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DEPARTMENT OF SURGERY

PRINCIPLES OF SURGERY EXAM

March 25, 2008

7:30 a.m. to 9:30 a.m.

EXAMINATION INSTRUCTIONS

1. Please write and code yor name on the !om"ter #nswer $heet % left side.

2. &his e'amination is mlti"le(choice. !hoose the single )est answer.

3. &his e'amination is two hors in length.

*. +'amination reslts will )e sent from the e"artment of $rgery

5. -estions mared with an asteris are o"tional for residents in the +/& and (/ "rograms.

Princi"les of $rgery +'am

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1.4 # 37 year old man is inoled in a high s"eed motor ehicle collision. 6e is

hemodynamically sta)le. # s"ine chest '(rays shows a "lmonary contsion and

"ossi)le widened mediastinm. &he most a""ro"riate stdy to diagnosis the "resence of a tramatic inry to the aorta is

# transeso"hageal echocardiogram

helical thin(ct !& angiogra"hy

! thoracic aortogram

M scan of the thora'

2. ;hich of the following statements a)ot the se of intraenos fat emlsions in

the ntritionally de"leted srgical "atient is /& tre

# daily infsion is associated with a higher incidence of infection

critically ill "atients achiee nitrogen )alance more easily with a mi'tre

of glcose and li"id com"onds than with glcose alone

! the re<irements for essential fatty acids can )e met with 1500 ml of 10=li"id "er wee

a 500 ml )ottle of 20= li"id contains a)ot 900 ilocalories

3. >n the acte("hase res"onse to inry or infection, leels of which of the followingserm "roteins is decreased

# !(reactie "rotein

fi)rinogen

! cerlo"lasmin

al)min

*. # 50 year old man deelo"s seere se"tic shoc following mani"lation of an

im"acted reteric stone. 6e is treated with aggressie olme resscitation,aso"ressor thera"y, and mechanical entilation. ;hich of the following thera"ies

may frther hel" him to srie his shoc

# infsion of >?(1 rece"tor antagonist

high dose steroid administration

! infsion of antiendoto'in anti)odies

infsion of actiated "rotein !


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5. # *@ year old woman who has )een on long(term "rednisone thera"y for

rhematoid arthritis needs an a)dominal hysterectomy for fi)roids. ;hich of the

following com"lications may )e e'"ected to occr in this "atient with greater thanaerage fre<ency

# "oor wond healing

"lmonary em)ols

! iles

renal failre

@. &he incidence of "ost(o"eratie enos throm)oem)olism is increased in "atients

with genetically determined "rocoaglant states. &he following are all "rocoaglant states, +A!+P&:

# antithrom)in(>>> deficiency

resistance to actiated "rotein ! BCactor D ?eiden

! anti"hos"holi"id anti)odies Bl"s anticoaglant

hy"ohomocystinemia

7. # 30 year old woman is )eing ealated for a)dominal "ain in the +mergency

oom when she sddenly deelo"s a grand mal seiEre with tonic clonicmoements. &he initial "harmacologic management of her seiEre shold )e

# "henytoin Bdilantin 1 gram >D Bloading dose

loraEe"am 0.1 mgFg >D

! "ro"rofol *0 mgs )ols >D

Pheno)ar)ital 10 mgsFg >D oer 1 hor


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8. # @5 year old woman "resents to the +mergency oom with a right hi" fractre.

$he is schedled for o"en redction and internal fi'ation the following day. &he

ortho"edic resident notices that the "atient is tachycardic and hy"er(refle'ic.lood tests confirm that the "atient has hy"erthyroidism. &he a""ro"riate "eri(

o"eratie management of this condition is

# close o)seration in the >!G "ost(o"eratiely

)egin "ro"ylthioracil and "roceed with srgery

! )egin )eta )locage with "ro"ranolol and "roceed with srgery

arrange rgent radio(iodine a)lation and "roceed with srgery

9. esscitation from hy"oolemic shoc re<ires large <antities of flids. ;hichof the following "arameters are /& hel"fl in assessing the ade<acy of flid

resscitation

# serm lactate

)ase deficit calclated from arterial )lood gases

! near infrared s"ectrosco"y

central enos "ressre

10.4 # 27 year old man is )roght to the +mergency oom after )eing thrown from amotorcycle at high s"eed. 6is systolic )lood "ressre is @0. # chest '(ray shows

a widened mediastinm. >n addition to a""ro"riate resscitation, the ne't ste" in

his management shold )e:

# immediate left thoracotomy

!& thora'

! aortic ach angiogram and "ossi)le stenting

a)dominal ltrasond BC#$&


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11. # 70 year old man with a history of ischemic heart disease, two "rior myocardial

infarctions, and "rior coronary artery )y"ass grafting, is schedled to ndergo

right total hi" re"lacement. +chocardiogra"hy confirms a decreased eectionfraction of *0= and no significant allar disease. $tress thallim scan confirms

a fi'ed "erfsion defect inferiorly and no eidence of reersi)le ischemia. Pre(

o"eratie medical thera"y to redce cardiac mor)idity and mortality in this "atientshold inclde

# an #!+ inhi)itor

)eta(adenergic )locade

! hydralaEine afterload redction

digo'in

12. egarding tight control of serm glcose leels in dia)etic "atients ndergoing

cardiac srgery, which of the following statements is correct:

# it has no affect on the incidence of "ost(o" com"lications

it significantly redces the incidence of dee" sternal wond infections

! it enhances nerto"hil "hagocytosis

it increases rine ot"t

13.4 # 50 year old trama "atient is admitted to the >!G with a !$ of 8, nilateral

"ostring, an intracranial "ressre B>!P of 25, and a mean arterial "ressre of 90.

#ll of the following treatments will hel" to "reent secondary )rain inry,+A!+P&:

# sedation and mscle "aralysis

!$C flid drainage for "ersistent eleated >!P

! administration of the calcim(channel )locer nimodi"ine

mild hy"erentilation to a "!2 of 35 mmF6g


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1*. ring fasting, the lier "rodces energy s)straits )y all of the following

mechanisms, +A!+P&

# glycogenolysis

glycolysis

! glconeogenesis from alanine

formation of etone )odies from fatty acids

15. #"o"tosis B"rogrammed cell death is an im"ortant reglatory mechanism thatlimits inflammatory tisse inry. >ndcers of a"o"tosis inclde all of the

following, +A!+P&

# hy"erglycemia

o'idant stress

! radiation

cytoines

1@. # 50 year old grossly malnorished alcoholic ndergoes srgery for "erforatedgastric lcer. Post(o"eratiely, he is started on total "arental ntrition )ecase of

se"sis and "rolonged iles. 6e is at ris of deelo"ing seere hy"o"hos"hatemia

secondary to refeeding syndrome. $ym"toms of seere hy"o"hos"hatemiainclde all of the following +A!+P&

# myocardial de"ression

atrial and entriclar arrhythmias

! mscle weaness leading to res"iratory failre

confsion, st"or, coma, seiEres

17. &he syndrome of ina""ro"riate secretion of anti(diretic hormone B$>#6 may

)e cased )y all of the following, +A!+P&

# lng tmors

congestie heart failre

! closed head inry

alcohol withdrawal


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18. &he "roliferatie "hase of wond healing is characteriEed )y collagen de"osition

and remodeling as well as wond contraction. &he cell most res"onsi)le for this

is

# the myocyte

the fi)ro)last

! the macro"hage

the endothelial cell

19.4 # 20 year old man sstained seere left thoracic trama after a fall of 20 feet. 6e

is awae, alert, and nerologically intact. Plse o'imetry demonstrates a 90=

o'ygen satration on nasal "rong 2 at *lFmin. !hest '(ray shows a left "nemothora' and a chest t)e is "laced which drains 500 mls of )lood. #n

a)dominal !& scan is normal. er the ne't * hors the chest t)e drains 250

mlsFhr and the "atient has intermittent hy"otension. &he ne't ste" in managementshold )e

# "lacement of a second chest t)e

!& angio of thora'

! aso"ressor thera"y

emergency thoracotomy

20. # 37 year old farmer rolls his tractor and is tra""ed nderneath for for hors. 6e

has a crsh inry to )oth legs inclding )ilateral femr fractres. &wenty(forhors after admission, he was fond to hae the following )lood wor:

/a 1*0

H 5.7

!l 100

6!3 10

!r 220

!PH 15,000


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&he first ste" in "reenting renal failre in this "atient is

# loo" diretic administration

mannitol administration

! restoring ade<ate circlating olme

alaliniEation of rine with sodim )icar)onate

Cor each of the following three B3 <estions, select the one answer that is closely

associated with the <estion stem.

# case control stdy

cohort stdy

! )oth

neither

21. Pros"ectie design

22. easona)le design when otcome is rare

23. $trength of association Bconclsions similar to randomiEed trials

2*. ;hich of the following statements concerning the meta)olic res"onse to sim"lestaration is /& tre

# staration reslts in a res"iratory <otient of 0.@(0.7, indicatie of fat as a

"rimary fel sorce.

&he !ori and #lanine cycles "roide car)on for glconeogenesis in the

lier

! esting energy e'"enditre decreases in sim"le staration

?i"ogenesis ensres maintenance of fat reseres


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25. # "atient who deelo"s angioedema after the administration of "enicillin

is schedled for a craniotomy to a)late a seiEre focs. ;hich of the

following o"tions is most a""ro"riate with res"ect to anti)iotic "ro"hyla'is

# no anti)iotic "ro"hyla'is

!efaEolin 1 gram >D at the time of indction

! Dancomycin 1 gram >D at the time of indction

Dancomycin 1 gram and entamyacin 1@0 mgs >D at the time of indction

2@. 6e"atocelllar carcinoma is e"idemiologically associated with all of the

following, +A!+P&

# 6e"atitis #

6e"atitis

! 6e"atitis !

alcoholic cirrhosis

27. # 75 year old woman ndergoes )ilateral total nee re"lacement. n the third

"ost(o"eratie day, she deelo"ed hy"otension with a )lood "ressre of 90F@0,

heart rate 120. #n electrocardiogram shows mared $& segment de"ression in thelateral leads. &he initial management of this hy"otension shold )e

# >D flid )ols

>nitiate inotro"ic s""ort

! emergency cardiac catheteriEation to attem"t coronary reasclariEation

s""ort cardiac fnction with intra(aortic )alloon "m"


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28. # 25 year old man driing a motorcycle stries a gard rail and is taen to the

nearest +mergency oom. 6e is fond to hae mlti"le left ri) fractres and a

small "nemothora' on chest '(ray. # !& scan shows a s)ca"slsar hematomaof the s"leen. # chest t)e is inserted )t nfortnately entered the a)domen and

r"tres the s)ca"slar hematoma necessitating la"arotomy and s"lenectomy.

Post(o"eratiely the "atient is doing well in the >ntensie !are Gnit. ;hat sholdthe srgeon tell the "atients wife

# I6e is doing wellJ

I6is s"leen was inred and we had to tae it otJ

! IGnfortnately, we cased his s"leen to )leed while treating his lnginry and we had to tae the s"leen otJ

I> am sorry, we almost illed yor hs)and with a chest t)e, )tfortnately we were a)le to resce himJ

29. Meta)olic acidosis with a high anion ga" may)e )e "rodced )y all of the

following, +A!+P&

# hy"oolemic shoc

acte renal failre

! acetylsalicylic acid into'ication

chronic diarrhea

30. adiation thera"y for malignancy "rimarily de"ends on /# damage. &he e'tentof /# damage following radiothera"y is de"endent on all of the following,

+A!+P&

# celllar o'ygen leel

the "hase of the cell cycle

! se of radiation sensitiEers sch as 5(floorocil

tisse intracelllar "6


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31. # *5 year old man who was inoled in a motor ehicle accident remains

hy"otensie des"ite attem"ted resscitation with crystalloids. #)dominal

sonogra"hy reeals a large amont of flid in the a)domen. &he "atient statesthat he will not acce"t )lood transfsions for religios reasons. &he ne't ste" in

his management shold )e

# angiogra"hy and em)oliEation of )leeding sites

secre an emergency cort order for )lood transfsion

! e'"loratory la"arotomy withot )lood "rodcts

administration of aso"ressor

32. ;hich of the following statements a)ot "ost(o"eratie infections is /& tre

# increases in "atients with dia)etes mellits

can )e redced with cli""ing erss dry shaing

! can )e redced )y "erio"eratie deliery of 80= o'ygen

can )e redced )y maintaining mild B35= intra(o"eratie hy"othermia

33. ;hich of the following statements concerning "ost(o"eratie hy"onatremia is

/& tre

# hy"erglycemia may )e a case of hy"onatremia

following craniotomy, hy"onatremia des"ite ade<ate salt administrationis sally cased )y occlt renal dysfnction

! hy"onatremia may occr when water is sed to re"lace sodim(containing

flids

in oligric "atients, celllar cata)olism with resltant meta)olic acidosis

increases celllar release of water and can contri)te to hy"onatremia


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3*. ;hich of following statements concerning re"erfsion inry is correct

# re"erfsion inry is initiated )y the formation of o'ygen(deried free

radicals

free radicals case mem)rane li"id "ero'idation rendering ca"illary

essels more "ermea)le

! the deleterios effects of free radicals is worsened )y s"ero'ide

dismtase

netro"hils "lay no role in re"erfsion inry

35. ring an emergency a""endectomy, a srgical resident sstains an inry from a

contaminated hollow()ore needle with s"ontaneos )leeding. ;hich of thefollowing )lood()orne diseases is most lie to )e transmitted, assming the

"atient was infected with all of these

# 6>D

6e"atitis

! 6e"atitis !

Malaria

3@. # fie wee old )oy had a fie day history of omiting and resltant weight lossof 0.* gs B*.0 gs to 3.@ gs. +'amination finds his anterior fontanels flattened

and his mcos mem)ranes dry. ?a)oratory data are as follows:

/a 132

H 3.2

!l 91

!2 28

!a"illary "6 7.

&his "atient is sffering from which of the following acid()ase disorders

# none

meta)olic alalosis

! res"iratory alalosis

com"ensated meta)olic acidosis


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37. # *7 year old man ndergoes resection of a large retro"eritoneal li"osarcoma.

Post(o"eratiely he deelo"s acte renal failre re<iring intermittent

hemodialysis. # dietitian estimates that he re<ires 70 grams of "rotein and 2500ilocalories "er day for o"timal wond healing. $ince he is in acte renal failre,

his ntritional goal shold )e adsted to:

# same % 70 grams "rotein, 2500 ilocalories

low "rotein diet % 35 grams "rotein, 2500 ilocalories

! adsted low "rotein diet % 35 grams "rotein, 1500 ilocalories

hy"eralimentation % 100 grams "rotein, 3500 ilocalories

38. #n 85 year old man ndergoes o"en redction and internal fi'ation for a right hi"fractre. n "ost(o"eratie day three he sffers a massie myocardial infarction

and is transferred to the >ntensie !are Gnit where he is entilated. >n the >!G, he

deelo"s "nemonia, acte renal failre, and a large left middle cere)ral arterystroe. #ll "hysicians caring for the "atient agree that the sitation is ho"eless,

)t the "atientKs family demands contination of all care, inclding entilation

and haemodialysis, )ecase of religios )eliefs. ;hat shold his treating "hysician do at this time

# efse to "roide ftile care and e't)ate the "atient

#s the hos"ital lawyer to o)tain a cort order to allow the "atient to )ee't)ated

! /egotiate with the family with the hel" of an a""ro"riate religios leader

!ontine all treatment and ho"e the "atient dies soon, ths freeing " the>!G )ed

39. o are reiewing a stdy com"aring medical s. srgical treatment ofinflammatory )owel disease. o notice that the "atients referred for srgery

tended to )e yonger and fitter than those treated medically. &he alidity of this

stdy is therefore com"romised )ecase of:

# selection )ias

measrement )ias

! confonding aria)les

e'ternal alidity BgeneraliEea)ility


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*0. Patients re<iring massie )lood transfsion often )ecome cooaglo"athic.

;hich of the following factors is /& a significant case of sch coaglo"athy

# diltion of coaglation factors

meta)olic acidosis

! hy"ocalcaemia

hy"othermia

*1.4 # 78 year old woman falls in her nrsing home and sstains a scal" laceration.$he is nconscios for for mintes. $he has a history of chronic atrial

fi)rillation for which she taes comadin.

>n the +mergency room she has a normal nerological e'am and normal !& head.

6er >/ is 2.2. #fter the laceration is stred, management shold consist of

# transfer )ac to nrsing home

admission to hos"ital, reersal of anticoaglation

! M imaging of head

#dmit to >!G for o)seration oernight

*2. # @0 year old woman sffers an isolated lier inry in a motor ehicle accident.

&hree months earlier, she was treated with "rednisone and "lasma"horesis for

idio"athic throm)ocyto"enic "r"ra. 6er "latelet conts hae remained normal

since thera"y was discontined two months earlier.

&wele hors after admission her )lood "ressre is 80F*0, heart rate 120, !DP 3mmFhg, 6g) 105. &he ne't ste" in her management shold )e

# la"arotomy

transfse of two nits "aced red )lood cells

! hydrocortisone 100 mgs >D )ols

leo"hed infsion


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*3. ;hich one of the following clinical signs or sym"toms is /& associated with a

serm sodim concentration )elow 125 m+<Fl

# headache

)radycardia

! hy"oentilation

hy"erthermia

**. # "atient re<ires re(o"eration one month after a ertical midline a)dominalincision has )een made. ;hich of the following "rocedres will "romote the

most ra"id gain in strength of the new incision

# se a se"arate transerse incision

e'cise the midline scar with a l cm margin

! reo"en the midline incision withot scar e'cision

the rate of strength gained is not affected )y the incision techni<e

*5. ;hat is the fndamental tisse "ro"erty measred )y a !& scan

# atomic nm)er

density

! relatie '(ray attenation

hydrogen content

*@ ;hich of the following is the )est screening test for significant carotid stenosis in

a "atient with an asym"tomatic carotid )rit

# M angiogra"hy

for(essel cere)ral angiogra"hy

! !& angiogra"hy

d"le' ltrasond scanning


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*7. #ll of the following are clinical featres of acte hy"ocalcemia, +A!+P&

# !hostes sign % facial mscle s"asm on stimlation of the facial nere

&rosseas sign %car"al s"asms following inflation of a )lood "ressre

cff

! hy"ertension

"rolonged -& interal

*8. #ll the following "atients re<ire int)ation and mechanical entilation. >n which/+ of these "atients is the se of sccinylcholine contraindicated

# "atient with cardiogenic shoc

"atient with 70= 3rd degree )rns

! trama "atient with ?efort >>> facial fractre

"atient with seere hy"oalemia

*9. # "atient wants yor adice a)ot recoery after an attac of acte low )ac "ain.

&he )est aaila)le stdy of this <estion descri)es time(to(time recoer for acohort of "atients with low )ac "ain. &he stdy fond that seeral aria)les

were related to "rognosis: seerity of "ain at onset, "resence of lm)ar disc

disease, nerological deficit sch as weaness and nm)ness, actiity followingthe attac and s"inal mani"lation. ;hich a""roach wold "roide the most

information in tailoring "rognosis to yor "articlar "atient

# stratified analysis

matching

! mltiariate analysis

sensitiity analysis

50. # 70 year old man is a)ot to ndergo a left total hi" re"lacement. 6e has ahistory of significant "enicillin allergy. ;hich of the following drgs wold /&

)e a""ro"riate for se as a "ro"hylactic agent for this "atient

# cefaEolin

clindamycin

! erythromycin

Dancomycin


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51.4 # 22 year old man is )roght to the +mergency oom after a motor ehicle

collision. 6is )lood "ressre is 80F*0 and his heart rate is 1*0 after 2000(ccs

)ols of normal saline. 6is !$ is 7 Beyes closed, no er)aliEation, "r"oseflmoement of all for e'tremities. 6e has cre"its and "al"a)le ri) fractres on

the left with e<al )reath sonds )ilaterally. 6e has an o)ios femr fractre

also on the left.

&he most liely e'"lanation for this hemodynamic "ictre is

# intracranial hemorrhage

left tension "nemothora'

! inter(a)dominal hemorrhage

)lood loss associated with femr fractre

52. ;hich of the following is the most im"ortant stimls for triggering the endocrineres"onse after inry

# afferent nere stimli from the inred area

hy"oolemia

! tisse acidosis

local wond factors

53. Many drgs sed in srgical "ractice are )ond to "lasma "roteins. ;hich of the

following statements is correct

# al)min is the "lasma "rotein largely res"onsi)le for )inding drgs

)inding is sally irreersi)le

! )inding to "lasma "roteins is highly s"ecific, that is, the )inding locs is

s"ecific for a gien drg

)ond drg has enhanced glomerlar filtration

5*. ;hich of the following can case s"riosly eleated "lse o'imeter readings

# methemoglo)inemia

finger nail "olish

! hy"er)ilir)inemia

>D methylene )le


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55. # 53 year old woman who nderwent )rain tmor resection for days ago

deelo"s left lower e'tremity "ain and swelling. #n ltrasond e'amination

demonstrates clot in the femoral "o"liteal eins on the left. &he most a""ro"riatetreatment for this is

# )egin am)lation and discontine )ed rest

)egin intraenos he"arin administration

! se intermittent leg com"ression and gradated(com"ression stocings.

"lace an >D! filter

[email protected] # 19 year old man is shot in the a)domen. ;hen +M$ arries his itals are heart

rate 130, )lood "ressre 90F@0, res"iratory rate 20. +M$ calls yo at the )asehos"ital to as for adice. o shold as the +M$ team to

# )ring the "atient to the +mergency oom #$#P

administer 1,000 cc 10= de'tran soltion on rote to the +

! int)ate the "atient in the field and administer flid on rote to the +

administer flid )ols in the field oer 10 mintes and then trans"ort

"atient to the +

57. # 57 year old man re<ires mechanical entilation )ecase of res"iratory failresecondary to a )lood transfsion B&#?>. es"ite an C>0 2 of 0.5, his P2 is

noted to )e only @0. &he case of this manKs hy"o'emia is

# right to left shnt

DF- mismatch

! increased diffsion )arrier

decreased mi'ed enos 2 satration


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58.4 # 30 year old man is inoled in a motor ehicle accident. 6e re<ires

emergency s"lenectomy and o"en redction and internal fi'ation of a left femr

fractre. n "ost(o"eratie day two in the >ntensie !are Gnit, he deelo"s adecreasing leel of consciosness B!$ 1* and seere hy"o'emia, necessitating

int)ation and mechanical entilation. 6e was noted to hae "etechiae on his

chest. &he case of his res"iratory failre is liely:

# as"iration

fat em)olism syndrome

! adlt res"iratory distress syndrome B#$

nosocomial "nemonia

59. #n 85 year old man deelo"s se"tic shoc following attem"ted remoal of an

o)strcting right reteric stone. 6e is transferred to the >!G and resscitation is

)egn with flids and "ressors. ;hich of the following anti)iotics wold /& )ea""ro"riate for se in this "atient while awaiting )lood and rine cltre reslts

# ceftria'one

ci"roflo'acin

! gentamycin

imi"enem


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@0.4 # 31 year old man was a )elted drier inoled in a high(s"eed motor ehicle

collision. 6is air )ag de"loyed. 6e was fond a""arently ninred at the scene.

>n the +mergency oom, he has right sided weaness des"ite a normal !& head.&he ne't ste" in is management shold )e

# close o)seration with serial nerological e'amination

nec immo)iliEation and !(s"ine '(ray

! !& angiogram of nec

++

@1. >n a se"tic "atient, cytoine(mediated effects on trace element meta)olism inclde

which of the following

# decreased serm iron leel

increased serm Einc leel

! increased serm co""er leel

decreased serm manganese leel

@2. Pre(o"eratie non(inasie testing for the "resence of indci)le myocardial

ischemia wold )e most a""ro"riate for which of the following "atients

# a healthy @0 year old man withot historical cardiac ris factors schedled

for a gastrectomy for gastric adenocarcinoma

a "atient with a history of myocardial infarction one year ago and good

e'ercise tolerance ndergoing a la"arosco"ic cholecystectomy

! a "atient with dia)etes and renal insfficiency ndergoing an in<inalhernia re"air

a "atient with limited e'ercise tolerance and dia)etes ndergoing a righthemi colectomy


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@3. ;ith regard to the s"read of neo"lasm, which of the following statements is

C#?$+

# metastatic cells enter the lym"h node ia the s)ca"slar s"ace and later

"ermeate the sinsoids of the node

carcinoma(in(sit is a lesion with histo"athological characteristics of

malignancy withot detecta)le inasion )eyond the )asement mem)rane

! lym"hatic inolement is common with e"ithelial neo"lasms, whereasmost sarcomas metastasiEe hematogenosly

the metastatic "rocess is highly efficient, as eidenced )y the fact that the

nm)er of circlating tmor cells correlates with the metastatic )rden

@*. # @7 year old man is admitted to hos"ital for treatment of )ilateral "lmonary

em)oli with a he"arin infsion. &he "atientKs "latelet cont on admission was

250,000 and three days later, it is noted to )e 75,000. n "hysical e'amination,the "atient is noted to hae ischemic changes in the right ""er and lower

e'tremities. ;hich of the following statements concerning this sitation is

correct

# low moleclar he"arin can )e safely sed as a s)stitte for nfractionated

he"arin

enos throm)osis is the most lie case of this manKs recent "hysicalfindings

! s)ctaneos administration of he"arin is not associated with this "ro)lem

direct throm)in(inhi)itors are sed as the first line of treatment

@5.4 # 25 year old woman is inoled in a motor ehicle accident. n arrial in the

+mergency oom, the !$ is 7. !$C is seen in her left ear. &here are o)iose'tremity fractres in )oth legs. &he "atient is int)ated. ;ith regards to her

head inry, what is the most im"ortant treatment "rior to getting a !& scan of the

head

# maintain normal )lood "ressre and o'ygenation

hy"erentilate "atient to a "!2 leel of 25

! administer 250 ccKs 10= mannitol oer 30 mintes

administer #ncef 1 gram >D


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@@. ;hich of the following statements a)ot "aced red )lood cells after three wees

of storage is &G+

# affinity for o'ygen decreases

they mst )e sed within one wee

! 2* hor "ost(transfsion red cell srial is less that 50=

"otassim concentration increases

@7. ;hich of the following conditions is /& a ris factor for "ost(o"eratie cardiacmor)idity

# $3 gallo" rhythm on ascltation

more than fie "csFminte on an +!

! coronary artery stenting in the "ast si' months

significant aortic stenosis

@8. # 37 year old homeless man "resents in the +mergency oom with left leg "ain.

6e has nmeros )rises and a)rasions on )oth legs. 6e has an area of erythema,tenderness, and indration starting on the medial as"ect of the left anle and

e'tending " the leg to the nee. &he left in<inal lym"h nodes are enlarged and

tender. &he microorganism most liely res"onsi)le for this clinical scenario is

# actinomycoses

enterococcs

! sta"hylococcs ares

stre"tococcs "yogenes

@9. # @5 year old dia)etic man is schedled for arteriogra"hy sing non(ionic

contract. 6is serm creatinine is 200. >n addition to hydration, which of the

following is indicated to redce the ris of contrast(indced ne"hro"athy

# low dose do"amine infsion

mannitol infsion

! hydrocortisone >D

acetylcysteine >D


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Cor each of the following three <estions, select the one answer that is most

closely associated with the <estion stem.

# corticosteroids

cyclos"orine

! myco"henolate mofetil

sirolims

70. locs the calcineron "athway

71. >nhi)itor of nclear factor of actiated &(cells

72. >nhi)its calcim(inde"endent "athways for & and cell actiation

73. ;hich of the following statements concerning glcagon is correct

# maor stimlants for the secretion of glcagon inclde hy"oglycemia

and e'ercise

the effects of glcagon are inhi)ited )y cortisol

! glcagon "lays a maor role in the deelo"ment of "ost(inry

hy"erglycemia

somatostatin "otentiates glcagon release from islet cells

7*. ;hich of the following statements concerning the cytoine interlein(1 B>?(1 is /& correct

# the cells most res"onsi)le for >?(1 "rodction are monocytes andmacro"hages

>?(1 may indce feer

! &(lym"hocyte "rodction of >?(2 is inhi)ited )y >?(1

>?(1 may agment wond healing )y increasing fi)ro)last "roliferation

and collagen synthesis


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75. Planned "rimary mltimodality thera"y reslts in im"roed srial or redced

mor)idity of treatment in all of the following tmors, +A!+P&

# infiltrating carcinoma of the )reast

;ilms tmor

! melanoma

sarcoma of the e'tremities

7@. # @0 year old trama "atient ndergoes tracheostomy )ecase of "rolongedres"iratory failre. Cie days following the "rocedre, large <antities of )right

red )lood are noted to )e coming from within and arond the tracheostomy t)e.

&he "resmed diagnosis is

# "lmonary em)ols

necrotiEing "nemonia

! tracheitis

tracheo(innominate artery fistla

77. # 75 year old woman is schedled to ndergo a right total hi" re"lacement. $he

taes comadin for chronic atrial fi)rillation. ;hich is the most a""ro"riate

management of her anticoaglation "re(o"eratiely

# sto" comadin fie days "re(o"eratiely and chec the >/ on the day of

srgery

sto" comadin fie days "re(o"eratiely, initiate low moleclar weighthe"arin s)ctaneosly twice a day and hold he"arin for 12 hors "rior to

srgery

! sto" comadin fie days "re(o"eratiely, admit "atient to hos"ital and start

>D nfractionated he"arin infsion. $to" he"arin infsion @ hors "re(o"eratiely

sto" comadin one day "re(o"eratiely and administer itamin H 1 10 mgs

s)ctaneosly. !hec >/ on day of srgery


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78. # 35 year old man sffers a significant closed head inry and r"tred s"leen in a

motor ehicle accident. 6e ndergoes emergency la"arotomy and s"lenectomy

and is transferred to the >ntensie !are Gnit "ost(o"eratiely. 6e has a history ofdee" enos throm)osis de to antithrom)in(>>> deficiency. &he "referred D&+

"ro"hyla'is for this "atient is

# antithrom)in >>> concentrate to maintain leels at 80 to 120= of normal

eno'a"arin 30 mgs s)ctaneosly )id

! he"arin 5000 nits s)ctaneosly )id

he"arin infsion to ee" P&& L@0

79. !lostridim difficile colitis is )ecoming increasingly common. ;hich of thefollowing statements a)ot this disease is correct

# not all anti)iotics can case !lostridim difficile colitis

!lostridim difficile colitis always indces seere diarrhea

! the mainstay of treatment is oral Dancomycin

emergency colectomy may )e re<ired

80. +ndocarditis "ro"hyla'is is recommended for which of the following "atients

# a "atient with mitral ale "rola"se withot mrmr ndergoing rigid

)ronchosco"y

a "atient with a history of rhematic feer with normal cardiac ales

ndergoing "rostatic )io"sy

! a "atient with a "rosthetic aortic ale ndergoing endosco"ic retrogradecholangiogra"hy for )iliary o)strction

a "atient with hy"ertro"hic cardiomyo"athy ndergoing tym"ano"lastyt)e insertion


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81. # *5 year old man deelo"s hy"erglycemia des"ite ade<ate leels of circlating

inslin dring his recoery from a la"arotomy for trama with s"lenectomy. Post

tramatic inslin resistance is "rimarily de to

# cortisol

inslin anti)odies

! redced inslin rece"tors

increased inslin clearance

82. # @5 year old man is inred in a motor ehicle collision. 6e sffers a chest wall

inry consisting of a flail segment BB5(9th ri)s and an nderlying "lmonary

contsion withot hemo or "nemothora'. #fter resscitation, he is receiing * l2 "er minte )y nasal canla. 6e rates his "ain as 8F10 and cannot tae a dee"

)reath or cogh. 6is res"iratory rate is 2* and he has mild res"iratory acidosis.

Grine ot"t is *0 mlFh. $"inal inry has )een rled ot. ;hich of the followingis the most a""ro"riate ne't ste"

# endotracheal int)ation and mechanical entilatory s""ort

continos e"idral analgesia

! flid resscitation

non(inasie entilatory s""ort with )i(P#P

83. ;hich of the following statements regarding the transcri"tion factor /CH is

correct

# it is anti(inflammatory

it inhi)its &/C and >?1 transcri"tion

! its actiation increases i/$ e'"ression

its "rimary site of action is the cyto"lasm


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8*. egarding inde'es of tisse "erfsion, which of the following statements is

correct

# normal cardiac inde' "recldes tisse hy"o'ia

normal or high mi'ed enos o'ygen satration B$ 02 "recldes tisse

hy"o'ia

! high "lasma lactate leels always reflect tisse hy"o'ia

there is a s""ly de"endence of o'ygen consm"tion on o'ygen deliery

in some circmstances

85. ;hich "art of the cell is thoght to )e the target of radiation damage

# mitochondria

ncles

! ncleols

cell mem)rane

8@. # 50 year old woman is fond to hae an adenocarcinoma of the cecm. !onsentis o)tained for Iright hemicolectomyJ. #t srgery a right hemicolectomy is

carried ot withot difficlty. /o eidence of metastatic disease is fond e'ce"t

for a ery )ly right oary, highly sggestie of metastatic disease BHren)ergtmor. >n this sitation, the srgeon shold

# close the a)domen and o)tain informed consent for ftre rightoo"horectomy "ost o"eratiely from the "atient

conslt a gynecologist a)ot the a""ro"riate action to tae in the

"erating oom

! scr) ot of the case and o)tain consent for right oo"horectomy from the

"atientKs hs)and

carry ot right oo"horectomy and inform the "atient "ost(o"eratiely


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87. # 50 year old man is admitted to the day srgery nit "rior to craniotomy for

meningioma. 6e is noted to )e hy"ertensie and tremlos. 6e admits to daily

heay alcohol se inclding the night "rior to srgery. &he o"timal managementof this "atient is

# cancel srgery, re)oo when the "atient has a)stained from alcohol forone month

transfer the "atient to a deto'ification centre and reschedle srgery in one

wee

! admit the "atient to the /erosrgery ;ard, sedate with )enEodiaEe"ine,

reschedle srgery when the "atient is free of withdrawal sym"toms

carry on with srgery and o)sere "atient in the >ntensie !are Gnit "ost(

o"eratiely

88. /e"hroto'icity from >D contrast agents is:

# cased )y contract "reci"itation in the distal t)le

redced )y oral acetylcystine

! increased )y iso(osmolar contrast medims

inde"endent of )aseline renal fnction

89. # 50 year old homeless alcoholic is admitted to hos"ital for treatment of left leg

celllitis. o are concerned that this "atient may )e ery malnorished and

re<ire s"ecial dietary thera"y. &he )est method of determining the ntritionalstats of this "atient is

# history and "hysical e'amination Bs)ectie glo)al assessment

calclate the creatinine(height inde'

! test for delayed hy"ersensitiity reaction to common recall antigens

measre serm al)min and transferrin


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90. ;hich of the following statements regarding methacillin resistent sta"h ares

BM$# is /& correct

# M$# is a common nosocomial "athogen, )t it can also )e detected in

the commnity

the treatment of choice is ancomycin

! M$# is more irlent than methacillin sensitie sta"h ares

hos"italiEed "atients coloniEe with M$# re<ire contact isolation

91. &he most accrate test for the diagnosis of adrenal insfficiency is critically ill

"atients is

# morning serm cortisol leel

morning serm #!&6 leel

! corticotro"hin B#!&6 stimlation test

meta"yrone oernight test

92. &he ey com"onents of informed consent, or the "rocess )y which "hysicians and "atients mae decisions together, inclde each of the following, +A!+P&

# disclosre

com"etency

! com"rehension

com"liance

93. $ignificant "rotein loss after seere inry is common. ;hich of the following

statements concerning this sitation is correct

# it reslts from im"aired "rotein synthesis

it occrs "rimarily from seletal mscle

! it occrs "rimarily at the site of inry

it can )e "reented )y enteral )t not "arenteral feeding


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9*. egarding renal fnction dring states of hemorrhagic shoc, which of the

following statements is correct

# the )lood flow to the idney, lie that to the )rain, is maintained ntil late

in the corse of hemorrhagic shoc

renal ischemia longer than 10 mintes "rodces irreersi)le renal damage

in most "atients

! fractional e'cretion of /a is less than 1(2= in most "atients withhemorrhagic shoc

alteration in the serm G/ leel is as sensitie a measrement of renal

fnction as is serm creatinine

95. ;hich of the following treatments is sed for the "reo"eratie "re"aration of

"atients with a nown "heochromocytoma

# flids, )lood, or )oth

diretics

! al"ha antagonists

)eta agonists

9@. # @0 year old man ndergoes total gastrectomy for carcinoma of the stomach.Post(o"eratiely he deelo"s an anastomotic lea at the eso"hageal anastomoses

and ndergoes frther srgery and "erctaneos drainage of mlti"le a)scesses.

er the corse of his hos"ital stay, he is noted to hae mared wasting of hisseletal mscles. &his is "rimarily cased )y:

# disease atro"hy

malntrition

! eleated leels of conter(reglatory hormones Bcortisol, glycogen,e"ine"hrine

eleated leels of cytoines sch as interlin(2 and tmor necrosis

factor


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97. # 75 year old woman is recoering from total a)dominal hysterectomy. n "ost(

o"eratie day fie, as she is )eing hel"ed ot of )ed, she sffers sdden cardiac

arrest. o are the first doctor to arrie at the )edside, @0 seconds later. +!monitor shows slow entriclar fi)rillation. or first action shold )e

# int)ate "atient

initiate chest com"ressions

! defi)rillate "atient

administer 1 mg e"ine"hrine >D and rechec rhythm

98. ;hich of the following statements concerning "ost(o"eratie lnar nero"athy is

correct

# it is more common in females

it can )e "reented )y "adding the arms dring anesthesia

! it is the least common "erio"eratie nere inry

it may hae delayed onset of sym"toms

99. a"id se<ence indction of anaesthesia is commonly sed for emergency

srgery in "atients who may hae significant <antities of flid in the stomach.

;hich of the following statements a)ot ra"id se<ence indction is correct

# "re(o'ygenation is not necessary

only a de"olariEing mscle rela'ant can )e sed

! cricothyroid "ressre has )een shown to decrease the incidence of

as"iration "nemonitis

hy"otension may reslt in hy"oolemic "atients

100. ;hich of the following is /& an aderse eent associated with the se of

<inoline anti)iotics Bsch as ci"roflo'acin

# tendonitis and "ossi)le tendon r"tre

seiEres

! clostridim difficile colitis

narrowing of -& interal

2008 exam

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