NMS Q&A Family Medicine

234 NMS Q&A Family Medicine17. The answer is C. Perform carotid endarterectomyfollowed by VSD repair. The main point to be made is thatthe carotid stenosis is not only severe enough to indicate arepair but also that the repair became more urgent whenthe carotid stenosis became symptomatic (ipsilateral quadrantanopia,a variant of amaurosis fugax). Althoughthere is less than a 1% chance of stroke fatality after noncardiacsurgery, it occurs in up to 6% of cases after cardiacsurgery. Such perioperative stroke carries up to a 22%mortality rate. If both cardiac surgery and carotid endarterectomyare indicated, the first to be performed is a matterof judgment. In the vignette, the carotid procedurebecame more urgent with the advent of the symptom.The cardiac condition, with concentric hypertrophy, mustbe repaired as well, but it does not represent decompensationsuch as would be manifested by systolic dysfunction.18. The answer is D. Dialysis within 24 hours andelectrolytes studies just before surgery. Patients on renaldialysis exhibit a 20% to 30% risk of postoperative hyperkalemiarequiring emergency dialysis. Another complicationparticularly likely in such patients is fluid overload, acondition amenable to timely dialysis. Other problemsseen at a rate greater than in patients not on dialysisinclude pneumonia and bleeding.19. The answer is C. Measure of 2 g/dL is one of thedefinitions of severe malnutrition. Others are a recentweight loss of 20 lb (9 kg); transferrin 100 mg/dL;prealbumin 7 mg/dL; and absolute lymphocyte count1,000 cells/mm 3 . A serum albumin level 3.5 (3) g/dLis considered mildly malnourished and a level of 3 but2 is considered moderately malnourished, assuming nospecial circumstances to account for the measurement asan isolated finding.20. The answer is A. Measure of 35 kcal/kg, of which20% should be protein, is the minimum caloric (and percentageprotein) oral intake criterion that the physicianshould expect from the patient before ruling out at leastoral supplementation given preoperatively.21. The answer is A. Lymph node biopsy in the neck areais considered a “clean” procedure as long as it does notinvolve entering the foregut or other part of the gastrointestinaltract. Any procedure that enters the gastrointestinaltract, the urinary tract, the respiratory tract, or biliarytract, or any procedure that involves operating on aninflamed area, requires prophylactic antibiotics.22. The answer is C. Surprisingly, patients with hypertrophiccardiomyopathy warrant preoperative antibioticprophylaxis against bacterial endocarditis. In none of theother conditions is prophylactic antibiotic indicated . Otherindications (not presented as choices here) are not surprisingand include the presence of prosthetic cardiacvalves, previous bacterial endocarditis, rheumatic andother valvular dysfunction, and the presence of significantcongenital cardiac malformations, even if they have beenrepaired.ReferencesAdler JS , Goldman L . Preoperative evaluation and perioperativemanagement . In: Tierney LM , McPhee SJ , Papadakis MA , eds.Current Medical Diagnosis and Treatment . 45th ed . New York :McGraw-Hill/Appleton & Lange ; 2006 : 35 – 49 .Friedman LS . Liver, biliary tract and pancreas . In: Tierney LM ,McPhee SJ , Papadakis MA , eds. Current Medical Diagnosisand Treatment . 45th ed . New York : McGraw-Hill / Appleton &Lange ; 2006 :649–701.Vanderhoff BT . Preoperative clearance and preparation . In:Rudy DR , Kurowski K , eds. Family Medicine: House OfficerSeries . Baltimore : Williams & Wilkins ; 1997 : 617 – 636 .