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Flashcards in 2010 Deck (97)
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*1. A 19 year old man suffers a stab wound to the mid-abdomen. On arrival in the Emergency Room his blood pressure is 80/50. Following rapid infusion of 4 liters of normal saline, his blood pressure is 110/80. Blood gasses taken at this time are:
ph 7.20
pO2 95
PCO2 25
HCO3 15
This patient’s metabolic acidosis would be best treated with?
a) 1 amp sodium bicarbonate IV
b) 2 units packed RBC stat
c) hyperventilation
d) immediate laparotomy



2. An elderly diabetic man is admitted to hospital for treatment of an infected foot ulcer. He is found to have a serum sodium of 119 and a blood glucose level of 33. His hyponatremic state should be treated with?
a) insulin infusion to reduce blood glucose level to normal
b) normal saline 150 cc/h until the serum sodium returns to normal
c) 3% NaCl at 400 cc/h until the serum sodium returns to normal
d) 1000 cc/day water restricted diet



3. A 77 year old man undergoes percutaneous nephrostomy because of an infected and obstructed left ureter. The patient develops a gram negative bacteremia immediately following the procedure. The earliest manifestation of sepsis syndrome in this patient is likely to be:
a) hypotension
b) lactic acidosis
c) elevated serum creatinine
d) hyperventilation with respiratory alkalosis



4. The following four factors affect the rate of flow of blood through a stenotic artery. Which is the most important?
a) diameter of stenosis
b) length of stenosis
c) blood viscosity
d) systolic blood pressure



5. What is the most common cause of an acquired hypercoagulable state?
a) cigarette smoking
b) heparin-induced thrombocytopenia (HIT)
c) antiphospholipid antibody (eg lupus anticoagulant)
d) oral contraceptives



6. Which of the following clinical conditions are indicated by the presence of serum antibodies against hepatitis B surface antigen (anti-HBs) and hepatitis B core antigen (anti-HBc) in the absence of HBs AG?
a) active acute infection with the hepatitis B virus
b) normal response to vaccination with hepatitis B vaccine
c) chronic active hepatitis due to the hepatitis B virus
d) recovery with subsequent immunity following acute hepatitis B infection



7. A 70 year old man has known cirrhosis of the liver complicated by portal hypertension and ascites. He is admitted to hospital because of increasing encephalopathy and low grade fever. Which of the follow statements about this situation is correct?
a) a diagnosis should be made clinically and the patient immediately started on antibiotics
b) infection, if present, is often polymicrobial
c) antibiotic therapy is reserved with patients with positive acidic fluid cultures
d) gram-negative enteric bacteria are often present in infected ascidic fluid


This presentation is consistent with spontaneous bacterial peritonitis: Clinical manifestations of spontaneous bacterial peritonitis include fever, abdominal pain, abdominal tenderness, and altered mental status.

In patients with suspected spontaneous bacterial peritonitis (SBP), empiric therapy should be initiated as soon as possible to maximize the patient's chance of survival [2,3]. However, antibiotics should not be given until ascitic fluid has been obtained for culture. Most cases of SBP are due to gut bacteria such as Escherichia coli and Klebsiella (both Gram negative), though streptococcal and staphylococcal infections can also occur (table 3). As a result, broad-spectrum therapy is warranted until the results of susceptibility testing are available


8. All the following proteins are primarily synthesized in the liver, EXCEPT?
a) albumin
b) fibrinogen
c) Factor VII
d) von Willebrand Factor


The liver manufactures serum albumin, fibrinogen, and the prothrombin group of clotting factors (except for Factors 8)

D- vWF is synthesized in endothelium (in the Weibel-Palade bodies), megakaryocytes (α-granules of platelets), and subendothelial connective tissue.[1]


9. Regarding the progression of cells from normal to cancerous, which of the following statements is NOT true?
a) dysplasia describes cells with altered size, shape, and organization
b) in the absence of atypia or dysplasia, hyperplasia confirms only a modest, if any, risk of cancer in a given tissue
c) all dysplastic tissues eventually progress to frank carcinoma
d) metaplastic changes may be reversible



*10. Primary blast injury is caused by the blast pressure wave as it propagates through air or water. Common injuries of this type include all of the following EXCEPT?
a) myocardial contusion
b) pulmonary contusion
c) hollow-viscous perforation
d) perforated eardrum



11. A 34 year old woman, know to use crack cocaine, is brought to the Emergency Room following a fall of approximately 20 feet. She has an obvious left tibia-fibula fracture and an open left humeral fracture. She is extremely agitated and uncooperative. Blood pressure is 180/120 and the heart rate is 130. Further investigation and management of this patient will require sedation. This is best accomplished by?
a) IM Haloperidol 5 mgs
b) IV Midazolam 2 mgs, repeated every 5 minutes as required
c) IV Fentanyl 50 micrograms, repeated every 5 minutes as required
d) IV Propofol 10 mgs/kg, followed by endotracheal intubation


I just looked this up and uptodate says use benzos for psychomotor agitation. She seems to be protecting her airway, so I don't know why she needs intubation other than agitation.

I think I would have said B unless the stem clearly said there was an airway/oxygenation issue

Below is from UTD:

Psychomotor agitation — Agitated patients are sedated as needed with benzodiazepines, after ensuring they are not hypoglycemic or hypoxic. We suggest diazepam be given in an initial dose of 10 mg IV, then 5 to 10 mg IV every three to five minutes until agitation is controlled. Monitor patients for respiratory depression and hypotension. Intramuscular lorazepam can be used if IV access is unavailable, but its peak effect is typically delayed (10 to 20 minutes).


12. A 35 year old man is injured in a high speed motor vehicle crash. When he is brought to the Emergency Room, his blood pressure is 90/50, heart rate 120, GSC 3. The anaesthesia resident can mask-bag the patient achieving an O2 saturation of 95, but cannot intubate the patient with a laryngoscope. The next step in management of the airway should be?
a) attempt intubation with a glide-scope
b) attempt fibroptic intubation
c) surgical airway
d) call for a staff anesthetist



13. Immunosuppression to facilitate organ transplant may result in many complications. Malignant lymphoma may occur years after the transplant. Which of the following statements about transplantation associated lymphomas is NOT true?
a) they are usually non-Hodgkin’s B-cell lymphomas
b) the malignant transformation may be caused by the Epstein-Barr virus
c) the incidence of lymphoma is directly related to the amount of immunosuppression received over time
d) upon diagnosis of the lymphoma, withdrawn of immunosuppression is rarely successful in eradicating the tumour

D - Reduction of immunosuppression is one of the first line treatments for eradication.

A) Classical Hodgkin lymphoma-like PTLD is the least common form of PTLD (but I think one of the more malignant ones?)

B) The pathogenesis of PTLD in most patients relates to the outgrowth of EBV-positive B cell proliferations in the setting of chronic T cell immunosuppression. However, EBV-negative tumors and T cell tumors can also occur.

C) The principal risk factors underlying the development of a post-transplant lymphoproliferative disorder (PTLD) are the degree of overall immunosuppression and the EBV serostatus of the recipient.

D) The main options for initial treatment are reduction of immunosuppression, immunotherapy with the CD20 monoclonal antibody rituximab, chemotherapy, radiation therapy, or a combination of these.


14. A 55 year old man underwent successful kidney transplantation two years ago. He is taking Mycophenolate, prednisone, and tacrolimus to prevent rejection. He presents in the Emergency Room with generalized peritonitis secondary to a perforated viscus and undergoes emergency surgery. In order to prevent organ rejection in the perioperative period, the surgeon should?
a) only provide stress-steroid coverage until the patient can resume oral intake
b) ask the pharmacist to convert his oral dosages to equivalent IV dosages until the patient can resume oral intake
c) continue oral intake with his usual meds in the expectation that his GI tract will be able to absorb most of the medication
d) supplement IV steroid stress coverage with IV antithymocyte globulin until the patient can resume oral intake



15. A 70 year old man is found to have a bulky mid-rectal adenocarcinoma without metastatic disease. He undergoes neoadjuvant chemo-radio therapy. On flexible sigmoidoscopy six weeks after completion of therapy, he is seen to have only a 2 cm residual tumour, 12 cms from the anal verge. At this point, the surgeon should?
a) continue to follow the patient to see if the tumour will regress completely
b) resume chemotherapy in the hope of totally irradiating the tumour
c) proceed to surgery to remove only the portion of the rectum containing the residual tumour
d) proceed with surgery to remove almost all of the rectum as if the patient had not had any adjuvant therapy



*16. Which of the following arteries cannot be ligated to stop uncontrolled bleeding because of the risk of distal ischemic damage?
a) common carotid artery
b) superior mesenteric artery
c) common femoral artery
d) descending thoracic artery



*17. The following treatments for hypotension due to acute blood loss are contraindicated, EXCEPT?
a) albumin-containing IV solutions
b) vasopressors
c) Trendelenburg positioning
d) tourniquet to acutely bleeding extremity

D - this is not conra-indicated and is used to prevent further exsanguination

A- The value of colloids (albumin solution, dextran) for resuscitation of traumatic shock is unproven [25,26]. Colloids effectively increase intravascular volume and may maintain plasma oncotic pressure at more normal levels compared with crystalloids. However, a systematic review of trials comparing resuscitation fluids found that use of colloids did not improve mortality or morbidity among trauma patients

B- In trauma don't use vasopressors are the patient needs volume and vasopressors can further lead to peripheral necrosis/ischemia

c- I didnt find anywhere that it's contra-indicated, but doesn't help to improve blood flow or oxygenation in hypovolemic patient


18. Peripheral nerve damage is the second most common anesthetic complication leading to malpractice suits. All of the following nerves may be injured, EXCEPT?
a) ulnar nerve
b) femoral nerve
c) brachial plexus
d) sciatic nerve

I found complications associated with all these nerves....

Ulnar neuropathy comprised one third of the injuries, the brachial plexus nerves 23% and lumbosacral roots 16%


19. A 79 year old man undergoes left hemicolectomy for an obstructing colon cancer. On post-operative day five he developed peritonitis and undergoes relaparotomy and exteriorization of his anastomotic leak. Following this procedure, he develops acute renal failure despite aggressive treatment in the ICU. NG feeds are initiated. His physician should aim for a protein intake of?
a) 0.3 grams/protein/kg/day
b) 0.8 grams/protein/kg/day
c) 1.4 grams/protein/kg/day
d) feed only with glucose and lipids because of his acute renal failure


Requirements: 250 mg of N/kgday or 1.7 g of protein equivalent/kgday. (Range: 0.8-2.0 g/kg/day)
• Energy Value: 4 kcal/gm
• 6.25 g protein:1 g N; 0.16 g N:1 g protein
• Protein is a mixture of single amino acids.
• Nitrogen to caloric ratio is given as g of N:kcal


20. A 45 year old man is severely injured in a motor vehicle crash. He undergoes laparotomy with splenectomy, repair liver laceration, and bowel resection. The abdomen is closed primarily. An open fracture of the left tibia is treated with an external fixator. The following morning, his vitals are:
heart rate 120
BP 88/50
CVP 11 mm/Hg
His urine output is 5 cc/h. Peek airway pressures have increased from 32 to 50 cc/H2O. His abdomen is distended and firm. Bladder pressure is 30 mmHg.
The next step in his treatment should be?
a) increase rate of fluid resuscitation
b) change the ventilator mode to pressure-control ventilation
c) inotropic therapy
d) immediate laparotomy

D - Likely bleeding from an intra-abdominal source causing intra-abdominal compartment syndrome. Although his pressure is not >35, he is showing signs of end organ dysfunction with associated Abdoinal hypertension

ACS frequently manifests via such end-organ sequelae as decreased urine output, increased pulmonary inspiratory pressures, decreased cardiac preload, and an
increased cardiac afterload.

Generally, no specific bladder pressure prompts therapeutic intervention, except when the pressure is >35 mm Hg. Rather, emergent decompression is carried out when intra-abdominal hypertension reaches a level
at which end-organ dysfunction occurs


*21. A 25 year old woman was an unbelted passenger in a high speed vehicle crash. She is intubated and a C spine collar is in place. Her GCS is 3T. She has a right pulmonary contusion and multiple lower extremity fractures. The diagnostic procedure of choice for radiologic clearance of her cervical spine is?
a) 3 view cervical spine x-rays
b) flexion – extension cervical spine x-rays
c) CT cervical spine
d) MR cervical spine



22. A 68 year old man sustains multiple injuries in a motor vehicle crash including a closed head injury with small frontal contusions, and interparenchymal hemorrhage on CT scan. He has been on coumadin 4 mgs a day for chronic atrial fibrillation for three years. His admission INR is 2.8. The most rapid method of reversing the anticoagulant effect of coumadin is?
a) recombinant factor VIIa
b) fresh frozen plasma
c) vitamin K1
d) octoplex



*23. A 45 year old man is brought to the Emergency room after a high speed motor vehicle crash. There was no loss of consciousness. He received 2000 ccs of normal saline en route to hospital. On arrival in the Emergency Room, his vitals are:
Heart Rate 140
Blood pressure 60 systolic
Respiratory Rate 24
GCS 14
On examination, he has no neck tenderness, good breath sounds bilaterally, and a distended tender abdomen. There is no pelvic tenderness or instability and no obvious extremity fractures. A portable chest x-ray shows a left 1st rib fracture only. The next step in his evaluation and treatment should be?
a) focused assessment with sonography for trauma (FAST ultrasound)
b) CT abdomen and pelvis
c) diagnostic laparoscopy
d) laparotomy


D was listed as the answer but wouldn't you do a FAST? He can't go to CT because he's unstable. I think the gold standard is still laparotomy for diagnosis so Laparoscopy would not be indicated.

Also I found this in Morrells (I would therefore choose A):

Blunt abdo trauma with hemodynamic instability should undergo DPL or FAST to rule out intraabdominal injury.

Indications for laparotomy in blunt trauma:
• positive examination
• positive DPL or FAST.

Ultrasound provides an important initial screening examination in the adult trauma patient. However, ultrasound is not a replacement for the more sensitive imaging studies often needed to identify specific injuries in patients with concerning abdominal or thoracic symptoms or signs. Most such patients, if hemodynamically stable, undergo computed tomography (CT). Unstable patients with intraperitoneal hemorrhage identified by ultrasound generally proceed directly to laparotomy.


24. A 66 year old woman with long-standing rheumatoid arthritis requires emergency surgery for perforated sigmoid colon diverticulitis. She has been receiving prednisone 10 mgs a day for at least the last five years. The recommended management of perioperative parenteral corticosteroids for this patient should be?
a) no systemic corticosteroids unless she demonstrates signs of adrenal insufficiency (eg hemodynamic instability)
b) a 100 mg bolus of hydrocortisone with induction of anaesthesia, then hydrocortisone 150 mgs/day, in divided doses until oral intake resumes
c) a 100 mgs bolus of hydrocortisone at induction of anaesthesia, hydrocortisone 300 mgs/day in divided doses until oral intake resumes
d) a 100 mg bolus of hydrocortisone at induction of anaesthesia, 300 mgs/day of hydrocortisone in divided doses on post operative day one followed by a taper of 50% per day over the next three days until oral intake resumes


B was listed but I think it's D based on Morrell's notes

Indications for stress dose steroids: supraphysiologic steroid doses for >1 week in past year (if in doubt
stim. test), known adrenal insufficiency

• Stress dosing: 1st dose pre-op, 300mg hydrocortisone/day (100mg q8h) x24hrs then rapid taper over 72hrs
(to avoid wound healing & infx complications)


25. Three days after knee arthroscopy, a 35 year old man presents with mild dyspnea on exertion. His temperature is 38 degrees centigrade. His chest is clear to auscultation except for right lower lobe rales. Minimal knee swelling is noted at the arthroscopy site. His white blood cell count is 12,400 and D-dimer level is normal. A chest x-ray shows that the right hemi-diaphragm is obscured. The next diagnostic test should be?
a) bilateral lower extremity Doppler ultrasound examination
b) ventilation/perfusion lung scan
c) CT chest with PE protocol
d) sputum culture



26. Which of the following statements about antithrombotic treatments is TRUE?
a) in the absence of antithrombin III, unfractionated heparin has no significant anticoagulant affect
b) low molecular weight heparin’s share the ability to accelerate the activity of factor 10a
c) warfarin inhibits the absorption of vitamin K from the intestinal track
d) Hirudin, a synthetic thrombin inhibitor, is dependent on antithrombin III for anti-coagulant activity


Heparin binds to the enzyme inhibitor antithrombin III (AT), causing a conformational change that results in its activation through an increase in the flexibility of its reactive site loop.[17] The activated AT then inactivates thrombin and other proteases involved in blood clotting, most notably factor Xa.

B- LMWHs and fondaparinux target antifactor Xa activity rather than antithrombin activity, with the aim of facilitating a more subtle regulation of coagulation and an improved therapeutic index.

C- Vit K antagonist. Does not inhibit absorption

D) Hirudin is the most potent natural inhibitor of thrombin. Unlike antithrombin, hirudin binds to and inhibits only the activated thrombin, with a specific activity on fibrinogen. Thus not necessitating antithrombin III


27. A 70 year old diabetic man with Childs C cirrhosis undergoes operative repair of an incarcerated umbilical hernia. On post-operative day one, the patient develops upper GI bleeding and requires four units of packed red cells. On the fifth post-operative day, the wound is noted to be painful and erythematous. All of the following are risk factors for developing a surgical site infection in this patient, EXCEPT?
a) intra-operative hyperglycemia
b) post-operative transfusion
c) cirrhosis
d) age

I feel like they're all associated with risk of SSI but the only one not listed in Schwartz is Cirrhosis

Risk factors associated with SSI (From Schwartz)

Patient factors
Older age
Diabetes mellitus
Chronic inflammatory process
Renal failure
Peripheral vascular disease
Chronic skin disease
Carrier state (e.g., chronic Staphylococcus carriage)
Recent operation
Local factors
Open compared to laparoscopic surgery
Poor skin preparation
Contamination of instruments
Inadequate antibiotic prophylaxis
Prolonged procedure
Local tissue necrosis
Blood transfusion
Hypoxia, hypothermia


28. Risk factors for clostridium difficile – associated diarrhea include all of the following EXCEPT?
a) advanced age
b) immunosuppressive agents
c) asymptomatic carrier status
d) naso-gastric intubation



29. A 60 year old woman with a 40 year history of smoking presents with a painless 2 cm nodule just anterior to the sternomastoid muscle and inferior to the angle of the mandible. The most appropriate means to obtaining a tissue diagnosis is?
a) fine-needle aspiration for cytology
b) ultrasound-guided core needle biopsy for histopathology
c) incisional surgical biopsy
d) excisional surgical biopsy



30. Bupivacaine (marcaine) injection for local analgesia may be associated with all of the following adverse affects, EXCEPT?
a) seizure
b) hypotension
c) heart block
d) methemoglobinemia