2006_ all reviewed Flashcards

Question

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

Answer 1

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.

Answer 2

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).

Answer 3

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.

Answer 4

B. Lung CA

Answer 5

D. Emergent Thoracotomy

Answer 6

A. Pain with passive toe extension

Answer 7

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

Answer 8

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)

Answer 9

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

Answer 10

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)

Answer 11

B. Pressure

Answer 12

C. Call the surgeon chief

Answer 13

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)

Answer 14

abnormal plt function

Answer 15

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)

Answer 16

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_

Answer 17

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

Answer 18

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)

Answer 19

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.

Answer 20

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).

Answer 21

Ans: A -racoon eyes and battle sign = basal skull #

Answer 22

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.

Answer 23

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)

Answer 24

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

Answer 25

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

Answer 26

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

Answer 27

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

Answer 28

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)

Answer 29

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.

Answer 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)

Answer 31

Ans: D -inhibits vit K-dependent coagulation factor synthesis (II, VII, IX, X, proteins C and S) 1972 Canada vs. Soviet union

Answer 32

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

Answer 33

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)

Answer 34

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 ```

Answer 35

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)

Answer 36

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.

Answer 37

□ 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…

Answer 38

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

Answer 39

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)

Answer 40

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.

Answer 41

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

Answer 42

□ 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

Answer 43

□ 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

Answer 44

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

Answer 45

``` □ 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 ```

Answer 46

□ Answer a: Absorbable monofilament | polydiaxanone

Answer 47

□ 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).

Answer 48

□ 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

Answer 49

□ Answer: all of these are side effects of vincristine

Answer 50

□ Answer C

Answer 51

□ Answer C

Answer 52

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

Answer 53

□ Answer C

Answer 54

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

Answer 55

□ 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)

Answer 56

□ answer B ASA 2

Answer 57

□ 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

Answer 58

□ answer C

Answer 59

□ 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

Answer 60

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

Answer 61

□ 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.

Answer 62

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

Answer 63

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

Answer 64

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).

Answer 65

□ 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.

Answer 66

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

Answer 67

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

Answer 68

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.

Answer 69

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

Answer 70

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.

Answer 71

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

Answer 72

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

Answer 73

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)

Answer 74

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

Answer 75

Answer: C.

Answer 76

Answer: C. implies lack of justice

Answer 77

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

Answer 78

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.

Answer 79

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.

Answer 80

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

Answer 81

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

Answer 82

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

Answer 83

Answer: B.

Answer 84

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

Answer 85

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.

Answer 86

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.

Answer 87

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.

Answer 88

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

Answer 89

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

Answer 90

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

Answer 91

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

Answer 92

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

Answer 93

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

Answer 94

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.

Answer 95

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

Answer 96

Answer: B. Classic repeated question.

Answer 97

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

Answer 98

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.

Answer 99

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.

Answer 100

Answer: D.

Answer 101

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

Answer 102

Answer: A Factor V leiden

Answer 103

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

Answer 104

Official answer: b I would say all of the above.

Answer 105

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

Answer 106

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

Answer 107

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.

Answer 108

not sure what the question is here. | something about keratocanthosis

Answer 109

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.

Answer 110

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

Answer 111

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

Answer 112

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.

Answer 113

again, not sure what the question is here.

Answer 114

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

Answer 115

Answer: C. 33 kg/m2 BMI = mass(kg)/ (height in m)^2 = 100/(1.75)(1.75) = 32.6

Answer 116

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.

Answer 117

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)

Answer 118

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

Answer 119

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

Answer 120

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

Answer 121

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

Answer 122

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

Answer 123

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

Answer 124

Answer: D. Inform the police.

Answer 125

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.

Answer 126

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)

Answer 127

Answer: D. Finger flexion (DIP joint) ``` C5- Elbow Flexors. C6 – Wrist Extensor. C7 – Elbow Extensor. C8 - Finger Flexion. T1 – Finger Abduction. ```

Answer 128

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)

Answer 129

Answer: B. Increased Lacrimation Horner Syndrome, Classic Findings: - ptosis - miosis - anhidrosis

Answer 130

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.

Answer 131

answer: a vs b, would depend on image.

Answer 132

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.

Answer 133

Answer: C. Factor VII FFP have factor II, V, X, XI

Answer 134

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.

Answer 135

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.

Answer 136

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.

Answer 137

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.

Answer 138

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.

Answer 139

Answer: B. Do another study with larger sample size. Indicates that your study may be underpowered to detect a statistically significant difference.

Answer 140

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

Answer 141

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

Answer 142

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;

Answer 143

Answer: D. Combined to Ammonia

Answer 144

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)

Answer 145

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

Answer 146

Answer: C. Multiple Fractures. Paget's doesn't normally have hypercalcemia, but can in instances of immobilization.

Answer 147

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)

Answer 148

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)

Answer 149

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

Answer 150

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

Answer 151

Answer: unknown, they could all be used.

Answer 152

Answer: C. SIADH SIADH causes fluid retention via increased ADH, causing hyponatreamia

Answer 153

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

Answer 154

Answer: C. Platelet Transfusion. Shouldn't give because it can potentiate thrombus formation in HIT. Warfarin can be given after bridging.

Answer 155

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.

Answer 156

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.

Answer 157

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.

Answer 158

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.)

Answer 159

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.

Answer 160

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"

Answer 161

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.

Answer 162

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.

Answer 163

Answer: C. CT Head Evidence of facial trauma and memory loss. Canadian CT Head Rules: a) High Risk (for neurological intervention) 1. GCS score

Answer 164

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

Answer 165

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.

Answer 166

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.

Answer 167

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.

Answer 168

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.

Answer 169

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.

Answer 170

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.

Answer 171

Answer: B. Normal Saline Need to fluid resuscitate.

Answer 172

Answer: D. Give lasix 40mg IV All the rest have been shown to decrease ICP.

Answer 173

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,

Answer 174

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

Answer 175

A. Na concentration

Answer 176

B. K and Mg

Answer 177

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

Answer 178

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

Answer 179

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.

Answer 180

B. Metoprolol

Answer 181

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

Answer 182

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 ```

Answer 183

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

Answer 184

B. Chest trauma Risk factors: - Asbestos exposure - Radiation therapy - Other occupational exposure Clinical presentation: - dyspnea - weight loss/anorexia - night sweats - weakness - chest pain

Answer 185

B. Inhibit osteoclast

Answer 186

B. Low PaO2, low SaO2, normal pulse ox

Answer 187

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

Answer 188

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

Answer 189

B. Surgery last > 3 hrs

Answer 190

B. Chest trauma

Answer 191

B. Group B strep

Answer 192

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

Answer 193

B. Immature liver glucorinide enzyme

Answer 194

B. Azathioprine

Answer 195

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]

Answer 196

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

Answer 197

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

Answer 198

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

Answer 199

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 ```

Answer 200

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.

Answer 201

B. Respond specifically to intralesional injection of triamcinolone

Answer 202

D. 30 y.o. male for hernia repair

Answer 203

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

Answer 204

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

Answer 205

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

Answer 206

C. Neuropathy

Answer 207

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

Answer 208

C. Leeches

Answer 209

B. Osteoradionecrosis

Answer 210

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

Answer 211

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%

Answer 212

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

Answer 213

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

Answer 214

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

Answer 215

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

Answer 216

Answer – A | Explanation –

Answer 217

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

Answer 218

Answer – A Explanation – To rule out aortic tear

Answer 219

Answer – B | Explanation -

Answer 220

Answer - C | Explanation –

Answer 221

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)

Answer 222

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

Answer 223

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

Answer 224

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

Answer 225

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

Answer 226

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

Answer 227

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.

Answer 228

Answer - C

Answer 229

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

Answer 230

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.

Answer 231

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)

Answer 232

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 (

Answer 233

Answer – A | Explanation -

Answer 234

``` 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 ```

Answer 235

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).

Answer 236

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

Answer 237

Answer - C

Answer 238

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

Answer 239

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).

Answer 240

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).

Answer 241

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.

Answer 242

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

Answer 243

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.

Answer 244

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

Answer 245

B. Angiogram

Answer 246

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

Answer 247

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

Answer 248

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

Answer 249

Answer - D

Answer 250

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

Answer 251

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

Answer 252

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.

Answer 253

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)

Answer 254

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.

Answer 255

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.

Answer 256

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)

Answer 257

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).

Answer 258

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

Answer 259

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”.

Answer 260

Answer – A

Answer 261

``` 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 ```

Answer 262

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)

Answer 263

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

Answer 264

Answer – C

Answer 265

Answer - C

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