Acheron: Musculoskeletal Rheumatoid GI & Endocrine Flashcards
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 patients 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
E. Intravenous fluids administration
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
D. Cirrhosis
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
C. She has mild renal insufficiency
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
E. All of these may be useful
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.
Thyroid storm
Treatment for thyroid storm consists of blocking the production of — hormones and decreasing the peripheral conversion of — to the more biologically active — hormone.
thyroid ; T4 ; T3
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.
beta blockers ; glucocorticoids ; thionamide (ie methimazole) ; iodine, or an iodinated contrast
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.
AFTER
Iodinated contrast agents have the added benefit of decreasing peripheral — conversion.
T4-T3
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
D. Request a more thorough irrigation of the second femoral shaft prior to cement insertion
— 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.
Bone Cement Implantation Syndrome (BCIS)
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.
Bone Cement Implantation Syndrome (BCIS)
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
D. Hyperglycemia is a concern
Hypothyroidism metabolize most drugs more — than the normal population and suffer from hindered compensatory responses to anesthetic medications.
slowly
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.
hypothyroidism
In the heart, — hormone acts directly to cause an increase in cardiac contractility, improve diastolic relaxation, and increase heart rate.
thyroid
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 RBCs 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
E. End stage renal disease
— disease is most contributing to this patient’s anemia.
End stage renal
The anemia due to chronic renal disease is usually — and —.
normochromic and normocytic.
The anemia of chronic blood loss is — and — due to the the decreased availability of iron for heme synthesis.
microcytic and hypochromic
Exogenous administration of — is used to treat this type of anemia.
erythropoeitin
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 patients 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
C. Increase the insulin drip rate
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
E. Carotid dissection
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.
C. She will have a decreased cardiac output
— is characterized by impaired mentation, hypothermia, hypoventilation and congestive heart failure. It is treated with ventilatory support and intravenous thyroid hormone.
Myxedema Coma
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
E. Premedication with beta blockers