POS 2019 Notes PDF - Past Paper

POS 2019 Notes Bold – answer after group consensus Italicised – unclear answer, or don’t remember other answer options Normal – Need to follow up with other residents for opinion Anesthesia / Peri-Op / Fluids / Electrolytes 1. What is the best post-op nausea method? a) Ondansetron b...

POS 2019 Notes Bold – answer after group consensus Italicised – unclear answer, or don’t remember other answer options Normal – Need to follow up with other residents for opinion Anesthesia / Peri-Op / Fluids / Electrolytes 1. What is the best post-op nausea method? a) Ondansetron b) Maxeran c) Gravol d) IV fluids - Schwartz: serotonin receptor antagonists (Ondansetron) are the most efficacious. Also discussed with anesthesia residents. 2. Intra-op patient develops hyperthermia, rigidity, difficulty ventilating. What do you do? a) manage with IV fluids, O2, and muscle relaxants b) complete surgery as fast as possible - don’t remember other options 3. What is seen in malignant hyperthermia? a) Hyperkalemia b) Hypocarbia c) Hypoglycemia 4. Patient post-intubation develops rigidity, hyperthermia. What was the most likely inciting agent? a) succinylcholine b) propofol c) fentanyl 5. Intra-op a patient develops diffuse rash, hypotension, and bronchospasm. What do you do? a) stop muscle relaxant and give IV epinephrine b) Dantrolene c) Topical steroid and inhaled beta agonist 6. 50 year old female is undergoing a TKA and develops intra-op right heart strain and tachycardia. Best next test? a) Troponin b) 12-lead ECG c) Trans-esophageal ECHO – PE causing right heart strain d) CXR 7. What is in normal saline? a) Na 154, Cl 154 b) Na 130, Cl 109 – Ringers !!!! c) Na 130, Cl 114 8. Patient comes in with a trauma and remains hemodynamically unstable after receiving 4L of IV fluids. Which of the following about large volume crystalloid resuscitation is true? a) Patients with renal failure should be resuscitated with a balanced salt solution like Plasmalyte b) Large volume normal saline resuscitation causes metabolic acidosis by dilution of bicarb c) Penta or Hexastarch solutions - debated A vs B 9. What is the appropriate maintenance fluid rate and solution for a 60kg lady who is NPO? a) 5% DW, 0.45%NS and 20KCl at 100cc/hr b) 5% DW, 0.9% NS at 80cc/hr c) 5% DW at 100cc/hr d) 0.9% NS with 40KCl at 80cc/hr 10. What is the first clinical sign of hypermagnesemia? a) stupor b) flaccid paralysis c) loss of deep tendon reflexes d) hypotension 11. What can the Mallampati score help predict? a) possible difficult airway b) aspiration risk c) peri-op complications 12. Lady on beta-blocker pre-op and is normotensive. How should her medication be managed peri-operatively? a) Stop 3 days before to reduce risk of MI b) Stop 3 days before to reduce risk of stroke c) Stop 7 days before to reduce risk of MI d) Continue beta-blocker unless there are concerns with hypotension 13. Patient is admitted for laparoscopic cholecystectomy. On ASA and betablocker for past MI (secondary prevention). What is best management of medications peri-op? a) stop both b) continue both c) stop ASA, continue beta-blocker 14. Patient is seen in pre-op clinic for inguinal hernia. Which of the following would increase the peri-op risk for this patient? a) >5 PVC/min b) CHF c) severe valvular heart disease d) angina with moderate-vigorous exertion - Detsky Modifined Multifactorial Index 1986. This table in Sabiston’s scores the following points for each cardiac risk index: 20 class IV angina, 20 suspected critical aortic stenosis, 10 alveolar pulmonary edema within 1 wk, 10 class III angina, 5 MI>6mo ago, 5 if >5PVCs any time before surgery. 15. Which of the following increases the patient’s peri-operative risk the most? a) severe valvular heart disease b) anginal symptoms c) CHF 16. A patient is examined in anesthesia clinic and found to have a grade II/VI systolic murmur. Which valvular lesions can cause this? a) MR, AS 17. What is the highest risk for peri-operative pulmonary complications a) quit smoking 2 years ago b) chronic steroid use c) age >80 d) asthma  - highest relative risk in decreasing order is ASA class >II, CHF, age >60, functional dependence, COPD, smoking, obesity 18. Lady wants elective blepharoplasty for her eye but had a DES two months ago after ACS. How long should she wait for surgery? a) wait 2 months b) wait 10 months c) does not matter, operate immediately d) wait 6 months 19. Patient admitted to hospital with anemia has ACS and treated with BMS. He is subsequently diagnosed with colon cancer. When is the best time to operate? a) 30 days b) 6 months c) 1 year 20. Which patient requires stress-dose steroids? a) 60mg daily for 5 days – not long enough b) 25mg daily for 3 weeks c) 5mg daily for >20 years - d) 10mg 3 months ago for 6 weeks 21. Patient with known allergy to lidocaine, requires excisional biopsy of skin lesion on her cheek. How should you manage? a) Bupivicaine without preservatives b) Bupivicaine c) Procaine d) General Anesthetic 22. What is the highest chance of retained foreign body (surgical needle)? a) elective surgery b) unexpected change in procedure c) BMI 25-30 d) Short procedure 23. Patient with breast cancer has oncologic resection followed by immediate reconstruction. Post-op is found to have a retained sponge. Which of the following is a risk factor? a) BMI 25 b) Multiple surgeons involved in the case 24. Plasma volume of 70kg male: a) 3L – Plasma Volume = 40 cc/kg (40*70 = 2800) b) 6L c) 9L d) 15L e) 25. CAGE questionnaire: cut back, annoyed, guilty, eye opener 26. Patient with comorbidities but no functional limitations. ASA classification? 2 27. Patient with comorbidities and functional impairment. ASA classification? 3 28. **Patient is having a procedure done under local anesthetic. Which of the following is true? a) patient with CHF will tolerate a larger dose of anesthetic  b) hepatic failure – should decrease dose administered c) renal failure – should decrease dose administered d) patient on propranolol can tolerate a higher dose 29. Which of the following is true regarding lidocaine versus bupivacaine? a) bupivacaine has longer duration of action than lidocaine + slower onset b) bupivacaine has shorter latent period 30. What is true of bupivacaine? a) bupivacaine has greater cardiotoxicity than lidocaine b) bupivacaine has lower pKA c) bupivacaine has shorter latent period than lidocaine d) Bupivacaine has shorter duration of action 31. What is the earliest symptom of local anesthetic toxicity? a) perioral numbness b) seizure 32. Immediately after induction of general anesthetic, patient develops hypertension, tachycardia. What is most likely medication? a) ketamine b) etomidate c) propofol d) thiopental 33. During endoscopy with midazolam for sedation, patient is has decreased LOC with bradycardia and hypotension. After airway management what do you do? a) flumazenil b) narcan c) IV fluids 34. After induction of general anesthetic, the anesthetist notices the patient’s temperature is low at 35 degrees. Which of the following is active rewarming? a) Increasing room temperature b) Warm blankets c) Rewarming BairHugger 35. What increases the risk of fire in the OR? a) using cautery in neck dissection – airway with flammable gases b) using cautery and CO2 during laparoscopy c) draping patient while cleaning solution still wet 36. Resident begins case using coagulation function instead of cut on the electrocautery and is unable to cut through the epidermis. What is the difference between coag and cut? a) low heat, low frequency b) high heat, high frequency c) low heat, high frequency d) high heat, low frequency 37. Hyponatremia commonly manifests as? a) Tachycardia/hypotension b) Dry mucous membranes, thick secretions c) ICP/headache d) ataxia - this was best answer  38. Patient with pancreatic cancer and bony metastases has nausea, vomiting and ECG findings of flattened T waves, short QT, and AV nodal block. What is most likely electrolyte abnormality? a) Hypercalcemia b) Hyperkalemia c) Hypernatremia d) Hypermagnesemia 39. Pancreatic cancer patient with euvolemia and hyponatremia. Ambulatory. Asymptomatic, admitted for pain control. Na 130, Urine Na 28, U/O good. What to do? a) Fluid restriction b) Hypertonic saline c) Isotonic saline 40. When is pain after surgery considered chronic pain? a) 1 month b) 3 months c) 6 months d) 12 months Cardiac Surgery 1. Which is true of bypass grafts? a) arterial is superior to venous b) venous and arterial are equivalent c) venous has superior long-term patency d) venous has superior short-term patency and long-term patency is unknown - Cardiac Surg supports a) arterial grafts are superior to venous ENT 1. What is the most common cause of parotitis? a) Staph Aureus b) Pseudomonas c) Strep pneumonia d) Moraxella 2. Man with 3cm mass anterior to his earlobe. What is the next best step? a) US b) FNA biopsy c) CT d) Superficial parotid excision - ENT res says the best answer is CT scan 3. Patient is admitted for elective endoscopic sinus surgery with image guided navigation to improve patient safety. The patient is anesthetised. Shortly after the team realises the pre-operative CT scan was completed at another institution and is incompatible with the present equipment. How should the surgeon proceed? a) review CT scan in detail and proceed with surgery b) wake up patient and ask them how they would like to proceed c) wake up patient and repeat CT scan at this institution d) ask the family what they think is best - I picked answer B because this is an elective surgery. 4. Ethics 1. What are the 4 main ethical principles? a) autonomy, justice, beneficence, non-maleficence 2. What is a contraindication to MAID? a) Intractable psychological suffering b) Physician with contradictory religious belief c) 16 year old patient – must be 18 years old d) unable to estimate time to death 3. The surgical foundations committee has decided that “every resident must suffer for 5 years so patients can benefit”. What ethical principle is violated? a) beneficence b) autonomy c) non-maleficence d) justice 4. Patient with metastatic pancreatic cancer and intolerable pain. Does he qualify for MAID a) Yes he has an intractable medical condition b) No he has not tried all opioids c) Yes he has 3 month prognosis d) No, he requires an alternate decision maker 5. A man in ED has a hand tendon laceration. He needs to be seen by a plastic surgeon. He is angry about the wait times and decides to leave AMA. What should you do? a) Ensure he signs AMA form b) Complete Form 1 as he does not have capacity to make decision c) Attempt to make follow up plan d) Do nothing, knowing he will inevitably have to return - I think attempting to make a follow up plan in the most reasonable course of action 6. What is beneficence? a) Doing good for others b) Doing the most good for the most people c) Do no harm 7. Patient with recent diagnosis of glioblastoma with headaches for the past 6 months. Previously assessed by numerous doctors without diagnosis. He requests his medical records. Which ethical principle is this? a) autonomy b) beneficence c) non-maleficence d) justice 8. Surgeon looking after a patient who suffers surgical complication. How to proceed? a) Ethically responsible to disclose complication immediately b) Report to hospital leadership and only disclose if patient worsens 9. What is the most common cause for surgeon litigation? a) poor communication b) technical error 10. A small hospital records outcome measures/complication rates and notes their rate is higher than average. Which is true? a) High volume centres have better outcomes/decreased complications b) 4-6 surgical procedures is enough to maintain procedural competency General Surgery 1. Patient post laparotomy and small bowel resection develops a temperature 38.9 within 24 hours. What must you rule out? a) atelectasis b) invasive wound infection c) anastomotic leak d) drug hypersensitivity reaction - I believe the answer is B) invasive wound infection. This is because less than 24 hours post-op. Anastomotic leak typically presents 5-7 days post-op and it would be expected to have atelectasis at this time. 2. 64 year old male with small bowel obstruction admitted for emergent surgery. Na 112, Cl 96, K 3.8, Glc 12. What is the most likely cause of his electrolyte abnormalities? a) SIADH b) Vomiting with gastric loss of sodium c) Dilutional from excess free water d) Caused by hyperglycemic state - I believe you must rule out Hyperglycemia as a cause of his hyponatremia. In addition his K is normal which is atypical for GI loss/SBO. Chloride was a bit low. In general UGI losses typically account for the electrolyte abnormalities in SBO, but this question was weird because the sodium was so low. 3. Man with unknown history presents with massive hematemesis. He has ascites, splenomegaly, and spider angiomas. In addition to transfusion of red blood cells what should you do while waiting for urgent endoscopy? a) Somatostatin (this is octreotide) b) Vasopressin c) Ranitidine d) Balloon tamponade 4. During laparoscopy, what occurs upon CO2 insufflation? a) decreased CVP b) increased respiratory complicance c) volume dependent changes in CO 5. What is the most common cause of esophageal perforation? a) endoscopy b) violent vomiting c) foreign body d) esophageal cancer 6. Which NSAID is least likely to cause a GI bleed? a) Celecoxib b) ASA c) Naproxen d) Ibuprofen 7. Indication for bariatric surgery? a) BMI >40 b) BMI 35 c) BMI 30 and systemic disease (diabetes) 8. POD#8 patient presents with 1cm defect in wound with persistent copious amounts of serosanguinous discharge. Diagnosis? a) wound seroma b) hematoma c) fascial dehiscence  9. Which of the following is seen in abdominal compartment syndrome? a) if due to high volume ascites (ex liver laceration) you cannot get rid of it with a drain b) low urine output, decreased preload, and increased intra-pulmonary pressure c) only seen if bladder pressure >35mmHg - apparently in ACS, CVP increased despite decreased preload? For option A if primary compartment syndrome due to liver lac/hemorrhage then the treatment is laparotomy for control of control of bleeding too. 10. In patients with cirrhosis what is true? a) they are protected against delirium b) more prone to thrombosis c) more sensitive to some general anesthetic medications d) less free drug available 11. Post-op thyroidectomy/neck dissection patient in the PACU develops stridor and pulsatile hematoma beneath surgical incision. What do you do? a) Open wound at bedside and take back to OR b) Intubate and observe in ICU c) neck US d) Intubate patient in OR 12. Hematology/Transfusion Medicine 1. What is the most common congenital bleeding disorder? a) Hemophilia A b) Hemophilia B c) Von Willebrand Disease 2. Most common indication for FFP a) Hemophilia A going for emergency surgery b) Patient on Plavix going for emergency surgery c) Emergent reversal of Warfarin d) Uncontrollable intra-op bleeding with INR 1.3 -Stupid question. I am not so sure about answer D (Ortho group selected). The lowest FFP can correct INR is 1.4-1.5 depending on the source you read. In addition Hemophilia A is caused by Factor VIII deficiency, which FFP does contain. Although Bloody Easy suggests use of DDAVP or Factor VIII replacement. Warfarin ideally reversed by PCC (and Vit K but slower), however if unavailable then FFP is the next best option. 3. What factor is measured by INR? a) XI b) VII c) VIII d) II - I don’t think II was an option, because it is in the common pathway and technically can affect INR. I believe the other option was IX 4. Which blood product has the highest rate of bacterial infection? a) Cryoprecipitate b) FFP c) pRBCs d) Platelets 5. What factor is required for platelets to adhere to collagen? a) VIII b) II  c) IX d) XI 6. What factor does vWF bind to? a) VIII 7. You are called urgently to the emergency department to see a patient who requires urgent laparotomy. She is taking Warfarin. What is the best way to reverse? a) PCC b) FFP c) Vitamin K 8. Patient with platelet count of 55, no abnormal bleeding, is undergoing wound debridement for burns. What is the best pre-op management? a) Transfuse platelets to reach 100 b) Do nothing c) FFP d) DDAVP 9. Which factor does the liver create? a) VIII b) IV c) VI d) I – fibrin 10. Which of the following has increased risk of bleeding? a) Factor V Leiden b) Congenital protein C deficiency c) Congenital afibrinogenemia – missing factor 1, unable to make clots 11. Female undergoing thyroid surgery who is healthy but has had prior DVT. What is the best DVT prophalaxis for her? a) LMWH b) ASA c) Warfarin d) Mechanical 12. Patient in MVC trauma with grade II liver laceration, open tibial fracture, and cerebral contusion. What modality in the literature has the best evidence for DVT prophylaxis? a) LWMH b) Early mobilization c) IVC filter d) Compression stocking and foot pump 13. Bariatric surgery patient with prior DVT. What kind of DVT prophylaxis? a) LMWH b) Warfarin c) Mechanical d) IVC filter 14. What is true about coagulation status in chronic dialysis patients? a) don’t give opioids as they cannot clear, give NSAIDs b) Dysfunctional platelets despite normal coagulation testing c) Thyrombocytopenia due to splenic sequestration d) Thrombocytopenia due to marrow suppression  15. Patient is scheduled for a TURP. What is the best management of perioperative Warfarin? a) hold for 5 days, restart 2-3 days later if no bleeding concerns b) Do not need to hold, relatively low-risk procedure c) Hold for 2 days before surgery 16. What is true regarding Surgicel? a) can be placed directly on bleeding tissue b) must be wet to use c) cannot be cut d) it is a non-absorbable mesh 17. Patient underwent complicated colonic resection for cancer requiring 12 units of pRBC intraoperatively. He is now hypoxic. Diagnosis? a) TACO b) TRALI c) Non-hemolytic febrile transfusion reaction d) Hemolytic transfusion reaction 18. What is the 1:1:1 ratio in massive transfusion protocols? a) 1 unit pRBC : 1 unit FFP : 1 unit Platelets b) 1 unit pRBC : 1 unit cryoprecipitate : 1 unit Platelets c) 1 unit pRBC : 1 unit FFP: 1 unit cryoprecipitate d) 1 unit pRBC : 1 unit Platelets: 1 L normal saline 19. Patient developed HIT, in addition to stopping LMWH what do you start them on? a) Argatroban b) Dabigatran c) Warfarin d) Rivaroxaban 20. How long to hold dabigatran in a patient with renal failure (Creatinine clearance 40, normal >90)? a) 24-48 hrs b) 48 hrs c) 4 days d) 1 week - debated B vs C. Bloody easy quotes half-life of 12-18 hrs with prolonged clearance in renal failure, thus recommends stopping Dabigatran 1-2 days before procedure if CrCl>50 and stopping it 2-4 days prior is CrCl 30-50 but also considering risk of bleeding 21. ICU / Nutrition 1. Why are vasopressors bad? a) does not improve MAP b) does not improve perfusion at tissue and cellular level c) affects beta adrenergic vasomotor tone d) requires administration of excessive fluids - all other options are incorrect statements 2. What is the biggest energy reserve in a 70kg man? a) Fat b) Glycogen c) Protein d) Water 3. What is the difference between energy expenditure in severe trauma and chronic starvation?  a) proteolysis b) lipids c) decreased metabolic rate d) nitrogen balance/usage? - Sabiston’s: Lipolysis involves hydrolysis of triacylglycerol stored in adipose tissue to release fatty acids and glycerol. Although glycerol can be used by the liver to synthesize glucose, fatty acids cannot be used to synthesize glucose in humans. As a result, during periods of stress or prolonged starvation, proteolysis occurs to maintain glucose homeostasis after depletion of glycogen stores. Proteolysis occurs primarily through degradation of muscle protein or solid organs. 4. The most important energy source in critical illness is? a) protein b) lipids c) carbohydrates 5. Trauma patient has perforated small bowel. Parenteral nutrition is started due to? a) critical illness b) inability to gain access to GI tract 6. For a 60kg man what is the daily minimum acceptable urine output? a) 200-400mL b) 500-800mL (0.5 x 60 kg = 30 x 24 hrs = 720 mL) c) 900-1200mL 7. How to manage air embolism? a) Reverse trendelenberg b) Right lateral decubitus position c) Rebreather mask to increase CO2 d) Insert venous catheter into right atrium and aspirate air 8. What is the TTE best for? a) valvular disease b) cardiac output c) MI d) Peri-op complications - I think best for assessing valvular disease (followed by cardiac output) 9. What is a complication of TPN a) hypoglycaemia b) hepatic steatosis c) intestinal villous hypertrophy 10. A patient with severe brain injury requires long term enteral feeds in the ICU. Best option? a) G-tube b) NG c) NJ 11. Which is true regarding NG enteral feeding? a) appropriate for all surgical patients b) should be started after 3 days if not tolerating oral feeds c) best suited for patients with normal mentation and intact laryngeal muscles who can protect their airway (wording slightly different) d) recommended for intubated patients - debated B vs C. Answer C kind of silly because if someone had normal mentation and intact airway protective mechanisms, then perhaps they should be able to swallow on their own? 12. What is true about aspiration? a) raising head of bed 10 degrees decreases risk b) NG tube not on suction stents open the lower esophageal sphincter c) Monitoring gastric residual lowers risk d) NG tube has lower risk than NJ - best answer ?A 13. Where are carbohydrates digested? a) small intestine b) stomach c) colon d) pancreas 14. Which of the following is the best indicator of septic shock? a) cardiac index 1.8 b) CVP 3mmHg - CI actually increases in septic shock 15. What is seen with septic shock? a) fever, increased pulse pressure, high WBC, tachycardiac, tachypnea, warm b) mottling, cold extremities, hypotension c) elevated CVP, narrow pulse pressure 16. What type of shock presents with warm extremities? a) septic b) obstructive c) hypovolemic d) cardiogenic 17. Which of the following is true regarding septic shock? a) septic shock is defined by hemodynamic parameters like HR and BP b) catecholamines are released by the parasympathetic nervous system c) … d) Pituitary releases ADH which decreases urine output - I think answer D was most correct 18. Activated Protein C may be given in sepsis. What is a possible complication? a) increased thrombosis b) increased bleeding 19. Which of the following represents the decompensation phase within the “vicious cycle” of shock? a) Hemodynamics maintained through neuroendocrine response (compensated phase) b) tissue hypoperfusion and cell death c) hemodynamic/cardiovascular collapse (this is the irreversible phase) 20. Why are obese patients harder to ventilate? a) decreased chest wall compliance and expansion 21. What is true in refeeding syndrome? a) seen with increased feeding in severely malnourished alcoholics b) due to overfeeding in obese patients c) happens only in NG fed patients 22. Diagnosis of brain death requires? a) minimal cerebral flow on ancillary studies  b) no change in LOC after sedation off for 24 hr c) something about no seizures on EEG d) deep coma, no motor response other than spinal reflexes 23. Patient with neurologic death in the ICU is reasonably stable with plans for organ donation but then crashes with hypotension, tachycardia and U/O increases to 1500cc/hr from previously 50cc/hr, Sodium increases from 140 to 158. What is the management? a) Switch IVF to D5W b) Start norepinephrine c) Start epinephrine infusion d) Start arginine vasopressin infusion 24. Anion gap? a) anion gap is normally less than 10 b) Hypoalbuminemia reduces the anion gap 25. High anion gap metabolic acidosis is caused by? a) Ketoacidosis b) Diarrhea 26. Patient has ABG with low pH, high pCO2, normal pO2, low HCO3. What is the abnormality? a) Respiratory alkalosis b) Respiratory acidosis c) Metabolic acidosis d) Respiratory acidosis and metabolic acidosis 27. During ECHO what is administered to demonstrate myocardial ischemia? a) Dobutamine b) Dipyramidole 28. ECHO is best for: a) cardiac output b) assessment of valvular disease 29. Which of the following is supportive of volume overload? a) increased CO b) decreased CVP c) hypotension 30. ICU patient on NG feeds develops tachycardia, hypotension, fevers. Best initial management is? a) stop NG feeds b) culture and start antibiotics 31. Patient in ICU with CVC develops erythema and pain and suspected line infection. Which of the following is associated with increased risk of bacteremia? a) placement in subclavien vein b) used for enteral feeds c) inserted by trainee (med student) 32. You are called to assess a 70 year old male post-op hip surgery patient with low urine output. He is diaphoretic and confused. He is tachycardic, hypotensive and on 3L nasal cannula. What do you do? a) IV bolus, lab investigations, call ICU b) ASA, CXR (?nitro) c) ASA, stat ECG (and something else) d) Lasix infusion, call ICU  - I put A since patient did not appear to be in pulmonary edema, nor was I comfortable starting ASA in post-op patient without any investigations as he did not complain of chest pain (although ACS post-op commonly does not have any chest pain and may be asymptomatic). 33. How does adrenal insufficiency differ from septic shock? a) hypoglycemia 34. Risk factor for delirium? a) pre-existing structural brain lesion b) drugs that increase acetylcholine 35. Elderly female patient with post-operative agitated delirium is shouting at nurses accusing them of trying to hurt her, climbing out of bed and pulling out her IV lines. What is the best initial management? a) benzodiazepines b) give minimal dose of antipsychotic medication to achieve effect c) use loud and assertive commands to achieve dominance d) apply mechanical restraints to protect patient and staff 36. Which of the following is an indication for albumin? a) large volume paracentesis b) trauma c) hypoalbuminemia 37. Carbon monoxide poisoning, what is the presentation? a) pale skin, O2 100%, acidotic b) red skin, O2 100% acidotic c) pale skin, O2 89% alkalotic d) red skin, O2 89% alkalotic - The pulse oximetry reading will be spuriously high as CO has higher affinity that oxygen for same biding site on hemoglobin and forms Carboxyhemoglobin which is measured as oxygenated hemoglobin. 38. Which of the following is true regarding oxygenation dissociation curve? a) chronic hypoxia shifts the curve right b) fetal hemoglobin shifts the curve left c) increased 2,3 BPG shifts the curve left d) increased acid (lower pH) shifts the curve left - wording of a or b may have been opposite in the exam. However, fetal hemoglobin does shift the curve left. Chronic hypoxia also shifts the curve left. --- left shift means higher affinity 39. Pulse oximetry sensitivity decreases below 92% - can’t remember the question involving this, but I remember this was the best answer 40. Patient develops renal failure, what is the most likely etiology? a) Lasix b) Nephrogenic diabetes insipidus c) ?don’t remember other options or the stem for that matter 41. Question with sepsis/venous capacitance? Infectious Diseases 1. When should Vancomycin be used as a preop antibiotic? a) History of rash to Penicillin b) Documented MRSA patient c) Anticipate bacteria other than Staph and Strep 2. What is the appropriate time interval to redose prophylactic pre-operative antibiotics? a) 3 hours b) Half life c) Two half lives d) Before the end of the procedure 3. When to give pre-op antibiotics? a) Within 1 hour of incision b) At the time of incision c) Must be broad spectrum 4. What is correct about prophylactic antibiotics? a) need time to get adequate levels at operative site prior to contamination b) need to continue for 48 hours post-op 5. Pathogen most commonly seen with catheter-related UTI a) E. Coli b) Pseudomonas c) Enterococcus d) Proteus 6. What is true of nosocomial UTI? a) must treat for 7 days b) Diagnosed with WBC on urine dip c) Do not need to treat if asymptomatic d) Remove catheter as quickly as possible 7. Which antibiotic causes tendon rupture? a) Ciprofloxacin b) Clindamycin c) Gentamicin d) Imipenem 8. You eat a raw hamburger and develop hematuria, purpura, epistaxis. What is the diagnosis? a) HUS b) Gaucher’s disease 9. Resident does pre-op prep under nurse supervision. Which is true regarding decreasing risk of surgical site infection? a) prep from outside to in b) prep immediately before so skin is still wet when starting procedure c) use electric clippers for hair removal d) iodine is better than chlorhexidine 10. Which of the following decreases SSI? a) Ioban b) Frequent saline rinses of the wound c) Antibiotic rinses 11. Which of the following increases your risk for SSI? a) blood transfusion b) hyperthermia c) (can’t remember other options but they were not correct) 12. Which of the following will reduce risk of SSI? a) quitting smoking 30 days before surgery b) antiseptic shower c) hair removal before incision (was this immediately before or several days before) - debated this, quitting smoking 6-8 prior shows effect so technically not 30 days. No good evidence for shower. Immediate hair removal prior to surgery can help. 13. What is normal bacterial flora found in a healthy person? a) oropharynx b) biliary tract c) CSF d) Distal respiratory tract 14. Your attending accidentally pokes you with a hollow bore-needle in known IVDU patient. What should you do regarding HIV prophylaxis? a) Prophylaxis not required b) Single agent prophylaxis is ok c) Do not start prophylaxis until testing patient first d) Start prophylaxis within a few hours - 2018 CDC guidelines- https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm. Essential elements of management of a HCW after needlestick injury includes evaluating the donor and recipient at time of exposure, counselling of HCW, and providing followup HIV testing. If unknown status then deciding to treat is a case-by-case basis. Can start PEP as soon as possible after exposure, reevaluation of exposed person within 72hrs post exposure, administer PEP for 4 weeks if tolerated, discontinue if source is HIV negative. A regimen containing three or more drugs is the preferred regimen. Antiretroviral drugs for PEP should be initiated within 72 hours of exposure and continued for 4 weeks. If known HIV-status of source person then should test, but also start PEP as soon as possible. Typically a two drug regimen with ZDV and 3-TC. 15. Which of the following are you most likely to get from a blood transfusion? a) HBV b) HCV c) HIV d) CMV 16. Patient presents with pseudomembranous colitis. Diagnosis could be confirmed by: a) inclusion bodies in small bowel biopsy b) stool culture c) stool toxin assay 17. Which of the following is a gram negative bacilli? a) enterobacter cloacae b) C. difficile c) Enterococcus sp. d) Streptococcus 18. Which of the following would cause you to intervene quickly on a CT-proven kidney stone? a) urinalysis with WBC 2-50  b) proximal hydronephrosis c) fever of 39 d) stone size >10mm - I don’t think a 10mm stone will pass on own without intervention, but fever does suggest septic stone. 19. 25 year old male who received full course of childhood tetanus vaccination series and has injury to wound a) administer tetanus toxoid only if last booster was >4 years ago b) administer tetanus toxoid only if last booster was >6 years ago c) administer both tetanus toxoid and tetanus immunoglobulin d) his wound is not tetanus prone - I think answer B was most correct. Don’t remember complete wording of question but he received full vaccination series and had a wound that needs tetanus booster 20. Which of the following can handwashing help prevent? a) TB b) Hepatitis A c) Hepatitis B d) HIV 21. Neurosurgery 1. What is the difference between Hypertonic Saline and Mannitol for lowering ICP? a) HTS has less of a diuretic effect than mannitol b) HTS doesn’t cross the BBB c) HTS has less coagulable effect than mannitol 2. Where is sodium most abundant? a) Extracellular b) Intracellular c) Juxtacellular d) Prevalent intra and extracellular 3. Patient has traumatic CSF leak through right ear canal. What is the appropriate management? a) Observation only, consult appropriate surgical service if persistent leak b) Observe, culture fluid and administer antibiotics based on culture c) Observe, start broad spectrum antibiotics d) Immediate Neurosurgical consultation for repair of CSF leak 4. Patient has no eye opening, no verbal or motor response. GCS? a) 0 b) 1 c) 3 d) 6 5. When do you see the Cushing triad (systemic hypertension, bradycardia, irregular respirations)? a) Increased ICP b) Subdural hematoma c) Seizure 6. What is the target for CPP? (MAP – ICP) a) 60-80 b) 80-100 c) 100-120 7. Blown pupil and contralateral paralysis a) transtentorial herniation and brainstem involvement b) subfalcine herniation with carotid artery occlusion c) hydrocephalus 8. Chronic empyema no completely drained with chest tube and patient clinically declining. CT demonstrates loculated empyema. Next step? a) IV antibiotics and nutritional support for 4 weeks b) Surgical excision of overlying rib and drainage c) Decortication d) Pleuerectomy 9. 65 year old male fall with hyperextension of neck but no radiographic findings of fracture. He has upper extremity weakness greater than his lower extremities. What kind of injury? a) Brown-Sequard b) Anterior cord syndrome c) Central cord syndrome 10. Young male fall from 9 feet off ladder with traumatic C-spine fracture with disassociation of pain and temperature. What kind of injury? a) Brown-Sequard b) Anterior cord syndrome c) Central cord syndrome 11. Young female with traumatic C7 complete cord transection injury. Hypotensive despite 2L of fluid resuscitation. Why? a) Neurogenic shock 12. Nerve injury with intact axon but impaired nerve conduction a) neuropraxia b) axonotmesis c) neurotmesis d) electromesis 13. Patient is positioned in lithotomy for hysterectomy. Post-operatively has foot drop. Which nerve is most likely injured? a) peroneal nerve b) tibial nerve c) femoral nerve 14. Patient with known lumbar disc herniation presents with progression of symptoms including inability to void urine. What to do? a) OR b) Foley  15. OBGYN 1. When is the best trimester for a pregnant patient to undergo surgery? a) First b) Second c) Third d) Does not matter 2. Patient is post-op day 5 after abdominal hysterectomy for uterine cancer. She develops SOB with 40% on NRB mask, tachycardia, normotensive. What is the most important test? a) ECG b) CXR c) CTPE d) Doppler US 3. Patient is pregnant at 20 weeks gestation and presents with RLQ pain. US is unable to visualize the appendix. What is the next best step? a) MRI b) CT abdo/pelvis c) Admit for observation and serial examinations d) Take to OR 4. Pregnant trauma patient, which of the following is true? a) Uterus is closer to anterior abdominal wall so peritonitis is seen earlier b) BP is lower in the second trimester c) Principle of resuscitation is to focus on saving the fetus d) Do not need to volume resuscitate as plasma volume is increased 5. Oncology 1. Cytotoxic effect of chemotherapeutics a) constant cell death b) constant percent cell death c) decreasing percent cell death per dose d) constant percent per tissue molar concentration - Chemotherapy kills cells via first order kinetics, thus always reducing burden of tumour cells by a percentage and not constant number of cells. 2. What is true of radiotherapy? a) Potentiated by hypoxia b) Acts independently of cell cycle c) Acts directly through DNA breakage - Radiaton directly damages DNA by breaking the sugar phosphate backbone. Radiation therapy is dependent on the cell cycle with most sensitive phases being G2 and M. Extent of DNA damage is dependent also on cellular oxygen (hypoxic cells less radiosensitive because oxygen prolongs half-life of free radicals) and medications that are cell sensitizers (oxygen mimicers like metronidazole, thymidine analogues, 5-FU, doxorubicin, etc.). 3. In Canada, which cancer is associated with highest mortality rate? a) Lung b) Pancreas c) Prostate in male, Breast in females d) Colon  - Schwartz & Sabiston’s epidemiology supports #1 diagnosis is prostate/breast but the #1 cause of mortality is lung for both total number and percentage of cases. Assume Canada is similar. 4. Patient with rectal cancer and solitary hepatic metastatic lesion. What is the most important consideration for outcome? a) multidisciplinary tumour board b) neoadjuvant chemo/radiation c) resectability of the primary d) resectability of the metastasis 5. Radiation using 5000cGY will reduce tumour burden from 1 million cells to 100,000. If wanting to reduce cells from 1000 to 100 what dose is required? a) 5000 b) 500 c) 50 d) 5 Since radiation is cell-cycle dependent and there is always a certain percentage of cells in each phase, then we can assume that each fraction treats a percentage of cells only, with G1 and S phase cells surviving then progressing via reassortment. 6. FDG-PET a) …Glycolysis b) Better than CT for detection of small metastases c) Can differentiate between infection and malignancy - UptoDate: PDG-PET is more accurate than CT in differentiating benign from malignant lesions as small as 0.7 to 1cm in diameter. FDG-PET correctly excludes cancer in most cases (good negative predictive value). However, it is not uncommon for an PDG-PET positive nodule to be infectious, inflammatory, or granulomatous in origin (moderate positive predictive value). 7. Orthopedics 1. At what level should a binder be applied for unstable pelvic fractures? a) umbilicus b) ASIS c) Greater trochanters d) Midshaft femur - I believe this is supported by ATLS manual 2. What pressure does compartment pressure need to exceed to cause compartment syndrome? a) venous pressure --- (usually only 8-10 mmHg ) b) arterial pressure c) capillary pressure - I think group consensus was venous pressure. However, Schwartz: compartment syndrome occurs after prolonged ischemia is followed by reperfusion. The capillaries leak fluid into the interstitial space in the muscles which are enclosed within a nondistensible fascial envelope. When the pressure inside the compartment exceeds the capillary perfusion pressure, nutrient flow ceases and progressive ischemia occurs, even in the presence of peripheral pulses. - Theoretically, compartment syndrome occurs when compartment pressures rise above the capillary perfusion pressure (i.e., 20-30 mmHg) resulting in decreased perfusion, increased tissue ischemia and increased swelling - a negatively reinforcing cycle leading to worsening compartment pressures and limb viability. Therefore, it is logical to expect that compartment pressures > 30 mmHg can provide objective evidence of compartmen 3. Patient with unstable pelvic fracture that is stabilized but unable to control haemorrhage. What is the next best step? a) Laparotomy for open ligation of vessels  b) IR for angioembolization c) Reposition fracture stabilization - Doesn’t ATLS stipulate that if unstable hemorrhage, should go to OR? 4. Patient has ORIF of distal radius with cast placed then bivalved with dressing over top. Nurses note pain and decrease capillary refills. What is the first step in management? a) Analgesics b) Take down cast and inspect wound c) Return to OR 5. Patient presents with open tibial fracture. How to manage antibiotics? a) prolonged course of post-operative antibiotics ?? don’t we usually just do like 3 doses ??? b) oral antibiotics for _days c) post-op antibiotics for 48 hours 6. 6 year old boy presents with leg pain and inability to weightbear. On exam he is most uncomfortable with passive movement of his left hip. Next best step? a) joint aspiration b) MRI c) XR d) Take to OR 7. Most common source of hemorrhage in pelvic fracture? a) femoral artery b) iliac artery c) posterior pelvic venous plexus 8. Bone healing question a) soft callus b) mineralization c) bridging 9. Pediatrics 1. 1 month old 4kg infant undergoing surgery. What is their total blood volume? a) 300mL b) 450mL c) 600mL d) 800mL 2. Pediatric bolus of IV fluids for a 15kg patient? a) 150mL b) 300mL (20cc/kg) c) 3. Baby presents with feeding intolerance and projectile vomiting with palpable olive on abdominal exam. What are the common electrolyte abnormalities? a) hypokalemic, hypochloremic, metabolic alkalosis 4. Child with easy bruising, hyper-mobile joints and rectal prolapse. What should you investigate for? a) Ehlers-Danlos b) Osteogenesis imperfecta 5. Duodenal atresia is associated with? a) Down Syndrome (Trisomy 21) Plastic Surgery / Wound Healing / Sutures 1. 17 year old female with 15% partial thickness burns and 5% full thickness burns. What are her fluid requirements in the first 24 hours? a) 1000mL b) 2400mL c) 4800mL d) 8000mL - if I recall she was 50kg, and all of the answers were incorrect after applying Parkland formula, nevertheless I chose the closest volume which was slightly greater than what is calculated 2. Burn injury, calculate volume required in first 4 hours after injury. a) correct answer was provided in this question 3. Burn wound very painful with blisters and weeping. What classification? a) superficial b) superficial partial thickness c) deep partial thickness d) full thickness 4. Patient has burns to both upper extremities, back, and head but face is spared. What is the TBSA? a) 30% b) 40.5% c) 45% d) 49% 5. Patient is 24 hours following significant burn with Temp 38.5, HR 120, BP 100/70, urine output 70mL/hr. What is the cause of fever? a) inadequate resuscitation b) burn related sepsis c) hypermetabolism 6. What is the most likely cause of (mortality) in burn patient? a) bronchopneumonia b) burn wound sepsis c) renal failure 7. Patient presents with grey discharge from wound with subcutaneous emphysema and pain out of proportion over wound. Next step? a) OR stat (necrotizing fasciitis) b) Broad spectrum antibiotics 8. Which suture takes the longest to be absorbed?  a) PDS b) Monocryl c) Vicryl d) Dexon 9. What is a side effect of silver sulfadiazine dressings? a) limits granulocytes b) nephrotoxic c) inhibits carbonic anhydrase d) methemoglobinemia 10. What can improve wound healing in a patient on steroids? a) Vitamin A b) Vitamin C c) Iron 11. Diabetic ulcer biopsy shows low collagen and inflammatory cells. Not infected. On corticosteroids for MG. What will help healing? a) Vitamin C b) Vitamin E c) Vitamin A d) Zinc 12. What type of collagen is most important in wound healing? a) 1 and 2 b) 1 and 3 c) 2 and 4 d) 3 and 4 13. What is true about the inflammatory stage of healing? a) aborted immediately by direct closure of wound b) epithelialization reduces the amount of time c) prolonged by STSG 14. Why do full thickness burns not heal and require skin graft? a) dermal appendages are gone b) dermis will heal but epidermis won’t c) epithelialization is inhibited 15. Patient presents 8 years after burn injury with a 1cm area of chronic skin breakdown and weeping. How to manage? a) Incisional biopsy b) Re-graft 16. What is the major benefit of split thickness skin grafting over full thickness? a) can put over infected site b) contracts less c) better sensation 17. What do you put on a split thickness skin graft? a) wet to dry dressing b) silver sulfadiazine c) sulfomylon d) VAC ---- I DON’t remember using a vac for STSG on plastics 18. Young male is involved in MVC rollover with significant skin and soft tissue degloving injury. After he is stabilized he is taken to the OR 6 hours later. How to manage his injury? a) removal foreign bodies b) removal foreign bodies, and debride necrotic tissue with observation of tissue of questionable viability c) removal foreign bodies, debride necrotic tissue and tissue of questionable viability d) removal foreign bodies, debride necrotic tissue and tissue of questionable viability with immediate split-thickness skin grafting 19. Vasoconstriction of wounds is known to decrease wound healing. Which of the following decreases vasoconstriction in surgical tissues? a) decreasing pain b) increasing supplemental O2 c) hypothermia d) blood transfusion 20. Open nephrectomy with accidental bowel injury in unprepped bowel with spillage of enteral contents. What wound classifications is this? a) clean b) clean-contaminated c) contaminated d) dirty 21. Farmer falls from ladder in his barn and has open tibial fracture. What type of wound? a) clean b) clean-contaminated c) contaminated d) dirty 22. Breast biopsy is what type of wound? a) clean b) clean-contaminated c) contaminated d) dirty 23. Traumatic lower leg laceration. What to close wound with? a) Vicryl b) Nylon c) PDS d) Cat gut - Nylon is the only non-absorbable option, also is monofilament. Also has minimal acute inflammatory reaction. 24. Patient returns to emergency with an inflamed wound. What suture was most likely used for closure? a) silk b) vicryl 25. What suture would you use to close an infected wound/abscess? a) Monofilament, non-braided b) Polyfilament, non-braided c) Monofilament, braided d) Polyfilament, braided 26. What do neutrophils do in inflammatory phase? a) phagocytosis  27. Which factor is most-likely to affect wound healing? a) malnutrition b) controlled HTN c) age >65 28. Grade II sacral ulcer, what is most important management? a) frequent repositioning b) surgical debridement with VAC c) culture and start antibiotics d) surgical debridement only 29. What is the different for hypertrophic scars compared to keloids? a) will regress over time b) increased collagen deposition c) fibroblasts secrete 40 times more collagen than normal d) goes beyond the borders of initial wound 30. Which cells are most important in the contraction phase of wound healing? a) myofibroblasts b) fibroblasts c) collagen d) epithelium Research & Statistics 1. What is true about prospective cohort studies? a) expensive b) can only choose one variable c) randomization is easier because you are not blinded d) good for rare diseases 2. What is the best study design for rare diseases? a) case control b) case series c) RCT d) Meta-analysis 3. What is a meta-analysis? a) best available evidence b) precise estimate of effect by combining sample sizes c) combines data to improve power 4. Which of the following is level 3 evidence? a) cohort study b) case series c) case-control study d) expert opinion 5. Which type of study can generate a hypothesis? a) cohort b) case control c) observational d) RCT 6. At journal club one of the surgeons mentions confounders. What are study confounders? a) A measured or unmeasured variable associated with exposure and outcome 7. What is the best test to determine causality between two variables? a) Chi square b) T-test c) Odds ratio d) PPV 8. Researcher wants to decrease the possibility that association between variable is due to chance. What are they aiming to minimize? a) Type 1 error A type I error occurs when the null hypothesis is true, but is rejected. Let me say this again, a type I error occurs when the null hypothesis is actually true, but was rejected as false by the testing. A type I error, or false positive, is asserting something as true when it is actually false. b) Type 2 error 9. “Failure to reject the null hypothesis when it is incorrect” ??? a) Alpha error b) Beta error - Alpha/Type 1 error occurs when one observes a difference in outcomes when such a difference does not actually exist. In general the null hypothesis is that there is no difference in outcome. If p