2010

Question 1

*1. 	A 19 year old man suffers a stab wound to the mid-abdomen.  On arrival in the Emergency Room his blood pressure is 80/50.  Following rapid infusion of 4 liters of normal saline, his blood pressure is 110/80.  Blood gasses taken at this time are:
ph	7.20
pO2	95
PCO2	25
HCO3	15
	This patient’s metabolic acidosis would be best treated with?
a)	1 amp sodium bicarbonate IV
b)	2 units packed RBC stat
c)	hyperventilation
d)	immediate laparotomy

Answer 1

d

Question 2

2. An elderly diabetic man is admitted to hospital for treatment of an infected foot ulcer. He is found to have a serum sodium of 119 and a blood glucose level of 33. His hyponatremic state should be treated with?
   a) insulin infusion to reduce blood glucose level to normal
   b) normal saline 150 cc/h until the serum sodium returns to normal
   c) 3% NaCl at 400 cc/h until the serum sodium returns to normal
   d) 1000 cc/day water restricted diet

Answer 2

a

Question 3

3. A 77 year old man undergoes percutaneous nephrostomy because of an infected and obstructed left ureter. The patient develops a gram negative bacteremia immediately following the procedure. The earliest manifestation of sepsis syndrome in this patient is likely to be:
   a) hypotension
   b) lactic acidosis
   c) elevated serum creatinine
   d) hyperventilation with respiratory alkalosis

Answer 3

d

Question 4

4. The following four factors affect the rate of flow of blood through a stenotic artery. Which is the most important?
   a) diameter of stenosis
   b) length of stenosis
   c) blood viscosity
   d) systolic blood pressure

Answer 4

a

Question 5

5. What is the most common cause of an acquired hypercoagulable state?
   a) cigarette smoking
   b) heparin-induced thrombocytopenia (HIT)
   c) antiphospholipid antibody (eg lupus anticoagulant)
   d) oral contraceptives

Answer 5

a

Question 6

6. Which of the following clinical conditions are indicated by the presence of serum antibodies against hepatitis B surface antigen (anti-HBs) and hepatitis B core antigen (anti-HBc) in the absence of HBs AG?
   a) active acute infection with the hepatitis B virus
   b) normal response to vaccination with hepatitis B vaccine
   c) chronic active hepatitis due to the hepatitis B virus
   d) recovery with subsequent immunity following acute hepatitis B infection

Answer 6

d

Question 7

7. A 70 year old man has known cirrhosis of the liver complicated by portal hypertension and ascites. He is admitted to hospital because of increasing encephalopathy and low grade fever. Which of the follow statements about this situation is correct?
   a) a diagnosis should be made clinically and the patient immediately started on antibiotics
   b) infection, if present, is often polymicrobial
   c) antibiotic therapy is reserved with patients with positive acidic fluid cultures
   d) gram-negative enteric bacteria are often present in infected ascidic fluid

Answer 7

d

This presentation is consistent with spontaneous bacterial peritonitis: Clinical manifestations of spontaneous bacterial peritonitis include fever, abdominal pain, abdominal tenderness, and altered mental status.

In patients with suspected spontaneous bacterial peritonitis (SBP), empiric therapy should be initiated as soon as possible to maximize the patient’s chance of survival [2,3]. However, antibiotics should not be given until ascitic fluid has been obtained for culture. Most cases of SBP are due to gut bacteria such as Escherichia coli and Klebsiella (both Gram negative), though streptococcal and staphylococcal infections can also occur (table 3). As a result, broad-spectrum therapy is warranted until the results of susceptibility testing are available

Question 8

8. All the following proteins are primarily synthesized in the liver, EXCEPT?
   a) albumin
   b) fibrinogen
   c) Factor VII
   d) von Willebrand Factor

Answer 8

d

The liver manufactures serum albumin, fibrinogen, and the prothrombin group of clotting factors (except for Factors 8)

D- vWF is synthesized in endothelium (in the Weibel-Palade bodies), megakaryocytes (α-granules of platelets), and subendothelial connective tissue.[1]

Question 9

9. Regarding the progression of cells from normal to cancerous, which of the following statements is NOT true?
   a) dysplasia describes cells with altered size, shape, and organization
   b) in the absence of atypia or dysplasia, hyperplasia confirms only a modest, if any, risk of cancer in a given tissue
   c) all dysplastic tissues eventually progress to frank carcinoma
   d) metaplastic changes may be reversible

Answer 9

C

Question 10

• 10. Primary blast injury is caused by the blast pressure wave as it propagates through air or water. Common injuries of this type include all of the following EXCEPT?
      a) myocardial contusion
      b) pulmonary contusion
      c) hollow-viscous perforation
      d) perforated eardrum

Answer 10

A

Question 11

11. A 34 year old woman, know to use crack cocaine, is brought to the Emergency Room following a fall of approximately 20 feet. She has an obvious left tibia-fibula fracture and an open left humeral fracture. She is extremely agitated and uncooperative. Blood pressure is 180/120 and the heart rate is 130. Further investigation and management of this patient will require sedation. This is best accomplished by?
    a) IM Haloperidol 5 mgs
    b) IV Midazolam 2 mgs, repeated every 5 minutes as required
    c) IV Fentanyl 50 micrograms, repeated every 5 minutes as required
    d) IV Propofol 10 mgs/kg, followed by endotracheal intubation

Answer 11

D

I just looked this up and uptodate says use benzos for psychomotor agitation. She seems to be protecting her airway, so I don’t know why she needs intubation other than agitation.

I think I would have said B unless the stem clearly said there was an airway/oxygenation issue

Below is from UTD:

Psychomotor agitation — Agitated patients are sedated as needed with benzodiazepines, after ensuring they are not hypoglycemic or hypoxic. We suggest diazepam be given in an initial dose of 10 mg IV, then 5 to 10 mg IV every three to five minutes until agitation is controlled. Monitor patients for respiratory depression and hypotension. Intramuscular lorazepam can be used if IV access is unavailable, but its peak effect is typically delayed (10 to 20 minutes).

Question 12

12. A 35 year old man is injured in a high speed motor vehicle crash. When he is brought to the Emergency Room, his blood pressure is 90/50, heart rate 120, GSC 3. The anaesthesia resident can mask-bag the patient achieving an O2 saturation of 95, but cannot intubate the patient with a laryngoscope. The next step in management of the airway should be?
    a) attempt intubation with a glide-scope
    b) attempt fibroptic intubation
    c) surgical airway
    d) call for a staff anesthetist

Answer 12

D

Question 13

13. Immunosuppression to facilitate organ transplant may result in many complications. Malignant lymphoma may occur years after the transplant. Which of the following statements about transplantation associated lymphomas is NOT true?
    a) they are usually non-Hodgkin’s B-cell lymphomas
    b) the malignant transformation may be caused by the Epstein-Barr virus
    c) the incidence of lymphoma is directly related to the amount of immunosuppression received over time
    d) upon diagnosis of the lymphoma, withdrawn of immunosuppression is rarely successful in eradicating the tumour

Answer 13

D - Reduction of immunosuppression is one of the first line treatments for eradication.

A) Classical Hodgkin lymphoma-like PTLD is the least common form of PTLD (but I think one of the more malignant ones?)

B) The pathogenesis of PTLD in most patients relates to the outgrowth of EBV-positive B cell proliferations in the setting of chronic T cell immunosuppression. However, EBV-negative tumors and T cell tumors can also occur.

C) The principal risk factors underlying the development of a post-transplant lymphoproliferative disorder (PTLD) are the degree of overall immunosuppression and the EBV serostatus of the recipient.

D) The main options for initial treatment are reduction of immunosuppression, immunotherapy with the CD20 monoclonal antibody rituximab, chemotherapy, radiation therapy, or a combination of these.

Question 14

14. A 55 year old man underwent successful kidney transplantation two years ago. He is taking Mycophenolate, prednisone, and tacrolimus to prevent rejection. He presents in the Emergency Room with generalized peritonitis secondary to a perforated viscus and undergoes emergency surgery. In order to prevent organ rejection in the perioperative period, the surgeon should?
    a) only provide stress-steroid coverage until the patient can resume oral intake
    b) ask the pharmacist to convert his oral dosages to equivalent IV dosages until the patient can resume oral intake
    c) continue oral intake with his usual meds in the expectation that his GI tract will be able to absorb most of the medication
    d) supplement IV steroid stress coverage with IV antithymocyte globulin until the patient can resume oral intake

Answer 14

A

Question 15

15. A 70 year old man is found to have a bulky mid-rectal adenocarcinoma without metastatic disease. He undergoes neoadjuvant chemo-radio therapy. On flexible sigmoidoscopy six weeks after completion of therapy, he is seen to have only a 2 cm residual tumour, 12 cms from the anal verge. At this point, the surgeon should?
    a) continue to follow the patient to see if the tumour will regress completely
    b) resume chemotherapy in the hope of totally irradiating the tumour
    c) proceed to surgery to remove only the portion of the rectum containing the residual tumour
    d) proceed with surgery to remove almost all of the rectum as if the patient had not had any adjuvant therapy

Answer 15

D

Question 16

• 16. Which of the following arteries cannot be ligated to stop uncontrolled bleeding because of the risk of distal ischemic damage?
      a) common carotid artery
      b) superior mesenteric artery
      c) common femoral artery
      d) descending thoracic artery

Answer 16

D

Question 17

• 17. The following treatments for hypotension due to acute blood loss are contraindicated, EXCEPT?
      a) albumin-containing IV solutions
      b) vasopressors
      c) Trendelenburg positioning
      d) tourniquet to acutely bleeding extremity

Answer 17

D - this is not conra-indicated and is used to prevent further exsanguination

A- The value of colloids (albumin solution, dextran) for resuscitation of traumatic shock is unproven [25,26]. Colloids effectively increase intravascular volume and may maintain plasma oncotic pressure at more normal levels compared with crystalloids. However, a systematic review of trials comparing resuscitation fluids found that use of colloids did not improve mortality or morbidity among trauma patients

B- In trauma don’t use vasopressors are the patient needs volume and vasopressors can further lead to peripheral necrosis/ischemia

c- I didnt find anywhere that it’s contra-indicated, but doesn’t help to improve blood flow or oxygenation in hypovolemic patient

Question 18

18. Peripheral nerve damage is the second most common anesthetic complication leading to malpractice suits. All of the following nerves may be injured, EXCEPT?
    a) ulnar nerve
    b) femoral nerve
    c) brachial plexus
    d) sciatic nerve

Answer 18

B
I found complications associated with all these nerves….

Ulnar neuropathy comprised one third of the injuries, the brachial plexus nerves 23% and lumbosacral roots 16%

Question 19

19. A 79 year old man undergoes left hemicolectomy for an obstructing colon cancer. On post-operative day five he developed peritonitis and undergoes relaparotomy and exteriorization of his anastomotic leak. Following this procedure, he develops acute renal failure despite aggressive treatment in the ICU. NG feeds are initiated. His physician should aim for a protein intake of?
    a) 0.3 grams/protein/kg/day
    b) 0.8 grams/protein/kg/day
    c) 1.4 grams/protein/kg/day
    d) feed only with glucose and lipids because of his acute renal failure

Answer 19

C

Requirements: 250 mg of N/kgday or 1.7 g of protein equivalent/kgday. (Range: 0.8-2.0 g/kg/day)
• Energy Value: 4 kcal/gm
• 6.25 g protein:1 g N; 0.16 g N:1 g protein
• Protein is a mixture of single amino acids.
• Nitrogen to caloric ratio is given as g of N:kcal

Question 20

20. A 45 year old man is severely injured in a motor vehicle crash. He undergoes laparotomy with splenectomy, repair liver laceration, and bowel resection. The abdomen is closed primarily. An open fracture of the left tibia is treated with an external fixator. The following morning, his vitals are:
    heart rate 120
    BP 88/50
    CVP 11 mm/Hg
    His urine output is 5 cc/h. Peek airway pressures have increased from 32 to 50 cc/H2O. His abdomen is distended and firm. Bladder pressure is 30 mmHg.
    The next step in his treatment should be?
    a) increase rate of fluid resuscitation
    b) change the ventilator mode to pressure-control ventilation
    c) inotropic therapy
    d) immediate laparotomy

Answer 20

D - Likely bleeding from an intra-abdominal source causing intra-abdominal compartment syndrome. Although his pressure is not >35, he is showing signs of end organ dysfunction with associated Abdoinal hypertension

ACS frequently manifests via such end-organ sequelae as decreased urine output, increased pulmonary inspiratory pressures, decreased cardiac preload, and an
increased cardiac afterload.

Generally, no specific bladder pressure prompts therapeutic intervention, except when the pressure is >35 mm Hg. Rather, emergent decompression is carried out when intra-abdominal hypertension reaches a level
at which end-organ dysfunction occurs

Question 21

• 21. A 25 year old woman was an unbelted passenger in a high speed vehicle crash. She is intubated and a C spine collar is in place. Her GCS is 3T. She has a right pulmonary contusion and multiple lower extremity fractures. The diagnostic procedure of choice for radiologic clearance of her cervical spine is?
      a) 3 view cervical spine x-rays
      b) flexion – extension cervical spine x-rays
      c) CT cervical spine
      d) MR cervical spine

Answer 21

C

Question 22

22. A 68 year old man sustains multiple injuries in a motor vehicle crash including a closed head injury with small frontal contusions, and interparenchymal hemorrhage on CT scan. He has been on coumadin 4 mgs a day for chronic atrial fibrillation for three years. His admission INR is 2.8. The most rapid method of reversing the anticoagulant effect of coumadin is?
    a) recombinant factor VIIa
    b) fresh frozen plasma
    c) vitamin K1
    d) octoplex

Answer 22

D

Question 23

*23. A 45 year old man is brought to the Emergency room after a high speed motor vehicle crash. There was no loss of consciousness. He received 2000 ccs of normal saline en route to hospital. On arrival in the Emergency Room, his vitals are:
Heart Rate 140
Blood pressure 60 systolic
Respiratory Rate 24
GCS 14
On examination, he has no neck tenderness, good breath sounds bilaterally, and a distended tender abdomen. There is no pelvic tenderness or instability and no obvious extremity fractures. A portable chest x-ray shows a left 1st rib fracture only. The next step in his evaluation and treatment should be?
a) focused assessment with sonography for trauma (FAST ultrasound)
b) CT abdomen and pelvis
c) diagnostic laparoscopy
d) laparotomy

Answer 23

D

D was listed as the answer but wouldn’t you do a FAST? He can’t go to CT because he’s unstable. I think the gold standard is still laparotomy for diagnosis so Laparoscopy would not be indicated.

Also I found this in Morrells (I would therefore choose A):

Blunt abdo trauma with hemodynamic instability should undergo DPL or FAST to rule out intraabdominal injury.

Indications for laparotomy in blunt trauma:
• positive examination
• positive DPL or FAST.

Ultrasound provides an important initial screening examination in the adult trauma patient. However, ultrasound is not a replacement for the more sensitive imaging studies often needed to identify specific injuries in patients with concerning abdominal or thoracic symptoms or signs. Most such patients, if hemodynamically stable, undergo computed tomography (CT). Unstable patients with intraperitoneal hemorrhage identified by ultrasound generally proceed directly to laparotomy.

Question 24

24. A 66 year old woman with long-standing rheumatoid arthritis requires emergency surgery for perforated sigmoid colon diverticulitis. She has been receiving prednisone 10 mgs a day for at least the last five years. The recommended management of perioperative parenteral corticosteroids for this patient should be?
    a) no systemic corticosteroids unless she demonstrates signs of adrenal insufficiency (eg hemodynamic instability)
    b) a 100 mg bolus of hydrocortisone with induction of anaesthesia, then hydrocortisone 150 mgs/day, in divided doses until oral intake resumes
    c) a 100 mgs bolus of hydrocortisone at induction of anaesthesia, hydrocortisone 300 mgs/day in divided doses until oral intake resumes
    d) a 100 mg bolus of hydrocortisone at induction of anaesthesia, 300 mgs/day of hydrocortisone in divided doses on post operative day one followed by a taper of 50% per day over the next three days until oral intake resumes

Answer 24

B

B was listed but I think it’s D based on Morrell’s notes

Indications for stress dose steroids: supraphysiologic steroid doses for >1 week in past year (if in doubt
stim. test), known adrenal insufficiency

• Stress dosing: 1st dose pre-op, 300mg hydrocortisone/day (100mg q8h) x24hrs then rapid taper over 72hrs
(to avoid wound healing & infx complications)

Question 25

25. Three days after knee arthroscopy, a 35 year old man presents with mild dyspnea on exertion. His temperature is 38 degrees centigrade. His chest is clear to auscultation except for right lower lobe rales. Minimal knee swelling is noted at the arthroscopy site. His white blood cell count is 12,400 and D-dimer level is normal. A chest x-ray shows that the right hemi-diaphragm is obscured. The next diagnostic test should be?
    a) bilateral lower extremity Doppler ultrasound examination
    b) ventilation/perfusion lung scan
    c) CT chest with PE protocol
    d) sputum culture

Answer 25

D

Question 26

26. Which of the following statements about antithrombotic treatments is TRUE?
    a) in the absence of antithrombin III, unfractionated heparin has no significant anticoagulant affect
    b) low molecular weight heparin’s share the ability to accelerate the activity of factor 10a
    c) warfarin inhibits the absorption of vitamin K from the intestinal track
    d) Hirudin, a synthetic thrombin inhibitor, is dependent on antithrombin III for anti-coagulant activity

Answer 26

A

Heparin binds to the enzyme inhibitor antithrombin III (AT), causing a conformational change that results in its activation through an increase in the flexibility of its reactive site loop.[17] The activated AT then inactivates thrombin and other proteases involved in blood clotting, most notably factor Xa.

B- LMWHs and fondaparinux target antifactor Xa activity rather than antithrombin activity, with the aim of facilitating a more subtle regulation of coagulation and an improved therapeutic index.

C- Vit K antagonist. Does not inhibit absorption

D) Hirudin is the most potent natural inhibitor of thrombin. Unlike antithrombin, hirudin binds to and inhibits only the activated thrombin, with a specific activity on fibrinogen. Thus not necessitating antithrombin III

Question 27

27. A 70 year old diabetic man with Childs C cirrhosis undergoes operative repair of an incarcerated umbilical hernia. On post-operative day one, the patient develops upper GI bleeding and requires four units of packed red cells. On the fifth post-operative day, the wound is noted to be painful and erythematous. All of the following are risk factors for developing a surgical site infection in this patient, EXCEPT?
    a) intra-operative hyperglycemia
    b) post-operative transfusion
    c) cirrhosis
    d) age

Answer 27

D
I feel like they’re all associated with risk of SSI but the only one not listed in Schwartz is Cirrhosis

Risk factors associated with SSI (From Schwartz)

Patient factors
Older age
Immunosuppression
Obesity
Diabetes mellitus
Chronic inflammatory process
Malnutrition
Smoking
Renal failure
Peripheral vascular disease
Anemia
Radiation
Chronic skin disease
Carrier state (e.g., chronic Staphylococcus carriage)
Recent operation
Local factors
Open compared to laparoscopic surgery
Poor skin preparation
Contamination of instruments
Inadequate antibiotic prophylaxis
Prolonged procedure
Local tissue necrosis
Blood transfusion
Hypoxia, hypothermia

Question 28

28. Risk factors for clostridium difficile – associated diarrhea include all of the following EXCEPT?
    a) advanced age
    b) immunosuppressive agents
    c) asymptomatic carrier status
    d) naso-gastric intubation

Answer 28

C

Question 29

29. A 60 year old woman with a 40 year history of smoking presents with a painless 2 cm nodule just anterior to the sternomastoid muscle and inferior to the angle of the mandible. The most appropriate means to obtaining a tissue diagnosis is?
    a) fine-needle aspiration for cytology
    b) ultrasound-guided core needle biopsy for histopathology
    c) incisional surgical biopsy
    d) excisional surgical biopsy

Answer 29

A

Question 30

30. Bupivacaine (marcaine) injection for local analgesia may be associated with all of the following adverse affects, EXCEPT?
    a) seizure
    b) hypotension
    c) heart block
    d) methemoglobinemia

Answer 30

D

Question 31

31. The intravenous anesthetic induction agent with the LEAST effect on the cardiovascular system is?
    a) propofol
    b) ketamine
    c) etomidate
    d) thiopental

Answer 31

C - Preserves BP

A- Decreases BP

B-
-Increases BP (bad for CAD)
- Increases HR (bad for CAD)
• Cardiac depressant but at low doses (15 – 20%), it causes the least BP of any induction agent.

D- Induces vasodilation and cardiac depression

Question 32

32. During an elective laparoscopic cholecystectomy, a 35 year old woman develops a sudden onset of hypotension, tachycardia, cyanosis, flushed warm skin and increasing end-tidal CO2 levels. Which of the following statements about this condition is NOT true?
    a) the diagnosis is confirmed by an in vitro muscle test
    b) informing family members of this reaction is critical
    c) treatment includes administration of dantrolene sodium
    d) local anesthetics can also trigger the reaction

Answer 32

D

A- Diagnosis is via muscle biopsy

Triggers for MH:

1. Some inhalational agents (“ane” drugs)
2. Depolarizing muscle relaxants such as SCh and decamethonium.
3. Amide based local anaesthetics (Sabiston 2001 is only source that list these as a trigger.)

Treatments

1. Stop anaesthetic and SCh
2. Hyperventillate with 100% O2
3. Dantrolene (2 – 10 mg/kg to block release of Ca from SR, give in 1 mg/kg increments)
4. Active cooling
5. Correction of lyte and acid-base abnormalities

Question 33

33. Prior to making the incision for an emergency open appendectomy, administering 0.5% bupivacaine without epinephrine into the area of the wound (including deep tissues) will?
    a) increase the risk of wound complications
    b) increase the use of non-steroidal anti-inflammatory medication
    c) decrease post-operative pain as measured by pain scales
    d) increase narcotic analgesic consumption

Answer 33

C

Question 34

34. Treatment of wounds with negative-pressure wound dressing (VAC dressings) may result in all of the following, EXCEPT?
    a) increased apoptosis
    b) increased granulation tissue
    c) improved microvascular blood flow to wound edges
    d) removal of excess fluid and debris

Answer 34

A

A is the only option that VACs don’t do

Question 35

35. A physician punctures her finger with a suture needle while securing a drain tube in a patient with AIDS. The most appropriate therapy for the physician will be?
    a) Zidovudine
    b) Zidovudine and Lamivudine
    c) Zidovudine, Lamivudine and Nelfinavir
    d) Indinavir and Nelfinavir

Answer 35

B

The answer was B but based on Up todate, they usually give triple therapy. So I’d say C. but the drugs listed in up to date are different.

We offer post-exposure prophylaxis (PEP) using a three-drug regimen to healthcare personnel (HCP) with a percutaneous, mucous membrane, or nonintact skin exposure to body fluids of concern

Data from animal models have supported the efficacy of zidovudine in preventing transmission of HIV infection

Question 36

36. Which of the following statements about the use of antibiotics for the prevention of surgical site infection is NOT true?
    a) antibiotics should be administered within 60 minutes of incision
    b) the therapeutic dose of the antibiotic should be administered intravenously
    c) adequate tissue concentration should be maintained during the operation by re-dosing as necessary
    d) antibiotics should be continued for 24 hours after operation

Answer 36

D

This is with some exceptions, arthroplasty for example

A - Antimicrobial therapy should be completely infused 60 minutes prior to surgical incision, if possible, to optimize adequate drug tissue levels at the time of initial incision
Some studies suggest lower infection risk with initiation of antimicrobial administration within 30 minutes before surgical incision, although thus far data are insufficient to support this approach as a routine practice

B- Agreed

C- To ensure adequate antimicrobial serum and tissue concentrations, repeat intraoperative dosing is warranted for procedures that exceed two half-lives of the drug and for procedures in which there is excessive blood loss (>1500 mL)

D- In general, repeat antimicrobial dosing following wound closure is not necessary and may increase the risk for development of antimicrobial resistance [30,52-56]. In a systematic review of randomized trials, there was no difference in the rate of SSI with single dose compared with multiple-dose regimens given for less than or more than 24 hours (combined odds ratio 1.04, 95% CI 0.86-1.25) [53].

For cases in which prophylaxis beyond the period of surgery is warranted, in general, the duration should be less than 24 hours [6,31].

Question 37

37. The detection of microscopic sulfur granules in a specimen of pus is pathoneumonic for infection with?
    a) actinomycosis
    b) mucormycosis
    c) stenotrophomonas maltophilia
    d) nocardia asteroides

Answer 37

A

The bacterium and typical microscopic findings include necrosis with yellowish sulfur granules and filamentous Gram-positive fungal-like pathogens.

Question 38

38. A 50 year old man requires amputation of his left arm for necrotizing fasciitis. Wound cultures grew clostridium septicum. Which of the following should be recommended after the patient recovers from the amputation?
    a) upper GI endoscopy
    b) colonoscopy
    c) positron emission tomography (PET Scan)
    d) tagged WBC scan

Answer 38

B

C. Septicum is associated to colon CA

Question 39

39. A 55 year old alcoholic male is admitted to hospital with cellulitis of the lower left leg. Despite appropriate antibiotic therapy, the cellulitis progresses and the patient becomes febrile and hypotenisve. Incision of the skin under local anaesthesia reveals necrotic subcutaneous fat. The next step should be?
    a) gram-stain to determine further therapy
    b) hyperbaric oxygen therapy
    c) above-knee amputation
    d) wide debridement of all necrotic tissues

Answer 39

D

Question 40

40. A 30 year old woman undergoes emergency Caesarian section for fetal distress. On post-operative day four, her wound dehisces and she is taken back to the operating room for resuturing of her wound. The following day, her abdomen is not distended but no bowel sounds are heard. Her physician is concerned about her nutritional state. The preferred route for nutritional intake in this patient is?
    a) regular oral diet
    b) NG tube feeding
    c) Fluoroscopic placement of an NJ feeding tube
    d) TPN via a PICC line

Answer 40

A

Question 41

41. During starvation, the liver maintains serum glucose levels near normal by synthesizing glucose from all the following molecules EXCEPT?
    a) lactate
    b) glycerol
    c) alanine
    d) arginine

Answer 41

D

Question 42

42.	A 70 year old man undergoes emergency aortic grafting because of a ruptured abdominal aortic aneurysm.  In the ICU immediately post-operatively he is on a ventilator and his IV is normal saline at 150 ccs/hr. His vitals and initial blood work are:
Blood pressure 	140/80			pH		7.2
Heart rate 		95			pCO2		 59
Urine output 	120 mls/hr		pO2		110
Hgb 		85			HCO3		15
WBC		14.9
Platelets		79,000
       His acidosis should be treated with?
a)	2 amps sodium bicarb over 30 minutes
b)	1,000 ccs normal saline bolus
c)	1 unit packed red blood cells
d)	increase minute ventilation

Answer 42

D

Question 43

43. An 80 year old woman undergoes laparotomy and ileostomy because of an obstructing unresectable carcinoma of her colon. Post-operatively she does well. Because of excessive ileostomy output she is kept on clear fluids by mouth. She receives IV 2/3-1/3 saline of 20 µmol/l HCL/l at 100 cc/h. On post-operative day four, her electrolytes are:
    Na 122
    K 4.8
    HCO2 22
    Cr 140
    Bun 2.5
    Her hyponatremia should be treated with?
    a) change IV to normal saline 75 ccs/h and replace ileostomy losses with normal saline
    b) infuse 3% NaCl 30 ccs/h
    c) make patient NPO and follow lytes carefully
    d) give lasix 20 mgs IV stat

Answer 43

A

Question 44

44. Which of the following is NOT a risk factor for surgical site infection?
    a) patient colonized with vancomycin-resistent enterococcus (VRE)
    b) cigarette smoking
    c) diabetes mellitus
    d) intra-operative hypothermia

Answer 44

A

Question 45

45. An 85 year old woman with a bleeding gastric ulcer receives 2 units of packed cells over two hours. One hour after her transfusion, she becomes severely dyspnic and is transferred to the ICU. Her physician suspects transfusion-related acute lung injury (TRALI) is responsible for her dyspnea. Which of the following data, obtained in the ICU, rules OUT TRALI?
    a) chest x-rays shows bilateral pulmonary edema
    b) core temperature is 36.8 degrees Centigrade
    c) no history of prior blood transfusions
    d) pulmonary artery wedge-pressure (PAWP) is 28 mm/Hg

Answer 45

ANS: D

• In most patients PAWP estimates LVEDP thus is an indicator of LVEDV (preload of the left ventricle)
  normally 6-12mmHg (1-5mmHg less than the pulmonary artery diastolic pressure)
  -In patients with PCWP >18 mmHg in the context of normal oncotic pressure suggests left heart failure.

As the TRALI definition must not have heart failure as a possible cause, D is the right answer.

Below are the criteria for TRALI

TRALI Criteria:

• Acute onset (during or within six hours of transfusion)
• Hypoxemia (Hypoxemia is defined as PaO2/FiO2 ≤300 or SpO2

Question 46

46. A 65 year diabetic man presents to the Emergency room with septic shock secondary to infected necrosis of his left foot and lower leg. Blood work demonstrates coagulopathy:
    INR 1.7 (n75,000)
    D-dimer 770 (n

Answer 46

D

Question 47

47. A 72 year old man with chronic renal failure on hemodialysis requires surgery to remove an infected hip prosthesis. The surgeon is worried about abnormal bleeding due to the patient’s uremia. All the following treatments will improve platelet functioning in uremic patients, EXCEPT:
    a) intensive dialysis pre-operatively
    b) intraoperative platelet transfusion
    c) intraoperative administration of DDAVP
    d) interaoperative administration of cryoprecipitate

Answer 47

B

A- Either hemodialysis or peritoneal dialysis can partially correct the bleeding time and other in vitro tests of platelet function in approximately two-thirds of uremic patients

C- The simplest, most rapidly acting, and probably least toxic acute treatment for platelet dysfunction in the uremic patient is the administration of desmopressin, an analog of antidiuretic hormone with little vasopressor activity

D-The infusion of cryoprecipitate (10 units intravenously every 12 to 24 hours) can shorten the bleeding time in many uremic patients [50].

Question 48

48. A 58 year old woman undergoes total hysterectomy, bilateral salpingoophorectomy and omentectomy for ovarian carcinoma. Post-operatively she receives an intravenous of 2/3-1/3 of 20 mmol of KCL/l at 100 ccs/h. On post operative day two, routine blood work records:
    Hg 98 (previously 125)
    Na 127
    K 6.3
    Cl 115
    Glucose 23.2
    Creatinine 75
    She has no history of diabetes or renal disease. The next step in her management should be?
    a) transfuse 2 units packed red blood cells
    b) give 10 units regular insulin subcutaneously
    c) give oral sodium polystyrene solution (potassium exchange agent)
    d) repeat blood work

Answer 48

D

Question 49

49. A 65 year old man is scheduled to have a left total knee replacement. He has a mechanical aortic valve and is permanently anticoagulated with coumadin. The most appropriate management of his anticoagulation pre-operatively is?
    a) continue coumadin until the day prior to surgery. Administer two units of fresh frozen plasma at the beginning of the surgery
    b) continue coumadin until the day prior to the surgery. Administer 10 units of Factor VIIa at the beginning of the surgery
    c) hold coumadin 5 days prior to surgery, give Fragmin subcutaneous daily, hold Fragmin on the day of the surgery
    d) hold coumadin 5 days prior to surgery, admit the patient to hospital and treat with IV unfractionated heparin. Hold the heparin two hours prior to the surgery

Answer 49

C

Question 50

50. A 64 year old man has shortness of breath and documented hypoxemia 2 days after right hemicolectomy for cancer. His chest x-ray is unremarkable. His ECG and serum troponin are normal. The next diagnostic test should be?
    a) thoracic CT scan
    b) ventilation-perfusion scan
    c) D-dimer assay
    d) Doppler ultrasound study of the lower extremity

Answer 50

A

Question 51

51.	A 45 year old woman has right sided chest pain and a nonproductive cough seven days after modified radical mastectomy for breast cancer.  Her vitals are:
Heart rate		110
Blood pressure	120/70
Respiratory rate 	24
Her ECG is normal. A thoracic CT scan shows a saddle embolus to the main pulmonary artery extending into both left and right main pulmonary arteries. Blood flow is not completely obstructed to either lung.  The most appropriate treatment would be?
a)	systemic heparin therapy
b)	system thrombolytic therapy
c)	percutaneous mechanical thrombectomy
d)	placement of IVC filter

Answer 51

A

Question 52

52. A 70 year old man develops a 2 cm nodule in the right lung two years after right hemicolectomy for colon cancer. Which of the following is the BEST predictor of the risk of pulmonary complications after lung resection for this patient?
    a) age >60 years
    b) predicted post-operative FeV1 45 torr
    d) pre-operative PaO2

Answer 52

B

Question 53

53. Which of the following statements about acute rejection of a transplanted kidney is NOT true?
    a) it is T-cell mediated
    b) it is related to organ-host human leukocyte antigen disparity
    c) treatment can save the grafted organ in 90-95% of cases
    d) it does not occur with living related donors

Answer 53

D

Question 54

54. Which of the following is an absolute contraindication for liver transplantation?
    a) hepatitis C
    b) synchronous extra hepatic malignancy
    c) alcohol-induced cirrhosis
    d) fulminant hepatic failure

Answer 54

B

Contra-indications to liver transplant
-Inability to withstand the operation usually due to bad heart or lungs.
• Recent IC hemorrhage (post-op coagulopathy)
• Irreversible neurologic impairement
• Active substance abuse (e.g. EtOH)
• Intractable hypotension
• Evidence of systemic infection
• Extrahepatic malignancy
• Inability to comply with f/u

Question 55

55-57. For each of the three statements below, fill in the most appropriate answer.

a) enteral nutrition
b) parenteral nutrition
c) both
d) neither 55. Pre-operative use decreases mortality in severely malnourished patients 56. Decreases infectious complications in critically ill patients 57. Routine post-operative use of after major cancer resection decreases mortality

Answer 55

C
A
D

Question 56

58. A 58 year old man has chronic duodenal ulcer disease because of noncompliance with medications. Over the past two weeks he has had increasing nausea and vomiting with weight loss. In the Emergency room he appears dehydrated with a serum creatinine of 170. All of the following metabolic abnormalities are expected, EXCEPT?
    a) elevated pH
    b) low serum sodium
    c) low serum chloride
    d) low serum potassium

Answer 56

B

Question 57

59. A 58 year old man has chronic duodenal ulcer disease because of noncompliance with medications. Over the past two weeks he has had increasing nausea and vomiting with weight loss. In the Emergency room he appears dehydrated with a serum creatinine of 170. Initial fluid resuscitation of the above patient should consist of?
    a) Ringers lactate solution
    b) normal saline with 20 mmol K Cl/l
    c) half-normal saline with 20 mmol K Cl/l
    d) 3% hypertonic saline

Answer 57

B

Question 58

60. Severe closed head injury often results in increased intra-cranial pressure. Which of the following treatments would NOT help relieve intracranial hypertension?
    a) pulse steroid therapy with decadron
    b) sedation with propofol and muscle paralysis with short-acting agents
    c) hypertonic saline bolus IV
    d) mannitol bolus IV

Answer 58

A

Question 59

61. A 24 year old woman comes to the Emergency Room because of left leg pain. Twelve hours previously she noticed a small puncture wound on the sole of her foot. Over the last six hours, her foot and lower leg have become erythematous, swollen and very tender. She also complains of feeling febrile, with chills and malaise. On examination, her lower leg is edematous and the skin erythematous. No areas of fluctuance are noted. The leg below the knee is extremely tender. Blood work demonstrates a WBC of 25,000. A plain x-ray of the leg does not show any subcutaneous emphysema. The most appropriate treatment of this would be?
    a) oral Keflex and pain meds and return to the Emergency Room in am for reassessment
    b) admit the patient to hospital. Administer Cefazolin IV and elevate leg
    c) admit to hospital. Treat with broad spectrum antibiotics and explore under general anaesthestia if she develops signs or symptoms of compartment syndrome
    d) admit to hospital. Start broad spectrum antibiotics, explore leg under general anaesthesia in OR

Answer 59

D

Question 60

62. The greatest risk of death due to a blood transfusion is from?
    a) HIV transmission
    b) Hepatitis C
    c) ABO incompatibility
    d) Bacterial contamination

Answer 60

C

Question 61

• 63. A 17 year old man driving a snowmobile runs into a tree at high speed. There is no loss of consciousness. He is taken to the local hospital. On clinical examination he has multiple right rib fractures. Abdominal examination is unremarkable. The blood pressure was 130/80 on admission to the Emergency Room and 30 minutes later drops suddenly to 80/40. The most likely cause of this hypotension is?
      a) myocardial contusion
      b) right tension pneumothorax
      c) intraabdominal bleed
      d) thoracic aortic injury

Answer 61

B

Question 62

• 64. A 60 year old male unbelted driver is involved in a high speed motor crash. When evaluated in the Trauma Centre, he is found to be suffering from a significant left epidural hematoma, a false aneurysm in his thoracic aorta, severe lung contusions, a grade II liver laceration, and an open fracture of the left tibia and fibula. Which operation should be carried out first?
      a) craniotomy for epidural hematoma
      b) repair of thoracic aortic aneurysm
      c) laparotomy for hepatic injury
      d) ORIF left tib-fib fracture

Answer 62

A

Question 63

65. Which of the following urinary findings is NOT consistent with the diagnosis of acute renal failure secondary to tubular necrosis?
    a) presence of heme-granular casts
    b) urine sodium concentration >50
    c) urine osmolality 50 ml/min/m2

Answer 63

D

Question 64

66. A patient with acute adrenal insufficiency would be expected to show each of the following, EXCEPT?
    a) hypotension
    b) hyperglycemia
    c) hyperkalemia
    d) hyponatremia

Answer 64

B

Question 65

67. A 75 year old man suffers a pulmonary embolus after a bowel resection for cancer. He is treated with an IV infusion of unfractionated heparin. Two weeks later he is still on his heparin infusion and his platelets drop from 350,000 to 75,000 in two days. Which of the following is a risk factor for the development of heparin induced thrombocytopenia?
    a) heparin given for over ten days
    b) patient over 65 year of age
    c) use of unfractionated heparin
    d) none of the above

Answer 65

D

Is D supposed to be All of the Above?

A- Heparin-induced thrombocytopenia (HIT) has been reported in up to 5 percent of patients exposed to heparin for more than four days

B- Older age may be a risk factor for HIT, but good data illustrating a relationship between age and HIT are lacking.

C- HIT occurs more commonly after exposure to unfractionated heparin than exposure to low molecular weight (LMW) heparin

Question 66

*68.  	A 26 year old man was involved in a motor vehicle crash and suffers a closed fracture of his left femur.  This is treated surgically with an IM nail.  The following day he is found to be confused.  His vitals are:
			Temperature		39.2
			Heart rate 		130
			Blood pressure	130/80
			Respiratory rate	32
	Which of the following investigations is most likely to be diagnostic?
a)	blood culture
b)	MR head
c)	CT thorax  with PE protocol
d)	Doppler ultrasound of both legs

Answer 66

B

I think they’re eluding to Fat Embolism Syndrome, in which case the following are the clinical presentation:

1) Hypoxemia, dyspnea, and tachypnea are the most frequent early findings. A syndrome indistinguishable from acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) may develop. Approximately one-half of patients with FES caused by long bone fractures develop severe hypoxemia and require mechanical ventilation.
2) Neurologic abnormalities develop in the majority of patients with FES

It is usually a clinical diagnosis but some imaging can be usefu.

A- Not useful, and in this situation, he doesn’t really have a reason to be bacteremic

B- MRI of the brain may reveal high intensity T2 signal, which correlates with the degree of clinical neurologic impairment

C- Computed tomography of the chest generally shows focal areas of ground glass opacification with interlobar septal thickening but can occasionally show nodules and vascular filling defects.

Question 67

69. A 64 year old woman presents with sudden onset of a painful swollen left leg two days after stepping on a nail in a farm yard. She is hypotenisve (90/50) and febrile with a temperature of 395. Crepitus is noted in the lower left leg. This infection could be caused by all of the following organisms, EXCEPT
    a) bacteroides fragilis
    b) streptococcus A
    c) clostridium perfringens
    d) staphylococcus aureus

Answer 67

A

Question 68

70. Which of the following treatments has been shown to reduce mortality for patients with severe sepsis?
    a) activated protein C
    b) high-dose corticosteroids
    c) anti-endotoxin antibody
    d) Erythropoietin

Answer 68

A

Morrells notes Proven Strategies for Sever Sepsis:

1. Vt 6 – 8 ml/kg
2. Activated Protein C for those in shock with high Apache > 25
3. Early goal directed therapy (resuscitation)
4. Low dose steroids when refractory to pressors
5. Intensive insulin (controversial still)
6. Daily HD better than q2days (Prisma = 24x7 HD)

Question 69

71. A 62 year old man has hypokalemia refractory to potassium supplementation after laryngectomy for cancer. The most likely etiology is?
    a) hypomagnesemia
    b) hypochloremia
    c) hypoglycemia
    d) hyperphosphatemia

Answer 69

A

Hypomagnesemia is present in up to 40 percent of patients with hypokalemia [64]. In many cases, as with diuretic therapy, vomiting, diarrhea, or certain tubular toxins such as gentamicin and iphosphamide [3,65], there are concurrent potassium and magnesium losses.

Question 70

72. A 23 year old man has a subdural hematoma after a motor vehicle crash. This requires craniotomy shortly after his admission to hospital. He remains intubated and comatose in the ICU. On the fourth post-operative day, he develops an increased oxygen requirement and a CT thorax shows a pulmonary embolus. This should be treated with?
    a) infusion of unfractionated heparin
    b) infusion of a direct thrombin inhibitor (argartroban)
    c) sequential compression device on both legs
    d) place an IVC filter

Answer 70

D

High risk patient for bleeding (rencent surgery and recent bleeding) so IVF filter is recommended.

Question 71

73. A 60 year old man is scheduled for a low anterior resection of rectal cancer. He has hypertension controlled with an angiotension-coverting enzyme inhibitor. He does not smoke and is able to walk up two flights of stairs without difficulty. Pre-operative evaluation and management should include?
    a) dobutamine stress echocardiography
    b) myocardial perfusion scan
    c) perioperative beta blockers
    d) none of the above

Answer 71

D

Question 72

74. 	A 60 year old man is admitted to the ICU following an open aorta-iliac reconstruction.  On admission, his vitals are:
			heart rate		130
			blood pressure		80/40
			CVP			2 mm/Hg
			urine output		10 ccs in the past hour
	His abdomen is soft and nondistended.  His last haematocrit in the OR was 35%.  His low blood pressure should be treated with?
a)	Levophed infusion
b)	blood transfusion 
c)	Hydroxyethyl starch solution
d)	Isotonic crystalloid (N/S, R/L)

Answer 72

D

Normal hematocirt is 38.8 to 50 percent for men and 34.9 to 44.5 percent for women.

From the clinical history, he sounds volume deplete - tachy, hypotensive, low CVP and decrease UO. So D.

Question 73

75. Which of the following statements about alcohol withdrawal syndrome in an acutely ill patient with multiple injuries is TRUE?
    a) dilantin (phenytoin) should be administered prior to benzodiazepines to reduce the risk of seizures
    b) IV alcohol is superior to benzodiazepines for prevention of the syndrome
    c) proprofol may be used as an alternative to benzodiazepines for the treatment of established delirium tremens
    d) prophylactic regimes that include clonidine in addition to benzodiazepine reduce the incidences of cardiac complications

Answer 73

C

Drugs other than phenobarbital and propofol have been used with benzodiazepines or, rarely, alone to treat alcohol withdrawal. These agents are less well studied than benzodiazepines and may mask the hemodynamic signs of withdrawal, which can precede seizures. We believe they should not be used routinely in the treatment of moderate or severe alcohol withdrawal. Such drugs include:

●Ethanol
●Antipsychotics (eg, haloperidol)
●Anticonvulsants (eg, carbamazepine)
●Centrally acting alpha-2 agonists (eg, clonidine)
●Beta blockers (eg, propranolol)
●Baclofen

Question 74

76. A 55 year old woman undergoes mitral valve replacement with a St. Jude mechanical prosthesis. Coumadin therapy is started post-operatively. On post-op day 5, she develops signs and symptoms of DVT and is started on a unfractionated heparin infusion. On post-operative day nine she has an acute onset of shortness of breath and hypoxemia. CT thorax demonstrates multi pulmonary emboli. Her platelet count is found to have fallen from 300,000 to 50,000. Definitive management of this problem should be?
    a) discontinue unfractionated heparin and start low molecular heparin
    b) discontinue unfractionated heparin and begin argatroban infusion
    c) continue unfractionated heparin and place an IVC filter
    d) continue unfractionated heparin and give a platelet transfusion

Answer 74

B

Patient has likely developed HIT.
HIT antibodies activate platelets and can cause catastrophic arterial and venous thrombosis.

There are a number of alternative anticoagulants that can be used in a patient with HIT. These include parenteral direct thrombin inhibitors (eg, bivalirudin, argatroban); fondaparinux; danaparoid (not available in the United States); or lepirudin (discontinued in May 2012

C/D - in HIT, you stop all heparin related drugs

Question 75

77. A 60 year old man receiving total parenteral nutrition via a right arm PICC line, suddenly develops fever and malaise. The PICC line is removed and the tip is sent for culture. Peripheral blood cultures are obtained and the patient is started on cefazolin 1 gram IV tid. The tip grows >15 colony forming units of staph aureus at 24 hours and peripheral blood cultures are also positive for methicillin sensitive staph aureus at 48 hours. The patient is currently afebrile. The most appropriate treatment now would be?
    a) stop antibiotic, reculture if the patient again develops a fever
    b) continue cefazolin for seven days
    c) change antibiotic to vancomycin for seven days
    d) continue cefazolin for 14 days.
    * 78. Following crush injury and rhabdomyolysis the most important component of treatment to avoid renal failure is?
    a) mannitol
    b) furosemide
    c) bicarbonate
    d) volume replacement

Answer 75

D’

MANAGEMENT OF SUSPECTED TPN CATHETER SEPSIS
• Remove catheter when surrounding skin shows colonization > 103 orgs/sq cm
• If no skin cultures, take down the bottle and all tubing and replace. Culture the old stuff. Blood cultures
too.
• If fever then persists for > 8 hr after this, remove catheter and culture tip.
• No antibiotics are necessary unless fever persists for > 24 hr after this.
• Catheters are not changed over guide wires when catheter sepsis is suspected. (Changing over wires is
acceptable when another source is suspected.)
• If catheter is eventually shown to be the source, peripheral antibiotics are needed, and catheter will have to
be replaced after an interval when blood cultures remain sterile.

Question 76

• 79. A 20 year old woman was an unrestrained passenger in a high speed motor vehicle crash. She was found on the road 20 feet ahead of the car. She has no signs of life when the paramedics arrive but develops a pulseless rhythm during CPR on route to the Emergency Room. On arrival in the Emergency Room, she again loses her cardiac rhythm. The best course best of action now should be?
      a) immediate Emergency Department thoracotomy through the left chest
      b) immediate Emergency room thoracotomy through the right chest
      c) continue external CPR, resuscitate with IV fluids
      d) declaration of death

Answer 76

D

Question 77

80. A 75 year old man is brought to the Emergency room because of severe abdominal pain. Plain films of the abdomen demonstrate free air under both hemidiaphrams. At laparotomy a perforated duodenal ulcer is repaired with an omental patch. At the end of the operation, the anesthetist notes that despite fluid resuscitation, the patient’s blood pressure is 80/40, core temperature is 33.5, and he is unable to be extubated because of CO2 retention. This state could be due to any of the following conditions, EXCEPT?
    a) severe hypothyroidism
    b) acute adrenal insufficiency
    c) diabetic ketoacidosis
    d) severe malnutrition

Answer 77

D

Question 78

81. A 45 year old woman with type I diabetes mellitus is admitted to hospital and undergoes emergency cholecystectomy for gangrenous cholecystitis. Post-operatively, her serum glucose is difficult to control with an insulin infusion. Which of the following hormones is NOT a cause of her elevated blood sugar?
    a) epinephrine
    b) cortisol
    c) glucogen
    d) triodothyronine (T3)

Answer 78

D

Question 79

82. A 32 year old man presents to the Emergency Room in septic shock. He was well until two days ago when he developed a flu like illness. He has rapidly deteriorated since then. His past medical history is unremarkable except for a splenectomy at the age of two years. Which of the following organisms is likely to be the cause of his sepsis?
    a) staphylococcus aureus
    a) escherichia coli
    c) streptococcus pneumoniae
    d) pseudomouas aeruginosa

Answer 79

C

Encapsulated Organisms:

1) Hemophilus influenzae type b (Hib)[1]
2) Streptococcus pneumoniae (pneumococcus)[1]
3) Neisseria meningitidis (meningococcus)[1]
4) Group B streptococcus (GBS)[1]
5) Klebsiella pneumoniae
6) Salmonella typhi

Question 80

83. A 65 year old man is admitted to hospital to undergo right total hip replacement because of osteoarthritis. In the pre-op hold area an intravenous is started and he is given 1 gram of cefazolin IV. Two minutes after starting the infusion he developes hypotension, bronchospasm, cyanosis, and an urticarial skin rash. All of the following drugs will be useful in treating this condition EXCEPT?
    a) epinephrine
    b) dopamine
    c) solucortef
    d) benadryl

Answer 80

B

Question 81

84. A 60 year old woman is found to have ovarian cancer and requires total hysterectomy and bilateral salpingo-oophorectomy. She also has severe aortic stenosis with an aortic valve area of 1 cm2 and a pressure gradient of 60 mm/Hg across the valve. Which of the following statements about the management of this patient is TRUE?
    a) she would benefit from pre-operative balloon dilatation of the valve
    b) she would benefit from after load reduction to maintain cardiac output
    c) she should be fluid restricted peri-operatively to avoid problems with pulmonary edema
    d) epidural analgesia may be risky because of induced hypotension

Answer 81

D

Question 82

85. A 60 year old woman develops oliguria one day after total abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine cancer. She is known to have systemic lupus eythrematosis with renal involvement. The diagnostic test that most accurately distinguishes pre-renal versus renal etiology of the oliguria is?
    a) fractional excretion of sodium
    b) microscopic sediment analysis
    c) two hour creatinine clearance test
    d) urine specific gravity

Answer 82

A

Question 83

86. An 86 year old man with colon cancer with widespread hepatic metastases is admitted to hospital because of dehydration. He has been receiving feedings through a previously placed jejunal tube. He has an advanced directive stating that feeding and intravenous fluids should be discontinued if his condition worsens. The day after admission, he becomes comatose. Which of the following statements is TRUE?
    a) a metabolic work up is necessary and will likely discover a cause for the patient’s coma
    b) intravenous fluids and J-tube feeds should be withheld
    c) central venous access should be carried out if needed for comfort measures
    d) the patient’s son may override the patient’s wishes and have the J-tube feedings increased

Answer 83

B

Question 84

87. Which of the following statements is an example of communication promoting improved team functioning in the Operating Room?
    a) hello, my name is Dr. Doe, and I am in charge
    b) we’ve got a lot to do, so let’s be sure we’re all on the same page
    c) that is totally wrong!! No wonder you’re still a resident
    d) quiet! I’ve got a problem here

Answer 84

B

Question 85

88. Which of the following statements about the use of opioid analgesics in surgical patients is TRUE?
    a) meperidine is preferred to morphine sulfate in critical care patients with renal failure
    b) morphine is advantageous for patients with congestive heart failure due to its effects on venous capacitance
    c) morphine has a direct effect on myocardial contractility
    d) Fentanyl should not be used in patients with reactive airway disease

Answer 85

B

Question 86

89. Many cancers are now known to be caused by genetic defects. Which of the following statements concerning genetic testing for hereditary nonpolyposis colorectal cancer is TRUE?
    a) seeks to identify the responsible oncogene
    b) can predict the risk of desmoid tumour development
    c) is useful for at-risk family members when no mutation is detected in the proband
    d) can be preformed on peripheral white blood cells

Answer 86

D

Question 87

90. Solid organ transplantation has been made possible by the use of immunosuppressant drugs. Originally, all kidney transplant recipients had been treated with azothyoprine along with other drugs. Which of the following drugs has now replaced azothyoprine because of lower toxicity?
    a) cyclosporine
    b) tacrolimus
    c) mycophenolate mofetil
    d) daclizumab

Answer 87

C

Question 88

91. An 80 year old woman with advanced Alzheimer’s disease has been ill for four days and is transferred from the nursing home with fever, hypotension, and abdominal distention. CT scan reveals a superior mesenteric artery thrombosis and bowel ischemia with pneumatosis of the small bowel wall. She is acidotic and in acute renal failure. Which of the following statements about this patient’s care is TRUE?
    a) she is dying and palliative care is indicated
    b) the decision for future care should be left solely with the family
    c) operation is the only chance for cure of the bowel ischemia and should be performed
    d) aggressive ICU resuscitation is warranted and operation should be performed if the patient stabilize

Answer 88

A

Question 89

92. The use of positive end-expiratory pressure in a ventilated ICU patient:
    a) primarily affects PaO2
    b) primarily affects PaCO2
    c) both
    d) neither

Answer 89

A

Question 90

93. Adjustments of tidal volumes in a ventilated ICU patient:
    a) primarily affects PaO2
    b) primarily affects PaCO2
    c) both
    d) neither

Answer 90

C

Question 91

94. A 57 year old hypertensive man develops torsades de pointes arrhythmia four days after 4-vessel coronary artery bypass grafting for severe coronary artery disease associated with a recent anterior myocardial infarction. Which of the following electrolytes disturbances is likely contributing to the etiology of his arrhythmia?
    a) hyperkalemia
    b) hypermagnesium
    c) hypomagnesium
    d) hypocalcemia

Answer 91

C

Question 92

95. All of the following are involved in the control of aldosterone secretion, EXCEPT?
    a) angiotensin
    b) cortisol
    c) serum potassium
    d) serum sodium

Answer 92

B

Question 93

97. Which of the following practices help promote a culture of safety in the Operating Room environment?
    a) maintaining strict accountability for mistakes
    b) emphasizing timely completion of procedures
    c) reporting problems face-to-face
    d) stressing role flexibility in crisis situations

Answer 93

D

Question 94

98. Post-operative patients often develop hypoxemia and pulmonary embolus is suspected. Which of the following statements concerning the diagnosis of pulmonary embolus is TRUE?
    a) chest CT has excellent sensitivity for isolated peripheral pulmonary emboli
    b) the negative predictive value of chest CT for ruling out clinically significant pulmonary exceeds 99%
    c) elevation in D-dimer blood levels require empiric anticoagulation
    d) the best initial screening test is ventilation-perfusion radionuclide scanning

Answer 94

B

Question 95

• 99. A 25 year old male falls 15 feet from a ladder and is brought to the Emergency room. He has a GSC of 3 with reactive pupils. There are no other injuries. CT head shows evidence of diffuse axonal injury. He is taken to the Operating Room for placement of a ventriculostomy. In the ICU post-operatively he has a mean arterial blood pressure of 65 mm/Hg and and ICP of 32 mm/Hg. He is ventilated and his pupils are still reactive. Appropriate management of this situation includes all of the following, EXCEPT?
      a) chemical paralysis
      b) hyperventilation to PCO2 of 25 tor
      c) processors to maintain mean arterial pressure
      d) administration of mannitol

Answer 95

B

Question 96

100. An 87 year old male pedestrian is struck by a car while crossing a street. He is brought to the Emergency Room and found to have a heart rate of 80, blood pressure 80/40, O2 saturation of 92. There was no history of loss of consciousness. Chest x-ray is normal but the FAST ultrasound is positive. The surgeon tells the patient that he requires immediate laparotomy but the patient states that he does not want surgery and wishes only to be made comfortable. The surgeon should then?
     a) take the patient to the Operating Room, declaring him to be incompetent to make this decision
     b) attempt to contact family members to discuss the situation
     c) call the chaplain to discuss the situation with the patient
     d) transfer the patient to a ward bed with an appropriate analgesic orders and a DNR on the chart

Answer 96

D

Question 97

96. An 86 year old hypertensive man has left calf intermittent claudication after waking two blocks. His physician ordered an arteriogram. The patient’s creatinine is 240. Which of the following statements concerning contrast-induced nephropathy is TRUE?
    a) pre-procedure hydration with IV normal saline is contra-indicated because of the risk of congestive heart failure
    b) pre-procedure hydration with IV sodium bicarbonate is more effective at preventing contrast-induced nephropathy than IV hydration with normal saline
    c) an increase in serum creatinine of 25% is expected and generally not clinically significant after contrast arteriography
    d) the risk of renal failure from intra-arterial contrast is too high in this patient and alternative imaging should be considered

Answer 97

B