2011

Question 1

*1. A security guard sustains a left thoraco-abdominal stab wound. He is alert, talking and hemodynamically stable. On examination, his abdomen is soft and non-tender. The most appropriate management would be?1) observation2) diagnostic peritoneal tap3) CT thorax, abdomen and pelvis4) laparotomy

Answer 1

3

Question 2

2. Which of the following statements about the use of pulmonary artery catheters in high-risk surgical patients is TRUE?1) the incidence of renal failure is lower2) perioperative mortality is lower3) the length of stay is not affected4) the amount of fluid administration is lower

Answer 2

3

Question 3

3. A 52 year old diabetic man presents with a chronic ulcer on the dorsal aspect of the left foot. Examination of the wound shows that it probes to bone. The test with the greatest accuracy for the diagnosis of osteomyelitis is?1) plain x-ray2) technician bone scan3) CT scan4) MR scan

Answer 3

4

Question 4

4. A 65 year old non-diabetic man is admitted to the ICU following debridement of an extensive necrotizing soft tissue infection of the right leg. He is noted to have a blood glucose of 14 mmol/l and is started on an insulin infusion. All of the following contribute to his hyperglycemia, EXCEPT? 1) peripheral insulin resistance 2) increased hepatic gluconeogenesis 3) elevated levels of the counter-regulatory hormones (cortisol, glucagon, catecholamines) 4) decreased release of branch chain amino acids from skeletal muscles

Answer 4

4

Question 5

5. Initial treatment of a post-operative headache 24 hours after spinal anesthesia for out-patient knee surgery includes all of the following, EXCEPT?1) oral fluids2) bed rest3) oral analgesics4) epidural blood patch by anaesthesia

Answer 5

4

Question 6

6. Angiogenesis is important to all of the following conditions, EXCEPT?1) development of cartilage2) maintaining a chronic inflammatory state3) ulcer healing4) tumor growth

Answer 6

1

Question 7

*7. Which of the following statements regarding the focused assessment by sonography of trauma (FAST) examination is TRUE?1) it can reliably evaluate the retroperitoneum2) it can quickly detect the presence of pericardial fluid3) it is unable to assess the presence or absence of a pleural effusion4) it is useful in detecting a cardiac contusion

Answer 7

2

Question 8

8. A 29 year old man suffers a midshaft fracture of his right femur in a motor cycle crash. The following day he is taken to the operating room for open reduction and internal fixation of his fracture with an intramedullary nail. His pre-operative haemoglobin is 80 and blood transfusion is initiated after the induction of anaesthesia. Thirty minutes later, the patient becomes hypotensive. No urine is noted in his Foley catheter. His surgical wound is noted to be abnormally oozy. The most likely cause of the situation is?1) fat embolism syndrome2) ABO incompatible blood transfusion3) blood loss from unrecognized intra-abdominal injury4) malignant hyperthermia

Answer 8

2

Question 9

9. You wish to carry out a prospective randomized trial of laparoscopic appendectomy vs. open appendectomy. What would be the best clinical outcome measure to compare the two procedures?1) post-operative mortality (30 days)2) post-operative morbidity rate3) total cost of treatment4) post-operative health-related quality of life measures

Answer 9

4

Question 10

*10. A 27 year old refinery worker is brought to the Emergency Room after a large natural gas explosion at the plant. The best screening tool for diagnosing a primary blast injury in the patient is?1) chest x-ray2) otoscopic examination3) fundoscopic examination4) FAST ultrasound

Answer 10

2

Question 11

11. Which of the following statements about activated Factor VII is TRUE?1) first line therapy for coagulopathy of trauma2) thrombotic complications do not occur3) effective in acidotic patients4) effective for reversal of warfarin anticoagulation

Answer 11

4found in cryoprecipitate

Question 12

12. A 44 year old woman with a history of seizure disorder pours a pan of hot grease over herself during a seizure. She has burns to her chin, chest and abdomen. On initial evaluation, her wounds are red with pale areas centrally, slow to blanch and dry in the central portion of the wound. This patient has most likely sustained a?1) superficial burn2) superficial partial-thickness burn3) deep partial-thickness burn4) full-thickness burn

Answer 12

3First degree: confined to the epidermis, painful, eythematous, blanch to touch, epidermal layer is intact.• Second degree, superficial: superficial dermis, painful, blanch and often blister; re-epitheliaze fromretained epidermal structures in rete ridges, hair follicles, and sweat glands; some discoloration.• Second degree, deep: into the reticular dermis, remain painful to pinprick, re-epitheliaze from sweatgland and hair follicle keratinocytes, severe scarring.Third degree, aka full thickness: hard leathery eschar that is painless, heal by re-epitheliazation fromedges.• Fourth degree: involves deeper organs/muscle

Question 13

13. Hypernatremia is sometimes seen in surgical patients. Which of the following does NOT contribute to the development of hypernatremia.?1) excessive sweating2) hyperlipidemia3) Lithium treatment4) glycosuria

Answer 13

2Hypernatremia is most common cause of hypertonicity.• Etiology: DI, burns, exfoliative dermatitis, vomiting (gastric Na 30 – 100), diarrhea (colon Na 60),fistulas, endoluminal tubes, diabetic KA (diuresis), hyperglycemic induced diuresis, sweating, fever,respiratory losses, inadequate AVP secondary to ethanol intoxication.• Thirst is such a powerful drive to correct this that it is often self-corrected. Problems occur in elderly,infants and unconscious patients that can’t drink when thirsty.• When these patients get hypotensive the kidneys can no longer produce hypertonic urine and thus theycan’t achieve a net water balance.

Question 14

14. A 65 year old man with a long-standing history of hypertension and a 25 year history of cigarette smoking is scheduled for an elective transuretheral prostate resection. On examination, his blood pressure is 150/90. His electrocardiogram shows nonspecific ST segment changes. Appropriate cardiac intervention pre-operatively would include which of the following?1) obtain old medical records and any previous ECGs2) request a cardiology consultation3) obtain transthoracic echocardiogram4) start the patient on metoprolol and proceeded with surgery

Answer 14

1

Question 15

15. Septic surgical patients undergo multiple changes in their metabolic functions. Which of the following changes is NOT seen in septic surgical patients?1) decreased need for linoleic and arachadonic acids2) increased proteolysis3) elevated resting energy expenditure4) positive nitrogen balance

Answer 15

4

Schwarz
Severe trauma, burns, and sepsis are associated with increased protein catabolism. The rise in urinary nitrogen and negative nitrogen balance can be detected early after injury and peak by 7 days. This state of protein
catabolism may persist for as long as 3 to 7 weeks

Question 16

16. Which of the following products of surgical energy sources has been proven capable of transmitting viral infections to surgeons?1) electrocautery smoke2) laser plume3) ultrasonic scalpel vapor4) none of the above

Answer 16

2Laser plume has been shown, for the first time to our knowledge, to actually transmit disease. Strict care must be maintained by the laser practitioner to minimize potential health risks, especially when treating viral-induced lesions or patients with viral disease

Question 17

17. A 63 year old woman with known metastatic breast cancer to bones and liver, returns to see her surgical oncologist complaining of fatigueability, muscle weakness, anorexia, and nausea. The most likely cause of these symptoms is?1) depression related to her metastatic cancer2) hypercalemia secondary to bony metastases3) hypokalemia secondary to her chemotherapy4) metabolic alkalosis secondary to her chemotherapy

Answer 17

2”stones, bones, abdominal groans, thrones and psychiatric overtones”CNS• ↓ LOCNEUROMUSCULAR• Proximal muscle weakness• HyporeflexiaGI• A/N/V• Constipation• Paralytic ileus• PUD• PancreatitisRENAL• Polyuria (nephrogenic DI)• Nephrocalcinosis• NephrolithiasisCVS• HTN• Short QT• Exacerbates dig toxicityMSK• Bone pain

Question 18

18. Genomic instability increases the chance of specific gene mutations that are ultimately responsible for the various phenotypes of cancer cells. Which of the following statements about genomic instability is TRUE?1) the tumor suppressor gene p53 plays a critical role in maintaining genomic stability2) presence of the ras-oncogene causes genetic instability3) local over expression of TGF-ß may lead to genomic instability in areas of chronic inflammation4) DNA mismatch repair genes (MMR) can compensate for most causes of genetic instability

Answer 18

1

Question 19

19. A 19 year old man is severely injured in a motorcycle accident. His major injuries are: subdural hematoma treated with craniotomy, a grade III liver laceration (no treatment) and a fracture of his left tibia and fibula managed with external fixation. On post-injury day seven, he develops tachycardia and hypoxemia. CT scan of the head, chest, abdomen and pelvis show a large pulmonary embolus in the right lung and right ventricular dilatation. This should be treated with?1) IV unfractionated heparin (high-dose)2) IV thrombolysis3) percutaneous mechanical thrombectomy4) placement of an IVC filter

Answer 19

4INDICATIONS FOR IVC FILTER• Absolute (5):1. Recurrent embolism despite anticoagulation2. DVT or embolism in patient with contraindication to anticoagulation3. Complication of anticoagulation that forces therapy to be stopped4. Recurrent PE with associated pulmonary hypertension and cor pulmonale5. Immediately after pulmonary embolectomy for massive PE• Relative (3):1. PE of more than ½ of pulmonary vascular bed in patient who cannot tolerate additional emboli2. Propagating ileofemoral thrombus despite anticoagulation3. High-risk patient with large free-floating iliofemoral thrombus on venogram

Question 20

20. All of the following may be acute complications of crush injury and rhabdomyolysis, EXCEPT?1) hypercalcemia2) hyperkalemia3) acidosis4) hypophosphatemia

Answer 20

1

Question 21

21. A 32 year old woman presents six weeks after an uncomplicated laparoscopic cholecystectomy for biliary colic. She has left sided abdominal pain. Nine years previously she had a cadaveric renal transplant for end stage renal failure. Abdominal CT scan demonstrates retroperitoneal lymphadenopathy. The most likely cause of this adenopathy is?1) secondary to recent surgery2) B-cell lymphoma3) T-cell lymphoma4) plasmacytoma

Answer 21

2POST TRANSPLANT COMPLICATIONSNEOPLASIA• NHL:HL lymphoma is higher in Tx patients than in non Tx patients.• B cell lymphomas are more common than T cell lymphomas.

Question 22

22. A 12 year old child undergoes spinal fixation for severe scoliosis. Post-operatively the hemoglobin is found to be 6gm/dL. The parents and child are Jehovah Witnesses and refuse all blood products. The next step should be?1) withhold all blood products2) transfuse packed red blood cells3) administer erythropoietin4) obtain psychiatric assessment of the patient’s competence to make this decision

Answer 22

4

Question 23

23. A 60 year old type II diabetic on oral hypoglycemic drugs is scheduled for elective left total hip replacement. How should his diabetes be managed pre-operatively?1) take oral hypoglycemic drugs on the morning of the surgery and check blood glucose pre-operatively2) hold oral hypoglycemic drugs on the morning of the surgery and check glucose pre-operatively3) hold oral hypoglycemic drugs on the morning of the surgery and start IV D5W 50 cc/hr and insulin infusion on a sliding scale4) ask the medical consult service to convert the patient to insulin-therapy one week pre-operatively

Answer 23

2

Question 24

24. A 54 year old patient undergoes a right hemicolectomy for cecal cancer. On post-operative day one his temperature is 38.0 C. He is asymptomatic. The patients work up should include which of the following?1) no work-up needed2) history and physical examination3) history, physical examination, urinalysis, chest x-ray and blood culture4) history, physical examination, urinalysis, chest x-ray, blood culture and CT abdomen and pelvis

Answer 24

1Atelectasis is often blamed as a cause but is likely not causal.Immediate—The potential causes of fever in the immediate operative and postoperative period are mainly limited to: medications or blood products to which the patient was exposed during preoperative care either in the operating room or in the recovery area; trauma suffered prior to surgery or as part of surgery; infections that were present prior to surgery; and rarely malignant hyperthermia.Adverse medication reactions that produce immediate fever include immune-mediated reactions, such as reactions to antimicrobials and to transfused blood products. (See “Drug fever”.) The vasodilation that often accompanies these reactions makes hypotension a common presenting sign; rash may accompany fever in some patients with medication reactions.The initial clinical signs (ie, hypercarbia) of malignant hyperthermia typically present within 30 minutes following the administration of a triggering agent (eg, inhaled anesthetics, succinylcholine), but have been reported later in the operative course and also following cessation of anesthesia. If the malignant hyperthermia response is not recognized and aborted with dantrolene, high fever may develop as result of hypermetabolism. (See “Malignant hyperthermia: Clinical diagnosis and management of acute crisis”.)Fever due to the trauma of surgery usually resolves within two to three days. The severity and duration of these self-limited postoperative fevers depends on the type of surgery [18,19], but tends to be greater in patients with longer and more extensive surgical procedures [12]. Fever caused by severe head trauma can be persistent and may resolve gradually over days or even weeks [20].uptodate

Question 25

25. Lactic acidosis is not uncommon in surgical patients. Which of the following statements concerning lactic acidosis is NOT true?1) lactic acidosis is usually a consequence of tissue hypoxia caused by hypoperfusion2) lactic acidosis is worsened in patients with hepatic insufficiency3) the treatment of lactic acidosis require the administration of sodium bicarbonate4) serial lactate levels are a useful indication of the adequacy of treatment of hypovolemic shock

Answer 25

3

Question 26

26. A 60 year old alcoholic male is admitted to hospital because of GI bleeding. Investigations reveal a carcinoma of the cecum without metastatic disease. The patient refuses surgery and demands to be discharged from hospital. The surgeon should?1) seek advice from a medical ethisticist re: discharge2) ask for help from the hospital chaplain3) ask for a psychiatric assessment of competence4) discharge the patient

Answer 26

3

Question 27

27. Following left knee arthroscopy, a 37 year old man develops a clinically obvious left femoral vein thrombosis confirmed by Doppler ultrasound. He is admitted to hospital and treated with IV infractionated heparin. On his third hospital day, he complains of right calf pain and is found to have a right femoral vein thrombosis as well. The likely explanation for this course of events is?1) inadequate heparin dosage2) patient has antithrombin III deficiency3) patient should not have been immobilized in hospital4) patient has protein C deficiency

Answer 27

2Hypercoagulable state (7):1. Trauma2. Pregnancy3. OCP (↑ VII, VIII, IX, X and ↓ antithrombin III, ↑ plt aggregation)4. Malignancy5. Inherited coagulation deficiencies (Factor V Leiden – aka resitance to APC - is most common, proteinC/S deficiency, antithrombin III deficiency, lupus anticoagulant)6. Heparin induced thrombocytopenia7. Age > 40ANTITHROMBIN III DEFICIENCY• The most important plasma protease inhibitor.• Uncommon but significant risk for recurrent, life threatening thrombosis.• Most cases apparent before 50 yrs.• Can present with arterial thrombosis.• Antithrombin III is a serine protease inhibitor of thrombin (II), VIIa, IXa, Xa, XIa, and kallikreinin.• Suspect when patient cannot be adequately anticoagulated with heparin (heparin acts by potentiatingantithrombin III activity).• Dx: measure levels (heparin will ↓ antithrombin levels by 30% for up to 10 days) and activity.• Causes (7):1. Nephrotic syndrome (loss of factor)2. Liver disease (site of production)3. Malignancy4. Malnutrition5. Decreased protein production6. DIC7. Genetic (qualitative defects and quantitative defects)• Treatment of patient who needs anticoagulation: 1) antithrombin III concentrates (if available) or FFPwhile on heparin followed by 2) oral anticoagulants as per usual.

Question 28

28. A 36 year old, 22 week pregnant woman is involved in a motor vehicle crash and suffers a left femur fracture. This is repaired surgically. On post-operative day four she becomes acutely short of breath. Chest x-ray is normal and a pulmonary embolus is expected. The decision to start anticoagulation with unfractionated heparin should be based on which of the following investigations?1) pulmonary angiography2) ventilation perfusion scan of the lung3) CT thorax with PE protocol4) MR angiogram of the thorax

Answer 28

3

Question 29

*29. A 12 year old boy was intubated in the field for respiratory distress after a high speed bicycle collision. On arrival to the emergency room, he has ecchymosis over the sternum, good breath sounds bilaterally, and an O2 saturation of 99% (FI O2 1.0). He remains hypotensive (systolic blood pressure 90) despite ongoing resuscitation. FAST ultrasound of the abdomen is negative but considerable fluid is seen in the pericardial sac. The next step in management should be?1) CT thorax2) pericardial window3) median sternotomy4) laparotomy

Answer 29

3

Question 30

30. Pre-operative invasive cardiac testing is MOST appropriate for?1) A 62 year old man scheduled for laparoscopic incisional hernia repair who has been asymptomatic since coronary bypass surgery one year ago.2) A 57 year old woman who has been scheduled for lumpectomy and sentinel lymph node biopsy who takes warfarin for rate-controlled atrial fibrillation.3) A 62 year old man who has a 6 cm abdominal aortic aneurysm admitted with back pain and 2 mm inferior wall ST-depression on ECG4) A 48 year old man scheduled for sigmoid colon resection for a diverticular stricture who has aortic stenosis and dyspnea on walking 100 feet

Answer 30

4All patients scheduled to undergo noncardiac surgery should have an assessment of the risk of a cardiovascular perioperative cardiac event (algorithm 1). (See ‘Our approach’ above.)●Identification of risk factors is derived from the history, physical examination, and type of proposed surgery. (See ‘Initial preoperative evaluation’ above.)●We use either the Revised (Lee) Cardiac Risk Index or the ACS-National Surgical Quality Improvement Program risk prediction rule to establish the patient’s risk. (See ‘Estimating perioperative risk’ above.)●We obtain an electrocardiogram in patients with cardiac disease in large part to have a baseline available should a postoperative test be abnormal. (See ‘Initial preoperative evaluation’ above.)●For patients with known or suspected heart disease (ie, cardiovascular disease, significant valvular heart disease, symptomatic arrhythmias), we only perform further cardiac evaluation (echocardiography, stress testing, or 24-hour ambulatory monitoring) if it is indicated in the absence of proposed surgery. (See ‘Further cardiac testing’ above.)uptodate

Question 31

34. A 92 year old woman with chronic renal insufficiency has a sudden onset of abdominal pain. While in the emergency room, she suffers a cardiac arrest but is resuscitated and intubated at the request of her family. Abdominal ultrasound shows a ruptured abdominal aortic aneurysm. The family insists that this be repaired, but she has an advanced directive (living will) declining heroic measures. Which of the follow is the best option at this time?1) attempt repair of the aneurysm2) honor the patients advanced directive3) call for an ethics committee consultation4) ask the hospital lawyer to obtain an urgent judicial review of the situation

Answer 31

2

Question 32

35. Chronic adrenal insufficiency, if unrecognized, can result in which of the following conditions in surgical patients?1) hypothermia2) hypertension3) hyperkalemia4) hyperglycemia

Answer 32

3ADRENAL INSUFFICIENCY (‘ADDISONIAN CRISIS’)ETIOLOGY• Primary (6): autoimmune (most common in N/A), infection (most common in 3 rd world), vascular(hemorrhage, thrombosis, trauma), metastatic dz, deposition dzs (hemochromatosis, sarcoid, amyloid),drugs (ketoconazole, rifampin, anticonvulsants)• Secondary (3): pituitary failure, glucocorticoids (1-3 wks is enough to suppress for 8-12 months!),megestrol• Tertiary: hypothalamus failureSIGNS & SYMPTOMS• Fatigue• Weakness• Anorexia• Nausea & vomiting• Weight loss• Cutaneous and mucosal pigmentation• Hypotension → shock• Hypoglycemia• Decreased cold tolerance• Dizziness, syncope• ECG: ↓ voltage, prolonged PR and QT intervals• Early symptoms: weakness, fatigue, orthostatic hypotensionLABS• Na ↓• Cl ↓• Bicarb ↓• Hypoglycaemia• K ↑• +/- HypercalcemiaCOSYNTROPIN STIMULATION TEST• Used to distinguish primary from secondary/tertiary dz• Give synthetic ACTH (cosyntropin), then measure cortisol at 0, 30, 60 min• Baseline cortisol > 15 ug/dl = normal adrenal f’n (i.e. secondary/tertiary d/o)• Cortisol rise > 20 ug/dl = normal adrenal f’n (i.e. secondary/tertiary d/o)• Abnormal test = primary disorder (i.e. adrenal) or chronic secondary d/o (adrenal is so atrophied d/t lackof ACTH stimulation, it fails to respond)TREAMENT• IV volume & sugar replacement (D5NS)• Acutely: Dexamethesone 4 mg + hydrocortisone 100 mg q6h until condition stabilizes (no need formineralocorticoid replacement acutely – Sabiston)• Chronic/once acute phase has past: fludrocortisone (mineralocorticoid) + hydrocortisone

Question 33

36. A 55 year old man is admitted to hospital with acute uncomplicated sigmoid diverticulitis. He is treated with broad spectrum antibiotics. On day six of his hospital stay, he develops increasing abdominal pain, diarrhea, and an elevated white blood cell count. Which of the following diagnosis is most likely?1) pseudo membranous colitis2) progression of the diverticulitis3) cytomegalovirus colitis4) antibiotic induced small bowel malabsorbtion

Answer 33

1(C. diff)

Question 34

37. Which of the following statements concerning interleukin-two (IL-2) is FALSE?1) the proliferation of T lymphocytes is inhibited by IL-22) IL-2 is produced by activated T lymphocytes3) NK cell cytotoxicity is augmented by IL-24) cytokine release by macrophages is stimulated by IL-2

Answer 34

1

Question 35

38. Dose fractionation is frequently used when treating malignant tumors with radiotherapy. The reasons for dose fractionation include all of the following, EXCEPT?1) tumor cells are able to repopulate between treatments2) normal cells are able to repair damage between treatments3) tumor cells are redistributed through the cell cycle4) tumor cells become less hypoxic

Answer 35

1

Question 36

39. Cigarette smoking is known to have a detrimental effect on wound healing. Which of the following statements is NOT true?1) smoking inhibits oxygen delivery to the wound by causing sympathomimetic vasoconstriction2) the use of nicoderm patches also causes sympathomimetic vasoconstriction3) smoking elevates carboxy hemoglobin levels in the blood resulting in less available oxygen in the wound4) smoking shifts the oxygen delivery curve to the right because of the poor affinity of carboxy hemoglobin for oxygen

Answer 36

4CO has 200 times more afinity for Hb

Question 37

40. The body’s response to hypothermia includes all of the following, EXCEPT?1) decreased platelet function2) tachycardia3) cardiac arrhythmias4) increased risk of wound infection

Answer 37

2

Question 38

41. A seventy year old female presents with anemia and is found to have an adenocarcinoma of the right colon. On physical examination she has a palpable left supraclavicular lymph node. Which would be the most appropriate means of looking for metastatic disease in the node?1) CT thorax2) fine needle aspiration (FNA)3) ultrasound guided core needle biopsy4) surgical excision biopsy

Answer 38

2Biopsy.U/S guided is reserved for more difficult areas to biopsy (this is very superficial)For thyroid biopsies, but should be applicable?:INDICATIONS FOR ULTRASOUND-GUIDED FNA—Fine needle aspiration (FNA) biopsy is the procedure of choice for evaluating thyroid nodules and selecting candidates for surgery. If the presence of a thyroid nodule and indication for FNA is confirmed by diagnostic ultrasound, and the nodule corresponds to what is palpated on physical examination, FNA can be performed directly without ultrasound guidance. However, ultrasound guidance is often preferred [1,2]. Compared with palpation-guided FNA, the use of ultrasound improves the cytologic diagnostic accuracy rate and reduces the nondiagnostic rate [3-7]. In a retrospective evaluation of 9683 patients with thyroid nodules, 4986 and 4697 patients were evaluated by palpation and ultrasound-guided FNA, respectively [3]. The nondiagnostic rate was significantly higher after palpation-guided FNA (14.1 versus 8.5 percent). Over a 15-year period, over 1000 nodules were resected because of suspicious or malignant cytology on palpation or ultrasound-guided FNA. The false negative rate was higher in nodules that were biopsied via palpation rather than ultrasound (2.3 versus 1 percent).When available, we suggest ultrasound-guided FNA for the majority of nodules. Ultrasound-guided FNA is essential for those nodules that are:●Nonpalpable or difficult to palpate●Predominantly cystic●Nondiagnostic after palpation-guided FNA●Small and located in close proximity to blood vesselsIn addition, we typically use ultrasound to guide FNA in an area in a goiter that is different from the rest of the goiter (ie, firmer, painful, tender, growing, or has suspicious ultrasonographic characteristics) for assessment of recurrent thyroid cancer and for nonpalpable lymphadenopathy.

Question 39

*42. An 82 year old man has six rib fractures on the lower left chest after falling 12 feet. He is normotensive on arrival in the emergency room and his PAO2 is 65 torr on room air. Which of the following statements about his condition is NOT true?1) his outcome will be improved if an epidural catheter is used for pain control2) he is most likely to die in the first 48 hours of admission3) he is twice as likely to die as a 45 year old with similar injuries4) an abdominal CT scan should be obtained

Answer 39

21. For patients who do not have any contraindications, we suggest placement of a thoracic epidural catheter for the administration of epidural analgesic agents (Grade 2B). Patients who cannot have an epidural should be managed with parenteral opioid agents administered intravenously or via patient-controlled analgesia (PCA), and supplemented with non-steroidal antiinflammatory drugs. For patients failing to achieve adequate pain control with intravenous opioid agents, local anesthetic block is a useful option.3.MORBIDITY AND MORTALITY—A greater number of rib fractures is associated with increased morbidity and mortality [4-8,30]. The presence of six or more rib fractures significantly increases the risk for death, often due to associated injuries [6]. A review of data from the National Trauma Databank confirmed an increasing risk of pulmonary complications with increasing number of rib fractures, but identified age and Injury Severity Score (ISS) as the primary predictors of death [4,8,11].An increased number of rib fractures is more common in older patients who are clearly at a higher risk for complications [5,22,87-89]. In one study, patients over age 45 with ≥4 rib fractures had a significantly longer duration of mechanical ventilation and longer hospital stay compared with younger patients [87]. These data are likely driven by an increased incidence of infectious complications in older patients. For patients 65, the risk of pneumonia increased by 27 percent, and mortality increased by 19 percent. (See ‘Pneumonia’ above.)4. Fractured ribs or pelvic bones can lacerate intra-abdominal tissue. The risk of intraabdominal or intrathoracic injury increases if two or more rib fractures are present at the same level [13-16]. Fractures of the right lower ribs are more often associated with hepatic injury, fractures of the left lower ribs with splenic injury, and fractures of the posterior portion of the lower ribs with renal injury. Rib fractures – Observational studies suggest that rib fractures occur in almost two-thirds patients with chest trauma due to MVCs. However, most of these studies evaluated patients involved in high energy trauma admitted to trauma centers. In one study, researchers evaluated the chest radiographs of all alert blunt trauma patients presenting to their emergency department following blunt trauma [2]. They found that multiple rib fractures (>2) was the most common serious thoracic injury, and occurred in approximately 5 percent of patients. The presence of multiple rib fractures, particularly ribs one through three, increases the risk of intrathoracic injury, especially in the elderly.uptodate

Question 40

43. Which is the following is the most effective practice for reducing the incidence of central venous catheter-related bacteremia?1) changing the catheter over a guide wire every three days2) using betadine for skin preparation3) using antibiotic-impregnated catheters4) using a systems-based approach to catheter insertion

Answer 40

4.All-inclusive catheter-carts or kits. A study by Young and colleagues found that a systems-based intervention featuring a catheter kit (that contained a large sterile drape and 2% chlorhexidine gluconate) led to a significant reduction in CLABSI rates (11.3 per 1,000 CVC-days vs. 3.7 per 1000 CVCs, PPrevention of infection with central venous catheters*Replacement and relocation of catheterDo not routinely replace central venous catheters solely for the purpose of reducing the incidence of infection (including peripherally inserted, non-tunneled, or tunneled catheters and implantable devices).Replacement of catheter-site dressingReplace dressing when the catheter is removed or replaced, the dressing becomes damp, loosened, or soiled, or inspection of the site is necessary.Replace gauze dressing every two days, and transparent dressings every seven days on short-term catheters.Replace dressing no more than once per week until the insertion site is healed on long-term catheters. The necessity for dressing on well-healed exit sites of long-term culled and tunneled CVC is an unresolved issue.Replacement of administration setsReplace administration sets, including secondary sets and add-on devices, no more frequently than at 72-hour intervals, unless clinically indicated.Replace tubing used to administer blood, blood products, or lipid emulsions within 24 hours of initiating the infusion. No recommendation¶ for replacement of tubing used for intermittent infusions.Replace tubing used to administer propofol infusions every 6 or 12 hours, depending on its use.Hang time for parenteral fluidsComplete infusion of lipids or lipid-containing parenteral nutrition fluids (eg, 3-in-1 solutions) within 24 hours of hanging the fluid. When lipid emulsions are given alone, complete the infusion within 12 hours of hanging the emulsion.Complete infusion of blood or blood products within four hours of hanging the blood.No recommendation¶ for parenteral nutrition fluids.

Question 41

44. A 65 year old smoker is scheduled for an elective femoral-popliteal bypass. He has a history of myocardial infarction and is known to have stable angina. Pre-operative stress echocardiogram shows reversible ischemia in the area supplied by the left anterior descending artery, left ventricular ejection fraction of 40%, and normal valves. Which of the following would be MOST effective in decreasing post-operative cardiac events in this patient?1) pre-operative statin administration2) pre-operative left anterior coronary artery stenting3) peri-operative beta blockade4) peri-operative calcium-channel blocker therapy

Answer 41

2

Question 42

45. Following injury or severe infection, protein synthesis in the liver shifts to the production of acute phase reactants such as C-reactive protein, fibrinogen, haptoglobin, and so on. This shift in protein synthesis is initiated by?1) IL-12) IL-23) increased levels of serum cortisol4) prostaglandin E2

Answer 42

1IL-1• Produced by (5):1. Primarily monocytes and tissue macrophages2. Neutrophils3. Lymphocytes (B, Th, NK)4. Endothelial cells5. Keratinocytes• Stimulants of release (6):1. Microbe particles (endotoxin, virus particles, yeast particles, peptidoglycans, etc…)2. Ag-Ab complexes3. Ig4. C5a (opsonization)5. Other cytokines (TNF, IL-2, GM-CSF, IFNs, IL-1)6. TGF-beta• Effects (5 systemic and 4 local) (9):1. Induction of fever2. Stimulation of T and B lymphocytes3. Acute phase protein production and release4. Stimulates pit stress hormone release5. Myocardial depression6. Regulates skeletal muscle proteolysis in sepsis7. Potentiation of other inflammatory mediator release8. Chemoattraction of leukocytes9. Promotion of endothelial cell procoagulant effect

Question 43

46. Regarding the risk of surgery in patients with liver disease, which of the following statements is NOT true?1) Halothane and enflurane reduce hepatic arterial blood flow2) Hypercarbia increases portal blood flow3) Fentanyl, not morphine or meperidine (demerol) is the preferred narcotic agent4) Child class B cirrhotic patients undergoing cardiac operations have a high mortality rate

Answer 43

2

Question 44

47. Which of the following statements about wound healing is NOT true?1) denervation has no effect on wound contraction or epitelialization2) a bacterial count of 100 organisms per cm2 retards wound healing3) chemotherapy given 10-14 days after primary wound closure has little effect on the final status of the wound4) radiotherapy inhibits wound healing partly because of radiation-induced changes in the cell nuclei and concomitant cytoplasmic malfunction

Answer 44

2INFECTION• If the bacterial count in the wound exceeds 10^5 organisms/gram of tissue or if any beta-hemolyticstreptococcus are present, the wound will not heal by any means.

Question 45

48. Regarding the biology of malignant neoplasms, which of the following statements is TRUE?1) most malignant neoplasms arise from a single cell that has undergone transformation to form a malignant clone2) cancer cells proliferate faster than normal cells and the rate of proliferation increases as the tumor mass increases3) malignant cells are characterized by reversion to more primitative cell types, cellular monomorphism, and increased cohesion4) tumors double in size at least every 20 days and therefore essentially all human neoplasms are clinically detectable within one year after the inception of neoplastic transformation

Answer 45

1

Question 46

49. A 36 year old woman who is 20 weeks pregnant suffers a seizure and on CT scan of the head is noted to have a resectable malignant brain tumor. Which of the following measures should be taken to protect the fetus during craniotomy?1) no change from normal routine2) intra and post-operative monitoring of the fetal heart rate3) intra and post-operative transvaginal monitoring of amniotic fluid pH and PO24) magnesium sulfate infused intra-operatively to prevent uterine contractions

Answer 46

1

Question 47

50. A 65 year old man undergoes elective transuretheral resection of the prostate. Pre-operatively he was in good health, on no medications and had normal blood work. On the first post-operative day the patient reports headaches and nausea. On the second post-operative day, he becomes lethargic and unable to follow commands. On examination he is afebrile, blood pressure 150/90, heart rate 90, respiratory rate 15. Laboratory tests show: CBC normal Na 114 K 3.8 Cl 78 Bicarb 20 BUN 8 Creatinine 120 Which treatment is most appropriate at this time?1) free water restriction2) isotonic saline3) hypertonic saline4) furosemide

Answer 47

3Transurethral resection (TUR) of the prostate or bladder, a variety of hysteroscopy procedures, and certain other percutaneous procedures (such as percutaneous nephrolithotomy) may use large volume irrigation with nonconductive (ie, non-electrolyte) fluids to avoid thermal burns. Absorption of these irrigation fluids produces hyponatremia with varying degrees of hypoosmolality. Neurologic manifestations can occur when fluid absorption exceeds 500 mL and particularly 1000 mL.These problems can be avoided with bipolar electrosurgery, which permits the use of isotonic saline irrigation.Symptoms of hyponatremia include nausea and malaise. This may be followed by headache, lethargy, and obtundation, and eventually renal failure, seizures, coma and respiratory arrest. Patients exposed to glycine irrigant may complain of visual deficits or blindness.For patients with symptoms of hyponatremia and reduced plasma osmolality, we recommend treatment with hypertonic saline (Grade 1B). We suggest that 3 percent saline be given as a 100 mL (1.5 to 2 mL/kg) bolus that can be repeated twice at 10-minute intervals, if necessary (Grade 2C). The efficacy and safety of such therapy is uncertain in hyponatremic patients who have a normal or near normal serum osmolality (eg, greater than 275 mosmol/kg)There is little concern about overly rapid correction of the hyponatremia following TUR or hysteroscopy due to the extremely short duration of the hyponatremia. However, hyponatremia should not be overcorrected.uptodate

Question 48

51. Following a routine knee arthroscopy, a healthy 33 year old woman develops uncomplicated femoral deep vein thrombosis. A hypercoagulation evaluation is negative. Anticoagulation should be given for:1) 6 weeks2) 3 months3) one year4) for life

Answer 48

2For most patients with a first episode of proximal DVT (provoked or unprovoked), we recommend anticoagulation for a minimum of three months rather than for shorter periods (eg, four or six weeks) (Grade 1B). For patients with provoked DVT who have persistent but reversible risk factors (eg, continued estrogen use, prolonged immobility following trauma), we suggest extending anticoagulation for a finite period until the risk factor is resolved rather than stopping anticoagulation at three months (Grade 2C).Patients most likely to benefit from indefinite anticoagulation are those with a first or recurrent episode of unprovoked DVT, in particular those with proximal DVT. Indefinite anticoagulation should NOT be routinely administered to patients with an episode of VTE provoked by major transient risk factors (eg, surgery) or those in whom the risk of bleeding is considered to be high.uptodate

Question 49

52. In critically ill septic patients, transfusion of packed red blood cells?1) reduces ventilation perfusion mismatch2) increases septic morbidity and mortality3) is indicated for hemoglobin 4) reduces length of stay in the ICU

Answer 49

2The Surviving Sepsis Guidelines advocate restricting RBC transfusion in adults with severe sepsis/septic shock until Hb falls below 7.0 g/dL, and not transfusing above 9.0 g/dL, if ischemic heart disease, severe hypoxemia, or active bleeding is not present.Red blood cell transfusions—Based upon clinical experience, randomized studies, and guidelines on transfusion of blood products in critically ill patients, we typically reserve red blood cell transfusion for patients with a hemoglobin level ≤7 g per deciliter. Exceptions include suspicion of concurrent hemorrhagic shock or active myocardial ischemia.Support for a restrictive transfusion strategy (goal hemoglobin >7 g/dL) is derived from direct and indirect evidence from randomized studies of patients with septic shock:•One multicenter randomized study of 998 patients with septic shock reported no difference in 28 day mortality between patients who were transfused when the hemoglobin was ≤7 g/dL (restrictive strategy) and patients who were transfused when the hemoglobin was ≤9 g/dL (liberal strategy) [42]. The restrictive strategy resulted in 50 percent fewer red blood cell transfusions (1545 versus 3088 transfusions) and did not have any adverse effect on the rate of ischemic events (7 versus 8 percent).•Data from randomized studies of early goal directed therapy (EGDT) that use red blood cell transfusion as part of the protocol for treating patients with sepsis are conflicting. While one trial initially reported a mortality benefit from EGDT that included transfusing patients to a goal hematocrit >30 (hemoglobin level 10 g/dL) [18], two similarly designed studies published since then reported no benefit to this strategy [19,20]. These studies are discussed below. (See ‘Protocol-directed therapy’ below.)In further support of a restrictive approach to transfusion in patients with septic shock is the consensus among experts that transfusing to a goal of >7 g/dL is also preferred in critically ill patients without sepsis [43-45].

Question 50

53. Ten years after a renal transplant, a patient continues to have stable renal function. Drug therapy includes tacrolimus and prednisone. The patient complains of right hip pain and a plain x-ray shows marked osteoporosis. The most likely cause of this is?1) hyperparathyroidism2) Paget’s disease3) corticosteroid use4) osteomyelitis

Answer 50

3ADRENAL CORTICOSTEROIDS• Mechanisms (4):1. Profound ↓ in blood lymphocyte count occurs within 6 hrs (causes redistribution to the lymphoiddepots)2. Decreases ability of macrophages to respond to lymphocyte-derived signals3. Inhibits cytokine gene transcription and cytokine secretion by macrophages4. Suppresses PG synthesis• Side effects (11):1. HTN (mineralocorticoid effects)2. Weight gain3. Peptic ulcers4. GI bleeding5. Euphoric personality changes6. Cataract formation7. Hyperglycemia (could → DM)8. Pancreatitis9. Muscle wasting10. Osteoporosis11. Avascular necrosis

Question 51

54. Hyponatremia is commonly seen in post operative patients. Which of the following statements about the serum sodium concentration is TRUE?1) changes in serum sodium concentrations usually produce changes in extra cellular fluid volume2) the chloride ion is the main determinant of the osmolarity of the extra cellular fluid space3) extra cellular hyponatremia leads to depletion of intracellular water4) dry mucous membranes are characteristic of hyponatremia

Answer 51

1POSTOPERATIVE HYPONATREMIA• Stress of surgery increases AVP/ADH release.• Rapid, precipitious decline in Na to 100’s level has been described after GA for routine surgery.• At risk in particular are menstruant women with high U/O (> 3 litres in first 24 hrs postop)• This can be exacerbated by the administration of hypotonic fluids.2. False, sodium3. False, increase in intracellular water

Question 52

55. A 65 year old man undergoes coronary artery stenting following an uncomplicated myocardial infarction. He is started on plavix and ASA at the time of his MI. Two weeks following his stenting, rectal bleeding leads to a diagnosis of rectal cancer. When would it be safe to carry our surgical resection of this man’s tumor?1) six weeks after the MI2) 3 weeks after his stenting3) 1 week after stopping plavix4) consult with the patient’s cardiologist concerning the timing of surgery

Answer 52

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Question 53

56. Which one of the following tissues derives all their energy requirements from glucose?1) cardiac muscle2) red blood cells3) brain4) skeletal muscle

Answer 53

2Brain: usually sole fuel is glucose, but in starvation ketone bodies from liver can fuel brainAnaerobic oxidation of glucose (i.e., glycolysis) is the only source of energy for RBC.

Question 54

57. Which of the following statements regarding hand hygiene is NOT correct?1) health care workers (HCW) should clean their hands with an antiseptic containing agent before and after each contact with a patient2) the use of soap and water for hand washing is required when hands are visibly soiled with blood or bodily fluids3) alcohol-based hand rubs are inferior to antimicrobial soaps for hand decontamination4) vancomycin-resistant enterococci and MRSA are frequently isolated from the hands of HCW’s

Answer 54

3

Question 55

58. A 69 year old woman undergoes total abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine cancer. On post-operative day four she spikes a fever of 39˚ C. Peripheral blood cultures and a retrograde culture from a central line grow staph aureus sensitive to cloxacillin. The central line is removed. The most appropriate antibiotic treatment for this patient is?1) no antibiotics needed as the cause of the infection, the central line, has been removed2) IV cloxacillin for 72 hours or until the patient has been afebrile for 48 hours3) IV cloxacillin for 2 weeks4) IV cloxacillin for 6 weeks

Answer 55

3In general, for uncomplicated CRBSI with negative blood cultures following catheter removal or guidewire exchange and institution of appropriate antibiotic therapy, the duration of therapy is 10 to 14 days (day 1 is the first day on which negative blood cultures are obtained). Patients with persistent bacteremia >72 hours following catheter removal should receive treatment for at least four to six weeks. For patients with complications related to bacteremia (such as suppurative thrombophlebitis, endocarditis, osteomyelitis, metastatic infection), the duration of therapy should be tailored accordingly, depending on the nature of infection.

Question 56

59. A 60 year old man undergoes bilateral total hip replacement for severe osteoarthritis. An epidural catheter is inserted pre-operatively and pain is controlled post-operatively with an epidural infusion of local anesthetic. Twelve hours post-operatively you are called to see the patient because of hypotension. His vitals are: Blood pressure 90/60 Heart rate 70 Respiratory rate 14 Urine output 50 cc/h The patient is in no distress. Which of the following is the best management for this patient?1) observe the patient is well and do nothing2) give 500 cc bolus of normal saline3) check CBC stat and transfuse prn4) ask anaesthesia to remove the epidural catheter

Answer 56

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Question 57

60. A 65 year old man has unresectable pancreatic carcinoma. This has resulted in gastric outlet obstruction and obstructive jaundice. He has no other co-morbid factors. When considering palliative treatment, which of the following statements is NOT true?1) percutaneous biliary drainage will relieve his obstructive jaundice and lessen his pruritis2) the patient should participate in the choice of treatment plan after being informed of options and risks3) if the patient desires, the family may assist him in making decisions4) palliative operation is not indicated because his estimated survival is less than three months

Answer 57

4

Question 58

61. A 45 year old man is admitted to the ICU after a laparotomy for a gunshot wound to his abdomen. Just before his discharge from the ICU 10 days later, a stage II sacral decubitus ulcer is noted. Which of the following does NOT contribute to the risk of developing a pressure ulcer?1) APACHE II score on admission to the ICU2) number of days without nutrition3) development of multisystem organ failure in the ICU4) number of days in bed

Answer 58

1APACHE requires the input of many clinical variables, from which a severity score is derived. The resulting severity score is entered into a logistical regression equation, which predicts hospital mortality. The required variables differ among the versions, but generally include factors such as age, diagnosis, prior treatment location, and numerous acute physiologic and chronic health variables. APACHE uses the worst values from the initial 24 hours of ICU admission.

Question 59

62. A liver transplant is contra-indicated for?1) a 56 year old man four days after liver transplantation who has acute hepatic artery thrombosis and for whom arterial thrombectomy was unsuccessful2) 48 year old man with a history of alcoholic cirrhosis who has been abstinent for five years3) a 68 year old woman with cirrhosis secondary to chronic hepatic C infection4) a 52 year old man who has just undergone a wedge resection of a 1 cm focus of hepatocellular carcinoma involving the middle lobe of the right lung

Answer 59

4CONTRAINDICATIONS 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 60

63. A 78 year old man is in the ICU because of complications suffered after colon resection for perforated diverticulitis. He has a living will stating that he would not want to be intubated or resuscitated in the event of cardiac or respiratory failure. He develops increasing respiratory distress and the ICU staff believes he will die very soon without intubation and mechanical ventilation. The patient is mildly confused (to date and time) but able to communicate and consents to intubation. He adult son and daughter believe that their father would not want to be intubated if he was not confused and requests that he not be intubated. What should be done?1) The patients original will should be followed and he should not be intubated.2) The patient is confused and his next of kin are automatically granted medical guardianship.3) The patient’s confusion is not sufficient to preclude his own decision making and the endotrachial tube should be inserted.4) A psychiatric consultation should be obtained to determine his ability to make his own decisions.

Answer 60

3

Question 61

64. A fifty year old hypertensive male is being investigated for possible pheochromocytoma when he suddenly develops small bowel obstruction from an incarcerated groin hernia. He requires urgent surgery. How should you manage his blood pressure pre-operatively?1) start oral phenoxybenzanine 10 mgs po x1 dose2) start IV metoprolol boluses to keep blood pressures 3) transfer patient to ICU for pre-operative blood pressure monitoring4) operate immediately and let the anesthetists look after his blood pressure

Answer 61

4

Question 62

65. With regard to Von Willibrands disease, which of the following statements is NOT true?1) it is more common than hemophilia2) most patients have mild disease unless challenged by trauma or surgery3) it is best treated with cryoprecipitated plasma4) platelet function is usually normal in platelets with Von Willibrands disease

Answer 62

4Von Willebrand factor (VWF) is a large multimeric glycoprotein that performs two critical functions in hemostasis: it acts as a bridging molecule at sites of vascular injury for normal platelet adhesion, and under high shear conditions, it promotes platelet aggregation• Most common of congenital bleeding disorders (prevalence of about 1%.)• VWF causes plt adhesion to collagen, initiating plt plg formation. It also forms a complex with VIII (actsas carrier protein) in the blood.• Produced by endothelials and megakaryocytes unlike the rest of the coagulation proteins (except VIII)that are produced by the liver.• Most have a mild bleeding disorder.THREE TYPES:1. Type I: Autosomal dominant quantitative deficiency of normally functioning vWF. They have abnormal bleeding time, and mild reduction in VIII:C (b/c less carrier protein) and vWF.2. Type II: Variably inherited and qualitative defects in vWF. Dx is complicated by the many subtypes but in general there is a depressed ristocetin assay (which measures effectiveness of vWFin agglutinating platelets.)3. Type III: autosomal recessive with complete abscense of vWF and severe bleeding.• The bleeding is similar to bleeding from platelet dysfunction, ie: mucosal bleeding, petechiae, epistaxis,and menorrhagia. (Coagulation factor problems result in joint bleeding.)TREATMENT:1. DDAVP 0.3 mcg/kg. Give 1hr prior to surgery. 48 hrs must elapse before a second injection is given to allow time for VIII and vWF to reaccumulate in endothelials. (Stimulates release form endothelials.) (Epsilon-aminocaproic acid or tranexamic acid should be given to suppress fibrinolysis.) Useful in type I disease, no value in type II and III.2. Humate P – a fVIII product (not recombinant) which contains high concentrations of vWF3. Cryoprecipitate 1 bag/10 kg q8-12h for several days to prevent excessive bleeding after major operation. Pasteurized intermediate purity factor VIII concentrate contains large numbers of vWFsand is a safe alternative. Useful for all three types of the disease.

Question 63

*66. A 24 year old man is an unrestrained driver in a motor vehicle accident. The patient remains hypoxic despite the administration of oxygen. A chest x-ray shows bilateral infiltrates. Which of the following is most likely the diagnosis?1) adult respiratory distress syndrome (ARDS)2) aspiration pneumonitis3) atelectasis4) pulmonary contusion

Answer 63

4

Question 64

67. Post-operative delirium is common in surgical patients. Which of the following is NOT characteristic of post-operative delirium?1) disturbances of consciousness2) usually does not affect sleep-awake cycle3) change in cognition or perceptual disturbance4) develops over a short period of time

Answer 64

2

Question 65

68. An 80 year old man with atrial fibrillation undergoes emergency right femoral artery thrombectomy. Four hours post-operatively the right leg is noted to be edematous. Reperfusion injury such as this is caused by all of the following EXCEPT?1) complement activation in the leg2) microvascular emboli in the leg3) neutrophil margination in the leg4) reactive oxygen species

Answer 65

2
* Microvascular obstruction
* Damage due to local factors
* Oxygen and other free radicals—Free radicals are produced within minutes of reperfusion and continue to be generated for hours after the restoration of blood flow to ischemic tissue
* Leukocyte aggregation—Multiple factors induced by ischemia and reperfusion trigger leukocyte aggregation and activation
* Platelet activation—Circulating platelets become activated early during reperfusion, and their degree of activation is related to the duration of preceding ischemia
* Complement activation—Complement activation appears to play a role in the “no reflow” phenomenon and possibly reperfusion injury
Increased blood flow in the muscle following restoration of normal tissue pressure usually causes muscle edema. The extent of extremity swelling depends upon the duration and severity of ischemia, the predominant muscle cell type within a muscle, the location and mass of ischemic muscle, and the status of the venous circulation.Successful reperfusion liberates the byproducts of muscle ischemia and cell necrosis (rhabdomyolysis) into the circulation, including potassium, phosphate, organic acids, myoglobin, creatine kinase, and thromboplastin. The systemic effects of these byproducts may include hyperkalemia, hyperphosphatemia, metabolic acidosis, and myoglobinuria which can cause acute kidney injury, elevation of serum creatine kinase levels, and disseminated intravascular coagulationuptodate

Question 66

*69. A 40 year old male unrestrained driver is brought to the emergency room after being ejected from his car during a motor vehicle crash. Four hours after his injury he is in hemorrhagic shock with a GCS of 14. Core temperature is 34.0C, and he has a base deficit of -18. After primary and secondary surveys, his only injury is an isolated severely comminuted open distal right femur fracture. He has active bleeding from the crush injury to his mid right thigh. He is taken to the operating room but despite ongoing massive resuscitation he remains in shock and hypothermic (T31.5). The most appropriate management of his right leg injury is?1) above-knee amputation of the right leg2) angiography of the right leg follows by external fixation3) immediate ligation of the superficial femoral artery follows by external fixation4) application of a tourniquet to the right thigh, further resuscitation, and then application of an external fixator

Answer 66

1.
Previous Answer was 1, but in Schwarz is says that rarely amputation is required initially. Also, unless the stem specifically said that there as nerve transection and the it was a really bad crush with no tissue coverage etc. I don’t think it’ possible to really say that we would go straight to amputation. They also say that there’s controversy regarding arterial repair vs fixation….

Controversy exists regarding which should be done first, fracture fixation or arterial repair. The authors prefer placement of temporary intravascular shunts first
with arterial occlusions to minimize ischemia during fracture treatment, with definitive vascular repair following. Rarely, immediate amputation may be considered due to the severity of orthopedic and neurovascular injuries. This is particularly true if primary nerve transection is present in addition to fracture and
arterial injury.126 Collaborative decision making by the trauma, orthopedic, and plastic/reconstructive team is essential.

Primary amputation for open fracturesA mangled extremity is a life-threatening injury. Some extremity injuries are so severe that amputation is a safer and more humane option than attempted limb preservation. Injudicious efforts at salvage may be doomed to failure, with the risk of life-threatening complications, particularly infection.The decision whether to amputate, or to try to save, a severely injured limb is one of the most controversial in trauma surgery. The patient’s physical (and emotional) ability to tolerate injury and prolonged, extensive treatment must be taken into account.The level of surgical resources at the disposal of the treating surgeon will also influence the choice.AO

Question 67

70. All of the following are effective in decreasing mortality in severe sepsis, EXCEPT?1) achieving central venous oxygen saturation of 75% within 6 hours of presentation (early goal-directed therapy)2) activated protein C administration3) achieving super normal oxygen delivery (>600 mL/min/m2)4) intravenous corticosteroids for ACTH non-responders

Answer 67

3

Question 68

71. Twenty-four hours after sustaining an on-the-job puncture wound, a 33 year old construction worker has a temperature of 39.8° C. On examination he has extensive erythemia and induration surrounding the wound in his left forearm. Serum sodium is 129 mEq/L and the white blood cell count is 21,000. The most appropriate treatment now would be?1) intravenous broad spectrum antibiotics2) irrigation of the wound with antibiotic solution and reevaluation in 12 hours3) immediate operative wide debridement4) hyperbaric oxygen therapy

Answer 68

3

Question 69

72. A 46 year old woman is severely injured in a motor vehicle crash. She requires laparotomy, repair of multiple mesenteric tears, and external fixation of an open left tibial fibular fracture. On arrival in the ICU post-operatively, her first blood gas is: pH 7.15 pCO2 35 pO2 140 bicarb 8 Her acidosis is best corrected with?1) IV sodium bicarb 50 mgs over 30 minutes2) hyperventilate patient to pCO2 253) administer 50 ccs 50% glucose over 30 minutes4) continue volume resuscitation and repeat blood gas in two hours

Answer 69

4

Question 70

73. Many of our surgical patients are quite elderly. Which of the following statements about elderly patients is NOT true?1) tachypnea may not be present despite impending respiratory failure2) normal creatinine values decrease 3) hypothermia is more prevalent 4) fever remains a reliable sign of infection

Answer 70

4

Question 71

74. Which of the following conditions contraindicates nutritional supplementation with enteric feeds?1) recent GI surgery2) high-output enteric fistula3) head trauma with decreased level of consciousness4) cancer cachexia

Answer 71

4

Question 72

75. What is the approximate probability of transmission of hepatitis C virus to a health care worker through a needle stick injury from an infected source?1) 0.5%2) 5%3) 30%4) 50%

Answer 72

1

Question 73

76. A 59 year old man undergoes a radical nephrectomy for adenocarcinoma of the left kidney. On post-operative day 4 he developed acute dyspnea and hypotension. In the ICU after treatment of IV fluids, antibiotics, and vasopressors, his vitals are: Temperature 37.3 Heart rate 130 Blood pressure 90/50 CVP 15 mmHg O2 sat 89 on FIO2 0.6 ECG shows sinus tachycardia. Chest x-rays shows bilateral lower lobe atelectasis The most likely cause of his shock is:1) septic shock secondary to surgical site infection2) pneumonia secondary to aspiration3) massive pulmonary embolus4) myocardial infarction with cardiogenic shock

Answer 73

3

Question 74

77. A 55 year old man is found to have a rhabdomyosarcoma of the vastus lateralus muscle on the left thigh. The tumour is 5 cm in diameter and there is no metastatic disease. This tumour is best treated with?1) surgical excision followed by adjuvant radiotherapy2) neoadjuvant chemotherapy followed by surgical resection3) pre-operative radiotherapy, surgical excision, and post-operative adjuvant chemotherapy4) his treatment is best decided by a tumour board at the local cancer centre

Answer 74

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Question 75

78. An 8 year old girl has a 2.5 cm breast mass that is enlarging just beneath her left nipple-areolar complex. Her mother first noticed this mass 2 months previously. Management may include all of the following EXCEPT?1) in-depth history for a review of systemic symptoms2) ultrasound imaging3) fine-needle aspiration4) excisional biopsy

Answer 75

4

Question 76

79. Which of the following is NOT necessary to determine brain death?1) absence of brainstem reflexes2) apnea3) temperature > 36° C4) study confirming absence of cerebral blood flow

Answer 76

4

Question 77

80. A 79 year old previously healthy woman develops necrotizing fasciitis from a leg wound that developed after working in her garden. The wound is surgically debrided and she is treated with IV penicillin, clindamycin, and ceftriaxone. On post-operative day 4, she has decreased mental status, temperature is 38.9, and a WBC count of 45,000. Her blood pressure is 90 systolic and she has diffuse abdominal tenderness. A plain abdominal x-ray shows a grossly dilated colon. The next step in her management should be?1) immediate colectomy and ileostomy2) colonoscopy for colonic decompression3) insertion of nasogastric and rectal tubes and repeat x-ray in six hours4) neostigmine administration

Answer 77

1

Question 78

81. A 66 year old man with unresectable pancreatic cancer has significant abdominal pain caused by the tumour. He is a smoker and has mild COPD. Despite treatment with long-acting oral narcotics, his pain is increasing and he requires hospitalization for pain control. Which of the following statements about his further treatment is TRUE?1) adding serotonin antagonists to oral narcotics should be tried prior to intravenous narcotics2) intravenous narcotics can be given in increasing dosages without respiratory side effects3) use of high-dose narcotics raises serious ethical concerns4) a change in opiod type will usually enhance pain control

Answer 78

2

Question 79

83. A 32 year old patient undergoes an open appendectomy. Post-operatively she is noted to not have voided for four hours. Her vital signs are normal. What is the most appropriate management?1) administer 500 cc bolus of normal saline2) insert a Foley catheter3) continued intravenous solution at the current rate for an additional 2 hours, and, if the patient has still not voided, straight-catheterize the patient4) continue intravenous solution at the current rate for an additional 2 hours, and, if she still has not voided, insert a Foley catheter

Answer 79

3

Question 80

84. Effective management of gastric acid aspiration includes which of the following treatments?1) tracheal intubation and saline lavage of the lungs2) tracheal intubation, suctioning, and controlled ventilation with positive end expiratory (PEEP) therapy3) prophylactic antibiotic therapy4) 24 hour pulse steroid therapy

Answer 80

2

Question 81

85. With regards to clinical trials, which of the following statements is TRUE?1) phase II trials establish the maximum tolerated dose of an experimental agent2) comparing one group of patients receiving a given treatment with another that received a different treatment 10 years ago introduces observational bias into the study 3) randomization in clinical trials is done to ensure that each group of patients has a similar chance of achieving the desired outcome4) an example of a phase I trial would be studying whether Herceptin plus Docetaxol is effective in decreasing the size of metastases from breast cancer

Answer 81

3

Question 82

86. A 35 year old man suffers severe injuries in a motor vehicle crash. Trauma laparotomy showed a shattered spleen (removed) and multiple tears in the small bowel mesentery (over sewn). He requires 15 units red blood cell transfusion before and during the surgery. At the end of the surgery, it is noted that all raw surfaces are oozing blood. His temperature is 32.5°, pH 7.15, INR 1.4, platelet count 60,000. His coagulopathy is best treated with?1) 4 units of FFP, 2 units platelets2) 8 units cryoprecipitate3) Factor VIIa infusion4) rewarming and correction of acidosis in the ICU

Answer 82

4

Question 83

87. Which of the following bacteria is most likely with transfusion associated sepsis?1) staphylococcus aureus2) ß-hemolytic streptococcus3) bacteriodes fragilis4) pseudomonas species

Answer 83

4

Question 84

88-90. For each of the numbered word, phrase or statement, which of the following answers is most appropriate? 1) primary peritonitis 2) seconday peritonitis 3) both 4) neither88. Polymicrobial infection89. Paracentesis required for diagnosis90. Operation is the treatment of choice

Answer 84

88: 289: 190: 2

Question 85

31-33. For the following three questions, mark your answer sheet with the most appropriate answer: 1) adominal compartment syndrome 2) biventricular heart failure 3) both 4) neither 31. Pulmonary capillary wedge pressure 25 mm/Hg32. Preload decreased33. Initial treatment includes diuresis

Answer 85

31: 232: 133: 2

Question 86

91. Use of low molecular weight heparin compared with unfractionated heparin for the treatment of deep vein thrombosis is associated with a?1) higher incidence of all-cause mortality2) lower incidence of major bleeding complications3) higher incidence of recurrent symptomatic venous thrombo embolism at 3 months4) lower risk of heparin-induced thrombocytopenia

Answer 86

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Question 87

92-94. For the following 3 questions, mark the most appropriate answer on your answer sheet:1) increase in the pool of kidneys available for transplant2) improves renal graft survival3) both4) neither92. Laparoscopic donor nephrectomy93. ABO-incompatible transplants94. Living unrelated donor versus cadaveric transplant

Answer 87

92: 193: 194: 3

Question 88

95. The extracellular, extravascular fluid compartment (the interstitial space) is frequently enlarged in surgical patients. All of the following factors may contribute to this expansion, EXCEPT?1) increase in serum cortisol levels2) increase in capillary permeability3) decrease in plasma oncotic pressure4) increase in intravascular pressure

Answer 88

1

Question 89

96. Obese patients have an increased risk of deep vein thrombosis for all of the following reasons EXCEPT?1) increased abdominal weight and venous stasis2) polycythemia3) infrequent ambulation4) increased incidence of ischemic heart disease

Answer 89

4

Question 90

97. Lipolysis occurs commonly in chronically ill surgical patients. Which of the following statements about lipolysis is NOT true?1) insulin stimulates lipolysis2) lipolysis results in the formation of glycerol3) glucagon stimulates lipolysis4) with increased lipolysis, ketones are formed and released into the circulation

Answer 90

1

Question 91

98. A 45 year old woman is recovering well after surgery for perforated appendicitis. She is being treated with IV cefazolin and metronidazole. Her vitals are normal, abdomen soft and nontender. White blood cell count is normal but urine culture reveals candida species and enterococcus faecalis. Urinalysis shows many epithelial cells and many bacteria. She has a Foley catheter in place. Which of the following is the best treatment for this patient?1) start fluconazole and vancomycin intravenously2) start amphotericin B intravenously3) give amphotericin B bladder irrigation and vancomycin IV4) remove Foley catheter

Answer 91

4

Question 92

99. A 49 year old man undergoes right hemicolectomy for a malignant polyp. Post-operatively he develops an enterocutaneous fistula from his anastomosis. He is discharged home tolerating a regular solid diet with a stoma appliance over the fistula site. He is to be readmitted in three months for laparotomy and repair of his fistula. Which of the following treatments will help to decrease the risk of an anastomotic leak after his second operation?1) 2 weeks total parenteral nutrition prior to the surgery2) insist patient stops smoking immediately3) through bowel preparation prior to second surgery4) keep patient in the ICU post-op for meticulous fluid therapy and close observation

Answer 92

2

Question 93

100. A 65 year old diabetic undergoes above knee amputation for a gangrenous left leg. On post-operative day four he is found on the ward with blood pressure 90 systolic, heart rate 130. He was well the preceding evening but now appears acutely ill. Possible causes of his shock state include all of the following, EXCEPT? 1) sepsis2) diabetic ketoacidosis3) myocardial infarction4) pulmonary embolus

Answer 93

2

Question 94

82. Which of the following are NOT part of the vascular response to severe injury or infection?1) mast cell and macrophage activation of vascular endothelium2) vasodilation of local arterioles3) leukocyte margination4) upregulation of vascular endothelial tight-junctions

Answer 94

4