Case Synopsis A 79-year-old man presents with C1 and odontoid fractures sustained in a fall down stairs while he was intoxicated. He was found at the bottom of the stairs 2 days after the injury. In addition to alcoholism, the patient has a history of hypertension and smokes one to two packs of cigarettes per day. The patient is not oriented to time, place, or person…
Case Scenario Mrs. R, a 45-year-old woman, was admitted to the hospital pregnant with her fourth child. She was delivered of her daughter the next day but suffered hemorrhagic complications related to placenta accreta. Because of her religious beliefs, Mrs. R had refused blood transfusion. Nevertheless, when Mrs. R had lost approximately 80% of her blood volume, physicians first sought legal counsel and then after a…
Case Synopsis A 55-year-old man with severe chronic obstructive airway disease and steroid dependence is taken to the operating room emergently for an acute abdomen due to a perforated colonic diverticulum. The patient has been maintained on 10 mg of prednisone per day for the past year. Intraoperatively, he demonstrates hemodynamic instability requiring large-volume fluid resuscitation and the use of vasopressors. Postoperatively, he is transferred to…
Case Synopsis A 35-year-old man sustains a gunshot wound to the abdomen. He is taken emergently to the operating room where he is found to have a perforated colon with stool and pus in the abdomen. He undergoes a partial colectomy and colostomy. Throughout the surgery he becomes progressively more tachycardic and hypotensive requiring large-volume resuscitation and the initiation of vasopressors and invasive hemodynamic monitoring. At…
Case Synopsis A 50-year-old African American woman with known pulmonary sarcoidosis, stage III, is to undergo a thoracotomy for resection of a right upper lobe aspergilloma. Chronically, she has a hoarse voice, dyspnea at rest, and swollen ankles. She is receiving corticosteroids and ambulatory oxygen therapy at a rate of 2 L She complains of palpitations and fainting spells. Problem Analysis Definition Sarcoidosis is a systemic…
Case Synopsis A 65-year-old man is admitted for a colon resection for a nonobstructing cancer. He had a myocardial infarction 4 months ago with placement of a drug-eluting stent. He has been asymptomatic since the stent placement. The patient is currently taking clopidogrel and aspirin, as well as atenolol for his hypertension. Surgery is scheduled for 7 days from now. The anesthetic management of a patient…
Case Synopsis 1 A 64 – year-old man with low activity tolerance, a history of hypertension, obesity, and vague episodes of epigastric discomfort is scheduled for elective open partial colectomy. No preoperative electrocardiogram is obtained. The patient subsequently sustains a perioperative myocardial infarction secondary to undiagnosed coronary artery disease. Case Synopsis 2 A 73-year-old woman who is taking several diuretic medications is scheduled for elective hip…
Case Synopsis A 25-year-old male athlete presents for repair of the anterior cruciate ligament of his knee. He is currently not on any medications. He has a negative personal and family history of abnormal clotting or bleeding or easy bruising. Multiple tests, including prothrombin time and partial thromboplastin time (PTT), are ordered. The PTT results are reported as above normal. The surgery is postponed, and an…
Case Synopsis A 36-year-old woman with a history of intermittent abdominal pain was scheduled for elective laparoscopic cholecystectomy. Anesthesia and surgery were uneventful. On the first postoperative day, the patient was noted to be restless and was complaining of severe abdominal pain and vomiting. Her vital signs were heart rate 124 beats per minute, blood pressure 184/102 mm Hg, temperature 37.5° C, and respiratory rate 20…
Case Synopsis An 8-month-old boy undergoes myringotomy tube removal. Previous general anesthesia for tube placement was uneventful. Anesthesia is induced with intravenous thiopental and is maintained with nitrous oxide, halothane, and oxygen via a facemask. After removal of the myringotomy tube, the surgeon decides to perform an adenoidectomy. Airway obstruction at this time necessitates emergency intubation. After succinylcholine 2 mg/kg intravenously, an increase in masseter muscle…
Case Synopsis A 33-year-old woman presents for a partial mastectomy and axillary lymph node biopsy. She has a history of seizure disorder well controlled on levetiracetam and mild asthma requiring occasional rescue with an albuterol inhaler. Her physical examination is normal. Problem Analysis You’re Reading a Preview Become a Clinical Tree membership for Full access and enjoy Unlimited articles Become membership If you are a member.…
Case Synopsis A 55-year-old man with a Medtronic Micra Leadless pacemaker (programmed VVIR) undergoes right total hip arthroplasty under general anesthesia. His past medical history is significant for atrial fibrillation and complete heart block. In the operating room the anesthesiologist intends to temporarily program the pacemaker to an asynchronous pacing mode (i.e., VOO) by applying a magnet. Before the start of surgery the nurse places the…
Case Synopsis A physician’s husband has undergone partial nephrectomy at her hospital for a suspicious lesion in his left kidney. The surgery was complicated by fever and acute renal failure. While on call one evening, curious to see how her friend’s husband is doing, an anesthesiologist accesses the patient’s electronic medical record. In the course of reading about the patient’s progress, the anesthesiologist comes across a…
Case Synopsis A 22-year-old woman, 154 cm tall and weighing 44.2 kg, presents with a 4-month history of myasthenia gravis and mild generalized weakness (Myasthenia Gravis Foundation of America’s class IIA). The diagnosis is confirmed by the patient’s rapid improvement after the administration of intravenous edrophonium chloride and by the presence of antibodies to acetylcholine receptors (12.3 nmol/L; reference value <0.25 nmol/L). Nerve conductions and electromyography…
Case Synopsis A 58-year-old man with past medical history significant for poorly controlled hypertension, diabetes, and an active 30 pack-year smoking history presented to the operating room (OR) in cardiogenic shock following a failed emergency percutaneous coronary intervention (PCI). An intraaortic balloon pump (IABP) was emergently placed via the right femoral artery, and he was intubated before OR transfer for ongoing hemodynamic instability and pulmonary edema.…
Case Synopsis A 53-year-old woman with a long history of hypothyroidism and tobacco abuse presents to the emergency department with generalized weakness, lethargy, mild shortness of breath, edema of her lower extremities, constipation, and slow speech. She admits to stopping her thyroid replacement 2 years ago. Her current medication list includes only Flonase and Metamucil. Her physical examination is significant for hypothermia, lethargy, bradylalia, dry mucosa,…
Case Synopsis A 32-year-old woman undergoes emergent general anesthesia maintained with 1.2% isoflurane for fixation of a compound humeral fracture. Preoperative history is significant for anxiety and intolerance to heat. Physical examination is noteworthy for periorbital swelling; warm, moist skin with sweaty palms; and a noticeable midline lower neck mass consistent with an enlarged thyroid. Thirty minutes after induction, sinus tachycardia (128 beats per minute) with…
Case Synopsis A 27-year-old woman, at a gestational age of 37 weeks, is currently 4 cm cervical dilation and undergoing an induction of labor for worsening preeclampsia. Her blood pressure (BP) is 150/100 mm Hg after several doses of intravenous (IV) labetalol and she has 4+ patellar reflexes, right upper quadrant tenderness, and 4+ proteinuria. Her platelet count was 135,000/mm 3 on admission, but has decreased…
Case Synopsis A 34-year-old woman with known human immunodeficiency virus (HIV) infection and a recent diagnosis of acquired immunodeficiency syndrome (AIDS) with Pneumocystis jirovecii (previously carinii ) pneumonia presents for elective cesarean section at 38 weeks’ gestation. She has not been followed by health care clinicians during her pregnancy and has not been taking antiretroviral therapy. She is very short of breath and has a dry…
Case Synopsis A 95-kg, 70-year-old man is scheduled to have a left internal carotid endarterectomy. He takes amlodipine (5 mg/day) and irbesartan (150 mg/day), an angiotensin II receptor antagonist, for hypertension. He took his usual doses of both medications on the morning of surgery. Preoperative tests included a transthoracic echocardiogram that showed normal left ventricular systolic function and septal hypertrophy. Blood pressure and heart rate immediately…