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25 Cards in this Set
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48 year old woman develops constipation postoperatively and self-medicates with mild of magnesia. She presents to clinic at which time her serum electrolyte : Elevated Mg Which of the following represents the earliest clinical indication of Hypermagnesmia |
Ans) Loss of Deep Tendone Reflexessevere hypermg is rare, except in Renal failureHypermg is produced intentionally by Obsttricians as mx of pre-eclampsia until the loss of deep reflexes is reached. B, C, happen. in Sever hyper Mg D, may occur b/c of direct arteriolar relaxing effect of mg E, happen is LATE stages |
A) loss of deep tendon reflexes B) Flacid paralysis C) Respiratory Arrest D) Hypotensiton E) Stupor |
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5 days after an uneventful cholecystectomy , an asymptomatic middle aged woman is found to have serum Na of 125mEq/L. Most appropriate Mx for this pt? |
Ans) Restriction of Waterdx: hypo Na ( norm 135-145 )this is the initial and Definitive mx. A; in case of 120 or less Na = sx: headache seizures, coma, ICP. Rapid correction avoided as to not cause ' Myelinolysis' PS: find the underlying cause, and treat that. |
A) Administer hypertonic saline solution B) Restriction of free water C) Plasma ultrafiltration D) Hemodialysis E) Aggressive diuresis with furosemide |
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50 y pt presents with symptomatic nephrolithiasis. Reports that he underwent jejunoileal bypass for mobbed obesity when he was 39 Which is a complication of jejunoileal bypass? |
ans) D) Hyperoxaluria normally , fatty acids absorbed by terminal ileum, & Ca + oxalate combine as to NOT get absorbed. if no ileum, FA reach Colon, FA + Ca leaving free Oxalate that gets absorbed ( unabsorbed FA and Bile acid in colon promote oxalate uptake. ) which goes to kidney => Ca Oxalate stone formation C; is raped remineralization of bones =>hypoCa in hyperparathy A; hyperCa assx with parathyroid related peptide. E; is a benign lesion found in children |
A) Psueodhyperarathyroidism B) Hyperuric aciduria C) Hungry bone syndome D) Hyperoxaluria E) Sporadic unicameral Bone cyst |
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following surgery a pt develops oliguria. you believe its due to hypovolemia, but you seek corroborative data before increasing IV fluids Which values supports the diagnosis of hypovolemia ? |
ans) C) Fractional Excertion of Na less than 1 ( FENa) calculated as (urine Na x serum Cr) / (serum Na x Urinary Cr) x 100 if less than 1% suggest pre renal etiology for oliguria. oliguria post-op: PS: différentiante b/n low output caused by physiologic response to IV hypovolemia & caused by acute tubular Necrosis |
A) Urine Na of 28 mEa/L B) Urine Cl of 15mEa/L C)Fractional Excertion of Na less than 1 D) Urine/serum Cr ratio of 20 E) Urine osmolality of 350 most/Kg |
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45y woman with Crohn disease and a small int fistula develops tetany during second week of parenteral nutrition. Lab: Na: 135 mEz/L. Ca:8.2 K: 3.2 Mg: 1.2 Cl:103 PO4: 2.4 HCO3: 25 Albumin: 2.4 an arterial blood gas sample reveals pH: 7.42, PCO2: 38 mmHg, PO2: 38 mmhm , PO2: 84 , cause of tetany? |
ans) C) HypoMagnesium common in pt with GI fluid losses ECG diffrentiate b/n : HypoCa ( Prolonged QT intervak, T wave inversion, heart blocks ) & HypoMg (prolonged QT & PR intervals, ST depression, flattening / inversion of P , torsade de pointer ) A; norm pH, PCO2 ( no Hyperventilation) B; Ca mar when adjusted for low albumin ( + 0.8 mg/dL per 1 g/dL decrease in Albumin ) HypoMg => functional hypoparathyroidism => hypoCa |
A) hyperventilation B) HypoCa C) Hypomg D) Essential fatty acid deficiency E) Focal Seizure |
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a Pt with non obstruction carcinoma of the sigmoid colon is being prepared for elective resection. what will reduces the risk of postoperative infectious complication |
ans) A) Single PRE-op dose of Parenteral Ab effective against both. no greater than 1 hr prior to incision. There is no evidence to prove (B,C,D) is useful, instead should be avioded to prevent drug resistance E, may be appropriate during the procedure based on drug Half-life PS: broad spectrum coverage is required ONLY where such flora are expected ( Colon Resections) |
A) single preoperative parenteral dose of Ab effective against aerobes and anaerobes B)Avoidance of oral Ab to prevent emergence of Clostridium difficult C)Postop administer 48 hr of parenteral Ab effective against Aerobes & anaerobes D) Postop admin of parenteral Ab effective against both until pt IV lines and all other drains are removed E) Redosing of Ab in operating room if case lasts for more than 2 hr |
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75 y man with hx of MI 2 years ago, peripheral vascular disease with Sx of claudication after walking half a block, HTN, DM presents with large ventral hernia. wishes it repaired Next Pre-Op workup? |
D) Persantine Thallium stress test + Echocardio to assess his need for coronary angiogram with possible need for angioplasty, stunting , or surgical revascularizatio prior to hernia op B; no , due to his limited functional status y peripheral vascular disease. thus Pharma test better E; it increases pt risk (w/I 6 months) but is not prohibitive |
A) ECG B) Exercise stress test C) Coronary artery bypass prior to hernia op D) Persantine thallium stress test and Ehocarido E) hx of MI w/I 3 years prohibit Surgery. |
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previously healthy 55 y man undergo elective right hemicolectromy for stage 1 cancer of cancer ( T2N0M0 ) his Post-Op ileus is somewhat prolonged and on 5th day post-op his nasogastric tube is in place. Ex: diminished skin turgor, dry mucous membranes, orthostatic hypotension . Lab: ABG: ph 7.56, PCO2: 50, PO2: 85, Serum Electryolyte: Na: 132 , K 3.1, Cl: 80, HCO3: 42 Urine Electrolytes: Na 2 , K 5 , Cl 6 acid base abnormality? |
D) Metabolic alkalosis + Respiratory compensation 2ry to gastic Lises of HCL. elevated arterial PH and PCO2 with no lung sx. |
A) uncompnsated metabolic alkalosis B) Respiratory acidosis with metabolic Compensation C) Combined metabolic & Resp alkalosis D) Metabolic alkalis with Respiratory Compensation E) Mixed alkalosis |
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52 y man with gastric outlet obstruction 2ry to duodenal ulcer presents with hypoChloremic, hypoKalemic metabolic alkalosis Mx? |
A)Infusion of 0.9% NaCl w/ supplement KCL until clinal signs of volume depletion are eliminated it will correct his Hypovolemia and metabolic alkalosis B; unnecessary D; can be utilized to increase renal excretion of bicarbonate but should be avoided in volume depleted individuals , it will increase Na, and worsen the volume depletion |
A) Infusion of 0.9% NaCL with Supplement KCL until clinical signs of volume depletion are eliminated B) Infusion of isotonic (0.15 N) HCL via a central venous catheter C) Clamping the nasogastric tube to prevent. further acid loss D)Admin of acetazolamide to promote renal exception of bicarbonate e) intubation and controlled hypoventilation on a volume cycled ventilation to further increase PCO2 |
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23 y woman A&E where she apparently swallowed a handful of pills. SOB, tinnitus, refused to identify the pills. LAB: ABG: pH 7.45, PCO2: 12, PO2: 126 S Electro: NA: 138, K:4.8, Cl:102, HCO3: 8 overdose of which drug? |
B) Aspirin HNT: Tinnitus + Mixed metabolic acidosis & Resp Alkalosis |
A) Phenformin B) Aspirin C) Barbiturates D) Methanol E) Diazepam (Valium) |
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18 y previously healthy placed on IV heparin after PE after exploratory lapratomy for small bowel injury following a motor vehicle collision 5 days later his platelet : 90,000/uL and cont to decline pt blood +ve for Ab to heparin-platelet factor complexes next mx step? |
ans) D) Stop heparin and start lepirudin dx: heparin induced thrombocytopenia ( HIT ) Mx: stop heparin ( and LMW ) and start non heparin anticoagulant such as a direct thrombin inhibitor (e.g. Lepirudin ) and conversation to oral Warfarn when appropriate ( not started until platelet count is above 100,000 |
A) Stop all anticoagulation therapy B) Stop heparin and immediate institution of high dose warfarin therapy C)Stop heparin and insitiion of low molecular weight heparin D)Stop heparin and institution of lepirudin E)stop heparin and transfusion with platelet |
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65 y man undergoes technically difficult abdominal perineal resection for RECTAL CANCER he received 3 packs of RBC 4 hrs later , in ICU, he is bleeding heavily from his perineal wound Normal prothrombin time, Partial thromboplastin, and Bleeding times. Fibrin degradation NOT elevated Serum fibrinogen is Depressed Platelet 70,000/ uL Likely cause of Bleeding? |
C) Bleeding vessel in Surgical field Heamtological disorders not apparent during the long operation are most Unlikely to occur Post operative Factor VIII will cause bleeding during the operation ( and prolonged PTT) E; will not be able to form clots effectively but such is not seen |
A) Delayed blood transfusion reaction B) Autoimmune fibrinolysis C) a bleeding blood vessel in surgical field D) Factory VIII (8) deficiency E) Hypothermic coagulation |
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78 y man with hx of coronary artery Disease and an Asymptomatic reducible hernia asks for its repair which would be a valid reason to delay the surgery? |
C) Jugular Venous distention ??? |
A) Coronary Artery Bypass Surgery within 3 months B) hx of cigarette smoking C) jugular venous dissension D) HTN E) Hyperlipidemia |
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68 y man admitted to coronary care unit with an acute myocardial infarction Postinfarction couse is marked by congestive heart failure and Hypotention. on 4th day in hospital , he develops severe mid abdominal pain. On physical examination, blood pressure is 90/60 mmhm and pulse is 110 /m and regular Abdomen is soft with mild generalized tenderness and dissension Bowel sound are hypoactive; stool Hematest is positive not step in mx? |
C) Angiography diagnostic test for Dx: acute mesenteric ischemia HINT: either: systemic manifestation of arteriosclerotic vascular disease OR: low cardiac- output state assx with sudden Abdominal pain that is out of proportion to examination findings. THIS IS AN EMERGENCY. |
A) Barium enema B) Upper gastrointestinal series C) angiography D) Ultrasonogrophy E) Celiotomy |
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30 year old woman in her last trimester of pregnancy suddenly develops massive swelling of left lower extremity most appropriate workup and Mx? |
B) Duplex Ultrasound and heparin diagnostic for DVT ( venography gold standard but impractical with dye allergy and local thrombosis ) Heparin the anticoagulation treatment in pregnant women Vena caval filter no need due to no C/I of heparin |
A) Venography & heparin B)Duplex U/s & Heparin C)Duplex U/S & Heparin & Vena caval filter D)Duplex U/S & Heparin, Warfarin E) Impedance Plethysmography & Warfarin |
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20 y woman with family hx of Von Willbrand disease found to have an aPTT of 78 ( norm =38) on routine test prior to Cholecystectomy. PT of 13 ( norm 12), platelet 350,000 & abnormal bleeding time what do you give PRE-OP? |
E) Desmopressin ( DDVAP) lab due to VonWillebrand disease. vWF is imp for platelet aggregation at site of injury. and a circulating protien of VIII E: is a synthetic analogue of vasopressin => activate receptors that result in release of vWF A; ineffective, C;Mx of warfarin toxicity, D; inhibits fibrinolysis not indicated for vWD |
A) Factor VIII (8) B) Platelet C) Vit K D) Aminocaproic acid E) Desmopressin ( DDAVP ) |
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65 y man undergoes low ant resection for rectal cancer on 5th day Exam: temp 39C, BP 150/90, PR: 110, RR: 28 CT: abdomen : abscess in pelves Current condition diagnosis |
B) Sepsis A; involves 2 or more of following: Temp > 38 ore <36, PR: >90, RR>20 /paCO<32, WBC>12,000or<4000 or>10% immature neutrophils B;Sepsis = SIRS + Document infection (e.g. in this pt CT finding) C;= Sepsis + organ dysfunction or hypooerfusion ( lactic acidosis, oliguria, or altered mental status) D;= Severe Sepsis + Hypotention (systemic BP: <90 or>90 + vasopressors ) |
A) Systemic inflammatory response syndrome (SIRS) B) Sepsis C) Severe Sepsis D) Septic Shock E) Severe Septic Shock |
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blunt abd trauma has splenic and liver lacerations + unstable pelvic fracture Hypotensive and tachycardia : 150 bpm receiving 2 l of crystalloid en route to the hospital he was intubated prior to arrival due to declining mental status now taken to explarotory laparotomy and external fixation of pelvic fracture, Next best resuscitative strategy |
D) infusion of packed RBC and Early administration of fresh frozen plasma + platelet prior to return of lab value pt in class IV hemorrhagic shock (= loss of > 40% blood) , he needs Massive transfusion (= more than 10 units w/I 24 hr ) when large banked blood are transfused pt develop thrombocytopenia and Factor V & VIII deficiency; Early admin of fresh frozen plasma (FFP) + platelet proved to decrease mortality A; AVOIDed B; No role in damage control C; too late E; will take days to replace the clotting factors , too TOO late |
A)Infusion of another liter of crystalloid B)infusion f500 ml of 5%albumin C) infusiton of packed RBC followed by fresh frozen plasma and platelet as indicated by PT, & lab results D) infusion of packed RBC and Early administration of fresh frozen plasma + platelet prior to return of lab value E)Infusion of RBC and Vit K |
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62 y woman undergoes a pancreaticoduodenectomy for pancreatic head cancer Jejunostomy is placed to facilitate nutritional repletion as she is expected to have prolonged recover Best method for delivering Post-Op nutrition? |
B) Enteral feeding via Jejunostomy tube w/I 24 hr post op early feeding recommended in pt expected to have prolonged recovery. Stomach takes 24 hr after surgery to recover Small bowel take few hrs and able to accept nutrition via tubes Colon generally inactive 3-4 days |
A) institution of enteral feeding via the jejuostomy tube after return of bowel function as evidenced by passage of flatus or bowel movement B) Institiruito on enteral feeding via the jejunostomy tube w/I 24 hr post- op C) Institution of supplemental enteral feeding via jejunostomy tube ONLY if oral intake is inadequate after return of bowel function
D) Institution of a combo of immediate tropic (15mL/h) enteral feeds via the jejunostomy tube and parenteral nutrition to provide total nutritional support
E) complete nutrional support with Total parenteral nutrition |
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65 y woman life threatening PE ( pulmonary Embolus ) 5 days after removal of uterine malignancy She is immediately heparinized and maintained in good therapeutic range for next 3 days, then pass gross blood from vagina and develop: tachycardia, hypotension , oliguria following resuscitation an abdominal CT reveals major Retroperitoneal hematoma best next step in mx? |
A) Immediately reverse heparin by a calculated dose of protamine and place Vena - caval filter ( Greenfield filter ) Vena caval filter criteria: 1) failure / complication of anticoagulation. 2) known free floating venous clot 3) Prior hx of PE |
A) Immediately reverse heparin by a calculated dose of protamine and place Vena - caval filter ( Greenfield filter ) B)Reverse heparin w/ Protamine, explore and evacuate hematoma, ligate vena cava below the renal viens C) Switch to low-dose heparin D) stop heparin & observe E) Stop heparin, give FFP , begin warfarin |
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71 y man develops dysphagia of both solids and liquid and wt loss of 60 lb over past 6 months. Endoscopy: distal esophageal lesion Biopsy : Squamous Cell Carcinoma scheduled: Neoadjuvant chemoradiation followed by oephagectomy PRE-OP: started on total parenteral nutrition, given his severe malnutrition reflected by albumin <1 which will be a concern initially in starting total parenteral nutrition in this pt? |
D) Hypophosphatemia it is a complication of referring syndrome occurs in malnourished pt who are administered with IV glucose during periods of starvation eletrolyte are shifted to extracellular space to maintain , with referring insulin levels rise and electrolyte shift back in =resulting in Hypo K, Hypo Mg, Hypo Ph ???????? |
A) Hyper K B) Hyper Mg C) Hypo Glycemia D) Hypo Ph E) Hypo Cl |
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elderly dm woman + chronic steroid dependent bronchospasm , has ileocolectomy for perforated caecum taken to ICU, intubated and maintained on broad spectrum ab + renal dose dopamine + rapid steroid taper Post-op day 2: fever 39.2, hypotension, lethargy, Lab: hypoglycemia + Hyper K. likely explanation? |
C) Adrenal insufficiency HINT: abruptcessationor too rapid tapering of Chronic glucocorticoid therapy Diff b/n C & A, A ) needs HYPERglycemia MX for adrenal crises is IV steroids, volume resuscitation, other supportive measure ( dexamethasone used over hydrocortisone due to the seconds interference with ACTH measurement results ) can then be oral after the crises |
A) Sepsis b) Hypovolemia c) Adrenal insufficiency d) Acute tubular necrosis e) Diabetic ketoacidosis |
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cirrhotic pt w/ Abdominal coagualtion studies due to hepatic synthetic dysfunction requires urgent Cholecystectmy Transfusion of FFP planed to minimize risk of bleeding in surgery. Optimal timing for transfusion |
C) on call to surgery depends on half-life of factor, factor needed here is VII ( half-life 4-6 hr) would cover time till incision , during , and immediate post-op |
A) day before b) night before c) on call D) intra-op E) in recovery |
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Post op day 5: otherwise healthy 55 y man recovering from partial hepatectomy need fever 38.6 which is common nosocomial infection Post-op |
C) UTI mx: removal of indwelling of catheter |
A) wound infection B) Pneumonia C) UTI D) Intra-abdomenal abscess E ) IV catheter related in |
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10 d after exploratory laparotomy and lysis of adhesion, a pt who previously had low ant resection rectal cancer followed by chemoradiation, noted to have succus draining from wound adequate source control, she afebrile , w/ normal WBC. Output of fistula is owed to have 150 cc per day what factor proven closure of entercutaneous fistula? |
a) Previous radiation E; high output fistula ( > 500 cc /day ) is unlikely to close |
A) previous radiation B) prev Chemo c) recent surgery D) hx of malignancy E) more than 100 cc output / day |
