2004 AK(M) Flashcards
1
Q
- Which of the following is an IRREVERSIBLE inhibitor of the enzyme COX-1:
a. clopedriogel (Plavix)
b. Ticlopidine
c. Aspirin
d. Indomethacin
e. Warfarin
A
answer: C
Aspirin (irreversible inhibitor of COX 1 and COX 2)
Indomethacin (reversible inhibitor of COX 1)
2
Q
- Which of the following is LEAST likely to cause an upper GI bleed?
a. celecoxib
b. ibuprofen
c. naproxen
A
Answer: A - only COX2 inhibitor. Fewer GI s/e if used short term.
3
Q
- What is the commonest cause of death in patients with a tracheostomy?
a. bleeding
b. accidental decannulation and obstruction
c. infection
d. pneumothroax
A
b. accidental decannulation and obstruction
Are we sure? As long as the trach has been present for a week, if it decanulizes, there’s still a hole so can breath.
Schwarz says this about complications:
Complications of tracheostomy include pneumothorax, RLN injury, tracheal stenosis, wound infection with large-vessel erosion, and failure to close after decannulation
It also says this, but is rare:
The most dramatic complication of tracheostomy is tracheoinnominate artery fistula (TIAF) (Fig. 12-7).58,59 This occurs rarely (~0.3%) but carries a 50% to 80% mortality rate. TIAFs can occur as early as 2 days or as
late as 2 months after tracheostomy. A sentinel bleed occurs in 50% of TIAF cases, followed by a large-volume bleed. Should a TIAF be suspected, the patient should be transported immediately to the OR for fiberoptic evaluation.
4
Q
- which of the following bacteria can cause a bacteremic infection from a blood transfusion?
a. pseudomonas
b. yersinia enterocolita
c. campylobacter
d. proteus mirabilus
e. staphylococcus epidermis
A
b. yersinia enterocolita
Answer: uptodate
Psychrophilic organisms (ie, those capable of multiplication at cold temperatures), especially Yersinia enterocolitica and some Pseudomonas species (eg, Pseudomonas fluorescens), can survive and multiply in cold stored bank blood and have been said to account for up to 80 percent of red blood cell-associated TTBI
5
Q
- Which is the commonest bacteria cultured from indwelling cathether UTIs?
a. proteus mirabilis
b. klebsiella
c. E Coli
d. Staph aureus
A
Answer: (C) Campbell’s urology: E. coli is still the most common organism isolated, but Pseudomonas, Proteus, and Enterococcus species are very prevalent
6
Q
- Which of the following bacteria will flourish if
A
Answer: (A)
7
Q
- Elderly lady in the ICU post op, intubated. C.I. 1.6 (), CVP of 10 (), PCWP > 20 (), pulmonary artery pressure :30 (). What is your Dx?
a. hypervolemia
b. hypovolemia
c. CHF
d. Sepsis
e. Pulmonary embolus
A
Answer: e
normal PCWP 12-14; normal pa pressure 12-16. Both elevated here. By elimination: not hypervolemia (CVP low), hypovolemia will not cause elevated PA pressure, CHF would have high CVP, Sepsis has normal to high CO and does not elevated PA and PCWP. PE causes
8
Q
- HLA matching is routinely performed prior to transplants of the following organs:
a. lung
b. heart
c. kidney
d. liver
A
c. kidney
9
Q
- Which of the following is true re: skin infections?
a. mupirocin has a broad spectrum of activity and is considered to be the first line treatment with wound with a locally infected wound
b. Clindamycin is effective against pseudomonas
c. Fucidin is to be used in leg ulcers
d. Topical antibiotics are sufficient in wound with cellulitis
A
answer: a
10
Q
Middle aged male with a nodule in the left lower pole. Cold nodule. FNA shows thyroiditis. What do you do now?
a. I 131 therapy
b. Thyroidectomy
c. Repeat FNA
d. Observe
A
answer: d.
Subacute thyroiditis is self-limiting; therefore, the goals of treatment are to relieve discomfort and to control the abnormal thyroid function. The discomfort can usually be relieved with low-dose aspirin (divided every 4-6 h). In the rare cases that aspirin does not relieve the discomfort, administer prednisone for 1 week and then taper.
Propranolol can be used to reduce signs and symptoms of hyperthyroidism.
Low-dose levothyroxine may be necessary in some patients who develop hypothyroidism.
11
Q
- Male presents with a mass anterior to his ear.
a. FNA
b. CT scan…
A
answer: FNA?
is this what they’re getting at?
Actinic keratosis (AK) is one of the most common premalignant lesions encountered on the ear. It most often is observed in individuals with fair complexions. The average age of onset is 62 years. Both sexes are affected equally. Sun exposure is thought to be the cause of AK-emedicine
12
Q
- Women presents with feeling unwell. Retching and vomiting. There is subcutaneous crepitus just left of her midline of the neck. After a CXR what should you order next?
a. contrast esophagogram
b. CT
c. MRI
d. 24 hr pH study
A
no official answer given.
a for exam, b for real life? Both can be done.
Esophageal rupture is a rupture of the esophageal wall. Iatrogenic causes account for approximately 56% of esophageal perforations, usually due to medical instrumentation such as an endoscopy or paraesophageal surgery.[1] In contrast, the term Boerhaave’s syndrome is reserved for the 10% of esophageal perforations which occur due to vomiting.[2]
As in: “stop vomiting and Boerhaave properly!”
13
Q
- All of the following HLA types are routinely checked prior to transplantation EXCEPT?
a. HLA A
b. HLA B
c. HLA C
d. HLA DR
e. HLA DQ
A
e. HLA DQ
cause there’s no need to H-ol-LA if your going to the DQ
but for real:
There are many HLA markers. Each HLA marker has a name. The names are letters or combinations of letters and numbers. Doctors review at least 8 HLA markers for these minimum requirements: two A markers, two B markers, two C markers, and two DRB1 markers. Some doctors look for an additional marker, called DQ, to match.
bethematch.org
14
Q
- Woman is about to be the recipient of an allographic transplant from her sister. What is the probability that BOTH her sisters will NOT be HLA identical to her? [Schwartz page 366-67]
a. 25%
b. 12.5%
c. 6.25 %
d. 3.15%
e. 0%
A
answer: a. 25%
each has a 0.5 chance of not being identical
chance of both NOT being is 0.5x0.5=0.25
I think this is true for any given HLA, but to be a perfect match, as 6/6 I think the probability of being a match goes up. I have seen some questions answered as only 0.25 chance of each sibling being a match, so 0.75 chance of not being a match, so neither being a match would be 9/16.
15
Q
- Following are indications of using IVC filters in pulmonary embolisms EXCEPT?
a. recurrent P.E. despite adequate anticoagulation
b. allergic reaction to heparin
c. first time pulmonary embolism
A
answer: c
16
Q
- Child sustained a supracondylar humeral fracture and it underwent a closed reduction. Now he is complaining of ++ pain and he screams on passive finger extension. What should you do?
a. split the cast
b. remove the cast
c. check the blood flow to the fingertips with a pulse oximeter.
d. OR for immediate fasciotomy
e. arteriogram
A
a. split the cast
wow. A question that actually applies to us.
17
Q
- Patient was positioned in a lateral decubitus manner for hip surgery. Post op he woke up complaining of arm/hand weakness. Which of the following weaknesses would you expect?
a. finger flexion
b. wrist extension
c. finger adduction
d. finger abduction (ulnar nerve)
e. thumb flexion
A
b. wrist extension
radial nerve, I suppose this is most common when positioned lateral
18
Q
- Lady with weakness of right fifth finger flexion and pain along the medial side of her forearm. Dx?
a. Thoracic outlet syndrome
b. Cubital tunnel syndrome
c. Carpal tunnel syndrome
d. Meralgia paresthetica
e. Pronator Syndrome
A
answer: b. Cubital tunnel syndrome
19
Q
- Old lady brought into the ED. Received i.m. diazepam and 30 minutes later became obtunded. Tx?
a. observe
b. bag mask
c. Intubate
d. tracheostomy
A
answer: c
other answers were made up by me.
20
Q
- Hepatitis C causes all EXCEPT?
a. cryoglobulinemia
b. lymphoma
c. hepatocellular carcinoma
d. chronic carrier
e. cirrhosis
A
official answer: c
previous explanation was that Hep C causes cirrhosis, and the cirrhosis causes HCC
That’s like if I said: I didn’t kill that person, the knife I stabbed them with did…
21
Q
- Which of the following is the most infectious agent for a blood transfusion?
a. Hepatitis A
b. Hepatitis B
c. Hepatitis C
d. HIV
e. CMV
A
e. CMV
Answer: CMV 1/7500 (most common virus transmitted)
22
Q
- TMN staging has exerted its validity in all of the following EXCEPT?
a. better communication
b. reproducible results in trials
c. provides information on prognosis
d. widely used by professionals
A
b. reproducible results in trials
Some of the aims for adopting a global standard are to:
Aid medical staff in staging the tumour helping to plan the treatment.
Give an indication of prognosis.
Assist in the evaluation of the results of treatment.
Enable facilities around the world to collate information more productively.
wiki
23
Q
- What is the most prevalent cancer among Canadian males?
a. squamous cell cancer of the prostate
b. adenocarcinoma of the prostate
c. leukemia
d. Lung cancer
e. Colon cancer
A
b. adenocarcinoma of the prostate
most prevalent, lung causes most deaths
24
Q
After a trial in which it was shown that symptomatic carotid stenosis > 80% does better with carotid endarterectomy another group of researchers showed that carotid endarterectomy also is beneficial in those with > 60% asymptomatic carotid stenosis. The first group of researchers then decide to go back to their date and perform a sub group analysis amongst those with > 60% asymptomatic stenosis to see if this can be substantiated. Uonfortunately the results will lack validity because?
a) it is potentially biased
A
a) it is potentially biased
I suppose. Anything is “potentially” biased
25
25. Coin toss of randomization
whats the question?
26
26. What is the commonest cause of primary hyperaldosteronism?
a. unilateral adrenal carcinoma
b. bilateral adrenal hyperplasia
c. solitary adrenal adenoma
answer: c
Most Common:
Unilateral adrenal gland adenoma (2/3)
Bilateral adrenal gland hyperplasia (1/3)
27
27. What is the commonest cause of hypokalemia associated with INCREASED urine potassium?
a. prolonged thiazide diuretic use
b. spironolactone use
c. primary hyperaldosteronism
a. prolonged thiazide diuretic use
28
28.Young trauma fellow. Crushing chest injury. Initial chest tube drained 1500 cc of blood and now is draining 500 cc per hour. What is the next course of action?
a. emergency thoracotomy
b. needle decompression
c. chest tube
d. observe
answer: a. emergency thoracotomy
Blunt thoracic injury with the following conditions:
```
Previously witnessed cardiac activity (prehospital or in-hospital)
Rapid exsanguination from the chest tube (>1,500 mL immediately returned)
Unresponsive hypotension (SBP
```
29
29. What is the MOST important determinant in reducing the amount of fluid in the lungs in ARDS?
a. Positive end expiratory pressure
b. Tidal volume and minute ventilation
official answer a.
not sure, I think low tidal volume
In an ARDS Network study, patients with ALI and ARDS were randomized to mechanical ventilation either at a tidal volume of 12 mL/kg of predicted body weight and an inspiratory pressure of 50 cm water or less or at a tidal volume of 6 mL/kg and an inspiratory pressure of 30 cm water or less; the study was stopped early after interim analysis of 861 patients demonstrated that subjects in the low-tidal-volume group had a significantly lower mortality rate (31% versus 39.8%).[32]
30
30. Young fellow came into the ER with a circumferential abrasion and laceration of his right arm. It looks dirty. After irrigation what should you do?
a. Primary closure in the ER
b. Primary closure in the OR
c. Mechanical debridement
d. Skin graft
c. Mechanical debridement
31
31.
| Clinical picture consistent with ARDS with Pa O2 / FiO2
answer c: Decrease tidal volume to 5-7 cc/kg as per card 29.
32
32. What is the cytokine responsible for the proliferation of fibroblasts?
a. TGF beta
b. TGF α
c. Il 2
d. Il 6
TGF beta
TGF beta blasts!
33
33. All the following drug when administered will cause hypokalemia except?
a. Insulin
b. Vitamin B12
c. Salbutamol
d. corticosteroids
e. Digoxin
e. Digoxin causes hyper K
(Note the caveat: can cause low K when taken on a chronic basis)
Digitalis glycosides bind specifically to Na+/K+ -ATPase, inhibit its enzymatic activity, and impair active transport of extruding sodium and transport of potassium into the fibers (3:2 ratio). As a result, intracellular sodium ([Na+]i) gradually increases, and a gradual, small decrease in intracellular potassium ([K+]i) occurs
34
34. Elderly man brought into the ER after a fall. Past history includes a pacemaker. Although he could not recall the incident he is now mentally clear with nothing to find on exam except for a malar fracture. What is the most appropriate investigation?
a. CT scan with contrast
b. MRI
c. Stress EKG
d. Resting EKG and pacemaker check.
d. Resting EKG and pacemaker check.
this answer seems pretty intuitive
35
35. TPN patient. What is the best test to see if more AA needs to be added to the TPN?
a. Serum creatinin
b. Blood urea nitrogen
c. blood pH
d. ALT
b. Blood urea nitrogen
Here AA must refer to amino acid, not the battery.
36
36. Which of the following is true regarding branched chain amino acids?
a. arginine is an example of BCAA
b. they are metabolized by the liver
c. they are contraindicated in renal failure
d. increased caloric density
answer d. increased caloric density
arginine is an example of BCAA (false. Only leucine, isoleucine and valine are BCAAs)
they are metabolized by the liver (they are the ONLY AA metabolized outside the liver!) they are metabolized by the muscles. [RUSH]
37
37. The following are true of autologous blood transfusion EXCEPT:
a. increased subsequent transfusion post operatively
b. increased risk of infection
answer. a
38
38. What is the daily fluid requirement in a 6 kg child?
official answer 800cc.
| I get 6x4/hrx24hr=576
39
39. Trauma patient with flank pain and gross hematuria. CT shows a non expanding subcapsular hematoma. What is the most appropriate course of action?
a. Bed rest and repeat U/S in 3 days
b. OR now
c. OR in 3 days
a. bed rest and repeat U/S in 3 days
Surgical therapy is usually reserved for patients with signs of ongoing bleeding or hemodynamic instability. In some institutions, CT scan–assessed grade V splenic injuries with stable vitals may be observed closely without operative intervention, but most patients with these injuries will undergo an exploratory laparotomy for more precise staging, repair, or removal. Adult surgeons may be more likely to operate in cases of splenic injury but less likely to transfuse than their pediatric surgical colleagues. emedicine
40
40. Old man on coumadin for a prosthetic value has an INR of 3.3 and is scheduled for cholecystectomy (did not mentioned the word ‘open’). What is the most appropriate course of action?
a. stop coumadin 7 days pre op, then start low molecular weight heparin daily
b. stop coumadin 4 days pre op then start LMWH
c. stop coumadin and admit patient then start iv heparin (UFH)
d. stop coumadin and reverse INR with vitamin K
lower the dose of coumadin till the INR is 1.3 to 1.5 then operate.
answer: b
a: 7 days would be for plavix
c: pt shouldn't need admission preop
d: urgent sx
e: pt at high risk of clot, ok for afib.
41
60. Which of the following will NOT cause hypercalcemia?
a. Thiazide diuretics
b. Sarcoidosis
c. Pagets
d. Multiple fractures
e. ?
d. Multiple fractures
42
61. Heparin does all of the following EXCEPT:
a. Reduces available thrombin
b. Potentiates antithrombin III activity
c. Decreases thromboxane A2 production
d. Decreases platelet activation
e. ? decreases secondary platelet aggregation and binding? (odd wording)
c. Decreases thromboxane A2 production
Mechanism of Action: Potentiates the action of antithrombin III and thereby inactivates thrombin (as well as activated coagulation factors IX, X, XI, XII, and plasmin) and prevents the conversion of fibrinogen to fibrin; heparin also stimulates release of lipoprotein lipase (lipoprotein lipase hydrolyzes triglycerides to glycerol and free fatty acids)
Heparin seems to increase thromboxane A2 production (Thromboxane A2 is released by activated platelets and is a prothrombic)
Heparin seems to activate platelet activation/aggregation, in vitro anyways.
43
62. All of the following increase the risk of pulmonary embolism EXCEPT:
a. Chest trauma
b. Surgery within last 3 months
c. Cancer
d. History of DVT
e. Decreased mobility
a. Chest trauma
Unclear about the answer though... Could be b. as well
Surgery
44
63. All the following are effects of adrenal hyperplasia EXCEPT:
a. Aseptic necrosis of bone
b. Osteoporosis
c. Fat redistribution
d. Prolongation of closure of physis
e. Peptic ulcer disease
d. Prolongation of closure of physis
Most congenital adrenal hyperplasia conditions cause excessive sex hormones being produced. Decreased cortisol/aldosterone and shift towards androgens.
Late onset: accelerated linear growth but early fusion of physis (decreased growth height)
```
Adrenal hyperplasia is a cause of Cushing's syndrome.
Fat redistribution (Cushingoid)
```
Osteonecrosis (aseptic necrosis) of the femoral heads and rarely the humeral heads, usually only with chronic high-dose glucocorticoid therapy (ex: postop resection of tumor, the high dose cortisol has blunted the corticotropin-releasing hormone and ACTH so they need exogenous steroids)
Glucocorticoids increase risk of peptic ulcer disease (uptodate says predominantly when also taking NSAIDs)
45
64. Pancreatitis causes all of the following EXCEPT:
a. Fat necrosis
b. Pleural effusion
c. Dyspnea
d. Diarrhea
d. Diarrhea
Severe pancreatitis can cause dyspnea secondary to pleural effusion
46
65. Young male in MVC, sustains # T8 level, BP = 90/50, HR = 50, despite 4l crystalloid. Has been stable as above for 2h (unchanged since admission). No evidence of peritoneal fluid on fast U/S. What is the likely cause of persistent hypotension?
a. Inadequate fluid resuscitation
b. Neurogenic shock
c. Intra-abdominal source of bleeding
d. Anemia
e. ?
b. Neurogenic shock
47
66. Patient is POD#2 following simple repair of inguinal hernia (elective), presents with diaphoresis, SOB, dyspnea, CXR shown (shows black right lung, ? pneumothorax, with tracheal deviation towards left, white left lung, ? pleural effusion). What is the diagnosis?
a. Diaphragmatic hernia left
b. Pleural effusion left
c. Pneumothorax left
d. Pneumothorax right
e. Left sided pneumonia
d. Pneumothorax right
48
67. Patient presents following MVC with left hip injury (X-ray shows posterior dislocation of hip…and they specify for non-orthopods). Which nerve is most likely injured?
a. Sciatic
b. Femoral
c. Obturator
d. Superior gluteal
e. Iliofemoral
a. Sciatic
49
68. All of the following fractures are associated with avascular necrosis EXCEPT:
a. Scaphoid
b. 4 part proximal humerus
c. intertrochanteric hip fracture
d. talar neck
e. capitellum (humerus)
c. intertrochanteric hip fracture (0.5% risk of AVN as per orthobullets)
Previous answer: e. capitellum (humerus)
Scaphoid/talar neck classic high-risk # for AVN
4-part proximal humerus up to 21-75% risk AVN in some fracture patterns
Avascular necrosis is uncommon after open reduction
and internal fixation of these fractures, despite the
fact that the capitellar fragments usually have no
soft tissue attachments (Bryan and Morrey, 1985;
Holdsworth and Mossad, 1990; McKee et al., 1996).
Although the incidence of this complication has been
reported variably as 10 % and 30% (Jupiter et al., 1988;
Lansinger and Mare, 1981; Liberman et al., 1991;
Scapinelli, 1990), other authors have never encountered
this complication (Grantham et al., 1981; Inoue and
Horii, 1992; McKee et al., 1996; Poynton et al., 1996;
Silveri et al., 1994). Because of this low incidence of
avascular necrosis, encountering a free capitellar fragment
should not discourage the use of internal fixation
(Mehdian and McKee, 2000).
50
69. How long can amputated digits survive prior to microvascular reimplantation if properly stored on ice?
a. 6h
b. 8h
c. 10h
d. 12h
e. 18h
e. 18h
Time to replantation:
• proximal to carpus
o warm ischemia time
51
70. Most common cause of unilateral acute onset testicular pain in 30 year old man:
a. Torsion
b. Epididymitis/orchietitis
c. Tumour
d. ?
e. ?
b. epididymitis
Epididymitis is the most common cause of scrotal pain in adults in the outpatient setting
52
71. Best predictor of post-operative requirement for ventilator?
a. FEV1
a. FEV1
53
72. 70 year old male immediately post op with BP 70/50, HR = 105, ST depressions anteroseptal leads. Most appropriate management is:
a. b-blocker
b. nitro s/l
c. nitro IV
d. epinephrine
e. dobutamine
Previous answer d. epinephrine
I think this is an obsolete question. They don't really use epinephrine it seems like if patients have a pulse and blood pressure anymore (2016)
uptodate:
We recommend vasopressors (norepinephrine or dopamine) for initial management of patients with cardiogenic shock and severe hypotension (systolic blood pressure
54
74. All are true of carbon monoxide EXCEPT:
a. Reversibly binds hemoglobin
b. Shifts hemoglobin-O2 curve to the left
c. Intubation indicated when carboxyhemoglobin level > 20%
d. ?
e. ?
c. Intubation indicated when carboxyhemoglobin level > 20%
Indication for CO poisoning for intubation: all comatose patients and those with severely impaired mental status should be intubated without delay and mechanically ventilated (Grade 1B)
Criteria for hyperbaric oxygen therapy:
- CO level >25 percent
- CO level >20 percent in pregnant patient
- Loss of consciousness
- Severe metabolic acidosis (pH
55
75. Which of the following is most helpful in establishing causal relationship between exposure and disease?
a. Positive predictive value
b. Sensitivity
c. Odds ratio
d. T-test
e. ?
c. Odds ratio
Odds ratio does not take into consideration sensitivity/specifiticites (which are characteristics of a test, not a disease) like PPV does
56
76. Hydrogen ion is mainly secreted by kidney as:
a. Titratable acid
b. Ammonium
c. Free hydrogen
d. ?
e. ?
b. Ammonium
Acidosis stimulated ammonia production.
The kidney cannot filter free hydrogen ions
57
77. Disclosure includes all of the following EXCEPT:
a. Answering all of the patient’s questions
b. Explanation of alternative options
c. Explanation of expected outcome without treatment
d. Explanation of material risks
e. Likelihood of failure/success
These are all important?????
Previous answer: d. material risks
Material risk: "when a reasonable person in what the doctor knows or should know to be the patient's position, would be likely to attach significance to the risk or cluster of risks in deciding whether or not to forego the proposed therapy."
58
78. Most common cause of SVC syndrome is:
a. Lymphoma
b. Primary lung cancer (NOT bronchogenic carcinoma)
c. Mediastinal fibrosis
d. Tuberculosis
e. ?
b. Primary lung cancer (NOT bronchogenic carcinoma)
59
79. All is true of metabolism in state of starvation EXCEPT:
a. Decreased uptake of lactate by liver
b. ?
c. ?
d. ?
e. ?
a. Decreased uptake of lactate by liver
Great job, you are really good at answering multiple choice questions.
60
Part 2
31. Complicated case: elderly lady involved in an MVA, shocky and had a splenectomy. X Ray revealed pubic rami fractures. During the laparotomy they discovered a large retroperitoneal hematoma. Post operatively she still needs to be resuscitated with a BP of 90/40. She had had 4 units of PRBC. What is the next most appropriate management?
a. CT with contrast
b. Return to the OR immediately and pack the abdomen
c. External fixation of the pelvis
d. Angiogram and embolization of the bleeding vessels
e. MAST trousers
d. Angiogram and embolization of the bleeding vessels
This scenario has come up previously in similar questions. Answers included (b), (c), and (d). I doubt she would be bleeding such a large quantity from pubic rami fractures. My personal answer would be (d).
61
32. Patient has renal insufficiency and requires nutritional support. What is the recommendation?
a. lower the caloric/ nitrogen ratio
b. increase the caloric / nitrogen ratio
c. avoid branch chain amino acids (false according to RUSH)
d. recommend alternate source of calories other than glucose
b. increase the caloric / nitrogen ratio
Want to limit protein intake in patients with liver failure and renal failure to avoid ammonia buildup and possible worsening encephalopathy.
BCAA - leucine, isoleucine, valine ("LIV")
Metabolized in muscle
Essential amino acids
62
33. The most common cause of carpal tunnel syndrome is:
a. trauma
b. tenosynovitis
c. synovial sheath hypertrophy
d. ganglion cyst
e. amyloidosis
a. trauma
63
34. Which of the following is effective in preventing LATE complications of splenectomy?
a. administration of pneumococcal and H. flu vaccine
Not a full question.
Guidelines for Prevention of Postsplenic Sepsis
Vaccinate with polyvalent pneumococcal vaccine at least 10-14 d prior to splenectomy if possible
If splenectomy urgent, wait 14 days postprocedure to vaccinate
For high risk patients (immunosuppressed, children
64
35. Patient presents with arthalgia, weakness, nephrocalcinosis. Which of the following best explains the underlying pathophysiology?
a. problem with calcium
b. problem with oxalate
c. medullary sponge kidney
a. problem with calcium
Repeated question.
Nephrocalcinosis:
Risk factors: hypercalcemia, hyperphosphatemia, increased urine Ca/PO4 excretion, hypocitraturia
65
36. The best initial treatment for empyema is:
a. iv antibiotics
b. iv antibiotics and chest tube drainage
c. decortication
b. iv antibiotics and chest tube drainage
Empyema
Usually secondary to pneumonia and subsequent parapneumonic effusion (staph, strep)
Can also be due to esophageal, pulmonary, or mediastinal surgery
Sxs: pleuritic chest pain, fever, cough, SOB
Pleural fluid often has WBC > 500 cells/cc, bacteria, positive gram stain
Exudative phase (1st week) -- chest tube, abx
Fibroproliferative phase (2nd week) -- chest tube, abx
Organized phase (3rd week) -- tx: likely need decortication; fibrous peel around lung
66
37. Which of the following is the best antibiotic in a patient with empyema with culture positive with fusobacterium?
a. Penicillin?? Responsible for 10% sore throats, peritonsillar abscess
b. clavulin
c. erythromicin
d. imipenum
e. ciprofloxacin
a. Penicillin?? Responsible for 10% sore throats, peritonsillar abscess
Repeated question from 2005 test in which answer was (D).
Fusobacterium = anerobic gram negative bacilli (thin tapered ends). Part of the commensal flora of the oropharynx. It is an important pathogen for odontogenic infection. It has been associated with anaerobic pleuropulmonary infection (aspiration pneumonia, lung abscesses, nectrotizing pneumonia, empyema), brain abscesses, chronic sinusitis, liver abscesses, intraabdominal infections, skin infections (human bite wounds) and bacteremia. Typically susceptible to metronidazole, beta lactam/beta-lactamase inhibitor combinations and carbapenems. There is some resistance to penicillin and significant resistance to clindamycin and linezolid. Cephalosporins and moxifloxiacin do not have reliable activity.
67
38. [??] Effects of severe acidemia include all except:
a. impaired glucose utilization of lactic acid.
b. hypokalemia
b. hypokalemia
Transcellular K/H shift during academia results in hyperK.
68
39. Old male. Brought to the ER after a period of retching and vomiting from a food bolus. Sustained a pneumothorax. Chest tube inserted. 48 hours later he became febrile and toxic and chest tube began to drain offensive odour effluent. What is the diagnosis?
a. esophageal perforation
b. empyema from chest tube drainage.
c. Necrotic mediastinitis
b. empyema from chest tube drainage.
Repeated question from 2006 test in which answer was (C). Empyema is typically secondary to pneumonia and subsequent parapneumonic effusion. Also, I don't think it could present in 48 hours. My answer to this question would be (C), likely secondary to insertion of an chest tube in an unsterile manner,
69
40. Trauma patient with a crushing chest injury in which his sternum impacted onto his steering wheel. He complained of severe chest pain and X Ray showed a widened mediastinum. What is the most appropriate course of action?
a. Aortogram
b. Cardiac cathetherization
c. V/Q scan
d. Left sided chest tube
a. Aortogram
Aortic transection
Signs - widened mediastinum, 1st rib fractures, apical capping, loss of aortopulmonary window, loss of aortic contour, left hemothorax, tracheal deviation to right
Tear usually at ligamentum arteriousum
CXR normal in 5% of pts with aortic tears -- need aortic eval with significant mechanism (head on crash > 45 mph, fall > 15 ft)
Dx: aortogram and CTA of chest
Tx: need to control BP with Nipride and esmolol; left thoracotomy with partial left heart bypass
70
41. Which of the following increases the risk of incisional hernia?
a. obesity
b. anemia
c. wound infection
d. choice of suture material
Answer: All of the above
Incisional hernia
Most likely to recur
Inadequate closure most common cause
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42. Blood gas value showing a respiratory acidosis pH=7.23, PaCO2= 60, bicarbonate of 25. (inadequate metabolic compensation). Most likely scenario is:
a. Old man with COPD
b. Young woman with a severe asthmatic attack
c. renal disease
d. 45 year old man with 40% 2nd degree burn
e. 23 year old man with bacterial sepsis
b. Young woman with a severe asthmatic attack
Primary Compensation Factor
Metabolic acidosis Respiratory alkalosis 1:1
Metabolic alkalosis Respiratory acidosis 10:7
**Acute resp acidosis Metabolic alkalosis 10:1
Chronic resp acidosis Metabolic alkalosi 10:4
Acute resp alkalosis Metabolic acidosis 10:2
Chronic resp alkalosis Metabolic acidosis 10:5
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43. Post op ICU Swan numbers indicating hypovolemia. Most appropriate initial course of action is: fluid bolus.
Not a full question.
Fluid bolus.
Review of Cardiac Physiology
Parameter Normal Value
Cardiac output (L/min) 4-8
Cardiac index (relates CO to body surface area [heart performance to size of person]) 2.5-4
SVR 800-1400
Systemic vascular resistance index 1500-2400
PCWP 11 ± 4
CVP 7 ± 2
Pulm artery 20-30/6-15
Mixed venous oxygen saturation (SvO2) 75± 5
MAP = CO x SVR, CI = CO/BSA, SVRI = SVR x BSA
Kidney gets 25% CO, brain 15% CO, heart 5% CO
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44. What is the plasma volume in a 70 kg male?
a. 3 L
b. 6 L
c. 7 L
d. 9 L
e. 12 L
a. 3 L
Repeated question
• TBW = 0.60 x male weight, 0.50 x young female weight
• ECF = 1/3 of TBW and 20% body weight, plasma 1/4 of this, 3/4 interstitial/lymphatic
• Plasma represents 8% of TBW and 5% body weight
• Interstitial is 25% TBW and 15% body weight
ICF = 2/3 TBW and 40% body weight
PV = 70 x 0.6 x 1/12 = 3.5
74
45. Calculate the sodium deficit given a sodium of 125
Na deficit = 0.6 (0.5 for females) x (weight in kg) x (140-Na)
75
46. Which of the following is the most effective way in treating effects from hypoprothrombinemia?
a. whole blood
b. cryoprecipitate
c. FFP
d. Factor VIII concentrate
c. FFP
Cryoprecipitate -- highest concentrations of vWF VIII, used in vW disease and hemophilia A (F8 deficiency), also contains fibrinogen
FFP -- high levels of all factors (include labile F5 and F8), prot C/S, and AT3
76
47. You are called just 45 seconds into a cardiac arrest. The patient just had a hysterectomy and is in the recover room. Rhythm strip shows ventricular fibrillation. Which of the following is the most appropriate treatment?
a. lidocaine
b. defibrillation at 200 J
c. atropine
d. adenosine
e. order 12 lead EKG
C. defibrillation at 200 J
Repeated question from 2006 test. Same answer. ACLS algorithm.
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48. With regards to albumin, all of the following are true except:
a. It represents 70% of effective plasma oncotic pressure
b. It represents 40% of effective intravascular ….(?)
c. The half life of infused albumin is 24 hours
c. The half life of infused albumin is 24 hours
Repeated question from 2006 test in which answer was not in this years included choices; that is, the production of albumin increases during times of stress which is incorrect. It decreases. See below.
Albumin
• Normal person has 280 g
• Turnover is 9-12 g qD
• T1/2 is 15-28 d
• Albumin decrease in stress (liver switches to producing acute phase proteins i.e., CRP, ferritin)
• Manufactured by EtOH extraction of pool of 1000 donors
• 500 cc of 5% albumin = 25 g = 750 cc intravasc increase (250 cc from interstitium)
• 100 cc of 25% albumin = 25 g = 450 cc intravasc increase (350 cc interstitial)
• SE: circ overload, anaphylaxis (rare), hypotension (rare)
• Accounts for 70-80% oncotic pressure
• Extravasc albumin exceeds intravasx by 30%
• Not catabolized in starvation
• Indications
• Post paracentesis if >5L (pentaspan may be equally effective and less expensive)
• SBP -- resusc with abx + alb more effective than abx alone
• Hepatorenal syndrome
• Plasma exchange
○ Pentaspan may be equally effective
○ In TTP, FFP or cryosupernatant used for replacement
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49. The body system most sensitive to change in sodium homeostasis is:
a. CVS
b. CNS
c. Respiratory
d. Genitourinary
e. Musculoskeletal
b. CNS
Hyper/hypoNa -- neurologic sxs
79
50. X Ray of a patient with a leg fracture who is post ORIF. There is a medullary nail through it. Dx:
a. Non union
b. Mal union
c. Osteomyelitis
d. Re fracture of the leg
b. Mal union
Need to see the XR to diagnose. However, I think none of us need help with this question.
80
51. 45 year old female who is type II diabetic. She may have renal colic. She is due for her IVP and is well hydrated with a normal creatinine. Which of the following is the most likely outcome following injection of IV contrast?
a. no adverse event
b. anaphylactoid reaction
c. anaphylaxis
d. dehydration
a. no adverse event
81
52. Which of the following is responsible for a hypercoagulable state?
a. High protein S
b. Low protein C
c. Low factor VIII
d. Low fibrinogen
b. Low protein C
Protein C or C deficiency are a cause of abnormal hypercoagulability. Others include F5 Leiden, hyperhomocysteinemia, prothrombin gene defect G20210A, AT3 deficiency, polycythemia vera, lupus anticoagulant, and acquired hypercoagulability (tobacco [most common], malignancy, inflammatory states, IBD, OCPs, pregnancy, RA, post-op status)
82
53. All of the following are true of fractures in children EXCEPT:
a. Fracture across the growth plate has the greatest potential for growth disturbance
b. Fracture partially through the growth plate has the greatest potential for growth disturbance
c. Potential for remodeling is greater in children vs. adults
d. Intact periostium facilitates reduction in children
e. Greenstick fractures occur in children, but not in adults
b. Fracture partially through the growth plate has the greatest potential for growth disturbance
This is repeated question from the 2006 test in which the answer was (e).
83
54. 70kg male with peripheral edema, stable vital signs, serum sodium of 120, diagnosed with SIADH. Which of the following would be appropriate management:
a. lasix, 40 mg IV
b. restrict fluid to less than daily urine output
c. NS @ 150 cc/h
d. DDAVP
e. Desmocycline
b. restrict fluid to less than daily urine output
SIADH: free water restriction + tx underlying cause
For Na >120 water restrict to 7-10 mL/kg/d (50% maintenance)
NS may worsen SIADH
Hypertonic saline if sxs or Na fails to ↑ w/ free H2O restriction
• If Na
84
Part 1:
40. Old man on coumadin for a prosthetic value has an INR of 3.3 and is scheduled for cholecystectomy (did not mentioned the word ‘open’). What is the most appropriate course of action?
a. stop coumadin 7 days pre op, then start low molecular weight heparin daily
b. stop coumadin 4 days pre op then start LMWH
c. stop coumadin and admit patient then start iv heparin (UFH)
d. stop coumadin and reverse INR with vitamin K
e. lower the dose of coumadin till the INR is 1.3 to 1.5 then operate.
b. Stop coumadin 4 days pre op then start LMWH
So when reading through this topic on up todate, it's a lot more complicated than just bridging vs. not bridging. It depends on the type of valve and the number of risk factors the patients has, and the type of surgery to be performed. However, generally, I would go with B based on the below information:
Typically warfarin is discontinued five days before elective surgery (ie, last dose of warfarin is given on day minus 6) and, when possible, check the PT/INR on the day before surgery. If the INR is >1.5, we administer low dose oral vitamin K. We proceed with surgery when the INR is ≤1.4.
We generally reserve bridging for individuals considered at very high or high risk of thromboembolism (eg, recent stroke, mechanical heart valve, CHADS2 score of 5 or 6) if they require interruption of warfarin. In these cases, the bridging agent (eg, therapeutic dose subcutaneous low molecular weight [LMW] heparin) is started three days before surgery.
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41. Drug induced ATN. See:
a. pyuria and WBC casts
b. may see protein cast
A. Pyuria and WBC casts
This was the answer highlighted but up todate says the following:
The classic urinalysis in ATN reveals muddy brown granular, epithelial cell casts, and free renal tubular epithelial cells
86
42. Man with 8 weeks’ history of weakness and slurred speech. CXR shows mediastinal mass. What should you order next?
a. Tensilon (edrophonium ) test to rule out Myesthenia Gravis
b. CT scan
c. Carotid arteriogram!
d. Bronchoscopy
e. Deltoid muscle biopsy
a. Tensilon (edrophonium ) test to rule out Myesthenia Gravis
This is the answer given as the Tensilon test can detect MG (which is what I think they're getting at with this question - MG is related to fatigue and mediastinal masses). However Up todate also says the following:
The edrophonium ("Tensilon") test should be used only in those patients with obvious ptosis or ophthalmoparesis, in whom improvement after infusion of the drug can easily be observed
I would have said CT scan. MG is associated with thymoma and NHL and SCLC so you would want better imaging of the mass.
87
43. FE Na > 40 signifies intrinsic renal failure
There wasn't a question...
88
44. Which of the following applies to consent EXCEPT?
a. not a discreet process but continuous
b. finished once you sign on the dotted line
b. finished once you sign on the dotted line
89
45. NO heroic measures..old fellow with multiple things wrong with him wants no heroic measures. There is no negligence
Again, no question
90
46. Commonest cause of stroke post op:
a. hypotension
b. large vessel atherosclerosis
B. Large vessel atherosclerosis.
No clear answer anywhere, but my guess is carotid atherosclerosis embolizes
91
47. Callus. All of the following is true except:
a. After ORIF and plate callus does not form.
b. Mesenchymal cells differentiate into osteoblasts after 24 hours of fracture
c. Callus is formed by primitive extracellular matrix and osteoblasts
Ans: B
A- I'm assuming they're assuming it's primary bone healing
B- Mesenchymal cells differentiate into osteoblasts - this is during the remodelling phase which is days after fracture
C- True
There are 4 phases to Bone healing:
1. Inflammation (1-7 days)
Coagulation starts. Fibrin fibers are formed and stabilize the hematoma (hematoma callus
2. Soft callus formation (2-3 weeks post #)
This is where various cells come to help with the healing - fibroblasts produce collagen fibers etc.
3. Hard callus formation (3-12 weeks)
Endochondral ossification converts the soft callus to woven bone starting at the periphery and moving towards the center, further stiffening the healing tissue. This continues until there is no more interfragmentary movement.
4. Remodeling (months to years)
Source: AO
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48. Man sustained anterior cord syndrome at C5 after a diving accident. What do you see on examination?
a. normal proprioception in feet
b. normal bladder function
c. normal toe dorsiflexion
d. normal toe plantar flexion
e. normal pinprick to arms
A. Normal Proprioception
Exam will Reveal the following:
1) Lower extremity affected more than upper extremity
2) There is a loss of:
a) Lateral cortical spinal tract (motor)
b) Lateral spinal thalamic Tract (pain, temperature)
3) Preservations of:
a) Dorsal columns (proprioception, vibratory sense)
93
49. Respiratory quotient question: carbon dioxide production / oxygen consumption?
???
94
50. Least water seen in :
a. lean elderly women
b. lean man
c. newborn female –
d. lean middle age female
Ans: Lean elderly woman
B- Men have more water than women (men 58% and women 48%)
C- Babies have up to 80% water
D- As we get older, we lose lean body mass and gain adipose tissue, so older people will have less water content than younger
95
51. Facial trauma and mandibular fractures. Best way to provide initial airway is: oral endotracheal tube.
Need definitive airway management - ETT is good because have direct view through the cords. And by ATLS, need to deal with airway first, # fixation/management comes later.
Nasal intubation would not be a good option in facial fractures
96
52. middle age well to do man, quadraplegia and open ulcer down to ischial tuberosity.
Answer: Perform myocutaneous flap
97
55. What is the best definition of specificity
Specificty = TN/FP+TN
| It measures the proportion of negatives that are correctly identified as such
98
56. RCT vs. cohort trial vs. meta-analysis of retrospective studies. Which one gives you the best evidence?
Meta-analysis of RCTs
99
57. What is the commonest cause of cardiac arrest post blood transfusion?
Hypothermia due to rapid transfusion of large amounts of cold blood can cause arrhythmias or cardiac arrest
100
58. what is the mechanism of epinephrine during a cardiac arrest?
a. increase cardiac inotropy and vasoconstriction
Effects of Epi in ACLS:
1) Vasoconstriction effects: epinephrine binds directly to alpha-1 adrenergic receptors of the blood vessels (arteries and veins) causing direct vasoconstriction, thus, improving perfusion pressure to the brain and heart.
2) Cardiac Output: epinephrine also binds to beta-1-adrenergic receptors of the heart. This indirectly improves cardiac output by:
Increasing heart rate
Increasing heart muscle contractility
Increasing conductivity through the AV node
101
59. what is the difference between an omphalocele and gastroshisis?
a. the former lacks a peritoneal sac
Answer: Omphalocele is a similar birth defect, but it involves the umbilical cord, and the organs remain enclosed in visceral peritoneum.
102
60. Reperfusion limb injury. Options include all of the following except:
a. compartment syndrome
b. hypercalcemia
c. hyperkalemia
B. Hypercalcemia
A- Um yes. - All of them vascular patients who clot off their new graft and then need embolization and prophylactic fasciotomies
B- Happens later
C- Hyperkalemia -Greater risk when onset is rapid eg: reperfusion of a large vascular bed after greater than 4 hours of ischemia
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61. Wound strength at 3 days depends on:
a. Fibroblasts proliferation
b. Epithelialization
c. Sutures
C. Sutures
At day 3, we are in the inflammatory phase which consists of the following In order of appearance in the wound: plt, leukocytes, lymphocytes and macrophages
A- Fibroblasts are dominant in Proliferative phase
B- Epitheliazation occurs from the remaining dermal appendages in partial thickness wounds. In full thickness wounds, epitheliazation migrates in from the edges at a rate of 1 – 2mm/d, however, this rate is
critically dependent on the vascularity of the underlying granulation tissue
104
62. Inflammatory phase of wound healing:
a. epithelialization decreases it
b. prolonged with coverage with a skin graft into open wound
The questions said A.
I don't know that I understand the question
105
63. Earliest sign of hypomagnesemia:
a. decrease DTRs
b. tremour
c. constipation
B. tremour
A- With hypomagnesia, you have increased DTR, muscle spasms, tetany and could have choreiform activity. Most of the signs are neuro and cardiac related
C - I didn't find this as a sign
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64. Options of treatment of rhabdomyolysis:
a. fluid resuscitation until u/o > 0.5 cc/kg/hr
b. mannitol
c. bicarbonate
Ans: A
A- If a diuresis is established, fluids are titrated to maintain a urine output of 200 to 300 mL/hour.
B- The benefit of loop diuretics or mannitol in rhabdomyolysis is not established. Experimental studies suggested that mannitol might be protective by causing a diuresis, which minimizes intratubular heme pigment deposition and cast formation, and/or by acting as a free radical scavenger, thereby minimizing cell injury [10,11]. However, mannitol did not ameliorate proximal tubular necrosis, suggesting that the induced diuresis was of primary importance
C- There is no clear clinical evidence that an alkaline diuresis is more effective than a saline diuresis in preventing AKI
107
66. patient post transsphenoidal resection pituitary tumour. Now has mild DI . Just complain of thirst and Na 145. Best treatment option is:
a. fluids ad lib
b. R/L at 150 cc / hour
c. D5 at 150 cc/ hr
Ans: A
Thirst is essential so that the excess urinary water losses can be replaced. Patients without an intact thirst mechanism can develop severe hypernatremia.
108
67. Commonest cause of pediatric death is:
a. AML
b. Trauma
c. Child abuse
Trauma
109
69. EKG changes with hypokalemia (U wave is not included) {RUSH page 15}
a. ST segment elevation, T wave inversion
b. ST segment elevation, QRS narrowing
c. ST segment depression, T wave inversion
d. P wave amplitude lowered with QRS narrowing
e. ST segment depression, something else…??
Ans: C
There is depression of the ST segment, decrease in the amplitude of the T wave, and an increase in the amplitude of U waves which occur at the end of the T wave (waveform 1).
Source; UTD
Note: HypoK does not cause the arrhythmias, it enhances proarrhythmic effects of hypoMg and digitalis
Source: Morrells
110
70. Metabolic acidosis seen in all EXCEPT:
a. Prolonged starvation
b. Hypokalemia
B. Hypokalemia
There will be Hyperkalmia in met acidosis
111
71. 45 year old women brought in obtunded. Blood gas shows anion gap metabolic acidosis. Which of the following is the Dx?
a. salicylate poisoning
b. diarrhea
c. renal tubular acidosis
d. fistula
Ans: A
Mudpiles
```
Methanol
Uremia
DKA
Propylene glycol
Infection, isoniazide
Lactic Acidosis
Ethylene glycol
Salicylic Acid
```
112
74. Effective osmotic pressure of a body compartment is determined by the presence of:
a. plasma proteins
b. intravascular sodium
c. extracellular potassium
d. differences in diffusible ionized particles
PLasma proteins
113
75. Indications for intubation in a burn/inhalational injury patient:
a. progressive hoarseness
b. carbonaceous sputum
Both?
If there's ash in the mouth or nose, there's concern for inhalation injury.
114
76. Sympathetic supply to the eyelids originate from:
a. stellate ganglion
b. cervical sympathetic trunk
c. thoracic sympathetic trunk
A. Stellate Ganglia
The Quesitons has B as the answer but it's the Stelate ganglia that's affected in horners which causes ptosis so my feeling is that it's Stellate ganglia.
115
77. Cancer is:
a. clonal selection of cells with accumulated multiple genetic mutations
b. translocation to multiple proto-oncogenes
c. imbalance between cell growth and cell death
Ans: C.
Slightly weird question
There are 6 hallmarks of cancer:
(1) Cancer cells stimulate their own growth (Self-sufficiency in growth signals);
(2) They resist inhibitory signals that might otherwise stop their growth (Insensitivity to anti-growth signals);
(3) They resist their programmed cell death (Evading apoptosis);
(4) They can multiply indefinitely (Limitless replicative potential)
(5) They stimulate the growth of blood vessels to supply nutrients to tumors (Sustained angiogenesis);
(6) They invade local tissue and spread to distant sites (Tissue invasion and metastasis).
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1- all these tumor are associated with Hippel-Lindau syndrom except:
```
a- pheochroocytoma
b- cerebral hamengioblastoma
c- epidedemus cystadenoma
d- pancreatic adenocarcinoma
e- renal cell Ca
```
d. pancreatic adenocarcinoma
Memorization. Probably low yield to study this
von Hippel-Lindau (VHL) disease is an inherited, autosomal dominant syndrome manifested by a variety of benign and malignant tumors. A VHL gene abnormality is present in about 1 in 36,000 individuals
• Hemangioblastomas of the brain (cerebellum) and spine
• Retinal angiomas
• Clear cell renal cell carcinomas (RCCs)
• Pheochromocytomas
• Endolymphatic sac tumors of the middle ear
• Serous cystadenomas and neuroendocrine tumors of the pancreas
• Papillary cystadenomas of the epididymis and broad ligament
117
2- Treatment of Fusobacterium+ empayema
```
a- pinicillin
b- clarithromycin
c- cipro
d- claviulin
e- imipenim
```
e. imipenem??? (previous answer penicillin is wrong)
Fusobacterium is a major anaerobic pathogen in orodental and pulmonary infections. Gram(-).
Many Fusobacterium strains produce b-lactams, making all b-lactams a poor choice.
Anaerobic organisms are common, particularly among patients who present with empyema, and are difficult to culture. Therefore, antibiotics are usually selected to treat anaerobic organisms without the benefit of in vitro susceptibility tests. Options for empiric therapy that would cover anaerobic organisms include clindamycin, beta-lactam plus beta-lactamase inhibitors (eg, amoxicillin-clavulanate, ampicillin-sulbactam, or piperacillin-tazobactam), and carbapenems (eg, imipenem, meropenem, or ertapenem). Single agent therapy with either penicillin or metronidazole is not considered optimal.
Macrolides (clarithromycin) could be a good choice but there is limited clinical studies about it
Aminoglycosides (Cipro) could be a reasonable choice for isolated Fusobacterium
118
3- Amino acid in the urine responsible for collagen breakdown
```
a- methrmine
b- cystine
c- hydroxyproline
d- histadine
e- praline
```
c. Hydroxyproline in urine = best indicator of collagen breakdown.
119
4- severe acidemia all except:
```
a- sympathetic stimuli
b- hyperkalemia
c- increase catecholamine
d- insulin resistance
e- increase lactate
```
a. sympathetic stimuli?
This question would probably be easier if the question stem was more descriptive of the cause of acidemia.
Think about a trauma patient. Increased lactate, acidosis (with shift of H+ ions into cells, which shifts K+ out of cells) = hyperkalemia (not in all acidoses, but can in severe acidosis). There is decreased contractile response to catecholamines during acidosis. ?increased catecholamine release with hypoxia (the only reference I found for this was in rainbow trouts…).
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5- lower esophageal sphincter all except
```
a- innervated by vagus
b- affected by smoking
c- affected by alcohol
d- will decrease the reflux
e- decrease LOS tone with decrease esophageal peristalsis
```
???
A. The lower esophageal sphincter is innervated by both parasympathetic (vagus) and sympathetic (primarily splanchnic) nerves; however, the vagal pathways are the ones that are essential for reflex relaxation of the lower esophageal sphincter
B. Cigarette smokers have prolonged esophageal acid clearance times due to hyposalivation
C. host of factors that can reduce LES pressure: gastric distension, cholecystokinin, various foods (fat, chocolate, caffeine, alcohol), smoking, and many drugs.
D. ? impossible to answer given the question stem/answer choice. Decreased LES tone will increase reflux.
E. Many patients with nutcracker esophagus also have a hypertensive or poorly relaxing LES.
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6- the digit will be viable to finger retransplant in
```
a-18h
b-12h
c-10h
d-8h
e-6h
```
a. 18h
time to replantation
• proximal to carpus
o warm ischemia time
122
7- which cell is radio resistance
```
a- lymphocyte
b- epidemocyte
c- gut enterocyte
d- neural cell
e- spermatocyte
```
Adult neurons and astrocytes demonstrate substantial radioresistance; in contrast, human neural stem cells (NSC) are highly sensitive to radiation via induction of apoptosis
123
8- manifestation of acute pancreatitis all except:
```
a- plural effusion
b- confusion
c- dyspnea
d- fat necrosis
e- patechial rash
```
b. confusion???
Answer: You can have all of these with pancreatitis?
You can get pleural effusion which can lead to dyspnea.
Pancreatitis is a rare cause of fat embolism which can lead to petechial rash – pretty unusual though
124
9- 2L of diarrhea will result in all except:
```
a- decrease effective circulatory volume
b- decrease urine Na
c- increase thirst
d- increase ADH
e- decrease serum Cl
```
e. decreased serum Cl
you get hyperchloremic metabolic acidosis from losses of HCO3- with compensatory Cl- elevation (this balances the equation in anion gap so you get non-anion gap met. Acidosis)
125
10- metabolic acidosis all except:
```
a- hypokalemia
b- renal failure
c- diarrhea
d- prolonged fasting
e- fistula
```
Answer: a. hypokalemia - Body tries to shift K+ out of cells to intake H+ to neutralize so you get hyperkalemia
b. The excretion of acid (NH4+) and regeneration of bicarbonate is impaired in the setting of a low glomerular filtration rate (GFR) resulting in metabolic acidosis. Much of the acid that is normally excreted by the kidney is the product of daily metabolism
c. Causes hyperchloremic metabolic acidosis normal anion gap
d. You can get starvation ketoacidosis
e. Small bowel fistula causes bicarb loss – normal anion gap met. acidosis
