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Question 1
Incorrect
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A cannula is inserted into the cephalic vein of a 30-year-old man. Which of the following structures does the cephalic vein pass through?
Your Answer: Tendon of biceps
Correct Answer: Clavipectoral fascia
Explanation:The cephalic vein is one of the primary superficial veins of the upper limb. The superficial group of upper limb veins begin as an irregular dorsal arch on the back of the hand.
The cephalic vein originates in the anatomical snuffbox from the radial side of the arch and travels laterally up, within the superficial fascia to join the basilic vein via the median cubital vein at the elbow.
Near the shoulder, it passes between the deltoid and pectoralis major muscles. It pierces the coracoid membrane (continuation of the clavipectoral fascia) to terminate in the axillary vein’s first part.
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This question is part of the following fields:
- Anatomy
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Question 2
Correct
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Regarding the classification of breathing systems, which of the following is true?
Your Answer: The Conway classification describes a functional classification based on whether a CO2 absorber is required
Explanation:Breathing system is an assembly of components which connects patient’s airway to anaesthesia machine through which controlled composition of gas mixture is dispensed. It delivers gas to the patient, removes expired gas and controls the temperature and humidity of the inspired mixture. It allows spontaneous, controlled, or assisted respiration. It may also provide ports for gas sampling, airway pressure, flow and volume monitoring.
Breathing systems have been classified by Conway and Mapleson.
Conway suggested a functional classification:
– Circuits requiring a CO2 absorber
– Circuits not requiring a CO2 absorberWilliam Mapleson designated varying arrangements of breathing system components (masks, breathing tubes, fresh gas flow inlets, adjustable pressure-limiting valves, and reservoir bags) as Mapleson A-E circuits.
Mapleson A: Arranged as FGF inlet, reservoir bag, APL valve, mask.
In this circuit, because the reservoir bag is between the FGF inlet valve and the APL valve, expired gas from the patient may re-enter the system and fill the reservoir bag during controlled ventilation. This is the most efficient system for spontaneous breathing as the FGF must only be equal to a patient’s minute ventilation to prevent rebreathing.Mapleson B: Arranged as reservoir bag, FGF inlet, APL valve, mask.
In this circuit, the FGF inlet is closer to the APL valve, which helps prevent the rebreathing concern in the Mapleson A circuit as above during controlled ventilation.Mapleson C: Arranged as reservoir bag, FGF inlet, APL valve, mask.
In this circuit, the arrangement is the same as the Mapleson B circuit. However, this circuit is shorter as it does not contain elongated corrugated tubing. This circuit also has the FGF inlet close to the APL valve to aid in preventing rebreathing.Mapleson D: Arranged as reservoir bag, APL valve, FGF inlet, and mask.
In this circuit, the arrangement interchanges the FGF inlet and APL valve of the Mapleson A circuit. This system prevents rebreathing by directing FGF towards the APL valve rather than towards the patient during exhalation.Mapleson E: Arranged as corrugated tubing, FGF inlet, and mask.
In this circuit, there is no reservoir bag and no APL valve. Given the inability to alter the pressure of the circuit, this is ideal for spontaneously ventilating neonates or paediatric patients where low-pressure ventilation is desired. The system prevents rebreathing, similar to the Mapleson D circuit.Jackson Rees later modified the Mapleson E by adding an open ended bag, which has since become known as the Mapleson F.
Mapleson F: Arranged as APL valve directly connected to reservoir bag, corrugated tubing, FGF inlet, and mask.
The system prevents rebreathing similarly to Mapleson D by directing FGF towards the APL valve. -
This question is part of the following fields:
- Anaesthesia Related Apparatus
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Question 3
Incorrect
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All of the following statements are true regarding calcium except:
Your Answer: Bronchospasm may be a sign of severe hypocalcaemia
Correct Answer: Serum calcium accounts for 10% of total body calcium stores
Explanation:Calcium is a very important ion and is involved in:
-cell homeostasis
-coagulation
-muscle contraction
-neuronal impulse transmission/membrane stabilization
-bone formation and skeletal strength
-secretion processes99% is found in bone and 1% in the plasma. Of the 1% that is in the plasma
-45% is free ionized calcium
-45% is bound to proteins, mainly Albumin
-10% is present as an anion complexReduced levels of IONIZED calcium give rise to features of hypocalcaemia , resulting in increased excitability of membranes. This results when the total calcium concentration goes below 2 mmol/L.
Features of mild to moderate hypocalcaemia are:
-paraesthesia (peri-oral, fingers)
-tetany
-spasm
-muscle cramps
-ECG changes (prolonged QT)
-Trousseau’s sign (inflation of tourniquet induces carpopedal spasm)
-Chvostek’s sign (tapping the facial nerve – cranial nerve VII – causes facial muscle twitch/spasm)Features of severe hypocalcaemia are:
-cardiogenic shock and congestive cardiac failure due to reduced myocardial contractility
respiratory distress due to bronchospasm, agitation, confusion, seizuresFeatures of hypercalcaemia (remember ‘bones, stones, groans and psychic moans’):
-Abdominal pain
-Vomiting
-Constipation
-Polyuria
-Polydipsia
-Depression
-Lethargy
-Anorexia
-Weight loss
-Hypertension
-Confusion
-Pyrexia
-Calcification in the cornea
-Renal stones
-Renal failure
-Decreased Q-T interval
-Cardiac shock/collapse -
This question is part of the following fields:
- Physiology And Biochemistry
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Question 4
Incorrect
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A caudal anaesthetic block is planned for a 3-year-old girl presenting for inguinal hernia repair. Choose the best answer that explains why the caudal epidural space is accessed via the sacral hiatus.
Your Answer: The dural sac ends at the level of the sacral hiatus
Correct Answer: The failure of fusion of the laminae of S4 and S5 provides a suitable point of entry
Explanation:The sacral hiatus is shaped by incomplete midline fusion of the posterior elements of the distal portion of S4 and S5. This inverted U shaped space is covered by the posterior aspect of the sacrococcygeal membrane and is an important landmark in caudal anaesthetic block. Distal most portion of the dural sac and the sacral hiatus usually terminate between levels S1 and S3. The dural sac ends at the level of S2 in adults and S3 in children.
An equilateral triangle is formed between the apex of the sacral hiatus and the posterior superior iliac spines. This triangle is used to determine the location of the sacral hiatus during caudal anaesthetic block.
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This question is part of the following fields:
- Anatomy
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Question 5
Incorrect
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Which of the following drug is enzyme inducer?
Your Answer: Rifampicin
Correct Answer: Erythromycin
Explanation:Rifampicin is a potent inducer of liver cytochrome enzymes. Other enzyme inducers are:
Carbamazepine
Sodium valproate
Phenytoin
Phenobarbitone -
This question is part of the following fields:
- Pharmacology
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Question 6
Correct
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A 55-year-old businesswoman presents to the emergency department complaining of shortness of breath and pleuritic chest pain. Her work requires her to travel internationally frequently. The consultant makes a diagnosis and treats her. Now, the consultant recommends placing a filter that will prevent future incidents. A needle is placed into the femoral vein and passed up into the abdomen to insert the filter. What is true regarding the organ where the filter is placed for this patient's condition?
Your Answer: It is located posteriorly to the peritoneum
Explanation:The patient likely suffers from pulmonary embolism due to her history of frequent international travels. A filter is placed in the inferior vena cava to decrease the risk of future episodes of pulmonary embolism. The IVC filter is a small, wiry device that can catch blood clots and stop them from going into the heart and lungs. Your IVC is a major vessel that brings deoxygenated blood from the lower body to the heart, from where it is pumped into the lungs.
The filter is placed via a thin catheter inserted into the femoral vein in the groin. The catheter is gently moved up into your IVC, and a filter is introduced.
The IVC is a retroperitoneal organ.
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This question is part of the following fields:
- Anatomy
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Question 7
Correct
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A laser is a device that stimulates atoms or molecules to emit light at particular wavelengths and amplifies that light, typically producing a very narrow beam of radiation. This can be of visible, infrared, or ultraviolet wavelengths. They have been widely utilized in theatre environment. Which of the following safety measures is most likely to reduce chances of eye injury to the theatre personnel?
Your Answer: Wearing laser protective goggles
Explanation:Eye damage is the most common potential hazard associated with laser energy. Everyone in the laser treatment room has the risk of eye exposure when working with a Class 3b or Class 4 healthcare laser system, and damage to various structures in the eye depending on wavelength of the laser if they are unprotected.
Red and near-infrared light (400-1400 nm) has very high penetration power. The light causes painless burns on the retina after it is absorbed by melanin in the pigment epithelium just behind the photoreceptors.
Infrared radiation (IR), or infrared light (>1060 nm), is a type of radiant energy that’s invisible to human eyes and hence won’t elicit the protective blink.
Ultraviolet light (<400 nm) is also a form of electromagnetic radiation which is can penetrate the cornea and be absorbed by the iris or the pupil and cause burn injuries or cataract occur due to irreversible photochemical retinal damage.
Safety eyewear is the best method of providing eye protection and are designed to absorb light specific to the laser being used. Laser protective eyewear (LPE) includes glasses or goggles of proper optical density (OD). The lenses should not be glass or plastic. The LPE should withstand direct and diffuse scattered laser beams.
The laser protection supervisor (LPS) or LSO is an individual who is responsible for any clinical area in which lasers are used. They are expected to have a certain level of equipment and determine what control measures are appropriate, for each individual system, but their presence does not guarantee the chances of having an eye injury.
Class 1 lasers are generally safe under every conceivable condition and is not likely to cause any eye damage. Class 3b or Class 4 medical laser systems are utilized in healthcare which have their own safety precautions.
Polarized spectacles can make your eyes more comfortable by eliminated glare, however, they will not be able to offer any protection against wavelengths at which laser act.
Using short bursts to reduce energy is also not correct as it would still be harmful to eye. -
This question is part of the following fields:
- Anaesthesia Related Apparatus
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Question 8
Correct
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Which of the following statements is true about an acute pulmonary embolism?
Your Answer: Thrombolysis administered through a peripheral vein is as effective as through a pulmonary artery catheter
Explanation:Acute pulmonary embolism occurs when a blood clot becomes embedded in a pulmonary artery and restricts lung blood flow.
Thrombolysis is recommended in patients with extremely compromised circulation rather than reduced oxygen in the blood. It is effective when administered via a peripheral vein or a pulmonary artery catheter.
Anticoagulant therapy (heparin use) decreases the risk of further embolic evens and decreases constriction of pulmonary vessels.
An ECG may be normal in patients with an acute pulmonary embolism.
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This question is part of the following fields:
- Pathophysiology
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Question 9
Correct
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A 30-year old female athlete was brought to the Emergency Room for complaints of light-headedness and nausea. Clinical chemistry studies were done and the results were the following: Na: 144 mmol/L (Reference: 137-144 mmol/L), K: 6 mmol/L (Reference: 3.5-4.9 mmol/L), Cl: 115 mmol/L (Reference: 95-107 mmol/L), HCO3: 24 mmol/L (Reference: 20-28 mmol/L), BUN: 9.5 mmol/L (Reference: 2.5-7.5 mmol/L), Crea: 301 µmol/l (Reference: 60 - 110 µmol/L), Glucose: 3.5 mmol/L (Reference: 3.0-6.0 mmol/L). Taking into consideration the values above, in which of the following ranges will his osmolarity fall into?
Your Answer: 300-313
Explanation:Osmolarity refers to the osmotic pressure generated by the dissolved solute molecules in 1 L of solvent. Measurements of osmolarity are temperature dependent because the volume of the solvent varies with temperature. The higher the osmolarity of a solution, the more it attracts water from an opposite compartment.
Osmolarity can be computed using the following formulas:
Osmolarity = Concentration x number of dissociable particles; OR
Plasma osmolarity (Posm) = 2([Na+]) + (glucose in mmol/L) + (BUN in mmol/L)Posm = 2 (144) + 3.5 + 9.5 = 301 mOsm/L
Suppose there is electrical neutrality, the formula will double the cation activity to account for the anions.
Plasma osmolarity (Posm) = 2([Na+] + [K+]) + (glucose in mmol/L) + (BUN in mmol/L)
Posm = 2 (144 + 6) + 3.5 + 9.5 = 313 mOsm/L
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This question is part of the following fields:
- Physiology
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Question 10
Incorrect
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Which of the following statement is correct regarding opioid receptors?
Your Answer: In the spinal cord, kappa receptors are predominantly localised in lamina IX
Correct Answer: Binding with an opioid agonist increases potassium conductance
Explanation:Opioid receptors are a large family of seven transmembrane domain receptors. They are of four types:
1) Delta opioid receptor
2) Mu opioid receptor
3) Kappa opioid receptor
4) Orphan receptor-like 1They contain about 372-400 amino acids and thus their molecular weight is different.
Opioid receptor activation reduces the intracellular cAMP formation and opens K+ channels (mainly through µ and δ receptors) or suppresses voltage-gated N-type Ca2+ channels (mainly κ receptor). These actions result in neuronal hyperpolarization and reduced availability of intracellular Ca2+ which results in decreased neurotransmitter release by cerebral, spinal, and myenteric neurons (e.g. glutamate from primary nociceptive afferents).
However, other mechanisms and second messengers may also be involved, particularly in the long-term -
This question is part of the following fields:
- Pharmacology
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Question 11
Incorrect
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Which of the following correctly explains the mechanism of sevoflurane preconditioning?
Your Answer: Antagonism at cardiac A1 receptors
Correct Answer: Closure of sarcolemmal KATP channels
Explanation:Sevoflurane is highly fluorinated methyl isopropyl ether widely used as an inhalational anaesthetic. It is suggested that sevoflurane preconditioning occurs via the opening of mitochondrial Potassium ATP dependent channel similar to that of Ischemic Preconditioning protection.
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This question is part of the following fields:
- Pharmacology
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Question 12
Correct
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A 57-year old lady is admitted to the Emergency Department with signs of a subarachnoid haemorrhage. On admission, her GCS was 7. She has been intubated, sedated and is being ventilated and is waiting for a CT scan. Her Blood pressure is 140/70mmHg. The arterial blood gas analysis shows the following: pH 7.2 (7.35 - 7.45), PaO2 70 mmHg (80-100), PaCO2 78 mmHg (35-45), BE -3 mEq/L (-3 +/-3), Standard bic 27 mmol/L (21-27), SaO2 94%. The most likely cause of an increase in the patient's global cerebral blood flow (CBF) is which of the following?
Your Answer: Hypercapnia
Explanation:PaCO2 is one of the most important factors that regulate cerebral vascular tone. CO2 induces cerebral vasodilatation and as a result, it increases CBF. Between 20 mmHg (2.7 kPa) and 80 mmHg (10.7 kPa), there is a linear increase of PaCO2.
Sometimes, there are areas where auto regulation has failed locally but not globally. Similarly, local vs. systemic acidosis will have similar effects. When the PaO2 falls below 50 mmHg (6.5 kPa), the CBF progressively increases.
An increase in the cerebral metabolic rate for oxygen (CMRO2) and therefore CBF can be caused by hyperthermia.
A late feature of cerebral injury is hyperthermia secondary to hypothalamic injury. Therefore this is not the most likely cause of an increased CBF in this scenario. -
This question is part of the following fields:
- Physiology
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Question 13
Correct
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Following a physical assault, a 28-year-old man is admitted to the emergency room. A golf club has struck him in the head. There is a large haematoma on the scalp, as well as a bleeding wound. In response to painful stimuli, he opens his eyes and makes deliberate movements. Because of inappropriate responses, a history is impossible to construct, but words can be discerned. Which of the options below best describes his current Glasgow Coma Scale (GCS)?
Your Answer: E2V3M5=10
Explanation:The Glasgow Coma Scale (GCS) has been used in outcome models as a measure of physiological derangement and as a tool for assessing head trauma.
Eye opening (E):
4 Spontaneously
3 Responds to voice
2 Responds to painful stimulus
1 No response.Best verbal response (V):
5 Orientated, converses normally
4 Confused, disoriented conversation, but able to answer basic questions
3 Inappropriate responses, words discernible
2 Incomprehensible speech
1 Makes no sounds.Best motor response (M):
6 Obeys commands for movement
5 Purposeful movement to painful stimulus
4 Withdraws from pain
3 Abnormal (spastic) flexor response to painful stimuli, decorticate posture
2 Extensor response to painful stimuli, decerebrate posture
1 No response.In this case, GCS = 2+3+5 = 10.
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This question is part of the following fields:
- Pathophysiology
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Question 14
Incorrect
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The outer muscular layer of the oesophagus is covered by?
Your Answer: None of the above
Correct Answer: Loose connective tissue
Explanation:The oesophagus has four layers namely; 1. the mucosal layer, 2. the submucosal layer, 3. the muscular layer and 4. the layer of loose connective tissue which binds to the outer mucosal layer. The oesophagus lacks the serosal layer and therefore holds sutures poorly.
The mucosal layer consists of muscularis mucosa and the lamina propria and is made up of non keratinised stratified squamous epithelium. The mucosal layer is the innermost layer of the oesophagus.
The submucosal layer being the strongest layer of all has mucous glands which are called as the tuboalveolar mucous glands.
The outer muscular layer has two types of muscle layers of which one is the circular layer and the other the longitudinal layer. The Auerbach’s and Meissner’s nerve plexuses lie in between the longitudinal and circular muscle layers and submucosally. The muscle fibres present in the upper 1/3rd part of the oesophagus are skeletal muscle fibres, the middle 1/3rd layer has both smooth and skeletal muscle fibres, but the lower 1/3rd only has smooth muscle fibres.
The loose connective tissue layer or the adventitious layer has dense fibrous tissue.
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This question is part of the following fields:
- Anatomy
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Question 15
Incorrect
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Regarding the treatment of bladder cancer, a study concerned with the usage of a combined or monotherapy was conducted. A forest plot was used for the visual representation of the data. Which of the following is true regarding forest plots?
Your Answer: Forest plots are lower on the hierarchy of evidence than randomised control trials
Correct Answer: Forest plots can present data from multiple studies
Explanation:Being the part of a meta analysis, forest plots are more valued as evidence then randomised control trials.
The notion that forest plots can only be used if the results are substantial is not true. They are good indicators of the significance of the data. If the diamond intersects the central line, the data is rendered significant. It also aggregates means and confidence intervals from studies conducted in the past which makes the study much more reliable as errors associated with individual studies tend to have less of an impact in this way.
The suggestion that forest plots are primarily used for qualitative data is factually incorrect. Forest plots require numerical values to function.
All in all, forest plots help us in determining whether or not there is a significant trend in that particular field of study.
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This question is part of the following fields:
- Statistical Methods
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Question 16
Correct
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A 70-year-old female is on bisoprolol, amitriptyline, and gabapentin medication and required hemiarthroplasty for a fractured neck of the femur. Spinal anaesthesia using 10 mg of IV ketamine to aid positioning was decided to be used. This resulting block extended to T8 and she required boluses of metaraminol for hypotension. She became profoundly hypertensive and had multiple ventricular ectopic beats on ECG following positioning in theatre. Which of the following is the cause for this?
Your Answer: Ketamine
Explanation:Ketamine is primarily used for the induction and maintenance of anaesthesia. It induces dissociative anaesthesia. But it is contraindicated in cardiovascular diseases such as unstable angina or poorly controlled hypertension.
Tricyclic antidepressants (TCA) are primarily used as antidepressants which is important for the management of depression. These are second-line drugs next to SSRI. They work by competitively preventing re-uptake of amines (noradrenaline and serotonin) from the synaptic cleft so increasing their concentration. But TCA overdoses are toxic and have cardiovascular effects, central effects, and anticholinergics effects. Cardiovascular effects like prolonged QT and widened QRS at lower doses progressing to ventricular arrhythmias and refractory hypotension at higher doses can be life-threatening. When used in the perioperative period, it can lead to increased sensitivity to circulating catecholamines therefore care is needed perioperatively.
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This question is part of the following fields:
- Pharmacology
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Question 17
Incorrect
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Which of the following is correct regarding nitric oxide?
Your Answer: Is generated from glutamine
Correct Answer: Is produced by both inducible and constitutive forms of nitric oxide synthetase
Explanation:Nitric oxide is generated from L-arginine by nitric oxide synthase. It is produced in response to haemodynamic stress by the vascular endothelium, and it produces both smooth muscle relaxation and reduced vascular resistance.
Nitric oxide may be inactivated through interaction with other oxygen free radicals, (e.g. oxidised low-density lipoprotein (LDL)).
Nitric oxide causes the production of the second messenger, cyclic guanosine monophosphate (cGMP).
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This question is part of the following fields:
- Pathophysiology
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Question 18
Correct
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Under general anaesthesia, a 48-year-old patient is scheduled for some dental extractions. He tells you that he has a heart murmur and that he has always received antibiotic prophylaxis at the dentist. There are no allergies that he is aware of. Which antibiotic prophylaxis strategy is most appropriate for this patient?
Your Answer: Prophylactic antibiotics are unnecessary for this patient
Explanation:The National Institute for Health and Care Excellence (NICE) has published guidelines on infective endocarditis prophylaxis (IE). The goal was to create clear guidelines for antibiotic prophylaxis in patients undergoing dental procedures as well as certain non-dental interventional procedures. A number of studies have found an inconsistent link between recent interventional procedures and the development of infective endocarditis in both dental and non-dental procedures.
Antibiotic prophylaxis against infective endocarditis is not advised or required in the following situations:
Dental patients undergoing procedures
Patients undergoing procedures involving the upper and lower gastrointestinal tracts, the genitourinary tract (including urological, gynaecological, and obstetric procedures, as well as childbirth), and the upper and lower respiratory tract (including ear, nose and throat procedures and bronchoscopy).Antibiotic resistance can be exacerbated by the indiscriminate use of prophylactic antibiotics, but this is not the primary reason for avoiding their use in these situations.
To reduce the risk of endocarditis, any patient who is at risk of developing IE should be investigated and treated as soon as possible. Patients with the following conditions are at risk of developing IE:
acquired valvular heart disease with regurgitation or stenosis
previous valve replacement
structural congenital heart disease
past history of IE, or
hypertrophic cardiomyopathy (HOCM)It would also be appropriate for high-risk dental procedures and those with severe gingival disease.
Although this patient may not have structural heart disease, ABs should be administered on a case-by-case basis.
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This question is part of the following fields:
- Pharmacology
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Question 19
Incorrect
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Regarding sine wave damping, which one would approach equilibrium the fastest at zero amplitude, without overshoot?
Your Answer: Optimal damping
Correct Answer: Critical damping
Explanation:A damped sine wave is a smooth, periodic oscillation with an amplitude that approaches zero as time goes to infinity. In other words, the wave gets flatter as the x-values become larger.
Critical damping is defined as the threshold between overdamping and underdamping. In the case of critical damping, the oscillator returns to the equilibrium position as quickly as possible, without oscillating, and passes it once at most.
In overdamping, the system moves slowly towards the equilibrium. An underdamped system moves quickly to equilibrium, but will oscillate about the equilibrium point as it does so.
Optimal damping has a damping coefficient of around 0.64-0.7. It maximizes frequency response, minimizes overshoot of oscillations, and minimizes phase and amplitude distortion.
In an undamped system, the amplitude of the waves that are being generated remain unchanged and constant over time.
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This question is part of the following fields:
- Clinical Measurement
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Question 20
Correct
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All of the following statements about dopamine is false except:
Your Answer: Infusions may increase splanchnic blood flow.
Explanation:Dopamine (DA) is a dopaminergic (D1 and D2) as well as adrenergic α and β1 (but not β2 ) agonist.
The D1 receptors in renal and mesenteric blood vessels are the most sensitive: i.v. infusion of a low dose of DA dilates these vessels (by raising intracellular cyclic adenosine monophosphate).
Moderately high doses produce a positive inotropic (direct β1 and D1 action + that due to NA release), but the little chronotropic effect on the heart.
Vasoconstriction (α1 action) occurs only when large doses are infused.
At doses normally employed, it raises cardiac output and systolic BP with little effect on diastolic BP. It has practically no effect on nonvascular α and β receptors; does not penetrate the blood-brain barrier€”no Central nervous system effects.
Dopamine is less arrhythmogenic than adrenaline
Regarding dopamine part of the dose is converted to Noradrenaline in sympathetic nerve terminals.
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This question is part of the following fields:
- Pharmacology
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