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Flashcards in 2009 with explanations (2009_day2_grdhg) Deck (102):
1

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: C (NG loss lead to hypokalemia which lead to chloride resistant shift of hydrogen ions into intracellular space leading to metabolic alkalosis, Hypokalemia also leads to weakness and ileus)
Metabolic alkalosis
Causes
There are five main causes of metabolic alkalosis
These can be divided into two categories, depending upon urine chloride levels.
Chloride-responsive (20 mEq/L)
· Retention of bicarbonate
· Shift of hydrogen ions into intracellular space - Seen in hypokalemia. Due to a low extracellular potassium concentration, potassium shifts out of the cells. In order to maintain electrical neutrality, hydrogen shifts into the cells, raising blood pH.
· Alkalotic agents - Alkalotic agents, such as bicarbonate (administrated in cases of peptic ulcer or hyperacidity) or antacids, administered in excess can lead to an alkalosis.
·
HYPOKALEMIA
· Mild hypokalemia is often without symptoms, although it may cause a small elevation of blood pressure,[2] and can occasionally provoke cardiac arrhythmias.
· Moderate hypokalemia, with serum potassium concentrations of 2.5-3 mEq/L, may cause muscular weakness, myalgia, and muscle cramps (owing to disturbed function of the skeletal muscles), and constipation (from disturbed function of smooth muscles).
· Severe hypokalemia, flaccid paralysis, hyporeflexia, and tetany may result. There are reports of rhabdomyolysis occurring with profound hypokalemia with serum potassium levels less than 2 mEq/L. Respiratory depression from severe impairment of skeletal muscle function is found in many patients.
· Some electrocardiographic (ECG) findings associated with hypokalemia are flattened or inverted T waves, a U wave, and prolongation of the QT interval. The prolonged QT interval
CAUSES
Hypokalemia can result from one or more of the following medical conditions:
1. Inadequate potassium intake
2. Gastrointestinal/integument loss
o A more common cause is excessive loss of potassium, often associated with heavy fluid losses that "flush" potassium out of the body. Typically, this is a consequence of diarrhea, excessive perspiration, or losses associated with surgical procedures. (by extrapolation NG losses)
o Vomiting can also cause hypokalemia, although not much potassium is lost from the vomitus. Rather, there are heavy urinary losses of K+ in the setting of post-emetic bicarbonaturia that force urinary potassium excretion (see Alkalosis below).
3. Urinary loss
4. Distribution away from ECF

2

2. Low magnesium, which is a sign?
a. absent DTRs
b. tremor
c. hypotension (no)
d. bradycardia

Answer: B
Deficiency of magnesium causes weakness, muscle cramps, cardiac arrhythmia, increased irritability of the nervous system with tremors, athetosis, jerking, nystagmus and an extensor plantar reflex. In addition, there may be confusion, disorientation, hallucinations, depression, epileptic fits, hypertension, tachycardia and tetany.

3

3. Patient with carpal tunnel syndrome, which are you most likely to find?
a. weak thumb abduction
b. weak thumb adduction
c. weak PIP flexion in all fingers
d. hypothenar atrophy

Answer: A
Compression of the median nerve as it runs deep to the transverse carpal ligament (TCL) causes wasting of the thenar eminence, weakness of the flexor pollicis brevis, opponens pollicis, abductor pollicis brevis, as well as sensory loss in the distribution of the median nerve distal to the transverse carpal ligament. There is a superficial sensory branch of the median nerve, which branches proximal to the TCL and travels superficial to it. This branch is therefore spared, and it innervates the palm towards the thumb.
In chronic cases, there may be wasting of the thenar muscles, weakness of palmar abduction of the thumb (difficulty bringing the thumb away from the hand).

4

4. Patient with mediastinitis (picture provided, large wound) post CABG. What is the best management?
a. Debridement, rigid sternal fixation, delayed primary closure
b. Debridement and secondary closure
c. Debridement, local myocutaneous flap
d. Debridement, rigid sternal fixation, myocutaneous flap

Answer: C
Derek says A – according to Journal of Cardio thoracic sx - modern management of mediastinitis with early aggressive debridement followed by delayed wound closure has been reported to reduce early mortality to less than 20%.
Surgical debridement is the mainstay of therapy for postoperative mediastinitis. Debridement may be followed by a short or long period of open packing, immediate closure of the debrided sternum with or without closed-wound irrigation, or resection of the sternum with primary or secondary closure of the wound using muscle or omental flaps

5

5. Shown picture of a child with burn to right thorax and right arm. Erythematous. What is the degree of burn?
a. First degree
b. Second degree
c. Third degree
d. Mixed second and third

Answer: B vs. C (I recall seeing whitish areas over the erythema- the erythema + blisters = 2nd degree burn, but the whitish skin = 3rd degree burn)

6


6. Shown picture of a large keloid on earlobe.
What is the management?
a. Surgical excision and careful closure
b. Surgical excision and radiation
c. Compressive dressings
d. Intralesional steroid injection

Answer: B
Derek says – D – this is what we routinely did on plastics

Most studies [18,29-31], but not all [32], have found radiation therapy to be highly effective in reducing keloid recurrence, with improvement rates of 70 to 90 percent when administered after surgical excision.

https://webvpn.mcgill.ca/http/www.utdonline.com/online/content/topic.do?topicKey=dermatol/7243&selectedTitle=1%7E39&source=search_result#H6

An auricular keloid occurring following ear-piercing remains a difficult condition to treat. Various treatments have been described, with different reported degrees of success. Pressure therapy has been shown to be an effective treatment for auricular keloids, although the devices used have not all been universally accepted. We assessed 30 patients, between 1989 and 1999, who had been fitted with pressure devices made from Zimmer splints. There was a 50% or greater reduction in the size of each keloid when assessed at 1 year

7

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

Answer: B
Neuropathy is present in over 80 percent of patients with foot ulcers; it promotes ulcer formation by decreasing pain sensation and perception of pressure, by causing muscle imbalance that can lead to anatomic deformities, and by impairing the microcirculation and the integrity of the skin. Once ulcers form, healing may be delayed or difficult to achieve, particularly if infection penetrates to deep tissues and bone and/or there is diminished

8

8. Shown picture of venous stasis ulcer, which is best management?
a. compressive dressings
b. revascularization
c. sulfadiazine lotion

Answer: A (compressive is for prevention of ulcers and of recurrence; occlusive dressings are a treatment option of venous ulcers)
Occlusive dressings may be fully occlusive (impermeable to gases and fluids) or semi-permeable (impermeable to fluids and partially permeable to gases like oxygen and water vapor). Occlusive dressings speed reepithelialization, stimulate collagen synthesis, and create a hypoxic environment at the wound bed that encourages angiogenesis [92]. Infection rates with occlusive dressings are lower than the rate of infection in general wound care. This may be due to several factors including effective barrier protection and reducing local pH [93]. Up to date
The continued use of graduated compression stockings after ulcer healing reduces recurrence and patients. Up to date

9

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?
a. Observe
b. Heparinize
c. leeches
d. urgent exploration

Answer: C

Salvage Procedures for the Failing Flap
Monitoring the free flap during the postoperative phase is critical to ensure flap survival. When recognized early and managed promptly (

10

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?
a. FNA
b. Incisional biopsy of the mole
c. Incisional biopsy of the mole and normal skin
d. Shave biopsy of entire lesion

Answer: C
Derek says – B – according to Shwartz – under melanoma treatment – 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.
· Simple excisional biopsy is the procedure of choice for removal and diagnosis of a melanocytic nevus. All removed melanocytic nevi should be submitted for microscopic evaluation. It is optimal to strive for complete excision of a given lesion, if at all possible, when melanoma is considered in the differential diagnosis.
· A complete excisional biopsy permits all available histopathological criteria to be applied to a lesion and thus enables a more precise diagnosis.
· When a partial punch or shave biopsy sample is taken from a lesion, the interpreting pathologist cannot apply important criteria, such as symmetry and circumscription (lateral demarcation), to the assessment of the lesion. If a partial biopsy specimen of a larger lesion is obtained because of clinical necessity, the fact that the specimen is partial should be clearly indicated on the requisition form.
· Partial biopsy samples can sometimes lead to misdiagnosis because of sampling error.
· Partial biopsy samples can inflate the number of procedures required for diagnosis because a partial biopsy sample that does not enable a definitive diagnosis to be made necessarily leads to subsequent reexcision of the lesion in question.
http://emedicine.medscape.com/article/1058445-diagnosis

11

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?
a. Superinfection
b. SCC
c. Osteosarcoma
d. Something else

Answer: B
Squamous cell carcinoma (SCC) is a rare, but well-documented complication of osteomyelitis and chronic wounds. Treatment of choice for these tumors commonly occurring on the legs has been amputation. Two recent articles have suggested the utility of Mohs micrographic surgery (MMS) as a limb saving procedure.
OBJECTIVE:

12

12. What is the deepest burn that you can get for spontaneous epithelialization to still occur?
a. epithelium
b. superficial papillary dermis
c. deep papillary dermis
d. reticular layer

2nd Reticular layer + Third degree burn = no epithelization
BURN CLASSIFICATION

Degree Description
1st Sunburn (epidermis)
2nd Superficial Dermis (Papillary) Painful to touch; blebs and blisters; hair follicle intact; blanches
2nd Deep Dermis (Reticular) Decreased sensation; loss of hair follicles (need skin grafts)
3rd Leathery feeling (charred parchment); down to subcutaneous fat
4th Down to bone, into adjacent adipose or muscle tissue

13

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

A???

14

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?
a. Immediate escharotomy hand and arm
b. Immediate fasciotomy
c. Cloxacillin

Answer: B
Pain on passive stretch of fingers = CLASSIC SIGN FOR COMPARTMENT SYNDROME = urgent fasciotomy
ESCHAROTOMY INDICATIONS (perform within 4-6 hours)
1. Circumferential burns
2. Low temperature; weak pulse; capillary refill;  pain sensation; and  neurologic function in extremity → may need fasciotomy if compartment syndrome suspected
3. Problems ventilating patient with significant chest torso burns

15

15. Shown picture of kid with dog bite to face. What is the best management?
a. Irrigate, debride, and careful multiple layer closure
b. Irrigate, debride, and healing by secondary intention
c. Irrigate, debride, and primary closure 3 days later
d. Irrigate, debride, and careful one-layer closure

Answer: D
I was bitten by pittbull in face (age= 16), Chief of Plastic Surgery at Sunnybrook Hospital (Major trauma hospital) in Toronto treated me with tetanus shot, irrigation, debridement, one layer closure with nylon sutures…. source: life experience

16

16. Resident appointed chief at some hospital where he has never been. On arrival, he introduces himself to head nurse and familiarizes himself with hospital procedures and stuff. What CanMEDs role is he demonstrating?
a. Collaborator
b. Communicator
c. Professional
d. Manager

Answer: D ?
Different elements of CANMEDS role can be applied here ie: collaborator, communicator but I think manager fits the best see table below

Manager · utilize resources effectively to balance patient care, learning needs, and outside activities
· allocate finite health care resources wisely
· work effectively in a health care organization
· utilize information technology to optimize patient care, life-long learning and other activities

17

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

Answer: A (see table)

Health Advocate · identify the important determinants of health affecting patients
· contribute effectively to improved health of patients and communities
· recognize and respond to those issues where advocacy is appropriate

18

18. Anion that is not measured and contributes to your normal anion gap?
a. lactate
b. urea
c. potassium
d. albumin

D
In normal subjects, the AG is primarily determined by the negative charges on the plasma proteins, particularly albumin.
-negatively charged proteins account for about 10% of plasma anions and make up the majority of the unmeasured anion represented by the anion gap under normal circumstances.

Potassium is also not usually measured but contributes to the anion gap. However, it is a CATION and the questions asks specifically for an anion

19

19. What gives you decreased platelet count and qualitative defect in platelet function?
a. Bernard-Soulier - deficiency of platelet glycoprotein protein Ib, which mediates the initial interaction of platelets to the subendothelial components via the von Willebrand protein. It is a rare but severe bleeding disorder. Platelets do not aggregate to ristocetin. The platelet count is low, but, characteristically, the platelets are large
b. vWD – not typically thrombocytopenic
c. Liver failure
d. Uremia - Bleeding time is generally very prolonged in patients with uremia, signifying a major defect in platelet function, which improves after dialysis.

Answer: A

20

20. 15 year-old guys shows up with retracted testicle, absent cremasteric reflex, 6 hours post start of pain. Best management?
a. Insert a foley
b. Give antibiotics
c. Go to OR urgently for detorsion of left testicle and left orchiopexy
d. Go to OR urgently for detorsion of left testicle and bilateral orchiopexy.

**Do not delay surgery for diagnostic procedures
Answer: D
Testicular Torsion – Shwartz
- At time of surgery, orchipexy should be preformed by fixing the testicle to the scrotal wall at three different points. The anatomic predisposition to torsion affects both sides, therefore, the contralateral testicle shoulde be similarily repaired.

21

21. Shown an axial slice of CT showing right SC 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?
a. Endotracheal intubation
b. Cric
c. SC joint reduction
d. Chest decompression with chest tube

Answer: C

22

22. Woman with medullary thyroid cancer, has 12 and 15 year old child. What is most appropriate screening test for her children?
a. Ret
b. P53
c. CT scan
d. Other wrong answers

Answer: A
· Medullary thyroid cancer (MTC) is a neuroendocrine tumor of the parafollicular or C cells of the thyroid gland; it accounts for approximately 3 to 5 percent of thyroid carcinomas. A characteristic feature of this tumor is the production of calcitonin. Most cases are sporadic. (See 'Clinical presentation' above.)
· The most common presentation of sporadic MTC (in 75 to 95 percent of patients) is a solitary thyroid nodule. In most patients, the disease has already metastasized at the time of diagnosis. (See 'Clinical presentation' above.)
· Some patients with apparently sporadic MTC have unsuspected germline RET mutations (the underlying defect in MEN2) and, therefore, heritable disease. We agree with the 2009 American Thyroid Association Guidelines for Management of Medullary Thyroid Cancer that all patients with C cell hyperplasia or MTC be offered germline RET testing. (See 'Genetic screening in sporadic MTC' above.)
· Given the possibility that any patient with MTC may have MEN2, preoperative testing must also include measurement of serum calcium (to rule out hyperparathyroidism requiring concomitant surgical intervention) and testing for pheochromocytoma. We suggest plasma fractionated metanephrines as the initial screen for pheochromocytoma. (See 'Testing for coexisting tumors' above.)

23

23. 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?
a. Portable CXR to confirm suspicion - NO
b. Chest tube in 6th ICS, mid axillary line – Yes, but first…
c. Needle decompression 2nd ICS mid clavicular line
d. Urgent thoracotomy – Only if you’re a crazy emerge cowboy…NO

Answer: C

24

24. Which of the following is not an absolute indication to a chest tube?
a. Spontaneous pneumo
b. Open pneumo
c. Chylothorax
d. s/p thoracic surgery for drainage

A

25

25. 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?
a. 0.1%
b. 1%
c. 5%
d. 10%

Acc to question 17 2007 answer is 10%
Answer: A vs. B

26

26. Which of the following is not a feature of acute rejection in kidney transplant.
a. Hypertension – kidney not functioning
b. pancytonia
c. tenderness at graft - yes
d. increased graft size - yes

Answer: B
CLINICAL MANIFESTATIONS — Patients with acute renal allograft rejection present with an acute rise in the serum creatinine, which suggests underlying renal allograft dysfunction. A rising serum creatinine level, however, is a relatively late development in the course of a rejection episode and usually indicates the presence of significant histological damage. Some additional clinical manifestations include decreased urine output, increased blood pressure, pyuria, and/or new or worsening proteinuria.
Many patients who have acute rejection episodes are asymptomatic. Fever, graft pain and/or tenderness, and graft swelling are currently uncommon with modern immunosuppressive drug therapy unless immunosuppression is completely discontinued.

27

27. Regarding acute rejection in transplant, all true except?
a. Cell mediated
b. Most common rejection reaction
c. Most are asymptomatic
d. Biospy shows intravascular coagulation

ANSWER: D

a. Cell mediated- TRUE
b. Most common rejection reaction – USED TO BE, BUT NOW CHRONIC
c. Most are asymptomatic -
d. Biospy shows intravascular coagulation – Bx of acute reaction shows: - cellulat infiltrate, membrane damage, and apoptosis of graft cells v.s……HYPERACUTE- shows intravascular coagulation

28

28. Which of the following causes reversible nephrotoxicity?
a. Cyclophosphamide
b. Azathioprine
c. Cyclosporin A
d. Steroids

C

Patients treated with the calcineurin inhibitors cyclosporine and tacrolimus are at high risk of developing renal injury [1]. Calcineurin inhibitor nephrotoxicity (CIN) is manifested both as acute azotemia which is largely reversible after reducing the dose, or as chronic progressive renal disease which is usually irreversible [2-5]. Other renal effects of the calcineurin inhibitors include tubular dysfunction, and rarely a hemolytic uremic syndrome (HUS) that can lead to acute graft loss [2]. A similar pattern of renal injury from cyclosporine is seen with the use of tacrolimus, thereby suggesting a drug class effect.

29

29. In heart transplant, all are used except?
a. methotrexate
b. tacrolimus
c. azathioprine

A

30

30. Guy post multiple trauma, in ICU. Has pH 7.38, PCO2 of 30, bicarb of 20. What is most likely?
a. respiratory alkalosis, compensated
b. respiratory alkalosis and metabolic acidosis
c. some other ridiculous answers

Review ABGs

31

31. 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?
a. increase FiO2
b. increase tidal volume
c. increase dead space of tubing
d. sedate patient more

Answer: A

32

32. Which of the following is the most common mechanism of hypoxia in acute lung injury?
a. diffusion problem
b. right to left shunt
c. ventilation perfusion mismatch
d. something else

Answer: A vs. B?? they do not tell you what type of lung injury

33

33. What is the rate of transmission of HCV from a single unit PRBC transfusion?
a. 1/30
b. 1/300
c. 1/300,000
d. 1/3,000,000

Answer: D
HCV: 1:1,000,000
HBV: 1:30-250,000
HIV: 1:400,000 to 1:2,400,000

34

34. What is not a criteria for SIRS?
a. respiratory rate > 20
b. temp > 38.5
c. HR

C

Systemic inflammatory response syndrome (SIRS) — SIRS refers to the consequences of a dysregulated host inflammatory response. It is clinically recognized by the presence of two or more of the following (table 1):

SIRS Criteria (≥ 2 meets SIRS definition):
Temp >38°C (100.4°F) or 90
Respiratory Rate > 20 or PaCO2 12,000/mm>3, 3, or > 10% bands

35

35. Which is not consistent with severe PE?
a. increased CVP
b. increased wedge pressure
c. decrease in PaCO2
d. increase in A-a gradient

Answer: B
A severe PE will cause increased CVP. Will get hypocapnia on the blood gas. With a PE will get an increased in the A-a gradient

36

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

A

Contra-indications for tPA as per Schwartz:
1) Intracranial hemorrhage, major surgery within the previous 2 weeks, GI or genitourinary hemorrhage in the previous 3 weeks, platelet count less than 100,000/μL, and systolic blood pressure >185 mmHg are among the contraindications to tPA therapy

37

37. 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?
a. SCDs
b. Unfractionated heparin q12h
c. LMWH
d. Warfarin

Answer: C
No contraindication to use LMWH in this patient. LMWH has been shown to be superior to the other options.

38

38. What determines dBP?
a. peripheral vascular resistance
b. cardiac output
c. blood volume

Answer:A

39

39. 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?
a. Acute PE
b. Fat embolus
c. MI
d. Anaphylaxis

Answer: B
Fat emboli are characterized by petechia, hypoxia, and confusion. Occur most common with long bone fractures.

40

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

Answer: C

41

41. Patient weighs 80kg with burn to anterior thorax, both legs, and half of left arm (third degree). What is the management?
a. Ringers at 680 cc/hr for 16 hours then 1300 cc/hr for 8 hours.
b. Ringers at 750 cc/hr for 16 hours then 1500 cc/hr for 8 hours.
c. Ringers at 1300 cc/hr for 8 hours, then 680 cc/hr for 16 hours.
d. Ringers at 1500 cc/hr for 8 hours, then 750 cc/hr for 16 hours.

Answer: C
For burns, replace fluid according to the % of the body surface that is burned.
Replace with 4cc/kg/%BSA of RL over 24 hrs. Give 1/2 in first 8 hours and next 1/2 in next 16 hours.
In this case, the % burned is 58.5%.

42

42. What is not consistent with elderly?
a. Increase mortality with head injury
b. Increase mortality with elective vascular surgery
c. Increase mortality with burns
d. Increase quality of life post CABG

Answer: D
There is an increased mortality in the elderly with head injury and with burns. Found a study that showed a strong association between age and mortality after elective AAA repair. They said that increase in age have an increase in mortality.

43

43. What best predicts perioperative morbidity in the elderly?
a. Exercise tolerance
b. ASA
c. ADLs
d. Subjective global assessment test

Answer: B

44

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

Answer: A
This is a repeat question from an earlier exam.

45

45. What is an absolute indication to reimplantation?
a. Complete ring avulsion of 4th digit in 45 year old woman
b. 15 year old had saw injury with amputation at MCP joint of thumb
c. 25 year old with amputation through proximal phalanx of index finger, and multiple fractures in rest of finger.
d. Amputation through 5th metacarpal in 50 year old male.

Answer: B
These are the indications for reimplantation as per the Wheeless textbook of orthopaedics.
- Thumb amputation
- Multiple digit amputations
- Metacarpal amputation
- Almost any body part in a child
- Wrist or forearm amputation
- Individual digit distal to FDS insertion (see Zone I)
- replantation at level distal to insertion of FDS often results in satisfactory function;
- avgerage ROM at PIP joint is 82 deg, & 2-point discrimination avg 11.7 mm in adults (9.2 mm in children).
- cold intolerance subsides after approximately 2 years.

46

46. Which is true about management of a contaminated open fracture?
a. Irrigation and debridement and primary closure should be done
b. Prolonged antibiotics is the best predictor of decrease rate of osteomyelitis
c. Early fracture immobilization decreases the rate of infection
d. In general, high energy mechanism results in less soft tissue trauma than low energy injury.

Answer: A

47

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

Answer: A

48

48. During ureteral repair, which of the following is not true?
a. Debridement
b. Stent placement is optional
c. Water tight closure
d. Tension-free anastomosis

Answer: B
Principles of ureteral repair as per emedicine:
• Carefully mobilize the ureter to preserve the adventitia (blood supply).
• Judiciously débride the nonviable tissue until the edges bleed.
• Spatulate the edges and repair with 5-0 absorbable suture under magnification.
• Anastomosis should be watertight and tension-free over an internal stent.
• The repair must be isolated from infection, retroperitoneal fibrosis, and cancer.
• The omentum or retroperitoneal fat can be used to cover the repair; this decreases the risk of fibrosis and increases the blood supply to the repair region. (Wrapping the repair reportedly also allows the ureter to remain unscarred and to resume normal peristalsis).
• The retroperitoneum should be drained with a gravity drain.

49

49. Which of the following has the highest metabolic rate 1 week post injury?
a. Major burn
b. Peritonitis/sepsis
c. Elective abdominal procedure
d. Skeletal procedure

Answer: A
In order of highest to lowest:
Major burn - Peritonitis/sepsis - elective abdominal procedure - skeletal procedure

50

50. Someone with 6th and 7th rib fractures, has failed SQ and PO narcotics, what do you do?
a. Chest physio
b. Epidural
c. Surgical fixation of fractures
d. Bracing

Answer: B
As we know from doing trauma, patients with rib fractures consistently get offered epidurals because they are very painful.

51

51. What tissue has longest warm ischemia time?
a. skin
b. muscle
c. kidney
d. small bowel

Answer: A

52

52. What is the general recognized maximal ischemia time for muscle and nerve?
a. 4 hours
b. 6 hours
c. 8 hours
d. 10 hours

Answer: B
Infarction times after ischemia
Brain: 4-8 min
Heart: 17-20 min
Lower extremitiy: 5-6 hours (Sabiston, 2008)

53

53. Young chap with 20% grease burn to hand and upper extremity. What is the management?
a. Start Ringers at 3500 cc/hr, give tetanus toxoid, and local wound care
b. Start resuscitation, give tetanus shot and transfer to tertiary burn unit
c. Early debridement and skin grafting
d. Splint it

Answer: B
Initial treatement: 100% O2 facemask, AB (IV access – LR. Parkland 4cc/kg X % TBSA burn) CD, cover burn with clean/dry dressing, cover with blanket (keep warm), tetanus
Transfer to Burn Unit Criteria
Partial Thickness burn >10% TBSA
Burns involving face, hands, feet, genitalia, perineum, major joints
Electrical buns plus lightning injury
Chemical burns
Inhalational injury
Burns in pts with medical d/o complicating management or outcome
Burns with concomitant trauma: ie #
Burned children in hospitals w/o personnel or equipment to treat them
Burns in patients with special social, emotion or longterm rehab issues

54

54. Which factor is most deplete in PRBC?
a. II
b. V
c. VII
d. XII

Answer: B
PRBC with additive solution – store 42 days. w/o additive 21 days
Factors V and VIII are depleted in PRBCs stored at 1-4C (Sabiston, 124)

55

55. What factor is necessary for platelet adherence to collagen injury?
a. II
b. VIII
c. X
d. XII

Answer: A
Platelet Adhesion
Damaged endothelial cells expose subendothelial tissue factor and collagen
*Platelet adherence to exposed collagen is dependent primarily on vWf and fibrinogen
*vWf binds collagen and platelet surface receptor glycoprotein Ib/IX
*Fibrinogen binds the glycoprotein IIb/IIIa receptors on platelets
*Fibrinogen is activated to fibrin by IIa (thrombin)
Factor VIII makes a complex with factor IX which activates factor X to Xa (intrinsic)
Factor XII makes a complex with collagen, prekallikrein and HMWK to activate intrinsic path
Factor V coverts factor II to IIa (prothrombin to thrombin)

56

56. Principles of informed consent, all except?
a. Capacity
b. Autonomy
c. Voluntariness
d. Disclosure

Answer: B?

57

57. Guys presents with pelvic rami fracture, stable. Has blood at the meatus, and abdo CT scan is normal. What is the best management?
a. Give him time to pee
b. Retrograde urethrogram
c. Insert Foley
d. Insert suprapubic Foley

Answer: B
Urethral injury: blood at meatus, inability to void with distended bladder
Perform: rectal exam (rectum & prostate), perineal exam
If blood at meatus or urethral blood, must perform retrograde urethrogram before foley

58

58. Patient goes to OR for liver lac. This is dealt with. Patient stable after 2 units PRBC, on further exploration, non expanding retroperitoneal hematoma is found. What is best management?
a. Intraop IVP
b. Intraop angiogram
c. Explore
d. Close patient and get CT

Answer: C or D – incomplete question
Answer depends on 2 things: location of hematoma and mechanism (blunt vs penetrating)
Retroperitoneum is divided into 3 zones (Sabiston, 2008)
Zone 1: midline retroperitoneum
* must explore with penetrating and blunt trauma
Zone 2: perinephric space (2 sides)
Blunt trauma: if non-expanding – do not explore
Penetrating: must explore, unless patient is so unstable then return later to explore
Zone 3: pelvic retroperitoneum
Penetrating trauma: must explore
Blunt: do not explore if not expanding. If expanding, may be injury to major vessels – then
must explore

59

59. Patient with hemophilia A, before intracranial surgery. Which level do you want?
a. 20%
b. 40%
c. 60-80%
d. 100%

Answer: D
Factor VIII deficiency
Sex linked recessive.
Levels need to be 100% preop and 30% postop
Prolonged PTT, normal PT (Absite review, 6)

60

60. Which of the following is the least common in compartment syndrome?
a. Pulselessness
b. Pain on passive stretch
c. Sensory deficit
d. Paralysis

Answer: D

61

61. Hypercalcemia is seen in all except?
a. Pagets
b. Multiple fractures
c. Thiazide diuretics
d. Bed rest

Answer: B

Causes of hypercalcemia
Endocrine: Hyperparathyroidism, Hyperthyroidism, Adrenal Insufficiency, Pheochromocytoma
Familial hypercalcemic hypocalciuria
Hypophosphatemia
Chronic liver disease (late manifestation)
Chronic Renal Failure (tertiary parathyroidism. HD dependent)
Granulomatous disease: sarcoidosis, tuberculosis
Cancer: esp multiple myeloma, lymphoma, solid tumor mets to bone, PTHrp (lung, breast)
Drugs: thiazide, vit A and D, theophylline, lithium, Milk-Alkali syndrome
Immobility (esp young people)
Paget’s disease: can have hypercalcemia or hypocalcemia (Harrison’s, 16th ed)

62

62. Acute hypocalcemia can be seen in all except?
a. Acute pancreatitis
b. Parathyroidectomy
c. Tumor lysis syndrome
d. Blood transfusion post-op

Answer: D
Pancreatitis: part of Ranson criteria is decrease in calcium
Parathyroidectomy: must replace calcium immediately postop
Blood Transfusion: citrate in stored blood causes hypocalcemia. Only occurs with massive transfusion.
Tumor lysis syndrome: hyperuricemia, hyperkalemia, hyperphosphatemia, lactic acidosis, hypocalcemia and ARF. The hypocalcemia comes after the hyperphosphatemia which causes precipitation of calcium in soft tissues and bone. (Harrison’s, emedicine)

63

63. Isolated pelvis fracture, already has an ex-fix. Still unstable BP. What do you do?
a. Ex lap and pack pelvis
b. Ex lap and ligate internal iliac artery
c. Angio and embolize
d. ORIF of pelvis

Answer: C
If unstable -> DPL -> if positive -> OR. If negative -> angio
Indication for angiography: hypotension after resuscitation and attributable to pelvic # and requirement of >4-6 units within first 2 hours after injury.

64

64. Pregnant chick with jaundice, second trimester. What is consistent with hepatocellular etiology?
a. Increase unconjugated bilirubin
b. Increase conjugated bilirubin
c. Increase GGT
d. Increase ALP

Answer: C Too much beer in the chicken coop.
GGT: normal levels in pregnancy. However, GGT is the most sensitive blood test for liver damage. GGT will be elevated in both intrahepatic and extrahepatic biliary obstruction.
Bilirubin Pathway
Heme breakdown -> bilirubin -> (liver) -> conjugation (with UDP glucuronosyltransferase) -> excretion bile -> urobilinogen and stercobilinogen
Direct (Conjugated bilirubin): elevationin hepatocellular disease, biliary tract obstruction,
Dubin Johnson syndrome, Rotor’s Syndrome, and hepatic storage disease. You will also get an increase in conjugated bilirubin if there is an increase in unconjugated bilirubin.
Total bilirubin measures both unconjugated and conjugated bilirubin (Harrison’s, 16th Ed)

65

65. Most common parotid tumor?
a. Pleomorphic adenoma
b. Warthins tumor (cystadenoma)
c. Mucoepidermoid cyst
d. Metastasis

Answer: A (Yes according to Shwartz)
80% parotid tumors are benign
Pleomorphic adenomas: 40-70% of tumors in salivary gland. Most common in tail of parotid
Warthin’s tumor (papillary cystadenoma lymphomatosum): 2nd most common – old white men
Mucoepidermoid carcinoma: most common malignant tumor of parotid gland (Sabiston)

66

66. Which brain tumor has best prognosis?
a. Medulloblastoma
b. Ependymoma
c. Meningioma
d. Glioblastoma multiforme


Answer: C
Medulloblastoma
* in children
* undifferentiated, anaplastic, in cerebellum
* homer-wright rosettes, neurosecretory granuales and gfap staining, linear chains
* malignant – poor px if untreated
* tx excision and radiation – 75% 5 yr survival
Ependymoma
* in 1-20 yrs: 4th ventricle (5-10% primary tumors) >20 yr: spinal cord
* solid or papillary masses. Clear demarcation
* regular, round nuclei, perivascualr pseudorosettes, GFAP
* poor px 2nd progressive obstruction of ventricles, CSF dissemination
* survival 4 yrs after xrt and sx
Meningioma
* benign tumors of adults
* arise from meningothelial cell of arachnoid – found on dura
* rounded masses have clear encapsulation
* epithelial origin. Rarely can have malignant tumors
* slow growing. Usually solitary – if multiple think neurofibromatosis 2
Glioblastoma Multiforme
* looks like anaplastic astrocytoma with necrosis and vascular/endothelial cell proliferation
* path: glomeruloid body and peudopalisading
* become more anaplastic with time
* mean survival 8-10 mo. 10% survival in 2 years

67

67. 8 kg infant, what is daily fluid requirement?
a. 300cc
b. 500cc
c. 800cc
d. 1000cc

Answer: C
Use 4:2:1 rule = 4cc/kg for 1st 10 kg, then 2cc/kg for 2nd 10 kg, then 1cc/kg for the rest
4x8 = 32 cc/hr 32cc/hr x 24 hr/day = 768 = 800cc/day

68

68. What is true about preop in children?
a. You should always premedicate to decrease anxiety
b. Explaining procedure to child increases anxiety
c. Infants need IV hydration to compensate for 6 hours of NPO necessary for GA.
d. Infants do no routinely need pre-op investigations for day surgery.

Answer: D

69

69. Principles of Canada health act, all except?
a. portability
b. universality
c. full disclosure
d. public administration

Answer: C
Canada Health Act:

1) Public Administration, administered and operated on a non-profit basis by a public authority, accountable to the provincial or territorial government for decision making, and whose records and accounts are publicly audited.
2) Comprehensiveness, must cover all insured health services provided by hospitals, physicians or dentists, and similar or additional services rendered by other health care practitioners.
3) Universality, all insured residents entitled to health services, on uniform terms and conditions
4) Portability, permit a person to receive necessary services in relation to an urgent or emergent need when absent on a temporary basis, such as on business or vacation, and between provinces/territories
5) Accessibility, unprecluded or unimpeded, either directly or indirectly, by charges (user charges or extra-billing) or other means (e.g., discrimination on the basis of age, health status or financial circumstances).

70

70. In Canada, which is true about informed consent?
a. Reasonable physician would say
b. Whatever a reasonable person would want to know
c. Whatever a particular person in this particular situation would want to know
d. Whatever the patient in capable of understanding

Answer: B
Disclosure: The patient must have been given an adequate explanation about the nature of the proposed investigation or treatment and its anticipated outcome as well as the significant risks involved and alternatives available.
The obligation to obtain informed consent must always rest with the physician who is to carry out the treatment or investigative procedure.
Standard of disclosure: The adequacy of consent explanations is judged by the "reasonable patient" standard, or what a reasonable patient in the particular patient's position would have expected to hear before consenting.

Recent legal judgments repeatedly refer to the need to disclose "material" risks to patients. Generally speaking, the more frequent the risk, the greater the obligation to discuss it beforehand. Further, even uncommon risks of great potential seriousness should be disclosed.
Consent disclosure in research and experimentation: When it comes to research and experimentation, a fair explanation must be given about what is proposed, its risks and discomforts, what if any benefits might accrue and, if applicable, what appropriate alternative treatments or procedures might be offered. If a blind study is involved, patients must be aware they could stand to derive no benefit at all.
Informed refusal: Our courts have reaffirmed repeatedly a patient's right to refuse treatment even when it is clear treatment is necessary to preserve the life or health of the patient. Physicians must at the same time explain the consequences of the refusal without creating a perception of coercion in seeking consent.
Informed discharge: Physicians have an obligation to properly inform patients in the post-operative or post-discharge period, most specifically about clinical signs and symptoms that may indicate the need for immediate treatment.
(CMPA website)

71

71. Mineralization of osteoid matrix is decreased by all except?
a. Low PO vitamin D intake
b. Deficiency in fat soluble vitamins
c. Increased ALP
d. Renal tubular acidosis (or something similar)

Answer: C
Vitamin D3 is synthesized in the skin during summer under the influence of ultraviolet light of the sun, or it is obtained from food, especially fatty fish. After hydroxylation in the liver into 25(OH)D and kidney into 1,25(OH)2D, the active metabolite can enter the cell, bind to the vitamin D-receptor and subsequently to a responsive gene such as that of calcium binding protein, e.g. osteocalcin or calcium binding protein. The calcium binding protein mediates calcium absorption from the gut. The production of 1,25(OH)2D is stimulated by PTH and decreased by calcium. Risk factors for vitamin D deficiency are premature birth, skin pigmentation, low sunshine exposure, obesity, malabsorption and advanced age. Risk groups are immigrants and the elderly. Vitamin D status is dependent upon sunshine exposure. Severe vitamin D deficiency causes rickets or osteomalacia, where the new bone, the osteoid, is not mineralized. Less severe vitamin D deficiency causes an increase of serum PTH leading to bone resorption, osteoporosis and fractures. A negative relationship exists between serum 25(OH)D and serum PTH. The threshold of serum 25(OH)D, where serum PTH starts to rise is about 75nmol/l according to most surveys. Vitamin D supplementation to vitamin D-deficient elderly suppresses serum PTH, increases bone mineral density and may decrease fracture incidence especially in nursing home residents. Prog Biophys Mol Biol. 2006 Sep;92(1):4-8. Epub 2006 Feb 28.
Renal osteodystrophy:
1) Osteitis fibrosa cystica, in which bone turnover is increased due to secondary hyperparathyroidism (main abnormalities: high phosphate, low calcium, low Vit D)
2) Adynamic bone disease, because of aluminum deposition, or excessive suppression of PTH glands. Most seen in HD patients.
3) Osteomalacia, low bone turnover, with increased portion of unmineralized bone, due primarily to aluminum deposition; can be related to Vit D deficiency
4) Mixed uremic osteodystrophy: combination of high and low bone turnover.
(UTD)
Renal tubular Acidosis:
Type I (distal) is due to the kidneys inability to secrete acid leading to normal anion-gap metabolic acidosis, low K, stones (alkaline urine, hypercalciuria, low urine citrate), nephrocalcinosis, bone deminerlization (causing rickets and osteomalacia)
Type II (proximal) is failure of the kidneys to reabsorb bicarb from the urine, but because the distal cells are presumable normal, the academia is not as bad as in Type I. Type II is usually associated with generalized proximal tubule cell dysfunction like Fanconi’s – whose principle feature is osteomalacia or rickets due to phosphate wasting.
(Wiki)

72

72. Guy gets trauma with copper wire. A week later presents to ER with swelling and pain on passive stretch of one finger. What do you do?
a. Splint in slight flexion
b. Irrigation and debridement of tendon sheath
c. Irrigation and debridement of PIP
d. PO antibiotics and send home

Answer: B
Infectious tenosynovitis can be caused by trauma with direct inoculation, contiguous spread from infected adjacent soft tissue, hematogenous spread Manifestations: tender along the sheath, symmetric enlargement of the affected digit, slightly flexed finger at rest, pain along tendon with passive extension.
Stage 1 – distension of the inflamed tendon with exudative fluid
Stage 2 – distension of the inflamed tendon with pus
Stage 3 – septic necrosis and destruction of the tendon sheath and surrounding retinacular structures
Management requires surgical intervention and antibiotics. Stage 1 can be managed with sheath I & D, Stage 2 or 3 should be managed with surgical debridement of the tendon sheaths and surrounding necrotic tissue, maybe requiring amputation.

73

73. Young hot good looking 25 year-old male, wearing cowboy hat and boots, works on a farm. Presents with difficulty swallowing and muscle weakness. Mentions that he had an injury while working on the farm a week ago? What is most likely?
a. Tetanus
b. Botulism
c. Meningitis
d. Guillain-Bare syndrome

Answer B
Tetanus: after infection, incubation is usually 7-8 days. Clincal: intense painful spasm of masseter muscles (lockjaw), progressive to generalized tetanus with symptoms of autonomic hyerpactivity (early), and tonic contractions and intermittent spasms(late). Spasms may cause dysphagia, periods of apnea. The usual duration of clinical tetanus is four to six weeks because recovery requires the growth of new axonal nerve terminals. Treatment: wound debridement, Pencillin G or Flagyl, human tetanus Ig, immunize with dTap, control of muscle spasm and dysautonomia.
Botulism: food-borne (i.e. home-canned), infant/adult with ingestion of honey/dust, wound, inhalational. toxin produces an irreversible disruption in stimulation-induced acetylcholine release by that presynaptic nerve terminal. Return of synaptic function requires sprouting of a new presynaptic terminal with subsequent formation of a new synapse, a process that requires approximately six months. Clinical: with Food-borne, symptoms within 12-36 hrs, Prodromal symptoms of nausea, vomiting, abdominal pain, diarrhea, and dry mouth with sore throat. Cranial nerve involvement marks symptomatic illness: blurred vision (b/c fixed pupillary dilation and CN III, IV, and VI palsies), diplopia, nystagmus, ptosis, dysphagia, dysarthria, and facial weakness. Descending muscle weakness usually progresses to the trunk and upper extremities, followed by the lower extremities. Urinary retention and constipation are common resulting from smooth muscle paralysis. Paresthesias and asymmetric limb weakness can be seen. Respiratory difficulties (eg, dyspnea) requiring intubation and mechanical ventilation are common, caused by diaphragmatic paralysis, upper airway compromise, or both. Despite the evidence of neurologic involvement, cerebrospinal fluid analysis is normal. For wound botulism, presents like food-borne, but no GI prodrome, incubation 10 days
Meningitis: The classic triad of acute bacterial meningitis consists of fever, nuchal rigidity, and a change in mental status
Guillainn Barre: pathogenesis involves molecular mimicry, most commonly identified with Campylobacter, but also associated with CMV, EBV, HIV. A small % of patients develop GBS after another triggering event such as immunization, surgery, trauma, and bone-marrow transplantation. Clinical: The cardinal clinical features of GBS are progressive, mostly symmetric muscle weakness and absent or depressed deep tendon reflexes. The weakness can vary from mild difficulty with walking to nearly complete paralysis of all extremity, facial, respiratory, and bulbar muscles. Severe respiratory muscle weakness necessitating ventilatory support develops in about 30 percent, and dysautonomia occurs in 70 percent of patients. GBS usually progresses over a period of about two weeks. Dx: CSF analysis (increased protein, normal WBC) and neurphysiology; Treatment: supportive care, plasma exchange, IVIG, steroids…
(UTD)

74

74. What is true regarding glucose metabolism – all except?
a. Increased lipogenesis with glucose running at 7mg/kg/min
b. Decrease RQ with increase carbs
c. Glycogen stores will be depleted in 48 hours of starvation
d. Something else

Answer: B
Carbohydrate stores can be exhausted in 1 indicates overfeeding with glucose or fat or both, while a RQ

75

75. Best suture for elective AAA repair?
a. Monofilament, absorbable
b. Monofilament, non-absorbable
c. Polyfilament, absorbable
d. Polyfilament, non-absorbable

Answer: B

76

76. Wound strength at 3 days is due to?
a. Epithelium
b. Collagen
c. Angiogenesis
d. Sutures

Answer: D

77

77. After a wound heals, why is it more susceptible to avulsion?
a. Because squamous cells are not layered properly
b. Because they are missing rete pegs, because reticular dermis is not attached to rete pegs
c. Because they have problems with basement membrane ??
d. Because they have lower extracellular matrix type IV collagen

?? look it up

78

78. Where do calcium and iron gets absorbed?
a. duodenum
b. jejunum
c. proximal ileum
d. distal ileum

Answer: A

79

79. Short bowel syndrome patient secondary to ischemia of proximal small bowel s/p resection. What is most likely to be deficient?
a. Vitamin B12
b. Phosphorus
c. Vitamin C
d. Vitamin K

Answer: C
Loss of greater than 80% of the small bowel is associated with increased requirement for parenteral nutrition support, and decreased overall survival. When the ileocecal valve is lost, the resulting bacterial contamination of the small intestine mandates more small intestine for tolerance of oral/enteral feeding. Also, the ICV is required for regulating the exit of fluid and malabsorbed nutrients from the small bowel into the colon. Fats and fat soluble vitamins, however are absorbed in the ileum. Bile salts are excreted from the liver into the duodenum; these are required for the absorption of long chain fatty acids and fat soluble vitamins in the ileum. Vitamin B12 binds to intrinsic factor (produced in the stomach) and is also absorbed in the terminal ileum. Fluids and electrolytes are predominantly absorbed in the ileum and in the colon. When the duodenum and/or jejunum are resected, the ileum can largely adapt to perform their absorptive functions. However, the duodenum and jejunum cannot adapt to perform the functions of the ileum
Deficiencies include: ADEK, vit B12, (calcium, magnesium, iron, zinc)
(http://depts.washington.edu/growing/Assess/SBS.htm)
Hypophosphatemia causes (of decreased intestinal absorption):
1) inadequate intake
2) Drugs with aluminum and magnesium can cause hypophosphatemia
3) Steatorrhea or chronic diarrhea can cause mild to moderate hypophosphatemia, due to decreased phosphate absorption from the gut and renal phosphate wasting, the latter caused by secondary hyperparathyroidism induced by concomitant vitamin D deficiency.
(UTD)

80

1. All are indications for TPN except?
a. Hepatic failure
b. Crohn’s
c. Short bowel syndrome
d. Gastrocutaneous fistula

Answer: B (correct!!!)
Indications for TPN (Sabiston):

Primary therapy: Gastrocutaneous fistula, RF (ATN), Short Bowel, Burns, Hepatic Failure; (efficacy not shown for Crohn’s, Anorexia Nervosa)

Supportive therapy: Acute radiation enteritis, Acute chemo toxicity, Prolonged ileus, Weight loss post-op; (efficacy not shown for pre-op cardiac surgery, prolonged resp support, large wound losses)

81

2. Kid gets bitten by dog, presents 24 hours later with swollen, red, and tender hand. Kid looks well and no lymph nodes. What do you do?
a. parenteral clinda
b. clavulin
c. I & D
d. Vanco

Answer: B
Wound care for an animal bite: irrigate with NS or 1% proviodine +/- debridement. Primary closure OK for head and neck wounds initially seen within 24 hrs, and for aesthetics. Primary closure OK for low-risk bites of the arms/legs/trunk seen within 6-12 hrs. Bites in the hands and feet are left open; 1/3 of dog bites of the hand become infected. heal by secondary intent. The infections that develop 24 hours after the bite is usually caused by Pasteurella. Antibiotics: clavulin PO (alternatives cefoxitin or clindamycin AND cipro(/TMP-SMX). (Sab)

82

3. All true about wound infections except?
a. Strep produces erythema and watery discharge
b. Cellulitis with associated lymphangitis is usually caused by staph
c. Staph abscess is thick yellow pus
d. Strep can cause infection with 10 x 3 organisms

Answer: B
In normal hosts, group A beta-hemolytic strep are the most common causes of lymphangitis (not Staph.).

83

4. Patient post embolectomy and fasciotomy of leg, on heparin, gets red urine. What do you do?
a. Stop heparin
b. Lasix
c. Mannitol and bicarb
d. Something else

Answer: C vs A
They may be suggesting myoglobinuria in which mannitol and bicarb would be OK, but the red urine should not have developed suddenly, particularly if he could have presented with a compartment syndrome.
Also, the patient may not have had a compartment syndrome, and that the red urine is the result of overanticoagulation, in which case the heparin should be stopped.
We could do a urinalysis first. May need to stop the heparin

EDIT: 2016 - probably obsolete question
The treatment of renal failure due to myoglobinuria has
shifted away from the use of sodium bicarbonate for alkalinizing the urine, to merely maintaining brisk urine output of 100 mL/h with crystalloid fluid infusion. Mannitol and furosemide are not recommended. (Schwartz)

84

5. Contaminated class III wound, which of the following?
a. GI case with no spillage
b. I+D of purulent wound
c. Break in sterile technique
d. Devitalized tissue

Answer: C

I. Clean:
- Uninfected, no inflammation
- Resp, GI, GU tracts not entered
- Closed primarily
Examples: Ex lap, mastectomy, neck dissection, thyroid, vascular, hernia, splenectomy

II. Clean-contaminated:
- Resp, GI, GU tracts entered, controlled
- No unusual contamination
Examples: Chole, SBR, Whipple, liver txp, gastric surgery, bronch, colon surgery

III: Contaminated:
- Open, fresh, accidental wounds
- Major break in sterile technique
- Gross Spillage from GI tract
- Acute nonpurulent inflammation
Examples: Inflamed appy, bile spillage in chole, diverticulitis, Rectal surgery, penetrating wounds

IV: Dirty:
- Old traumatic wounds, devitalized tissue
- Existing infection or perforation
- Organisms present BEFORE procedure
Examples: Abscess I&D, perforated bowel, peritonitis, wound debridement, positive cultures pre-op

85

6. Old guy with preauricular lesion, what do you do?
a. FNAC
b. Excisional bx
c. Incisional bx

Answer: A
(but it depends on the size of the lesion or whether it’s deep or superficial (e.g skin lesion like basal cell, in which case you would do a excisional bx). Judging by the answer, I assume it’s a lesion in the parotid. The parotid gland is the most common location of salivary gland tumors, accounting for 50 to 85 percent. About 50 to 80 percent of salivary gland lesions are benign. (UTD

86

7. Patient with labs: Na 139 K 3.2 Cl 110 HCO3 14 uPH 5.5 uNa 85 uK uCl 104. What does he have?
a. Proximal tubular acidosis
b. Distal tubular acidosis
c. Diarrhea
d. Acetazolamide

Answer: C
Normal AG met acidosis:
Type 1 RTA (distal) impaired distal acidification. Major Cause: autoimmune, hypercalciuria.

Type 2 RTA (proximal): reduction in proximal bicarbonate reabsorptive capacity that leads to bicarbonate wasting in the urine until the plasma bicarbonate concentration has fallen to a level low enough to allow all of the filtered bicarbonate to be reabsorbed. Major Cause: monoclonal immunoglobulin, acetazolamide (carbonic anhydrase inhibitor)
Type 3 RTA: rare autosomal recessive syndrome (resulting from carbonic anhydrase II deficiency), combination of Type 1 and 2 features

Type 4 RTA: decreased aldosterone secretion or aldosterone resistance. These patients have a mild metabolic acidosis (plasma bicarbonate concentration above 17 meq/L) with the major manifestation being hyperkalemia.
Urinary ammonium excretion is not increased in RTA. In patients with type 1 RTA, the urine anion gap is positive, because the defect in distal acidification results in low urine NH4+ levels. In patients with a normal anion gap metabolic acidosis and hypokalemia due to diarrhea, the urine anion gap is negative because urine ammonium excretion rises appropriately in response to the acidosis. Urine AG = Urine (Na + K - Cl). Ammonium is an unmeasured cation; as a result, an increase in its excretion as NH4Cl will lead to a rise in the urine Cl concentration and a negative urine AG, usually ranging from -20 to -50 meq/L.
In type 1 RTA, there is an inability to excrete the daily acid load. In the absence of
alkali therapy, this results in progressive hydrogen ion retention and a plasma bicarbonate concentration that may fall below 10 meq/L. To make a diagnosis of type 1 RTA, the urine sodium should be above 25 meq/L (lower levels can impair distal acidification in subjects without RTA) and the urine anion gap and urine osmolar gap should be consistent with low rates of ammonium excretion. Urine pH > 5.3
In type 2 RTA, bicarbonate wasting occurs only when the plasma bicarbonate concentration is above the bicarbonate reabsorptive threshold. Since the more distal segments have substantial bicarbonate reabsorptive capacity, the plasma bicarbonate concentration is usually between 12 and 20 meq/L in this disorder.
(UTD)

87

8. Hyperadrenalism, all except:
a. Hypertension
b. Hypokalemia
c. Met acidosis
d. Hypernatremia

Answer: C
Conn’s syndrome (aldosterone producing adrenal adenoma): hypokalemia, diastolic hypertension, muscle weakness/fatigue, polyuria, polydipsia, proteinuria, renal failure, hypernatremia, metabolic alkalosis and elevated serum bicarb (Harrison’s 16th Ed)
(N.B hyperaldosteronism can cause met alkalosis. AR)

88

9. Which of the following is not an indication for kidney exploration?
a. Persistent bleeding from kidney
b. Laceration into collecting system
c. Expanding hematoma
d. Pulsatile hematoma

Answer: B
Absolute indication for renal exploration
* evidence of persistent renal bleeding, expanding perirenal hematoma, pulsatile perirenal hematoma
Relative indication for renal exploration
* urinary extravasation, nonviable tissue, delayed diagnosis of arterial injury, segmental arterial injury, incomplete staging

89

10. Picture of sub-ungual melanoma. What is most likely diagnosis?
a. acral lentiginous
b. lentigo maligna
c. superficial spreading

Answer: A
Acral lentiginous melanoma is also known as subungual melanoma. (Wikipedia)
Melanoma: lentigo maligna (least aggressive, radial growth), superficial spreading (most common, on sun-exposed), nodular (most aggressive, vertical growth), acral lentiginous (very aggressive, pals/sole, black people) (AR)
Acral lentiginous melanoma is observed on the palms, soles and under the nails.[3] It occurs on non hair-bearing surfaces of the body which may or may not be exposed to sunlight. It is also found on mucous membranes. Unlike other forms of melanoma, acral lentiginous melanoma does not appear to be linked to sun exposure. (Wiki)

90

11. Strabismus surgery lady, subcutaneous emphysema. All are appropriate except?
a. CT scan
b. Immediate neck exploration
c. Esophagoscopy
d. Bronchoscopy

Answer: ?????

91

12. 45 y/o woman in RR s/p hemithyroidectomy. Has stridor and desats. Most appropriate management?
a. Intubate
b. Cric
c. Open wound and evacuate clot
d. Aspirate hematoma

Answer: C
Post-Thyroid surgery complications:
1) Postoperative bleeding can be a devastating complication of thyroid surgery. An unrecognized or rapidly expanding hematoma can cause airway compromise and asphyxiation. The incidence of hemorrhage after thyroid surgery is low (0.3-1%), but the surgeon must be aware of this potentially fatal complication. Patients with postoperative bleeding present with neck swelling, neck pain, and/or signs and symptoms of airway obstruction (eg, dyspnea, stridor, hypoxia). Immediately examine such patients for evidence of hematoma. Imaging studies are of no benefit in this evaluation.
If a neck hematoma is compromising the patient's airway, open the surgical incision at the bedside to release the collection of blood, and immediately transfer the patient to the operating room. In the case of a hematoma without impending airway obstruction, transfer the patient to the operating room as soon as is practical. Remain with the patient and be prepared to assist with intubation or tracheostomy. In the operating room, open the surgical incision, explore the wound, irrigate it, control all bleeding sites, and close the wound.
2) The recurrent laryngeal nerve (RLN) innervates all of the intrinsic muscles of the larynx with the exception of the cricothyroid muscle, which is innervated by the superior laryngeal nerve (SLN). Mechanisms of injury to the RLN include complete or partial transection, traction, contusion, crush, burn, misplaced ligature, and compromised blood supply. The consequence of an RLN injury is true vocal-fold paresis or paralysis. Unilateral paralysis: Definite vocal changes may not manifest for days to weeks. The paralyzed vocal fold atrophies, causing the voice to worsen. Other potential sequelae of unilateral vocal-fold paralysis are dysphagia and aspiration. Bilateral paralysis: stridor, respiratory distress
3) The SLN has 2 divisions: internal and external. The internal branch provides sensory innervation to the larynx. It enters the larynx through the thyrohyoid membrane and, therefore, should not be at risk during thyroidectomy. The external branch provides motor function to the cricothyroid muscle and is at risk during thyroidectomy. This muscle is involved in elongation of the vocal folds. Trauma to the nerve results in an inability to lengthen a vocal fold and, thus, an inability to create a high-pitched sound. The external branch of the SLN is probably the nerve most commonly injured in thyroid surgery. The rate of injury to the external branch of the SLN is estimated at 0-25%. This rate is probably underestimated, because the diagnosis is frequently missed.
4) Hypoparathyroidism
5) Thyrotoxic storm (intraop, with manipulation of thyroid gland in patients with hyperthyroidism)
6) Infection
7) Hypothyroidism
(Emed)

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13. Compared to 1st and 2nd generation cephalosporins, 3rd generation cephalosporins:
a. Offer increased coverage against enterococcus
b. Offer decreased coverage against staphylococcus
c. Have more cross-reactivity for allergic reactions with penicillin

Answer: B

93

14. Patient bitten by dog, you suspect a pasteurella infection. When you do a gram stain, your suspicion will be confirmed when you see:
a. Gram positive cocci
b. Gram negative cocci
c. Gram positive bacilli
d. Gram negative bacilli

Answer: D vs B
Pasteurella multocida is a small, gram-negative, nonmotile, non–spore-forming coccobacillus (emedicine).

94

15. All of the following are features of the metabolic syndrome except:
a. hypertension
b. hypercholesterolemia
c. insulin resistance
d. hypothyroidism

Answer: D
Current National Cholesterol Education Program (Adult Treatment Panel ATP III criteria define the metabolic syndrome as the presence of any three of the following five traits:
· Abdominal obesity, defined as a waist circumference in men >102 cm (40 in) and in women >88 cm (35 in)
· Serum triglycerides ≥150 mg/dL (1.7 mmol/L) or drug treatment for elevated triglycerides
· Serum HDL cholesterol

95

16. You are doing a study and want to determine whether there is a statistical difference between the means of 2 normally distributed groups. The best statistical test for this is:
a. t-test
b. chi-square
c. 2 other wrong options

Answer: A

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17. The action of accepting null hypothesis when it is actually false is called:
a. alpha error
b. beta error

Answer: B
Type I (alpha) rejects the null hypothesis incorrectly
Type II (beta) accepts the null hypothesis incorrectly (AR)
Power = 1 – probability of Type II error = (probably of making the right conclusion)

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18. A study that has a low power is more prone to?
a. type I error
b. type II error

Answer:B

98

19. At the American College of Surgeons conference, a panel of experts gets together to discuss DVT prophylaxis. At the end of that meeting, they put together a guideline for DVT prophylaxis. The level of evidence is:
a. I
b. II
c. III
d. IV

Answer: C??
US Preventive Services Task Force
■ Level I: Evidence obtained from at least one properly designed randomized controlled trial.
■ Level II-1: Evidence obtained from well-designed controlled trials without randomization.
■ Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.
■ Level II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.
■ Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
[edit]
(Wikipedia)
National Health Service
■ Level A: Consistent Randomised Controlled Clinical Trial, cohort study, all or none (see note below), clinical decision rule validated in different populations.
■ Level B: Consistent Retrospective Cohort, Exploratory Cohort, Ecological Study, Outcomes Research, case-control study; or extrapolations from level A studies.
■ Level C: Case-series study or extrapolations from level B studies.
■ Level D: Expert opinion without explicit critical appraisal, or based on physiology, bench research or first principles.

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20. Which of the following is true regarding non randomized controlled trials?
a. Case series are powerful evidence in cases where disease has a high mortality rate without treatment
b. Historically controlled studies are good because they do not incorporate newer techniques that arise during the trial
c. Meta-analyses can draw conclusions from poorly designed studies as it pools their results together
d. Something else

Answer: B???

100

21. Which is true about the study of a new surgical technique?
a. The learning curve of surgeons does not affect outcome
b. Study should only start once this new procedure has been in practice for a while
c. More than one surgeon should be involved in order to assess that technique is reproducible
d. Something else

Answer: C

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22. Which of the following translates into less bias?
a. You have direct financial gain from doing the study
b. The study is financed by industry
c. Something else
d. Something else that was obviously the best answer and not related to industry

Answer: D

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23. If we want to eventually reduce/eliminate the rationing of health care, we should:
a. Order diagnostic tests that are less costly
b. Only perform procedures that are clinically indicated
c. Give your patients advantages
d. Treat patients on first come first serve basis

Answer: B