hi all, from second practice shelf i got the following questions wrong and was hoping for some feedback on the reasoning behind them:
1. Patient scheduled for AAA repair (6 cm, palpable), with hx of HTN controlled with drug therapy. ECG shows normal findings. which study is most appropriate to predict this patient's risk for perioperative MI?
a. measurement of serum cholesterol concentration
b. 24hr ambulatory ECG monitoring
c. coronary angiography
d. surface echo
e. radionuclide scan with thallium and dipyrimadole
surface echo is wrong, i put that since they focus on EF% so often in practice questions; not sure why that is wrong. my next guess would be e, the stress test.
I think it's E, the stress test. You can rule out all the other answers. The 24-hr ECG isn't going to show you something the ECG already didn't show. Coronary angiography is too invasive. A doesn't make too much sense here. There's also nothing suggesting a compromised EF.
2. Patient (77F) in nursing home brought to ED bc of 2 day hx of fever+vomiting. alert but can't give hx. asks repeatedly for drink of water. temp is 101.5, BP 100/60. distended, nontender abdomen with sparse high pitched bowel sounds. XRay shows multiple dilated loops of small bowel and gas within the small bowel and within the liver. what's the most likely cause?
a. bacterial cholangitis caused by Klebisella pneumoniae
b. cholecystoduodenal fistula with impacted gallstone
c. emphysematous cholecystitis with intrahepatic perforation
e. perforated duodenal ulcer with subhepatic abscess
f. pylephlebitis caused by sigmoid diverticulitis
c is wrong; not sure what else would cause gas in the liver.
It's B, checystoduodenal fistula. Air in the biliary tree is a classic finding for a fistula between the gallbladder and small intestine -- because of the large fistula, you have a large gallstone pass into the small intestine and cause gallstone ileus.
3. during exploratory celiotomy, cystadenoma found in tail of pancreas. most appropriate management?
a. internal drainage into roux en Y limb of jejunum
b. simple external drainage
c. distal pancreatectomy
d. total pancreatectomy
e. whipple
b is wrong; would the answer be a then?
Distal pancreatectomy. A cystadenoma is not an abscess to just drain...
4. 2 days post carotid endarterectomy, patient has stroke like symptoms and intraparenchymal hemorrhage; carotid duplex US normal. this complication is caused by:
a. carotid thrombosis (wrong)
b. HTN
c. intracranial aneurysm
d. intracranial tumor
e. platelet dysfunction
I think it's incracranial aneurysm.
5. hospitalized teen has progressive SOB for 2 hrs after appendectomy yesterday; hasn't been out of bed since then. had mild dry cough, no chest pain. 2 L NS given over past 24h. alert, temp 99.8, RR:22, HR:90, BP: 105/64. No JVD. Decreased breath sounds. Dullness to percussion over right midlung field with egophony. no wheezes or gallops. holosystolic murmur radiating to axilla. what's most likely underlying cause of patient's shortness of breath?
a. acute thrombosis of right pulmonary artery
b. aspiration of gastric contents during preop intubation
c. collapse of right middle lobe of the lung from decreased inspiratory effort
d. postop infection from hospital acquired organisms
e. severe MR with periop volume overload (wrong)
I think it's B. Not entirely sure, though.
6. 9 days after pylorus-sparing pancreatoduodenectomy, pt has dyspnea. NG tube draining 500 mL/d. Over past 3 days, an operative drain in the RUQ draining 200 to 300 mL/d clear fluid; fluid has amylase> 5000 U/L. HR:90, RR:24, BP:130/70. Serum:
Na: 138
Cl:112
K: 4.2
HCO3: 18
ABG: pH=7.32; PCO2= 22; PO2= 95
What is the cause of these findings?
a. adrenal insufficiency
b. inadequate renal blood flow
c. increased lactic acid production
d. injury to the renal tubules
e. loss of bicarbonate from GI tract
f. loss of bicarbonate from kidneys (wrong)
g. NG suction
It's a metabolic acidosis with a normal anion gap. I would go with loss of HCO3- from the GI tract.
7. Patient extubated after 4hr op for bleeding duodenal ulcer. ABG on FiO2 of 40%:
pH=7.24; PCO2=85; PO2=60
What's the most appropriate next step in management?
a. encouraging deep breathing and cough
b. increasing the FiO2 to 80% (wrong)
c. IV administration of 1 L Ringer's over 30 min
d. IV naloxone
e. reintubation and mechanical ventilation
Reintubation and ventilation. The patient's issue is with ventilation -- simply increasing FiO2 isn't going to do anything and none of the other answer choices make sense. You need to protect the airway (ABCs) -- choice E is the best one here.
Do you work in the same health care system I do? One thing I've learned in this crazy process is "they can always hurt you more".
