Consultative and Perioperative Medicine Practice Questions

Q: Which of the following is the necessary pre-operative investigation which has to be done in a patient with Down's syndrome posted for surgery?

Echocardiography to assess congenital heart defects. ***Echocardiography to assess congenital heart defects*** - Patients with **Down syndrome (Trisomy 21)** have a high incidence of congenital heart defects, most commonly **atrioventricular septal defects**, which require evaluation prior to surgery due to their anesthetic and surgical implications. - Pre-surgical echocardiography is crucial to identify and characterize these defects, allowing for appropriate perioperative management and optimization of cardiac function. *Cervical spine X-Ray to evaluate atlantoaxial instability* - While **atlantoaxial instability** is a known concern in Down syndrome, particularly important for procedures involving neck manipulation, it is not universally necessary for *every* surgical patient. - Cervical spine imaging is typically reserved for elective procedures where neck manipulation is anticipated or if there are clinical signs suggestive of myelopathy. *Abdominal ultrasound to detect gastrointestinal anomalies* - Gastrointestinal anomalies like **duodenal atresia** or **Hirschsprung disease** are more prevalent in Down syndrome but are usually identified and treated in infancy or childhood due to symptomatic presentation. - Unless there are specific clinical symptoms or a history of unaddressed GI issues, a routine preoperative abdominal ultrasound is generally not indicated. *Brain CT scan to identify structural abnormalities* - Individuals with Down syndrome often have developmental brain differences, but a routine preoperative brain CT scan is not standard practice unless there are neurological symptoms or a history of conditions like seizures or hydrocephalus requiring investigation. - It would not be considered a necessary **pre-operative investigation** for general surgical fitness in the absence of specific indications.

Q: A patient posted for Lap Cholecystectomy had drug eluting stent placed two years back. Patient has no symptoms since then. Which of the following set of investigation should be done in this patient?

ECG, CBC, Stress echocardiography. **ECG, CBC, Stress echocardiography** - A patient with a **drug-eluting stent (DES)** placed two years prior, who is now asymptomatic, typically requires a **non-invasive cardiac assessment** before surgery. [1] - **Stress echocardiography** is an appropriate investigation to assess for inducible ischemia in an asymptomatic patient with a history of DES, especially when determining readiness for non-cardiac surgery. [1] *Coronary angiography, Thallium scan* - **Coronary angiography** is an invasive procedure and is generally not indicated for asymptomatic patients two years post-DES unless there are new symptoms or high-risk findings on non-invasive tests. [2] - A **Thallium scan** (myocardial perfusion scintigraphy) is a valid stress test, but **stress echocardiography** provides similar information regarding ischemia and ventricular function without radiation exposure. [1] *ECG, CBC, Coronary angiography* - While **ECG** and **CBC** are standard preoperative tests, **coronary angiography** is an invasive procedure and is not the first-line investigation for an asymptomatic patient two years post-DES without other indications. [2] - The patient's asymptomatic status suggests that invasive testing is not immediately warranted for surgical clearance. *ECG, CBC, Stress echocardiography, coronary angiography* - Performing both **stress echocardiography** and **coronary angiography** in an asymptomatic patient two years after DES placement is **redundant** and subjects the patient to an unnecessary invasive procedure. [1], [2] - The results of a non-invasive stress test like stress echocardiography would guide the need for any further invasive intervention.

Q: Most sensitive marker for post-transplant rejection of liver is:

ALT. ***ALT*** - **Alanine aminotransferase (ALT)** is primarily found in the liver and is a highly sensitive indicator of **hepatocellular damage**. [1] - Elevations in ALT often precede other markers in cases of **acute cellular rejection** in liver transplant recipients. *GGT* - **Gamma-glutamyl transferase (GGT)** can be elevated in liver injury, but it is also increased in **biliary obstruction** and due to certain medications like alcohol. [1] - While GGT can be a general marker of liver stress, it is less specific than ALT for hepatocellular rejection. *AST* - **Aspartate aminotransferase (AST)** is found in the liver, heart, skeletal muscle, and kidneys, making it **less specific** to liver injury than ALT. - Although AST levels rise in liver damage, ALT is generally considered a more liver-specific enzyme. *Bilirubin* - **Bilirubin** levels primarily reflect the liver's ability to conjugate and excrete bilirubin, often indicating **cholestasis** or severe hepatocellular dysfunction. - While elevated bilirubin can occur with rejection, it is typically a **later and less sensitive marker** compared to transaminases for early hepatocellular rejection.

Q: A 70-year-old man with chronic obstructive pulmonary disease (COPD) is scheduled for abdominal surgery. What is the most important preoperative consideration?

Smoking cessation. ***Smoking cessation*** - **Smoking cessation** for at least **6-8 weeks** prior to surgery significantly reduces postoperative pulmonary complications, especially in patients with **COPD** [1]. - This allows for improvement in mucociliary clearance, reduction in airway inflammation, and decreased sputum production [1]. *Pulmonary function tests* - While pulmonary function tests (PFTs) can provide a baseline assessment of lung function, they are **not the most important immediate preoperative intervention** to reduce risk. - PFTs help characterize the severity of COPD but do not directly mitigate surgical risk as much as smoking cessation. *Bronchodilator therapy* - **Optimizing bronchodilator therapy** is important for patients with COPD to improve airflow and reduce bronchospasm [1]. - However, it addresses ongoing symptoms rather than the fundamental inflammatory and secretory effects of smoking, making it less impactful than smoking cessation as the **most important single consideration**. *Chest X-ray* - A **chest X-ray** provides structural information about the lungs and can detect acute processes like pneumonia or effusions. - While useful for preoperative assessment, it is a diagnostic tool and does not actively modify the patient's physiological risk in the way that smoking cessation does.

Q: Monoclonal antibodies to the CD25 (IL-2α) receptors are used for the treatment of:

Kidney transplant rejection. ***Kidney transplant rejection*** - Monoclonal antibodies targeting **CD25 (IL-2α receptor)** interfere with T-cell activation and proliferation, which are critical in mediating transplant rejection [1], [2]. - Examples include **basiliximab** and **daclizumab**, which are used as induction therapy to prevent acute rejection in organ transplantation [2]. *Hematological malignancies* - While some monoclonal antibodies are used for hematological malignancies (e.g., rituximab for CD20), those targeting **CD25** are not primary treatments for most hematological cancers. - **CD25** can be expressed on some leukemias (e.g., hairy cell leukemia), but the main use of CD25 antibodies is in immunosuppression. *Autoimmune disorders* - Although immune activation is central to autoimmune diseases, specific **CD25-targeting antibodies** are not widely established as frontline treatments for most autoimmune disorders. - Other immunomodulators and biologics are more commonly used in this context. *Bone marrow transplant complications* - While some immunosuppressants are used to manage complications like **graft-versus-host disease (GVHD)**, agents specifically targeting **CD25** are not primary treatments for these complications. - GVHD treatment often involves corticosteroids and other broad immunosuppressants.

Q: What is the best treatment advice for a 69-year-old male patient with coronary artery disease and asymptomatic gallbladder stones, who has no history of biliary colic or jaundice?

Observation without surgery for gallbladder stones. ***Observation without surgery for gallbladder stones*** - For **asymptomatic gallbladder stones**, especially in patients with **coronary artery disease** (which increases surgical risk), observation is the recommended approach [1]. The risk of developing symptoms or complications (e.g., cholecystitis, cholangitis, pancreatitis) is low (1-2% per year), and the risks of surgery generally outweigh the benefits [1]. - Due to the patient's age (69 years) and existing **coronary artery disease**, avoiding elective surgery reduces the risk of perioperative cardiac events and other surgical complications. *Open cholecystectomy* - This is an **invasive surgical procedure** with higher risks of postoperative pain, infection, and longer recovery compared to laparoscopic cholecystectomy. - It is generally reserved for complicated cases or when laparoscopic surgery is contraindicated, which is not indicated here given the asymptomatic nature of the stones. *Laparoscopic cholecystectomy* - While less invasive than over surgery, it is still a **surgical procedure carrying inherent risks**, including those related to general anesthesia and potential complications like bile duct injury or bleeding. - Elective surgery for asymptomatic gallstones is generally not recommended as the potential benefits do not outweigh the procedural risks, especially in a patient with significant comorbidities like **coronary artery disease**. *ERCP and removal of gallbladder stones* - **ERCP (Endoscopic Retrograde Cholangiopancreatography)** is a procedure primarily used to visualize and address issues within the bile ducts and pancreatic duct, such as common bile duct stones. - It is **not used for removing stones directly from the gallbladder** itself and is an invasive procedure with risks like pancreatitis, perforation, and bleeding, making it inappropriate for asymptomatic gallbladder stones.

Question 1

All of the following are contraindications to femoral vein phlebotomy, EXCEPT?

Accepted Answer

Loss of sensation

Answer

Venous occlusive disease of the extremities

Answer

Previous surgery of the knee

Answer

Acquired bleeding disorder

Question 2

Which of the following is the necessary pre-operative investigation which has to be done in a patient with Down's syndrome posted for surgery?

Accepted Answer

Echocardiography to assess congenital heart defects

Answer

Cervical spine X-Ray to evaluate atlantoaxial instability

Answer

Abdominal ultrasound to detect gastrointestinal anomalies

Answer

Brain CT scan to identify structural abnormalities

Question 3

A patient posted for Lap Cholecystectomy had drug eluting stent placed two years back. Patient has no symptoms since then. Which of the following set of investigation should be done in this patient?

Accepted Answer

ECG, CBC, Stress echocardiography

Answer

Coronary angiography, Thallium scan

Answer

ECG, CBC, Coronary angiography

Answer

ECG, CBC, Stress echocardiography, coronary angiography

Question 4

Most sensitive marker for post-transplant rejection of liver is:

Accepted Answer

ALT

Answer

GGT

Answer

AST

Answer

Bilirubin

Question 5

A 72-year-old male with a history of coronary artery disease and a previous myocardial infarction is scheduled for an elective colectomy for a large adenomatous polyp. What perioperative cardiac evaluations and interventions are necessary to optimize surgical outcomes?

Accepted Answer

Cardiology consultation, stress testing, and possible coronary intervention are necessary.

Answer

Only routine blood tests.

Answer

Proceeding with surgery without further evaluation.

Answer

Considering the patient’s dietary preferences.

Question 6

A 70-year-old man with chronic obstructive pulmonary disease (COPD) is scheduled for abdominal surgery. What is the most important preoperative consideration?

Accepted Answer

Smoking cessation

Answer

Pulmonary function tests

Answer

Bronchodilator therapy

Answer

Chest X-ray

Question 7

Monoclonal antibodies to the CD25 (IL-2α) receptors are used for the treatment of:

Accepted Answer

Kidney transplant rejection

Answer

Hematological malignancies

Answer

Autoimmune disorders

Answer

Bone marrow transplant complications

Question 8

What is the best treatment advice for a 69-year-old male patient with coronary artery disease and asymptomatic gallbladder stones, who has no history of biliary colic or jaundice?

Accepted Answer

Observation without surgery for gallbladder stones

Answer

Open cholecystectomy

Answer

Laparoscopic cholecystectomy

Answer

ERCP and removal of gallbladder stones

Consultative and Perioperative Medicine — MCQs

Consultative and Perioperative Medicine — MCQs

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