischemia time
54. ABO

Answer 49

Answer: #1

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.
Long-term survival is also best in HLA-identical, particularly living related, kidneys and worst in randomly matched cadaver kidneys.
Source: Up to date

Question 50

51. Which of the following is not a side effect of Vincristine:
52. hypofibroginemia
53. paralytic ileus
54. thrompocytopenia
55. leukopenia

Answer 50

Answer: #1
Source: Morell notes

Question 51

52. Which is not a complication of massive blood transfusions:
53. hypercalcemia
54. thrombocytosis
55. metabolic acidosis
56. hypocalcemia

Answer 51

Answer: #1 and #2. Complications include. Both metabolic alkalosis and acidosis. Hypocalcemia from all the citrate being transfused (citrate chelates calcium), hypothermia, DIC, thrombocytosis, bleeding. Hyperkalemia
Source: Up to date.

look this up - there are two questions with different answers

Question 52

53. Most common anterior mediastinal mass is:
54. Thymoma
55. Teratoma
56. Bronchogenic cyst
57. Pericardial cyst

Answer 52

Answer: #1. Thymomas represent 20 percent of all mediastinal neoplasms in adults; they are the most common anterior mediastinal primary neoplasm in adults but are rarely seen in children. They occur with equal frequency in males and females, and commonly present between the ages of 30 and 50.
Benign teratomas are the most common anterior mediastinal neoplasm in infants and are often seen in adults between 20 and 40 years of age. Although patients with disseminated systemic lymphoma often have involvement of the mediastinum, 5 to 10 percent of patients with lymphoma present with primary mediastinal lesions. Primary mediastinal lymphoma accounts for 10 to 20 percent of primary mediastinal masses and is the second most common primary anterior mediastinal mass in adults.
Source: Up to date and Sabiston

Question 53

54. Normal hemodynamic changes during pregnancy include all of the following except:
55. hemodilution
56. increased red cell mass
57. leukocytosis
58. eosinophilia

Answer 53

Answer: #4. Red cell mass increases, physiologic anemia occurs because a greater increase in intravascular volume occurs. Pregnancy does not cause increased eosinophils.
Source: Up to date and Gyne Obst Invest. 2006

Question 54

55. The advantage of a split-thickness skin graft to a full thickness skin graft is that:
56. It scars less and blends in with the surrounding skin
57. better over bony
58. better scar contraction
59. better take

Answer 54

Answer: #4. STSG includes epidermis and various amounts of dermis. Full thickness includes sebaceous glands and sweat glands. Thicker grafts have less tendency to undergo contraction, while the thinner the STSG the better the take.
Source: Wheeless online. Emedicine.com

Question 55

56. A 20 year old man presents to the ER with a 1.5 cm deep and 5 cm long laceration to his
    forearm after being cut by a lawnmower blade. He has lived in Canada his whole life and had
    all of his childhood immunizations. The wound is full of dirt and grease. He is not sure of his
    tetanus status. What is the most appropriate treatment plan:
57. tetanus toxoid
58. tetanus immunoglobin
59. tetanus toxoid and immunoglobin
60. antibiotics for 10 days and then a tetanus toxoid

Answer 55

Answer: #3. Patient will need tetanus toxoid and immunoglobulin immediately. He will also need Abx, but you cannot give him tetanus toxoid 10 days post-injury.
Source: M.Bernstein M.D.

Question 56

57. What is the most common cause of a febrile reaction following blood transfusions:
58. WBC alloantibodies
59. Platelet alloantibodies
60. RBC alloantibodies
61. Sepsis

Answer 56

Answer: #1. Most common transfusion reaction is a febrile, non-hemolytic transfusion reaction. These are benign. They are immune related caused by accumulated cytokines that are realeased from WBC alloantibodies.
Source: Up to date.

Question 57

58. A man is injured waterskiing, resulting in a massive laceration across his chest. He presents to the ER with a stable BP of 100/60, HR of 100, and a chest tube is inserted draining 1200 ml immediately. He is stabilized at the community hospital and when he arrives at the trauma center he continues to drain 600 ml over the hour. What is the next step?
59. CT chest
60. Insert another chest tube
61. Irrigate, debride and repair the chest would and clamp off the chest tube
62. Emergent thoracotomy

Answer 57

Answer: #4. Indications for emergent thoracotomy. 1. Initial drainage of >1500cc. 2. > 200-300 cc/hr
Source: M.Bernstein, M.D. and Morell notes.

Question 58

59. A 30 y old woman presents with a 2cm nodule in the left posterior cervical area. What should you do first:
60. FNA
61. Open Biopsy
62. Excisional biopsy
63. CT scan of abdomen and neck

Answer 58

Answer: #1 Adult patient with a neck mass, you must r/o malignant process. In the head and neck region, the diagnosis is first confirmed with fine needle aspiration.
Source: Up to date

Question 59

60. A man presents with a tibial fracture which was ORIFed. 4 h following, he presents with a red, swollen and painful leg. What is the most sensitive sign for his present condition:
61. absence of pedal pulses
62. paresthesia of the lower limb
63. pallor on examination
64. pain with passive toe extension

Answer 59

Answer: #4. The best way to diagnose a compartment syndrome is via passively moving those tendons that are in the compartment of concern. All other signs are late findings and are too late.
Source: M.Bernstein, M.D.

Question 60

61. Comparing the metabolic rate in a trauma patient to that of a person in a starvation state, which of the following is false:
62. increased lipolysis
63. increased epinephrine
64. decreased oxygen utilization
65. something about cortisol, but I forget if it said increase or decrease

Answer 60

Answer: #3 Trauma patients will have increased metabolic rate, increased oxygen consumption, increased catecholamines, increased lipolysis. Starvation state is a “hibernation state”.
Source: Greenfield Surgery.

Question 61

62. What is the source of the enzymes that degrade tissue in an abscess:
63. neutrophils
64. macrophages
65. eosinophils
66. mast cells

Answer 61

Answer: #1 Neutrophils release proteases that cause tissue destruction.
Source: M.Bernstein, M.D.

Question 62

63. HLA matching is routinely performed prior to transplants of the following organs:

lung
heart
kidney
liver

Answer 62

KIDNEY
□ all these organs require a cross match
□ liver is the only organ that does not require an ABO compatibility
□ ABO compatibility is determined to avoid hyperacute rejection of renal allografts
□ potential donors and recipients are typed for HLA-A, HLA-B, and HLA-DR molecules
□ HLA matching is the best means of prolonging allograft survival. The larger the number of HLA-A, HLA-B, and HLA-DR alleles that are matched between both donor and recipient, the better the survival rate, particularly in the first year after transplantation
□ three types of graft rejection occur
o Hyperacute rejection occurs within minutes to days after transplantation and is mediated primarily by preformed antibody. This type of rejection is prevented by screening the recipient for preformed antibodies, not by classic antirejection pharmaceuticals.
o Acute rejection is mediated primarily by T lymphocytes and first occurs between 1 and 3 weeks after solid organ transplantation without immunosuppression. Acute rejection episodes are most common in the first 3 to 6 months after transplantation but can occur at any time. Acute rejection can quickly destroy a graft if left untreated. The new immunosuppressive agents have made acute rejection increasingly less common.
o Chronic rejection occurs over a span of months to years and is the most common cause of graft loss after 1 year. From an immunologic standpoint, chronic rejection is mediated by both T- and B-cell responses.

Question 63

o 64. Which organ is the most immunogenic:

kidney
liver
heart
skin

Answer 63

Skin

Question 64

65. Hepatitis C causes all except:

cryoglobulinemia
lymphoma
hepatocellular carcinoma
cirrhosis

Answer 64

All these diseases occur in hep. C

□ extrahepatic diseases have been associated with chronic HCV infection, and in most cases appear to be directly related to the viral infection
o Hematologic diseases such as cryoglobulinemia (type II or mixed most common) and lymphoma
o Autoimmune disorders such as thyroiditis and the presence of autoantibodies
o Renal disease: most commonly membranoproliferative glomerulonephritis (MPGN)
o Dermatologic conditions such as lichen planus and porphyria cutanea tarda
o Myalgias, arthralgias
□ HCV accounts for approximately one-third of HCC cases in the United States. Estimates of the risk of developing HCC once cirrhosis has developed have varied from 0 to 3 percent per year in various reports.
□ In contrast to hepatitis B virus infection, HCC in patients with hepatitis C occurs almost exclusively in those with cirrhosis suggesting that it is cirrhosis that is the major risk factor.

Question 65

66. Which of the following is the most infectious agent for a blood transfusion:

HAV
CMV 
HBV
HCV 
HIV

Answer 65

CMV

Blood is not routinely tested for CMV; prevalence of CMV Ab: 50% to 80% of the population; can cause problems in neonates or immunocompromised patients and can be prevented by transfusing CMV negative Blood or frozen, deglycerolized RBC’s.

HBV 1 in 66,000
HCV 1 in 121,000
HIV 1 in 563,000

Question 66

67. A foreign body is more prone to infections because:

it suppresses T-cell activation
It suppresses B-cell activation
It forms a glycocalyx to which bacteria can attach

Answer 66

It forms a glycocalyx to which bacteria can attach

□ S epidermidis forms glycoprotein matrix around FB which protects pathogen fr host phagocytosis
□ extensive glycocalyx served a protective function for the bacteria and was important in bacterial adherence
□ interaction of PMN with a nonphagocytosable foreign body induces a complex PMN defect, which may be partly responsible for the high susceptibility to infection of foreign bodies.

Question 67

68. A young man presents to the emergency department with a nearly complete circumferential laceration to the right arm. The would itself is extremely dirty. After ample irrigation you should:
69. perform a primary closure in the ER
70. perform a primary closure in the OR
71. Perform a mechanical debridement
72. Harvest a skin graft to cover the defect

Answer 67

3. Perform a mechanical debridement

□ Classification: clean, clean-contaminated, contaminated, dirty
□ Anesthetize, explore, irrigate, debride then clean, inspect, clip surrounding hair, ensure hemostasis, adequate debridement nonviable tissue and foreign bodies, fresh edge for reapproximation

Question 68

What is the cytokine responsible for the proliferation of fibroblasts:

1. TGF beta
2. TNF alpha
3. TGF

Answer 68

1. TGF
   TGF beta

□ TGF alpha stimulates epidermal growth and angiogenesis
□ TNF alpha mediates inflammation and angiogenesis

□ TGFbeta stimulates fibroblast proliferation indirectly by releasing PDGF
□ TGFbeta chemoattracts and stimulates fibroblast production of collagen and fibronectin and angiogenesis macrophages must be present for this to occur

Question 69

70. What is the daily protein turnover in a 80 kg man:
71. 1%
72. 3%?
73. 6%
74. 9%

Answer 69

Answer: #2
□ total body protein is 15-18% of healthy man
□ during homeostasis 2.5% of total body protein is broken down and resynthesized again every 24hours (digestion, Hb turnover, muscle protein synth, mmune fn)
□ decreases with age (neonate 25 g/kg/d, 7 g/kg/d 1 year, adults 3 g/kg/d, less in elderly)
□ protein yields 3.5cal/g
□ adult protein requirements 1-2 g/kg/d (1.5-1.75g/kg/d for sx pts)
□
A 70-kg man has between 10 and 11 kg of protein, otherwise referred to as lean body mass. In the fed state, daily protein turnover amounts to between 250 and 300 g, or 3%.

Question 70

71. A pregnant woman is brought to the trauma suite with substantial intra-abdominal trauma. She expresses that she is a Jehovah’s witness and cannot accept blood or blood product transfusion. Her baby is stable at present. Patient consents to undergo surgery and intra-operatively, the patient becomes hypotensive, placing the unborn child at risk. Of the following people, who has the right to act on the patient’s behalf as POA in aiding in the decision making in this situation:
72. the baby’s biological father
73. the patient’s common-law partner
74. the patient’s sibling
75. the physician

Answer 70

Answer: #2

The following is the Hierarchy of SDMs in the Health Care Consent Act, s.21:

1. Guardian of the Person with authority for Health Decisions
2. Attorney for personal care with authority for Health Decisions
3. Representative appointed by the Consent and Capacity Board
4. Spouse or partner
5. Child or Parent or CAS (person with right of custody)
6. Parent with right of access
7. Brother or sister
8. Any other relative
9. Office of the Public Guardian and Trustee

Question 71

72. the most water content can be seen in:
73. 60 y old man
74. 60 y old woman

Answer 71

Answer: #1
□ decreases w age (infant 70-80%TBW; adult 60% TBW)
□ increases w lean body mass/males (muscle has more water than adipose tissue)

Question 72

73. A 45 y old man is rushed to the OR after identification of a leaking aortic aneurysm on CT scan in the trauma evaluation following a high speed MVC. The patient declares that he is a Jehovah’s witness and therefore consented to the surgery but not to the administration of any blood or blood products. During the surgery the patient’s blood pressure falls and it becomes clear the patient will likely not survive without blood transfusions. The nurse then comes into the OR stating that the wife is outside and threatens to sue you unless you do everything you can to save her husband, emphasizing that you should administer blood if that’s “what he needs”. The most appropriate action at this time is:
    . listen to the wife because she is the POA while the patient is incapable of making this decision on his own under the general anesthetic
74. administer blood and disguard the evidence
75. do not administer any blood products and continue to rescusitate the patient to the best of your ability

Answer 72

3

Question 73

74. Cancer is caused by all except:
75. HBV
76. HCV
77. TH1 cells
78. CMV

Answer 73

Answer: #3
□ human T cell leukemia virus 1 (HTLV 1): adult human T cell leukemia
□ EBV: Burkitt’s lymphoma, nasopharyngeal ca, ?gastric cancer
□ HBV/HCV: HCC
□CMV: prostate ca, Kaposi’s sarcoma (this was their answer, but I think it’s wrong)
□HPV: cervical ca
□H pylori: gastric ca, MALT gastric lymphoma
□HHV-8: Kaposi’s sarcoma

Question 74

75. What suture material would you use to sew an abdominal aorta repair:
76. absorbable braided
77. absorbable monofilament
78. non-absorbable braided
79. non-absorbable monofilament (nylon, polypropylene)

Answer 74

Answer : #4
• The thrombogenicity of five suture materials - polypropylene (Prolene), polyester (Mersilene=braided), polyglactin 910 (Vicryl=abs braided), nylon (Ethilon), and silk (=nonabs braided) - was examined in vivo by scanning electron microscopy. The most blood-compatible material appeared to be Prolene. A rather satisfactory antithrombogenciity was shown by Mersilene, in comparison with which Ethilon and Vicryl provided less thromboresistance

Question 75

• 76. Which of the following is the most ideal place to bring out an end colostomy from a sigmoid colon resection:

1. left upper quadrant lateral to the rectus sheath
2. Right lower quadrant above the inguinal ligament
3. Left lower quadrant through the rectus sheath
4. Left lower quadrant lateral to the rectus sheath

Answer 75

Answer:#3

Question 76

77. The treatment of malignant hyperthermia involves all of the following except:
78. cooling blankets
79. Oxygen
80. Dantrolene
81. Diazepam

Answer 76

Answer: #4
• autosomal dominant trait, reduced penetrace, variable expressivity
• sudden increase intracellular Ca in skeletal and ♥ muscle → activates ATPase and phosphorylase → muscle contraction, massive increase O2 consumption → fulminant hypermetabolic crisis
• unexplained tachycardia and tachypnea are first signs
• sudden marked increase in ETCO2, muscle rigidity, hypermetabolic activity w hyperthermia
• most common causes: halothane, succinylcholine

Treatment:
o dantrolene (before tissue ischemia!): inhibits Ca release from SR
o supportive and cooling measures, d/c trigger
o ETT, hyperventilate
o Fluid, diuretics, procainamide, bicarb as needed

Question 77

78. A 40 y old assembly line worker presents to the ER with a mangled right distal forearm. He describes that the paramedics had a very difficult time controlling the bleeding but finally managed with the tighly bound dressing the patient has around the distal forearm. The most appropriate next step is:
79. send the patient for X-rays
80. remove the dressing and inspect the wound
81. perform a physical examination of the hand
82. proceed immediately to the OR to remove the dressing and examine the patient under anesthesia

Answer 77

Answer: #3

Question 78

79 . Lower esophageal sphincter is affected by all of the following except:

1. caffeine
2. smoking
3. alcohol
4. impaired peristalsis of the esophagus
5. all of the above

Answer 78

Answer #5
• LES basal tone: vagal drive, to a lesser extent gastrin, ↑ w intra-abd pressure
• increase LES tone: cholinergics, prokinetics, alpha agonists, beta blockers, gastrin, substance p, bombesin
• decrease LES tone: alpha blockers, beta blockers, CCB, CCK, estrogen, progesterone, somatostatin, secretin, caffeine, fats

Question 79

80. The process of disclosure with regards to a surgical procedure involves which of the following:
81. describing what any person under the exact situation would want to know
82. what any person would want to know
83. what other reasonable physicians would say
84. only what you want to tell them

Answer 79

Answer: #2

Question 80

81. Pancreatitis causes all of the following except:
82. Makes the patient delusional
83. fat necrosis
84. pleural effusion
85. dyspnea
86. pain

Answer 80

Answer: #1

Question 81

83. Which of the following is the latest and least complete to return after the surgical repair of a severed nerve:
84. pin prick sensation
85. 2 point discrimination
86. temperature sensation
87. deep pressure

Answer 81

□ neuropraxia: block of impulse conduction without anatomic destruction
o spontaneous recovery is the rule
□ axonotmesis: axonal fibers completely divided, covering intact
□ neurotmesis: complete transaction of nerve
o need accurate approximation of cut nerve ends
o primary 1cm
o S4, same and 2pt discrimination

Question 82

84. A patient develops acute pancreatitis post ERCP. The best way to feed this patient is:
85. enteral
86. parenteral
87. enteral via gastric tube
88. clear fluids per os

Answer 82

Answer: #1.

From Schwarz
Enteral nutrition should be commenced after initial fluid resuscitation and within the first 24 hours of admission. It can be introduced through a nasogastric tube and increased in step-wise fashion over 2 to 3 days. The tube can be advanced to the jejunum, by endoscopy or fluoroscopy, if there is evidence of feeding intolerance.

o limitation of enteral feeding has been the norm, but recent data suggest this is unnecessary
o enteral feeding avoids high cost TPN/catheter complications and supports intestinal mucosal integrity; b/c of aspiration risk, prefer NJ to NG feeds

Question 83

85. Following operative debridement of non-viable bone, which of the following is the best approach for covering the resultant overlying tissue defect:
86. primary skin closure
87. STSG (split thickness skin graft)
88. Myocutaneous flap
89. Allow closure by secondary intent

Answer 83

Answer: #3

□ Flap coverage within 6 days: less infection, less time to union

Question 84

86. A patient arrives in the ER following a significant trauma. On exam, he is unconscious, his right pupil is fixed and dilated and he is tachypneic with a RR of 45. His trachea is deviated to the right. His blood pressure is 80/30 and his HR is 110 bpm. What is the most appropriate immediate action:
87. CXR
88. Intubation with propofol for induction
89. IV access
90. Chest tube

Answer 84

ATLS = ABCDE = airway first = Intubation?

A unilateral dilated pupil in an altered patient is secondary to herniation until proven otherwise

Question 85

87. The Sx with greatest risk of DVT:
88. Total hip arthroplasty
89. vein stripping
90. C-section

Answer 85

Answer: #1
Risk factors
• Stasis: immobility, CHF, pregnancy, Sx, obesity, paralysis
• Hypercoag: trauma, pregnancy, OCP, malignancy, inherited, HIT, age>40
• Endothelial damage
• Prev DVT/PE

Question 86

90. What is the primary determinant of myocardial oxygen supply in a healthy person:
91. blood pH
92. sympathetic activity
93. oxygen content of the blood
94. myocardial oxygen demand

Answer 86

Answer: #4
• O2 content of blood (rel constant) : Hb, degree of systemic oxygenation
• rate of coronary flow (major determinant): coronary perfusion pressure, coronary vascular resistance (autoreg, neural factors, humoral factors, metabolic control, compressive forces)

Question 87

91. All of the following are causes of fat embolism except:
92. diabetes
93. sickle cell
94. fat aspiration
95. COPD

Answer 87

Answer: #4
□	traumatic 
o	long bone # (esp femur)
o	other #
o	ortho sx
o	blunt trauma to fatty organs (liver)
o	liposuction
o	BM bx

□	Nontraumatic 
o	Pancreatitis
o	DM
o	Lipid infusion
o	Sickle cell crisis
o	Burns
o	CBP
o	Corticosteroids
o	Osteomyelitis
o	Alcoholic fatty liver
o	Acute fatty liver of pregnancy
o	Lymphangiography
o	Cyclosporine infusion

Question 88

92. Which is most associated with the authorship of a publication:
93. participated in the writing of the paper
94. provided lab space
95. developed the background behind the hypothesis question
96. responsible for the content of the publication
97. assisted in the technical aspect of the experiment

Answer 88

Answer: #4

Question 89

93. If minute ventilation and carbon dioxide production are fixed, which of the following will decrease PaCO2?
94. add PEEP
95. decrease the respiratory rate
96. increasing the tidal volume
97. increasing the residual volume

Answer 89

Answer: #3
□ Minute ventilation = tidal volume X RR
□ Increasing the tidal volume but keeping minute vent the same, means you’re decreasing the resp rate BUT you increase the minute ventilation going to alveolar vent (rather than dead space), so they have better gas exchange therefore their CO2 goes down

Question 90

94. Humerus #, which nerve injured/ what action will be affected

Answer 90

• Radial nerve
• Wrist extension, finger extension (present with wrist and finger drop)
• Sensory to dorsum of hand

Question 91

95. Autonomic dysreflexia - what is it?

Answer 91

• unopposed parasympathetic
  □ spinal cord injuries above the T6 level at any time after the stage of spinal shock
  □ hyperhidrosis, headache, and vasodilatation above the level of the neurologic loss with nasal stuffiness
  □ Paroxysmal hypertension is the cardinal sign; bradycardia is present inconsistently
  □ Precipitated by distention or manipulation of the bladder or rectum or intraabdominal pathology → massive reflex sympathetic outflow → HTN, reflex brady, VD (above the level of the spinal cord lesion)
  □ Place patient in an upright position and remove the stimulus, e.g., by bladder decompression; vasodilators for severe hypertension

Question 92

97- 149 skipped due to annoying formatting

Answer 92

zzz

Question 93

151. a pt post dental abscess came in with dysphagia and odynophagia, not distressed, sitting well, but uncomfortable when lying down, P/E showed elevated floor of the mouth with browny neck in the submandibular area with edema (looks like submandibular space abscess with spread to the floor of the mouth), what to do? …
     a. Consult anesthesia for fiberoptic nasal intubation and trach if needed
     b. I&D in ER
     c. Take to ICU and intubate
     d. Admit and start antibiotics

Answer 93

Answer: A
Source: Jankowska B et al. Deep neck space infection, International Congress Series 1240 (2003): 1497-1500

Question 94

151. spinal cord injuy at C3-C4, worry about

Answer 94

Answer: ventilation

C3, 4, 5 keeps the diaphragm alive

Question 95

152. pt who is DM, came in with scrotal edema and swelling what to do? ….

Answer 95

Fournier’s gangrene

Answer: aggressive debridement in the OR, aggressive fluid resuscitation, broad spectrum IV abx, ICU

“Fournier’s gangrene is now defined as an abrupt, rapidly progressive, gangrenous infection of the external genitalia, perineum, or abdominal wall.” (Schwartz)

Question 96

154. dog bite yesterday in the hand, swelling and erythema, what to do?

Answer 96

R/O flexor tenosynovitis -> I+D

Question 97

1.	Highest body water content:
Young male
Old male
Young female
Old female

Answer 97

Answer: young male

Question 98

156. Osmotic pressure depends on:
157. Na concentration
158. Diffusible ions
159. Albumin concentration

Answer 98

Answer: Na concentration (previously: albumin concentration)

Osmotic pressure: depends on osmolality; determinants are concentrations of Na, glucose, and urea.
Albumin concentration gives the oncotic pressure.

** Look this up - there are conflicting answers

Question 99

157.	Major intracellular cations are:
Na + Ca
K + Mg
PO and protein
Cl and HCO3

Answer 99

Answer: K + Mg

Question 100

158.	Woman with MI 18 months ago, insulin-dependent diabetes and active leg ulcers.  Her ASA classification is:
ASA II
ASA III
ASA IV
ASA V

Answer 100

Answer: ASA III

ASA classification (Sabiston p.252)
I – Normal healthy patient
II – Mild systemic disease
III – Severe systemic disease that limits activity but is not incapacitating
IV – Incapacitating disease that is a constant threat to life
V – Moribund patient not expected to survive 24 hours with or without operation

Question 101

159. ALL of the following carry high mortality rate except:

Gallop 3
MI 18 months
Valve disease
CABG 3 years ago

Answer 101

Answer: CABG 3 years ago

Goldman Cardiac Risk Index (1977)  (Sabiston p.254)
o	Third heart sound or ↑ JVP		11 points
o	Recent MI			10
o	Nonsinus rhythm or PACs		7
o	> 5PVCs				7
o	Age >70				5
o	Emergency operations		4
o	Poor general medical condition	3
o	Thoracic, abdominal or aortic sx	3
o	Important valvular AS		3
Complication rate:  	0-5 points	1%
			6-12		7%
			13-25		14%
			>26		78%

Question 102

160. Healthy smoker patient going for surgery. All are correct except:

At least ASA II
High postoperative complication
High risk of wound infection

Answer 102

Answer: high post-operative complication

Several studies have shown the importance of smoking cessation in prevention of serious post-op pulmonary complications; however, the risk of developing such a complication in a healthy smoker is relatively small. (Sabiston)

Question 103

161. Best analgesia for obese patient post thoracotomy:
     PCA
     IV infusion
     Epidural

Answer 103

Answer: epidural

“Thoracic epidural analgesia is the current gold standard for post-thoracotomy analgesia because most believe that this technique produces subjectively better analgesia than any other method does.” (Miller’s anesthesia)

Question 104

162. The will approved medication that reduce perioperative mortality:

Captopril
Metoprolol
Lipitor

Answer 104

Answer: metoprolol

“The current AHA/ACC recommendations are to start β-blocker therapy in medium- to high-risk patients undergoing major- to intermediate-risk surgery as early as possible preoperatively and titrate to a heart rate of 60 beats per minute. The choice of agent and duration of therapy are still being debated.” (Sabiston)

Question 105

163. CO poisoning, which is correct:

N or high PaO2, Sat O2 is low, low Pulse oxymetry
Low PaO2, low SatO2, N P.oxymetry
High PaO2, high SatO2, high Pulse oxymetry

Answer 105

Answer: low PaO2, low O2 sat, normal pulse oxymetry

Question 106

1. 1L of RL will increase intravascular volume by:
   a. 1L
   b. 500cc
   c. 250cc
   d. 100cc

Answer 106

C 250cc
Water is distributed evenly throughout all fluid compartments of the body so that a given volume of water increases the volume of any one compartment relatively little. Sodium, however, is confined to the extracellular fluid compartment, and because of its osmotic and electrical properties, it remains associated with water. Therefore, sodium-containing fluids are distributed throughout the extracellular fluid and add to the volume of both the intravascular and interstitial spaces. While the administration of sodium-containing fluids will expand the intravascular volume, it also expands the interstitial space by approximately three times as much as the plasma. Plasma 5% of total body weight, Interstitial 15% of total body weight.
Schwartz

Question 107

178. What is the most common solid tumor in children younger than 4 years:
     a. Ewing’s sarcoma
     b. Neuroblastoma
     c. Wilm’s tumor
     d. Astrocytoma

Answer 107

B Neuroblastoma ?? Vs Astrocytoma
Neuroblastoma accounts for 7–10% of pediatric malignancies and is the most common solid neoplasm outside the CNS. Fifty percent of neuroblastomas are diagnosed before age 2 years and 90% before age 5 years. Current Pediatrics
Brain tumors are the most common solid tumors of childhood, accounting for 1500–2000 new malignancies in children each year in the United States and for 25–30% of all childhood cancers. Astrocytoma is the most common brain tumor of childhood. ( ± 49% of brain tumors so 12.5 to 15% of childhood cancer)Current Pediatrics

Question 108

179. what is the most common thyroid cancer:
     a. Papillary
     b. Follicular
     c. Medullary
     d. Anaplastic

Answer 108

A Papillary adenocarcinoma
Papillary carcinoma accounts for 80% of all thyroid malignancies in iodine-sufficient areas and is the predominant thyroid cancer in children and individuals exposed to external radiation.

Question 109

180. 40 year old female patient with L thyroid nodule, History of low-dose irradiation to neck/face as a child. What is the most appropriate next step:
     a. Thyroxin suppression test
     b. Radioactive iodine
     c. Lt thryoidectomy
     d. Total thyroidectomy

Answer 109

Total thyroidectomy
An exception to this general rule is the patient who has had previous irradiation of the thyroid gland or who has a family history of thyroid cancer. In these patients total or near-total thyroidectomy is recommended because of the high incidence of thyroid cancer ( 40%) and decreased reliability of FNA biopsy in this setting. There is a 40% chance that patients presenting with a thyroid nodule and a history of radiation have thyroid cancer. Of those patients who have thyroid cancer, the cancer is located in the dominant nodule in 60% of patients, but is in another nodule in the thyroid gland in the remaining 40% of patients.

Question 110

181. melanoma in the back with 3 mm thickness, what will be the margins:
     a. 1 cm
     b. 2 cm
     c. 3 cm
     d. 4 cm

Answer 110

B 2cm
Four randomized prospective trials have been completed to address the issue of resection margins.166 The results of these trials suggest that lesions 1 mm or less in thickness can be treated with a 1-cm margin. For lesions 1 mm to 4 mm thick, a 2-cm margin is recommended. Schwartz

Question 111

182. Neonate in ICU with multifocal osteomyelitis, what is the most common organism:
     a. Staph. aureus
     b. Groub B strept
     c. Strop pneumonia
     d. E.coli

Answer 111

S Aureus
The previous answer was Group B Strep. ?? Found no data on it. Multiple article on S Aureus plus textbook. Hematogenous osteomyelitis is an infection that predominantly occurs in children. The most common causative organism is Staphylococcus, but any bacteria can produce osteomyelitis.

Question 112

183. The standard treatment for C.diff colitis is:
     a. PO flagyl
     b. IV flagyl
     c. PO vanco
     d. IV vanco

Answer 112

A

Sanford 2008 If PO OK and WBC 20 Vanco Po

Question 113

184. All are side effect of vincristin except:
     a. Hypofibrinogenemia
     b. Leucopenia
     c. Thrombocytopenia
     d. Paralytic ileus

Answer 113

A Hypofibrinogenemia
Mild myelosuppression, neuropathy, ileus, SIADH
vinca alkaloid It is a mitotic inhibitor, and is used in cancer chemotherapy (lymphoma, leukemia and nephroblastoma)

Question 114

185. what mediates hyperacute rejection:
     a. IgG
     b. IgM
     c. T cell
     d. B cell

Answer 114

answer IgG
Acute allograft reaction is a T-cell-mediated reaction is the main cause of rejection.
Hyperacute rejection typically occurs within minutes of engraftment and is due to the reaction of preformed anti-ABO antibodies in the recipient with ABO antigens on the surface of the endothelium of the graft.
The plasma contains antibody against the absent antigens; i.e., people with blood group A have antibodies to B in their plasma. These antibodies are formed against cross-reacting bacterial or food antigens, are first detectable at 3–6 months of age, and are of the IgG and IgM class. However, even patients with presence of IgM do not necessarily get hyperacute rxn. IgM is responsible for hyperacute in vitro— but IgG (specifically IgG3) in vivo.

Question 115

186. Which of the following regulate fibrogenesis:
187. IL-6
188. TGF-beta (also PDGF, FGF-2, EGF, IGF-1)
189. TGF-alpha
190. PGF

Answer 115

Answer: #2

Question 116

187. 3 days post operatively, the strength of the wound depends on:
188. Epithelium
189. Fibroblast
190. Collage
191. Sutures

Answer 116

Answer: #4

In general strength of the wound depends of collagen

Question 117

199. which is the responsible for wound contraction:
200. Fibroblast
201. Myofibroblast
202. Collagen
203. Epithelium

Answer 117

The myofibroblast has been postulated as being the major cell responsible for contraction

Question 118

200. All are true about the structure of collagen except:
     a. Glycine every third amino acid
     b. Triple helix 3 alpha chains
     c. Lysl-lysine bond
     d. Contain hydroxyserine

Answer 118

Contain hydroxyserine

Question 119

201. What is true about malignant hyperthermia:
     a. Autosomal dominant
     b. End tidal CO2 decreases
     c. Potentiated by opioids
     d. Hypokalemia occurs
     e. Early symptoms include a rise in temperature

Answer 119

A Autosomal dominant
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. Triggering agents include all volatile anesthetics and the depolarizing muscle relaxant succinylcholine.

Question 120

202. which of the following will have the least strength by 3 month:
     a. Prolene
     b. Nylon
     c. Steel
     d. Silk

Answer 120

D Silk

Question 121

203. Which is the best suture that you can use in infected wound:
     a. Nonabsorb, monofilament
     b. Absorb, polyfilament
     c. Nonabsorb, polyfilament
     d. Absorb, monofilament

Answer 121

A

Question 122

204. Keloid scar:
     a. Familial
     b. Respond specifically to intralesion injection of triamcinolone
     c. Common in the back
     d. Common in white people

Answer 122

Previous answer: familial
The treatment of choice for keloids and intractable hypertrophic scars is still injection of triamcinolone acetonide, 10 mg/mL (Kenalog-10 Injection), directly into the lesion.

Question 123

205. Treatment of Keloid includes all except:
     a. Vit E
     b. Intralesion steroids
     c. Pressure
     d. Interferon
     e. Silicon

Answer 123

Vitamin E, particularly in the form of topical [alpha]-tocopherol in an oil base, is a popular agent in the treatment of acute and chronic dermal wounds [17•]. Though the in-vitro antioxidant effects of vitamin E have been well investigated and its role in cardiac protection is a topic of great scrutiny, research on the effects of vitamin E in vivo on skin healing is surprisingly scant. Indeed, some have found that topical vitamin E provides no more effect than other emollient-type ointments and may actually worsen scars or cause a contact dermatitis in an unacceptably large percentage of patients [18].
Scar management: prevention and treatment strategies
Margaret A. Chena and Terence M. Davidson 2005

Question 124

206. The effect of pressure therapy is cause by all except:
     a. Reduce collagen fibers
     b. Reduce the number of fibroblast
     c. Cell death

Answer 124

Answer: C, cell death
• I’m not sure about the answer, but the mechanism I found…. Compression causes decrease in o2 tension by occlusion of small blood vessels leads to reduction in tissue metabolism and fibroblast proliferation and hence reduction on collagen synthesis (eMedicne,MB)

Question 125

207. The action of vitamin C in wound healing is:
     a. Collagen cross linkage
     b. Collagen synthesis
     c. Hydroxylation of proline
     d. Fibroblast activation

Answer 125

C. Hydroxylation of proline
Prolyl hydroxylase requires oxygen and iron as cofactors, -ketoglutarate as co-substrate, and ascorbic acid (vitamin C) as an electron donor.

Question 126

208. ATN is diagnosed by:
     a. Specific gravity of 1.021
     b. Urine Na >80 mmol/l
     c. UOP 10cc/hr

Answer 126

C. UO 10cc/h
Previous answer UNa >80 mmol/l
ATN is a class of ARF which can present with oliguria. Urine Na is usually >20.

ATN = AKI + scenario consistent with ATN (ischemia, toxic insult)

Guidelines for Acute Kidney Injury defined AKI as one or more of three criteria [1]. The first two were a rise in serum creatinine of at least 0.3 mg/dL (26.5 micromol/L) over a 48-hour period and/or ≥1.5 times the baseline value within the seven previous days [1].
Uptodate

Essentials of Diagnosis:
Acute kidney injury.
Clinical scenario consistent with diagnosis (ischemic or toxic insult).
Urine sediment with pigmented granular casts and renal tubular epithelial cells is pathognomonic but not essential.

Question 127

209. which of the following radiation therapies has the highest skin-sparing feature:
     a. Linear accelerator
     b. Brachytherapy
     c. Cobalt

Answer 127

B Brachytherapy

Question 128

210. What is the primary pathophysiology of chronic diabetic ulcer:
     a. Infection
     b. Microvasculopathy
     c. Neuropathy
     d. Charcot joint

Answer 128

C Neuropathy Previous answer microvasculopathy
It is estimated that 60 to 70% of diabetic ulcers are due to neuropathy, 15 to 20% are due to ischemia, and another 15 to 20% are due to a combination of both. The neuropathy is both sensory and motor, and is secondary to persistently elevated glucose levels. The loss of sensory function allows unrecognized injury to occur from ill-fitting shoes, foreign bodies, or other trauma. The motor neuropathy or Charcot’s foot leads to collapse or dislocation of the interphalangeal or metatarsophalangeal joints, causing pressure on areas with little protection. There is also severe micro- and macrovascular circulatory impairment. Schwartz

Question 129

211. What is the most common injured nerve in craniocerebral injury:
     a. Abducens (VI)
     b. Occulomotor (III)
     c. Facial (VII)
     d. Olfactory (I)

Answer 129

Answer: #D.

Question 130

212. Patient with 2.1 cm SCC in the lower lip. Metastatic work-up (physical exam, CT, etc) is negative. What is the appropriate treatment:
     a. Surgical excision
     b. Surgical excision with radiotherapy
     c. Chemo and radiotherapy
     d. Surgical excision with chemotherapy

Answer 130

Surgical excision with radiotherapy

Question 131

213. You are a witness against a patient who is suing the hospital. The patient ends up in Emerg, and you are asked to see him by the emerg doc since you’re on call. You should:
     a. Refuse to see the patient
     b. Provide direction for immediate care issues if OK with the patient, and then defer care to one of your colleagues
     c. Tell the ERP to send the patient to a different community for care
     d. Provide full care to the patient

Answer 131

Provide direction for immediate care issues if OK with the patient, and then defer care to one of your colleagues

Question 132

214. Patient had total thyroidectomy for papillary carcinoma, which marker will indicate recurrence:
     a. TSH
     b. T4
     c. T3
     d. Thyroglobulin

Answer 132

Thyroglobulin

Question 133

215. What is the plasma volume of 70kg male patient:
     a. 3L
     b. 4L
     c. 2L
     d. 2.5L

Answer 133

Easy formula is plasma = 4-5% of total weight

Male = 50% water, woman 60% water
ECF = 1/3 of total water
Plasma = 1/4 of ECF
Plasma % = 55% (45% hematocrit) of intravascular volume

Therefore:
70kg * 0.5 / 3 / 4
= 3.5L?

Question 134

216. Protein requirement for patient with sever trauma and burn:
     a. 0.8-1g/kg/d
     b. 1-2
     c. 2-3

Answer 134

2-2.5 g/kg/d
recommended dose of amino acid protein for stressed or septic patients without renal dysfunction is 1.5 to 2 g/kg/day.In burn patients, administration of 2 to 2.5 g/kg/day is desirable due to excessive urinary losses and the inability to accurately assess wound losses of nitrogen.

Question 135

217. Picture showing normal CXR and EKG (S1, Q3, T3) for patient having chest pain post total hip replacement. What is the most appropriate initial investigation:
     a. Angiogram
     b. I.V. enhanced chest CT
     c. Lung scan
     d. Echo

Answer 135

I.V. enhanced chest CT

Question 136

218. Patient was positioned in Lt Lateral decubitus for surgery. Post operatively, he complains of weakness/numbness in his hand. What is the most affected movement:
219. Weak finger flexion (Median, Ulnar)
220. Weak wrist extension (Radial)
221. Weak finger adduction
222. Weak elbow flexion

Answer 136

2. Weak wrist extension (Radial)

Question 137

219. The most common chest x-ray finding of aortic injury is:
     a. Wide mediastinum
     b. Tracheal deviation
     c. Pleural cap
     d. Loss of aortic knob

Answer 137

Widen mediastinum

Question 138

1. 70 year old patient with history of A.fib and arthritis. Developed sudden sever abdominal pain. Had one BM today and vomited twice. Abdominal exam revealed generalized tenderness but not peritonitis. She had tubal ligation in the past. What is the most probable diagnosis:
   a. Acute mesenteric embolic ischemia
   b. Perforated PUD
   c. Intestinal obstruction
   d. Rupture AAA.

Answer 138

Acute mesenteric ischemia

Question 139

222. The ability of a test to appropriately identify people with disease is:
     a. Sensitivity
     b. Specificity
     c. Validity
     d. PPV

Answer 139

Sensitivity

Question 140

223. If you did small RCT and you found significant difference but is not statistically significant. What should you do:
     a. Change the study outcome
     b. Do another study with larger sample
     c. Ignore the result

Answer 140

Do another study with larger sample (not enough power)

Question 141

224. You are planning to run a study to assess the dose and the morbidity of a new drug. This will be similar to:
     a. Phase I trial
     b. Phase II
     c. Phase III
     d. Cohort study

Answer 141

Phase I trial

Phase I: Researchers test a new drug or treatment in a small group of people for the first time to evaluate its safety, determine a safe dosage range, and identify side effects.
Phase II: The drug or treatment is given to a larger group of people to see if it is effective and to further evaluate its safety.
Phase III: The drug or treatment is given to large groups of people to confirm its effectiveness, monitor side effects, compare it to commonly used treatments, and collect information that will allow the drug or treatment to be used safely.
Phase IV: Studies are done after the drug or treatment has been marketed to gather information on the drug’s effect in various populations and any side effects associated with long-term use.

Question 142

226. What is the most consistent finding post splenectomy:
     a. Neutropenia
     b. Thrombocytosis
     c. Spherocytosis
     d. Absence of Howell-Jolly bodies

Answer 142

Thrombocytosis
Splenectomy results in characteristic changes to blood composition, including the appearance of Howell-Jolly bodies and siderocytes. Leukocytosis and increased platelet counts commonly occur following splenectomy as well. In patients with preoperative thrombocytopenia, platelet counts usually rise within 2 days, but may not peak for several weeks (see the “Hematologic Outcomes” section of this chapter). Similarly, the white blood cell count typically rises within 1 day after splenectomy, but may remain elevated for up to several months.

Question 143

227. Old diabetic patient has contaminated wound and tetanus immunization is unknown. What should you do:
     a. Give Ig and vaccine (tetanus toxoid)
     b. Give Ig only
     c. Give Vaccine only
     d. Give nothing

Answer 143

Give Ig and vaccine

Question 144

228. In Sunderland classification of nerve injury, what is correct regarding grade II:
     a. Recovery is expected in days to weeks
     b. Complete recovery is expected
     c. No regeneration
     d. Regeneration rate is 1 cm /day.

Answer 144

Complete recovery is expected

Neurapraxic injuries usually are reversible, and patients recover within days to weeks.4, 6 In axonotmesis, although axons regenerate, functional recovery depends on the associated injuries, the amount of healthy proximal axon remaining after injury, and the age of the patient. Recovery from axonotmetic injuries usually occurs over months.4 In neurotmesis, regeneration occurs but function rarely returns to normal.

Grade1 (Neuropraxia): Integrity preserved, conduction defect. Patients can expect full recovery, matter of days to weeks. Motor>sensory defect
Grade2 (Axonotmesis) Integrity axon interruoted, intact endoneurium. Wallerian degeneration takes place, regeneration about 1mm/d, variable recovery but full recovery is possible, all modality equally affected
Grade3: Neurotmesis, preservation of perineurium, endoneuriu, is disrupted, 60- 80% recovery,
Grade4: Neurotmesis, preservation of epineurium, nerve grafting required
Grade 5 Complete transection of nerve trunk, bypass grafting required

Question 145

229. A patient with C8 injury. BP 80/50 and HR 50. He remained hypotensive despite 2L of RL. What is the most common cause:
     a. Neurogenic shock
     b. Spinal shock
     c. Cardiac tamponade
     d. Tension pneumothorax

Answer 145

Neurogenic shock

The classic description of neurogenic shock consists of decreased blood pressure associated with bradycardia (absence of reflexive tachycardia due to disrupted sympathetic discharge), warm extremities (loss of peripheral vasoconstriction), motor and sensory deficits indicative of a spinal cord injury, and radiographic evidence of a vertebral column fracture.

Question 146

230. What is the contraindication for extension-flexion cervical x-ray:
     a. Brown-sequard syndrome
     b. Pain and tenderness of the spine
     c. Spinal shock
     d. Anterior cord syndrome

Answer 146

• Contraindications:
  
  • altered state of consciousness (closed head injury, intoxication, or combativeness);
  • documented neurologic deficit;
  • inability of patient to flex and extend the neck w/o assistance

(Wheeless)

Question 147

231. H ion is excreted by the kidney mainly as:
     a. Free H ion
     b. Organic acid
     c. Combined to HCO3
     d. Combined to ammonia

Answer 147

D

(ammonia + H+ -> ammonium) -> excreted

Question 148

232. All of the following are true except:
     a. Necrosis is a non controlled process that leads to stimulation of inflammation
     b. Apoptosis is important for tissue growth
     c. Both necrosis and apoptosis happen in reperfusion injury
     d. Apoptosis initiated by Golgi apparatus

Answer 148

Answer: #D.

Question 149

233. All can cause hypercalcemia except:
     a. Paget’s disease
     b. Malignancy
     c. Multiple fractures
     d. Bed rest

Answer 149

Multiple fractures
Hypercalcemia

Etiology

Increased intake or absorption
Milk-alkali syndrome
Vitamin D or vitamin A excess

  Endocrine disorders 
Primary hyperparathyroidism 
Secondary hyperparathyroidism (renal insufficiency, malabsorption) 
Acromegaly 
Adrenal insufficiency

  Neoplastic diseases 
Tumors producing parathyroid hormone (PTH)-related protein (ovary, kidney, lung) 
Multiple myeloma (osteoclast-activating factor)

Other
Thiazides, sarcoidosis, Paget’s disease of bone, hypophosphatasia, immobilization, familial hypocalciuric hypercalcemia, sarcoidosis, tuberculosis

The symptoms and signs of hypercalcemia include nausea, vomiting, constipation, polyuria, muscular weakness and hyporeflexia, confusion, psychosis, tremor, and lethargy.

Question 150

234. 40 year old healthy lady has 2 cm mass in front of Lt ear with no LN what is the most appropriate action:
     a. CT
     b. US
     c. Incisional biopsy
     d. FNA

Answer 150

FNA vs US
Fine-needle aspiration is an acceptable method of diagnosing most soft tissue sarcomas, particularly when the results correlate closely with clinical and imaging findings.28 Schwart
Since grading is based on the cellular architecture and invasive nature of the tumor, FNAB is not a typically useful biopsy technique for the initial diagnosis of a sarcoma. If a tumor is small (

Question 151

235. Febrile reaction post blood transfusion is related to:
     a. Leukocyte
     b. Antibodies
     c. Donor RBC
     d. Infection

Answer 151

Antibodies

Question 152

236. All are physiological changes during pregnancy except:
     a. Increase cardiac output
     b. Increase RBC mass
     c. Eosinophilia
     d. Hemodilution

Answer 152

Eosinophilia

CO Progressive increases throuhout pregnancy to as much as 50% above baseline value by the 24th week
maternal blood volume increases, reaching a level 40% above baseline by the thirtieth week.1–3 This increase is due both to a 20% to 40% increase in the number of erythrocytes and a larger 40% to 50% increase in plasma volume. A mild dilutional anemia results, with a decrease in hematocrit of about 12%.

Question 153

237. Silver sulfadiazine is used in burn wound. It can cause all except:
     a. Granulocyte reduction
     b. Metabolic acidosis
     c. Pigmentation
     d. Anemia

Answer 153

Answer: Anemia

I think the answer is metabolic acidosis.
I think it can cause Anemia. This is from UTD drug section:

Dermatologic: Discoloration of skin, erythema multiforme, itching, photosensitivity, rash

Hematologic: Agranulocytosis, aplastic anemia, hemolytic anemia, leukopenia

Hepatic: Hepatitis

Renal: Interstitial nephritis

Schwarz:
Silver sulfadiazine has a reputation for causing neutropenia, but this association is more likely due to neutrophil margination from the inflammatory response.

Silver sulfadiazine destroys skin grafts and is contraindicated on burns or donor sites in proximity to newly grafted areas. Also, silver sulfadiazine may retard epithelial migration in healing partial-thickness wounds

Adverse Reactions
Frequency not defined.
Dermatologic: Itching, rash, erythema multiforme, discoloration of skin, photosensitivity
Hematologic: Hemolytic anemia, leukopenia, agranulocytosis, aplastic anemia
Hepatic: Hepatitis
Renal: Interstitial nephritis
Miscellaneous: Allergic reactions may be related to sulfa component

Question 154

238. The best intervention to prevent hypermetabolic phase that occur post abdominal surgery is:
     a. Perioperative TPN/feeding
     b. PCA
     c. Epidural analgesia

Answer 154

Answer: epidural analgesia

Question 155

239. Which is correct regarding linear Vs depressed skull fracture:
     a. Linear fracture is critical if occurred over a vessel
     b. Linear fracture indicate more sever impaction
     c. Depressed fracture is not associated with brain contusion

Answer 155

Linear fracture is critical if occurred over a vessel

In Schwarz, it doesn’t say anywhere specifically about linear vs not linear over a vessel, but says this regarding #’s in general:

Fractures that cross meningeal arteries can cause rupture of the underlying vessels and subsequent epidural hematoma (EDH) formation.

And this for depressed #’s
However, fractures overlying dural venous sinuses require restraint. Surgical exploration can lead to lifethreatening hemorrhage from the lacerated sinus.

Question 156

240. In comparison to FTSG, spilt thickness skin graft is characterized by all except:
     a. Has better take on contaminated wound
     b. Has more pigmentation
     c. Because it has less contraction, it is the best for wound in the face
     d. Can be used to cover larger wound

Answer 156

Because it has less contraction, it is the best for wound in the face
Thinner split-thickness grafts (0.01–0.015 inch) become vascularized more rapidly and survive transplantation more reliably. This is important in grafting on less than ideal recipient sites, such as contaminated wounds, burn surfaces, and poorly vascularized surfaces (eg, irradiated sites).

Question 157

241. If the study has CI of 95%. What is the chance to have population out side this interval?
     a. 1:5
     b. 1:10
     c. 1:20
     d. 1:95

Answer 157

1:20

Question 158

242. Mechanism of action of cyclosporine is:
     a. Inhibit B cell lymphocyte
     b. Inhibit IL-2 activated T cell and cytotoxic T cell
     c. Inhibit IL-6 activated T cell
     d. Inhibit macrophage

Answer 158

Inhibit IL-2 activated T cell and cytotoxic T cell

Question 159

243. Patient diagnosed with L4/L5 disc herniation; symptoms include:
     a. Numbness between 1st/2nd toes + weak great toe dorsiflexion
     b. Loss of patellar reflex + numbness over medial lower leg
     c. Loss of plantar flexion + numbness lateral foot
     d. Gastroc weakness + numbness on sole of foot

Answer 159

Loss of patellar reflex + numbness over medial lower leg. (compresses L4 nerve root.)

That was the given answer but I looked it up because I didn’t agree….. Schwarz doesn’t follow ASIA but anyways.

Schwarz Says (page 1742, in the table):
At L3/4, L4 nerve root is affected, patellar reflex, quadriceps weakness, anterior thigh numbness
At L4/5, L5 nerve root is affected, no associated reflex, Tibialis anterior weakness, and first toe numbness
At L5/S1, S1 is affected, plantar reflex, Gastroc weakness, and numbness in lateral foot

Question 160

244. DVT prophylaxis is required in all of the following patients, EXCEPT:
     a. 32 year old woman on birth control pill, undergoing appendectomy
     b. 58 year old man undergoing hemi-colectomy
     c. 65 year old woman undergoing palliative re-routing procedure for pancreatic cancer
     d. 45 year old man undergoing inguinal hernia repair

Answer 160

A vs D
BCP is now low estrogen and not a risk factor
Minor surgery 30 mins. Age

Question 161

245. The appropriate treatment of patient with severe vomiting:
246. Dextran
247. Normal saline
248. HCL infused slowly
249. HCO3 drip

Answer 161

Answer: normal saline.

Question 162

246. You are working in community hospital. Patient comes in with laceration to forearm – you suspect ulnar nerve injury. Appropriate treatment includes:
     a. Exploration in emerg
     b. Suture, place in splint & re-check in 4 weeks for return of function
     c. Irrigate, close, place in splint and send to referral centre to appropriate specialist.

Answer 162

Irrigate, close, place in splint and send to referral centre to appropriate specialist.

Question 163

247. 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 163

Pain on passive dorsiflexion of toe

Compartment syndrome

Question 164

248. 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 164

Answer: Treat patients on first-come first-serve basis. You need to treat sick patients first.

Question 165

248. 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 165

Answer: Treat patients on first-come first-serve basis. You need to treat sick patients first.

Question 166

251. Patient with heterotrophic ossification, and decreased ROM of joint. Which of the following is true regarding HO?
     A. Common in head injury
     B. Visible on x-ray before limiting patient clinically
     C. May be reduced by use of NSAIDs

Answer 166

Answer: A/C

• Heterotopic ossification is the formation of mature, lamellar bone in nonskeletal tissue, usually in soft tissue surrounding joints. Its exact etiology is unknown.
• Heterotopic ossification is commonly seen in patients with traumatic brain injury, spinal cord injury, CVA, burns, fractures, trauma, or muscle injuries and after total joint arthroplasty. More recently, heterotopic ossification has been described in patients after prolonged sedation, ventilation, critical illness, and immobilization (specifically… polytrauma, burns, pancreatitis, ARDS).
• The incidence rate reported in the literature varies from 11% to 75% in patients with severe traumatic brain injury and spinal cord injury.
• The bone formation in heterotopic ossification differs from that in other disorders of calcium deposition in that heterotopic ossification results in encapsulated bone between muscle planes, which is not intra-articular or connected to periosteum.
• Limitation of physical activity usually precedes radiographic evidence of calcification, which is located in the muscle and surrounding soft tissue of the joint. Although the mechanism causing HO is not known, it has been suggested that bleeding into the soft tissue due to aggressive physical therapy is the culprit. (Schwartz)
• NSAIDs can be used not only for analgesia of the patient but also to reduce bone formation by the inhibition of prostaglandin synthetase. NSAIDs inhibit arachidonic acid metabolism, thereby inhibiting prostaglandin production, reducing inflammation, and slowing bone metabolism.
• Studies have shown that indomethacin, ibuprofen, and other NSAIDs have been effective for prevention of heterotopic ossification in total hip arthroplasty and in high-risk spinal cord–injured patients. Indomethacin has been the most widely used NSAID in prophylaxis for heterotopic ossification and is commonly used after surgical resection to prevent recurrence
• Ref: Frontera: Essentials of Physical Medicine and Rehabilitation, 2nd ed.

Question 167

252. 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

Answer 167

Answer: D

Question 168

253. In head injured patient, target CPP would be:
A. 30 mmHg
B. 70 mmHg
C. 30 cm H2O
D. 70 cm H2O

Answer 168

Answer: B
• General principles of the management of cerebral injuries have changed in recent years. Attention is now focused on maintaining or enhancing cerebral perfusion rather than merely lowering intracranial pressure (ICP). For example, it has been found that hyperventilation to a PCO2 less than 30 mm Hg to induce cerebral vasoconstriction actually exacerbates cerebral ischemia in spite of decreasing ICP. Nevertheless, the measurement of ICP is still important and is efficiently accomplished with a ventriculostomy tube. The tube also permits the withdrawal of cerebrospinal fluid, which is the safest method for lowering ICP. Although an ICP of 10 mm Hg is believed to be the upper limit of normal, therapy is not usually initiated until the ICP reaches 20 mm Hg. Cerebral perfusion pressure (CPP) is an important measurement which is used to monitor therapy. CPP is equal to the mean arterial pressure (MAP) minus the ICP, and 60 mm Hg is the lowest acceptable pressure (Schwartz)
• In normal brain, cerebral blood flow (CBF) remains fairly constant at around 50 mL/100 g brain tissue per minute as long as cerebral autoregulation is intact so that a constant CBF is maintained as long as CPP is about 50 to 150 mm Hg.
• Multiple studies have looked at outcomes when CPP is maintained at 70 mm Hg, none has convincingly demonstrated improved outcomes. Oxygen delivery studies have demonstrated that over a CPP of 60 mm Hg, little improvement in cerebral oxygen delivery is achieved by higher levels, with the important exception of patients with regional ischemia. Patients whose CPP is kept at 70 mm Hg appear to have a higher incidence of ARDS. While the advocates of Lund therapy would recommend a CPP of 50 mm Hg, there is not enough data to make this a widely accepted approach. The current synthesis of this data appears to be that of Robertson which is that, except in cases of regional ischemia, a CPP of 60 mm Hg is adequate and no benefit and some harm may come from elevating CPP to 70 mm Hg.

Question 169

254. Diabetic on insuline and had MI 18 months going to inguinal hernia:
255. a. ASA II
256. b. ASA III
257. c. ASA IV
258. d. ASA V

Answer 169

Answer: B
• From Sabiston: The ASA has developed a graded, descriptive scale as a means of categorizing preoperative comorbidity. The classification is independent of operative procedure and serves as a standardized method of communicating patient physical status to anesthesiologists and other health care providers. Patients are categorized as follows:
ASA I—No organic, physiologic, biochemical, or psychiatric disturbance.
ASA II—A patient with mild systemic disease that results in no functional limitation. Examples are well-controlled hypertension and uncomplicated diabetes mellitus.
ASA III—A patient with severe systemic disease that results in functional impairment. Examples are diabetes mellitus with vascular complications, previous myocardial infarction, and uncontrolled hypertension.
ASA IV—A patient with severe systemic disease that is a constant threat to life. Examples are congestive heart failure and unstable angina pectoris.
ASA V—A moribund patient who is not expected to survive with or without the surgery. Examples are ruptured aortic aneurysm and intracranial hemorrhage with elevated ICP.
ASA VI—A declared brain-dead patient whose organs are being harvested for transplantation.
E—Emergency surgery is required. For example, ASA IE represents an otherwise healthy patient undergoing emergency appendectomy.

Question 170

255. Mechanism of action of bisphosphonate
256. a. Activate osteoblast
257. b. inhibit osteoclast
258. c. Decrease GI absorption
259. d. Increase renal loss

Answer 170

Answer: B
•	bisphosphonates (also called: diphosphonates) are a class of drugs that inhibit osteoclast action and the resorption of bone (Wikipedia)

Question 171

256. Feature of CO:
257. a. Shift the curve to left
258. b. Pulse oxymetry is usually low
259. c. Can be diagnosed by pulse oxymetry
260. d. High affinity to iron containing protein.

Answer 171

Answer: A
Carbon Monoxide
Hemoglobin binds with carbon monoxide 240 times more readily than with oxygen. The presence of carbon monoxide on one of the 4 heme sites causes the oxygen on the other heme sites to bind with greater affinity. This makes it difficult for the hemoglobin to release the oxygen to the tissues and has the effect of shifting the curve to the left. With an increased level of carbon monoxide, a person can suffer from severe hypoxemia while maintaining a normal PO2. Binds the FE site on hemoglobin.

• The majority of house fire deaths can be attributed to CO poisoning. CO is a colorless, odorless, and tasteless gas with an affinity for hemoglobin (Hb) approximately 200 times that of oxygen. When inhaled and absorbed, CO binds to Hb to form carboxyhemoglobin (COHb). COHb interferes with oxygen delivery to the tissues by at least five mechanisms. First, it prevents reversible displacement of oxygen on the Hb molecule. Second, COHb shifts the oxygen-Hb dissociation curve to the left, thereby decreasing oxygen unloading from normal hemoglobin at the tissue level.111 Third, CO binds to reduced cytochrome a3, resulting in less effective intracellular respiration.112 Fourth, CO can bind to cardiac and skeletal muscle, resulting in direct toxicity.113 Finally, CO can act in the central nervous system in a poorly understood fashion, causing demyelination and associated neurologic symptoms. Levels of COHb are easily measured, but the degree of impairment may not directly correlate with blood levels of COHb.115 Levels less than 10% typically do not cause symptoms. At a COHb level of approximately 20%, healthy persons complain of headache, nausea, vomiting, and loss of manual dexterity. At approximately 30%, patients become weak, confused, and lethargic. In a fire, this level can be fatal because the victim loses the desire and ability to flee. At levels of 40 to 60%, the patient lapses into a coma, and levels greater than 60% are usually fatal. CO is reversibly bound to the heme molecules of Hb, and despite intense affinity, readily dissociates according to the laws of mass action. The half-life (t1/2) of COHb when breathing room air is approximately 4 hours. On 100% oxygen, the t1/2 is reduced to 45 to 60 minutes.116 In a hyperbaric oxygen chamber at 2 atm, it is approximately 30 minutes, and at 3 atm it is about 15 to 20 minutes. The use of pulse oximetry (SpO2) to assess arterial oxygenation in the CO-poisoned patient is contraindicated, as the COHb results in erroneously elevated SpO2 measurements. (Schwartz)

Question 172

257. what is the most common thyroid cancer:
258. a. papillary
259. b. follicular
260. c. medullary
261. d. anaplastic

Answer 172

Answer: A

• Papillary carcinoma accounts for 80% of all thyroid malignancies in iodine-sufficient areas and is the predominant thyroid cancer in children and individuals exposed to external radiation (Schwartz)

Question 173

258. The most common cause of primary hyperaldosteronism:
259. a. Pituitary adenoma
260. b. Adrenal hyperplasia
261. c. Solitary adrenal adenoma
262. d. Bilateral adrenal adenomas

Answer 173

Answer: C

• Primary hyperaldosteronism results from autonomous aldosterone secretion, which, in turn, leads to suppression of renin secretion. Primary aldosteronism usually occurs in individuals between the ages of 30 and 50 years and 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%). Adrenocortical carcinoma and glucocorticoid suppressible hyperaldosteronism are rare, each accounting for less than 1% of cases. (Schwartz)s

Question 174

259. what mediates hyperacute rejection:
     a. IgG
     b. IgM
     c. T cell
     d. B cell

Answer 174

Answer: B

• no good answer found

I think the answer is IgG. Saw it elsewhere. Basically you have preformed antibodies hanging around (IgG) that attack the graft immediately.

Question 175

260.	 Which of the following can reduce the effect of steroid on wound healing: 
.	a. Vit A 
.	b. Vit E 
.	c. Vit C 
.	d. Vit D

Answer 175

Answer: A

• Vitamin A has been found to reduce the effects of steroids on wounds and may speed healing. (http://www.surgery.ucla.edu/plastic/rec_wound.shtml)…also in Morrell notes

Question 176

261. Patient with pelvic # and hypotensive. Did not respond to fluid. What is the next appropriate step:
262. a. Laparatomy
263. b. Angiogram
264. c. External fixation
265. d. Try more fluid

Answer 176

Answer: B

I think laparotomy for packing is usually more appropriate if patient is unstable, especially if they have other reasons to go to the OR. If you can get to angio

Question 177

262. When a test tested what is it is supposed to test is called:
263. a. Sensitivity
264. b. Specificity
265. c. Power
266. d. Validity

Answer 177

Answer: D
• Validity ( Table 5-3 ) refers to how well the item, scale, or instrument measures the attribute it is intended to measure. (Campbell’s urology)

Question 178

263. H ion is excreted by the kidney mainly as:
     a. Free H ion
     b. Organic acid
     c. Compound to HCO3
     d. Compound to ammonia

Answer 178

Answer: D
Urinary Buffering
The role of urinary buffering serves two purposes; to a) excrete the daily acid load and b) regenerate bicarbonate lost during extracellular buffering. It is a process whereby seceted hydrogen ions are buffered in the urine by combining with weak acids (titratable acidity) or with NH3 (ammonia) to be excreted. It is a necessary process because the kidney cannot easily excrete free hydrogen ions.
Renal Acid Exretion; Take Home Points 1. The net quantity of H+ ions excreted in the urine is equal to the amount of H+ excreted as titratable acidity and NH4+ minus any H+ added to the body because of urinary HCO3- loss. Net acid excretion(NAE) = titratable acidity + NH4+ - urinary HCO3- Note that normally there is no urinary HCO3- and therefore: Net acid excretion(NAE) = titratable acidity + NH4+ 2. Titratable acidity is dependent on the dietary intake of phosphate and cannot be regulated to increase acid excretion 3. The kidney ‘s main response to an increased acid load is to increase ammonium production and excretion 4. A very important feature of titrable acidity and ammonium excretion is the regeneration of bicarbonate ions. 5. The kidney must reabsorb all filtered HCO3- in order to maintain acid base balance. 6. Hydrogen ion secretion in the collecting tubule is very important in maximally acidifying the urine. 7. In states of acidosis, maximal acidification of the urine in the collecting tubule must occur for adequate ammonium excretion. 8. In states of acidosis, ammonium excretion is increased by increasing ammonium production and increased hydrogen ion secretion in the collecting duct. 9. Aldosterone stimulates secretion of hydrogen ion in the collecting duct . 10. Although the extracellular pH is the primary physiologic regulator of net acid excretion, in pathophysiologic states, the effective circulating volume, Aldosterone, and the plasma K+ concentration all can affect acid excretion, independent of the systemic pH.

Question 179

264. All are causes of hypernatremia except:
     a. IV saline
     b. Hyperaldosteronism
     c. SIADH
     d. DI

Answer 179

Answer: C

• SIADH causes hyponatremia

Question 180

1. 265. 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

Answer 180

Answer: B

• Factor VIII has a half-life of 8 to 12 hours (Hoffman: Hematology)

Question 181

266. 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 181

Answer: C????????? Look this up

Influence of Preoperative Allograft Function (Effective Renal Plasma Flow) on the Short-Term Outcome Following Living Donor Kidney Transplantation S.-S. Changa, C.-J. Hunga, Y.-J. Lina, T.-C. Choua, J.-P. Chuanga, P.-Y. Chunga, Y.-S. Lina and P.-C. Lee, a, aDepartment of Surgery, Division of Organ Transplantation, National Cheng-Kung University Hospital, College of Medicine, National Cheng-Kung University Abstract
Predonation kidney function is supposed to be an important factor affecting graft outcome. Controversial evidence suggests that higher predonation glomerular filtration rate (GFR) positively correlated with posttransplant graft outcome.

Question 182

267. diarrhea gives you what metabolic defect
     a) metabolic alkalosis
     b) metabolic acidosis, non AG
     c) metabolic acidosis, AG

Answer 182

Answer: B

Question 183

268. most common location for cystic ganglion
     a) DIP
     b) wrist
     c) elbow

Answer 183

Answer: B

• Joint and tendon ganglions (or ganglia) are among the most common benign soft-tissue tumor masses in the upper extremity, representing up to 50 to 75% of reported tumors. Although they can be located anywhere, the majority are at the middorsal wrist; the volar radial wrist; the digital flexor sheath at the metacarpal flexion crease (seed or pea ganglia that are extremely small, but hard and tender); and at the dorsum of the distal interphalangeal joint and nail base (mucous cyst). (Schwartz)

Question 184

269. 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 184

Answer: C

Circulatory and metabolic pathophysiology of septic shock
The predominant hemodynamic feature of septic shock is arterial vasodilation. Diminished peripheral arterial vascular tone may result in dependency of blood pressure on cardiac output, causing vasodilation to result in hypotension and shock if insufficiently compensated by a rise in cardiac output. Early in septic shock, the rise in cardiac output often is limited by hypovolemia and a fall in preload because of low cardiac filling pressures. When intravascular volume is augmented, the cardiac output usually is elevated (the hyperdynamic phase of sepsis and shock). Even though the cardiac output is elevated, the performance of the heart, reflected by stroke work as calculated from stroke volume and blood pressure, usually is depressed. Factors responsible for myocardial depression of sepsis are myocardial depressant substances, coronary blood flow abnormalities, pulmonary hypertension, various cytokines, nitric oxide, and beta-receptor down-regulation.
Peripheral circulation during septic shock
An elevation of cardiac output occurs; however, the arterial-mixed venous oxygen difference usually is narrow, and the blood lactate level is elevated. This implies that low global tissue oxygen extraction is the mechanism that may limit total body oxygen uptake in septic shock. The basic pathophysiologic problem seems to be a disparity between the uptake and oxygen demand in the tissues, which may be more pronounced in some areas than in others. This is termed maldistribution of blood flow, either between or within organs, with a resultant defect in capacity to extract oxygen locally. During a fall in oxygen supply, cardiac output becomes distributed so that most vital organs, such as the heart and brain, remain relatively better perfused than nonvital organs. However, sepsis leads to regional changes in oxygen demand and regional alteration in blood flow of various organs.
The peripheral blood flow abnormalities result from the balance between local regulation of arterial tone and the activity of central mechanisms (eg, autonomic nervous system). The regional regulation, release of vasodilating substances (eg, nitric oxide, prostacyclin), and vasoconstricting substances (eg, endothelin) affect the regional blood flow. Development of increased systemic microvascular permeability also occurs, remote from the infectious focus, contributing to edema of various organs, particularly the lung microcirculation and development of acute respiratory distress syndrome (ARDS).
In patients experiencing septic shock, the delivery of oxygen is relatively high, but the global oxygen extraction ratio is relatively low. The oxygen uptake increases with a rise in body temperature despite a fall in oxygen extraction.
In patients with sepsis who have low oxygen extraction and elevated arterial blood lactate levels, oxygen uptake depends on oxygen supply over a much wider range than normal. Therefore, oxygen extraction may be too low for tissue needs at a given oxygen supply, and oxygen uptake may increase with a boost in oxygen supply, a phenomenon termed oxygen uptake supply dependence or pathological supply dependence. However, this concept is controversial because other investigators argue that supply dependence is artifactual rather than a real phenomenon. Maldistribution of blood flow, disturbances in the microcirculation, and, consequently, peripheral shunting of oxygen are responsible for diminished oxygen extraction and uptake, pathological supply dependency of oxygen, and lactate acidemia in patients experiencing septic shock.

Question 185

270. 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 185

Answer: B

• About 30% of patients with thymoma have myasthenia gravis, and about 15% of patients with myasthenia develop a thymoma
• Fifty percent of thymomas are first identified in an asymptomatic patient on a chest x-ray obtained for another purpose. Symptomatic patients may present with chest pain, dysphagia, myasthenia gravis, dyspnea, or superior vena caval syndrome.
• Besides myasthenia, thymomas can produce a variety of paraneoplastic syndromes. These include cytopenias, red cell aplasias, and hypogammaglobulinemias as well as autoimmune disorders such as rheumatoid arthritis, lupus erythematosus, and polymyositis.
• The diagnosis of myasthenia gravis can be made from the patient’s history of easy fatigability and associated decremental response in muscular contraction to repeated stimulation of the motor nerve or from improvement in these abnormalities in response to edrophonium (Tensilon), a short-acting anticholinesterase drug.

Question 186

271. Systemic diastolic blood pressure is determined by:
     a) cardiac output
     b) elasticity of great vessels
     c) peripheral vascular resistance
     d) end diastolic pressure

Answer 186

Answer: C

Question 187

272. Which of the following is seen in basal skull fracture
     a) subgaleal hematoma
     b) anosmia
     c) hemotympanum
     d) decreased level of consciousness

Answer 187

Answer: all can be seen with basal skull #. C sounds like the most correct answer
•Symptoms from skull base fractures include cranial nerve deficits and CSF leaks. A fracture of the temporal bone, for instance, can damage the facial or vestibulocochlear nerve, resulting in vertigo, ipsilateral deafness, or facial paralysis. A communication may be formed between the subarachnoid space and the middle ear, allowing CSF drainage into the pharynx via the eustachian tube or from the ear (otorrhea). Extravasation of blood results in ecchymosis behind the ear, known as Battle’s sign. A fracture of the anterior skull base can result in anosmia (loss of smell from damage to the olfactory nerve), CSF drainage from the nose (rhinorrhea), or periorbital ecchymoses, known as raccoon eyes. (Schwartz)
•Subgaleal hemorrhage or hematoma is bleeding in the potential space between the skull periosteum and the scalp galea aponeurosis. Subgaleal hematoma has a high frequency of occurrence in associated head trauma (40%), such as intracranial hemorrhage or skull fracture.
•Basilar skull fractures include breaks in the posterior skull base or anterior skull base. The former involve the occipital bone, temporal bone, and portions of the sphenoid bone; the latter, superior portions of the sphenoid and ethmoid bones. (Wikipedia)

Question 188

273. most common bilateral tumor parotid
     a) Warthin’s
     b) Pleomorphic adenoma
     c) Mucoepidermoid carcinoma

Answer 188

Answer: A

• Warthin tumor (papillary cystadenoma lymphomatosum or adenolymphoma) is the second most common benign parotid tumor (5%) and is the most common bilateral benign neoplasm of the parotid
• Acinic cell carcinoma is an intermediate-grade malignancy with low malignant potential. This tumor may be bilateral or multicentric and is usually solid, rarely cystic. – I think this would be the answer to choose if they specify malignant
• Benign pleomorphic adenoma or benign mixed tumor is the most common parotid neoplasm (80%)
• Mucoepidermoid carcinoma is the most common malignant tumor of the parotid gland, accounting for 30% of parotid malignancies. (e-medicine)

Question 189

274. Cardiac toxicity in hyperkalemia would be BEST treated with:

A. Insulin
B. Metoprolol
C. Calcium
D. Bicarbonate

Answer 189

Answer: C

When ECG changes are present, calcium chloride or calcium gluconate (5 to 10 mL of 10% solution) should also be administered to counteract the myocardial effects of hyperkalemia. It should be used cautiously in patients on digitalis as digitalis toxicity may occur. (Schwartz)

Question 190

275. A 67-year-old ♀ is on a ventilator in the ICU. Her blood pressure is noted to be 100/72. The tidal volume is noted to be 15cc/kg. The PaO2:FiO2 ratio is

Answer 190

Answer: A
• This question talking about a pt with ARDS:
• Diagnositic criteria for ALI (acute lung injury) and ARDS (ICU book chap 22):

1 Acute onset

2 Presence of a predisposing condition…anything that can trigger SIRS… conditions that commonly cause ARDS:

• intracrainal HTN
• multiple transfusion
• pneumonia
• pulmonary contusion
• cardiopulmonary bypass
• pancreatitis
• aspiration
• urosepsis…or any sepsis
• amniotic fluid embolism
• long bone racture
• drug overdose

3 Bilateral infiltrates on frontal CXR

4 PaO2/FiO2 30 then decrease TV by 1ml/kg steps until plateau press drops below 30 or TV down to 4ml/kg
 3rd stage: PERMISSIVE HYPERCAPNIA…to pH >7.15
• monitor ABG for resp acidosis
• target pH = 7.3-7.45
• if pH 7.15-7.3, increase RR until pH > 7.3 or RR = 35
• if pH 7.15

Question 191

276. A patient has renal insufficiency and requires nutritional support. Which of the following is the BEST recommendation?

A. Lower the caloric/ nitrogen ratio
B. Increase the caloric / nitrogen ratio
C. Avoid branched chain amino acids
D. Recommend an alternate source of calories other than glucose

Answer 191

Answer: B

• The preferred ratio of nonprotein calories to nitrogen varies with the stress level. In minimally stressed patients, 200:1 to 300:1 is appropriate, but it is decreased to 150:1 in moderately stressed and to 100:1 or less in severely stressed patients. In patients with hepatic or renal failure, protein restriction may be warranted. (Sabiston)
• Patients in renal failure (serum creatinine over 2 mg/dL) with a normal metabolic rate who cannot undergo dialysis should receive a concentrated (minimal volume) enteral or parenteral diet containing just the essential amino acids, dextrose, and limited amounts of sodium, potassium, magnesium, and phosphate. (Lange surgery)

Question 192

277. The BEST initial treatment for empyema is:

A. IV antibiotics only
B. IV antibiotics and chest tube drainage
C. Decortication
D. Thoracotomy and lobectomy

Answer 192

Answer: B

• Treatment of empyema is dependent on its phase but involves the identification and systemic treatment (antibiotics) of the causative organism and complete drainage of the pleural space. In the acute and early fibrinopurulent phases, complete thoracentesis can be both diagnostic and therapeutic if the effusion is drained entirely. The prior administration of antibiotics may lead to a sterile tap, but Gram stain (organisms), cell count (polymorphonuclear leukocytic predominance in bacterial empyema and lymphocytic predominance in tuberculous empyema), chemistries (protein, LDH, amylase, and glucose), and pH (

Question 193

278. An elderly woman is brought in to the ER obtunded. A blood gas shows an anion gap metabolic acidosis. Which of the following is the MOST likely diagnosis?
A. Salicylate poisoning
B. Diarrhea
C. Renal tubular acidosis
D. Fistula

Answer 193

Answer: A

•	Causes of anion gap met acidosis:
•	(Toronto notes) “MUDPILES CAT”
o	M: methanol
o	U: uremia
o	D: diabetic ketoacidosis/starvation ketoacidosis
o	P: paraldehyde, phenformin
o	I: isoniazide, iron, ibuprofen, isopropyl alcohol
o	L: lactate (… ie. anything that causes shock or seizures)
o	E: ethylene glycol
o	S: salicylates
o	C: cyanide, CO
o	A: alcoholic ketoacidosis
o	T: toluene theophyline

•	(ICU book) the common causes are:
o	lactic acidosis
o	ketoacidosis
o	end-stage renal failure
o	toxic ingestions: methanol (which forms formic acid), ethylene glycol (which forms oxalic acid), propylene glycol (which accelerates the formation of lactic acid and pyruvic acid) and salycilates (which form salicylic acid)

Question 194

279. The MOST accurate measurement of CVP for a patient receiving positive pressure ventilation is:

A. At end expiraton
B. At end inspiration
C. At mid-expiration
D. At mid-inspiration

Answer 194

Answer: A

• In spontaneously breathing patients, readings should be taken at the end of a normal inspiration. If the patient is receiving positive-pressure ventilation, the CVP changes during the respiratory cycle are reversed, rising with inspiration and decreasing with expiration. In these patients, readings should be taken near the end of expiration.(MD consult)

Question 195

280. Which of the following INCREASES the risk of developing a postoperative surgical site infection?

A. Surgeon scrub for less than 5 minutes
B. Perioperative blood transfusion
C. Forced warm air in the OR
D. Preoperative shower

Answer 195

Answer: B

Question 196

281. What creates the osmotic forces between the intravascular and extravascular compartments of the extracellular fluid volume?

A. Intravascular sodium content
B. Intravascular protein content
C. Extravascular sodium content
D. Extravascular protein content

Answer 196

Answer: B. Na is the same in the extravascular and intravascular space. To drive from the intravascular to extravascular is the osmotic force.

Fluid movement between the intravascular and interstitial spaces occurs across the capillary wall and is determined by the Starling forces—capillary hydraulic pressure and colloid osmotic pressure. The transcapillary hydraulic pressure gradient exceeds the corresponding oncotic pressure gradient, thereby favoring the movement of plasma ultrafiltrate into the extravascular space.

Question 197

282. Which of the following is TRUE regarding the immune system’s response to tumour cells?

A. Humoral response decreases tumour growth
B. Cellular response decreases tumour growth
C. Cellular response increases tumour growth
D. Humoral response increases tumour growth

Answer 197

Answer: B

• The strongest evidence that the immune system can exert clinically meaningful antitumor effects comes from allogeneic bone marrow transplantation. Adoptively transferred T cells from the donor expand in the tumor-bearing host, recognize the tumor as being foreign, and can mediate impressive antitumor effects (graft-versus-tumor effects). In general, antibodies are not very effective at killing cancer cells. (Harrison’s)

Question 198

283. Which of the following accurately describes the mechanism underlying citrate toxicity with massive transfusion?

A. Binds available Ca2+ resulting in a deleterious effect on myocardium
B. Citric acid is directly toxic to tissues
C. The resultant acidosis is itself toxic
D. The free citrate causes seizures

Answer 198

Answer: A

• Massive transfusion of citrated blood products can lead to transiently decreased levels of ionized calcium. The effects of hypocalcemia include hypotension, narrowed pulse pressure, and elevated left ventricular end-diastolic, pulmonary artery, and central venous pressures. Electrocardiographic abnormalities (e.g., prolonged QT intervals) also occur. (access surgery – Trauma)

Question 199

284. A post op CABG patient develops C Diff colitis. She is placed on TPN for several days. She is also on ASA, prednisone, metoprolol and lasix at home. The patient then develops a non-anion gap hyperchloremic metabolic acidosis. What is the MOST likely cause?

A. Intraabdominal sepsis
B. Lasix
C. TPN
D. Decreased cardiac output

Answer 199

Answer: C

Causes of Normal AG Metabolic Acidosis (e-medicine)
• GI loss of HCO3 -, diarrhea
• Pancreatic fistula
• Renal HCO3 - loss - Type 2 (proximal) RTA
• Renal dysfunction
• Some cases of renal failure
• Hypoaldosteronism (ie, type 4 RTA)
• Hyperventilation
• Ingestions - Ammonium chloride, acetazolamide, hyperalimentation fluids, some cases of ketoacidosis, particularly during treatment with fluid and insulin

Question 200

285. Which of the following scenarios constitutes secondary prevention?

A. Completely avoiding a carcinogen
B. Detecting a cancer early when it is more amenable to successful therapy
C. Treatment of complications arising from cancer
D. Encouraging patients to quit smoking

Answer 200

Answer: B

• From Toronto notes:
o Primary: before disease occurs ex: immunization
o Secondary: early detection of disease ex: mammography
o Tertiary: treatment and rehab of existing disease ex. ACEI form HTN

Question 201

287. Hypokalemia produces which of the following ECG changes?

A. decreased R-R interval, shortened QRS duration, and ST depressions
B. ST elevations, prolonged QRS, inverted T waves
C. ST elevations, shortened QRS, inverted T waves
D. Flattened P wave, shortened QRS

Answer 201

Answer: A

• ECG changes suggestive of hypokalemia include (Schwartz):
o U waves
o T-wave flattening
o ST-segment changes…depression
o Arrhythmias (especially if patient is taking digitalis)

Question 202

288. Signs of cardiac tamponade include all of the following EXCEPT:

A. Narrow pulse pressure
B. Pulsus alternans
C. Left atrial pressure greater than the right atrial pressure
D. Hypotension
E. Distended neck veins

Answer 202

Answer: C

• Patients with acute cardiac tamponade have hypotension, distended neck veins, and distant heart wounds, pulsus paradoxus, defined as a greater than 10 mm Hg decline in systolic pressure at the end of the inspiratory phase of respiration, a phenomenon that is best observed on pressure tracings from an arterial line. (Sabiston)
• Pulsus alternans, in which the amplitude of the pulse alternates every other beat during sinus rhythm, occurs when cardiac contractility is very depressed. (access medicine)

Question 203

289 What is the BEST measure of the adequacy of burn resuscitation?
A. MAP B. CVP C. sBP D. Urine output

Answer 203

Answer: D
• Ultimately, the volume and rate of infused fluid should maintain a urine output of 30 mL/h in adults (0.5 mL/kg per hour), with lower limits acceptable in the face of known renal insufficiency, and 1.0 to 1.5 mL/kg per hour in children. (Schartz)

Question 204

290. Activated protein C has been shown to be useful in sepsis, but may come with an INCREASED risk of:

A. Hemorrhage
B. Thrombosis
C. Anaphylaxis
D. Renal Failure

Answer 204

Answer: A

• Patients treated with the drug showed a trend toward a higher incidence of serious bleeding (3.5% versus 2.0%; p = 0.06). (Schwartz)

Question 205

291. Which cytokine may reduce scar hypertrophy?

A. EGF
B. FGF
C. IFN-gamma
D. IL-2

Answer 205

Answer: C

• IFN-gamma is in inhibitor of collagen synthesis (Morrell notes)

Question 206

292. A patient sustains a transverse fracture through the pterygoid plate, inferior to floor of maxillary sinus. What type of fracture does this represent?

A. LeFort I
B. Lefort II
C. Lefort III
D. Panfacial fracture

Answer 206

Answer: A

• Midface fractures involving the maxilla can be classified by fracture patterns know as Le Fort I, II, and II. These patterns also represent progressive gradation of severity and reflect increasing causal impact energies.
oLe Fort I fractures traverse the maxilla horizontally at the level of the piriform rim.
oLe Fort II fractures involve the nasofrontal junction, nasal process of the maxilla, medial portion of the inferior orbital rim, and across the anterior maxilla.
oLe Fort III fractures refer to complete disjunction of the facial skeleton from the skull base.

Question 207

293. The MOST common cause of SVC syndrome is:

A. Lymphoma
B. Primary lung cancer
C. Mediastinal fibrosis
D. Tuberculosis

Answer 207

Answer: B

• Malignant tumors are the cause in 80–90% of cases; lung cancer accounts for about 90%.

Question 208

294. A patient has their ulnar nerve transected at the wrist. He/she will be unable to:

A. Flex DIP of 5th digit
B. Extend 4th digit
C. Adduct the thumb
D. Cross 1st and 2nd fingers

Answer 208

Answer: C and D

• terminal branches in the hand:
  - guyon’s canal:
  - superficial cutaneous branch to ulnar portion of palm & volar surfaces of ulnar 1 1/2 fingers,
  - deep motor branch passes adjacent to hook of hamate;
• deep branch, innervating hypothenar muscles & third & fourth lumbricales, adductor pollicis, all interossei, & deep head of FPB;
• division of ulnar nerve at wrist results in paralysis of all small muscles of hand except first & second lumbricales & most of thenar muscles;
• • paralysis of adductor pollicis produces Froment’s sign;

• Flexor capri ulnaris and flexor digitorum profundus strength should be assessed. Intrinsic muscle function is tested by asking the patient to cross the long finger over the index finger (ie, crossed finger test). Only 2 muscles can be tested accurately in the hand, the abductor digiti quinti and the first dorsal interosseous. The tendons or bellies of these muscles can be palpated or visualized. Weakness of thumb pinch may be elicited by the Froment sign. A Martin-Gruber anastomosis in the forearm or a Riche-Cannieu anastomosis in the palm may deceive the examiner by apparent functioning of ulnar-innervated muscles.

Question 209

295. Lidocaine needs to be adjusted in the case where:
     a. Decreased with hepatic dysfunction
     b. Decreased with renal dysfunction
     c. Increased dose with CHF
     d. Increase dose with rifampin
     e. Increase dose with other local aesthetics

Answer 209

Answer: A

• Lidocaine Dosing: Hepatic Impairment (access surgery) Reduce dose in acute hepatitis and decompensated cirrhosis by 50%.

Question 210

296. A patient with chronic renal failure on haemodialysis has a coagulopathy. What is the most appropriate explanation:
     a. Thrombocytopenia
     b. Qualitative platelet defect
     c. Hypoprothrombinemia
     d. Vitamin K deficiency
     e. Anaemia of chronic disorders

Answer 210

Answer: B

• Patients with acute renal failure often have defective platelet function (American Journal of Pharmaceutical Education)

Question 211

297. MENII screening test for the siblings of affected adult is:
     a. P53 protooncogene
     b. RET oncogene
     c. Ca levels
     d. Parathyroid scan
     e. CT scan

Answer 211

Answer: B
• Patients with a family history of MEN II should have a RET-2 proto-oncogene screening test (Internet journal of surgery)
• The RET gene encodes for a transmembrane receptor tyrosine kinase that plays a role in proliferation, migration, and differentiation of cells derived from the neural crest. Gain-of-function mutations in the RET gene are associated with medullary thyroid carcinoma in isolation or multiple endocrine neoplasia type 2 (MEN2) syndromes.

Question 212

298. 45 year old patient sustained an inhalation burn injury all of the following are done in the initial management except:
     a. Intubation
     b. Bronchoscopy and esophagoscopy
     c. IV access
     d. Tracheotomy
     e. All of the above

Answer 212

Answer: D

• Management of inhalation injury is directed at maintaining open airways and maximizing gas exchange while the lung heals. A coughing patient with a patent airway can clear secretions effectively, and effort is made to manage patients without mechanical ventilation if possible. If respiratory failure is imminent, intubation is instituted, with frequent chest physiotherapy and suctioning performed to maintain pulmonary toilet. Frequent bronchoscopy may be needed to clear inspissated secretions. (Sabiston)

Question 213

299. All of the following findings are associated with a diabetic patient who is hypotensive, tachycardic in coma except:
     a. Ketonemia
     b. High glucose
     c. Leukocytosis
     d. Hyperkalemia
     e. Uraemia

Answer 213

Answer: E. Uremia

• Glycosuria of 4+ and strong ketonuria with hyperglycemia, ketonemia, low arterial blood pH, and low plasma bicarbonate are typical of diabetic ketoacidosis. Serum potassium is often elevated despite total body potassium depletion resulting from protracted polyuria or vomiting. Elevation of serum amylase is common but often represents salivary as well as pancreatic amylase. Thus, in this setting, an elevated serum amylase is not specific for acute pancreatitis. Serum lipase may be useful if the diagnosis of acute pancreatitis is being seriously considered. Azotemia may be a better indicator of renal status than serum creatinine, since multichannel chemical analysis of serum creatinine (SMA-6) is falsely elevated by nonspecific chromogenicity of keto acids and glucose. Most laboratories, however, now routinely eliminate this interference. Leukocytosis as high as 25,000/mcL with a left shift may occur with or without associated infection. The presence of an elevated or even a normal temperature would suggest the presence of an infection, since patients with diabetic ketoacidosis are generally hypothermic if uninfected.

Question 214

300. 35year old female in the third trimester found to have a thyroid mass, the biopsy shows papillary cancer. The most appropriate management is:
     a. Wait until delivery and do thyrodectomy
     b. Total thyrodectomy now
     c. Terminate pregnancy and do thyrodectomy
     d. Chemotherapy
     e. Radiotherapy

Answer 214

Answer: A

Question 215

301. Which of the following anesthesitic agents do not cause malignant hyperthermia:
     a. Local amide
     b. Local ester
     c. Pancronium
     d. Succinylcholine

Answer 215

Answer: C

• Triggers of MH:
ovolatile anesthetic
osuccinylcholine
oamide local anesthetics (ACTUALLY THIS IS NO LONGER TRUE, local doesn’t cause it)

Question 216

302. What is the definition of neoadjuvant chemotherapy:
     a. Chemotherapy pre op
     b. Chemotherapy post op
     c. Chemotherapy intra op
     d. Chemo and radiotherapy
     e. None of the above

Answer 216

Answer: A

Question 217

303 The majority of CO2 in the blood is found as :

a. HCO3
b. Carbonic acid
c. Dissolved CO2 gas
d. Bound to haemoglobin
e. None of the above

Answer 217

Answer: A

• CO2 is carried in blood in three different ways. (The exact percentages vary depending whether it is arterial or venous blood). Most of it (about 70% – 80%) is converted to bicarbonate ions HCO3− by the enzyme carbonic anhydrase in the red blood cells, by the reaction CO2 + H2O → H2CO3 → H+ + HCO3−. 5% – 10% is dissolved in the plasma. 5% – 10% is bound to hemoglobin as carbamino compounds. (Wikipedia)

Question 218

304. Given multiple clinical scenarios, which most likely represents a septic patient (the exact scenarios provided may have been slightly different)
     A. Leukocytosis, fever, warm extremities, wide pulse pressure
     B. Narrow pulse pressure, normothermia, tachycardia
     C. Decreased mental status, low cardiac output, mottled extremities
     D. Distended jugular veins, cool hands, tachypneic

Answer 218

Answer: A

Question 219

305. Given the following table, what is the formula for specificity?

a (+ disease, + test), b (- disease, + test)
c (+ disease, - test), d (-disease, -test)

A. d/c+d
B. a/a+c
C. d/d+b
D. a/a+b / c/c+d

Answer 219

Answer: C

• Specificity is the proportion of people without disease who have a negative test
• Sensitivity is the proportion of people with disease who have a positive test (=a/a+c)

Question 220

306. A 12 year old boy is in a serious accident. On examination he has blood at the urethral meatus. The next appropriate step is:
     E. Insert a foley catheter.
     F. Perform a retrograde urethrogram
     G. Insert a suprapubic catheter and perform cystography
     H. Stat pelvic CT
     I. Stat pelvic MRI

Answer 220

Answer: F

Question 221

307. The effect of positive end expiratory pressure (PEEP) can include all except:
     a. Increased risk of pneumothorax
     b. Decreased cardiac output
     c. Decreased venous return
     d. Decreased central venous pressure
     e. All of the above

Answer 221

Answer: D

• PEEP can decrease cardiac output by several mechs including (ICU book):
o Reduced venous return
o Reduced ventricular compliance
o Increased RV outfow impedance
o Ventricular external constraint by hyperinflated lungs
o Note: the creased in CO from PEEP is esp in hypovelemic pts

Question 222

308. If a dose of 200 cGy of Cobalt-60 radiation reduces the number of viable cells in a tumor from 100,000,000 to 60,000,000, then a subsequent dose of 200 cGy will reduce the number of viable cells to:
A.	10,000,000
B.	16,000,000
C.	20,000,000
D.	24,000,000
E.	36,000,000

Answer 222

Answer: E

Question 223

309. A 23 year old rock climber falls 30 feet, sustaining a fracture at the T10 level. She subsequently is diagnosed with a Brown-Sequard syndrome. On physical exam she has a loss of light touch along her left T10 dermatome as well as:
310. Loss of proprioception and motor function in her left leg and loss of pain and temperature sense in her right leg
311. Loss of pain and temperature sensation and motor function in her left leg and proprioception in her right leg
312. Loss of proprioception and pain and temperature sensation in her left leg and loss of motor function in her right leg
313. Loss of proprioception, pain and temperature sensation and motor function in her left leg, with no loss in her right leg
314. None of the above

Answer 223

Answer: A
• Brown-Sequard Syndrome: This syndrome results from hemitransection of the spinal cord with unilateral damage to the corticospinal (motor) and spinothalamic tracts (pain/temp/crude touch), with subsequent loss of ipsilateral motor and dorsal column function (light touch/vibration/proprioception), and contralateral pain and temperature sensation. Substantial recovery may be expected from this syndrome. (access surgery: Trauma)

Penetrating trauma is far more likely to cause this uncommon syndrome than vehicular crash, fall, or crushing injury

Question 224

310. The best management of chronic empyema is?
     a. Closed tube thoracostomy
     b. Decortication
     c. Pneumonectomy
     d. Subresection and open drainage
     e. IV antibiotics for 4 weeks

Answer 224

Answer: B

Question 225

1. What is the most common lung cancer associated with SIADH?
   a. Squamous cell.
   b. Large cell.
   c. Small cell.
   d. Adenocarcinoma.
   e. Carcinoid tumour.

Answer 225

Answer: C

• The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) can occur following head injury or surgery to the central nervous system, but it also is seen in association with drugs (such as morphine, nonsteroidals, and oxytocin) and in a number of pulmonary (pneumonia, abscess, and tuberculosis) and endocrine disease states (hypothyroidism and glucocorticoid deficiency). Additionally, it can be seen in association with a number of malignancies (most notably small-cell cancer of the lung, but also pancreatic carcinoma, thymoma, and Hodgkin’s disease). PTH secretion is caused by squamous cell ca.

Question 226

311 A patient in renal failure needs dose adjustment for all of the following antibiotics EXCEPT:

a. Ampicillin
b. Cefazolin
c. Metronidazole
d. Septra
e. Tobramycin

Answer 226

Answer: C

-all the other need dose adjustment with renal impairment

Question 227

312. Most common cause of infection following domestic animal bite
     a. Staph aureus
     b. Beta hemolytic strept
     c. Pasturella multicida

Answer 227

Answer: C

• Dog bites differ from human bites in that they are a more crushing-type injury because of the animal’s round teeth and strong jaws. Mixed organisms, both aerobic and anaerobic, have been cultured from dog bite wounds. The most common organisms include Pasteurella multocida, Staphylococcus species, alpha-hemolytic streptococci, Eikenella corrodens, Actinomyces, and Fusobacterium.(Schwartz)
• Dog bites cause open wounds, often with tissue necrosis secondary to crush injury. Infection is unusual, and antimicrobial prophylaxis is not indicated in routine cases. Cat bites cause deep puncture wounds with little crush injury and are associated with a high risk of infection, mainly with Pasteurella multocida. (Lange Emerg)

Question 228

313. Prophylactic antibiotics for a clean contaminated operation should be given when?
     a. 8h pre op
     b. 4h pre op
     c. On call to OR
     d. At the time of skin incision
     e. In the recovery room post op

Answer 228

Answer: C

For most patients undergoing elective surgery, the first dose of prophylactic antibiotics are given intravenously at the time that anesthesia is induced. It is unnecessary and may be detrimental to start them more than 1 hour preoperatively, and it is unnecessary to give them after the patient leaves the operating room. A single dose, depending on the drug used and length of the operation, is often sufficient. For operations that are prolonged, the prophylactic agent chosen is given in repeated doses at intervals of one to two half-lives for the drug being used. (Sabiston)

Table 14-2 – Surgical Wound Classification According to Degree of Contamination (Sabiston)
WOUND CLASS DEFINITION

Clean An uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, or infected urinary tract is not entered. Wounds are closed primarily and, if necessary, drained with closed drainage. Surgical wounds after blunt trauma should be included in this category if they meet the criteria

Clean-contaminated An operative wound in which the respiratory, alimentary, genital, or urinary tract is entered under controlled conditions and without unusual contamination

Contaminated Open, fresh, accidental wounds. In addition, operations with major breaks in sterile technique or gross spillage from the gastrointestinal tract and incisions in which acute, nonpurulent inflammation is encountered are included in this category

Dirty Old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation

Question 229

1. The skin preparation that has the most immediate activity and greatest decrease in bacterial count is:
   a. Iodophores.
   b. Chlorhexidine.
   c. Isopropyl alcohol.
   d. Soap.
   e. Hexachlorophene.

Answer 229

Answer: C

DESCRIPTION OF SKIN PREPARATION ANTI-SEPTIC AGENTS
Chlorhexidene Gluconate
Chlorhexidene gluconate (CHG) has immediate, persistent, and residual anti-microbial properties. This product has a strong tendency to bind the tissue, which contributes to its extended anti-microbial action. Depending on the concentration, it exerts bacteriostatic and bactericidal effects on a broad range of gram-positive and gram-negative bacteria. CHG has limited sporicidal activity (Paulson, 2003).
Iodophor
Povidine-iodine (PVI) is the most commonly used form of iodophor and the most widely used pre-operative skin anti-septic. This product has an excellent immediate anti-microbial effect. PVI has good local tolerability: it is not irritating or painful to the skin. It is effective against gram-positive and gram-negative bacteria, fungi, and protozoa. With the appropriate length of exposure time and concentration, iodophors are also effective against mycobacterium, spores of Bacillus spp and Clostridium spp. PVI may be less effective in the presence of blood, necrotic tissue, or purulence (Paulson, 2003).
Parachlorometaxylenol
One of the oldest anti-microbials, parachlorometaxylenol (PCMX, also known as chloroxylenol) is relatively safe for human use. It has fair to good anti-microbial efficacy. It is not widely used as a skin preparation agent because of its comparatively less effective anti-microbial action (Paulson, 2003).
Alcohol and Alcohol-Based Agents
Alcohols are broad spectrum, fast-acting anti-microbials. They are ineffective against bacterial spores but generally effective against fungal species and some viruses. Although alcoholic anti-septics have excellent immediate anti-microbial action, they have limited persistence and residual effects (Paulson, 2003).
Currently, many products incorporate alcohol along with other anti-septic agents to address the lack of persistence of alcohol. The addition of other anti-septic agents such as iodophor or CHG to an alcohol-based agent is necessary to extend its persistence. Another strategy to improve persistence of alcohol is to add a preservative such as zinc pyrithione (ZPT). The addition of ZPT provides persistence to alcohol that is absent if it is used alone. This combination of alcohol and ZPT demonstrates rapid reduction of resident and transient flora, which exceeds FDA requirements (Seal & Paul-Cheadle, 2004).
The combination of alcohol with CHG shows an improvement in immediate anti-microbial properties that provide superior clinical efficacy as a skin anti-septic agent. The CHG component of this combination results in persistent anti-microbial action (Paulson, 2003).
Another anti-septic agent, which may benefit from the addition of alcohol, is iodophor. The combination of isopropyl alcohol and iodophor results in a product with immediate efficacy that requires less time for application in comparison with typical iodophor agents (Segal & Anderson, 2002).