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Flashcards in 2006_ all reviewed Deck (298):
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

31

31. 36. Man with tibial plateau fracture, ORIF performed. 4 hours post op developed a red, swollen, painful leg. What is the most sensitive sign to his condition?
A. Pain with passive toe extension
B. Absence of pedal pulses

A. Pain with passive toe extension

32

32. Shown an x-ray of an anterior column fracture of the pelvis. What is the source of bleeding from this fracture?
A. Pelvic venous plexus
B. Bleeding bone ends
C. Superior gluteal artery
D. External iliac artery

B. Bleeding Bone ends

-type of acetabular #: Anterior Column Fracture - This fracture extends from the middle of the pubic ramus through to any point exiting the anterior segment of the iliac crest. The iliac oblique view reveals disruption of the iliopectineal line and the weight-bearing dome of the acetabulum. CT scan can be useful in evaluating this fracture.
-if # involves greater sciatic notch the sup gluteal artery can bleed

33

33. 38. Which of the following conditions is MOST frequently associated with duodenal atresia?
A. Trisomy 21
B. Aortic coarctation
C. Colonic atresia

A. Trisomy 21

-Down syndrome occurs in 20–30% of patients with duodenal atresia. Other congenital anomalies that are associated with duodenal atresia include malrotation (20%), esophageal atresia (10–20%), congenital heart disease (10–15%), and anorectal and renal anomalies (5%). (Nelson’s Pediatrics)

34

34. How to decrease hypermetabolic response after intraabdominal surgery
A. preop NSAID
B. PCA
C. epidural
D. periop enteral/parenteral nutrition

C. Epidural

Answer was in the document but I can't find why.

35

35. Most important factor in renal transplant for success
A. ABO compatability
B. Rh comp
C. HLA comp
D. Low level preformed Antibodies
E. Same race

A. ABO compatibility

(( couldn't find a good source - this was in the document already)
- Registry data demonstrate that, even with current immunosuppression regimens, better HLA-matched allografts have better survival. This benefit applies both to living and deceased donor kidneys. The better outcomes are presumably related to fewer immunologic failures. Recent evidence suggests that the benefits of HLA matching are diminishing and are much less pronounced in living donor recipients (although a large survival advantage is still seen in those with two haplotype matches). (MD consult – Brennar’s The Kidney chap65)

36

36. During neck surgery, the IJ is cut, what is the first step to be done:
A. ask anesthesia to decrease the ventilation rate
B. pressure
C. put patient in the trendelenburg position
D. repair with 6-0 nylon

B. Pressure

37

37. Your working with your staff in the OR and he is struggling and you think that he is under the influence of ETOH, what should you do:
A. help him complete the case and talk to him in private later.
B. call another resident to complete the case
C. call the surgeon chief

C. Call the surgeon chief

38

38. Nephrotoxins affect the kidney by:
A. causing deposition of protein casts then lead to afferent arteriole constriction

A.

- In general, nephrotoxins cause renal injury by inducing a varying combination of intrarenal vasoconstriction, direct tubule toxicity, and intratubular obstruction. (MD consult – Brennar’s The Kidney)

39

39. Renal failure + bleeding

(There wasn't a questions)

abnormal plt function

40

40. What is the Indication for thrombolytic therapy in PE ?

Ans: Hypotension/unstable patient

Most clinicians and society guidelines accept that thrombolysis in acute PE with hypotension is likely beneficial and therefore is an accepted indication [1]. Most societal guidelines also suggest catheter-directed thrombolysis as rescue therapy following failed systemic thrombolysis in centers with appropriate expertise [1].

Few trials have evaluated the effects of systemic thrombolytic therapy in hemodynamically unstable patients, but those that did found a consistent trend toward improved mortality [2-6]. A meta-analysis that included those trials did a subgroup analysis of 154 patients with massive PE and found that systemic thrombolytic therapy decreased the composite endpoint of death and recurrent thromboembolism (9.4 versus 19 percent, odds ratio 0.45, 95% CI 0.22-0.92)

41

41. Hyperacute rejection :
A. IgG mediated
B. IgM mediated
C. B cell mediated
D. T cell mediated

Ans: A

Hyperacute rejection occurs usually within the first 24 hours after transplantation. This response occurs so quickly that the tissue never becomes vascularized. It is characterized by thrombotic occlusions and hemorrhage of the graft vasculature that begins minutes to hours after the graft is placed. Hyperacute rejection is caused by preexisting host antibodies that bind to antigens present in the graft endothelium. Antigen recognition activates the complement system. There is also an influx of neutrophils.The resulting inflammation prevents vascularization of the graft. The graft then suffers irreversible damage from ischemia.

- Both IgM and IgG alloantibodies can be detected in the serum and in the allografts (of animals and humans) that are being rejected. Preformed anti-HLA class I antibodies, and occasionally, antiendothelial antibodies, play an important role in hyperacute rejection and accelerated vascular rejection observed in previously sensitized transplant recipients. (MD consult – Brenner’s The Kidney_

42

42. Appropriate Abx for treatment of G-ve, G+ve, aerobic and anaerobic infections:
A. Pen
B. Ceftriaxone
C. Clinda and Flagyl
D. Vanco and Flagyl

B. Ceftriaxone (3rd Gen cephalosporin)

The answer listed was B and Heather (Pharmacist - confirmed that this would likely be the best answer). However, we discussed it, and none are perfect options. Here's some info I found:

Like other third-generation cephalosporins, it has broad-spectrum activity against Gram-positive bacteria and expanded Gram-negative coverage compared to second-generation agents.

-Penicillin: covers gram +ve and clostridium and Actinomyces, and anaerobic Streptococcus species

-Ceftriaxone: coverage (proteus, E coli, klebsiella, H flu, moraxella) but does not cover pseudomonas.

-Clinda + flagyl: Clindamycin is used primarily to treat anaerobic infections caused by susceptible anaerobic bacteria. It also covers Aerobic Gram-positive cocci, including some members of the Staphylococcus and Streptococcus (e.g. pneumococcus) genera, but not enterococci. It however does not cover gram negative aerobic bacteria (pseudomonas).
Flagyl covers Gram-negative and Gram-positive anaerobic bacteria

-vanco and flagyl: Vanco covers Gram-positive bacteria

43

43. All of the following influence the risk of transmission of HIV except:
A. hollow vs solid needle
B. depth of the needle stick
C. degree of contamination
D. strain of virus

D. strain of virus

FACTORS CONTRIBUTING TO THE RISK FOR OCCUPATIONAL HIV INFECTION
Exposure factors
1. Route of exposure (e.g. percutaneous, * mucous membrane, cutaneous)
MD Consult
2. Inoculum size
• Size of the device producing injury
• For needlestick exposures, type of needle (i.e. hollow-bore * vs solid)
• Extent of contamination (e.g. visible blood on device, † whether or not device had been placed in an artery or vein †)
• 'Depth/severity' of exposure * †
• Type of contamination (e.g. blood, * pleural fluid, etc.)
Source/'donor' factors
1. Extent of viremia (e.g. by polymerase chain reaction or branch-chain DNA assay)
2. Stage of illness (as a presumed surrogate for extent of viremia † )
3. Circulating free (as opposed to cell-associated) virus
4. Antiretroviral chemotherapy (presumably reducing level of viremia)

44

44. When a test detects what it is intended to detect, this is called:
A. sensitivity
B. specificity
C. validity
D. positive predictive value

C. Validity

The validity of a measurement tool (for example, a test in education) is considered to be the degree to which the tool measures what it claims to measure; in this case, the validity is an equivalent to accuracy.

45

45. Most common site for ganglion in the hand is:
A. flexor surface of the wrist.
B. extensor surface of the DIP
C. radial side of the extensor surface of the wrist

C. Radial Side of the Extensor surface of the wrist

-The most frequent site of origin is the dorsal scapholunate ligament. Ganglions frequently are palpable between the second and fourth extensor tendon compartments. The second most frequent site is volar just radial to the flexor carpi radialis tendon. Ganglions on the dorsum of the wrist usually are firm, smooth, fluctuant, and round. Ganglions extending proximally along the extensor tendons are likely to be less firm, multilocular, and irregular, but still contain the slightly yellow, gelatinous, stringy fluid common to all ganglions. The most common site in a flex or tendon is at the level of the metacarpophalangeal joint flexor skin crease(Campbell’s Orthopedics).

46

46. Pt. with a history of fall while climbing, prolonged time to transfer. She has peri-orbital and post auricular bruising. What # is she most likely to have:
A. basal skull #
B. leforte I
C. leforte II

Ans: A

-racoon eyes and battle sign = basal skull #

47

47. America College of…experts meet in their annual meeting and at the end reach a consensus and publish guidelines for managing a certain disease. What level of evidence would that be:
A. level I
B. level II
C. level III
D. level IV

D. IV

Based on the following explanation, I think it's actually level V, but that isn't an option

1a: Systematic reviews (with homogeneity) of randomized controlled trials
1b: Individual randomized controlled trials (with narrow confidence interval)
1c: All or none randomized controlled trials
2a: Systematic reviews (with homogeneity) of cohort studies
2b: Individual cohort study or low quality randomized controlled trials (e.g.

48

48. Which of the following markers is most specific for the matched cancer:
A. PSA  prostate
B. BHG  choriocarcinoma)
C. CA 19-9  pancreatic Ca

B. BHCG

-All choriocarcinomas produce beta HCG.!! CA 19-9 is detected with an immunoassay, and the upper limit of normal for a healthy adult is 37 U/mL. Sensitivities of CA 19-9 in the diagnosis of pancreatic cancer range from 67% to 92%, with specificities ranging from 68% to 92%. The utility of CA 19-9 as a diagnostic marker is limited in a number of ways. First, patients with negative Lewis-A blood group antigen cannot synthesize CA 19-9, and therefore it is not used as a serologic marker in these individuals, who make up about 10% of the population. Second, patients with benign biliary tract disease can have levels up to 400 U/mL, with 87% having concentrations higher than 70 U/mL. Significant numbers of patients with pancreatitis, either acute or chronic, also have elevated levels. Third, besides pancreatic cancer, CA 19-9 levels are also elevated in patients with other cancers, including those of the biliary tree (95%), stomach (5%), colon (15%), liver (HCC, 7%) and lung (13%). For colorectal cancer, CA 19-9 levels add little clinically useful information to determination of CEA levels. (Sabiston)

49

49. Which of the following sutures with be the last to degrade :
A. POLYGLYCOLIC (DEXON)
B. POLYGLACTIC (VICRYL)
C. POLYDIAXONE (PDS, BIOSIN)

Ans: C. recall that PDS is technically an abosorbable suture. Even though it lasts quite long and can be used in presence of infection.
-polyglycolic (Dexon) 60-90days
-polyglactic (Vicryl) 60-90days
-polydiaxone (PDS) 180days

50

50. 1 L of RL would increase the plasma volume by:
A. 1 L
B. 500 ml
C. 250 ml
D. 100 ml

C. 250ml

RL is considered equivalent to NS for water distribution. In these solutions, there is no free water for distribution across the whole TBW. Usually free water will spread equally across the ECF (1/3 of TBW) and ICF (2/3). With RL and NS, all goes to the ECF and then spreads according to 1/3 (or 1/4 I've seen both written) to the intravascular space, and 2/3 (or /4) to the extravascular space.

So using 1/4 to the intravascular space, we Multiply 1000cc x 1/4 = 250cc to the intravascular space

51

51. What is the chemical substance in snake venom that permits it to spread via lymphatics:
A. hirudin
B. papain
C. hylarudinase

Ans: C

Most venoms contain hyaluronidase, which enhances the rapid spread of venom by way of the superficial lymphatics. (Schwartz).

Hirudin is found in leeches that helps prevent continued venous congestion.

Papain (papaya proteinase I) is an enzyme in papayas

52

52. What is the half life of factor VIII in FFP?
A. 3-6 hours
B. 8-12 hours
C. 1-2 days
D. 4-7 days

Ans: B

Factor VIII has a half-life of 8 to 12 hours (Hoffman: Hematology)
Factor 8, so 8 hours

53

53. 59 year old diabetic women with claudication. Angiogram reveals atherosclerosis of the superior femoral artery. According to Poiseuille’s law, an artery with a 4 cm segment of 80% atherosclerotic narrowing would have a decrease in blood flow:
A. directly proportional to the radius and inversely proportional to the length
B. indirectly proportional to the radius to the fourth and directly proportional to the length
C. indirectly proportional to the radius and directly proportional to the length
D. directly proportional to the radius to the fourth and directly proportional to the length

Ans: B (previously "D if Length said indirectly, no good answer")

-Poiseuille’s law: The volume of a homogeneous fluid passing per unit of time through a tube is directly proportional to the pressure difference between its ends and to the fourth power of its internal radius, and is inversely proportional to its length and to the viscosity of the fluid.

They are asking about the DECREASE in blood flow so the decrease is greater if the length is greater (directly), and the radius is less (indirectly)

54

54. If you were planning a clinical trial to test the efficacy and the morbidity of a new drug compared to the standard chemotherapeutic agent, what type of clinical trial would that be?
A. Phase I trial
B. Phase II trial
C. Phase III trial
D. Cohort study

Ans: C
-Phase 0 is a recent designation for exploratory, first-in-human trials.
-Phase I trials are the first stage of testing in human subjects. Normally, a small (20-80) group of healthy volunteers will be selected. This phase includes trials designed to assess the safety, tolerability, pharmacokinetics, and pharmacodynamics of a drug.
-Phase II trials are performed on larger groups (20-300) and are designed to assess how well the drug works, as well as to continue Phase I safety assessments in a larger group of volunteers and patients.
-Phase III studies are randomized controlled multicenter trials on large patient groups (300–3,000 or more depending upon the disease/medical condition studied) and are aimed at being the definitive assessment of how effective the drug is, in comparison with current 'gold standard' treatment
-Phase IV trial is also known as Post Marketing Surveillance Trial. Phase IV trials involve the safety surveillance and ongoing technical support of a drug after it receives permission to be sold.

55

55. In an otherwise healthy looking 3 week old infant who has been vomiting for the last 24 hours and has a palpable “olive” on abdominal exam, you would expect the electrolyte profile to look like:
A. Na 132, Cl 78, K 3.2, HCO3 28
B. Na 145, Cl 99, K 3.6, HCO3 24
C. Na 154, Cl 101, K 4.5, HCO3 20
D. Na 128, Cl 79, K 2.9, HCO3 30

Ans: D
-The classic physiologic derangement seen with HPS is hyponatremic, hypochloremic, hypokalemic met alkalosis. Early, the loss of gastric secretions from vomiting leads to dehydration and aldosterone-stimulated potassium excretion in the urine in an attempt to conserve sodium. As potassium depletion worsens, hydrogen ion is exchanged for sodium across the renal tubule, resulting in the “paradoxical aciduria” characteristic of pts with dehydration and met alkalosis from protracted vomiting. (Google books – Mastery of surgery)

56

56. The mechanism of action of Warfarin is:
A. Interferes with thrombin and thus the fibrinogen to fibrin conversion
B. Interferes with the absorption of Vitamin K
C. Decreases formation of factors II, V, VII, IX
D. Decreases formation of factors II, VII, IX, X

Ans: D
-inhibits vit K-dependent coagulation factor synthesis (II, VII, IX, X, proteins C and S)

1972 Canada vs. Soviet union

57

57. A 23 year old male is stabbed in the neck and sustains a carotid artery injury. He has been in a coma for two hours. What is the best intervention to prevent permanent sequelae?
A. carotid artery
B. Repair carotid artery
C. Observe
D. Heparinize

Ans: C vs. B. No clear answer from sources

According to MORRELL notes, guy in a coma, you observe. No ligation, no repair.
-The need to reconstruct the carotid artery of a patient with a clear preoperative hemispheric neurologic deficit has long been a subject of controversy. Current evidence supports revascularization regardless of the patient's neurologic status, accepting that prognosis is poor in the presence of a profound neurologic deficit (i.e., coma) with or without revascularization. (Sabiston)
-While it would seem obvious that all penetrating carotid injuries should be repaired, this may not be the case. During the 1960s surgeons attempted to revascularize patients who suffered acute strokes due to atherosclerotic carotid artery disease. It quickly became apparent that these patients fared worse than those who were treated nonoperatively. This unfortunate outcome was believed to be due to the conversion of an ischemic infarct to a hemorrhagic infarct that was associated with a higher mortality rate. The same phenomenon is believed by some to occur in patients with carotid injuries. In fact, subsequent studies have rarely identified this complication. This has led to a more aggressive approach of repairing all penetrating carotid injuries regardless of the patient's neurologic status, or repairing all except those in comatose patients. (Schwartz)

When the patient is truly comatose with a Glasgow Coma Scale score

58

58. Low molecular weight heparin
A. should be stopped 24 hours prior to surgery
B. should be stopped 12 hours prior to surgery
C. increases risk of epidural hematoma following epidural
D. should be monitored by increase PTT level
E. B + C

Ans: A
-stop heparin 12 hours before for bid dosing
-stop heparin 24 hours before for daily dosing

10-40% renal clearance

LMW heparin – We discontinue LMW heparin 24 hours before the planned surgery or procedure, based on a biologic half-life of most subcutaneous LMW heparins of approximately three to five hours [7,59,63]. If a twice-daily LMW heparin regimen is given, the evening dose the night before surgery is omitted, whereas if a once-daily regimen is given (eg, dalteparin 200 international units/kg), one-half of the total daily dose is given on the morning of the day before surgery. This ensures that no significant residual anticoagulant will be present at the time of surgery, based on studies that have shown a residual anticoagulant effect at 24 hours after stopping therapeutic-dose LMW heparin, and it is consistent with the 2012 ACCP Guidelines [7,11,64,65]. (uptodate)

59

59. 45 year old man sustains a laceration to his forearm while using a lawnmower. His tetanus status is uncertain. Do you administer:
A. tetanus vaccine only
B. tetanus immunoglobulins only
C. tetanus toxoid and immunoglobulins
D. inject immunoglobulins into the would directly

Ans: C

Clean and minor wound:
• Tetanus vaccine if =3 doses but last dose >=10 years ago
• No immune globulin

Other wounds (like this one):
• Tetanus vaccine if =3 doses but last dose >=10 years ago
• Immune globulin if =3 doses in lifetime)
Uptodate

60

60. 78 year old woman with breast cancer presents with hypercalemia, normal lytes and BUN. What is your treatment:
A. NS infusion followed by lasix
B. Bisphosphonates
C. Calcitonin
D. Radiation treatment for bony mets

answer A

Basically hydrate with NS + diurese is first line. Add calcitonin + bisphosphonates for severe hypercalcemia

□ intravenous isotonic saline should be given to expand ECF, increase urine flow, enhance calcium excretion, and reduce the serum level
□ Furosemide and intravenous sodium sulfate are other methods of increasing renal calcium excretion
□ Plicamycin is particularly useful for hypercalcemia associated with metastatic cancer
□ Adrenal corticosteroids are useful for hypercalcemia associated with sarcoidosis, vitamin D intoxication, and Addison's disease
□ Calcitonin is indicated in patients with impaired renal and cardiovascular function. When renal failure is present, hemodialysis may be required.

SALINE HYDRATION — Initial therapy of severe hypercalcemia includes the simultaneous administration of saline, calcitonin, and a bisphosphonate (see 'Severe hypercalcemia' above). Isotonic saline corrects possible volume depletion due to hypercalcemia-induced urinary salt wasting and, in some cases, vomiting. Hypovolemia exacerbates hypercalcemia by impairing the renal clearance of calcium (table 1) (uptodate)

61

61. 56 year old woman with recurrence of breast cancer in a radiated bed. Your treatment of choice is:
A. tissue expander
B. free flap
C. STSG
D. Local flap

Answer D?

62

62. Which is most important factor for early success of live donor kidney transplant
A. cold ischemic time
B. warm ischemic time
C. pre harvest urine output

Answer C.
This questions basically is to see if you know that ischemia time is not the most important factor - more important to have the suitable donor kidney for the suitable patient

"Best predictor of LRD - living related donor- kidney function: donor kidney u/o just prior to nephrectomy."

When organ allocation is based upon HLA typing, one concern is the effect of cold ischemia time upon long-term survival. The beneficial effect of HLA matching appears to generally outweigh the detrimental effect of prolonging the cold ischemia time in transported kidneys. The current registry data indicate that the five-year graft survival of six-antigen-matched cadaver kidneys is the same regardless of whether the kidneys undergo 3 or 36 hours of cold ischemia. A stepwise reduction of 1 to 2 percent in survival has been observed in association with incremental 12-hour increases in cold ischemia time.

63

63. 40 yo female patient history of low dose radiation for acne as a teen presents with left thyroid mass
A. open biopsy
B. total thyroidectomy
C. left hemithyroidectomy

□ Answer B. Most authors agree that patients with high-risk tumors (judged by any of the classification systems discussed above) or bilateral tumors should undergo total or near-total thyroidectomy. Uptodate: We recommend total thyroidectomy for most patients with thyroid cancer.
□ The only instance I could find with an indication for a hemithyroidectomy with a cancer is if the surgeon is inexperienced and wants to avoid bilateral nerve damage…

64

64. Skin graft warm boggy pricked blue blood
A. leeches
B. surgical exploration with re-anastamosis
C. heparin
D. observe
E. answer a

□ Answer: A. Leeches to decrease venous congestion
Another common question about leeches is that they secrete hirudin (anticoagulant)

65

65. Most common cause of primary hyperaldosteronism
A. solitary adenoma
B. unilateral adrenal hyperplasia
C. bilateral adrenal hyperplasia
D. pituitary CA

Answer a
□ Primary hyperaldosteronism results from autonomous aldosterone secretion, which, in turn, leads to suppression of renin secretion.
□ ages of 30 and 50 years, accounts for 1% of cases of hypertension
□ Primary hyperaldosteronism is usually associated with hypokalemia; however, more patients with Conn's syndrome are being diagnosed with normal potassium levels.
□ Most cases result from a solitary functioning adrenal adenoma (approximately 70%) and idiopathic bilateral hyperplasia (30%).
□ Secondary: stimulation of the renin–angiotensin system from renal artery stenosis and low-flow states (CHF, cirrhosis)

66

66. Postop colectomy. massive MI in cardiogenic shock with hypotension
A. decrease preload, afterload and add inotropes
B. IABP
C. angioplasty
D. maximize oxygenation

Answer: C
□ ABC (judicious volume, inotropes)
□ Patients whose cardiac dysfunction is refractory to cardiotonics may require mechanical circulatory support with an intra-aortic balloon pump (IABP). 9-22% survival at 1 year is used in isolation
□ thrombolytic therapy reduces mortality in patients with acute myocardial infarction, its role in cardiogenic shock is less clear.
□ Current guidelines of the American Heart Association recommend percutaneous transluminal coronary angiography for patients with cardiogenic shock, ST elevation, left bundle-branch block, and age less than 75 years. Early definition of coronary anatomy and revascularization is the pivotal step in treatment of patients with cardiogenic shock from acute MI.When feasible, PTCA (generally with stent placement) is the treatment of choice.

67

67. TPN in renal failure should have calorie: nitrogen ratio
A. 80:1
B. 150:1
C. 200:1
D. 300:1

Answer A. Usual ratio of nonprotein energy to grams of nitrogen: 125:1. Renal failure (serum creatinine greater than 2 mg/dL) who cannot be dialyzed: low-nitrogen TPN. Renal failure who can undergo dialysis may receive the standard or high-nitrogen TPN formulations, with special attention directed toward minimizing potassium and phosphate intake

68

68. ORIF. bone then heals by
A. primary
B. secondary
C. tertiary
D. callus

□ Answer A. primary bone healing occurs without callus formation. Direct attempt by the cortex to re-establish itself after interruption. Need anatomic restoration of the fracture fragments (rigid internal fixation) and stability of fracture reduction

69

69. MVA. T7 vertebra exploded – paraplegic. numerous litres of volume infused, still hypotensive. abd US no hemoperitoneum. closed pelvis fracture. likely cause of hypotension?
A. undiagnosed abd injury
B. head injury
C. neurogenic shock

□ Answer C: decr perfusion d/t loss of vasomotor tone to peripheral arterial beds. loss of VC impulses: increased vascular capacitance, decreased venous return, and decreased cardiac output. usually spinal cord injuries from vertebral body fractures of the cervical or high thoracic region that disrupt sympathetic regulation of peripheral vascular tone. bradycardia, hypotension, cardiac dysrhythmias, reduced cardiac output, and decreased peripheral vascular resistance

70

70. Internal jugular vein lacerated during case. optimal next step:
A. suture with 4-0 vicryl
B. trendelenburg positioning
C. ask anesthesia to decrease RR

B.
Makes sense, decrease your JVP and therefore quantity of bleeding

71

71. Diarrhea gives you what metabolic defect
A. metabolic alkalosis
B. metabolic acidosis, non AG
C. metabolic acidosis, AG

□ Answer B
Also hyperchloremic (normal physiological response) to balance anions since there is a decrease in plasma bicarb
Anion gap = = ([Na+] + [K+]) − ([Cl-] + [HCO3−]) therefore need to increase chloride to keep non AG true

72

72. Which suture will you use to close after debriding an infected wound
A. pds
B. vicryl
C. silk
D. some other multifilament

□ Answer a: Absorbable monofilament
polydiaxanone

73

73. What drug don’t you use post cardiac transplant
A. azathioprine
B. fk-506 (tacrolimus)
C. mmf
D. cyclosporine

□ Answer A (previous answer here was B).

previous exams: don’t use methotrexate

Most modern immunosuppressive regimens consist of a two- or three-drug regimen, including a calcineurin-inhibitor (either cyclosporine or tacrolimus), an antimetabolite agent (typically mycophenolate mofetil), and tapering doses of corticosteroids over the first year.

MMF (mycophenolate mofetil) has replaced azathioprine as preferred antimetabolite agent - some trial showed that the ones treated with MMF had lower mortality and rejection at 1 year

Although tacrolimus and cyclosporine are both highly effective agents, evidence from clinical trials suggests that tacrolimus-based immunosuppression may offer an advantage over cyclosporine-based regimens with respect to decreased rates of acute rejection and an overall more favorable metabolic derangement profile (decreased incidence of hypertension and hyperlipidemia but higher incidence of post-transplant diabetes).

74

74. late cardiac transplant failure presents as
A. proximal discrete coronary lesions
B. chf +/- arrythmia

□ Chronic rejection in the cardiac allograft typically manifests as aggressive and premature coronary artery disease
o develops months to years after the procedure
o transplant-associated coronary artery disease is generally more diffuse, involving all the vessels of the heart including the arteries, veins, and great vessels

75

75. Side effects of vincristine all except:
A. ileus
B. thrombocytopenia
C. leukopenia

□ Answer: all of these are side effects of vincristine

76

76. 2 months postop cemented THR. Pus aspirated.
A. observe, await cultures
B. 6 weeks IV abx then 6 weeks PO abs
C. operative removal of all THR components
D. operative thorough debridement then 6 weeks IV abx

□ Answer C

77

77. worst prognosis of breast lesions:
A. ductal metaplasia
B. papillary metaplasia
C. ductal metaplasia with atypical cells

□ Answer C

78

78. most common breast lesion
A. fibrocystic change
B. DCIS
C. fibroadenoma
D. Paget’s disease

□ Answer A
□ After fibrocystic changes, fibroadenoma is most common benign breast lesion

79

79. Most sensitive CXR sign of aortic tear:
A. apical cap
B. sail sign
C. wide mediastinum
D. deep sulcus sign
E. loss of paraspinal shadow

□ Answer C

80

80. cerebral autoregulation attempts to maintain cerebral perfusion pressure of
A. 30 mmHg
B. 70 mmHg
C. 30 cm h2o
D. 70 cm H2O

answer b (see Q253 2007): CPP is equal to the mean arterial pressure (MAP) minus the ICP, and 60 mm Hg is the lowest acceptable pressure

81

81. 63 y o female non-insulin diabetic with coronary disease and an MI 18 months ago. ASA score:
A. 2
B. 3
C. 4
D. 5

□ answer B ASA 3

ASA grade Description Examples
1 A healthy, fit patient
Ex: Caleb
2 A pats with mild systemic disease
Ex: Controlled DM2, Controlled essential HTN, Obesity, Smoker.
3 Pt. with severe systemic disease that limits activity
Ex: Angina, Prior MI, COPD, uncontrolled DM, obesity
4 Pt. with incapacitiating disease that is a constant threat to life
Ex: CHF, Renal Failure, ARF
5 A moribund pt. not expected to survive 24 hr. with/wihtout surgery
Ex: Ruptured AAA, Head trauma (high ICP)

82

82. Patient with a smoking history. What is their ASA score?
A. 1
B. 2
C. 3
D. B

□ answer B ASA 2

83

83. Lacerated the dura during a routine back dissection, sewed it up fine, no apparent CSF leak. do you
A. not tell patient / family
B. tell them about need to watch for CSF leak but don’t explain why
C. tell them about complication, need to watch for CSF, possibility for reoperation
D. tell only hospital risk assessment team

C

84

84. re epithelialization
A. only occurs from wound edges
B. bacteria and foreign bodies inhibit it

□ answers A and B are true
□ Mitoses appear in epithelium a few cells away from the wound edge. The new cells migrate over the cells at the edge and into the unhealed area and anchor to the first unepithelialized place that they encounter

85

85. Concerning oxygen in septic shock
A. increased delivery increased uptake
B. decreased delivery decreased uptake
C. increased delivery decreased uptake
D. decreased delivery increased uptake

□ answer C

86

86. C.diff treatment, first choice
A. po vanco
B. po flagyl
C. iv vanco
D. iv flagyl

□ answer B
First-line therapy for mild to moderate CDI : PO flagyl
Severe: vancomycin PO 10-14 days
Critically ill: PO vanco + IV flagyl

uptodate

87

87. Resistant c. diff treatment, all EXCEPT:
A. po vanco
B. po flagyl
C. iv vanco
D. iv flagyl

□ answer C
Intravenous vancomycin has no effect on C. difficile colitis since the antibiotic is not excreted appreciably into the colon

88

88. what colour is fat on MRI
A. dark on T1 and T2
B. light on T1 and T2
C. dark T1 light T2
D. light T1 dark T2

□ answer D
□ T1: realignment of nuclear spins with magnetic field T1-weighted images show fluid black, fat white; contrast improvement with gadolinium-enhancement (ie, vascularity) and fat suppression: abdominal MRI.
□ T2: dephasing of nuclear spins with transverse field T2-weighted images show fluid white, fat dark; pelvic MRI.

89

89. Treatment A reduces death from 26% to 16%. Calculate the NNT.
A. 1
B. 10
C. 100
D. 1000

answer B
□ NNT = 1/ARR
□ ARR = |CER - EER| CER = control group event rate EER = experimental group event rate
□ ARR=.26-.16=.1 NNT=1/0.1=10

10% absolute risk reduction
1/10% = 10 NNT

90

90. MVA. Forearm laceration bled profusely requiring 2 u transfusion but stopped with pressure in ER. What is an appropriate strategy for DVT prophylaxis?
A. Wait 48 hours
B. SC UFH
C. IV UFH via PTT adjusted nomogram
D. SCD

Answer D vs A

Logically it would depend on the patient's activity level (comatose in ICU vs. walking around)

91

91. Which cranial nerve is injured most?
A. II
B. III
C. V
D. VII

D


Depends on what the mechanism is... but I found this:
CN I most affected.

Cranial nerve injury after minor head trauma:
Posttraumatic single nerve palsy was observed in 38 patients (77.6%), and multiple nerve injuries were observed in 11 (22.4%). Cranial nerves were affected in 62 cases. The most affected CN was the olfactory nerve (CN I), followed by the facial nerve (CN VII) and the oculomotor nerves (CNs III, IV, and VI).

92

92. Pt sustains 50% BSA burn. What fluid?
A. RL
B. 5% albumin
C. D5/0.45
D. D5W

□ Answer A

Parkland formula: 4ml per kg body weight X %Total body surface area in 24h, with half in first 8h and other half in the next 16h

□ Most patients can be resuscitated with crystalloid, specifically lactated Ringer's solution. NS should be avoided, as the volumes required for resuscitation invariably lead to a complicating hyperchloremic metabolic acidosis.

93

93. Which of the following contraindicates flexion / extension views of C spine post MVA?
A. Previous C3-4 fusion
B. Pain on palpation of spinous process
C. documented unstable injuries

Answer: C
Flexion/extension views are absolutely contraindicated in documented unstable injuries

94

94. Pt has documented real allergy to Lidocaine. What do you use?
A. bupivicaine
B. procaine
C. mepivicaine

□ Answer B (ester)
□ true allergy to amides (eg, lidocaine, bupivacaine) is exceedingly rare

95

95. Post motorcycle accident, pt found to have open book pelvis fracture. After bedsheet fixation he remains hypotensive despite aggressive resuscitation. Next step
A. Re-apply pelvis fixation
B. laparotomy
C. angio for coil embolization

Answer: B??

Preperitoneal packing + ex-fix. Angio if CTA shows active arterial bleed

Previous answer C.

Uptodate:
Hemodynamic instability likely due to retroperitoneal bleeding from the pelvic fracture, we suggest operative control of hemorrhage using external fracture fixation plus preperitoneal pelvic packing to tamponade bleeding, rather than external pelvic fracture fixation plus arteriography and angioembolization (Grade 2C).

The majority of severe bleeding due to pelvic fractures is venous in origin and only a small percentage of patients will have a bleeding site that is amenable to embolization. Fracture fixation decreases pelvic volume, promotes tamponade of venous bleeding, and prevents shifting of the bony elements limiting secondary hemorrhage. Preperitoneal pelvic packing involves the placement of laparotomy sponges into the preperitoneal space via an incision, which reduces the available volume of the retroperitoneal space and tamponades pelvic bleeding.

96

96. Which is true about neonate pharmacokinetics as compared with adults
A. decreased hepatic metabolism
B. increased GFR
C. increased fat distribution

answer A

relative immaturity of neonatal hepatic function prolongs the duration of action for drugs that depend primarily on hepatic metabolism

97

97. On post operative day 3, wound strength that has been closed by primary closure is determined primarily by:
A. fibroblasts
B. collagen
C. re-epithelialization from wound surface edges
D. sutures

answer D

• In first 3 weeks, wound strength and collagen content correlate.
• After 21 days, strength increase with no increase in collagen content, reflecting scar remodelling.
• Collagen turnover causes hydroxy-proline spillage in urine.

98

98. Diabetic foot ulcers display inferior wound healing due to:
A. diminished microcirculation
B. Collagen type I to III ratio alteration
C. balance of macrophages to other cell types in ECM
D. altered cell membrane transport due to glycosylation

A

Peripheral artery disease in combination with diabetic neuropathy contributes to higher rates of non-healing ulcers and limb loss in diabetic patients compared with those without diabetes

99

99. Elderly African-American lady presents with a new, persisting dark streak in the nail bed. You suspect melanoma. The most likely diagnosis is:
A. lentigo maligna
B. acrolentigious melanoma
C. superficial spreading melanoma
D. nodular melanoma.

Answer B

superficial spreading: most common, flat, anywhere on the skin except the hands and feet, long radial growth phase before vertical growth begins

nodular: darker and raised, lack of radial growth peripheral to the area of vertical growth

lentigo maligna: mostly on the neck, the face, and the back of the hands of elderly people

Acral lentiginous
o least-common subtype, 2 to 8% of melanoma in whites
o palms and soles and in the subungual regions
o acral lentiginous type accounts for 29 to 72% of all melanomas in dark-skinned people (Bob Marley)
o subungual lesions appear as blue-black discolorations of the posterior nail fold and are most common on the great toe or thumb. The additional presence of pigmentation in the proximal or lateral nail folds (Hutchinson's sign) is diagnostic of subungual melanoma

100

100. Middle aged male patient presents with parathyroid adenoma. The most likely findings in the serum are:
A. increased PO4
B. decreased Ca2+
C. decreased PO4
D. increased Ca2+

answer D
The most common clinical presentation of primary hyperparathyroidism (PHPT) is asymptomatic hypercalcemia.

□ elevated serum calcium and intact PTH (iPTH) establishes the diagnosis of PHPT with virtual certainty
□ 50%: decreased serum phosphate
□ 60%: elevated 24-hour urinary calcium concentrations
□ 80%: mild hyperchloremic metabolic acidosis, w an elevated chloride:phosphate ratio (>33)

101

251.
All of the following are indications for laparotomy in a trauma patient, EXCEPT:
A. Intra-peritoneal bladder rupture
B. Fractured kidney
C. Ruptured diaphragm
D. Penetrating abdominal gunshot injury

Answer: B.
The only absolute indication for surgical renal exploration is a patient with external trauma and persistent renal bleeding. Signs of continued renal bleeding are a pulsatile, expanding, or uncontained retroperitoneal hematoma. Another sign is avulsion of the main renal artery or vein as noted by CT or arteriography.
emedicine-Renal Trauma

102

252.
Patient involved in ski accident, with displaced tibial plateau injury. That evening, patient develops severe pain in leg, not relieved with elevation or analgesics. The most sensitive clinical finding to diagnose the patient’s problem is:
A. Pulselessness
B. Paresthesia
C. Pain on passive dorsiflexion of toe


Answer: C.

103

253.
In attempting to practice medicine that pays attention to minimizing economic burden/appropriate resource use, you should do all of the following, EXCEPT:
A. Avoid inappropriate tests
B. If choice exists, use less costly materials
C. Give your patients advantages
D. Treat patients on first-come first-serve basis

Answer: C.

implies lack of justice

104

254. The most important investigation of a solitary thyroid nodule is:
A. CT scan
B. Ultrasound
C. FNA

C. FNA
Fine-needle aspiration biopsy

FNAB has emerged as the most important step in the diagnostic evaluation of thyroid nodules.[11] Data from numerous studies have established FNAB as highly accurate, with mean sensitivity higher than 80% and mean specificity higher than 90%. The accuracy of FNAB in diagnosing thyroid conditions highly depends on the cytopathologist's expertise and experience and the technical skill of the physician performing the biopsy. In addition, FNAB is highly cost-effective compared with traditional workups that heavily depended on nuclear imaging and ultrasonography. Routine use of FNAB in the evaluation of thyroid nodules can reduce the need for diagnostic thyroidectomy by 20-50% while increasing the yield of cancer diagnoses in thyroid specimens by 15-45%.
emedicine- Thyroid Nodule

105

255. In severe injury to lower leg, which of the following play a role in decision to salvage limb vs. amputation:
A. Presence of vascular injury
B. Severe underlying fractures, with missing bone
C. Intact posterior tibial nerve
D. Large soft tissue defect

C. Intact posterior tibial nerve.
I think this answer is old (1996). Now something called Mangled Extremity Salvage Score
but as per test answer:
Answer: C. Absolute indications to amputate primarily. 1. Tibial nerve transection. 2. Crush injury with warm ischemia time >6 hrs. The most important decision is can the remaining limb be somewhat functional – without nerve function it is not. Posterior tibial nerve innervates the plantar aspect of the foot and is a major determinant in salvaging a limb.

106


256. Regarding nephrotoxicity with IV contrast, which is TRUE:
A. Hyperosmolarity of contrast does not play a role
b. Pre-scan hydration status does not matter
c. Direct toxic effect to renal cells
d. Reduced cortical flow, causing medullary ischemia

c. Direct toxic effect to renal cells
Risk factors: 1. Diabetes; 2. Age >75; 3. Pre-procedural volume depletion; 4. Heart failure; 5. Cirrhosis; 6. NSAIDs. Pathogenesis: direct toxic injury to renal tubule cells and ischemic injury mediated by ROS. The osmolarity of the contrast medium DOES play a role.
Source: NEJM. Prevention of Contrast induced nephropathy. 2006.

107

257. OR with greatest risk of DVT
a. Hip replacement
b. Vein stripping
c. APR
d. C-section

Answer: A. hip replacement. Orthopaedic surgery on hip and knee replacement have the highest risk of DVT.
Go ortho!

108

258. Authorship on a paper could be acceptable to all of the following, EXCEPT:
a. Person who did majority of research/work
b. Person who did major revisions
c. Person who approved final version for publication
d. Person who lent their lab space for experiments to be carried out in

d. Person who lent their lab space for experiments to be carried out in

109

259. Which of the following is appropriate when providing nutritional support to a patient in renal failure?
a.Increased TFI
b. High fat to calorie ratio
c. Increase calorie to nitrogen ratio

c. Increase calorie to nitrogen ratio
Just think that too much protein is hard on the kidneys.
Ivan take note.

110

260. Which of the following contraindicates flexion / extension views of C spine post MVA?
a. previous C3-4 fusion
b. pain on palpation of spinous process

Answer: B.

111

261. Person has difficulty chewing, vision problems, lower extremity weakness and a 7cm mass in the anterior thorax. What is the test that will definitively tell you the diagnosis:
a) alpha-fetoprotein
b) tensilon test
c) CT scan
d) muscle biopsy

Answer: B. Patient has a thymoma and associated Myasthenia Gravis. Tensilon test is diagnostic.
Edrophonium (by the so-called Tensilon test) is used to differentiate myasthenia gravis from cholinergic crisis and Lambert-Eaton myasthenic syndrome. In myasthenia gravis, the body produces autoantibodies which block, inhibit or destroy nicotinic acetylcholine receptors in the neuromuscular junction.
wiki

112

262. Why hypertrophic scar - which of the following works to decrease the effects EXCEPT
a. place pressure overtop of the scar to cause b. some cellular degeneration
c. collagen will re-align itself in line
fibroblasts will align themselves properly

Answer: C. Hypertrophic scars rx include. 1. Pressure garments; 2. Topical silicone; 3. Excision and reclosure. The pressure garments cause the COLLAGEN to re-align.
Source: Current Surgical Treatment. P1223.

113

263. Child is bitten by a dog. Dog appears OK. What is the most appropriate management?
a. local wound care and observe the dog for 10 days
b. contact public health officer
c. sacrifice dog and send brain for pathologic exam
d. vaccinate the child against rabies and administer anti-rabies immunoglobulin only if dog manifests symptoms of rabies
e. reassurance as attack most likely provoked by child


Answer: A. You need to ensure that the dog does not have rabies – so you observe. You do not prophylactically give the child a rabies vaccine as these are toxic.

114

264. Which of these is a contaminated wound?
a. traumatic and open
b. bacteria and pus
c. perforated viscus
d. GI case that is open, but without fecal spillage

Answer: C. as per test answer
I disagree. open trauma considered contaminated.
Dirty wound: traumatic and opened, bacteria and pus. Definition: Perforated viscus is a dirty wound, while an acute traumatic and open wound is considered traumatic. acute inflammation, traumatic, GI tract spillage, or major break in sterile technique. Bacteria and pus = infected wound. GI case that is opened without spillage = “clean contaminated”
Source: Surgery Recall, Essentials of Surgery, Lawrence.

115

265. Major intracellular cations are:
a. Na + Ca
b. K + Mg
c. PO and protein
d. Cl and HCO3

Answer: B. K+ and Mg2+
I remember by potassium and magnesium are good for you, so you want them in the cell.

116

266. ALL of the following carry high mortality rate except:
a. Gallop 3
b. MI 18 months
c. Valve disease
d. CAGB 3 years ago

Answer: D. Once treated with CABG, the disease coronary vessels are removed, therefore the mortality rate should theoretically be eliminated.

117

267. CO poisoning, which is correct:
a. N or high PaO2, Sat O2 is low, low Pulse oxymetry
b. Low PaO2, low SatO2, N P.oxymetry
c. High PaO2, high SatO2, high Pulse oxymetry

Answer: B.
Source: NEJM. CO poisoning. 2002.
Not sure if PaO2 is necessarily low.

118

268. PA catheter, all are correct except:
a. Reduce mortality
b. Can guide resuscitation
c. Can measure LV pressure

Answer: A. It does not reduce mortality.
Source: NEJM. PAC: Peace at Last. 2006.

119

269. 60 year old male patient with bilateral painless parotid swelling:
a. Pleomorphic adenoma
b. Mixed tumor
c. Warthin tumor
d. Cystoadenosarcoma

Answer: C Warthin tumor. The most common bilateral parotid tumor.
Pleomorphic adenoma…….. 70 % if Unilateral , high recurrence , only 10% bil
Mixed tumor
Warthin tumor…….Bilateral.
Cystoadenosarcoma……..MC malignat

120

270. Which one is commonly associated with post chemo lymphoproliferative disease:
a. CMV
b. EBV
c. HCV

Answer: B. EBV. Post chemo or transplant lymphoproliferative disorder occurs 2-5% post cardiac transplant patients and is often fatal. It is caused by EBV.
Source: Journal heart and lung transplantation. 2008.
I remember by EBV-->mono--> lymphnodes

121

271. All are true regarding gas gangrene (Clostridium) Except:
a. Caused by C. perferinges
b. Can follow minor trauma
c. Gas in X-ray is pathognomonic
d. Treated by penicillin

Answer: C. produced by exotoxin of bateria, Clostridium (perfrigens, septicum). PCN is given as adjuvant abx, but operative debridement is necessary. Can follow minor trauma.

122

272. Which of the following is associated coronary artery disease:
a. Tacrolimus
b. Cyclosporine
c. Azathioprine
d. MMF

Answer: A
MMF – GI (diarrhea) and leucopenia; Azathioprine – leucopenia, liver dysfunction, cholestasis;
Cyclosporine – tumor, neurotoxic, hyperuricemia, HTN, high blood glucose, high K+, gingival hyperplasia, liver dysfunction, hirsutism;
Tacrolimus – kidney, neurotoxic, high blood sugar, high K+, HTN, liver, alopecia.
Tacrolimus has been associated with CAD (patient presented with angina)
Source: Morell Notes, Nephrol Dial Transplant. 2006

123

273. Which of the following regulate fibrogenesis:
a. IL-6
b. TGF-beta
c. TGF-alpha
d. PGF

Answer: B. Classic repeated question.

124

274. The action of vitamin C in wound healing is:
a. Collagen cross linkage
b. Collagen synthesis
c. Hydroxylation of proline
d. Fibroblast activation

answer: c
as in: Hydro-C-lation of proline

125

275. Side effect of protamine sulfate include all except:
a. DIC
b. Can cause immunogenic reaction in patient taking NPH insulin
c. Neutropenia
d. Bradycardia
e. Thrombocytopenia

Answer: A. side effects: 1. Leucopenia ; 2 thrombocytopenia; 3. Flushing; 4. Bradycardia; 5. Hypotension; 6. Administration of protamine might cause serious complications especially in patients treated preoperatively with NPH insulin.
Source: Morrell, Ann Chir Gyne 2000.

126

276. Comparing renal and cardiac transplant, which is correct:
a. Rejection is high with renal transplant
b. Both has the same survival rate
c. Atheromatus plaque in coronary artery is the reason for rejection
d. Negative T-cell cross-reaction is needed for renal transplant but not for cardiac transplant.

Answer: D.
The current survival at 3 years for renal is ~90-93%. Heart transplant survival rates are lower than renal.
Source: Current Status of Cardiac Transplantation. JAMA 1998.

127

277. No pulse after closed reduction of knee dislocation What would you do:
a. Exploration
b. Doppler
c. Anticoagulation
d. Angiogram

Answer: D.

128

278. Picture showing CXR. Lt side is totally white. Patient was involved in MVA. What is the most important initial management:
a. Lt chest tube
b. Rt chest tube
c. Lt needle decompression
d. CT chest

Answer: A. Patient has a hemothorax. Needs urgent chest tube.

129

279. What is the most common inherited factor deficiency:
a. Factor V
b. Factor VII
c. Factor VIII
d. Factor IX

Answer: A Factor V leiden

130

280. What is the rate of seroconversion form –ve to +ve after hollow needle prick with HIV +ve blood:
a. 0.3%
b. 3
c. 30
d. 50

Answer: A. 0.3%.
Source: www.goaskalice.columbia.edu
HIV is low.

131

281. What is the contraindication for extension-flexion cervical x-ray: Except
a. Brown-sequard syndrome
b. Pain and tenderness of the spine
c. Spinal shock
d. Anterior cord syndrome

Official answer: b

I would say all of the above.

132

282. Silver sulfadiazine is associated with:
Carbonic anhydrate inhibition
Pain
Poor eschar penetration
Neutropenia

Answer: D, C. this is a broad spectrum antimicrobial agent. It does not penetrate an eschar well, may leave black tattoos and inhibits epitheliazation. It causes neutropenia and leucopenia.
Source: Morrell notes

133

283. Albumin: if he says except
a. Makes up 50% of plasma protein
b. Contribute to 70% of oncotic pressure
c. Increase hepatic synthesis in severe stress
d. Half life is 21 days

Answer: C. Albumin has a half life of 20 days. Therefore, it does not reflect acute liver injury but rather chronic. Its main function is to maintain intravascular colloid osmotic pressure, and to bind and serve as a carrier for a variety of compounds.
Source: Liver Disease in children

134

284. Patient developed fever/chills and systolic murmur left to the sternum after having his wisdom teeth out. What is the most likely diagnosis?
a. Mitral valve endocarditis with regurgitation
b. Mitral valve endocarditis with stenosis
c. Aortic valve endocarditis with regurgitation
d. Aortic valve endocarditis with stenosis

Answer: A. mitral regurg murmurs are heard along the L parasternal border at the base of the heart and is the most common murmur associated with infective endocarditis
Source: Up to date.

135


285. Keratoacanthosis (keratoAkanthoma =correct)
a. Actinic (aka, solar) keratosis

not sure what the question is here.
something about keratocanthosis

136

286. All are true about acute embolic leg ischemia except:
a. Common femoral artery is the most common affected artery
b. Should be heparinized
c. Usually distal pulses are absent.

Answer: all are true. CFA (common femoral artery), is most commonly affected 28%; it is rare to have acute leg ischemia without decrease in pulse intensity; there is no doubt that once the diagnosis is made, the patient should be started on IV heparin.

137

287. Criteria for extubation include all, EXCEPT:
a. Negative inspiratory pressure 15ml/kg
c. TV > 5ml/kg
d. FEV-1 > 50% predicted


Answer: D.
Vital Capacity > 15 cc/kg Negative Inspiratory Force 5 cc/kg (may not be important) 48 % false negative prediction of outcome; PaO2 > 300 mm Hg on FiO2 of 100%; Trial of room air @CPApp4fvn[CPAP:
- IMV rate of 0, FiO2 of 21%, & CPAP of 5 cm H20
Ventilatory rate 7.35 - pCO2

138

288. The criteria for ARDS include all, EXCEPT:
a. PaO2:FiO2 ratio

Answer: D. Hypotension is not a feature of ARDS.

139

289. Most common source of hemorrhage following pelvic fracture:
a. Pelvic venous plexus
b. Iliac artery
c. Femoral artery
d. Pudendal artery

Answer: A. Sources of bleeding in pelvic fractures. Arterial, venous, bone. Venous is the most common; however if a patient is hypotensive and has a pelvic fracture then the cause is likely an arterial.

140

290. Reduced cortical flow, causing medullary ischemia .. yes
a. THERE Is reduction in renal blood flow, especially in the outer medulla

again, not sure what the question is here.

141

201. What is the plasma volume of 70kg male patient:

A. 3L
B. 4L
C. 2L
D. 2.5L

Answer: None

Plasma Volume = 1/4 ECF
ECF =1/3 TBW
ICF = 2/3 TBW
TBW = 0.6(weight KG) males, or 0.5(weight KG females

Plasma volume = (1/4)(1/3)(0.6)(70kg)
=3.5

142

202. What is the body mass index of 100kg patient with a height of 175cm:

A. 18
B. 24
C. 33
D. 55

Answer: C. 33 kg/m2

BMI = mass(kg)/ (height in m)^2
= 100/(1.75)(1.75)
= 32.6

143

203. All are component of Harris-Benedict equation except:
A. Age
B. Sex
C. Body mass index
D. Body water content

Answer: D. Body water contenet

The Harris Benedict Equation is a formula that uses your BMR and then applies an activity factor to determine your total daily energy expenditure (calories). The only factor omitted by the Harris Benedict Equation is lean body mass. It takes into account, weight, height, age.

144

204. Protein requirement for patient with severe trauma and burn:

A. 0.8-1g/kg/d
B. 1-2 g/kg/d
C. 2-3 g/kg/d

B. 1-2 g/kg/d

• Calories required: 25 kcal/kg lean body mass + 40 kcal/%TBSA (Curreri formula) In contrast normal caloric requirements are about 35 kcal/kg/day.

• Optimal dietary protein in burns: 1 – 2 g/kg/day

• TPN is associated with complications and mortality compared with enteral therapy, nonetheless, acute
burns is a primary indication for TPN.

(Morells Notes)

145

295. A patient tells you that he intends to harm another person. What is your legal responsibility?
a. Chart the incident and tell no one
b. Inform the person in question
c. Call psych
d. Inform the police

Answer: D. Inform the police.
Seems obvious, but this might not be the right answer as per case: Tarasoff v. Regents of the University of California

In the decision of the Supreme Court of California, Justice Tobriner stated that:

"When a therapist determines, or pursuant to the standards of his profession should determine, that his patient presents a serious danger of violence to another, he incurs an obligation to use reasonable care to protect the intended victim against such danger. The discharge of this duty may require the therapist to take one or more of various steps, depending upon the nature of the case. Thus it may call for him to warn the intended victim or others likely to apprise the victim of the danger, to notify the police, or to take whatever other steps are reasonably necessary under the circumstances."
royal college website

146

206. All are life threatening condition except:

A. Open femur fracture
B. Bilateral femur fracture
C. Traumatic extremity amputation
D. Thigh compartment syndrome

Answer: D. Thigh Compartment Syndrome

Compartment Syndrome is limb threatening, but the remaining options also can threaten life through blood loss and sepsis.

147

291. Patient with heterotrophic ossification, and decreased ROM of joint. Which of the following is true regarding HO?
a. Common in head injury
b. Visible on x-ray before limiting patient clinically
c. May be reduced by use of NSAIDs

official answer: c
I think all of the above, might have actually been an "all of the following are true except" question

148

292. To complete a retrospective study with a dichotomous outcome i.e. yes or no, the following tests could be used except:
a. Chi Square
b. Fisher T
c. Students T
d. Odds ratio

Answer: C. The Students T test, determines if a statistical significance exists between two population / sample MEANS. used for continuous variables (weight, age, etc.)
Source: Wikipedia

whereas: The test (Fisher) is useful for categorical data that result from classifying objects in two different ways; it is used to examine the significance of the association (contingency) between the two kinds of classification. Source: Wiki

149

293. The technology utilized in PET scanning?
a. Oxygen metabolism
b. Glucose metabolism
c. Calcifications

Answer: B glucose metabolism, linked to a radioactive substance. (i.e. FDG)
Source: Up to date.

150

220. All are signs of suppurative tenosynovitis except:

A. Takes flexion position
B. Redness of the finger
C. Tender when you palpate the flexor site
D. Tenderness in passive extension of the fingers

Answer: B. Redness of the Finger

Kanavel’s Four Cardinal signs of suppurative flexor tenosynovitis:
(1) fusiform digital swelling
(2) semiflexed digital posture
(3) significant pain from passive extension
(4) tenderness along the entire flexor sheath

151

295. A patient tells you that he intends to harm another person. What is your legal responsibility?
a. Chart the incident and tell no one
b. Inform the person in question
c. Call psych
d. Inform the police

Answer: D. Inform the police.

152

207. Picture showing open femur fracture. What is the most appropriate initial management:

A. Antibiotic
B. Anti-tetanus
C. Open reduction and internal fixation
D. Skin traction

Answer: A. Antibiotics

Time to Antibiotics has been shown to reduce morbidity and mortality, but if limb had neurovascular compromise, first step would be to re-align- traction is not part of the absolute initial management.

153

208. Picture showing normal CXR and EKG (S1, Q3, T3) for patient having chest pain post total hip replacement. What is the most appropriate initial investigation:

A. Angiogram
B. I.V. enhanced chest CT
C. Lung scan
D. Echo

Answer: B. IV enhanced chest CT (CTPA)

S1, Q3, T3 is EKG finding correlating to Pulmonary Embolus- next step would be a CTPA.

Abnormalities historically considered to be suggestive of PE (S1Q3T3 pattern, right ventricular strain, new incomplete right bundle branch block) are infrequent (less than 10 percent)

(UptoDate)

154

209. How can you test for C8 root function:

A. Wrist extension
B. Wrist flexion
C. Finger extension
D. Finger flexion (DIP joint)

Answer: D. Finger flexion (DIP joint)

C5- Elbow Flexors.
C6 – Wrist Extensor.
C7 – Elbow Extensor.
C8 - Finger Flexion.
T1 – Finger Abduction.

155

210. What is the most common cause of enterovesicular fistula:

A. Colon cancer
B. PID
C. Sigmoid diverticulosis
D. Bladder cancer

Answer: C. Sigmoid diverticulosis

Enterovesicular fistula = abnormal connection between the bowel and the bladder.

Only occur in presence of diverticular disease or cancer, diverticular disease being more common (UptoDate)

156

211. Horner’s syndrome includes all except:

A. Anhydrosis
B. Increased lacrimation
C. Miosis
D. Bleoptosis

Answer: B. Increased Lacrimation

Horner Syndrome, Classic Findings:
-ptosis
-miosis
-anhidrosis

157

296. A patient is post op 5 hours from AAA repair. The CVP is 5, CI is low, PAWP is normal, PA pressures are normal. What is the most appropriate management?
a. Start Inotropes
b. Return to the OR
c. Transfuse
d. Shock
e. Give fluid

Answer: E. CVP is low, hypovolemic. CI is low, pump is dry. PAWP is normal, and PA pressure are normal indication not in failure. Initial therapy would be to fill the pump, give a bolus of fluids. Afterwards, u can start inotropes.

158

297. Patient underwent intramedullary nailing for closed distal tibia fracture comes back 1 year post op complaining for 6 months of constant ankle pain.what is the diagnosis:
the picture was difficult to see but there was a fine radiolucent line on 2 images
a. nonunion
b. malunion
c. new fracture
d. calus healing

answer: a vs b, would depend on image.

159

212. Candida infection is associated with all of the following except:

A. Single +ve blood culture is significant
B. Can be diagnosed by ocular lesion
C. Need aggressive treatment
D. +ve urine culture is diagnostic

Answer: D +ve urine culture is diagnostic

Positive urine culture can also be caused by colonization.

Blood cultures are +ve 50% of the time.
Occular lesions are diagnostic. Require aggressive treatment as can become systemically ill very quickly.

160

213. Stored FFP is deficient of which of the following clotting factor:

A. Factor II
B. Factor V
C. Factor VII
D. Factor X

Answer: C. Factor VII

FFP have factor II, V, X, XI

161


214. What is the most common manifestation of latex allergy:

A. Intraoperative hypotension
B. Anaphylaxis
C. Contact dermatitis
D. Brochospasm

Answer: C. Contact dermatitis

Approx 1% of the population has latex allergy with IgE response. Most common reaction is contact dermatitis but can range to as severe as anaphylaxis.

162

215. 70 year old patient with history of A.fib and arthritis. Developed sudden sever abdominal pain. Had one BM today and vomited twice. Abdominal exam revealed generalized tenderness but not peritonitis. She had tubal ligation in the past. What is the most probable diagnosis:

A. Acute mesenteric embolic ischemia
B. Perforated PUD
C. Intestinal obstruction
D. Rupture AAA.

Answer: A. Acute mesenteric embolic ischemia.

Risk factor is A-Fib- should be thinking embolus. Lack of peritonitis eliminates perforated PUD. Ruptured AAA would present with sudden severe hypotension, and pain radiating into the back. Intestinal obstruction is ruled out due to BM that AM.

163

216. Power is:

A. Probability to detect statistically significance if one exists
B. A calculation of sample size
C. A calculation of validity
D. Positive predictive value

Answer: A: Probability to detect statistically significance if one exist

Power = (1-beta) = probability of rejecting the null hypothesis when it is false.

Alpha =

**answer on the notes said calculation of sample size, this is incorrect. Sample size calculation is used to determine appropriate number to power a study.

164

217. The ability of a test to appropriately identify people with disease is:

A. Sensitivity
B. Specificity
C. Validity
D. PPV

Answer: A. Sensitivity

= number of people who test positive for the disease/ number who have the disease.

Higher sensitivity, the higher the probability that the test will accurately identify a person with the disease with a corresponding positive test.

165

218. When the test has 95% sensitivity, it means:

A. 95% of the patient will be positive
B. 95% of patients with the disease will test positive.
C. Patients who are tested positive, 5% will have the disease

Answer: B. Patients who are tested positive

Sensitivity of a test = proportion of patients who have the disease who will test positive with that test.

166

219. If you did small RCT and you found significant difference but is not statistically significant. What should you do:

A. Change the study outcome
B. Do another study with larger sample
C. Ignore the result

Answer: B. Do another study with larger sample size.

Indicates that your study may be underpowered to detect a statistically significant difference.

167

220. All are signs of suppurative tenosynovitis except:

A. Takes flexion position
B. Redness of the finger
C. Tender when you palpate the flexor site
D. Tenderness in passive extension of the fingers

Answer: B. Redness of the Finger

Kanavel’s Four Cardinal signs of suppurative flexor tenosynovitis:
(1) fusiform digital swelling
(2) semiflexed digital posture
(3) significant pain from passive extension
(4) tenderness along the entire flexor sheath

168

221. A patient with C8 injury. BP 80/50 and HR 50. He remained hypotensive despite 2L of RL. What is the most common cause:

A. Neurogenic shock
B. Spinal shock
C. Cardiac tamponade
D. Tension pneumothorax

Answer A: Neurogenic Shock

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

Signs:
-Hypotension
-Bradycardia
-Warm extremities

169

222. What is the contraindication for extension-flexion cervical x-ray:

A. Brown-sequard syndrome
B. Pain and tenderness of the spine
C. Spinal shock
D. Anterior cord syndrome

Answer: A, B & D

Question should probably read: which is not a contraindication for flex/ex views.

Contraindications:
-altered state of consciousness (closed head injury, intoxication, or combativeness);
- documented neurologic deficit;
- inability of patient to flex and extend the neck w/o assistance;

170

223. H ion is excreted by the kidney mainly as:

A. Free H ion
B. Organic acid
C. Combined to HCO3
D. Combined to ammonia

Answer: D. Combined to Ammonia

171

224. All of the following are true except:

A. Necrosis is a non controlled process that leads to stimulation of inflammation
B. Apoptosis is important for tissue growth
C. Both necrosis and apoptosis happen in reperfusion injury
D. Apoptosis initiated by Golgi apparatus

Answer: D. Apoptosis initiated by Golgi apparatus.

Mitochondria initiates apoptosis.

Internal triggering occurs when cells respond to environmental stress (eg, heat, x-rays, ultraviolet irradiation), to damage to deoxyribonucleic acid (DNA) (genotoxic injury), or to misfolded proteins (endoplasmic stress). These events alter the function of mitochondria, an organelle that is essential not only for cell survival but also for the regulation of entry into cell death [11]. (UptoDate)

172

225. 70 year old male patient was involved in MVA. Vitally stable with no complaint but could not recall what happened. What is the most appropriate action:

A. Discharge home
B. CT head
C. Skull x-ray
D. Intubation

Answer: B. CT Head

Showing evidence of possible cerebral damage (amnesia), age >65, with high-energy mechanism. Indication for CT Head.

Canadian CT Head Rules:

a) High Risk (for neurological intervention)
1. GCS score

173

226. All can cause hypercalcemia except:

A. Paget’s disease
B. Malignancy
C. Multiple fractures
D. Bed rest

Answer: C. Multiple Fractures.

Paget's doesn't normally have hypercalcemia, but can in instances of immobilization.

174

227. 40 year old healthy lady has 2 cm mass in front of Lt ear with no LN what is the most appropriate action:

A. CT
B. US
C. Incisional biopsy
D. FNA

Answer: D. Fine Needle Aspiration

Fine needle aspiration biopsy (FNA) is frequently used to make an initial tissue diagnosis of a head and neck cancer when a patient presents with a neck mass (metastatic cervical lymph node) without an obvious primary mucosal/upper aerodigestive tract site. This technique has high sensitivity and specificity and a diagnostic accuracy that ranges from 89 to 98 percent [9-11]. Nondiagnostic aspirations occur in 5 to 16 percent of cases, most commonly in cystic neck masses, as is common in the presentation of patients with HPV associated oropharyngeal cancers. If an initial FNA is negative from a suspicious neck node, repeat FNA may be considered before doing an excisional biopsy. (UptoDate)

175

228. Febrile reaction post blood transfusion is related to:

A. Leukocyte
B. Antibodies
C. Donor RBC
D. Infection

Answer: B. Antibodies

Febrile Non-hemolytic transfusion relations were thought to be immune in nature since they have been associated with class I HLA antibodies (or sometimes granulocyte specific antibodies) directed against contaminating leukocytes in red cell concentrates [2,8]; however, such antibodies are not always found. (UptoDate)

176

229. Silver sulfasalazine is used in burn wound. It can cause all except:

A. Granulocyte reduction
B. Metabolic acidosis
C. Pigmentation
D. Anemia

Answer: B. Metabolic Acidosis

Adverse Reactions Topical Silver Sulfasalazine:

-Dermatologic: Burning sensation of skin, erythema, pruritus, Stevens-Johnson syndrome, stinging of the skin, toxic epidermal necrolysis
-Hematologic & oncologic: Agranulocytosis, aplastic anemia, hematologic abnormality
-Hepatic: Fulminant hepatic necrosis
-Hypersensitivity: Hypersensitivity reaction
-Local: Local irritation, localized edema, erythema multiforme, discolouration of skin, photosensitivity
-Neuromuscular & skeletal: Systemic lupus erythematosus

177

230. What is the most common reason for Fem-Pop bypass failure after 2 years:

A. Atherosclerosis
B. Technical error
C. Graft compression
D. Intimal proliferation

Answer: A. Artherosclerosis

Graft occlusion is the most common long-term reason for graft failure in the literature.

178

231. All could be used adjuvant therapy for malignant tumors except:

A. Monoclonal antibodies
B. Interferon
C. BCG

Answer: unknown, they could all be used.

179

232. All are causes of hypernatremia except:

A. IV saline
B. Hyperaldosteronism
C. SIADH
D. DI

Answer: C. SIADH

SIADH causes fluid retention via increased ADH, causing hyponatreamia

180

233. Which of the following has the fastest and greatest reduction in organism:

A. Chlorohexiden
B. Isosorpyl alcohol
C. Povidine

Answer: B. Isoporpyl Alcohol

Has the fastest and broadest spectrum antimicrobial properties. We don't use in the OR because of its' flammable properties.

181

234. Patient was on prophylactic heparin. His platelet went down to 25,000. all are acceptable treatment except:

A. Stop heparin
B. Send for antibodies
C. Platelet transfusion
D. Warfarin

Answer: C. Platelet Transfusion.

Shouldn't give because it can potentiate thrombus formation in HIT.

Warfarin can be given after bridging.

182

235. In patient with cirrhosis and ascites, hyponatremia is caused by:

A. Expanded extravascular fluid volume
B. Expanded intravascular fluid volume
C. Renal loss of Na
D. Depleted intravascular volume

Answer: A. Expanding extracellular volume.

Cirrhosis causes increased salt and water wasting from the cells. Salt is leaked and water follows extravascularly. Renin angiotensin system causes more salt absorption and water absorption from the kidneys, which then just leaks extravascularly potentiating the increase in ascites.

183

236. Crohn’s patient with hypocalcemia. You gave him Ca supplement and sent him home. He comes back to ER with tetany. What should you do?

A. Give Vit D
B. Give Calcitonin
C. Replace Mg
D. Hydration

Answer: C. Replace Mg.

Tetany is a symptom of hypomagnesemia. Too much calcium intake can decrease Mg absorption (both 2+ cations, absorbed together)

Clinical Manifestations of HypoMg
• 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.

184

237. If the study has CI of 95%. What is the chance to have population out side this interval?

A. 1:5
B. 1:10
C. 1:20
D. 1:95

Answer: C. 1:20

CI 95% means that 95% of values will fall within the range, meaning 5% of them can fall outside the range = 1:20.

185

238. Mechanism of action of cyclosporine is:

A. Inhibit B cell lymphocyte
B. Inhibit IL-2 activated T cell and cytotoxic T cell
C. Inhibit IL-6 activated T cell
D. Inhibit macrophage

Answer: B. Inhibit IL-2 activated T-cell and cytotoxic T cel

Actions of Cyclosporin (5):
1. Inhibition of IL-1 production
2. Inhibition of IL-2 production by activated T cells.
3. Inhibition of IL-2 producing T cells and Tc cells.
4. Inhibtion of mitogen activation of IL-2 producing T cells
5. Inhibition of resting T cell activation in response to alloantigen and exogenous lymphokine. (Note it
does not inhibit activation of T cells in response to exogenous IL-2.)

186

239. All are true about TNM classification of tumors except:

A. Standardize the treatment
B. Facilitate discussion
C. Predict prognosis during initial presentation

Answer: A. Standardizes treatment

Such staging assists in:
(1) selection of therapy - does not standardizes it, assists in determining what can be used.
(2) estimation of prognosis
(3) evaluation of treatments
(4) exchange of information among treatment centers
(5) continued investigation of human cancers.

187

240. In patient with right sided MI, which will improve prognosis?

A. Inotropes
B. Reduce preload
C. IV fluid
D. Reduce afterload

Answer: C. IV Fluid

Need to increase preload in right-sided heart failure. Reduction in after load only affects left side of heart. Ionotropes can be used once the "tank is filled"

188

241. MRI is useful in assessing all of the following, EXCEPT:

A. Brain
B. Cortical bone
C. Soft tissue injury
D. Bone marrow

Answer: B. Cortical Bone

MRI is great for soft tissues, fat containing substances (tumor, bone marrow), brain tissue. Cortical bone is best seen using CT scan.

189

242. All are associated with increased risk of BCC except:

A. UV
B. Nevus sebaceous
C. Keratoacanthosis
D. Actinic keratosis

Answer: C. Karatoacanthosis

-Basal cell ca. slow-growing tumors. Rarely metastasize. Risk factors: sunlight, immunusupression, DNA repair defects.
-Actinic keratosis (pre-malignant changes in epidermis after chronic exposure to sunlight – analogous to pre-malignant changes in cervix), if they do go on to malignancy they turn more often into SCC but can transform to BCC. -Keratoacanthosis is a rapidly developing neoplasm that looks like SCC, but usually resolves spontaneously.
-Nevous sebaceous can turn malignant and when it does, it turns into a BCC.

190

244. Man brought into emerg after falling at shopping mall. HR, BP, RR all normal, neuro exam normal. Well-healed pacemaker scar. Evidence of malar #. Can’t remember events of fall. In addition to arranging for repair of #, you should do:

A. EKG & pacemaker interrogation
B. ECHO
C. CT head
D. Stress test

Answer: C. CT Head

Evidence of facial trauma and memory loss.

Canadian CT Head Rules:

a) High Risk (for neurological intervention)
1. GCS score

191

150. MVA. T7 vertebra exploded – paraplegic. numerous litres of volume infused, still hypotensive, abd US no hemoperitoneum. Closed pelvis fracture. likely cause of hypotension?
A. undiagnosed abd injury
B. head injury
C. neurogenic shock

C. Neurogenic shock

Loss of sympathetic tone. Usually have decreased HR and BP with warm skin. Tx: give volume first, then pressors after resuscitation.

192

151. Re carbon monoxide
A. carboxyhemoglobin binds O2 with less affinity
B. half life of carboxyhemoglobin is 45 – 60 min on room air
C. CO binds Fe containing proteins

C. CO binds Fe containing proteins

Half life of CoHb is 5-6 hours on room air; this is reduced to 90 minutes with O2 administration.

193

245. A group of surgeons meets to create treatment guidelines for the management of pulmonary embolism. This type of evidence is:

A. Class I
B. Class II
C. Class III
D. Class IV

Answer: D. Class IV

Level 1. Randomized controlled trials—includes quasi-randomized processes such as alternate allocation.

Level 2. Non-randomized controlled trial—a prospective (pre-planned) study, with predetermined eligibility criteria and outcome measures.

• Level 3. Observational studies with controls—includes retrospective, interrupted time series (a change in trend attributable to the intervention), case-control studies, cohort studies with controls, and health services research that includes adjustment for likely confounding variables.

• Level 4. Observational studies without controls (e.g., cohort studies without controls, case series without controls, and case studies without controls). Expert opinion.

194

246. Patient diagnosed with L4/L5 disc herniation; symptoms include:

A. Numbness between 1st/2nd toes + weak great toe dorsiflexion
B. Loss of patellar reflex + numbness over medial lower leg
C. Loss of plantar flexion + numbness lateral foot
D. Gastroc weakness + numbness on sole of foot

Answer: B. Loss of patellar reflex + numbness over medial lower leg.

L4 nerve root compromised: weak dorsiflexion, paresthesias medial side of leg, patellar reflex compromised.

195

248. Patient involved in MVC. “Damage control” surgery appropriate in all except the following:

A. Uncontrolled arterial bleeding
B. Unstable, hypotensive patient
C. Patient temp 34 degrees
D. Patient lactate >5

Answer: A. Uncontrolled arterial bleeding

Damage control surgery is appropriate when the patient is in “extremis”. This would apply if patient is hypothermic, coagulopathic, acidemic, unstable. If there is an uncontrolled arterial bleeding you need to definitively fix it or the patient will die.

196

248. Patient involved in MVC. “Damage control” surgery appropriate in all except the following:

A. Uncontrolled arterial bleeding
B. Unstable, hypotensive patient
C. Patient temp 34 degrees
D. Patient lactate >5

Answer: A. Uncontrolled arterial bleeding

Damage control surgery is appropriate when the patient is in “extremis”. This would apply if patient is hypothermic, coagulopathic, acidemic, unstable. If there is an uncontrolled arterial bleeding you need to definitively fix it or the patient will die.

197

151. Re carbon monoxide
A. carboxyhemoglobin binds O2 with less affinity
B. half life of carboxyhemoglobin is 45 – 60 min on room air
C. CO binds Fe containing proteins

C. CO binds Fe containing proteins

Half life of CoHb is 5-6 hours on room air; this is reduced to 90 minutes with O2 administration.

198

249. The appropriate treatment of patient with severe vomiting:

A. Dextran
B. Normal saline
C. HCL infused slowly
D. HCO3 drip

Answer: B. Normal Saline

Need to fluid resuscitate.

199

250. Patient with head injury, in ICU. Treatment of elevated ICP includes all, EXCEPT:

A. Hyperventilate to PCO2 of 34
B. Control pain
C. Sedate
D. Give lasix 40mg IV

Answer: D. Give lasix 40mg IV

All the rest have been shown to decrease ICP.

200

152. An elderly man was involved in a MVA with head trauma and currently is agitated which of the following agents can be used to sedate him for 2-3 days:
A. midazolam
B. propofol
C. lorazepam
D. haloperidol

B. Propofol

Iif intubated in the ICU; midaz if he is mild head trauma on the floor. Midazolam because lorazepam is long acting and haloperidol should be avoided because it decreases seizure threshold in head injury,

201

160. CNS lidocaine side effect all are correct except:
A. Seizure
B. Nystagmus
C. Confusion
D. Hemiparesis

D. Hemiparesis

IV lidocaine has actually been used to control nystagmus and tinnitus, but has also been reported to cause it.

Miller’s Anesthesia – CNS toxicity
- Light-headedness/dizziness
- Visual disturbances (difficulty focusing)
- Auditory disturbances (tinnitus)
- Disorientation
- Drowsiness
- Shivering
- Muscle twitching
- Tremors
- Generalized convulsions

202

154. Osmotic pressure depends on:
A. Na concentration
B. Diffusible ions
C. Albumin concentration

A. Na concentration

203

155. Major intracellular cations are:
A. Na + Ca
B. K + Mg
C. PO and protein
D. Cl and HCO3

B. K and Mg

204

156. When calculating the amount of solutes per unit of water, the concentrations of which of the following serum values is not required?
A. Sodium
B. Glucose
C. Urea
D. Chloride

D. Chloride

“The principal determinants of osmolality are the concentrations of sodium, glucose, and urea (blood urea nitrogen [BUN])” (Schwartz)

205

157. Post operatively, what is the medication that has onset of action 2-4 min and half life of 40-60 min:
A. Morphine
B. Demerol
C. Fentanyl

C. Fentanyl

Fentanyl -- 80 x strength of morphine (doesn't cross react in pts with morphine allergy).

206

158. Best analgesia for obese patient post thoracotomy:
A. PCA
B. IV infusion
C. Epidural

C. Epidural

Epidural -- causes sympathetic denervation and vasodilation. Morphine in epidural can cause resp depression. Lidocaine can cause bradycardia and hypotension. Tx for acute hypotension and bradycardia: turn down epidural, fluids, phenylephrine, atropine.

207

159. The approved medication that reduce perioperative mortality:
A. Captopril
B. Metoprolol
C. Lipitor

B. Metoprolol

208

160. CNS lidocaine side effect all are correct except:
A. Seizure
B. Nystagmus
C. Confusion
D. Hemiparesis

D. Hemiparesis

IV lidocaine has actually been used to control nystagmus and tinnitus, but has also been reported to cause it.

Miller’s Anesthesia – CNS toxicity
- Lightheadedness/dizziness
- Visual disturbances (difficulty focusing)
- Auditory disturbances (tinnitus)
- Disorientation
- Drowsiness
- Shivering
- Muscle twitching
- Tremors
- Generalized convulsions

209

161. Hypomagnesemia all are correct except:
A. Increases DTR
B. Tetany
C. Tremor
D. Fasciculation

D. Fasciculations

HyperMg: lethargic state, depressed DTRs, respiratory depression
HypoMg: similar to hypoCa signs

Magnesium depletion signs/symptoms (Schwartz)
- CNS hyperactivity (similar to hypocalcemia)
Hyperactive reflexes
Muscle tremors
Tetany (+ve Chvostek’s sign)
Delirium & seizures (when severe)
- ECG changes
Prolonged QT and PR
ST depressions
Flat or inverted P waves
Torsade or other arrhythmias

210

162. Hypokalemia is associated with:
A. Metabolic acidosis
B. Renal failure
C. Diarrhea
D. U wave

D. U wave

Renal failure: Potassium is eliminated by renal excretion (90%) and in stools (10%). Renal failure therefore causes hyperkalemia.

Metabolic acidosis: Cellular shifts occur in the form of K+ / H+ transfer. Increased H+ in the blood will result in a net intracellular shift; as this happens K+ moves from intracellular to extracellular, causing hyperkalemia.

Diarrhea causes non-AG metabolic acidosis

211

163. Which of the following patients with hyponatremia should receive salt replacement?
A. Patient with inappropriate ADH secretion
B. Hyponatremic, hypochloremic patient with metabolic alkalosis
C. Volume depleted patient
D. Na

D. Na

212

171. All are associated with mesothelioma Except:
A. Asbestos
B. Chest trauma
C. Hypoglycemia
D. Lethargy
E. Hypertrophic osteodystrophy

B. Chest trauma

Risk factors:
- Asbestos exposure
- Radiation therapy
- Other occupational exposure

Clinical presentation:
- dyspnea
- weight loss/anorexia
- night sweats
- weakness
- chest pain

213

165. Mechanism of action of bisphosphonate:
A. Activate osteoblast
B. Inhibit osteoclast
C. Decrease GI absorption
D. Increase renal loss

B. Inhibit osteoclast

214

166. CO poisoning, which is correct:
A. N or high PaO2, Sat O2 is low, low Pulse oxymetry
B. Low PaO2, low SatO2, N P.oxymetry
C. High PaO2, high SatO2, high Pulse oxymetry

B. Low PaO2, low SaO2, normal pulse ox

215

167. Feature of CO:
A. Shift the curve to left
B. Pulse oxymetry is usually low
C. Can be diagnosed by pulse oxymetry
D. High affinity to iron containing proteins

A. Shifts curve to left and D. high affinity to Fe containing proteins

216

168. Septic patient in shock, which is not true:
A. CI 3.5
B. CVP 18
C. SVR 300
D. Hypotension

B. CVP 18

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

217

176. When you should give the second dose of prophylactic antibiotic:
A. If the procedure last longer than the half life of Abx
B. Surgery last > 3 hrs
C. Blood loss > 750 cc

B. Surgery last > 3 hrs

218

170. Patient post hernia repair under spinal anesthesia, developed respiratory distress after morphine, failed intubation and difficult bagging, what’s next:
A. Nasotrachial
B. Tracheostomy
C. Cricothyroidotomy
D. Laryngeal mask

D. LMA

219

171. All are associated with mesothelioma Except:
A. Asbestos
B. Chest trauma
C. Hypoglycemia
D. Lethargy
E. Hypertrophic osteodystrophy

B. Chest trauma

220

172. All are associated with cancer Except:
A. CMV
B. EBV
C. HPV
D. HCV

A. CMV

221

173. Chronic leg osteomyelitis developed chronic ulcer and discharge. What is the most common cancer will develop in this ulcer:
A. BCC
B. SCC
C. Osteosarcoma

B. SCC

222

174. Neonate in ICU with multifocal osteomyelitis, what is the most common organism:
A. Staph. aureus
B. Groub B strept
C. Strop pneumonia
D. E.coli

B. Group B strep

223

175. All are true regarding gas gangrene (clostridium) Except:
A. Caused by C. perfringes
B. Can follow minor trauma
C. Gas in X-ray is pathognomonic
D. Treated by penicillin

C. Gas in X-ray is pathognomonic

• Most clostridial infections typically involve underlying muscle (clostridial myonecrosis or gas gangerene
○ C perfringens infections
§ Necrotic tissue decreases redox potential -- ideal env for C perfringens
§ C perfringens has alpha toxin
§ Pain out of proportion to exam
§ May not show signs with deep infection
§ Gram stain -- GPRs w/o WBCs
§ Myonecrosis and gas gangrene -- common presentations
§ Farming injuries
§ Tx: early debridement, high dose PCN
• Most non-clostridial infections spread in SC layer b/w skin and muscle
○ Necrotizing fasciitis
§ Beta-hemolytic GAS
§ Overlying skin may be pale red and progress to purple with blister or bullae devt
§ Skin can look normal in early stages
§ Thin, gray, foul-smelling drainage, crepitus
§ Tx: early debridement, high dose PCN
• Note: most soft tissue infections with gas are not gas gangrene
Most bacteria will produce insoluble gas when forced to use anaerobic metabolism

224

177. Why you should adjust drug dose in children:
A. Reduced GFR
B. Immature liver glucorinide enzyme
C. High risk of side effect

B. Immature liver glucorinide enzyme

225

178. Which of the following is associated with cholestasis:
A. Cyclosporine
B. Azathioprine
C. Steroid
D. 5FU

B. Azathioprine

226

179. Which of the following regulate fibrogenesis:
A. IL-6
B. TGF-beta
C. TGF-alpha
D. PGF

B. TGF-beta

○ Stimulants of collagen synth
§ Ascorbic acid, TGFb, IGF-1/2
○ Inhibitors of collagen synth
§ IFN-y
§ Glucocorticoids
□ Inhibit collagen mRNA transcription
□ Inhibits procollagen secretion [can be prevented w/ Vit A]

227

185. Which of the following can reduce the effect of steroid on wound healing:
A. Vit A
B. Vit E
C. Vit C
D. Vit D

A. Vit A

Glucocorticoid effects
i. IL-2 prodn suppression
ii. Inh lymphocyte activation
iii. Inh monocyte and neutrophil migration to areas of inflammation
iv. Inh histamine release and histamine-induced lysosomal degranulation by mast cells
v. Inh B cell activation and proliferation at high doses
vi. Retards entry of free water into cells
vii. Decreases capillary permeability to water
viii. Weak mineralocorticoid effect
ix. Stim of angiotensin release (maintains BP)
x. Inh PGI2 (potent vasodilator) -- maintenance of BP
xi. Impaired collagen mRNA transcription and fibroblast activity
xii. Inh osteoblast activity
xiii. Promotes early closure of epiphyseal plates in kids
Long term effects
i. Catabolic state with neg N balance
ii. Body fat redistribution -- truncal obesity
iii. Emotional and psychological disturbances
iv. Cataracts
Corneal ulcers

228

181. How many suture size between 2.0 and #2:
A. 1 size
B. 2 sizes
C. 3 sizes
D. 4 sizes

C. 3 sizes

Sizes (from small to big):6-0, 5-0, 4-0, 3-0, 2-0, 1-0, 0, 1, 2……

229

187. ATN is diagnosed by:
A. Specific gravity of 1.021
B. Urine Na >80 mmol/l
C. UOP 10cc/hr

B. urine Na > 80 mmol/L

The gold standard in the ability to distinguish prerenal disease secondary to volume depletion or hypotension from postischemic or nephrotoxic ATN is the response to fluid repletion: return of renal function to the previous baseline within 24 to 72 hours is considered to represent prerenal disease, whereas persistent renal failure is called ATN. The urinalysis is normal or near normal in prerenal disease; hyaline casts may be seen, but these are not an abnormal finding. In comparison, the classic urinalysis in ATN reveals muddy brown granular and epithelial cell casts and free epithelial cells

230

182. Which will last longer:
A. Vicryl
B. Dexon
C. Chromic
D. PDS

D. PDS

Polydiaxone (PDS, Biosyn)
○ Absorption: 180 days
○ Effective strength: 40-60 days
○ Maintains integrity in presence of infection
○ Minimal tissue reaction
○ Monofilament
Absorption via hydrolysis

231

183. All are true of Langer’s lines EXCEPT:
A. Perpendicular to direction of muscle action
B. Created by muscle pull and joint movement
C. Genetically predetermined
D. Incision cross is associated with hypertrophic scar

A. Perpendicular to direction of muscle pull

Kraissel lines. They correspond to the alignment of the collagen fibrils. Incisions made parallel heal with less scar. Directional changes of Langer’s line change within a lifetime.

232

184. Keloid scar:
A. Familial
B. Respond specifically to intralesion injection of triamcinolone
C. Common in the back
D. Common in white people

B. Respond specifically to intralesional injection of triamcinolone

233

185. Which of the following can reduce the effect of steroid on wound healing:
A. Vit A
B. Vit E
C. Vit C
D. Vit D

A. Vit A

234

186. All need prophylactic heparin except:
A. 25 year female going for appendectomy on OCCP
B. 60 year old male going for colectomy
C. 50 year old female going for hip replacement
D. 30 year old male going for hernia repair

D. 30 y.o. male for hernia repair

235

193. Patient had SCC in the floor of the mouth which was resected and followed by radiotherapy. 1 year later, he came with painful ulcer in the floor of mouth with exposed mandible in the base of the ulcer. What is the diagnosis:
A. Recurrent SCC
B. Osteoradionecrosis
C. Osteosarcoma
D. Infection

B. Osteoradionecrosis

In the oral cavity SCC usually presents as a non healing ulcers. Treatment is surgical resection with radiotherapy. Mandible can be involved.

Osteoradionecrosis of the skull base may be seen in patients who have received prior high-dose radiation therapy for head and neck cancer (notably of the nasopharynx) or for sellar or parasellar pathology. This typically appears as a mixed lytic and sclerotic process on CT scans and as heterogeneous marrow signal intensity on MRI. The differentiation from chronic osteomyelitis can be difficult, and, in fact, infection may complicate osteoradionecrosis. Most commonly affected bone in head and neck is mandible, results from external beam or brachytherapy. Presents as exposed bones in previously radiated area that does not heal for 3 months. Associated with pain, discharge, dehiscence of mucosa or fistulisation to the skin

236

188. All are indications for IVC filter except:
A. Streptokinase allergy
B. Contraindication for anticoagulation
C. Progression of thrombosis despite max medical anticoagulation
D. Free floating thrombus in the ileofemoral vein

A. Streptokinase allergy

IVCF indications
Absolute
§ Recurrent embolism despite anticoag
§ DVT or PE in patient with CI to anticoagulation
§ Complication of anticoagulation forcing therapy to be stopped
§ Recurrent PE with assoc pulm HTN and cor pulmonale
§ Immed after pulm embolectomy for massive PE
§ Free floating thrombus or thrombus enlargement despite anticoag
§ Can't tolerate another PE
Relative
§ PE > 1/2 pulmonary vascular bed in pt who cannot tolerate additional emboli
§ Propagation of iliofemoral thrombus despite anticoagulation
§ High risk pt with large free-floating iliofemoral thrombus on venogram
§ Going for thrombectomy

237

189. What is the unique infective agent in human bite:
A. Staph aureus
B. Stap epid
C. Strep
D. Ekinella

D. Eikenella

• Most common in humans: Strep viridans (#1) then S aureus, H parainfluenza, K pneumoniae, Eikenella, Bacteroides, Fusobacterium, anaerobic cocci (Peptostreptococci)
○ More likely to get infected
○ Related to depth and extent of wound and bacterial pathogenicity
• Dogs: pasteurella; typically polymicrobial staph (20-40%), strep (50%), bacteroides
• Cats: pasteurella

238

190. What is the primary pathophysiology of chronic diabetic ulcer:
A. Infection
B. Microvasculopathy
C. Neuropathy
D. Charcot joint

C. Neuropathy

239

191. All are causes of chronic leg ulcer except:
A. Chronic infection
B. Peripheral artery disease
C. Peripheral neuropathy
D. Venous stasis

A. Chronic infection

5-10% PAI: Essentials of Diagnosis
Intermittent claudication.
Ischemic rest pain.
Decreased pulses.
Nonhealing wounds.
Pallor of foot on elevation, rubor on dependency.
Necrosis and atrophy.
Low ankle-brachial index.

80-90% CVI is a major and costly medical problem affecting an estimated 600,000 patients in the United States.97 Patients complain of leg fatigue, discomfort, and heaviness. Signs of CVI may include varicose veins, pigmentation, lipodermatosclerosis, and venous ulceration. Importantly, severe CVI can be present without varicose veins.

Neuropathy is primary pathophysiology of chronic diabetic ulcer

240

192. Patient has muscle flap. The flap became swollen and congested, aspiration showed dark blood. No hematoma or tension on the pedicle of the flap. What is most appropriate next step:
A. Observation
B. Anticoagulation
C. Leeches
D. Exploration

C. Leeches

241

193. Patient had SCC in the floor of the mouth which was resected and followed by radiotherapy. 1 year later, he came with painful ulcer in the floor of mouth with exposed mandible in the base of the ulcer. What is the diagnosis:
A. Recurrent SCC
B. Osteoradionecrosis
C. Osteosarcoma
D. Infection

B. Osteoradionecrosis

242

101. Pulmonary artery catheter measures directly:
a. cardiac index
b. mVO2 = mixed venous oxygen
c. LVEDP
d. SVR – systemic vascular resistance

Answer – B
Explanation:
Cardiac index = hemodynamic parameter that releast the cardiac output in one minute to the total body surface area – thus relating heart performance to the size of the individual in L/min/m2
LVEDP = left ventricle end diastolic pressure
SVR = systemic vascular resistance
Pulmonary artery catheter aka Swan-Ganz catheter allows direct, simultaneous management of pressures in the right atrium, right ventricle, pulmonary artery and the filling/wedge pressure of the left atrium
Pulmonary artery catheter directly measures:
- Central venous pressure
- Right sided intracardiac pressures
- Pulmonary arterial pressures
- Pulmonary artery wedge pressures
Which allows for an estimation of
- Cardiac output
- Systemic vascular resistance
- Pulmonary vascular resistance

243

102. Intra-aortic balloon pump is used to achieve the following:
a. decrease the need for ionotropic support given to the patient
b. inflate the balloon during systole
c. deflate the balloon just prior to systole
d. maintain diastolic blood pressure

Answer – C
Explanation –
Intra-aortic balloon pump improves the function of only the left ventricle
- Balloon inflates in diastole to help increase blood flow to the heart and rest of the body
- Balloon delates for systole to create extra space in the aorta allow the hear to pump out more blood and decrease the workload of the heart
- Blood flow is increased by improved diastolic perfusion and afterload is reduced
- Cardiac index typically improves after insertion and preload decreases
- Typical myocardial oxygen consumption is diminished by approximately 15%

244

103. The most sensitive finding in Volkmann’s ischemia in an 8 year old male who underwent closed reduction following a supracondylar fracture of the humerus:
a. pain on passive flexion of the fingers
b. pain on passive extension of the fingers
c. pain on active flexion of the fingers
d. pain on active extension of the fingers

Answer – B
Explanation –
Volkmann’s ischemic contracture occurs when there is a lack of blood to the forearm usually due to compartment syndrome- pain on passive stretch

245

104. The following is true regarding linear and depressed skull fractures:
a. is often associated with decreased LOC
b. often occurs in the thickest portion of the skull
c. not significant unless it crosses a major vascular channel
d. is often associated with low energy trauma

Answer – A
Explanation –
Criteria for surgical repair of a depressed skull fracture:
- Depression greater than 8-10 mm or greater than the thickness of the skull
- Brain function difficulties related to pressure or injury of the underlying brain
- Cerebrospinal fluid leakage
- Open depressed skull fracture, or a fracture exposed by a cut in the scalp

246

105. The patient had a massive blood transfusion following a major trauma. His CXR demonstrates bilateral pulmonary infiltrates, urine outputs is 30 cc/hr, CVP is 12. His respiratory demands in the ICU are increasing. The most likely etiology is:
a. Pulmonary embolus
b. ARDS
c. pulmonary contusion
d. cardiogenic pulmonary edema

Answer – B
Explanation
ARDS = acute change in lunch function, bilateral infiltraons on CXR, wedge pressure

247

106. The patient underwent closed reduction of femoral-tibial fracture in the ER. Shortly afterwards his ankle pulses disappear and you find decreased capillary refill in the toes. The most appropriate course of action is:
A. angiography
B. skeletal traction
C. immediate exploration
D. streptokinase

Answer – A
Explanation – suspect vascular injury – angiogram to assess

248

107. Dee an x-ray 1st with a spiral #, then a second with a rod going though that seems to be broken in the middle.... Patient had a tibial # which was fixed by ORIF. Since the time of the operation she has had continuous pain. Which of the following explains her condition:
a. non-union
b. mal-union
c. refracture

Answer – A
Explanation –

249

108. What is the best way to test for thyroid cancer recurrence post thyroidectomy
a. T4
b. calcitonin
c. TSH
d. Thyroglobulin

Answer – D
Explanation –
Surveillance guideline using TSH- stimulated Tg (thyroidglobulin) levels for patients who have undergone total or near-total thyroidectomy and I131 ablation for thyroid cancer and have no clinical evidence of residual tumor with a serum Tg below 1 ug/liter during THST
See more at: http://press.endocrine.org/doi/abs/10.1210/jc.2002-021702#sthash.3lKSaqbV.dpuf

250

109. shown a CXR with widened mediastinum and an ECG - Pt with previous MVC and now having issues post-op hernia repair... which investigation would you want to order:
a. contrast CT
b. VQ scan

Answer – A
Explanation –
To rule out aortic tear

251

110. Just graduated. Will be doing a procedure for the first time since residency. With respect to consent:
a. need to tell the patient that this is the first procedure you are doing since residency
b. don't need to tell the patient b/c it is obvious that you are a qualified surgeon
c. don't need to tell the patient if you have done the surgery during your residency unobserved.

Answer – B
Explanation -

252

111. Shown a picture of an angulated, displaced open fracture (xray and color picture) of a person’s leg. What is your first choice of management:
a. ORIF
b. irrigate and debride
c. re-align

Answer - C
Explanation –

253

112. Showen a blackened toe which belongs to DM patient - smells bad. What is the best choice of ABx
a. vancomycin
b. ceftriaxone
c. penicillin

Answer – B
Explanation –
Empiric Therapy for Diabetic Foot Ulcer:
Mild = (cephalexin + metronidazole) or (doxycycline + metronidazole) or amoxicillin-clavulanate or (cefazolin + metronidazole)
MRSA suspected = (doxycycline + metronidazole) or add TMP/SMX to above regimins listed for mild
Moderate to severe = (clindamycin + ciprofloxacin)
Failure of oral therapy or known/suspected ESBL/Amp C-producing organisms = Ertapenem
MRSA suspected in Moderate to severe = (vancomycin + ceftriaxone+ metronidazole)
Limb- threatening = piperacillin-tazobactam or (imipenem + vancomycin)

254

113. Shown a chest x-ray of a child - both inspiratory and expiratory. On expiratory see a hyperinflated right lung. What should you do:
a. place chest tube on left
b. place chest tube on right
c. get a CT

Answer – C
Explanation –
This is most in keeping with a foreign body aspiration which technically you can diagnose based solely on x-ray and then you would do bronchoscopy to removed the object. However since that isn’t an option you can also consider a CT to better visualize the object if its radiolucent on x-ray

255

114. What help contraction in a wound:
a. myoblasts
b. fibroblasts
c. collagen

Answer – A
Explanation –
Wound contraction – all wounds generate contractile forces adaptive process to fascilitate earlier closure of open wounds
- in loose skinned animals surrounding skin is pulled over the wound. This occurs much faster - than epitheliazation and also covers the wound with sensate skin
- humans don’t have same degree of mobility of skin – in some regions (perineum) 90% skin closure is by contracture. In other regions (leg) this process accounts for 30% which is part of the reason leg ulcers heal slowly
- when a contraction occurs over an active area of motion a decrease in mobility may occur – a contracture is a scar that limits the function range of motion of a joint
- fibroblasts have actin microfilaments like muscle cells and appear as myofibrils in wound contractures
- Myofibroblasts have been postulated as being the major cell responsible for contraction – differs from normal fibroblasts in that it possess a cytoskeletal structure

256

115. A patient has ulcer which has gone through to the subcutaneous tissue, but has not gone though the basement membrane vs fascia.?? This is an example of
a. stage I ulcer
b. stage II ulcer
c. stage III ulcer
d. stage V ulcer

Answer – C
Category/Stage I: Non-blanchable erythema
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons.
Category/Stage II: Partial thickness
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation.
*Bruising indicates deep tissue injury.
Category/Stage III: Full thickness skin loss
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.
Category/Stage IV: Full thickness tissue loss
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable

257

116. Side effects of chlorambucil:
a. paralytic ileus
b. bone marrow suppression
c. cardiomyopathy

Answer – B
Explanation –
Side effects include bone marrow suppression, fertility effects, secondary malignancy, seizures, and skin reactions

258

117. Abdominal Aortic Aneurysm measuring 5.5 cm – What is the risk of rupture in 5 years?
a. 1%
b. 10%
c. 25%
d. 55%

Answer – C
Explanation
Risk of rupture of small aneurysms (smaller than 4.0 cm) is much less than the risk of rupture of large aneurysms (larger than 6.0 cm). In addition to size, risk of rupture depends upon rate at which aneurysm is expanding evidence suggests that aneurysms expand at an average rate of 0.3 to 0.4 cm per year. The annual risk of rupture base upon aneurysm size is estimated as:
- less than 4.0 cm in diameter – less than 0.5%
- between 4.0 to 4.9 cm in diameter – 0.5 to 5 %
- between 5.0 to 5.9 cm in diameter – 3 to 15%
- between 6.0 to 6.9 cm in diameter – 10 to 20%
- between 7.0 to 7.9 cm in diameter – 20 to 40%
- greater than or equal to 8.0 cm in diameter – 30 to 50%

For 5.5 cm AAA growing 0.4 cm/year x 5 years = 5.5 cm + 2.0 = 7.5 cm in 5 years so risk would be 20-40% so answer should be C

259

118. What is the maximum survival time for a properly prepared amputated digit?
a. 6 hours
b. 12 hours
c. 18 hours
d. 24 hours

Answer – D
Explanation –
Recommended ischemia times for reliable success with replantation are 12 hours of warm and 24 hours of cold ischemia for digits and 6 hours of warm and 12 hours of cold ischemia for major replants, although successful replantation has been reported for longer ischemia times.

260

119. An elderly gentleman with a leaking AAA says that he does not want blood. His wife insists that he received blood. What do you do?
a. Do what the wife wants
b. Ask courts to allow you to give blood
c. Resuscitate with no blood
d. Give blood but don’t tell patient

Answer - C

261

120. Most common type of tumor in children

Answer – D
Explanation –
Most common cancers of children are:
- Leukemia – 30% of cancers in children
- brain and other central nervous system tumours – 26% of childhood cancers
- neuroblastoma – 6% of childhood cancers
- Wilms tumour – 5% of childhood cancers
- lymphoma (including both Hodgkin and non-Hodgkin) – 3-5% of childhood cancers
- Rhabdomyosarcoma – 3% of childhood cancers
- Retinoblastoma – 2% of childhood cancers
- bone cancer (including osteosarcoma and Ewing sarcoma) – 3% of childhood cancers

262

121. Which virus can cause post transplant lymphoproliferative disease:
a. CMV
b. EBV
c. HIV
d. Papovirus

Answer – B
Explanation –
EBV associated with post-transplant lymphoproliferative disorders
Postransplant lymphoproliferative disorder (PTLD) (Schwartz): Lymphomas constitute the largest group of noncutaneous neoplasms in transplant recipients. The vast majority (>95%) of these lymphomas consist of a spectrum of B-cell proliferation disorders associated with EBV, known collectively as PTLD. Risk factors include a high degree of immunosuppression, anti–T-cell antibody therapy, tacrolimus, and primary EBV infection posttransplant.

263

122. Excision margin for a 3 mm thick melanoma
a. 0.5 cm
b. 1.0 cm
c. 2 cm
d. 3 cm

Answer – C
Explanation –
T1 4mm ( 66% mets )
Wide local excision with margins depending on the T stage 0.5 cm to 3 cm for T1-T4
T1 +/- 1 cm margin
T2 and T3 +/- 2 cm margin + node dissection for palpable noes (therapeutic), SNB for nonpalpable nodes
T4 +/- at least 3 cm and node dissection if nodes are positive (therapeutic) or negative (prophylactic)

264

123. What is true of a patient with Antithrombin III deficiency:
a. Patient will be very sensitive to heparin
b. Warfarin is contraindicated
c. There is no known treatment to treat Antithrombin III deficiency
d. May cause recurrent arterial and venous thrombosis

Answer – D
Explanation -
Antithrombin normally neutralizes thrombin and other coagulation factors (IX, X, XI). Therefore, antithrombin deficiency causes a hypercoagulable state. This may cause recurrent venous and arterial thrombosis, although arterial ones are quite rare (

265

124. Body water highest for:
a. Male 60 years
c. Male > 60 years
d. Female

Answer – A
Explanation -

266

125. The following is true of patients with systemic candidiasis EXCEPT:
a. Retinal findings are diagnostic.
b. Blood cultures are only positive some of the time.
c. Urine culture is diagnostic.
d. Just one blood culture is significant

Answer – C
Explanation -
Blood cultures are positive only 50% of the time. Urine cultures can be positive in colonization, UTI, and systemic candidiasis, and therefore they are not diagnostic.
Can lead to complications in multiples organs:
- eyes (endophthalmitis)
- skin
- brain/meninges
- myocardium

267

126. What side effect are you most likely to see with giving Cephatholin?
a. Thrombocytopenia
b. Hypersensitivity
c. Hemolytic anemia
d. Neutropenia
e. Anaphylaxis

Answer – B
Explanation -
Cephalosporins are sensitizing, and a variety of hypersensitivity reactions occur, including anaphylaxis, fever, skin rashes, nephritis, and hemolytic anemia (Current Medical Diagnosis and Treatment).

268

127. Alveolar hypoventilation is best assessed by?
a. PaO2
b. SaO2
c. PaCo2
d. PAco2
e. Examination

Answer - C
Explanation –
Failure of ventilation will be reflected by an increase in CO2 in the blood, here PaCO2.

269

128. Systemic diastolic blood pressure is determined by:
a. cardiac output
b. elasticity of great vessels
c. peripheral vascular resistance
d. end diastolic pressure

Answer - C

270

129. The endothelium creates a substance that effects blood pressure, capillary permeability, and vascular flow, what is it?
a. Nitric Oxide
b. Bradykinin
c. Acetylcholine
d. Prostacyclin
e. Norepinephrine

Answer – A
Explanation -
Lange Physiology. Prostacyclin inhibits platelet aggregation and promote vasodilation
NO vasodilation, vascular remodeling, angiogenesis

271

130. Prophylaxis of DVT is indicated in which of the following circumstances?
a. 32 yr old male undergoing a total colectomy for familiar polyposis
b. 62 yr old man undergoing inguinal hernia repair
c. both of the above
d. neither of the above

Answer - A
Explanation -
Guidelines from the American College of Chest Physicians, 2008
2.1 General Surgery
2.1.1. For low-risk general surgery patients who are undergoing minor procedures and have no additional thromboembolic risk factors, we recommend against the use of specific thromboprophylaxis other than early and frequent ambulation (Grade 1A).
2.1.2. For moderate-risk general surgery patients who are undergoing a major procedure for benign disease, we recommend thromboprophylaxis with LMWH, LDUH, or fondaparinux (each Grade 1A).
2.1.3. For higher-risk general surgery patients who are undergoing a major procedure for cancer, we recommend thromboprophylaxis with LMWH, LDUH three times daily, or fondaparinux (each Grade 1A).
2.1.4. For general surgery patients with multiple risk factors for VTE who are thought to be at particularly high risk, we recommend that a pharmacologic method (ie, LMWH, LDUH three times daily, or fondaparinux) be combined with the optimal use of a mechanical method (ie, graduated compression stockings [GCS] and/or IPC) [Grade 1C].
2.1.5. For general surgery patients with a high risk of bleeding, we recommend the optimal use of mechanical thromboprophylaxis with properly fitted GCS or IPC (Grade 1A). When the high bleeding risk decreases, we recommend that pharmacologic thromboprophylaxis be substituted for or added to the mechanical thromboprophylaxis (Grade 1C).
2.1.6. For patients undergoing major general surgical procedures, we recommend that thromboprophylaxis continue until discharge from hospital (Grade 1A). For selected high-risk general surgery patients, including some of those who have undergone major cancer surgery or have previously had VTE, we suggest that continuing thromboprophylaxis after hospital discharge with LMWH for up to 28 days be considered (Grade 2A).

272

131. A patient with obstructive jaundice and hypoprothrombinemia. This is because:
a. poor fat absorption

Answer - A
Explanation –
Patient with obstructive jaundice has decreased fat absorption (dependent on bile). Remember that the fat soluble vitamins are A, D, E, and K. Patient with obstructive jaundice will therefore be deficient in vitamin K, and in all the vitamin K-dependent coagulation factors (II aka prothrombin, VII, IX, X).

273

131. Which one of the following does not interfere with platelet function:
a. ASA
b. Dextran
c. Dipyridamole
d. Phenylbutazone
e. Papaverin

Answer – E
Explanation –
ASA does (duh). Dextran adheres to plt surface and impairs aggregation, secretion and procoagulant activity. Dipyridamole inhibits platelet function in vitro. Phenylbutazone is a NSAID and inhibit platelet COX.
Papaverine relaxes smooth muscle cells, used to treat spasms in many different organs (vasodilator) – no link to platelets.

274

194. You are a witness against a patient who is suing the hospital. The patient ends up in Emerg, and you are asked to see him by the emerg doc since you’re on call. You should:
A. Refuse to see the patient
B. Provide direction for immediate care issues if OK with the patient, and then defer care to one of your colleagues
C. Tell the ERP to send the patient to a different community for care
D. Provide full care to the patient

B. Provide direction for immediate care issues if OK with the patient, and then defer care to one of your colleagues

275

195. Patient with metastatic cancer, no further treatment options available. Ends up requiring admission for something small, and during discussion of code status, states that he wants FULL CODE in case of cardiorespiratory arrest. Your options to deal with this situation include all, EXCEPT:
A. Negotiation
B. Arbitration
C. Rationing
D. Autonomy

C. Rationing

Physicians are not required to provide life-sustaining treatments that are deemed medically futile. This can override requests by patients or family members to continue aggressive therapy.

The governing principle in end-of-life decision making is patient autonomy, which takes precedence over physicians' judgment of what is most appropriate care. Patients have a right to refuse treatment, even if it delays appropriate treatment or results in the patient's death.

276

196. No pulse after closed reduction of knee dislocation What would you do:
A. Exploration
B. Doppler
C. Anticoagulation
D. Angiogram

D. Angiogram

An angiogram should be considered in all cases of knee dislocation.

277

197. Patient with pelvic # and hypotensive. Did not respond to fluid. What is the next appropriate step:
A. Laparatomy
B. Angiogram
C. External fixation
D. Try more fluid

B. Angiogram

278

198. What is the content of RL:
A. Na 154, K 0, Cl 113, HCO3 0
B. Na 130, K4, CL 109, HCO3 28
C. Na 135, K0, CL 103, HCO3 26

B. Na 130, K4, CL 109, HCO3 28

279

199. Patient with ulcerating lesion in the face (picture) with central keratin crust and fleshy edges, what is the most appropriate management:
A. Excisional biopsy
B. Incisional biopsy
C. Excision with 1 cm margin
D. Excision with 2 cm margin

A. Excisional bx

All suspicious lesions should undergo excisional biopsy. A 1-mm margin of normal skin is taken if the wound can be closed primarily. If removal of the entire lesion creates too large a defect, then an incisional biopsy of a representative part is recommended. Biopsy incisions should be made with the expectation that a subsequent wide excision of the biopsy site may be done. Once a diagnosis of melanoma is made, the biopsy scar and any remains of the lesion need to be removed to eradicate any remaining tumor. Four randomized prospective trials have been completed to address the issue of resection margins.166 The results of these trials suggest that lesions 1 mm or less in thickness can be treated with a 1-cm margin. For lesions 1 mm to 4 mm thick, a 2-cm margin is recommended. There is little data to support the use of margins wider than 2 cm.167 The surrounding tissue should be removed down to the fascia to remove all lymphatic channels.
Presence of ulceration in a lesion carries a worse prognosis. For unknown reasons these melanomas are more aggressive than those without ulceration. The 10-year survival rate for patients with local disease (stage I) and an ulcerated melanoma was 50%, compared to 78% for the same stage lesion without ulceration

280

200. What is the plasma volume of 70kg male patient:
A. 3L
B. 4L
C. 2L
D. 2.5L

A. 3L

• 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

281

132. Which is responsible for capillary bleeding?
a. Vasoconstriction
b. Fibrin clot
c. Platelet plug
d. Endothelial swelling

Answer - D

282

133. Most common benign breast disease:

Answer – Fibrocystic
Explanation -
“Fibrocystic disease is most frequent lesion of the breast; common from 30 to 50 years of age but rare after menopause”
Features:
♣ Painful, multiple, bilateral masses
♣ Rapid fluctuation in mass size
♣ Symptoms increase during premenstrual phase of cycle

283

134. A 40 year old patient with a three month history of a 1 cm thyroid lump. Otherwise asymptomatic and euthyroid. Had radiation to neck as a child. Your next move.
a. total thyroidectomy
b. partial thyroidectomy
c. reassurance and follow-up in 6 months
d. CT scan
e. Thyroxine suppression and follow up

Answer – A
Explanation –
Best option would be thyroid scintigraphy, ultrasound then FNA to determine whether this is malignant but as this isn’t an option, total thyroidectomy given the history of radiation

284

135. SCC of the lip in an 85 yo male. Metastatic work-up is negative (node negative, no mets). Size of the lesion measures 2.1 X 1 cm. What is the best management:
a. excision only
b. excision and radiation
c. excision and chemotherapy
d. excision and bilateral neck dissection
e. excision and radiation and chemotherapy

Answer – A
Explanation –
The risk of local regional recurrence and regional or distant metastasis is the most important factor in determining the approach to the treatment of cutaneous SCC.
The major treatment options for cutaneous SCC with features that suggest a low-risk for recurrence and metastasis are surgical excision, cryotherapy, electrosurgery, and radiation therapy. The specific choice of treatment modality depends upon the experience of the clinician, the expected cure rate, cosmetic factors, and patient preference.
Situations in which radiation therapy generally should be avoided include the following:
●Tumors located on the hands and feet. These areas are subjected to greater trauma and tension than skin on the head, neck, trunk, and proximal extremities, and may be more likely to break down and ulcerate as a result of the atrophy and poor vascularity of irradiated tissue.

285

136. During an excisional cervical lymph node biopsy, the thoracic duct is transected. The best action at this time is:
a. ligation of the duct
b. re-anastamosis of the duct to the subclavian vein
c. primary repair of the duct
d. closed suction drain
e. compression dressing and drain

Answer – A
Explanation -
3 options for cervical thoracic duct injury recognized intraop:
- ligation (safe as has many collaterals, highly satisfactory res.)
- repair (although technically difficult and time-consuming)
- implantation into adjacent vein (used to be performed when ligation was thought to be unsafe)

286

137. Management of pancreatic fistula following nephrectomy:
a. NPO and TPN.
b. Drain and TPN.
c. Drain.
d. Pancreaticojejunostomy.

Answer – A
Explanation -
Overall, the physiologic classification, diagnosis, management, and outcome of postoperative external pancreatic fistulas are similar to that for external intestinal fistulas. Diagnosis of the fistula is heralded by increased surgical drain output of serous to cloudy fluid with a high amylase content.
Once a pancreatic fistula has formed, medical management results in spontaneous closure in almost all fistulas. Octreotide therapy is beneficial because it significantly reduces fistula output and decreases the time until fistula closure. Endoscopic retrograde cholangiopancreatography (ERCP) is valuable because it allows the placement of a stent to bypass the high resistance of the sphincter of Oddi. The stent may also block the ductal opening of the fistula. Operative treatment of a benign pancreaticocutaneous fistula depends on the location of the fistula (proximal versus distal portion of the pancreas) and the status of the pancreatic duct (dilated versus stenotic duct). High excision of the fistula with fistuloenterostomy is associated with the best results.
Found no great source, some say TPN is the way to go initially to optimize their catabolic state, but initiate enteral nutrition as early as possible. Treatment seems to depend on whether fistula is intraabdominal or cutaneous.

287

138. A pregnant woman presents with jaundice. What lab values suggest that this is secondary to a hepatocellular problem?
a. Increased GGT
b. Increased ALP
c. Decreased urobilinogen (?urinary)
d. Increased indirect (unconjugated) bilirubin

Answer – A
Explanation -
Increased ALP presents with a picture of cholestasis, whereas increased indirect bilirubin is “pre-liver”, usually heme problems. Urobilinogen is formed in the GI tract by catabolism of conjugated bili by bacteria. It is then excreted in the urine. Urobilinogen levels tested in the urine an increase is usually related to hemolytic processes or hepatocellular problems, whereas as decrease is seen with obstructive jaundice or broad-spectrum abx (wipes out normal intestinal flora).
An increase in GGT can be seen in both cholestasis and hepatocellular problems.

288

139. Which of the following is seen in basal skull fracture:
a. Subgaleal hematoma
b. Anosmia
c. Hemotympanum
d. Decreased level of consciousness

Answer – C
Explanation -
Clinical signs of basal skull fracture:
- CSF otorrhea and rhinorrhea
- Hemotympanum or laceration of EAC
- Postauricular ecchymoses (Battle’s sign)
- Periorbital ecchymoses (raccoon’s eyes)
- Cranial nerve injury
- VII and/or VIII (with temporal bone fractures)
- I (anterior fossa, results in anosmia)
- II (anterior fossa extending into optic canal)
- VI (through clivus)
- Shearing of pituitary gland (seen in severe BSF)

289

140. What is the best vein to access the superior vena cava for long term hypertonic TPN?
a. internal jugular
b. external jugular
c. cephalic
d. basilic

Answer - A
A more recent trend is to use peripherally inserted central catheters (PICCs) introduced via the basilic vein, both in the inpatient setting and also for longer-term outpatient therapy. When evaluated in controlled trials, PICC lines show similar rates of line sepsis as traditional central catheters but have an increased incidence of local complications such as leakage, thrombophlebitis, and malpositioning. At best, a PICC line in the outpatient setting has a lifetime of 4 to 6 weeks before malfunctioning or becoming infected. Therefore, for long-term TPN administration, a more permanent solution is needed. The devices available consist of either subcutaneously tunneled central catheters (Hickman, Broviac, Groshong) or self-contained implantable chambers that connect to the central venous system (portacath). The catheter of these devices can be inserted into the vein percutaneously (e.g., the subclavian, internal jugular, or femoral).

290

141. A person who is ASA III is likely :
a. expected to die imminently
b. suffering severe major medical illness
c. healthy
d. asymptomatic systematic disease
e. suffering mild symptomatic systemic disease

Answer – B
Explanation –
ASA I – a normal healthy patient
ASA II – a patient with mild systemic disease
ASA III – a patient with severe systemic disease
ASA IV – A patient with sever systemic disease that is a constant threat to life
ASA V – a moribund patient who is not expected to survive without the operation
ASA VI – a declared brain-dead patient whose oranges are being removed for donor purposes

291

142. All of the following are benefits of smoking cessation 6 weeks prior to surgery except
a. improved ciliary function
b. decreased airway reactivity
c. decreased co2 retention
d. increased secretion clearance

Answer – C
Explanation -
According to Miller’s Anesthesia, “an improvement in mucociliary transport and small-airway function and a decrease in airway secretions and reactivity occur over a period of several weeks after cessation of smoking”.

292

143. Which has been shown to decrease peri-op cardiac morbidity in patients with cardiac history
a. atenolol
b. enalapril
c. ASA
d. Nitroglycerine

Answer – A

293

144. Which drug does not cause hypokalemia
a. Lasix
b. vit B12
c. insulin
d. digoxin

Answer – D
Explanation -
Etiology for hypokalemia (Harrison’s exhaustive list)
- Inadequate intake
Starvation
Clay ingestion
- Excessive renal excretion
♣ Increased distal flow
Osmotic diuresis
Diuretics
Salt-wasting nephropathies
♣ Increased secretion
Mineralocorticoid excess (e.g. hyperaldosteronism)
Distal delivery of non-reabsorbed anion (e.g. vomiting, type 2 RTA, DKA, penicillins)
Penicillin (promotes renal tubular loss)
- Gastrointestinal losses
Diarrhea
- Intracellular shifts
♣ Acid-base
Metabolic alkalosis
♣ Hormonal
Insulin
Beta2-adrenergic agonists
Alpha-adrenergic antagonists
♣ Anabolic state
Vitamin B12 or folic acid (RBC production)
GM-CSF (WBC production)
TPN
♣ Other
Pseudohypokalemia
Hypothermia
Hypokalemic periodic paralysis
Barium toxicity

294

145. X-Ray of a tibia with IM nail - X-ray AP and lateral
a. demonstrates failure of hardware with nonunion
b. answer
c. refracture
d. nonunion

Answer: A

295

146. X-Ray of severe lytic lesion involving entire tibia. Hx includes long standing infection intermittently treated with Abx. Clinical photo demonstrates a large superficial bleeding lesion. What is most likely diagnosis?
a. osteosarcoma
b. super infection

Answer - ? SCC
Not in the choices above but likely SCC given clinical features.
1999: McGrory et al published a retrospective review of 53 patients with neoplasms arising in chronic osteomyelitis. Results:
- SCC (50 patients)
- Fibrosarcoma (1)
- Myeloma (1)
- Lymphoma (1)

296

148. Forearm radial artery – median vein fistula 3 months ago. few weeks numbness, weakness atrophy around fistula
a. heparin
b. dilate fistula
c. thrombolyse
d. obliterate fistula

Answer - D
Explanation –
Steal syndrome
o Pain
o Weakness
o Paresthesia
o Muscle atrophy
o Gangrene (if left untreated)
Treatment is ligation of fistula

297

149. MVA. T7 vertebra exploded – paraplegic. numerous litres of volume infused, still hypotensive. abd US no hemoperitoneum. closed pelvis fracture. likely cause of hypotension?
a. undiagnosed abd injury
b. head injury
c. neurogenic shock

Answer – C

298

150. Re carbon monoxide
a. carboxyhemoglobin binds O2 with less affinity
b. half life of carboxyhemoglobin is 45 – 60 min on room air
c. CO binds Fe containing proteins
d. Half life of CoHb is 5-6 hours on room air; this is reduced to 90 minutes with O2 administration.

Answer - C