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Iron deficiency affects the heme portion of hemoglobin, leading to hypochromia and to microcytosis. When examined 2 days later, an annular 7-cm lesion has slightly elevated, peripheral erythema with overlying scale. The characteristic features are: mild proteinuria, haematuria, oedema and mild hypertension. Congestive heart failure can lead to acute tubular injury, but it is not associated with a rash or proteinuria. Without additional cellular proliferative features, this is not likely to be a neoplasm. Which of the following laboratory tests should be performed on this patient in the immediate postoperative period On physical examination, she is hypotensive and tachycardic with deep, rapid, labored respirations. Practical Considerations for Perioperative Peripheral Neuropathies There are some practical considerations that should be taken to prevent perioperative peripheral neuropathies. She recovers and hepatic function returns to normal, but spontaneous abortion occurs at 18 weeks. Diabetic neuropathy with decreased sensation increases the risk of repeated trauma, which enhances the risk of ulcerations that cause infection and inflammation that promotes gangrene. Which of the following analytes is most likely to be increased in his in serum or plasma He has cutaneous striae over the lower abdomen and ecchymoses scattered over the extremities. Consequently, decreased vascular absorption facilitates and maintains intraneural local anesthetic uptake. Others, such as dental damage or corneal abrasion, are less common but self-limited or repairable. Both respiratory rate and tidal volume are decreased, with respiratory rate decreases occurring at lower doses of opioids and tidal volume decreases occurring at higher doses. A number of primary glomerular and systemic diseases are characterised by formation of crescents. As a result of rise in portal venous pressure and obstruction in the portal circulation within or outside the liver, the blood tends to bypass the liver and return to the heart by development of porto-systemic collateral channels (or shunts or varices). Notably, the negative isomer of dobutamine begins to stimulate the 1 adrenoceptor at infusion rates >5 g/kg/ min, an action that limits the magnitude of 2 adrenoceptor-mediated vasodilation. Differences in acoustic impedance of a structure relative to its surrounding tissue dictate whether the structure will be visible. Hypocalcaemia due to hypoparathyroidism can develop and may require intravenous calcium supplementation. An increase in carcinoembryonic antigen is seen in some gastrointestinal tract neoplasms, but this patient is young to have such malignancies. Management of an oral hypoglycemic and insulin regimen is of particular concern in the perioperative period, as non per os status significantly impacts exogenous glucose consumption (Table 18-16). Platelet transfusion may be indicated when platelets are decreased as a result of dilution, bleeding, destruction, or sequestration. Hypercholesterolemia would predispose to atherogenesis with coronary artery narrowing and ischemic heart disease. Patients with hyperaldosteronism have low serum potassium levels, and sodium retention occurs. In summary, the sequence of onset and recovery from peripheral nerve block depends on a combination of the topographical arrangement of the nerve fibers within a mixed peripheral nerve and their inherent susceptibility to local anesthetic blockade. The resulting decreased hepcidin-ferroportin interaction allows for increased ferroportin activity, increased iron efflux from enterocytes, giving rise to systemic iron overload in hereditary hemochromatosis. No fibrin split products are detected, and direct and indirect Coombs test results are negative. Clearance is calculated as the volume of distribution times the exiting transfer rate constant.

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It is most likely an invasive squamous cell carcinoma that has infiltrated the subepithelial region. Beta blockers titrated to heart rate and blood pressure are probably recommended for patients undergoing vascular surgery who are at high cardiac risk owing to coronary artery disease or the finding of cardiac ischemia on preoperative testing. Capillary proliferation, hemorrhage, necrosis, and hemosiderin deposition are often found in the mammillary bodies and the periaqueductal gray matter, resulting in paralysis of the extraocular muscles. The findings are similar to those of other viral infections, and serologic testing shows the specific organism. In addition, they are prone to cervical joint instability, which must be taken into consideration during intubation. A hemarthrosis forms with joint trauma and hemorrhage in and around the joint capsule, but does not involve calcification. Therefore, as water diffuses passively out of the cells, the osmolarity of the tubular fluid increases to a maximum at the very tip of the loop of Henle. Half-life (t1/2) combines the concepts of volume of distribution (Vd) and elimination clearance ClE in the following relation: t1/2 = 0. Xanthomas are soft, yellow nodules that may form in the dermis from collections of lipid-laden macrophages in individuals with hyperlipidemia. The enlargement of the spleen in prolonged portal hypertension is called congestive splenomegaly (page 387). Additional criteria exist to determine when patients are "street fit" and ready for discharge from the ambulatory surgery area. This regulates blood flow, glomerular filtration, sodium and water reabsorption, and activity of the renin angiotensin system. On examination he is afebrile and normotensive and has a reduced level of consciousness with aphasia. Microsatellite instability is a feature of Lynch syndrome, also called hereditary nonpolyposis colon cancer syndrome, characterized by right-sided colon cancer and, in some cases, endometrial cancer. Propofol causes decreased systemic arterial pressure on induction, due partially to direct action on vascular smooth muscle. A second line from the greater trochanter of the femur to the sacral hiatus is drawn. Other causes include alcoholic hepatitis, nonacetaminophen drug toxicity, and pregnancy-related hepatic diseases. An 80-year-old female received midazolam 2 mg for premedication for an uneventful 30-minute gynecologic procedure (propofol infusion and fentanyl). Newborns may exhibit withdrawal syndrome from benzodiazepines administered to the mother. Balanitis Bowen disease Condyloma acuminatum Primary syphilis Soft chancre 13 A 19-year-old man has worsening local pain and irritation with difficult urination over the past 3 years. Like regional and local anesthesia, use of a laryngeal mask airway instead of endotracheal intubation is reserved for patients undergoing short procedures requiring low insufflation pressures and minimal Trendelenburg. C: Context-sensitive half-time, or time in minutes to a 50% decrease in effect-site concentrations after an infusion is stopped. Meningiomas occur in adults; they are circumscribed, solid mass lesions adjacent to the dura, and may be multiple in neurofibromatosis. Which of the following is the most likely cause of the repeated infections in this child Autopsy findings include hepatosplenomegaly and cardiomegaly, serous effusions in all body cavities, and generalized hydrops. An organizing subdural hematoma would leave a uniform area of compression with flattening of the underlying hemisphere. Most patients need only this focused history and physical examination before undergoing anesthesia. Corynebacterium diphtheriae is the cause of diphtheria, which produces laryngitis with a characteristic dirty gray membrane that may slough and be aspirated. Intravenous boluses or infusions of phenylephrine are most often used intraoperatively for short-term treatment of hypotension resulting from vasodilation. Subsequent trials in civilian settings comparing hypertonic saline to isotonic fluid for resuscitation in trauma patients are sparse in number but have failed to show significant clinical improvement and, in fact, may worsen outcomes. When aerobic glycolysis is stimulated there is a reciprocal decrease in oxidative phosphorylation.

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Congenital myopathies are often named for their characteristic histologic features. There are a variety of superficial fungal infections caused by dermatophytes, such as Tinea corporis producing a scaling plaque. Macrocytosis would accompany a history of chronic alcoholism, probably because of poor diet and folate deficiency. Extensive and severe aspergillosis and candidiasis are more likely to occur with profound neutropenia, not lymphocytopenia. Pursuit of these options usually implies that mask ventilation will not be problemintubation, intubating stylet or tube changer, light wand, and atic. Malignant lymphomas and leiomyosarcomas are less common and tend to form bulky masses in the fundus. Extrinsic factors include direct- and indirect-acting pharmaceutical and recreational drugs, fear, hyperthermia, and others that affect heart rate through modulation of intrinsic factors. Inhibition of guanylate cyclase activity is most likely responsible for true tolerance to organic nitrates. Nocardial and actinomycotic infections often lead to chronic abscesses without significant liquefaction and affect immunocompromised individuals. In typical case, the peritoneal cavity contains blood-stained ascitic fluid and white flecks of fat necrosis in the omentum, mesentery and peripancreatic tissue. Over several hours, the response to sustained elevations in carbon dioxide diminishes as bicarbonate ions are likely transported into the cerebrospinal fluid, neutralizing the stimulating hydrogen ions formed by elevated carbon dioxide levels. Physical examination yields no remarkable findings except for a blood pressure of 174/116 mm Hg. Similar to many paraneoplastic syndromes, it is most often associated with small cell carcinoma of the lung. Over the next 5 years, she developed congestive heart failure from hypertrophic cardiomyopathy. The epididymis and the upper aspect of the right testis have extensive granulomatous inflammation with epithelioid cells, Langhans giant cells, and caseous necrosis. Human papillomavirus infection is associated with condylomata acuminata and with squamous epithelial dysplasias. Psoriasis is an inflammatory dermatosis that can be associated with underlying arthritis, myopathy, enteropathy, or atherosclerotic heart disease. Which of the following conditions most likely predisposed him to development of these recurrent lesions Candida albicans infection Circumcision Human papillomavirus infection Neisseria gonorrhoeae infection Paraphimosis Phimosis 18 An 18-year-old man comes to his physician for a routine health maintenance examination. Echocardiography reveals mitral valve prolapse and an aneurysm in his ascending aorta. Did You Know Maintenance of sufficient intravascular volume to support organ perfusion, tissue oxygenation, and aerobic metabolism is the chief goal of perioperative fluid administration. Its primary purpose is to enable rapid filling of a deflated rebreathing bag or ventilator bellows. Lymphocyte depletion Lymphocyte predominance Lymphocyte rich Mixed cellularity Nodular sclerosis 41 A 29-year-old woman has experienced fatigue, fever, night sweats, and painless lumps in the right side of her neck for the past 3 months. Bronchoalveolar lavage is performed, and microscopic examination of the fluid shows narrow branching septate hyphae. Postoperatively, intravenous fluids should be limited and oral hydration resumed as soon as possible. Lichen planus in the oral cavity usually appears with similar skin lesions; it forms whitish patches that may ulcerate. Aldosterone is increased with increased renin and angiotensin production and leads to reduced sodium excretion. Additionally, some medications with known rebound side effects when withdrawn abruptly.

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A Congenital malformation of the bronchial walls B Damage to bronchial mucosa by major basic protein of eosinophils C Diffuse infiltration by bronchogenic carcinoma D Recurrent inflammation with bronchial wall destruction E Unopposed action of neutrophil-derived elastase on bronchi 19 A study of persons with atopic asthma reveals that they develop pathologic changes in their airways with repeated bouts. Except in emergent circumstances, hypernatremia should not be corrected more quickly than 0. In patients with mutations in the ryanodine receptor, there is impaired reuptake of calcium into the sarcoplasmic reticulum with increased intracellular calcium leading to hypermetabolism. Ferritin levels are markedly increased in hereditary hemochromatosis, in which iron deposition in joints can produce a chronic arthritis similar to osteoarthritis or pseudogout. About 5% of squamous cell carcinomas of the head and neck initially manifest as a nodal metastasis, without an obvious primary site. The commonest site is the fundus, followed next in frequency by the neck of the gallbladder. Tay-Sachs disease of infancy and childhood is caused by a deficiency of hexosaminidase A. Meningiomas most often arise in the cranial cavity and have plump, pink, round to spindle-shaped cells, often with psammoma bodies. The clinical presentation is extremely variable but it should always be considered as a possibility in a patient in whom there is persistent sterile pyouria, microscopic haematuria and mild proteinuria after effective antibiotic therapy for urinary tract infection. A chest radiograph shows bronchial dilation with bronchial wall thickening, focal atelectasis, and areas of hyperinflation; his heart shadow appears mainly on the right. Marfan syndrome does not have abnormal lysosomes, and the vascular disorders are not the result of atherosclerosis accelerated by dietary factors. Medullary carcinomas tend to be large; they account for only about 1% of all breast carcinomas. Short-acting muscle relaxants are preferable in patients with renal disease, and the two agents atracurium and cis-atracurium, which are metabolized by spontaneous nonenzymatic degradation, are the drugs of choice. Lastly, infusions are subject to context-sensitive half-time, meaning the time required for plasma concentrations to decrease after an infusion is stopped. At his age, a common etiologic agent is Neisseria meningitidis, initially presenting as pharyngitis, and untreated proceeding to Waterhouse-Friderichsen syndrome with disseminated intravascular coagulopathy. Since tubular cells have not regained normal functional capacity, the urine is of low or fixed specific gravity. Postoperative nausea and vomiting is more common with etomidate than with propofol or thiopental and it lacks any analgesic properties. Cerebral edema sufficient to produce herniation would cause papilledema, not noted in this case. Tetanus has been studied extensively for durations of 5 seconds, so clinicians should always use 5-second durations to evaluate neuromuscular function. Granulomatous destruction of the adrenal glands suggests disseminated tuberculosis as a cause of Addison disease, which leads to adrenal insufficiency if bilateral, not unilateral. The combination of dyslipidemia, diabetes, and hypertension predisposes obese patients to atherosclerosis and hence coronary and cerebrovascular disease. Prior to peritoneal access, the stomach and bladder are decompressed in order to minimize the likelihood of bowel or bladder injury. Eczema may turn into lichen simplex chronicus if the irritant is not removed and there is considerable scratching and rubbing of itchy lesions. Polypoid cystitis results from inflammation but may mimic a tumor mass, and could obstruct one or both ureteral orifices with hydroureter. Pulmonary changes in 1-antitrypsin deficiency in the form of emphysema are described in Chapter 17. Chlamydia trachomatis Cytomegalovirus Herpes simplex virus Neisseria gonorrhoeae Staphylococcus aureus 2 A 7-year-old child has had worsening performance in school for the past 4 months from decreased vision. The temperance ditty mentioned in the 3 B Chronic irritation is the most likely cause for an "irritation" fibroma of the buccal mucosa, which is due to connective tissue hyperplasia. The lateral femoral cutaneous nerve carries only sensory fibers, so there is no motor disability when it is injured.

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Aspergillus fumigatus Cryptococcus neoformans Plasmodium falciparum Taenia solium Toxoplasma gondii Trypanosoma gambiense 46 A 52-year-old woman with leukemia undergoes chemotherapy. A pancreatic neuroendocrine tumor (islet cell adenoma) secreting insulin could account for hypoglycemia, but not for the other metabolic changes. However, infusions of benzodiazepines for anesthesia are associated with prolonged emergence and are typically used only in patients who are expected to remain intubated. Histologic examination of a biopsy specimen from the lesion shows small, round tumor cells, some of which have eosinophilic straplike cytoplasm. It is formed from low columnar cells that have their apical membranes exposed to the tubular fluid and the basilar aspect in contact with cells of the mesangium and the afferent arteriole. Anemia and thrombocytopenia result from suppression of normal hematopoiesis by the leukemic clone in the marrow. In such cases, an electrically powered piston delivers a tidal volume to the patient. Pain out of proportion to the pathologic findings suggests a somatoform pain disorder, but she does have significant pathologic findings that explain her continued pain. Thymic disorders are common in myasthenia gravis, either thymic hyperplasia or thymoma (as in this case). Clinical manifestations can be mild to severe, and at its extreme, cerebral edema, coma, or seizures may develop. A fall in oxygen saturation measured with a pulse oximeter is most likely to occur most rapidly when the anesthetic is: A. There are a variety of medical professionals who will be encountered on an anesthesia rotation (Table 19-3). For most adults, an initial dose of 2 g is advised; 3 g is recommended for patients weighing 120 kg, and weightbased dosing is used for pediatric patients. The breakdown products of laudanosine and acrylates have no clinical significance. Did You Know Acute hemolytic transfusion reactions most often result from errors made by medical personnel. Cryptococcus neoformans can cause granulomatous disease in immunocompromised individuals. Clinically, there is a predictable progression of sensory and motor function blockade, starting first with loss of temperature sensation, followed by proprioception, motor function, sharp pain, and lastly light touch. The majority of these advanced monitors focus on hemodynamic measurements, including blood pressure, cardiac output, and blood volume. One year later, he continues to have pain in the right leg, and a draining sinus tract has developed in the lateral lower right leg. The deep peroneal nerve provides cutaneous innervation to the web space between the first and second toe and terminates as the second, third, and forth dorsal interosseous nerves. Cushing syndrome with adrenal cortical hyperplasia could lead to hypertension with sodium retention, but she does not have hypokalemia or hyperglycemia. Immunocompromised individuals can have superinfection and dissemination with strongyloidiasis. However, there are several antiemetics available for prevention and treatment that are not sedating and are suitable in the outpatient setting. The nontoxic conjugates that are formed are largely excreted in the urine and bile. Contact dermatitis is one form that occurs following prior exposure and sensitization. Authors of three small studies observed a greater respiratory depressant effect of opioids in women than in men. The number of drops delivered through a calibrated infusor (60 drops = 1 mL) is the number of g/kg/min infused into the patient. To obtain the optimal view of a target nerve, a basic understanding of ultrasound physics is useful. Some patients have gynecomastia caused by androgenic or estrogenic hormone production (or both) by the tumor. Additional risk factors include firstdegree relatives with breast cancer, decreased testicular function, exposure to exogenous estrogens, infertility, obesity, prior benign breast disease, exposure to ionizing radiation, and residency in Western countries. It is lined by squamous epithelium that desquamates keratinaceous debris into the center of the expanding cyst. The following two examples serve to justify how open systems may be intrinsically safer than closed systems.

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Retrolental fibroplasia is a complication of high-dose oxygen therapy for neonates (often premature). Their duration of action, at equivalent doses, is similar (60 to 120 minutes), but onset of action is fastest for edrophonium, intermediate with neostigmine, and longest with pyridostigmine. All of the inhaled anesthetics inhibit hypoxic pulmonary vasoconstriction in animals, producing an intrapulmonary shunt, but their effects in humans during one lung ventilation may be less severe. When deposited in close proximity to a peripheral nerve, what fraction of the administered local anesthetic reaches the actual neural membrane and can participate in voltage-gated Na+ channel blockade Which of the following maneuvers will increase the lipid-soluble fraction of the solution (thereby improving the speed of onset and quality of conduction block) A 72-year-old, otherwise healthy man is scheduled for an open right thoracotomy and right middle lobectomy for a single cancerous lesion. These eventually coalesce into lobular veins, then further on to the four pulmonary veins, two each from left and right lung. For example, age-related autonomic dysfunction in the elderly is often manifest by postural syncope due to reductions in cerebral perfusion pressure and flow. Pulmonary hypoxic vasoconstriction decreases shunt by decreasing perfusion to lung areas with poor ventilation. When congestion is severe, the anoxia can cause centrilobular necrosis with transaminase elevation. This is characterized by fade of responses to repetitive stimulation and amplification of muscle responses after high-frequency stimulation (posttetanic potentiation), similar to nondepolarizing block. Colonoscopy is performed, followed by partial colectomy; the gross appearance of the lesion is shown in the figure. Chronic blood loss and iron deficiency produce a microcytic pattern of anemia, as does dietary iron deficiency. Aortic body chemoreceptors found around the aortic arch also deliver signals regarding partial pressure of oxygen via the vagus nerve. Secondary hyperparathyroidism is seen in patients with chronic renal failure, but the serum phosphorus should be high. The cut surface shows cysts throughout the renal parenchyma varying in size from tiny cysts to 4-5 cm in diameter. Recurrent gonococcal infection indicates that the patient is sexually active and at risk for additional infections, but is not the cause for the condylomata. Did You Know Higher frequency ultrasound probes have less penetration but greater resolution and are therefore useful for visualizing superficial structures including most peripheral nerves. Genetic factors are important in the pathogenesis of atopic asthma and linkage to cytokine genes that map on 5q are strongly associated with development of asthma and other atopic allergies. Hypoparathyroidism: symptoms of hypocalcemia develop within 24 to 48 hours and include laryngospasm. Which of the following histologic findings in the brain of the dog is most likely to be present During the past 3 months, he has had increasing problems with motor function and is now unable to stand or walk. Context-sensitive Half-time the context-sensitive half-time is a more relevant parameter, and it is defined as the time required for plasma drug concentration to decrease by 50% after discontinuing an infusion of a specific duration. Hemolysis is not seen in bioprostheses and is rare in modern mechanical prostheses. It cannot be overemphasized that this convenience comes at the price of complexity. The heart has the highest oxygen extraction ratio of any organ (70%); as a result, under normal conditions the venous oxygen saturation of blood in the coronary sinus (30%) is lower than that in the right atrium (70%). Common sites include ovaries, uterine ligaments, rectovaginal septum, and pelvic peritoneum. The fraction of sodium reabsorbed in the proximal tubule varies according to prevailing conditions (Table 5-2). Anencephaly is the absence of a fetal cranial vault, which leads to absence of most of the brain. Lastly, sympathetic blocking drugs such as labetalol, esmolol, or metoprolol can blunt these hemodynamic responses and may decrease postoperative pain compared with the more commonly used opioids (6). In most institutions, a score of nine or more is needed for transfer into the next phase of recovery. In this case, the skin eruptions, organomegaly, and lesion in the mastoid suggest infiltrates in multiple organs. This catecholamine activates both a1 and b1 adrenoceptors similar to epinephrine, but norepinephrine exerts few if any effects on the 2 adrenoceptor. Conductive heat loss occurs through contact between the patient and the cold operating room table, other equipment, and to the air layer surrounding the skin. Fluid Management Almost all patients receiving general anesthesia will have at least one intravenous catheter inserted.

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Conversely, persons with lymphoid malignancies may develop secondary immunodeficiency, with increased risk for opportunistic infection. Cortical Adenoma Cortical tubular adenomas are more common than other benign renal neoplasms. Regulation of salt-water balance by hormones secreted both intra- and extra-renally. The brown discoloration from hemosiderin deposition in the left anterior frontal lobe suggests a subacute to remote hemorrhage. A mutation in a gene encoding for which of the following is most likely to be present in this girl Hemoglobin electrophoresis reveals decreased Hgb A1 with increased Hgb A2 and Hgb F. Embryonal carcinoma cells are common in nonseminomatous tumors, however, and are often mixed with other cell types. This action increases systolic Ca2+ availability by enhancing transsarcolemmal Ca2+ influx and Ca2+-induced Ca2+ release from the sarcoplasmic reticulum to produce a positive inotropic effect independent of the 1 adrenoceptor. The paravertebral ganglia are organized into right and left sympathetic chains that parallel the length of the thoracolumbar column. In addition, microscopic haematuria and hypertension may be present at the onset or may develop during the course of the disease. Hip flexion >90 degrees results in lateral displacement of the anterior superior iliac spine and stretch of the inguinal ligament. Loss of thyroid hormone from follicular epithelium leads to hypothyroidism typified by modest weight gain, coarse and dry skin, and constipation, but without significant electrolyte disturbances. These combined effects serve to reduce myocardial oxygen demand while simultaneously increasing supply. Glomerular lesions in diabetes mellitus are particularly common and account for majority of abnormal findings referable to the kidney. Both respiratory compensation for primary metabolic disorders, and renal compensation for primary respiratory disorders can occur within minutes. The infant becomes severely hypoxemic 24 hours later, and seizure activity is observed. Once drug reaches the capillary, it can enter tissue by diffusion or active transport. These agents are only available for intravenous administration and are primarily used in treatment of acute coronary syndrome. McArdle disease is an autosomal recessive condition resulting from a deficiency in muscle phosphorylase and does not produce progressive weakness. The inhaled asbestos fibers become encrusted with iron and appear as the characteristic ferruginous bodies with iron stain. Joint hemorrhages are a feature of hemophilia A and B, not von Willebrand disease. It is frequently used in conjunction with general anesthesia because children cannot generally tolerate the needle insertion. A spontaneously breathing anesthetized patient becomes accidently disconnected from the anesthetic circuit and breathes room air. B: Abduction of the arm beyond 90 degrees transitions the neurovascular bundle to where it now lies on the extension side of the shoulder joint. Bilateral adrenal cortical atrophy is typically seen in cases of Addison disease or after long-term exogenous glucocorticoid therapy. This potent neurotoxin disrupts the neuromuscular junction by inhibiting acetylcholine release. Sudden death occurs from hypoxemia or from acute cor pulmonale with right-sided heart failure. Cases of acute tubular necrosis typically occur from toxic or ischemic renal injuries. Coronavirus Corynebacterium diphtheriae Haemophilus influenzae Parainfluenza virus Prevotella intermedia Group A streptococcus 13 A 19-year-old man noted progressive swelling on the left side of his face over the past year.

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Pulse oximeter waveform analysis may also be used to estimate intravascular volume status and volume responsiveness through analysis of the changes in pulse wave contour during the respiratory cycle. In summary, inward positive currents, mediated by Na+ ions, depolarize the membrane, and in contrast, outward positive currents, mediated by K+ ions, repolarize the membrane. Acute cholecystitis can produce severe abdominal pain, but bloody diarrhea and absence of bowel sounds (paralytic ileus) are unlikely. They are treated as if they have systemic disease; some chemotherapy protocols afford benefit for 1 year or more, but cure is uncommon. Thus, it is characterized by a relatively slower onset compared with that of lidocaine, but it has an extended duration of action. Some of these individuals develop progressive loss of vision characterized initially by diffuse deposits in Bruch membrane and by atrophy of retinal pigment epithelium. Some drugs are sufficiently hydrophilic to be excreted via passive filtration or active transport unchanged by the kidneys. Platelet production is normal, but platelets are consumed by widespread thrombosis of small vessels. Diffuse alveolar damage is an acute restrictive lung disease from a severe underlying injury, such as sepsis. Neurologic Monitoring Monitoring the electrical activity of the brain via a processed electroencephalogram. The gross appearance of the lung shown in the figure is representative of her disease. In this patient, the disease is decompensating, as evidenced by the elevated blood ammonia level. A squamous cell carcinoma continues to grow irregularly, invade adjacent tissues, and ulcerate. Posterior urethral valves produce bladder outlet obstruction in utero, with oligohydramnios. Mitoxantrone, an antineoplastic agent, reduces lymphocyte counts to delay progression to secondary degenerative phase. Iron deficiency anemia is typically microcytic and hypochromic, but could be partially masked here by reticulocytosis, which would not be as marked if iron were not available, but his diet is supplying needed iron. There is no serosal barrier above the diaphragm, so esophageal contents spill into the chest cavity, producing marked mediastinitis that is hard to treat. Aggressive, can be cured by chemotherapy Aggressive, often spreads to liver, spleen, and marrow Aggressive, often transforms to acute leukemia Indolent, can be cured by chemotherapy Indolent, often undergoes spontaneous remission Indolent, survival of 7 to 9 years without treatment 25 A 9-year-old boy living in Uganda has had increasing pain and swelling on the right side of his face over the past 8 months. Smokers are most likely to develop squamous cell carcinomas and small cell anaplastic carcinomas. As expected, based on this unique adrenergic receptor pharmacology, dobutamine enhances myocardial contractility and modestly reduces arterial vasomotor tone through activation of 1 and 2 adrenoceptors, respectively. The mass is surgically removed; the figure shows the gross features of a section of the excised mass. Chronic myelogenous leukemia Hairy cell leukemia Hodgkin lymphoma, lymphocyte depletion type Leukemoid reaction Myelodysplastic syndrome 4 A 23-year-old woman has noticed that she develops a skin rash if she spends prolonged periods outdoors. However, in a fourth of cases there may be an underlying neoplasm, so that local invasion and even metastases are possible. Although flexible scope-aided intubation is a versatile and vital Table 20-11 Common Reasons for Failure of Flexible Scope intubation Lack of provider experience Failure to adequately dry the airway: Antisialagogue underdose, rushed technique Failure to adequately anesthetize the airway (awake patient) Nasal cavity bleeding: Inadequate vasoconstriction/lubrication, rushed technique Obstructing base of tongue: Insufficient tongue displacement (may require jaw thrust/tongue extrusion) Hang-up: Endotracheal tube/scope diameter ratio too large Flexible scope fogging: Suction or oxygen not attached to working channel, cold bronchoscope 20 Airway Management 391 Table 20-12 Criteria for Use of an emergent invasive Airway When all five criteria are met, an emergent invasive airway is indicated: Cannot intubate Cannot ventilate Cannot awaken patient Supraglottic airway has failed Clinically significant hypoxemia technique, there are several pitfalls. Raynaud phenomenon occurs in exposed, colder areas of the body, such as the fingers and toes. Acute haemorrhagic pancreatitis seldom develops into chronic pancreatitis, but instead develops pancreatic pseudocysts following recovery. Beta-blockers should be used in conjunction with alpha-blockers, as predominant beta-blockade can lead to unopposed alpha effect of catecholamines and worsen hypertension (8). Tubular carcinomas of the breast are uncommon, most are less than 1 cm in diameter, and most have small tubular structures in a noncellular stroma. Cultures of the lesions of impetigo usually grow coagulase-positive Staphylococcus aureus or group A -hemolytic streptococcus. Tissue oxygenation requires complex physiologic processes, which may be better elucidated quantitatively when problems arise. At a time when recovery of neuromuscular function is almost complete, administration of even small doses of neostigmine (30 g/kg) may produce upper airway collapse and decrease the activity of the genioglossus muscle, rendering the patient susceptible to aspiration.