Finals MCQs-August 2009

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Finals Black Bank | Apr09 | Finals MCQs-March 2010

MCQs from the FINALS Exam 28th August 2009 
 
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Q1-36 Posted at 12:37 28/8/09

MH56 (NEW) Bleeding patient. What is relative contraindication to Prothrombinex?
A. History of HITS
B. Von Willebrands
C. Haemophilia B
D. Warfarin overdose
E. Renal failure
F. Overdose vit K (not warfarin)

Answer is A (it contains 192 IU heparin per vial) [1]

TMP-128 [Aug09] Indication for percutaneous closure of ASD

A. Ostium primum < 3cm
B. Ostium primum > 3cm
C. Ostium secundum < 3 cm
D. Ostium secundum > 3cm
E. Sinus venosus ASD


TMP-129 [Aug09] Methylene blue given intravenously has the effect:

A. Pulse oximetry goes down
B. Blood Gas Pa02 decrease
C. Hypotension
D. Metabolic acidosis
E. Increased heart rate


TMP-130 [Aug09] Essential diagnostic criteria on ECG for LBBB

A. Loss of septal Q's in V5 and V6
B. RSR in V1
C. Large slurred S in V6
D. T-waves opposite to direction of QRS
E. QRS duration minimum 0.2 s


MH57 (NEW) Patient over-warfarinised and is for surgery. Prothrombinex 50U/kg may NOT reverse an INR of 5.5 because it contains:

A. Citrate
B. Heparin
C. Anti-thrombin III
D. Not enough Factor VII
E. Not enough Factor X


PL29 (NEW) Ventricular fibrillation (VF) following caudal anaesthesia in 20kg six year old child. The recommended dose of of Intralipid 20% is:

A. 10mls
B. 20mls
C. 30mls
D. 40mls
E. 50mls


7. (NEW) Regarding College Professional Document PS9 – sedation for colonoscopy – the following equipment must be present (NB: The wording was 'present', not 'ready access to' as used for defib in PS9)
a. Defibrillator
b. Mechanical ventilator
c. Anaesthetic machine
d. Suxamethonium
e. Dantrolene

Did all of the options get remembered correctly? Because the only thing mentioned in the college document is "ready access to a defibrillator". A means of inflating the lung is "a self-inflating bag". Emergency drugs that must be present did not include sux or dantrolene (although one would wonder what you're supposed to do with the laryngoscope and tube without muscle relaxant of some description)

This question did not refer to "PS9", it was just what must you have before undertaken sedation for colonoscopy. It was the next question that referred to PS9

8. (NEW) According to PS9 for sedation with Propofol for colonscopy, the staff required is/are:
a. Medical practitioner other than proceduralist
b. Nurse other than proceduralist
c. Anaesthetist in addition to the proceduralist
d. Assistant
e. Proceduralist alone

Answer is A

  • Propofol may be used by a medical practitioner with airway and resuscitation skills, and training in sedation for conscious sedation in ASA P 1-2 patients.
  • Intravenous anaesthetic agents such as propofol must only be used by a second medical practitioner trained in their use because of the risk of unintentional loss of consciousness. These agents must not be administered by the proceduralist...From PS9

TMP-131 [Aug09] Troponin is elevated post-infarct

A. 1-2 days
B. 2-5 days
C. 5-14 days
D. 7-21 days
E  ?


ALT: Duration of Troponin elevation

A. 12-24 hours
B. 24-48 hours
C. 2-5 days
D. 5-14 days
E. 2-4 weeks


TMP-132 [Aug09] Laparoscopic cholecystectomy patient with hyperparathyroidism and ionised calcium of 2.0 mmol/l. The BEST initial treatment is:

A. Calcitonin
B. Magnesium
C. Dialysis
D. IV fluids
E. Frusemide


11. (NEW) Your patient given thiopentone by mistake has a porphyric (acute intermittent) crisis with abdominal pain and then seizures. What drug is contraindicated?
a. Phenytoin
b. Morphine
c. can't remember others
d. ?
e. ?

A

12. (NEW) Fit lady for elective laparoscopic cholecystectomy seen in PreAdmission Clinic. ECG shows LAD, RSR in V1, wide slurred S in V6 and QRS duration 0.2 msec. Your options
a. Refer to cardiology
b. Crack on
c. Place permanent pacemaker
d. Place temporary pacing wires
e. Give atropine premedication

EDIT - duration was 0.13msec i.e. only slightly elongated = unifascicular block. LAD + RBBB is either LAFB of LPFB, sorry can't be bothered to look it up now. DOn't think it needs investigation though.

I thought this question provided the ECG description, rather than an actual ECG to interpret, and definitely said QRS 0.2s
The question only described an ECG in words which i interpreted as a bifasicular block, As per AHA/ACC crack on

13. (NEW) All these nerves provide some sensation to upper arm EXCEPT
a. Musculocutaneous
b. Intercostobrachial
c. Radial
d. Circumflex
e. Median antebrachial?

NB: Musculocutaneous nerve is:

  • musculo- (ie motor) ABOVE the elbow THEN
  • sensory (as lateral cutaneous nerve of the forearm) BELOW the elbow -ie NO sensory above elbow.

14. (NEW) Advantage if supraclavicular over interscalene nerve block for shoulder surgery
a. Less phrenic nerve block
b. Easier landmarks in obese patient
c. Arm can be in any position for block
d. Less risk pneumothorax
e. Better cover for shoulder surgery?

A probably given that phrenic nerve block is an expected outcome of the interscalene block. Doesn't matter where the arm is, and in the fat patient both might be difficult. Closer to pleura with SCB and you might miss supraclavicular with SCB as it comes off early from the superior trunk.

15. (Variation of old question NV27) The basilic vein
a. Arises from the dorsum of the hand
b. Follows the superficial radial artery
c. Pierces the clavipectoral fascia
d. Becomes the brachial vein at the cubital fossa
e. Arcs around the radial side of the forearm

A? It arises from the medial (ulnar) side of the dorsal venous of plexus of veins (thank god wikipedia); hence does not follow the superficial radial artery. It joins the brachial vein to become the axillary vein in the axilla. The cephalic vein does B,C and E.

I vote for "C": A,B and E are for the cephalic vein, D is wrong because the basilic vein Joins the brachial vein to become the axillary vein. Andrew 13/01/10

A: true (although cephalic vein also arises from dorsum of the hand) B; False - Travels up ulna aspect of arm C: False - Pierces the Brachial fascia midway up upper arm (Cephalic v pierces clavipectoral fascia) D: False - see above comments E: False - see comment for B Reference: Netters Atlas of Human Anatomy (2nd ed), Plates: 174, 406, 448, 449


AC158 [Aug09] [Aug10] Long duration of surgery, arms stretched out, head turned 30 degrees to right. On waking patient has a neurological deficit. Sensory loss over ventral lateral palm and 3 fingers, some weakness of the hand, weakness of the wrist, some paraesthesia of the forearm and weak elbow flexions. Most likely injury is

A. Median nerve
B. Ulnar nerve
C. C5 nerve root
D. Upper cervical trunk
E. Musculocutaneous

17. (Variation of old Question). Paediatric ALS – 20 kg, VF has had 2 shocks only. Next step
a. Adrenaline
b. Amiodarone
c. Shock 50J
d. Shock 100J

A

This question gave no weight for the child. I think he was 5 which made him 18kg. Adrenaline was my answer but the maths didn't fit with 50 or 100kj shock anyway

In a VF paediatric arrest (witnessed) you give three stacked shocks, the first at 2J/kg the next two at 4J/kg. Hence the child needs an 80J shock (4x20kg). Then CPR for 2min, then reassess rhythm/adrenaline. I don't think you can dial up 80J on most defibrillators. You can only choose 50J or 100J. Hence you would round up to 100J. Hence answer would be D. saraht

Question doesn't say whether it's witnessed or not. The algorithm would have you giving 2 shocks anyway before adrenaline. You can dial up 70J on a Philips Heartstart - if the child was 5 this would be closest to 4J/kg. Need the real question.


18. (NEW) Patient with known severe aortic regurgitation. Auscultation reveals loud mid diastrolic murmur in aortic area. You also hear a quiet mid diastolic murmur in the apex. This is
a. Functional mitral stenosis
b. Mitral valve incompetence
c. Impaired LV function
d. Papillary muscle dysfunction

Sounds like they're talking about the "Austin-Flint" murmur, where the regurgitant jet strikes the anterior leaflet of the mitral vale. A

Austin Flint - Classically, it is described as being the result of mitral valve leaftlet displacement and turbulent mixing of antegrade mitral flow and retrograde aortic flow:[6]

Displacement: The blood jets from the aortic regurgitation strike the anterior leaflet of the mitral valve, which often results in premature closure of the mitral leaflets. This can be mistaken for mitral stenosis. (Wikipedia) Disco 27/6/10


TMP-133 [Aug09] Hetastarch 130/0.4. The 0.4 means: A. 40 mg/l B. 40 g/l C. 4 hydroxylations of every 10 glucose molecule D. every 4the glucose is hydroxyethylated E. ?


TMP-134 Hetastarch. What one to use for intermediate plasma expansion and intermediate plasma half life

A. 450/0.4 (10%)
B. 130/0.7 (6%)
C. 130/0.4 (6%)
D. ?
E. ?


TMP-134 A Hetastarch of intermediate plasma expansion and intermediate plasma duration is

A. 10% HES 250/0.6
B. 10% HES 200/0.5
C. 6% HES 450/0.7
D. 6% HES 130/0.4
E. 3% HES 200/0.5


21. (NEW) Maternal collapse post-delivery. What is NOT consistent with Amniotic fluid embolism?
a. Seizure
b. Petechial rash
c. Hypotension
d. Coagulopathy
e. Cardiac arrest

B'.

22. (Repeat) Trauma with # pelvis and femur. Has a splenectomy. Day 2 patient thrombocytopenia, confused and hypoxic. Diagnosis is
a. fat embolism syndrome
b. pneumcoccal pneumonia
c. thromboembolism

23. (NEW) Indications for steroids in neurosurgery
a. Cerebral abscess
b. Subdural haematoma
c. Meningioma
d. SAH
e. Traumatic brain injury

C, but possibly 2 right answers to this question. "Steroids are used for brain tumours or abscesses with significant surrounding vasogenic oedema". Neurosurgery: an introductory text Peter McL. Black, Eugene Rossitch. Pg 83

My answer is C - quick Google search found this reference of questionable authority, too late at night to search further: ACNR • VOLUME 5 NUMBER 1 • MARCH/APRIL 2005 " In general steroids are not used in brain abscess patients due to the immunosuppression associated with these drugs. However, extensive oedema may surround the abscess and contribute to raised intracranial pressure. In a deteriorating clinical situation steroids can improve the clinical status of patients when there appear to be few options remaining. This is probably due to a reduction in the inflammatory process reducing concomitant oedema." --Pukeko 04:57, 16 Jul 2010 (EDT)


24. (NEW) Rate of phenytoin administration:
a. 50 mg/min
b. 70 mg/min
c. 100 mg/min
d. Over 5 minutes
e. As fast as possible

I think option e was: over 10 minutes

A Admin by slow IVI (max 50 mg/min) into large vein via catheter (from MIMS)

25. EV08 Hypothetical anaesthetic agent. Flows 2 L oxygen and 2L nitrous. Copper kettle vaporiser flow 0.5 L. Volatile with SVP 380 mmHg. Inspired volatile concentration (no numbers were exactly correct)
a. 2%
b. 5%
c. 10%
d. 11%
3. 15%

It's 10% (C). Reading the explanation in Morgan and Mikhail, if 0.5L of gas enters the vapouriser, 1L exits, with a volatile concentration of 50%. This is diluted by 4L of FGF, so you have a total of 5L of gas. 500mL in 5L is 10%. Doesn't make sense? A copper kettle has a dedicated flow meter which is dialed up separately. To make your 0.5L of gas flow fully saturated with vapour at an SVP of 380mmHg, you need to double it (ie 380mmHg of vapour in 380mmHg of gas). This is mixed with the FGF which is separate; thus giving 500mL of vapour, 500mL of gas which went into the copper kettle, 2L of oxygen and 2L of nitrous.

26. (NEW) Negative pressure leak test in a Boyles type machine. This means
a. Vaporiser leak
b. Circuit leak
c. Brain leaking out of my ears by now
d. Leak in non return valve

Rehash of old question - EZ84. A

27. (NEW) As per ANZCA Acute Pain Guidelines (2nd ed update), after a prophylactic subcutaneous dose of heparin, minimum time before you can remove epidural catheter is
a. 2 hours
b. 4 hours
c. 6 hours
d. 8 hours
e. 10 hours

C. From update guidelines "Thromboprophylaxis with SC heparin is not a contraindication to neuraxial blockade. To identify heparin-induced thrombocytopenia, a platelet count should be done prior to removal of an epidural catheter in patients who have had more than 4 days of heparin therapy. Epidural catheters should be removed a minimum of 6 hours after the last heparin dose and not less than 2 hours before the next dose."

Interestingly this does not corresponde with most of the world wide guidelines who say 4 hours.


also: LMWH - wait 12 hrs after dose to insert

                   first dose 2hrs after removal

28. (NEW) Utility of BNP (brain naturietic peptide) is for
a. Dyspnoea after pneumonectomy
b. Loss of consciousness after ..
c. Confusion after CABG

Both BNP and NT-proBNP levels in the blood are used for screening, diagnosis of acute congestive heart failure (CHF) and may be useful to establish prognosis in heart failure and in Anesthesiology, preoperative BNP independently predicts in-hospital ventricular dysfunction, hospital length of stay (HLOS) and mortality up to 5 years after primary CABG surgery. So hard to know without the real question. Other things I've read suggest that BNP can help differentiate dyspnoea due to cardiac failure from other causes. After pneumonectomy, there is a sudden increase in PVR, so perhaps this is indicative of whether the right heart is coping. I think the key is dyspnoea; when the real answers appear (in the next exam no doubt) its utility is to suggest whether the dyspnoea is related to cardiac failure or something else.

29. (NEW) Which patients do not get pulmonary hypertension
a. ASD
b. Chronic thromboembolism
c. Tetralogy
d. MR
e. MS

Must be C as you have some degree of RVOT obstruction thus pulmonary blood flow is decreased, and your mitral valve is competent so there is no increase in LA pressure.

30. (NEW) Drug LEAST likely to cause hypoxia in ARDS
a. Noradrenaline
b. Milrinone
c. Isoprenaline
d. Isoflurane
e. SNP

A. All the others would bugger up your HPV.

31. PI82 (NEW) Pulmonary hypertension, which will affect PVR the most
a. Isoflurane
b. Sevoflurane
c. Desflurane
d. Propofol
e. Remifentanil

Tricky question both 30 and 31. In Eger's book Pg 87 it is clear that all volatiles inhibit HPV much to the same extent, and produced lower arterial oxygen partial pressures and higher shunt fractions than did anaesthesia with propofol. But drops the PVR with normal gas exchange but abnormal vasculature? It also begs the question, in which direction? This article seems to suggest that propofol doesn't change PVR much, Des may raise it, and Sevo and Iso both decreased it with Sevo decreasing it to a greater amount than Iso. This article seems to suggest remi decreases PVR in the cat... but I can't find any studies in humans. So with only one article to go on I suspect B, Sevo might be the answer.

32. (NEW) In body protected OR with a Line Isolation Monitor reading 0 mA. If you touch one active wire what will happen.
a. nothing, because no connection to earth is completed
b. you get shocked
c. nothing because the floor is insulated
d. nothing because your shoes are nonconductive
e. RCD trips

A. 0mA means everything is fine and properly isolated so the circuit is not earth referenced.

this link explains line isolation monitors nicely http://biomedgbis.com/line_isolation.htm

33. (NEW) Best way prevent first phase of heat loss after induction
a. Prewarming the patient with forced air warming
b. Warm blankets
c. Warm fluids
d. Warm theatre
e. Humidified gases

A From my own 1st part notes; pre-warming eliminates the gradient between core and peripheries thus the redistribution phase does not occur.

34. (NEW) Best way to assess fluid resuscitation after burns is
a. Urine output
b. mixed venous sats
c. blood pressure
d. cvp
e. capillary refill

My answer - A - urine output - from Blue Book 2005 - "End points of resuscitation The optimal end points for burns resuscitation continue to generate much debate. Despite the administration of fluid therapy according to prescribed guidelines, problems frequently noted at the end of the burn resuscitation are generalized oedema, decreased efficiency of pulmonary gas exchange, hypoalbuminaemia and intermittent episodes of hypotension and oliguria. Some problems may indicate over resuscitation, whereas others are suggestive of ongoing hypovolaemia. Clinical examination, together with assessment of end organ perfusion (urine output 1⁄2 to 1 ml/kg/hr; intact sensorium), is the minimum assessment possible to guide burn resuscitation. Pulmonary artery catheters and other more invasive forms of monitoring of haemodynamic parameters have not been shown to improve outcome in surgical, medical or burns patients. Both subcutaneous and splanchnic oxygenation are sensitive indicators of evolving haemorrhagic shock, and have been used in burn care to monitor tissue oxygenation indices during burn shock and resuscitation.15 Recently, Rivers et al investigated the use of central venous oxygen saturation (ScvO2) as part of a package to guide therapy for severe sepsis, and showed an improvement in outcome when it was used in a single centre.16 However, the role of ScvO2 to guide resuscitation of burn shock is not established. A single centre Australasian study is planned.

And from UpToDate 2009: Monitoring fluid status — Confirmation of adequate resuscitation is more important than strict adherence to Parkland or any fluid resuscitation formula. Monitoring urine output using an indwelling bladder catheter (eg, Foley catheter) is a readily available means of assessing fluid resuscitation. Hourly urine output should be maintained at 0.5 mL/kg in adults and 1.0 mL/kg in children who weigh less than 25 kg. Patients with minimal or no urine output following severe burns, despite fluid resuscitation, generally do not survive. --Pukeko 05:24, 16 Jul 2010 (EDT)



35. (NEW) Emergence delirium in a kid in recovery. To treat
a. Fentanyl 1mc/kg
b. Midazolam 0.1 mg/kg
c. Propofol
d. Clonidine 1mc/kg
e. Sucrose

Must be more to this question, perhaps what's not treatment? Emergence Delirium in Children: Many Questions, Few Answers states "Rescue" medication includes analgesics, benzodiazepines, and hypnotics. Fentanyl IV 1–2 µg/kg (22), propofol IV 0.5–1.0 mg/kg (39), and midazolam IV 0.02–0.10 mg/kg (12,84) have all been used for the treatment of ED. A single bolus dose of dexmedetomidine 0.5 µg/kg was also shown to be efficient in the PACU for ED (85). Perhaps in the age group likely to get ED, sucrose probably isn't going to do the trick as usually that's reserved for the neonates.

  • Emergence agitation in children: an update - Current Opinion in Anaesthesiology 2005, 18:614–619
    • Possibly key is patient in recovery - fentanyl, midazalom and clonidine are referenced in above article for prevention. Not much is mentioned about PACU except..."all possible causes, such as physiologic compromise, physical discomfort or pain should be ruled out."
  • Post anaesthesia excitation - Paediatric Anaesthesia 2002 12: 293–295
    • "In contrast with prevention, there is no scientific support for any method of treatment. Opioids are widely used and seem to be effective in most but not all cases"

36. (NEW) Pain in 3 year old, best objective tool
a. FLACC (crying limbs activity consolability)
b. Wong baker Faces pain
c. Self reporting
d. Mum reporting
e. Nurse reporting

A. Wong Baker faces (revised) for 4 to 12 years. Any form of self reporting usually not possible until the age of 4. From APMSE 3rd edition.

37. ECG given. No scale, poor copy, can just make out large and small squares in the upper part, is blurry down low, in absence of scale the squares look bigger than 1mm! Shows anterolateral T inversion, maybe subtle ST sag, no Q's. At first glance looks like big negative QRS's in V2 and big positive QRS's in V5 to suggest LVH, but having struggled to make out squares as above, total pos & neg deflection adds up to approx 5 big squares. (In summary, voltage criteria for LVH with lateral strain pattern - no BBB)
a. longstanding hypertension
b. anterolateral infarct
c. some sort of BBB?

38. ECG given. P pulmonale, Tall R V1, T inversion V1-3
a. Primary pulmonary hypertension.
b. post. Infarct

39. Best time to collect serum tryptase after suspected anaphylaxis
a. within 15 minutes
b. 1 - 3 hours
c. 3 - 6 hours
d. 12 - 24 hours
e. greater than 36 hours

40. Suspect drug cardiac toxicity (can't remember which drug - please help!) Auscultation findings which support this are
a. Bibasal crackles
b. Systolic murmur LSE
c. Systolic murmur Apex
d. ?
e. ?

41.(NEW) Patient with Hemophilia A with known high titres of inhibitors to factor 8. What would you give to prevent bleeding in the patient for ot
a. FVIIa
b. High dose FVIII concentrate
c. FFP
d. Cryo
e. Platelets

A The whole reason why novoSeven exists in the first place. A particular therapeutic conundrum is the development of "inhibitor" antibodies against factor VIII due to frequent infusions. These develop as the body recognises the "normal form" factor VIII as foreign, as the body does not have its own "copy". The problem is that in these patients, factor VIII infusions are ineffective. Recently[update] activated factor VII (NovoSeven) has become available as a treatment for haemorrhage in patients with haemophilia and factor inhibitors. Wikipedia. Disco 28/6/10

42. (Variation) Pregnant women whose paternal uncle has MH. Nobody has been tested. What's the best test to exclude MH in this patient?
a. Genetic test lady
b. genetic test dad of lady
c. muscle biopsy lady
d. muscle biopsy dad

(I'm sure the answer was muscle biopsy the dad. This is because the lady was pregnant and so you wouldn't do it on her (why not?). Also, the genetic test is of no use if it comes back negative (It doesn't help you exclude MH in this lady; and the crux of the wording of the question was which test most appropriate to exclude MH in this lady. BUT surely the best way is to wait & test the lady AFTEr she is non-pregnant)

JM

You never anaesthetise a pregnant woman unless you absolutely have to given the possibility of precipitating pre-term labour. The safest thing to do would be to do a muscle biopsy of the Dad. A genetic test can mean you are MHS if you have the same mutation but does not mean you're not sensitive if it's negative as you can have a different mutation.

Not all patients can have a biopsy, these include children less than 10-12yrs (30kgs), pregnant women, and patients on prolonged steroid therapy. If the proband cannot be tested, eg a young child or deceased, then the nearest most appropriate relative is tested. In the case of a young child this would be the parents. Once the proband has been confirmed as MH susceptible, a blood sample taken at the time of the biopsy will be screened to see if they carry one of the genetic mutations that can be used to test for MH. At present only around 60% of families carry one of these mutations of which there are currently 27.From British Malignant Hyperthermia Association Disco


43. A woman is being treated for pre-eclampsi. She is given 10 grams Magnesium sulphate in 1 h, instead of 1 gr per 1 h, Mg level 5-6, and patient is hyporeflexia. The best treatment is:
a. calcium
b. IV fluid
c. Furosemide
d. ?

Was there and option of waiting to repeat the level a few hours later? Cos with that level but not cardiovascular instability often you'd just hold off until reflexes are normal. In many countries where serum Mg levels aren't so widely available when the original Magpie trial was done, decreased DTR was the end point in developing countries. Otherwise its A, Ca Gluconate 1g over 10 minutes,

44. Disease associated with malignant hyperthermia
a. central core disease
b. myasthenia gravis
c. myotonia congenita
d. ?

  • A Central core disease...kingfed
    • MH, CEA Vol 3, No 1 5-9

45.Endotracheal tube to circuit connectors
a. 15/22 mm
b. lots of other wrong combo's

46.Appropriate infection control measures when anaesthetising a patient with suspected variant-CJD, the airway equipment should be
a.thrown away
b.plastic sheath, reuse
c.sterilization with ethylene oxide
d. sterilization with heat at 134 degrees for 3 minutes
e. Autoclave

Reading a number of guidelines, [3], [4], it would suggest that options B through E is inadequate. Oral Tissues (unless you hit the tonsils, which are classed as medium risk) are generally low risk, and processing and reuse is acceptable. The process is particularly nasty and involved concentrated sodium hydroxide or 2% bleach heated up to various temperatures. Steam autoclave alone would mean 18 minutes at 134°C (hmm, wonder what would get through that unscathed). So A would probably be the right option. As they articles specifically state, covered items are still not guaranteed to be prion- free as there is always a bit of splashback.


47. Mechanism of action of antiepileptics in chronic pain, which is false?
a. Phenytoin workes at Na channels
b. Gabapentin increases gaba in cns
c. Carbamazepine works at Na channels
d. Valproate increases GABA in the CNS e. lamotrogine acts at Ca channel

Just noting the controversial ones, while gabapentin is not a GABA precursor, agonist or antagonist, it does seem to have some effect on glutamate carboxylase which converts glutamate to GABA increasing CNS levels. Lamotrigine is definitely wrong as it acts on a Na+ Channel.

E

48. (Repeat) Timing of worst coagulopathy after liver transplant
a. 1-2 days
b. 3-4 days
c. 5-6 days
etc

A, Teik Oh 6E states "8-hourly for the first 24 hours, thereafter daily unless indicated. The fall in PT is more important than the actual value. FFP should be withheld to assess graft function although platelet support should be provided as usual". So that would imply the worse function is early.

49. Anaesthetic management in patient with cardiac tamponade
a. bradycardia for the ventricle filling time
b. inotropes
c. volume loading
d. ?

Depends... they need to be both full, fast and tight. So really B and C are both indicate; depends on the specific stem.

50.(Repeat Apr 09) 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

B

51. (Repeat) 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.

  • Sounds like D, with both cuffs in LMB. Pull back so tracheal cuff above carina and bronchial cuff still in LMB. Real answer is use a FOB.
  • I thought it's "C", a bronchial cuff hernia that sits on the carina and shuts down the left main if you try and ventilate. That can happen with a right sided DLT (afraid of closing down the RUL branch with your bronchial cuff,so deflate and insert a further cm and recheck sounds best to me. And FOB is of course the best answer.
  • Thought about this a bit more - they haven't said whether you're using a R or L DLT. The purists would use a R, but a lot of people would use a L. If using R DLT then I'd say you're in the wrong bronchus and should come out and start again. If using a L DLT then you're in too far.
  • The pt is having a left thoracotomy, but the actual operation (i.e thoracoscopy, lobectomy, pneumonectomy) is not specified, which may affect which type of tube you place - e.g. left pneumonectomy you might be more likely to place a right-sided tube. However, the question does say that ventilating down the bronchial lumen gives you left sided ventilation, which means this a left-sided tube. I agree that the answer is C, and the likely mechanism is the bronchial cuff isolating the L) main bronchus, but herniating and partially (or completely) obstructing the R) main bronchus as well. This would explain why you can isolate the left-side easily, but when trying to ventilate the right side the pressures are very high. I would have thought that it would be very difficult to put a double lumen tube in far enough to get the tracheal cuff in the left main bronchus as well. I do agree though, that you would also check with bronchoscope, but I would probably push it in a bit more first.

52. (Repeat) 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
E. trendelenburg

  • C If hemorrhage originates from a tear in the superior vena cava, volume replacement and drug treatment may be lost into the surgical field unless they are administered through a peripheral intravenous line placed in the lower extremity...Miller
    • Trendelenberg useful in minor haemorrhage

53. (Repeat) 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

C - Specifically noted not to predict anaesthetic/surgical risk

54. (Repeat) What is true regarding arterial pressure transducer systems
Underdamping overestimates systolic BP
Underdamping underestimates SBP
Compliant tubing?
wide range of damping coefficient associated with good performance if system has high natural frequency

55. 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

Sounds like LVH with strain; as long as the S waves in V1 or V2 and R waves in V5 or V6 added up to 35mm. Which lead were the bicuspid p waves in? With RA enlargement you'd get an enlarged P wave, but with LA enlargement you may see a secondary peak in the P wave. The normal situation is that you'd have a bicuspid p in V1 anyway.

56. 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. ?

B; remember pulsus paradoxus is NOT a paradox in itself. The BP falls, but by greater than 10mmHg.

The paradox in pulsus paradoxus is that, on clinical examination, one can detect beats on cardiac auscultation during inspiration that cannot be palpated at the radial pulse.[1] It results from an accentuated decrease of the blood pressure, which leads to the (radial) pulse not being palpable (Wikipedia) Disco 28/6/10

57. 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

Trickly wording! "Widely accepted indications for antibiotic prophylaxis are contaminated and clean-contaminated surgery and operations involving the insertion of an artificial device or prosthetic material." Australian Prescriber. So this patient would likely get cephazolin, but not for BE prophylaxis. The new guidelines state that the following patients should be given BE prophylaxis;

  • Prosthetic valve or valve repair material
  • pHx of BE
  • Unrepaired cyanotic congenital heart disease
  • Partially repaired cynanotic CHD with defect over the repair
  • Repaired CHD within the 1st 6 months of repair
  • Heart transplant with valvulopathy

So the devil is in the detail!

58. (Repeat) Plasma glucose level compared to blood glucose level
a)32% higher
b)14% higher
c)same
d)14%lower
e)32% lower

B Because red blood cells (erythrocytes) have a higher concentration of protein (e.g., hemoglobin) than serum, serum has a higher water content and consequently more dissolved glucose than does whole blood. To convert from whole-blood glucose, multiplication by 1.15 has been shown to generally give the serum/plasma level. Wikipedia Disco 28/6/10

59. 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

I'll go B Management of Regional Analgesia for Labour and PS26...Kingfed

60. 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

61. 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

  • A FALSE
    • Relieved with squatting and passive leg raise
  • B FALSE
    • Relieved with Valsalva
  • C FALSE
    • A Continuous murmur
  • D TRUE
    • Characteristic
  • E FALSE

62. 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 withdrawal

63. 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


64. A patient has a suspected anaphylactic reaqction under GA. What is the best time to perform the tryptase test?
A><1 hour
B>1 to 3 hours
C>3 to 6 hours
D>numerous other options

65>You are anaesthetising a patient with multiple sclerosis. The best way to avoid a flare up of this patients multiple sclerosis following the anaesthetic is to
A. Avoid dehydration
B. Avoid overheating the patient
C. ?
D. ?

  • B "...increases in body temperature should be avoided. Demyelinated fibres are extremely sensitive to increases in temperature; an increase of as little as 0.5 C may completely block conduction"...Morgan and Mikhail p588

66. 70 y old patient with AF (rate 80/min) in pre-admission clinic booked for ant resection. (it was not mentioned if AF was old or new or if on patient was on any medication) What management?
A. Crack on
B. Echocardiography and Cardioversion
C. Immediate Cardioversion
D. ?
E. ?

67.(NEW) Ketamine for acute pain relief
A. an appropriate dose is 0.5 -1 mg/kg
B. Midazolam does not help in unpleasant dreams / delirium
C. Morphine is contraindicated
D. Hallucinations are common
E. Subcut is better than IV

A. FALSE

  • Usual dose is 0.1 - 0.3mg/kg/hour (or as an initial bolus)

B. FALSE

  • Midazolam is useful

C. FALSE

  • Need an opioid for best effect

D. TRUE

  • Don't know about it being common, but...

E. FALSE

  • S/c is not better than; but can be used instead of IV. "however SC infusion is also used, especially in palliative care, with a bioavailability (similar to IM) of approximately 90% (Clements et al, 1982)." From APMSE

68. AB50 TRALI most likely after transfusion of
A. Red Blood Cells
B. Platelets
C. FFP
D. ?
E. ?

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

EM66 Aneurysm clipping. Best monitor of depth of block during this is:
A. TOFR
B. TOFC
C. DBS
D. PTC

71. PI81 Which volatile has the minimum effect on ICP at 1 MAC
A. Isoflurane
B. Sevoflurane
C. Desflurane
D. Enflurane
E. Halothane

72. 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

this is question SG59 (repeat)


73.SZ10The absorption of fluid into the circulation during transurethral prostatectomy (TURP) is NOT related to
A. prostate size
B. height of the irrigation fluid bag
C. duration of surgery
D. surgical technique
E. type of irrigation fluid


74. In patients undergoing thoracotomy, techniques which reduce the incidence of intraoperative atrial fibrillation include
A. hyperventilation
B. pre-operative loading with digoxin
C. rocuronium, rather than pancuronium
D. thoracic epidural bupivacaine
E. thoracic epidural morphine


75. SG53 During laparoscopic surgery, pneumoperitoneum usually results in a fall in cardiac output when intra-abdominal pressure exceeds
A 10mmHg
B 20mmHg
C 30mmHg
D 40mmHg
E 50mmHg


76. AZ73 A fourteen-year-old girl is scheduled to have a termination of pregnancy. With regard to consent for this procedure, which of the following statements most truly reflects the law in Australasia?
A. A fourteen-year-old girl is able to give consent independently of her parents/guardians if she is considered, by her treating doctors, to be of sufficient maturity to understand the issues.
B. A fourteen-year-old girl is able to give consent independently of her parents/guardians, only if a court deems her sufficiently mature.
C. Minors are not able to give consent, independently of parents/guardians, until sixteen years of age.
D. Minors are not able to give consent, independently of parents/guardians, until eighteen years of age.
E. Only life-saving treatment may be administered to a fourteen-year-old without parental/guardian consent.


77. A multi-trauma patient opens his eyes and withdraws to painful stimuli, but does not respond to voice. He is moaning but makes no comprehensible sounds. His Glasgow Coma Score is
A. 5
B. 6
C. 7
D. 8
E. 9


78. Respiratory function in quadriplegics is improved by
A. abdominal distension
B. an increase in chest wall spasticity
C. interscalene nerve block
D. the upright position
E. unilateral compliance reduction


79. An INCORRECT statement regarding the autonomic nervous system is that
A. autonomic dysfunction is a predictor for worse long term survival after myocardial infarction
B. heart rate responses are primarily mediated through the sympathetic nervous system
C. inhalation anaesthetics all impair autonomic reflex responses
D. autonomic dysfunction is a predictor for haemodynamic instability following anaesthetic induction
E. low heart rate variability is associated with worse cardiac outcomes following non-cardiac surgery


80. Correct statements regarding expiratory-inspiratory flow-volume loops include all of the following EXCEPT
A. in obstructive disease the expiratory curve has a scooped out or concave appearance
B. in restrictive disease expiratory flows are usually decreased in relation to lung volume
C. in restrictive disease the expiratory curve has a convex appearance
D. the expiratory curve is largely effort independent
E. the inspiratory curve is effort dependent


81. Carbon dioxide is the most common gas used for insufflation for laparoscopy because it
A. is cheap and readily available
B. is slow to be absorbed from the peritoneum and thus safer
C. is not as dangerous as some other gases if inadvertently given intravenously
D. provides the best surgical conditions for vision and diathermy
E. will not produce any problems with gas emboli as it dissolves rapidly in blood


SZ11 Lowering intra-ocular pressure by applying pressure to the globe (e.g. Honan balloon) is typically contraindicated in a patient having
A. a revision corneal graft
B. a revision trabeculectomy
C. an extra-capsular lens extraction
D. a redo vitrectomy
E. repeat retinal cryotherapy


SZ14b Following a cadaveric renal transplant under general anaesthesia, your patient's plasma K+ increases to 6.0 mmol.l-1 in recovery after being 5.0 mmol.l-1 pre and intra-operatively. This patient requires
A. an intravenous infusion of CaCl2 (10 mls over 20 minutes)
B. arterial blood gases to ascertain the acid/base status
C. potassium exchange resins rectally
D. sodium bicarbonate infusion (50- 100 mEq over 5- 10 minutes)
E. urgent haemodialysis


84. Obstructive sleep disorder in children
A. is associated with pulmonary hypertension and dysfunction of left and right ventricles
B. has obesity as a major risk factor
C. is rarely seen in children less than 8 years old
D. is four times more prevalent in boys than girls
E. does NOT usually require tonsillectomy for its management


85. Factors associated with post-operative ulnar nerve palsy include all of the following EXCEPT
A. male gender
B. sternal retraction for cardiac surgery
C. cardiopulmonary bypass for cardiac surgery
D. internal jugular vein catheterisation
E. diabetes mellitus


86. 32 year old with early acute liver failure (not paracetamol related). Management includes
A. prophylactic antibiotics
B. N-acetyl cysteine as general liver protection
C. avoid early intubation so can assess for encephalopathy
D. INR> 3 means should be considered for transplant??
E. avoid saline as resuscitation fluid


87. 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


88. 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 ???


89. The intraoperative hypothermia for aneurysm surgery trial (IHAST) showed that cooling to a target temperature of 33°C

A. did NOT improve neurological outcome in WFNS (World Federation of Neurosurgical Surgeons) in grade I-III patients
B. did NOT improve neurological outcome in WFNS grade IV-V patients
C. improved neurological outcome in WFNS grade I-III
D. improved neurological outcome in WFNS grade III
E. improved neurological outcome in WFNS grade IV-V


90. 12 year old child with hip dislocation at 4pm. Ate something 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


91. 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


92. Anaemia in chronic renal failure is characteristically
A. due to haemolysis in the renal vascular bed
B. normochromic and microcytic
C. due to defective haemoglobin synthesis
D. responsive to ion and folate therapy
E. associated with increased 2,3-DPG levels in blood cells


93. Histamine release in anaphylaxis does NOT cause:
A. Tachycardia
B. Myocardial depression
C. Coronary artery vasodilatation
D. Prolonged PR interval
E. Decreased impulse conduction


94. Pre-ganglionic sympathetic fibres pass to the
A. otic ganglion
B. carotid body
C. ciliary ganglion
D. coeliac ganglion
E. all of the above


95. Codeine phosphate
A. is converted by the liver to its active metabolite, oxycodone
B. is not associated with tolerance on chronic use
C. is not effective as an analgesic in approximately 20% of Causcasians
D. is poorly absorbed from the gastrointestinal tract
E. when given orally has approximately 5% of the analgesic potency of intramuscular morphine


96. Branches of the mandibular nerve do NOT include the
A. auriculotemporal nerve
B. long buccal nerve
C. lingual nerve
D. great auricular nerve
E. chorda tympani nerve


97. Which of the following reduces the incidence of severe phantom limb pain following amputation
A. Use spinal anaesthesia
B. Ketamine…? (can’t remember)


98. Preoperative assessment shows a Mallampati (ML) score of III and thyromental distance (TMD) of < 6cm. A grade 3 to 4 on Cormark and Lehane is predicted. Compared to the ML score, the TMD is
A less sensitive, less specific
B less sensitive, more specific
C more sensitive, less specific
D more sensitive, more specific
E equal sensitivity an specificity


99. The innervation of the human larynx is such that
A. the internal laryngeal branch of the superior laryngeal branch of the vagus supplies the lingual surface of the epiglottis
B. in the cadaveric position the cords are fully abducted
C. the recurrent laryngeal nerve supplies all the intrinsic muscles of the larynx
D. the glossopharyngeal nerves are sensory to the laryngeal mucous membrane above the level of the vocal cords
E. cord paralysis can be produced by a distended endotracheal cuff in the larynx compressing a branch of the recurrent laryngeal nerve against the thyroid cartilage


100. In a trial, 75 patients with an uncommon, newly described complication and 50 matched patients without this complication are selected for comparison of their exposure to a new drug.
The results show

Complication present Complication absent
Exposed to new drug 50 25
NOT exposed 25 25

From this data
A. the relative risk of this complication with drug exposure CANNOT be determined
B. the odds ratio of this complication with drug exposure CANNOT be determined
C. the relative risk of this complication with drug exposure is 2
D. the odds ratio of this complication with drug exposure is 1.33
E. none of the above

101. (NEW) Max Sedation time post oral midazolam 0.5mg/kg
a. 10min
b. 20min
c. 30min
d. 40min
e. 50min

If this means time to max sedation, then 30min. Pediatric Anesthesia 2007 17: 1143–1149

Different to previous question which gave a range of 20-30mins

102. (NEW) EM68 Art line system
a. Overdamped exaggerates mean
b. Underdamping increases mean
c. Underdamping underestimates systolic
d. Long random option about multiple damping coefficients in an optimal system
e. Compliant tubing is good

Think option D was the correct answer as the others all were wrong


103. EM67 The tapered connector between the ETT and machine is
a.12-20mm
b. 15-22mm
c. 20-30mm
d. 22-30mm
e. 25-35mm

Ward's anaesthetic equipemnt 5E Pg 187 [5]


104. The best formula to determine the weight of an infant is
a. weight = (age+4) x 2
b. ?
c. ?
d. ?
e. ?

105.(NEW) Which drug is an example of a specific PDE III inhibitor:
a. Aminophyline
b. Sildenafil
c. Milrinone
d. Dipyridamole
e. ?

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