Finals MCQs-April 2009

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Finals Black Bank | Aug09 MCQs | (Without comments)

MCQs from the FINALS MCQ Exam April 2009. 

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Contents

Anaesthesia

Doing an awake CEA. Patient becomes confused & combative after carotid clamped and opened. Priority is...
a) tell surgeon to release clamp
b) tell surgeon to place shunt
c) induce GA
d) give midazolam

Place shunt? Can't imagine it'd be A since the carotid is open so releasing the clamp isn't such a good idea.

OHA pg 436 states shunt, Gingermegs

AT28 You intubate a young male patient for a left thoracotomy with a 39FG Robert Shaw tube. When you inflate both cuffs and ventilate the bronchial lumen you get left sided ventilation. When you attempt to ventilate the tracheal lumen the pressures are very high and you get no air entry. Yet when you deflate both cuffs you can ventilate the patient through the tracheal lumen. The most appropriate step to take next is:

A. Change to a 41FG tube
B. Change to a 37FG tube
C. Deflate both cuffs and insert further cm and recheck
D. Deflate both cuffs and withdraw a few cm and recheck
E. Pull ETT out and start again.


AT A patient comes to see you in clinic for a pneumonectomy for SCLS. His spirometry shows an FEV1 of 2.5L (>40% predicted). What do you advise about his fitness for surgery?
A. He is not fit for the procedure
B. He is fit for the procedure
C. He needs referral for formal exercise testing
D. He needs a blood gas

Answer B? Answer is B according to CEACCP Vol.6 No3, 2006, Fig.3 Andrew 12/01/10


OHA p 353 FEV1 > 55% predicted for pneumonectomy and >40% predicted for lobectomy and exercise testing useful in borderline cases. M+M p 595 has FEV1 < 2L as being "high risk" patient, so 2.5L is above this. If the values are remembered correctly then I agree B. If they are more borderline then I think C would be useful. D also needs to occur as part of routine work up. - Gingermegs


gb- this is only one leg of 3 leg table, so we need ABG and exercise testing.

Disagree - many texts state that FEV1 is the most important and some explicitely state that if their PPOFEV1 is >40% then no further testing is required. I doubt that the DLCO on the dodgy lung is going to be contributing more to the gas diffusion than the good one is, and many thoracic centres don't offer CPX.

On bypass, for mitral stenosis repair immediately after cardioplegia the following happens:

MAP to 25
SvO2 80%
CVP1

Next step in management:
A) metaraminol
B) give volume
C) increase pump flows
D) adrenaline infusion
E)

Answer A

This case report of hypotension going onto bypass and with each dose of cardioplegia outlines tretment and supports A also, as in alpha agonism of some form. However, it was really about vasopressin saving the day. Gingermegs. (J Thorac Cardiovasc Surg 2000;120:401-402)

This scenario is common, it is all about finding the right balance in circulating volume, pump flow and vascular tone. I tend more towards volume and pump flow first before using drugs. So therefore answer B for me. Andrew 12/01/10

I guess by the time you put the pleg in you're already running at full flow so theoretically the volume status should have been optimised. You've excluded the heart from the circulation so you don't have to worry about that MS haemodynamics business. I'd give squeezer. A

Redo CABG following median sternotomy surgeon states he has accidentally cut a vein graft, immediately followed by ST elevation on ECG and VF, next action.
A) External defibrillation 200J (Biphasic)
B) Heparin IV then femoral cutdowns for bypass
C) Hand ventilate with 100% oxygen
D) GTN infusion
E) metaraminol

Answer A

Spoke to a cardiac anaesthetist about this MCQ - he thinks that defibrillation is unlikely to be effective as the reason why you're in VF is you've suddenly rendered a part of the heart completely ischaemic. Yes, the chance of arrhythmias is higher given this is a redo and we always put pads on, but in this specific instance he thinks crashing onto bypass is more likely to save the day. It'll be interesting to see what the actual question says.


Mitral valve replacement for Mitral stenosis. Pulmonary artery catheter in situ. Following separation from bypass, copious frank haemoptysis via ETT. Next step in management"
A) Insert double lumen tube
B) Go back on bypass
C) Give protamine
D) Deflate and pull back PAC
E) Perform fibreoptic bronchoscopy

Answer A

I disagree and think the answer is B in this situation. There is a suggested treatment algorithm in this article, which although old is out of Melbourne. Ann Thorac Surg 1998;66:1242–5. This suggests that going back on bypass comes before insertion of DLT. Gingermegs.

Changing a/w ? There is copious frank blood. Not a good idea. I agree it is time to go back on bypass. Ref. to Slinger and Barash (damn where do I know these guys from?) in Journal of Cardiothoracic and Vascular Anesthesia, Vol.15, Issue 3, Pg 377-380 Answer B Andrew, 12/01/10

Young man on the ward post ORIF # tib/fib. On morphine PCA, high demands/bolus given ratio, used 40mg morphine in last 2 hours (or something else high). Is a bit drowsy but has severe constant leg pain. Next step in management
A. admit to intensive care
B. increase bolus dose morphine PCA
C. decrease lockout interval of PCA
D. organise urgent orthopaedic review
E. give more morphine until comfortable (or something else rubbish)

Answer D, to exclude compartment syndrome?

I agree with D, compartment syndrome is likely as tib/fib is high risk injury and morphine use is out of proportion to expected pain. Gingermegs

I agree, highest incidence of compartment syndrome in Tib/Fib's Answer D Andrew 12/01/10

Patient with IV in right arm, has mediastinal mass and SVC compression undergoing mediastinal biopsy, suddenly uncontrolled surgical bleeding in mediastinum. Next step in management prior to thoractomy:
A. insert femoral cannulae and place on bypass
B. insert IV in left arm
C. insert IV into foot
D. insert jugular CVC

Answer C

Agree with C, see OHA page 364, Gingermegs

AZ ASA grading was introduced to
A. predict intraop anaesthetic risk
B. Predict intraop surgical and anaesthetic risk
C. Standardise the physical status classification of patients
D. Predict periop anaesthetic risk
E. Predict periop anaesthetic and surgical risk

answer: c

(Shown a CT slice of the neck with a massive tumour that is causing left sided tracheal deviation) The thing that is the most concern to the anaesthetist is: A. Difficult intubation due to tracheal deviation to the left B. Difficult intubation due to tracheal deviation to the right.

Equipment

Why does a proseal LMA provide a better airway seal?
A. More stable position due to oesophageal tube
B. Doral cuff pushes ventral cuff...?
C. Presence of oesophageal lumen
D. Higher cuff pressure
E. ?

I think D. Here is a link to the propaganda, http://www.lmana.com/proseal.php - Gingermegs

I'm going with B. Dorsch & Dorsch Understanding Anaesthesia Equipment p475 5th Ed says that the Proseal LMA has a 2nd dorsal cuff, which pushes the LMA anteriorly to provide a better seal at the glottic apeture. It also helps anchor the LMA in place, and the Ventral cuff is larger than the classic LMA to help improve the seal. Taz

I agree with Answer B, Ref: LMA Bible Brimacombe pg 508, Table 19.1 Andrew 12/01/10

Depends if they mean higher "cuff pressure" or higher "cuff seal pressure". The cuff pressure in both shouldn't be greater than 60cmH2O as that would increase the incidence of mucosal ischaemia and sore throat.

Which of the following is the most frequent complication after use of LMA?
A. dysphagia
B. dysarthria
C. sore throat
D. hoarse voice
E. dry mouth

Another stupid question. Barash Clinical Anesthesia quotes the following
Sore throat 0 - 70%
Hoarseness 4 - 47%
Dysphagia 4 - 24%
So C perhaps?

Nope, the Answer is E, Mr "LMA" Brimacombe again, chapter 21, pg 554-555 specifically lists all the problems with LMA. Dry mouth 62-64% Sore throat 13% Dysphagia 11.5% Dysarthria 5.3% Andrew 12/01/10

What is true regarding arterial pressure transducer systems
A. Underdamping overestimates systolic BP
B. Underdamping underestimates MAP
C. Compliant tubing?

Medicine

MM Features of Eaton Lambert syndrome include all EXCEPT:

A. Associated with SCLC
B. Improvement with exercise
C. Defect in acetylcholine release from motor end plate
D. Dry mouth
E. Fatigue with exercise

I think C incorrect, as B is what distinguishes it from M. gravis clinically. They get blockade of the calcium channels reducing calcium influx into cells and thus reduced Ach release. OHCM states get better power with repeated movement. --Kom 22:59, 17 Apr 2009 (EDT) Tthe answer is more likely to be E. All the others are associated with Eaton Lambert Syndrome. (Or Lambert Eaton Syndrome for the North Americans out there. --Drawnover 05:59, 19 Apr 2009 (EDT)

I agree with E, exercise improves the condition. Kumar and Clark, 5th ed p 1223 has a good summary paragraph which includes the following: "This rare non-metastatic manifestation of small-cell carcinoma of the bronchus is due to defective Ach release at the NMJ" which seems to rule out C, Gingermegs

Agree with Gingermegs Answer E, ELS (=myasthenic syndrome) classically improves with exercise, Ref.: Yentis A to Z pg 352 Andrew 12/01/10

Look here also Myaesthenic syndrome

MC 60 year old vascular patient. ECG given.
Showed large positive R waves in lateral leads, large negative S waves in anterior leads. ST depression laterally  ie LVH with strain; bicuspid p waves
A. LVH with strain
B. Enlarged RA
C. Lateral ischaemia
D. LBBB
E. L posterior hemiblock
(I remember it as a straightforward LBBB. But no callibration on the ECG so couldn't diagnose LVH anyway)
There WAS a scale on the top left corner of the ECG that most people missed! It depicted the length corresponding to 1mV. The ECG satisfied LVH. It looked very similar to the following:--Asclepius

lvhlah.gif

Pulsus paradoxus is:
A. Reduced BP on inspiration unlike normal (ie normally increased on insp)
B. Reduced BP on inspiration exaggerated from normal
C. Reduced BP on expiration unlike normal
D. Reduced BP on expiration exaggerated from normal
E. ?

answer B gb

Agree with B, good explanation in Kumar and Clark 5th Ed p 710, Gingermegs

What antibiotics are required for bacterial endocarditis prophylaxis in a woman with MV prolapse for cholecystectomy.
A. None
B. gentamicin
C. ampicillin and gentamicin
D. ampicillin
E. cephazolin

answer - A- gb

Agree with none, so A. This is the link to the new guidelines, http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.108.190377 - Gingermegs

Male 60’s sudden onset of chest pain , L arm weakness and hoarse voice, ECG is unchanged from old (T inversion laterally), CXR normal, BP135/80, Pulse 110/min. Next step in management:
A)Aspirin
B)SNP infusion
C)GTN infusion
D)Metoprolol
E)Heparin

Answer D gb- i will first give asprin as it seems more of infarction than ischemia. I actually think the history is trying to paint a picture of aortic dissection and would agree with answer D

Plasma glucose level compared to blood glucose level
a)32% higher
b)14% higher
c)same
d)14%lower
e)32% lower
answer- D -gb
No, the PLASMA IS HIGHER - B if correctly remembered

Obstetrics

You are called for a labour epidural. The woman is extremely distressed and in the middle of your consent process states “Just take my pain away” . You:

A. Place epidural then when calmed return to advise her of risks and complications
B. Explain she has to hear all the potential complications and refuse to place epidural without consent
C. Take consent from partner
D. Perform spinal to relieve pain, then consent her for epidural
E. Go away and return when she is more cooperative

The actual question stated that she refuses to listen to your repeated attempts at explaining the risks.

I remember the question as her being only 3cm dilated, and that one of the options was a bit less aggressive than B. Saying something along the lines of explaining to her that there are major risks that she need to know about before placing the epidural. Safely by the book, B? The rest wrong.

Agree B is best from the lot. As we prepare/clean prep etc. we would still briefly inform the patient about "common side effects" and "rare, but serious complications" and ask if she is happy for us to procede. Andrew 12/01/10

Found where this question came from I think (the actual answers here probably doesn't exactly quote the exam paper) "Just put it in!" Consent for epidural analgesia in labour. Editorial by MJ Paech Anaesthesia and Intensive Care 2006.34(2)147-9. He clearly states that A is the correct answer. While this is not necessarily what most of us are comfortable with, I suspect this question references that article. --Dr_Al 06:34, 18 Feb 2010 (EST)


You are on call for a maternity hospital. Your junior registrar calls you after having inserted a labour epidural in an extremely anxious 19 yo parturient, and obtained blood in the catheter. He informs you the epidural space was found by LOR at 6cm and the catheter has been inserted to 12 cm. Your first instruction should be:

A. Flush with saline then check again for blood (NOT an option - option was just flush with saline and secure and use)
B. Aspirate again for blood
C. Give 3mls 2% lidnocaine with 1:200 000 adrenaline
D. Pull back 2cm and check again for blood
E. Remove epidural and start again

Pull back to 4cm in space, check, and score. D


Pre-eclamptic woman BP 180/110. Aim to drop BP to

a) 150-160
b) 140-150
c) 120-130
d) 110-120
e) 100-110

B. As per Obs SIG.


Highest likelihood of motor block with labour epidural analgesia:

A)Nurse initiated epidural topups

B)Anaesthetist initiated epidural topups

C)PCEA

D)Continuous epidural infusion

E)All associated with same motor block

British Journal of Anaesthesia, 2002, Vol. 89, No. 3 459-465 "Patient-controlled epidural analgesia versus continuous infusion for labour analgesia: a meta-analysis" demonstrated the PCEA was associated with less motor block cf CEI. Oxford handbook of obstetric anaesthesia states that intermittent top-ups are associated with low incidence of motor block (except for my I don't know where the epi is let's give 2% lignocaine!); clinically these women will probably end up with less boluses than PCEA given they'd have to wait every time a bolus is wanted. I'd therefore think D would be most likely to be correct.

ANZCA pain book page 189: comparison with continuous epidural (vs PCEA) first study quoted found higher incidence motor block with continuous (but also better pain scores), next paragraph muddies the waters and states that more recent studies have found no difference in side effects (including motor block) ANZCA doesnt give a key message summary here, so I'm going for D. Very nice of them to ask a MCQ when even they are not sure of the answer.

Trauma pregnant patient (?32wks) BP 70/40, P 50, intubated in emergency department, next management step:

A)L tilt pelvis

B)IV fluid bolus

C)Arrange urgent caesarean section

D)Vasopressor options (?Adrenaline, Metaraminol)

A. Basics first, then fluid, then pressor.


Emergency caesarean section for foetal distress (and foetal acidosis on scalp probe?). what is best option to raise gastric pH preop:

A)Oral Na Citrate

B)Ranitidine IV

C)Ranitidine oral

D)Omeprazole IV

E)Omeprazole oral

F)Metoclopramide 20 IV

A. 30ml 0.3M, concur?
Did they give the option of ranitidine oral effeverscent vs ranitidine oral tablet?

Answer A - Yes it's Na Citrate in Emergency CS only. Non EM CS it is Combi of NaCitrate po and Ranitidine iv. ANZCA OBS Bible pg 59, Andrew 12/01/10

Yes, ranitidine effeverscent has a biphasic response to raising pH due to the bubbles.

Surgery

70 year old man having lung resection for SCC of left lung FEV1 2.3L (? % predicted), FVC 3.5L (? % predicted). Do you...

A. Accept for lobectomy or pneumonectomy

B. Decline pneumonectomy, proceed to lobectomy

C. Cardiopulmonary exercise testing

D. Differential V/Q scan

E. Decline both pneumonectomy and lobectomy

[1] says if the FEV1 is >2L then they are fit for a pneumonectomy as you'd leave them with and FEV1 of >1L.

Anatomy

NU Which distinguishes C8-T1 from an ulnar nerve lesion at elbow?
A. Paraethesia of the 5th digit
B. Paraesthesia over index finger
C. Flexor carpi ulnaris function
D. Paraesthesia/sensory loss over medial forearm
E. Adductor pollicis function

A, B, E incorrect. Sensory supply over medial forearm is by medial antebrachial cutaneous nerve, a branch of BP (and is dermatome T1). Thus correct answer is C or B?. FCU is supplied by ulnar nerve but C6/7. (Hey this is rehashed NV44 just swapping stems AbdPB for FCU and putting in AddP as a distractor.)

Answer is D. The medial cutaneous nerve of the forearm arises from the medial cord of the brachial plexus which is prior to the formation of the ulnar nerve.

Regional Anaesthesia

RH Asking the patient to look up and in during a retrobulbar block increases the risk of injury to:
A. Inferior oblique
B. Superior oblique
C. optic nerve
D. globe
E. ophthalmic artery

C The Atkinson “up and in” position of the gaze was abandoned when Liu et al. and Unsöld et al. confirmed that it increased the risk of optic nerve injury. From “regional anaesthesia for eye surgery” Regional Anesthesia and Pain Medicine, Vol 30, No 1 (January–February), 2005: pp 72–82.--Kom 22:50, 17 Apr 2009 (EDT)


RL A man presents for an ankle fusion. Which of the following combinations will provide the best block:
A. Sciatic nerve
B. Common peroneal and saphenous
C. Tibial and saphenous
D. ?Sural and tibial
E. Ankle block

There was no option with saphenous and sciatic as in previous version, not sure any of options would be adequate.
A Sciatic nerve would be probably be the best option - it splits into the common peroneal and tibial somewhere in the popliteal fossa and is indicated for surgery involving lower leg, ankle foot. You might miss part of the saphenous nerve innervation but you might get away with it...


alt remembered

patient having ankle fusion. doing regional. which would be adequate? a) femoral nerve block
b) common peroneal and femoral
c) tibial and femoral
d) ankle block
e) sciatic nerve block

RN18 Stellate ganglion block associated with all except:

A. Ptosis
B. Miosis
C. Sweating
D. Facial flushing
E. Nasal stuffiness


Spinal anaesthesia, T3 level a) bradycardia due to unapposed vagus b)autonomic response more if lever higher

Intensive Care

18yo patient in a psych unit, being treated for frequent vomiting. Collapses and found unconscious.
ABG's:

pH 7.22
CO2 40
PO2 100
HCO3 16
Na 138
K 4.0
Cl 105

Diagnosis is:
A. anorexia nervosa
B. diabetic ketoacidosis
C RTA
D. Normal saline administration
E) Gastric outlet obstruction

comment: the gas definitely showed a metabolic acidosis with AG 21; pO2 was safe.
High anion gap metabolic acidosis with normal chloride - only one that fits is DKA. B


60yo with history of hypertension. Presents with chest pain, hoarse voice, left arm weakness. Has lateral T-wave changes on ECG, also present on an old ECG. Heart rate 110, BP 130/80 (definitely this value), SpO2 96% or something. First drug to give:
A. aspirin
B. metoprolol
C. GTN
D. nitroprusside
E. Heparin

The question is whether this represents dissection or AMI. Didn't think hoarse voice and left arm weakness are typically associated with AMI; thus I think the question is getting at dissection. The history of HTN is also associated. The first drug to give would be a beta-blocker of some description; thus B


Trauma patient with GCS 6 with hard collar. HR and BP unstable. What is the best way of clearing neck?
A. CT
B. Cervical spine trauma series
C. MRI
D. Leave had collar indefinitely??
E. Clinically

Depends on the wording - either leave collar on until stable, or CT when stbale is what you'd actually do.

Patient (?48h post) SAH following bloods:

Na 155
Plasma osmolality 350
urine osmolality 250

Management includes:
A)DDAVP (?nasally)
B)Water restriction

basically hypernatremia with high plasma osmolality N=280 and low urine osmolality (ranges from 50-1400, but average is 500-800), suggests DI ie inadequate ADH secretion - therefore treatment DDVAP

Alt 6 hour post pituitary surgery, Serum Na 153, next step in management
a)Dext 5%
b)Normal saline
c)DDAVP
cant remember other options

Paediatrics

Neonate if febrile with rash and periodic breathing. which is likely ABG?
a) metab acidosis resp acidosis
b) metab acidosis compensated
c) resp acidosis
d) alkalosis
e) alkalosis

2 month old systolic murmur heard at apex no change with posture, now on 5th centile for weight after being on 30th at birth, mother states has difficulty feeding. Peripheral pulses reduced femoral more than upper body. Most likely cause:
A. HOCM
B. VSD
C. PDA
D. venous hum
E. ASD

Answer C

PDA - collapsing pulse with sharp upstroke from ejection of large volume of blood into empty aorta during systole, low diastolic pressure due to rapid decompression of aorta, hyperkinetic apex, single S2 if large or even reversed splitting of S2, continous loud "machinary murmur at 1st LIC space. sometimes associated with flow murmur through left heart eg. mitral mid diastolic murmur. (Talley + O'Connor 3rd Ed.)

If the pulmonary-to-systemic blood ratio approaches or exceeds 2:1, an apical flow rumble, caused by high flow into the left ventricle, is frequently present. Also, because flow through the left ventricle into the aorta is increased, an aortic ejection murmur may be present. History of difficulty feeding, low birth wt or poor growth, prematurity. www.emedicine.medscape.com --Asleep 06:14, 22 Dec 2009 (EST)


4 yr old presents for elective surgery, otherwise fit healthy, murmur at left sternal edge on auscultation heard in systole and diastole, disappears on lying down. Most likely cause:
A. HOCM
B. VSD
C. PDA
D. venous hum
E. ASD

Answer : D

Venous Hum - systolic + diastolic components, not really a murmur. Benign medical condition where 20% of the blood flow travels to the brain and back to the heart. Due to the large amount of blood it can move quite fast causing the vein walls to vibrate which can create a humming noise to be heard by the patient.The murmur disappears when the patient is in the supine position. Tally&O'connor 3rd Ed p79-83 and wikipaedia. --Asleep 06:14, 22 Dec 2009 (EST)


18/12 old undergoing routine SV GA under LMA. Sudden onset SVT with HR 220 BP 84/60 ETCO2 32 SpO2 98.Management:
A. Adenosine 100mcg
B. DCR 2J/kg
C. DCR 4J/kg
D. Amiodarone 5mg/kg
E. CPR

A. wrong (dose is 30 to 50mcg/kg, so 300 to 500mcg in this case, besides not the first choice anyway)
B. wrong (dose is 0.5 to J/kg in paeds for SVT)
C. wrong (see above)
D. best answer here
E. wrong, BP's fine
Andrew 13/01/10

I bet the actual question says adenosine 100mcg/kg which is the dose in the RCH book. Ever given amiodarone for SVT? I haven't.

Textbook of pediatric emergency procedures - Christopher King, Fred M. Henretig, Brent R King - 2007 SVT table - Adenosine (100,200,400 mcg/kg/min) then syncronised cardioversion (0.5,1,2 J/kg) That would suggest in its current form that B may be correct. Disco


What is the appropriate LMA size for an 8kg child:
A. 1
B. 1.5
C. 2
D. 2.5
E. 3

Answer: B

LMA sizes (Drug Doses Frank Shann Book) <5kg = 1, 5-10kg = 1.5, 10-20kg = 2, 20-30kg = 2.5, 30-50kg = 3.0, 50-70kg = 4.0, 70-100kg = 5.0, >100kg = 6 --Asleep 06:14, 22 Dec 2009 (EST)


Neonate born to known drug abusing mother brought to emergency department by grandmother, unwell lethargic, slightly jaundiced, ABG shows following:

pH 7.52
Na 135
Cl 87
K 3
pCO2 38

Which of the following is the Diagnosis?
A) Septicaemia
B) Hepatitis
C) Pyloric stenosis
D) Pneumonia
E) Opioid withdrawl

Hypokalaemic, hypochloraemic metabolic alkalosis; classic for pyloric stenosis. The other stuff is probably a distraction.


15kg child found fitting on paeds ward ?24h ?48h postop while on infusion of 60ml/h ½ NS + Dextrose. Now intubated. Na is 119, next management step:
A) frusemide
B) hypertonic saline
C) Normal saline at 20ml/hr
D) Water restrict
E) Phenytoin

B. Symptomatic hyponatraemia = hypertonic saline.

Pharmacology

PN: A man on PCA controlled with 2 mg morphine bolus is having a lot of pruritus. You decide to switch him to fentanyl. Which dose is the most appropriate bolus to be equi-analgesic with morphine 2mg:
A. 10mcg
B. 20mcg
C. 40mcg
D. 60mcg
E. 80mcg

A bit of a tricky question - a straight conversion would be 20mcg. However, according to APMSE, the optimal dose of a morphine PCA is 10mcg, while fentanyl might be 30 or 40mcg. So while from a efficacy point of view the equivalent dose would be 20mcg, clearly clinically it is not. Nearly all morphine PCAs start 1 mg but I can't remember the last time I've seen a fentanyl PCA at 10mcg (except in little old ladies)... Votes?

Though in the APMSE it does make the point that the higher doses of fentanyl were infused over 10mins, possibly altering the effect of that dose. It also asks about the equi-analgesic dose as opposed to the most effective dose, if this isn't splitting hairs too much.

Ah but this is the MCQs - it is entirely about splitting hairs.

A patient with chronic pain using morphine PCA after lower limb orthopaedic surgery. Daily usage of IV morphine works out at about 400mg/day. What dose of oral methadone would you start him on to replace the morphine?
A. 60mg/day
B. 120mg/day
C. 400mg/day
D. 600mg/day
E: 1200mg/day

Methadone replacement depends on dose of oral morphine
Daily Dose : Conversion Ratio
<100mg 3:1
100 - 300mg 5:1
300 - 600mg 10:1
600mg - 800mg 12:1
800mg - 1000mg 15:1
>1000mg 20:1
400mg IV = 1200mg oral. 20:1 conversion so 60mg of methadone per day = A


PR For muscle relaxant,placing the nerve stimulator to stimulate FPB (Flexor pollicis brevis) compared to Abductor pollicis brevis is likely to
A. show a slower recovery to NMB
B. show the same recovery
C. show a faster recovery to NMB Cannot remember other options

Do you mean flexor hallicus brevis? That would make a lot more sense as when you stimulate the ulnar nerve both APB and FPB can be stimulated but no one actually monitors FPB. On the other hand FHB would make sense as you may not have access to the arm (or can't see it). There are lots of papers comparing FHB and APB including this review (Monitoring neuromuscular block: an update Anaesthesia Volume 64, Issue s1, Pages 82-89) which says the two sites are clinically equivalent. B

EM66 Aneursym clipping, BEST monitor of depth of block during this is
A. TOFR
B. TOFC
B. DBS
C. PTC

C? I gues you really don't want them to move do you?

PV
Closed circuit anaesthesia with 70%N2O,70kg man (low flow i think) what is the uptake of N2O after 90 mins anaesthesia:
A. less than 50ml/min
B. 100ml/min
C. 200ml/min
D. 500ml/min
E. 1000 ml/minut

Severinghaus equation (Miller 87) – uptake = solubility x CO x A-V difference x proportion of inspired gas mix.

Old question - uptake is 1000 divided by the square root of the time administered in minutes (which works out roughtly to be B)
See AZ29

Rapid infusion of mannitol IV initially causes:
A. Raised ICP
B. Reduced CBF
C. Reduced K
D. Reduced Na
E. ?

A. The physical bolus of Mannitol causes an initially transient increase, then decreases as interstitial water is drawn out.

Granisitron, which is incorrect:
A) Decreased serotonin release
B) Metabolism by carbamoyl ?...
C) 5HT3 antagonism

gb-A westmead page 242


Who has got minimum effect on ICP at 1 MAC a)isoflurane b)sevoflurane c)desflurane d)enflurane e)halothane


gb- i suppose isoflurane

Physiology

PH An ABG showing a raised anion gap. Which of the following would explain this ABG?
A. Salicylate poisoning
B. DKA
C. Lactic acidosis
D. 6L of normal saline (or did this option belong to another Q?)

Need to look at the ABG as A,B,C can cause an raised anion gap but salicylate poisoning is the weird one that causes a respiratory alkalosis beyond what is expected in compensation.

Or maybe a which of these does not question?

Young woman with subarachnoid haemorrhage, hyponatraemia and increased urinary sodium (did not specify if high sodium concentration or total amount lost). What is likely cause?
A. cerebral salt wasting syndrome
B. SIADH
C. HHH therapy
D. Excess NS administration
E. diabetes insipidus

gb-CSWS is usually caused by brain injury/trauma or cerebral lesion, tumor, or hematoma. CSWS is a diagnosis of exclusion and may be difficult to distinguish from the syndrome of inappropriate antidiuretic hormone (SIADH), which develops under similar circumstances and also presents with hyponatremia. The main clinical difference is that of total fluid status of the patient: CSWS leads to a relative or overt hypovolemia whereas SIADH is consistent with a normal to hypervolemic range. Random urine sodium concentrations tend to be lower than 100 mEq/L in CSWS and greater in SIADH . If blood-sodium levels increase when fluids are restricted, SIADH is more likely. [3]


[edit] Treatment

Statistics

Which of the following can be used to describe the spread of non-parametric data?
A. standard deviation
B. interquartile range
C. confidence interval
D. standard error
E. variance coefficient

B (CEACCP 7(4): 127-130, answer on p129). Jo, Aug 09.

Repeats

PP Most resistance in the circuit of an intubated neonate

MC Investigation of choice for aortic dissection in potentially unstable patient

Blunt abdo trauma, liver injury, for conservative management if a)haemodynamically stable b) blood <500 ml in the peritonium c) low grade injury on CT

best way to protect kidney

maintain a)cvp b) RBF c) PAP

Equipment: Difference between cardiac protected and body protected area a)LIM - line isolation monitor b) equipotential earth


PN: elderly what is false a)reversal with neostigmine b) atropine and heart rate

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