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1. A 32-year-old female falls form the 10th floor of her apartment building in an apparent suicide attempt. Upon presentation, the patient has obvious head and extremity injuries. Primary survey reveals that the patient is totally apneic. By which method is the immediate need for a definitive airway in this patient best provided? (A) (B) (C) (D) (E) orotracheal intubation nasotracheal intubation percutaneous cricothyroidotomy intubation over a bronchoscope needle cricothyroidotomy 2. An 18-year-old man is brought to the emergency department after falling down a flight of stairs and losing consciousness for 3 minutes. A cervical collar is in place. The cervical spine is considered to be free of serious injury following which procedure? (A) (B) (C) (D) (E) a physical examination revealing no pain or tenderness a lateral cervical spine x-ray complexity negative findings on neurological examination anteroposterior (AP), lateral, and odontoid views of the neck flexion and extension views of the neck 3. A 16-year-old boy presents to the emergency department with a stab wound to the anterior midneck. On physical examination, it is difficult to determine if the plane of the platsyma has been violated. However, subcutaneous emphysema is found on palpation. What is the next management step? (A) (B) (C) (D) (E) esophagogram arteriography surgical exploration esophagoscopy CT scan of the neck with oral and intravenous contrast 4. A 20-year-old woman presents to the emergency department after being hit in the face during a baseball game. On physical examination, the patient's blood pressure is 90mmHg, and there is significant bleeding from the nose that cannot be controlled either by fracture reduction or by anterior and posterior nasopharyngeal packing. What is the next step in management? (A) (B) (C) (D) (E) external carotid artery ligation bilateral internal maxillary artery ligation angiographic evaluation and embolization foley catheter balloon tamponade of bleeding insertion of nasogastric tube 5. A 30-year-old man is brought in the emergency department in respiratory distress following a shotgun wound to the face. There is a possible cervical spine injury. Which is the best way to gain rapid control of the airway? (A) (B) (C) (D) (E) nasotracheal intubation percutaneous jet ventilation cricotyroidotomy endotracheal intubation aspiration of blood from pharynx and kaw thrust 6. Following a car crash in which her face hit the steering wheel, a 37-year-old woman presents to the emergency department with facial deformity. Facial x-rays showed a transverse fracture through the articulation of the maxillary and nasal bones with the frontal bone. The fracture also passed below the zygomatic bone. What is the diagnosis? (A) (B) (C) (D) (E) sphenoid wing fracture LeFort II fracture Petrous temporal fracture Palatal split Mandibular disruption 7. A 40-year-old man is hit in the face with a baseball bat and presents to the emergency department with massive facial swelling, ecchymosis, and an elongated face. There is mobility of the middle third of the face on digital manipulation of the maxilla. What is likely the diagnosis. (A) (B) (C) (D) (E) lamdoid injury odontoid fracture LeFort III fracture Palatal split Mandibular disruption 8. With regard to neck injuries, which of the following is true? (A) (B) (C) (D) (E) The internal jugular vein may be ligated unilaterally without unfavorable sequelae. Unilateral ligation of the common carotid artery results in neurologic deficiency in 90% of cases. Esophageal injuries should be drained externally only when extensive devitalization is present. Tracheostomy is indicated in dealing with most laryngeal or tracheal injuries. Injuries to the trachea must be drained externally. 9. A 24-year-old woman with blunt trauma to the head sustained in a car accident presents with a history of loss of consciousness for approximately 10 minutes at the scene of the accident. She is currently fully awake, oriented, and responsive. With regard to the appropriate care of this woman, which of the following statements is true? (A) (B) (C) (D) (E) In this setting, a fully awake patient who has a normal examination does not require hospital admission for observation. If skull x-rays show no fracture, the likelihood of significant intracranial injury is low, and hospital admission is unwarranted. If fundoscopic examination of this patient shows no papilledema, elevated intracranial pressure can be ruled out. The initial effects of elevated intracranial pressure are bradycardia and hypertension. If this patient were to exhibit a sudden fall in blood pressure and alteration in mental status, spinal cord or brain stem injury would be most likely. 10. A 20-year-old woman presents to the emergency department with a stab wound to the neck above the angle of mandible. The patient's blood pressure is 110/80mmHg, her pulse rate is 100bpm, and her respiration rate is 24 breaths per minute. Between initial presentations and insertion of intravenous lines, the hematoma in the upper neck enlarges significantly. What should be the next step in the patient's management? (A) (B) (C) (D) (E) barium swallow flexible endoscopy operative exploration Doppler ultrasound Angiography 11. A 65-year-old man is brought into the emergency department with a gunshot wound to the neck. His blood pressure is 80/50 mmHg. The patient undergoes rapid resuscitation and is brought immediately to the OR, where a carotid artery injury is found in zone II (between the angle of mandible and cricoid). The patient has no internal carotid flow; just before surgery, his neurological status deteriorates, and he becomes unresponsive. The operative management should be which of the following? (A) (B) (C) (D) (E) immediate intravascular bypass shunt ligation of the internal carotid artery primary anastomosis interposition saphenous vein graft patch vein graft 12. A 19-year-old man is brought to the emergency department with a stab wound at the base of the neck (zone I). The most important concern for patients with such injuries is which of the following? (A) (B) (C) (D) (E) upper extremity ischemia cerebral infarction exsanguinating hemorrhage mediastinitis tracheal stenosis 13. A 64-year-old woman is admitted to the emergency department with multiple injuries. She requires a central venous pressure line. To minimize the possibility of infection, the principal management of the catheter should be which of the following? (A) (B) (C) (D) repeated attempts via the same cannula in the neck after failure at one site, use of the same cannula at another site use of multiport catheters avoidance of wound contamination by application of tincture of iodine for more than 4 seconds selection of subclavian vein over femoral vein (E) 14. A 40-year-old woman was involved in a car accident. She was unconscious for 5 minutes. X-ray revealed a depressed fracture in the frontal region. Which is true of skull fracture? (A) (B) (C) (D) (E) It always requires surgical exploration It is compound if multiple. It requires burr holes if compound In the anterior cranial fossa, it may produce rhinorrhea It requires steroid administration 15. A 30-year-old man is brought to the emergency department following a highspeed car accident. He was the driver, an the windshield of the car was broken. On examination, he is alert, awake, oriented, and in no respiratory distress. He is unable to move any of his four extremities; however, his extremities are warm and pink. His vital signs on admission are: heart rate 54 bpm and blood pressure 70/40 mmHg. What is the diagnosis? (A) (B) (C) (D) (E) hemorrhagic shock cardiogenic shock neurogenic shock septic shock irreversible shock Questions 16 and 17 A 14-year-old boy with a known bleeding tendency since infancy has severe epistaxis. Examination reveals an equinus contracture of the right leg and a large hemarthrosis. 16. What is the most likely diagnosis? (A) (B) (C) (D) diethylstilbestrol (DES) was taken by the mother during pregnancy aplastic anemia hemophilia Wilson's disease with cirrhosis 17. Treatment should include which of the following: (A) (B) (C) (D) (E) penicillamine transfusion of factor VIII to 30% of normal transfusion of factor VIII to 10% of normal platelet transfusion exploration of joint 18. A 10-year-old boy with history of prolonged bleeding after minor injury is scheduled for tonsillectomy. The bleeding time, PT, and fibrinogen are normal. What would be the most helpful investigation? (A) (B) (C) (D) (E) fibrinolysis (euglobulin clot lysis time) platelet count thrombin time partial thromboplastin time (PTT) factor VII assay 19. In a 12-year-old boy who sustained severe head injury caused by a fall from the third floor of a building, the syndrome of diabetes insipidus is characterized by which of the following? (A) (B) (C) (D) (E) low serum sodium high urinary specific gravity or osmolality high serum osmolality low urine output expanded extracellular fluid volume 20. A 30-year-old woman with a history of an uneventful tonsillectomy at age 4 is scheduled for exploratory laparotomy. Preoperative assessment that identifies the risk of intraoperative bleeding is which of the following? (A) (B) (C) (D) (E) bleeding time platelet count PT and PTT Complete blood cell count None of the above 21. A 43-year-old woman with von Willebrand's disease is scheduled for FESS. It can be stated that preoperative evaluation will reveal which of the following? (A) (B) (C) (D) (E) normal bleeding time, PT, and PTT platelet aggregate with restocetin increased bleeding time and PTT, and normal PT increased bleeding time and PT, and normal PTT increased bleeding time, and normal PT and PTT 22. Following admission to the emergency department, a 26-year-old woman with severe epistaxis states that both her father and sister have a bleeding disorder. The hemostatic disorder transmitted by autosomal-dominant mode is which of the following? (A) (B) (C) (D) (E) factor X deficiency von Willebrand's disease factor VIII deficiency (true hemophilia) factor IX deficiency (Christmas disease) factor V deficiency (parahemophilia) 23. A 75-year-old man is found to have prolonged bleeding from intravenous puncture sites. Platelet aggregation is inhibited by which of the following? (A) (B) (C) (D) (E) Adenosine diphosphate (ADP) calcium magnesium aspirin serotonin Question 24 and25 A 64-year-old woman undergoing modified radical neck dissection under general anesthesia is transfused with 2 U of packed red blood cells (RBCs). 24. A hemolytic transfusion reaction during anesthesia will be characterized by which of the following? (A) (B) (C) (D) (E) shaking chills and muscle spasms fever and oliguria hyperpyrexia and hypotension tachycardia and cyanosis bleeding and hypotension 25. The specific test to identify the cause of transfusion reaction for the patient is which of the following? (A) PT (B) PTT (C) Platelet count (D) Bleeding time (E) Free plasma hemoglobin 26. A 56-year-old man underwent total laryngectomy. He bled excessively and urgently required blood over and above that which had been requested before surgery. In deciding on an appropriate blood transfusion protocol, what should be kept in mind? (A) (B) (C) (D) (E) Group AB is the universal donor. Serum from the recipient stored for 1 week is suitable for testing Hypothermia is indicated if cryoglobulin is found. Cross-matching should be done before dextran administration. All of the above should be remembered. 27. A 60-year-old man with carcinoma of the esophagus is admitted with severe malnutrition. Nutritional support is to be initiated. What should his daily caloric intake be? (A) (B) (C) (D) (E) 1 kcal/kg body weight/day 5 kcal/kg body weight/day 15 kcal/kg body weight/day 30 kcal/kg body weight/day 100 kcal/kg body weight/day