Preoperative Assessment Framework — MCQs
Which of the following signs of congestive cardiac failure constitute a major risk to the surgical patient undergoing anaesthesia ?
What is the correct sequence of medication administration for pre-operative prophylaxis in pheochromocytoma?
An intubated patient with eye opening to pain with abnormal flexion. What is the GCS score?
Most sensitive method of monitoring cardiovascular ischemia in the perioperative period is -
Preoperative medication of thyrotoxicosis are all except?
A 62-year-old patient with uncontrolled hypertension resulting in a ruptured aortic aneurysm submitted to surgery belongs to ASA class-
Awareness during anaesthesia can be assessed by:
A moribund patient unlikely to survive 24 hours without surgery is classified as
A patient scheduled for elective inguinal hernia surgery has a history of myocardial infarction (MI) and underwent coronary artery bypass grafting (CABG). What should be included in the preoperative assessment?
Preanaesthetic medication glycopyrrolate is primarily used for:
Preoperative Assessment Framework Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following signs of congestive cardiac failure constitute a major risk to the surgical patient undergoing anaesthesia ?
- A. Pedal oedema
- B. Jugular venous distention and third heart sound (Correct Answer)
- C. Basal crepitations on auscultation
- D. Cardiomegaly
Explanation: ***Jugular venous distention and third heart sound*** - **Jugular venous distention (JVD)** indicates elevated right atrial pressure and **central venous pressure**, signifying significant volume overload and potential right ventricular dysfunction. - A **third heart sound (S3)** is a strong indicator of **ventricular dysfunction** and high filling pressures, suggesting severe heart failure and poor cardiac reserve, which poses a major risk during anesthesia. *Pedal oedema* - **Pedal edema** can be a sign of fluid overload, but it is a relatively mild and chronic symptom of heart failure compared to acute decompensation. - While it reflects increased hydrostatic pressure, it doesn't alone signify the immediate, critical hemodynamic instability that poses a major perioperative risk. *Basal crepitations on auscultation* - **Basal crepitations** (rales) suggest **pulmonary congestion** due to left ventricular failure, indicating fluid in the small airways. - Although concerning, this sign primarily reflects lung involvement and not necessarily the critical, global hemodynamic compromise indicated by JVD and S3. *Cardiomegaly* - **Cardiomegaly** (enlarged heart) is an imaging finding that reflects chronic cardiac remodeling due to long-standing heart disease. - It indicates a history of heart failure but does not directly reflect the **acute hemodynamic status** and immediate risk of decompensation during surgery.
Question 2: What is the correct sequence of medication administration for pre-operative prophylaxis in pheochromocytoma?
- A. Beta blockade followed by alpha blockade
- B. Simultaneous alpha and beta blockade
- C. Alpha blockade followed by beta blockade (Correct Answer)
- D. Alpha blockade only
Explanation: ***Alpha blockade followed by beta blockade*** - **Alpha blockade** should always be initiated first to control **hypertension** and prevent a **hypertensive crisis** during surgery. This is critical because pheochromocytoma causes excessive catecholamine release, leading to profound vasoconstriction. - **Beta blockade** is then added only after adequate alpha blockade has been achieved to control **tachycardia** and arrhythmias, preventing **unopposed alpha-adrenergic stimulation** which could paradoxically worsen hypertension. *Simultaneous alpha and beta blockade* - Administering both simultaneously is dangerous because **beta blockade** can mask the effects of inadequate alpha blockade. - This can lead to **unopposed alpha-adrenergic stimulation** after beta blockade, causing severe **vasoconstriction** and hypertensive crisis. *Beta blockade followed by alpha blockade* - Initiating with **beta blockade** without prior **alpha blockade** is absolutely contraindicated in pheochromocytoma. - This can lead to severe and potentially fatal **hypertension** due to **unopposed alpha-adrenergic stimulation** as beta blockade prevents vasodilation. *Alpha blockade only* - While essential for initial management, **alpha blockade alone** might not fully control all symptoms, especially **tachycardia** and **arrhythmias** caused by high circulating catecholamine levels. - Adding a **beta blocker** after achieving adequate alpha blockade helps in controlling these cardiac effects, optimizing patient preparation for surgery.
Question 3: An intubated patient with eye opening to pain with abnormal flexion. What is the GCS score?
- A. E2VTM3 (Correct Answer)
- B. E2V1M3
- C. E2VNTM3
- D. E2VTM4
Explanation: ***E2VTM3*** - **Eye opening to pain** corresponds to an E score of **2** [1]. - Since the patient is **intubated**, the verbal component is untestable, denoted as **VT**. - **Abnormal flexion** corresponds to an M score of **3**. *E2V1M3* - This option incorrectly assigns a verbal score of 1, implying **no verbal response**, which is inappropriate for an intubated patient. - For intubated patients, the verbal component is typically marked as untestable (VT) rather than assigned a numerical value for no response. *E2VNTM3* - While **E2** and **M3** are correct, the presence of **"NT"** for the verbal component is redundant with **"VT"** if only one is to be used. - The standard abbreviation for an untestable verbal component in an intubated patient is **VT**. *E2VTM4* - This option incorrectly assigns a motor score of **4** for **withdrawal from pain**, whereas the description states **abnormal flexion** [2]. - **Abnormal flexion (decorticate)** is distinct from withdrawal and corresponds to an M score of **3** [2].
Question 4: 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 5: 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 6: A 62-year-old patient with uncontrolled hypertension resulting in a ruptured aortic aneurysm submitted to surgery belongs to ASA class-
- A. VI
- B. V
- C. III
- D. IV (Correct Answer)
Explanation: ***IV*** - An **ASA Class IV** patient has a **severe systemic disease** that is a constant threat to life. - An **uncontrolled ruptured aortic aneurysm** with uncontrolled hypertension clearly signifies a life-threatening condition, which is the hallmark of ASA Class IV. *VI* - **ASA Class VI** is reserved for a **brain-dead patient** whose organs are being removed for donor purposes. - This patient is alive and undergoing surgery, so Class VI does not apply. *V* - **ASA Class V** describes a **moribund patient** who is not expected to survive without the operation. - While a ruptured aortic aneurysm is severe, ASA V implies an even more immediate and profound risk of death, often associated with multiple organ failure or profound shock, which is not explicitly stated here. *III* - **ASA Class III** is defined by **severe systemic disease** that limits activity but is not incapacitating. - Uncontrolled hypertension and a ruptured aortic aneurysm represent a critical, life-threatening situation, classifying the patient beyond a simple Class III.
Question 7: Awareness during anaesthesia can be assessed by:
- A. ARTERIAL B.P
- B. ETCO2
- C. BIS (Correct Answer)
- D. NEUROMUSCULAR MONITOR
Explanation: ***
Question 8: 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 9: A patient scheduled for elective inguinal hernia surgery has a history of myocardial infarction (MI) and underwent coronary artery bypass grafting (CABG). What should be included in the preoperative assessment?
- A. History + c/e + routine labs + V/Q scan
- B. History + c/e + routine labs
- C. History + c/e + routine labs + stress test (Correct Answer)
- D. History + c/e + routine labs + angiography to assess graft patency
Explanation: ***History + c/e + routine labs + stress test*** - A **stress test** is crucial in patients with a history of MI and CABG to assess **myocardial ischemia** and functional capacity, guiding perioperative management. - This evaluation helps determine the patient's **cardiac risk** for non-cardiac surgery and the need for further cardiac optimization. *History + c/e + routine labs + angiography to assess graft patency* - **Coronary angiography** is an invasive procedure and is generally not indicated as a routine preoperative assessment unless there are new, significant cardiac symptoms or signs of **graft dysfunction**. - Assessing graft patency through angiography carries risks and would only be justified if there were strong clinical indications suggesting acute or severe **cardiac ischemia**. *History + c/e + routine labs* - While critical for any preoperative assessment, **routine history, physical examination, and basic laboratory tests** are insufficient for a patient with a significant cardiac history like MI and CABG. - This approach would **underestimate the cardiac risk** and might miss undetected ischemia, leading to adverse perioperative cardiac events. *History + c/e + routine labs + V/Q scan* - A **ventilation-perfusion (V/Q) scan** is primarily used to diagnose **pulmonary embolism** or assess regional lung function. - It does not provide information about myocardial ischemia or cardiac functional capacity, making it **irrelevant** for assessing cardiac risk in this clinical scenario.
Question 10: Preanaesthetic medication glycopyrrolate is primarily used for:
- A. Decrease secretion (Correct Answer)
- B. Antisialagogue effect
- C. Prevent aspiration
- D. Reduce bronchial secretions
Explanation: ***Decrease secretion*** - Glycopyrrolate is an **anticholinergic drug** that primarily works by blocking muscarinic acetylcholine receptors, thereby reducing glandular secretions throughout the body. - This effect includes reducing **salivary**, **bronchial**, and **gastric secretions**, which is beneficial during anesthesia. *Reduce bronchial secretions* - While glycopyrrolate does **reduce bronchial secretions**, this is a specific aspect of its broader effect of decreasing secretions, making "decrease secretion" a more comprehensive answer. - Reducing bronchial secretions helps in maintaining a **clear airway** and preventing atelectasis. *Prevent aspiration* - By decreasing gastric and salivary secretions, glycopyrrolate can indirectly help to **reduce the risk of aspiration** of gastric contents or saliva into the lungs. - However, preventing aspiration is a beneficial **consequence** of reduced secretions, not the direct pharmacological action described as "decrease secretion." *Antisialagogue effect* - The **antisialagogue effect**, which means reducing saliva production, is a prominent action of glycopyrrolate and is part of its overall secretion-decreasing property. - Reducing salivary secretions creates a **dry operative field** during procedures involving the oral cavity or airway.
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