Anesthesia and Perioperative medicine

Anesthesia and Perioperative medicine US Medical PG Question 1: A 4-year-old boy is brought to the emergency department by his mother after cutting his buttock on a piece of broken glass. There is a 5-cm curvilinear laceration over the patient's right buttock. His vital signs are unremarkable. The decision to repair the laceration is made. Which of the following will offer the longest anesthesia for the laceration repair?

• A. Lidocaine
• B. Lidocaine mixed with bupivacaine
• C. Bupivacaine with epinephrine (Correct Answer)
• D. Lidocaine with epinephrine
• E. Bupivacaine

Anesthesia and Perioperative medicine Explanation: ***Bupivacaine with epinephrine*** - **Bupivacaine** is a long-acting local anesthetic, and adding **epinephrine** to it further prolongs its duration of action by causing vasoconstriction, which slows systemic absorption. - This combination would provide the **longest duration of anesthesia** suitable for a laceration repair that requires extended pain control. *Lidocaine* - **Lidocaine** is an intermediate-acting local anesthetic with a relatively shorter duration of action compared to bupivacaine. - While effective for initial anesthesia, its effect would likely wear off sooner than desired for a comprehensive repair. *Lidocaine mixed with bupivacaine* - Mixing lidocaine with bupivacaine can provide a **faster onset of action** (due to lidocaine) and a longer duration (due to bupivacaine) as compared to lidocaine alone. - However, the overall duration would typically still be *shorter* than bupivacaine with epinephrine due to the lack of vasoconstriction from epinephrine, leading to faster systemic absorption. *Lidocaine with epinephrine* - Adding **epinephrine** to **lidocaine** prolongs its duration of action by inducing vasoconstriction. - While this is a practical choice for many procedures, bupivacaine inherently has a longer duration than lidocaine, making *bupivacaine with epinephrine* the longest-acting option among those given. *Bupivacaine* - **Bupivacaine** alone provides longer anesthesia than lidocaine alone. - However, without **epinephrine**, its duration is not as long as it could be, as epinephrine would delay its absorption and prolong its local effect.

Anesthesia and Perioperative medicine US Medical PG Question 2: A 52-year-old obese man is brought to the emergency department 30 minutes after he was involved in a high-speed motor vehicle collision. He was the unrestrained driver. On arrival, he is lethargic. His pulse is 112/min, respirations are 10/min and irregular, and blood pressure is 94/60 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 91%. The pupils are equal and react sluggishly to light. He withdraws his extremities to pain. There are multiple bruises over his face, chest, and abdomen. Breath sounds are decreased over the left lung base. Two large bore peripheral venous catheters are inserted and 0.9% saline infusion is begun. Rapid sequence intubation is initiated and endotracheal intubation is attempted without success. Bag and mask ventilation is continued. Pulse oximetry shows an oxygen saturation of 84%. The patient has no advance directive and family members have not arrived. Which of the following is the most appropriate next step in the management of this patient?

• A. Nasotracheal intubation
• B. Video laryngoscopy
• C. Cricothyrotomy (Correct Answer)
• D. Comfort measures only
• E. Tracheostomy

Anesthesia and Perioperative medicine Explanation: ***Cricothyrotomy*** - In a trauma patient with **failed endotracheal intubation** and declining oxygen saturation (from 91% to 84% despite bag-mask ventilation), an emergent cricothyrotomy is indicated for **immediate airway control**. - This procedure provides a definitive airway in a **can't intubate/can't ventilate** scenario, preventing further hypoxia and potential brain damage. *Nasotracheal intubation* - **Nasotracheal intubation** is generally contraindicated in patients with suspected **facial or skull base fractures** due to the risk of intracranial intubation. - Given the high-speed collision and facial bruises, such fractures are possible, making this a less safe option compared to cricothyrotomy. *Video laryngoscopy* - While **video laryngoscopy** can be helpful for difficult airways, it was already implied that intubation was attempted and failed, suggesting the issue might be with visualization or access, not just technique. - Critically, the patient's oxygen saturation is dropping rapidly, requiring a quicker, more definitive solution than another attempt at orotracheal intubation. *Comfort measures only* - The patient has **no advance directive**, and family members have not arrived to make decisions regarding end-of-life care. - Despite the severity of his injuries, the patient is still alive and does not have clear indications for **comfort measures only** at this stage; resuscitative efforts are warranted. *Tracheostomy* - **Tracheostomy** is a surgical procedure for establishing a long-term airway and is not suitable for **emergent airway management** in a rapidly decompensating trauma patient. - It typically requires specialized surgical expertise and takes longer to perform than a cricothyrotomy, which is a faster, life-saving measure in this acute situation.

Anesthesia and Perioperative medicine US Medical PG Question 3: A 36-year-old male with fluctuating levels of consciousness is brought to the emergency department by ambulance due to a fire in his home. He currently opens his eyes to voice, localizes painful stimuli, responds when asked questions, but is disoriented and cannot obey commands. The patient’s temperature is 99°F (37.2°C), blood pressure is 86/52 mmHg, pulse is 88/min, and respirations are 14/min with an oxygen saturation of 97% O2 on room air. Physical exam shows evidence of soot around the patient’s nose and mouth, but no burns, airway obstruction, nor accessory muscle use. A blood lactate is 14 mmol/L. The patient is started on intravenous fluids. What is the next best step in management?

• A. Methylene blue
• B. Hyperbaric oxygen
• C. Sodium thiosulfate and sodium nitrite
• D. Intravenous epinephrine
• E. 100% oxygen, hydroxycobalamin, and sodium thiosulfate (Correct Answer)

Anesthesia and Perioperative medicine Explanation: ***100% oxygen, hydroxycobalamin, and sodium thiosulfate*** - This patient presents with signs of both **carbon monoxide poisoning** (fire exposure, disoriented, altered mental status) and **cyanide poisoning** (fire exposure, very high lactate, normal oxygen saturation despite altered mental status). This combination therapy directly addresses both. - **100% oxygen** competes with carbon monoxide for hemoglobin binding and helps clear it, while **hydroxycobalamin** and **sodium thiosulfate** are antidotes for cyanide poisoning, converting cyanide into less toxic compounds. *Methylene blue* - **Methylene blue** is used to treat **methemoglobinemia**, a condition where iron in hemoglobin is oxidized, leading to impaired oxygen transport. - The patient's symptoms (fire exposure, altered mental status, and a high lactate with normal SpO2) are not characteristic of methemoglobinemia, but rather strong indicators of carbon monoxide and cyanide poisoning. *Hyperbaric oxygen* - **Hyperbaric oxygen** is a treatment for severe carbon monoxide poisoning, but it is not the initial or sole treatment for a patient with suspected co-existing cyanide poisoning. - While recommended for **severe CO poisoning**, it doesn't directly address cyanide toxicity, which is suggested by the metabolic acidosis with a high lactate level despite normal oxygen saturation. *Sodium thiosulfate and sodium nitrite* - This combination (the **Lilly kit**) is traditionally used to treat **cyanide poisoning**, with sodium nitrite inducing methemoglobinemia to sequester cyanide, and sodium thiosulfate aiding its excretion. - The patient also requires treatment for **carbon monoxide poisoning**, and hydroxycobalamin is generally preferred over sodium nitrite as it does not induce methemoglobinemia, which can worsen hypoxia in CO poisoning. *Intravenous epinephrine* - **Epinephrine** is a powerful vasoconstrictor and bronchodilator primarily used to treat **anaphylaxis** or **cardiac arrest**. - There is no indication of anaphylaxis or cardiac arrest in this patient, and epinephrine would not be an appropriate treatment for carbon monoxide or cyanide poisoning.

Anesthesia and Perioperative medicine US Medical PG Question 4: A 30-year-old man with history of intravenous drug use and methamphetamine-associated chronic thromboembolic pulmonary hypertension (CTEPH) is brought to the emergency department by his girlfriend for worsening abdominal pain and fevers. The patient said the pain was initially around his umbilicus, but he is now experiencing intense tenderness near his groin. He was initially prescribed rivaroxaban, but due to insurance issues, he was switched to warfarin for management of CTEPH two weeks ago. His temperature is 102°F (38.9°C), blood pressure is 95/60 mmHg, pulse is 95/min, respirations are 22/min. He states that his blood pressure usually runs low. His physical exam is notable for an unremarkable cardiac exam, bibasilar crackles, and RLQ tenderness with rebound tenderness when the LLQ is palpated. Laboratory results are shown below: Hemoglobin: 11 g/dL Hematocrit: 35 % Leukocyte count: 16,000/mm^3 with normal differential Platelet count: 190,000/mm^3 Serum: Na+: 137 mEq/L Cl-: 100 mEq/L K+: 3.7 mEq/L HCO3-: 23 mEq/L BUN: 40 mg/dL Glucose: 110 mg/dL Creatinine: 0.8 mg/dL Ca2+: 9.1 mg/dL AST: 34 U/L ALT: 45 U/L International normalized ratio (INR): 6.2 Prothrombin time (PT): 40 seconds Partial thromboplastin time: 70 seconds Blood type: O Rhesus: Positive Antibody screen: Negative A clinical diagnosis is made and supported by the surgical consult team in lieu of imaging. The next operating room for an add-on procedure will not be available for another 5 hours. Appropriate medical therapy is initiated. What is the best next step for surgical optimization?

• A. Fresh frozen plasma
• B. Prothrombin complex concentrate (Correct Answer)
• C. Protamine
• D. Do nothing
• E. Phytonadione

Anesthesia and Perioperative medicine Explanation: ***Prothrombin complex concentrate*** - The patient has **warfarin over-anticoagulation (INR 6.2)** and requires **emergency surgery** for suspected appendicitis with peritonitis, necessitating rapid reversal of anticoagulation. - **Prothrombin complex concentrate (4-factor PCC)** contains concentrated factors II, VII, IX, and X (and proteins C & S), providing **rapid and complete reversal** of warfarin's anticoagulant effects within minutes, which is crucial in emergency surgical situations. - PCC is **preferred over FFP** per current guidelines (ACCP, AHA) for urgent warfarin reversal due to faster administration, smaller volume, and more predictable INR correction. - **Vitamin K should be administered concurrently** to provide sustained reversal (takes 12-24 hours), but PCC is essential for immediate correction before surgery. *Fresh frozen plasma* - While FFP contains all coagulation factors and can reverse warfarin, it requires **larger volumes (4-6 units)**, takes longer to thaw and administer, and is **less effective** in rapidly correcting INR to normal range compared to PCC. - Administering large volumes of FFP can lead to **volume overload** (especially concerning in CTEPH patients) and **transfusion-related complications**. - PCC is superior for urgent reversal in patients requiring emergency surgery. *Protamine* - **Protamine** is used to reverse the anticoagulant effects of **unfractionated heparin** (and partially reverses low molecular weight heparin), not warfarin. - It would have **no effect** on the patient's elevated INR due to warfarin use. - Note: The elevated PTT (70s) in this case may suggest concurrent heparin bridging therapy or other factor deficiency, but the primary issue requiring reversal is the critical warfarin over-anticoagulation. *Do nothing* - This patient has **surgical peritonitis** (appendicitis with peritoneal signs) and requires emergency surgery with an INR of 6.2, creating **high risk of surgical bleeding**. - Proceeding to surgery without reversing anticoagulation would result in **life-threatening hemorrhage**. - Delaying treatment would likely result in further **clinical deterioration** with possible perforation and sepsis. *Phytonadione* - **Phytonadione (Vitamin K)** reverses warfarin's effects by restoring hepatic synthesis of vitamin K-dependent clotting factors, but its onset of action is **slow (12-24 hours for full effect)**, making it unsuitable as the sole agent for immediate reversal in patients requiring emergent surgery. - While **Vitamin K should be administered** alongside PCC to provide sustained reversal, it is **not sufficient alone** for rapid correction in surgical emergencies.

Anesthesia and Perioperative medicine US Medical PG Question 5: A group of researchers is studying various inhaled substances to determine their anesthetic properties. In particular, they are trying to identify an anesthetic with fast onset and quick recovery for use in emergencies. They determine the following data: Inhalational anesthetic Blood-gas partition coefficient A 0.15 B 0.92 C 5.42 Which of the following statements is accurate with regard to these inhaled anesthetic substances?

• A. Agent C has the fastest onset of action
• B. Agent A has the fastest onset of action (Correct Answer)
• C. Agent B is the most potent
• D. Agent B has the fastest onset of action
• E. Agent A is the most potent

Anesthesia and Perioperative medicine Explanation: ***Agent A has the fastest onset of action*** - **Agent A** has the lowest blood-gas partition coefficient (0.15), indicating very low solubility in blood. - A **low blood-gas partition coefficient** means the anesthetic quickly equilibrates between the lungs and blood, leading to a rapid rise in partial pressure in the brain and thus **fast onset of action** and **quick recovery**. *Agent C has the fastest onset of action* - **Agent C** has the highest blood-gas partition coefficient (5.42), indicating high solubility in blood. - High solubility means the anesthetic takes longer to saturate the blood and reach the brain, resulting in a **slow onset of action** and **slow recovery**. *Agent B is the most potent* - **Potency** of an inhaled anesthetic is inversely related to its **Minimum Alveolar Concentration (MAC)**, not directly to its blood-gas partition coefficient. - While a higher blood-gas coefficient can sometimes correlate with other properties, it does not directly determine potency. *Agent B has the fastest onset of action* - **Agent B** has a blood-gas partition coefficient of 0.92, which is higher than Agent A (0.15). - A higher blood-gas partition coefficient means the anesthetic is more soluble in blood, leading to a **slower onset of action** compared to Agent A. *Agent A is the most potent* - **Agent A** has the lowest blood-gas partition coefficient (0.15), which indicates **fast onset** and **rapid recovery**, but not necessarily high potency. - **Potency** is determined by MAC (Minimum Alveolar Concentration), which is the concentration of anesthetic at 1 atmosphere that produces immobility in 50% of patients challenged with a surgical incision.

Anesthesia and Perioperative medicine US Medical PG Question 6: A previously healthy 44-year-old man is brought by his coworkers to the emergency department 45 minutes after he became light-headed and collapsed while working in the boiler room of a factory. He did not lose consciousness. His coworkers report that 30 minutes prior to collapsing, he told them he was nauseous and had a headache. The patient appears sweaty and lethargic. He is not oriented to time, place, or person. The patient’s vital signs are as follows: temperature 41°C (105.8°F); heart rate 133/min; respiratory rate 22/min; and blood pressure 90/52 mm Hg. Examination shows equal and reactive pupils. Deep tendon reflexes are 2+ bilaterally. His neck is supple. A 0.9% saline infusion is administered. A urinary catheter is inserted and dark brown urine is collected. The patient’s laboratory test results are as follows: Laboratory test Blood Hemoglobin 15 g/dL Leukocyte count 18,000/mm3 Platelet count 51,000/mm3 Serum Na+ 149 mEq/L K+ 5.0 mEq/L Cl- 98 mEq/L Urea nitrogen 42 mg/dL Glucose 88 mg/dL Creatinine 1.8 mg/dL Aspartate aminotransferase (AST, GOT) 210 Alanine aminotransferase (ALT, GPT) 250 Creatine kinase 86,000 U/mL Which of the following is the most appropriate next step in patient management?

• A. Dantrolene
• B. Acetaminophen therapy
• C. Hemodialysis
• D. Ice water immersion (Correct Answer)
• E. Evaporative cooling

Anesthesia and Perioperative medicine Explanation: ***Ice water immersion*** - This patient presents with signs and symptoms consistent with **heat stroke**, including high body temperature (41°C), altered mental status, and a history of working in a hot environment (boiler room). **Rapid aggressive cooling** is the most critical immediate intervention to prevent organ damage. - **Ice water immersion** is the fastest and most effective cooling method for heat stroke, aiming to reduce core body temperature to less than 39°C (102.2°F) within 30 minutes. *Dantrolene* - **Dantrolene** is primarily used to treat **malignant hyperthermia** and **neuroleptic malignant syndrome**, conditions caused by abnormal calcium release in muscle cells, not environmental heat exposure. - While both conditions involve hyperthermia, the underlying pathophysiology and triggers are different from heat stroke. *Acetaminophen therapy* - **Acetaminophen** is an antipyretic that works by inhibiting prostaglandin synthesis in the central nervous system, affecting the hypothalamic thermoregulatory center. - It is **ineffective** for the hyperthermia seen in heat stroke, which is due to a failure of thermoregulation rather than an altered hypothalamic set point, and could potentially worsen liver injury. *Hemodialysis* - **Hemodialysis** is indicated for severe **renal failure**, drug overdose, or certain electrolyte imbalances. Although this patient has acute kidney injury (elevated BUN and creatinine, dark urine suggestive of rhabdomyolysis), aggressive cooling is the immediate life-saving intervention for heat stroke. - While renal support might be necessary later if kidney injury progresses, it is not the most appropriate *initial* next step for hyperthermia and altered mental status. *Evaporative cooling* - **Evaporative cooling** (e.g., spraying with lukewarm water and using fans) is a cooling method that can be effective, particularly in environments with low humidity. - However, for severe heat stroke with a temperature as high as 41°C, **ice water immersion** provides a more rapid and aggressive temperature reduction, which is crucial for improving outcomes.

Anesthesia and Perioperative medicine US Medical PG Question 7: A 23-year-old man is brought to the emergency department by ambulance following a motor vehicle accident. He was pinned between 2 cars for several hours. The patient has a history of asthma. He uses an albuterol inhaler intermittently. The patient was not the driver, and admits to having a few beers at a party prior to the accident. His vitals in the ambulance are stable. Upon presentation to the emergency department, the patient is immediately brought to the operating room for evaluation and surgical intervention. It is determined that the patient’s right leg has a Gustilo IIIC injury in the mid-shaft of the tibia with a severely comminuted fracture. The patient’s left leg suffered a similar injury but with damage to the peroneal nerve. The anesthesiologist begins to induce anesthesia. Which of the following agents would be contraindicated in this patient?

• A. Halothane
• B. Propofol
• C. Etomidate
• D. Succinylcholine (Correct Answer)
• E. Neostigmine

Anesthesia and Perioperative medicine Explanation: ***Succinylcholine*** - Given the history of the patient being pinned between two cars for several hours, there is a significant risk of **rhabdomyolysis** and subsequent hyperkalemia. - **Succinylcholine**, a depolarizing neuromuscular blocker, can cause a sudden and significant release of potassium from muscle cells, leading to **life-threatening hyperkalemia** in patients with rhabdomyolysis or crush injuries. *Halothane* - While **halothane** has been associated with **malignant hyperthermia**, the patient's history does not directly suggest an increased risk for this condition here. - It also has a bronchodilating effect, which could be beneficial for a patient with a history of **asthma**. *Propofol* - **Propofol** is a commonly used intravenous anesthetic for induction and maintenance, providing rapid onset and recovery. - There are generally no specific contraindications for propofol in a patient with a crush injury or asthma. *Etomidate* - **Etomidate** is an intravenous anesthetic agent known for its **cardiovascular stability**, making it a good choice for hemodynamically unstable patients. - It can cause adrenal suppression, but this is usually a concern with prolonged infusions, not a single induction dose. *Neostigmine* - **Neostigmine** is an acetylcholinesterase inhibitor used to reverse the effects of non-depolarizing neuromuscular blockers. - It is not an induction agent and would not be used at the beginning of anesthesia induction.

Anesthesia and Perioperative medicine US Medical PG Question 8: An obese 52-year-old man is brought to the emergency department because of increasing shortness of breath for the past 8 hours. Two months ago, he noticed a mass on the right side of his neck and was diagnosed with laryngeal cancer. He has smoked two packs of cigarettes daily for 27 years. He drinks two pints of rum daily. He appears ill. He is oriented to person, place, and time. His temperature is 37°C (98.6°F), pulse is 111/min, respirations are 34/min, and blood pressure is 140/90 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 89%. Examination shows a 9-cm, tender, firm subglottic mass on the right side of the neck. Cervical lymphadenopathy is present. His breathing is labored and he has audible inspiratory stridor but is able to answer questions. The lungs are clear to auscultation. Arterial blood gas analysis on room air shows: pH 7.36 PCO2 45 mm Hg PO2 74 mm Hg HCO3- 25 mEq/L He has no advanced directive. Which of the following is the most appropriate next step in management?

• A. Comfort care measures
• B. Cricothyroidotomy (Correct Answer)
• C. Tracheostomy
• D. Intramuscular epinephrine
• E. Tracheal stenting

Anesthesia and Perioperative medicine Explanation: ***Correct: Cricothyroidotomy*** - This patient has **impending complete airway obstruction** evidenced by inspiratory stridor, severe tachypnea (34/min), hypoxia (O2 sat 89%), and a large obstructing laryngeal mass - **Cricothyroidotomy** is the emergent surgical airway procedure of choice when there is **imminent or actual complete upper airway obstruction** and endotracheal intubation cannot be safely performed - The subglottic mass makes endotracheal intubation **extremely dangerous** - instrumentation could precipitate complete obstruction and inability to ventilate - Cricothyroidotomy provides **immediate airway access** (can be performed in 30-60 seconds) below the level of obstruction, making it life-saving in this emergency - In the "cannot intubate, cannot ventilate" scenario, cricothyroidotomy is the definitive emergency intervention per ATLS and airway management guidelines *Incorrect: Tracheostomy* - While tracheostomy provides definitive airway management, it is a **controlled, elective procedure** typically performed in the OR that takes 20-30 minutes - This patient requires **immediate airway access** - waiting for OR setup and performing tracheostomy risks complete airway collapse and death - Tracheostomy may be performed later as a planned procedure once the airway is secured with cricothyroidotomy - The presence of stridor indicates **critical airway narrowing** requiring emergency intervention, not elective surgery *Incorrect: Comfort care measures* - The patient is **alert and oriented** without an advanced directive indicating wishes for comfort care only - This is an **acute, reversible condition** with appropriate emergency airway intervention - Presumed consent applies in life-threatening emergencies when the patient cannot formally consent but intervention would be life-saving - Comfort care would be inappropriate without documented patient wishes or irreversible terminal condition *Incorrect: Intramuscular epinephrine* - Epinephrine is indicated for **anaphylaxis** or angioedema causing airway edema from allergic/inflammatory mechanisms - This patient has **mechanical obstruction** from a solid tumor mass, which will not respond to epinephrine - Epinephrine causes vasoconstriction and reduces mucosal edema but cannot reduce tumor mass - Would delay definitive airway management and not address the underlying problem *Incorrect: Tracheal stenting* - Tracheal stenting requires **bronchoscopy** in a controlled setting and is used for palliation of tracheal narrowing - Cannot be performed emergently in an unstable patient with impending airway obstruction - The obstruction is at the **laryngeal/subglottic level**, not typically amenable to emergency stenting - Requires time for procedure setup and sedation, which this patient cannot afford given the critical airway emergency

Anesthesia and Perioperative medicine US Medical PG Question 9: A 58-year-old man with type 2 diabetes mellitus comes to the emergency department because of a 2-day history of dysphagia and swelling in the neck and lower jaw. He has had tooth pain on the left side over the past week, which has made it difficult for him to sleep. Four weeks ago, he had a 3-day episode of flu-like symptoms, including sore throat, that resolved without treatment. He has a history of hypertension. Current medications include metformin and lisinopril. He appears distressed. He is 180 cm (5 ft 11 in) tall and weighs 100 kg (220 lbs); his BMI is 31.6 kg/m2. His temperature is 38.4°C (101.1°F), pulse is 90/min, and blood pressure is 110/80 mm Hg. Oral cavity examination shows a decayed lower left third molar with drainage of pus. There is submandibular and anterior neck tenderness and swelling. His leukocyte count is 15,600/mm3, platelet count is 300,000/mm3, and fingerstick blood glucose concentration is 250 mg/dL. Which of the following is the most likely diagnosis?

• A. Angioedema
• B. Peritonsillar abscess
• C. Lymphadenitis
• D. Sublingual hematoma
• E. Ludwig angina (Correct Answer)

Anesthesia and Perioperative medicine Explanation: ***Ludwig angina*** - This patient presents with **rapidly progressive submandibular and anterior neck swelling**, dysphagia, fever, and a history of a recent dental infection (decayed molar with pus drainage). These are classic signs of **Ludwig angina**, a severe cellulitis of the floor of the mouth. - The patient's **poorly controlled diabetes** and **obesity** are risk factors for severe infections, and the elevated leukocyte count further supports an active bacterial infection. *Angioedema* - **Angioedema** typically presents with rapid swelling of the face, lips, tongue, or larynx, but it is usually **non-pitting** and **painless**, without systemic signs of infection (fever, pus, elevated leukocytes). - While lisinopril can cause angioedema, the presence of **fever, pus drainage from a tooth, and tenderness** makes an infectious etiology more likely than an allergic or bradykinin-mediated angioedema. *Peritonsillar abscess* - A **peritonsillar abscess** is characterized by severe **sore throat**, **trismus**, **"hot potato" voice**, and a **uvular deviation**, which are not reported in this patient. - While it can cause dysphagia and fever, the primary swelling in this case is submandibular and anterior neck, not peritonsillar. *Lymphadenitis* - **Cervical lymphadenitis** involves painful, enlarged **lymph nodes**, often in response to an infection. While the patient has an infection, lymphadenitis would present as discrete node enlargement rather than diffuse, board-like swelling of the floor of the mouth and submandibular space. - The extensive swelling, dysphagia, and involvement of fascial planes are more consistent with a spreading cellulitis like Ludwig angina. *Sublingual hematoma* - A **sublingual hematoma** would typically result from **trauma** or a **coagulopathy**, neither of which is indicated in this patient's history. - It would also not explain the fever, pus drainage, and elevated leukocyte count indicative of an active infection.

Anesthesia and Perioperative medicine US Medical PG Question 10: A 63-year-old man presents to the clinic complaining of burning bilateral leg pain which has been increasing gradually over the past several months. It worsens when he walks but improves with rest. His past medical and surgical history are significant for hypertension, hyperlipidemia, diabetes, and a 40-pack-year smoking history. His temperature is 99.0°F (37.2°C), blood pressure is 167/108 mm Hg, pulse is 88/min, respirations are 13/min, and oxygen saturation is 95% on room air. Physical exam of the lower extremities reveals palpable but weak posterior tibial and dorsalis pedis pulses bilaterally. Which of the following is the best initial treatment for this patient's symptoms?

• A. Exercise and smoking cessation (Correct Answer)
• B. Lovenox and atorvastatin
• C. Lisinopril and atorvastatin
• D. Balloon angioplasty with stenting
• E. Femoral-popliteal bypass

Anesthesia and Perioperative medicine Explanation: ***Exercise and smoking cessation*** - This patient presents with symptoms highly suggestive of **peripheral artery disease (PAD)**, characterized by **intermittent claudication** (leg pain worsening with activity and improving with rest), and risk factors like diabetes, hypertension, hyperlipidemia, and smoking. - **Smoking cessation** is the single most important modifiable risk factor, and a supervised **exercise program** (walking to the point of claudication) is the most effective initial treatment to improve walking distance and quality of life for PAD patients. *Lovenox and atorvastatin* - **Atorvastatin** is appropriate for dyslipidemia and cardiovascular risk reduction in PAD patients, but **Lovenox (low molecular weight heparin)** is an anticoagulant typically used for acute thrombotic events or VTE prophylaxis, not initial management of chronic stable claudication. - While statins are important for secondary prevention, Lovenox does not directly address the primary management of claudication symptoms or underlying atherosclerotic progression in this stable setting. *Lisinopril and atorvastatin* - **Lisinopril** is an ACE inhibitor suitable for hypertension, which is important for overall cardiovascular health but not the primary initial treatment for claudication symptoms. - While both medications address risk factors, they do not directly target the improvement of walking function and symptom relief as effectively as exercise and smoking cessation in the initial phase. *Balloon angioplasty with stenting* - Invasive revascularization procedures like **balloon angioplasty with stenting** are typically reserved for patients with more severe symptoms (e.g., rest pain, non-healing ulcers, critical limb ischemia) or those who have failed conservative management like exercise therapy. - This is not the **best initial treatment** for a patient with stable claudication. *Femoral-popliteal bypass* - **Femoral-popliteal bypass** is a surgical revascularization procedure indicated for more severe PAD, particularly in cases of critical limb ischemia or long-segment occlusions that are not amenable to endovascular repair. - Like angioplasty, it is a more aggressive intervention and not the **initial treatment of choice** for intermittent claudication.

Anesthesia and Perioperative medicine Flashcard 1 of 6

Question: EF < _____% and MI within _____ months are absolute contraindications to non-cardiac surgery

Answer: 35

Extra Information:  https://onlinemeded.org/spa/surgery?ref=anki 

Anesthesia and Perioperative medicine Flashcard 2 of 6

Question: A _____ is indicated when an emergency airway is required or orotracheal / nasotracheal intubation is unsuccessful / contraindicated

Answer: cricothyrotomy

Anesthesia and Perioperative medicine Flashcard 3 of 6

Question: Patients who have undergone _____ surgery can sometimes manifest with symptoms of hypoparathyroidism and hypocalcemia.

Answer: Thyroid

Anesthesia and Perioperative medicine Flashcard 4 of 6

Question: Echinococcus granulosus cysts are injected with _____ during surgery to kill larvae and prevent spread/anaphylaxis

Answer: ethanol

Anesthesia and Perioperative medicine Flashcard 5 of 6

Question: What is the treatment for osteosarcoma?_____

Answer: En bloc resection and chemotherapy

Anesthesia and Perioperative medicine Flashcard 6 of 6

Question: If a patient has a varicocele, consider surgical ligation or _____ if associated with pain or infertility

Answer: catheter embolization