Practice Test

Questions

DIRECTIONS (Questions 1-150): Each of the numbered items or incomplete statements in this section is followed by answers or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each case.

1. A 58-year-old male is undergoing open repair of a 6.8 cm infrarenal aortic aneurysm. Preoperative CT-angiogram does not show any evidence of aortic occlusion. Clamping of the distal aorta in this patient will most likely be followed by

(A) increased cardiac output

(B) decreased arterial blood pressure

(D) increased stroke volume

(E) stable heart rate

2. During surgery for strabismus in an otherwise healthy 3-year-old boy, you note that the patient is likely demonstrating the oculocardiac reflex and you inform the surgeon. All of the following are associated with the oculocardiac reflex EXCEPT

(A) sinus tachycardia

(B) sinus bradycardia

(D) fatigability of the reflex

(E) regional anesthesia

3. A 68-year-old female is admitted to the ICU for management of peritonitis from a perforated diverticulum demonstrated on CT scan of the abdomen. Her hemodynamic evaluation is consistent with a picture of septic shock.
Which one of the following statements regarding the use of hetastarch for volume expansion is most accurate?

(A) Hetastarch is less likely than crystalloid solutions to cause renal insufficiency.

(B) Hetastarch is a synthetic colloid.

(D) Hetastarch, when used in dose >20 mL/kg does not interfere with coagulation.

(E) Hetastarch is metabolized in the liver to glucose monomers.

DIRECTIONS: Use the following scenario to answer Questions 4-5: A 27-year-old G1P0 patient presents at 39 weeks gestational age for induction of labor. Her prenatal course was complicated by a history of myasthenia gravis (MG). She is currently being treated with pyridostigmine.

4. True statements regarding myasthenia gravis in pregnancy include all of the following EXCEPT

(A) smooth muscle and cardiac muscle are not affected by the disease

(B) the disease affects twice as many women as men

(C) the course of MG in pregnancy varies with one-third showing improvement of symptoms, one-third showing worsening of symptoms, and one-third showing no change

(D) there is an association between MG and other autoimmune diseases

(E) the first stage of labor is prolonged in patients with MG

5. The anesthetic management of this patient includes all of the following EXCEPT

(A) opioids should be used cautiously in this patient

(B) neuraxial anesthesia is the preferred method for pain management during labor

(C) patients with severe bulbar involvement or respiratory compromise may require general anesthesia for cesarean section

(D) succinylcholine should be avoided during emergent cesarean section

(E) small doses of neostigmine may be used for reversal of neuromuscular blockade

6. A 2-year-old child weighing 12 kg is having a repair of an umbilical hernia and a right inguinal hernia. The surgeon asks you how many milliliters of 0.5% bupivacaine may be used for local infiltration at the incision sites. Which one of the following is the most appropriate dose for this patient?

(A) 3 mL

(B) 6 mL

(D) 18 mL

(E) 24 mL

7. An 18-year-old male takes atenolol daily to prevent cardiac arrhythmias following his diagnosis of congenital long QT syndrome. He is scheduled for outpatient arthroscopic surgery of the knee. He also has a history of severe rash following administration of beta lactam antibiotics. Appropriate perioperative antimicrobial therapy would be with

(A) clindamycin

(B) azithromycin

(D) gentamicin

(E) tetracycline

DIRECTIONS: Use the following figure to answer Question 8:

8. The figure depicts which mode of mechanical ventilation?

(A) Pressure support

(B) Pressure control

(D) Volume control, decelerating waveform

(E) Airway pressure release ventilation

9. The PaCO₂ of a patient on cardiopulmonary bypass

(A) is determined by the oxygen concentration of the fresh gas

(B) is generally adjusted through changes in fresh gas flow rate

(D) should be maintained at less than 30 mmHg

(E) is determined by the type of oxygenator

10. A 5-year-old child presents for general anesthesia for closure of a severe scalp laceration. He ate a sandwich 2 h before his accident. He should

(A) have a rapid sequence induction with propofol and succinylcholine

(B) have a nasogastric tube passed to remove gastric contents before induction

(D) have vomiting induced

(E) be allowed to awaken with the endotracheal tube in place at the end of the procedure

11. You are seeing a pediatric patient preoperatively prior to surgery for correction of scoliosis. In order to be properly prepared for possible intraoperative blood loss and to plan for appropriate monitoring, you ask the family what type of scoliosis the patient has. All of the following types of scoliosis are associated with large expected amounts of intraoperative blood loss during scoliosis correction EXCEPT

(A) Duchenne muscular dystrophy

(B) spinal muscular atrophy

(D) Marfan syndrome

(E) idiopathic infantile scoliosis

12. Well known respiratory physiologic changes that occur at term in pregnancy include all of the following EXCEPT

(A) a 40% rise in respiratory rate

(B) a 45% increase in tidal volume

(D) a decrease in respiratory reserve volume of 15%

(E) a combined respiratory alkalosis and compensatory metabolic acidosis

13. Anesthesia for carotid endarterectomy generally involves all of the following EXCEPT

(A) hypercapnia

(B) normal or slightly increased arterial oxygen tension

(D) systemic heparinization

(E) normothermia

14. The primary mechanism of spinal opioid analgesia is via

(A) activation of presynaptic opioid receptors

(B) activation of postsynaptic opioid and GABA receptors

(D) activation of opioid receptors on the rostral ventromedial medulla

(E) inhibition of small spinal interneurons

15. A 3-month-old, full term infant, weighing 5 kg presents for ventriculoperitoneal shunt placement. The patient is asymptomatic at this time. In reviewing labs for this patient, you note that the hematocrit is 30. Which one of the following statements is true?

(A) The hematocrit has reached its lowest post-delivery value.

(B) The patient is anemic and should receive a blood transfusion prior to surgery.

(D) The hematocrit is likely low due to dilution from IV fluid infusions.

(E) The patient is anemic and should be started on iron supplementation.

16. A 48-year-old, 111 kg female presents for surgical excision of a pheochromocytoma, for which she has already received a 14-d course of phenoxybenzamine. The patient is scheduled for a combined epidural and general anesthetic. The agent that should be avoided during maintenance of anesthesia is

(A) nitrous oxide

(B) propofol

(D) isoflurane

(E) sevoflurane

17. When ventilating the patient with a head injury, all of the following statements are true EXCEPT

(A) the patient should be kept supine

(B) prolonged hyperventilation has diminished efficacy in reducing ICP

(D) hypoxia and hypercarbia should be avoided

(E) coughing should be minimized

18. Esmolol

(A) is a β₁-adrenoceptor agonist

(B) has a half-life of 4 h

(D) is more likely than propranolol to cause bronchospasm

(E) is metabolized in the liver

19. In the adult, the tracheobronchial tree

(A) divides at an uneven angle, making foreign bodies more apt to go to the left side

(B) divides into right and left bronchi, the left bronchus being narrower and longer

(D) is lined with squamous epithelium

(E) is protected by circular cartilaginous rings throughout

20. Which one of the following is most likely to result in an underestimation of the anion gap in critically ill patients?

(A) Hyperchloremia

(B) Lactic acidosis

(D) Hypoalbuminemia

(E) Hypocapnia

21. Mannitol may lead to subdural hematoma by

(A) increasing cerebral edema

(B) interfering with the clotting mechanisms

(D) producing hypertension

(E) direct passage through the vein wall

22. A patient is referred to you with facial pain. Which one of the following statements is true?

(A) The pain of glossopharyngeal neuralgia is very similar to that of trigeminal neuralgia but affects the anterior two-thirds of the tongue, tonsils, and pharynx.

(B) Giant cell arteritis is a vasculitic condition that can lead to visual loss but has never been reported in a case of stroke.

(D) Pure facial pain is rarely associated with sinusitis alone.

23. A 135 kg, 48-year-old female is scheduled for a laparoscopic cholecystectomy under general anesthesia. The factor most significant in affecting intraoperative arterial oxygenation is

(A) body position

(B) mode of ventilation

(D) presence of pneumoperitoneum

(E) lung compliance

24. Well known hematologic changes that occur in pregnancy include each of the following EXCEPT

(A) maternal blood volume increases by approximately 45% at term

(B) plasma cholinesterase levels decrease by about 25% resulting in a clinically relevant prolongation of paralysis after a single dose of succinylcholine

(D) the concentrations of most coagulation factors increase during pregnancy thus representing a relative hypercoagulable state

(E) red blood cell volume increases secondary to increased production of erythropoietin as well as the erythropoietin-like effects of progesterone, prolactin, and placental lactogen

DIRECTIONS: Use the following scenario to answer Questions 25-29: A 65-year-old male has a right hilar mass with postobstructive pneumonia.

25. In evaluating this patient’s suitability for pneumonectomy, which one of these tests would be the LEAST useful?

(A) PaCO₂

(B) PaO₂

(D) FVC

(E) Ventilation/perfusion scan (V/Q scan)

26. The patient is hypoxic on preoperative evaluation. Which therapy is LEAST likely to be effective?

(A) Lateral position

(B) Chest physical therapy

(D) Supplemental oxygen

(E) Pneumonectomy

27. The best method to provide good surgical exposure for a left lower lobectomy is

(A) using a large single-lumen endotracheal tube

(B) using an endotracheal tube with a ballooned catheter (Univent) placed on the operative side

(D) using a left sided double-lumen tube

(E) using an LMA

28. After induction of general anesthesia, the patient is intubated with a left-sided double-lumen tube. When the circuit is connected to the double-lumen tube, it is possible to ventilate the left lung, but not the right lung. Possible causes include all EXCEPT

(A) the tube is advanced too far

(B) the right mainstem bronchus is blocked by tumor

(D) the tube is not advanced far enough

(E) the tube is in the wrong side

29. The patient underwent uneventful right pneumonectomy and remains intubated at the end of the procedure. On transferring the patient from the operating room table to the bed for transfer to the intensive care unit, there is a sudden decrease in blood pressure. Pulses are faint. Appropriate maneuvers include all of the following EXCEPT

(A) placing the patient laterally on his left side

(B) applying suction to the chest tube

(D) providing oxygen and managing the airway

(E) supporting cardiac function with an inotropic agent

30. A 32-year-old G1P0 patient presents for an anesthesia consult at 20 weeks gestational age. She has a history of tonic-clonic seizures that are well-controlled on phenytoin. You tell her all of the following statements about her condition are true EXCEPT

(A) approximately 0.5% of all parturients have a chronic seizure disorder

(B) single-agent anticonvulsant therapy is preferred over combination therapy

(D) there is no contraindication to neuraxial anesthesia

(E) higher estrogen concentrations increase the seizure threshold during pregnancy

31. The agent with the highest ratio of β-adrenergic agonist to α-adrenergic agonist activity is

(A) isoproterenol

(B) dobutamine

(D) norepinephrine

(E) phenylephrine

DIRECTIONS: Use the following scenario to answer Questions 32-36: A 33-year-old multiparous female just delivered healthy twin girls vaginally. After delivery she has poor uterine tone, resulting in postpartum hemorrhage. Her mental status and blood pressure decline, and you are called to assist with management. You intubate the patient, place intravenous access, and resuscitate the patient with fluids and blood products while the obstetricians control the bleeding. Once stabilized, she is brought to the ICU for further care. Over the course of two hours, she develops worsening oxygenation. Her vital signs are T 37.3°C, HR 93, BP 113/64, Spo₂ 92% on FIO₂ 1.0. She is 5 feet, 2 inches and 76 kg. Her hemoglobin is 8 mg/dL. Chest x-ray shows bilateral diffuse infiltrates. A bedside echocardiogram is unremarkable.

32. Which one of the following is the most appropriate ventilator setting?

(A) Volume control TV 250, RR 20, PEEP 5, FIO₂ 1.0

(B) Volume control TV 300, RR 20, PEEP 5, FIO₂ 1.0

(D) Volume control TV 440, RR 20, PEEP 5, FIO₂ 1.0

(E) Volume control TV 440, RR 20, PEEP 12, FIO₂ 1.0

33. Six hours later, she is hemodynamically stable and has required no further transfusions. Repeat hemoglobin is 7.8 g/dL. INR is 1.6. Platelet count is 86,000/mm³. Which one of the following is the most appropriate therapeutic intervention?

(A) No transfusion

(B) Transfuse one unit of packed red blood cells

(D) Transfuse one unit of fresh frozen plasma

(E) Transfuse a single donor unit of platelets

34. Twenty four hours later, the patient has had a dramatic improvement in her pulmonary status, and she is extubated successfully. Which one of the following is the most likely cause of her respiratory failure?

(A) Amniotic fluid embolism

(B) Pneumonia

(D) TRALI (transfusion related acute lung injury)

(E) Volume overload

35. Mechanical ventilation with PEEP results in which one of the following?

(A) Decreased preload and left ventricular afterload

(B) Decreased preload and increased left ventricular afterload

(D) Increased preload and left ventricular afterload

(E) Increased preload and right ventricular afterload

36. Which one of the following has been shown to reduce the number of days that a patient requires mechanical ventilation?

(A) Daily recruitment maneuvers

(B) Daily spontaneous breathing trials

(D) Scheduled suctioning

(E) Volume control ventilation

37. The atypical antipsychotics like clozapine and olanzapine differ from antipsychotic agents like haloperidol and chlorpromazine in that they

(A) cause less extrapyramidal effects

(B) do not produce hypotension

(D) have less anticholinergic effects

(E) have not been associated with a risk of new-onset type 2 diabetes

38. General anesthesia as compared to regional anesthesia in parturients is associated with all of the following EXCEPT

(A) less hypotension

(B) less cardiovascular instability

(D) more rapid induction

(E) better control of the airway

39. A 2-year-old child is brought to the emergency department with a 6-d history of increasing cough and wheezing. Symptoms have not responded to bronchodilator therapy and broad-spectrum antibiotics. On examination, the child is agitated, tachypneic, and has a heart rate of 150 bpm. There are decreased breath sounds in the right lower zone of the lung fields. This clinical presentation is most consistent with

(A) right lower lobe pneumonia

(B) exacerbation of underlying asthma

(D) acute laryngotracheobronchitis

(E) ruptured congenital bullus

40. The blood flow during total cardiopulmonary bypass

(A) is not adjustable

(B) is virtually nonpulsatile

(D) is a pulsatile flow

(E) mimics normal flow in all respects

41. In neurosurgical patients, dextrose containing solutions

(A) are the fluids of choice

(B) may cause excessive diuresis

(D) may produce brain edema

(E) lead to water retention

42. All of the following statements regarding headaches are true EXCEPT

(A) the International Headache Society’s diagnostic criteria for cervicogenic headaches includes unilaterality of symptoms and relief of pain by diagnostic anesthetic blocks

(B) migraine with aura is more common than migraine without aura

(D) cluster headaches are more prevalent in men than in women

(E) tricyclic antidepressants are a mainstay of treatment for both migraine and tension-type headaches

43. Dexmedetomidine

(A) is a hypnotic agent used for the induction of general anesthesia

(B) can markedly reduce the MAC of inhalational anesthetics

(D) will result in adrenal suppression when infused continuously for postoperative sedation

(E) causes more respiratory depression than opioids and benzodiazepines

44. Preeclampsia is associated with which one of the following findings?

(A) Hypovolemia

(B) Low serum creatinine

(D) Decreased serum uric acid

(E) Hypotension

45. Carbon dioxide is sometimes added to the fresh gas supply of the oxygenator during hypothermic cardiopulmonary bypass

(A) to decrease pulmonary vascular resistance

(B) to increase the affinity of hemoglobin for oxygen

(D) to maintain the corrected PaCO₂ at 40 mm Hg

46. A relative, but not absolute, contraindication to an epidural steroid injections is

(A) preexisting neurologic disorder (e.g., multiple sclerosis)

(B) sepsis

(D) localized infection at injection site

(E) patient refusal

47. You are giving a talk to a group of pregnant women during a birthing class about the options of analgesia during labor. You specifically discuss epidural analgesia. In your discussion, you pull out a diagram of the lumbar spine and you specifically state that a catheter will be placed

(A) below the dura

(B) between the dural and the arachnoid

(D) between the dura and the pia

(E) between the ligamentum flavum and the dura

48. A 74-year-old man is undergoing a transurethral resection of prostate with sorbitol irrigation under spinal anesthesia. Approximately 1 h after the beginning of the resection, he begins to complain of difficulty breathing. He becomes progressively more confused, tachycardic, and hypertensive. The serum sodium concentration is 114 mEq/L. While informing the surgeon and asking him to complete the procedure expeditiously, the most appropriate next step would be to

(A) administer labetalol

(B) ask the surgeon to change the irrigating solution to normal saline

(D) induce general endotracheal anesthesia

(E) administer 3% sodium chloride

49. As the neurosurgeon manipulates tissue in the posterior fossa, there is sudden bradycardia. The anesthetist should

(A) lower the head

(B) administer lidocaine

(D) turn off all volatile anesthetics

(E) administer naloxone to reverse effects of opioids

50. Prostaglandin E₁

(A) is a potent vasoconstrictor

(B) should be given by bolus

(D) is useful in closing a patent ductus arteriosus

(E) may cause hypotension

51. Post-herpetic neuralgia

(A) is common in children and adolescents

(B) is best treated with opioids

(D) usually responds to tricyclic antidepressants

(E) is a difficult syndrome to treat and success is limited

52. A 61-year-old male with Marfan syndrome is referred for surgical repair of a 6.4 cm ascending aortic aneurysm that will include replacement of the aortic valve. The surgeon informs you that the repair will require deep hypothermic cardiac arrest with an expected duration of over 30 min. In addition to effective cooling of the patient to a core temperature of 25°C, the best strategy for the prevention of cerebral ischemia during surgery is which one of the following?

(A) Ice packs around the patient’s head

(B) Selective antegrade cerebral perfusion with cold, oxygenated blood into a single aortic arch branch vessel

(D) Retrograde cerebral perfusion with cold, oxygenated blood into the superior vena cava (SVC)

(E) Administration of high-dose glucocorticoids

DIRECTIONS: Use the following scenario to answer Questions 53-55: A 24-year-old female pedestrian was struck by a car 3 d ago. She was brought to the emergency department by emergency medical personnel, where she was intubated for confusion and combativeness. Her initial trauma evaluation revealed a positive FAST scan. She was taken emergently to the operating room where she underwent a splenectomy for a ruptured spleen. She subsequently underwent a more complete trauma evaluation that revealed a T10 burst fracture and an acetabular fracture. She has been intubated while awaiting repair of her fractures. You are called to the bedside because the patient has developed fever, tachycardia, hypoxia, and increased secretions. Chest x-ray shows a new pulmonary infiltrate. She has rhonchi but no other changes in her physical examination.

53. Which one of the following is the most appropriate next step in management?

(A) Administer an antipyretic

(B) Administer post-splenectomy vaccines

(D) Obtain cultures

(E) Start antibiotics

54. Which one of the following is the most appropriate pharmacotherapy?

(A) Ceftriaxone

(B) Levofloxacin

(D) Vancomycin + ceftriaxone

(E) Vancomycin + levofloxacin + cefepime

55. Forty-eight hours later, the patient is afebrile with decreased secretions and improved oxygenation. Sputum culture obtained before initiation of antibiotics revealed Haemophilus influenzae. What is the most appropriate next step in management?

(A) Change antibiotics to ceftriaxone only

(B) Change antibiotics to clindamycin only

(D) Continue current antibiotics

(E) Discontinue all antibiotics

56. All of the following statements are true concerning somatosensory evoked potentials EXCEPT

(A) waveform peaks are described in terms of amplitude, latency, and polarity

(B) amplitude of evoked potentials is greater than those of the EEG

(D) brain stem potentials are more resistant to anesthetic influences than cortical potentials

(E) volatile anesthetics produce dose-dependent alterations in evoked potentials

57. You are called to a delivery room where the obstetrician has decided to perform a low outlet forceps delivery in a patient. All of the following techniques are appropriate EXCEPT

(A) bilateral pudendal block

(B) paracervical block

(D) caudal block

(E) epidural block

58. Terbutaline

(A) is an α-adrenergic agonist

(B) is a selective β₂-adrenergic agonist

(D) should be avoided in patients with heart disease

(E) causes hyperkalemia

59. The one best block for pain secondary to pancreatic cancer is a(n)

(A) stellate ganglion block

(B) Bier block

(D) celiac plexus block

(E) intrathecal neurolysis

60. Pulmonary vascular resistance is increased by

(A) sevoflurane

(B) desflurane

(D) nitrous oxide

(E) oxygen

DIRECTIONS: Use the following figure to answer Questions 61-62:

61. The tracing in the graph shows a pattern referred to as

(A) early deceleration

(B) late deceleration

(D) variable deceleration

(E) sinusoidal deceleration

62. This type of fetal heart rate pattern is usually associated with

(A) uteroplacental insufficiency

(B) head compression

(D) severe fetal asphyxia

(E) prematurity

63. Complications of spinal cord stimulation include all of the following EXCEPT

(A) lead migration

(B) increased risk of development of chordoma

(D) bleeding

64. A 58-year-old otherwise healthy man is undergoing repair of an Achilles tendon rupture. The orthopedic surgeon asked that the lower extremity tourniquet remain inflated through the entire 2-h procedure. Upon release of the tourniquet, you will expect to see

(A) decreased end-tidal CO₂

(B) metabolic alkalosis

(D) decreased body temperature

(E) increase in anesthetic requirements

65. A 72-year-old male with Parkinson disease on levodopa is scheduled for surgery. The anesthetic plan should include

(A) stopping levodopa for 24 h before induction

(B) avoidance of phenothiazines

(D) anticipated need for larger than usual doses of pressors

(E) use of high concentrations of a volatile agent in lieu of a nondepolarizing muscle relaxant

66. Acute treatment of cerebral edema includes all of the following EXCEPT

(A) osmotic diuretics

(B) loop diuretics

(D) surgical decompression

(E) drainage of CSF

67. You are called to the labor and delivery suite to evaluate a patient who has just delivered. The obstetrician states the uterus is atonic. Each of the following may be used to treat the uterine atony EXCEPT

(A) uterine massage

(B) intramuscular methylergonovine

(D) intravenous methylergonovine

(E) intravenous oxytocin

DIRECTIONS: Use the following figure to answer Question 68:

68. The flow/volume curve shows

(A) normal inspiratory and expiratory volume curves

(B) fixed intrathoracic or extrathoracic obstruction

(D) variable extrathoracic obstruction

69. A 6-month-old infant, born full term, presents for elective inguinal hernia repair. The infant is otherwise healthy, and in no acute distress. Which one of the following are normal heart rate, blood pressure and O₂ consumption for this patient?

(A) HR 120, BP 90/60, O₂ consumption 5 mL/kg

(B) HR 140, BP 90/60, O₂ consumption 10 mL/kg

(D) HR 120, BP 90/60, O₂ consumption 15 mL/kg

(E) HR 120, BP 110/70, O₂ consumption 10 mL/kg

70. Diagnostic criteria for cervicogenic headache by the International Headache Society and the International Association for the Study of Pain (IASP) include all of the following EXCEPT

(A) unilateral headache

(B) relief of acute attacks by blocking the V2 branch of the trigeminal nerve with local anesthetic

(D) decreased range of neck motion

71. Upon doing a morning postoperative check on a patient who underwent a total thyroidectomy for a longstanding multinodular goiter the previous afternoon, you notice he is somewhat stridorous, with sternal retractions. He asks why the anesthesia has made his fingers and toes tingle. On evaluation you note

(A) a positive Chvostek sign

(B) diminished reflexes

(D) edema of his upper extremities

(E) incisional swelling

72. α-adrenoceptors in the adrenergic nervous system

(A) are stimulated by isoproterenol

(B) are blocked by metoprolol

(D) cause bronchial dilatation

(E) are found on adipocytes

73. Patients with acute subarachnoid hemorrhage may demonstrate all of the following EXCEPT

(A) ST segment elevation consistent with myocardial ischemia

(B) cardiac arrhythmia

(D) depressed ventricular function

(E) pulmonary hypertension

74. All of the following are indicative of fetal well-being EXCEPT

(A) good long-term variability

(B) biophysical profile score of 8/10

(D) a positive oxytocin contraction stress test

(E) fetal scalp pH of 7.27

75. A healthy 29-year-old woman delivers a healthy full term neonate. There have been no problems or complications during pregnancy or labor and delivery. The neonate’s 1- and 5-min Apgar scores were 8 and 9, respectively. Both mother and infant are doing well. All of the following would be expected to occur in the first 24 h of life of this neonate EXCEPT

(A) functional closure of the foramen ovale

(B) functional closure of the ductus arteriosus

(D) increase in pulmonary blood flow

(E) large increase in volume load on left ventricle

76. In terms of complex regional pain syndrome (CRPS), which one of the following statements is true?

(A) The incidence of CRPS is 20% after brain lesion.

(B) Extremities affected by a brain injury are at higher risk of developing CRPS than unaffected extremities.

(D) Lower extremities are more commonly affected than upper extremities.

77. A patient is scheduled for a CO₂ laser ablation of a laryngeal tumor. The risk of airway fire is decreased by

(A) a fresh gas flow less than 2 L/min

(B) use of a clear PVC endotracheal tube

(D) substitution of helium for N₂O

(E) use of the laser in continuous mode

78. In preeclamptic or eclamptic patients

(A) regional anesthesia is contraindicated

(B) hyporeflexia is common

(D) resistance to vasopressors is common

(E) significant coagulopathies may occur

79. An 81-year-old woman slipped on a piece of ice and in the process sustained an open right distal ulna fracture in her outstretched hand. All of the following are reasonable regional anesthetic blocks for surgeries distal to the elbow EXCEPT a(n)

(A) axillary block

(B) supraclavicular block

(D) interscalene block

80. A 6-year-old patient is undergoing a craniotomy in the prone position for removal of a posterior fossa tumor. You are concerned about venous air embolism and hemodynamic instability during this surgery so you are using multiple monitors during this surgery in addition to the standard ASA monitors. These include an arterial catheter, end-tidal nitrogen, and esophageal stethoscope. Of the following monitors, which one is the most sensitive indicator of a venous air embolism?

(A) End-tidal nitrogen

(B) Blood pressure

(D) Change in ECG

(E) Esophageal stethoscope

81. A 1-month-old infant presents for exploratory laparotomy for symptoms of bowel obstruction. The initial temperature after induction is noted to be 35.6°C. At the time of incision, the temperature is noted to be 34.9°C. All of the following are mechanisms by which an infant under anesthesia loses body heat EXCEPT

(A) the metabolism of brown fat

(B) breathing dry gases

(D) cold skin preparation solutions

(E) exposure of abdominal contents

82. Which one of the following is a possible advantage of acupuncture over other methods of pain therapy?

(A) Safety, since the physiology of the patient is not disturbed

(B) A tonic or regulatory effect on the body

(D) An anti-inflammatory effect

83. A 72-year-old patient with a history of closed angle glaucoma presents for cataract surgery. In order to prevent an increase in intraocular pressure, one should avoid

(A) hypothermia

(B) hypercarbia

(D) hypotension

(E) topical timolol

84. A 68-year-old male is scheduled to have endovascular stent graft repair of a 7.4 cm descending thoracic aortic aneurysm. The patient’s past medical history is significant for insulin dependent diabetes, hypertension, hypercholesterolemia, and myocardial infarction. The patient’s past surgical history is significant for infrarenal aortic aneurysm repair. In order to decrease the risk of spinal cord ischemia, the patient will undergo preoperative placement of a lumbar drain for CSF drainage. Which one of the following additional interventions is most appropriate to decrease the risk of spinal cord ischemia in this patient?

(A) Deep hypothermic circulatory arrest (DHCA)

(B) Pulse dose glucocorticoid therapy

(D) Deliberate mild to moderate systemic hypothermia

(E) Deliberate mild to moderate hypotension

85. β₂-adrenoceptors in the autonomic nervous system

(A) are stimulated by isoproterenol

(B) are antagonized by esmolol

(D) cause vasoconstriction

(E) are the principal prejunctional receptors that inhibit sympathetic neurotransmitter release

DIRECTIONS: Use the following scenario to answer Questions 86-87: A 67-year-old woman with COPD is admitted to the ICU with pneumonia and respiratory failure several days following video-assisted thoracoscopic lung resection of squamous cell carcinoma. Her height is 63 inches, weight 80 kg (ideal body weight 52 kg). Vital signs are T 38.2°C, HR 98, BP 110/72, RR 36, Spo₂ 96% while mechanically ventilated with FIO₂ 1.0. Sputum cultures reveal abundant growth of Streptococcus pneumoniae.

86. Which one of the following ventilator settings is most likely beneficial in preventing ventilator induced lung injury?

(A) Tidal volume 520 mL

(B) PEEP equal to 0 cm H₂O

(D) Plateau pressure < 30 cm H₂O

(E) Recruitment maneuver with CPAP = 40 cm H₂O

87. After 24 h of mechanical ventilation, a spontaneous breathing trial (SBT) is conducted. Which one of the following combinations of criteria during the SBT suggest that extubation should be considered?

(A) RR 36, Spo₂ 95%, HR 88

(B) RR 18, Spo₂ 91%, HR 90

(D) RR 32, Spo₂ 96%, patient reporting shortness of breath and anxiety

(E) RR 12, Spo₂ 89%, HR 87

88. Increased neonatal depression has been observed after nonurgent cesarean delivery in which one of the following circumstances?

(A) General anesthesia compared to regional anesthesia

(B) An elapsed time of 8 min between induction and delivery

(D) An elapsed time of 4 min between uterine incision and delivery

(E) epidural versus spinal anesthesia

89. Concerning induced hypotension in neurosurgery

(A) induced vasodilation may facilitate perfusion during ischemia

(B) is best provided with phenoxybenzamine

(D) may decrease physiologic dead space

(E) is relatively contraindicated for any length of time during intracranial surgery

DIRECTIONS: Use the following scenario to answer Questions 90-91: A-22 year-old male presents for left shoulder arthroscopy with a rotator cuff repair after sustaining a basketball injury. The following ultrasound-guided nerve block was performed for postoperative analgesia.

90. The nerve that will most likely be spared is the

(A) phrenic nerve

(B) musculocutaneous nerve

(D) suprascapular nerve

(E) radial nerve

91. Thirty minutes after the block is performed the patient is noted to have sensation on the cape of the ipsilateral shoulder. The most likely reason for this is failure to

(A) block the axillary nerve

(B) block the superficial cervical plexus

(D) anesthetize the musculocutaneous nerve

(E) perform a T1 paravertebral block

92. A 5-year-old boy presents for elective outpatient repair of an inguinal hernia. His parents inform you that he has a runny nose with yellow nasal discharge and a mild occasional wet cough. They deny any fevers. He has been eating and drinking normally and has been active as usual. Lungs are clear to auscultation bilaterally. You inform the parents that you will

(A) proceed with surgery today

(B) prescribe antibiotics for the patient

(D) postpone surgery for 2-4 weeks

(E) administer an albuterol nebulizer preoperatively and postoperatively as needed

93. An advantage of selective COX-2 inhibitors over nonselective COX inhibitors is

(A) protective renal effects

(B) protective cardiovascular effects

(D) fewer GI side effects

94. The medication occasionally used as a bedtime sedative that is associated with CNS excitation a few hours after taking it is

(A) diphenhydramine

(B) ethanol

(D) eszopiclone

(E) melatonin

95. What is the meaning of the term “left dominant” on a cardiac catheterization report?

(A) It refers to the blood supply of the sinus node by the left circumflex artery.

(B) It indicates that the patient has left ventricular hypertrophy.

(D) It indicates that the posterior descending artery is supplied by the left circumflex artery.

(E) It indicates a large left anterior descending artery.

96. Complex regional pain syndrome is characterized by all of the following EXCEPT it

(A) may result from a gunshot wound

(B) is generally less severe in persons with underlying anxiety or depression

(D) is often accompanied by dystrophic changes of bone

97. Seizures

(A) produce cerebral alkalosis

(B) are terminated by isoflurane anesthesia at 1 MAC

(D) reduce regional cerebral blood flow and metabolism

(E) are initiated by most general anesthetics

98. A 5-week-old infant presents for pyloromyotomy. The anesthetic plan includes a rapid sequence induction and intubation. Several steps in positioning and equipment selection are taken to aid in securing the airway as rapidly as possible. All of the following are true of the infant’s airway relative to an adult’s airway EXCEPT

(A) the infant has a more cephalad-placed larynx

(B) the infant’s epiglottis is long and omega shaped

(D) the narrowest area of the infant’s airway is at the rima glottidis

(E) the infant’s tongue is larger relative to the rest of the airway

99. A 30-year-old G4P0 patient with a history of antiphospholipid syndrome and recurrent pregnancy loss presents at 20 weeks gestational age for an anesthesia consult. She is currently on aspirin and a prophylactic dose of low molecular weight heparin (LMWH) once daily. She asks about her disease and pregnancy. You tell her that

(A) epidural anesthesia is contraindicated secondary to the increased risk of bleeding with lupus anticoagulant present

(B) she must wait 24 h from the last dose of LMWH to receive neuraxial anesthesia

(D) lupus anticoagulant and anticardiolipin antibody are associated with both venous and arterial thrombotic events

(E) women diagnosed with antiphospholipid syndrome on the basis of a history of recurrent pregnancy loss and evidence of antiphospholipid antibody, but without prior thrombotic events, often suffer thrombotic events during pregnancy

100. Arrhythmia is associated with all of the following EXCEPT

(A) orbital decompression

(B) tentorial manipulation

(D) arterial venous malformation embolization

(E) carotid artery balloon angioplasty

101. Preeclampsia is characterized by all of the following EXCEPT

(A) intravascular volume depletion

(B) proteinuria

(D) no change in placental perfusion

(E) decreased production of renin

102. An active agent useful in the performance of a neurolytic block is

(A) 40% potassium hydroxide

(B) 10% glycerin

(D) 100% phenol

103. A major side effect of valproic acid is

(A) decreased renal function

(B) elevation in liver enzymes

(D) arrhythmias

(E) anemia

DIRECTIONS: Use the following scenario to answer Questions 104-106: A 42-year-old female with a longstanding history of type I diabetes and end-stage renal disease requiring dialysis has received the call that an appropriate kidney is now available for transplant. She is scheduled for immediate transplant, and arrives, quite anxious, directly from dialysis to the preoperative area. She has been NPO for 4 h. Preoperative labs include Hgb of 8.4 g/dL, glucose 183 mg/dL, and [K⁺] 5.3 mEq/L. Her vital signs are BP 112/62, HR 104 bpm, Spo₂ 97%. The anesthetic plan is for general anesthesia.

104. The anesthetic agent best avoided in this patient is

(A) etomidate

(B) N₂O

(D) sevoflurane

(E) vecuronium

105. The surgeon is concerned about the risk of a postoperative epidural hematoma, and asks that you use parenteral opioids for postoperative analgesia rather than place an epidural catheter. As he completes the procedure, the surgeon expresses concern about the functioning of the transplanted kidney. The opioid that would be affected the most by this patient’s renal dysfunction is

(A) fentanyl

(B) hydromorphone

(D) sufentanil

106. Which one of the following maneuvers is the most effective means to prevent acute tubular necrosis and thereby facilitate immediate graft function in this patient?

(A) Volume expansion with saline, albumin and/or blood

(B) Volume expansion plus mannitol

(D) Volume expansion plus furosemide

107. A 27-year-old G1P0 patient presents for an anesthesia consult at 20 weeks gestational age. Her prenatal course is notable for a history of corrected idiopathic scoliosis. True statements regarding her disease in pregnancy include all of the following EXCEPT

(A) pregnant women with corrected idiopathic scoliosis tolerate pregnancy, labor, and delivery well

(B) insertion of an epidural needle in the fused area may not be possible

(C) the spread of injected local anesthetic may be altered resulting in an increased incidence of inadequate analgesia after epidural placement

(D) 80% of patients undergo fusion to the lowest lumbar levels, limiting the potential for neuraxial anesthesia

(E) there is a higher incidence of dural puncture

108. A 72-year-old female patient is undergoing right pneumonectomy for lung cancer. After starting one-lung ventilation with oxygen and isoflurane, a tidal volume of 500 mL, and a rate of 10 breaths per minute, the patient’s oxygen saturation starts to fall as the surgeon is opening the chest. The most effective means of improving the oxygen saturation is

(A) increasing oxygen flow to the anesthesia circuit

(B) adding 10 cm H₂O PEEP to the ventilated lung

(D) starting intravenous nitroglycerin

(E) increasing the concentration of isoflurane

109. A 35-year-old G1P0 patient with a history of chronic hypertension who takes lisinopril presents for her first prenatal visit at 12 weeks gestational age. The obstetrician calls and asks your opinion regarding her medication. You advise the obstetrician that which one of the following drugs has the best safety profile in pregnancy?

(A) Labetalol

(B) Nifedipine

(D) Furosemide

(E) Captopril

110. Management of the airway during induction of general anesthesia in a patient in a halo brace for a nondisplaced unstable fracture of C6 incurred in a high-speed motor vehicle accident includes all of the following EXCEPT

(A) assessment for injuries of the face

(B) awake fiberoptic intubation

(D) removal of the cervical brace for intubation

(E) nasal or oral route of intubation

111. An elderly gentleman presenting to the pain clinic complains of right-sided thoracic pain. He developed a very painful rash that started about 6 months ago. The lesions are now gone, but he states that the pain is persistent. A beneficial therapy modality is

(A) high-dose aspirin

(B) TENS (transcutaneous electrical nerve stimulation)

(D) opioids

112. A 3-year-old, previously healthy child, presents for an urgent left sided VATS procedure and chest tube placement for a parapneumonic effusion. The child is on 3 liters of oxygen by nasal cannula with Spo2 of 92-95%. She is tachypneic, but does not appear to be in distress and is hemodynamically stable. Which one of the following is true regarding management of ventilation in this patient?

(A) Use of a double lumen tube would be the best way to provide lung isolation in this case.

(B) Because the blocker tube is attached to the main endotracheal tube in a Univent tube, there is greater chance of displacement of the blocker than when other blockers are used.

(D) An arterial catheter will be necessary to guide ventilation management.

(E) If a bronchial blocker is used to provide lung isolation for this procedure, a larger endotracheal tube will be required in order to allow the passage of the fiberoptic bronchoscope and the bronchial blocker.

113. The neural pathways that are responsible for the transmission of pain during the first and second stages of labor are

(A) T6 – T12 and S1 – S4

(B) T8 – L2 and S1 – S3

(D) T10 – L5

(E) T12 – L3 and S2 – S5

114. A 38-year-old woman presents with palpitations and is found to be in atrial fibrillation. She is otherwise healthy and active. An echocardiogram is performed that reveals a congenital cardiac lesion. The most likely diagnosis in this patient is

(A) ventricular septal defect

(B) atrial septal defect

(D) patent ductus arteriosus

(E) pulmonary stenosis

DIRECTIONS: Use the following scenario to answer Questions 115-116: A 65-kg patient presents for elective CABG. Induction of anesthesia is facilitated with fentanyl 15 mcg/kg, midazolam 150 mcg/kg, propofol 0.8 mg/kg, and rocuronium 0.8 mg/kg. Anesthesia is maintained with isoflurane 0.7 MAC in oxygen and air, and initial minute ventilation is set at 4 L/min. During the prebypass period the patient develops tachycardia, hypotension, and subsequent ST elevations in lead V, as well as a rise in the pulmonary artery (PA) pressure.

115. The rise in PA pressure is most likely caused by

(A) myocardial ischemia

(B) pulmonary embolism

(D) hypovolemia

(E) light anesthesia

116. Administration of which one of the following agents is most appropriate in this situation?

(A) Epinephrine

(B) Glycopyrrolate

(D) Sodium nitroprusside

(E) Nicardipine

DIRECTIONS: Use the following scenario to answer Questions 117-118:A 2-year-old child presents for strabismus repair. The child is otherwise healthy. After an uneventful induction and intubation, surgery begins. During the procedure the patient’s heart rate acutely decreases from sinus rhythm at 110 bpm to sinus rhythm at 50 bpm. The blood pressure is normal and stable.

117. Which one of the following is the best treatment for this?

(A) Preoperative atropine

(B) A retrobulbar block

(D) Administration of vecuronium

(E) Administration of neostigmine

118. Which one of the following are the respective afferent and efferent limbs of the reflex that resulted in the patient’s bradycardia?

(A) Ciliary nerve and vagus nerve

(B) Trigeminal nerve and facial nerve

(D) Vagus nerve and ophthalmic nerve

(E) Ciliary nerve and facial nerve

119. A 30-year-old G2P1 patient presents for an anesthetic consultation at 20 weeks gestational age. Her prenatal course is complicated by Graves disease. She has not undergone radioactive iodine treatment to date and is currently on methimazole. True statements regarding her care include all of the following EXCEPT

(A) radioactive iodine is contraindicated during pregnancy

(B) the mainstay of treatment for hyperthyroidism during pregnancy is the use of antithyroid medication

(D) thyroid storm occurs in 2-4% of pregnant patients with hyperthyroidism

(E) hyperthyroid patients should receive glucocorticoid supplementation

120. In comparing zaleplon and triazolam, which one of the following adverse effects is LEAST likely to occur with zaleplon although it commonly occurs with the use of triazolam?

(A) Prolonged sedation

(B) Abolition of REM sleep

(D) Ventilatory depression

(E) Amnesia

121. Therapy for a patient with closed head trauma and elevated intracranial pressure may include

(A) avoidance of sedation to maintain an unequivocal neurological exam

(B) use of pressors to maintain cerebral perfusion pressure at 80 mm Hg or above

(D) endotracheal intubation and mechanical ventilation for hypoxemia

(E) routine hyperventilation

122. A newborn is noted to have aspirated meconium. The oropharynx is suctioned and the patient remains stable with oxygen administered by nasal cannula. Which one of the following is true of this patient?

(A) This patient was likely born prematurely.

(B) The long-term outcome for this patient is poor.

(D) This patient most likely had in utero stress and fetal hypoxia.

(E) Vagal stimulation may cause passage of meconium in utero.

123. α1-antitrypsin deficiency is

(A) a nonvascular lung disease

(B) determined by a serum assay

(D) due to a lack of an enzyme produced by the lung

(E) the most common cause of COPD

124. The prevalence of obesity in the general population has been growing at an alarming rate and is reaching epidemic proportions. All of the following are true statements regarding morbid obesity in pregnancy EXCEPT

(A) there is a significantly higher failure rate of epidural blocks

(B) longer-than-normal spinal needles are more frequently required for neuraxial anesthesia than longer-than-normal epidural needles

(C) morbid obesity further increases the risks of maternal morbidity, fetal injury, and anesthesia-related maternal death during and after cesarean section

(D) there is a higher risk of both preterm delivery and delivery of a low-birth-weight infant

(E) morbidly obese patients who have undergone cesarean section should be monitored with continuous pulse oximetry after discharge from the postanesthesia care unit

DIRECTIONS: Use the following scenario to answer Questions 125-126: A 52-year-old man is admitted to the ICU after he was rescued from a burning home. He was intubated without sedative medications in the emergency department and transferred to the ICU on mechanical ventilation. He has neither evidence of burns to his skin nor evidence of inhalation injury on external exam. He is comatose. Vitals show T 37.8°C, HR 122, BP 145/90, Spo₂ 100% on FIO₂ 1.0. A head CT scan is unremarkable.

125. Which one of the following is the most likely explanation for the normal oxygen saturation?

(A) Carboxyhemoglobin

(B) Sickle cell anemia

(D) Methylene blue administration

(E) High FIO₂

126. The patient is transported to the hyperbaric oxygen (HBO) chamber for therapy. Which one of the following complications of HBO treatment may be seen in the chamber?

(A) Bradycardia

(B) Skin erythema

(D) Seizures

(E) Chest pain

127. You are called to help resuscitate a newborn in the delivery room. The neonate is a 38-week gestational age female with an Apgar score of 4 at one minute. All of the following are appropriate interventions EXCEPT

(A) clearing of the airway with a bulb syringe

(B) intubation immediately

(D) stimulation of the neonate

128. Which one of the following medications is MOST selective for inhibiting COX-2?

(A) Celecoxib

(B) Ibuprofen

(D) Ketorolac

(E) Acetaminophen

129. When properly positioned, a left-sided double-lumen tube will have its lumens ending

(A) in the left bronchus and the right bronchus

(B) in the left bronchus and in the trachea

(D) in the left upper lobe bronchus and in the left lower lobe bronchus

(E) both in the trachea

130. A 68-year-old patient is on long term COX inhibitor therapy as part of her treatment for severe rheumatoid arthritis. The most common adverse effect of this class of drugs is

(A) gastric side effects

(B) ischemic heart disease

(D) analgesic nephropathy

(E) hypersensitivity

131. A 3-year-old child experiences burn injuries to 50% of her body surface area. She also has significant inhalation injury. Which one of the following statements is true?

(A) Within 4 d an amount of albumin equal to about the total body plasma content is lost through the wound.

(B) Immediately after injury, cardiac output is increased.

(D) Evaporative fluid losses are approximately 4 liters for each square meter of burned surface per day.

(E) Intubation should be avoided in this patient.

132. An anesthesiologist has a drinking problem. After coming to work on several occasions with alcohol on his breath, he was confronted by the Physicians’ Health Committee and convinced to seek treatment. Which one of the following actions that he might take would be least effective in helping him maintain sobriety?

(A) He gets an injection of naltrexone every two weeks.

(B) He takes a disulfiram tablet each day.

(D) He has blood drawn randomly once or twice a week for measurement of alcohol concentration.

(E) He has a 50-min counseling session with his therapist once weekly.

133. Spinal cord stimulation

(A) requires an external generator

(B) involves an electrical stimulator placed in the subarachnoid space

(D) may be helpful in patients with intractable back pain

134. At the molecular level, the effect of benzodiazepines is most accurately described as increasing

(A) sodium conductance

(B) potassium conductance

(D) endozepine binding to its receptor

(E) acetylcholine binding to its receptor

135. You suspect nerve root impingement in the lumbar spine in a patient. Which one of the following physical findings would support this diagnosis?

(A) You suspect L2 nerve root involvement and the patient has weakness of hip flexion and sensory loss on the lateral aspect of the calf.

(B) You suspect L4 nerve root involvement and the patient has weakness of leg extension and loss of patellar reflex.

(C) You suspect L5 nerve root involvement and the patient cannot dorsiflex his big toe and has a loss of the Achilles reflex.

(D) You suspect S3 nerve root involvement and the patient has loss of sensation over the bottom of the foot. The Achilles tendon reflex is normal.

136. Fetal hemoglobin is necessary to allow transfer of oxygen from mother to fetus. Which one of the following is the reason why this transfer is able to occur?

(A) Fetal hemoglobin has a dissociation curve shifted to the right relative to that for adult hemoglobin.

(B) Fetal hemoglobin interacts with 2,3-diphosphoglycerate.

(D) Fetal hemoglobin has a greater affinity for oxygen than adult hemoglobin at any given partial pressure.

137. A 3-month-old infant, 46 weeks post-conceptual age, requires an inguinal hernia repair. The child was born by a spontaneous vaginal delivery, had an uncomplicated perinatal course, and was discharged home 2 weeks later. Which one of the following statements is true?

(A) In order to minimize disruption of feeding and sleep, the infant should be operated on as an ambulatory surgical patient.

(B) Spinal anesthesia is not a suitable technique.

(C) Induction of anesthesia with sevoflurane is inadvisable because of the relatively slow uptake of inhalational agents in infants.

(D) Halothane may cause depression of the chemoreceptor pathways, but is a suitable choice of inhalational agent.

(E) A caudal epidural injection should not be performed due to the more caudal location of the spinal cord in the neonate compared to adults and older children.

DIRECTIONS: Use the following scenario to answer Questions 138-139: A patient with a history of asymmetrical cardiac septal hypertrophy (HOCM) is undergoing a liver resection for hepatocellular carcinoma. During the case there is sudden large volume blood loss. In addition to volume replacement, the patient is started on phenylephrine, followed by addition of epinephrine due to persistent hypotension. Shortly after initiation of epinephrine infusion, the patient has visible cyanosis and worsening hemodynamic instability.

138. An emergent TEE performed intraoperatively is most likely to reveal which one of the following findings?

(A) Dilated right atrium and ventricle, and collapsed left atrium and ventricle

(B) Decreased left ventricular function

(D) Large VSD

(E) Aortic dissection

139. Which one of the following interventions is most likely to improve this patient’s hemodynamic instability?

(A) Addition of milrinone

(B) Discontinuation of epinephrine

(D) Discontinue volume replacement

(E) Addition of nitroglycerin

140. A 5-year-old child with obstructive sleep apnea presents for tonsillectomy and adenoidectomy. The child has no other past medical history. The parents note that the patient snores loudly and has frequent pauses in breathing when sleeping. All of the following are possible complications or necessary interventions in this child EXCEPT

(A) pharyngeal airway obstruction may occur on induction of anesthesia

(B) use of an oral airway may be necessary during induction of anesthesia

(C) continuous positive airway pressure should not be used as it may inflate the stomach and make the patient more likely to have postoperative nausea and vomiting

(D) smaller than expected doses of opioid may produce pronounced respiratory depression

(E) difficulty in proper placement of an LMA may be encountered

DIRECTIONS (Questions 141-142): Each group of items below consists of lettered headings followed by a list of numbered phrases or statements. For each numbered phrase or statement, select the ONE lettered heading or component that is most closely associated with it. Each lettered heading or component may be selected once, more than once, or not at all.

(A) Intraparenchymal hemorrhage

(B) Disseminated intravascular coagulation

(D) Liver failure

(E) Uremia

(F) Factor VIII deficiency

(G) Von Willebrand disease

(H) Salicylate toxicity

For each patient with head trauma, select the most appropriate diagnosis to explain the hemorrhage.

141. A middle-aged man is brought to the operating room emergently for open head injury after an assault that occurred at least three hours before presentation to the hospital. He has a depressed skull fracture and scalp laceration with exposed brain; he is bleeding actively from the scalp. No previous medical history is available. Blood alcohol content is 0.5% by volume. Heart rate is 128 and non-invasive blood pressure is 85/35; esophageal temperature is 32°C after induction of general anesthesia. During debridement of the brain there is a significant brain laceration and marked bleeding from the scalp requiring replacement with multiple units of packed red blood cells to support intravascular volume; hematocrit is normal after transfusion. Intraoperatively, the PT and aPTT are prolonged; fibrinogen and platelet count are reduced.

142. A 25-year-old male with kidney failure from glomerular nephropathy requiring dialysis three times weekly is brought to the operating room emergently for evacuation of a subdural hematoma that developed after a blow to the head during a softball game. The patient underwent dialysis 36 h earlier; BUN is 67 mg/dL and creatinine is 8.3 mg/dL. He presented to the emergency department with a headache but suffered a progressive decline in mental status. After successful induction of general anesthesia, the cranium was opened and the hematoma removed. Intraoperatively the PT, aPTT, and platelet counts are normal. Profuse bleeding from the scalp and dura, requiring transfusion of packed red blood cells, complicates closure.

DIRECTIONS (Questions 143-146): Each group of items below consists of lettered headings followed by a list of numbered phrases or statements. For each numbered phrase or statement, select the ONE lettered heading or component that is most closely associated with it. Each lettered heading or component may be selected once, more than once, or not at all.

(A) Acute alcohol intoxication

(B) Delirium

(D) Dementia

For each patient with agitation, select the most likely diagnosis.

143. A 32-year-old female is in the hospital recovering after repair of a right lower extremity fracture sustained three days ago after jumping off a trampoline. On morning rounds, the patient is disoriented, tremulous, and pulling at her gown and IV lines. Her vitals are T 37.7°C, HR 121, BP 164/89, RR 26, Spo₂ 96%.

144. An 83-year-old female is in the ICU recovering from a colon resection for diverticulitis. On morning rounds, you find the patient talking to her incentive spirometer. As you approach, she is startled and asks how you got into her house. Her vitals are T 37.3°C, HR 89, BP 142/73, RR 18, Spo₂ 97% on 2 L O₂ via nasal cannula. When you return to see the patient with your attending, she greets you by name and recounts the final moments of last night’s televised basketball game.

145. A 74-year-old female is brought to her internist’s office by her daughter. She has become concerned because her mother has gotten lost while in familiar environments and has forgotten to pay several bills over the last several months. The patient is pleasant. When asked about her symptoms, she suggests that her daughter is overreacting. Her Mini Mental Status Exam score is 20. Her vitals are T 36.9°C, HR 72, BP 128/78, RR 16, Spo₂ 98%.

146. A 67-year-old female is brought to the Emergency Department by paramedics after a motor vehicle collision. She has a laceration of her left forearm. When she stands to change into the hospital gown, she is unsteady and nearly falls. She falls asleep on the stretcher. When the staff wakes her to assess her vitals, she is uncooperative and confused. She demands to be left alone.

DIRECTIONS (Questions 147-148): Each group of items below consists of lettered headings followed by a list of numbered phrases or statements. For each numbered phrase or statement, select the ONE lettered heading or component that is most closely associated with it. Each lettered heading or component may be selected once, more than once, or not at all.

(A) Epinephrine

(B) Sodium bicarbonate

(D) Calcium

(E) Volume expander

(F) Dobutamine

(G) Milrinone

(H) Albumin

For each patient, select the most appropriate medication or therapy.

147. After birth, a newborn remains apneic with a heart rate of less than 60 beats per minute despite adequate ventilation and chest compressions.

148. This drug is no longer recommended during the resuscitation of the newborn.

DIRECTIONS (Questions 149-150): Each group of items below consists of lettered headings followed by a list of numbered phrases or statements. For each numbered phrase or statement, select the ONE lettered heading or component that is most closely associated with it. Each lettered heading or component may be selected once, more than once, or not at all.

(A) Mid-esophageal four chamber

(B) Mid-esophageal two chamber

(D) Transgastric two chamber

(E) Transgastric mid-papillary short axis

(F) Mid-esophageal aortic valve short axis

(G) Mid-esophageal aortic valve long axis

(H) Mid-esophageal bicaval

(I) Mid-esophageal right ventricular inflow-outflow

(J) Deep transgastric long axis

(K) Upper esophageal aortic valve short axis

(L) Upper esophageal aortic valve long axis

(M) Transgastric long axis