Complications of minimally invasive surgery US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Complications of minimally invasive surgery. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Complications of minimally invasive surgery US Medical PG Question 1: A 33-year-old woman comes to the emergency department because of a 1-hour history of severe pelvic pain and nausea. She was diagnosed with a follicular cyst in the left ovary 3 months ago. The cyst was found incidentally during a fertility evaluation. A pelvic ultrasound with Doppler flow shows an enlarged, edematous left ovary with no blood flow. Laparoscopic evaluation shows necrosis of the left ovary, and a left oophorectomy is performed. During the procedure, blunt dissection of the left infundibulopelvic ligament is performed. Which of the following structures is most at risk of injury during this step of the surgery?
- A. Bladder trigone
- B. Uterine artery
- C. Kidney
- D. Ureter (Correct Answer)
Complications of minimally invasive surgery Explanation: ***Ureter***
- The **infundibulopelvic ligament** (also known as the suspensory ligament of the ovary) contains the **ovarian artery and vein** and is in close proximity to the ureter as it crosses the pelvic brim.
- During dissection or clamping of this ligament, especially in an emergency setting or when anatomy is distorted (e.g., by an enlarged ovary or edema), the **ureter** is highly susceptible to injury.
*Bladder trigone*
- The **bladder trigone** is the smooth triangular region at the base of the bladder, formed by the openings of the ureters and the internal urethral orifice.
- It is not directly adjacent to the infundibulopelvic ligament and is therefore at a comparably lower risk of injury during dissection of this ligament.
*Uterine artery*
- The **uterine artery** travels within the cardinal ligament and supplies the uterus; it is located more medially and inferiorly within the broad ligament.
- While important in pelvic surgery, it is not in the immediate vicinity of the infundibulopelvic ligament dissection itself.
*Kidney*
- The **kidneys** are retroperitoneal organs located much higher in the abdominal cavity, far superior to the pelvis.
- They are not at risk of direct injury during pelvic surgery involving the infundibulopelvic ligament.
Complications of minimally invasive surgery US Medical PG Question 2: A 63-year-old woman is brought to the emergency department because of severe abdominal pain and vomiting for 3 hours. She had previous episodes of abdominal pain that lasted for 10–15 minutes and resolved with antacids. She lives with her daughter and grandchildren. She divorced her husband last year. She is alert and oriented. Her temperature is 37.3°C (99.1°F), pulse is 134/min, and blood pressure is 90/70 mm Hg. The abdomen is rigid and diffusely tender. Guarding and rebound tenderness are present. Rectal examination shows a collapsed rectum. Infusion of 0.9% saline is begun and a CT of the abdomen shows intestinal perforation. The surgeon discusses the need for emergent exploratory laparotomy with the patient and she agrees to it. Written informed consent is obtained. While in the holding area awaiting emergent transport to the operating room, she calls for the surgeon and informs him that she no longer wants the surgery. He explains the risks of not performing the surgery to her and she indicates she understands but is adamant about not proceeding with surgery. Which of the following is the most appropriate next step in management?
- A. Consult hospital ethics committee
- B. Obtain consent from the patient's daughter
- C. Obtain consent from the patient's ex-husband
- D. Continue with emergency life-saving surgery
- E. Cancel the surgery (Correct Answer)
Complications of minimally invasive surgery Explanation: ***Cancel the surgery***
- The patient is **alert and oriented** and has indicated she understands the risks of refusing surgery, demonstrating **decision-making capacity**. An adult with intact capacity has the right to refuse medical treatment, even if it is life-saving.
- While the decision may seem medically unwise, **patient autonomy** is a fundamental ethical principle that must be respected once capacity is confirmed.
*Consult hospital ethics committee*
- An ethics committee consultation is typically reserved for situations where there is **uncertainty about a patient's capacity**, a conflict among healthcare providers, or a difficult ethical dilemma where principles of patient care are in clear conflict.
- In this case, the patient's capacity seems clear, and her refusal is unequivocal.
*Obtain consent from the patient's daughter*
- The patient's daughter cannot provide consent for her mother if the mother is **competent and able to make her own decisions**. **Surrogate decision-makers** are only legally authorized when the patient lacks capacity.
- The patient's expressed wishes directly override any potential preferences of her next-of-kin.
*Obtain consent from the patient's ex-husband*
- As the patient is divorced, her ex-husband has **no legal standing** to make medical decisions on her behalf.
- Even if they were still married, a spouse can only act as a surrogate if the patient lacks decision-making capacity.
*Continue with emergency life-saving surgery*
- Performing surgery against a **competent patient's explicit refusal** would be an act of **battery** and a violation of her **autonomy**.
- Even in life-threatening situations, a patient with capacity has the right to refuse treatment.
Complications of minimally invasive surgery US Medical PG Question 3: A 34-year-old woman is recovering in the post-operative unit following a laparoscopic procedure for chronic endometriosis. She had initially presented with complaints of painful menstrual cramps that kept her bedridden most of the day. She also mentioned to her gynecologist that she had been diagnosed with endometriosis 4 years ago, and she could not find a medication or alternative therapeutic measure that helped. Her medical history was significant for surgery she had 6 years ago to remove tumors she had above her kidneys, after which she was prescribed hydrocortisone. An hour after the laparoscopic procedure, she calls the nurse because she is having difficulty breathing. The nurse records her vital signs include: blood pressure 85/55 mm Hg, respirations 20/min, and pulse 115/min. The patient suddenly loses consciousness. Intravenous fluids are started immediately. She gains consciousness, but her blood pressure is unchanged. Which of the following is the most likely cause of the hypotension?
- A. Bleeding profusely through the surgical site
- B. Improper supplementation of steroids (Correct Answer)
- C. Infection involving the suture line
- D. High doses of anesthetic drugs
- E. Loss of fluids during the procedure
Complications of minimally invasive surgery Explanation: ***Improper supplementation of steroids***
- The patient's history of **bilateral adrenalectomy (tumors above kidneys)** for which she was prescribed **hydrocortisone** indicates **adrenal insufficiency**. Stressful events like surgery require an increased dose of steroids, and improper supplementation can lead to an **adrenal crisis**.
- The symptoms of **hypotension, tachycardia, and loss of consciousness** are characteristic of an **adrenal crisis (acute adrenal insufficiency)**, which occurs when the body lacks sufficient cortisol during stress.
*Bleeding profusely through the surgical site*
- While **hemorrhage** can cause hypotension and tachycardia, the patient regained consciousness with IV fluids but her **blood pressure remained unchanged**, which is less typical for isolated blood loss if volume is restored without addressing the underlying cause.
- There is no direct mention of visible bleeding, the prompt only states the patient lost consciousness and her blood pressure is unchanged.
*Infection involving the suture line*
- **Surgical site infections** typically manifest several days post-op, presenting with **fever, erythema, and purulent drainage**, not acute hypotension and loss of consciousness an hour after surgery.
- The immediate post-operative timeline and systemic symptoms are not consistent with a localized wound infection as the primary cause of this acute decline.
*High doses of anesthetic drugs*
- Anesthetic drugs can cause **vasodilation and hypotension**. However, their effects are usually transient and would likely resolve more completely with IV fluids, especially an hour after a laparoscopic procedure.
- If it was due to anesthetic drugs, the patient's blood pressure would likely normalize with fluid administration once the effects of the anesthetic began to wear off, which is not the case here.
*Loss of fluids during the procedure*
- **Fluid loss** during surgery can cause hypotension, but intravenous fluids were administered, and the patient regained consciousness.
- If fluid loss were the sole cause, resolving consciousness and maintaining low blood pressure typically indicates the fluid loss was not completely compensated, but the primary cause for the persistent hypotension is not just volume.
Complications of minimally invasive surgery US Medical PG Question 4: Two hours after undergoing elective cholecystectomy with general anesthesia, a 41-year-old woman is evaluated for decreased mental status. BMI is 36.6 kg/m2. Respirations are 18/min and blood pressure is 126/73 mm Hg. Physical examination shows the endotracheal tube in normal position. She does not respond to sternal rub and gag reflex is absent. Arterial blood gas analysis on room air shows normal PO2 and PCO2 levels. Which of the following anesthetic properties is the most likely cause of these findings?
- A. Low blood solubility
- B. High lipid solubility (Correct Answer)
- C. Low brain-blood partition coefficient
- D. High minimal alveolar concentration
- E. Low cytochrome P450 activity
Complications of minimally invasive surgery Explanation: ***High lipid solubility***
- Anesthetics with **high lipid solubility** accumulate in **adipose tissue** and are slowly released, prolonging their effect, especially in obese patients.
- The patient's **obesity (BMI 36.6 kg/m2)** contributes to a larger reservoir for lipid-soluble drugs, leading to delayed recovery and decreased mental status.
*Low blood solubility*
- **Low blood solubility** implies a rapid equilibrium between the lungs and the blood, leading to a **faster onset and offset** of anesthetic action.
- This property would result in a quicker recovery from anesthesia, which contradicts the patient's prolonged unconsciousness.
*Low brain-blood partition coefficient*
- A **low brain-blood partition coefficient** means the anesthetic does not accumulate significantly in brain tissue relative to blood.
- Agents with this property equilibrate quickly and leave the brain rapidly upon discontinuation, resulting in **fast recovery**, which is inconsistent with the patient's persistent decreased mental status.
*High minimal alveolar concentration*
- **High minimal alveolar concentration (MAC)** means that a higher concentration of the anesthetic gas is required to produce immobility in 50% of patients.
- A high MAC describes the **potency** of an anesthetic and does not directly explain prolonged recovery or decreased mental status in an obese patient, but rather indicates that a larger dose or concentration was needed to achieve anesthesia.
*Low cytochrome P450 activity*
- **Low cytochrome P450 activity** would lead to slower metabolism of drugs that are primarily cleared by this system, potentially prolonging their effects.
- While relevant for some drugs, the primary issue for inhaled anesthetics is their **physical distribution and elimination**, not typically metabolic clearance via Cytochrome P450 enzymes.
Complications of minimally invasive surgery US Medical PG Question 5: A 52-year-old woman is brought to the emergency department by fire and rescue after being involved in a motor vehicle accident. The paramedics report that the patient’s car slipped off the road during a rainstorm and rolled into a ditch. The patient was restrained and the airbags deployed during the crash. The patient has a past medical history of hypertension, hyperlipidemia, hypothyroidism, and gout. Her home medications include hydrochlorothiazide, simvastatin, levothyroxine, and allopurinol. The patient is alert on the examination table. Her temperature is 98.2°F (36.8°C), blood pressure is 83/62 mmHg, pulse is 131/min, respirations are 14/min, and SpO2 is 96%. She has equal breath sounds in all fields bilaterally. Her skin is cool with diffuse bruising over her abdomen and superficial lacerations, and her abdomen is diffusely tender to palpation. She is moving all four extremities equally. The patient’s FAST exam is equivocal. She is given several liters of intravenous fluid during her trauma evaluation but her blood pressure does not improve.
Which of the following is the best next step?
- A. Diagnostic laparoscopy
- B. Chest radiograph
- C. Emergency laparotomy (Correct Answer)
- D. Abdominal CT
- E. Diagnostic peritoneal lavage
Complications of minimally invasive surgery Explanation: ***Emergency laparotomy***
- The patient presents with **hypotension (83/62 mmHg), tachycardia (131/min)**, diffuse abdominal tenderness, and signs of significant trauma (diffuse bruising, superficial lacerations, motor vehicle accident with roll-over). Despite receiving **several liters of intravenous fluids, her blood pressure does not improve**, indicating ongoing hemodynamic instability likely due to uncontrolled intra-abdominal bleeding.
- An **equivocal FAST exam** in a hemodynamically unstable patient, coupled with failure to respond to fluid resuscitation, necessitates immediate surgical intervention to identify and control the source of hemorrhage, making **emergency laparotomy** the most appropriate next step.
*Diagnostic laparoscopy*
- While diagnostic laparoscopy can be used to evaluate abdominal injuries, it is a **minimally invasive procedure** that may not be suitable for a hemodynamically unstable patient with suspected active hemorrhage, as it can be time-consuming and risks missing larger bleeders.
- In this patient's unstable condition, a **more rapid and definitive intervention** is required to control bleeding.
*Chest radiograph*
- A chest radiograph is important for evaluating intrathoracic injuries, but the patient's presentation of **abdominal tenderness, diffuse bruising over her abdomen, and equivocal FAST exam** points more towards an abdominal source of instability.
- While it might be performed as part of a trauma workup, it is **not the best next step to address the immediate life-threatening abdominal bleeding** in a hemodynamically unstable patient.
*Abdominal CT*
- An abdominal CT scan is a valuable diagnostic tool for evaluating abdominal injuries but requires the patient to be **hemodynamically stable** to be safely transported to and through the scanner.
- This patient's **persistent hypotension and tachycardia despite fluid resuscitation** indicate ongoing instability, making transport to CT potentially dangerous and delaying definitive treatment.
*Diagnostic peritoneal lavage*
- Diagnostic peritoneal lavage (DPL) is a highly sensitive test for detecting intra-abdominal hemorrhage but has largely been replaced by the **Focused Assessment with Sonography for Trauma (FAST) exam** in many trauma centers.
- The FAST exam was already performed and was **equivocal**, and given the patient's clinical picture of instability, proceeding directly to **emergency laparotomy** is more efficient and life-saving than performing another diagnostic test that would delay definitive treatment.
Complications of minimally invasive surgery US Medical PG Question 6: A 35-year-old man presents to pulmonary function clinic for preoperative evaluation for a right pneumonectomy. His arterial blood gas at room air is as follows:
pH: 7.34
PaCO2: 68 mmHg
PaO2: 56 mmHg
Base excess: +1
O2 saturation: 89%
What underlying condition most likely explains these findings?
- A. Cystic fibrosis
- B. Bronchiectasis
- C. Chronic obstructive pulmonary disease (Correct Answer)
- D. Obesity
- E. Acute respiratory distress syndrome
Complications of minimally invasive surgery Explanation: ***Chronic obstructive pulmonary disease***
- This patient exhibits **compensated respiratory acidosis** (low pH, high PaCO2, slightly elevated base excess) and **hypoxemia** (low PaO2), which are characteristic findings in chronic obstructive pulmonary disease (COPD) with underlying respiratory failure.
- The history of a planned **pneumonectomy** also suggests a significant pre-existing lung pathology often seen in patients with severe COPD.
*Cystic fibrosis*
- While cystic fibrosis can lead to chronic lung disease, it typically presents at a younger age and is associated with a history of recurrent infections and exocrine gland dysfunction.
- While it can manifest similarly in ABG, the age and the planned pneumonectomy make COPD a more likely primary cause in this context.
*Bronchiectasis*
- Bronchiectasis involves permanent dilation of the bronchi, often leading to chronic cough, sputum production, and recurrent infections.
- While it can cause respiratory compromise, the ABG findings are more classically associated with the widespread air trapping and V/Q mismatch seen in COPD.
*Obesity*
- Severe obesity can lead to **obesity hypoventilation syndrome**, presenting with hypercapnia and hypoxemia.
- However, the patient's age and the context of a planned pneumonectomy make an underlying primary lung disease like COPD a more focused explanation for the ABG pattern.
*Acute respiratory distress syndrome*
- Acute respiratory distress syndrome (ARDS) is an **acute** and severe form of respiratory failure characterized by severe hypoxemia and bilateral opacities on chest imaging.
- The ABG findings in ARDS typically show **severe hypoxemia** with **respiratory alkalosis** early on, evolving to acidosis, and it is an acute process, not a chronic pre-existing condition suitable for elective surgery.
Complications of minimally invasive surgery US Medical PG Question 7: A 32-year-old man is brought to the emergency department after a skiing accident. The patient had been skiing down the mountain when he collided with another skier who had stopped suddenly in front of him. He is alert but complaining of pain in his chest and abdomen. He has a past medical history of intravenous drug use and peptic ulcer disease. He is a current smoker. His temperature is 97.4°F (36.3°C), blood pressure is 77/53 mmHg, pulse is 127/min, and respirations are 13/min. He has a GCS of 15 and bilateral shallow breath sounds. His abdomen is soft and distended with bruising over the epigastrium. He is moving all four extremities and has scattered lacerations on his face. His skin is cool and delayed capillary refill is present. Two large-bore IVs are placed in his antecubital fossa, and he is given 2L of normal saline. His FAST exam reveals fluid in Morison's pouch. Following the 2L normal saline, his temperature is 97.5°F (36.4°C), blood pressure is 97/62 mmHg, pulse is 115/min, and respirations are 12/min.
Which of the following is the best next step in management?
- A. Diagnostic peritoneal lavage
- B. Emergency laparotomy (Correct Answer)
- C. Upper gastrointestinal endoscopy
- D. Close observation
- E. Diagnostic laparoscopy
Complications of minimally invasive surgery Explanation: ***Emergency laparotomy***
- The patient remains **hemodynamically unstable** (BP 97/62 mmHg, HR 115/min after 2L IV fluids) with evidence of **intra-abdominal fluid on FAST exam** (fluid in Morison's pouch).
- This clinical picture indicates active intra-abdominal hemorrhage requiring **immediate surgical intervention** to identify and control the source of bleeding.
*Diagnostic peritoneal lavage*
- **Diagnostic peritoneal lavage (DPL)** has largely been replaced by the focused abdominal sonography for trauma (FAST) exam and CT scans.
- While it can detect intra-abdominal bleeding, it is **invasive** and would delay definitive treatment in a hemodynamically unstable patient with positive FAST.
*Upper gastrointestinal endoscopy*
- This procedure is primarily for diagnosing and treating **upper gastrointestinal bleeding** or mucosal abnormalities.
- It is **not indicated** for evaluating traumatic intra-abdominal hemorrhage or hemodynamic instability following blunt abdominal trauma.
*Close observation*
- Close observation is appropriate for **hemodynamically stable patients** with blunt abdominal trauma and minor injuries or equivocal findings.
- This patient's persistent hypotension, tachycardia, and positive FAST findings rule out observation as a safe or appropriate next step.
*Diagnostic laparoscopy*
- **Diagnostic laparoscopy** is a minimally invasive surgical procedure used to evaluate the abdominal cavity.
- While it can be diagnostic, it is generally **contraindicated in hemodynamically unstable patients** as it can prolong the time to definitive hemorrhage control if a major injury is found.
Complications of minimally invasive surgery US Medical PG Question 8: A 30-year-old male gang member is brought to the emergency room with a gunshot wound to the abdomen. The patient was intubated and taken for an exploratory laparotomy, which found peritoneal hemorrhage and injury to the small bowel. He required 5 units of blood during this procedure. Following the operation, the patient was sedated and remained on a ventilator in the surgical intensive care unit (SICU). The next day, a central line is placed and the patient is started on total parenteral nutrition. Which of the following complications is most likely in this patient?
- A. Mesenteric ischemia
- B. Hypocalcemia
- C. Refeeding syndrome
- D. Sepsis (Correct Answer)
- E. Cholelithiasis
Complications of minimally invasive surgery Explanation: ***Sepsis***
- This patient has undergone **major abdominal surgery** after a **gunshot wound**, which carries a high risk of **peritoneal contamination** and subsequent infection.
- He also has several risk factors for sepsis, including **intubation**, central line placement, and possibly prolonged ventilation, all of which increase the risk of nosocomial infections and subsequent sepsis.
*Mesenteric ischemia*
- While possible in critically ill patients, there is no direct evidence such as advanced age, atherosclerosis, or specific signs of **bowel ischemia** (e.g., severe abdominal pain disproportionate to exam, bloody diarrhea) presenting in this case.
- The initial injury was to the small bowel, but the current context points more to systemic complications rather than a focal vascular event.
*Hypocalcemia*
- Hypocalcemia can occur in critically ill patients due to various reasons, but it is not the *most likely* complication given the patient's presentation primarily focused on surgical trauma and subsequent interventions.
- Dilutional effects from massive transfusions or **citrate toxicity** could contribute to temporary hypocalcemia, but sepsis poses a more immediate and widespread threat.
*Refeeding syndrome*
- Refeeding syndrome occurs when severely malnourished patients are rapidly refed, leading to shifts in **electrolytes** (especially **phosphate**, potassium, magnesium).
- Although the patient is starting **total parenteral nutrition (TPN)**, there's no indication of prior severe malnutrition, making sepsis a more prominent immediate concern due to the gunshot wound and surgery.
*Cholelithiasis*
- **Cholelithiasis** (gallstones) can be a long-term complication of total parenteral nutrition (TPN) due to gallbladder stasis.
- However, it is unlikely to develop so acutely within a day of starting TPN and is thus not the most immediate or likely complication for this patient's acute critical state.
Complications of minimally invasive surgery US Medical PG Question 9: A 45-year-old man presents to the emergency department because of fever and scrotal pain for 2 days. Medical history includes diabetes mellitus and morbid obesity. His temperature is 40.0°C (104.0°F), the pulse is 130/min, the respirations are 35/min, and the blood pressure is 90/68 mm Hg. Physical examination shows a large area of ecchymosis, edema, and crepitus in his perineal area. Fournier gangrene is suspected. A right internal jugular central venous catheter is placed without complication under ultrasound guidance for vascular access in preparation for the administration of vasopressors. Which of the following is the most appropriate next step?
- A. Confirm line placement by ultrasound
- B. Begin to use the line after documenting the return of dark, non-pulsatile blood from all ports
- C. Begin infusion of normal saline through a central line
- D. Obtain an immediate portable chest radiograph to evaluate line placement (Correct Answer)
- E. Begin infusion of norepinephrine to maintain systolic blood pressure over 90 mm Hg
Complications of minimally invasive surgery Explanation: **Obtain an immediate portable chest radiograph to evaluate line placement**
- The most appropriate next step after central venous catheter placement is to **confirm its correct position** and rule out complications like **pneumothorax** via imaging.
- A **chest radiograph** is the standard and immediate method to confirm proper placement of the tip in the lower superior vena cava and rule out pneumothorax, especially given the patient's critical condition.
*Confirm line placement by ultrasound*
- While ultrasound is used during placement to visualize the vessel and guide needle insertion, it is **not sufficient for confirming the final tip position** of the catheter or for ruling out pneumothorax.
- Ultrasound confirmation usually involves visualizing a **saline flush** in the right atrium, but a chest X-ray is still required for comprehensive evaluation.
*Begin to use the line after documenting the return of dark, non-pulsatile blood from all ports*
- Documenting blood return confirms that the catheter is in a vein but does not confirm **optimal tip placement** or exclude potential complications like **pneumothorax**.
- Using the line without radiological confirmation can lead to administering medications into incorrect locations (e.g., subclavian artery) or exacerbating unnoticed complications.
*Begin infusion of normal saline through a central line*
- Administering fluids before confirming proper line placement carries the risk of **extravasation** or infusing into an artery or other unintended space, which could worsen the patient's condition.
- Although IV fluids are needed in this septic patient, **confirmation of line placement** is a higher priority before commencing infusions.
*Begin infusion of norepinephrine to maintain systolic blood pressure over 90 mm Hg*
- While norepinephrine is crucial for managing septic shock and **hypotension** in this patient, starting it before confirming central line placement is dangerous.
- **Vasopressors require a secure central line** to prevent severe local tissue damage if extravasation occurs.
Complications of minimally invasive surgery US Medical PG Question 10: A 62-year-old man is brought to the emergency department after his wife found him unresponsive 1 hour ago. He had fallen from a flight of stairs the previous evening. Four years ago, he underwent a mitral valve replacement. He has hypertension and coronary artery disease. Current medications include aspirin, warfarin, enalapril, metoprolol, and atorvastatin. On arrival, he is unconscious. His temperature is 37.3°C (99.1°F), pulse is 59/min, respirations are 7/min and irregular, and blood pressure is 200/102 mm Hg. The right pupil is 5 mm and fixed. The left pupil is 4 mm and reactive to light. There is extension of the extremities to painful stimuli. The lungs are clear to auscultation. Cardiac examination shows a systolic click. The abdomen is soft and nontender. He is intubated and mechanically ventilated. A mannitol infusion is begun. A noncontrast CT scan of the brain shows a 6-cm subdural hematoma on the right side with an 18-mm midline shift. Which of the following is the most likely early sequela of this patient's current condition?
- A. Multifocal myoclonus
- B. Right eye esotropia and elevation
- C. Bilateral lower limb paralysis
- D. Left-side facial nerve palsy
- E. Right-sided hemiplegia (Correct Answer)
Complications of minimally invasive surgery Explanation: ***Right-sided hemiplegia***
- The patient has a **right-sided subdural hematoma** causing **uncal herniation** with significant midline shift (18 mm).
- **Kernohan's notch phenomenon** is a false localizing sign where the contralateral cerebral peduncle (left side) is compressed against the edge of the tentorium cerebelli by the herniating brain.
- This contralateral peduncle compression paradoxically produces **ipsilateral hemiplegia** (same side as the lesion) - in this case, right-sided hemiplegia from a right-sided mass.
- This is an **early sequela** of severe herniation and represents a classic false localizing sign in neurosurgery.
*Multifocal myoclonus*
- This indicates widespread cortical irritability or **metabolic encephalopathy** (e.g., uremia, hypoxia, drug toxicity).
- Not a typical early focal sequela of subdural hematoma with uncal herniation.
- May occur later with diffuse hypoxic brain injury but is not the most likely early finding.
*Right eye esotropia and elevation*
- **Oculomotor nerve (CN III) palsy** causes the eye to be displaced "**down and out**" (exotropia and depression), not esotropia and elevation.
- The right fixed dilated pupil indicates CN III compression from uncal herniation, but this would cause lateral deviation and depression of the eye.
- The described eye position is inconsistent with CN III palsy.
*Bilateral lower limb paralysis*
- Would require **bilateral cerebral involvement** of motor cortices or **spinal cord injury**.
- A unilateral subdural hematoma, even with herniation, would not typically cause isolated bilateral lower limb paralysis as an early sequela.
- Not consistent with the focal nature of this injury.
*Left-side facial nerve palsy*
- While **contralateral hemiplegia** (left-sided weakness) would be expected from direct mass effect of a right-sided lesion, isolated facial nerve palsy is less likely.
- **Central facial palsy** (upper motor neuron) would affect the lower face and could occur contralaterally, but complete hemiplegia including the face would be more common than isolated CN VII palsy.
- Kernohan's notch phenomenon specifically affects the motor pathways in the cerebral peduncle, making ipsilateral hemiplegia the most characteristic early motor sequela.
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