2009 exam part II

Question 1

Guy with NG, output is 1500 cc/day. He becomes lethargic and weak, and has ileus. What is most likely?

a) hypomagnesemia
b) hypochloremic metabolic alkalosis
c) hypokalemic metabolic alkalosis
d) hyponatremia

Answer 1

NG = hypokalemia, met alk

Question 2

Low magnesium, which is a sign?

Answer 2

tremor

its when you have HIGH mag that you have loss of DTRs, hence when a patient is on mag you check the reflexes as a way to monitor mag levels and toxicity

Question 3

Patient with carpal tunnel syndrome, which are you most likely to find?
weak thumb abduction
weak thumb adduction

Answer 3

weak thumb abduction

Question 4

Patient with mediastinitis (picture provided, large wound) post CABG. What is the best management?

Answer 4

Debridement, rigid sternal fixation, myocutaneous flap

Question 5

Shown picture of a child with burn to right thorax and right arm. Erythematous. What is the degree of burn?

Answer 5

second or third degree.
second degree = blistering
third degree is fullthickness and extends thru the entire dermis

Question 6

Shown picture of a large keloid on earlobe. What is the management?

Answer 6

intralesional steroid injection ( kenalog)

Question 7

Shown picture of an ulcer on the sole of a diabetic foot. What is the mechanism by which this occurs?

Answer 7

neuropathy

Question 8

Shown picture of venous stasis ulcer, which is best management?

Answer 8

compression stalking/dressings

Question 9

Shown picture of TRAM to right breast POD#2. Upper part of flap is good cap refill, good pulse by Doppler, and warm. Picture shows upper part is normal color, but lower looks venous congested and has small bullae. What is the best management?

Answer 9

leeches

anytime there is venous congestion from a graft or flap its leech therapy. god knows why we cant come up with something better

Question 10

Shown a picture of mole on face. You do not feel that you can excise the lesion and do primary closure. What is the best management?

• FNA
• Incisional biopsy of the mole
• Incisional biopsy of the mole and normal skin
• Shave biopsy of entire lesion

Answer 10

if its melanoma you need to take the whole thing, plus some normal skin =
incisional + normal skin

Question 11

Shown picture of big ulcerated lesion over lower leg. Patient had tibia fracture 20 years ago with chronic draining sinus, which has been enlarging for past few months. What is most likely?

• Superinfection
• SCC
• Osteosarcoma
• Something else

Answer 11

SCC

Question 12

What is the deepest burn that you can get for spontaneous epithelialization to still occur?

Answer 12

deep papillary dermis

Question 13

Shown picture of carpal tunnel release intraop, with 2 longitudinal lines that are thin and look like veins.  What is the etiology?
Congenital
Systemic disease
Inflammation
Factitious

Answer 13

congenital

Question 14

Shown picture of electrical burn to right hand and arm, no eschar. Patient has extreme pain on passive stretch of fingers. What do you do?

Answer 14

immediate fasciotomy

Question 15

Shown picture of kid with dog bite to face. What is the best management?

Answer 15

Irrigate, debride, and careful multiple layer closure

Question 16

Senior resident never respects gowning and hand-washing procedure during an MRSA outbreak. What CanMEDs competency is he failing to show?

Answer 16

professionalism

Question 17

Anion that is not measured and contributes to your normal anion gap?

Answer 17

albumin

Question 18

What gives you decreased platelet count and qualitative defect in platelet function?

Answer 18

VWF

Question 19

15 year-old guys shows up with retracted testicle, absent cremasteric reflex, 6 hours post start of pain. Best management?
Go to OR urgently for detorsion of left testicle and left orchiopexy
Go to OR urgently for detorsion of left testicle and bilateral orchiopexy.

Answer 19

OR, bilateral pexy to correct the congenital bell clapper deformity that is likely present on both sites and is the most common cause of testicular torison

Question 20

Shown an axial slice of CT showing right SC(sterno clavicular) joint dislocation, with head of clavicle displaced posteriorly. There is no pneumo at the lung apices. Patient has distended neck veins, plethora in the face, and complains of respiratory distress. What is the best management?

Answer 20

SC joint reduction

reduce the joint!!

Question 21

Woman with medullary thyroid cancer, has 12 and 15 year old child. What is most appropriate screening test for her children?

Answer 21

RET

Question 22

Guy post MVC, presents with tachypnea, tachycardia, decreased air entry on one side, hyperresonant percussion, and trachea deviated to contra-lateral side. What do you do?

Answer 22

Needle decompression 2nd ICS mid clavicular line

Question 23

Which of the following is not an absolute contraindication to a chest tube?
Spontaneous pneumo
Open pneumo
Chylothorax
s/p thoracic surgery for drainage

Answer 23

spont pneumo??

Question 24

Patient comes in with trauma, needs blood. His blood is checked for ABO and Rh compatibility, but not cross-matched. What is the chance that he will get an acute hemolytic reaction?

Answer 24

0.1%

Question 25

``` Answer: A Which of the following is not a feature of acute rejection in kidney transplant. hypertension pancytonia tenderness at graft increased graft size ```

Answer 25

pancytopenia Im guessing is what they were trying to say

Question 26

``` Regarding acute rejection in transplant, all true except? Cell mediated Most common rejection reaction Most are asymptomatic Biospy shows intravascular coagulation ```

Answer 26

asymptomatic - thats not true at all

Question 27

``` Which of the following causes reversible nephrotoxicity? Cyclophosphamide Azathioprine Cyclosporin A Steroids ```

Answer 27

cyclosporin A

Question 28

In heart transplant, all are used except? methotrexate tacrolimus azathioprine

Answer 28

methotrexate

Question 29

``` Patient with pH 7.55, pCO2 24, PO2 60 on 30% O2. He is on respirator at RR 12 and tidal volume 10cc/kg, PEEP 5. What is the first step? increase FiO2 increase tidal volume increase dead space of tubing sedate patient more ```

Answer 29

increase FiO2

Question 30

``` Which of the following is the most common mechanism of hypoxia in acute lung injury? diffusion problem right to left shunt ventilation perfusion mismatch something else ```

Answer 30

diffusion problem

Question 31

What is the rate of transmission of HCV from a single unit PRBC transfusion?

Answer 31

1 in 300,000

Question 32

``` What is not a criteria for SIRS? respiratory rate > 20 temp > 38.5 HR < 85 sBP < 90 ```

Answer 32

recall that SIRS is actually just heart rate, resp rate, temp and white count. BP is not in there, and the HR value they gave here is incorrect

Question 33

``` Which is not consistent with severe PE? increased CVP increased wedge pressure decrease in PaCO2 increase in A-a gradient ```

Answer 33

increased PCWP pulm cap wedge pressure. this is a reflection of pressure in the left atrium

Question 34

What is a contraindication to tPA? Surgery 10 days ago Old stroke on CT Failure of urokinase

Answer 34

A- surgery ten days ago

Question 35

``` Patient with pmhx of dvt, gets into MVC. Fracture L femur and R medial malleolus. Cerebral edema on MRI, rest of scans normal. What is the best way to anticoagulate? SCDs Unfractionated heparin q12h LMWH Warfarin ```

Answer 35

LMWH

Question 36

What determines dBP? peripheral vascular resistance cardiac output blood volume

Answer 36

peripheral vascular resistance

Question 37

``` Lady with breast ca, getting intramedullary nail of femur for impending fracture. Anesthetist alerts you that she has become hypotensive, tachypneic, and difficult to ventilate. What is the diagnosis? Acute PE Fat embolus MI Anaphylaxis Answer: B ```

Answer 37

fat embolus

Question 38

``` Guy with open fracture of tibia, loss of anterior coverage of 6 cm. What is the best option for coverage? Primary closure Rotational flap medial gastroc flap free tissue transfer ```

Answer 38

free tissue transfer

Question 39

What is the best option to eliminate dead space post debridement of dead bone? Myocutaneous flap Closed suction drain Skin graft

Answer 39

myocutaneous flap

Question 40

What is an absolute indication to reimplantation? Complete ring avulsion of 4th digit in 45 year old woman 15 year old had saw injury with amputation at MCP joint of thumb

Answer 40

any amputation through the thumb is an indication for surgery

Question 41

Which is true about management of a contaminated open fracture?

Answer 41

early immobilization decreases infection risk

Question 42

Shown an outlet view of a pelvis, obvious open book fracture. What is the mechanism? AP compression Lateral compression Vertical shear

Answer 42

AP compression

Question 43

``` During ureteral repair, which of the following is not true? Debridement Stent placement is optional Water tight closure Tension-free anastomosis ```

Answer 43

stent placement is optional

Question 44

``` Which of the following has the highest metabolic rate 1 week post injury? Major burn Peritonitis/sepsis Elective abdominal procedure Skeletal procedure ```

Answer 44

major burn

Question 45

``` omeone with 6th and 7th rib fractures, has failed SQ and PO narcotics, what do you do? Chest physio Epidural Surgical fixation of fractures Bracing ```

Answer 45

epidural

Question 46

``` What tissue has longest warm ischemia time? skin muscle kidney small bowel ```

Answer 46

skin

Question 47

``` What is the general recognized maximal ischemia time for muscle and nerve? 4 hours 6 hours 8 hours 10 hours Answer: B ```

Answer 47

6 hrs you have to get a pulseless limb to the OR in 6 hrs

Question 48

Young chap with 20% grease burn to hand and upper extremity. What is the management? Start Ringers at 3500 cc/hr, give tetanus toxoid, and local wound care Start resuscitation, give tetanus shot and transfer to tertiary burn unit

Answer 48

resus, give tetanus, transfer to burn center