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66 Cards in this Set

  • Front
  • Back
SG31 [1988]

Which of the following is the best guide to fluid replacement in a burns patient?
A. Haemoglobin and haematocrit

B. Urine output

C. Urine osmolality

D. Plasma volume

E. Specific gravity
ANSWER B
Can05-155

Please use the Parkland formula to calculate the appropriate fluid requirements for a patient
who is 50 kg with a 40% full thickness BSA burn, which occurred 4 hours ago.

A. Ringer’s Lactate 500cc/hr x 8 hours then 250cc/hr x 16 hours

B. Ringer’s Lactate 250cc/hr x 4 hours then 125cc/hr x 16 hours

C. Ringer’s Lactate 1000cc/hr x 4 hours then 250cc/hr x 16 hours

D. Ringer’s Lactate 250cc/hr x 16 hours then 125cc/hr x 8 hours
ANSWER C

Mls of fluid in 1st 24 hours (time taken from time of burn)

= % burn x wt in kgs x 4
= 40 x 50 x 4
= 8,000 mls

* Half of this is given in the first 8 hours after a burn. As 4 hours has passed, then give this half in the next 4 hours. Thus, 1,000mls/hr for 4 hours

* Second half given over next 16 hours. So give (4000/16) = 250mls/hr for next 16 hours.

* Note that fluids need to be adjusted based on urine output (aim for 1ml/kg/hour) and frequent clinical assessment.
SG53 ANZCA version [2005-Sep] Q134

During laparoscopic surgery, pneumoperitoneum usually results in a fall in systemic blood pressure when intra-abdominal pressure exceeds

A. 5 mmHg

B. 10 mmHg

C. 20 mmHg

D. 30 mmHg

E. 40 mmHg
ANSWER B

FROM CEACCP ARTICLE

* IAP < 10 mm Hg: increases VR, increases CO

* IAP 10–20 mm Hg decreases VR, decreases CO BUT increases SVR and therefore BP unchanged or increased

* IAP > 20 mm Hg greater decrease VR, greater decrease CO, so decreases BP
SG53b ANZCA Version [2006-Mar] Q141, [Jul06] Q97 [Aug 09] Q75

During laparoscopic surgery, pneumoperitoneum usually results in a fall in cardiac output when intra-abdominal pressure exceeds

A. 10 mmHg

B. 20 mmHg

C. 30 mmHg

D. 40 mmHg

E. 50 mmHg
ANSWER B

FROM CEACCP ARTICLE

* IAP < 10 mm Hg: increases VR, increases CO

* IAP 10–20 mm Hg decreases VR, decreases CO BUT increases SVR and therefore BP unchanged or increased

* IAP > 20 mm Hg greater decrease VR, greater decrease CO, so decreases BP
SG49 ANZCA version [2003-Apr] Q139, [2003-Aug] Q52, [2004-Aug] Q56, [2005-Apr] Q56 [March 06] Q30

Hoarseness following a total thyroidectomy may be due to damage to the:

A. Deep cervical plexus

B. External branch of superior laryngeal nerve

C. Hypoglossal nerve

D. Internal branch of superior laryngeal nerve

E. Superficial cervical plexus.
ANSWER B

The superior laryngeal nerve (SLN) has 2 divisions: internal and external.

* The internal branch provides sensory innervation to the larynx. It enters the larynx through the thyrohyoid membrane and therefore should not be at risk during thyroidectomy.


* The external branch provides motor function to the cricothyroid muscle and is at risk during thyroidectomy. This muscle is involved with elongation of the vocal folds. Trauma to the nerve results in an inability to lengthen a vocal fold and thus to create a higher-pitched sound. The external branch of the SLN is probably the most commonly injured nerve in thyroid surgery. The rate of injury to the external branch of the SLN has been estimated at 0-25%. This rate is probably underestimated, because the diagnosis is frequently missed.
SG50 ANZCA version [2003-Apr] Q103, [Mar06] Q74, [Jul06] Q40

The most important effect of Lugol's iodine administration prior to thyroid surgery is

A. a reduced incidence of thyroid storm

B. a reduced incidence of vocal cord palsy

C. an increased chance of preservation of the parathyroid glands

D. increased pigmentation to assist in gland identification

E. reduced vascularity of the gland
ANSWER A

Lugol's iodine
* 5% iodine and 10% potassium iodide distilled in water
* administered preoperatively to reduce the release of thyroid hormone and the vascularity
-3 drops twice daily beginning 10 days preop
-in thyroid storm it can be given IV 0.5-1gm every 8-12 hours.

However, more rapid control of the hyperthyroid state can be achieved with beta blockers, thionamides.
SG54 ANZCA version [2005-Sep] Q133, [Jul06] Q49

Pneumoperitoneum to a pressure greater than 10 mmHg for laparoscopic surgery usually results in

A. a decreased arterial to end-tidal CO2 difference

B. a decrease in airway resistance

C. an increase in pulmonary compliance

D. an increase in physiological dead space

E. an increase in functional residual capacity (FRC)
ANSWER D
SG55 ANZCA version [2005-Sep] Q139, [Jul06] Q38, [Apr07]

Phosphate-containing bowel preparations for colonoscopy are contra-indicated in frail, elderly patients because of the

A. frequent nausea, bloating and abdominal pain

B. risk of hypercalcaemia

C. risk of hypokalaemia

D. risk of hypomagnesaemia

E. risk of large fluid shifts
ANSWER E
SG58 ANZCA Version [Jul06] Q133

The Pringle manoeuvre (a surgical intervention when faced with exanguinating haemorrhage from
the liver) involves clamping the

A. aorta above the coeliac axis

B. hepatic artery only

C. hepatic vein only

D. portal pedicle

E. splenic artery only
ANSWER D

An important advance is the use of the Pringle maneuver (clamping of the hepatoduodenal ligament only) for vascular inflow occlusion as an alternative to total vascular occlusion (clamping of the portal vein, hepatic artery and supradiaphragmatic as well as infradiaphragmatic portion of the inferior vena cava)

The Pringle manoeuvre was performed by placing a clamp on the hepatic artery and portal vein.
IC80 ANZCA Version [Jul06] Q105, [Apr07] Q3

A 30-year-old man presents to the Emergency Department following a high speed motor vehicle accident. He has marked abdominal distenson, a pulse rate of 130 and a blood pressure of 80/50 mmHg. The most appropriate initial investigation would be

A. abdominal angiogram

B. abdominal paracentesis

C. CAT scan of the abdomen

D. plain X-ray of the abdomen

E. FAST (focussed abdominal sonography for trauma) scan
ANSWER E

FAST should be done first if available since it is rapid, sensitive and specific. Patient does not need to be transferred to obtain hence can be done in the department. No unstable patient should go for CT and AXR is not sensitive in picking up injury in blunt abdominal trauma. FAST when available would take initial precendent over a DPL which is used for unstable patients when the abdominal examination is equivocal. If free fluid/blood is seen on FAST, there is no need for a DPL.
IC82 ANZCA Version [Jul06] Q102

A 30-year-old man presents to the Emergency Department following a high speed motor vehicle accident. He has a Glasgow Coma Score of 7 and arrives with a cervical collar in situ and an 18 gauge intravenous cannula in his right hand. You first priority in managing this patient would be to

A. insert a large bore intravenous cannula

B. perform a CAT scan of the brain

C. perform a cervical spine X-ray

D. perform a plain chest and pelvic X-ray

E. secure the airway with an endotracheal tube
ANSWER A
CV74 [Feb06]

The organ most UNLIKELY to demonstrate an increase in blood flow in response to decreased capillary partial pressure of oxygen?

A. Liver

B. Skeletal muscle

C. Heart

D. Kidneys

E. Lung
ANSWER E
AC96d ANZCA version [2003-Apr] Q127

Haemodynamic responses to pneumoperitoneum include all the following EXCEPT

A. decreased cardiac output

B. decreased venous vascular resistance

C. increase in pulmonary artery occlusion pressure

D. increased systemic vascular resistance

E. increased systemic blood pressure
ANSWER B
AC96c ANZCA version [2001-Apr] Q146,[2001-Aug] Q105

Haemodynamic changes associated with carbon dioxide pneumoperitoneum, for laparoscopy,
include increased

1. central venous pressure

2. stroke volume

3. mean arterial pressure

4. cardiac output
ANSWER 1 and 3
AC96b ANZCA version [2005-Apr] Q98, [2004-Apr] Q112

The observed fall in cardiac output induced by carbon dioxide pneumoperitoneum (with intra-
abdominal pressures below 12 mmHg), during laparoscopic cholecystectomy is primarily a result of

A. a fall in venous return to the heart

B. an increase in systemic vascular resistance

C. increased pressure transmitted to intra-thoracic baroreceptors

D. increased pulmonary vascular resistance

E. reflex bradycardia
ANSWER B

VR will fall if pressure > 15mmHg

SVR will increase over all ranges
AC96a ANZCA version [2002-Aug] Q76 (Similar question reported in [Mar00] [Jul07])

The observed fall in cardiac output induced by carbon dioxide pneumoperitoneum during laparoscopic cholecystectomy is primarily a result of

A. a fall in venous return to the heart

B. reflex bradycardia

C. an increase in systemic vascular resistance

D. head-up tilt of patient

E. increased pulmonary vascular resistance
ANSWER A

VR will fall if pressure > 15mmHg

SVR will increase over all ranges
SG52 [Apr07]

Post liver resection, the time when prothrombin time derangement is maximal is:

A. day 1-2

B. day 3-4

C. day 4-5

D. day 6-7

E. unpredictable time after surgery
ANSWER A

After major liver resection
1. Factor depletion secondary to consumption and the half life dependent decay
a. Factor II (72 hour half life)
b. Factor VII (8 hour half life)
c. Factor IX (24 hour half life)
d. Factor X (39 hour half life)
2. transient synthetic insufficiency of the remnant liver
3. Further compounded by massive transfusion : dilutional coagulopathy

As a result, prolongation of the PT is a common finding after major hepatic resection.
ANZCA Version [Jul07][mar10]

A 30-year-old man presents to the emergency department following a high speed motor vehicle accident. His blood pressure is 70/50 mmHg with a strongly positive FAST (focused abdominal sonography for trauma). His chest X-ray shows a widened mediastinum. The most appropriate method to assess the widened mediastinum in this patient is

A. aortogram

B. CT angiogram of the chest

C. repeat chest X-ray

D. intraoperative TOE (transoesophageal echocardiography)

E. transthoracic echocardiography
ANSWER D
SG51 [Apr07] [Jul07]

In regards to laparotomy and hemicolectomy, the least effective way to minimize post op surgical infection is:

A. Aggressive peri-operative fluid management

B. Timely administration of prophylactic antibiotics

C. Perioperative hyperoxia

D. Avoidance of hypothermia

E. Avoidance of blood transfusion
ANSWER A

Factors that can be optimized in the perioperative period can be divided into:

(i) Well-established interventions (supported
by good evidence)
(a) antibiotic prophylaxis,
(b) hand hygiene,
(c) aseptic technique during invasive
procedures,
(d) perioperative thermoregulation.

(ii) Less certain interventions (some supporting
evidence)
(a) face masks and theatre traffic,
(b) regional anaesthesia techniques,
(c) inspired oxygen,
(d) glycaemic control.

(iii) Speculative interventions (no supportive
evidence as yet)
(a) goal-directed fluid management,
(b) minimizing blood transfusions,
(c) enhanced recovery after surgery
(ERAS),
(d) avoidance of selected opioids.


CEACCP Preventing postoperative infection: the anaesthetist's role
SG59 [Apr07] [Aug 09] q72

Blunt liver trauma can be treated non surgically if

A. No peritoneal signs

B. Low Grade injury on CT scan

C. Severe COPD

D. Haemodynamically stable

E. US confirms <500mls peritoneal fluid collection
ANSWER D
AZ69b ANZCA version [2003-Aug] Q129, [2004-Apr] Q77, [Mar06] Q71, [Apr07] Q129, [Jul07]

During elective major vascular surgery the best way to reduce the risk of acute renal failure is
to maintain a normal

A. central venous pressure

B. mean arterial blood pressure

C. renal blood flow

D. systemic vascular resistance

E. urine output
ANSWER C
SG13 ANZCA version [1985] [1986] [1987] [Aug91] [Mar95] [2003-Aug] Q59, [2005-Sep] Q96, [Jul07]

A 46 year old brewery worker has cirrhosis of the liver with oesophageal varices and has bled from these varices on one occasion. A portacaval shunt is being considered as definitive treatment for his portal hypertension. The operation would be contraindicated if he had

A. a serum bilirubin greater than 50 micromol.litre-1

B. a serum albumin less than 30 gram.litre-1

C. ascites

D. all of the above are true

E. none of the above are true
ANSWER E

Transjugular Intrahepatic Portosystemic Shunt

INDICATIONS
Absolute
1. Multiple episodes of variceal bleeding
2. Refractory variceal hemorrhage despite adequate endoscopic treatment
3. Refractory ascites

Relative
* Bleeding portal hypertensive gastropathy
* Bleeding gastric varices
* Gastric antral vascular ectasia
* Refractory hepatic hydrothorax
* Hepatorenal syndrome
* Budd-Chiari syndrome
* Veno-occlusive disease
* Hepatopulmonary syndrome
* Protein-losing enteropathy due to portal hypertension

CONTRAINDICATIONS
Absolute
1. RHF
2. Severe Encephalopathy
3. Pulmonary hypertension
4. Biliary obstruction
5. Sepsis
6. Hepatic cysts
7. CCF

Relative
1. Haematoma
2. Coagulopathy INR >5
3. Thrombocytopenia
4. Hepatocellular carcinoma
SG60 ANZCA version [Jul07]

Pneumoperitoneum for laparoscopy is commonly associated with an INCREASE in each of the following EXCEPT

A. arterial pressure

B. inotropic state

C. secretion of vasopressin

D. systemic vascular resistance

E. venous resistance
ANSWER B
SG62 [Jul07]

Patient presents with carcinoid syndrome and developes hypotension intraoperatively. Best drug to treat it is:

A. Noradrenaline

B. Adrenaline

C. Metaraminol

D. Octreotide

E. Ephedrine
ANSWER D

The occurrence of intraoperative carcinoid crisis manifesting as bronchospasm or hypotension is treated with IV octreotide 100-200 mcg.
SG61 [Jul07]

45 y.o for elective laproscoptic choecystectomy. No recent hx cholelithiasis. Drinks 40g of alcohol per week and smokes 40/day. URTI 1/52 ago. Finishing course of augmentin. No respiratory symptoms now. LFTS done – ALP 300, GGT 300, ALT normal, AST normal, albumin normal. What is next step?

A. LFTS changes likely due to recent illness. Proceed with case

B. Defer case until liver USS done

C. Cancel case as patient has early cirrhosis

D. Perform hepatitis screen pre-operation

E. likely secondary to drugs, so just continue
ANSWER B
SG33e ANZCA version [2003-Aug] Q109, [2004-Aug] Q33, [2005-Sep] Q28, [Apr07]

The most effective method of deep venous thrombosis (DVT) prophylaxis for a fifty-year-old
woman presenting for anterior resection for cancer of the colon would be

A. electrical calf stimulation

B. Dextran 70 infusion

C. graduated compression stockings

D. intermittent pneumatic leg compression

E. low dose heparin (5000 units bd)
ANSWER E

* heparin is the most studied, and seems to reduce the DVT rate by 66%-75% - LMWH are slightly better (ACCP)

* mechanical methods reduce the DVT rate by 50%-66% (HTA)

* dextran 70 reduces DVT rate by 50%, the same as warfarin (HTA)
SG65 ANZCA version [Apr08] Q108

Prolonged Trendelenburg (head-down) positioning causes:

A. no change in intracranial pressure

B. no change in intraocular pressure

C. no change in pulmonary venous pressure

D. increased myocardial work

E. increased pulmonary compliance
ANSWER D
SG63 ANZCA version [Apr08] Q118

Each of the following statements regarding the haemodynamic changes during pneumoperitoneum
for laparoscopy is true EXCEPT:

A. in patients with severe cardiac disease changes are qualitatively similar to those in normal patients

B. right atrial pressure is NOT a reliable indicator of cardiac filling

C. they are well tolerated by morbidly obese patients

D. they are well tolerated in cardiac transplant patients with good ventricular function

E. they are well tolerated in patients with low cardiac output secondary to low preload
ANSWER E
Black Bank April 2008

SG (Q103 Aug 2008) After a difficult thyroidectomy for thyroid carcinoma, a 63 year old woman develops stridor immediately following extubation. The most likely cause is

A hypocalcaemia

B neck oedema

C recurent laryngeal nerve palsies

D tracheomalacia

E vocal cord oedema
ANSWER C

Although all possible causes for stridor post thyroidecotomy, RLN palsy is most likely.
Black Bank April 2008

SG2. Called to ward for Postoperative thyroidectomy bleeding in ward. SpO2 92% on 6L, tachycardic and ?hypertensive and neck haematoma. What is the least appropriate management:

a. call and arrange CT scan of his neck

b. call OT and arrange urgent surgery

c. release staples

d. increase oxygen supply
ANSWER A
Black Bank April 2009

Trauma patient with GCS 6 with hard collar. HR and BP unstable. What is the best way of clearing neck?
A. CT

B. Cervical spine trauma series

C. MRI

D. Leave had collar indefinitely??

E. Clinically
ANSWER D
Black Bank August 2009

22. (Repeat) Trauma with # pelvis and femur. Has a splenectomy. Day 2 patient thrombocytopenia, confused and hypoxic. Diagnosis is

a. fat embolism syndrome

b. pneumcoccal pneumonia

c. thromboembolis
ANSWER A

Incidence
Fat embolism occurs in < 10% of trauma cases, but is present in about 90% of fatal trauma cases. Fat (& marrow) embolism occurs very quickly after the injury (eg see reference below about Mt Erebus crash), but the clinical syndrome typically presents from 24-72hrs post injury


Associations
* major trauma - this is responsible for 95% of all fat embolism
o long bone fractures
o pelvic fractures
o severe soft tissue injuries including burns
* iatrogenic causes
o elective major orthopaedic procedures
o liposuction
o bone marrow harvesting and transplant
o glucocorticoids
o lipid infusion
* rarer causes
o pancreatitis
o diabetes
o osteomyelitis and panniculitis
o sickle cell crisis
o acute fatty liver

Clinical Features
* respiratory changes
o acute lung injury through to ARDS
* neurological abnormalities
o acute confusional state / delerium is very common
o focal neurological signs can occur
o seizures rarely
* haematological abnormalities
o petechial rash in about 50%
o DIC if severe

Treatment
* supportive
* corticosteroids shown to helpful for prophylaxis
o they appear unhelpful for the treatement of established fat embolism however
* aspirin may be useful
o heparin appears not to be
TMP-128 [Aug09] Indication for percutaneous closure of ASD

A. Ostium primum < 3cm

B. Ostium primum > 3cm

C. Ostium secundum < 3 cm

D. Ostium secundum > 3cm

E. Sinus venosus ASD
ANSWER C
Black Bank August 2009

23. (NEW) Indications for steroids in neurosurgery

a. Cerebral abscess

b. Subdural haematoma

c. Meningioma

d. SAH

e. Traumatic brain injury
ANSWER C
Black Bank August 2009

73.SZ10The absorption of fluid into the circulation during transurethral prostatectomy (TURP) is NOT related to

A. prostate size

B. height of the irrigation fluid bag

C. duration of surgery

D. surgical technique

E. type of irrigation fluid
ANSWER E
Black Bank August 2009

74. In patients undergoing thoracotomy, techniques which reduce the incidence of intraoperative atrial fibrillation include

A. hyperventilation

B. pre-operative loading with digoxin

C. rocuronium, rather than pancuronium

D. thoracic epidural bupivacaine

E. thoracic epidural morphine
ANSWER D
Black Bank August 2009

77. A multi-trauma patient opens his eyes and withdraws to painful stimuli, but does not respond to voice. He is moaning but makes no comprehensible sounds. His Glasgow Coma Score is

A. 5

B. 6

C. 7

D. 8

E. 9
ANSWER D
Black Bank August 2009

50. (Repeat Apr 09) Doing an awake CEA. Patient becomes confused & combative after carotid clamped and opened. Priority is...

a) tell surgeon to release clamp

b) tell surgeon to place shunt

c) induce GA

d) give midazolam
ANSWER B
SZ11 ANZCA version [2003-Aug] Q111, [Mar06] Q94, [Jul06] Q57, [Jul07], [Apr08] [Aug09] Aug10

Lowering intra-ocular pressure by applying pressure to the globe (e.g. Honan balloon) is typically contraindicated in a patient having

A. a revision corneal graft

B. a revision trabeculectomy

C. an extra-capsular lens extraction

D. a redo vitrectomy

E. repeat retinal cryotherapy
ANSWER B
Black Bank August 2009

89. The intraoperative hypothermia for aneurysm surgery trial (IHAST) showed that cooling to a target temperature of 33°C

A. did NOT improve neurological outcome in WFNS (World Federation of Neurosurgical Surgeons) in grade I-III patients

B. did NOT improve neurological outcome in WFNS grade IV-V patients

C. improved neurological outcome in WFNS grade I-III

D. improved neurological outcome in WFNS grade III

E. improved neurological outcome in WFNS grade IV-V
ANSWER A
Black Bank August 2009

52. (Repeat) Patient with IV in right arm, has mediastinal mass and SVC compression undergoing mediastinal biopsy, suddenly uncontrolled surgical bleeding in mediastinum. Next step in management prior to thoractomy:

A. insert femoral cannulae and place on bypass

B. insert IV in left arm

C. insert IV into foot

D. insert jugular CVC

E. trendelenburg
ANSWER C
Black Bank August 2009

51. (Repeat) You intubate a young male patient for a left thoracotomy with a 39FG Robert Shaw tube. When you inflate both cuffs and ventilate the bronchial lumen you get left sided ventilation. When you attempt to ventilate the tracheal lumen the pressures are very high and you get no air entry. Yet when you deflate both cuffs you can ventilate the patient through the tracheal lumen. The most appropriate step to take next is:

A. Change to a 41FG tube

B. Change to a 37FG tube

C. Deflate both cuffs and insert further cm and recheck

D. Deflate both cuffs and withdraw a few cm and recheck

E. Pull ETT out and start again.
ANSWER C
TMP-116 [Mar10]

Post thyroidectomy patient, patient in PACU for 30 minutes. Develops respiratory distress.
MOST likely cause?

A. Hypercalcemia from taking parathyroids

B. Bilateral laryngeal nerve palsies

C. Bleeding and haematoma

D. Tracheomalacia

E. ?
ANSWER C
TMP-118 [Mar10] [Aug10]

What is the area burnt in man if Half of left upper arm, all of left leg and anterior abdomen (repeat Q)

A. 27%

B. 32%

C. 42%

D. ?

E. ?
ANSWER A

Based on the 'rule of nines', the estimated burn surface area would be as follows:

- half of upper arm = approx 2%
- all of left leg = 18%
- anterior abdomen = approx 9% depending on what proportion is burnt; whole thorax/abdomen on either anterior or posterior is 18% - i.e. 36% for front and back

-> TOTAL = 29%
[Jul07]

To improve oxygenation in a patient intubated and ventilated for a laparotomy you adjust the ventilator settings to apply 10 cm H2O of PEEP (positive end-expiratory pressure).

The patient's blood pressure falls from 130/80 to 90/50 mmHg. The addition of PEEP may result in a fall in blood pressure because PEEP causes

A. decreased myocardial contractility

B. decreased venous return

C. increased left ventricular afterload

D. increased left ventricular compliance

E. increased right ventricular afterload
ANSWER B
SG56 ANZCA version [2005-Sep] Q106, [April 06] Q81

During surgery there is increased secretion of each of the following hormones EXCEPT

A. aldosterone

B. glucagon

C. growth hormone

D. thyroid stimulating hormone

E. vasopressin
ANSWER E
SG47 ANZCA version [2003-Aug] Q149, [2004-Apr] Q90, [2005-Apr] Q93

A 20kg child suffered 15% full thickness burns 6 hours ago. Optimum crystalloid resuscitation
for the first hour is

A. 160ml

B. 260ml

C. 360ml

D. 460ml

E. 660ml
ANSWER C
SG46 ANZCA version [2002-Mar] Q75, [2002-Aug] Q77, [2003-Aug] Q89, [2004-Apr] Q76, [2005-Sep] Q87

The most correct statement regarding a 70 kg male who has sustained third degree burns to all of
his right arm and second degree burns to the anterior aspect of his trunk is that

A. he has burns to 21% of his body

B. he will require 2 to 4 ml of Hartmann’s solution per kilogram per percent burn in the first 8 hours after admission

C. a normal blood gas and chest X-ray on admission will be useful in excluding inhalational injury

D. prophylactic antibiotics and steroids are of proven benefit if he has suffered an inhalational injury

E. alkalinizing the urine will prevent renal damage if the burns were electrical
ANSWER A
SG44 [Apr98] [Jul98] (type A)

Which ONE of the following do you NOT expect to see in a fit young ASA 1 patient when the abdomen is inflated with CO2?

A. Atelectasis

B. Increase airway pressure

C. VQ mismatch

D. ?

E. Hypoxia
ANSWER E
SG43 ANZCA version [Jul97] [Apr98] [Jul98] [Apr99] [Aug99] [2001-Aug] Q33, [2002-Mar] Q37, [2003-Apr] Q7, [2004-Aug] Q37, [2005-Apr] Q12

Bowel preparation for colonoscopy


A. may cause hypophosphaturia, hypercalcaemia and dehydration

B. can be avoided in high risk patients

C. no longer causes significant fluid loss with modern formulations

D. may cause Trousseau’s sign to be positive

E. may result in arrhythmias and a shortened QT interval
ANSWER D

A. may cause hypophosphaturia, hypercalcaemia and dehydration

* False - hyperphosphataemia and uria due to high absorption and secondary hypocalcaemia. Dehydration yes, of course.

B. can be avoided in high risk patients

* False - unfortunately not because then you can't see. No prep = no colonoscopy (according to my wife, a gen surg reg).

C. no longer causes significant fluid loss with modern formulations

* False - much less with polyethylene glycol granted but 'Fleet' is still being used a lot.

D. may cause Trousseau’s sign to be positive

* True - classic sign of hypocalcaemia, the physiologic derangement which tends to predominate (see Tan's article below)

E. may result in arrhythmias and a shortened QT interval

* False - very unlikely; the hypocalcaemia causes a long QT.
SG41 [Apr96] [Jul98] [Apr99] (type K)

Child with 70% burns:

1. Myoglobinuria & haemoglobinuria

2. Anaemia, thrombocytopaenia & coagulopathy

3. Anaemia, thrombocytosis & hypercoagulable

4. Infrequently see hypertension late in the hospital stay
ANSWER 1
SG40 [Aug94] [Jul00]

Bowel obstruction:

A. Need to place NGT, suction & IV fluids first no matter what

B. Antibiotics if bowel ischaemia is suspected

C. Small bowel resection is easier than large bowel obstruction

D. Colloid only required if ischaemic bowel is present
ANSWER A, B, C
SG31 [1988]

Which of the following is the best guide to fluid replacement in a burns patient?

A. Haemoglobin and haematocrit

B. Urine output

C. Urine osmolality

D. Plasma volume

E. Specific gravity
ANSWER B
SG30 ANZCA version [1985] [1987] [Mar93] [Aug96] [Apr97] [Jul00] [2001-Apr] Q16


A patient has suffered flash burns of the upper half of the left upper limb,
all of the left lower limb and the anterior surface of the abdomen. The approximate percentage of the body surface which has been burned is:

A. 18%

B. 23%

C. 32%

D. 41%

E. 48%
ANSWER C
SG29

Which of the following is most likely to be the first sign of hypoparathyroidism following total thyroidectomy?

A. Carpopedal spasm

B. Positive Chvostek's sign

C. Circumoral tingling

D. ?Tachycardia ?Tetany

E. All of the above
ANSWER C
SG28 [Mar93]

The earliest indication of hypocalcaemia following thyroidectomy is usually:

A. Tingling of face, nose & hands

B. Positive Chvostek's sign

C. Carpopedal spasm

D. Hyperthermia

E. Tachycardia
ANSWER A
SG26

A patient had an abdomino-perineal resection for carcinoma of the rectum. The postoperative course was uneventful for 5 days. On the 6th day, the abdomen became distended, the patient began vomiting and bowel function ceased. On examination, the patient's temperature was 36C, the BP 90/50 with tachycardia. He was in pain. Diagnosis is:

A. Secondary haemorrhage

B. Septicaemia

C. Large bowel obstruction

D. Small bowel obstruction

E. Any of the above
ANSWER B,C,D
SG18

Complications of pancreatitis include:

A. Pseudocyst

B. Retroperitoneal haematoma

C. Tetany

D. Abscess formation
ALL TRUE

* Acute respiratory distress syndrome (ARDS), acute renal failure, cardiac depression, hemorrhage, and hypotensive shock all may be systemic manifestations of acute pancreatitis in its most severe form.
* Fat necrosis may cause hypocalcemia.

Clinical
History
* The main presentation of acute pancreatitis is epigastric pain or right upper quadrant pain radiating to the back
* Nausea and/or vomiting
* Fever
* Query the patient about recent surgeries and invasive procedures (ie, endoscopic retrograde cholangiopancreatography) or family history of hypertriglyceridemia.
* Patients frequently have a history of previous biliary colic and binge alcohol consumption, the major causes of acute pancreatitis.

Physical
* Tachycardia
* Tachypnea
* Hypotension
* Fever
* Abdominal tenderness, distension, guarding, and rigidity
* Mild jaundice
* Diminished or absent bowel sounds
* Because of contiguous spread of inflammation (effusion) from the pancreas, lung auscultation may reveal basilar rales, especially in the left lung.
* Occasionally, in the extremities, muscular spasm may be noted secondary to hypocalcemia.
* Severe cases may have a Grey Turner sign (ie, bluish discoloration of the flanks) and Cullen sign (ie, bluish discoloration of the periumbilical area) caused by the retroperitoneal leak of blood from the pancreas in hemorrhagic pancreatitis.

Main causes of ascites
* Hepatic - cirrhosis, veno-occlusive disease
* Cardiac - right ventricular failure, constrictive pericarditis
* Renal - nephrotic syndrome, renal failure
* Malignancy - ovarian, gastric, colorectal carcinoma
* Infection - tuberculosis
* Pancreatitis
* Lymphatic - congenital anomaly, trauma
* Malnutrition
* Myxoedema
SG19 [1988] [Aug96]

Acute pancreatitis associated with all EXCEPT:

A. ARDS

B. Pleural effusions

C. Ascites

D. Hypocalcaemia

E. Hepatocellular failure
ANSWER E

* Acute respiratory distress syndrome (ARDS), acute renal failure, cardiac depression, hemorrhage, and hypotensive shock all may be systemic manifestations of acute pancreatitis in its most severe form.
* Fat necrosis may cause hypocalcemia.

[edit]
Clinical
[edit]
History

* The main presentation of acute pancreatitis is epigastric pain or right upper quadrant pain radiating to the back
* Nausea and/or vomiting
* Fever
* Query the patient about recent surgeries and invasive procedures (ie, endoscopic retrograde cholangiopancreatography) or family history of hypertriglyceridemia.
* Patients frequently have a history of previous biliary colic and binge alcohol consumption, the major causes of acute pancreatitis.

[edit]
Physical

* Tachycardia
* Tachypnea
* Hypotension
* Fever
* Abdominal tenderness, distension, guarding, and rigidity
* Mild jaundice
* Diminished or absent bowel sounds
* Because of contiguous spread of inflammation (effusion) from the pancreas, lung auscultation may reveal basilar rales, especially in the left lung.
* Occasionally, in the extremities, muscular spasm may be noted secondary to hypocalcemia.
* Severe cases may have a Grey Turner sign (ie, bluish discoloration of the flanks) and Cullen sign (ie, bluish discoloration of the periumbilical area) caused by the retroperitoneal leak of blood from the pancreas in hemorrhagic pancreatitis.

[edit]
Main causes of ascites

* Hepatic - cirrhosis, veno-occlusive disease
* Cardiac - right ventricular failure, constrictive pericarditis
* Renal - nephrotic syndrome, renal failure
* Malignancy - ovarian, gastric, colorectal carcinoma
* Infection - tuberculosis
* Pancreatitis
* Lymphatic - congenital anomaly, trauma
* Malnutrition
* Myxoedema
SG20 [1988]

A 40 year old man, 18 hours after a gastrectomy, suddenly becomes hypotensive with a blood pressure of 80/60, tachycardia of 110/min, CVP +2 cmsH2O and a temperature of 39C. The likely diagnosis is:

A. Ruptured anastomosis

B. Haemorrhage

C. Acute gastric dilatation

D. Pulmonary embolism

E. Septicaemia
ANSWER A
SG21a [Aug96]

A 55 year old man suddenly develops left sided chest pain 18 hours after an inguinal hernia repair. He has a nonproductive cough, dyspnoea, a fever of 38C, pulse rate of 110/min and tachypnoea. The ECG shows non-specific ST changes.

Provisional diagnosis:

A. Atelectasis

B. Pneumothorax

C. Pulmonary embolism

D. Myocardial infarction

E. Bronchopneumonia
ANSWER C
SG22 [1987] [1988] [Mar91] [Aug94]

A 65 year old man one week after an appendectomy suddenly experiences
left sided (?pleuritic) chest pain with dyspnoea. The previous night
he had been restless with a temperature of 37.2C. ECG was normal. No leg signs. Immediate therapy would be:

A. Intranasal oxygen and serial chest xrays

B. Heparinisation

C. Antibiotics

D. Observe closely for further signs

E. Chest physiotherapy
ANSWER D
SG17 [1986] [1989] [Aug91]

With pancreatic carcinoma:

A. Can get jaundice without pain

B. May present with thrombophlebitis migrans

C. A barium meal may be negative even if carcinoma is advanced

D. Hepatic enlargement only if secondaries are present
ANSWER 1 (2, 3)

The early clinical diagnosis of pancreatic cancer is fraught with difficulty. Unfortunately, the initial symptoms are often quite nonspecific and subtle in onset.

* Patients typically report the gradual onset of nonspecific symptoms such as anorexia, malaise, nausea, fatigue, and midepigastric or back pain.
* Significant weight loss is a characteristic feature of pancreatic cancer.
* These initial symptoms can be easily attributed to other processes unless a physician has a high index of suspicion for the possibility of underlying pancreatic carcinoma. Delayed diagnosis is a common problem in patients with pancreatic cancer, with fewer than a third of patients being diagnosed within 2 months of the onset of their symptoms.
* Pain is the most common presenting symptom in patients with pancreatic cancer. Typically, it is midepigastric in location, with radiation of the pain sometimes occurring to the mid- or lower-back region. Back radiation of the pain is a worrisome sign indicating retroperitoneal invasion of the splanchnic nerve plexus by the tumor.
* Weight loss may be related to anorexia and/or subclinical malabsorption from pancreatic exocrine insufficiency caused by pancreatic duct obstruction by the cancer.
* The onset of diabetes mellitus within the previous year is sometimes associated with pancreatic carcinoma. However, only about 1% of cases of new-onset diabetes mellitus in adults are actually related to occult pancreatic cancer.
* The most characteristic sign of pancreatic carcinoma of the head of the pancreas is painless obstructive jaundice.
o Patients with this sign may come to medical attention before their tumor grows large enough to cause abdominal pain.
o These patients usually notice a darkening of their urine and lightening of their stools before they or their families notice the change in skin pigmentation. Physicians can usually recognize clinical jaundice when the total bilirubin reaches 2.5-3 mg%. Patients and their families do not usually notice clinical jaundice until the total bilirubin reaches 6-8 mg%. Urine darkening, stool changes, and pruritus are often noticed by patients before clinical jaundice.
o Pruritus may accompany obstructive jaundice.
* Depression is reported to be more common in patients with pancreatic cancer than in patients with other abdominal tumors. In some patients, depression may be the most prominent presenting symptom. This may be, in part, secondary to the high frequency of delayed diagnosis with this disease.
* Migratory thrombophlebitis (ie, Trousseau sign) and venous thrombosis also occur with higher frequency in patients with pancreatic cancer. (10% of cases)
SG16 [Apr98] [Jul98] [Mar00] (type A)

Initial metastatic deposits in the liver are best indicated by:

A. Increased bilirubin

B. Decreased serum albumin

C. Increased alkaline phosphatase

D. Increased gamma globulins

E. Increased AST (?ALT)

F. Increased INR
ANSWER C
SG15

Useful tests in assessing secondary metastases to the liver:

A. Serum bilirubin

B. Serum alkaline phosphatase

C. BSP excretion

D. Cephalin flocculation tests
ANSWER B
SG12 ANZCA version [2001-Apr] Q12, [2002-Aug] Q4

In patients with portal hypertension undergoing surgery, laboratory results associated with an increase in postoperative mortality include

A. an elevated aPTT (activated partial thromboplastin time)

B. a total bilirubin over 25 micromol.l-1 (normal range 3 - 17)

C. a serum albumin less than 30 g.l-1 (normal range 35 - 50)

D. an ALT (alanine transaminase) of 80 (normal range < 55)

E. a serum albumin greater than 55 g.l-1 (normal range 35 - 50)
ANSWER B

* A. an elevated aPTT (activated partial thromboplastin time)

* B. a total bilirubin over 25 micromol.l-1 (normal range 3 - 17) - false: Child Pugh scoring only rates BR>34. <34 does not increase a Child Pugh score. (See Harrison's table 295-4)

* C. a serum albumin less than 30 g.l-1 (normal range 35 - 50) - true: This patient will have a Child Pugh score of >7.

* D. an ALT (alanine transaminase) of 80 (normal range < 55)

* E. a serum albumin greater than 55 g.l-1 (normal range 35 - 50)