Co-Director, University of Louisville School of Medicine
Adenocarcinoma Hamartoma Large cell carcinoma Mesothelioma Non-Hodgkin lymphoma Squamous cell carcinoma 71 A 59-year-old man who has smoked one pack of cigarettes per day for the past 43 years has developed a severe cough with hemoptysis over the past month cholesterol wine purchase gemfibrozil discount. Bilateral upper lobe cavitation Diaphragmatic pleural calcified plaques Extensive areas of infiltrates Invasive perihilar mass Pneumothorax Subpleural nodule with hilar adenopathy Upper lung nodule with air-fluid level 74 A 40-year-old man has had an increasing cough with hemoptysis for 2 weeks definition of cholesterol and importance cheap gemfibrozil line. His condition improves with antibiotic therapy; however cholesterol triglyceride ratio calculator gemfibrozil 300mg visa, the cough and hemoptysis persist for 2 more weeks. Bronchoscopic examination shows a tan, circumscribed obstructive mass filling a right upper lobe bronchus. Adenocarcinoma Carcinoid tumor Hamartoma Kaposi sarcoma Large cell carcinoma 75 A 24-year-old man has had increasing dyspnea for the past 10 weeks. There is dullness to percussion over the lungs posteriorly and decreased breath sounds. A chest radiograph shows large bilateral pleural effusions and widening of the mediastinum. Thoracentesis is performed on the left side and yields 500 mL of milky white fluid. Laboratory studies of the fluid show a high protein content; microscopy shows many lymphocytes and fat globules. Asbestos Bird dust Coal dust Cotton fibers Ozone Silica 76 A 68-year-old man has had increasing dyspnea with cough productive of frothy sputum for the past 5 months. A chest radiograph shows blunting of costophrenic recesses bilaterally and cardiomegaly with prominent right and left heart borders. Cavitary tuberculosis Congestive heart failure Malignant mesothelioma Non-Hodgkin lymphoma Pneumococcal pneumonia Small cell carcinoma 77 A 78-year-old man has had increasing dyspnea without cough or increased sputum production for the past 4 months. Microscopic examination of a pleural biopsy specimen shows spindle and cuboidal cells that invade adipose tissue. On microscopic examination, the mass is composed of spindle cells resembling fibroblasts with abundant collagenous stroma. Intralobar sequestrations within lung parenchyma typically are diagnosed in childhood in association with recurrent infections. Foregut cysts in the hilum or mediastinum are not connected to airways and can produce a mass effect if large, but most are not. The normal amount of amniotic fluid excludes the oligohydramnios sequence that often leads to pulmonary hypoplasia. The sharp bone can penetrate the pleura and produce an air leak, resulting in pneumothorax. Although pneumothorax can complicate rupture of a bulla in emphysema, this is more likely to occur in paraseptal emphysema or distal acinar emphysema than in centrilobular emphysema with increased anteroposterior diameter. Although pulmonary embolus with V/Q mismatch and pneumonia with patchy infiltrates are possible complications in hospitalized patients, they would not occur this quickly. Pleural space fluid (hydrothorax) and edema are 3 E Resorption atelectasis is most often the result of a mucous or mucopurulent plug obstructing a bronchus. Air in alveoli distal to the obstruction is resorbed and that portion of lung collapses. Compression atelectasis results from accumulation of air or fluid in the pleural cavity, which can happen with a pneumothorax, hemothorax, or pleural effusion. Microatelectasis can occur postoperatively, in diffuse alveolar damage, and in respiratory distress of the newborn from loss of surfactant.
In patients with no history of significant ethanol ingestion cholesterol reducing medication side effects buy discount gemfibrozil on-line, a nonalcoholic steatohepatitis may be considered cholesterol levels results buy discount gemfibrozil 300mg, with obesity cholesterol lab test discount 300mg gemfibrozil fast delivery, diabetes mellitus, or both as possible causes. Excessive acetaminophen ingestion can cause centrilobular necrosis or diffuse necrosis. Aspirin may be associated with a microvesicular steatosis as Reye syndrome in children. Though there may be hepatocyte loss and inflammation, these are not the most prominent features. In this patient, the disease is decompensating, as evidenced by the elevated blood ammonia level. Risk factors of metabolic syndrome and type 2 diabetes mellitus are driven by obesity. Familial hypercholesterolemia mainly drives atherosclerosis, without liver disease. Chronic viral hepatitis may have an element of steatosis, but not marked, and without vascular disease. The iron accumulation of hemochromatosis may produce cardiomyopathy as well as chronic liver disease without much steatosis. Biliary atresia with marked hyperbilirubinemia becomes apparent in the neonatal period. Hepatic venous thrombosis leads to Budd-Chiari syndrome, which is typically a disease of adults that complicates such conditions as polycythemia or pregnancy. Hepatoblastomas may be congenital, but they are mass lesions unlikely to be associated with such marked increases in liver enzymes. Intrahepatic lithiasis is unlikely to occur in children and is unlikely to produce marked increases in liver enzymes. Neonatal giant cell hepatitis can produce findings of acute hepatitis in neonates, not in children. Because performance is primarily correlated with skill and training, the potential gain from muscle mass is problematic, particularly in view of the deleterious effects, such as hepatic cholestatic hepatitis. Chlorpromazine is more likely to produce a pure cholestasis as an idiosyncratic (unpredictable) reaction. Obstructive jaundice with biliary tract lithiasis results in mostly conjugated hyperbilirubinemia. The total bilirubin concentration may be increased in patients with viral hepatitis or cirrhosis and in individuals taking drugs such as oral contraceptives. Although direct and indirect hyperbilirubinemia may occur in these conditions, conjugated hyperbilirubinemia predominates. The microcytic anemia and the blood in the stool suggest gastrointestinal tract hemorrhage, and a colonic adenocarcinoma should be suspected as the primary site for the hepatic metastases in this case. Antiphospholipid syndrome predisposes to thrombosis with venous obstruction, in which case hepatic enzyme levels should be higher, and the partial thromboplastin time should be prolonged. Ascending cholangitis is typically caused by bacteria such as Escherichia coli or Klebsiella, and patients develop acute symptoms of fever, chills, jaundice, and abdominal pain. Chronic alcoholism is not accompanied by an increase in the alkaline phosphatase level, and there is often a macrocytic anemia. Sclerosing cholangitis would increase the bilirubin concentration and the alkaline phosphatase level.
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At autopsy lowering cholesterol with diet change order online gemfibrozil, there is cerebral atrophy in a predominantly frontal and parietal lobe distribution cholesterol medication beginning with a order gemfibrozil 300 mg on line. Microscopic examination of the brain shows numerous neuritic plaques in the hippocampus cholesterol test at the chemist order gemfibrozil 300 mg mastercard, amygdala, and neocortex. Congo red staining shows amyloid in the media of the small peripheral cerebral arteries. Which of the following genetic abnormalities is the most important factor in the development of her disease He wandered about his neighborhood, complaining to the neighbors about everything. On physical examination, there were no motor or sensory deficits and no gait disturbances or tremor. At autopsy, the frontal cortex microscopically shows extensive neuronal loss, and some remaining neurons show intracytoplasmic, faintly eosinophilic, rounded inclusions that stain immunohistochemically for tau protein. Alzheimer disease Huntington disease Leigh disease Multiple system atrophy Parkinson disease Pick disease Vascular dementia 59 A 55-year-old man has had increasing difficulty with initiation of voluntary movements and increasing inability to perform activities of daily living for 1 year. On physical examination, he has difficulty initiating movement, but he can keep moving if he follows someone walking ahead of him. The left side of the figure shows the gross appearance of the midbrain of this patient; on the right is a section through normal midbrain. What additional clinical feature is most closely associated with this abnormality Ataxia with ambulation Choreiform movements Loss of short-term memory Symmetric weakness in the extremities Tremor at rest 58 A 60-year-old woman had problems related to movement for 5 years. Physical examination showed cogwheel rigidity of limbs and a festinating gait, which she had difficulty initiating. Two years later, she had difficulty performing activities of daily living and showed marked cognitive decline. Autopsy findings include mild cerebral atrophy and loss of substantia nigra pigmentation. Microscopically, cortical neurons show spheroidal, intraneuronal, cytoplasmic, and eosinophilic inclusions. Immunohistochemical staining for which of the following proteins is most likely to be positive in these inclusions She is disturbed and depressed by these developments because her mother and brother died 5 years after experiencing the same symptoms. Which of the following genetic abnormalities is most likely to be present in this woman On physical examination, she showed difficulty with balance while walking, dysarthria, poor hand coordination, absent deep tendon reflexes, and a bilateral Babinski sign. Over the next 5 years, she developed congestive heart failure from hypertrophic cardiomyopathy. At autopsy, there was increased perinuclear iron deposition within cardiac myocytes. Which of the following genetic abnormalities with trinucleotide repeat expansions was most likely present in this patient He comes to the emergency department following a generalized tonic-clonic seizure. Diffuse large B-cell lymphoma Glioblastoma Hemangioblastoma Medulloblastoma Pilocytic astrocytoma 62 A 36-year-old man who had been healthy all his life now has progressive, symmetric muscular weakness. A year ago, he noted weakness in the area of the head and neck, which caused difficulty with speech, eye movements, and swallowing. In the past year, the weakness in the upper and lower extremities has increased, and he can no longer stand, walk, or feed himself.
Current recommendations from the American Heart Association/American College of Cardiology call for postponing elective surgery for a minimum of 4 weeks after placement of a bare-metal stent and 12 months after placement of a drug-eluting stent (Figure 16-2) cholesterol nutrition facts order gemfibrozil canada. However cholesterol low eggs generic 300mg gemfibrozil fast delivery, recent evidence suggests the risk of adverse events after placement of a drug-eluting stent may stabilize after 6 months cholesterol test fasting australia buy discount gemfibrozil line. Whenever possible, dual antiplatelet therapy, or at least aspirin, should be continued throughout the perioperative period. For most implantable cardioverter defibrillators, external application of a magnet will disable tachycardic therapy but will have no effect on pacemaker settings. When the site of surgery is more than 6 inches from the pacemaker, application of a magnet is unnecessary. Table 16-8 Important Information to be Determined about Cardiovascular Implantable Electronic Devices during the Preanesthetic Evaluation Reason for placement Device type, manufacturer, model Date of last interrogation and results (6 months for defibrillator, 12 months for pacemaker) Is the patient pacemaker dependent Hypertension Induction of anesthesia results in sympathetic stimulation that manifests as a rise in blood pressure of about 20 to 30 mm Hg and heart rate of about 15 to 20 beats per minute. This response is exaggerated in patients with preexisting hypertension, especially those who are untreated or poorly controlled with medications. Patients with undiagnosed hypertension are also more likely to exhibit intraoperative blood pressure lability. Whether to postpone elective surgery in patients with poorly controlled hypertension is controversial. Pulmonary Disease Postoperative pulmonary complications occur significantly more often than cardiac complications in an estimated 5% to 10% of surgeries. The risk of their occurrence is related to both patient and surgical factors (Table 16-9). This includes atelectasis, pneumonia, prolonged mechanical ventilation, exacerbation of underlying lung disease, and bronchospasm. Patient Factors As expected, patients with pre-existing lung disease, including obstructive diseases such as asthma or chronic obstructive pulmonary disease, and restrictive diseases such as pulmonary fibrosis, have an increased risk of pulmonary complications compared with healthy adults. Evidence is conflicting as to the magnitude of this increased risk, and, in general, there is no level of pulmonary dysfunction for which elective surgery is contraindicated, so long as the patient is medically optimized. Smoking Tobacco and nicotine increase sputum production, reduce ciliary function, stimulate the cardiovascular system, and increase carboxyhemoglobin levels. Although smoking cessation for as little as 2 days decreases carboxyhemoglobin levels and improves mucociliary clearance, most studies suggest it takes at least 8 weeks of smoking cessation to reduce the rate of postoperative pulmonary complications. Physical signs include body mass index >25 kg/m2, neck circumference >17 inches in men or >16 inches in women, and tonsillar hyperplasia (Table 16-10). Postoperatively, these patients may require monitoring in a setting with continuous pulse oximetry. If outpatient surgery is planned, discharge should be delayed until postoperative respiratory function has returned to baseline. When possible, it is useful to minimize the use of opioids in favor of nonnarcotic analgesics. Surgical Factors the site of surgery is the most important factor related to the risk of developing pulmonary complications postoperatively. Patients having thoracic and upper abdominal surgeries are far more likely to suffer pulmonary complications relative to those having lower abdominal or extremity procedures. Abdominal aortic aneurysm repair, head and neck surgery, and neurosurgical procedures are also associated with a higher risk of pulmonary complications relative to other surgeries.
