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Aldosterone Endothelin Erythropoietin Natriuretic peptide Vasopressin 26 A 58-year-old man is found to have mild hypertension. An insulinoma arising in the pancreas could account for episodic weakness, but the glucose level would be low. Physical examination reveals a fine violaceous rash on her face, predominantly palpebral. Hemostasis Laboratory tests in cirrhotic patients often show alterations in the procoagulant system. Acute lymphoblastic leukemia Acute myelogenous leukemia Chronic lymphocytic leukemia Chronic myelogenous leukemia Idiopathic thrombocytopenic purpura 18 A 7-year-old boy has complained of a severe headache for the past week. A 20-year-old male with sickle cell disease develops acute chest pain and cough 1 hour after a splenectomy. Hypotension, high mean airway pressures during mechanical ventilation, and sympathetic stimulation should be avoided to the extent possible. Prilocaine Prilocaine also has a similar clinical profile to lidocaine and is used for infiltration, peripheral nerve blocks, and spinal and epidural anesthesia. Foregut cysts in the hilum or mediastinum are not connected to airways and can produce a mass effect if large, but most are not. Besides the general clinical features described on page 630, post-necrotic cirrhosis is seen as frequent in women as in men, especially in the younger age group. Candida albicans Chlamydia trachomatis Gardnerella vaginalis Herpes simplex virus Human papillomavirus Neisseria gonorrhoeae Trichomonas vaginalis 4 A 25-year-old woman has experienced discomfort during sexual intercourse for the past month. Midazolam is the preferred benzodiazepine for continuous infusion due to the long context-sensitive half-lives of diazepam and lorazepam. Review the digital videos of airway fiberoptic examinations if they are available. Malignant Hepatocellular (liver cell) carcinoma Hepatoblastoma (Embryoma) Cholangiocarcinoma Combined hepatocellular and cholangiocarcinoma Cystadenocarcinoma Angiosarcoma Embryonal sarcoma Benign A. A 70-year-old male receives atenolol 50 mg each morning for treatment of hypertension. Thymoma is associated with myasthenia gravis that tends to progress more slowly, though a superimposed myasthenic crisis with respiratory difficulty can occur acutely. By the time a breast cancer becomes palpable, lymph node metastases are present in more than 50% of patients. The first postoperative day he complained of numbness in the fourth and fifth digits of his right hand, but no loss of motor function. Hypercholesterolemia would predispose to atherogenesis with coronary artery narrowing and ischemic heart disease. Wall source hoses are connected to the back of the anesthesia machine through noninterchangeable fittings, each with a diameter specific to its respective gas (the diameter index safety system). The posterior tibial nerve provides motor innervation (plantar flexors), cutaneous innervation (plantar surface of the foot), and bony innervation to the foot. Although anesthetics most likely make patients unconscious by acting on the brain, immobility appears to result from effects on the brainstem. Von Willebrand disease is one of the most common bleeding disorders and results from qualitative or quantitative defects in von Willebrand factor. A ramp under the chest elevates the cervical and thoracic spine, limiting cephalad spread of hyperbaric local anesthetic. The hypercalcemia produces a chronic tubulointerstitial disease of the kidneys that is initially manifested by loss of concentrating ability. If not properly treated, peptic ulcers can produce many complications, including massive bleeding that can be fatal. Which of the following histologic features is most likely to be found in a liver biopsy specimen Apoptosis Centrilobular congestion Cholestasis Hemosiderin deposition Macrovesicular steatosis Mallory-Denk bodies Portal fibrosis 52 A 41-year-old, previously healthy woman has noted abdominal discomfort for the past month.

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Compression atelectasis results from accumulation of air or fluid in the pleural cavity, which can happen with a pneumothorax, hemothorax, or pleural effusion. Overshoot hypotension and tachycardia is a particularly common setting of hypovolemia, such as is often observed in patients with poorly controlled essential hypertension and parturients with pregnancy-induced hypertension. Review of her medical record reveals that a salpingo-oophorectomy for ectopic pregnancy was performed on the left side 3 months ago. This condition is endemic in regions of the world where there is a deficiency of iodine. Defects in platelet function are believed to be responsible for venous thrombosis. Peripheral platelet destruction is often immunologically mediated and can result from well-known autoimmune diseases such as systemic lupus erythematosus, or it can be idiopathic. The proximal edge of the aponeurosis is sufficiently thick in 80% of men and 20% of women to be distinct anatomically from the remainder of the tissue. Which of the following complications of transfusion has most likely occurred in this man A Donor antibodies were directed against his granulocytes B Donor blood was contaminated with hepatitis C virus C Fluid overload led to congestive heart failure D Mislabeled specimens were processed in the laboratory E Foreign T lymphocytes attacked his tissues 61 A 72-year-old woman undergoes laparotomy for ruptured diverticulitis. Such surgeries can be performed under general anesthesia or regional anesthesia (supraclavicular or interscalene block). Escherichia coli is a likely cause of ascending urinary tract infections with pyelonephritis, but it is an uncommon cause of endocarditis. Chondrosarcoma Liposarcoma Metastatic adenocarcinoma Nodular fasciitis Osteosarcoma Rhabdomyosarcoma 53 A 6-year-old boy complains of discomfort in the right upper neck that has worsened over the past 6 months. When this history is not elicited, and the patient is not continued on the corticosteroid therapy, a crisis ensues, in this case made worse by the stress of surgery. These peripheral chemoreceptors are found at the bifurcation of the common carotid artery and communicate to the respiratory centers via the afferent glossopharyngeal nerve. An abdominal ultrasound shows enlarged kidneys with the representative gross appearance shown in the figure. Hydrocortisone can alleviate the symptoms of many dermatologic conditions, but it cannot reverse actinic damage. Which of the following laboratory findings is most likely to be present on examination of his stool A stool sample is negative for occult blood, ova, and parasites, and a stool culture yields no pathogens. The malignant counterpart that grows larger and is more aggressive is the dermatofibrosarcoma protuberans. Lyme disease, caused by Borrelia burgdorferi, is best known for producing chronic arthritis, but meningoencephalitis, neuritis, and neuropathy may complicate this illness. Extubating the patient at a deep plane of anesthesia and using mask ventilation for emergence is a useful strategy. Her medical history indicates that for the past 30 years she has had hypertension and type 2 diabetes mellitus. It is frequently used in conjunction with general anesthesia because children cannot generally tolerate the needle insertion. Context-sensitive Decrement Times To one extent or another, all tissues in the body act as drug depots. Increased volume of distribution and elimination half-life because of high lipophilicity. Granulomas can have epithelioid macrophages and lymphocytes, but the thymus is an unusual location for them. The pulmonary capillaries arrive at the alveoli with blood that has a lower partial pressure of oxygen than the air entrained in the alveoli. A regional block can be used in conjunction with general anesthesia to reduce the need for opioids, which cause nausea and sedation.

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This solution may cause pain on injection, which may be reduced by preadministration of intravenous lidocaine. A choriocarcinoma with trophoblastic cells is usually gestational in origin and has a hemorrhagic appearance. Intraoperative Considerations Equipment and Positioning Whenever possible, patients should position themselves on the operating table. Physical examination shows a 2-cm shallow, nonhealing ulceration of the left medial malleolus. Mucinproducing malignancies of the stomach are most likely to have a signet ring cell pattern and diffusely infiltrate the gastric wall. A punch biopsy specimen of axillary skin shows undulating epidermal acanthosis with hyperkeratosis and basal layer hyperpigmentation. If time permits, the cause for unusual bleeding should be carefully elucidated and therapy precisely targeted. The intrinsic renal vasodilator with the greatest contribution to vasodilation is: A. Axillary Block the axillary block is a more distal approach to the brachial plexus when compared with the infraclavicular and supraclavicular blocks. He has a history of diabetes mellitus (metformin), hypertension (hydrochlorothiazide), atrial fibrillation (amiodarone), and depression (sertraline). The most significant association of cancer of the gallbladder is with cholelithiasis and cholecystitis, though there is no definite evidence of causal relationship. In addition, the operating room environment offers several avenues for heat loss: radiation, conduction, convection, and evaporation. The newly oxygenated blood is then sent back into the systemic circulation for distribution to the rest of the body. Nonatopic asthma is typically episodic and rarely progresses to extensive interstitial disease. Effect of perioperative systemic alpha2 agonists on postoperative morphine consumption and pain intensity: Systematic review and meta-analysis of randomized controlled trials. However, the increased muscle mass required to carry the increased body weight does contribute substantially to the increased dose requirements. Additionally, deoxygenated hemoglobin buffered with hydrogen ions is able to bind carbon dioxide, allowing transport in the form of a carboamino compound. During that interval in the respiratory cycle, after a certain pressure threshold has been reached, typically 2-cm H2O, the spill valve will open and vent the excess gas into the scavenging hose. On physical examination, there is a 3-cm nodule in the right upper neck, medial to the sternocleidomastoid muscle and lateral to the trachea at the angle of the mandible. It is segmental or global glomerular collapse of the tuft along with the presence of hyperpasia and hypertrophy of podocytes producing a pseudo-crescent and a rapid decline in renal function. It is used not only for intraoperative anesthesia but also for the many benefits of prolonged postoperative analgesia. The peripheral blood smear shows schistocytes, and the serum D-dimer level is elevated. Corticosteroids, particularly when administered in critical illness for prolonged periods in conjunction with neuromuscular blockade, will markedly increase the risk of myopathy (up to 50% of mechanically ventilated patients who receive both drugs). Philadelphia: Wolters Kluwer Health/Lippin, cott Williams & Wilkins; 2014:17, with permission. Congenital syphilis produces osteochondritis with skeletal deformities, not fractures, and without a bleeding tendency. The extraerythrocytic phase of malaria with plasmodium infection includes the liver. Isolated cryptorchidism is a developmental defect that is usually sporadic and is not inherited in the germline. Lupus nephritis is associated with extensive inflammatory changes of glomeruli that are noninfectious. He has developed fever, nonproductive cough, dyspnea, pleuritic chest pain, and hemoptysis over the past week. The dura mater further encases the arachnoid membrane, forming the dural sac, a tough covering around the central neuraxis. Diabetes mellitus and heart failure are features of hemochromatosis, a condition of iron overload.

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Mucor has broad, nonseptated hyphae and can result in sinusitis, particularly in the setting of ketoacidosis. Tubulointerstitial diseases can be categorised according to initiating etiology into 4 groups: vascular, infectious, toxic and obstructive. Comprehensive anesthesia textbooks should be consulted for a more thorough discussion of hepatic anatomy and physiology relevant to anesthesia. However, as the muscle relaxant effects wear off, the twitches reappear gradually beginning with only one twitch. Antihistamines Diphenhydramine is a histamine-1 antagonist that has sedative, antiemetic, and anticholinergic properties. Superinfection with which of the following viruses has most likely occurred in this man A liver biopsy is done; microscopically, there are minimal portal mononuclear cell infiltrates with minimal interface hepatitis and mild portal fibrosis. Cirrhotic patients may require albumin for replacement after large-volume paracentesis in the presence of spontaneous bacterial peritonitis or hepatorenal syndrome. The spinal nerves have components of both sensory afferent and motor efferent fibers and emerge from C2 to S2-3 to control all body functions as well as movement. Moraxella is a bacterial organism most often causing sinusitis, otitis, and upper respiratory infections. Adipocyte Endothelial cell Fibroblast Skeletal muscle Smooth muscle 50 A 47-year-old man has had dull, constant pain in the midsection of the right thigh for the past 4 months. Rarely, in a life-threatening emergency, anesthesia and surgery may proceed without informed consent. Incomplete recovery of neuromuscular function is common and is associated with hypoxemia, airway obstruction, and an increased risk of postoperative pulmonary complications (3). This herniation can cause a "stalk section" effect, however, with loss of prolactin inhibition and hyperprolactinemia. Fibromuscular dysplasia can involve one or more renal arterial layers and produce focal stenosis. In addition, muscle relaxation provides optimal conditions for endotracheal intubation and improves surgical exposure during intra-abdominal and intrathoracic procedures. The involvement of axillary lymph nodes is the most important prognostic factor listed. Sickle cell disease and thalassemia are the most clinically relevant hemoglobinopathies. The posterior tibial nerve will be located slightly posterior and deep to the posterior tibial artery. Its use is contraindicated in cases of known allergy, history of thromboembolic disease, and pre-existing seizure disorders. Channelopathies typically present as periodic paralysis with abnormalities in serum potassium. A chest radiograph shows blunting of costophrenic recesses bilaterally and cardiomegaly with prominent right and left heart borders. Acute myelogenous leukemia Chronic myelogenous leukemia Infectious mononucleosis Pneumocystis jiroveci pneumonia Pseudomonas aeruginosa septicemia Pulmonary Mycobacterium tuberculosis 9 A 23-year-old, previously healthy man has experienced malaise and a low-grade fever and sore throat for 2 weeks. Microscopically they have plump pink cells that show positive immunohistochemical staining for inhibin. The tumor may appear decades after exposure, and is not related to amount or length of exposure. Ganglion cyst Giant cell tumor Lipoma Nodular fasciitis Rheumatoid nodule Tophus 47 A 25-year-old man has had right knee pain with "popping and catching" for the past 2 years. Ventilation and Perfusion In order for gas exchange to occur, ventilated alveoli must be exposed to blood within pulmonary capillaries. This contributes to peripheral pain sensitization, general pain perception, and the sickness syndrome consisting of fever, anorexia, and changes in mood and sleep patterns (1). Patient Factors As expected, patients with pre-existing lung disease, including obstructive diseases such as asthma or chronic obstructive pulmonary disease, and restrictive diseases such as pulmonary fibrosis, have an increased risk of pulmonary complications compared with healthy adults. As the alveolus begins to overdistend, the surfactant concentration decreases and alveolar shrinkage is favored (2,3). The 1 adrenoceptormediated vasoconstriction occurs through phospholipase C-inositol 1,4,5triphosphate, signaling through an inhibitory guanine nucleotide-binding (Gi) protein.

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Consequently, it has long been taught that three or four times as much crystalloid must be administered as colloid to achieve the same plasma volume expansion. Antimicrosomal and antithyroglobulin antibodies are seen in Hashimoto thyroiditis (and Graves disease), but thyroiditis is a diffuse process and unlikely to produce a solitary nodule. While being treated with cyclosporine, azathioprine, and high doses of corticosteroids, he began to experience headaches and became lethargic. Both terms describe the solute concentration of a solution, and due to the negligible difference in their values, are often used interchangeably. In 90% of cases, acute cholecystitis is caused by obstruction in the neck of the gallbladder or in the cystic duct by a gallstone. The radiologic appearance of the mass in this child is typical for a malignant tumor, with bone destruction and soft-tissue extension. This chondrosarcoma has infiltrated the medullary cavity and invaded the overlying cortex, characteristics of a malignant process. A 30-year-old male is undergoing retinal eye surgery under general endotracheal anesthesia, including positive pressure ventilation and pharmacologic paralysis. Drug Allergies Information about drug allergies should be elicited during the preanesthetic interview. An abnormality involving which of the following organs is most likely to be present in affected males A chest radiograph shows a 3-cm nodule with an air-fluid level in the right upper lobe. In the operating room, dexmedetomidine has been used primarily as an adjunct to general anesthesia for patients who require alternative mechanisms of analgesia. Post-traumatic dementia from repeated blows to the head often has pathologic findings of neurofibrillary tangles and neuritic plaques similar to Alzheimer disease. Water reabsorption, which occurs to a much greater extent in the collecting duct than the connecting segment, is under the influence of antidiuretic hormone (arginine vasopressin). In isolation, ketamine is a direct myocardial depressant, but secondary to this indirect release of catecholamines, it acts as a cardiac stimulant, causing increased blood pressure, heart rate, and cardiac output. Although most are histologically and biologically benign, with multinucleated cells in a stroma predominantly composed of spindle-shaped mononuclear cells as shown in the figure, in rare cases, a sarcoma can arise in a giant cell tumor of bone. An infarct is not likely to produce pronounced associated brain swelling, and a mass effect in occipital lobe is unlikely to affect the third nerve. Candida albicans Lactobacillus acidophilus Listeria monocytogenes Staphylococcus aureus Viridans streptococci 3 A 30-year-old woman sustained a traumatic blow to her right breast. Ixodes scapularis is the tick that is the vector for Borrelia burgdorferi organisms, which cause Lyme disease and erythema chronicum migrans. The reduction in Cmax associated with epinephrine is more pronounced for the less lipid-soluble local anesthetics, while increased neural and perineural tissue binding may be a greater determinant of systemic absorption with increased lipid solubility. Each time, she has a prodrome of lightheadedness followed by a brief loss of consciousness. There would be scattered granulomas that are rounded and tan with granulomatous diseases of the spleen, such as histoplasmosis. Did You Know Context-sensitive halftime merely refers to the time it takes for the plasma concentration to decline by 50% after terminating an infusion. A hemangioblastoma is a rare cystic mass in adults, typically arising in the cerebellum, and may be associated with polycythemia. Mutations in the -globin chain can give rise to hemoglobinopathies such as sickle cell anemia. Fibroadenomas contain ducts with stroma and are not highly vascular; these lesions are not located in ducts. You plan to use a rapid sequence induction with propofol and succinylcholine (Mallampati 1 airway). A patient may appear completely awake yet have no recollection of events at a later time. Gestational trophoblastic disease predisposes patients to preeclampsia, but hydatidiform mole is excluded by the presence of a fetus, and a partial mole would be unlikely to persist into the third trimester. The Physiologic Basis of Diuretic Action Diuretics are typically classified according to their site of action in the nephron. There is a predisposition to aseptic necrosis and osteomyelitis, particularly with Salmonella.

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The paralysis of respiratory muscles may be life threatening, although many patients recover after weeks of ventilatory support. Melanomas of the eye are seen in adults and have spindle or polygonal cell patterns, and are often pigmented. Dermatofibroma Leiomyoma Merkel cell carcinoma Neurofibroma Schwannoma 21 A 30-year-old man is known for his large appetite. Pneumoconioses with exposure to dusts such as silica can produce interstitial fibrosis over many years, and the risk of neoplasia is increased slightly for silicosis and greatly for asbestosis. Rheumatic heart disease develops after the immune response directed against the bacterial antigens (similar to cardiac antigens, and thus a form of molecular mimicry) damages the heart because streptococcal antigens cross-react with the heart. This is because cardiac output is high in advanced liver disease and drug action is terminated primarily by redistribution. Common bile duct atresia Hepatic vein thrombosis Hepatoblastoma Intrahepatic duct lithiasis Microvesicular steatosis Multinucleated giant cell hepatitis 35 A 20-year-old primigravida gives birth at term following an uncomplicated pregnancy to a boy infant of normal weight and length. Antibodies against the acetylcholine receptor disrupt the function of the myoneural junction. IgG deposition can be seen in systemic lupus erythematosus and in bullous pemphigoid. The anesthesia provider must be vigilant and prepared to respond quickly once local anesthetic toxicity is manifested. Patients with chronic viral hepatitis may have generalized malaise and weakness that is not related to specific muscle disease. On physical examination, there is 4/5 motor strength in the right upper extremity and decreased sensation to pinprick on the right arm and hand. Seborrheic keratoses are seen in older adults and are raised, pigmented lesions of thickened epidermis. Of note, patients who are dialysis dependent should ideally be dialyzed as soon prior to surgery as feasible (usually the day before surgery) to optimize preoperative fluid and electrolyte status. There is an abnormality of ciliary dynein arms that diminishes the mucociliary function of the respiratory epithelium, predisposing to recurrent and chronic infections of both upper and lower respiratory tract. Emboli exiting the aorta at the celiac axis generally take the straight route to the spleen. The t(9;22) translocation gives rise to the Philadelphia chromosome of chronic myelogenous leukemia. Candidiasis often produces a scant, white, curdlike vaginal discharge; gonorrhea may have an associated urethritis; and Trichomonas may produce a profuse homogeneous, frothy, and adherent yellow or green vaginal discharge. The second, maintenance drug dose is in comparison very small and only blocks a small proportion (10% to 15%) of the free receptors. In about 70% of cases, it is joined by the main pancreatic duct to form the combined opening in the duodenum (ampulla of Vater). Inhaled anesthetics may cause a decrease in renal blood flow as a result of decreased cardiac output and blood pressure or an increase in renal vascular resistance. Neoplasms usually produce solid masses, although sometimes a renal cell carcinoma is cystic. Subsequently, both cardiac output and systemic vascular resistance normalize within 10 to 15 minutes. Neuromuscular monitors are either battery-operated, hand-held devices or can be incorporated into the anesthesia workstations as modular units. Which of the following factors is most likely to be associated with the greatest number of male breast carcinomas Greater immunogenicity Greater likelihood of metastases Greater risk of familial breast cancer Higher response to therapy Higher tumor stage Higher tumor grade the Breast 365 25 A 51-year-old woman has noticed an area of swelling with tenderness in her right breast that has worsened over the past 2 months. Visual acuity may be maintained while glaucoma is progressing, and loss of acuity alone does not identify the cause. A double tourniquet is placed on the upper arm with the proximal and distal tourniquets clearly identified.