Preoperative Evaluation — MCQs

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Preoperative Evaluation — MCQs

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In an accident case, after the arrival of medical team, all should be done in early management except;

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

Patient with BMI 40 presents for emergency surgery. All are correct about airway management EXCEPT:

In anesthesiology, mild systemic disease is classified under which ASA grade?

Most sensitive method of monitoring cardiovascular ischemia in the perioperative period is -

Anticholinergic which can be used as sedative and antiemetic premedication is

During preanaesthetic evaluation, an anaesthetist wrote a Mallampati grade 3. What does this signify?

Which one of the following is not a component of THORACOSCORE?

Modified Mallampati grading is used in assessment of -

Q10

Who coined the term 'anaesthesia'?

Preoperative Evaluation Indian Medical PG Practice Questions and MCQs

Question 1: In an accident case, after the arrival of medical team, all should be done in early management except;

A. Glasgow coma scale
B. Check BP (Correct Answer)
C. Stabilization of cervical vertebrae
D. Check Respiration

Explanation: ***Check BP*** - In the **immediate/early management** of trauma (primary survey), while circulation assessment is crucial, the **initial assessment of circulation** focuses on: - **Pulse rate and quality** (radial, carotid) - **Capillary refill time** - **Skin color and temperature** - **Active hemorrhage control** - **Formal blood pressure measurement** with a cuff, while important, is typically recorded during or after these rapid initial assessments, as it takes more time to obtain an accurate reading. - In the context of this question, among the four options listed, BP measurement is relatively less immediate compared to the other life-saving priorities (airway protection, breathing assessment, C-spine stabilization, and GCS). - **Note:** This is a nuanced distinction - BP is assessed during primary survey, but the other three options have more immediate life-threatening implications if not addressed. *Glasgow coma scale* - **GCS assessment** is part of the **"D" (Disability)** step in the ATLS primary survey. - It is performed early to assess neurological status and level of consciousness. - GCS <8 indicates need for **definitive airway protection** (intubation). - This is a critical early assessment that guides immediate management decisions. *Stabilization of cervical vertebrae* - **C-spine immobilization** is part of the **"A" (Airway)** step - "Airway with cervical spine protection." - It is performed **simultaneously** with airway assessment using a **rigid cervical collar**. - This is the **first priority** in trauma management to prevent secondary spinal cord injury. - All trauma patients should be assumed to have C-spine injury until proven otherwise. *Check Respiration* - **Respiratory assessment** is part of the **"B" (Breathing)** step in the ATLS primary survey. - This involves checking: - **Respiratory rate and pattern** - **Chest wall movement** - **Air entry bilaterally** - **Signs of tension pneumothorax or flail chest** - This is an immediate life-saving priority and must be assessed early.

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: Patient with BMI 40 presents for emergency surgery. All are correct about airway management EXCEPT:

A. Extended ramping
B. Avoid cricoid pressure (Correct Answer)
C. Rapid sequence induction
D. Avoid preoxygenation

Explanation: ***Avoid cricoid pressure*** - While **cricoid pressure** (Sellick's maneuver) is used to prevent **aspiration** by compressing the esophagus, its effectiveness in **obese patients** is highly debated and often hindered by excess neck tissue. - In obese patients, cricoid pressure can actually worsen the view during laryngoscopy, making intubation more difficult and potentially causing airway trauma. *Extended ramping* - **Ramping** the patient, where the head and shoulders are elevated, is crucial in **obese patients** to align the **oral, pharyngeal, and laryngeal axes**. - This position improves the view during laryngoscopy and facilitates successful intubation by effectively displacing excess tissue. *Rapid sequence induction* - **Rapid sequence induction (RSI)** is often indicated in **obese patients** undergoing emergency surgery due to their increased risk of **gastric reflux** and **pulmonary aspiration**. - RSI involves administering a sedative and a paralytic agent in rapid succession, followed immediately by intubation, to minimize the time the airway is unprotected. *Avoid preoxygenation* - **Preoxygenation** is essential in **obese patients** to maximize their **oxygen reserves** before intubation. - Obese patients have reduced **functional residual capacity (FRC)** and increased **oxygen consumption**, making them desaturate rapidly during apnea, so preoxygenation significantly prolongs safe apnea time.

Question 4: In anesthesiology, mild systemic disease is classified under which ASA grade?

A. 2 (Correct Answer)
B. 4
C. 3
D. 1

Explanation: 2 - ASA Grade 2 is defined as a patient with mild systemic disease that is well-controlled and does not limit daily activities. - Examples include a controlled hypertension, controlled type 2 diabetes without systemic complications, or a mild obesity (BMI 30-40). 4 - ASA Grade 4 indicates a patient with severe systemic disease that is a constant threat to life. - This includes conditions such as recent myocardial infarction, stroke, or severe valvular disease, which pose significant risks to patient safety during surgery. 3 - ASA Grade 3 describes a patient with severe systemic disease that limits activity but is not incapacitating. - Examples include poorly controlled hypertension or diabetes, stable angina, or moderate chronic obstructive pulmonary disease (COPD). 1 - ASA Grade 1 is assigned to a healthy patient without any systemic disease. - This classification implies no physiological, physical, or psychological disturbance, other than the condition requiring surgery.

Question 5: Most sensitive method of monitoring cardiovascular ischemia in the perioperative period is -

A. NIBP
B. ECG
C. Pulse oximeter
D. TEE (Correct Answer)

Explanation: ***TEE*** - **Transesophageal echocardiography (TEE)** is the most sensitive method for detecting perioperative myocardial ischemia because it can visualize **regional wall motion abnormalities** and changes in **ventricular function** much earlier than ECG. - **Ischemia** directly impairs the contractility of the affected myocardium, leading to subtle changes in wall motion that TEE can identify. *NIBP* - **Non-invasive blood pressure (NIBP)** monitoring can detect **hemodynamic changes** (like hypotension or hypertension) that may precede or accompany ischemia. - However, these changes are **non-specific** and occur relatively late, making NIBP a less sensitive indicator of early ischemia. *ECG* - **Electrocardiography (ECG)** monitors the electrical activity of the heart and can detect **ST-segment changes** indicative of ischemia. - While useful, ECG changes may appear later than wall motion abnormalities, and **silent ischemia** can be missed if the leads are not optimally placed or if the ischemia does not produce significant electrical changes. *Pulse oximeter* - A **pulse oximeter** measures **oxygen saturation** in the peripheral blood. - It is primarily used to assess **respiratory function** and tissue oxygenation, and it does not directly monitor myocardial ischemia or cardiac function.

Question 6: Anticholinergic which can be used as sedative and antiemetic premedication is

A. Atropine
B. Hyoscine (Correct Answer)
C. Promethazine
D. Glycopyrrolate

Explanation: ***Hyoscine*** - **Hyoscine** (scopolamine) is a muscarinic antagonist that readily crosses the **blood-brain barrier**, allowing it to exert central effects such as **sedation** and potent **antiemetic** actions. - Its ability to reduce secretions and prevent **nausea and vomiting** makes it a suitable anticholinergic for premedication. *Atropine* - **Atropine** is primarily used to increase **heart rate**, reduce **salivary and bronchial secretions**, and as an antidote for cholinesterase inhibitors. - While it is an anticholinergic, its central effects are less pronounced at clinical doses compared to hyoscine, making it less suitable as a sole sedative or antiemetic. *Promethazine* - **Promethazine** is an antihistamine with significant **anticholinergic, sedative**, and **antiemetic** properties. - However, it is primarily classified as an **H1-receptor antagonist** rather than a pure anticholinergic for premedication, although it is often used for these effects. *Glycopyrrolate* - **Glycopyrrolate** is a quaternary ammonium anticholinergic that does not readily cross the **blood-brain barrier**. - Its action is largely peripheral, making it effective for reducing secretions but without significant **sedative** or **antiemetic** effects.

Question 7: During preanaesthetic evaluation, an anaesthetist wrote a Mallampati grade 3. What does this signify?

A. Limited neck extension
B. An enlarged epiglottis
C. Jaw stiffness
D. Soft palate and base of uvula visible (Correct Answer)

Explanation: **Soft palate and base of uvula visible** - A **Mallampati grade 3** classification indicates that only the **soft palate** and the **base of the uvula** are visible when the patient opens their mouth and protrudes their tongue. - This grade suggests a moderate difficulty for **endotracheal intubation** because the visualization of the glottis may be partially obstructed. *Limited neck extension* - Limited **neck extension** is assessed separately during a preanesthetic evaluation and is not directly indicated by the Mallampati score. - It is a factor that can independently contribute to a difficult airway by limiting the ability to achieve the **sniffing position** for intubation. *An enlarged epiglottis* - The **epiglottis** is not visible during a standard awake Mallampati examination, which assesses oral pharyngeal structures. - Visualization of the epiglottis typically occurs during **laryngoscopy** and an enlarged epiglottis (e.g., in epiglottitis) is a medical emergency, not a Mallampati finding. *Jaw stiffness* - **Jaw stiffness** or limited mouth opening is assessed by measuring the **interincisor distance** and is not directly part of the Mallampati classification process. - Significant jaw stiffness can independently predict a difficult airway by restricting the view during laryngoscopy, even with a favorable Mallampati score.

Question 8: Which one of the following is not a component of THORACOSCORE?

A. Performance status
B. Complication of surgery (Correct Answer)
C. Priority of surgery
D. ASA grading

Explanation: ***Complication of surgery*** - THORACOSCORE is a **risk prediction model** for thoracic surgery used to estimate the *probability of mortality and significant morbidity*, but it does not account for the complications of surgery itself as a component. - The score uses **pre-operative patient characteristics** and co-morbidities to predict outcomes, not post-operative events. *Performance status* - **Performance status**, such as the **ECOG scale**, is a crucial component of THORACOSCORE, reflecting the patient's general health and functional capacity prior to surgery. - A lower performance status (indicating poorer functional ability) increases the predicted risk in THORACOSCORE. *Priority of surgery* - The **priority of surgery** (e.g., elective, urgent, emergency) is an important factor in THORACOSCORE, as emergency procedures generally carry a higher risk. - This variable helps to capture the urgency and associated physiological stress on the patient at the time of presentation for surgery. *ASA grading* - The **American Society of Anesthesiologists (ASA) physical status classification system** is a component of THORACOSCORE, assessing the patient's overall health status and anesthetic risk. - A higher ASA grade (indicating more severe systemic disease) contributes to a higher predicted risk in the THORACOSCORE model.

Question 9: 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.

Question 10: Who coined the term 'anaesthesia'?

A. Morgan
B. Priestly
C. Morton
D. Holmes (Correct Answer)

Explanation: ***Holmes*** - Dr. Oliver Wendell Holmes Sr., an American physician and poet, is credited with coining the term **"anaesthesia"** in 1846. - He suggested the term to Dr. William T.G. Morton to describe the state produced by ether for surgical procedures, deriving it from Greek words meaning "without sensation." *Morton* - **William T.G. Morton** was the dentist who successfully demonstrated the use of **ether** for surgical anaesthesia in 1846. - While he pioneered its practical application, he did not coin the term "anaesthesia" itself. *Morgan* - This name is not historically associated with the coining of the term "anaesthesia" or its early development. - There is no prominent historical figure named Morgan with a significant contribution to the origin of the term. *Priestly* - **Joseph Priestley** was an 18th-century chemist famous for discovering **oxygen** (dephlogisticated air) in 1774. - His work was crucial to understanding respiratory gases but not directly related to the concept or term of anaesthesia.

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