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Flashcards in 2005 With Explanations (2005 AK No Answers) Deck (135)
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1

103. All are true for Vit D EXCEPT?

a) Decreases PTH secretion
b) Transformed to 25-OH Vit D in the liver
c) Transformed to 1,25-(OH)2 Vit D in the kidney
d) Transformed to 24,25-(OH)2 Vit D in the kidney

a) Decreases PTH secretion.

Vit D does not directly modulate PTH. It instead modulates calcium and phosphorous which have the ability to modulate PTH secretion.

Vit D Pathway:
1. Activated by sunlight in the skin (Vit D)
2. Hydroxylated to 25-(OH)Vit D in the liver (calcidiol)

Next transported to the Kidney where:
3a. Hydroxilated to 1,25-(OH)2 Vit D (cholecalciferol) in the kidney **active form of VitD
OR 3b. Hydroxylated to 24,25-(OH)2 Vit D in the kidney **inactive form

Effects of Cholecalciferol:
-promotes osteoclasts for Ca2+ resorbtion in bone
-increases Ca2+ absorption in stomach

2

104. A 30 yo ♂fell 15m. He sustained a T8 burst fracture and a complete spinal cord lesion. He is alert and oriented wih a BP of 90/50, HR 50 and no change after 2 L Ringer’s. A FAST is negative. What is the MOST likely cause of his hypotension?

A. Unrecognized thoracic injury
B. Unrecognized abdominal injury
C. Inadequate fluid resuscitation
D. Neurogenic Shock

D. Neurogenic Shock

Low HR and low BP indicate compromise of sympathetic response as a result of spinal cord injury.

Signs:
-Hypotension
-Bradycardia
-Warm extremities

3

105. A patient is receiving chemotherapy with doxorubicin. The medication goes interstitial during administration through a vein in the forearm. What is the MOST appropriate immediate treatment?

A. Instill leukovarin antidote immediately
B. Cold compress, elevation, and topical burn ointment
C. Topical sodium mafenide ointment
D. Debride devitalized tissues immediately

B. Cold compress, elevation and topical burn ointment.

** answer may also be D, literature does not point to burn ointment, instead refers to local analgesia.

-Leukovarin is antidote to methotrexate.
-Only substance shown to improve outcomes with anthracyclin extravasation (doxorubicin included), is dexrazoxane.
-Cold compress and elevation is first management
- Irrigation and debridement of necrotic tissue to follow if openly visible or persistent pain for >10 days.

Management of chemotherapy extravasation: ESMO–EONS Clinical Practice Guidelines.Ann Oncol (2012) 23 (suppl 7): vii167-vii173.
doi: 10.1093/annonc/mds294

4

106. Parathyroid hormone does all of the following EXCEPT:

A. Decreases 1,25-VitD3 (OH)2
B. Decreases PO4
C. Decreases urinary Ca2+
D. Decreases 25-hydroxyvitamin D

A. Decreases 1,25-VitD3 (OH)2

Stimulates the production of 1,25-VitD3(OH)2 aka cholecalciferol. Will decreased 25OHVitD by stimulating pathway for it to become cholecalciferol.

PTH:
-stimulated by low serum Ca2+ and high serum Phosphate
-Increased Ca2+
-Increased Calcitriol
-Decreased Phosphate

5

107. A 70 y.o. ♂ immediately post op has a BP 70/50, HR = 105 and ST depression in the anteroseptal leads. The MOST appropriate management is:

A. β blocker
B. Nitro s/l
C. Nitro IV
D. Epinephrine
E. Dobutamine

D. Epinephrine

Cardiogenic Shock. Ionotrope, Chronotrope, Vasoconstriciton

Indicated in:
-anaphylaxis
-cardiogenic shock
-cardiac arrest

Dobutamine is only indicated in low cariogenic shock where there is no evidence of infarct. Dobutamine is mostly b1 for inotropy but can also do to some extent b2 which can vasodilate peripherally which is not desirable if the patient is in shock.

First line is norepinephrine from ER trial, with dobutamine as second line (add it since the norepi will counteract possible vasodilation).

6

A 58 y.o. ♂ with cirrhosis presents with an UGI bleed. Initial resuscitation measures are carried out. What is the MOST helpful adjunct to treatment?

A. Synthetic vasopressin
B. Somatostatin
C. Ranitidine
D. NG tube

D. NG Tube

A. Synthetic vasopressin - should volume resuscitate
B. Somatostatin or octeotride are indicated in variceal bleeds
C. PPIs are indicated not H2 blockers

7

An achondroplastic dwarf is undergoing spinal fusion surgery and is placed in the prone position. In the recovery room, he is unable to see out of either eye. What is the MOST likely cause of his blindness?

A. Retinal detachment
B. Acute open angle glaucoma
C. Retinal ischemia
D. Occipital artery infarct

C. Retinal Ischemia

In patients undergoing spine surgery, prolonged use of the prone position is also implicated as a risk factor for PION (posterior ischemic optic neuropathy), presumably by increasing venous pressure and secondarily decreasing arterial perfusion pressure

8

3. A middle-aged ♂ patient could not urinate 8 hours postoperatively following an inguinal hernia repair. A Foley catheter was inserted and only drained 15cc. It was noted that it was difficult to inflate the balloon with more than 1cc of saline. What is the BEST next step?

A. Deflate the balloon and remove the catheter
B. Deflate the balloon and advance the catheter even further
C. Insert a suprapubic catheter
D. Increase the patient’s IVF rate

B. Deflate the baloon and advance the catheter

The incidence of urinary retention following laparoscopic inguinal and femoral hernia repair varies depending upon the type of anesthesia used and the nature of the repair [7-11]. Urinary retention occurs in about 2.2 percent of patients if the repair is performed under general anesthesia and 0.4 percent if local anesthesia is used

(Up to date)

9

4. Macrophages are the most predominant cell type in which phase of wound healing?

A. Lag phase
B. Proliferative phase
C. Maturational phase
D. Remodelling phase

Lag Phase (Also known as inflammatory)

10

5. When do platelets return to normal function after stopping naproxen?

A. 2 days
B. 4 days
C. 6 days
D. 8 days

TBD

11

6. 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

C. IT hip #

Previous answer thought it was capitellum, but IT # is extra-articular and shouldn’t cause AVN, and Orthobullets says capitellum # has risk of AVN whereas AVN not listed as complication for IT#

12

7. Cardiac toxicity in hyperkalemia would be BEST treated with:

A. Insulin
B. Metoprolol
C. Calcium
D. Bicarbonate

C. Calcium

Calcium directly antagonizes the membrane actions of hyperkalemia [3], while hypocalcemia increases the cardiotoxicity of hyperkalemia [4]. As discussed elsewhere, hyperkalemia-induced depolarization of the resting membrane potential leads to inactivation of sodium channels and decreased membrane excitability
Calcium only lasts 30-60minutes so needs to be combined with alternative therapy
CaCl provides 3x the amt of calcium compared to calcium gluconate

13

8. The process of disclosure includes all EXCEPT:

A. Risks of procedure
B. Risks and expected outcome of not doing procedure
C. Alternative treatment modalities available
D. Whatever a reasonable physician would say

D. Whatever a reasonable physician would say

14

9. A chest xray shows a right tension pneumothorax and a left diaphragmatic hernia. What is the MOST appropriate immediate action?

A. Insert chest tube on the right
B. Insert chest tube on the left
C. Perform an emergent thoracotomy
D. Insert NG tube

A. Insert chest on the right

15

10. Define standard deviation.

A. Difference between mean and median
B. Measure of variance and dispersion
C. The midpoint in a series of numbers
D. Measure of dispersion around the mode

B. Measure of variance and dispersion

16

11. The initial treatment of thyrotoxic storm may include all of the following EXCEPT:

A. Propranolol
B. Urgent thyroidectomy
C. Propylthiouracil (PTU)
D. Lithium

B. Urgent thyrodectomy

Answer: Tx with PTU (thyroid blocker), beta-blocker, iodine or lithium.

Thyroid can be very vascular so not a good option.

17

12. A patient presents after having a total non–cemented hip arthroplasty 6 months earlier. No pain but dramatically limited range of motion. An Xray shows heterotopic ossification (HO). Which of the following may have limited the degree of HO?

A. Bisphosphanates
B. NSAIDS
C. Low molecular weight heparin
D. Intraarticular cement

B. NSAIDs

18

13. The body system MOST sensitive to changes in sodium homeostasis is:

A. CVS
B. CNS
C. Respiratory
D. Musculoskeletal

CNS

19

14. A 67-year-old ♀ is on a ventilator in the ICU. Her blood pressure is noted to be 100/72. The tidal volume is noted to be 15cc/kg. The PaO2:FiO2 ratio is
MISSING END OF THE QUESTION

A. Decrease the Vt to 5-7cc/kg

PaO2:FiO2 of 100-200 is moderate ARDS.

PaO2:FiO2 rtio at atm should be 500mmHg.
Normal CO = ~5L/min


So if this is ARDS, we should be treating with low tidal volumen ventilation

20

15. A patient has renal insufficiency and requires nutritional support. Which of the following is the BEST recommendation?

A. Lower the caloric/ nitrogen ratio
B. Increase the caloric / nitrogen ratio
C. Avoid branched chain amino acids
D. Recommend an alternate source of calories other than glucose

B. Increase the caloric / nitrogen ratio

Up to date wasn’t very clear – but essentially need to increase calorie intake to improve overall nutrition, and improve albumin.

21

16. A 60 year old man with carcinoma of the colon is started on morphine
for abdominal pain. On review the next day, his family reports that he has
been having hallucinations. You would:

A. Rotate to hydromorphone
B. Rotate to fentanyl as it has less metabolites
C. Use haloperidol
D. Use a benzodiazepine (typically clonazepam)
E. Avoid opioids (try a NSAID or steroid instead)

A. Rotate to hydromorphone

Answer: Colon cancer likely GI bleed. Do not use NSAIDS. Hydromorph less active metabolites and lower incidence of delerium.

22

17. Which of the following is the LEAST consistent with child abuse?

A. Multiple bruises on anterior shins
B. Long bone spiral fractures in toddler
C. Retinal hemorrhages
D. Femur fracture in non-walking infant
E. Sharply demarcated burns

A. Multiple bruises on anterior shins


Others are al documented signs of child abuse

23

18. Which of the following is MOST effective in preventing LATE complications of splenectomy?

A. Adminstration of pneumococcal and H. flu vaccines
B. Perform only laparoscopic splenectomy
C. Perform sub-total splenectomy
D. Give patients antibiotic prophylaxis post-operatively

A. Adminstration of pneumococcal and H. flu vaccines

At risk for encapsulated organisms

24

19. Which of the following is the MOST sensitive indicator of malignancy in an incisional biopsy for an epithelial tumour?

A. Aneuploidy on flow cytometry
B. Positive stain for cytokeratin
C. Tumor cells breaking through the basement membrane layer
D. Multiple mitotic figures and prominent nucleoli

C.

From Schwarz:
A feature of malignant cells is their ability to invade the surrounding normal tissue. Tumors in which the malignant cells appear to lie exclusively above the basement membrane are referred to as in situ cancer, whereas tumors in which the malignant cells are demonstrated to breach the basement membrane, penetrating into surrounding stroma, are termed invasive cancer.
The ability to invade involves changes in adhesion, initiation of motility, and proteolysis of the extracellular matrix (ECM

25

20. Which of the following causes of polyuria is associated with a high urine specific gravity?

A. Diabetes Mellitus
B. SIADH
C. Acute non-oliguric renal failure
D. ATN

A. DM

A. Diabetes Mellitus – High urine specific gravity and polyuria
B. SIADH – I don’t think they have polyuria
C. Acute non-oliguric renal failure – usually decreased specific gravity
D. ATN – Also decreased specific gravity

26

21. A patient was placed in a left lateral decubitus position for total hip arthroplasty which lasts over 4 hours. Post operatively he wakes up complaining of arm/hand weakness. What is the MOST likely abnormality?

A. Weak finger flexion
B. Weak wrist extension
C. Weak finger adduction
D. Weak finger abduction

B. Weak wrist extension

27

108. Which cytokine may reduce scar hypertrophy?

A. EGF
B. FGF
C. IFN-gamma
D. IL-2

C. IFN-gamma

Inhibits collagen synthesis. Remaining choices promote wound healing.

28

109. Which factor deficiency is MOST likely to cause a high INR but normal
PTT?

A. VII
B. VIII
C. IX
D. XI

A. VII

PT/INR measures: extrinsic pathway (VII) and common pathway factors including , V, X,
prothrombin/thrombin (II), and fibrinogen/fibrin.

PTT measures: intrinsic pathway factors (HMWK, prekallikrein, VIII, IX, XI, XII) and common pathwayfactors (II/thrombin, V, X and fibrinogen/fibrin)

29

110. Hypomagnesemia MOST likely causes:

A. Decreased deep tendon reflexes
B. Tremor
C. Constipation
D. Muscle paralysis

B. Tremor

Clinical Manifestations of Mg

-Cardiac manifestations (7):
1. Prolonged PR interval
2. Prolonged QT
3. T-wave flattening
4. Tachyarrhythmias (unstable VT)
5. A. fib
6. Torsades de pointes
7. Digitalis toxicity enhanced as both inhibit the membrane pump

-Neurologic manifestations:
• Changes in mental status, seizures, Tremors, Hyperreflexia
• All uncommon, non-specific and have little clinical value
• Tremor is the MOST CHARACTERISTIC finding with hypomagnesemia but tetany is first sign.

30

111. A patient sustains a transverse fracture through the pterygoid plate, inferior to floor of maxillary sinus. What type of fracture does this represent?

A. LeFort I
B. Lefort II
C. Lefort III
D. Panfacial fracture

A. Lefort I

LEFORT I: Through maxilla (separates maxilla from rest of skull)
LEFORT II: Maxilla inferior orbit lacrimal bone (bridge of nose)
LEFORT III: Zygomatic arch lateral orbit inferior orbit lacrimal bone