PASS MACHINE QBANK 1

Question 1

Primary causes of ascites

Answer 1

Budd-Chiari
CHF
PERITONEAL carcinomatosis
Chyle leak

Question 2

secondary cause of ascites

Answer 2

PLEURAL carcinomatosis

Question 3

most common long-term complication after splenectomy

Answer 3

BACTERIAL post splenectomy overwhelming infection

thrombosis also as a potential complication

Question 4

when he is a solitary pulmonary nodule consider benign

Answer 4

SPNs that are entirely calcified or radiologically stable by CT of the chest for a minimum of 2 years are likely to be benign.26,27

Review of old radiographs or other prior imaging studies will assist in evaluation of changes in the mass.

Question 5

tertiary contractions on band swallow and manometry

Answer 5

nutcracker esophagus

Question 6

initial treatment of nutcracker esophagus

Answer 6

Treatment

The treatment of nutcracker esophagus is medical. Calcium channel blockers, nitrates, and antispasmodics may offer temporary relief during acute spasms. Bougie dilation may offer some temporary relief of severe discomfort but has no long-term benefits. Patients with nutcracker esophagus may have triggers and are counseled to avoid caffeine, cold, and hot foods.

NG tube and nifedipine/isosorbide/nitroglycerin

Question 7

management of pheochromocytoma in first trimester pregnancy

Answer 7

Surgical resection of pheochromocytoma during the first or second trimester of pregnancy has good prognosis for both mother and the fetus. In fact, alpha blockade anytime during pregnancy reduces the risk of fetal death. Vaginal delivery is undesirable; cesarean must be encouraged.

Question 8

The appropriate surgical management of a sigmoid cancer without metastasis includes the resection of the

Answer 8

sigmoid and distal descending colon and its mesentery which will include the sigmoidal and superior hemorrhoidal vessels. The left colic artery should be spared to ensure blood supply to the remaining left colon.

Question 9

APRV ventilator mode he uses

Answer 9

Airway pressure release ventilation

uses high, continuous positive airway pressure (CPAP) and minimizes the need for neuromuscular blocking agents?

uses high CPAP to allow lung emptying

spells of high CPAP to facilitate spontaneous respirations, thereby limiting the need for neuromuscular blocking agents.

Question 10

PC-IRV

Pressure-controlled, inverse ratio ventilation

Answer 10

,indicated for severe acute lung injury,

adopts paralysis as a technique to increase the duration of the inspiratory phase over the expiratory phase.

Question 11

PSV

Answer 11

is good for the awake, alert intubated patient,

Question 12

CPAP

Answer 12

used in the nonintubated patient to improve ventilatory function.

Question 13

major and relative contraindications to the autologous breast reconstruction after mastectomy

Answer 13

Previous abdominal surgery such as abdominoplasty, liposuction, open cholecystectomy, or other major abdominal procedures compromise circulation to the skin and tissue over the flap.

Obesity, smoking, a history of blood clots, and other major systemic medical conditions are other relative contraindications.

Question 14

recommendations with the diagnoses of Budd-Chiari syndrome

Answer 14

(1) An acute or chronic illness occurs with upper abdominal pain, ascites, or liver enlargement; (2) A liver disease occurs in a patient with known risk factors for thrombosis; (3) A liver disease occurs in a patient with an extensive network of subcutaneous veins of the trunk suggesting inferior vena cava obstruction; (4) A liver disease remains unexplained after other common or uncommon causes have been excluded.

Question 15

guidelines her preoperative fasting with

Answer 15

A limited amount of non-fatty light food in patients without risk factors for aspiration should be discontinued at least 6 hours prior to anesthesia. A judicious amount of clear liquids can be taken until 2 hours prior to anesthesia. Breast milk can be taken until 4 hours prior to anesthesia. Formula should be discontinued at least 6 hours prior to anesthesia. Medications can be taken with liquids until 2 hours before surgery; it is essential to continue certain medications on the day of surgery, in particular those affecting the cardiovascular system, since withdrawal of those medications can increase the incidence of perioperative cardiovascular complications and perioperative morbidity and mortality.

Question 16

hich one of the following nondepolarizing muscle relaxants is a highly acceptable replacement for succinylcholine to facilitate endotracheal intubation in the intensive care unit (ICU)?

Answer 16

Rocuronium with an onset of action similar to that of succinylcholine, and similar intubation conditions 1 minute after administration is a highly acceptable replacement for succinylcholine in the ICU. Although it has a longer duration of action, it is noncumulative, and without any associated cardiovascular side effects or histamine release. Atracurium, cisatracurium and vecuronium have a long onset of action, while atracurium and cisatracurium can also release histamine. Although mivacurium has a shorter duration of action, it has a slower onset, stronger histamine-releasing properties compared with rocuronium, and with comparable intubation conditions only after 4 to 5 minutes. Aside from adverse effects of muscle hypertonia, myalgia, hypersalivation, elevated intraocular and intracranial pressures, and induction of malignant hyperthermia, succinylcholine has the strongest histamine-releasing effect of all muscle relaxants.

Question 17

Pancreatic necrosis is a complication of severe pancreatitis usually with Ranson’s criteria of

Answer 17

5 or greater.

Question 18

estimated mortality of a pancreatic necrosis

Answer 18

There is an associated mortality of greater than 40%.

Question 19

treatment of pancreatic necrosis

Answer 19

Treatment consists of operative debridement and open or closed retroperitoneal drainage.

Question 20

Percutaneous cholecystostomy drainage offers the best approach in patients when

Answer 20

still on pressors.

Question 21

when should steroid to be used in the ICU

Answer 21

only be used in those patients whom the blood pressure is unresponsive to adequate fluid resuscitation and appropriate pressors.

Question 22

breast pressors for shock

Answer 22

Norepinephrine or dopamine are first choices for vasopressor agents to correct hypotension in septic shock.

Question 23

Which one of the following most accurately guides the duration of preoperative preparation in a child with pyloric stenosis?

Answer 23

Degree of dehydration and the clinical response to fluid replacement therapy

Question 24

`The esophagus is approximately how long

Answer 24

25 cm

Question 25

the arterial supply of the esophagus

Answer 25

The arterial supply is segmental

 arises from 
superior thyroid, 
thyrocervical arteries, 
bronchial, 
inferior phrenic,
left gastric, 
inferior thyroid arteries. 

A terminal capillary network is formed along the esophageal wall from these arteries.

Question 26

the lymphatic drainage of the esophagus

Answer 26

extends longitudinally

along the length of the esophagus before drainage into regional lymph nodes.

Question 27

described the vagus nerve in relationship to the esophagus

Answer 27

The vagus nerve forms a plexus on either side of the esophagus until it reaches the diaphragmatic hiatus at which a left and right trunk is formed.

LAPR

Question 28

Jejunostomy is indicated in patients with

Answer 28

a functioning gut who are unable to eat and in whom gastrostomy is contraindicated or not possible.

Question 29

contraindications a gastrostomy

Answer 29

gastric conditions such as
gastroesophageal reflux

aspiration,
gastroparesis,
gastric outlet obstruction,
previous gastric resection.

Question 30

Contraindications for jejunostomy include

Answer 30

nonfunctioning gut, 
pregnancy, 
morbid obesity, peritonitis, 
inflammatory bowel disease, 
massive ascites, 
severe bleeding disorders.

Question 31

Based on Haggitt’s classification in the management of patients with large bowel polyps which contain invasive adenocarcinoma,

Answer 31

patients with levels 1 to 3 require no operation.

Only patients with level 4 invasion require resection.

Sessile rectal polyps with invasion of muscularis mucosae are level 4 with a high risk for lymph nodes and distant metastasis, and require aggressive intervention.

Level 0 is associated with carcinoma-in-situ, without invasion of muscularis mucosae; Level 1 carcinoma invades muscularis mucosae into submucosa, but limited to head of polyp; Level 2 is carcinoma to neck of polyp; Level 3 involves carcinoma in stalk. Level 4: carcinoma in submucosa of bowel wall below the stalk, above muscularis propria.

Question 32

The administration of succinylcholine results in release of

Answer 32

The administration of succinylcholine results in release of potassium and elevation of the serum levels by 0.5 to 1 mEq/L. The proliferation of extrajunctional receptors may result in excessive release of potassium and cardiac arrest during use of succinylcholine in certain clinical situations such as denervation injury, stroke after 2 weeks, burn after 24 hours and certain neuromuscular disorders. In patients with end-stage renal disease, there is no excessive release of potassium and as long as the starting potassium level is normal, the use of succinylcholine is not contraindicated. Succinylcholine can trigger MH in susceptible patients.

Question 33

n patients taking digitalis preparations and in those undergoing a catechol-releasing stress, electrolyte abnormality

Answer 33

Potassium depletion,

Question 34

Drugs that can cause hyperkalemia include

Answer 34

potassium supplements, salt substitutes, potassium-sparing diuretics, nonsteroidal anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, beta-blockers, heparin, digoxin overdose, and trimethoprim sulfate.

It is essential to correct potassium deficits before elective operations

Question 35

Rapid growth, pain, facial nerve weakness, paresthesias, skin fixation, and cervical lymphadenopathy are suggestive of

Answer 35

malignancy.

Question 36

after pneumonectomy A new air-fluid level on a CXR is concerning for

Answer 36

a bronchopleural fistula in a patient who is status post a pneumonectomy.

Question 37

initial treatment for bronchopleural fistula

Answer 37

Initial management includes chest tube drainage and IV antibiotics.

Question 38

standard heparin bolus and what is the half life

Answer 38

With a standard 100 to 150 U/kg bolus

the half life of heparin is 60 to 90 minutes.

The half-life increases with the dose because of saturation of the binding to endothelium.

Question 39

to neutralize heparin

Answer 39

The antidote for heparin is protamine: 1 mg of protamine can neutralize 100 U of heparin.

Question 40

In the surgical management of an obturator hernia, which one of the following approaches is most commonly preferred?

Answer 40

The abdominal approach via a low midline incision is most commonly preferred, given the benefits of this approach in “establishing a diagnosis, avoidance of obturator vessels, better exposure of the obturator ring, and facilitation of bowel resection, if necessary.”

The laparoscopic approach is an alternative modality in the management of obturator hernia in some cases.

Question 41

Obturator hernia involves the

Answer 41

obturator canal, which is 2 to 3 cm long and 1 cm wide, and contains the obturator nerve and vessels.

Question 42

According to the 2002 American College of Cardiology and the American Heart Association practice guidelines evaluating perioperative cardiopulmonary risk of patients, which one of the following noncardiac surgical procedures is considered high cardiac risk?

Answer 42

Repair of a strangulated hernia with bowel obstruction entails large fluid shifts and blood loss and is considered high-risk, i.e., more than 5% of fatal and nonfatal myocardial infarctions.

Question 43

Which one of the following is the most common functional neuroendocrine tumor of the pancreas in patients with multiple endocrine neoplasia type 1?

Answer 43

Gastrinomas arise in pancreas most often (up to 70%) and to a lesser extent in duodenum, and are the most common neuroendocrine tumor in multiple endocrine neoplasia type 1. They are malignant at diagnosis. On the other hand somatostatinomas are tumors of D cell origin. The symptoms of diabetes arise from inhibition of insulin and glucagon, gallstones arise when cholecystokinin secretion is affected, and as pancreatic lipases are inhibited symptoms of steatorrhea become apparent due to failed intestinal absorption of lipids. In vipomas, there is a secretion of vasoactive intestinal polypeptide (VIP), a 28 amino acid polypeptide that binds to high-affinity receptors on intestinal epithelial cells, leading to activation of cellular adenylate cyclase and cAMP production. As fluid and electrolyte is secreted into the lumen, a watery diarrhea, hypokalemia, and hypochlorhydria, characteristic of Verner-Morrison syndrome occurs. Tumors of the pancreas that produce too much insulin are called insulinomas, most of which are non-cancerous (benign) tumors, with only 5% to 10% cancerous. Hypoglycemia and in serious cases seizures, coma, and even death can result. Gastrinomas are gastrin-secreting tumors occurring in pancreas or duodenum, half of which are malignant and can metastasize to regional lymph nodes and the liver. Similar to the symptoms of common peptic ulcer disease, bleeding (e.g., melena, hematemesis), gastric outlet obstruction (e.g., vomiting), and perforation (e.g., peritoneal irritation).Other symptoms include gastroesophageal reflux, diarrhea, steatorrhea, and weight loss, as well as vitamin B12 malabsorption.

Question 44

A 30-year-old female with ESRD secondary to focal segmental glomerulosclerosis underwent a living-related donor transplantation 4 years ago. She has done very well and now wishes to become pregnant. Her creatinine is 1.3 mg/dl and she is in good health. Which one of the following is her pregnancy most likely to be complicated by?

Answer 44

Increased duration of living-related donor transplantation is common and many women of child-bearing age with a kidney transplant wish to become pregnant. With adequate renal function (as in this case), the most common complication of pregnancy in women with renal transplants is preterm delivery. Preeclampsia and IUGR occur at a slightly higher risk than non-transplant patients, but are not as common as preterm delivery.