Mcq Salad 004

Front 1

You are asked to see a patient in your ward, 7days following a left hemicolectomy. The patient has a discharging wound. Thedischarge oozes freely between the sutures and is profuse, watery andblood–stained.There are no signs of inflammation. What is the most likelydiagnosis:

Back 1

dehiscence of the wound

Front 2

You have been asked to see a 68–year–old woman who has developed abdominal distension 5 days after a total hip replacement. Her abdomen is distended but soft. There is no localised tenderness,and rectal examination is unremarkable. A few scattered bowel sounds can be heard. The plain abdominal film shows gas all the way to the rectum and a dilated caecum and ascending colon. The radiological diameter of the caecum measures 14 cm.What will you do as immediate management of this patient?

Back 2

arrange for decompression by colonoscopy

Front 3

A previously fit 55–year–old man has undergone an emergency right hemicolectomy for a perforated caecal carcinoma. Two days after the operation you note the following on his fluid balance sheet – intravenous input 2 L, nasogastric aspirate 2 L, drain losses 700 mL, urine output 500 mL. Biochemistry shows [Na+] 135 mmol/L, [K+] 3.0 mmol/L, [Cl−] 100 mmol/L, [HCO−3 ] 27\nmmol/L. Which of the fluid balance regimens below would you order for the next 24–hour period?

Back 3

3 L N saline + 2 L dextrose 5% + 100 meq KCl

Front 4

Endoscopic surgery:

Back 4

enables cholecystectomy to be performed as day case surgery in some patients

Front 5

Surgical drains:

Back 5

are removed when they are no longer necessary

Front 6

Nutritional markers include the following

Back 6

skin fold thickness mid–arm muscle circumference serum albumin skin recall antigens

Front 7

The requirement for intravenous nutrition per day is:

Back 7

50 kcal/kg body weight

Front 8

Marasmus is characterised by the following characteristics

Back 8

inadequate intake of an otherwise balanced diet cachexia in the adult decreased metabolic rate easy

Front 9

correction with standard nutrition Treatment of critically ill patients in an intensive care unit:

Back 9

is associated with a 15% death rate overall Infection in critical illness is often found where often found in the lungs or abdomen

Front 10

The systemic inflammatory response syndrome:

Back 10

consists of at least two from a list of four categories of physiological and haematological abnormality

Front 11

Intravenous fluid resuscitation of hypotensive, hypovolaemic critically ill patients should be:

Back 11

rapid and complete using crystalloids or colloids or both

Front 12

The best prophylaxis against infection in dirty wounds is achieved by:

Back 12

removing foreign bodies and devitalised tissues

Front 13

Opportunistic infections caused by Candida albicans and fungi are associated with:

Back 13

cancer diabetes the administration of cytotoxic drugs the use of immunosuppressant drugs after cardiac transplantation

Front 14

What is not an example of metastatic infection?

Back 14

colo–vesical fistula due to diverticular disease of the colon

Front 15

These are all metastatic infections:

Back 15

b liver abscess after portal pyaemia

c infection in a prosthetic heart valve

d brain abscess secondary to a furuncle

e staphylococcal osteomyelitis in the absence of trauma

Front 16

Appendisectomy wounds are classified as being:

Back 16

clean–contaminated

Front 17

The concept of Universal Precautions is based on:

Back 17

the need to regard all patients as being potentially infectious

Front 18

Immunosuppression:

Back 18

has the side effects of increased risk of infection and malignancy

Front 19

Organ donation:

Back 19

requires that brain stem death criteria are fulfilled

Front 20

transplantation:

Back 20

can be life saving in cases of fulminant hepatic failure

Front 21

Pancreas transplantation:

Back 21

can be undertaken using the whole pancreas or just the islets of Langerhan

Front 22

Ionising radiation is particularly effective intreatment of

Back 22

a Hodgkins disease

b. Carcinoma of the breast

c Cancer of the rectum

d Cancer of the uterine cervix

It is not effective for

e Cutaneous melanoma

Front 23

Screening for malignant disease is effective in the following situations

Back 23

Where a tumour is detected at a stage where it can be cured by treatment

There is high public acceptance of the process

Specificity of screening is high

Sensitivity of screening is high

but it is **** when done on an individual basis

Front 24

Universal precautions:

Back 24

impose a physical barrier between patients and carers

Front 25

Sutures:

Back 25

made of catgut lose tensile strength within 3 weeks

Front 26

Commonly applied critical care organ support involves

Back 26

mechanical ventilation for hypercarbia

haemodiafiltration for uraemia

platelet transfusion for thrombocytopaenia

inotropic infusions for low cardiac output states

Front 27

Kidney transplantation:

Back 27

has a 5–year kidney survival rate of approximately 75–85% Liver

Front 28

The following statements in relation to simultaneous regional lymph node dissection at the time of primary tumour excision are true

Back 28

a Allows more accurate tumour staging

b Allows provision of appropriate prognosis to the patient

d Allows appropriate adjuvant treatment to be undertaken

e May confer a survival advantage

but there is a high morbidity

Front 29

In gastro–oesophageal reflux, the following statements are true

Back 29

a alcohol consumption and smoking are important aggravating factors

b is often associated with disordered oesophageal motility

d barretts oesophagus may develop

e iron deficiency anaemia may occur as a result of chronic blood loss

Front 30

The following statements on the management of\ngastro–oesophageal reflux are correct

Back 30

b a proton pump inhibitor is an effective treatment

c laryngeal spill–over is an indication for surgery

d the most appropriate operation is a laparoscopic fundoplication

e dysphagia may complicate anti–reflux surgery

Front 31

For patients suffering from oesophageal cancer, which of the following symptoms indicates the WORST prognosis?

Back 31

hoarseness of voice

Front 32

A 75–year–old man complains of progressive dysphagia for 2 months. He has loss of 10 lb in weight and can only tolerate a liquid diet. Oesophageal cancer is suspected. Which of the following investigations is MOST likely to detect evidence of distant metastases from his cancer?

Back 32

PET

Front 33

Out of the following, the MOST LIKELY risk factor for the development of a squamous cell cancer of the oesophagus is:

Back 33

history of cancer of the larynx

Front 34

The most common benign tumour of the oesophagus is:

Back 34

leiomyoma

Front 35

The diagnosis of chylous leak after oesophagectomy is helped by:

Back 35

analysis of chylomicrons in the chest tube output lymphangiogram milk challenge test for triglyceride in chest tube output

Front 36

Which of the following is true concerning intravenous contrast– induced renal toxicity?

A. The highest prevalence is caused by the intravenous contrast material used for computed tomography (CT).

B. Most patients with a rise in creatinine eventually require renal replacement therapy. C. The cause of renal injury is precipitation of iodinated contrast material within the tubules. D. Use of contrast agents with a lower osmolarity can significantly reduce the risk for renal injury.

E. N-Acetylcysteine has been shown to be highly effective in preventing renal failure.

Back 36

A N S W E R : D

COMMENTS: It is true that contrast agents with lower osmolarity have a lower risk for toxicity in high-risk patients. Most patients with contrast-induced nephropathy experience a transient rise in creatinine that peaks in 2 to 6 days and then returns to normal; only a small percentage eventually require dialysis. The highest prevalence is found in patients who have undergone angiography. Experimental evidence suggests that the renal toxicity is secondary to the production of oxygen radicals. N-Acetylcysteine is an antioxidant that has been theorized to counteract the effect of oxygen radicals at the renal tubule level, although the results of studies have thus far been equivocal. If there is no contraindication to volume expansion, this has generally been accepted as the best prophylaxis against contrast-induced renal toxicity in high-risk patients. Volume expansion can be achieved with either isotonic saline or isotonic bicarbonate solution given for several hours before and after infusion of the contrast agent; the effectiveness of one regimen over the other has not been proved definitively.

Front 37

A liver transplant candidate has worsening encephalopathy and decreased urine output. Laboratory and physiologic abnormalities that are present in patients with hepatorenal syndrome (HRS) include all of the following except:

A. High urinary sodium

B. High urinary osmolality

C. Azotemia

D. Vasodilation

E. Oliguria

Back 37

A N S W E R : A

COMMENTS: Hepatorenal syndrome is characterized by azotemia, oliguria, low urinary sodium (<10 mEq/L), and high urinary osmolality. It is theorized to be caused by a combination of systemic vasodilation, hypovolemia, and increased activity of the reninangiotensin-aldosterone system associated with chronic liver failure. Although this syndrome does occur spontaneously in patients with advanced cirrhosis, specific precipitants are more common. Such precipitants include sepsis (especially spontaneous bacterial peritonitis), increased intraabdominal pressure secondary to tense ascites, gastrointestinal bleeding, and hypovolemia. It is important to prevent excessive diuresis with diuretics or lactulose or aggressive paracentesis without intravascular repletion to avoid precipitating HRS. Treatment of HRS should be aimed at reversing these causative factors. Transjugular intrahepatic portosystemic shunt (TIPS) placement has shown modest improvement in renal function in patients who are not candidates for or are awaiting liver transplantation. The best treatment to reverse renal failure is treatment of the underlying primary liver disease or successful orthotopic liver transplantation.

Front 38

Which one of the following may suggest an acute adrenal crisis:

A. Random cortisol level of 34 mcg/dL

B. Hypothermia

C. Hyperglycemia

D. Hypokalemia

E. Increase in cortisol of 5 mcg/dL after stimulation with cosyntropin

Back 38

A N S W E R : E

COMMENTS: Impairment of the normal stress response of the hypothalamic-pituitary-adrenal axis can result in acute adrenal insufficiency in postoperative or critically ill patients. Clinical suspicion should be raised in any patient with persistent hypotension or sepsislike symptoms. Supporting laboratory findings may include hyponatremia, hyperkalemia, hypoglycemia, and azotemia. The diagnosis can be made with a random cortisol level of less than 15 mcg/dL. A patient with a cortisol level of 15 to 34 mcg/dL should undergo a cosyntropin stimulation test. An increase of less than 9 mcg/dL is suggestive of adrenal insufficiency.

Front 39

A patient with type 2 diabetes has a blood glucose level of 700 mg/dL and mental status changes. Although no ketones are evident on urinalysis, the patient has severe serum electrolyte abnormalities, including hypernatremia. Treatment of this condition differs from that of diabetic ketoacidosis (DKA) in that:

A. Insulin infusion should be initiated immediately

B. More aggressive fluid replacement should be instituted after calculating the free water deficit

C. The potassium level should be monitored closely

D. Glucose infusion should begin once the blood glucose level is less than 250 mg/dL

E. The patient should be evaluated for an inciting infection

Back 39

A N S W E R : B

COMMENTS: This patient has hyperosmolar hyperglycemic nonketotic syndrome (HHNS). The key to differentiating this condition from the other hyperglycemic emergency, diabetic ketoacidosis, is lack of ketone formation. This phenomenon occurs because intrinsic pancreatic insulin secretion remains more intact, although significantly impaired, enough to prevent fatty acid lipolysis and ketoacidosis. The changes in mental status and degree of hyperglycemia tend to be more severe, and there is no anion gap acidosis. Consequently, the time from onset to diagnosis and treatment tends to be longer in patients with HHNS than in those with DKA. Patients with HHNS can have a total body water deficit of up to 100 to 200 mL/kg. Aggressive intravascular repletion is the mainstay of therapy and needs be more dramatic than in DKA, although care must be taken to avoid decreasing serum osmolality greater than 3 mOsm/kg/hr to prevent the development of acute cerebral edema. As for DKA, insulin infusion, close monitoring and correction of electrolytes, and treatment of precipitating conditions are the other goals of treatment. Both entities can quickly progress to severe shock with cardiovascular collapse, severe metabolic acidosis, and death if not recognized and treated immediately.

Front 40

Stress-related hyperglycemia is thought to be due to increased release of all of the following except:

A. Glucocorticoids

B. Growth hormone

C. Thyroid-stimulating hormone (TSH)

D. Glucagon E. Epinephrine

Back 40

A N S W E R : C

COMMENTS: Stress-related hyperglycemia is present in critically ill or injured patients who have increased blood glucose levels without a background diagnosis of diabetes. It is thought to be due to insulin resistance secondary to increased release of counterregulatory hormones. Increased catecholamine and cortisol levels suppress pancreatic insulin release. Glucagon stimulates glycogenolysis and gluconeogenesis. Because hyperglycemia in the perioperative period has been associated with increased morbidity and mortality, tight glucose control in surgical ICU patients has become an important quality control measure.

Front 41

The physiologic parameters used in the definition of SIRS include all of the following except:

A. Temperature lower than 36° C

B. Respiratory rate greater than 20 breaths/min C. Paco2 less than 32 mm Hg

D. Systolic blood pressure lower than 90 mm Hg

E. Heart rate greater than 90 beats/min

Back 41

A N S W E R : D

COMMENTS: Coined by Bone and colleagues in 1992 at the American College of Chest Physicians/Society of Critical Medicine (ACCP/SCCM) Consensus Conference, the definition of systemic inflammatory response syndrome includes abnormalities in temperature, heart rate, respiratory rate, Paco2, and white blood cell count (Box 1-1). Blood pressure is not included in the consensus definition of SIRS.

Front 42

The syndrome of multi–organ system failure (MOF):

A. Involves sequential insults that lead to systemic hyperinflammation

B. Requires the documentation of active infection

C. Has decreased in incidence over the past decade

D. Requires diagnosis within 3 days of the systemic insult

E. Demonstrates consistent improvement after blood transfusion

Back 42

A N S W E R : A

COMMENTS: The “two-event” model of multi-organ system failure involves an initial insult that results in a primed inflammatory response; sequential events during this vulnerable period then lead to a dysfunctional state of hyperinflammation. MOF can develop without overt infection. It has been shown to occur in a bimodal distribution: early, within 3 days of the initial insult, and late, 6 to 8 days after the insult. Blood transfusion has been shown to have immunomodulatory effects and may be detrimental in patients with MOF. MOF has actually increased in incidence, probably because of the improved initial survival of critically ill patients.

Front 43

Critically ill patients who undergo a major abdominal operation enter a stressed state of starvation. This condition differs from nonstressed starvation in that:

A. The primary substrates for metabolism are generated by lipolysis

B. The glucose-using tissue requires 300 kcal/day

C. It can be maintained for up to 90 days

D. There is an expected ebb and flow phase of starvation

E. Its hallmark is an anabolic state

Back 43

A N S W E R : D

COMMENTS: Metabolism in the stressed, starved state is very different from that in the nonstressed, starved state. In nonstressed starvation (hypometabolic), the primary substrates for metabolism are free fatty acids generated by lipolysis, with only a small amount of proteolysis occurring to provide the 300 kcal/day needed for glucose-dependent tissues; this condition can be maintained in the nonstressed state for up to 90 days. In the stressed starvation state, there is a brief hypometabolic “ebb” phase followed by a pronounced hypermetabolic “flow” phase. The hallmarks are catabolism, proteolysis, and gluconeogenesis.

Front 44

A patient in the surgical ICU has severe nutritional deficiencies secondary to dysphagia and resulting anorexia. An echocardiogram demonstrates an ejection fraction of just 25%, and the patient complains of diffuse muscle soreness. You should consider a deficiency of which mineral as the cause of these clinical sequelae?

A. Copper

B. Selenium

C. Chromium

D. Zinc

E. Manganese

Back 44

A N S W E R : B

COMMENTS: Selenium deficiency is a rare condition that has received attention because of the reversible nature of its effects. It produces cardiomyopathy, diffuse skeletal myalgia, loss of pigmentation, and erythrocyte macrocytosis. Selenium is a trace mineral that is found in seafood and meat; it is also ingested in grains and seeds, but in this form the content depends on the concentration of selenium in the soil. Garlic, asparagus, Brazil nuts, and mushrooms are all good sources of dietary selenium. The dose appropriate for daily supplementation is very small; beneficial and toxic effects occur within a very narrow range for this trace mineral. Parenteral nutrition will typically include 100 micrograms of selenium daily, with normal dietary intake being approximately 70 to 150 micrograms/day.

Front 45

Preservation of normothermia in surgical patients is important and has become one of the goals of the Surgical Care Improvement Project (SCIP). All of the following are negative outcomes that have been directly associated with perioperative hypothermia except:

A. Coagulopathy

B. Wound infections

C. Nosocomial pneumonia

D. Myocardial ischemia

E. Delayed wound healing

Back 45

A N S W E R : C

COMMENTS: Hypothermia results in peripheral vasoconstriction, which leads to decreased subcutaneous oxygen tension and antibiotic delivery. Both neutrophil activity and leukocyte chemotaxis are impaired. All of these sequelae give rise to an increased incidence of wound infections. Globally reduced enzyme function leads to coagulopathy. Collagen cross-linking and therefore wound healing are affected by hypothermia. An increased risk for myocardial ischemia in patients with known coronary artery disease has been associated with hypothermic states. There has not been a direct correlation between the development of nosocomial pneumonia and hypothermia. SCIP Inf-10 aims to achieve a target temperature of 36.0°C in perioperative patients by using active warming methods.

Criteria for Four Categories of Systemic Inflammatory Response Syndrome Systemic Inflammatory Response Syndrome (SIRS) (2 or more of the following): • Temperature (core) >38° C or <36° C • Heart rate >90 beats/min • Respiratory rate of >20 breaths/min for patients spontaneously ventilating or a Paco2 of <32 mm Hg • White blood cell count >12,000 cells/mm3 or <4000 cells/mm3 or >10% immature (band) cells in the peripheral blood smear Sepsis Same criteria as for SIRS but with a clearly established focus of infection Severe Sepsis Sepsis associated with organ dysfunction and hypoperfusion Indicators of hypoperfusion: • Systolic blood pressure <90 mm Hg • >40–mm Hg fall from normal systolic blood pressure • Lactic acidemia • Oliguria • Acute mental status changes Septic Shock Patients with severe sepsis who: • Are not responsive to intravenous fluid infusion for resuscitation • Require inotropic or vasopressor agents to maintain systolic blood pressure

Front 46

11. Fifteen days following severe burns, excision, and autograft surgery, an increase of>25% of insulin requirements is noted over the previous 24-hour period. What is the bestnext step in the management of this patient?A. Schedule further surgery to decrease hypermetabolic response.B. Further increase the insulin drip until a glucose level of 140 to 180 mg/dLis reached.C. Order cultures and band neutrophil of peripheral blood.D. Repeat blood glucose level testing and order a new metabolic panel.

Back 46

C

Front 47

12. Four weeks postinjury, during the daily abdominal examination, you palpate the loweredge of the liver 4 cm below the edge of the ribs. No tenderness to palpation is reported andthere is no evidence of jaundice. Which of the following best explains the findings seen inpathology?A. Increased dietary intake of fatsB. Increased synthesis of fats from sugar-enriched dietC. Excessive peripheral lipolysis.D. Decreasedβ-oxidation of fat in liver mitochondria

Back 47

C

Front 48

Fetal wound healing is different from adult wound healing in that:A. Fetal wounds heal without scarring and without dermal appendages.B. Fetal wounds have increased amounts of TGF-β and FGF-2.C. Fetal fibroblasts have decreased prolyl hydroxylase activity.D. Fetal wounds have increased responses to inflammation and growth factor stimulation.E. The ECM of the fetal wound has low levels of hyaluronic acid.

Back 48

B

Front 49

Elastin is:A. Organized in mammalian skin in a basket weave pattern to resistmultidimensional tensile stressB. Produced late in life; has a high turnover rateC. An extremely hydrophilic molecule, which accounts for its functionalpropertiesD. An important component of the extracellular matrix of blood vessels;mutations causing elastin protein deficiency result in intimal hyperplasia,leading to arterial narrowing.E. Affected in Ehlers-Danlos syndrome, which is characterized by fragile skin

Back 49

D

Front 50

The cells or cell components central to wound healing are:A. B cellsB. T cellsC. LeukocytesD. MacrophagesE. Platelets

Back 50

D