Medicine Flashcards

Question

Transfusion reaction

Answer 1

Cross-agglutination of blood by antibodies in plasma S/S: fever, ↓ BP, sweats/chills, hives, anaphylaxis/dyspnea, vomiting, flank pain, headache

Answer 2

* Maintain BP & Renal perfusion * IV fluids: NS, strict i/o's * Consult nephrology * if no diuretic response ~ 2-3h, assume ATN(acute tubular necrosis) , don’t give more IVF * Diurese w/ Lasix 40-80mg (+2mg/kg) > 100 cc urine/h * Dialyze, watch electrolyes, give benadryl

Answer 3

- Leukemia: Increase lifespan of myeloid or lymphoid cells. - Pathogenesis: Block in stem cells differentiation

Answer 4

AML: - Increase number of immature myeloid cells. - Occur in adult, more men - Risk factor: Down syndrome, radiation, cisplatin and carboplatin - Fatigue , dyspnea , dizziness, weight loss , fever, infection, gingivitis , easy bleeding. - Work up: CBC (low wbc, anemia and thrombocytopenia), BMP, coagulation labs PT/PTT/INR

Answer 5

-Malignant myeloproliferative disorder associated with Philadelphia chromosome. - common in adult > 60 M - CBC shows wbc between 50,000-200,000 - Tx: Tyrosin kinase inhibitor , chemo and bone marrow transplant

Answer 6

- Malignancy by proliferation of immature lymphoid cells - More common in children 80% and 20% in adult - Fatigue , pallor , lymphadenopathy , mouth ulceration, oral bleeding and numb chin syndrome which is numbness along mental nerve distribution. - Work up requires a CT of neck, chest, abdomen, and pelvis. CT/MRI head for those with neurological symptoms. - They have anemia, thrombocytopenia, low and high WBC - More responsive to treatment.

Answer 7

- Psychiatric disorder characterized by chronic and recurrent psychosis. - Positive symptoms: - Hallucination, delusion, disorganized thought - Negative symptoms: - Apathy, flat affect, Aloofness

Answer 8

- First generation dopamine receptor blockade: works also on serotonin type 2 (5-HT2), alpha-1, histaminic - Chlorpromazine - Haloperidol Haldol. - Fluphenazine - Perphenazine - Second generation D2 blockade : - Seroquel - clozapine (agranulocytosis low level of WBC require serial CBC ), side effect hypotension , weight gain , glucose intolerance. - Side effect both drugs: 1- Tremor 2- Tardive dyskinesia (involuntary movement of perioral region and extremity) 3- Prolonged QT interval = can cause cardiac arrest

Answer 9

- CBC (clozapine can cause (agranulocytos) - BMP - EKG to assess the QT interval = high risk of ventricular dysrthymia. - Assess for substance abuse (50% of schizophrenic pts have substance abuse) - Avoid ketamine = can worse the hallucination - Obtain appropriate level of sedation.

Answer 10

Hemophilia A: 80% common - X linked recessive bleeding disorder characterized by congenital deficiency of factor VIII. - M>F - Dx: - Genetic testing - family hx - PTT prolonged, PT is normal, platelet is normal - Hem A factor 8 activity is below 40%

Answer 11

Hemophilia B: 20% common - X linked recessive bleeding disorder characterized by congenital deficiency of factor IX. - M>F - Genetic testing - family hx - PTT prolonged, PT is normal, platelet is normal - Hem B factor 9 activity is below 40%

Answer 12

Classification of hemophilia A & B: - Mild disease: factor level greater than 5-40% - Moderate disease: factor activity 1-5% - Sever: factor level below 1%

Answer 13

- Spontaneous bleeding - Prolong bleeding. - Gingival bleeding. - Hemarthrosis - Intracranial hemorrhage - GI bleeding - Muscle bleeding

Answer 14

- I will contact the hematologist to discuss and get more details about the severity of the condition and to appropriately co-manage the patient. - Obtain labs CBC, BMP, PT, PTT and coagus - Avoid NSAID and aspirin. - I will give recombinant factor concentrates of factor VIII or IX. - Goal is to raise the levels 80–100% prior to surgery and maintain 50% 1–2 weeks postoperatively. The factor should be giving 20-minute prior surgery due to short half-life. - I will use hemostatic adjunct

Answer 15

- Tranexamic acid: Antifibrinolytic agent, inhibits conversion of plasminogen into plasmin. Dosage: - 25mg/kg PO qid - 5% mouth wash with 10ml - 10mg/kg IV. All for 5-7 days. - Amicar: Antifibrinolytic agent, inhibits conversion of plasminogen into plasmin - Dosage: - 6g PO QID, can be giving preop 5g 30-minute prior - Desmopressin: Synthetic analog vasopressin Causes release of stored vWF and factor 8 from endothelial cells. - Dosgae: - IV 0.3 μg/kg over 20 minutes. - Intranasal 150 μg spray to each nostril. Monitor free water intake as there is a risk of hyponatremia and seizures.

Answer 16

- Congenital platelet bleeding disorder due to a deficiency or dysfunction of von Willebrand factor (vWF). - vWF is responsible for mediating platelet adhesion and prevent factor 8 degradation. - Can be inheritance or acquired due to autoimmune disorders such as SLE OR hypothyroidism.

Answer 17

1- Partial quantitative, most common. AD 85% 2- Partial qualitative, 2A, 2B, 2N,2M. AD 15% 3- Total quantitative autosomal recessive - Symptoms: - mucous membrane bleeding - Gingiva bleeding. - Menorrhagia. - Epistaxis. - GI bleeding. - Type III can result in more severe symptoms including joint bleeding.

Answer 18

- CBC, PT, PTT are normal. - Factor 8 decrease - vWF antigen decrease. Diagnosis: Gold standard: Ristocetin cofactor a

Answer 19

**- Type 1:** - Desmopressin (DDAVP) Synthetic analog vasopressin Causes release of stored vWF and factor 8 from endothelial cells. - Dosgae: - IV 0.3 μg/kg over 20 minutes. - Intranasal 150 μg spray to each nostril. Monitor free water intake as there is a risk of hyponatremia and seizures. **- Type 2 and 3:** - Cryoprecipitate can be used to treat all types of vWD. - Is portion of the plasma that Contains Factors 8, 9, vWF, fibrinogen, and fibronectin. - Peds 1-2 unit per 10kg - adult 1 unit per 10kg. - Each unit increases fibrinogen by ~5–10 mg/dL in adults. - Humate-P (vWF/Factor VIII) concentrate: It is a blood clotting factor replacement therapy used in the treatment of hemophilia A and von Willebrand disease. Loading dose 40-60 IU/kg then taper the dose.

Answer 20

Malignancy of lymphocyte that arise usually in lymph node. - Two main types: - Hodgkin lymphoma (HL) - Non Hodgkin lymphoma (HL)

Answer 21

- Malignancy of lymphocyte that arise in lymph node. - Present as painless lymphadenopathy usually supraclavicular 75% in the neck - Spleen involved in 20% - Male age 15-35 years **- B symptoms: ** - Night sweats, fever and weight loss - Characterized by the presence of Reed- Sternberg malignant cells that are seen on histopathology (binucleated cells with owl eye nuclei). **-Work up:** -Biopsy - CT and PET scan for staging - CBC, BMP to look for anemia, leukocytosis, thrombocytosis, and hypoalbuminemia. **-Tx: ** - Radiation 20G - chemotherapy (bleomycin…)

Answer 22

- Albumin is protein produced by the liver and is a major component of blood plasma. Normal value 3.5 to 5.0 g/dL.

Answer 23

- Malignant lymphoproliferative lesions that are not Hodgkin lymphoma. - 85% are of B cell origin. - Express CD20 marker - B symptoms: night sweats, fever and weight loss - Virus may play role: EBV (Burkitt’s lymphoma, HIV and Hep B) - Can also see extranodal involvement – bone marrow, lungs, liver, bone. - Work up: - Biopsy, CT and PET scan for staging, CBC, BMP to look for anemia, leukocytosis, thrombocytosis, and hypoalbuminemia. - Tx: - Radiation 20G - chemotherapy (Rituximab anti CD20…)

Answer 24

- Malignant of plasma cells causing osteolytic lesion, hypercalcemia, osteopenia and pathologic fracture. - Affect more male, 60-70. **Clinical presentation:** - Jaw lesion in 30% - bone pain - Hypercalcemia - Anemia - Petechiae due to platelet dysfunction - Amyloidosis in soft tissue - Renal failure from Bence-Jones protein (Amyloid is nephrotoxic) - Radiograph: Punched out radiolucency without sclerotic border in skull

Answer 25

- Clinical exam - Protein electrophoresis to detect monoclonal protein - serum and urine M protein - bone marrow biopsy - CBC, anemia , platelet dysfunc - BMP - CT and PET scan - Peripheral smear shows Rouleaux formation (stacked RBCs resembling coins)

Answer 26

- CBC, BMP , coagus and type and screen - Consult hematologist. - Transfuse if necessary. - Maximize hydration. - Pre and post op abx - Avoid steroid, can precipitate tumor lysis. - Consider risk of MRONJ , avoid IAN if bleeding concerns.

Answer 27

Neuromuscular disease caused by mutation of dystrophin gene leads to progressive necrosis of the muscle fiber. Epidemiology: 1 in 3,600 boys. Onset: Early childhood with motor delays, learning disabilities, attention issues. Progression: Wheelchair-bound; life expectancy ~20 years (respiratory failure, heart failure, arrhythmias, pneumonia).

Answer 28

Muscle: Calf/tongue pseudohypertrophy, long bone fractures, kyphoscoliosis (↓ respiratory function). Weakness of Pharyngeal muscles causing aspiration, nasal regurgitation, nasal speech. Cardiac: Mitral valve regurgitation tachycardia (tall R wave) arrhythmias.

Answer 29

Labs: ↑ Serum CK. EMG: Myopathic pattern. Biopsy: Muscle atrophy and hypertrophy. DNA: Dystrophin gene mutation.

Answer 30

Pre-op: - Steroid supplementation - assess for ACE inhibitors, beta blockers, digoxin (toxicity: N/V, visual changes). Pre-op Workup: EKG, echo, chest X-ray. Anesthesia: - TIVA preferred; avoid volatile agents (risk: malignant hyperthermia). - No succinylcholine (risk: rhabdomyolysis, hyperkalemia). - Use desflurane if needed. - NPO: Longer duration (gastroparesis). - Pre-induction: H2 agonist + metoclopramide. - Avoid narcotics - monitor TMJ subluxation, - ↓ pulmonary reserve → ICU post-op if required.

Answer 31

Autoimmune disorder features by autoantibodies affecting postsynaptic neuromuscular nicotinic ACH receptor It is characterized by weakness and fatigue of the skeletal muscles with improvement with rest.

Answer 32

- Fatigue of voluntary muscles most commonly eyelid ptosis - Generalized weakness - Thymoma in 15% of patients - Slow speech, jaw claudication, swallowing difficulty - Respiratory weakness - Peek sign: patient closes eyes and after a short time scleral show begins due to orbicularis oculi weakness.

Answer 33

- Anti-acetylcholine receptor antibody test is the confirmatory diagnostic test of choice. - Edrophonium chloride (Tensilon) test. Patient is injected with anticholinesterase with improved strength. - Treatment: - Pyridostigmine (anticholinesterase) Inhibits acetylcholinesterase, increasing acetylcholine at the neuromuscular junction to enhance muscle contraction. first line of treatment. - IV immunoglobulin

Answer 34

- Consider reduced or avoidance of sedatives or opioids in those with reduced respiratory reserve. - Short-acting opioids such as remifentanil are preferred. - Warn patient of possible need for prolonged ventilatory support. - Usually resistant to succinylcholine and sensitive to non-depolarizing muscle relaxants. - Rapid sequence intubation, succinylcholine should be adjusted to 1.5–2 mg/kg - Nitrous oxide is safe. - Avoid aminoglycosides (e.g., gentamycin) as they are known to impair neuromuscular transmission. Erythromycin, azithromycin, fluoroquinolones, and tetracycline have reports of increased myasthenic weakness. - Inhalational agents such as sevoflurane, isoflurane, and halothane are known to reduce neuromuscular transmission and may be exacerbated in the myasthenic patient. - Reports of adverse effects with ketamine and etomidate. - Propofol is safe in these patients. - Controversial on reversal of neuromuscular blockage due to concern postoperative weakness due to cholinergic crisis or inadequate muscular transmission. - Cholinergic crisis, excess of acetylcholine. Normally due to administration of excess anticholinesterase drugs resulting in involuntary twitches and fasciculation and muscle weakness. - Differentiate from myasthenic crisis by administration of the edrophonium test. In myasthenic crisis, pupils will be dilated as well.

Answer 35

Demyelinating disease of the central nervous system (CNS) marked by relapses, followed by periods of remission. Pathogenesis – demyelination in the periventricular areas of the brain. MS is an autoimmune disease triggered by unknown environmental factors. Diagnosis: MRI and CSF study Symptoms: visual disturbances, gait disturbances, ascending paresis - Treatment of major relapses is with IV methylprednisolone (500–1000 mg daily for 3–5 days), and sometimes followed by a taper of oral prednisone. - Other therapies include treatment with interferon-B. There is no cure for MS.

Answer 36

- I will contact the physician who’s managing the MS to Rule out cardiovascular or respiratory issues in those MS with advance disease. - I will get recent labs CBC , BMP and EKG as some of the medication such as interferon can cause anemia, neutropenia, and thrombocytopenia. - No elective surgery during periods of relapse - Provide adequate anxiolysis and pain management to avoid exacerbations. - The informed consent discussion should include the possibility of worsening MS symptoms. - Consider stress-dosing the patient who is on long-term steroids. - Avoid succinylcholine in patients with paralysis or paresis because of the potential for hyperkalemia.

Answer 37

Irreversible disease that causes airway obstruction by either chronic bronchitis and/or emphysema. - Risk factors include smoking (most common), respiratory infection, occupational exposure.

Answer 38

wheezing chronic cough productive cough hyperinflation of chest hypertrophy of the accessory muscles weight loss fatigue dyspnea on exertion pulmonary hypertension leading to neck vein distention and peripheral edema.

Answer 39

COPD patients typically exhibit hypercarbia and hypoxemia. Advanced disease can lead to pulmonary hypertension and cor pulmonale. What is Gold criteria – severity of COPD What is FEV 1 – amnt of air expelled in 1 sec I Mild: FEV1 > 80% Short acting bronchodilator II Moderate: FEV1 > 50-79% Long acting bronchodilator III Sever: FEV1 > 30-49% Inhaled steroid IV very sever: FEV1 < 30% Oxygen, pulmonary rehab

Answer 40

*** Chronic bronchitis (“blue bloaters”):** chronic hypersecretion of mucus in the bronchi resulting in airway obstruction. *** Emphysema (“pink puffers”)** enlargement of the airway due to destruction of the airway walls leading to loss of elasticity/recoil of the bronchioles. Alpha-1 antitrypsin (AAT) deficiency

Answer 41

- Pulmonary function tests including spirometry - How does PFTs work? Pulmonary function tests (PFTs) measure lung function by assessing airflow, lung volumes, and gas exchange. They work by having the patient perform specific breathing maneuvers, and the results are recorded by a spirometer or other devices How is it diagnosed? pulmonary function test like an exercised induced stress test or a methacholine (miminc acetyholine, induce bronchospasm) - Bronchitis diagnosis is based on a history of a productive cough for at least 2 consecutive years. - Chest radiographs look for lung nodules, bullae, hyperinflated lungs, masses, or fibrotic changes. - Blood labs may show hypercarbia, polycythemia and leukopenia.

Answer 42

- Consult with a pulmonologist and optimize prior surgery. - Smoking cessation for 6 weeks - EKG to rule out right-sided heart disease and ischemic heart disease. - Chest X-ray warranted if concern for respiratory infection or occult malignancy. - No sedation because patients have limited ability to tolerate hypoventilation as they have a diminished response to hypercarbia. - Presence of extensive bullae translates to a higher risk pneumothorax. - Delay surgery if any signs of active infection purulent sputum, or worsening cough. - Nitrous oxide has the potential to expand and possible rupture pulmonary bullae. - Consider β-2 agonist and an antimuscarinic (e.g., robinul) to increase airway patency. - Maintain oxygen saturation between 88% and 92%. - Opioids diminish the respiratory drive and predispose the patient to apnea (use opioids judiciously). - Local anesthesia is preferred.

Answer 43

Psychiatric disorder characterized by abnormal eating habits with psychological implications and excessive concern about body weight.

Answer 44

Binge eating disorder followed by purging at least once a week for 3 months. Patients have strong negative views on their personal shape and weight

Answer 45

Eating disorder characterized by intentional restricted caloric intake leading to low body weight BMI (less than 18.5 kg/m2)

Answer 46

- Low body mass index. - Dehydration. - Delayed gastric emptying. - Resting bradycardia. - Hypertrophic salivary glands. - Hypokalemia, hypocalcemia, hyponatremia, and hypoproteinemia. - Amenorrhea and atrophy of breasts in females. - Seizures. - Hypothermia. - Anxiety. - Dry skin (normally scaly, yellow, and erythematous patches) and hair loss (alopecia). - Lethargy. - Hypokalemic hypochloremic metabolic alkalosis may occur secondary to excessive vomiting. - Russell sign – callus on dorsal surface of index and long finger due to induced vomiting (seen in bulimia).

Answer 47

- Fluid rehydration – patients are commonly dehydrated leading to hypotension. - EKG – preoperative EKG should be monitored for Bradycardia, dysrhythmias including PVCs, T wave inversions, and heart blocks. - CBC – review white blood cell, platelet, and preoperative hemoglobin. This may be severely reduced due to malnutrition. BMP: evaluate for hydration based on BUN/creatinine ratio elevation. Rule out unsafe levels of electrolytes LFTs – hypoproteinemia and reduced liver function may make patients more susceptible to bleeding and may decrease wound healing. NPO period – increase of NPO time due to delay in gastric emptying. Slowly titrate medications because these patients have amplified response to the medication due to low body fat level and low protein plasma which increase bioavailability Patients may require an extended time to emerge from anesthesia

Answer 48

- Cardiovascular: Increase HR, CO by 30%, benign systolic murmur S3 d/t relative anemia, DVT 2/2 uterine compression of inferior vena cava. - Hematology: Hemodilution anemia, hypercoagulable state risk for PE&DVT, leukocytosis, suppression of immune system due to decrease chemotaxis. - Respiratory: decrease residual volume, decrease FRC, respiratory alkalosis 2/2 increase in minute ventilation and rapid desaturation. - Genitourinary: increase GFR, renal blood flow, Cr, bladder capacity decreases due to pressure which increase risk of UTI due to stasis, decrease lower esophageal sphincter tone, increase gastric pressure heart burn and reflux and hypoglycemia.

Answer 49

Chronic gingivitis, 5% develop pyogenic granuloma.

Answer 50

- Preeclampsia: Abnormal placental implantation results in hypertension and proteinuria that occurs after 20 weeks of gestation. - Eclampsia: Form of severe preeclampsia characterized by seizures or coma. - HELLP Syndrome: Syndrome characterized by hemolysis, elevated liver enzymes, and low platelet counts. - Gestational Hypertension Elevated blood pressure without proteinuria. SBP ≥140 mm Hg and/ or DBP ≥90 mm Hg

Answer 51

- Aspirin: Cause intrauterine growth restriction and intra cranial brain bleeds. - NSAID: Avoid third trimester, may close PDA. - Gentamicin: ototoxicity in fetus. - Tetracycline: Cause tooth staining and decrease bone development. - Benzodiazepine and barbiturates: risk for fetal craniofacial anomalies, cleft lip/palate

Answer 52

- No elective care in the first trimester, urgent treatment only. - Second trimester is the safest and most ideal. - If the patient develop supine hypotension roll the patient to the left side. This occurs secondary to compression of the inferior vena cava. - Patients are more prone to emesis due to relaxation of the lower esophageal sphincter and longer gastric emptying times. - Pregnant patients are more sensitive to local anesthesia and have reduce onset time. - Consultation with the patient’s obstetrician should be considered to determine the need for intraoperative fetal monitoring. - Perioperative antibiotics may be indicated in the setting of gestational diabetes and reduced immune capability. - N2O is controversial, as evidence of use without scavenging unit in dental assistants has shown increase in spontaneous abortion.

Answer 53

Yes, pano , ICAT and PA are ok It is estimated that a radiation dose of >10 Gy (5 Gy first trimester) can cause congenital fetal anomalies. - A standard full mouth series, orthopantogram, or cone beam radiation exposure to the fetus is estimated 0.01-0.00001 Gy.

Answer 54

The Pregnancy and Lactation Labeling Rule (PLLR) replaces the old FDA pregnancy letter categories (A, B, C, D, X) Provides risk summary, clinical considerations, and data on medication use during pregnancy. * P1/L1, safest, data available * P2/L2, safe, limited data * P3/L3, probably safe, no data * P4/L, probably hazardous, human trials suggest risk * P5/L, hazardous, major risk likely to exceed benefits

Answer 55

"The effects of catecholamine surge cause impaired uteroplacental perfusion which is dangerous to fetus." Do not sedate pregnant patients!

Answer 56

BMP: Concerns include carcinogenicity and teratogenic effects 5FU: - Use in 1st trimester can cause congenital abnormalities and miscarriage - Use during 2nd and 3rd trimester can cause growth restriction and stillbirth.

Answer 57

* OB consult * Consider fetal monitoring: * Fetal monitoring monitors fetus heart rate and uterine tone to avoid uteroplacental insufficiency. * Left lateral position using bump under right hip - Moves uterus off inferior vena cava and aorta - Position slowly (changes in maternal position can have profound hemodynamic effects) . Rapid sequence induction and extubate fully awake d/t risk of aspiration * Avoid hypotension, hypoxia, hypercarbia, hypoglycemia and hypothermia - If these factors are controlled, there is no increased risk of fetal anomalies, miscarriage, or preterm labor.

Answer 58

Long-term kidney damage to the glomerulus or tubules, leading to irreversible complications over months to years. CRD occurs when the GFR is reduced to 50 mL/ min.

Answer 59

Cardiovascular: dyslipidemia, CHF, left ventricular hypertrophy, HTN. Anemia, platelet dysfunction GI issues nausea and vomiting, risk of aspiration Risk of infection due to impaired phagocytosis , neutrophil Acid base disturbance and hyperkalemia. Oral manifestation: halitosis, stomatitis, gingival bleeding, osteolytic changes

Answer 60

CBC: Anemia , platelet dysfunction BMP: check the electrolyte and Hyperkalemia EKG, Echo

Answer 61

- DC diuretics, ARB and ACE the day of surgery - antiemetic due to risk of aspiration - Avoid sevo, has compound A - Avoid Succ cause hyperkalemia - Avoid NSAID - consider abx prophy. - Propofol is safe – metabolize by liver. - Fentanyl is safe = lipid soluble - Benzo uses with caution.

Answer 62

Stage I : slight renal damage GFR>90 Stage 2 : mild damage GFR 60-89 Stage 3 : Moderate damage 30-59 Stage 4 : Sever damage 15-29 Stage 5 : ESRD GFR <15

Answer 63

fluorinated volatile anesthetic agent with a low blood/gas partition coefficient, therefore a rapid onset and recovery from anesthesia. The MAC is 1.71.

Answer 64

The concentration of an inhaled anesthetic, at 1ATM, that prevents skeletal muscle movement in response to a painful stimulus (skin incision) in 50% of patients. A MAC of 1.3 prevents movement in approximately 95% of individuals undergoing surgery.

Answer 65

Circuit or ETT obstruction (kinking), airway secretions or mucous plugging, bronchospasm.

Answer 66

1- Suction ETT and trachea with suction catheter. 2- Albuterol MDI 8-10 puffs into endotracheal tube on inspiration, through chamber, or a 60cc syringe connected to the anesthesia circuit close to the ETT. 3- If this doesn’t work, then epinephrine 0.3mg IM.

Answer 67

Malignant Hyperthermia. - Hypermetabolic state that occurs on exposure to volatile anesthetics agents (except nitrous oxide) and succinylcholine. Due to a genetic mutation in the ryanodine receptor - lowers the threshold of calcium release channel activation. Elevated calcium levels lead to sustained muscle contraction. **- Testing includes:** 1- caffeine-halothane contracture test 2- muscle biopsy 3- RYR1 gene testing.

Answer 68

- History (and family history) - 70% of MH-susceptible patients have increases of resting concentrations of creatine kinase. - The earliest clinical signs of MH include unexplained sustained elevation in ETCO2 - Tachycardia. - Arterial hypoxemia - Metabolic and respiratory acidosis - Increase in body temperature (late finding). - Dysrhythmias, peaked T waves on EKG due to hyperkalemia - Masseter spasm

Answer 69

- Activate EMS - Stopping the triggering agent - Changing the anesthesia circuit - Hyperventilating with 100% O2 - IV fluids to maintain urine output to 2 mL/ kg/h. - Administering 2.5mg/kg Dantrolene Sodium IVP and repeat every 10-15 minutes as needed (up to 10mg/kg) - Initiate active cooling (cold IV saline - Gastric lavage with cold saline - Diuresis 1 mg/kg IV. - Correct metabolic acidosis with sodium bicarbonate 1–2 mEq/kg IV as guided by arterial pH - Hyperkalemia treated with calcium chloride 5–10 mg/kg IV or regular insulin 0.15 U/kg in 1 mL/kg of 50% dextrose. - The patient must be transported to and managed in an ICU setting at the appropriate time.

Answer 70

Administering 2.5mg/kg Dantrolene Sodium IVP and repeat every 10-15 minutes as needed (up to 10mg/kg) **Preparation of Dantrolene:** 20 mg dantrolene bottle mixed with 60 mL sterile water and 3 g of mannitol. **Ryanodex (Concentrated Formulation):** Each vial contains 250 mg of dantrolene sodium and requires minimal preparation. Add 5 mL of sterile water to the vial. Shake the vial vigorously for 10 seconds Each mL delivers 50 mg/mL of dantrolene.

Answer 71

- Neurodegenerative disease characterized by the progressive loss of cortical neurons. - AD is the most common neurodegenerative disease and the most common cause of dementia in persons older than 65 years of age. - Hallmarks of the disease include impaired memory, judgment, and decision-making, and emotional lability.

Answer 72

- Classification: - **Familial form (early-onset AD) ** o Rare. o Early onset, usually before age 60. **- Sporadic form ** o More common. o Typically occurs after 60 years of age.

Answer 73

* The clinical diagnosis of AD is by exclusion. * Definitive diagnosis is usually made on post- mortem examination via autopsy (presence of **accumulation of amyloid plaques** and neurofibrillary tangles). * MRI imaging is preferred in diagnosis of AD. Will demonstrate marked **cortical atrophy with ventricular enlargement.**

Answer 74

* There is no cure for AD and treatment focuses on control of symptoms. Even with treatment, prognosis is poor. * The pharmacological agents for AD include cholinesterase inhibitors (tacrine, donepezil, rivastigmine, and galantamine), and the glutamate antagonist, memantine.

Answer 75

* Patients with AD are often confused and can be uncooperative. While some patients may tolerate a procedure with local anesthesia, many may need some sort of procedural sedation. * Inquire who makes health care decisions for the patient if the patient does not possess capacity (power of attorney/health care advocate). * Doses of sedative-hypnotics should be reduced by 30% **due to increased sensitivity and slower distribution and reduction in clearance. ** * Preferred medications include short-acting sedative-hypnotics, anesthetic agents, and narcotics since they allow a more rapid recovery. * Centrally acting anticholinergics, such as atropine and scopolamine, may contribute to post- operative cognitive dysfunction and should be avoided if possible. * Glycopyrrolate, which does not cross the blood–brain barrier, is the preferred agent when an anticholinergic is needed. * Have the patient continue their AD medications preoperatively.

Answer 76

- Neurodegenerative disease characterized by the classic triad of bradykinesia, rigidity, facial immobility, and resting (pill-rolling) tremor. - It is caused by the progressive loss of dopaminergic neurons in the pars compacta in the basal ganglia

Answer 77

- The diagnosis of PD is made according to the clinical signs of tremor, bradykinesia, muscular rigidity, and postural instability.

Answer 78

Treatment: - The goal is to increase the concentration of dopamine in the basal ganglia. 1- Carbidopa-levodopa (Sinemet®) is the main- stay of treatment of PD. - Levodopa is a dopamine precursor combined with carbidopa and prevent conversion of levodopa to dopamine, thereby optimizing the amount of levodopa entering the CNS. 2- Selegiline and rasagiline are type B mono- amine oxidase (MAO-B) inhibitors that help control PD symptoms by inhibiting the catabolism of dopamine in the CNS. 3- Surgical tx: Thalamotomy, deep brain stimulator.

Answer 79

- Continue medication preop. - Nausea/vomiting are side effects of levodopa and may be treated with ondansetron, dexamethasone, and transdermal scopolamine. - Avoid phenothiazines (promethazine), butyrophenones (droperidol), and metoclopramide because their antidopaminergic activity can exacerbate symptoms. - Diphenhydramine may be used for patients with tremor. - Propofol is relatively safe. - Opioids should be used judiciously as patients with PD have a higher incidence of chest wall rigidity. - Be mindful of serotonin syndrome risk on patients taking MAOI (hypertension, tachycardia, hyperthermia, diaphoresis, confusion and agitation). - Ketamine may be relatively contraindicated due to elevated blood pressure.

Answer 80

Sudden onset of abnormal, highly discharges of neurons.

Answer 81

Chronic disorder defined as recurrent seizures, two separate unprovoked seizures are required to make the diagnosis of epilepsy.

Answer 82

Seizures classification: **- Partial focal seizure: **affect single area of the brain. - simple partial with intact consciousness - complex with impaired consciousness **- Generalized seizures-** **Diffuse. Affect most of the brain. - Absence (petit mal) most commonly in children. Brief loss of awareness+ blank stare - Tonic Clonic (Grand mal): stiffening and movement - Myoclonic: quick, repetitive movement

Answer 83

Etiology: - Syncope is most common cause in OMFS office then seizure - Anesthesia / drugs - Alcohol - Brain tumor - CNS disease - Head trauma - CVA - Other metabolic changes that produce seizure activity include hypoglycemia, hypernatremia, hyponatremia and hypomagnesemia. - Presentation: - LOC - Confusion - Abnormal movement - Tongue /lip biting - Incontinence

Answer 84

Work up: -MRI, EEG , electrocorticography

Answer 85

- Consult neurologist. - Ask about how bad is the seizure, frequency and medication. - Propofol and benzo are good. - Nitrous is safe. - Sevo lowering seizure threshold - Avoid ketamine, tramadol, methohexital and flumazenil. (lowering seizure threshold) - Alfentanil is contraindicated due to excessive impact on EEG activity. - Continue meds - Get a CBC as some meds cause bone marrow suppression - Be aware of any hepatically metabolized meds you use as their effect could be prolonged due to the use of antiepileptic drugs

Answer 86

- Phenytoin, aka “Dilantin” 1.300mg po daily 2.Stabilizes inactive state of voltage gated Na+ channels 3.Levels need to b between 2-20 4.Metabolized in liver 5.Causes blood dyscrasias so get CBC and LFT’s - Keppra, aka “Levitiracetem” - 500mg BID - Inhibits Ca++ channels - Valproic Acid, “Depakote” 1.Works on Na+ and Ca++ channels 2.Produces thrombocytopenia and GI symptoms - Topiramate, aka “Topamax” 1.GABA, Na+, Ca++ channels 2.Used for migraines also - Tegretol, “Carbamazepine” 1.Produces n/v and somnolence 2.Works on voltage gated Na+ channels

Answer 87

seizure lasting more than 30 min or multiple seizures in a row. Treat as status epilepticus after 5 min of seizing

Answer 88

Binds to synaptic protein 2A in the brain to regulate neurotransmitte

Answer 89

Blocks voltage-gated sodium channels

Answer 90

- Activate EMS/911 if no self-resolution in 5 minutes. - Airway Breathing Circulations (ABCs), vitals, ECG. Patient may require airway protection with endotracheal intubation. - Supplemental oxygen. - Establish venous access – consider administering benzodiazepines. - Consider drawing labs for electrolytes, toxicology, anticonvulsant drug levels, and hematology. - Midazolam: 10 mg for >40 kg, 5 mg for 13–40 kg. - Lorazepam: 0.1 mg/kg/dose, max: 4 mg/dose. - Diazepam 0.15–0.2 mg/kg/dose, max: 10 mg/dose. - Rule out hypoglycemia and treat as needed (50 mL of 50% dextrose). - Routine glucose administration is not indicated because hyperglycemia can exacerbate brain injury. - Arterial blood gas draws to monitor for metabolic acidosis and to assess ventilation. - Hyperthermia frequently occurs and requires active cooling. - If seizure continues, consider second-line therapy such as phenobarbital (10–15 mg/ kg at 100 mg/min) or phenytoin (15–18 mg/ kg T 50 mg/min) or anesthetic dose of propofol.

Answer 91

A sudden onset of neurological deficits that occurs secondary to cerebral ischemia or cerebral hemorrhage. ## Footnote Also known as stroke.

Answer 92

Sudden onset of focal neurological deficits that resolve within 24 hours. ## Footnote TIA is often considered a warning sign for future strokes.

Answer 93

Neurological deficit that lasts more than 24 hours but resolves in less than 3 weeks. ## Footnote RIND indicates a temporary but significant disruption in blood flow.

Answer 94

- Thrombotic, caused by atherosclerotic plaques. - Embolic origin is mostly from the atrium of the right heart as seen in atrial fibrillation or left ventricle from an MI. ## Footnote Embolic strokes mostly originate from the heart, particularly in conditions like atrial fibrillation.

Answer 95

Mostly intracerebral, with the remaining being subarachnoid. ## Footnote These types of strokes are due to bleeding into the brain or surrounding areas.

Answer 96

Contralateral deficits of motor and sensory nerves of the cerebral hemisphere involved. ## Footnote This means that if one side of the brain is affected, the opposite side of the body will show deficits.

Answer 97

Hypertension, smoking, atrial fibrillation, diabetes, ischemic heart disease, peripheral vascular disease, increased homocysteine levels, excessive alcohol consumption.

Answer 98

Hemiplegia, aphasia, dysarthria, hemineglect, seizures, and gait disturbances.

Answer 99

Headache, loss of consciousness, nausea, and vomiting.

Answer 100

Symptoms manifest clinically based on the anatomical area of neurological involvement (e.g., hemiplegia due to cortico-spinal tract involvement).

Answer 101

Facial droop, ptosis, ocular muscle weakness, weakened parapharyngeal muscles (weakened gag and swallowing reflex), anosmia, visual field deficits, and disturbances in tongue movement.

Answer 102

- CT scan w/o contrast - Echo to rule out of emboli. - CTA/MRA and carotid doppler - Coagulopathy: CBC, BMP, coags , pregnancy test, cardiac enzyme.

Answer 103

- Statins reduce risk of stroke even in the absence of hyperlipidemia.

Answer 104

- IV tissue plasminogen activator (tPA) converts plasminogen into plasmin, in patients who meet criteria and in whom treatment can begin within 3–4.5 hours from initial symptom. - Inclusion criteria: - 18 years or older, ischemic stroke with neuro deficit, time within 3 hours - Exclusion criteria: - Intracranial bleeding, hx of brain bleed, uncontrolled HTN >185/110, known AV malformation, neoplasm, or aneurysm.

Answer 105

- DC and reverse all anticoagulation. - Consider fresh frozen plasma. - Neurosurgery consult for possible placement of EVD. - If pt intubated, mechanical hyperventilation help reduce ICP - Elevated ICP can be managed with IV mannitol 3g/kg, or hypertonic saline, avoid hypotonic. - Monitor blood glucose.

Answer 106

- Identify high-risk patients (e.g., risk factors and recent CVA). - The patient should be considered ASA class II if patient had a CVA >6 months earlier and has no evidence of residual neurologic deficit. - The patient should be considered ASA class III if patient had a CVA >6 months earlier and has some evidence of residual neurologic deficit. - The patient should be considered ASA IV if patient had a CVA <6 months earlier or if substantial residual deficit remains. - Maintain adequate oxygenation. - Monitor EKG - Discuss drug holiday with physician. - Avoid ketamine. - Maintain adequate blood pressure. - Can do elective cases within 6 months after stroke if the pt is stable.

Answer 107

Cincinnati Prehospital Stroke Scale - Facial droop: Have the patient smile or show teeth. - Arm drift: close eyes, extend your arm straight out with palm up for 10 seconds. - Speech: Have the pt say “You can’t teach an old dog new tricks “ - Time to act. - FAST Time is brain – Critical time goals: - Immediate assessment within 10 minutes of arrival - Neurologic assessment, CT scan within 25 minute - Interpretation of CT scan within 45 minutes - Initiation of tPA within 3 hours

Answer 108

* disease affecting lungs, pancreas 2/2 defect in CFTR protein * 1:3000 * Dx = genetic test, sweat test * Tx: Supplement with vitamins: ADEK, dornase alpha, inhaled cortico, chest PT * Chronic infxns: P. aeruginosa... * Tx: levofloxacin inhaled

Answer 109

infection of the heart's inner lining or valves 2/2 S. viridans * Can be fatal 6 wks-1 year * S/S: fever, cough, SoB, joint pain, diarrhea, flank pain + Murmur * Osler nodes - raised tender lumps on fingers/toes * Janeway lesions - palms, soles * Splinter hemorrages

Answer 110

* Increase production of TH r/i hypermetabolic state, tremors, ↑ reflexes * Causes: Graves’, goiter, tumors, overdose of TH meds * Dx: TFTs showing ↑T4-->T3 * Tx: propylthiouracil/methimazole inhibit TH Anesthesia concerns: * delay case until controlled * avoid sympathomimetics * be aware of potential for thyroid storm * Tx: propanolol, cooling, IVF

Answer 111

* Hypometabolic state ↓TH 2/2 autoimmune disease, throidectomy, iodine ↓ * S/S: ↑ weight, cold intolerance, fatigue, lethargy, dull * Dx: ↓ T4 * Tx = replace TH * Anesthesia: slow recovery

Answer 112

Decrease in the synthesis of the beta-globin chain of Hgb. Autosomal recessive More commonly found in mediterranean populations, middle east, Africans, Greeks.

Answer 113

- Minor: mild microcytic anemia due to DNA splicing defect, decreased HbA, increase in RBC count, HbA2 and ferritin production, usually no treatment - Major: severe hemolytic anemia due to a nonsense mutation of a stop codon, no production of HbA, increased HbA2 and HbF Patients have a lifelong danger of iron overload and lifelong need for transfusions

Answer 114

- Check hemoglobin, manage anemia (transfuse if needed), and assess for iron overload, cardiac, and liver function. - Ensure oxygenation, avoid hypoxia and acidosis, and monitor bleeding risk. - Maintain hydration and provide careful pain management. Consult hematology or cardiology if complications are present.

Answer 115

- What is the HTN? - Systemic vascular disease characterized by persistently elevated arterial blood pressure of 130/80 mmHg or higher. - What is the essential HTN? - HTN with no identifiable cause 90% of HTN pts - What is secondary HTN: - HTN with identifiable cause like renal artery stenosis, Cushing syndrome, pheochromocytoma, pregnancy. - How do you diagnose HTN: - Diagnosed by 2 elevated readings of at least 130/80 mmHg on 2 or more visits.

Answer 116

- The JNC 7 Classification: – Normotension <120/80 mmHg – Elevated 120–129/<80 mmHg – Stage I 130–139/80–89 mmHg – Stage II >140/90 mmHg

Answer 117

For me a blood pressure over 160/100 I will start to get more concerned about uncontrolled HTN

Answer 118

- Smoking release nicotine, which can cause blood vessels to constrict or narrow. - Nicotine stimulates the release of adrenaline which lead to increase HR and eventually increase BP. - Smoking increase the inflammation on the blood vessels and interfere with their ability to regulate the BP.

Answer 119

- Left ventricular hypertrophy - CHF - Stroke - Renal disease

Answer 120

- Obesity - Diabetes - Alcohol - Aging - Smoking - OSA - Family history - Ethnicity (African American) - Sex (Males have higher rates of HTN)

Answer 121

- Standard ASA monitors, BP cuff, puls ox , end tidal CO2, three lead EKG and temperature measure will be readily available.

Answer 122

Myself and two ancillary staff that are BLS certified.

Answer 123

A combination of checking response to stimuli, airway, spontaneous ventilation, vital signs and Verrill sign which is ptosis when the upper eyelid cover the upper half of the pupil.

Answer 124

- Calcium channel blocker: decrease the influx of Ca ions resulting in vasodilation. Example: amlodipine, verapamil, diltiazem, felodipine - ACE inhibitors: Block the conversion of angiotensin I to angiotensin II. Angiotensin II responsible for vasoconstriction (e.g., lisinopril, fosinopril, enalapril, captopril, ramipril). - Angiotensin II (AII) receptor blockers (ARBs) – block the effects of AII through antagonism of AII receptors leading to decreasing vasoconstriction and aldosterone secretion. (e.g., losartan, valsartan, Olmesartan, telmisartan). - β-blockers – block β-adrenergic receptors resulting in a decrease in myocardial contractility, decrease in renin production, and relaxation of smooth muscles (e.g., metoprolol, atenolol, esmolol, carvedilol, labetalol). - Thiazide diuretics – block the reabsorption of NaCl in the distal convoluted tubule of the nephron leading to a contracted intravascular volume (e.g., hydrochlorothiazide, chlorthalidone). - Vasodilators – work by decreasing vascular smooth muscle tone (e.g., hydralazine, sodium nitroprusside). - Alpha-2 adrenergic agonist – works on central adrenergic receptors leading to decreased norepinephrine release (e.g., clonidine). - Direct renin inhibitor – prevents renal release of renin with a subsequent decrease in AII production (e.g., aliskiren).

Answer 125

- Get CBC, BMP and EKG - Monitor EKG for sign of myocardial ischemia. - Defer elective cases if BP > 180/120 and refer to PCP if they are asymptomatic, if they have symptoms send the pt to the ER. - Amide LA metabolism can be reduced in patient taking B blocker. - Continue antihypertension meds. - Look for hypokalemia in patients using ACE and ARBs. - patients using ACE and ARBs more prone to anesthesia induced hypotension. - LA with vasoconstriction 0.04mg with epi that’s the limit. - Avoid ketamine - Contact EMS for evidence of a hypertensive crisis (BP 180/120 with signs/symptoms of myocardial ischemia, bradycardia, hypertensive encephalopathy, dyspnea, chest pain, confusion, nausea/vomiting, headache, seizures, and pulmonary edema).

Answer 126

Typically, I have nurse in my office who will recover the patient, they will stay in the room for 15 minutes after the anesthetics, and will take some vital sings, we use modified Aldrete score. Assigns a score of 0–2 to the following categories: activity, breathing, circulation, consciousness, and oxygen saturation. A score of 9 out of 10 is required for discharge from the facility/PACU.

Answer 127

- Atherosclerosis: - Hardening of the arteries due to lipid accumulation within the arterial wall. - Risk factor: Genetic, dyslipidemia 240mg/dl increase chance CAD, elevated LDL, elevated HDL is good is protective from CAD, tobacco, HTN, DM. - Pathophysiology: - Damage to endothelium, then leukocytes accumulated, smooth muscles secrete matrix that traps the lipid and form a bulk, matrix also form cap, as lesion increase in size the cape rupture and thrombus form. LDL ("bad cholesterol") deposits cholesterol in arteries, increasing plaque and heart disease risk. HDL ("good cholesterol") removes cholesterol from arteries, reducing heart disease risk.

Answer 128

Inability of the heart to pump enough blood to meet the metabolic demands of the body.

Answer 129

- Due to impaired contractility of the heart or high afterload (chronic volume overload from mitral and aortic regurgitation, dilated cardiomyopathies, HTN, aortic stenosis). - Ejection fraction <40%. HFrEF

Answer 130

- Due to impaired diastolic relaxation or ventricular failing of the heart (caused by left ventricular hypertrophy, restrictive cardiomyopathy, myocardial fibrosis, myocardial infarction). - Can have preservation of the ejection fraction (>50%). HFpEF

Answer 131

- Risk Factors o Ischemic heart disease. o Hypertension. o Myocardial infarction. o Valvular diseases. o Congenital heart disease. o Cardiomyopathies.

Answer 132

o Dyspnea. o Paroxysmal nocturnal dyspnea. o Orthopnea. o Pulmonary congestion. o Clinically can appreciate a third heart sound (S3) and pulmonary rales. S4 sound with diastolic failure.

Answer 133

- Most common cause is left-sided heart failure. - Abdominal discomfort. - Anorexia. - Hepatomegaly. - Peripheral edema. - Jugular venous distension.

Answer 134

* CLASS I – heart disease with no symptoms or limitation of physical activity. * CLASS II – No symptoms at rest and slight limitation with ordinary activity. * CLASS III – Marked limitation of activity with minimal exertion. * CLASS IV – Symptoms at rest. Severe limitation of activity.

Answer 135

CHF Workup: - EKG - ECHO - Chest xray - CBC to evaluate for anemia. - BMP- Look for hypokalemia. - LFTs to evaluate hepatic function and congestion. - Fasting glucose level to assess for diabetes. - Clinical exam- auscultation for sign of volume overload rales and S3, JVD, pedal edema and hepatomegaly. - Test: Normal BNP BELOW 100pg/ml - Brain natriuretic peptide BNP, BNP>35 diagnostic for non-acute onset CHF, BNP >100pg/ml for acute onset CHF.

Answer 136

Treatment of CHF: - Diuretics (Lasix): treat systemic and pulmonary congestion. - Beta Blocker: decrease myocardial oxygen consumption. - Digoxin: increase cardiac contractility. - Signs and symptoms of digitalis toxicity which include xanthopsia (vision deficiency leading to predominance of yellow vision) nausea, vomiting, confusion, paresthesias, ventricular tachycardia, premature ventricular contractions, heart block, bigeminy, trigeminy. - Narrow therapeutic range. 0.5– 0.9 ng/ml.

Answer 137

- Autosomal dominant connective tissue disorder affecting cardiac, skeletal, and ocular tissue. Mutation in extracellular matrix protein fibrillin-1, - The pt will be tall, thin, has an outward displacement of ribs, micrognathia, malar hypoplasia, high arched palate, glaucoma, myopia aortic dissection, MVR.

Answer 138

- Versed/ Propofol, I will avoid fentanyl in this patient, control BP, fluids, ventilatory pressure should be reduced to prevent barotrauma.

Answer 139

- AHA does not recommend abx , cardiology consult for evaluation of valvular function, monitor EKG , ECHO, control BP, pulmonary function evaluation since these patients exhibits restrictive lung disease , chest x ray

Answer 140

- Clinical evaluation A systolic murmur heard over the apex of the heart, ECHO, MRI

Answer 141

- CHF, continue BP meds to prevent and control BP to prevent sharing force on the vessels and TMJ dislocation

Answer 142

- Zoloft (sertraline) or any other selective serotonin reuptake inhibitor (SSRI), concern of bleeding this medication can affect platelet function, it can affect the clearance and metabolism of fentanyl causing serotonin syndrome which increase serotonin activity in the central nervous system. - Prozac = Fluoxetine SSRI - Lexapro SSRI

Answer 143

- An adverse drug reaction producing excess serotonergic effects of the central nervous system. - Serotonin syndrome typically occurs shortly after an increase in the dose of a serotonin agonist (a MAOI or an SSRI inhibitor) and meperidine, fentanyl and tramadol) and ondansetron - Onset of the reaction can be within minutes of drug administration or over the course of several hours. Fortunately, most reactions are mild and resolve within several hour - Clinical diagnosis. No labs - Symptoms include hypertension, diarrhea, tachycardia, hyperthermia, hyperkalemia, diaphoresis, ataxia, myoclonus, mydriasis, hallucinations, and confusion. - Concern for rhabdomyolysis, ventricular arrhythmia, respiratory arrest, and coma. - Some can be severe and life-threatening mimicking malignant hyperthermia.

Answer 144

- Activate 911 to transfer for definitive treatment. - Chilled IV fluids and ice until EMS transfer. - If intubation is indicated, avoid succinylcholine, which can cause additional hyperkalemia. - Lorazepam 1–2 mg IV push for agitation. 0.1mg/kg for pediatric - Methysergide 2–6 mg to counteract serotonin. - Labetalol or propranolol for HTN and tachycardia. - Cyproheptadine histamine-1 receptor antagonist 4 mg po to counteract serotonin. Comes only oral. DO NOT GIVE PREGNANT PATIENT cause congenital deformity. - Dantrolene for severe cases: hyperthermia, rhabdomyolysis, hyperkalemia and DIC.

Answer 145

- Avoid drugs that may trigger serotonin syndrome (fentanyl, tramadol, ondansetron). - Look for signs of serotonin syndrome. - EKG monitoring for lithium-induced dysrhythmias. - Patients on MAOIs are at risk for orthostatic hypotension. - Careful use of sympathomimetic agents – vasoconstrictors may have exaggerated effects, especially in patients on TCAs. - Ephedrine should be avoided in patients with MAOIs. Ketamine use should be carefully considered due to sympathetic effects. - CYP450 inhibitors such as macrolide antibiotics may lead to toxic levels of TCAs.

Answer 146

Neuroleptic Malignant Syndrome (NMS) occurs due to a dopamine deficiency in the central nervous system caused by dopamine receptor blockade. Antipsychotic medications, particularly first-generation (typical) antipsychotics, block dopamine D2 receptors, leading to: Hyperthermia (>38°C) Muscle rigidity lead pipe stiff (tachycardia, hypertension, diaphoresis) Altered mental status (agitation, delirium, or coma) Management: Discontinue antipsychotic immediately. Provide supportive care (IV fluids, cooling). Consider medications: Dantrolene (muscle relaxant) dopamine agonists like bromocriptine

Answer 147

- Genetic connective tissue disorders characterized by defects in fibrillar collagen production leading to changes in skin, tendons, blood vessels, and viscera. - 80% of cases fall under the classical and hypermobile (most frequent) types. - There are six major subtypes based on the Villefranche nosology. - Vascular EDS subtype is life threatening due to spontaneous rupture of small and large arteries.

Answer 148

- Joint hypermobility with subluxation. - Skin hyperelasticity. - Easily bruised. - Gorlin sign – ability to touch tongue to tip of nose - Abnormal scarring. - Extremely soft skin. - Hernias are common.

Answer 149

- CBC, BMP , EKG and Echo - Cardiac evaluation to monitor risk of aortic root dilatation and mitral valve prolapse, usually non-significant. - 26% of patients have platelet aggregation defects. Consider discussion with hematologist for plan of action (commonly desmopressin) . Additionally, use of prophylactic tranexamic acid should be considered. - Individuals can be resistant to local anesthetic, most commonly seen in hypermobility subtype. - Be cognizant of TMJ subluxation during intubation and neck extension instability (occipitoatlantoaxial) - Reduce airway pressures due to pneumothorax risk. - Postural orthostatic tachycardia syndrome prevalent in hypermobile variant, ensure adequate hydration. - Consider avoiding NSAIDs for pain control due to bruising risk. - Commonly have dental issues with poor periodontal health due to fragility of periodontium, especially in vascular subtype. - Subtypes with vascular fragility should have type and cross match. - Skin tape placement should be minimized

Answer 150

A metabolic disorder, which results in a defect in insulin secretion, action, or both, resulting in hyperglycemia.

Answer 151

Type 1 diabetes mellitus is due to impaired production of insulin and occurs early in life. Type 2 diabetes mellitus is characterized by insulin resistance.

Answer 152

The functions of insulin are to increase glycogen synthesis, decrease gluconeogenesis, increase potassium uptake, and increase lipid synthesis.

Answer 153

Fasting glucose of >126 mg/dl on 2 or more occasions glucose tolerance test (readings >200 mg/dl 2 hours after a 75-gram glucose load) HgB A1C of 6.5 or greater non-fasting plasma glucose ≥200 mg/dl and symptoms of DM.

Answer 154

Metformin.

Answer 155

Decrease hepatic gluconeogenesis and decrease intestinal glucose absorption.

Answer 156

I want to know how well the DM is controlled, the regimen, and check the HgB A1C for glycemic control. DM patients can develop silent ischemia and are at risk of infection.

Answer 157

- NPO 12 hours for IDDM - early morning appointments - pre and post op finger stick to assess glucose - obtain recent HbA1c - give fluids 100-200ml of 5% dextrose solution hourly, avoid LR - stop oral hypoglycemics on day of surgery. - Omit short-acting insulin on morning of procedure. - Take between 1⁄2 - 2/3 total morning dose of intermediate acting glucose. - If the pt blood glucose < 100mg/dl , consider D5W with 0.45% NS and consider NS if blood glucose >130.

Answer 158

Long-standing DMII can lead to peripheral neuropathy, CAD, silent ischemic episodes, diabetic retinopathy, and nephropathy.

Answer 159

Rapid development of diabetic ketoacidosis, infection risk, managing blood glucose levels, and adjusting insulin doses preoperatively.

Answer 160

Oral regimens should be discontinued, glucose levels should be measured, and metformin should be stopped due to lactic acidosis risk. Discontinuation of sulfonylureas is due to its association with hypoglycemia and increased risk of perioperative myocardial ischemia and infarction.

Answer 161

I will ask the patient to come in and examine her.

Answer 162

DKA is a metabolic condition that occurs secondary to an insulin shortage that results in hyperglycemia, ketonemia, and an anion gap metabolic acidosis. To diagnosed DKA we must have high anion gap metabolic acidosis and ketonemia

Answer 163

Vomiting, confusion, polydipsia, polyuria, dehydration, abdominal pain, Kussmaul breathing, hyperglycemia, hyperkalemia, ketotic 'fruity' breath, dry mucous membranes, and hypotension.

Answer 164

Kussmaul breathing in DKA occurs due to severe metabolic acidosis caused by excess ketone production. The body compensates by deep and rapid breathing (hyperventilation) to expel CO₂ and reduce acidity, helping to raise the blood pH.

Answer 165

To differentiate DKA from HHS, the key distinguishing features are acidosis and ketosis. In DKA, glucose levels are typically 250–600 mg/dL, with a pH <7.3, bicarbonate <18 mmol/L, and the presence of elevated ketones in the blood and urine. An elevated anion gap (>12) is also characteristic, and the onset is rapid over hours to 1–2 days. In contrast, HHS presents with much higher glucose levels, typically >600 mg/dL, without significant acidosis (pH >7.3) or ketosis, and bicarbonate >18 mmol/L. The hallmark of HHS is severe hyperosmolarity (>320 mOsm/kg) due to profound dehydration, and the onset is more gradual, over days to weeks. The key difference is that DKA involves acidosis and ketosis, whereas HHS is characterized by severe hyperglycemia and hyperosmolarity without significant acidosis.

Answer 166

CVA, MI, UTI, stress, cocaine usage, and inadequate insulin.

Answer 167

Result of the breakdown of fatty acids through the ketogenesis cycle.

Answer 168

ABG IV fluids 0.9% NS 15-20 mL/kg/hour (~1 L/hour) IV regular insulin 0.1 units/kg/hour replace K correct pH with bicarb if <7.

Answer 169

Because insulin drives K into the cell, causing hypokalemia.

Answer 170

most common in Type 1 diabetes Why DKA is More Common in Type 1 Diabetes: Absolute insulin deficiency: In Type 1 diabetes, the pancreas produces little to no insulin, leading to unchecked lipolysis (fat breakdown) and production of ketone bodies, resulting in ketoacidosis. Triggers: DKA can be triggered by missed insulin doses, illness, or infection

Answer 171

Analysis: pH: 7.25 (Acidemia) A pH < 7.35 indicates acidosis, and the value of 7.25 suggests moderate acidosis. Bicarbonate: 22-28 12 mmol/L (Low) A low bicarbonate level confirms metabolic acidosis as the primary disturbance. Normal bicarbonate is 22–28 mmol/L. Anion Gap: 8-12 mEq/L normal 19 (Elevated) Anion gap = Na⁺ - (Cl⁻ + HCO₃⁻). An elevated anion gap (>12) indicates high anion gap metabolic acidosis, consistent with DKA, where excess ketones contribute to the elevated gap. Glucose: 278 mg/dL (Hyperglycemia) Although not extremely high, a glucose level of >250 mg/dL is one of the diagnostic criteria for DKA. Potassium: 5.2 mmol/L (Slightly elevated) In DKA, potassium may appear elevated due to extracellular shift caused by acidosis, even though total body potassium is depleted due to urinary losses. This requires careful monitoring and correction as insulin treatment can cause hypokalemia.

Answer 172

Insulin resistance increases sympathetic nervous system activity and contributes to endothelial dysfunction.

Answer 173

Due to impaired chemotaxis and phagocytosis 2/2 glycosylation of the neutrophils.

Answer 174

Glycosylation of LDLs triggers a stronger inflammatory response, weakening the fibrous cap of atheromas.

Answer 175

250 mg/dl, as osmotic diuresis can occur which increases the risk of dehydration and DKA.

Answer 176

- Insulin - oral hypoglycemics: - biguanides: Metformin - sulfonylureas: stimulates beta cells to produce insulin ex Glipzide - Thiazolidinediones: promote insulin sensitivity in adipose, hepatic and muscle tissue. ends with zone - Meglitinides: bind ATP-dependent potassium channel to increase beta cell secretion of insulin (e.g., Repaglinide). - GLP1 agonists: synthetic peptide of glucagon- stimulates insulin secretion and decreases glucagon secretion. Ozempic, manjaro - DPP4 inhibitors: prevents inactivation of GLP1 and GIP leading to increased insulin secretion (e.g., Sitagliptin aka Januvia®). SGLT2 inhibitors: decrease blood sugar by significant glycosuria, don't cause hypoglycemia. flozins (canagliflozin, dapagliflozin, empagliflozin, ertugliflozin)

Answer 177

For DMT2, decrease blood sugar by significant glycosuria, don't cause hypoglycemia. SGLT2 inhibitors -flozins (canagliflozin, dapagliflozin, empagliflozin, ertugliflozin) - decrease blood sugar by significant glycosuria, don't cause hypoglycemia - Perioperative concerns? - Urinary tract infections, urosepsis, pyelonephritis - Euglycemic diabetic ketoacidosis - Recommended hold time: 3-4 days - Resume medications when normal PO intake is resumed (outpatients are at lower but not negligible risk of DKA)

Answer 178

An insulin pump is a small, wearable device that delivers continuous subcutaneous insulin to manage diabetes. It mimics the function of the pancreas by providing: Basal Insulin: Continuous delivery of small amounts of insulin to maintain blood glucose between meals and overnight. Bolus Insulin: Extra insulin doses delivered before meals or to correct high blood glucose levels. Managing Insulin Pumps Before Scheduled Surgery – Board Answer Preoperative Management: Consult the patient’s endocrinologist before surgery for specific recommendations. Ensure the patient understands perioperative insulin pump adjustments. Day of Surgery: Basal insulin: Continue at a reduced rate (e.g., 50–80% of usual basal rate) to maintain baseline glucose levels. Bolus insulin: Suspend meal boluses as the patient will be fasting. For sedation DO NOT MESS WITH IT

Answer 179

Urinary tract infections, euglycemic diabetic ketoacidosis, recommended hold time: 3-4 days.

Answer 180

The adrenal gland has two main components: - Adrenal cortex: Produces glucocorticoids (cortisol), mineralocorticoids (aldosterone and 11-deoxycorticosterone), and androgens (dehydroepiandrosterone). - Adrenal medulla: Produces norepinephrine and epinephrine.

Answer 181

- Corticotropin releasing factor (CRF) from the hypothalamus regulates the secretion of adrenocorticotropic hormone (ACTH) by the pituitary gland, which in turn controls cortisol secretion.

Answer 182

Cushing syndrome is a condition caused by excess free plasma glucocorticoids, often due to chronic use of glucocorticoid products (e.g., prednisone, dexamethasone).

Answer 183

Buffalo hump Weight gain and truncal obesity Plethora Striae Cognitive dysfunction and depression Proximal muscle weakness Osteopenia Hyperglycemia and hypertension

Answer 184

Diagnosis involves measuring: - Blood cortisol levels - 24-hour urine free cortisol levels - Dexamethasone suppression test - ACTH levels

Answer 185

- Addison’s disease is a disorder of insufficient production of glucocorticoids and mineralocorticoids by the adrenal cortex. - Common symptoms include: Weakness, anorexia, arthralgia Abdominal pain, hyperpigmentation Hypotension Electrolyte imbalances (hyponatremia, hyperkalemia)

Answer 186

Diagnosis is made when: - low morning cortisol levels are detected. If cortisol levels are <3 mcg/dL in the morning, no further testing is needed. - A corticotropin stimulation test may be performed if necessary.

Answer 187

- Increased risk of infection and delayed wound healing – use prophylactic antibiotics. - Glucose intolerance – use sliding scale insulin for glycemic control. - Risk of sleep apnea and GERD – take precautions during anesthesia. - Ensure proper positioning due to fragile skin and risk of osteoporosis.

Answer 188

- Check serum potassium preoperatively and regularly. - Patients with primary adrenal insufficiency typically require 100 mg IV hydrocortisone. - Avoid excessive supraphysiological dosing unless needed.

Answer 189

Adrenal crisis is a life-threatening condition caused by major physical stress, leading to: Severe circulatory collapse and hypotension not responsive to vasopressors. Fever, lethargy, severe flank or abdominal pain, tachycardia, delirium, and potentially coma.

Answer 190

- Patients with secondary adrenal insufficiency due to exogenous steroids or autoimmune conditions have a 1–2% risk of adrenal crisis. - These patients typically require lower doses of steroids compared to those with primary adrenal insufficiency.

Answer 191

- Minor Surgical Stress (e.g., dentalalveolar procedures): Intraoperative steroids: Usual dose. Taper: None required. - Moderate Surgical Stress (e.g., orthognathic surgery): Intraoperative steroids: 50 mg hydrocortisone or equivalent preoperatively. Taper: Continue 25 mg hydrocortisone every 8 hours for 24 hours, then resume regular dosage. Major Surgical Stress (e.g., free flap surgery): Intraoperative steroids: 100 mg hydrocortisone or equivalent preoperatively. Taper: Continue 50 mg hydrocortisone every 8 hours for 24 hours. Taper by half every day to usual dosage.

Answer 192

- Asthma is a chronic reversible lower respiratory tract disease characterized by wheezing, dyspnea, coughing, and chest tightness.

Answer 193

- Mild Intermittent- symptoms less than 2 per week - Mild persistent- symptoms more than 2 per week - Moderate persistent- daily symptoms - Severe persistent- continues - The asthma classification is based on the occurrence of symptomatology, interference with normal activity, and impact of obstruction (altered FEV1).

Answer 194

- Dust, Mold, URI, Pollen Anxiety/stress – NSAIDs and Exercise

Answer 195

- Theophylline relaxes the smooth muscles located in the bronchial airways and pulmonary blood vessels.

Answer 196

Erythromycin and macrolides inhibit cyp450 elevate theophylline level.

Answer 197

- Tremors (most common), restlessness, agitation, and altered mental status.

Answer 198

- Bronchospastic episode that does not respond to treatment and is considered life threatening.

Answer 199

Treatment * Supplemental oxygen to maintain an SaO2 of >90%. * β2-agonists by metered dose inhaler every 15–20 minutes. * Intravenous corticosteroids. * IV magnesium sulfate. * Epinephrine 0.3 mg 1:1000 administered subcutaneously. * Tracheal intubation for a PaCO2 > 50 mm Hg. If the patient is responsive, administer 6–10 puffs via an MDI (β-2 agonist albuterol). If deeply sedated and airway patent attempt nebulized, albuterol or 4–8 puffs with space chamber attachment.

Answer 200

* Assess the severity of asthma at the preoperative visit. * For elective cases, postpon the case for 6 weeks in case of active infection. * Auscultation of chest to rule active disease processes such as wheezing. * Prophylactic preanesthetic use of β2-agonist inhaler to reduce chances of bronchospasm is recommended. Very light sedation or deep general anesthesia is desired to avoid stage II, which increases odds of laryngospasm/ bronchospasm. * Use of anesthetic agents that result in bronchodilation is preferred, such as propofol, ketamine, sevoflurane, and isoflurane. Desflurane is very pungent and should be avoided. * Medications that result in histamine release should be avoided such as meperidine and morphine. Also, opioids should be used judiciously to decrease the risk of chest wall rigidity. * Use of adenosine and other nonspecific β-blockers (e.g., Labetalol) should be avoided since they will result in bronchoconstriction. * Be cautious using NSAIDs and cyclooxygenase inhibitors as this can induce an asthma attack and rash. Some patients may have Samter’s triad (nasal polyps, ASA sensitivity, and asthma)

Answer 201

Mild Intermittent Asthma: Symptom frequency: <2 per week Night-time symptoms: <2 per month FEV₁: >80% β-adrenergics: Short-acting, <2 days per week Mild Persistent Asthma: Symptom frequency: >2 per week Night-time symptoms: >2 per month FEV₁: >80% β-adrenergics: Short-acting, >2 days per week (not daily, and not more than once on any day) Steroids: Inhaled low-dose Leukotriene inhibitor: Yes Cromolyn: Alternative Moderate Persistent Asthma: Symptom frequency: Daily Night-time symptoms: >1 per week FEV₁: 60–80% β-adrenergics: Short-acting daily, can add long-acting Steroids: Inhaled medium-dose Leukotriene inhibitor: Yes Cromolyn: PRN Severe Persistent Asthma: Symptom frequency: Continuous Night-time symptoms: Frequent FEV₁: <60% β-adrenergics: Short-acting >2 times/day, can add long-acting Steroids: Inhaled and high-dose systemic Leukotriene inhibitor: Yes Cromolyn: PRN

Answer 202

In asthma, capnography shows a shark fin waveform from prolonged expiration and bronchospasm. ETCO₂ is low initially (hyperventilation) but may rise in severe cases (hypoventilation).

Answer 203

- A chronic systemic inflammatory disease characterized by inflammatory polyarthritis (synovitis) with progressive destruction of joint, bone, and articular cartilage. - F>M, 5-6 decades.

Answer 204

Morning stiffness and swelling of the joints involved for over 1 hour.

Answer 205

Ulnar deviation, subluxation of the metacarpophalangeal joints, swan-neck deformity, and Boutonnière deformities.

Answer 206

Non-painful, firm nodules present in 1/5th of patients, typically on the extensor surface of the forearms.

Answer 207

The cervical spine, most often a C1–C2 (atlantoaxial) subluxation.

Answer 208

Pericarditis, myocarditis, coronary artery disease (CAD), and aortitis.

Answer 209

Eye pain, redness, and keratoconjunctivitis.

Answer 210

Pleural effusion, rheumatoid nodules, and restrictive lung disease.

Answer 211

Anemia and Felty syndrome (RA with splenomegaly and leukopenia).

Answer 212

- Increased rheumatoid factor titers - Elevated erythrocyte sedimentation rate (ESR), - Elevated C-reactive protein.

Answer 213

Symptoms must be >6 weeks and 4/7 criteria must be met: - Morning stiffness (≥1 hour) - Swelling of 3+ joints - Swelling of hand joints - Symmetrical swelling - Subcutaneous nodules - Serum rheumatoid factor - Radiographic evidence of erosive arthritis.

Answer 214

Prednisone to decrease swelling and stiffness, but long-term use can cause osteoporosis and poor wound healing.

Answer 215

Medications used to slow and halt progression of the disease, including methotrexate, hydroxychloroquine, antimalarials, minocycline, and tofacitinib.

Answer 216

It inhibits metabolism of folic acid via dihydrofolate reductase.

Answer 217

CBC and BMP to rule out anemia, thrombocytopenia, renal compromise, and electrolyte disturbances. EKG to rule out ischemic heart disease, cardiopulmonary exam for murmurs, PFTs for restrictive lung disease, and consideration of supplemental antibiotics and steroid supplementation.

Answer 218

Hoarseness or stridor may indicate cricoarytenoid joint involvement, TMJ involvement should be identified, and cervical spine flexion deformity may complicate intubation.

Answer 219

Atlantoaxial subluxation should be confirmed with a radiograph to prevent spinal cord damage during laryngoscopy.

Answer 220

Acute, partial, or complete obstruction in the pulmonary arterial vasculature leading to a ventilation perfusion mismatch.

Answer 221

Thrombus from a vein of the lower extremity, mural thrombus from atrial fibrillation, and fat embolism from long bones.

Answer 222

Chest pain, dyspnea, tachypnea, tachycardia, hemoptysis, coughing, jugular venous distension, cyanosis, rales and rhonchi, diminished breath sounds.

Answer 223

(Virchow’s triad – stasis, damage to the endothelium, and a hypercoagulable state) Immobility, malignancy, disability or obesity, oral contraceptives, pregnancy, Factor V Leiden, antiphospholipid syndrome, protein C and S deficiency, DVT, recent long bone fracture, hormone replacement therapy.

Answer 224

CT angiography. * Signs and symptoms of a PE. * D-dimer assay highly sensitive If negative, then a PE is unlikely. Normal less than 0.50mg * CT angiography gold standard. * Venous ultrasonography to rule out DVT. * Arterial blood gas – can see hypoxemia, respiratory alkalosis, and hypocapnia. * Wells criteria >4 probable PE.

Answer 225

Highly sensitive for pulmonary embolism; if negative, a PE is unlikely. D-dimer is a fibrin breakdown clot product used to assess PE

Answer 226

A scoring system where a score >4 indicates a probable pulmonary embolism.

Answer 227

Clinical signs/symptoms of DVT: 3.0 points High suspicion of PE as the diagnosis: 3.0 points Heart rate > 100 BPM: 1.5 points Surgery within 1 month or immobility > 3 days: 1.5 points History of PE or DVT: 1.5 points Malignancy: 1.0 point Hemoptysis: 1.0 point Interpretation of Total Score: >6 points: High probability of PE 2–6 points: Moderate probability of PE <2 points: Low probability of PE

Answer 228

- Consult with the physician managing anticoagulation - Obtain preoperative INR if warfarin is utilized. - Use judicious hemostatic measures - Avoid NSAID use in the setting of anticoagulation to decrease the chance of perioperative bleeding.

Answer 229

ASA III if CVA > 3 months with remaining neuro deficits; ASA II if no deficits > 6 months.

Answer 230

EKG, INR, PT/PTT.

Answer 231

Hemorrhagic and ischemic.

Answer 232

A serious heart rhythm disorder characterized by irregular and rapid heartbeats.

Answer 233

Irregular or rapid heartbeat, heart palpitations, fatigue, shortness of breath, dizziness or lightheadedness.

Answer 234

Age-related changes, high blood pressure, heart attacks, abnormal heart valves, overactive thyroid, chronic lung diseases, excessive alcohol, obesity.

Answer 235

EKG and ECHO.

Answer 236

Antiarrhythmic drugs and anticoagulants.

Answer 237

MI, PE, pneumothorax, CHF exacerbation, cardiac arrhythmia, atelectasis.

Answer 238

Evaluate ABC, check airway, ask for symptoms, give O2, obtain vitals, listen to lung and heart, order ABG, chest x-ray, and 12 lead EKG.

Answer 239

Unfractionated heparin to a goal PTT of 60–85, low molecular weight heparin with bridging to warfarin for a goal INR of 2–3.

Answer 240

An inferior vena cava filter.

Answer 241

I want to get more details about RA, any multiple system involvement such as cardiovascular (pericarditis, CAD, and myocarditis), and if he has ever experienced any respiratory problems.

Answer 242

These patients tend to have pleural effusion and rheumatoid nodule restrictive disease.

Answer 243

I want to ask if he has been on steroid treatment, how much, and how often?

Answer 244

I would ask what happens when exposed to latex. I want to ask how bad is his allergy? Has he ever had an anaphylactic shock?

Answer 245

Yes - irritation dermatitis, delayed hypersensitivity, and anaphylaxis. There are four types of hypersensitivity reactions: Type I (Immediate): IgE-mediated; includes anaphylaxis, asthma, and hay fever. Type II (Cytotoxic): IgG or IgM-mediated; includes hemolytic anemia and transfusion reactions. Type III (Immune Complex): Antigen-antibody complex-mediated; includes lupus and serum sickness. Type IV (Delayed): T-cell-mediated; includes contact dermatiti

Answer 246

Yes, they can. Repeat exposure to latex can cause anaphylaxis.

Answer 247

Using latex-free products, patient screening, signs in the waiting area encouraging disclosure of latex allergy, staff training to recognize anaphylaxis, emergency kit and crash cart readiness, and staying updated regarding latex-free products.

Answer 248

I'm concerned about adrenal suppression and need for preop steroids.

Answer 249

Rule of two's: adrenal suppression may occur if a patient is taking 20 mg of cortisone or its equivalent daily, for 2 weeks within 2 years of dental treatment.

Answer 250

Symptoms such as fatigue, weakness, ACTH stimulation test, serum cortisol level.

Answer 251

The cervical spine is commonly involved, most often a C1–C2 (atlantoaxial) subluxation. Limitation of neck extension should be practiced with SLE patients to demonstrate range of motion to avoid damage to the spinal cord.

Answer 252

An inflammatory mediated process with active hepatocellular damage and necrosis with lobular inflammatory response.

Answer 253

When inflammation lasts for 6 months or less.

Answer 254

RNA virus with an incubation period of 30-70 days. It is self-limiting.

Answer 255

Fecal-oral route, often through sewage contaminated shellfish.

Answer 256

Fever, malaise, myalgia, nausea, vomiting, diarrhea, and jaundice.

Answer 257

No chronic form.

Answer 258

Supportive treatment and vaccination.

Answer 259

DNA virus with an incubation period of 60-110 days.

Answer 260

Vertical transmission (mother to fetus), percutaneous, and sexual.

Answer 261

Vaccination and Hepatitis B IgG.

Answer 262

20% progress to cirrhosis, and 4% to hepatocellular carcinoma.

Answer 263

RNA virus with an incubation period of 30-70 days.

Answer 264

Interferon and ribavirin; there is no vaccine.

Answer 265

Percutaneous route.

Answer 266

IV drug use, incarceration, needle stick injuries, tattoos, body piercing, hemodialysis, and blood transfusions.

Answer 267

Hepatitis C patients have an increased risk of non-Hodgkin lymphoma.

Answer 268

An RNA retrovirus that infects CD4 cells and causes varying levels of immunosuppression, potentially progressing to AIDS.

Answer 269

Through sexual contact, exposure to infected blood, organ donations, perinatally, or via IV drug abuse.

Answer 270

The result of progressive HIV infection with a weakened immune system meeting specific diagnostic criteria.

Answer 271

1. CD4+ T-cell count of 200 cells/μL or less. 2. CD4+ T-cell percentage of total lymphocytes of 15% or less. 3. Other illnesses such as Burkitt’s lymphoma and encephalopathy, Kaposi.

Answer 272

Diagnosis: - Screen enzyme immunoassay for IgM and IgG anti-HIV antibodies detected 3-5 week after infection. - CBC exhibit hematological disorders - CD4 reflect of immune status. Normal 500-1500 - Viral load, predictor of rate of progression to AIDS. Normal less than 20-75 copies. - Albumin and prealbumin (nutritional status)

Answer 273

leukopenia, anemia, thrombocytopenia

Answer 274

Normal CD4 count is 500-1500 cells/μL. Reflect of immune status.

Answer 275

It is a predictor of the rate of progression to AIDS, with normal being less than 20-75 copies.

Answer 276

Fever, fatigue, headache, night sweats, myalgias, generalized lymphadenopathy, weight loss, and temporal wasting.

Answer 277

Left ventricular hypertrophy, myocarditis, and diastolic heart failure.

Answer 278

Predisposition to pneumonia, TB, and Kaposi sarcoma.

Answer 279

Meningitis, peripheral neuropathy, and CNS lymphoma.

Answer 280

Glucose intolerance and adrenal insufficiency.

Answer 281

Leukopenia, anemia, thrombocytopenia, and a hypercoagulable state.

Answer 282

HIV nephropathy can lead to ESRD, and protease inhibitors may cause acute tubular necrosis and nephrolithiasis.

Answer 283

Temporal wasting due to lipodystrophy, parotid gland enlargement, dermatitis of the scalp, lymphoma, lymphoepithelial cysts, gingivitis, xerostomia, fungal infections, candidiasis when CD4 is lower than 500, and aphthous ulcers.

Answer 284

Highly active antiretroviral therapy that inhibits HIV replication.

Answer 285

Usually consists of three drugs: two NRTIs and one protease inhibitor or NNRTI.

Answer 286

Zidovudine (AZT), lamivudine (3TC), stavudine (D4T), tenofovir, and emtricitabine.

Answer 287

Nausea, headache, peripheral neuropathy, anemia, and thrombocytopenia.

Answer 288

Nevirapine and efavirenz (EFV).

Answer 289

Dizziness, rash, vivid dreams, and suicidal thoughts.

Answer 290

A combination drug used in the treatment of HIV, consisting of emtricitabine, tenofovir, and efavirenz.

Answer 291

A combination drug used in the treatment and prevention of HIV, also approved for Pre-exposure prophylaxis (PrEP).

Answer 292

Ritonavir. GI disturbances, glucose metabolism issues, and paresthesias.

Answer 293

Interleukin II or interferon-alpha.

Answer 294

Trimethoprim/sulfamethoxazole (Bactrim®) to decrease the risk of Pneumocystis jirovecii pneumonia.

Answer 295

Macrolide (azithromycin or clarithromycin) to decrease the risk of Mycobacterium avium complex (MAC) infection.

Answer 296

Communication with the physician (PCP or infectious disease) is paramount in clinical decision-making.

Answer 297

CBC, CHEM 10, LFTs, glucose, coagulation studies, immunological status via CD4+ lymphocyte cell count, and viral load during the previous 3 months.

Answer 298

Chest radiographs and EKG for cardiopulmonary abnormalities and screening for opportunistic infections.

Answer 299

Standard antibiotic prophylaxis protocol.

Answer 300

They may have impairment of CYP450 hepatic enzymes, prolonging the effects of benzodiazepines, opiates, and lidocaine.

Answer 301

Etomidate, atracurium, remifentanil, and desflurane as they are not dependent on CYP450 hepatic metabolism.

Answer 302

It is a potential risk in patients with progressive neuropathy, myopathy, or muscle wasting.

Answer 303

Propofol, due to potential interactions with NRTIs that may promote mitochondrial toxicity and lactic acidosis.

Answer 304

Pulmonary complications leading to respiratory distress and hypoxemia.

Answer 305

Excessive alcohol intake leading to a fatty liver, followed by hepatitis and cirrhosis.

Answer 306

50 g daily (5 standard drinks) for 10 years or more.

Answer 307

A spectrum of disease: alcoholic steatosis, alcoholic steatohepatitis, cirrhosis, and hepatocellular carcinoma.

Answer 308

Alcohol cessation and nutritional support are the first steps. Folic acid, thiamine, and zinc are important when deficiencies are noted.

Answer 309

Daily administration of methylprednisolone or equivalent corticosteroid for 1 month.

Answer 310

Hepatic inflammation and fibrosis leading to liver cirrhosis and ultimately liver failure.

Answer 311

Fibrosis deposition increases resistance of intrahepatic blood flow.

Answer 312

Gastroesophageal varices with hemorrhage, ascites, and hypersplenism.

Answer 313

Infection of ascitic fluid, in pts with cirrhosis with a high mortality rate.

Answer 314

Timely administration of antibiotic therapy.

Answer 315

Due to destruction of the hepatic reticuloendothelial system.

Answer 316

Stop alcohol, maintain a diet rich in calories and protein, manage varices, treat ascites, and consider liver transplant.

Answer 317

Child-Pugh score and Model for End-Stage Liver Disease (MELD) equation.

Answer 318

90-day mortality without liver transplantation, based on: ICBN I: INR C: Creatinine B: Bilirubin Na: Sodium (for MELD-Na)

Answer 319

Survival rate up to 2 years, based on: A BEAN: A: Ascites B: Bilirubin E: Encephalopathy A: Albumin N: INR (formerly Prothrombin Time)

Answer 320

Spider nevi, jaundice, splenomegaly, ascites, hepatomegaly, and caput medusa.

Answer 321

Cirrhotic cardiomyopathy, baseline oxygen saturation, CBC, LFTs, PT/INR, serum albumin, and prealbumin.

Answer 322

It is a better marker for chronic nutritional status but less useful in acute settings. 3.5–5.5 g/dL Reflects long-term nutritional and liver function (half-life ~21 days).

Answer 323

It reflects short-term changes in nutritional intake and is preferred for monitoring acute malnutrition. 15–36 mg/dL Indicates short-term nutritional status (half-life ~2 days).

Answer 324

Transfusion should be considered.

Answer 325

Consider vitamin K 10mg IM.

Answer 326

They might need a lower dose due to increased CNS sensitivity.

Answer 327

They exhibit cross-tolerance to volatile and intravenous anesthetics.

Answer 328

Rapid-sequence induction should be used due to increased gastric volumes and delayed gastric emptying.

Answer 329

Cisatracurium, atracurium, and succinylcholine, as they preserve hepatic blood flow.

Answer 330

They are degraded in the liver, so a reduction in the amount may be necessary.

Answer 331

Those that undergo glucuronidation (e.g., oxazepam, temazepam, and lorazepam).

Answer 332

Isoflurane and sevoflurane, as they do not reduce hepatic blood flow.

Answer 333

Halothane, as it is believed to cause immune-mediated liver damage.

Answer 334

Lower dosages should be used due to prolonged half-lives.

Answer 335

It retains a short half-life.

Answer 336

Hypotension.

Answer 337

They are on a sodium-restricted diet preoperatively, and overall fluid administration should be limited.

Answer 338

Colloid intravenous fluids (albumin) to avoid sodium overload. 0.9% Normal Saline: Maintains hemodynamic stability without exacerbating hyponatremia.

Answer 339

CBC, Chem 10, Ca, PO4, Mg, HIV test, liver enzymes, and coag panel.

Answer 340

Bleeding Metabolism of drugs Ability to fight infection Withdrawal Compliance with treatment Cardiac complications.

Answer 341

Yes, it can lead to complications such as depression, suicidal thoughts, cardiac arrhythmia, seizures, and respiratory problems.

Answer 342

6–24 hours after the last intake of alcohol.

Answer 343

Tremors, agitation, nausea, sweating, vomiting, hallucinations, insomnia, tachycardia, hypertension, delirium, and seizures.

Answer 344

Delirium tremens (hyperthermia, tremors, and seizures), which has a high mortality rate.

Answer 345

Complications can include depression, suicidal thoughts, cardiac arrhythmia, seizures, and respiratory problems.

Answer 346

Alcohol withdrawal begins 6–24 hours after the last intake of alcohol.

Answer 347

Signs and symptoms include tremors, agitation, nausea, sweating, vomiting, hallucinations, insomnia, tachycardia, hypertension, delirium, and seizures.

Answer 348

The most dreaded complication is delirium tremens, which includes hyperthermia, tremors, and seizures, and has a high mortality rate.

Answer 349

Treatment includes benzodiazepines (such as diazepam or chlordiazepoxide), electrolyte/fluid deficit correction, and administration of a banana bag (thiamine, folic acid, magnesium, and a multivitamin).

Answer 350

The goal of thiamine therapy is to prevent Wernicke-Korsakoff syndrome, which includes ataxia, anterograde amnesia, nystagmus, and peripheral polyneuropathy.

Answer 351

The CAGE questionnaire is used to assess alcohol's effect on health and social well-being. A score greater than 2 is concerning.

Answer 352

1. Have you ever felt you should Cut down on your drinking? 2. Have you been Annoyed by other people criticizing your drinking? 3. Have you ever felt Guilty about drinking? 4. Have you ever taken a drink in the morning to steady your nerves or ease a hangover (Eye-opener)?

Answer 353

Preoperative labs include CBC, Basic Metabolic Panel (BMP), and Liver Function Tests (LFTs).

Answer 354

The goal INR is < 3 and platelets > 50,000, depending on the surgery.

Answer 355

Treatment in a hospital setting should be employed, including vitamin K, clotting factors, fresh frozen plasma, or platelets to correct coagulopathies.

Answer 356

During emergency anesthesia, rapid sequence induction is indicated due to possible aspiration of stomach contents.

Answer 357

Chronic alcohol use increases dose requirements for general anesthetic agents as the minimal alveolar concentration is increased. - In acutely intoxicated, non-habituated patients, the minimal alveolar concentration (MAC) of inhalational agents is reduced. Acutely intoxicated patients are more sensitive to the effects of opioids, benzodiazepines, and barbiturates. Sensitivity to other drugs may occur due to competitive inhibition from elevated blood ethanol concentration.

Answer 358

Neuromuscular blocking agents that undergo hepatic metabolism may have a prolonged duration of action due to hepatic impairment.

Answer 359

Attention to pain control measures, oxygenation, and correction of metabolic disturbances can mitigate acute confusion or delirium after an operation.

Answer 360

Consider intravenous haloperidol (0.5–10 mg may be repeated after 20–30 minutes), chlorpromazine, risperidone, and olanzapine for acute agitation.

Answer 361

Cocaine is an amphetamine that blocks the reuptake of norepinephrine, serotonin, and dopamine transporting mechanisms in the CNS, leading to intense stimulation, euphoria, and pleasure.

Answer 362

Chronic abusers may develop 1- Cocaine-induced cardiomyopathy. Acute use can cause 1- Coronary vasospasm, myocardial ischemia/infarction, and ventricular dysrhythmias.

Answer 363

EKG findings may show prolonged QRS and QT intervals and premature ventricular contractions, which can degenerate into deadly ventricular dysrhythmias.

Answer 364

There is a risk of alveolar hemorrhaging and pulmonary edema from crack cocaine use.

Answer 365

Snorting cocaine can lead to mucosal ulcerations, causing epistaxis and nasal septal destruction.

Answer 366

Cocaine activates platelets, increases platelet aggregation, and promotes thrombus formation, adding risk for cardiac and cerebrovascular events.

Answer 367

Cocaine-induced thrombocytopenia can occur, similar to idiopathic thrombocytopenia purpura.

Answer 368

Cocaine alters pain perception, leading to potentially lower pain thresholds and challenges in analgesia administration.

Answer 369

Chronic cocaine use causes delayed gastric emptying, increasing the risk for aspiration.

Answer 370

Determine last use of cocaine and severity of use. 8 hours is sufficient for general anesthesia if the patient is stable. 48 hours for sedation d/t cardiopulmonary complication

Answer 371

Urine testing can detect cocaine and its metabolites for up to 6 days, or even 10 days for chronic users.

Answer 372

Avoid sympathomimetic agents (e.g., ketamine) as the myocardium of patients using cocaine is more sensitive to catecholamines.

Answer 373

Monitor use of local anesthetics containing epinephrine due to the risk of dysrhythmias.

Answer 374

Be prepared to treat intraoperative myocardial ischemia and cocaine-induced seizures.

Answer 375

- CBC - BMP - EKG, Echo in chronic user may show cardiomyopathy - Longer NPO 10 hours d/t gastropheresis - Determine last use of cocaine, for sedation wait 48 hours. GA 8 hours - Avoid ketamine - Be prepare to treat ischemia and bronchospasm.

Answer 376

Marijuana is a recreational drug from the cannabis plant.

Answer 377

The desired effects are euphoria, increased awareness of sensation, and increased libido.

Answer 378

The most active cannabinoid in marijuana is Δ9-trans-tetrahydrocannabinol (THC).

Answer 379

Low dose use stimulates the sympathetic nervous system, leading to hypertension and tachycardia. High dose use inhibits it, leading to hypotension and bradycardia.

Answer 380

Chronic usage can result in compromised pulmonary function: - Increased airway reactivity - Higher susceptibility to respiratory complications due to tar deposits. This makes patients more susceptible to anesthesia-related respiratory complications (e.g., laryngospasm and bronchospasm).

Answer 381

Determine last use of marijuana and cancel cases when intoxication is suspected.

Answer 382

For office-based anesthesia, consider waiting 72 hours after consumption.

Answer 383

Monitor EKG and blood pressure continuously throughout the procedure.

Answer 384

Drugs with known sympathomimetic action should be avoided.

Answer 385

Consider a dose of steroids due to the risk for uvular edema.

Answer 386

Patients will be more sensitive to inhaled anesthetics. - Chronic users exhibit tolerance and cross tolerance, which may lead to decreased levels of sedations/combativeness during intravenous sedations.

Answer 387

Chronic users require higher doses of narcotics to obtain analgesia.

Answer 388

CBC BMP EKG (PVCs, Afib, AV block). - Determine last use wait 72 hours for office-based anesthesia. - Consider steroids to prevent uvular edema in recent users. - Avoid sympathomimetic drugs in acute users. - Perform pre-op auscultation to check for pulmonary issues. - Consider albuterol and glycopyrrolate for airway sensitivity. - Watch for increased bleeding risk due to platelet drop. - Chronic users may need higher doses of benzodiazepines, opioids, propofol, and narcotics.

Answer 389

Hyperkeratosis Candidiasis Leukoplakia Lichenoid reaction Pemphigus White spongy nevus Oral manifestation of IBD (Crohn’s disease)

Answer 390

Crohn’s disease (oral manifestation).

Answer 391

Inflammation: Patchy, transmural commonly affect terminal ileum Symptoms: Nonbloody diarrhea, low-grade fever, pain, weight loss, perianal disease Location: Anywhere in the GI tract (mouth to anus), commonly terminal ileum Diagnosis: Colonoscopy with biopsy Malignancy Risk: Questionable increased risk Treatment: Steroids, immunosuppressants, sulfasalazine

Answer 392

Inflammation: Diffuse, continuous mucosal inflammation affecting the colon including the rectum Symptoms: Bloody diarrhea, urgency, tenesmus, abdominal pain, weight loss Location: Colon only, always involves rectum Diagnosis: Colonoscopy with biopsy and stool studies Malignancy Risk: Increased risk Treatment: Mesalamine, steroids, surgery

Answer 393

Heroin (diacetylmorphine) is an opioid drug synthesized from morphine, a naturally occurring substance from the opium poppy plant.

Answer 394

The desired effect of heroin is an intense euphoria.

Answer 395

Heroin can be inhaled, smoked, or injected intravenously.

Answer 396

Opioids are narcotic drugs derived from the opium plant that bind to opioid receptors in the CNS and PNS, resulting in analgesia.

Answer 397

Common effects of opioids include euphoria, sedation, nausea, constipation, chest wall rigidity, and respiratory depression.

Answer 398

Manifestations include miosis, respiratory depression, motor slowness, euphoria, slurred speech, gastric atony, and pulmonary edema.

Answer 399

Findings include poor hygiene, malnourishment, cutaneous scarring, hyperpigmentation, and inflamed skin excoriations.

Answer 400

Hepatitis (B and C) is the most frequent complication, with roughly 40% of IV heroin users exposed.

Answer 401

Signs include jaundice, telangiectasia, ascites, and scleral icterus.

Answer 402

Higher risk for lung abscesses, bacterial pneumonia, respiratory depression, pneumonitis, and fibrosis.

Answer 403

There is a higher risk of endocarditis; any new murmur or unexplained fever should be considered endocarditis until proven otherwise.

Answer 404

There is a higher risk of infection due to malnourishment and HIV.

Answer 405

Acute intoxication is treated with naloxone (opioid receptor antagonist) and supportive care in a hospital setting.

Answer 406

It manifests after abrupt withdrawal of opioids.

Answer 407

Symptoms include tachycardia, hypertension, lacrimation, yawning, nausea, vomiting, diarrhea, muscle spasms, abdominal cramping, hyperthermia, diaphoresis, and mydriasis.

Answer 408

Treatments include supportive care for GI distress, methadone, buprenorphine, and clonidine.

Answer 409

Methadone is a mu opioid agonist used for the management of opioid addiction.

Answer 410

Buprenorphine is a synthetic mixed mu agonist-antagonist used for opioid addiction, administered sublingually.

Answer 411

Clonidine is an alpha-2 adrenergic agonist used to reduce sympathetic manifestations of withdrawal.

Answer 412

Preoperative labs include LFTs, hepatitis titers, HIV titers, and CBC to rule out thrombocytopenia from splenomegaly.

Answer 413

Any doubt should result in a cancelled appointment and toxicology screening ordered.

Answer 414

Intravenous access may be difficult due to collapsed veins and fibrosis.

Answer 415

Avoid preoperative administration of mixed agonist/antagonist (buprenorphine) as it could precipitate withdrawal syndrome. * Peri-operative management * Discontinue this medication 1 to 3 days preoperatively to prevent its antagonist effect against postoperative opioid medication. * Low dose opioid may be required to prevent withdrawal * Can be resumed post-op once acute pain is no longer an issue * For a minor procedure patients should continue until the morning of surgery to prevent withdrawal symptoms Alwayse say I will communicate with his doctor, explain the procedure and pain managment requirement and have them manage that.

Answer 416

Illicit narcotic use can have additive effects with other CNS depressants, risking respiratory or cardiovascular failure.

Answer 417

Tolerance means patients usually require higher doses of an opioid to achieve the desired effect.

Answer 418

Cross tolerance occurs when patients develop tolerance to other CNS depressants, affecting anesthesia levels.

Answer 419

Be prepared to treat opioid overdose with naloxone, supportive care, and contact EMS.

Answer 420

Preoperative antibiotics should be administered.

Answer 421

Pain management can be difficult due to tolerance; acetaminophen should be used sparingly in patients with liver function issues.

Answer 422

Consider using NSAIDs instead of opioids, and tailor opioid use to the surgical procedure.

Answer 423

Discuss the pain management plan with the patient, primary care physician, or pain manager/drug abuse manager.

Answer 424

Patients may have a prolonged QT interval which can degenerate into torsades de pointes.

Answer 425

- CBC - LFTs (prothrombin time, PTT, INR). - Hepatitis titers. - HIV titers. - EKG prolonged QT interval - Communicate with pain physician to manage post op pain. - If IE present, consider abx prophy

Answer 426

Methamphetamines are potent central nervous stimulators. Commonly abused forms include 3,4-Methylenedioxymethamphetamine (MDMA, AKA ecstasy) and methamphetamine hydrochloride (AKA crystal meth or ice).

Answer 427

They increase neurotransmitters, especially at the 5-HT receptor, and slow the reuptake of dopamine, norepinephrine, and serotonin in parts of the central nervous system.

Answer 428

They have psychedelic effects that last for up to 6 hours and are typically taken by mouth.

Answer 429

Ecstasy is commonly packaged in pill form with fillers. 'Molly' is pure molecular MDMA without the fillers.

Answer 430

The desired effects include euphoria, aphrodisia, heightened sensation, and increased empathy.

Answer 431

Physical manifestations include mydriasis, hyperthermia, tachycardia, hypertension, diaphoresis, anorexia, tremors, dehydration, bruxism, and insomnia.

Answer 432

Autonomic hyperactivity is a major feature in patients presenting with MDMA toxicity and is dose-dependent.

Answer 433

Serotonin syndrome is a condition caused by central 5-HT receptor hyperstimulation, resulting in hyperthermia, mental status changes, autonomic instability, and altered muscle tone and/or rigidity.

Answer 434

Hyponatremia can lead to seizures and death, stemming from increased water intake, excessive sweating, and the release of vasopressin leading to SIADH.

Answer 435

MDMA can lead to potentially fatal neurologic outcomes, including subarachnoid hemorrhage, cerebral infarction, or intracranial bleeds.

Answer 436

Hepatotoxicity ranges from asymptomatic liver injury to fulminant acute hepatic failure.

Answer 437

Long-term usage can lead to dental caries due to decreased salivary production, commonly referred to as 'Meth Mouth.'

Answer 438

Bath salts, such as MDPV, mephedrone, and methylone, contain synthetic cathinones. - The principal active ingredients of bath salts products are synthetic cathinones. - Cathinones are beta-ketone amphetamine analogs.

Answer 439

They stimulate alpha and beta adrenergic receptors, causing hyper-alertness, hypertension, tachycardia, mydriasis, and diaphoresis.

Answer 440

Cardiovascular abnormalities include tachycardia, hypertension, chest pain, and dysrhythmias.

Answer 441

They can cause hallucinations, muscle spasms, insomnia, agitation, anxiety, delusions, seizures, and aggression.

Answer 442

Excited delirium is a medical emergency due to violent behavior and hallucinations often accompanied by elevated body temperature.

Answer 443

Management includes assessing sodium levels, urine drug testing, and monitoring EKG for ischemic changes. CBC BMP EKG

Answer 444

Signs such as anxiety, extreme agitation, panic reactions, and seizures may require benzodiazepines and restraints.

Answer 445

Clozapine results in a marked and immediate reversal of MDMA-induced hyperthermia.

Answer 446

Avoid sympathomimetic drugs such as ketamine.

Answer 447

The main acute danger is its association with hyperpyrexia reaction and subsequent rhabdomyolysis.

Answer 448

Carvedilol and dantrolene are effective in reducing hyperthermia.

Answer 449

MAC decreases with acute intoxication and increases with chronic use.

Answer 450

- Hydrocephalus is a neurological condition characterized by an abnormal accumulation of cerebrospinal fluid (CSF) within the cavities (ventricles) of the brain. This excess fluid can lead to an increase in intracranial pressure, which may cause damage to brain tissue. - Types: congenital, acquired, communicating and non-communicating - Symptoms: Nausea, vomiting , headache , diplopia , enlargement of head - Diagnosis: CT /MRI -How would you manage this pt? - I would treat this pt in the OR under GA, avoid any meds that can increase sympathetic system like ketamine, sevo is fine.

Answer 451

- Headache, nausea/vomiting , visual changes , seizure, papilledema, Cushing triad (hypertension, bradycardia, irregular RR)

Answer 452

- Neurodevelopment behavioral syndrome, causing impaired social interaction, impaired communication skills with onset prior to age 3. - Caused by mutations in proteins involved in the formation and function of synapses. - Sign and symptoms: - 75% of autistic have mental retardation. - Hyperactivity - Anxiety - Short attention span - Oral manifestation are periodontal issues , poor tongue coordination, xerostomia as side effect of methylphenidate, gingival hypertrophy 2/2 to phenytoin. - Methylphenidate: central nervous system stimulant works by inhibiting the reuptake of norepinephrine and dopamine.

Answer 453

Life-threatening condition due to excessive thyroid hormone levels usually in untreated hyperthyroidism. Triggers: • Infection, surgery, trauma, iodine exposure, stopping antithyroid meds. Symptoms: • Fever, tachycardia, arrhythmias, agitation, delirium, vomiting, abdominal pain. Diagnosis: • Clinical diagnosis with elevated free T3/T4, suppressed TSH. Management: 1. Supportive care: IV fluids, cooling, oxygen. 2. Antithyroid drugs: PTU or Methimazole. 3. Beta-blockers: Propranolol or Esmolol. 4. Iodine: Lugol’s solution after antithyroid meds. 5. Glucocorticoids: Dexamethasone. 6. Treat underlying cause. Prognosis: High mortality without treatment; prompt care improves outcomes.

Answer 454

An autoimmune disorder that causes the thyroid gland to produce too much thyroid hormone What are symptoms of hyperthyroidism? Hypertension, tachycardia, heat intolerance, fatigue, weight loss What medication might he have taken for Grave’s disease before thyroidectomy? Methimazole

Answer 455

A stress test evaluates cardiac function and perfusion under physical or pharmacologic stress to detect ischemia, arrhythmias, or assess exercise tolerance. Types: Exercise Stress Test: Treadmill/bike test with continuous ECG monitoring. Positive test: ST changes, arrhythmias, or angina. Pharmacologic Stress Test: Uses dobutamine, adenosine in patients unable to exercise. Often combined with echocardiography or nuclear imaging. Stress Echo/Nuclear Test: Detects ischemia via wall motion abnormalities (echo) or perfusion defects (nuclear imaging).

Answer 456

BMI is calculated by dividing a person’s weight in kilograms by the square of their height in meters. Metric Units: BMI = Weight in kilograms/ Height in meters2 Imperial Units: BMI = Weight in pounds ×703/ Height in inches 2

Answer 457

Prednisone is a synthetic corticosteroid used to reduce inflammation and suppress the immune response. MOA: inhibits the release of inflammatory mediators (e.g., prostaglandins, cytokines), leading to reduced inflammation and immune activity.

Answer 458

The CHA₂DS₂-VASc score is a clinical tool used to estimate the risk of stroke in patients with atrial fibrillation (AF) and guide anticoagulation therapy decisions. Interpretation Score 0 (males) or 1 (females): No anticoagulation needed. Score ≥ 1 (males) or ≥ 2 (females): Consider anticoagulation. Score ≥ 2 (males) or ≥ 3 (females): Oral anticoagulation recommended (e.g., warfarin, DOACs).

Answer 459

Attention deficit hyperactivity disorder is a disease characterized by the inability to concentrate with bouts of excessive activity. The disease is believed to be related to decreased activity of dopamine and catecholamines in the prefrontal cortex What is the mechanism of action of Ritalin®? Ritalin® (generic methylphenidate) prevents the reuptake of dopamine and catecholamines in the central nervous system. Hold the methylphenidate day off surgery OMFS concern: - Methylphenidate may significantly reduce effects of midazolam Post-operative nausea and vomiting – Central dopamine is increased by methylphenidate and amphetamines – Methylphenidate exacerbates emetogenic effects of ketamine

Answer 460

chronic autoimmune disease causing inflammation and damage to multiple organs * SLE is mostly seen in women of child-bearing age with the African American, Asian, and Hispanic demographic having the higher prevalence. The most common symptoms are constitutional symptoms (fever, fatigue, weight gain), arthralgias, rash (e.g., malar rash/butterfly rash), and serositis. * Arthritis and arthralgias occur in 90% of SLE patients during the course of their disease. Multisystem: Cardiovascular: Pericardaitis , valvular abnormality, cardiac arrhythmias, hydroxychloroquine is known to cause a prolonged QT interval. Pulmonary – Pleuritis, Pleural effusions, pulmonary arterial hypertension, restrictive lung pattern. Renal – nephritis and glomerulonephritis Maxillofacial – The cutaneous and mucous membranes are commonly affected. The oral cavity may have lichenoid lesions butterfly facial rash with nasolabial fold sparing is the classic rash of SLE (seen in up to 60% of patients Anemia, Leukopenia and thrombocytopenia

Answer 461

- ANA (Antinuclear Antibody): A nonspecific marker found in many autoimmune diseases, including SLE. Positive in >95% of SLE patients. - Anti-dsDNA: Highly specific for SLE, associated with lupus nephritis and disease activity. - Anti-Sm (Anti-Smith Antibody): The most specific antibody for SLE, but less sensitive, found in about 30% of patients. The American College of Rheumatology requires four or more of the criteria met * DOPAMINE RASH is a mnemonic for SLE. – Discoid rash – Oral ulcers – Photosensitivity – Arthritis > 2 joints – Malar rash – Immunologic criteria: anti-Sm Ab, anti-DSDNA – Neurologic symptoms: seizures, psychosis – ESR elevated – Renal disease – ANA positive – Serositis: pleurisy, pericarditis – Hematologic disorders: hemolytic anemia, leukopenia, thrombocytopenia Treatment: Antimalarial drugs such as hydroxychloroquine (Plaquenil®) are used long term to control disease flare-ups. Long-term use, greater than 400 mg daily, can lead to eye toxicity and should be monitored every 6–12 months. Methotrexate for sever cases

Answer 462

Peptic Ulcer Disease (PUD) PUD involves ulcers in the gastric or duodenal mucosa, caused by H. pylori, NSAIDs, or acid hypersecretion. Types: Gastric Ulcers: Pain worsens with meals. Higher risk of malignancy (requires biopsy). Duodenal Ulcers: 100% caused by H.p Pain improves with meals, worsens 2–5 hours after eating. Rarely malignant. Diagnosis: Endoscopy (gold standard). H. pylori testing (urea breath test, stool antigen, or biopsy). Treatment: H. pylori eradication: PPI + 2 antibiotics (clarithromycin + amoxicillin/metronidazole). Acid suppression: Proton pump inhibitors (PPIs). Avoid NSAIDs, smoking, and alcohol.

Answer 463

Anxiety is an excessive and persistent feeling of worry, fear, or nervousness that interferes with daily life.

Answer 464

I will transport the patient to the hospital , I’m concerning about negative pressure pulmonary edema - How do you treat NPPE - Supportive respiratory care and diuretics

Answer 465

Angioedema is sudden swelling of skin or mucosa due to allergies, ACE inhibitors, or C1 esterase inhibitor deficiency

Answer 466

A severe form of hypothyroidism characterized by mucopolysaccharide deposition in the skin and tissues, leading to non-pitting edema, and, in extreme cases, life-threatening myxedema coma. Symptoms: General: Fatigue, weight gain, cold intolerance. Skin: Dry, thickened skin, non-pitting edema, puffy face. Neurological: Slow speech, cognitive impairment. Cardiovascular: Bradycardia, hypotension. Myxedema coma: Hypothermia, hypoventilation, hypotension, coma. Treatment: Hypothyroidism: Oral levothyroxine. Myxedema Coma: IV levothyroxine loading dose 200–400 mcg, supportive care (airway, fluids, rewarming), and treat precipitating factors (e.g., infection).

Answer 467

Depression is a mood disorder causing persistent sadness, loss of interest, and functional impairment, with symptoms lasting at least two weeks. * MAOIs – Nonselective inhibition of MAO (A&B) resulting in decreased metabolism of 5HT and catecholamine neurotransmitters – Drug-drug interaction – MAOI + Meperidine -> hyperthermia, BP instability, Szs, and coma Tricyclic Antidepressants * Inhibit norepinephrine and serotonin reuptake to varying degrees SSRIs * Inhibit serotonin reuptake in CNS

Answer 468

A mood disorder characterized by episodes of mania and depression Lithium – * Mood stabilizer used for prophylaxis and treatment * Lithium toxicity – narrow therapeutic window – Vomiting – Tremors – EKG – inverted and flattened T-waves; widened QRS, heart block – Diuretics should be taken with caution b/c increase in Li levels * NSAIDs avoided or used with caution as they increase lithium levels

Answer 469

abrupt decline in GFR by rise in SCr or decline in UOP ***KDIGO guidelines*** (electrolyte abnormalities, anemia, fluid overload, hypoalbuminemia > pulm edema, uremia (plt dysfunction), metabolic acidosis) - Criteria o UOP < 0.5cc/hr x 6 hrs o increase SCr > 0.3 mg/dL within 48 hrs o Increase SCr > 1.5 x baseline in past 7 days - Causes o Pre-renal – hypovolemia, blood loss (FENa < 1%) o Intrinsic – glomerulonephritis, nephritis (FENa > 2%) o Post-renal - obstruction etc - Dx: serum electrolytes, urine lytes, FENa Normal value: Serum Creatinine: 0.6–1.2 mg/dL Blood Urea Nitrogen (BUN): 7–20 mg/dL.

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