Other

Question 1

In acute spinal cord injury, pCO2 greater than 50 mmHg and PaO2 less than or equal to 50 mmHg on room air are
most commonly due to which of the following factors?
Answers:
A. Chest trauma
B. Phrenic nerve injury
C. Aspiration pneumonia
D. Pulmonary embolus
E. Lack of accessory muscles of respiration

Answer 1

Lack of accessory muscles of respiration

Patients with spinal cord injury lose accessory muscles of respiration, which can lead to respiratory failure despite maintained diaphragmatic innervation. Phrenic nerve injury itself is rare with SCI. Chest trauma, PE and aspiration are possible explanations, but aren’t as common as lack of accessory muscle use.

Question 2

A previously healthy 50-year-old man undergoes elective craniotomy for resection of a glioma.
Which of the following strategies is recommended for prevention of venous thromboembolism?
Answers:
A. Enoxaparin SQ
B. Hypovolemia
C. Daily BLE ultrasound
D. Heparin drip
E. Aspirin

Answer 2

Enoxaparin SQ

Deep Venous Thrombosis (DVT) prophylaxis for post-op craniotomies is with manual compression devices and enoxaparin SQ. A heparin drip and aspirin are not routinely used for prophylaxis due to the increased risks of postoperative hemorrhage. Daily ultrasounds are not indicated, and ultrasound should only be used if the patient has clinical suspicion of DVT. Hypovolemia would increase the chances of developing a DVT.

Question 3

In research involving human subjects, which of the following is required by the ethical principle
“respect for persons”?
Answers:
A. Beneficence
B. Non-maleficence
C. Justice
D. Truth-telling
E. Autonomy

Answer 3

Beneficence

The principle of beneficence requires that the procedure or intervention being provided is done so in an effort to achieve better for the patient. As the patient has been determined to be moribund, the morphine is being used to treat the presumed pain and respiratory distress with such a situation. While the hastening of the patient’s death should certainly be considered in the setting of non-maleficence, the benefit achieved through treatment of the patient’s suffering outweighs and, ultimately, does not change the end outcome.

Question 4

Which of the following substances increases the permeability of the blood-brain barrier?
Answers:
A. All of the answer choices
B. Morphine
C. Cocaine
D. Alcohol
E. Nicotine

Answer 4

All of the answer choices

Many both legal and illegal substances increase the permeability of the blood brain barrier including nicotine, cocaine, alcohol, morphine and methamphetamine. The blood-brain barrier (BBB) is formed by an endothelial cell (EC) monolayer between the blood and central nervous system (CNS) that contributes to maintaining structural and functional homeostasis in the brain. The BBB structure interacts with perivascular pericytes, microglial cells, astrocytes, and neurons that, together, form the neurovascular units. The BBB is formed by an EC network rigidly connected by complex junction systems comprised of smaller trans-membrane tight junction (TJ) proteins, including junction adhesion molecules (JAM), endothelial cell-selective adhesion molecules, occludins, and claudins. This creates a boundary between the CNS and peripheral circulation for regulating blood-CNS exchange. Drugs of abuse cause BBB dysfunction by altering TJ formation and protein expression.

Question 5

Which of the following cells are most associated with the local inflammatory response in the brain
resulting from multiple concussive head injuries?
Answers:
A. Neurons
B. Microglia
C. Hemoglobin
D. Neutrophiles
E. Red Blood Cells

Answer 5

Microglia

In moderate to severe TBI, there is evidence for microglia activation and recruitment of macrophages, dendritic cells, neutrophils, B cells and T cells, and meningeal inflammation. In addition to active recruitment mechanisms, peripheral immune cells can infiltrate with hemorrhage alongside red blood cells (RBCs) and the release of hemoglobin (Hgb), and other damage associated molecular patterns (DAMPs, which are one set of initiators of the immune response). In mild TBI, there is little evidence of infiltrating immune cells to the brain tissue in humans or animal models that do not produce hemorrhage or skull opening. In mild TBI, there is evidence of meningeal inflammation, microglial activation, and some monocyte/macrophage recruitment to the cerebrovasculature.

Question 7

A 25-year-old man with severe traumatic brain injury undergoes decompressive craniectomy. Postoperative axial
cranial CT scans of the brain and bone settings are shown. Which of the following errors is indicated by these figures?
Answers:
A. Incomplete evacuation of hematoma
B. Wrong-side surgery
C. Failure to decompress middle fossa floor
D. Inadvertent entry into the frontal sinus
E. Inadequate size of craniectomy

Answer 7

Inadequate size of craniectomy

The craniotomy size in the picture is too small and there is brain mushrooming out with contusions at the bony edge. The standard craniectomy should be at least 15cm in diameter. None of the other options are shown here.

Question 8

A 50-year-old woman is status post transsphenoidal resection of clinically non-functioning pituitary
macroadenoma. Her preoperative pituitary function was normal. One week later, she presents to
the emergency department with nausea and emesis. On laboratory studies, serum sodium level is
114 mEq/L. Which of the following is the most appropriate initial step in management?
Answers:
A. Recheck Na in 6 hours to ensure it is not dropping further.
B. Give DDAVP and recheck Na level.
C. Administer oral sodium chloride tablets
D. Give Lasix and recheck Na level.
E. Send urine sodium and urine osmolality, assess for volume status and check TSH, LH,
FSH, Prolactin and Vasopressin.

Answer 8

Send urine sodium and urine osmolality, assess for volume status and check TSH, LH, FSH, Prolactin and Vasopressin.

DDAVP is the treatment for DI, which is not consistent with a Na of 114. Lasix can be appropriate in the setting of hyponatremia but we have not identified the cause of hyponatremia here, and if this is caused by CSW then diuresis will exacerbate the problem. This is very likely a triphasic response and she is currently in the second phase (transient SIADH), but we cannot be sure; thus, assessing for volume status, urine sodium and urine osmolality will aid in diagnosis. She is severely hyponatremic and is symptomatic, thus simply rechecking the Na in 6 hours is not appropriate. In central DI there is a “triphasic” presentation. Briefly, the patient begins with a tendency towards hypernatremia, then develops a tendency towards hyponatremia, and finally ends with a chronic tendency towards hypernatremia. In the first phase, caused by ischemia or direct trauma to the vasopressin-secreting neurons of the hypothalamus, there is an initial polyuric phase that lasts for approximately 4-5 days. Urine osmalality drops and hypernatremia ensues. In the second phase, there is a transient SIADH that occurs as a result of leakage of vasopressin from the damaged posterior pituitary tissue and severed axons. Hyponatremia (ie, serum Na < 135 mmol/L) with concomitant hypo-osmolality (serum osmolality < 280 mOsm/kg) and high urine osmolality are the + hallmark of SIADH. SIADH is a volume-expanded state because of antidiuretic hormone-mediated renal water retention. CSW is characterized by a contracted volume depleted state resulting from renal salt wasting. Making an accurate diagnosis is important because the treatment of each condition is quite different. In the third phase, after the neurons have died and released their vasopressin, patients develop chronic DI. Central DI is characterized by failure of ADH release from the posterior pituitary resulting in a disorder of renal water conservation leading to a loss of urine that is largely devoid of solute. It is diagnosed by polyuria (urine output >30mL/kg body weight or >200 mL/h for 2 hours), hypernatremia (Na > 145) and SG<1.005 or urine osmolarity <300 mOsm/kg.

Question 9

A 48-year-old man undergoes a transsphenoidal resection of a nonfunctional pituitary macroadenoma. An abdominal fat graft was harvested for intraoperative CSF leak repair. The patient is discharged on postoperative day 1 and is doing well. On postoperative day 8, he comes to the emergency department with a new complaint of moderately severe nausea and fatigue. Laboratory studies show: WBC count 9.8/mm3, Serum Na+ 130 mEq/L, K+ 3.9 mEq/L, Urea nitrogen BUN 15 mg/dL, Glucose 114 mg/dL and Creatinine 1.0 mg/d. Which of the following is the most appropriate next step in management?
Answers:
A. Give Tolvaptan.
B. Give Lasix.
C. Give 1L fluid bolus and recheck Na level.
D. Test for corticotroph pituitary function and assess volume status.
E. Surgical exploration

Answer 9

Test for corticotroph pituitary function and assess volume status.

Eight days after transsphenoidal resection of pituitary lesion, the most likely cause is the triphasic response with the second phase being hyponatremia. However, before treating hyponatremia it is important to assess for cause, assess volume status and, in the setting of recent transsphenoidal surgery, to check pituitary function so the condition can be appropriately diagnosed and treated.

Question 10

A 24-year-old man sustained an injury to the pelvis and both lower extremities in a motor vehicle collision 30 hours ago. Abdominal-pelvic CT scans with a nonionic contrast agent showed no other abnormalities. During the past four hours, his urine output decreased, his serum creatinine level doubled, and his urine turned a brownish color. The most likely cause of the acute renal failure in this patient is which of the following?
Answers:
A. Contrast administration
B. Hemorrhagic shock
C. Rhabdomyolysis
D. Sepsis
E. Medication induced

Answer 10

Rhabdomyolysis

The rate of kidney failure due to nonionic contrast is low. Hemorrhagic shock could be an explanation, but is less likely without any signs on the CT. Medications are also possible, but the question does not mention any nephrotoxic medication administration. Sepsis is not likely given the mechanism and time course. Rhabdomyolysis is common after trauma with soft tissue and long bone injuries.

Question 11

Which of the following is the rate of caloric expenditure following a traumatic brain injury (TBI)?
Answers:
A. Mean 80% of expected energy expenditure unless paralyzed or in barbiturate coma.
B. Mean 100% of expected energy expenditure unless paralyzed or in barbiturate coma.
C. Unknown
D. Mean 80% of expected energy expenditure unless paralyzed or in barbiturate coma.
E. Mean 140% of expected energy expenditure unless paralyzed or in barbiturate coma.

Answer 11

Mean 140% of expected energy expenditure unless paralyzed or in barbiturate coma.

Data measuring metabolic expenditure in rested comatose patients with isolated TBI yielded a mean increase of approximately 140% of the expected metabolic expenditure with variations from 120% to 250% of that expected. Researchers found that, in TBI patients, paralysis with pancuronium bromide or barbiturate coma decreased metabolic expenditure from a mean of 160% of that expected to 100–120%. The main consequences of traumatic injury in body composition are weight loss; consumption of lean body mass, mainly skeletal muscle mass; negative nitrogen balance; and water and salt retention. These leave patients prone to immune depression and increased susceptibility to infection, sepsis, and generalized organ failure, leading to prolonged intensive care unit (ICU) and hospital stays and increased morbidity and mortality. Thus, nutrition therapy should be initiated early, ideally within the first 24 h after injury, and provide more than 50% of resting energy expenditure (REE) with 1.0 to 1.5 g protein/kg, for the 2 weeks subsequent to the injury. This intervention is critical in limiting the intensity of the inflammatory response to TBI and improving the outcome.

Question 12

The passage of molecules across the blood-brain barrier is facilitated by which of the following?
Answers:
A. Glucose transporter (GLUT-1) protein
B. Passive uptake of neurotransmitters
C. Tight junctions between endothelial cells
D. Binding to plasma proteins
E. Low-lipid soluble compounds

Answer 12

Glucose transporter (GLUT-1) protein

GLUT-1 proteins facilitate the passage of glucose across the Blood Brain Barrier (BBB). Tight junctions and binding to plasma proteins impede passage across the BBB. Compounds that are highly lipid soluble are more likely to pass the BBB than low-lipid soluble ones. Neurotransmitters are actively taken-up, not passively.

Question 13

A 28-year-old man underwent an emergency craniotomy following a motor vehicle collision. One
day postoperatively, a CT scan of the head shows a retained Raney clip. Which of the following is
the most appropriate next step in management?
Answers:
A. Return to operating room to retrieve the retained product but do not discuss this finding
with patient
B. Discuss finding with patient but do not retrieve the retained product
C. Discuss finding the patient and offer to retrieve the product while discussing both the risks
and benefits of removal versus not removing
D. Discuss with patient that there is something abnormal on CT but you do not know what it
is
E. Do not discuss finding with the patient as no surgical management required

Answer 13

Discuss finding the patient and offer to retrieve the product while discussing both the risks and benefits of removal versus not removing

Disclosure of retained surgical products is crucial. It is the duty of the surgeon to disclose these findings early and discuss the ramifications of these findings with the patient. This leads to improved patient experience and overall patient outcomes. The decision to remove the device can be made based on a risk and benefit discussion of all options available between the physician and the patient.

Question 14

Practicing cost-effective health care and resource allocation without compromising the quality of
care is which of the following core competencies, as outlined by the Accreditation Council for
Graduate Medical Education (ACGME)?
Answers:
A. Medical Knowledge
B. Interpersonal and Communication Skills
C. Professionalism
D. Systems-Based Practice
E. Patient Care

Answer 14

Systems-Based Practice

The Accreditation Council for Graduate Medical Education (ACGME) has outlined six core competencies which should be attained by every new practitioner at the completion of their training. In addition to those listed above, practice-based learning and improvement is also considered one of these competencies. Practicing cost-effective health care and understanding effective resource allocation is part of the systems-based practice competency. This calls for practitioners to have a better understanding and awareness of the larger context and system of health care.

Question 15

A 34-year-old man with acromegaly undergoes resection of a growth hormone-secreting pituitary
macroadenoma. Two days postoperatively, urine output is 2 L during the past 12 hours and serum
sodium level is 135 mEq/L. Which of the following is the most appropriate management?
Answers:
A. Free water restriction
B. Continued observation
C. 3% NaCl infusion
D. Intranasal DDAVP
E. Urine FeNa

Answer 15

Continued observation

The patient is mobilizing his intraoperative IV fluids and this is a normal pattern after surgery. DI is defined by passage of >3L urine over 24 hours, and the urine is typically dilute (300mOsm/kg). Below that, one can assume this patient is mobilizing his intraoperative IV fluids, although calculation of input versus output is critical. His sodium is low, which is the opposite of what would be expected with DI. His sodium is not dangerously low and he is asymptomatic, so there is no need for hypertonic saline or free water restriction. Urine osmolality or urine sodium can help diagnosis hyponatremia, but is not necessary in this case.

Question 16

In research involving human subjects, which of the following is required by the ethical principle
“respect for persons”?
Answers:
A. Individual autonomy does not need to be recognized in the setting of research
B. Individuals should be treated as autonomous persons
C. Individuals with diminished autonomy are good research subjects
D. Individuals with diminished autonomy should be protected
E. Individuals should be treated as autonomous persons and those with diminished
autonomy should be protected

Answer 16

Individuals should be treated as autonomous persons and those with diminished autonomy should be protected

In the setting of human research, maintaining patient autonomy is of critical importance to ensure that patients can make appropriate decisions about whether they would like to participate in this research or not. Arguably, even more important is protecting patients who have diminished autonomy. The capacity for autonomy can be lost to a varying degree due to illness, mental disability or instances where liberty is severely restricted. Some patients require extensive protection, even up to the point of not being included in particular studies.

Question 17

Which of the following is the most effective means of treating symptomatic increased intracranial
pressure resulting from intracerebral hematoma?
Answers:
A. Evacuation of mass lesion.
B. Paralytics.
C. Corticosteroids
D. Hypertonic therapy.
E. Sedation.

Answer 17

Evacuation of mass lesion.

Correct treatment for intracranial hypertension due to a mass lesion is surgical evacuation. Sedation, paralytics, hypertonic therapy may be used in the setting of elevated ICP with no mass lesion. Steroids are not indicated.

Question 18

Which of the following best describes the effect of decompressive craniectomy for adult patients with severe traumatic brain injury and elevated intracranial pressure (ICP) that are refractory to first-tier therapies?
Answers:
A. Decreased mortality for surgical patients
B. Increased ICU length of stay for surgical patients
C. Lower rate of adverse events in surgical patients
D. There are no studies examining these outcomes
E. Similar rate of vegetative state between surgical and non-surgical patients

Answer 18

Decreased mortality for surgical patients

The RESCUE-ICP trial showed a decreased mortality for surgical patients with refractory ICP when compared to medical management. The trial also showed a decreased ICU length of stay, higher rates of vegetative state, and higher rate of adverse events.

Question 19

A 29-year-old man is slow to awaken from anesthesia one hour after craniotomy for resection of a
temporal glioma. His serum sodium level is 126 mEq/L, and his preoperative serum electrolyte
levels were normal. Which of the following is the most likely cause of this patient’s condition?
Answers:
A. SIADH
B. Inadequate tonicity of intravenous fluids
C. CSW
D. DI
E. Inadequate tonicity of intravenous fluids

Answer 19

Inadequate tonicity of intravenous fluids

The most common cause of immediate post-op hyponatremia in a patient with a normal pre-op sodium is use of intra-op intravenous fluids that are relatively hypotonic. Strict attention to type and exact amount of input and output of fluids in hospitalized patients is critical for preventing iatrogenic hyponatremia, especially in very young patients. In iatrogenic hyponatremia due to the administration of hypotonic intravenous fluids, either isotonic or hypertonic fluids can be administered for treatment. If hypovolemic hyponatremia is suspected (urine [Na ] less than 30 mEq/L and/or signs of hypovolemia on physical examination), volume repletion with isotonic saline (0.9% NaCl) should be given in order to replace the ECF volume and restore organ perfusion. +

Question 20

The pathology in the sagittal section of the cerebellum shown (superior is at the top of the figure) is
most likely the result of which of the following?
Answers:
A. Meningitis
B. Spongiform encephalopathy
C. Spinocerebellar ataxia
D. Alcoholism
E. Multiple sclerosis

Answer 20

Alcoholism

The degeneration pattern in the anterior superior vermis seen is most commonly associated with alcohol use. In spinocerebellar ataxia, the anterior and posterior lobes and pons are atrophic with a widened 4 th ventricle. Meningitis would show thickened arachnoid. Spongiform encephalopathy would show patchy areas of degeneration. Multiple sclerosis will show plaques in the white matter in the cerebellum.

Question 21

A patient with back pain has a serum calcium level of 12 mg/dL, a serum phosphorus level of 1.5
mg/dL, and an increased serum alkaline phosphatase level. X-ray films show demineralization.
The most likely diagnosis is
Answers:
A. Chronic Kidney Disease
B. Hyperparathyroidism
C. Osteoporosis
D. Lung Cancer
E. Thiazide Diuretics

Answer 21

Hyperparathyroidism

Hyperparathyroidism causes elevated calcium levels and bone reabsorption. It causes bone reabsorption. It causes an increase in serum alkaline phosphatase. Hypercalcemia is common in lung cancer but not associated with hypophosphatemia (that is often low). Chronic kidney disease causes hypocalcemia. Thiazide diuretics may increase blood calcium levels by decreasing urine calcium levels but does not increase serum alkaline phosphatase.

Question 22

A 75-year-old man is evaluated because of a six-hour history of increasing headache and leftsided weakness. He has atrial fibrillation treated with warfarin 5 mg once daily. The international normalized ratio (INR) is 3.0. A CT scan of the head shows an acute right basal ganglia hemorrhage. Which of the following is the most effective treatment to immediately reverse this patient’s coagulopathy?
Answers:
A. PO Vitamin K and PCC
B. IV Vitamin and rFVII
C. IV Vitamin K and PCC
D. Fresh frozen plasma
E. IV Vitamin K

Answer 22

IV Vitamin K and PCC

Vitamin K alone does not act rapidly enough in the setting of an intracranial hemorrhage. Vitamin K should be given intravenously because it produces more rapid reversal than oral vitamin K, and oral administration is problematic if the patient is obtunded. Although rFVIIa lowers the INR in patients on vitamin K antagonists (VKAs) who present with Intracranial Hemorrhage (ICH), it does not restore thrombin generation nor does it affect the duration of bleeding while PCC and FFP do. Prothrombin Complex Concentrate (PCC) contains a full complement of factor VII, factor IX, factor X, and prothrombi. The concentrates are processed to inactivate the clotting factors and treated to inactivate transfusion-transmitted viruses. Fresh frozen plasma (FFP) contains all of the clotting factors. PCC is superior to FFP for VKA reversal in ICH patients based on the results of the INR normalization in patients with ICH related to VKA trial. Compared with FFP, 4-factor PCC more effectively normalized the INR and significantly reduced the risk of hematoma expansion at 3 and 24 hours. By 48 hours, there were 5 deaths because of hematoma expansion in the FFP group and none in the group given PCC. Additionally, FFP takes longer to administer due to the volume.

Question 23

MBX1136 Global cerebral blood flow in adults normally averages which of the following?
Answers:
A. 100 ml/(100g min)
B. 250 ml/(100g min)
C. 10 ml/(100g min)
D. 15% of cardiac output
E. 30% of cardiac output

Answer 23

15% of cardiac output

The cerebral blood flow is equivalent to 15% of cardiac output or 50 ml/(100g min)

Question 24

A 25-year-old man comes to the emergency department because of a three-day history of
confusion, nausea, dizziness, and fatigue. Three weeks ago, the patient underwent resection of
a craniopharyngioma at another hospital. Temperature is 37.0°C (98.6°F), pulse is 110/min, and
blood pressure is 98/60 mmHg. Laboratory studies show: WBC count 7/mm, Serum Na+ 128
mEq/L, Glucose 45 mg/dL. Which of the following is the most likely underlying cause of this
patient’s presentation?
Answers:
A. Dehydration
B. Hypoglycemia secondary to nausea and poor appetite.
C. SIADH.
D. Secondary adrenal insufficiency.
E. Sepsis.

Answer 24

Secondary adrenal insufficiency.

Secondary adrenal insufficiency is caused by lack of Adrenocorticotropic Hormone (ACTH), which is produced by the pituitary and can be low after transsphenoidal resection. It leads to low Na, hypotension, low glucose and feeling tired, nauseous and confused. Sepsis is very unlikely in the setting of a normal white count and no fever. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) causes hyponatremia but not the other listed symptoms.

Question 25

Cessation of neural synaptic transmission without cell membrane breakdown is most likely to occur
at which of the following cerebral blood flow rates (mL/100 g/min)?
Answers:
A. > 50 ml/100 g/min
B. < 8 ml/100 g/min.
C. 16 to 18 ml/100 g/min.
D. 8 to 23 ml/100 g/min.
E. 25-40 ml/100 g/min.

Answer 25

8 to 23 ml/100 g/min.

Neural synaptic transmission ceases without cell breakdown at rates between 8 and 23 ml/100 g/min. At less than 8, the cell membranes break down. At 25-40, there is transmission. 16-18 is too narrow of a window. Blood perfusion is responsible for the delivery of oxygen, which is necessary for the neuronal oxidative metabolism of energy substrates (mostly glucose, but also ketone bodies and lactate). Because of the limited capacity of neurons for anaerobic metabolism (at rest, up to 92% of the adenosine triphosphate in the brain results from oxidative metabolism of glucose), CBF is critical. CBF ensures proper delivery of oxygen and energy substrates and the removal of waste products from metabolism. Processing by neurons is based on the movements of multiple ions across the cells. In particular, the generation of action potentials, which result from influx and efflux of Na+ and K+ across the neuronal cell membrane, forms the basis of information transmission by neurons to distant sites. To maintain the Na+ and K+ concentration gradient and facilitate ion transport against the gradient, the neurons require energy in the form of adenosine triphosphate (ATP). The ATP consumption by Na+ and K+-ATPase in the basal state accounts for approximately 50% of the total ATP consumption of the brain. Thus, when the brain does not get enough blood flow, neural synaptic transmission ceases because it cannot generate action potentials.

Question 26

A 79-year-old Vietnamese woman, who speaks little English, has been treated for neck pain and
radiculopathy for the past several years. Her physician believes that an anterior cervical
discectomy should be performed. Which of the following must be done to obtain informed consent
from the patient for the procedure?
Answers:
A. Informed consent could be obtained using translation software
B. Informed consent could be obtained using a staff member who is moderately proficient in
conversational Vietnamese
C. Informed consent could be obtained from the patient directly without any translation aid
D. Informed consent could be obtained using a certified medical translator
E. Informed consent could be obtained with a family member serving as a translator

Answer 26

Informed consent could be obtained using a certified medical translator

While others may be able to convey information to the patient with regards to the procedure, the most appropriate course of action in obtaining informed consent is to use an official medical translator. As medical translators are specifically trained to appropriately convey medical information, this is the best option for obtaining informed consent. Published studies report positive benefits of professional interpreters on communication errors and comprehension, utilization, clinical outcomes, and satisfaction with care.

Question 27

Which of the following is one of the general competencies required for residency education by the
Accreditation Council for Graduate Medical Education (ACGME)?
Answers:
A. Medical Knowledge
B. Interpersonal and Communication Skills
C. All the answers
D. Professionalism
E. Patient Care
F. Systems-Based Practice

Answer 27

All the answers

The Accreditation Council for Graduate Medical Education (ACGME) provides six core competencies which must be attained by each practitioner prior to exiting training. These include patient care, medical knowledge, professionalism, systems-based practice, interpersonal and communication skills, and practice-based learning and improvement. Throughout training, residents are routinely assessed for progress in each of these areas as they move towards a postresidency career.

Question 28

Current Procedural Terminology codes are used by physicians to submit claims to insurers based
on which of the following?
Answers:
A. Patient diagnosis
B. Service/procedure(s) rendered
C. Patient condition
D. Procedure related complications
E. All of the above

Answer 28

Service/procedure(s) rendered

Current Procedural Terminology (CPT) codes are set forth by the CPT editorial panel by way of the American Medical Association (AMA). These codes describe medical, surgical and diagnostic services performed. This is done in such a way to allow for the communication of uniform information about medical services and procedures. While these codes are similar to those of ICD-10, CPT codes are based on services rendered as opposed to the diagnosis on the claim.

Question 29

A neurosurgeon wants to participate in an outcomes study that requests surgical histories and
follow-up data on patients he has seen over the preceding three years. He practices at an
institution that is a covered entity under the Health Insurance Portability and Accountability Act
(HIPAA). Under the terms of the HIPAA privacy rule, he may supply this information under which of
the following circumstances?
Answers:
A. Waiver of authorization obtained from Institutional IRB obtained when research presents
no more than minimal risk to the privacy of individuals involved
B. Research performed only on decedent patients
C. Data being used only for preparation of research (i.e. to assess feasibility of a prospective
study)
D. All the other answers
E. Individual authorization obtained from each patient for participation in research

Answer 29

All the other answers

The HIPAA privacy rule outlines the conditions under which protected health information may be used or disclosed by covered entities for research purposes. Based on the data being used, multiple options are available to allow institutions to proceed with research. First, individual authorization may be obtained from each patient according to the guidelines set forth in the privacy rule. However, there are situations where protected health information (PHI) may be used without obtaining individual authorization. A waiver may be obtained from institutional review boards when certain conditions are met. Mainly, there needs to be no more than minimal risk to patient privacy for the research protocol. Also, the research needs to not be able to be conducted without access to the PHI and it also needs to be deemed that obtaining individual authorization is not practical. Finally, if the data is only being used for preparation of research or is only being performed on deceased patients, the privacy rule also allows this to be conducted without obtaining individual authorizations.

Question 30

According to the Institute of Medicine, which of the following is classified as an adverse event?
Answers:
A. Tethered cord syndrome after myelomeningocele repair
B. Local recurrence of glioblastoma 6 months after surgery and chemotherapy/radiation
C. Development of proximal junctional kyphosis after a long segment thoracolumbar fusion
D. Intraoperative spinal cerebrospinal fluid leak that requires return to the operating room
E. Hemorrhage expansion in a patient with underlying coagulopathy

Answer 30

Intraoperative spinal cerebrospinal fluid leak that requires return to the operating room

An adverse event is defined as an event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient. While the other options can be attributed to the patient’s pathology, cerebrospinal fluid leak, especially one that ultimately requires a return to the operating room, would almost certainly be classified as either an error of omission or commission.

Question 31

Cost-effective health care and resource utilization refer most accurately to which of the following
core competencies?
Answers:
A. Medical Knowledge
B. Systems-Based Practice
C. Interpersonal and Communication Skills
D. Professionalism
E. Patient Care

Answer 31

Systems-Based Practice

The Accreditation Council for Graduate Medical Education (ACGME) has outlined six core competencies which should be attained by every new practitioner at the completion of their training. Practicing cost-effective health care and understanding effective resource allocation is part of the systems-based practice competency. This calls for practitioners to have a better understanding and awareness of the larger context and system of health care.

Question 32

In research involving human subjects, which of the following is required by the ethical principle
“beneficence”?
Answers:
A. Benefits should be maximized and potential harms should be minimized to patients
participating in research
B. Patients should be appropriately protected from harm during research participation as best
as possible
C. Patients should be appropriately protected from harm during research participation as best
as possible and benefits should be maximized and potential harms should be minimized to
patients participating in research
D. Patients should be appropriately compensated for their participation in research
E. Patients should be appropriately compensated and protected from harm during research

Answer 32

Patients should be appropriately protected from harm during research participation as best as possible and benefits should be maximized and potential harms should be minimized to patients participating in research

Beneficence is another important ethical concept in the treatment of research subjects in human studies. This concept encompasses one of the most basic ethical principles in medicine: “do no harm.” This certainly has to be taken into account when designing research studies, especially in studies where some or all of the side effects or possible complications are unknown. Ultimately, it is the duty of the researcher to maximize benefit and minimize risk with any study design.

Question 33

A scien st is in receipt of a de-iden fied pa ent outcomes data set sent from a clinical registry with which he has a business associate agreement. In order to use the data to generate new knowledge relevant to the improvement of health care services, he must do which of the following?
Answers:
A. Obtain written permission for each individual patient
B. The data can only be used for a quality project at the hospital
C. If the data is de-identified appropriately, no further action is required
D. Obtain documentation from the IRB for their institution
E. Obtain a waiver for use of PHI for research

Answer 33

If the data is de-identified appropriately, no further action is required

The HIPAA privacy rule requires written permission be obtained from patients prior to protected health information (PHI) being used for research purposes. If written permission is not obtained, a waiver must be obtained from either the Institutional Review Board or Privacy Board. However, if the data set is appropriately de-identified, there is no requirement for a written agreement or waiver. It is important to ensure that the data has been appropriately de-identified. There are 18 different identifiers that must be de-identified to ensure that this is the case.

Question 34

A 40-year-old woman is brought to the emergency department with multiple intraparenchymal contusions after a motor vehicle collision. Her intracranial pressure increases to a sustained level of 30 mmHg refractory to CSF drainage. She is currently positioned with the head of the bed elevated. On physical examination, her eyes are closed, and she briskly localizes to noxious stimulations. Respirations are 16/min with a ventilator setting of 12/min. Current osmolality level is 330 mOsmol/kg H2O. Which of the following is the most appropriate next step in the medical management of this patient’s intracranial hypertension?
Answers:
A. Paralytics
B. Mannitol bolus
C. Assess cerebral autoregulation
D. Decompressive craniectomy
E. Barbiturate coma

Answer 34

Assess cerebral autoregulation

Tier 3 strategies for refractory ICP include barbiturate coma, paralytics and secondary decompressive craniectomy. However, before proceeding to this, tier 2 strategies must be exhausted. This includes cerebral autoregulation assessment, per TQIP and SIBICC guidelines. Cerebral autoregulation is assessed by increasing the mean arterial pressure and watching for a concordant increase in the intracranial pressure. If the ICP is maintained while the MAP increases, autoregulation is intact. Alternatively, many advanced neuromonitoring devices can track autoregulation over time by measuring the pressure reactivity index (prx). A mannitol bolus is contraindicated due to the osmolality

Question 35

A 67-year-old man sustained an abducens nerve palsy after placement of a subthalamic nucleus deep brain electrode. Follow-up MR imaging shows hypointensity on T1-weighted MR images in the area of the abducens nucleus. Which of the following is the most appropriate message to communicate to the family?
Answers:
A. Do not communicate this MRI finding as unlikely related to surgical procedure
B. Communicate the MRI finding and its likely relationship to the surgical procedure at as soon family available to discuss
C. Communicate that this MRI finding is unrelated to the surgical procedure
D. Communicate the MRI finding but discuss that its relation to the surgery is unclear
E. Communicate the MRI finding and its likely relationship to the surgical procedure at six week follow up visit

Answer 35

Communicate the MRI finding and its likely relationship to the surgical procedure at as soon family available to discuss

It has been noted that surgical complications which are discussed directly with the patient lead to improved patient experience and patient outcomes. Attempting to avoid discussion with regards to the complication is not only medically unethical, but also not in the best interest of the patient with regards to their overall care.

Question 36

The mechanism of flow of CSF through arachnoid granulations into the venous system occurs because of?
Answers:
A. Pressure-dependent gradient
B. Ciliated ependyma
C. Na K ATPase
D. The mechanism is not known
E. Membrane transport proteins

Answer 36

Pressure-dependent gradient

The CSF from the subarachnoid space is eventually reabsorbed through outpouchings into the superior sagittal sinus (SSS) known as the arachnoid granulations. Arachnoid granulations act as an avenue for CSF reabsorption into the blood circulation through a pressure-dependent gradient. The arachnoid granulations appear as outpouchings into the SSS due to the pressure in the subarachnoid space being greater than the venous sinus pressure.

Question 37

A 56-year-old year man has a persistent headache and enhancing right frontal mass. After stereotactic biopsy, he is diagnosed with a WHO Grade IV glioblastoma. In private, his wife urges you to delay telling him the true diagnosis until after his daughter’s wedding next month. She claims it would devastate him emotionally, thrust him into depression, and ruin a once-in-a-lifetime event for the family. When the patient asks to hear about his diagnosis, he is alert, oriented, and fully competent. Which of the following ethical principles most closely describes the reason the patient should be informed of his true diagnosis?
Answers:
A. Non-maleficence
B. Beneficence
C. Autonomy
D. Truth-telling
E. Justice

Answer 37

Autonomy

Autonomy means that a patient has complete control of their own medical decision making and this must be free of coercion or coaxing. Despite the request of the patient’s wife, not discussing the diagnosis with the patient, especially when the patient directly asks about said diagnosis, would be unethical. While the emotional effect of such a diagnosis cannot be overlooked, it must also be considered that withholding this diagnosis from the patient for over 1 month and, thus, not allowing him to make informed decisions about his own care could lead to significantly detrimental clinical effects.

Question 38

A 68-year-old woman loses approximately 4 L of blood during removal of a thoracic renal cell
metastasis and receives a transfusion of packed red blood cells and platelets. One day
postoperatively, there is high output from the wound drain, and bleeding from the intravenous
catheter sites is noted. Hemoglobin is 9 g/dL, platelet count is 110,000/mm3, and fibrinogen level is
1.0 g/L. Administration of which of the following is most appropriate at this time?
Answers:
A. PCC
B. tPA
C. Platelets
D. FFP
E. Heparin

Answer 38

FFP

This patient likely has disseminated intravascular coagulation (DIC). She is at increased risk for this given the blood transfusion. This is shown by her decreased platelet count and fibrinogen. The correct treatment for this case is FFP. tPA and heparin would worsen the hemorrhage. The platelet count, although low, is at an acceptable level at this point. A platelet transfusion would be indicated if platelets were below 50,000. PCC would be reasonable for refractory coagulopathy.

Question 39

Medical emergencies on commercial airline flights are estimated to occur more than 40,000 times
annually worldwide. In 1998, the Aviation Medical Assistance Act was passed. With respect to a
physician traveling on a flight in which medical assistance is requested, which of the following statements is applicable?
Answers:
A. The Good Samaritan provision protects the physician from liability, even in the setting of gross negligence or willful misconduct
B. If a physician responds to a request, they assume medical liability for the patient
C. A physician on a flight is legally obligated to respond to a medical emergency
D. A physician on a flight should not respond to a medical emergency that is outside their specialty
E. If a physician responds to a request, they do not assume medical liability secondary to a Good Samaritan provision

Answer 39

If a physician responds to a request, they do not assume medical liability secondary to a Good Samaritan provision

The Aviation Medical Assistance Act, when passed, included a Good Samaritan provision which allows physicians to respond to a medical emergency in flight without medical liability. The exception to this is a case of gross negligence or willful misconduct. While there is no legal obligation for a physician to respond to a medical emergency, most feel that it is a moral and professional obligation to respond to these situations.

Question 40

Which of the following is the final step toward certification by the American Board of Neurological
Surgery?
Answers:
A. Passing the oral examination
B. Completing 180 cases post-residency with 3-month outcomes
C. Completion of residency
D. Completing 150 cases post-residency with 3-month outcomes
E. Passing the primary examination

Answer 40

Passing the oral examination

The oral examination is the final step in the process to becoming board certified by the American Board of Neurological Surgery. Candidates should be scheduled for oral examination, the final step in the certification process, within five years of completing training. The application process generally takes about 18 months between submission of an application (including practice data) and sitting for oral examination. Compliance with this regulation requires early submission of all information. If the five-year limit lapses, the individual is no longer considered to be within the certification process and must repass the primary examination to return to tracking toward certification. Three years (not another five) will then be allowed to complete the process. To sit for this examination, a candidate must submit 125 cases with three month follow up within three years of residency completion.

Question 41

A 62-year-old man is evaluated because of a three-week history of progressive somnolence,
nausea, and vomiting. Eight months ago, he underwent uncomplicated resection of a left temporal
glioblastoma. A CT scan of the head shows communicating hydrocephalus. MR imaging with
contrast shows small nodular enhancement in the left internal acoustic meatus. Which of the
following is the most likely cause of this patient’s hydrocephalus?
Answers:
A. Leptomeningeal spread of glioblastoma
B. Subarachnoid blood from surgery
C. Radiation induced hydrocephalus
D. Ventricular entry during surgery
E. Meningitis

Answer 41

Leptomeningeal spread of glioblastoma

The nodular enhancement on the cranial nerves is a clear indication that this patient has leptomeningeal spread of the disease. This often presents with hydrocephalus and cranial nerve findings. The nodule on the cranial nerve makes the other options less likely. Radiation doesn’t tend to induce hydrocephalus and would be less likely here given the nodule at the IAC. Meningitis could also be possible but less likely given the time-course, as it would be an early complication after surgery.

Question 42

According to the Institute of Medicine, which of the following terms differentiates an injury caused
by medical management from an injury caused by an underlying disease?
Answers:
A. Medical Error
B. Never Event
C. Adverse Event
D. Complication
E. Near Miss

Answer 42

Adverse Event

An adverse event is defined as an event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient. Near misses are simply adverse events which do not have an associated poor outcome. Medical error is a broader term which refers to any act of omission or commission that exposes patients to potential harm. A complication can be defined as any event which deviates from the planned course of treatment.

Question 43

A 75-year-old woman comes to the emergency department 12 hours after tripping and falling and hitting her head on the ground. She is currently asymptomatic and denies loss of consciousness, headache, or vomiting. She has taken warfarin for atrial fibrillation for the past five years. Physical examination shows a small abrasion on her forehead; no other abnormalities are noted. The international normalized ratio (INR) is 6.5. A CT scan of her head shows no acute traumatic lesions. Which of the following is the most appropriate next step in management?
Answers:
A. Continue the coumadin
B. Hold coumadin
C. Hold coumadin and give sub q Vitamin K
D. Hold coumadin and give oral Vitamin K
E. Hold coumadin and give FFP

Answer 43

Hold coumadin and give oral Vitamin K

Warfarin inhibits vitamin K dependent activation of clotting factors II, VII, IX and X through inhibition of vitamin K epoxide reductase (VKORC1), thereby resulting in an increased anticoagulant effect. Thus, giving Vitamin K can help INR normalize more quickly (12-24 hours). In healthy people, an INR of 1.1 or below is considered normal. An INR range of 2.0 to 3.0 is generally an effective therapeutic range for people taking warfarin for disorders such as atrial fibrillation, DVT and PE. When the INR is between 4.5 and 9, guidelines recommend holding coumadin in the setting of no bleeding and adding Vitamin K (orally) if patient has risk for bleeding, which this patient does due to recent trauma. The patient requires treatment because her INR is 6.5. FFP is not indicated because she does not have a life-threatening hemorrhage. Oral Vitamin K is more effective than subcutaneous Vitamin K.

Question 43

In a patient with a severe traumatic brain injury, which of the following is the average nitrogen loss in the first week after injury?
Answers:
A. Sufficient nitrogen to reduce weight by 2-5% per week.
B. Sufficient nitrogen to reduce weight by 15% per week.
C. 75% of the nitrogen that would be lost if the patient were active.
D. 50% of the nitrogen that would be lost if the patient were active.
E. Unknown

Answer 43

Sufficient nitrogen to reduce weight by 15% per week.

Nitrogen balance is an important measure of the adequacy of caloric intake and metabolism. Data show that starved TBI patients lose sufficient nitrogen to reduce weight by 15% per week. Hypercatabolism is a state characterized by high breakdown of skeletal muscle protein into carbon skeletons and nitrogen. Traumatic brain injury patients can lose up to 1000 grams of muscle tissue per day due to the metabolic preferences for amino acids as a source of energy rather than use of ketone bodies, which result from fat breakdown. TBI patients suffer from a negative nitrogen balance due to high protein breakdown and low protein synthesis at the same time. Full caloric replacement can be achieved within 7 days by starting nutritional therapy for TBI within the first 72 hours post injury. The Brain Trauma Foundation (2007) recommends that 15–20% of total calories should be provided as nitrogen calories to reduce nitrogen loss. An intake of 1.2-1.5 g/kg/day of protein is generally sufficient for nitrogen equilibrium in critically ill patients. Nitrogen balance is calculated using the difference between excreted nitrogen (urinary and estimation of nonmeasurable losses) and ingested nitrogen.

Question 44

A 72-year-old patient with nonrheumatic atrial fibrillation on warfarin has a chronic subdural
hematoma, requiring burr hole drainage. Which of the following factors is most important in
determining this patient’s risk of thromboembolic stroke off anticoagulation?
Answers:
A. Age 65-75
B. Prior Stroke or transient ischemic attack (TIA)
C. Heart Failure
D. Hypertension
E. Diabetes

Answer 44

Prior Stroke or transient ischemic attack (TIA)

CHADS2 VASc was added to the CHADS2 score to give better risk stratification for low risk patients. CHA2DS2 stands for (Congestive heart failure, Hypertension, Age ( > 65 = 1 point, > 75 = 2 points), Diabetes, previous Stroke/transient ischemic attack (2 points). VASc stands for vascular disease (peripheral arterial disease, previous myocardial infarction, aortic atheroma) and sex category (female gender), which are also included in this scoring system. Each risk factor receives 1 point except age > 75 and stroke/TIA, which receive 2 points. Patients with 2 or more points should receive full anticoagulation and patients with 1 point can be treated with aspirin alone.

Question 45

A 20-year-old man presents to the emergency department status post a helmet-to-helmet football collision injury. He has a nonfocal examination with a Glasgow Coma Scale score of 6 on arrival. CT scan of the brain shows diffuse hemispheric edema. The emergency department physician intubates the patient, and his vital signs are stable. Which of the following is the most appropriate next step in treatment?
Answers:
A. Vasopressor administration
B. Decompressive craniectomy
C. Insertion of intracranial pressure monitors
D. CT angiogram
E. Antiepileptic administration

Answer 45

Insertion of intracranial pressure monitors

This patient has radiographic evidence of cerebral edema and elevated intracranial pressure (ICP). To manage this, ICP monitoring is necessary. A CT angiogram is not unreasonable, but monitors should be placed first. Vasopressors and craniectomy might be used in the management and would be appropriate for low CPP and refractory ICP, respectively. There’s no indication for AEDs, as the patient has no intracranial hemorrhage or symptoms of seizure.

Question 46

A new antiepileptic agent has been advertised for the treatment of refractory seizures.
Administration of the agent after six months demonstrates evidence of complete seizure control in
45% of patients receiving the study drug and 25% of patients in the placebo groups. However, the
agent has some significant adverse effects. In order for a physician to decide whether to
incorporate this into a practice and counsel patients appropriately, which of the following is the
number of patients needed to treat in order to result in a benefit?
Answers:
A. 5
B. 2
C. 15
D. 10
E. 50

Answer 46

5

Number needed to treat (NNT) is an important value to understand the benefit provided by a particular intervention in comparison to either a previously accepted treatment regimen or the natural history of the disease. To calculate this number, the absolute risk reduction (ARR) needs to be calculated. In this case, the incidence of seizure control in the new drug group is 45% while the incidence of seizure control in the control group is 25%. Thus, the ARR is 0.45-0.25 = 0.2. The NNT is then calculated as the inverse of the ARR. Thus, the NNT in this case is 5.

Question 47

Current American College of Surgeons Trauma Quality Improvement Program best practice
guidelines include which of the following regarding hyperosmolar therapy regimens for severe
traumatic brain injury patients with elevated intracranial pressure refractory to initial (i.e., Tier 1)
maneuvers?
Answers:
A. Hyperosmolar therapy should not be used as a second tier strategy
B. Hypertonic solutions should be held if sodium exceeds 150 mEq/L
C. Mannitol should be administered as a continuous infusion
D. Mannitol should be held if serum osmolality exceeds 320 mOsm/L
E. Hypertonic saline should be administered as a continuous infusion

Answer 47

Mannitol should be held if serum osmolality exceeds 320 mOsm/L

Hypertonic saline and mannitol should be administered as bolus, not as continuous infusions, for second line therapy. Hypertonic saline should be held if Na exceeds 160 while mannitol should be held if osmolality exceeds 320. Doses given with high serum osmolality risk kidney injury.

Question 48

**

Which of the following is the most important prerequisite to identifying and resolving medical
errors?
Answers:
A. A hospital culture of blame, shame, and punishment
B. Standardized nomenclature of medical errors
C. A hospital culture that works toward recognizing safety challenges
D. A hospital that has Joint Commission certification
E. The physician must be recognized as the major safety officer of the team

Answer 48

A hospital culture that works toward recognizing safety challenges

Although it is important to have standardized nomenclature of medical errors so that staff recognizes what is defined as a medical error, a hospital culture that works toward recognizing safety challenges is the most important prerequisite to identifying and resolving medical errors. Hospital staff must feel safe and supported in identifying and acknowledging safety issues, as well as want to work to correct them. A hospital culture of blame, shame, and punishment will only result in staff who will not want to report errors for fear of being shamed or punished. Thus, patient care will suffer as medical errors are not identified. The physician cannot be recognized as the major safety officer of the team, as everyone on the team is important for safety. Having Joint Commission evaluate the hospital is a good check for safety and compliance; however, the day-today ability of the hospital staff to recognize safety challenges is more important.

Question 49

A 22-year-old man is brought to the emergency department after a motor vehicle collision. On arrival, he localizes painful stimuli bilaterally and opens his eyes to pain, but does not speak. Seven hours later, he does not vocalize or open his eyes and intracranial pressure has increased. CT scans at the time of admission (top) and seven hours later (bottom) are shown. Which of the following is the most appropriate next course of action?
Answers:
A. Induced hypotension
B. Craniotomy and clot evacuation
C. CT angiogram
D. Vasopressors to increase CPP > 80 mmHg
E. Intubation

Answer 49

Intubation

ABC’s (airway/breathing/circulation) are the most important factors in neurotrauma. While vasopressors, craniotomy and angiogram might be indicated, they are not the next step, which is airway protection. Induced hypotension should not be used.

Question 50

A neurosurgeon’s husband pages her in the clinic to inform her that his best friend has been
seriously injured in a motor vehicle collision and admitted by the trauma team at the
neurosurgeon’s hospital. Which of the following is the most appropriate response by the
neurosurgeon?
Answers:
A. “I will review his available imaging to better understand the severity of his injuries.”
B. “I will call the trauma team right away to get an update.”
C. “I will review his chart to ensure he is getting the best care possible.”
D. “I will allow the trauma team to care for him as they would any other patient”
E. “I will call the trauma surgeon directly to get an update immediately”

Answer 50

“I will allow the trauma team to care for him as they would any other patient”

Situations in which family or friends of physicians require medical care can be exceptionally challenging. There is responsibility for both the treating physician and the family or friend physician to maintain patient confidentiality and respect their privacy. Thus, no further information should be given in this situation and the other physician should not interfere in the care of this patient.