prodigy final 4

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Practice Exam Version 1.2 Prodigy Anesthesia Educational Services

Simulation Exam 1 1 Which of the following drugs would be most appropriate to use while performing conscious sedation for CT scan where the patient needs to hold absolutely still? Answer Propofol has been used with great success for conscious sedation for procedures such as CT scan and MRI. Ketamine and etomidate should be avoided as they predispose the patient to spontaneous limb movement and myoclonus respectively, which can interfere with the clarity of the images. 2 A patient is undergoing general anesthesia for strabismus surgery. Which of the following is not true regarding anesthesia during this procedure? Answer: Strabismus surgery is the most common pediatric ocular surgery and may be an indicator that there is underlying disease as it is associated with a high incidence of CNS diseases such as meningomyelocoele, hydrocephalus, cerebral palsy, and myopathies. It is associated with a higher than normal incidence of masseter rigidity and malignant hyperthermia, and postop nausea and vomiting occurs in 50-80% of these patients. Hyperventilation should not be avoided. In fact, hypoventilation resulting in hypercapnia increases the risk of bradycardia due to the oculocardiac reflex which can occur due to traction on the ocular muscles. 3 Mediastinoscopy can result in decrease blood flow through which vessel? Answer: The mediastinoscope can compress the innominate artery which gives rise to the right subclavian, right common carotid, and right vertebral arteries. 4 Shoulder arthroscopies are usually performed in Answer: Shoulder arthroscopy may be performed in semi-sitting position (also known as beach chair or barber chair position) or lateral decubitus position. Semi-sitting position is often preferred as it facilitates maintaining the MAP < 80 mmHg to reduce subacromial bleeding. 5 All of the following symptoms are consistent with inadvertant bladder perforation during a transurethral resection of the prostate (TURP) in a patient under general anesthesia except: [Answer Bladder perforation occurs in as many as 1 out of every 100 TURPs. Poor return of the irrigation fluid may signal that a perforation has taken place. Awake patients may exhibit abdominal pain, diaphoresis, and nausea. Any episode of sudden hypotension or hypertension, especially when combined with bradycardia in a patient under regional or general anesthesia should elicit suspicion of a bladder perforation. 6 Which of the following respiratory parameters is decreased in elderly patients? Answer: In the elderly patient, closing capacity increases and by age 65 it exceeds tidal volume in the sitting position resulting in airway collapse. The increase in airway collapse

increases residual volume as well. The alveolar surface area decreases with age resulting in decreased efficiency of gas exchange. 7 What would you predict the PaO2 of a healthy, 70 year-old patient to be under normal conditions at room air? Answer: The formula for predicting the decline in PaO2 with age is: PaO2 = 100 - (0.4 X age in years) mmHg which in this instance = 100 - 28 or 72 mmHg. 8 A drug with a high hepatic extraction ratio may exhibit a prolonged elimination half-life in an elderly patient because: Answer: Hepatic transminase levels and hepatic enzyme activity do not normally change with increased age. Hepatic mass does decrease with age, but the clearance of drugs with a high hepatic extraction ratio relies on hepatic blood flow not hepatic mass. Hepatic blood flow decreases by as much as 40% by 80 years of age. 9 During a craniotomy, a patient's blood pressure decreases from 120/80 to 60/30. Which of the following would happen? Answer: In response to a decreased MAP, cerebral vessels dilate. Between MAPs of 60 and 160 this mechanism is able to keep CBF constant but outside of this range CBF becomes pressure dependent. This patient's MAP decreased to 40, therefore CBF would decrease despite compensatory mechanisms.

10 The nine year-old child of a Jehovah's Witness has presented for surgery for repair of a tear in the abdominal aorta following an automobile collision. The patient is hypotensive and the hematocrit is 21%. The patient's parents state that the child is not to receive blood products under any circumstances. Which of the following actions would represent an understanding of the current legal standards on this matter? [A] Withholding blood products from the patient [B] Administering no more than one unit of PRBCs to the child [C] Administering blood products as needed to the patient [D] Administering blood products only after administration of 5cc/kg of crystalloid Answer: C Although the legal system allows an adult to martyr themselves for their religious beliefs, no court has upheld the decision of a parent to martyr their child. In an emergency situation, blood should be administered as needed to the patient to ensure their safety. 11 A patient presents to the emergency department with a diagnosis of epiglottitis. He is drooling, complains of sore throat, and exhibits stridor. Your preoperative exam for this

patient should include: [A] Thorough airway exam to determine Mallampati score and jaw opening [B] CBC with differential white blood cell count [C] Chest X-ray [D] None of the above Answer: D In the patient with epiglottitis and symptoms of impending airway obstruction such as drooling, dysphagia, and increasing stridor, it is imperative that airway examination be avoided to prevent additional swelling due to manipulation. Also, the importance of a complete blood count and chest x-ray are secondary to securing the airway. The preoperative evaluation should be brief and the efforts of the anesthesia staff should be focused on rapidly securing a difficult airway. 12 Which of the following would be an appropriate indication for surgical lumbar sympathectomy? [A] Causalgia (B] Raynaud's phenomenon [C] Ischemic ulceration of the lower limbs [D] All of the above Answer: D Surgical sympathectomy of the lumbar region is performed to improve blood flow to ischemic areas by identifying preganglionic fibers along their segmental origins and resecting the corresponding ganglia. The L2 and L3 ganglia are typically resected for most lumbar sympathectomies. This technique is used in ischemic conditions such as causalgia, Raynaud's phenomenon, frostbite, toe gangrene, and ischemic ulceration of the lower extremities. 13 Pain during the latent stage of labor is usually confined to what dermatomes? [A] T4-T8 [B] T8-T10 [C] T10-T12 [D] T12-L2 Answer: C During the latent phase of labor, the pain is due primarily to uterine contractions and cervical dilation and thus is confined to the T10-T12 dermatomes. As it progresses to the active phase of labor, however, it will involve the T10-L1 dermatomes. 14 Which of the following conditions is not a component of HELLP syndrome? [A] Thrombocytopenia [B] Elevated transaminase levels [C] Lysis of erythrocytes [D] All of the above are components of HELLP syndrome Answer: D HELLP syndrome is a condition associated with pregnancy in which the patient exhibits

hemolysis, elevated liver enzymes, and a low platelet count. 15 You are placing an epidural in an obstetric patient in labor. You know that pain during the second stage of labor is transmitted primarily by which dermatomes? [A] T6 - L1 [B] T10 - L1 [C] L1 - L5 [D] S2 - S4 Answer: D The pain experienced during the second stage of labor is primarily perineal, which is transmitted through the S2-S4 segments. The pain experienced during the first stage of labor is transmitted primarily through the T10 -L1 dermatomes. 16 All of the following statements regarding administration of analgesics to a laboring parturient are true except: [A] Ketamine 0.2-0.4 mg/kg IV does not produce neonatal depression [B] Fentanyl may be administered safely to a laboring parturient [C] Meperidine produces greater respiration depression in neonates than morphine [D] Naloxone can be administered intravenously to newborns Answer: C Meperidine produces less respiratory depression in neonates than an equivalent dose of morphine. Ketamine 0.2-0.4 mg/kg IV provides analgesia without producing respiratory depression in the neonate. Fentanyl 1 mcg/kg IV can be administered without producing severe respiratory depression in the neonate. In the neonate that does exhibit respiratory depression, naloxone may be administered IV directly into the newborn at a dose of 10 mcg/kg. 17 Which surgery would you expect to require the greatest degree of postoperative pain control? [A] Tonsillectomy [B] Adenoidectomy [C] Myringotomy [D] Bronchosopy Answer: A In order from least amount of expected postoperative pain to the greatest is myringotomy (pain score of 1-3 on a scale of 1-10), bronchoscopy (pain score 3-4), adenoidectomy (pain score 3-5), and tonsillectomy (pain score 6-9). 18 Patients with cardiac valvular disorders undergoing tonsillectomy are at risk for endocarditis from chronic tonsillar infection by [A] Staphlococcal organisms [B] Streptococcal organisms

(C] Cryptococcal organisms [D] Diplococcal organisms Answer: B Chronic tonsillar infection places the patient with cardiac valvular disease at risk for endocarditis due to chronic streptococcal bacteremia. 19 What is the most common causative diagnosis for patients requiring renal transplant? [A] Diabetes [B] Polycystic kidney disease [C] Hypertensive nephrosclerosis [D] Renal graft failure Answer: A The most common diagnosis for patients requiring renal transplant is type 2 diabetes. The next three most common causative diagnoses in order are hypertensive nephrosclerosis, renal graft failure, and and type 1 diabetes. 20 Which of the following is considered an absolute contraindication to performing extracorporeal shock wave lithotripsy? [A] Presence of an aortic aneurysm near the site of the renal stone [B] Presence of an orthopedic appli