Acheron: Musculoskeletal Rheumatoid GI & Endocrine

Question 1

An obese 21 year old patient with history of type 1 diabetes mellitus presents for exploratory laparotomy after having suffered a ruptured appendix at home. He is septic and is on an antibiotic infusion of levofloxacin and metronidazole as he is transferred to the OR. Current vital signs show a blood pressure of 100/60, heart rate of 120, respiratory rate 28, and a temperature of 100.4. His preoperative labs show a bicarbonate level of 15 and a blood sugar of 400. pH is 7.02. Blood smears show gram positive cocci in pairs. The patient’s home medications include insulin, and lisinopril. As you are inducing him you notice he has a disheveled appearance, and you note he has a faintly sweet aroma. Which of the following is the MOST important next step in management?

A. IV bicarbonate
B. IV vancomycin
C. IV insulin drip
D. Adjust ventilatory settings to provide 8-12 respirations per minute
E. Intravenous fluids administration

Answer 1

E. Intravenous fluids administration

Question 2

A 42 year old patient with long standing systemic lupus erythematosus presents for preoperative evaluation. Remembering the natural course of the disease you know that these patients are at high risk of all of the following EXCEPT:

A. Coronary artery disease
B. Non-ischemic cardiomyopathy
C. Renal Failure
D. Cirrhosis
E. Thrombocytopenia

Answer 2

D. Cirrhosis

Question 3

A 33 year old G1P0 with hyperemesis gravidarum and poorly controlled diabetes requests an epidural for her impending delivery. A complete blood panel, comprehensive metabolic panel and urinalysis is ordered along with a PT/INR is ordered prior to placement of the epidural. Pertinent findings include a hemoglobin of 8.3 mg/dL, creatinine of 2.5, GFR of 50 mL/min, glucose of 331, and 4+ glucose and 2+ protein in urine. Which of the following most appropriately describes her current state of renal health?

A. She is in overt renal failure
B. She has end stage renal disease
C. She has mild renal insufficiency
D. She has moderate renal insufficiency
E. She has normal renal function but is moderately dehydrated

Answer 3

C. She has mild renal insufficiency

Question 4

A 25 year old female with exophthalmos, tremors, and tachycardia needs emergent laparotomy due to a motor vehicle accident with a hepatic laceration. Post operatively the patient is extubated and is initially alert and speaking. You note that as time passes her symptoms seem to worsen, and later the patient develops fever and an altered mental status. All of the following medications may be indicated in treating this patient’s most likely presenting condition EXCEPT:

A. Propranolol
B. Methimazole
C. Dexamethasone
D. Iodinated radiographic contrast
E. All of these may be useful

Answer 4

E. All of these may be useful

Question 5

Symptoms include anxiety, fever, cardiovascular instability, altered mental status, nausea, congestive heart failure, and moist skin. — may mimic malignant hyperthermia, but does not cause muscle rigidity or breakdown.

Answer 5

Thyroid storm

Question 6

Treatment for thyroid storm consists of blocking the production of — hormones and decreasing the peripheral conversion of — to the more biologically active — hormone.

Answer 6

thyroid ; T4 ; T3

Question 7

Treatment options include — to decrease sympathetic response, — to decrease peripheral T4-T3 conversion, — to block new hormone synthesis, and finally, — agent to suppress new hormone synthesis.

Answer 7

beta blockers ; glucocorticoids ; thionamide (ie methimazole) ; iodine, or an iodinated contrast

Question 8

Although iodine loads can precipitate thyroid storm by providing a fresh substrate upon which to create more thyroid hormone, when given — thionamide to block thyroid hormone production, a sharp decrease in thyroid hormone production is seen.

Answer 8

AFTER

Question 9

Iodinated contrast agents have the added benefit of decreasing peripheral — conversion.

Answer 9

T4-T3

Question 10

An 85 year old patient with congestive heart failure (ejection fraction 25%) and cor pulmonale is undergoing a bilateral total hip replacement. You are monitoring the patient with a transesophageal echo and pulmonary artery catheter. The surgeon is choosing to use cement fixation with a cement gun. During the insertion of the first prosthesis the patient becomes hypoxic and you calculate pulmonary vascular resistance at 215 dyn x S x cm-5. Systolic blood pressure falls to 85 mmHg from a previously stable 128 mmHg. After treatment the patients vital signs stabilize. Which of the following would have been inappropriate during this case?

A. Pressure support with phenylephrine
B. Give an IVF bolus
C. Increase O2 concentrations to 100%
D. Request a more thorough irrigation of the second femoral shaft prior to cement insertion
E. Request that the surgeon use non-cemented prosthesis prior to the procedure

Answer 10

D. Request a more thorough irrigation of the second femoral shaft prior to cement insertion

Question 11

— is a complication which results in hypoxemia, altered sensorium (if using only neuraxial anesthesia), and hypotension. It can result in death. The etiology is likely embolization of large quantities of femoral medullary contents released into circulation during manipulation by the surgeon.

Answer 11

Bone Cement Implantation Syndrome (BCIS)

Question 12

Treatment for — is similar to that of right ventricular failure which includes direct acting alpha agonist as first line pressor therapy or a pressor with positive inotropic effects, ensure adequate preload, and increase oxygenation until symptoms resolve.

Answer 12

Bone Cement Implantation Syndrome (BCIS)

Question 13

You have a case this afternoon involving a poorly controlled hypothyroid patient. Which of the following is not true regarding a patient with hypothyroidism?

A. They are at high risk of hypothermia
B. They are sensitive to the hypotensive effects of anesthesia
C. They are more sensitive to the respiratory depressant effects of opiods
D. Hyperglycemia is a concern
E. Muscle relaxants may have longer duration of action

Answer 13

D. Hyperglycemia is a concern

Question 14

Hypothyroidism metabolize most drugs more — than the normal population and suffer from hindered compensatory responses to anesthetic medications.

Answer 14

slowly

Question 15

As a result patients with — have impaired cardiac output and baroreceptor reflexes, and are therefore more sensitive to the hypotensive effects of anesthetic agents and opioids.

Answer 15

hypothyroidism

Question 16

In the heart, — hormone acts directly to cause an increase in cardiac contractility, improve diastolic relaxation, and increase heart rate.

Answer 16

thyroid

Question 17

A patient with a past medical history of diabetes, hypertension, end-stage renal disease, diverticulitis, and myasthenia gravis, presents for an elective AV-graft placement to prepare for dialysis. You note on pre-operative labs a hemoglobin of 9.3 and hematocrit of 27.6. The RBC’s show an MCV of 88, and are normochromic. What is likely the MOST significant contributing factor to his anemia?

A. Chronic hypertension
B. Long standing diabetes mellitus
C. Myasthenia gravis
D. Chronic blood loss from diverticula
E. End stage renal disease

Answer 17

E. End stage renal disease

Question 18

— disease is most contributing to this patient’s anemia.

Answer 18

End stage renal

Question 19

The anemia due to chronic renal disease is usually — and —.

Answer 19

normochromic and normocytic.

Question 20

The anemia of chronic blood loss is — and — due to the the decreased availability of iron for heme synthesis.

Answer 20

microcytic and hypochromic

Question 21

Exogenous administration of — is used to treat this type of anemia.

Answer 21

erythropoeitin

Question 22

Your patient is a 32 year old type 1 diabetic. The patient presents with an insulin drip started prior to surgery for treatment of diabetic ketoacidosis. The patient is still slightly ketotic and you have decided to continue the drip through the surgery. You note that your drip is running at a rate of 0.2 units/hour. The patient’s blood glucose is 103. The surgeon is about to make his first incision in what is to be a coronary artery bypass case. You would expect to do which of the following as the operation progresses?

A. Decrease the insulin drip rate
B. Turn off the insulin drip
C. Increase the insulin drip rate
D. Add dextrose to the IV fluids
E. add bicarbonate to the IV fluids

Answer 22

C. Increase the insulin drip rate

Question 23

A 29 year old female with malignant thyroid nodule presents for total thyroidectomy. Prior to the surgery she asks you what complications may arise from the surgery. Which of the following is the least likely complication of thyroidectomy?

A. Hypocalcemia
B. Pneumothorax
C. Tracheal collapse
D. Voice hoarseness
E. Carotid dissection

Answer 23

E. Carotid dissection

Question 24

A 42 year old patient with a past medical history of partial thyroidectomy and pancreatitis is scheduled to undergo a hysterectomy. In her history she relates that she has been using “natural remedies” to supplement her thyroid function and a TSH and T4 level are ordered. The TSH is 47 and the T4 is 2.3. She is largely asymptomatic and does not wish thyroid replacement prior to surgery. You note her vitals show a BP of 105/62 and a heart rate of 54. Which of the following is correct?

A. The surgery must be delayed until the patient agrees to thyroid therapy
B. She will likely be resistant to the hypotensive effects of anesthetics
C. She will have a decreased cardiac output
D. She will require steroid replacement therapy prior to surgery
E. Sevoflurane is the inhaled anesthetic of choice.

Answer 24

C. She will have a decreased cardiac output

Question 25

— is characterized by impaired mentation, hypothermia, hypoventilation and congestive heart failure. It is treated with ventilatory support and intravenous thyroid hormone.

Answer 25

Myxedema Coma

Question 26

A 63 year old woman with past medical history of dementia and hypertension has fallen and fractured her acetabulum. She will undergo a hip replacement surgery in your operating theater. She is too demented to remain still making general anesthesia a necessity. These surgeries are associated with a host of potential complications. Which of the following is least helpful in preventing some of these complications?

A. Arterial monitoring
B. Intraoperative blood salvage
C. Use of neuraxial anesthesia
D. Subcutaneous erythropoeitin
E. Premedication with beta blockers

Answer 26

E. Premedication with beta blockers

Question 27

Which of the following agents should not be used for induction in a patient with suspected Addisonian Crisis?

A. Etomidate
B. Halothane
C. Nitrous Oxide
D. Desflurane
E. Propofol

Answer 27

A. Etomidate

Question 28

— inhibits the synthesis of cortisol and should be avoided in patients with acute or at risk of adrenal insufficiency.

Answer 28

Etomidate

Question 29

Which of the following is unique to neurogenic diabetes insipidus?

A. Urine output greater than 3 liters per day
B. Nocturia
C. Treated with desmopressin
D. Patients are hypernatremic
E. Chlorpropamide can be used for treatment

Answer 29

C. Treated with desmopressin

Question 30

— is a disorder in which the posterior pituitary fails to secrete anti-diuretic hormone, or in which the kidneys fail to respond to circulating anti-diuretic hormone (neurogenic diabetes insipidus and nephrogenic diabetes insipidus respectively).

Answer 30

Diabetes insipidus

Question 31

In both nephrogenic and neurogenic diabetes insipidus the patient experiences increased output of dilute urine in excess of — liters per day.

Answer 31

3

Question 32

— is an anti-diuretic hormone analogue which acts on renal receptors to decrease renal water excretion.

Answer 32

Desmopressin

Question 33

Treatment with desmopressin will only work while renal receptors are sensitive to the hormone, meaning it only works in — diabetes insipidus.

Answer 33

neurogenic

Question 34

— diabetes insipidus can be treated with chlorpropanide which sensitizes renal anti-diuretic hormone receptors to circulating anti-diuretic hormone.

Answer 34

Nephrogenic

Question 35

— diabetes insipidus is not uncommon following surgeries which require manipulation of the pituitary gland and is normally transient if the gland has been left intact.

Answer 35

Neurogenic

Question 36

A 37 year old African American male with chronic hypertension presents for percutaneous pinning of his #5 digit on the right hand. A routine comprehensive metabolic panel reveals he has a GFR of 30 mL/min. Which of the following most appropriately describes his current state of renal health?

A. He is in overt renal failure
B. He has end stage renal disease
C. He has mild renal insufficiency
D. He has moderate renal insufficiency
E. He has normal renal function

Answer 36

D. He has moderate renal insufficiency

Question 37

The — test is the best test to determine renal functioning.

Answer 37

creatinine clearance

Question 38

A creatinine clearance of greater than — mL/min is considered normal renal function on laboratory testing, however a true normal is — mL/min so significant renal function decline can occur before a drop in GFR is noted in labwork.

Answer 38

120 ; 180

Question 39

Mild renal insufficiency seen at GFR of — mL/min, and moderate renal insufficiency is from — mL/min.

Answer 39

40-60 ; 25-40

Question 40

A GFR of less than — mL/min is seen in overt renal failure, while a GFR of less than — mL/min is seen in end stage renal disease.

Answer 40

25 ; 10

Question 41

A 32 year old patient with history of Crohn’s disease is scheduled for a partial small bowel resection due to a severe obstruction. This patient is currently on 5 mg of prednisone daily for maintenance along with 5-asa. The patient states that 5 months ago he had a particularly severe flare with and bumped his dose of prednisone up to 60 mg a day for 6 weeks. He has been tapered to his usual dose now. He also takes amlodipine 10 mg for hypertension control and carvedilol 6.25mg orally twice daily. Which of the following is true?

A. The patient does not need supplemental steroid dosing as their prednisone dose is 5mg/day or less
B. Secondary adrenal insufficiency is uncommon in patients taking steroids for less than one year.
C. The most common cause of adrenal insufficiency is autoimmune destruction of the adrenal glands
D. An appropriate supplemental stress dose of steroid would be about 25 mg of hydrocortisone IV times one dose
E. Dexamethasone can be given prior to an ACTH stimulation test

Answer 41

E. Dexamethasone can be given prior to an ACTH stimulation test

Question 42

The most common cause of adrenal insufficiency is exogenous — administration.

Answer 42

steroid

Question 43

The most common non-iatrogenic cause is autoimmune destruction of the adrenal glands (— disease).

Answer 43

Addisons

Question 44

Patients who have been on greater than — mg of prednisone for greater than — weeks in the past — months should be considered to have adrenal insufficiency.

Answer 44

20 ; 3 ; 12

Question 45

If adrenal insufficiency is suspected, but empiric coverage with steroids may be detrimental, an — stimulation test may be performed to asses adrenal response to pituitary stimulation.

Answer 45

ACTH

Question 46

All supplemental steroids interfere with the results of ACTH stimulation tests except —, thus it can be given if necessary prior to testing.

Answer 46

dexamethasone

Question 47

For a moderate surgery such as colonic resection a dose of — mg hydrocortisone should be given perioperatively and tapered over — days.

Answer 47

50-75 ; 1-2

Question 48

Minor surgery (inguinal hernia, colonoscopy) requires only — mg hydrocortisone one time dose.

Answer 48

25

Question 49

High stress surgery requires — mg hydrocortisone IV (cardiovascular, liver, whipple).

Answer 49

100-150

Question 50

Critically ill patients requiring intensive care ought to receive — mg q— hrs for — days then tapered according to patient improvement.

Answer 50

50-100 ; 6-8 ; 2

Question 51

A 19 year old patient has been diagnosed with a familial pheochromocytoma. He is known to have a tumor that secretes predominantly norepinephrine. Two weeks prior to surgical removal his internist started the patient on phenoxybenzamine. The patient has been admitted on the day prior to surgery and is taking 40mg of phenoxybenzamine PO twice a day. His blood pressure on your examination is 212/115. The hospitalist increases his dose of phenoxybenzamine to 40 mg po 3 times a day and adds propranolol 10 mg PO 4 times daily. His blood pressure improves and is now 160/90 Surgery is scheduled for 8 am the next day. The patient states that his blood pressure has continued to be labile the last 2 weeks. He also notes that he has been sick to his stomach recently. Chemistry panel shows a sodium of 135, chloride 80, bun 28, and a creatinine of 1.3 What should you be sure to do?

A. Ensure the patient receives the full doses of phenoxybenzamine and propanolol the morning of surgery
B. Avoid histamine releasing medications
C. Use IV magnesium to attenuate sympathetic responses
D. Use IV nitroprusside as the antihypertensive agent of choice
E. Postpone the surgery

Answer 51

E. Postpone the surgery

Question 52

Anti-catecholamine medications should be initiated at least — days prior to surgery for removal of a familial pheochromocytoma, longer if signs of cardiac dysfunction or uncontrolled high blood pressures.

Answer 52

10

Question 53

Regarding the dosing of phenoxybenzamine, the medication dose should be decreased or discontinued in the — hour window before surgery in anticipation of the sudden drop in circulating catecholamines after resection.

Answer 53

24-48

Question 54

If high levels of — remain in the system at this time it will be difficult to maintain adequate blood pressures due its sympathetic receptor antagonism.

Answer 54

phenoxybenzamine

Question 55

For removal of a familial pheochromocytoma, — releasing medications can stimulate catecholamine release and should be avoided (morphine, atracurium).

Answer 55

histamine

Question 56

For removal of a familial pheochromocytoma, medicines which antagonize the — nervous system (—) or are — nervous system stimulants (—/—) can be detrimental.

Answer 56

parasypmathetic (atropine) ; sympathetic (pancuronium/succinylcholine)

Question 57

— is contraindicated as it causes severe hypertension in the setting of pheochromocytoma.

Answer 57

Metoclopramide

Question 58

IV — can, in fact be used as an adjunctive medication to help control blood pressure and decrease catecholamine release.

Answer 58

magnesium

Question 59

The antihypertensive of choice must be potent and short acting since the hypertension will resolve quickly once the tumor is removed, thus — is ideal for use in removal of pheochromocytoma.

Answer 59

sodium nitroprusside

Question 60

Expect variations in blood pressure intraoperatively as nearly all patients will experience systolic blood pressures greater than — mmHg during tumor manipulation.

Answer 60

200

Question 61

Pheochromocytoma patients will likely be resistant to — due to down-regulation of peripheral receptors.

Answer 61

sympathomimetic pressors

Question 62

An obese 30 year old patient presents for surgery and relates a history of having high blood sugar. He is unsure if he is a type I or type II diabetic patient. He takes insulin aspart injections combined with insulin glargine and has been doing so since he was 10 years old. Which of the following types of diabetes is this patient most likely to be suffering from?

A. Type 1 insulin dependent diabetes mellitus
B. Type 1 non-insulin dependent diabetes mellitus
C. Type 2 Insulin dependent diabetes mellitus
D. Type 2 Non-insulin dependent diabetes mellitus
E. Delayed onset type 1 diabetes mellitus

Answer 62

A. Type 1 insulin dependent diabetes mellitus

Question 63

A 33 year old G1P0 with hyperemesis gravidarum and poorly controlled diabetes requests an epidural for her impending delivery. A complete blood panel, comprehensive metabolic panel and urinalysis is ordered along with a PT/INR is ordered prior to placement of the epidural. Pertinent findings include a hemoglobin of 8.3 mg/dL, creatinine of 2.5, GFR of 50 mL/min, glucose of 331, and 4+ glucose and 2+ protein in urine. Which of the following most appropriately describes her current state of renal health?

A. She is in overt renal failure
B. She has end stage renal disease
C. She has mild renal insufficiency
D. She has moderate renal insufficiency
E. She has normal renal function but is moderately dehydrated

Answer 63

C. She has mild renal insufficiency

Question 64

Systemic Lupus Erythematosus (SLE) rarely causes severe — damage directly.

Answer 64

liver

Question 65

Patients with — suffer from a multi-organ autoimmune disease. These patients can sustain damage to nearly every organ system via antibody complex formation directed toward blood vessels, or cell surface molecules. Manifestations may include, but are not limited to: fever, myalgia, weight loss, edema, renal failure, arthralgia and synovitis, malar skin rash, pneumonitis, pulmonary hypertension, decreased lung volumes, pericarditis, coronary artery disease, embolic phenomenon, thrombocytopenia, anemia, and leukopenia.

Answer 65

Systemic Lupus Erythematosus (SLE)