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1

1. A patient was placed in a left lateral decubitus position for total hip arthroplasty, which lasts over 4 hours. The upper arm was not padded properly. 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

That's what has been written, but my understanding had been that ulnar is most common

2

2. Which properties of a suture material will incite the LEAST amount of inflammatory reaction?

A. Monofilament, absorbable
B. Monofilament, non absorbable
C. Polyfilament
D. Braided

B. Monofilament, non absorbable
nylon
prolene

3

3. With regards to post heart transplant allograft vasculopathy, all of the following are true EXCEPT:

A. It is associated with CMV
B. It is the #1 cause of late death in heart transplant patients
C. It is characterized by proximal, discrete coronary lesions
D. It is associated with immune-related endothelial injury

C. It is characterized by discrete coronary lesions


-development of rapidly progressing coronary artery disease in the arteries of the transplanted heart (called allograft vasculopathy), becomes the most common cause of death by five years (UptoDate)
-Transplant vasculopathy remains the most daunting long-term complication of heart transplantation, with an annual incidence rate of 5 to 10%. After the first postoperative year, cardiac allograft vasculopathy becomes increasingly important as a cause of death.
-The risk of transplant vasculopathy increases as the number of HLA mismatches and the number and duration of rejection episodes increase. CMV infection and ischemia-reperfusion injury also increase the risk, as do classic risk factors for atherosclerotic disease. Transplant vasculopathy can develop as early as 3 months after transplantation and is detected angiographically in 20% of grafts at 1 year and in 40 to 50% at 5 years. (Cecil)
-In contrast to eccentric lesions seen in atheromatous disease, cardiac allograft vasculopathy produces concentric narrowing from neointimal proliferation of vascular smooth muscle cells and affects the entire length of the coronary tree, from the epicardial to the intramyocardial segments, leading to rapid tapering, pruning, and obliteration of third-order branch vessels.

-The majority of patients will not experience anginal symptoms because of denervation of coronary arteries, so the first clinical manifestation may be myocardial infarction, heart failure, ventricular arrhythmia, or sudden death.

4

4. Which of the following is indicative of a blood test post splenectomy?

A. Thrombocytosis
B. Neutropenia
C. Spherocytosis
D. Leukocytosis

A. Thrombocytosis

Postsplenectomy reactive thrombocytosis has an incidence of about 75% to 82%.

5

5. Toxic shock syndrome is caused by:

A. Staph aureus septiciemia
B. Staph aureus toxin
C. Streptococcus septicemia
D. Streptococcus toxin

B. Staph aureus toxin

-Toxic shock syndrome is an acute febrile illness caused by toxin-producing strains of S. aureus or, less commonly, Streptococcus (toxic shock–like syndrome.

6

6. Malignant hyperthermia is characterized by:

A. Early hyperthermia
B. Autosomal dominant transmission
C. Late increased end-tidal CO2
D. Hypokalemia

B. Autosomal dominant transmission

-The classic MH crisis entails a hypermetabolic state, tachycardia, and the elevation of end-tidal CO2 in the face of constant minute ventilation. Respiratory and metabolic acidosis and muscle rigidity follow, as well as rhabdomyolysis, arrhythmias, hyperkalemia, and sudden cardiac arrest. A rise in temperature is often a late sign of MH. (Schwartz)
- The syndrome is genetically transmitted as an autosomal dominant trait. (Crit Care –access surg)

7

7. A post-op patient is in respiratory distress. Upon exam, he has a Grade IV view and bag-valve mask ineffective. What is the MOST appropriate next step?

A. Perform a tracheostomy
B. Perform a cricothyroidotomy
C. Insert an LMA
D. Attempt nasopharyngeal intubation

C. Insert an LMA

FC. LMA. first step of difficult airway algorithm. if you can't intubate and you can't ventilate. you go to LMA

8

8. Which of the following mechanisms BEST explains the coagulopathy associated with severe hemorrhagic shock?

A. Decreased circulating coagulation factors
B. Decreased circulating platelets
C. Acidosis and hypothermia
D. Increased fibrinolysis

C. Acidosis and hypothermia

- Hypothermia is one of the most common and least well recognized causes of altered coagulation in surgical patients, especially those receiving massive transfusion. Body temperatures as low as 30°C to 34°C can be associated with coagulopathy, even if levels of factors and platelets are normal. Nonmechanical bleeding can occur and be uncontrollable and lethal. The best course is to terminate the surgical procedure as expeditiously as possible, pack the bleeding areas as needed, close the surgical incision, and attempt to rewarm the patient as rapidly as possible in the intensive care unit. Damage control celiotomy for trauma, which includes an abbreviated celiotomy with control of gross bleeding, overt enteric contamination, packing and staged delayed definitive repair of injuries, and abdominal closure, has become key in preventing the triangle of death: hypothermia, acidosis, and coagulopathy.

9

9. A young male is involved in an MVC. He sustains a closed head injury + pelvic # and on presentation has a decreased GCS, BP 90/50, HR = 105, RR = 20 and an increased ICP at 22mmHg. All of the following are acceptable courses of action, EXCEPT:

A. Propofol and intubation
B. Lasix, 40mg IV
C. Mannitol, 20mg/kg IV
D. IV morphine for pain control

B. Lasix, 40mg IV

I don't think this needs an explanation

10

10. Regarding branched chain amino acids, which of the following is TRUE?

A. Alanine is the major type
B. Increase protein synthesis by muscle
C. Metabolized by liver
D. Contraindicated in renal failure
E. Increase caloric density

B. Increase protein synthesis by muscle

1- The 3 BCAAs are leucine, isoleucine and valine
2- Branched chain amino acids are essential amino acids that cannot be synthesized in the body.
3- The three branched chain amino acids are unique among amino acids in that their first catabolic step cannot occur in the liver.
4- They don't seem to be contrindicated in renal patients, but adjusted doses may be required
5- They don't have increased caloric density

11

11. A 30 yo male fell 15m. He sustained a T8 burst fracture and a complete spinal cord lesion. He is alert and oriented with 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

Neurogenic shock is a distributive type of shock resulting in low blood pressure, occasionally with a slowed heart rate, that is attributed to the disruption of the autonomic pathways within the spinal cord.

Also warm extremities.

12

12. A young patient sustains a clean laceration to the volar forearm. There is no significant soft tissue injury and he presents to your ER in the periphery. Clinically, you detect a deficit in the ulnar nerve distribution, and suspect ulnar nerve injury from laceration. What is the NEXT most appropriate action?

A. Irrigate, close, and send urgently to appropriate surgical specialist
B. Irrigate, close, splint wrist, and arrange for F/U in 4/52
C. Explore wound to confirm clinical suspicion
D. Leave open, pack with saline-soaked gauze, refer to appropriate surgical specialist
E. Immediately consult appropriate surgical specialist

A. Irrigate, close, and send urgently to appropriate surgical specialist

13

13. What is the BEST predictor of requirement for post-operative ventilation?

A. FEV1

A. FEV1 50
vd/vt>0.6
paO2 300mmHg on 100


14

14. The least toxic radiation to skin is:
A. Linear accelerator.
B. Brachytherapy.
C. Cobalt.

B. Brachytherapy

15

15. Commonest thyroid carcinoma is:
A. Papillary.
B. Follicular.
C. Medullary.
D. Anaplastic

A. Papillary

Follicular is scond

16

16. Causes of polyuria with high specific gravity :
A. DM.
B. DI.
C. Diuretic Rx.
D. Renal tubular acidosis

A. DM

INCREASED:
Volume depletion, CHF, adrenal insufficiency, DM, SIADH, increased proteins (nephrosis), newborn state; if markedly increased (1.040–1.050), artifact or recent administration of radiographic contrast media

DECREASED:
Diabetes insipidus, pyelonephritis, glomerulonephritis, water load with normal renal function (note effective management in kidney stone patients, hydrate to keep SG very low)

17

17. After debridement of devitalized bone. The best way to close dead space is:
A. Myocutaneous flap.
B. FTSG
C. Primary closure
D. Closure with a drain

A. Myocutaneous flap

18

18. In Sunderland classification of nerve injury. In grade 2:
A. Recovery is expected in days to weeks.
B. Partial recovery.
C. Complete recovery is expected

C. Complete recovery

In 1951, Sunderland expanded Seddon's classification to five degrees of peripheral nerve injury:

1- First-degree (Class I)
Seddon's neurapraxia and first-degree are the same.
It is a temporary interruption of conduction without loss of axonal continuity.[3]In neurapraxia, there is a physiologic block of nerve conduction in the affected axons.

It is the mildest type of peripheral nerve injury. There are sensory-motor problems distal to the site of injury. The endoneurium, perineurium, and the epineurium are intact.
There is no wallerian degeneration.
Conduction is intact in the distal segment and proximal segment, but no conduction occurs across the area of injury.[4]
Recovery of nerve conduction deficit is full,and requires days to weeks.
EMG shows lack of fibrillation potentials (FP) and positive sharp waves.

2- Second-degree (Class II)
Seddon's axonotmesis and second-degree are the same.

It involves loss of the relative continuity of the axon and its covering of myelin, but preservation of the connective tissue framework of the nerve ( the encapsulating tissue, the epineurium and perineurium, are preserved ).[5]

Wallerian degeneration occurs distal to the site of injury.
There are sensory and motor deficits distal to the site of lesion.
There is no nerve conduction distal to the site of injury (3 to 4 days after injury).
EMG shows fibrillation potentials (FP),and positive sharp waves (2 to 3 weeks postinjury).
Axonal regeneration occurs and recovery is possible without surgical treatment. Sometimes surgical intervention because of scar tissue formation is required.

Third-degree (Class II)
Sunderland's third-degree is a nerve fiber interruption. In third-degree injury, there is a lesion of the endoneurium, but the epineurium and perineurium remain intact. Recovery from a third-degree injury is possible, but surgical intervention may be required.

Fourth-degree (Class II)
In fourth-degree injury, only the epineurium remain intact. In this case, surgical repair is required.

Fifth-degree (Class III)
Fifth-degree lesion is a complete transection of the nerve. Recovery is not possible without an appropriate surgical treatment.

19

19. Patients with Hepatitis C are more liable to have all the following EXCEPT:
A. Cryoglobulinemia.
B. Lymphoma.
C. Chronic infection.
D. Hepatoma.

D. Hepatoma

Cryoglobulinemia, B-Cell NHL are both associated with Hep C, and chronic Infection seems like a reasonable.
HCV is associated with HCC, but can't find association to hepatoma

20

20. All are true regarding obtaining consent EXCEPT:
A. Disclosure.
B. Voluntary.
C. Capacity.
D. Autonomy

D. Autonomy

Elements of valid consent: (Toronto notes)
-voluntary
-capacity
-informed

21

21. All the following are acute effects of radiation therapy EXCEPT:
A. Blood vessel sclerosis and stenosis.
B. Hair loss.
C. Desquamation of skin

A. Blood vessel sclerosis

Hair loss and desquamation are acute effects. Vessel sclerosis is late effect

22

22. Cause of increased bleeding in Obstructive jaundice is :
A. Decreased fibrinogen
B. Decreased absorbtion of Vit K
C. Decreased platelet function

B. Decreased absorption of Vit K

Parenteral vitamin K replacement corrects coagulopathy related to biliary obstruction, bacterial overgrowth, or malnutrition. Vitamin K is less effective for coagulopathy caused by severe parenchymal liver injury.

23

23. Most commonly reported side effects of electrocautery is :
A. Cutaneous burns
B. Explosional flame
C. Interference with monitoring devices
D. arrhythmia

A. Cutaneous burns

-1st in the list of s/e in Schwartz

24

24. Effects of NO include all except:
A. Selective vasodilatation of pulmonary circulation with less effect on systemic circulation
B. Decrease reperfusion injury in transplanted lung
C. May have beneficial effect in ARDS
D. Increase Cyclic GMP

B. Decrease reperfussion injury in transplanted lung

-(Schwartz): NO is derived from endothelial surfaces in response to acetylcholine stimulation, hypoxia, endotoxin, cellular injury, or mechanical shear stress from circulating blood. Normal vascular smooth muscle relaxation is maintained by a constant output of NO. NO also can reduce microthrombosis by reducing platelet adhesion and aggregation. NO also mediates protein synthesis in hepatocytes and electron transport in hepatocyte mitochondria. It is a readily diffusible substance with a half-life of a few seconds. NO spontaneously decomposes into nitrate and nitrite. NO is formed from oxidation of L-arginine, a process catalyzed by nitric oxide synthase (NOS). Cofactors of NOS activity include calmodulin, ionized calcium, and reduced nicotinamide adenine di-nucleotide phosphate (NADPH). In addition to the endothelium, NO formation also occurs in neutrophils, monocytes, renal cells, Kupffer cells, and cerebellar neurons.

-(Critical Care): Since Roissant and colleagues published their initial experience using inhaled nitric oxide as a therapy for ARDS, there has been a rapid expansion of interest and literature in this field.273–278 Given via inhalation, NO has several potentially salutary effects in ARDS. It selectively vasodilates pulmonary capillaries and arterioles that subserve ventilated alveoli, diverting blood flow to these alveoli (and away from areas of shunting). The vasodilating effect, signaled by a fall in pulmonary artery pressure and pulmonary vascular resistance, appears maximal at very low concentrations (0.1 ppm) in patients with ARDS.

-(Google): It also diffuses into the vascular smooth muscle cells adjacent to the endothelium where it binds to and activates guanylyl cyclase. This enzyme catalyzes the dephosphorylation of GTP to cGMP, which serves as a second messenger for many important cellular functions, particularly for signalling smooth muscle relaxation.

-(Annals of Phramacotherapy): Five published studies evaluated iNO therapy in patients after lung transplantation. Variable results, including inconsistent findings of improvement in hemodynamic parameters and decreased incidence of rejection, have been reported. A large, well-designed trial showed no benefit of iNO on hemodynamic parameters, mechanical ventilation duration, ICU and hospital length of stay, or mortality.8





25

25. A 65Y old gentleman with BPH and bilateral hydronephrosis, Foley inserted then started to pass 300cc/hr, mechanism of diuresis include all except :
A. Excretion of retained extra fluid
B. Nephrogenic DI
C. Increased ANP
D. Vasodilatation of afferent arteriole and vasoconstriction of efferent venule

Ans: D

The natriuresis is due in part to the excretion of retained urea (osmotic diuresis). The increase in intratubular pressure very likely also contributes to the impairment in net sodium chloride reabsorption, especially in the terminal nephron segments. Source: Harrison.

26

26. Which cell is radio resistance
A. lymphocyte
B. epidemocyte
C. gut enterocyte
D. neuronal cell
E. spermatocyte

D. Neuronal Cell

1- High Radiosensitivity
Lymphoid organs, bone marrow, blood, testes, ovaries, intestines

2- Fairly High Radiosensitivity
Skin and other organs with epithelial cell lining (cornea, oral cavity, esophagus, rectum, bladder, vagina, uterine cervix, ureters)

3- Moderate Radiosensitivity
Optic lens, stomach, growing cartilage, fine vasculature, growing bone

4- Fairly Low Radiosensitivity
Mature cartilage or bones, salivary glands, respiratory organs, kidneys, liver, pancreas, thyroid, adrenal and pituitary glands

5- Low Radiosensitivity
Muscle, brain, spinal cord


Reference: Rubin, P. and Casarett. G. W.: Clinical Radiation Pathology (Philadelphia: W. B. Saunders. 1968).

27

27. In pregnancy all except
A. increase red cell mass
B. hemodilution
C. increase eosoniphils
D. increase plasma protein

C. increased eosinophils

The plasma volume increases by 50% and the red blood cell volume increases only by 20–30%.[13] Consequently, the hematocrit decreases on lab value; this is not a true decrease in hematocrit, however, but rather due to the dilution. The white blood cell count increases and may peak at over 20 mg/mL in stressful conditions. Conversely, there is a decrease in platelet concentration to a minimal normal values of 100-150 mil/mL.

28

28. Most common cause of death in children
A. trauma
B. congenital
C. child abuse

A. Trauma

29

29. What is the most common cause of SVC syndrome?
A. Lymphoma
B. Lung cancer
C. Teratoma
D. Thrombosis from IJ cath

B. Lung CA

30

30. Man waterskiing, run over by his boat resulting in massive chest laceration. Presents to peripheral ER BP 100/60, HR 100. Chest tube inserted, 1200 cc blood returned immediately. Transferred to tertiary care centre, drained 700 cc over the next hour. BP 80/60, HR 130 now. What is the next step?
A. CT chest
B. Insert another chest tube
C. Irrigate, debride and repair chest wound
D. Emergent thoracotomy

D. Emergent Thoracotomy