Early mobilization protocols US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Early mobilization protocols. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Early mobilization protocols US Medical PG Question 1: Two hours after admission to the intensive care unit, a 56-year-old man with necrotizing pancreatitis develops profound hypotension. His blood pressure is 80/50 mm Hg and he is started on vasopressors. A central venous access line is placed. Which of the following is most likely to decrease the risk of complications from this procedure?
- A. Placement of the central venous line in the femoral vein
- B. Replacement of the central venous line every 7-10 days
- C. Initiation of anticoagulation after placement
- D. Preparation of the skin with chlorhexidine and alcohol (Correct Answer)
- E. Initiation of periprocedural systemic antibiotic prophylaxis
Early mobilization protocols Explanation: ***Preparation of the skin with chlorhexidine and alcohol***
- **Chlorhexidine** with alcohol is the most effective skin antiseptic for preventing **catheter-related bloodstream infections (CRBSIs)** by significantly reducing skin microbial counts.
- Proper skin preparation is a cornerstone of preventing **infectious complications** associated with central venous catheter insertion.
*Placement of the central venous line in the femoral vein*
- The femoral site is generally associated with a **higher risk of infection** and **deep venous thrombosis** compared to subclavian or internal jugular sites in adult patients.
- Femoral access is often reserved for situations where other sites are inaccessible or contraindicated, due to its **less favorable complication profile**.
*Replacement of the central venous line every 7-10 days*
- Routine replacement of central venous lines at fixed intervals, without clinical indication, has **not been shown to reduce infection rates**.
- This practice can actually **increase the risk** of mechanical complications and introduce new opportunities for infection with each procedure.
*Initiation of anticoagulation after placement*
- Routine systemic **anticoagulation** after central venous line placement is generally **not recommended** due to an increased risk of **bleeding complications**.
- Anticoagulation is typically reserved for specific indications such as documented **catheter-related thrombosis**.
*Initiation of periprocedural systemic antibiotic prophylaxis*
- Routine **systemic antibiotic prophylaxis** is **not recommended** for central venous catheter insertion as it promotes **antibiotic resistance** without significantly reducing CRBSIs.
- Strict adherence to **aseptic technique** and proper skin antisepsis are more effective for preventing infections.
Early mobilization protocols US Medical PG Question 2: A 27-year-old soldier stationed in Libya sustains a shrapnel injury during an attack, causing a traumatic above-elbow amputation. The resulting arterial bleed is managed with a tourniquet prior to transport to the military treatment facility. On arrival, he is alert and oriented to person, place, and time. His armor and clothing are removed. His pulse is 145/min, respirations are 28/min, and blood pressure is 95/52 mm Hg. Pulmonary examination shows symmetric chest rise. The lungs are clear to auscultation. Abdominal examination shows no abnormalities. There are multiple shrapnel wounds over the upper and lower extremities. A tourniquet is in place around the right upper extremity; the right proximal forearm has been amputated. One large-bore intravenous catheter is placed in the left antecubital fossa. Despite multiple attempts, medical staff is unable to establish additional intravenous access. Which of the following is the most appropriate next step in management?
- A. Irrigate the shrapnel wounds
- B. Perform endotracheal intubation
- C. Establish intraosseous access (Correct Answer)
- D. Establish central venous access
- E. Replace the tourniquet with a pressure dressing
Early mobilization protocols Explanation: ***Establish intraosseous access***
- The patient is in **hemorrhagic shock** (tachycardia, hypotension) and requires rapid fluid resuscitation, but peripheral intravenous access is difficult to obtain. **Intraosseous (IO) access** provides a rapid and reliable route for fluids and medications, especially in emergencies when IV access is challenging.
- IO access is a **bridge to definitive venous access** and is crucial for immediate life-saving interventions in trauma.
*Irrigate the shrapnel wounds*
- While wound irrigation is important for preventing infection, it is **not the immediate priority** when the patient is in hemorrhagic shock.
- Addressing the circulatory compromise takes precedence over local wound care.
*Perform endotracheal intubation*
- The patient is **alert and oriented** with symmetric chest rise and clear lungs, indicating he does not currently have an airway crisis requiring intubation.
- Intubation is an invasive procedure that carries risks and should only be performed when indicated for airway protection or respiratory failure.
*Establish central venous access*
- While central venous access is useful for long-term fluid management and monitoring, it is generally **more time-consuming and technically challenging** to establish than IO access, especially in an emergent, unstable patient.
- Given the urgency of rapid fluid administration, IO access is preferred as the immediate next step.
*Replace the tourniquet with a pressure dressing*
- The patient has an above-elbow amputation, suggesting significant injury, and the tourniquet is currently controlling the bleed. Removing the tourniquet prematurely without proximal surgical control can lead to **recurrent catastrophic hemorrhage**.
- A definitive surgical approach is needed to manage the amputation, not simply replacing the tourniquet with a pressure dressing, which may be insufficient to control arterial bleeding.
Early mobilization protocols US Medical PG Question 3: A 65-year-old man presents to his primary care physician for a pre-operative evaluation. He is scheduled for cataract surgery in 3 weeks. His past medical history is notable for diabetes, hypertension, and severe osteoarthritis of the right knee. His medications include metformin, hydrochlorothiazide, lisinopril, and aspirin. His surgeon ordered blood work 1 month ago, which showed a hemoglobin of 14.2 g/dL, INR of 1.2, and a hemoglobin A1c of 6.9%. His vital signs at the time of the visit show BP: 130/70 mmHg, Pulse: 80, RR: 12, and T: 37.2 C. He has no current complaints and is eager for his surgery. Which of the following is the most appropriate course of action for this patient at this time?
- A. Tell the patient he will have to delay his surgery for at least 1 year
- B. Medically clear the patient for surgery (Correct Answer)
- C. Repeat the patient's CBC and coagulation studies
- D. Schedule the patient for a stress test and ask him to delay surgery for at least 6 months
- E. Perform an EKG
Early mobilization protocols Explanation: **Medically clear the patient for surgery**
- The patient's **blood pressure is well-controlled** (130/70 mmHg), and his **hemoglobin A1c of 6.9%** indicates good glycemic control, both of which are favorable for elective surgery.
- He is currently on **aspirin**, which, for cataract surgery (a low-risk bleeding procedure), can generally be continued, and his **INR of 1.2 is within a safe range** for surgery.
*Tell the patient he will have to delay his surgery for at least 1 year*
- There are **no indications for such a prolonged delay** based on the provided clinical information.
- His chronic conditions (diabetes, hypertension) are **adequately managed**, and his lab values are acceptable.
*Repeat the patient's CBC and coagulation studies*
- The **existing blood work from 1 month ago is recent enough** for a pre-operative evaluation for cataract surgery, especially with no new symptoms.
- Repeating these tests without a clinical indication would be **unnecessary and inefficient**.
*Schedule the patient for a stress test and ask him to delay surgery for at least 6 months*
- The patient has **no active cardiac symptoms** (e.g., chest pain, shortness of breath), and his well-controlled hypertension does not automatically warrant a stress test for low-risk surgery.
- A stress test and a **6-month delay are not indicated** for a low-risk procedure like cataract surgery in an asymptomatic patient.
*Perform an EKG*
- While an EKG might be considered in some pre-operative evaluations for patients with cardiac risk factors, there are **no specific symptoms or significant new risk factors** presented that necessitate an EKG for this low-risk cataract surgery.
- Given his stable condition and controlled hypertension, an EKG is **not a mandatory part of medical clearance** for this procedure.
Early mobilization protocols US Medical PG Question 4: Three days after undergoing laparoscopic colectomy, a 67-year-old man reports swelling and pain in his right leg. He was diagnosed with colon cancer 1 month ago. His temperature is 38.5°C (101.3°F). Physical examination shows swelling of the right leg from the ankle to the thigh. There is no erythema or rash. Which of the following is likely to be most helpful in establishing the diagnosis?
- A. D-dimer level
- B. Compression ultrasonography (Correct Answer)
- C. CT pulmonary angiography
- D. Transthoracic echocardiography
- E. Blood cultures
Early mobilization protocols Explanation: ***Compression ultrasonography***
- This patient's presentation with **unilateral leg swelling and pain** after surgery, especially given his recent **colon cancer diagnosis** (a hypercoagulable state), is highly suspicious for a **deep vein thrombosis (DVT)**.
- **Compression ultrasonography** is the gold standard, non-invasive imaging modality for diagnosing DVT, allowing direct visualization of thrombi and assessing venous compressibility.
*D-dimer level*
- While a **positive D-dimer** indicates recent or ongoing clot formation, it is **non-specific** and can be elevated in many conditions, including surgery, cancer, and infection.
- A normal D-dimer can rule out DVT in low-probability patients, but a high D-dimer in a high-probability patient (like this case) requires further imaging for confirmation, making it less definitive than ultrasound.
*CT pulmonary angiography*
- This imaging is used to diagnose a **pulmonary embolism (PE)**, which is a complication of DVT, but the primary symptoms here are localized to the leg.
- While PE is a concern, diagnosing the source (DVT) in the leg is the immediate priority for treatment and prevention of future complications.
*Transthoracic echocardiography*
- **Echocardiography** evaluates cardiac structure and function and can sometimes detect large clots in the right heart leading to PE, but it is not the primary diagnostic tool for DVT in the leg.
- It would be done if signs of cardiac strain or shunting associated with acute PE were prominent, which is not the case here.
*Blood cultures*
- **Blood cultures** are used to diagnose **bacteremia or sepsis**, which might explain a fever, but the prominent, unilateral leg swelling and pain are not typical for a primary infectious cause in the leg without local signs of cellulitis or abscess.
- While a low-grade fever is present, the absence of erythema or rash makes a primary infectious etiology less likely than DVT given the risk factors.
Early mobilization protocols US Medical PG Question 5: A 74-year-old man presents to the emergency department by paramedics for slurred speech and weakness in the left arm and leg for 1 hour. The patient was playing with his grandson when the symptoms started and his wife immediately called an ambulance. There is no history of head trauma or recent surgery. The patient takes captopril for hypertension. The vital signs include: pulse 110/min, respiratory rate 22/min, and blood pressure 200/105 mm Hg. The physical examination shows that the patient is alert and conscious, but speech is impaired. Muscle strength is 0/5 in the left arm and leg and 5/5 in the right arm and leg. A non-contrast CT of the head shows no evidence of intracranial bleeding. The lab results are as follows:
Serum glucose 90 mg/dL
Sodium 140 mEq/L
Potassium 4.1 mEq/L
Chloride 100 mEq/L
Serum creatinine 1.3 mg/dL
Blood urea nitrogen 20 mg/dL
Cholesterol, total 240 mg/dL
HDL-cholesterol 38 mg/dL
LDL-cholesterol 100 mg/dL
Triglycerides 190 mg/dL
Hemoglobin (Hb%) 15.3 g/dL
Mean corpuscular volume (MCV) 83 fL
Reticulocyte count 0.8%
Erythrocyte count 5.3 million/mm3
Platelet count 130,000/mm3
Partial thromboplastin time (aPTT) 30 sec
Prothrombin time (PT) 12 sec
Although he is within the time frame for the standard therapy of the most likely condition, the treatment cannot be started because of which of the following contraindications?
- A. A platelet count of 130,000/mm3
- B. Age of 74 years
- C. Cholesterol level of 240 mg/dL
- D. Creatinine level of 1.3 mg/dL
- E. Systolic blood pressure of 200 mm Hg (Correct Answer)
Early mobilization protocols Explanation: ***Systolic blood pressure of 200 mm Hg***
- The patient presents with symptoms highly suggestive of an **acute ischemic stroke**, including **slurred speech** and **left-sided weakness**.
- For patients with acute ischemic stroke who are candidates for **thrombolytic therapy (e.g., alteplase)**, a **systolic blood pressure consistently >185 mm Hg or diastolic >110 mm Hg is a contraindication** due to increased risk of hemorrhagic transformation.
*A platelet count of 130,000/mm3*
- A platelet count of 130,000/mm³ is above the **contraindication threshold for thrombolytic therapy**, which is typically <100,000/mm³.
- Therefore, this platelet count would **not prevent** the initiation of tPA.
*Age of 74 years*
- While older age was once considered a relative contraindication, current guidelines **do not consider age alone (including 74 years old) as an absolute contraindication** for thrombolytic therapy in acute ischemic stroke.
- Eligibility is determined by a comprehensive risk-benefit assessment, not solely by age.
*Cholesterol level of 240 mg/dL*
- An elevated **cholesterol level** is a **risk factor for atherosclerosis** and ischemic stroke, but it is **not a contraindication for acute thrombolytic therapy**.
- It relates to the underlying cause of the stroke rather than the immediate treatment decision.
*Creatinine level of 1.3 mg/dL*
- A **creatinine level of 1.3 mg/dL** indicates **mild renal impairment**, but it is **not a contraindication for thrombolytic therapy**.
- Renal function more significantly impacts the use of certain anticoagulants, but not typically alteplase in the acute setting.
Early mobilization protocols US Medical PG Question 6: A 58-year-old man is brought to the emergency department because of confusion, weight loss, and anuria. He has chronic kidney disease, hypertension, and type 2 diabetes mellitus. He was diagnosed with acute lymphoblastic leukemia at the age of 8 years and was treated with an allogeneic stem cell transplantation. He is HIV-positive and has active hepatitis C virus infection. He drinks around 8 cans of beer every week. His current medications include tenofovir, emtricitabine, atazanavir, daclatasvir, sofosbuvir, insulin, amlodipine, and enalapril. He appears lethargic. His temperature is 36°C (96.8°F), pulse is 130/min, respirations are 26/min, and blood pressure is 145/90 mm Hg. Examination shows severe edema in his legs and generalized muscular weakness. Auscultation of the lung shows crepitant rales. Laboratory studies show positive HCV antibody and positive HCV RNA. His HIV viral load is undetectable and his CD4+ T-lymphocyte count is 589/μL. Six months ago, his CD4+ T-lymphocyte count was 618/μL. An ECG of the heart shows arrhythmia with frequent premature ventricular contractions. Arterial blood gas analysis on room air shows:
pH 7.23
PCO2 31 mm Hg
HCO3- 13 mEq/L
Base excess -12 mEq/L
The patient states he would like to donate organs or tissues in the case of his death. Which of the following is an absolute contraindication for organ donation in this patient?
- A. HIV infection
- B. Childhood leukemia (Correct Answer)
- C. Alcoholism
- D. No absolute contraindications
- E. Acute kidney injury
Early mobilization protocols Explanation: ***Correct: Childhood leukemia***
- **History of hematologic malignancy** (including acute lymphoblastic leukemia) is an **absolute contraindication** for solid organ donation according to UNOS and OPTN guidelines.
- Even though this patient was treated 50 years ago with allogeneic stem cell transplantation, the concern for **residual malignant cells** or **transmission to immunosuppressed recipients** makes this an absolute exclusion.
- Unlike solid tumors (which may be acceptable after long disease-free intervals), **leukemias and lymphomas carry lifelong exclusion** from organ donation due to their systemic nature and potential for dormant cells.
*Incorrect: Acute kidney injury*
- **Acute kidney injury (AKI)** is NOT an absolute contraindication for organ donation.
- While the kidneys themselves may not be suitable for transplantation, other organs (heart, liver, lungs, corneas) could still be viable.
- Each organ is assessed individually for suitability.
*Incorrect: HIV infection*
- **Well-controlled HIV infection** (undetectable viral load, stable CD4 count >200) is no longer an absolute contraindication.
- Under the **HOPE Act (HIV Organ Policy Equity Act)**, organs from HIV-positive donors can be transplanted into HIV-positive recipients.
- This patient has excellent viral control (undetectable VL, CD4 589), making HIV not an absolute barrier.
*Incorrect: Alcoholism*
- **Alcohol use disorder** alone is not an absolute contraindication for organ donation.
- The suitability depends on individual organ assessment (e.g., liver function, cardiac health).
- This patient drinks 8 beers/week, which is moderate consumption and doesn't preclude donation of undamaged organs.
*Incorrect: No absolute contraindications*
- This patient **does have an absolute contraindication**: his history of hematologic malignancy (acute lymphoblastic leukemia).
- Despite the long time since treatment, hematologic cancers remain absolute exclusions for organ donation.
Early mobilization protocols US Medical PG Question 7: Four days after undergoing a craniotomy and evacuation of a subdural hematoma, a 56-year-old man has severe pain and swelling of his right leg. He has chills and nausea. He has type 2 diabetes mellitus and chronic kidney disease, and was started on hemodialysis 2 years ago. Prior to admission, his medications were insulin, enalapril, atorvastatin, and sevelamer. His temperature is 38.3°C (101°F), pulse is 110/min, and blood pressure is 130/80 mm Hg. Examination shows a swollen, warm, and erythematous right calf. Dorsiflexion of the right foot causes severe pain in the right calf. The peripheral pulses are palpated bilaterally. Cardiopulmonary examination shows no abnormalities. Laboratory studies show:
Hemoglobin 10.1 g/dL
Leukocyte count 11,800/mm3
Platelet count 230,000/mm3
Serum
Glucose 87 mg/dL
Creatinine 1.9 mg/dL
Which of the following is the most appropriate next step in treatment?
- A. Urokinase therapy
- B. Iliac stenting
- C. Warfarin therapy
- D. Unfractionated heparin therapy (Correct Answer)
- E. Inferior vena cava filter
Early mobilization protocols Explanation: ***Unfractionated heparin therapy***
- The patient presents with classic symptoms of **deep vein thrombosis (DVT)**, including unilateral leg pain, swelling, warmth, erythema, and a positive Homan's sign (pain on dorsiflexion). The recent craniotomy places him at high risk for DVT.
- **Unfractionated heparin is the anticoagulant of choice** for this patient due to TWO critical factors:
1. **Recent craniotomy (4 days ago)**: Requires a rapidly reversible anticoagulant in case of intracranial bleeding; UFH can be reversed with protamine sulfate
2. **Chronic kidney disease on hemodialysis**: Low molecular weight heparin (LMWH) is contraindicated in severe renal failure (CrCl <30 mL/min) as it is renally eliminated and increases bleeding risk. UFH is not renally cleared and can be monitored with aPTT.
*Urokinase therapy*
- **Urokinase is a thrombolytic agent** used to dissolve existing clots, primarily in cases of massive pulmonary embolism or severe DVT with limb-threatening ischemia (phlegmasia cerulea dolens).
- Given the patient's **recent craniotomy and subdural hematoma evacuation**, thrombolytic therapy is **absolutely contraindicated** due to very high risk of intracranial hemorrhage. Recent neurosurgery is a contraindication for at least 2-4 weeks.
*Iliac stenting*
- **Iliac vein stenting** is a procedure typically used to treat chronic **iliac vein compression** (e.g., May-Thurner syndrome) or chronic post-thrombotic obstruction.
- This is an **acute DVT presentation** (4 days post-op) with no indication of chronic iliac vein compression or obstruction. Stenting has no role in acute DVT management.
*Warfarin therapy*
- **Warfarin is an oral anticoagulant** used for long-term DVT treatment but has a **delayed onset of action** (requires 5-7 days to reach therapeutic INR).
- It is **not suitable for acute initial treatment** of DVT, especially in a patient requiring rapid anticoagulation. Warfarin must be overlapped with parenteral anticoagulation (heparin) initially.
- Additionally, warfarin dosing is complex in dialysis patients due to altered vitamin K metabolism.
*Inferior vena cava filter*
- An **IVC filter** is indicated for patients with DVT who have an **absolute contraindication to anticoagulation** (e.g., active bleeding, recent hemorrhagic stroke) or who develop recurrent thromboembolism despite adequate anticoagulation.
- This patient **does not have a contraindication to anticoagulation**. While he had recent neurosurgery, unfractionated heparin is safe to use with careful monitoring and is rapidly reversible if needed.
- IVC filters have significant complications (thrombosis, filter migration, IVC perforation) and should be avoided when anticoagulation is feasible.
Early mobilization protocols US Medical PG Question 8: Three days after being admitted to the hospital because of a fall from the roof of a two-story building, a 27-year-old man is being monitored in the intensive care unit. On arrival, the patient was somnolent and not oriented to person, place, or time. A CT scan of the head showed an epidural hemorrhage that was 45 cm3 in size and a midline shift of 7 mm. Emergency surgery was performed with craniotomy and hematoma evacuation on the day of admission. Perioperatively, a bleeding vessel was identified and ligated. Postoperatively, the patient was transferred to the intensive care unit and placed on a ventilator. His temperature is 37°C (98.6°F), pulse is 67/min, and blood pressure is 117/78 mm Hg. The ventilator is set at a FiO2 of 55%, tidal volume of 520 mL, and positive end-expiratory pressure of 5.0 cm H2O. In addition to intravenous administration of fluids, which of the following is the most appropriate next step in managing this patient's nutrition?
- A. Enteral feeding via nasogastric tube (Correct Answer)
- B. Oral feeding
- C. Keep patient NPO
- D. Total parenteral nutrition
- E. Enteral feeding using a percutaneous endoscopic gastrostomy (PEG) tube
Early mobilization protocols Explanation: ***Enteral feeding via nasogastric tube***
- This patient has been **somnolent** and on a ventilator for 3 days after a significant head injury, indicating a prolonged period without oral intake and an inability to protect his airway for oral feeding. **Early enteral nutrition** via a nasogastric tube is preferred in critically ill patients, especially those with head injuries, as it helps maintain gut integrity and reduces complications compared to parenteral nutrition.
- The patient's **hemodynamic stability** (blood pressure and pulse are within a reasonable range for a ventilated patient) suggests he can tolerate enteral feeding, and there are no signs of gut ischemia or ileus that would contraindicate it.
*Enteral feeding using a percutaneous endoscopic gastrostomy (PEG) tube*
- While a PEG tube provides enteral nutrition, it is typically reserved for patients requiring **long-term enteral support** (usually more than 4-6 weeks) or those who cannot tolerate a nasogastric tube.
- Given that it has only been 3 days post-injury, a **less invasive method** like a nasogastric tube is initially preferred.
*Oral feeding*
- The patient is described as **somnolent** and on a ventilator, meaning he is not awake enough or able to protect his airway to safely receive oral feeding.
- Attempting oral feeding in this state carries a high risk of **aspiration pneumonia**.
*Keep patient NPO*
- Keeping the patient NPO (nil per os) for an extended period in critical illness is associated with several negative outcomes, including **gut mucosal atrophy, increased infection risk**, and poorer clinical outcomes.
- After 3 days, initiating nutritional support is crucial to prevent these complications.
*Total parenteral nutrition*
- **Total parenteral nutrition (TPN)** is generally considered a last resort when the gastrointestinal tract is non-functional or enteral feeding is contraindicated.
- TPN is associated with a **higher risk of complications**, such as central line infections, liver dysfunction, and metabolic disturbances, compared to enteral feeding.
Early mobilization protocols US Medical PG Question 9: A 65-year-old woman comes to the physician because of progressive weight loss for 3 months. Physical examination shows jaundice and a nontender, palpable gallbladder. A CT scan of the abdomen shows an ill-defined mass in the pancreatic head. She is scheduled for surgery to resect the pancreatic head, distal stomach, duodenum, early jejunum, gallbladder, and common bile duct and anastomose the jejunum to the remaining stomach, pancreas, and bile duct. Following surgery, this patient is at the greatest risk for which of the following?
- A. Wide-based gait
- B. Calcium oxalate kidney stones
- C. Microcytic anemia (Correct Answer)
- D. Increased bile production
- E. Hypercoagulable state
Early mobilization protocols Explanation: ***Microcytic anemia***
- The surgical procedure described is a **Whipple procedure**, which involves partial gastrectomy and duodenectomy. This significant alteration to the upper GI tract can lead to **iron malabsorption**, as iron is primarily absorbed in the duodenum and proximal jejunum, and gastric acid is crucial for converting dietary iron to its absorbable ferrous form.
- **Iron deficiency** is the most common cause of **microcytic anemia**, characterized by small, pale red blood cells, due to impaired hemoglobin synthesis as a result of insufficient iron availability for the heme component.
*Wide-based gait*
- A **wide-based gait** is typically associated with **ataxia** or conditions affecting cerebellar function or proprioception, which are not direct complications of a Whipple procedure.
- While nutritional deficiencies can occur post-surgery, a wide-based gait specifically points to neurological impairment rather than postsurgical metabolic issues.
*Calcium oxalate kidney stones*
- **Calcium oxalate kidney stones** are often associated with conditions causing **hypercalciuria** or malabsorption of fat, which leads to increased oxalate absorption in the colon. While fat malabsorption can occur after a Whipple due to pancreatic insufficiency, dietary oxalate intake and hydration status are generally more significant determinants of stone formation.
- The surgery itself does not directly increase the risk for calcium oxalate kidney stones more than other listed complications.
*Increased bile production*
- A Whipple procedure involves the removal of the **gallbladder** and rerouting of the **bile duct** directly into the jejunum. This does not lead to increased bile production, but rather a different regulation and flow of bile.
- In fact, the absence of the gallbladder means there is no storage for bile, leading to a continuous, unregulated flow of bile into the small intestine, potentially contributing to maldigestion or diarrhea, but not "increased production."
*Hypercoagulable state*
- While surgery, including a Whipple procedure, can transiently increase the risk of a **hypercoagulable state** (e.g., deep vein thrombosis, pulmonary embolism) in the immediate postoperative period due to immobility and tissue injury, this risk is generally mitigated with prophylactic anticoagulation.
- The question asks about the **greatest risk** post-surgery, and long-term complications related to altered anatomy and malabsorption, such as microcytic anemia, are more direct and sustained consequences unique to the extent of the resection.
Early mobilization protocols US Medical PG Question 10: Twelve days after undergoing total pancreatectomy for chronic pancreatitis, a 62-year-old woman notices oozing from her abdominal wound. She first noticed fluid draining 8 hours ago. Her postoperative course has been complicated by persistent hypotension requiring intravenous fluids and decreased ability to tolerate food. She has type 1 diabetes mellitus and glaucoma. The patient smoked one pack of cigarettes daily for 30 years, but quit 2 years ago. She drank a pint of vodka every day starting at age 20 and quit when she was 35 years old. Her current medications include subcutaneous insulin and timolol eye drops. She appears comfortable. Her temperature is 37°C (98.6°F), pulse is 95/min, and blood pressure is 104/78 mm Hg. The abdomen is soft and mildly tender to palpation. There is a 12-cm vertical wound beginning in the epigastrium and extending caudally. 25 mL of a viscous, dark green substance is draining from the middle of the wound. There is a small amount of dried fluid on the patient's hospital gown. The wound edges are nonerythematous. There is no pus draining from the wound. Laboratory studies show:
Hematocrit 38%
Leukocyte count 8,000/mm3
Serum
Na+ 135 mEq/L
Cl- 100 mEq/L
K+ 3.4 mEq/L
HCO3- 23 mEq/L
Urea nitrogen 13 mg/dL
Creatinine 1.1 mg/dL
Glucose 190 mg/dL
Which of the following is the most appropriate next step in management?
- A. Intravenous antibiotic therapy
- B. Surgical exploration of the abdomen
- C. Total parenteral nutrition and ostomy pouch (Correct Answer)
- D. Wound debridement and irrigation
- E. Oral food intake and intravenous fluid administration
Early mobilization protocols Explanation: ***Total parenteral nutrition and ostomy pouch***
- The patient, having undergone total pancreatectomy, is experiencing an **enterocutaneous fistula** from an anastomotic leak (e.g., gastrojejunostomy or choledochojejunostomy), presenting as viscid, dark green drainage from the wound.
- An **ostomy pouch** will protect the skin from digestive enzymes and allow quantification of output, while **total parenteral nutrition (TPN)** provides bowel rest, promoting spontaneous healing of the fistula.
- This conservative approach is appropriate given the patient's **hemodynamic stability** and **absence of signs of sepsis or peritonitis**.
*Intravenous antibiotic therapy*
- While infection is a concern, there are **no clear signs of systemic infection** (e.g., fever, leukocytosis, erythema, purulent drainage) in this patient.
- **Antibiotics alone** would not address the underlying anatomical leak and its resulting drainage.
*Surgical exploration of the abdomen*
- **Surgical exploration** is typically reserved for cases with signs of **sepsis**, **peritonitis**, **uncontrolled leak**, or failure of conservative management.
- Given the patient is hemodynamically stable without signs of severe infection or acute abdomen, a **conservative approach** is preferred initially.
*Wound debridement and irrigation*
- **Wound care** is important, but debridement and irrigation alone will **not stop the internal leakage** of enteric content from the gastrointestinal tract.
- The primary issue is an internal fistula, not a localized wound infection requiring debridement.
*Oral food intake and intravenous fluid administration*
- **Oral food intake** would exacerbate the fistula by stimulating digestive secretions and increasing enteric output, hindering natural healing.
- While **intravenous fluids** are used for hydration and electrolyte balance, they do not address the fistula, and **bowel rest is crucial** for spontaneous closure.
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