AFP Journal Review. March 1, 2007. Articles. Preparation of the Cardiac Patient for Noncardiac Surgery Autoimmune Polyglandular Syndrome, Type II Iron Deficiency Anemia Asbestos-Related Lung Disease Erythema Nodosum. Strength of Recommendation Grades.
March 1, 2007
* Generally do not require further pre-op cardiac testing
excellent (> 4 METs)
Poor (<4 METs)
Intermediate or low
surgical risk procedure
Post-op risk stratification and risk factor reduction
Subsequent care dictated by
Findings and tx results
excellent (> 4 METs)
Poor (< 4 METs)
Post-op risk stratification
and risk factor reduction
dictated by findings
Consider delay or
Subsequent care dictated
by findings and treatment
and risk factor modification
Figure 1. Computed tomographic scan of the chest demonstrating severe asbestosis. There is marked parenchymal remodeling and tissue destruction ("honeycombing" [arrow]), leading to restrictive lung disease (forced vital capacity: 56 percent of predicted) and decreased oxygen exchange.
Figure 2. Chest radiograph of a patient with previous asbestos exposure who has developed pleural plaques (arrows)). These plaques are characteristically located symmetrically along the lateral chest wall but also may occur on the domes of the diaphragm.
Irregular diffuse pleural thickening / mass on left
Blunting of costophrenic angle
Loss of left diaphragmatic silhouette
Left hemithorax larger
Classically located on pretibial surface of lower extremity.
1. Which one of the following statements about perioperative risk assessment and intervention in cardiac patients undergoing noncardiac surgery is correct?
A. Emergency surgery should be delayed until a formal risk stratification can be completed.
B. Most patients will benefit from beta blockade or alpha agonists.
C. Functional status and exercise tolerance are important factors in decision making.
D. There is strong evidence from prospective trials that starting a statin before surgery improves outcomes.
2. Which one of the following medications has been shown in prospective trials to improve outcomes in high-risk perioperative patients?
A. Calcium channel blockers.
C. Beta blockers.
3. Which one of the following statements about treatment of autoimmune polyglandular syndrome, type II is correct?
A. To avoid precipitating adrenal crisis, thyroid hormone therapy should be given before treating adrenal insufficiency.
B. Cortisone usually can be tapered over weeks to months.
C. Dexamethasone (Decadron) should be avoided because it interferes with steroid measurement during adrenocorticotropic hormone testing.
D. Fludrocortisone (Florinef) should be used to treat primary adrenal insufficiency.
4. Which one of the following groups is at highest risk of iron deficiency anemia?
A. Non-Hispanic white women.
B. Men 70 years and older.
C. Black women.
D. Mexican women living in the United States.
5. Which of the following is the preferred initial diagnostic test in women with a low mean corpuscular volume and suspected iron deficiency anemia?
A. Serum iron.
B. Serum ferritin.
C. Transferrin saturation.
D. Serum transferrin receptor level.
6. Which one of the following is the most common pathologic pulmonary response to asbestos inhalation?
A. Malignant mesothelioma.
B. Pleural effusion.
C. Small cell lung carcinoma.
E. Pleural plaques.
7. Which one of the following statements about asbestosis is correct?
A. It progresses more rapidly than idiopathic pulmonary fibrosis.
B. It often has mild clinical symptoms.
C. Decreased vital capacity typically occurs before decreased diffusion capacity.
D. Honeycombing is an early radiographic manifestation.
E. Lung biopsy is necessary to diagnose asbestosis
8. A 30-year-old woman with a history of Crohn\'s disease presents with diarrhea and skin lesions. Erythema nodosum and a recurrence of inflammatory bowel disease are diagnosed. Which one of the following symptoms best supports a diagnosis of erythema nodosum?
A. Ulcerating lesions on the shin.
B. Painless red nodules.
C. Asymmetric lesions on flexor surface of arms.
D. Healing lesions in some areas with bruise-like appearance.
9. A 25-year-old woman reports fatigue, cough, fever, and joint aches beginning two weeks earlier. She now has painful red nodules on her shins. Which one of the following tests should be performed in the initial work-up for erythema nodosum?
A. Punch biopsy.
B. Antistreptolysin-O titer.
C. Computed tomography of the chest.
D. Blood cultures.
10. According to the 2006 update of the American College of Cardiology/American Heart Association guidelines, perioperative beta blockade is recommended for which of the following groups of patients?
A. High-risk patients undergoing vascular surgery.
B. Low- to moderate-risk patients undergoing non-vascular surgery.
C. Patients currently taking a beta blocker for another indication.
D. Low- to moderate-risk patients undergoing vascular surgery
11. Which of the following statements about the standard cosyntropin (Cortrosyn) test, a diagnostic test for adrenal insufficiency, is/are correct?
A. It can be performed at any time of day.
B. Serum cortisol levels greater than 14 mcg per dL (390 nmol per L) indicate a normal result.
C. The result must be compared with a basal cortisol level.
D. Cortisol levels must be at least double for the test to be considered positive
12. Lower endoscopic evaluation is recommended in which of the following groups of patients with iron deficiency anemia with no obvious benign cause?
A. Men of all ages.
B. Premenopausal women.
C. Postmenopausal women.
D. Infants and children.
13. A 65-year-old man presents with a complaint of dyspnea. His occupational history reveals that for many years he renovated buildings. This work included asbestos removal. Which of the following tests should be included in the initial assessment?
A. High-resolution computed tomography.
B. Chest radiography.
D. Pleural biopsy.