Risk Stratification — MCQs
Which of the following signs of congestive cardiac failure constitute a major risk to the surgical patient undergoing anaesthesia ?
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 patient who met with an accident presented to the emergency department, he lost 25% of his total blood volume approximately, blood pressure is normal. He/she will be classified under which class of hypovolemic shock?
Which of the following is not a component of the Goldman Revised Cardiac Risk Index?
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?
According to the DSM-5 criteria for Autism Spectrum Disorder, which of the following is required for diagnosis in children?
In modified Pugh's classification score of 8, what is the line of management?
Which of the following is the best method to assess the adequacy of fluid replacement?
A moribund patient unlikely to survive 24 hours without surgery is classified as
ASA classification is done for – a) Status of patient b) Risk c) Pain d) Lung disease
Risk Stratification 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: 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 3: A patient who met with an accident presented to the emergency department, he lost 25% of his total blood volume approximately, blood pressure is normal. He/she will be classified under which class of hypovolemic shock?
- A. Class II (Correct Answer)
- B. Class I
- C. Class III
- D. Class IV
Explanation: ***Class II*** - A 25% blood loss (within the **15-30% range**), with **blood pressure remaining normal**, categorizes this patient into **Class II hypovolemic shock**. - In Class II, compensatory mechanisms such as increased **heart rate** and **peripheral vasoconstriction** maintain systolic blood pressure despite significant volume loss. - Patients typically present with **tachycardia (100-120 bpm)**, **narrowed pulse pressure**, mild **anxiety**, and **normal systolic BP**. *Class I* - Class I shock involves **minimal blood loss** (up to 15%), with blood loss <750 mL in adults. - Patients in Class I typically present with **normal vital signs** and minimal to no clinical symptoms. - The 25% blood loss exceeds the threshold for Class I classification. *Class III* - Class III shock is characterized by blood loss of **30-40%** (1500-2000 mL in adults). - This level of loss typically results in **decreased systolic blood pressure**, **marked tachycardia (120-140 bpm)**, **confusion**, and clinical instability. - The patient's normal blood pressure and 25% loss are **below the threshold** for Class III shock. *Class IV* - Class IV shock involves massive blood loss of **greater than 40%** (>2000 mL in adults). - Presents with profound **hypotension**, **severe tachycardia (>140 bpm)**, **altered consciousness**, and **imminent cardiovascular collapse**. - This patient's normal blood pressure and stable condition are inconsistent with Class IV shock.
Question 4: Which of the following is not a component of the Goldman Revised Cardiac Risk Index?
- A. History of preoperative treatment with insulin
- B. History of preoperative serum creatinine >2.0 mg/dL
- C. Age > 80 yrs (Correct Answer)
- D. History of ischemic heart disease
Explanation: ***Age > 80 yrs*** - **Age** is not a parameter included in the Goldman Revised Cardiac Risk Index for predicting postoperative cardiac complications. - The index focuses on specific medical conditions and surgical risk factors. *History of preoperative treatment with insulin* - This is a component of the **Goldman Revised Cardiac Risk Index**, indicating **insulin-dependent diabetes mellitus**. - Diabetes requiring insulin treatment is a significant risk factor for cardiac complications during surgery. *History of preoperative serum creatinine >2.0 mg/dL* - An elevated **serum creatinine** (>2.0 mg/dL) is a recognized component of the index, reflecting **renal insufficiency**. - **Renal impairment** is associated with increased cardiac risk in the perioperative period. *History of ischemic heart disease* - This is a key component of the Goldman Revised Cardiac Risk Index, as a history of **ischemic heart disease** (e.g., prior myocardial infarction, angina) significantly increases perioperative cardiac risk. - Patients with existing heart disease are more susceptible to cardiac events during and after surgery.
Question 5: 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 6: According to the DSM-5 criteria for Autism Spectrum Disorder, which of the following is required for diagnosis in children?
- A. Language delay before age 2
- B. Persistent deficits in social communication and interaction (Correct Answer)
- C. Presence of seizure disorder
- D. Intellectual disability
Explanation: ***Persistent deficits in social communication and interaction*** - This is a **core diagnostic criterion** for Autism Spectrum Disorder (ASD) according to DSM-5, encompassing difficulties in social-emotional reciprocity, nonverbal communicative behaviors, and developing/maintaining relationships. - These deficits must be present across **multiple contexts** and not better explained by other conditions. *Language delay before age 2* - While language delay is common in ASD, it is **not a mandatory diagnostic criterion** in the DSM-5; some individuals with ASD may have typical or even advanced language skills. - The focus has shifted from specific language milestones to broader **social communication deficits**. *Presence of seizure disorder* - **Seizures** are a co-occurring medical condition that can affect individuals with ASD, but they are absolutely **not a diagnostic criterion** for the disorder itself. - The presence of a seizure disorder suggests comorbidity, not a defining feature of autism. *Intellectual disability* - **Intellectual disability** frequently co-occurs with ASD (approximately 30-50% of cases), but it is **not a required criterion** for diagnosis. - Many individuals with ASD have average or above-average intellectual abilities.
Question 7: In modified Pugh's classification score of 8, what is the line of management?
- A. Sclerotherapy
- B. Shunt surgery
- C. Conservative management (Correct Answer)
- D. Orthotopic liver transplant
Explanation: Conservative management - A modified Child-Pugh score of 8 falls into Child-Pugh class B, indicating **moderate liver dysfunction**. - At this stage, **medical management** aimed at addressing complications and improving liver function is the primary line of treatment. *Orthotopic liver transplant* - Liver transplantation is generally considered for patients with **Child-Pugh class C** (scores 10-15) or those with class B who are unresponsive to medical therapy and have a high risk of mortality [1]. - While a score of 8 indicates significant disease, it's not immediately indicative of the need for transplant without failure of conservative measures or other specific indications [1]. *Sclerotherapy* - **Sclerotherapy** is a procedure primarily used to treat **esophageal varices** to prevent or treat bleeding [2]. - It is a targeted intervention for a specific complication of portal hypertension, not a general management strategy for a Child-Pugh score of 8. *Shunt surgery* - **Shunt surgery**, such as a Transjugular Intrahepatic Portosystemic Shunt (TIPS), is used to decompress the **portal venous system** in cases of severe portal hypertension [3]. - It's typically reserved for patients with recurrent variceal bleeding or refractory ascites, and not a primary management for a Child-Pugh score of 8 as a whole [3].
Question 8: Which of the following is the best method to assess the adequacy of fluid replacement?
- A. Blood pressure
- B. Decrease in thirst
- C. Increased PaO2
- D. Increase in urine output (Correct Answer)
Explanation: ***Increase in urine output*** - An **increasing urine output** (typically above 0.5-1 mL/kg/hr in adults) is a reliable indicator that **renal perfusion** is improving and the body's fluid status is normalizing, especially in hypovolemic states. - This reflects restored **circulating volume** and adequate **organ perfusion**, which is the primary goal of fluid replacement. *Blood pressure* - While an increase in **blood pressure** can indicate improved fluid status, it is a relatively late and often conserved compensatory mechanism; the body can maintain blood pressure even with significant fluid deficits. - Blood pressure can be influenced by many factors other than fluid status, such as **vasoactive medications** or underlying cardiac conditions, making it less specific than urine output. *Decrease in thirst* - A decrease in thirst might indicate subjective improvement, but it is a **subjective symptom** and not an objective, quantifiable measure of adequate fluid replacement or organ perfusion [1]. - Thirst can be influenced by psychological factors and may not accurately reflect the body's true **hydration status** or the adequacy of fluid resuscitation, especially in critically ill patients [2]. *Increased PaO2* - An increase in **PaO2 (partial pressure of oxygen in arterial blood)** primarily reflects improved oxygenation and ventilation, not necessarily the adequacy of fluid replacement. - While severe hypovolemia can compromise tissue oxygen delivery, an increase in PaO2 alone is not a direct or primary indicator of successful volume resuscitation; it's more specific to **respiratory function**.
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: ASA classification is done for – a) Status of patient b) Risk c) Pain d) Lung disease
- A. ac
- B. a
- C. ab (Correct Answer)
- D. bc
Explanation: ***ab*** - The **American Society of Anesthesiologists (ASA) Physical Status Classification System** is used to assess a patient's **overall health (status)** before surgery. - This classification helps in determining the **anesthetic risk** and guides anesthetic management. *ac* - While patient status is assessed, ASA classification does not primarily classify **pain** or pain management strategies. - **Lung disease** can influence a patient's ASA status, but it's not the sole or primary factor being classified independently. *a* - The ASA classification evaluates the patient's **overall health or status** but significantly aims to assess the **risk** associated with anesthesia and surgery. - Without considering risk, the classification loses its primary purpose in surgical planning. *bc* - The ASA system is indeed used to stratify **risk** for anesthesia and surgery, but it primarily does this by categorizing the patient's **overall physical status**. - It does not directly classify **pain** as an independent variable; patient conditions causing pain would contribute to their overall status.
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