Surgery 1 review, mcqs, previous year question paper

BHAGATH M S RAJEEV BISWAS > MCQs for practice > Previous Year Question Papers, > Review from Professors, combined with Sayed’s

SURGERY 1

2013 BATCH

MCQ : For Practice

Cardiopulmonary Resuscitation - CPR 1. The most common cause of cardiopulmonary arrest in adults is A) asystole.

B) pulseless electrical activity.

C) ventricular fibrillation.

D) atrial fibrillation.

E) paroxysmal supraventricular tachycardia.

2. Which of the following are factors proven to enhance prehospital survival.

A) Occurrence of a witnessed arrest B) Rapid implementation of bystander CPR C) Presence of ventricular fibrillation as the initial rhythm D) Early defibrillation E) All of the above 3. The most crucial link in the “chain of survival” is A)early access.

B) early basic CPR. C) early defibrillation.

D) early ACLS. E) none of the above.

4. Cardiac output generated through CPR during cardiac arrest is roughly A) 5-10 percent.

B) 10-20 percent.

C) 20-30 percent.

D) 40-50 percent.

E) 50-60 percent.

5. Which of the following statements is true?

A) Coronary perfusion pressures of at least 5 mm Hg are associated with a higher rate of return of spontaneous circulation.

B) The effectiveness of epinephrine is thought to be due to its α2 effects.

C) Phenylephrine is superior to epinephrine for treatment of ventricular fibrillation.

D) Epinephrine is associated with a higher incidence of hospital discharge than norepinephrine.

E) None of the a 6. Which of the following statements is true?

A) The dose of vasopressin for ventricular fibrillation is 40 U every 3 to 5 minutes.

B) The vasoconstrictor effect of vasopressin is due to its effects on α1 receptors.

C) Vasopressin is shorter acting than epinephrine.

D) The effect of vasopressin can be blunted with metabolic acidosis.

E)Vasopressin has a more favorable effect than epinephrine on myocardial oxygen demand in the postresuscitative phase.

7. Which of the following is an adverse effect related to intravenous amiodarone?

A) Hypotension B) Seizures C) Torsades de pointes D) Diarrhea E) Hypokalemia 8. Which antiarrhythmic is associated with a higher rate of hospital discharge following ventricular fibrillation?

A) Lidocaine B) Amiodarone C) Procainamide D) Bretylium E) None of the above 9. Which antiarrhythmic is associated with the highest incidence of hypotension?

A) Amiodarone B) Lidocaine C) Bretylium D) Adenosine E) None of the above 10. Which of the following is not an acceptable therapy for asystole?

A) CPR B) Defibrillation C) Epinephrine D) Atropine E) Intubation

Surgery

11. Which of the following are causes of pulseless electrical activity (PEA)?

A) Hypovolemia B) Drug overdose C) Tension pneumothorax D) Hypokalemia E) All of the above 12. Which of the following is not a potentially harmful effect of sodium bicarbonate?

A) Tissue hypercarbia B) Intracellular acidosis C) Iatrogenic alkalosis D) Hyperkalemia E)Decrease in myocardial contractility 13. Which of the following drugs can be administered through an endotracheal tube?

A) Amiodarone B) Bretylium C) Epinephrine D) Procainamide E) Vasopressin 14. The first drug administered following electrical defibrillation following ventricular fibrillation is A) epinephrine.

B) amiodarone.

C) lidocaine.

D)sodium bicarbonate.

E)atropine.

15. The survival rate following asystole is approximately A) 1 percent.

B) 5 percent.

C) 10 percent.

D) 15 percent E) 20 percent.

Hypovolemic Shock 1. A mainstay of therapy for virtually all forms of shock is A) intravenous fluids.

B) epinephrine.

C) phenylephrine.

D) red blood cells.

2. Dehydration is primarily a loss of A) intracellular and interstitial sodium.

B) intracellular and interstitial water.

C) interstitial and intravascular sodium.

D) interstitial and intravascular water.

3. Cell damage and death due to hypovolemic shock may be a function of A) the primary insult.

B) reperfusion injury.

C) both a and b.

D) neither a or b.

4. Which of the following parameters in the Starling equation describing fluid transport is obtainable in most hospital settings (at least an indirect estimate is possible)?

A) Capillary filtration coefficient B) Tissue hydrostatic pressure C) Capillary hydrostatic pressure D) Net transvascular flow rate 5. In a healthy 20-year-old man who has lost less than 10 mL/kg of fluids from the body during exercise, which of the following set of measurements is most likely to be present?

A) Heart rate less than 100, respiratory rate less than 20, normal blood pressure and urine output B) Heart rate less than 100, respiratory rate less than 20, decreased blood pressure and urine output C) Heart rate greater than 100, respiratory rate greater than 20, increased blood pressure and urine output D) Heart rate greater than 100, respiratory rate greater than 20, decreased blood pressure and urine output

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MCQ : For Practice 6. Which of the following parameters should not be used routinely to monitor patients in the early stages of shock?

A) Mental status changes from baseline B) Blood pressure recordings C) Urine output through Foley catheter D) Mixed venous oxygen saturation 7. Which of the following intravenous solutions is least useful, and possibly harmful, as the initial resuscitation solution in a patient with a head injury who has blood loss?

A) 5% dextrose in water B) Normal saline C) Lactated Ringer’s D) Hypertonic saline

Vasopressors and Inotropes in Shock 1. Conditions that can result in a lowering of blood pressure in critically ill patients include A) decreased cardiac output.

B) decreased pulmonary capillary wedge pressure.

C) systemic vasodilation.

D) all the above.

E) none of the above.

2 The central venous pressure (CVP) catheter is a device that is used to effectively perform what function in critically ill patients?

A) Obtain venous blood samples B) Administer drugs directly into the central circulation C) Accurately determine blood volume 8.Which of the following statements concerning the intravenous administration D) a and b only of 5% albumin is true?

E) All the above A) All of it stays in the intravascular space until it is eliminated from the body.

B)All of it stays in the interstitial space until it is eliminated from the body.

3. A pulse oximeter is placed on a finger of a critically ill patient to determine what C)For a short time it remains intravascular; then it crosses into the interstitial physiologic parameter? space.

A) Arterial oxygen saturation D) For a short time it remains intravascular; then it crosses into the intracellular B) Venous oxygen saturation space.

C) Blood pressure D) Core blood temperature 9. Which of the following fluids would be expected to cause the largest expanE) Intramucosal pHi sion of the intravascular compartment within minutes of its administration?

A) 250 mL of 5% albumin 4. A parameter that determines the effect of therapy on regional perfusion is B) 250 mL of 6% hetastarch A) arterial blood lactate concentration.

C) 500 mL of normal saline B) arterial-mucosal PCO2 gap.

D) 100 mL of 25% albumin C) oxygen delivery.

D) oxygen consumption.

10. Which of the following solutions may result in a patient having a misdiagE) systemic vascular resistance. nosis of pancreatitis?

A) 5% albumin 5. Stimulation of the adrenergic receptor and G-protein by adrenergic agonists B) 25% albumin results in a clinical response mediated by C) 6% hetastarch A) pulmonary artery pressure.

D) Hypertonic saline B) cyclic AMP. C) cyclic GMP. 11. Which of the following solutions is contraindicated in a patient with a D) intramucosal pHi. suspected intracranial bleed?

E) nitric oxide.

A) 5% albumin B) 25% albumin 6. A drug that stimulates the following adrenergic receptors (alpha, beta, dopaC) 6% hetastarch mine-1, and domaine-2) is D) Hypertonic saline A) dobutamine.

B) dopamine.

12. Which of the following therapies is most likely to save the life of a patient C) dopexamine. who is bleeding profusely secondary to a knife wound to the abdomen (presume D) epinephrine. the patient has only a 15-minute transport time to the nearest hospital)?

E) norepinephrine.

A) Normal saline administered as fast as possible at the scene to achieve a mean arterial pressure of 100 mm Hg and then transport to the hospital 7. A drug with primary (1-adrenergic receptor activity and mild (2 and (1 activity B) Lactated Ringer’s administered as fast as possible at the scene to achieve a that exists as a racemic mixture is mean arterial pressure of 80 mm Hg and then transport to the hospital A) dobutamine.

C) Normal saline administered as fast as possible to achieve a mean arterial B) dopamine. pressure of 20 mm Hg and then transport to the hospital C) dopexamine D) After rapid assessment, transport the patient immediately to the hospital with D) epinephrine. placement of intravenous lines while enroute E)norepinephrine.

13. Which of the following is the least likely complication of packed red blood cell administration?

A) HIV infection B) Hypocalcemia C) Hypothermia D) Transfusion reaction 14. Which of the following tests requires the use of a right-sided heart catheter (pulmonary artery catheter) for routine measurements in the intensive care unit setting?

A) Lactate concentration B) Cardiac output C) Base deficit D) Intramucosal stomach pH 15. Which of the following medications is least likely to aggravate an existing vasoconstrictive state?

A) Dopamine 15 µg/kg per minute B) Dobutamine 10 µg/kg per minute C) Norepinephrine 8 µg/min D) Epinephrine 8 µg/min

Surgery

8. Development of lactic acidosis by a vasopressor catecholamine is caused by A) enhanced vasoconstriction in peripheral arteries.

B) enhanced glycogenolysis.

C) mobilization of lactate from peripheral tissues.

D) a and b only.

E) all the above.

9. Extravasation of a vasopressor catecholamine can be treated pharmacologically with intradermal injections of A) phentolamine.

B) phenylephrine.

C) nitric oxide.

D) vasopressin.

E) none of the above.

10. Which of the following catecholamines is associated with a transient fall in intramucosal pHi and transient rise in blood lactate concentration during treatment?

A) Dobutamine B) Dopamine C) Dopexamine D)Epinephrine E)Norepinephrine Page 2

MCQ : For Practice 11. A preferred catecholamine to treat hypotension in a septic shock patient with concomitant tachycardia is A) dobutamine.

B) dopamine.

C) phenylephrine.

D) epinephrine.

E) norepinephrine.

12. The only catecholamine associated with a reduced mortality in septic shock patients is A) dobutamine.

B) dopamine.

C) dopexamine.

D) epinephrine.

E) norepinephrine.

13. Which of the following is true about low-dose dopamine?

A) Plasma concentrations are predictable at various dosages.

B) It results in an increase in mucosal perfusion and a higher pHi. C) It may resolve oliguria; it has no effect on reducing the incidence of acute renal failure.

D) Extravasation does not result in tissue sloughing.

E) Dopamine is derived from enzymatic oxidation or arginine.

14. Which adverse drug effect is not seen with dopamine?

A) Tachycardia B) Bradycardia C) Increased pulmonary capillary wedge pressure D) Increased intrapulmonary shunt E) Decreased PO2 15. What agent has been used successfully to treat hypotension refractory to vasopressor catecholamines in septic shock patients?

A) Dopexamine B) Dobutamine C) Vasopressin D) Milrinone E) None of the above 1. Which of the following smoking-cessation therapies has been found to be most efficacious?

A) Nicotine patch B) Placebo C) Bupropion D) Bupropion plus nicotine patch E) All of the above therapies are equally effective in smoking cessation.

2. Which of the following therapeutic interventions has been associated with a decrease in the long-term decline in FEV1?

A) Smoking cessation B) Ipratropium C) Sympatomimetics D) Theophylline E) All of the above therapies are associated with a long-term decline in FEV1.

6. Which of the following is the preferred route of administration of β2-agonists?

A) Inhalation via nebulizer B) Inhalation via metered-dose inhaler C) Oral D) Parenteral 7. Which of the following therapies used in COLD does not exert therapeutic bronchodilatory effects?

A) Ipratropium B) Sympathomimetics C) Theophylline D) Corticosteroids 8. What is the recommended loading dose of theophylline in a theophylline-naive patient?

A) 6 mg/kg B) 5 mg/kg C) 0.6 mg/kg D) 0.5 mg/kg 9. GG is a 65-year-old male with chronic stable COLD. He is currently taking ipratropium MDI 6 puffs qid and prn albuterol. His albuterol usage has increased over the last several months, and his therapy is to be changed. Which of the following therapeutic management plans would you recommend?

A) Continue ipratropium MDI 6 puffs qid and prn albuterol and add theophlline 400 mg once daily.

B) Continue ipratropium MDI 6 puffs qid, discontinue prn albuterol, and add salmeterol 2 puffs bid.

C) Continue ipratropium MDI 6 puffs qid and prn albuterol and add salmeterol 2 puffs bid.

D) Discontinue ipratropium MDI 6 puffs qid and prn albuterol and replace both with prednisone 30 mg once daily.

10. Which of the following treatments should not be considered in an acute exacerbation of COLD? A) Systemic corticosteroid B) Inhaled corticosteroid C) Inhaled sympathomimetic D) Inhaled ipratropium 11. MM is a 70-year-old male with chronic stable COLD. He is currently taking ipratropium MDI 6 puffs qid, salmeterol 4 puffs bid, and prn albuterol. A decision is made to add another agent to his chronic regimen. Which of the following agents are appropriate to add to MM’s current regimen?

A) Inhaled corticosteroid B) Oral corticosteroid C) Oral theophylline D) Any of the above agents would be appropriate.

12. Which of the following agents would be most preferred in an individual with cor pulmonale and COLD? A) Furosemide B) Digoxin C) Minoxidil D) Hydralazine

13. Which of the following pathogens is not commonly present in individuals with acute exacerbations of COLD? 3. Which of the following therapies is considered the drug of choice for episodic A) H. influenzae B) M. catarrhalis symptomatic management of symptoms in COLD? C) S. pneumoniae A) Ipratropium D) S. aureus B) Inhaled rapid-acting β2-agonist (e.g., albuterol) C) Inhaled delayed-acting β2-agonist (e.g., salmeterol) D) Theophylline E) Inhaled corticosteroid

4. Which of the following therapies is considered the drug of choice for an individual with COLD with chronic mild symptoms and no current chronic treatment?

A) Ipratropium B) Scheduled β2-agonist C) As-needed β2-agonist D) Theophylline E) Inhaled corticosteroid 5. Which of the following are side effects associated with ipratropium?

A) Blurred vision B) Urinary retention C) Tachycardia D) Osteoporosis E) Dry mouth

Surgery

14. PF is a 50-year-old male with COLD. Over the past 3 days he has developed increased dyspnea, increased sputum volume, and sputum purulence. This is his first acute exacerbation, and his FEV1 is greater than 50 percent of predicted. A decision is made to start antimicrobial therapy. Which of the following regimens is most appropriate for PF? A) Erythromycin B) Clarithromycin C) Amoxicillin-clavulanic acid D) Gatifloxacin 15. MM is a 70-year-old male who presents to the emergency room with an acute exacerbation of COLD. He lives in a nursing home, and this is his sixth exacerbation of COLD this year. His FEV1 is less than 35 percent of predicted. He has no clinical signs of sepsis. He is admitted to the hospital, and oxygen, ipratropium, and albuterol are initiated. Which of the following antimicrobial agents would not be appropriate for MM? A) Levofloxacin B) Antipseudomonal β-lactamase penicillin (e.g., ticarcillin-clavulanate) C) Clarithromycin D) Antipseudomonal cephalosporin (e.g., ceftazidime) Page 3

MCQ : For Practice

Liver Transplantation 1. Absorption of which of the following agents is most likely to be affected in a transplant recipient with percutaneous drainage of bile through a T-tube?

A) Neoral B) Prograf C) Sandimmune D) Cellcept E) Imuran 2. What therapy should be used for prophylaxis against Pneumocystis carnii in a transplant patient who has a documented allergy to sulfa?

A) Bactrim SS one tablet orally three times a week B) Inhaled pentamidine 300 mg monthly C) Acyclovir 200 mg orally twice daily D) Ganciclovir 1 g orally three times daily E) None of the above 3. At a follow-up clinic visit, a patient’s tacrolimus concentration was found to have doubled from a baseline concentration. The tacrolimus dose had not been changed. Which of the following is the most likely explanation?

A) Metoprolol was started to treat hypertension.

B) The patient was treated with ganciclovir for a CMV infection.

C) The patient’s serum creatinine increased from 1.2 to 2.0 mg/dL. D) Fluconazole was started to treat a Candida albicans urinary tract infection.

E) Acyclovir therapy was stopped.

4. A liver transplant recipient receiving standard immunosuppression and prophylactic drug therapy is complaining of tremors in his hands. Which of the following is most likely to be a contributing factor for this finding?

A)Tacrolimus B) Mycophenolate mofetil C) Prednisone D) Nystatin E) Bactrim 5. A liver recipient receiving tacrolimus 4 mg PO bid, prednisone 15 mg PO qd, and azathioprine 50 mg PO qd was found to have a white blood cell count of 2.7/mm3. Which of the following outlines the best course of action?

A) Decrease tacrolimus dose.

B) Decrease prednisone dose.

C) Decrease azathioprine dose.

D) Start neupogen.

E) Hold all immunosuppressive agents until white blood cell count is greater than 5.0/mm3.

6. A liver transplant patient is experiencing frequent diarrhea. His medications include cyclosporine, mycophenolate mofetil, and prednisone. Which of the following the best plan to improve the patient’s symptoms?

A) Decrease prednisone dose.

B) Administer prednisone with food.

C) Add loperamide.

D) Administer mycophenolate mofetil with antacids.

E) Administer mycophenolate mofetil with food.

7. Which of the following chronic diseases can occur or worsen with the chronic use of immnunsuppressive agents?

A) Hypertension B) Diabetes C) Hyperlipidemia D) a and b E) All of the above 8. For which of the following immunosuppressive agents is routine serum concentration monitoring recommended?

A) Mycophenolate B) Tacrolimus C) Sirolimus D) Azathioprine E) All of the above 9. Which of the following statements is false regarding the use of Muromonab-CD3?

A) The usual dose is 5 mg intravenous push daily for 5-14 days.

B) Adverse effects include fever chills and chest tightness.

C) For the first dose patients should be premedicated with antipyretics, antihistamines, and steroids.

D) The drug is a polyclonal antibody against numerous T cell components.

E) The drug is indicated for steroid-resistant organ rejection.

Surgery

10. For the prevention of recurrent hepatitis B following liver transplantation, patients are treated with a combination of hepatitis B immune globulin and which of the following?

A) Lamivudine B) Ganciclovir C) Interferon-α D) Ribavirin E) None of the above 11. Which of the following laboratory parameters are important in assessing liver status and function following a liver transplant?

A) Serum bilirubin B) GGTP C) INR D) a and b E) All of the above 12. Which of the following symptoms is not associated with an episode of acute rejection?

A) Tenderness at graft site B) Increased serum bilirubin C) Leukopenia D) Decreased quantity of bile E) Fever 13. Which of the following is not indicated for the treatment of acute rejection in a liver transplant recipient?

A) Daclizumab B) Methylprednisolone C) Muromonab-CD3 D) Thymoglobulin E) All of the above are indicated.

14. Which of the following would not be appropriate to provide to a patient when providing counseling on tacrolimus therapy?

A) Adverse effects can include tremors, headache, nightmares, and kidney problems.

B) Inform your physician before starting any new medication, including vitamins or over-the-counter products.

C) Take your tacrolimus at the same time each day.

D) If stomach upset occurs, take your tacrolimus with an antacid.

E) The patient should be informed of all these statements.

15. Which of the following agents is likely to result in a decreased tacrolimus concentration?

A) Diltiazem B) Phenytoin C) Erythromycin D) Verapamil E) All of the above

Disorders of Sodium, Water, Calcium and Phosphorus Homeostatis 1. A 60-year-old man presents to the emergency room with a 2-week history of nausea and vomiting. On physical examination, the patient’s weight is 70 kg, skin turgor is decreased, and there is postural hypotension. Laboratory studies show serum sodium, 126 meq/L (normal 135-145 meq/L); serum creatinine, 1.8 mg/ dL (normal 0.8-1.3 mg/dL); urine osmolality, 1000 mOsmol/kg; and urine sodium concentration, 4 meq/L. Which of the following interventions is most appropriate in the emergency room?

A) 1000-1200 mL daily water restriction.

B) Bolus infusion of 0.9% saline until the postural hypotension resolves C) Infusion of 0.45% saline at 100 mL/h D) Infusion of 3% saline at 55 mL/h 2. A 72-year-old woman is seen for complaints of increased confusion. One week ago she developed intractable diarrhea. On physical examination, she is lethargic. Her weight is 64 kg. Her blood pressure is 110/60 mm Hg supine, 80/50 mm Hg standing. Her heart rate is 110 beats per minute. Laboratory studies show serum sodium, 115 meq/L (normal 135-145 meq/L); creatinine, 1 mg/dL (normal 0.6-1.2 mg/dL); urine sodium, 5 meq/L; and urine osmolality, 900 mOsmol/kg. Correct statements regarding the pathogenesis of the hyponatremia in this patient include all the following except

A) hypovolemia is inducing release of ADH. B) the patient was totally deprived of water.

C)intracellular water content is increased.

D) the extracellular fluid volume is decreased.

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MCQ : For Practice 3. A 68-year-old man is found to have hyponatremia during a routine office visit. He is on no medications and has smoked 1 pack of cigarettes per day for 40 years. On physical examination, he is alert and oriented. His weight is 60 kg. His blood pressure is 120/80 mm Hg. There is no edema, and his chest is clear to auscultation. Laboratory studies show serum sodium, 125 meq/L (normal 135-145 meq/L); creatinine, 1.3 mg/dL (normal 0.8-1.3 mg/dL); urine sodium, 85 meq/L; and urine osmolality, 600 mOsmol/kg. The most appropriate treatment is A) infusion of 0.9% saline at 640 mL/h over next day.

B) infusion of 3% saline at 48 mL/h over the next day.

C) 1000-1200 mL fluid restriction.

D) desmopressin acetate 10 µg intranasally once daily.

4. An 80-year-old man was found comatose by his family in his apartment after last being seen 1 week ago. On physical examination, he is unresponsive and does not move his right side. His weight is 50 kg. His blood pressure is 90/40 mm Hg supine. His heart rate is 120 beats per minute. His skin turgor is decreased. There is no edema. Laboratory studies show serum sodium, 165 meq/L (normal 135-145 meq/L); creatinine, 2.0 mg/dL (normal 0.8-1.3 mg/ dL); urine sodium, 10 meq/L; and urine osmolality, 1000 mOsmol/kg. The most appropriate treatment is A) 0.9% saline at 250 mL/h over the initial 24 h of hospitalization.

B) 0.45% saline at 250 mL/h over the initial 24 h of hospitalization.

C) D5W at 80 mL/h over the first day of hospitalization.

D) 0.9% saline 1200-mL bolus or until the postural hypotension resolves, followed

by D5W at 80 mL/h over the first day of hospitalization.

5. A 19-year-old woman is referred for polyuria and polydipsia. On physical examination, her weight is 80 kg, her blood pressure is 126/80 mm Hg, her heart rate is 100 beats per minute, and there is no edema. Laboratory studies show serum sodium, 144 meq/L (normal 135-145 meq/L); creatinine, 0.6 mg/ dL (normal 0.6-1.2 mg/dL); urine osmolality, 80 mOsmol/kg; and glucose, 92 mg/dL (normal 60-120 mg/dL). The urine osmolality remains less than 100 mOsmol/kg after 3 hours of water deprivation but increases to 600 mOsmol/kg after administration of desmopressin acetate 5 µg subcutaneously. Which of the following represents the best treatment option for this patient?

A) Intranasal desmopressin acetate 10 µg twice daily B) Intravenous D5W at 48 mL/h over the next 24 hours.

C) Hydrochlorothiazide 25 mg daily D) Demeclocycline 15 mg/kg per day in three divided doses for 2 days, followed by 150 mg qid chronically.

6. A 12-year-old boy is brought to the emergency room by his parents with a 1-day history of lethargy. Over the past week he has been at home with the “flu.” His parents have been pushing fluids and homemade chicken soup. On physical examination, the boy’s weight is 50 kg, his blood pressure is 130/80 mm Hg, and his heart rate is 70 beats per minute. His lungs are clear. There is trace ankle edema bilaterally. His urine output is measured as 1000 mL over the first 6 hours of hospitalization. Laboratory studies show serum sodium, 155 meq/L (normal 135-145 meq/L); creatinine, 0.8 mg/dL (normal 0.8-1.3 mg/dL); urine sodium, 100 meq/L; and urine osmolality, 600 mOsmol/kg. The best therapeutic option is A) 0.9% saline at 100 mlLh. B) D5W at 100 mL/h and furosemide 20 mg intravenously.

C) Desmopressin acetate 10 µg twice daily.

D) 0.45% saline at 100 mL/h.

(Solution :: The clinical findings are compatible with sodium overload that is resulting in edema, an osmotic diuresis (sodium is the responsible solute), and polyuria. Treatment is directed toward replacing the water deficit relative to sodium and increasing the excretion of sodium with a loop diuretic. The expected change in the serum sodium following administration of 1 L of D5W is estimated as follows: (0 - 155 meq/L) ÷ [(0.6 × 50 kg) + 1 L] = -5 meq/L Thus 2400 mL of D5W (or an infusion rate of 100 mL/h) would be required to decrease the serum sodium by 12 meq/L in 24 h.)

7. A 39-year-old woman presents with a several-month history of polyuria and polydipsia. On physical examination, her weight is 90 kg, her blood pressure is 156/80 mm Hg, and her heart rate 92 beats per minute. There is trace ankle edema. Laboratory studies show serum sodium, 145 meq/L (normal 135-145 meq/L); creatinine, 1.2 mg/dL (normal 0.6-1.2 mg/dL); and urine osmolality, 115 mOsmol/kg. Her weight falls by 1 kg after 4 hours of water deprivation.

The urine osmolality increases to 200 mOsmol/kg over this interval and then rises to 255 mOsmol/kg following administration of 5 µg desmopressin acetate subcutaneously. Which of the following statements is true?

A) The findings of the water deprivation test are consistent with partial central diabetes insipidus.

B) Treatment should include use of a thiazide diuretic.

C) Spironolactone is helpful when this syndrome is associated with lithium therapy.

D) Hypocalcemia may cause the water deprivation test findings.

Surgery

8 A 26-year-old woman presents with new-onset edema. On physical examination, there is lower extremity pitting edema up to the knees bilaterally. Laboratory studies show serum sodium, 130 meq/L (normal 135-145 meq/L); creatinine, 0.8 mg/ dL; and albumin, 2.5 g/dL. Urinalysis shows 3+ proteinuria. A renal biopsy is performed and shows findings compatible with minimal-change disease. The patient is started on furosemide at a dose of 160 mg three times daily. She returns 1 week later in no distress, but her weight and peripheral edema are unchanged. She states that she has been taking her diuretic religiously. Which of the following represents the best next step in her management?

A) Increase the furosemide dose to 200 mg every 6 hours.

B) Add spironolactone 25 mg daily.

C) Admit for a continuous intravenous furosemide infusion.

D) Admit for intravenous infusions of albumin.

9 A 56-year-old man with advanced cirrhosis is admitted for management of tense ascites. On physical examination, his blood pressure is 96/40 mm Hg. There is tense ascites but no peripheral edema. Laboratory studies show serum sodium, 134 meq/L (normal 135-145 meq/L); creatinine, 0.6 mg/dL (normal 0.8-1.3 mg/dL); and albumin, 2.0 g/dL. Urinalysis is normal. Which of the following statements is true?

A) The net diuresis should be limited to 500 mL/day in order to decrease the risk of diuretic-induced renal failure.

B) Hydrochlorothiazide is a first-line diuretic for patients with cirrhosis and a creatinine clearance of less than 50 mL/min.

C) The serum potassium should be measured daily to monitor for hyperkalemia, which may precipitate hepatic encephalopathy.

D) ACE inhibitors are a useful adjunctive measure for treating hyponatremia associated with cirrhosis.

10. Which of the following statements regarding diuretic use in patients with congestive heart failure (CHF) is true?

A) Hydrochlorothiazide has no role in the management of edema in patients with CHF. B) Patients with CHF have been shown to have normal absorption of orally administered diuretics.

C) The most effective measure to increase diuretic efficacy for patients with CHF is to increase the frequency of diuretic administration.

D) The most effective measure to increase diuretic efficacy for patients with CHF is to increase the total daily dose.

(Solution : Thiazide diuretics may be used as the first-line diuretic agent for patients with CHF and are also useful in patients with resistant edema despite maximal doses of loop diuretics by inhibiting uptake of tubular sodium in the distal nephron. Patients with CHF have abnormally slow absorption of loop diuretics, as well as diminished response to maximally effective doses of diuretics. Dose increases do not augment diuretic efficacy, but increased frequency of dosing has been shown to improve the response.)

Disorders of Potassium and Magnesium Homeostatsis 1. The active transport system that facilitates transcellular potassium movement is which of the following?

A) Aldosterone B) Na+/K+-ATPase pump C) Insulin D) Epinephrine E) None of the above 2. Which of the following substances causes an intracellular movement of potassium?

A) Epinephrine B) Bicarbonate C) Digoxin D) a and b E) a, b, and c 3. Potassium contributes to which of the following biochemical processes?

A) Glycogen synthesis B) Cellular metabolism C) Protein synthesis D) Electrical action potential E) All the above 4. Which of the following drugs does not contribute to the development of hypokalemia?

A) Hydrochlorothiazide B) Furosemide C) Amiloride D) Amphotericin B E) Sorbitol Page 5

MCQ : For Practice 5. Which of the following statements is false?

A) Hypertension and cardiac arrhythmias are the primary signs and symptoms of hypokalemia.

B) Signs and symptoms of hypokalemia are usually nonspecific and highly variable among patients.

C) Hypomagnesemia should be corrected before treating hypokalemia.

D) The body cannot effectively store potassium.

E) None of the above are false.

6. Intravenous potassium replacement should be used in which of the following conditions?

A) Serum potassium concentration < 3.0 meq/L B) Thrombophlebitis C) Continuous nausea and vomiting D) Hospitalized patients with normal electrocardiographic (ECG) rhythms E) All the above 7. Hyperkalemia generally is not present in which of the following conditions?

A) Metabolic alkalosis B) Addisonâ&#x20AC;&#x2122;s disease C) Rhabdomyolysis D) Chronic renal insufficiency E) Diabetic ketoacidosis 8. Immediate first-line therapy for hyperkalemia associated with ECG changes is which of the following?

A) Furosemide 40 mg PO B) Calcium gluconate 1 g IV C) Sodium polystyrene sulfonate 60 g PO D) Sodium bicarbonate 50 meq IV E) Regular insulin 10 U IV 9. Which of the following therapies result in potassium exchange and removal from the body?

A) Dialysis B) Sodium polystyrene sulfonate C) Insulin D) a and b E) a, b, and c 10. Which of the following drugs will not cause a transcellular movement of potassium?

A) Furosemide B) Insulin C) Sodium bicarbonate D) Glucose E) Albuterol 11. Which of the following statements is false?

A) Magnesium is an important cofactor for ATP-dependent systems.

B) Magnesium homeostasis is maintained primarily by the liver.

C) Disorders of magnesium balance are manifested as neurologic or cardiovascular dysfunction.

D) Magnesium is found primarily in bone.

E) All the above 12. Which of the following conditions can contribute to the development of hypomagnesemia?

A) Nausea B) Vomiting C) Diarrhea D) a and b E) a, b, and c 13. Which of the following are limitations of magnesium replacement therapy?

A) Intramuscular therapy is often painful and intolerable to the patient.

B) Oral therapy can result in a high incidence of diarrhea.

C) Intravenous infusion can result in flushing and hypotension.

D) Up to 50 percent of a magnesium dose is eliminated in the urine.

E) All the above 14. Which of the following are often overlooked as causes of hypermagnesemia in patients with chronic renal insufficiency?

A) Milk of magnesia B) Parenteral nutrition C) Furosemide D) a and b E) a, b, and c

Surgery

15. What is the preferred treatment of hypermagnesemia in patients with adequate renal function?

A) Saline bolus B) Furosemide C) Hemodialysis D) a and b E) a, b, and c

Pain Management 1. Regarding pain, all the following descriptors are applicable except A) always subjective.

B) always associated with actual tissue damage.

C) a sensory and emotional experience.

D) a primary reason patients seek medical advice.

E) often undertreated.

2. We can think of nociceptive pain in terms of A) stimulation.

B) transmission.

C) perception.

D) modulation.

E) all of the above.

3. Neuropathic pain is A) not distinctly different from nonciceptive pain.

B) due in part to anatomic and biochemical changes in the nervous system.

C) seen immediately after most traumatic injuries.

D) is sustained by the normal processing of sensory input by the peripheral or central nervous system.

E) none of the above.

4. When evaluating the pain of a 50-year-old women who has just had her gall bladder removed, the most important characteristic to consider when assessing her immediate postoperative pain would be A) the history of past surgeries.

B) the time elapsed since the patient was in surgery.

C) pain severity.

D) the amount of tissue damage.

E) the amount of time spent in surgery.

5. The following drug would be preferred when treating acute mild pain in a 30-year-old man with no significant medical history and on no medications: A) nalbuphine.

B) propoxyphene.

C) codeine with acetaminophen.

D) acetaminophen.

E) tramadol.

6. Therapeutic doses of morphine given to patients in severe pain will cause A) blood pressure to drop.

B) respiratory depression.

C) a decrease in myocardial oxygen demand in myocardial ischemia.

D) an increase in the propulsive contractions of the gastrointestinal tract.

E) urinary incontinence.

7. The following would be the drug(s) of choice in severe acute pain secondary to trauma: A) morphine plus a nonsteroidal anti-inflammatory drug.

B) morphine alone.

C) meperidine alone.

D) meperidine plus promethazine.

E) pentazocine plus a nonsteroidal anti-inflammatory drug.

8. The only indication for the use of an opioid analgesic on an â&#x20AC;&#x153;as neededâ&#x20AC;? basis is when A) the patient is over 75 years old.

B) the patient is depressed.

C) the analgesic is used to treat breakthrough pain.

D) the analgesic is administered epidurally.

E) the patient is experiencing constipation.

9. When treating moderate to severe cancer pain, A) assess the frequency/duration/occurrence/etiology of the pain.

B) use sustained-release opioid in an around-the-clock fashion.

C) use prn immediate-release opioids with the sustained-release drugs.

D) titrate opioids based on the response of the patient.

E) all of the above.

Page 6

MCQ : For Practice 10. Chronic nonmalignant pain A) is often psychosomatic.

B) is best treated with nalbuphine.

C) is exacerbated with the use of tricyclic antidepressants.

D) may be treated with anticonvulsants.

E) usually has distinct autonomic characteristics.

5. The best clinical marker of the adequacy of short-term nutrition in a critically ill stressed ICU patient who does not have multisystem organ failure is A) transferrin.

B) albumin.

C) prealbumin.

D) retinol-binding protein.

11. The best treatment of opioid-induced constipation is A) prevention with the proper intake of fluids and fiber.

B) prevention by using propoxyphene.

C) concomitant use of acetaminophen with the opioid.

D) concomitant use of aspirin.

E)all of the above.

Questions 6 and 7 refer to the following case.

12. Nonpharmacologic therapies A) should be considered only in chronic nonmalignant pain.

B) often are underused in acute pain.

C) can detract from pharmacologic treatment in cancer patients.

D) can induce a number of opioid-like side effects.

E) none of the above.

13. When tramadol is being considered to treat neuropathic pain, which of the following may prevent the clinician from starting this agent?

A)Drug interactions with capsaisins B) History of diabetes C) History of gastrointestinal bleeding D) Drug interactions with the nonsteroidal anti-inflammatory drugs E) None of the above 14When treating bone pain associated with breast cancer, the best therapy would be A) ibuprofen plus amitriptyline.

B) ibuprofen plus sustained-release opioids.

C) ibuprofen plus prn immediate-release opioids.

D) ibuprofen plus amitriptyline plus sustained-release opioids.

E) amitriptyline plus sustained-release opioids.

15. Which of the following is appropriate pain management?

A) Ibuprofen alone to treat acute severe pain B) Tricyclic antidepressants to treat acute pain C) Morphine dose titration in severe pain D) The use of a placebo to diagnosis pain E) All of the above

Assessment of Nutrition Status and Nutrition Requrment 1. A patient with marasmus usually will have A) peripheral edema.

B) skeletal muscle wasting.

C) low serum albumin.

D) low serum transferrin.

2. A nutrition assessment program using a subjective global assessment would include evaluation of all the following except A) current body weight compared with usual body weight.

B) presence of gastrointestinal symptoms such as diarrhea or pain.

C) serum albumin and prealbumin concentrations.

D) presence of edema or ascites.

3. A 45-year-old man presents to clinic today for a yearly physical examination.

His weight is 250 lb (114 kg), and his height is 5 ft, 10 in. He complains of lack of energy and admits to getting no exercise on most days. His body mass index (BMI) is A) 16.4 kg/m2.

B) 35.9 kg/m2.

C) 64 kg/m2.

D) unknown (not enough information given to calculate BMI).

4. An infant is seen in clinic today for evaluation of gastroesophageal reflux disease. His weight today is 5 kg (10th percentile weight for age), and his length is 50th percentile for age. His weight 2 months ago was 4.5 kg (50th percentile for age), and his length was plotted at the 50th percentile. Based on assessment of weight gain, you can say that A) he is growing well, and nutrition is not a concern.

B) his weight gain is excessive, and overnutrition is a concern.

C) his weight gain is slower than expected, but since his length is at the 50th percentile, nutrition does not need to be addressed.

D) his weight gain is slower than expected, and nutrition needs to be addressed.

Surgery

Case 1. The surgery team has tried to wean Mr. Jones (50 years old, 70 kg, 6 ft tall) from the ventilator for several days without success due to increasing CO2. A metabolic gas monitor evaluation (i.e., indirect calorimetry) reveals an REE of 1600 kcal and an RQ of 1.1. Mr. Jonesâ&#x20AC;&#x2122; current parenteral nutrition (PN) solution provides the following: mL/day, 2700; total kcal/day, 2928; NPC/day, 2640 (2040 from CHO; 600 from fat); and protein/day, 72 g.

6. The results of the indirect calorimetry show that Mr. Jones is primarily using which of the following substrates as energy?

A) Fat B) Carbohydrate C) Protein D) Mixed carbohydrate and fat 7. Based on the indirect calorimetry findings, Mr. Jones is receiving A) too many calories each day.

B) not enough calories each day.

C) too much protein each day.

D) too little protein each day.

8. TC (weight, 72 kg; height, 6 ft) is 7 days out from a motor vehicle accident in which he sustained multiple injuries including bowel perforation. He did not require an ostomy, however, and is having one to two bowel movements per day. He is receiving PN that provides him with 1800 mL/day, 75 g protein per day and 1400 nonprotein calories per day (60 percent carbohydrate, 40 percent fat). A 24-h UUN reveals a value of 18 g nitrogen. TCâ&#x20AC;&#x2122;s nitrogen balance is A) -2.

B) -6.

C) -10.

D) none of the above.

9. A patient requiring a bowel resection due to mesenteric artery thrombosis 3 years ago complains of weakness and has symptoms consistent with a peripheral neuropathy. He is also found to be anemic on laboratory assessment. Which of the following nutrients is most likely responsible for his symptoms?

A) Vitamin A B) Thiamine C) Iron D) Vitamin B12 10. A patient with severe diarrhea and a enterocutaneous fistula is most likely to become deficient in A) thiamine.

B) zinc.

C) essential fatty acids.

D) molybdenum Questions 11 and 12 refer to the following case.

Case 2. A 2-month-old infant who was born prematurely at 27 weeks has been receiving PN since birth due to a congenital gastrointestinal anomaly (gastroschisis).

He has failed to gain weight over the last 10 days despite earlier appropriate weight gain. He also became hypoglycemic with attempts at cycling his PN solution. He is receiving a standard dextrose, amino acid, lipid regimen with supplementation of vitamins, trace elements, and electrolytes.

11. Which nutrient deficiency is most likely responsible for his symptoms?

A) Essential fatty acids B) Insulin C) Zinc D) Carnitine 12. His liver function tests are found to be elevated on todayâ&#x20AC;&#x2122;s laboratory assessment: total bilirubin, 4.5 mg/dL; direct bilirubin, 3.8 mg/dL. Which of the following should be omitted from the PN solution?

A) Manganese B) Zinc C) Chromium D) Selenium

Page 7

MCQ : For Practice 13. The most appropriate maintenance intravenous fluid rate for a 70-kg man would be A) 50 mL/h.

B) 70 mL/h.

C) 100 mL/h.

D) 200 mL/h.

9. Which of the following amino acids is considered conditionally essential in preterm and term infants?

A) Arginine B) Leucine C) Valine D) Cysteine

14. The best indicator of adequate nutrition in an infant is A) nitrogen balance .

B) prealbumin.

C) albumin.

D) weight gain.

10. Which of the following amino acids is not included in commercially available crystalline amino acid solutions and is considered to be conditionally essential in adults?

A) Glutamine B) Phenylalanine C) Leucine D) Isoleucine

15. QW is a 65-year-old woman who suffered a stroke 1 month ago that has left her bedridden. She now presents with a 10-lb weight loss. Enteral nutrition therapy is suggested. She weighs 60 kg and is 5 ft, 5 in tall. Using the equations given for estimating energy expenditure, what are QWâ&#x20AC;&#x2122;s current calorie requirements?

A) 1200 kcal/day B) 1400 kcal/day C) 1600 kcal/day D) 2000 kcal/day

11. Which of the following parenteral nutrition solutions is most likely to provide the least risk of thrombophlebitis?

A) 10 g protein, 60 g dextrose in total volume of 300 mL B) 85 g protein, 200 g dextrose in total volume of 2040 mL C) 90 g protein, 270 g dextrose in total volume of 1800 mL D) 95 g protein, 290 g dextrose in total volume of 1440 mL

12. Which of the following combinations of additives is not recommended for addition to parenteral nutrition solutions?

A) Potassium phosphate 15 mmol/L, calcium gluconate 10 meq/L, sodium acetate Questions 1â&#x20AC;&#x201C;7 refer to the following information: 75 meq/L B) Sodium phosphate 20 mmol/L, calcium gluconate 15 meq/L, cysteine 160 mg A 70-kg man is receiving the following parenteral nutrition regimen as a 2-in-1 C) Potassium phosphate 20 mmol/L, magnesium sulfate 12 meq/L, albumin 25 g system: (final concentrations) 5% amino acids/20% dextrose at 85 mL/h contin- D) Sodium phosphate 30 mmol/L, calcium gluconate 5 meq/L, sodium bicarbonate 50 uous infusion with 20% IV lipid emulsion 250 mL/day via piggyback infusion meq/L over 24 h.

13. Complications commonly associated with parenteral nutrition therapy include 1. The daily gram amount of protein provided by this regimen is A) nephrolithiasis.

A) 25.

B) pulmonary fibrosis.

B) 50.

C) hyperglycemia.

C) 102.

D) hypertension.

D) 120.

14. Recommendations for initiating parenteral nutrition in severely malnourished 2. The daily gram amount of dextrose provided by this regimen is patients with significant weight loss include starting the regimen with A) 482.

A) 75 percent calculated caloric requirements and cycle the infusion over 16 hours.

B) 408.

B) 50 percent calculated caloric requirements and advance over 3-4 days.

C) 240.

C) dextrose calories only and advance protein dose over 3-4 days.

D) 98.

D) dextrose calories only and add 10-15 U/L regular insulin to the parenteral nutrition solution.

3 The mg/kg/min dose of glucose provided by this regimen is A) 2.

15. Methods of limiting costs of parenteral nutrition therapy include B) 4.

A) selection of appropriate candidates based on current consensus statements.

C) 6.

B) use of daily serum electrolytes and liver function test monitoring in all patients.

D) 8.

C) minimizing use of enteral nutrition.

D) use of a 3 bags per day (8-hour bag) parenteral nutrition system.

4. The daily gram amount of nitrogen provided by this regimen is A) 50 .

B) 30.

C) 22.

D) 16.

Parenteral Nutrition

5. The volumes of 10% amino acids and 70% dextrose stock solutions required to provide daily protein and carbohydrate amounts for this regimen are A) 102 mL amino acids, 408 mL dextrose.

B) 500 mL amino acids, 200 mL dextrose .

C) 1020 mL amino acids, 582 mL dextrose.

D) 1200 mL amino acids, 685 mL dextrose.

6. The daily total calories provided by this regimen is A) 1795.

B) 2245.

C) 2295.

D) 2345.

7. The amount of IV lipid emulsion provided by this regimen is A) appropriate for the patientâ&#x20AC;&#x2122;s weight.

B) an inappropriate percentage of total calories.

C) being infused too rapidly.

D)an inappropriate concentration for an adult.

8. The percentage of total calories provided as essential fatty acids required to prevent essential fatty acid deficiency in adults and pediatric patients is A) 0.5-1.5 percent.

B) 2-5 percent.

C) 10-15 percent.

D) 20-30 percent.

Surgery

Page 8

SEU: Previous Year Question Paper Part A. MCQs (1 point for each question)

C. An epidural injection may be performed anywhere along the vertebral column, while spinal injections are typically performed below the second 1. Which of the folowing fluids would be expected to cause the largest lumbar vertebral expansion of the intravascular compartment within minutes of its admin- D. It is easier to achieve segmental anasthesia using spinal route istration?

A. 250mL of 5% albumin 12. Which one is not the indication of spinal anesthesia?

B. 250mL of 5% hetastarch A. low extremities procedures C. 500mL of normal saline B. low abdominal procedures D. 100mL of 25% albumin C. perineal procedures D. unilateral upper limb 2. suspected of having circulatory insufficiency from decreased plasma volume ?

13. Which of the following local anesthesias belong to long-duration A. Systolic and diastolic blood pressure agents?

B. Assessment of mental status A. lidocaine C. Complete physical examination B. bupivacaine D. Hourly urine output (no catheter) C. procaine D. 2-choroprocaine 3. Which of the following parameters should not used routinely to monitor patients in the early stages of shock?

14. The goal of anesthesia induction is to _________ A) Mental status changes from baseline A. achieve general anaesthesia and tracheal intubation B) Blood pressure recordings B. assess and optimize the patient C) Urine output through Foley catheter C. give the patient premedications D) Mixed venous oxygen saturation D. propose the protocol of anesthesia 4. Development of lactic acidosis by a vasopressor catechoamine is caused by : A) enhanced vasoconstriction in peripheral arteries.

B) enhanced glycogenolysis.

C) mobilization of lactate from peripheral tissues.

D) a and b only.

E) all the above.

5. Which of the following is a feature of hypocalceamia ?

A. Adson’s sign (for thoracic outlet syndrome) B. Chovstek’s sign C. Gorlin’s sign (for Ehlers-Danlos syndrome) D. Kanavel sign (for Flexor tenosynovitis) E. Becker’s sign (for Aortic Insufficiency or Grave’s disease) [F. Trousseau sign for Metabolic Alkalosis] 6. Medications to be given when treating severe hyperkalemia include: A. Methylprednisolone & mannitol B. Mannitol & regular insulin C. Digoxin & Diuretics D. 10% calcium gluconate & regular insulin E. Normal saline

15. The intraoperative body heat loss cannot be caused by _____: T A. Vasoconstrictors B. Cold fluid infusions C. Low room temperature D. Fluid evaporation from body cavities 16. Warfarin treatment is instructed to cause ______ days before scheduled surgery.

A. 1-2 days B. 2-3 days C. 4-5 days D. 5-6 days 17. Which one is not included in the risk factors of regulation during anesthesia induction ?

A. Full stomache B. Bowel obstruction C. Paralytic ileus D. Advanced age

18. Which of the following describes of flaps is false?

A. z-plasties are use to gain length B.muscle flaps-important for filling deep defects or for improving function 7. Regarding hemodynamic support, which of the following agents is the C. composite flaps-very useful for cover in major trauma best initial therapeutic intervention ?

D. split-skin graft is a simple skin flap A. 5% albumin B. Lactated Ringer’s solution 19. Which is the main indications for organ transplantation?

C. HTS (hypertonic saline) A. end-stage organ failure D. Norephinephrine B. brainstem death E. Dopamine C. HIV D. Metastatic carcinoma 8. All of the following statements about the treatment of water intoxication are correct, EXCEPT? 20. Which one is wrong for the treatment of tetanus?

A. Water restriction: stop near intake A. Neutralisation of unbound toxin B. Transfer the patient to ICU for more invasive monitoring and conB. Wound debridement trolled manipulation of fluids and electrolytes C. Control of spasms C. The administration of diuretics or hypertonic saline should be under- D. No antibiotics taken immediately D. Dialysis: peritoneal dialysis or hemodialysis 21. Which one is derived from primary infection?

A. Acquired community or endogenous 9. Recovery of consciousness occurs when the concentration of anasB. Poor wound care after surgery thetic in the drops below a certain level.

C. Inadequately filtered air in operating theatre A. Lung D. Contamination at surgery B. Cardiac C. Brain 22. AIDS result from infection with ______.

D. Kidney A. lentovirus B. retrovirus 10. Brachial plaxus block can be performed for ______ surgery C. Pseudomonas aeruginosa A. fore-neck D. HIV-1 B. unilateral upper limb C. unilateral lower limb 23. An adult male is brought to the emergency department following injury D. inferior belly in a house fire. The patient was found in a closed room. He has singed facial hair and full thickness burns over 30% of his body surface area. All 11. Difference between spinal & epidural anaesthesia: of the followings are important in his initial stabilization & treatment except A. A smaller dose of drag is typically necessary for epidural than for which ? spinal A. Endotracheal intubation B. The onset of analgesia is faster with epidural B. Intravenous fluid resuscitation Surgery

Page 9

SEU: Previous Year Question Paper C. Insertion of a ureteral catheter D. Systemic antibiotics 24. What are indications for formal thoractomy?

A. More than 1.0 litres initial blood loss B. Continuing loss of >120ml/h C. Retained foreign bodies >0.5cm in diameter D. Cardiac tamponade 25. Which of the following is the most common source of bleeding about acute subdural hematoma ?

A.Cotical ateries B. Bridiging veins flowing into superior sagitattal sinus C. Sylvian veins flowing into sphenopariental sinus D. Labbe vein E. Vein of Galen 26. How long after brain injury causing subacute subdural hematoma ?

A. 24 hours to 3 weeks B. 3 days to 3 weeks C. 1 week to 3 weeks D. 24 hours to 2 weeks E. days to 2 weeks 27. How long the worst cerebral edema come out after cerebral contusion and laceration?

A. hours B. 2 days C. 4 days D. 6 days E. per 1 week 28. Which of the following is the most predilection site of astrocytoma ?

A. Cerebral cortex B. Cerebral ventricle C. Nuclei D. Cerebral white matter E. Base of skull

D. Eisenmanger’s syndrome 35. Which one is not the [requent clinical] manifestation of coronary heart disease ?

A. angina B. myocardial infarction C. sudden death D. atrial fibrillation A 55 years old woman was admitted to the hospital because of sudden left hemiparalysis of the body. The Neurology doctor made the diagnosis of the cerebral embolism. Physical examination revealed cyanosis, engorgement of jugular veins, heart auscultation included irrhythmia and an apical holo-diastolic rumble murmur, enlargement of liver and dependent edema at the lower limbs.

36. What is the most evaluable examination for the final diagnosis on our opinion ?

A. chest radiography B. Electrocardiogram C. Ultrasonic cardiogram D. Cardiac catheterization 37. Examinations showed that the electrocardiogram indicated artial fibrillation, chest X-rays indicated a double contour of the right heart border, elevation of the left mainstem bronchous, straight left heart border and pulmonary congestion; ultrasonic cardiogram revealed that reduced diastolic excursion of the leaflets and thickening and calcification of the mitral valve, thickening and calcification of the aortic valve, estimate mitral valve area 1.8 cm2 and aortic valve area 3.0 cm2 , and the globular thrombus in the left atrium. What diagnosis do you think for the patient?

A. Aortic insufficiency B. Mitral insufficiency C. Aortic stenosis D. Mitral stenosis

38. What is the most important therapy on yout mind?

A. thromboslysis B. control of heart failure 29. The early clinical manifestation of mucal* herniation is {ques not clear} C. Mitral valve replacement D. Aortic valve replacement A. Loss of consciousness and reducing of breathing rates B. Bilateral mydrindis* Patient: Female, 54 yrs. Complaints: Intermittent fever, sweating and chest C. Unilateral mydrindis* and paralysis of contralateral limbs pain for 4 years, finding a mass in left lower lobe (LLL) of the lung for 2 D. Bilateral mydrindis* and loss of consciousness E. Loss of consciousness, unilateral mydriasis and paralysis of contrayears.

Present history: four years before admission she got a high fever after lateral limbs laboured working, tempertature reached 39°C, with sweating and weakness, no cough and sputum, no hemoptysis, no chest pain and dyspnea.

30. The objective indication of adult intracranial hypertension is She went to see doctor and had antibiotics infused and then better, chest A. headache films files showed “pneumonia“. But repeated attacks occured 2-3 times B. disturbance of consciousness per year. Two years ago fever ocurred again and a peripheral mass was C. vomiting found in her LLL of the lung in the chest CT scanning. Still “pneumonia” is D. brain midline shifting 2m E. papilledema considered, three months before admission a high fever recurred. In Qinhai People’s hospital, unsure tuberculosis bacteria were found in her sputum smear. The anti-tuberculosis chemotherapy was given to her for a month 31. Which of the following is not the cause of increased intracranial and stopped for the further treatment. No obvious weight loss. pressure?

Past history: healthy A. Intracranial tumor growth B. Intraventricular *** accumulates too much Personal history: non-smoker C. The cranial cavity chronic hemmorhage Physical examination: rather normal, no palpable LNs, trachea central, D. The skull had exotosis* steady breath resonance percussed and normal breath sound heard in E. Depressed fracture of skull wide lung field, no rales.

Chest CT scanning: a peripheral mass in her LLL of the lung 32. The volume compensation compensatory of high ICP mainly depends on the Questions:: A. Compression of brain tissue 39. Which is NOT the primary diagnosis considered?

B. The cranial cavity expansion A. lung cancer C. Cerebrospinal fluid is dishcarged outside the skull B. tuberculosis D. The fall in blood pressure C. chronic inflammation E. The shift of the brain tissue D. pulmonary contusion 33. What disease has the auscultation which ***** a **stalic ** **** murmur, often called machinery murmur?

A. Atrial Septal Defect B. Patent Ductus Arteriosis C. Mitral Stenosis D. Ventricular Septal Defect

40. How can we obtained pathological diagnosis for this patient?

A. Bronchoscopy B. Positrion Emission Tomography C. Lymph node biopsies D. Thoracotomy

34. Which one is not thermodynamic change of mitral stenosis?

A. hypertension of pulmonary artery B. hypertension of left atrium C. right heart failure Surgery

Page 10

SEU: Previous Year Question Paper PART B. Medical Terminology Interpretation (4 points for each question) 1. Septic Shock sepsis-induced low blood pressure that persists despite treatment with intravenous fluids. Low blood pressure reduces tissue perfusion pressure, causing the tissue hypoxia that is characteristic of shock.

2. Bag valve mask (BVM) It is a hand-held device used to provide positive pressure ventilation, it is a normal part of a resuscitation kit for trained professionals and is self-filling with air, although additional oxygen (O2) can be added.

3. Untidy wounds

4. Raccoon eyes It is a sign of basal skull fracture or subgaleal hematoma, a craniotomy that ruptured the meninges, or (rarely) certain cancers.

5. Eisenmanger’s syndrome the process in which a long-standing left-to-right cardiac shunt caused by a congenital heart defect (typically by a ventricular septal defect, atrial septal defect, or less commonly, patent ductus arteriosus) causes pulmonary hypertension and eventual reversal of the shunt into a cyanotic right-to-left shunt.

PART C. Question & Answer (10 points for each question) 1. Please describe the main cause of hypokalaemia?

• Inadequate K+ intake: prolonged administration of potassium-free parenteral fluids.

• Continued obligatory loss: loss of gastrointestinal secretions or excessive renal excretion (potassium-losing medications).

• Movement of potassium into cells: diabetic coma treated by insulin.

• Beware if diabetic insulin gets K+ into cell.

•Beware if Ketoacidosis – H+ replaces K+, which is lost in urine.

• adrenergic drugs or epinephrine.

• Trauma: potassium excretion increasing. This loss is greatest during the first 24 hrs and lasts, for example in the case of partial gastrectomy, for about 3 or 4 days.

Another Previous Year Question Paper choice question

1. The word ‘debridement’means what?

A.wound excision B.fasciotomy C.wound closure D.haematomas 2.What is the main difference between ture or flase cysts?

A.congenital or acquired B. the sac is lined with cells of epithelial origin or not C. fluid collections or contain cholesterol D.all above 3.Which of the following describes of flaps is false?

A.z-plasties are use to gain length B.muscle flaps-important for filling deep defects or for improving function C.composite flaps-very useful for cover in major trauma D.split-skin graft is a simple skin flap

multiple-choice question

1.How to you get an ideal scar?

A. Achieve quiet primary healing B.Clean incised edges, no tissue loss C.Avoid dehiscence or infection D.Minimise tension 2.What are the basic requirement of the ideal ulcer dressing?

A.maintain high humidity between wound and dressing B.absorbent,removes excess exudate C. adherent D.non-allergic 3.A few key principles of the application of plastic surgical techniques to wound closure,there are: A.adequate debridement B.careful technique C.gentle handling of tissues D.consideration blood supply

Nouns explain

1.Untidy wounds : 2. Ulcer: 3. The reconstructive ladder:

Answer the following question

1. What is the difference between tidy ang untidy wounds?

2. Describe the criteria for extubation of tracheal tube after general anesthesia?

– adequate spontaneous breathing – airway reflexes recovered – swallowing reflexes recovered – consciousness recovered – hemodynamics are stable 3. What is immediate care of the burn patient in prehospital? > Ensure the rescuer safety > Stop the burning process > Check for other injuries > Cool the burn wound > Give oxygen > Elevate 4. **, 57 years old, Female, Effort dyspnea for 5years, paroxysmal nocturnal dyspnea for 1 year : hemoptysis occured last week.

PE: Temperature: 36.5° C, Blood pressure: 110/50mmHg, Respiration: 20/min, Heart rate: 100/min, Atrial fibrillation rhythm, Hepatosplenomegaly, edema of both lower extremities.

Questions: 1. Please give the diagnosis and the reason you make these diagnosis/ 2. What extra examinations are needed to improve your diagnosis?

3. Your plan for treating this patient

Surgery

Page 11

SEU: Review Salvaged Autotransfusion: the blood is collected from the peritoneal cavity, filtered by a piece of sterile gauze, and put into a sterile container suitable for connecting to transfusion tubing.

Predeposited Autotransfusion: For major elective procedures, the pt may ‘donate’ his or her own blood, withdrawal and storage taking place up to 3 wks before it is required.

Septic shock: defined as sepsis-induced low blood pressure that persists despite treatment with intravenous fluids. Low blood pressure reduces tissue perfusion pressure, causing the tissue hypoxia that is characteristic of shock.

Anesthesia: It is a pharmacologically induced and reversible state of amnesia ,analgesia ,loss of responsiveness, loss of skeletal muscle reflex or decreased stress response, or all simultaneously.

Fick principle: The amount of oxygen consumed by an individual (Vo2) equals the difference between arterial and venous (a–v) oxygen content (C) (CaO2 and CvO2) multiplied by CO. Pulse Oximetry: beat to beat analysis of oxygenation depending on differences in light absorption between oxyHb and deoxyHb. Red and Infra-red light frequencies transmitted through a translucent portion. (finger-tip or earlobe) Microprocessors then analyze amount of light absorbed by the 2 wavelengths, comparing measured values, then determining concentrations of oxygenated and deoxygenated forms. (oxy- and deoxy-) Airway management: is the medical process of ensuring there is an open pathway between a patient’s lungs and the outside world, as well as ensuring the lungs are safe from aspiration.

Cardiopulmonary resuscitation (CPR): is an emergency procedure that combines chest compression often with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest.

Cardiopulmonary bypass (CPB): is a technique that temporarily takes over the function of the heart and lungs during surgery, maintaining the circulation of blood and the oxygen content of the patient’s body.

Bag valve mask (BVM): Is a hand-held device used to provide positive pressure ventilation, it is a normal part of a resuscitation kit for trained professionals and is self-filling with air, although additional oxygen (O2) can be added.

Oropharyngeal airways (OPA): are plastic curved devices used to hold tissue (such as the tongue) away from the airway to keep it open.

Nasopharyngeal airway (NPA): is a soft rubber or plastic hollow tube that is passed through the nose into the posterior pharynx. (Patients tolerate NPAs more easily than OPAs) Tracheal intubation: placement of a flexible plastic tube into the trachea to maintain an open airway.

Surgery

Mallampati classification: a frequently performed test that examines the size of the tongue in relation to the oral cavity, it has four classes, the greater the tongue obstructs the view of the pharyngeal structures, the more difficult intubation may be.

General Anesthesia: is an altered physiological state characterized by reversible loss of consciousness, analgesia, amnesia, and some degree of muscle relaxation.

Minimum Alveolar Concentration: is the alveolar concentration that prevents movement in 50% of patients in response to a standardized stimulus (eg, surgical incision).

Target Controlled Infusion (TCI): A computer dosing system which automatically adjusts the infusion rate of an intravenous anesthetic to meet a target blood drug concentration according to pharmacokinetic and pharmacodynamics of the anesthetic, and different age and body weight of a patient to control the depth of anesthesia.

Snake skin pattern: hypertensive congestive gastropathy with congested gastric mucosa producing a characteristic mosaic pattern that has also been called the “snake skin pattern”.

Total parenteral nutrition (TPN): is defined as the intravenous provision of all nutritional requirements, without the use of the gastrointestinal tract.

Decisive period: The acute inflammatory, humoral and cellular processes take up to 4 hours to mobilize the body’s response to a breach in its defenses.

Cellulitis: non-suppurative invasive infection of tissues caused by β-haemolytic streptococci, staphylococci, C. perfringens.

Burn depth: is defined by how much of the two skin layers is destroyed by the heat source.

FIRST-DEGREE BURN: A first-degree burn is confined exclusively to the outer surface and is not considered a significant burn. No barrier functions are altered. The most common form is a Sunburn which heals by itself in less than a week without scar.

SECOND-DEGREE BURN: This degree burn destroys the epidermal layer and portions of the dermis. Since it does not extend through both layers, it is termed a partial thickness burn. It can be divided into Superficial Second-Degree Burn (Superficial partial-thickness burns) and Deep Second-Degree Burn (Deep partial-thickness burn).

THIRD-DEGREE BURN (Full- thickness burns): Both layers of skin are completely destroyed leaving no cells to heal. Any significant burn will require skin grafting. Small burns will heal with scar.

Allograft: an organ or tissue transplanted from one individual to another.

Syngeneic graft (Isograft): a transplant between two identical twins.

Xenograft: a graft performed between different species.

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SEU: Review Orthotopic graft: a graft placed in its normal anatomical site (replantation of a cardiac, severed limb) Heterotopic graft: a graft placed in a site different from that where the organ is normally located (kidney).

Cushing’s reflex: is a physiological nervous system response to increased intracranial pressure (ICP) that results in Cushing’s triad of increased blood pressure, irregular breathing, and a reduction of the heart rate.

Battle’s sign, (also mastoid ecchymosis): is an indication of fracture of posterior cranial fossa of the skull, Graft-versus-host disease (GVHD): and may suggest underlying brain trauma. Battle’s sign consists of The donor (liver and small bowel) contain large numbers of im- bruising over the mastoid process, as a result of extravasation of munocompetent lymphocytes, and these may react against HLA blood along the path of the posterior auricular artery. antigens expressed by recipient tissues, leading to GVHD. Raccoon eye: Calcineurin (CaN): is a sign of basal skull fracture or subgaleal hematoma, a craniotois a calcium and calmodulin dependent serine/threonine protein my that ruptured the meninges, or (rarely) certain cancers. phosphatase (also known as protein phosphatase 3, and calcium-dependent serine-threonine phosphatase). It activates the T CSF rhinorrhea: cells of the immune system and can be blocked by drugs. refers to the drainage of cerebrospinal fluid through the nose. It is a sign of basal skull fracture.

Radical surgery for cancer: involves removal of the primary tumor and as much of the surAneurysm (cerebral): rounding tissue and lymph node drainage as possible.

A cerebral aneurysm is a bubble like outpouching from an artery which predisposes its carrier to cerebral hemorrhage and stroke.

Plastic surgery (reconstruction surgery, forming surgery): It is a branch of surgery, which repair congenital or acquired Subarachnoid Hemorrhage (SAH): tissue defects and deformities by using transplanting organiza- Hemorrhage in subarachnoid space, which is the space between tions or organization substitutes as the main means, in order to arachnoid mater and pia mater, it contains lots of vessels. improve or restore physical function and form, and to promote human appearance and physical beauty.

Brain Hernia: Brain tissue shifts to low pressure region from high pressure w/ Mechanical ventilation: intracranial-occupying lesion resulting in compress and displace of is the medical term for artificial ventilation where mechanical brain tissue, vessels, cranial nerves… bring out a series of severe means is used to assist or replace spontaneous breathing. clinical symptoms and signs.

Laparotomy: is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity. It is also known as a celiotomy.

Damage control Surgery: the concept of saving life after major trauma by deferring treatment of anatomical disruptions and focusing on restoring the patient’s physiology.

Intracranial pressure (ICP): The pressure of the brain contents within the skull.

Cerebral Perfusion Pressure (CPP): The pressure of the blood flowing through the brain.

Mean arterial pressure (MAP): The pressure of the blood in the body.

Epidural Hematoma (EDH): Collection of blood between dura mater and bones of skull.

Subdural hematoma (SDH): Collection of blood under the dura mater, mostly from tearing of a bridging vein between the cerebral cortex and a draining venous sinus.

Intra Cerebral Hematoma (ICH): Formed within brain tissue & caused by shearing or tensile forces that mechanically stretch and tear deep small caliber arterioles. Most common in temporal and frontal regions.

Concussion: Temporary & brief interruption of neurological function after minor head injury Due to shearing / stretching of white matter fibres at the time of impact or temporary neuronal dysfunction.

Surgery

Flail Chest: A flail chest occurs when a segment of the chest wall does not have bony continuity with the rest of the thoracic cage. This condition usually results from blunt trauma associated with multiple rib fractures, i.e. three or more ribs fractured in two or more places.

Pneumothorax: is an abnormal collection of air in the pleural space that causes an uncoupling of the lung from the chest wall.

Tension pneumothorax: A tension pneumothorax develops when a ‘one-way valve’ air leak occurs either from the lung or through the chest wall. Air is forced into the thoracic cavity without any means of escape, completely collapsing the affected lung. The mediastinum is displaced to the opposite side, decreasing venous return and compressing the opposite lung. The clinical presentation is dramatic.

Sucking chest wound (Open pneumothorax): a large open defect in the chest (> 3 cm), leading to equilibration between intrathoracic and atmospheric pressure. Air is drawn freely through the hole in the chest wall (sucking wound), Air accumulates in the hemithorax (rather than in the lung) with each inspiration, leading to profound hypoventilation on the affected side and hypoxia.

Barrett’s esophagus: Barrett’s esophagus is a condition whereby an intestinal columnar epithelium replaces the stratified squamous epithelium that normally lines the distal esophagus. Metaplastic columnar epithelium at lower end of esophagus above the gastroesophageal junction.

Tetrology of Fallot (TOF): lesion consists of four major defects caused by anterior deviation of the outlet septum: 1. Pulmonary Stenosis 2. VSD 3. Dextroposiotion and overriding of the aorta 4. Hypertrophy of the right ventricle Page 13

SEU: Review Coronary Artery Bypass Graft: is a surgical procedure to restore normal blood flow to an obstructed coronary artery. Under CPB, or use beating heart technique, use left internal mammary artery (LIMA) to graft left ascending artery (LAD), and use saphenous vein to graft other target vessels.

solely for situations where bases have been lost or where the degree of acidosis is so severe that myocardial function is compromised (this is rare).

• The acute acidosis seen in prolonged cardiac arrest may require the infusion of 50 mmol of 8.4 per cent sodium bicarbonate soln.

Ques:: Types of hemorrhage?

1. Primary: occurring at the time of injury or operation.

2. Reactionary: mainly due to rolling (‘slipping’) of a ligature, dislodgement of a clot or cessation of reflex vasospasm.

3. Secondary (7-14 days later): due to infection and sloughing of part of the wall of an artery.

4. External: visible.

Eisenmenger’s syndrome: 5. Internal: invisible, concealed hemorrhage. It may become is defined as the process in which a long-standing left-to-right revealed as in hematemesis or melaena from a bleeding peptic cardiac shunt caused by a congenital heart defect (typically by a ulcer, as in hematuria from a ruptured kidney, or via the vagina in ventricular septal defect, atrial septal defect, or less commonly, accidental uterine hemorrhage of pregnancy. patent ductus arteriosus) causes pulmonary hypertension and eventual reversal of the shunt into a cyanotic right-to-left shunt. Ques:: How to minimize further blood loss in hemorrhage?

• Pressure and packing Ques :: Water intoxication treatment.

1. First-aid: anything handy which is soft and clean.

• Water restriction: stop water intake.

2. digital pressure: • Transfer the patient to ICU for more invasive monitoring and 3. Packing: by means of rolls of wide gauze. controlled manipulation of fluids and electrolytes.

• Position and rest: Elevation of limbs • The administration of diuretics or hypertonic saline should • Op. Techniques: Artery forceps, ligation, diathermy and suturing, not be undertaken lightly as rapid changes in serum sodium silver clips, packing, excising the bleeding viscus. concentration may result in neuronal demyelination and a fatal outcome.

Ques:: How to prepare for giving blood?

• selection and preparation of the site.

Ques:: What are the causes of hypokalemia?

• careful checking of the donor blood: a compatibility label stating • Inadequate K+ intake: prolonged administration of potassithe pt’s name, hospital reference number, ward and blood group. um-free parenteral fluids.

• insertion of the needle or cannula.

• Continued obligatory loss: loss of gastrointestinal secretions or • giving detailed written instructions: the rate of flow (e.g. 40 drops/ excessive renal excretion (potassium-losing medications). min).

• Movement of potassium into cells: diabetic coma treated by • In acute emergencies, it may be necessary to increase the rate of insulin. flow and it is possible to give 1-2 units in 30 min. using a pressure • Beware if diabetic insulin gets K+ into cell. cuff around a plastic bag of blood.

•Beware if Ketoacidosis – H+ replaces K+, which is lost in urine. • Warming blood. reducing the risk of cardiac arrest from large • adrenergic drugs or epinephrine. volumes of cold blood.

• Trauma: potassium excretion increasing. This loss is great• Filtering blood. A filter with an absolute filtration rating of 40 est during the first 24 hrs and lasts, for example in the case of micron will filter off platelet aggregates and leucocytes membranes partial gastrectomy, for about 3 or 4 days. in stored blood.

• Salvaged Autotransfusion: the blood is collected from the periQues:: What are treatment principles of hypokalemia? toneal cavity, filtered by a piece of sterile gauze, and put into a • Prevention of this state. sterile container suitable for connecting to transfusion tubing.

• Oral replacement is the first choice.

• Predeposited Autotransfusion: For major elective procedures, • No potassium replacement before a good UO obtained (> 40 the pt may ‘donate’ his or her own blood, withdrawal and storage ml/h). taking place up to 3 wks before it is required.

• No more than 40 mmol. in a liter of iv. fluid.

• No more than 20-40 mmol. per hour.

Ques:: Complications of Blood Transfusion?

• In the absence of redistribution, the relationship btw the de1. Congestive cardiac failure gree of hypokalemia and the extent of total body K+ depletion is 2. Transfusion reactions: Incompatibility, Simple pyrexial reactions, relatively predictable.

Allergic reactions, Sensitisation to leucocytes and platelets, Immunological sensitisation.

Ques:: What is the treatment of hyperkalemia?

3. Infections: HIV, Bacterial, Malaria • If time, decrease intake and increase renal excretion.

4. Thrombophlebitis.

• Insulin + glucose.

5. Air embolism.

• Bicarbonate.

6. Coagulation failure: dilution of clotting factors/platelets, • Ca+2 counters effect on heart. disseminated intravascular coagulation (DIC).

• Withholding of exogenously administered K+.

• Reducing the serum potassium level: sodium lactate or 5 Ques: How to deal with transfusion reactions ％NaHCO3 (do not mix with calcium soln), Glu + Insulin (limited (incompatibility)? to 1 unit per 5 gm. or more of glucose), cation-exchange resins, 1. Stop the infusion immediately, and all intravenous tubing should hemodialysis or peritoneal dialysis. be changed.

• Temporary suppression of the myocardial effects of a sudden 2. Check the identity of the donor unit and recipient, as most ABO rapid rise of K+ level (if the serum K+ level is greater than 7.5 reactions today are the result of clerical error. Repeat a crossmmol/L): 10％ CaGl or CaCl2 (10 to 30 ml. iv over 15 to 30 match. minutes).

3. Maintenance of intravascular volume, and preservation of renal • Correction of the underlying cause if possible. function.

What is the treatment of metabolic acidosis?

4. Maintain UO at greater than 100 ml/hr.

• Restoration of adequate tissue perfusion is vital 5. Alkalization of the urine to a pH of more than 7.5 by adding • The administration of bicarbonate solns should be reserved sodium bicarbonate.

Paraneoplastic syndromes: are distant manifestations of lung cancer (not metastases) as revealed in extrathoracic nonmetastatic symptoms. The lung cancer affects these extrathoracic sites by producing one or more biologic or biochemical substances.

Surgery

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SEU: Review Ques:: How to do monitoring for patients in shock?

Ques:: In Fluid deficit, how to choose which fluid? How much? How fast?

Minimum Additional Modulities The composition and volume of the fluid given should be similar to • ECG • Central venous pressure that which it is replacing.

• Pulse oximetry • Invasive blood pressure The rate of administration should equal the rate of loss (ongoing • Blood pressure (pulse) • Cardiac output losses plus maintenance rate) plus a rapid replacement of any • Urine output • Base deficit and serum pre-existing deficit. lactate • Extravascular deficit is treated with saline.

• Intravascular deficit is ideally treated with colloid, the best is Ques::What are the objectives and plan of treatment of blood. shock?

• The exception: in the sever fluid loss from the total body or the • Objectives: increase CO and to improve tissue perfusion extravascular compartment, the immediate priority is to restore • The plan of action should be based on: the intravascular compartment, so colloid is used for resuscitation 1. The primary problem: arrest of hemorrhage, draining pus regardless of the nature of the original deficit.

2. Improving ventricular filling: giving adequate fluid replaceStructure of Formal Discharge Letter ment (Hartmann soln ) • Preop. finding.

3. Improving myocardial contractility: inotropic agents • Management operative and non-operative 4. Correcting acid-base disturbances, using molar sodium bicar- • Postop. complications bonate when the pH of ABG is < 7.2, and electrolyte abnormali- • Pathology results ties, especially potassium and calcium levels.

• Future core plan • Prognosis and how much the pt and relatives know of this Ques:: What are the treatments of hypovolemia?

1. Restoration and maintenance of the circulating volume is the Ques:: Features of Central Venous Pressure monitoring. first priority, for which there is no substitute.

1. Reflects pressure at junction of vena cava + RA 2. Inotropes: for optimization of cardiac function.

2. Reflects the balance between intravascular volume, venous 3. Occult hypovolemia is very difficult to diagnose. Encourage capacitance, and right ventricular function oral fluid intake 3. CVP is driving force for filling RA + RV 4. Aim: no thirst, good urine volumes and normal urinalysis.

4. CVP provides estimate of: Intravascular blood volume + RV 5. The overriding principle: fluid overload is easy to treat, where- preload as fully established organ failure is incurable.

5. Trends in CVP are very useful 6. Measure at end-expiration Ques:: Damage control surgery goals are?

7. Central Venous Pressure (CVP): 1-10 mmHg • Arrest haemorrhage • Control sepsis Ques:: Hypothermia is associated with what?

• Protect from further injury 1. delayed drug metabolism • Nothing else 2. increased blood glucose 3. vasoconstriction Ques:: Consensus Conference Definition SIRS & Sepsis 4. impaired coagulation Stages 5. impaired resistance to surgical infections 1. Systemic Inflammatory Response Syndrome (SIRS): Two 6. have deleterious effects perioperatively: (tachycardia, vasodilaor more of the parameters. • Temperature of >38ºC or <36ºC • tion, neurological injury) Heart rate of >90 bpm • Respiratory rate of >20 bpm or PaCO2 < 4.3kPa •WBC count >12×109/L or <4×109/L or 10% immature Ques:: Complications of tracheal intubation? forms (bands)  Physiologic responses 2. Sepsis: SIRS plus a culture-documented infection 1. cardiovascular responses (tachycardia, hypertension, ischemic 3. Severe Sepsis: Sepsis plus organ dysfunction, hypoTN, or myocardia, reflex bradycardia) hypoperfusion (including but not limited to lactic acidosis, oligu- 2. bronchospasm ria, or acute mental status changes)  Trauma 4. Septic Shock: hypoTN (despite fluid resuscitation) plus hy1. lacerations of lips, gums, pharynx poperfusion 2. perforation of pharyngeal mucosa 3. chips or avulsion of teeth Ques:: What should an operation note include?

4. injury to the vocal cords and arytenoid cartilages • The first postop. task of op. surgeon  Tube malposition • The main points: 1. prolonged or failed intubation 1. The operative findings 2. insufficient insertion 2. The subsequent procedure 3. bronchial intubation 3. Initial management plan.

4. accidental and unrecognized esophageal intubation • Procedure-specific or non-routine monitoring should be listed  Airway foreign bodies along with suitable action plans.

1. teeth 2. laryngoscope bulbs Ques:: What is Problem-based Structure of Postop. Notes 3. stylet (SOAP)?  Prolonged intubation complications: Infections – Laryngotra• Subjective condition: It is best recorded using the patient’s cheobronchitis – Sinusitis - Pneumonia - Laryngeal ulceration own words wherever possible.

Vocal cord granuloma - Tracheomalacia - Tracheal stenosis - Vocal • Objective condition: observation-specific, Patient-specific. cord paralysis.

• Active problems arising from the subjective and objective findings above.

Ques:: What are Mallampati classification classes?

• Plan: decisions regarding management or further investigaClass I = the entire palatal arch, including the bilateral faucial tion. pillars, are visible down to their bases Class II the upper part of the faucial pillars and most of the uvula are visible.

Class III = only the soft and hard palates are visible Surgery

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SEU: Review Ques:: What are Mallampati classification classes?

Class I = the entire palatal arch, including the bilateral faucial pillars, are visible down to their bases Class II the upper part of the faucial pillars and most of the uvula are visible.

Class III = only the soft and hard palates are visible Class IV = only the hard palate is visible Ques:: Describe the harm of hypothermia.  Delayed recovery from general anesthesia  Blood flow in the capillary becomes slow  When it drops down below 35 ℃, cardiac problem could occur—— ventricular fibrillation  disturbance of blood coagulation Ques:: What is the criteria for extubation?

– adequate spontaneous breathing – airway reflexes recovered – swallowing reflexes recovered – consciousness recovered – hemodynamics are stable Ques:: Difference between spinal and epidural anesthesia?  Direct injection of local anesthetic into CSF for spinal anesthesia allows a relatively small dose and volume of local anesthetic to achieve dense sensory and motor blockade  the same local anesthetic concentration is achieved within nerve roots only with much larger volumes and quantities of local anesthetic molecules during epidural and caudal anesthesia  the injection site (level) for EA must generally be close to the nerve roots that must be anesthetized Ques:: What are Koch’s postulate It must be found in considerable numbers in the septic focus It should be possible to culture it in a pure form from that septic focus It should be able to produce similar lesions when injected into another host Ques:: What are the priorities in the management of a major burn?

1. Air way control 2. Breathing and ventilation 3. Circulation 4. Disability –neurological status 5. Exposure with environmental control 6. Fluid resuscitation Ques:: What are the Full-thickness burns and obvious deep dermal wounds options for topical treatment of deep burns?

1. -1% silver sulphadiazine cream 2. -0.5% silver nitrate solution 3. -Mafenide acetate cream 4. -Serum nitrate Ques:: What is the immediate care of burn patient in prehospital stage?

1. Ensure the rescuer safety 2. Stop the burning process 3. Check for other injuries 4. Cool the burn wound 5. Give oxygen 6. Elevate

Ques:: What is the immediate care of burn patient in hospital stage?

(ABCDEF) > Airway control > Breathing and ventilation > Circulation > Disability (neurological status) > Exposure with environmental control > Fluid resuscitation Ques:: Surgery has several roles for cancer, what are they?

Including diagnosis, removal of primary or metastatic disease, palliation, prevention and reconstruction.

Ques:: What are hallmarks of modern war injury?

1. Multiple injuries to different body systems 2. The aim of warfare is to maim not kill 3. Fragments are the commonest wounding agents 4. No characteristic war wound 5. Variety of injuries require intuitive care Ques:: What are the steps of primary survey and resuscitation?

A—Establish a patent airway B—Ensure that both lungs are ventilated C—Restore circulating volume and compress external bleeding sites D—Check for neurologic deficit E—Fully expose (undress) the patient and cover with warmed blankets Ques:: What are damage control surgery phases? > Phase 1 is the initial surgical procedure when only the minimum is done to stop haemorrhage and limit or contain contamination before the operation is aborted > Phase 2 occurs in the intensive care unit and involves attempts to restore normal physiological parameters before returning to the operating theater for phase 3, definitive surgery Ques:: What is the ATLS Approach for trauma?

Primary survery including ABCDE. Secondary survey including Ample history - Trauma imaging Definitive care and tertiary survey Ques:: What are symptoms and signs of increased ICP? 1. Diminishing level of consciousness 2. Headache, vomiting, seizures 3. Cushing’s Triad – bradycardia - hypertension – abnormal respiration 4. Pupillary changes 5. Papilledema Ques:: What is the classification of primary head injuries?

According to mechanism: Blunt injury and penetrating injury.

According to severity: GCS assessment areas 3-15 scale.

According to morphology: Scalp injury (cephal hematoma or subgaleal hematoma), skull fractures (vault), and basilar injuries.

MANAGEMENT OF MILD HEAD INJURY (GCS13 -15): 1. History 2. General examination 3. limited neurologic examination 4. C-spine and other X-rays as indicated 5. CT Scan MANAGEMENT OF MODERATE HEAD INJURY (GCS 9-12): Initial Examination - Same as for mild head injury - CT scan brain – obtained in all cases - Admission for observation After Admission

Surgery

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SEU: Review Ques:: MANAGEMENT OF SEVERE HEAD INJURY (3-8): 1. Primary Survey and Resuscitation 2. Secondary Survey and ‘AMPLE’ history 3. Admit to facility – neurosurgical care 4. Neurologic Re-evaluation – Eye opening – Motor response – Verbal response – Pupillary reaction Ques:: Classification of SAH: 1. Primary SAH (spontaneous SAH) 2. Secondary SAH (ICH with ruptures into the ventricles, subarachnoid spaces) 3. Traumatic SAH Ques:: Symptoms of ruptured aneurysm: 1. The worst headache of your life 2. Localized and intense headache 3. Nausea and vomiting 4. Stiff neck or neck pain 5. Blurred or double vision 6. Pain above and behind eye 7. Dilated pupils 8. Sensitivity to light 9. Loss of sensation Ques:: What is the initial management of tension pneumothorax and open pneumothorax?

Tension pneumothorax Management

Open pneumothorax Management

-Treatment consists of immediate decompression and is managed initially by rapid insertion of a large-bore needle into the second intercostal space in the mid-clavicular line of the affected hemithorax -Followed by insertion of a chest tube through the fifth intercostal space in the anterior axillary line.

-Initial management: promptly closing the defect with a occlusive dressing , making open chest trauma to the closed one -A chest tube is inserted as soon as possible in a site remote from the injury site.

-Definitive treatment may warrant formal debridement and closure, preferably in the operating room -For suspected patients with interthoracic injury, thoracotomy should be done -Antishock management

Ques:: How to judge if it is an ongoing bleeding hemothorax or not.

When hemothorax diagnosed, one should judge if it is an ongoing bleeding hemothorax or not. The following findings suggest the ongoing bleeding: 1. Pulse progressively quicker and BP ↓.

2. BP going down or up and down after aggressive treatment of shock.

3. Hb, RBC, HCT progressively going down.

4. Chest film shows the shadow expending and no blood sucked out in thoracocentesis.

5. Blood drainage more than 200ml/h, for consequent 3 hours after tube thoracostomy.

Ques:: What are the pathologic types (classification) of Lung Cancer and their characteristics?

Non-small-cell lung cancer (NSCLC) 1. Squamous carcinoma: arising in large airway, mainstem bronchus, central lesion, growth slow, sensitive to radiotherapy and chemotherapy, early lymphatic metastases, late blood metastases.

2. Large-cell carcinoma (10%): not common, peripheral location, metastasize relatively early. bad differentiation, bad prognosis.

3.Adenocarcinoma (45%): young women, peripheral lesion, moderate growth rate, hematogenous metastasis early.

Bronchoalveolar carcinoma (two types: nodule and difussive) lower malignancy, growth slow, and metastasis locally along the wall of the bronchus and bronchia.

Small-cell lung cancer (SCLC) (20%): (neuroendocrine tumors) high malignancy and aggressive tendency to metastasize.

Mixed types of lung cancer: Adenosquamous carcinoma.

Ques:: What are the pathologic types of Carcinoma of the Esophagus?

1. Medullary 2. Mushroom 3. Ulcerative 4. Coarctation (sclerotic) Ques:: What is the concept of CPB and its function?

Desaturated (venous) blood drains by gravity from the patient’s right atrium or vena cava via the venous cannula and the venous line to a reservoir. A pump propels blood from the venous reservoir to through a membrane oxygenator, followed by an arterial filter, into the patient’s aorta via the arterial line and the aortic cannula.

Four functions: > Oxygenation, > Ventilation, > Circulation > Temperature control.

Ques:: What is the definition of tetralogy of fallot?

The lesion consists of four major defects caused by anterior deviation of the outlet septum: 1. Pulmonary Stenosis 2. VSD 3. Dextroposiotion and overriding of the aorta 4. Hypertrophy of the right ventricle Ques:: What are the investigations of coronary heart disease?

1. Blood tests: full blood count, clotting, electrolytes, and organ functions.

2. Chest x-ray: heart size, calcification of the aorta.

3. Coronary angiography: location and length of lesions, grade of stenosis, condition of run-off.

4. Echocardiography: heart function, valve problems.

Ques:: What is the etiology of chronic empyema?

1. Inappropriate management of acute empyema.

2. Delay in both diagnosis and treatment (>7~10 days after onset).

3. Foreign body remained in pleural.

4. Complications of tracheal or esophageal fistulae.

5. Uncontrollable of initial infection places.

6. Special infections (tuberculosis, fungus and so on).

Surgery

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