Finals MCQs-April 2008

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Finals Black Bank


This page has NEW MCQs that have been remembered from the FINALS MCQ Exam on 11 April 2008.

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Status: New - 53; Old MCQs: 93 = total = 146

Contents

Anaesthesia

AA26 Anaphylaxis, which is wrong:
A. higher incidence in females (females have a higher incidence of anaphylaxis to neuromusclar drugs)
B. ??avocados, bananas and latex (edit: cross reactivity between...)
C. vecuronium - more likely to cause an anaphylactoid reaction than anaphylaxis
D. 99% within mast cells
E. peak tryptase in 1hr


AB60 Sepsis from Yersinia infection from blood transfusion, mortality?
A. <5%
B. 20%
C. 40%
D. 60%
E. 80%


AC157 Obese female having gynae surg. Uneventful induction. Anaesthetic stable. Goes into reverse trendelenberg and pneumoperitoneum and then 10 mins later desats to about 80%. BP 120/80. pCO2 44 mmHg: What is most likely cause?
A. Pneumothorax
B. Endobronchial intubation
C. Air embolus
D. Hypoventilation
E.


AC MC103 TMP-122 [Apr08]] Patient, 60 year old, renal failure. Has had a total knee replacement. Three days postop, pt develops SOB, chest pain and tachycardic. Shown an ECG - RBBB, R wave in VI, S wave in I, Q wave in III, t wave inversion in III (i.e. S1Q3T3). What is the diagnosis? (also had widespread ST elevation)

A. Myocardial infarction
B. Pulmonary embolus
C. Hyperkalemia
D. pericarditis
E. ?


AM49 All of the following tests useful in diagnosing MH except:

A. MRI spectroscopy
B. caffeine stimulated release of calcium from B Lymphocytes
C. resting CK >800
D. muscle contraction on exposure to halothane
E. myofibillary necrosis on histology


AP AP43 TMP-123 [Apr08] Antidepressants have benefit in all the following except:

A. Chronic headache
B. Chronic back pain
C. Chronic pain after acute herpes zoster
D. Trigeminal neuralgia
E. Acute herpes zoster


MC104 TMP-124 [Apr08] During which is procedure is it most important to re-program a pacemaker?

A. ECT
B. MRI
C. Lithotripsy
D. Percutaneous transhepatic cholangiogram
E. ?


AZ83 TMP-125 [Apr-125]] [Apr08] All the following are predictors of difficult intubation EXCEPT:

A. TMD <6cm
B. Samsoon classification score IV
C. Prominent C1 spinous process
D. Mouth opening <3cm
E. Prominent maxillary canines


TMP-126 [Apr08] Regarding infection control, which is NOT true?

A. prophylactic antibiotics should be given 30 minutes before incision
B. prophylactic antibiotics should be given at the time of incision
C. give vancomycin routinely if in a MRSA prevalent area
D. ?
E. ?


AZ Image of an ultrasound of neck with arrow pointing to carotid artery. Regarding what is arrow pointing to:
A. This will collapse with pressure
B. With doppler will be red if probe directed caudally
C. Is part of the brachial plexus
D. Will get smaller with Valsalva
E. Should centre image over this for CVC insertion

Answer B Red-Towards scanhead/Blue-Away scanhead. Tortis (so if the probe pointing cranially then bluue is artery and red is vein-gb

Equipment

EM EM69
BP measurement - overestimates with:
A. big (wide) cuff
B. skinny arm
C. severely peripherally vasoconstricted
D. atherosclerosis (it was arteriosclerosis)
E. slow cuff deflation

D - See this article: [1]


EM EM08d
What is the most sensitive method for detecting intraoperative air embolism?
A. capnography
B. TOE
C. Praecordial Doppler
D. Oesophageal stethoscope
E.

Answer is B (TOE) can be found in both Miller & Yao/ Artusio


EM52 or EM62 or possibly a new question. Capnograph -
This is most likely caused by
A. leaking gas sample line
B.
C.
D.
E.


EZ Electrical safety. A device that detects a 10mA difference in active and neutral leads and causes turning off of the circuit within 40 ms. this is a :
A. Class 1 device
B. Equipotential earthing
C. LIM
D. Residual Current Device
E. Fuse

D - see http://www.usyd.edu.au/anaes/lectures/electricity.html

EZ What is the best way to improve resolution on a 2D ultrasound?
A. adjust frame rate
B. increase probe frequency
C. increase 2D gain
D. ?something about waveform scatter?
E. increase TGC

Answer B- Increased frequency increases resolution, decreases penetration.

Medicine

MC TMP-127 [Apr08] When considering an acute MI
A. Aspirin and clopidogrel should not be given together
B. PCI is better than thrombolysis
C. Aspirin should not be given prior to MI confirmed with cardiac enzyme rise
D. Reperfusion can be delayed for 24hrs
E. something about confirming cardiac enzyme elevation before instituting reperfusion strategies


ME Hyperparathyroidism and increased Ca+
A. Long QT
B. Polydipsia and polyuria
C. Short PR
D. Increased GFR E.

Answer is B

Agree with B - from "Crash Course in Internal Medicine" p 324, great source I know. Gingermegs

MH Haemophilia A associated with
A. haemarthroses in infant female
B. haemarthroses in infant male
C. factor IX deficiency
D. Incr APTT but not PT
E. Incr APTT and PT

Answer is D

MM Carcinoid syndrome - finding on examining heart:
A. Fine inspiratory crepitations
B. Systolic murmur at apex
C. Systolic murmur at left sternal edge
D. Murmur at apex with opening snap
E. Pericardial rub

Answer is C--tricuspid regurg


MM You are anaesthetising a patient with acute intermittent porphyria. Which drug will most likely cause an attack of porphyria?
A. Droperidol
B. prochlorpazine
C. ondansetron
D. metoclopramide
E. tropisetron

Answer is D

A is correct too: Droperidol can precipitate acute porphyria.

D is worst. http://www.drugs-porphyria.com --Stmz 00:43, 24 Aug 2008 (EDT)

OHA 1st ed p.95 says USE droperidol as a pre-med! Then lists it in the table overleaf as "probably safe"; metoclopramide "definitely unsafe" and ondansetron "controversial". knm


MN Central anticholinergic syndrome, which is NOT true:
A. Will improve with neostigmine
B. Peripheral anticholinergic symptoms
C. Caused by Anti-Parkinson drugs
D. CNS depression
E. Associated with agitation, delirium, and ???

Answer is A--does not cross BBB


MN Old man with small cell lung ca, post lobectomy, in PACU, SOB, desaturating. Shoulder abduction and hip flexion weakness, weak but sustained handgrip. 8mg cisatrac given 90 minutes earlier, reversed with 2.5mg neostigmine and 1.2mg atropine. Most likely cause:
A. Eaton-Lambert syndrome
B. Myasthenia gravis
C. Steroid myopathy
D.
E.

Answer is A

Agree with A, Kumar and Clark 5th Ed p 1223, Gingermegs


MZ Hyponatraemia and hypovolaemia all except
A. SIADH
B. Pancreatitis
C. Nephritis
D. Renal tubular acidosis
E. Addisons

Answer is A


MZ After 3L normal saline, expect to see:
A. hyponatremic acidosis
B. hyponatremic alkalosis
C. hyperchloremic acidosis
D. hyperchloremic alkalosis
E. none of the above

Answer is C


MZ MM21 Serotonin syndrome:
A. difficult to distinguish from NMS but it is not essential to differentiate as treatment is similar
B. Has direct antidote promethazine
C. May be contributed to by pethidine
D. familial linkage (can't remember exact wording) - no, this option belonged in NMS question with options "Fever does not Always occur/ is related to MH/ major feature raised creatinINE kinase)
E.

Answer is C

Surgery

SF What increases the risk of threading an epidural catheter into a blood vessel?
A. not doing a CSE
B. injecting saline prior to threading catheter
C. LOR to saline instead of air
D. paramedine instead of midline approach
E. sitting position instead of lateral

Answer is D

Disagree, Answer is A. Anaesthesia and Intensive Care, states doing CSE decreases risk of "threading" because it ensures you are midline, We are not asking about making an intravscular puncture, but risk of treading catheter into vessel...it states LOR to saline vs air, or midline vs paramedian no effect......spooky


[2]

Answer is E: In addition to the above reference, Canadian Journal of Anesthesia 51:577-580 Canadian Anesthesiologists' Society, 2004. Obstetrical and Pediatric Anesthesia

gb-answer is definately E-see-http://www.cja-jca.org/cgi/content/full/48/1/48

Agree E: http://journals.cambridge.org/action/displayAbstract;jsessionid=F7067D88A98D23FDDB9609EE69F29AC4.tomcat1?fromPage=online&aid=294726 European Journal of Anaesthesiology (2005), 22:2:103-106 knm

Answer E - Anesth Analg 2009;108:1232–42. systematic review including papers mentioned above.


SF 38yo obese female with DM, other comorbidities, undergoing LSCS with spinal anaesthetic with a 27G whitacre needle, having this and that, blah, blah. then two days later complains of numbness on a small patch on lateral aspect of mid-thigh. On full neuro exam - no other signs/symptoms.
A. conus medullaris injury
B. L2 nerve root compression
C. L3 root lesion
D. L4 root lesion
E. meralgia paraesthetica

Answer is E. Agree -see emedicine link: [3]


SG SG63 Which of the following patients will tolerate the head down position for pneumoperitoneum least?
A.
B. Cardiac transplant patient with stable cardiac function
C. ?pt with poor cardiac function will have qualitatively same effect??
D. low cardiac output state secondary to reduced preload
E. morbidly obese patient


SG SG64 At what level of intra-abdominal does cardiac output fall? (this exam was definitely cardiac output rather than BP as in other exams)
A. 10 mmHg
B. 20 mmHg
C. 30 mmHg
D. 40 mmHg
E. 50 mmHg

I vote A, from CEACCP 2004 4(4):107-110 – Laparoscopic Abdominal Surgery. M Perrin & A Fletcher


SG SG65 In the head down position with pneumoperitoneum:
A. cardiac work is increased
B. pulmonary compliance is increased
C. ICP unchanged
D. IOP unchanged
E. pulm venous pressure unchanged

B, C, D false This book reckons PCWP increases...http://books.google.co.nz/books?id=vHWr9U09CWIC&pg=PA432&lpg=PA432&dq=pneumoperitoneum+pulmonary+venous+pressure&source=bl&ots=njw2watBST&sig=eQlkuEMNiGF6FBKSqXM62aJi9_M&hl=en&ei=oe7TSa-pCoPSswPDqaStCg&sa=X&oi=book_result&ct=result&resnum=5 therefore I reckon A is answer..Rocket

Agree, from same CEACCP article as above: "The increasing SVR, systolic and diastolic blood pressures and tachycardia, result in a large increase in myocardial workload". knm


TMP-119 SN Clinical scenario where patient develops venous air embolus in sitting position. What is NOT part of your immediate management?
A. Tell surgeon and flood site with saline
B. Put pressure on neck veins
C. Aspirate CVC
D. Give iv fluids
E. Valsalva manoeuvre

SO Maximum time for arterial tourniquet for upper limb
A. 60 min
B. 90 min
C. 120 min
D. 150 min
E. 180 min

  • Answer is C: Miller suggested nerve injury occurs after 2hours
  • Agree with C, OHA p451 states 2hrs is Maximum, Gingermegs


TMP-120 SO 20 year old male, 8 hrs post admission for motorbike accident, # femur now in traction. Had femoral nerve block, plus 40 mgs dose morphine IV. Admission CXR normal. Now decreasing level of consciousness, decreasing sats (~85%) despite 6 lts O2, crackles both lungs. what is it?
A. Fat embolus syndrome
B. Pulmonary contusion
C. ?narcotized (drowsy and hypoventilating)
D. Pneumothorax
E. Aspiration


Anatomy

NH You are performing an awake nasal fibreoptic intubation and wish to topicalise the airway. Which nerves do you need to anaesthetise from proximal to distal..
A. Trigeminal, then glosspharyngeal, then vagal (different combinations of the nerves given in different orders)
B. Facial, trigeminal, vagal
C. Facial, trigeminal, glossopharyngeal
D. Trigeminal, vagal, glossopharyngeal
E. ?

Answer A....spooky

Regional Anaesthesia

RB A thoracic epidural inserted for pain relief:
A. Allows earlier return of bowel function
B. Prevents wasting of total body protein
C. Does NOT reduce the incidence of MI
D. Epidural opioids alone provide better analgesia than systemic opioids alone
E. Addition of adrenaline significantly reduces local anesthetic dose requirement

ANZCA Pain Book - A,B,E have merit, A best answer

According to ANZCA pain manual A,B,D,E true. Maybe it was a "which is wrong" question, and C is the answer, as manual states that MI incidence is reduced. --Stmz 01:46, 24 Aug 2008 (EDT)

From the pain bible

"For all types of surgery, epidural analgesia (except epidural analgesia using a hydrophilic opioid only) provides better postoperative pain relief compared with parenteral (including PCA) opioid administration (Level I)."

And Adrenaline improves block quality

But that means I still make A and B correct...--Chillibean 06:27, 28 Aug 2008 (EDT)

Think protein wasting only reduced with thoracic epidural and TPN (and NSAIDs). Reckon A is best answer. --Tortis 02:28, 14 Feb 2009 (EST)


RB Man with peripheral vascular disease, post unilateral lumbar sympathectomy injection - most likely Cx:
A. orthostatic hypotension
B. genitofemoral nerve neuralgia
C. ?L2-L4 paraesthesia
D. psoas haematoma
E.

gb- complications of lumbar symphatectomy-paralytic ileus,imjury to genitofemoral nerve, ureteric injury, major vessel and bowel injury

Genitofemoral Neuralgia occurs in 5% of all blocks. This causes pain in the L1 groin area and is thought to be due to bruising of the L1 nerve root by the needle passing by it. More than 90% of cases recover spontaneously after 6 weeks. [4] Everything else is reported to be rare. [5]


RH Patient has IDDM and stable angina. Present for cataract extration. Surgeon was not willing to do it with topical LA, but you accidently block the WRONG eye. After explanation and apologising to pt, what do you do next?
A. cancel surgery and re schedule on a day that is convenient to patient
B. cancel surgery, do not rebook case until an incident form has been processed and you are aware of the outcome of the enquiry
C. give a GA
D. block the other eye (topical) and continue (edit: i think this stem was proceed with eye block to correct side - definitely a block I agree)
E. proceed under topical LA (edit: convince the surgeon to do the correct eye with topical anaethesia)


RH Globe perforation with eye blocks is most likely with:
A. Axial length <25mm
B. Medial canthus peribulbar injection
C. Inferotemperal peripulbar injection
D. Age < 40 years
E. Sub-Tenons

Bit of a tricky question. Perhaps it's C? Trying to decide between C and D. Curr Opin Anaesthesiol 15:503±509 says medial canthal is safer than inferotemporal. I'm trying to think whether <40 would be more likely given the possibility of different indications for eye surgery in this age group.

RH Retrobulbar block is least likely to block which muscle?
A. Lateral rectus
B. Superior oblique
C. Levator palpebrae superioris
D. Inferior rectus
E. Medial rectus

B - Ripart,J. Regional anesthesia for eye surgery, Regional anesthesia and pain medicine, 2005; vol 30(1):pp72-82

ICU

IC IC92 When considering the problem of cardiac tamponade due to CVC insertion all are true EXCEPT?
A. positioning the CVC above the junction of the right atrium and SVC will avoid the problem (edit: "just above the junction...")
B. visceral chest pain with drug infusion is an early sign
C. symptoms develop within 1 week
D. L sided CVL positioned at midpoint of brachiocephalic v? (edit:...will not cause tamponade)
E. more common in catheters with more lumens


IC93 The maximum osmolality to go up to when managing raised ICP when using osmotic diuretics:
A. 300
B. 320
C. 340
D. 360
E. 280

?B "As mannitol is entirely excreted in the urine there is a risk of acute tubular necrosis, particularly if serum osmolarity exceeds 320 mOsmol/l [41]. Therefore, plasma osmolarity has to be monitored during therapy with hyperosmotic agents" Managing elevated intracranial pressure. Nicole Forster and Kristin Engelhard. Curr Opin Anaesthesiol 17:371–376. 2005. No Ans is D.. as per this article.. www.thewaltoncentre.nhs.uk/...us/.../raised_ICP_management.pdf

I don't know where you got that from but every other source I've read says 320

IC IC94 Traumatic brain injury?? systolic BP 140, MAP 100. CVP 8, ICP = 15. What is the cerebral perfusion pressure
A. 85
B. 92.5
C. ?70
D. 132
E. 125

IC IC95 Patient on ward, collapsed. nurse calls code blue when finds pt unresponsive. no signs of life. After ensuring airway is clear, 1st action?
A. DCR x3 200J
B. DCR x1 200J
C. praecordial thump
D. CPR
E. Adrenaline 1mg


IC IC96 Induced hypothermia of proven benefit in:
A. asystolic arrest
B. CVA
C. SAH
D. traumatic brain injury
E. perinatal ischemic encephalopathy

A

Disagree, it is proven for VF out of hospital arrest not asystolic arrest. i think answer is E, perinatal ischaemic encephalopathy......spooky

I also think it is E - in cochrane database, this was the only option that showed any benefit (review of 8 RCTs) - KM

I think it D as per the latest 2008 guidelines  .."

Accordingly, the BTF/AANS guidelines task force has issued a Level III recommendation for optional and cautious use of hypothermia for adults with TBI."

http://www.liebertonline.com/doi/abs/10.1089/neu.2007.0424

Think the jury is still out on TBI...

Paediatrics

PP 12 year old child with hip dislocation at 4pm. Ate 1 hour after injury. Now 11 pm. Best anaesthetic:
A. RSI with ETT
B. delay until next day then treat elective
C. inhalational induction and continue with face mask
D. Reduce immediately with iv sedation
E. inhalational induction and continue with face mask

"Most dislocations in children can be reduced with gentle manipulation. Urgent reduction of the hip within 6 hours of injury reduces the risk of osteonecrosis." [6]. Don't think this should wait. Erring on the side of caution and going with A (prob ongoing pain/opiates). --Tortis 22:53, 14 Feb 2009 (EST)


PP child for grommets with clear runny nose, coryza. dry cough, clear chest, otherwise well, no fever. management:
A. delay 2 weeks
B. delay 1 week
C. crack on with ETT (haha i'd like to see an mcq that says "crack on"! but yes, proceed with...)
D. crack on with face mask
E.

D. The ideal anaesthestic if you decide to do the child with URTI is "minimally invasive". I.e. if you can use a face mask use one, if you can use an LMA use one as instrumentation of the reactive airway can get you into trouble.

PP When using a T piece for a small child, which is not an advantage?
A. Can use low gas flows
B. Feel compliance
C. Assess tidal volume
D. Can rapidly change levels of CPAP
E. low resistance

A

Could it be that this question was not negative, ie. what IS an advantage? In that case it would be option E, as all the other options are wrong with classic T-piece. --Stmz 02:15, 24 Aug 2008 (EDT) Depends if they are referring to classic T-piece or Jackson-Rees modification to T-piece.

I agree with A - it is clearly incorrect, and the all others are the correct reasons for why people still use T-pieces like the Mapleson F or D (at least for inductions) in small children, despite the higher gas flows required cf circle systems


PP Haemoglobin in infants:
A. 30% fetal Hb at birth, adult levels by 3 months
B. 70% fetal Hb at birth, negligible amounts by 6 months
C. Hb 90 at 6 months normal doesn't need Ix
D. Hb 200 at birth unless delayed cord clamping
E. ?

B

I think it's D; OHA p761 says post delivery Hb 13-20, avg 18, nadir of 10-12 at 3 months, 80-90% HbF at birth, declines to 10-15% by 4 months

I'm voting for A. Illustrated textbook of Paediatrics, Lissauer & Clayden, 2nd edition, Mosby, 2001. Page 303, see graph of beta, gamma (fetal), (and delta) haemoglobin chains from 6 months before birth to 6 months after birth. I'm sure lots of other books have a similar graph.

The answer is B as per Power and Kam, p 361. "At birth, HbF forms 75-80% of the total haemoglobin, but this gradually decreases so that at 6 months after birth it is replaced by adult haemoglobin (HbA)."

Pharmacology

PC Clonidine is
A. Alpha 2 agonist centrally that acts presynaptically
B. Alpha 1 agonist
C. Alpha 2 antagonist
D. Alpha 1 antagonist
E. ?

A. Smith and Sasada, Gingermegs (obvious I know but good to have ref)


TMP-121 PC Levosemendin:
A. Increases contractility and myocardial oxygen consumption
B. Increases SVR
C. Binds to troponin C and induces a conformational change
D. Increases contractility by increasing calcium influx
E. Causes coronary vasodilation but NOT peripheral vasodilation


PZ Gabapentin:

A. Adjust dose in renal failure
B. Adjust dose in hepatic failure
C. ?
D. ?
E. ?
  • A
  • Agree A, Smith and Sasada, Gingermegs
  • Agree, in fact gabapentin is excreted renally entirely unchanged so all you need a post dialysis dose until the next time they're dialysed.

Physiology=

PH What is 1 MET uptake of oxygen DUKE'S ?
A. 1-2 ml O2/kg/min
B. 2-3 ml O2/kg/min
C. 3-4 ml O2/kg/min
D. 5-6 ml O2/kg/min
E. 7-8mls O2/kg/min

C (actually 3.5ml/kg/min=1MET)--Chillibean 08:04, 28 Aug 2008 (EDT)

Statistics

ST Numbers needed to treat is the inverse of:
A. ?
B. reduction of absolute risk
C. absolute decrease in relative risk
D. relative risk
E. odds ratio

B - NNT = 1/Absolute Risk Reduction

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