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50 Cards in this Set
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DIRECTIONS (Questions 94 through 100): Each set of matching questions in this section consists of a list of lettered options followed by several num- bered items. For each numbered item, select the appropriate lettered option(s). Each lettered option may be selected once, more than once, or not at all.Questions 94 through 96
(A) Copper deficiency (B) Chromium deficiency (C) Zinc deficiency (D) Manganese deficiency (E) Vitamin A deficiency (F) Vitamin D deficiency (G) Vitamin E deficiency (H) Vitamin K deficiency (I) Vitamin C deficiency A48-year-old man with severe liver cirrhosis is admitted to the hospital with hematemesis. What coagulation factors are not synthesized in the liver? SELECT TWO. |
(D, H)
All the coagulation factors except throm- boplastin, calcium, and factor VIII are synthe- sized in the liver. Factors II, VII, IX, and X are vitamin K dependent. |
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DIRECTIONS (Questions 94 through 100): Each set of matching questions in this section consists of a list of lettered options followed by several num- bered items. For each numbered item, select the appropriate lettered option(s). Each lettered option may be selected once, more than once, or not at all.Questions 94 through 96(A) Copper deficiency(B) Chromium deficiency(C) Zinc deficiency(D) Manganese deficiency(E) Vitamin A deficiency(F) Vitamin D deficiency(G) Vitamin E deficiency(H) Vitamin K deficiency(I) Vitamin C deficiency What is the coagulation factor involved exclu- sively in the extrinsic coagulation system? SELECT ONE.
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(C)
There are two coagulation pathways— extrinsic and intrinsic. In the extrinsic system, tissue thromboplastin (a lipoprotein) interacts with factor VII. The intrinsic pathway requires factors XII, XI, IX, and VIII. Factor XII is the ini- tial step in the coagulation cascade. Factor XII, activated by contact with a nonendothelial sub- stance, will activate factor XI (plasma throm- boplastin antecedent). However, factor XI can be activated even when factor XII is deficient. Calcium is required for nearly all of the enzyme reactions in both the intrinsic and extrinsic sys- tems. The amount of ionized calcium required for these reactions is extremely small, and clin- ical hypocalcemia itself is not a cause of abnor- mal bleeding. Fibrin split products are not part of the normal pathway in either the intrinsic or extrinsic system. The excessive breakdown of fibrinogen results in measurable amounts of the breakdown products of fibrinogen in the blood. Their presence may signal DIC if the PT and platelet count are deranged. In pure fibri- nolysis, fibrinogen breakdown product levels also may be increased. |
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DIRECTIONS (Questions 94 through 100): Each set of matching questions in this section consists of a list of lettered options followed by several num- bered items. For each numbered item, select the appropriate lettered option(s). Each lettered option may be selected once, more than once, or not at all.Questions 94 through 96(A) Copper deficiency(B) Chromium deficiency(C) Zinc deficiency(D) Manganese deficiency(E) Vitamin A deficiency(F) Vitamin D deficiency(G) Vitamin E deficiency(H) Vitamin K deficiency(I) Vitamin C deficiency A 72-year-old man requires blood transfusion. He was initially given stored plasma. He is most likely to show a deficiency of what? SELECT TWO.
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(B, D)
Factor V and VIII are deficient in stored plasma. In contrast, fresh-frozen plasma con- tains all the coagulation factors. The major dis- advantage of plasma administration, however, is the risk of hepatitis. |
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DIRECTIONS (Questions 94 through 100): Each set of matching questions in this section consists of a list of lettered options followed by several num- bered items. For each numbered item, select the appropriate lettered option(s). Each lettered option may be selected once, more than once, or not at all.Questions 94 through 96(A) Copper deficiency(B) Chromium deficiency(C) Zinc deficiency(D) Manganese deficiency(E) Vitamin A deficiency(F) Vitamin D deficiency(G) Vitamin E deficiency(H) Vitamin K deficiency(I) Vitamin C deficiency A42-year-old man with small-bowel fistula has been receiving TPN with standard hypertonic glucose-amino acid solution for the previous 3 weeks. The patient is noticed to have scaly, hyperpigmented lesions over the acral surfaces of elbows and knees, similar to enterohepatic acrodermatitis. What is the most likely cause of this condition? SELECT ONE.
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(C)
Zinc is one of the metalloenzymes involved in lipid, carbohydrate, protein, and nucleic acid metabolism. Skin lesions similar to enterohepatic acrodermatitis are the most common signs seen in zinc deficiency. Other manifestations include hypogonadism, diminished wound healing, and immunodeficiencies. Copper deficiency is characterized by microcytic hypochromic anemia. |
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DIRECTIONS (Questions 94 through 100): Each set of matching questions in this section consists of a list of lettered options followed by several num- bered items. For each numbered item, select the appropriate lettered option(s). Each lettered option may be selected once, more than once, or not at all.Questions 94 through 96(A) Copper deficiency(B) Chromium deficiency(C) Zinc deficiency(D) Manganese deficiency(E) Vitamin A deficiency(F) Vitamin D deficiency(G) Vitamin E deficiency(H) Vitamin K deficiency(I) Vitamin C deficiency A40-year-old woman with no previous history of diabetes is receiving TPN. After 4 weeks, she is hyperglycemic, and it is difficult to control her glucose despite insulin therapy. SELECT ONLY TWO.
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(B, D)
Chromium is an insulin cofactor. Defi- ciency state results in hyperglycemia. Manganese is a cofactor of enzyme of energy and protein metabolism and also of fat synthesis. Besides causing glucose intolerance, manganese defi- ciency also causes hypocholesterolemia. |
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DIRECTIONS (Questions 94 through 100): Each set of matching questions in this section consists of a list of lettered options followed by several num- bered items. For each numbered item, select the appropriate lettered option(s). Each lettered option may be selected once, more than once, or not at all.Questions 94 through 96(A) Copper deficiency(B) Chromium deficiency(C) Zinc deficiency(D) Manganese deficiency(E) Vitamin A deficiency(F) Vitamin D deficiency(G) Vitamin E deficiency(H) Vitamin K deficiency(I) Vitamin C deficiency A45-year-old man receiving TPN has signs of retarded wound healing. SELECT ONLYTHREE.
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(C, E, I)
Zinc deficiency, vitamin A deficiency, and vitamin C deficiency. Zinc is a metalloen- zyme involved in protein and nucleic acid metabolism. Deficiency results in diminished wound strength and healing rates. Vitamin A deficiency results in delayed wound healing, specifically epithelization. Vitamin C deficiency results in defective sulfonated mucopolysac- charides and chondroitin sulfate with retarded wound healing. |
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A 90-year-old woman with a fractured neck of femur is receiving low-molecular-weight heparin (LMWH). Which of the following state- ments regarding LMWH is true?
(A)It has molecular weight below 4000 d. (B)Its anticoagulant effect is by binding to antithrombin III. (C)It should be administered two to three times a day. (D) It has lower bioavailability than standard heparin. (E)It has a greater rate of heparin-associated thrombocytopenia. |
(B)
Low molecular weight heparins (LMWH) are fragments of unfractionated standard heparin with mean molecular weights between 4000 and 64,000 d. They bind to and accelerate the activity of antithrombin III. LMWH has greater bioavailability, more effective antico- agulant effect, lower incidence of heparin- associated thrombocytopenia, and can be administered once daily. |
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A70-year-old man, who weighs 70 kg, is admit- ted with acute cholecystitis. His calculated daily fluid requirement for maintenance is approximately which of the following?
(A)1 L (B)2 L (C) 2.5 L (D)3 L (E)4 L |
(C)
Daily maintenance fluid requirements are calculated on the basis of 100 mL/kg for the first 10 kg of body weight, 50 mL/kg for the second 10 kg of body weight, and 20 mL/kg for each additional kg of body weight (i.e., 100 × 10 + 50 × 10 + 20 × 50 = 2500 mL). Hourly fluid requirement can be calculated using the 4, 2, 1 rule as follows: 4 mL/kg, for the first 10 kg, 2 mL/kg for second 10 kg, and 1 mL/kg for each additional kg of body weight (i.e., 4 × 10 + 2 × 10 + 1 ( 50 = 110 mL/h). |
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A 47-year-old woman with chronic renal failure has been maintained on chronic dialysis for several years. She had undergone kidney transplantation but because of rejection, she was placed back on dialysis. She had repeated bouts of pain in the RUQ and was intolerant to fatty meals. Ultrasound showed cholelithiasis.The most appropriate management of this patient is the administration of which of the following?
(A) Heparin (B) Protamine sulfate (C) Fresh-frozen plasma (D) Desmopressin (E) Factor VIII concentrate |
(D)
The coagulation changes can be reversed with desmopressin or cryoprecipitate. |
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A 47-year-old woman with chronic renal failure has been maintained on chronic dialysis for several years. She had undergone kidney transplantation but because of rejection, she was placed back on dialysis. She had repeated bouts of pain in the RUQ and was intolerant to fatty meals. Ultrasound showed cholelithiasis. Following elective cholecystectomy, severe bleeding occurred. This was most likely attrib- uted to which of the following?
(A) Elevated PT (B) Elevated PTT (C) Low platelet count (D) Decreased platelet aggregation (E) Sepsis |
(D)
Abnormal hemostasis, common in chronic renal failure, is characterized by prolonga- tion of bleeding time, decreased activity of platelet factor 3, abnormal platelet aggrega- tion, and adhesiveness. The prolonged bleeding time is related to failure of platelet interaction with von Willibrand’s factor (factor 8-VWF)Answers: 80–96 27This interaction can be corrected by using desmopressin or by transfusing cryoprecipitate. |
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A34-year-old male has serum sodium of 114 mEq/L. Correction of hyponatremia can be done by raising serum sodium by what amount?
(A) 1 mEq/L/h (B) 3 mEq/L/h (C) 5 mEq/L/h (D) 7 mEq/L/h (E) 10 mEq/L/h |
(A)
Rapid correction of hyponatremia >1–2 mEq/L/h can lead to central pontine myeli- nolysis. Serum sodium level should not be raised >25 mEq/Lwithin 48 hours of starting therapy. Only symptomatic hyponatremia requires treatment with hypertonic saline, oth- erwise fluid restriction is sufficient. |
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A70-year-old female has been admitted to your ICU in shock. You determine that a PAcatheter is needed. Which of the following is not a known complication associated with the inser- tion of PA catheter?
(A) Transient arrhythmias such as ventricular tachycardia (B) Right bundle branch block (C) Pneumothorax (D) Mural thrombus (E) Cardiac perforation |
(D)
Transient arrhythmias and right bundle branch block are seen during the insertion of the PAcatheter as it may hit the wall of the right ventricle causing these electrical distur- bances. Pneumothorax is a risk associated with the insertion of the introducer for the PA catheter. Cardiac perforation is certainly a risk anytime a catheter is being placed through the heart. Mural thrombus is not a known complication. |
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A 70-year-old man was administered 20,000 U of heparin before femoral artery embolectomy. Following surgery, he is noted to have gener- alized bleeding from the wound margins. Immediate management should consist of administration of which of the following?
(A) Fresh-frozen plasma (B) Cryoprecipitate (C) Platelet transfusion (D) Intravenous protamine sulfate (E) Intravenous sodium bicarbonate |
(D)
Intravenous protamine sulfate. The cause of bleeding is circulating heparin. The antico- agulative effect of heparin can be immediately neutralized by intravenous protamine sulfate. One milligram of protamine sulfate usually neutralizes 100 U of heparin. Fresh-frozen plasma is given to counteract the effect of war- farin (Coumadin). Cryoprecipitate is useful in treating patients with hemophilia. Intravenous sodium bicarbonate is indicated after mis- matched blood transfusion to alkalinize the urine. Platelet transfusions are necessary to cor- rect dilutional thrombocytopenia seen after massive blood transfusion. |
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A 50-year-old woman with adult respiratory distress syndrome (ARDS) is intubated. The oxyhemoglobin curve is shifted to the rightQuestions: 76–89 13with increased oxygen delivery by which of the following?
(A) Metabolic acidosis (B) Older age (C) Decreased 2,3-diphosphoglycerate (DPG) (D) Decreased thyroid hormone level (E) Hypothermia |
(A)
The oxyhemoglobin dissociation curve is a convenient method to study the affinity of hemoglobin for oxygen. It is S-shaped, which provides an efficient method of uptake and release of oxygen. It holds on to the oxygen at high concentrations and as the blood enters the lower pressures encountered in the capillaries, it releases the oxygen. Hemoglobin is 75% satu- rated at a PO2 of 40 mm Hg and 50% saturated at a PO2of 27 mm Hg. At the peripheral tissues, a right or left shift does have a real impact on the affinity of hemoglobin for oxygen. If the S-curve is shifted to the right, there is a decreased affin- ity of hemoglobin for oxygen (more oxygen is released). Aright shift occurs with increase in 2,3-DPG, acidosis, increase in temperature, and increase in hormones (cortisol, thyroid, or aldos- terone). Aleft shift occurs with a decrease in temperature, alkalosis, low DPG, carboxyhemo- globinemia, and old age. |
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An 85-year-old male is admitted to the ICU in septic shock. A pulmonary artery (PA) catheter is placed. The PAcatheter does not directly measure which one of the following ?
(A) PA systolic pressure (B) PCWP (C) Systemic vascular resistance (D) Right ventricular diastolic pressure (E) Right atrial pressure |
(C)
Systemic vascular resistance (an approxi- mation of afterload) is a calculated value. All the other choices are directly measured. |
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A42-year-old man who weighs 60 kg is receiv- ing 3 Lof standard hypertonic 25% glucose- amino acid solution. He has no history of smoking or bronchial asthma. In the ICU, he is alert, afebrile, and hemodynamically stable, but he remains intubated and attempts to wean him off the ventilator have been unsuccessful. What is the most likely cause?
(A) Copper deficiency (B) Excess fat calories (C) Excess glucose calories (D) Excess amino acids (E) Inadequate glucose calories |
(C)
Glucose infusion should not exceed 4–5 mg/kg/min, equivalent to 365–432 g for this patient. The patient is receiving 750 g of glucose. Glucose has a respiratory quotient of1. Excess glucose results in increased produc- tion of CO2, making it difficult to wean the patient off ventilator. Treatment consists of reducing glucose load and providing fat calo- ries (up to 40% of total calories). Fat has a res- piratory quotient of 0.7, resulting in decreased production of CO2. |
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A40-year-old woman with inflammatory bowel disease has been receiving TPN for over 3 weeks. Workup reveals pelvic abscess. She under- goes exploratory laparotomy, resection of small bowel with anastomosis, and drainage of pelvic abscess. During surgery, TPN is maintained at the original rate of 125 mL/h. In the recovery room, the patient is found to have a urine output of 200 mL/h. CVPis 1, and laboratory results are Na, 149; K, 3.5; Cl, 110; HCO3, 18; BUN, 40; and creatinine, 1 mg/dL. Which of the following statements is true regarding this condition?
(A) The patient’s urine output is secondary to fluid overload during surgery. (B)The patient is in high-output renal failure. (C) Hyperosmolar-nonketotic coma will develop if the condition is not aggressively treated.(D)Diuresis is a normal response to stress of surgery. (E) Potassium supplementation is not indicated. |
(C)
Hyperosmolar-nonketotic coma is a seri- ous complication seen when an excessive amount of glucose is given, especially in the presence of sepsis, steroids, or inadequate insulin. Furthermore, the combination of sur- gery and sepsis results in an increased insulin- resistant state. The increased urine output is secondary to osmolar load from blood glu- cose. Low CVP, hypernatremia, and BUN-to- creatinine ratio over 20 suggest hypovolemia and not fluid overload. Normal creatinine level and BUN-to-creatinine ratio over 20 rules out high-output renal failure. The stress of surgery is characterized by water retention and not diuresis. Management consists of aggressive hydration, discontinuation of TPN, and insulin drip. Insulin drives the potassium intracellu- larly and potassium must be replaced. |
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A 24-year-old man with multiple injuries is receiving standard TPN. The following is true regarding glutamine.
(A)It is a major fuel for the brain. (B)It is an essential amino acid. (C)It is a major fuel for the gut. (D)It is synthesized de novo in the kidney. (E)It is a component of TPN solutions.82. A50-year-old man with small-bowel fistula has been receiving TPN for the previous 3 weeks through a single-lumen central venous catheter. He is scheduled for exploratory laparotomy and closure of fistula. On the morning of the day of surgery, TPN is discontinued and intra- venous infusion with balanced salt solution (Ringer’s lactate) is started. An hour later, the patient is found to be anxious, sweating, and tachycardic. What is the most likely cause?(A) Anxiety(B) Hypoglycemia(C) Hypovolemia(D) Unexplained hemorrhage(E) Hyperglycemia |
(C)
It is a major fuel for the gut. It is readily syn- thesized de novo in skeletal muscle, lung, and liver. Glutamine is a nonessential amino acid. It is not a component of presently available TPNsolutions because of its lack of stability. Glutamine is a major fuel for the small intes- tinal mucosa and other replicating cells such as lymphocytes, macrophages, fibroblasts, and endothelial cells. Glucose is the primary source of fuel for the brain. |
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A30-year-old man with a gunshot wound to the abdomen has severe injuries involving the liver, duodenum, pancreas, and colon. Why is parenteral nutrition support preferred over enteral nutrition support?
(A) It is less expensive. (B)It preserves gut mucosal mass and mucosal immunity. (C) It prevents gut permeability and translocation. (D)It is easy to start and administer nutrient requirement rapidly. (E) It attenuates hypermetabolic response to surgery. |
(D)
It is easy to start and administer nutrient requirements rapidly. Parenteral nutritionshould be administered when enteral access cannot be obtained, when enteral nutrition support fails to meet nutritional requirements, or when feeding into the GI tract is contraindicated. Current evi- dence suggests that in addition to safety, con- venience, and cost, enteral feeding is well tolerated, preserves gut mucosal mass and normal gut flora, prevents increased gut per- meability to bacteria and other toxins, main- tains mucosal immunity, and attenuates the hypermetabolic response to surgery. As com- pared to parenteral nutrition, enteral nutri- tion is also associated with significantly reduced septic complications. Therefore, enteral feeding is preferred over TPN when feasible. |
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Increase in energy expenditure by 100% over normal, or two times greater than normal, is seen in a patient with which of the following?
(A) Pyloric obstruction from chronic duodenal ulcer (B) Fractured femur (C) Perforated diverticulitis of colon (D)Severe thermal burns of more than 30% total body surface area (BSA) (E) Right inguinal herniorrhaphy for incarcerated inguinal hernia |
(D)
Resting energy expenditure is decreased fol- lowing starvation (e.g., inthe patientwith pyloric obstruction) and increased after the stress of sur- gery, trauma, or sepsis. The increase in energy expenditure correlates with the severity of insult being 1.2 times greater after minor operation (e.g., right inguinal herniorrhaphy), 1.35 times greater after skeletal trauma (e.g., fractured femur), 1.6 times greater after major sepsis (e.g., perforated diverticulitis), and 2 times greater after severe thermal burns. |
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A55-year-old man with oat cell carcinoma of the lung is suspected to have SIADH. This is characterized by which of the following?
(A) Decreased total body water (TBW) (B) Low serum sodium (C) Increased urine output (D)Urine sodium of <10 mEq/L (E) Low urinary specific gravity |
(B)
Patients with SIADH have low urinary output with hyponatremia. Urine-specific grav- ity or osmolality is increased, urinary excretion of sodium is increased (>20 mEq/L), and TBW is increased as manifested by low serum osmo- lality. SIADH is seen after various CNS disor- ders, in neoplastic disease, pulmonary diseases, and with some drugs and may be idiopathic. |
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A patient is being weaned from mechanical ventilation. Weaning parameters are obtained prior to deciding on extubation. Successful weaning from a ventilator is suggested by the presence of which of the following?
(A) An alveolar arterial gradient of more than 350 mm Hg (B) A PaO2/FiO2 ratio of <200 (C) A PaCO2 over 55 mm Hg (D)Atidal volume of over 5 mL/kg (E) A minute ventilation of 12 L/min |
Answers: 62–79 2576.(D)
Successful weaning from the ventilator is suggested by the presence of(a) PaO2 of 70 mm Hg or more with an FiO2 of 0.35 or less(b)An alveolar arterial gradient of <350 mm Hg(c) A PaO2-to-FiO2 ratio of >200(d) A PaCO2 of over 30 mm Hg and <55 mm Hg(e)AVC of more than 10–15 mL/kg(f) A maximum negative inspiratory force of more than -25 cm H2O(g) A minute ventilation of <10 L/min(h)Atidal volume of over 5 mL/kg(i) A respiratory rate of <30 breaths/min |
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A60-year-old man is being weaned from a ven- tilator in the ICU. The likelihood that weaning is going to fail is suggested by the presence of which of the following?
(A) A respiratory rate of 24 breaths/min (B) A PaO2 of 80 mm Hg on FiO2 of 40%(C)Avital capacity (VC) of 5 mL/kg body weight (D) A minute ventilation of 8 L/min (E) A maximum negative inspiratory pressure of −30 cm H2O |
(C)
Vital capacity (VC) of 5 mL/kg body weight. See Answer |
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A 60-year-old man had undergone exploratory laparotomy for perforated gastric ulcer with severe peritoneal contamination. Six hours after surgery, he is tachycardic, hypertensive, and has shallow respirations. Intubation and insti- tution of ventilatory support is indicated in the presence of which of the following?
(A) Respiratory rate of 23 breaths/min (B) PaCO2 of 45 mm Hg (C) PaO2 of 55 mm Hg on room air (D)HR of 140 bpm (E)BPof 150/100 mm Hg |
(C)
The criteria for need for ventilatory support are apnea, respiratory rate >30 breaths/min, PaO2 <60 mm Hg on room air, and PaCO2>55 mm Hg (except in patients with chronic obstructive pulmonary disease [COPD]). |
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A 70-year-old woman has low cardiac output with increased and increased systemic vascular resistance. What should be the drug of choice?
(A) Dopamine (B) Norepinephrine (C) Dobutamine (D) Epinephrine (E) Phenylephrine |
(C)
Dobutamine is the drug of choice for improving cardiac function. It is a b1-receptor agonist and increases myocardial contractibil- ity and also reduces afterload by b2 effect. Dopamine at low doses (1–3 mg/kg/min) stim- ulates dopaminergic receptors and increases renal blood flow. At moderate doses (3–10 mg/kg/min), it stimulates b-receptors, resulting in a positive inotropic and chronotropic effect. Systolic and mean BP are increased; whereas, diastolic BP is usually unchanged. At higher doses (10–20 mg/kg/min), stimulation of a- receptors occurs and it significantly increases systemic vascular resistance. Norepinephrine, epinephrine, and phe-nylephrine are powerful vasoconstrictors. |
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A40-year-old paraplegic is taken to the OR for cholecystectomy for acute cholecystitis. SheQuestions: 62–75 11is given succinylcholine before intubation. Immediately after induction of anesthesia, she develops cardiac arrest. What is the most likely cause?
(A) Esophageal intubation (B) Hyperkalemia (C) Perforation of gallbladder (D) Hypovolemic shock (E) Myocardial infarction |
(B)
Administration of a depolarizing anesthetic agent such as succinylcholine in quadriplegics, in paraplegics, or after burns and severe trauma can result in life-threatening hyper- kalemia from release of intracellular potassium. |
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A 25-year-old man sustained laceration of the liver and rupture of the spleen in an automo- bile accident. He was hypotensive for more than 1 hour and received 10 Lof crystalloids and 10 U of blood. On the second postoperative day, he is intubated, his HR is 120 bpm, his BP is 110/60 mm Hg, his urine output is 40 mL/h, and his CVPis 13 cm H2O. His ABGs on 70% oxygen reveal a pH of 7.42, a PO2 of 58 mm Hg, and a PCO2 of 35 mm Hg. What is the most appropriate management?
(A) Increase the fraction of inspired oxygen (FiO2). (B) Increase the tidal volume (VT). (C)Administer Lasix, 20 mg IV. (D) Institute positive end-expiratory pressure (PEEP). (E) Decrease FiO2. |
(D)
Institute positive end-expiratory pressure (PEEP). This patient has developed ARDS, which is associated with a significant decrease in functional residual capacity (FCR) of the lungs from collapse of alveoli and increased shunt from perfusion of unventilated alveoli. The most appropriate way to improve his oxy- genation is by instituting PEEP. |
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A 55-year-old man involved in an automobile accident is unresponsive and is intubated at the scene. On arrival in the emergency department, he responds to painful stimulation. His systolic BPis 60 mm Hg, his HR is 140 bpm, his neck veins are distended, and his breath sounds are absent on the left side. Immediate management should involve which of the following?
(A)Insertion of a central venous line on the right side (B)Insertion of an 18-gauge needle in the left second intercostal space (C) Pericardiocentesis (D) Peritoneal lavage (E)CT scan of head |
(B)
The patient has tension pneumothorax, as evidenced by distended neck veins and absent breath sounds. Increased intrathoracic pressure interferes with venous return to the heart, resulting in shock. Immediate management should be insertion of a large-bore needle in the left second intercostal space, followed by insertion of a chest tube. In a trauma patient, venous access should be achieved by inserting two large-bore (16-gauge) angiocatheters in the cubital veins. Insertion of a central venous line on the right side should not be done, because it carries the risk of producing pneumothorax in the opposite side. |
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A 40-year-old woman with deep vein throm- bosis is being treated with IV heparin, 1000 U/h. On the seventh day of treatment, her lab- oratory values are hemoglobin, 14 g/dL; WBC count, 7600/mm3; platelet count, 30,000/mm3; PT, 13 seconds (control, 12.5 seconds); and PTT, 50 seconds (control, 26 seconds). What man- agement would be appropriate?
(A)Continue with heparin at the same dosage (B) Increase heparin (C) Decrease heparin (D) Discontinue heparin (E) Continue heparin and start warfarin (Coumadin) |
(D)
Thrombocytopenia is a common complica- tion of heparin therapy. The most common form, type I (seen in up to 30% of patients), is a milderform that occurs after 2–3 days of heparin therapy. The platelet countremains over 50,000/mm3 and has no clinical significance. Type II, seen in 1–2%, usually occurs 7–10 days after heparin treatment. It is immune mediated and can be caused by heparin therapy in any form, in any dose, including heparin flushes and heparin-bonded intravenous catheters. Treat- ment consists of immediate cessation of heparin administration in any form. |
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A75-year-old woman who is in the ICU after undergoing cholecystectomy for acute chole- cystitis is hypotensive and tachycardic. Pulmonary capillary wedge pressure (PCWP) is elevated to 18 mm Hg, and cardiac output is 3 L/min. She is in shock best described as which of the following?
(A) Hypovolemic shock (B) Septic shock (C) Cardiogenic shock (D) Anaphylactic shock (E) Neurogenic shock |
(C)
Low cardiac output in the presence of ele- vated filling pressures is characteristic of cardio- genic shock. PCWPis decreased in all the other types of shock. |
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A68-year-old man has a history of myocardial infarction. He undergoes uneventful left hemi- colectomy for carcinoma of the colon. In the recovery room, he is hypotensive and given a fluid bolus of 500 mLRinger’s lactate over 30 minutes. He is intubated, and his neck veins are distended. His HR is 130 bpm, his BPis 80/60 mm Hg, and his urine output is 20 mL over the last hour. What should be the next step in his management?
(A) Administration of Ringer’s lactate, 500 mLover 1 hour (B) Administration of dopamine (C) Insertion of a Swan-Ganz catheter (D) Administration of Lasix (E) Extubation of the patient |
(C)
The patient’s clinical picture is suggestive of cardiogenic shock. However, he may still be hypovolemic, because distension of neck veins does not accurately reflect the filling pressures of the heart. A Swan-Ganz catheter should be inserted for appropriate assessment of hemody- namic status and institution of appropriate ther- apy. Fluid therapy will worsen cardiogenic shock, and Lasix will make the patient hypov- olemic. Dopamine will increase BPbut is delete- rious to the heart. The patient should not be extubated until he is stable. |
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In septic shock, which of the following is true?(A)The mortality rate is between 10% and 20%.
(B) Gram-negative organisms are involved exclusively. (C) The majority of patients are elderly. (D)The most common source of infection is the alimentary tract. (E) Two or more organisms are responsible in most cases. |
(C)
Most patients are elderly. The underlying conditions leading to septic shock occur more commonly in elderly patients. The mortality is higher in this patient population. The overall mortality rate exceeds 40–50%. Gram-positive organisms, parasites, or fungi also may be responsible. The genitourinary and respiratory tracts are more common sources for initiating sepsis. Two or more organisms are found in 10–20% of cases. |
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Following urinary tract infection associated with extraction of a bladder stone, a 64-year-old woman developed gram-negative septicemia. Which statement is true for gram-negative bac- terial septicemia?
(A) Pseudomonas is the most common organism isolated. (B)Many of the adverse changes can be accounted for endotoxin release. (C)The cardiac index is low. (D) Central venous pressure (CVP) is high. (E) Endotoxin is mainly a long-chain peptide. |
(B)
Many of the adverse changes can be accounted for by endotoxin release. Escherichia coli is the most common organism involved in gram-negative septicemia, followed by Klebsiella, Aerobacter, Proteus, and Pseudomonas. The car- diac index is high, peripheral resistance is decreased, and CVPis low to normal. The most common conditions leading to gram-negative sepsis are those of the urinary tract, followed by respiratory and biliary tract and abdominal visceral infections. Endotoxins are lipopolysac- charide complexes. The lipid Aportion is prob- ably responsible for the toxicity. |
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In metabolic alkalosis, there is which of the following?
(A)Gain in fixed acid (B)Loss of base (C) Hyperkalemia (D)Rise in base excess (E) Hyperchloremia |
(D)
In metabolic alkalosis, there may be a loss of fixed acids or excess of base. It is associated with hypokalemia because of renal conser- vation of H+ ions and urinary potassium loss. Loss of hydrochloric acid as seen in vomiting in patients with pyloric obstruction results in hypochloremic, hypokalemic, metabolic alkalosis. |
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A 35-year-old man with duodenal stump leak after partial gastrectomy is receiving central parenteral nutrition containing the standard D25W, 4.25% amino acid solution. Which is TRUE of essential fatty acid deficiency seen after hyperalimentation?
(A)It occurs if soybean oil is given only once weekly. (B)It is usually noted at the end of the first week. (C)It causes dry scaly skin with loss of hair. (D)It is accompanied by hypercholesterolemia.(E)It is treated with insulin. |
(C)
Essential fatty acid deficiency usually occurs if hyperalimentation is extended for more than 1 month and when soybean oil is not administered at least twice a week. There is a decrease in linolenic, linoleic, and arachidonic acids and an increase in oleic and palmitoleic acid. In addition to the skin changes, there may be poor wound healing, increased susceptibil- ity to infection, lethargy, and thrombocytope- nia. It is characterized by a triene-to-tetraene ratio >0.4. |
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After undergoing subtotal gastrectomy for car- cinoma of the stomach, a 64-year-old woman is receiving peripheral parenteral nutrition. To increase calories by the peripheral route, what should be prescribed?
(A) D5W in normal saline (B) Multivitamin infusion (C) D25W (25% dextrose in water) (D) Soybean oil (E) Lactulose |
(D)
Lipid emulsions derived from soybean or safflower oils are widely used. One of the real advantages of lipid emulsion is that a large amount of calories can be provided through a peripheral vein. The 10% solution provides 4.62 kJ/mL and the 20% solution, 9.24 kJ/mL. Dextrose concentration in peripheral route is 10%. Concentrations >10% require administra- tioninto a central vein to prevent phlebitis owing to hypertonicity of the solutions. Lactulose is used to treat hepatic encephalopathy. |
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TPN is initiated in a 44-year-old woman with Crohn’s disease. In parenteral alimentation, carbohydrates should be provided in an opti- mal ratio of which of the following?
(A) 1 kcal/g nitrogen (B) 5 kcal/g nitrogen (C) 10 kcal/g nitrogen (D) 100 kcal/g nitrogen (E) 1000 kcal/g nitrogen |
(D)
The baseline protein requirements are cal- culated as 1 g/kg/d. Following stress, there is an increased protein requirement, and protein intake should be 1.5 g/kg/d after surgery, 2 g/kg/d after polytrauma, and after sepsis. Glucose and amino acids must be infused simultaneously to appropriately utilize nitrogen. The ideal ratio is 100 nonprotein kcal/g of nitrogen. In starvation, the nonprotein calorie- to-nitrogen ratio of 150 kcal/g is adequate. |
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A60-year-old man with carcinoma of the esophagus is admitted with severe malnutri- tion. Nutritional support is to be initiated. What should be his daily caloric intake?
(A) 1 kcal/kg body weight/day (B) 5 kcal/kg body weight/day (C) 15 kcal/kg body weight/day (D) 30 kcal/kg body weight/day (E) 100 kcal/kg body weight/day |
(D)
In general, total caloric needs for the majority of patients ranges between 25 and 35 kcal/kg/d.An alternative formula for calcu- lating daily caloric requirements is the Harris- Benedict equation, which is based on sex, age, weight, and height. The caloric requirements of humans also varies by amount of activity, degree of stress of surgery, trauma, sepsis, or burns. |
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A 56-year-old man underwent prostatectomy. He bled excessively and urgently required blood over and above what had been requested before surgery. In deciding on an appropriate blood transfusion protocol, what should be kept in mind?
(A)Group AB is the universal donor. (B)Serum from the recipient stored for 1 week is suitable for testing. (C) Hypothermia is indicated if cryoglobulin is found. (D) Cross-matching should be done before dextran administration. (E) Fresh-frozen plasma can be given instead of 4 U of packed cells. |
(D)
Cross-matching should be done before dex- tran administration. Group O is the universal donor, and if there is insufficient time to do appropriate cross-matching of blood, this type of blood should be used. Serum of the recipient should be <24 hours old, because antigenicity may be altered in blood stored for a longer time. Before hypothermia is undertaken, the patient’s (recipient’s) blood should be tested for cold agglutinin titer. Cryoglobulin may be present in patients with lymphomaor leukemia. Blood must be given at room temperature to such patients. |
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A41-year-old woman has an episode of mild right upper quadrant (RUQ) pain associated with jaundice that resolves completely with antibiotics. Workup reveals numerous large stones in the gallbladder. The patient has poly- cythemia vera, a hematocrit of 58%, and a platelet count of 1.8 million. What is the pre- ferred course of treatment for this patient?(A)She should be referred to the medical clinic for follow-up care and be observed.
(B) She should undergo phlebotomy and then be scheduled for cholecystectomy.Questions: 47–61 9 (C) She should be treated with chlorambucil for 6 weeks and then undergo cholecystectomy. (D) She should receive miniheparin and urgent cholecystectomy. (E) She should undergo cholecystectomy. |
(C)
Patients with polycythemia vera do poorly in general surgery if they have not had appro- priate treatment to reduce the RBC and platelet count. With chlorambucil treatment, elective cholecystectomy should be performed to avoid the possible need to perform the operation on an emergency basis when the patient is not fully prepared. |
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A 64-year-old woman undergoing radical hysterec- tomy under general anesthesia is transfused with 2 U of packed RBCs.The specific test to identify the cause of trans- fusion reaction for the patient is which of the following?
(A) PT (B) PTT (C) Platelet count (D) Bleeding time (E) Free plasma hemoglobin |
(E)
Acute hemolytic transfusion reaction due to transfusion of incompatible blood in a patientAnswers: 42–61 23under general anesthesia usually presents asgen- eralized bleeding due to DIC. PT, PTT, and bleed- ing time will be abnormally high, and platelets may be decreased because of DIC. The most spe- cific tests to determine hemolysis are free plasma hemoglobin and hemoglobinuria. The labora- tory criteria are hemoglobinuria with a con- centration of free hemoglobin over 5 mg/dL, a serum hepatoglobin level below 50 mg/dL, and serological criteria to show antigen incompati- bility of the donor and recipient blood. |
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A 64-year-old woman undergoing radical hysterec- tomy under general anesthesia is transfused with 2 U of packed RBCs.A hemolytic transfusion reaction during anes- thesia will be characterized by which of the following?
(A) Shaking chills and muscle spasms (B) Fever and oliguria (C) Hyperpyrexia and hypotension (D) Tachycardia and cyanosis (E) Bleeding and hypotension |
(E)
In the anesthetized patient, the classic signs of transfusion reaction are masked. The sudden unexplained onset of bleeding and hypoten- sion should include transfusion reaction in the differential diagnosis. In the conscious patient, chills, fever, pain in the lumbar region, a tight sensation over the chest, flushing of the face, and dark-colored urine may be evident. |
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After undergoing a transurethral resection of the prostate, a 65-year-old manexperiences excessive bleeding attributed to fibrinolysis. It is appro- priate to administer which of the following?
(A) Heparin (B) Warfarin (Coumadin) (C) Volume expanders and cryoprecipitate (D) Aminocaproic acid (Amicar) (E) Fresh-frozen plasma and vitamin K |
(D)
Fibrinolysis may be primary or acquired. Primary fibrinolysis is seen after fibrinolytic ther- apy with streptokinase or urokinase; surgical procedures on the prostate gland (which is rich in urokinase) and severe liver failure. Secondary fibrinolysis is most commonly seen in DIC. If the PT, PTT, and platelet count are normal, DIC is unlikely to be present. Aminocaproic acid inhibits plasminogen activation to plasmin and can be used if there is excessive fibrinolysis. It must not be given in DIC, because serious intravascular clotting may occur. |
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A50-year-old man withatrial fibrillation istaking warfarin (Coumadin). The effect of Coumadin is decreased by which of the following?
(A)The presence of vitamin K deficiency (B) Phenylbutazone (C) Quinidine (D) Barbiturates (E) Thyrotoxicosis |
(D)
Patients receiving barbiturates, oral contra- ceptive agents, and corticosteroids often require larger amounts of Coumadin to maintain ade- quate anticoagulation. In patients with vitamin K deficiency or impaired liver function and in those with thyrotoxicosis, there is increased effect of Coumadin. Also, the cholesterol-lowering agent clofibrate, D-thyroxine, and certain antibiotics given concomitantly with Coumadin enhance its anticoagulant effect. It is important to adjust the dose of Coumadin when initiating anticoag- ulation therapy in such patients. |
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A 45-year-old woman with deep vein throm- bosis is taking warfarin (Coaumadin), 5 mg/d. Seven days after initiation of therapy, she has warfarin-induced skin necrosis. Which of the following statements regarding this condition is true?
(A) It commonly occurs after warfarin therapy.(B) It usually involves the upper extremities. (C)It improves with an increase in the dose of Coumadin. (D)It improves with a decrease in the dose of Coumadin. (E) It requires cessation of Coumadin and infusion of heparin. |
(E)
Requires cessation of Coumadin and infu- sion of heparin. Warfarin (Coumadin)-induced skin necrosis is a rare complication with high morbidity and mortality. It usually occurs 3–10 days after initiation of therapy, affects women more commonly than men, and most often involves the skin of thighs, buttocks, abdomen, and breast. The exact mechanism is unknown but may be related to depression of protein C levels in some patients. Management involves immediate cessation of Coumadin and admin- istration of heparin IV. |
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A75-year-old man is found to have prolonged bleeding from intravenous puncture sites. Platelet aggregation is inhibited by which of the following?
(A) Adenosine diphosphate (ADP) (B) Calcium (C) Magnesium (D) Aspirin (E) Serotonin |
(D)
ADP, serotonin, and thromboxane A2 are important mediators of platelet aggregation. In the presence of calcium, magnesium, and platelet factor 4, they cause release of platelet content and their granules resulting in the for- mation of a platelet plug. This process is inhib- ited by aspirin. |
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Following admission to the emergency depart- ment, a 26-year-old woman with severe men- orrhagia states that both her father and sister have a bleeding disorder. The hemostatic dis- order transmitted by autosomal-dominant mode is which of the following?
(A) Factor X deficiency (B) von Willebrand’s disease (C) Factor VIII deficiency (true hemophilia) (D) Factor IX deficiency (Christmas disease) (E) Factor V deficiency (parahemophilia) |
(B)
von Willebrand disease is the most common hemostatic disorder transmitted by autosomal- dominant mode. Other disorders transmitted by this mode are hereditary hemorrhagic telangiectasia and factor XI deficiency. Diseases transmitted by an autosomal-recessive mode are factor X, factor V, factor VII, and factor I deficiencies. Factor VIII (true hemophilia) and factor IX (Christmas disease) deficiencies are sex-liked recessive. |
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A 43-year-old woman with von Willebrand’s disease is scheduled for cholecystectomy. It can be stated that preoperative evaluation will reveal which of the following?
(A)Normal bleeding time, PT, and PTT (B) Platelet aggregate with restocetin (C)Increased bleeding time and PTT, and normal PT (D)Increased bleeding time and PT, and normal PTT (E) Increased bleeding time, and normal PT and PTT |
(C)
von Willebrand disease is characterized by decreased level of factor VIIIc (procoagulant). It has autosomal-dominant inheritance. These patients have prolonged bleeding times and PTT, with normal PTs. In contrast to platelets of normal patients that aggregate when resto- cetin is added, in von Willebrand’s resease, platelets fail to aggregate in presence of restocetin. |
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A30-year-old woman with a history of an uneventful tonsillectomy at age four is sched- uled for exploratory laparotomy. Preoperative assessment that identifies the risk of intraop- erative bleeding is which of the following?
(A) Bleeding time (B) Platelet count (C)PT and PTT (D) Complete blood cell count (E) Obtaining a detailed history |
(E)
Obtaining a detailed history is the most important preoperative information that pre- dicts the risk of unexpected intraoperative bleeding complication. It is even more reliable than laboratory tests. |
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An 18-month-old boy slipped and hurt his right knee while walking. He presents with a tender, swollen, warm knee with significant hemarthrosis. His PT is 12 (normal, 13 seconds), PTT is over 100 (normal, 25 seconds), platelet count is 300,000/mm3, and bleeding time is normal. Initial management should consist of which of the following?
(A) Fresh-frozen plasma (B) Aspiration of knee (C) Factor VIII concentrate (D) Passive exercise (E) Long-leg cast |
(C) The boy has hemophilia. Management con- sists of infusion of factor VIII concentrate. Bed rest and local cold packs are helpful. Aspiration of the knee to remove blood and passive exer- cise are not recommended for fear of recurrent bleeding. In contrast, active exercise is benefi- cial because movement beyond the point when bleeding can recur is limited owing to pain. Fresh-frozen plasma has a low level of factor VIII (0.6 U/mL) and is not useful because the required volume is excessive. Patients can use long leg splint.
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