A 65-year-old nonsmoker is scheduled to undergo right knee replacement. His cardiac history is negative, and he takes aspirin, 81 mg/day, to prevent cardiovascular problems. He also takes simvastatin (Zocor), 20 mg/day, for hypercholesterolemia, and metoprolol (Lopressor), 25 mg twice daily, for hypertension. His body mass index (BMI) is 26 kg/m2 , his heart rate is 60 beats/min, and his blood pressure is controlled.
Which one of the following is the best recommendation regarding metoprolol?
Correct Answer E: The College of Cardiology/Heart Association guidelines recommend continuing ß-blockers in patients undergoing surgery who take them for angina, symptomatic arrhythmias, hypertension, or other Class I indications.
A 50-year-old female with significant findings of rheumatoid arthritis presents for a preoperative evaluation for planned replacement of the metacarpophalangeal joints of her right hand under general anesthesia. She generally enjoys good health and has had ongoing medical care for her illness. Of the following, which one would be most important for preoperative assessment of this patient’s surgical risk?
Correct Answer E: While all of the options listed may have some value in evaluating the preoperative status of a patient with long-standing rheumatoid arthritis, imaging of the patient’s cervical spine to detect atlantoaxial subluxation would be most important for preventing a catastrophic spinal cord injury during intubation. In many cases, cervical fusion must be performed before other elective procedures can be contemplated. Although rheumatoid arthritis may influence oxygen saturation and the erythrocyte sedimentation rate, these tests would not alert the surgical team to the possibility of significant operative morbidity and mortality. Resting pulse rate and rheumatoid factor are unlikely to be significant factors in this preoperative scenario.
A patient presents with an ulcer on the sole of her foot. X-ray shows necrosis of part of the 2nd and 3rd metatarsal bone.
What is the appropriate management?
Correct Answer A: Necrotizing subcutaneous infection is typically caused by a mixture of aerobic and anaerobic organisms that cause necrosis of subcutaneous tissue, usually including the fascia. This infection most commonly affects the extremities and perineum. Affected tissues become red, hot, and swollen, resembling severe cellulitis.
Without timely treatment, the area becomes gangrenous. Patients are acutely ill. Diagnosis is by history and examination and is supported by evidence of overwhelming infection. Treatment involves antibiotics and surgical debridement. Prognosis is poor without early, aggressive treatment.
Which one of the following is most typical of acute Achilles tendon rupture?
Correct Answer D: Acute Achilles tendon rupture usually presents as a sudden sensation of being kicked in the posterior heel region. Because other muscle functions of the lower extremity are preserved, there may be some active range of motion. However, the patient will not be able to do a single-leg toe raise on the affected side. Dorsiflexion of the affected foot with a blood pressure cuff inflated around the calf to 100 mm Hg will normally cause an increase to 140 mm Hg. In patients with Achilles tendon rupture this rise does not occur. There is also a loss of plantar flexion power in the affected foot.
Clinical tests: “Hyper-dorsiflexion” sign - With the patient prone and knees flexed to 90º, maximal passive dorsiflexion of both feet may reveal excessive dorsiflexion of the affected leg. Thompson test - With the patient prone, squeezing the calf of the extended leg may demonstrate no passive plantar flexion of the foot if its Achilles tendon is ruptured. O’Brien needle test - Insert a needle 10 cm proximal to the calcaneal insertion of the Achilles tendon. With passive dorsiflexion of the foot, the hub of the needle will tilt rostrally when the Achilles tendon is intact.
A 32-year-old male is admitted to the Emergency Department 1h after he sustained major fire burns to the thorax, the neck and the face. Aside from hypovolemic shock, the most immediate life-threatening complication to anticipate is:
Correct Answer B: Many people who have been burned in fires have also inhaled smoke. Sometimes people inhale smoke without sustaining skin burns. Smoke inhalation often causes no serious, lasting effects. However, if the smoke is unusually hot or dense or if inhalation is prolonged, serious problems can develop. The hot smoke can burn the windpipe (trachea), resulting in swelling. As the swelling narrows the trachea, airflow into the lungs is obstructed. Inhalation of chemicals released in the smoke, such as hydrogen chloride, phosgene, sulfur dioxide, and ammonia, can swell and damage the lungs and trachea. Eventually, the small airways leading to the lungs narrow, further obstructing airflow. Smoke can also contain chemicals that poison the body's cells, such as carbon monoxide and cyanide.
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