Preoperative Assessment for Outpatients — MCQs

10 questions

A 63-year-old man presents for an elective laparoscopic cholecystectomy. He is obese, has angina at rest, and chronic obstructive pulmonary disease (COPD). Which of the following would be his American society of Anesthesiologists (ASA) physical status classification

Which pre-operative investigation is recommended before surgical procedures in a patient on warfarin therapy?

Which of the following agents is not used to provide induced hypotension during surgery ?

Preoperative medication of thyrotoxicosis are all except?

In the immediate postoperative period, body potassium is

Which of the following is not done in the primary survey of trauma?

Which of the following is the LEAST significant risk factor for postoperative pulmonary complications?

A 55-year-old male, known smoker, complains of calf pain while walking. He experiences calf pain while walking but can continue walking with effort. Which grade of claudication does this patient fall under?

A moribund patient unlikely to survive 24 hours without surgery is classified as

Q10

Modified Mallampati grading is used in assessment of -

Preoperative Assessment for Outpatients Indian Medical PG Practice Questions and MCQs

Question 1: A 63-year-old man presents for an elective laparoscopic cholecystectomy. He is obese, has angina at rest, and chronic obstructive pulmonary disease (COPD). Which of the following would be his American society of Anesthesiologists (ASA) physical status classification

A. ASA II
B. ASA I
C. ASA IV
D. ASA III (Correct Answer)

Explanation: ***ASA III*** - This patient has **severe systemic disease** (angina at rest, COPD, obesity) that limits activity but is not incapacitating, aligning with the criteria for **ASA III**. - **Angina at rest** and **chronic obstructive pulmonary disease (COPD)** are significant comorbidities that place the patient in this category. *ASA II* - **ASA II** is defined by **mild systemic disease** that does not limit activity. - The patient's conditions such as **angina at rest** and **COPD** are more severe than what would be considered mild. *ASA I* - **ASA I** is reserved for a **normal, healthy patient** with no systemic disease. - This patient has multiple significant systemic diseases, unequivocally ruling out ASA I. *ASA IV* - **ASA IV** describes a patient with **severe systemic disease** that is a constant threat to life. - While critical, the patient's conditions (angina at rest, COPD) are stabilised enough for an **elective procedure** and are not an immediate, constant threat to life.

Question 2: Which pre-operative investigation is recommended before surgical procedures in a patient on warfarin therapy?

A. International Normalized Ratio (INR) (Correct Answer)
B. Partial Thromboplastin Time (PTT)
C. Clotting Time
D. Differential Count

Explanation: ***International Normalized Ratio (INR)*** - The **INR** is specifically used to monitor the effectiveness of **warfarin** therapy, as it standardizes the prothrombin time (PT) for variations in thromboplastin reagents. - Before surgery, an INR measurement helps assess the patient's **coagulation status** and guides decisions on temporary cessation or bridging therapy to minimize bleeding risk. *Partial Thromboplastin Time (PTT)* - **PTT** primarily measures the **intrinsic and common pathways** of coagulation and is used to monitor **heparin** therapy, not warfarin. - While prolonged in some bleeding disorders, it is not the standard test for assessing warfarin's anticoagulant effect. *Clotting Time* - **Clotting time** is a very general and less precise measure of overall coagulation that is **rarely used** in modern clinical practice due to its low sensitivity and specificity. - It does not offer sufficient detail or standardization to guide pre-operative management for patients on warfarin. *Differential Count* - A **differential count** measures the different types of **white blood cells** within a blood sample and is used to diagnose infections, inflammatory conditions, or hematologic disorders. - It provides no information about a patient's coagulation status or the effects of anticoagulant medications like warfarin.

Question 3: Which of the following agents is not used to provide induced hypotension during surgery ?

A. Mephenteramine (Correct Answer)
B. Sodium nitroprusside
C. Hydralazine
D. Esmolol

Explanation: ***Mephenteramine*** - **Mephentermine** is a **vasopressor** used to **increase blood pressure**, acting primarily through the release of **norepinephrine**. - Its effects are opposite to what is desired for **induced hypotension** during surgery, as the goal is to lower systemic blood pressure to reduce blood loss and improve surgical field visibility. *Sodium nitroprusside* - **Sodium nitroprusside** is a potent **vasodilator** that directly relaxes both **arterial** and **venous smooth muscle**, leading to a rapid and significant decrease in blood pressure. - Its rapid onset and offset of action make it a valuable agent for **controlled induced hypotension** during surgery. *Hydralazine* - **Hydralazine** is a **direct-acting arterial vasodilator** that primarily relaxes arterial smooth muscle, leading to a decrease in **peripheral vascular resistance** and blood pressure. - It can be used to induce or maintain **hypotension** during surgery, although its onset of action is slower compared to nitroprusside. *Esmolol* - **Esmolol** is a **short-acting beta-1 selective adrenergic blocker** that reduces heart rate and myocardial contractility, thereby decreasing cardiac output. - By reducing cardiac output, esmolol can contribute to **induced hypotension**, often used in conjunction with vasodilators or in situations where controlling heart rate is also desired.

Question 4: Preoperative medication of thyrotoxicosis are all except?

A. Carbimazole
B. PTU
C. Propranolol
D. Levothyroxine (Correct Answer)

Explanation: Levothyroxine - Levothyroxine is a synthetic thyroid hormone used to treat hypothyroidism, meaning it increases thyroid hormone levels, which would worsen thyrotoxicosis [1]. - Its administration would be contraindicated in a patient with thyrotoxicosis, as the goal is to reduce thyroid hormone levels preoperatively. Carbimazole - Carbimazole is a thionamide drug that inhibits the synthesis of thyroid hormones, making it a critical medication for treating hyperthyroidism and preparing patients for surgery [1]. - It reduces the amount of thyroid hormone produced by the thyroid gland, thus mitigating the risks associated with thyrotoxicosis during surgery. PTU - Propylthiouracil (PTU), like carbimazole, is a thionamide that blocks thyroid hormone synthesis and also inhibits the conversion of T4 to T3 [1]. - It is used in the preoperative management of thyrotoxicosis to achieve a euthyroid state and prevent a thyroid storm. Propranolol - Propranolol is a beta-blocker used to manage the symptoms of thyrotoxicosis, particularly the cardiovascular effects such as tachycardia, palpitations, and tremors [1]. - While it does not affect thyroid hormone levels directly, it helps control symptoms and stabilize the patient preoperatively, making them a safer candidate for surgery [1].

Question 5: In the immediate postoperative period, body potassium is

A. Retained in body
B. Exchanged with magnesium
C. Exchanged with calcium
D. Excreted excessively (Correct Answer)

Explanation: ***Excreted excessively*** - In the immediate postoperative period, the body often experiences **stress-induced hormonal changes**, such as increased cortisol and aldosterone, and activation of the **renin-angiotensin-aldosterone system**. - These hormonal changes can lead to increased renal potassium excretion and **catabolism** of muscle tissue, releasing intracellular potassium which is then excreted. *Retained in body* - **Potassium retention** is typically seen in conditions like **renal failure** or in states of **hypoaldosteronism**, which are not characteristic of the immediate postoperative period. - The stress response and potential for **acidosis** generally shift potassium out of cells, leading to increased excretion rather than retention. *Exchanged with magnesium* - While potassium and magnesium are both important intracellular cations and their levels can influence each other, a direct "exchange" in the immediate postoperative period is not the primary mechanism of potassium handling. - **Hypomagnesemia** can impair potassium reabsorption leading to **hypokalemia**, but this is a secondary effect, not a direct exchange causing excessive excretion. *Exchanged with calcium* - There is no primary physiological mechanism for direct "exchange" of potassium with calcium in the context of general body fluid and electrolyte regulation in the immediate postoperative period. - **Calcium and potassium** have different regulatory pathways and serve distinct roles, though imbalances in one can indirectly affect the other's transport or cellular function.

Question 6: Which of the following is not done in the primary survey of trauma?

A. Intubation
B. NCCT head (Correct Answer)
C. ICD drainage
D. CXR

Explanation: ***NCCT head*** - A **Non-Contrast CT (NCCT) head** is typically performed during the **secondary survey** once the patient is hemodynamically stable and life-threatening conditions have been addressed. - The primary survey focuses on immediate **life-saving interventions** for airway, breathing, circulation, disability, and exposure. *Intubation* - **Intubation** is a critical intervention during the primary survey, specifically under the **'A' (Airway)** component, to establish and secure a patent airway in a compromised patient. - Failure to establish an airway can rapidly lead to **hypoxia** and death. *ICD drainage* - **Intercostal drain (ICD) drainage** is an urgent intervention in the primary survey, falling under **'B' (Breathing)**, to manage conditions like **tension pneumothorax** or massive hemothorax. - These conditions can severely compromise ventilation and circulation, requiring immediate relief. *CXR* - A **Chest X-ray (CXR)** is a rapid and essential diagnostic tool in the primary survey, also under **'B' (Breathing)**, to identify life-threatening thoracic injuries such as pneumothorax, hemothorax, or mediastinal shift. - It provides quick information crucial for immediate management decisions.

Question 7: Which of the following is the LEAST significant risk factor for postoperative pulmonary complications?

A. Age > 60 years (Correct Answer)
B. ASA class 3 and 4 patients
C. Longer surgeries >2 hr
D. Upper Abdominal surgery

Explanation: ***Age > 60 years*** - While age is a factor, it is generally considered **less significant** than other comorbid conditions or surgical factors in predicting postoperative pulmonary complications. - Pulmonary function naturally declines with age, but healthy elderly individuals may still tolerate surgery well if other risk factors are controlled. *ASA class 3 and 4 patients* - Patients classified as **ASA (American Society of Anesthesiologists) 3 or 4** have severe systemic disease or life-threatening systemic disease, respectively. - This significantly increases their risk of **postoperative pulmonary complications** due to their underlying health issues. *Longer surgeries >2 hr* - **Prolonged duration of surgery** (typically defined as >2-3 hours) is a significant independent risk factor for pulmonary complications. - This is due to longer periods of **immobility**, ventilation, and exposure to anesthetics, contributing to atelectasis and pneumonia risk. *Upper Abdominal surgery* - **Upper abdominal surgery** is one of the highest risk categories for postoperative pulmonary complications. - Incisions in this area can cause *diaphragmatic dysfunction*, pain leading to shallow breathing, and impaired cough reflex.

Question 8: A 55-year-old male, known smoker, complains of calf pain while walking. He experiences calf pain while walking but can continue walking with effort. Which grade of claudication does this patient fall under?

A. Grade I (Mild claudication)
B. Grade II (Moderate claudication) (Correct Answer)
C. Grade III (Severe claudication)
D. Grade IV (Ischemic rest pain)

Explanation: ***Grade II (Moderate claudication)*** - **Grade II claudication** is characterized by **intermittent claudication** where the patient experiences pain while walking but can **continue walking with effort**. - This level of claudication reflects a moderate degree of peripheral arterial disease, where blood flow is sufficiently compromised to cause pain with exertion but not severe enough to force immediate cessation of activity. - The patient in this scenario can continue ambulation despite discomfort, which is the defining feature of this grade. *Grade I (Mild claudication)* - **Grade I claudication** involves discomfort or pain that the patient can **tolerate without significantly altering their gait or pace**. - In this stage, the pain is minimal, and the patient may perceive it as a dull ache or mild fatigue rather than true pain. - Walking can continue without significant effort or limitation. *Grade III (Severe claudication)* - **Grade III claudication** is marked by pain that is **severe enough to stop the patient from walking within a short distance** (typically less than 200 meters). - The pain forces the patient to rest and recover before they can resume walking. - This represents significant functional limitation in daily activities. *Grade IV (Ischemic rest pain)* - **Grade IV**, also known as **critical limb ischemia**, involves **pain even at rest**, especially in the feet or toes, often worsening at night when the limb is elevated. - This stage indicates severe arterial obstruction and is frequently associated with **ulcers, non-healing wounds, or gangrene**. - This represents advanced peripheral arterial disease requiring urgent intervention. **Note:** This grading system is a simplified clinical classification. The standard medical classifications for peripheral arterial disease are the **Fontaine classification** (Stages I-IV) and **Rutherford classification** (Categories 0-6).

Question 9: A moribund patient unlikely to survive 24 hours without surgery is classified as

A. ASA V (Correct Answer)
B. ASA III
C. ASA VI
D. ASA I

Explanation: ***ASA V*** - An **ASA V** patient is defined as a **moribund patient** who is not expected to survive without the operation. - This classification applies to patients with a high risk of death, often within **24 hours**, even with surgical intervention. *ASA III* - An **ASA III** patient has **severe systemic disease** that functional limitations, but is not incapacitating. - While serious, their condition is not immediately life-threatening to the extent of a moribund patient. *ASA VI* - An **ASA VI** patient is declared **brain-dead** and is undergoing surgery for **organ donation**. - This classification describes a patient who is already deceased from a neurological perspective, rather than one on the verge of death. *ASA I* - An **ASA I** patient is a **normal healthy** individual with no systemic disease. - This is the lowest risk category and contrasts sharply with the critical condition described in the question.

Question 10: Modified Mallampati grading is used in assessment of -

A. Difficulty of intubation (Correct Answer)
B. Obstruction of the airway
C. Aspiration-related death
D. Endotracheal intubation procedure

Explanation: ***Difficulty of intubation*** - The **Modified Mallampati score** assesses the visibility of pharyngeal structures, which directly correlates with the ease or difficulty of performing **direct laryngoscopy** and **endotracheal intubation**. - A higher Mallampati class (e.g., III or IV) indicates less visibility of the soft palate, uvula, and pillars, suggesting a more difficult airway and increased likelihood of a challenging intubation. *Obstruction of the airway* - While a high Mallampati score might indirectly indicate potential for **airway obstruction** during anesthesia due to anatomical features, its primary purpose is not to diagnose or quantify existing airway obstruction. - Airway obstruction is more directly assessed by monitoring breathing sounds, respiratory effort, and oxygen saturation. *Aspiration-related death* - The **Mallampati score** helps predict the difficulty of securing the airway but does not directly assess the risk of **aspiration**. - Aspiration risk is evaluated based on factors like gastric contents, gag reflex, and patient positioning. *Endotracheal intubation procedure* - The **Modified Mallampati score** helps in **planning the intubation procedure** by identifying potential difficulties but is not a measure of the intubation procedure itself. - It is a **pre-procedure assessment tool** to gauge airway anatomy, not a description or evaluation of the steps involved in endotracheal intubation.

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