High-frequency oscillatory ventilation

A patient with severe acute respiratory distress syndrome (ARDS) develops a pneumothorax requiring insertion of a chest drain. You decide to institute high-frequency oscillatory  ventilation (HFOV). Regarding this case which of the following options is CORRECT?

a) Positive end expiratory pressure (PEEP) levels during HFOV would be similar to those in an optimal conventional ventilator strategy

b) Tidal volumes employed in HFOV are generally only 1 to 2 mL/kg more than the physiological dead-space volume

c) Maximum ventilation frequency may be up to 300 per minute

d) On commencement of HFOV a drop in cardiac output and central venous pressure and a rise in pulmonary artery pressure would be expected

e) The tidal volume generated during HFOV is directly related to both the driving pressure and ventilator frequency, both of which are controlled by the operator

Systemic lupus erythematosus

Regarding systemic lupus erythematosus (SLE), the following statements are correct EXCEPT which one?

a) There is a 10:1 female preponderance, particularly affecting women of childbearing age

b) Patients with SLE and isolated lupus anticoagulant antibody are clinically coagulopathic contraindicating central neuraxial blockade

c) Peri-partum high dose steroid therapy may be necessary

d) Pregnant patients are at increased risk of pregnancy-induced hypertension, regardless of their pre-pregnancy renal status

e) More than 50% of patients with SLE have demonstrable psychiatric or neurological abnormalities including seizures and cerebrovascular events

Toxicology and blood gases

A patient is brought into the resuscitation room with a reduced conscious level. He was   recognised as having been admitted a week earlier with deliberate self-poisoning. His blood gases were as follows: pH 7.01; PaO2 9.8 kPa; PaCO2 6.1 kPa; HCO3 – 12 mEq/L; base excess –18; anion gap 9 mEq/L.

Which one of the following is the patientMOST LIKELY to have been poisoned with?

a) Amitriptyline

b) Methadone

c) Paroxetine

d) Ethanol

e) Organophosphates

Acromegaly

Regarding a person with acromegaly presenting for transsphenoidal hypophysectomy, which of the following statements is MOST LIKELY to be true?

a) The patient is more likely to be male than female

b) Males with acromegaly are as likely to suffer fromobstructive sleep apnoea as females

c) Patients with acromegaly are more likely to have a distal rather than a proximal myopathy

d) They are likely to have raised adrenocorticotrophic hormone (ACTH) levels

e) They are likely to have raised levels of insulin-like growth factor-1 (IGF-1)

Preoperative anaemia

A 30-year-old Chinese woman who has been in the United Kingdom for the last year is scheduled to have a laparoscopic cholecystectomy. She has no significant past medical  history other than rheumatoid arthritis for which she takes occasional analgesia only.

She has been feeling tired over the last few months. Clinical examination is consistent with rheumatoid arthritis but otherwise unremarkable. She has a microcytic, hypochromic anaemia with a haemoglobin of 9.6 g/dL. Which of the following is LEAST LIKELY to be the cause?

a) HbH disease

b) Alpha-thalassaemia trait

c) Anaemia secondary to rheumatoid arthritis

d) Beta-thalassaemia minor

e) Anaemia secondary to menorrhagia

Somatosensory evoked potentials

In a patient having cortical somatosensory evoked potentials monitoring of spinal cord integrity during spinal surgery, the following may produce important inaccuracies EXCEPT which one?

a) Blood pressure variations

b) Temperature variations

c) Neuromuscular blocking drugs

d) Haemorrhage down to a haemoglobin of 5.5 g/dL

e) Maintenance of anaesthesia with sevoflurane

Stopping smoking

After cessation of smoking 20 cigarettes a day for 20 years, which one of the following takes the LONGEST to show signs of significant improvement?

a) Small airway function

b) The negative inotropic effect of smoking

c) Excess sputum production

d) Polycythaemia

e) Risk of chest infection

Fluid management

Regarding peri-operative fluid management, which one of the following statements is MOST CORRECT?

a) In patients with acute kidney injury, potassium-containing balanced electrolyte solutions should be avoided

b) Higher molecular weight hydroxyethyl starch solutions should be avoided in severe sepsis

c) For patients with acute kidney injury, if free water is required 5% dextrose solution should be avoided

d) In patients without gastric emptying disorders, oral water is acceptable preoperatively except in the last hour prior to induction of anaesthesia

e) Elderly patients are more likely to benefit from 4% dextrose/0.18% saline fluid as maintenance

Disseminated intravascular coagulation

A 29-year-old multiparous woman suffers an antepartum haemorrhage secondary to

placental abruption and in the course of the resuscitation and subsequent emergency caesarean section receives twelve units of packed red blood cells and four units of fresh frozen plasma. The following laboratory results would be expected in acute disseminated intravascular coagulation EXCEPT which one? 

a) Reduced soluble fibrin

b) Moderate thrombocytopenia

c) Decreased factor VII levels

d) Gradual decrease in fibrinogen

e) Prolonged activated partial thromboplastin time

Refeeding syndrome

Refeeding syndrome can manifest with the following derangements EXCEPT which one?

a) Hypophosphataemia

b) Hyperkalaemia

c) Hypomagnesaemia

d) An increase in the minute volume and respiratory quotient

e) Increased extracellular fluid volume

Phenylephrine

Regarding the use of phenylephrine following central neuraxial block in obstetric

anaesthesia, the following statements are true EXCEPT which one?

a) Continuous infusion produces fewer periods of hypotension than intermittent boluses

b) It results in less umbilical artery acidaemia than ephedrine

c) It produces less bradycardia compared to ephedrine

d) It produces less supraventricular tachycardia compared to ephedrine

e) It has not been shown to exhibit tachyphylaxis

Implantable cardiac defibrillators

Regarding implantable cardiac defibrillators, which one of the following statements is TRUE?

a) An implantable defibrillator must be turned off before surgery involving diathermy

b) If the indifferent grounding pad is greater than 15 cm from the defibrillator, the risk from unipolar diathermy electrocautery is eliminated

c) An internal cardioversion shock of two joules will cause painful skeletal and diaphragmatic contraction in the awake patient

d) External cardiac pacing is contraindicated in the presence of implantable defibrillator leads

e) In approaching 90% of cases, a functioning implantable defibrillator will successfully terminate a malignant arrhythmia within 15 seconds

Brain-stem testing

Regarding cranial nerve examination during testing for brain-stem death, the following  cranial nerves are examined EXCEPT which one? 

a) Cranial nerve VIII

b) Cranial nerve V

c) Cranial nerve XI

d) Cranial nerve IX

e) Cranial nerve X

Clostridium difficile

A patient on the intensive care unit develops offensive diarrhoea following treatment for ventilator-associated pneumonia. Clostridium difficile toxin has been detected in the stool. Which one of the following statements regarding C. difficile infection is TRUE?

a) Following initial treatment of C. difficile colitis recurrence is uncommon

b) Over 50% of adults carry C. difficile asymptomatically

c) The pathogenesis of C. difficile is secondary to the production of two types of

exotoxin

d) Treatment with broad spectrum cephalosporins carries the highest risk of developing C. difficile colitis compared with treatment with other antibiotic types or groups

e) Non-toxin producing strains of C. difficile may cause pseudomembranous colitis

Avoiding drugs

According to the product information leaflets, which one of the following statements

is TRUE?

a) Albumin solution should not be used in patients with known egg allergy

b) The use of 20% Intralipid is safe in patients with a known peanut allergy

c) Gelofusine® may be unacceptable for the management of a Hindu patient

d) Propofol should not be used in patients with a known egg allergy

e) The use of hydroxyl ethyl starch solutions in patients with gluten-sensitive

enteropathy should be avoided

Urinalysis

Regarding urinary chemical reagent dipstick testing, the following are true EXCEPT

which one?

a) The presence of leucocytes with no nitrites is more common than the presence of

nitrites with no leucocytes

b) Urine specific gravity measurements may need to be adjusted upwards if the

urine is strongly acidic

c) If the stick is left with a coating of excess urine after dipping, errors are most likely

to be found in the pH reading

d) Concurrent nephrotic syndrome may lead to overdiagnosing the syndrome of

inappropriate antidiuretic hormone (SIADH) when analysing dipstick specific

gravity

e) If the urine is allowed to stand for one hour, glucose testing may produce a false

negative

Peptic ulcer disease

Regarding the diagnosis and management of peptic ulcer disease, which one of the

following statements is CORRECT?

a) In the UK, gastric ulcers are, overall, more common than duodenal ulcers

b) Alcohol consumption is an independent risk factor for peptic ulcer disease

c) Peptic ulcers, almost universally, present with pain as one of the clinical features

d) The presence of night-pain tends to suggest a duodenal rather than gastric ulcer

e) A perforated peptic ulcer necessitates urgent laparotomy

Oxygenation indices

Regarding oxygenation indices the following statements are correct EXCEPT for which

one?

a) Calculating venous admixture requires a pulmonary artery flotation catheter

b) A PaO2:FiO2 ratio <26.6 kPa is a criterion for diagnosis of ARDS

c) P (a – a) O2 is the respiratory index

d) Ideally an oxygenation index should not vary with changes in FiO2

e) The alveolar gas equation is required for a number of oxygenation indices

Brachial plexus anatomy

Which one of the following statements regarding the anatomy of the brachial plexus is TRUE?

a) The median nerve derives contributions from spinal nerve roots C5 to C8

b) The upper, middle and lower trunks each have divisions that unite to form the

posterior cord

c) The axillary and radial nerves are both derived from the lateral cord

d) The medial cutaneous nerves of the arm and forearm are branches of the ulnar nerve

e) The lateral cutaneous nerve of the forearm is a terminal branch of the radial nerve

Coronary artery blood flow

Regarding normal coronary artery blood flow, the following statements are true EXCEPT which one?

a) Total left coronary artery flow is initially decreased by tachycardia

b) At rest, right coronary artery blood flow is greater than left coronary artery blood

flow at the beginning of systole

c) Flow in the left coronary artery at rest may be as high as 100 mL/min

d) Right coronary flow is at its lowest at the beginning of diastole

e) At rest, peak left coronary artery flow may be six times higher than peak right

coronary artery flow

Acute liver failure

Regarding acute liver failure, which one of the following statements is TRUE?

a) Subacute liver failure carries a better prognosis than hyperacute liver failure

b) Acute liver failure refers to ‘jaundice to encephalopathy time’ of one to four weeks

c) The commonest cause in the UK is infective hepatitis

d) Hyperglycaemia and hypokalaemia is the common metabolic derangement at

presentation

e) Deliberate self-harm patients cannot be considered for liver transplantation

Clinical features of valvular heart disease

An 82-year-old female is awaiting a hip hemiarthroplasty having sustained a fractured

neck of femur. She has mild dementia and is unable to relate her medical history. Her old notes are currently unavailable and as she has recently moved from out of the region her computer records are unhelpful. On examination she has a small volume, regular pulse. Her blood pressure is 136/72mmHg and her JVP is not raised. She has an undisplaced, tapping apex beat. On auscultation, she has a short rumbling diastolic murmur audible all over the praecordium. Which one of the following is the MOST LIKELY valve lesion?

a) Mitral stenosis

b) Aortic regurgitation

c) Mixed aortic valve disease

d) Tricuspid stenosis

e) Pulmonary regurgitation

Physics of vaporisers

An Ohmeda Isotec 5 vaporiser filled correctly with isoflurane has a 1 L/min fresh gas flow delivered to it at sea level and 20 °C. The control dial is set such that the splitting ratio is 5%.What is the resulting concentration of isoflurane at the outlet of the vaporiser?

a) 0.8%

b) 1.6%

c) 2.4%

d) 3.2%

e) 5.0%

Signs of anaphylaxis

In severe anaphylaxis under anaesthesia, which of the following is MOST COMMONLY the first to be detected?

a) Flushing of the skin

b) Facial oedema

c) Desaturation

d) Difficulty in ventilating

e) Decrease in arterial pressure

Contrast-induced nephropathy

A 55-year-old man requires cerebral angiography and possible coiling of a large basilar aneurysm. He is diabetic with impaired renal function. Which of the following has been shown to reduce most the chances of the patient developing a contrast-induced nephropathy (CIN)?

a) An infusion of isotonic sodium bicarbonate commenced prior to contrast infusion

b) An N-acetylcysteine infusion commenced prior to contrast infusion

c) The use of the lowest dose of an iso-osmolar contrast medium possible

d) Commencement of an aminophylline infusion prior to contrast infusion

e) An infusion of 0.9% sodium chloride commenced prior to contrast infusion

Ketamine

A 78-year-old male with advanced dementia presents with a large incarcerated inguinal hernia. He is extremely confused, agitated and combative. He is being physically violent and despite his age and weighing only 60 kg he is requiring four theatre staff to prevent him from falling off the theatre table. He has already kicked one theatre support worker and attempts to secure venous access have failed, prompting further violent outbursts from the patient. It is your judgement that he requires a rapid sequence induction but that he currently poses a risk of harm to himself and others. It is your intention to provide sedation sufficient to tolerate intravenous cannulation whereupon you will pre-oxygenate and perform an intravenous rapid sequence induction. You request ketamine, 100 mg/mL, which you plan to deliver  intramuscularly. Which one of the following is the most suitable volume to administer?

a) 0.6mL

b) 1.2mL

c) 2.4mL

d) 4.2mL

e) 6.0mL

Peri-operative risks

In peri-operative care, which one of the following interventions reduces the risk of wound infections by 80%, the risk of requiring secondary surgery by 70% and therisk of pulmonary complications by 80%.

a) Screening for and treating MRSA colonisation

b) Avoiding inadvertent peri-operative hypothermia

c) Stopping smoking eight weeks pre-operatively

d) Intraoperative goal directed therapy

e) Preoperative safety briefing

Preoperative airway assessment

A 45-year-old male presents for microlaryngoscopy following the development of a

persistent hoarse voice. He mentions that when he had an appendicectomy age 12, the

anaesthetist told him he had struggled to place his breathing tube. Which one of the

following would MOST PREDICT a potential difficulty with tracheal intubation?

a) Thick beard and moustache

b) Maximal mouth opening of 4 cm

c) Sternomental distance of 12cm

d) Patel’s distance of 6.5 cm

e) Wilson score 1

Autonomic neuropathy

Regarding making the diagnosis of autonomic neuropathy, which one of the following

statements is CORRECT?

a) Anhydrosis is the most common presenting symptom

b) A normal sinus arrhythmia involves mild elevation of heart rate during expiration

and mild depression during inspiration

c) A Valsalva manoeuvre is of no use as a bedside test

d) During a sustained handgrip, a normal response would be an increase in diastolic

blood pressure of >16mmHg in the opposite arm

e) The patient’s ability to perform mental arithmetic may aid diagnosis at the bedside

Fentanyl and morphine

Regarding opioids, which one of the following statements is CORRECT?

Compared to fentanyl, morphine has

a) A higher lipid solubility, a lower potency and a higher proportion bound to

plasma protein

b) A lower lipid solubility, a higher potency and a higher proportion bound

to plasma protein

c) A higher lipid solubility, a higher potency and a lower proportion bound to

plasma protein

d) A lower lipid solubility, a lower potency and a higher proportion bound to

plasma protein

e) A lower lipid solubility, a lower potency and a lower proportion bound

to plasma protein

Burns fluid replacement

A 55-year-old, 75 kg male sustains 40% body surface area (BSA) burns in a house fire.

Using the Parkland formula, in addition to maintenance fluids, the extra intravenous

fluid he should receive in the first eight hours following injury is:

a) 3000mL of crystalloid

b) 3000mL of colloid

c) 750mL colloid and 2250mL of crystalloid

d) 4000mL of crystalloid

e) 6000mL of crystalloid

Gadolinium

Regarding the magnetic resonance imaging (MRI) contrast medium gadolinium, which one of the following statements is TRUE?

a) Gadolinium is usually administered as the soluble salt, gadolinium chloride

b) Unlike X-ray contrast media, gadolinium is safe to administer to patients with stage

3 chronic kidney disease

c) Gadolinium is paramagnetic in its Gd3+ state

d) The main role in MRI for gadolinium is to enhance the brightness of neural tissue

e) Gadolinium produces a similar incidence of severe allergic reactions compared to

X-ray contrast media

Stridor

Regarding aspects of acute stridor in children, which one of the following statements is CORRECT?

a) Respiratory syncytial virus (RSV) most commonly causes laryngotracheobronchitis

b) Because of the potential for complete airway obstruction, an intravenous cannula

should be sited as a priority

c) Steroids no longer have a place in the treatment of croup

d) Once intubated, patients with a diagnosis of croup tend to have longer time to

extubation than those with epiglottitis

e) A two day history of high fever and barking cough in a 4-year-old is typical for a

diagnosis of croup

Cardiac tamponade

A 25-year-old man requires urgent assessment in the emergency department. Recently admitted following a fall of 20mwhile climbing, he has suddenly become hypotensive (BP 55/30 mmHg), hypoxaemic (SpO2 88% on 15 L/min O2 via a non-rebreathe mask) and tachycardic (HR 160 bpm) having been cardiovascularly stable with good saturations  on admission 60 minutes earlier. He has sustained multiple bilateral rib fractures, a sternal fracture, bilateral fractured scapulae and a mid-shaft femoral fracture but no pelvic fracture. Auscultation of his lung fields reveals bilateral air entry, his trachea is midline, his abdomen is soft and non-distended and there has been no response to administration of 3000mL of crystalloid. Which of the following is the MOST LIKELY diagnosis to explain the sudden deterioration?

a) Blood loss secondary to multiple fractures

b) Cardiac tamponade

c) Severe, bilateral pulmonary contusions

d) Tension pneumothorax

e) Liver laceration

APACHE II

Regarding the Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system, which one of the following statements is TRUE?

a) There are 15 physiological variables incorporated within the APACHE II scoring

system

b) The maximum number of age points that can be assigned is ten

c) A similar patient will score fewer chronic health points if they are a non-operative

critical care admission than if they are admitted following elective surgery

d) Points for the Glasgow Coma Score (GCS) are calculated by subtracting the actual

GCS from 15

e) The scores for the physiological variables are obtained by recording the most

abnormal variable in each category within the first 12 hours of admission to the

critical care unit