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Which of the following pathogenic mechanisms is most likely to produce these findings A Antigen-antibody complex-mediated injury B Antibody-mediated injury to basement membrane C Formation of mycolic acid as a result of tubercular infection D Generation of prostaglandins by basophil recruitment E Release of histamine from mast cells F Toxic injury to type I pneumocytes caused by inhaled dust 38 A 33-year-old woman has had increasing dyspnea with cough for the past 10 days skin care untuk kulit sensitif buy tretinak with visa. Over the past 2 days acne hyperpigmentation treatment generic tretinak 20 mg, her cough has become productive of chunks of gelatinous sputum skin care juarez tretinak 40 mg on line. A transbronchial biopsy is performed and the microscopic appearance with H&E staining is shown in the figure. Antibody directed against which of the following substances is most likely to cause her illness He is afebrile, his pulse is 70/min, his respirations are 27/min and shallow, and his blood pressure is 130/85 mm Hg. Which of the following clinical disorders is most likely to precede the appearance of the lesion shown Her condition improved, and she was able to get up and move about with assistance. A few minutes after walking to the bathroom, she experienced sudden onset of severe dyspnea with chest pain and diaphoresis. Which of the following is the most likely mechanism for sudden death in this patient Bronchoconstriction Compression atelectasis Hemorrhagic infarction Interstitial edema Acute cor pulmonale 40 A clinical study is performed that includes patients who are hospitalized for more than 2 weeks and who were bedridden for more than 90% of that time. These patients undergo Doppler venous ultrasound examination of the lower extremities, blood gas testing, and radiographic pulmonary ventilation and perfusion scanning. A cohort of patients is found who have abnormal ultrasound results suggestive of thrombosis, blood gas parameters with a slightly lower Po2, and small pulmonary perfusion defects. Which of the following symptoms and signs are most likely to be seen in this cohort of patients Dyspnea Hemoptysis Palpitations Pleuritic pain Orthopnea No symptoms 42 A 45-year-old man has had progressive dyspnea on exertion with fatigue for the past 2 years. On auscultation of his chest he has a prominent pulmonary component of S2, a systolic murmur of tricuspid insufficiency, and bruits over peripheral lung fields. Which of the following is the most likely disease process causing his pulmonary disease Atherosclerosis Pneumonitis Sarcoidosis Thromboembolism Vasculitis 43 A 75-year-old woman has had worsening lower leg edema and dyspnea for the past 5 years. Anesthesia is most likely to produce this effect via which of the following mechanisms Decreased ciliary function Diminished macrophage activity Hypogammaglobulinemia Neutropenia Squamous metaplasia Tracheal erosions 44 A 25-year-old woman has had progressive dyspnea and fatigue for the past 2 years. On physical examination, she has pedal edema, jugular venous distention, and hepatomegaly. Cardiac catheterization is performed, and the pulmonary arterial pressure is increased, without gradients across the pulmonic valve, and no shunts are noted. A transbronchial biopsy is performed, and microscopic examination shows plexiform lesions. A transbronchial lung biopsy on microscopic examination shows focal necrosis of alveolar walls associated with prominent intra-alveolar hemorrhage. Which of the following antibodies is most likely involved in the pathogenesis of his condition A transbronchial lung biopsy is performed, and microscopic examination shows necrotizing granulomatous capillaritis, a poorly formed granuloma, and intra-alveolar hemorrhage. The study group is found to have a higher incidence of pulmonary infections in the 2 weeks following their surgical procedure than patients who were not intubated and did not 49 A 71-year-old woman has smoked a pack of cigarettes per day for 50 years. Over the past 3 days she has become febrile, with a productive cough, and severe dyspnea. A chest radiograph shows a 3-cm round lesion with an air-fluid level in the right lower lobe. Which pair of the following organisms is most likely to be detected in his sputum Cryptococcus neoformans and Candida albicans Cytomegalovirus and Pneumocystis jiroveci Mycobacterium tuberculosis and Aspergillus fumigatus Nocardia asteroides and Actinomyces israelii Staphylococcus aureus and Bacteroides fragilis the Lung 235 54 A 4-year-old healthy girl from Utrecht in the Netherlands has had a fever with dyspnea, tachypnea, nonproductive cough, myalgias, and rhinorrhea for 3 days. Group A Streptococcus Bordetella pertussis Candida albicans Cytomegalovirus Haemophilus influenzae Human metapneumovirus 51 A 20-year-old man has had a mild fever with nonproductive cough, headache, and myalgias for the past week. Legionella pneumophila Mycobacterium fortuitum Mycoplasma pneumoniae Nocardia asteroides Respiratory syncytial virus 55 A 3-year-old boy has had a cough, headache, and slight fever for 5 days. On auscultation, there are inspiratory crackles, but no dullness to percussion or tympany. Hilar lymphadenopathy Hyperinflation Interstitial infiltrates Lobar consolidation Pleural effusions Upper lobe cavitation 52 A 26-year-old woman from East Asia developed a fever with chills over the past 4 days. Yesterday, she had increasing shortness of breath and a nonproductive cough, headache, and myalgias. Over the next 2 days, she has increasing respiratory distress requiring intubation and mechanical ventilation. Bronchoalveolar lavage specimens examined microscopically show macrophages filled with acid-fast infectious organisms.

An upper gastrointestinal endoscopy is performed and a biopsy specimen from the upper part of the small bowel shows severe diffuse blunting of villi and a chronic inflammatory infiltrate in the lamina propria skin care lines discount tretinak 10mg fast delivery. Which of the following serologic tests is most likely to be positive in this patient Various meats skin care owned by procter and gamble tretinak 40mg fast delivery, salads skin care laser clinic birmingham purchase tretinak 5mg, breads, and desserts that were brought in earlier that morning are served. By midafternoon, the single office restroom is being used by many employees who have vomiting and acute, explosive diarrhea accompanied by abdominal cramping. Which of the following infectious agents is most likely responsible for this turn of events Bacillus cereus Clostridium difficile Escherichia coli Salmonella enterica Staphylococcus aureus Vibrio parahaemolyticus 40 A 41-year-old woman has had diarrhea and fatigue with a 3-kg weight loss over the past 6 months. On physical examination, she is afebrile and has mild muscle wasting, but her motor strength is normal. A biopsy specimen from the upper jejunum is obtained, and microscopic findings are reviewed. Which of the following microscopic features is most likely to be seen in the biopsy specimen Crypt abscesses and mucosal ulceration Foamy macrophages within the lamina propria Lymphatic obstruction Noncaseating granulomas Villous blunting and flattening 44 A healthy 21-year-old woman develops a profuse, watery diarrhea 1 day after a meal of raw oysters. Cryptosporidium parvum Entamoeba histolytica Staphylococcus aureus Vibrio parahaemolyticus Yersinia enterocolitica 41 An epidemiologic study of children with failure to thrive is undertaken in Guatemala. Some of these children with ages 1 to 3 years have repeated bouts of diarrhea, but do not improve with dietary supplements. Jejunal biopsies show blunted, atrophic villi with crypt elongation and chronic inflammatory infiltrates. What is the most likely factor contributing to recurrent diarrhea in these children Microscopic examination of the stool shows numerous leukocytes and gram-negative curved rods. Bacillus cereus Campylobacter jejuni Clostridium perfringens Giardia lamblia Rotavirus 42 A 40-year-old man has episodic abdominal bloating, flatulence, and explosive diarrhea. Laboratory studies show no increase in stool fat and no occult blood, ova, or parasites in the stool. Autoimmune gastritis Celiac disease Cholelithiasis Cystic fibrosis Disaccharidase deficiency 46 A 36-year-old man experiences cramping abdominal pain with fever and watery diarrhea 2 days after eating a chicken salad sandwich. Physical examination shows mild diffuse abdominal pain on palpation, but there are no masses. Which of the following infectious agents is the most likely cause for their illness Cytomegalovirus Clostridium botulinum Norovirus Staphylococcus aureus Strongyloides stercoralis Vibrio cholerae 47 In an epidemiologic study of infections of the gastrointestinal tract, cases of patients living in Haiti from whom definitive cultures were obtained are analyzed for clinical and pathologic findings that may be useful for diagnosis. A group of patients is identified who initially had abdominal pain and diarrhea during week 1 of their illness. Campylobacter jejuni Clostridium perfringens Mycobacterium bovis Salmonella typhi Shigella sonnei Yersinia enterocolitica 50 A 5-month-old, previously healthy infant girl in Bangladesh develops a watery diarrhea that lasts for 1 week. The infant has a mild fever during the illness, but has no abdominal pain or swelling. Campylobacter jejuni Cryptosporidium parvum Escherichia coli Listeria monocytogenes Norwalk virus Rotavirus Shigella flexneri 48 A 65-year-old woman is being treated in the hospital for pneumonia complicated by septicemia. She has required multiple antibiotics and was intubated and mechanically ventilated earlier in the course. Bowel sounds are absent, and an abdominal radiograph shows dilated loops of small bowel suggestive of ileus. She has a low volume of bloody stool that is positive for Clostridium difficile toxin. Gas gangrene with myonecrosis Inflammatory bowel disease Ischemic bowel disease Pseudomembranous enterocolitis Toxic megacolon 51 A study of children living in rural Malawi in Africa reveals a high prevalence of iron deficiency anemia. Pruritus of the skin of their feet as well as cough are additional findings in many of these children. Which of the following parasitic infestations is the most likely cause for these findings Ancylostoma duodenale Ascaris lumbricoides Cryptosporidium parvum Enterobius vermicularis Schistosoma mansoni 52 A 31-year-old woman had increasingly severe diarrhea 1 week after returning from a trip to Central America. The diarrheal illness subsided within 4 weeks, but now she has become febrile and has pain in the right upper quadrant of the abdomen. An abdominal ultrasound scan shows a 10-cm, irregular, partly cystic mass in the right hepatic lobe.

You are on call and a 24-year-old gunshot victim is brought to the operating room acne out purchase line tretinak. The surgeon states that he has to perform an emergent laparotomy to determine the source of bleeding acne young living buy tretinak 10 mg mastercard. The patient is not intubated skin care during winter discount tretinak generic, and the blood pressure is 68/36 mm Hg with a heart rate in the 120s. You are asked to obtain informed consent from a patient for an elective cholecystectomy the following day. When meeting the patient, you find him to be confused about the plan and he repeatedly refers to the hospital as his house. His nurse states that she just met the patient for the first time and that the nurse on the previous shift has already left. Explain the risks and benefits of the anesthetic plan to the patient and obtain his consent. Airway Anatomy the term airway refers to the upper airway-consisting of the nasal and oral cavities, pharynx, larynx, trachea, and principal bronchi. Inferiorly, the trachea measures approximately 15 cm and ends at the carina where it bifurcates into the principal bronchi. The superior laryngeal nerve (branch of vagus nerve X) supplies sensation from the underside of the epiglottis to the surface of the vocal cords and motor innervation to the cricothyroid muscle. The recurrent laryngeal nerve, also a branch of the vagus nerve (cranial nerve X), supplies motor innervation to the remaining muscles of the larynx and sensation to the mucosal surface of the larynx and trachea (Table 20-1;. The glottic opening is the narrowest portion of the airway in infants, children and adults. Patient History and Physical Examination Airway management always begins with a thorough airway-relevant history, including a search for documentation of airway-related events during previous anesthetics. Signs and symptoms related to potentially difficult airway management including aspiration risk should be sought (Table 20-2), as many congenital and acquired syndromes are associated with difficult airway management (Table 20-3). Unfortunately, efforts to identify attributes that place patients at high risk for difficult laryngoscopy have been only modestly successful (Table 20-5) (1). Preoxygenation Preoxygenation (also termed denitrogenation) should be practiced in all cases when time allows. Under ideal conditions, a healthy patient breathing room air (fraction of inspired oxygen [FiO2] = 0. The dashed lines are nerve branches within the laryngeal-tracheal tree from the branches of the glossopharyngeal and vagus cranial nerves. In the same patient, several minutes of preoxygenation with 100% oxygen (O2) via a tight-fitting facemask may support 8 minutes of apnea before desaturation occurs. Patients with pulmonary disease, obesity, or conditions affecting metabolism frequently evidence desaturation sooner, owing to increased O2 extraction, decreased functional residual capacity, or rightto-left transpulmonary shunting. The most common reason for suboptimal preoxygenation is a loose-fitting mask, which allows entrainment of room air. Air leak around the edges of the mask can be prevented by gentle downward pressure. A two-handed grip or an elastic "mask strap" may be used to complement the left-hand grip. Patient Positioning Appropriate positioning of the patient is paramount for delivering positive pressure ventilation via facemask. With the patient supine, "ramped" or in reverse Trendelenburg position, the neck is flexed by 35 degrees and the head extended by 15 degrees. This sniffing position improves mask ventilation by anteriorizing the base of the tongue and the epiglottis. Difficult Mask Ventilation Table 20-6 describes five independent clinical predictors for difficult mask ventilation (2). Normally, no more than 20 to 25 cm water (H2O) pressure in the anesthesia circuit (created by squeezing the reservoir bag) is needed to inflate the lungs.

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Syndromes

• Sed rate (ESR)
• Chemotherapy use
• Hemoglobin electrophoresis
• Aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, Motrin, Advil, or Aleve
• Adults: 68 to 855
• Diurone
• Spread of infection in the same area
• Medullary cystic kidney disease

Peak respiratory depression occurs between 3 and 5 minutes after an intravenous dose acne medication reviews tretinak 10 mg low cost. Sufentanil Sufentanil is the most potent opioid commercially available for human use; 5 g of intravenous sufentanil is the analgesic equivalent to 50 g of fentanyl acne hacks cheap 10mg tretinak otc. Alfentanil Alfentanil reaches peak effect rapidly skin care for swimmers 20 mg tretinak for sale, 90 seconds after bolus intravenous dose, and plasma concentrations fall rapidly, similar to remifentanil. In contrast to remifentanil, however, termination of the effect of alfentanil after an infusion (context-sensitive half-time) is comparable to that of sufentanil. The combination of rapid onset of effect after bolus dosing and relatively prolonged termination of effect after an infusion may make alfentanil an attractive anesthetic adjunct during a stimulating surgery in which significant postoperative pain is anticipated. Remifentanil Remifentanil is a potent fentanyl congener characterized by rapid onset (within 90 seconds), short duration (3 minutes), and short context-sensitive half-time (5 minutes). It is metabolized by ester hydrolysis in the blood and tissues and is thus unaffected by hepatic or renal failure. Because it does not accumulate and its termination of effect is so reliable, it is suitable to use as a bolus dose for short, painful procedures performed under sedation, as an infusion for longer sedation procedures, and as an infusion during general anesthesia. It is an eminently titratable drug and allows the anesthesiologist to respond effectively to changing levels of surgical stimulation. Its very short context-sensitive half-time will terminate the analgesic effect shortly after the infusion is stopped. Therefore, if postoperative analgesia is required, a longeracting analgesic should be administered instead. Methadone Methadone is available in oral and intravenous forms and is most commonly used in the treatment of opioid addiction because its prolonged pharmacokinetics makes acute withdrawal symptoms unlikely. Reversal Agents and Associated Effects Naloxone is an opioid receptor competitive antagonist with the greatest affinity for the receptor. In the absence of opioid, naloxone administration has 10 Analgesics 183 no effect. In the presence of opioid, naloxone can reverse all clinical effects of opioids when dosed appropriately and is most often used to reverse opioidinduced ventilatory depression. Naloxone is rapidly metabolized in the liver and has a high clearance; thus, its duration of action is usually shorter than the opioid whose effects it is intended to reverse. Patients should be carefully monitored after administration of naloxone for a recurrence of ventilatory depression. Naloxone can cause tachycardia and, rarely, pulmonary edema and even sudden death in previously healthy individuals (14). The mixed opioid agonist-antagonists include nalbuphine, pentazocine, and butorphanol. These "partial agonists" have less abuse potential than opioid agonists but are also less effective at treating pain. They are most commonly used to attenuate side effects of opioids (ventilatory depression, pruritus) while maintaining some analgesia (the partial agonism). Did You Know Naloxone duration of action is usually substantially shorter than the opioids whose effects it is intended to reverse. Nonsteroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy. Effect of perioperative systemic alpha2 agonists on postoperative morphine consumption and pain intensity: Systematic review and meta-analysis of randomized controlled trials. Clinical Pharmacogenetics Implementation Consortium guidelines for cytochrome P450 2D6 genotype and codeine therapy: 2014 update. Naloxone reversal of morphine- and morphine-6-glucuronide-induced respiratory depression in healthy volunteers: A mechanism-based pharmacokinetic-pharmacodynamic modeling study. The time it takes for the plasma concentration of a drug to decrease by 50% after the infusion of the drug is stopped. The time it takes for the plasma concentration of a drug to reach 50% of its steady-state concentration during a constant infusion. The time it takes to increase the plasma concentration of a drug by 50% when the drug infusion rate is doubled. The time it takes to decrease the plasma concentration of a drug by 50% when the drug infusion rate is halved. In a patient weighing 140 kg with a fat free mass (lean body mass) of 70 kg, what would be the modified fat free mass to use for the initial calculation of the infusion rate of remifentanil The potassium ion (K+) channels in the nerve terminal area limit the extent of Ca+2 entry into the terminal and limit the transmitter quantal release, initiating nerve membrane repolarization. Did You Know the precision of the muscle contraction is determined by the number of muscle fibers each neuron innervates.