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A 53-year-old male is emergently brought to the operating room for repair of a bleeding gastric ulcer. The patient is sedated from a previous upper endoscopy performed to diagnose the bleeding. The patient weighs 133 kg, has a bull neck, and has a known difficult airway. The patient’s heart rate is 140 and his blood pressure is 90/60 mm Hg. He is breathing spontaneously and has an oxygen saturation of 94% on room air. The surgeon is waiting. What is your plan?
A 57-year-old female is scheduled for an urgent appendectomy. She is on vacation. She reports that 3 years ago she had a cardiac transplant in her home state. She reports feeling well now, and that she is seen regularly for all of her required follow-up appointments. What further information would you like? What testing or labs would you like? How does her cardiac transplant affect your anesthetic?
You are taking care of a 24-year-old female, G1P0, for a cesarean section. Her epidural has been dosed with 20 mL of 2% lidocaine plus 1:200,000 of epinephrine. She had adequate prenatal care and had been laboring without progression for the previous 20 hours. When the baby is delivered, the child makes no sound and no attempts at breathing. The nurses turn to you for help. What will you do? Can you leave the mother to attend to the baby? Who do you have the ultimate responsibility to care for? Assuming you get a colleague to help care for the mother, how would you evaluate and resuscitate the baby?
A 27-year-old male presents to the operating room after falling off scaffolding at a concert 3 hours ago. He is having his left tibia repaired. He denies any other injury. His toxicology screen is positive for alcohol and cocaine. What would be an acceptable evaluation of his cervical spine?
Three days after a reportedly uneventful bilateral mastectomy, the patient’s bilirubin is 7 mg/dL and she appears jaundiced. The patient is told that her jaundice is due to her anesthesia, and is referred to you to evaluate. How do you approach the patient? What do you say to the patient? What do you say to the surgeon? What tests or exams do you order? What are the management options available?
A 50-year-old female complains of persistent nausea and vomiting 5 hours after the drainage of a subhepatic abscess under general anesthesia. How will you proceed? What is your workup plan? What is your treatment plan?
A 60-year-old woman presents to the emergency department with a history of “the worst headache of her life.” Paramedics report that although she is presently drowsy, she did briefly lose consciousness in the ambulance. Her blood pressure is 175/80 mm Hg with a heart rate of 60. Her other vital signs are all stable. A CT scan reveals a grade 3 subarachnoid hemorrhage (SAH). The neurosurgical team posts the case as an aneurysm clipping scheduled for the following morning. What are your concerns? How will you evaluate the patient? How will you induce and maintain general anesthesia in this patient?
A 68-year-old female, 231 lb. and 5’1” tall, with a history of hypertension, diabetes mellitus, and large joint chronic arthritis, is scheduled for a laparoscopic cholecystectomy. The patient is noncompliant with her medication: atenolol and glyburide. On the morning of the surgery, the patient’s blood pressure was 145/86 mm Hg, heart rate (HR) 88, respiratory rate (RR) 20, oxygen saturation 97% on room air, and temperature 36.8 °C. Her blood glucose was 186 mg/dL. Physical examination revealed no abnormalities, and the airway was assessed as a Mallampati class II. After a smooth induction of general anesthesia with midazolam, fentanyl, propofol, and rocuronium, a #7.0 endotracheal tube was placed atraumatically. Anesthesia was maintained with mechanical ventilation, isoflurane, oxygen, air, fentanyl boluses, and rocuronium. About 30 minutes after the incision, the patient’s HR increased to 112 beats/min and her blood pressure became 184/99 mm Hg. The anesthesiologist also noticed a depression of the ST segment in the monitored V5 cardiac lead.
A 7-year-old male is scheduled for a herniorrhaphy. The child has no prior medical history. Per his parents, he had a previous tonsillectomy with no complications at age 2. He is adopted, so no family history is available. He has a mask induction with sevoflurane. After induction, an intravenous (IV) line is placed. Twenty minutes into the case the resident notes some mild tachycardia and a slowly increasing end-tidal CO2 (ETCO2). What are you concerned about? What tests would you order? Assuming this is malignant hyperthermia (MH), how would you treat it?
A 24-year-old male professional recording artist presents to an otolaryngologist with the complaint of hoarseness. On exam he was found to have vocal cord nodules and a laser laryngoscopy was scheduled. This patient has no significant medical history. His surgical history is significant for a tonsillectomy and adenoidectomy as a child under general anesthesia without any complications. What type of laser may be used? What safety precautions will be necessary in the operating room?
A 47-year-old female presents for an open reduction and internal fixation (ORIF) of the left femur after an automobile accident. Her past medical history is significant for hypertension. She has been a one-pack-per-day smoker for the past 20 years. The patient’s oxygen saturation is 93% on 2 L nasal cannula. What pre-operative tests would you like? Why? How will her low oxygen saturation affect your anesthetic plan?
A 25-year-old female, G2P1, in labor has a cervix dilated to 6 cm. You have placed an epidural and are verifying the level when the obstetrical resident comes in to rupture the patient’s membranes. Upon rupture, the fetal heart rate drops suddenly. The obstetrical resident notes that she can now feel the umbilical cord. What is the diagnosis? What is your anesthetic plan for this emergent cesarean section?
A 19-year-old male presents to the emergency room after falling two stories from a balcony. He is confused and agitated. His blood pressure is 198/99 mm Hg and his heart rate is 110 beats/min. The emergency medical services reports that the patient had one episode of emesis during his transport to the hospital. On examination his pupils are dilated. How do you determine whether the patient’s intracranial pressure (ICP) is increased? Why is it important to know? If elevated, what steps would you take to reduce ICP?
You are called to evaluate a patient on the floor who underwent a carotid endarterectomy earlier in the day. She is 68 years old, with a history of coronary artery disease, hypertension, and chronic obstructive pulmonary disease. Upon entering the room, you notice that she has significant neck swelling over the incision site. She also seems anxious and is unable to speak in full sentences. You apply a face mask/Ambu bag and have difficulty ventilating. What do you do next? Do you attempt to intubate, or do you open the wound?
A 22-year-old female presents to labor and delivery at 34 weeks’ gestation. She reports bleeding for several hours. She has mild abdominal tenderness. A toxicology screen is positive for cocaine. Would you recommend regional or general anesthetic for her cesarean section?
A 47-year-old male is scheduled for a cadaveric kidney transplant. He is due for hemodialysis today. His last hemodialysis was 2 days ago. An EKG, chest X-ray, and labs are sent. He is complaining of chest pressure and tightness. He last ate 8 hours ago. What are your primary anesthetic concerns? Does it matter when his last dialysis was? His potassium (K+) is 6.1 mEq/L. Does this change your anesthetic? The EKG and chest X-ray show left ventricular hypertrophy. Does that affect your management? Do you consider the patient to be NPO since he last ate 8 hours ago? Assuming you proceed with the surgery, what monitors will you use? Would you use general or regional anesthetic? What is your plan for the maintenance of anesthesia?