Preoperative Evaluation — 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
Preoperative medication of thyrotoxicosis are all except?
A patient after valve replacement will require follow up treatment with
All of the following are indicators of adequacy of pre-operative resuscitation except
Which of the following is the LEAST significant risk factor for postoperative pulmonary complications?
Who coined the term "balanced anaesthesia"?
Blood loss during major surgery is best estimated by:
What is the management of choice for a case of Sheehan syndrome presenting with unresponsive hypotension?
A 36 year old female is found to have a large pituitary mass on MRI imaging. She underwent transsphenoidal hypophysectomy. Postop replacement of which of the following hormone is not needed?
Preoperative Evaluation 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: 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 4: A patient after valve replacement will require follow up treatment with
- A. ACE inhibitors
- B. Beta blockers
- C. Thiazide
- D. Warfarin (Correct Answer)
Explanation: ***Warfarin*** - Patients with **mechanical prosthetic heart valves** require lifelong anticoagulation with **warfarin** to prevent life-threatening thromboembolic complications [1]. - The target **international normalized ratio (INR)** typically ranges from 2.5 to 3.5, depending on the valve type and position. *ACE inhibitors* - **ACE inhibitors** are primarily used for managing **hypertension**, **heart failure**, and **renal protection**, not as routine post-valve replacement prophylaxis [2]. - While they may be used if these co-morbidities exist, they are not a universal requirement after valve surgery. *Beta blockers* - **Beta blockers** are often prescribed to control heart rate, manage **hypertension**, or reduce myocardial oxygen demand, but they are not the primary follow-up treatment for all valve replacement patients. - They do not address the critical need for **anticoagulation** in mechanical valve recipients. *Thiazide* - **Thiazide diuretics** are used to treat **hypertension** and **edema** by increasing salt and water excretion. - They do not play a direct role in preventing **thromboembolism** post-valve replacement and are not generally indicated unless chronic heart failure or hypertension is present.
Question 5: All of the following are indicators of adequacy of pre-operative resuscitation except
- A. Hematocrit level
- B. Consciousness level
- C. C-reactive protein level (Correct Answer)
- D. Urine output
Explanation: ***C-reactive protein level*** - **C-reactive protein (CRP)** is an inflammatory marker and is not a direct indicator of the adequacy of pre-operative fluid and hemodynamic resuscitation. An elevated CRP suggests ongoing inflammation or infection, not necessarily a deficit in perfusion or hydration. - While inflammation can coincide with critical illness requiring resuscitation, CRP itself does not provide real-time information about **organ perfusion**, **oxygen delivery**, or **fluid status**. *Hematocrit level* - **Hematocrit** levels are crucial for assessing factors like **blood loss** and **hemoconcentration**, which directly impact the need for and adequacy of resuscitation. An increasing hematocrit can indicate hemoconcentration, while a decreasing hematocrit may suggest blood loss. - It helps guide decisions regarding **blood product transfusions** and overall fluid management. *Consciousness level* - The **level of consciousness** is a vital clinical indicator of **cerebral perfusion** and overall brain oxygenation. Deterioration can signal inadequate resuscitation and poor cerebral blood flow. - Improvements in consciousness level after interventions suggest improved **systemic perfusion** and oxygen delivery to the brain. *Urine output* - **Urine output** is a sensitive and widely used indicator of **renal perfusion** and overall systemic hydration status. Adequate urine output (e.g., >0.5 mL/kg/hr) suggests sufficient renal blood flow. - Low or absent urine output can indicate **hypovolemia**, **poor cardiac output**, or **renal hypoperfusion**, highlighting the need for further resuscitation.
Question 6: 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 7: Who coined the term "balanced anaesthesia"?
- A. Simpson
- B. Fischer
- C. Morton
- D. Lundy (John S. Lundy) (Correct Answer)
Explanation: ***Lundy (John S. Lundy)*** - **John S. Lundy** is credited with coining the term "**balanced anaesthesia**" in the early 20th century. - This concept describes the use of **multiple anesthetic agents** in combination, each contributing to different aspects of anesthesia (e.g., hypnosis, analgesia, muscle relaxation). *Simpson* - **Sir James Young Simpson** was a Scottish physician who pioneered the use of **chloroform** and ether as anesthetics in the mid-19th century. - While he significantly advanced the field of anesthesia, he did not coin the term "balanced anaesthesia." *Fischer* - **Emil Fischer** was a German chemist who won the Nobel Prize in Chemistry for his work on sugar and purine syntheses. - His contributions were primarily in organic chemistry and biochemistry, not directly in the field of clinical anesthesia terminology. *Morton* - **William T.G. Morton** was an American dentist who famously demonstrated the first public use of **ether** for surgical anesthesia in 1846. - He is known for popularizing ether as a surgical anesthetic but did not coin the term "balanced anaesthesia."
Question 8: Blood loss during major surgery is best estimated by:
- A. Transesophageal USG Doppler
- B. Visual assessment
- C. Suction bottles (Correct Answer)
- D. Cardiac output by thermodilution
Explanation: ***Suction bottles*** - Measuring the volume of fluid collected in **suction bottles** (after subtracting irrigating fluid) provides a direct and quantifiable estimate of blood loss. - This method is widely used in surgery due to its **simplicity and relative accuracy** for assessing blood collected from the surgical field. *Transesophageal USG Doppler* - This technique primarily assesses **cardiac function** and **blood flow dynamics**, not directly quantifying blood loss. - While it can indicate hypovolemia, it doesn't provide a precise measurement of the volume of blood lost. *Visual assessment* - **Visual estimation** of blood loss by surgical staff is notoriously inaccurate and can lead to significant underestimation or overestimation. - It is highly subjective and depends on factors like lighting, the color of the blood-soaked materials, and individual experience. *Cardiac output by thermodilution* - **Thermodilution** is used to measure cardiac output, which can reflect hemodynamic status and help guide fluid resuscitation. - It does not directly quantify the amount of blood lost but rather assesses the **body's response** to blood loss.
Question 9: What is the management of choice for a case of Sheehan syndrome presenting with unresponsive hypotension?
- A. Hydrocortisone (Correct Answer)
- B. Thyroxine
- C. Labetalol
- D. Epinephrine
Explanation: ***Hydrocortisone*** - **Unresponsive hypotension** in Sheehan syndrome is often due to **adrenal insufficiency** (ACTH deficiency), which requires immediate corticosteroid replacement [1]. - **Hydrocortisone** rapidly replaces cortisol, which is crucial for maintaining vascular tone and preventing hypotensive shock [1]. *Thyroxine* - While **hypothyroidism** can occur in Sheehan syndrome, **thyroxine** replacement acts slowly and is not an appropriate initial treatment for acute, life-threatening hypotension [1]. - Correcting profound hypotension takes precedence over addressing thyroid hormone deficiencies in an emergency. *Labetalol* - **Labetalol** is an **antihypertensive** agent that would worsen hypotension in a patient with Sheehan syndrome and adrenal crisis. - It would further decrease blood pressure and compromise circulation. *Epinephrine* - **Epinephrine** is a potent **vasopressor** and might be considered in extreme shock, but it is not the primary treatment for hypotension due to adrenal insufficiency. - Without adequate cortisol, the body is less responsive to catecholamines, making steroid replacement essential first.
Question 10: A 36 year old female is found to have a large pituitary mass on MRI imaging. She underwent transsphenoidal hypophysectomy. Postop replacement of which of the following hormone is not needed?
- A. Estradiol
- B. Glucocorticoids
- C. L-Thyroxine
- D. Mineralocorticoids (Correct Answer)
Explanation: ***Mineralocorticoids*** - **Mineralocorticoid** production (primarily aldosterone) is regulated by the **renin-angiotensin-aldosterone system** (RAAS) in the kidneys, not directly by the pituitary gland [1]. - Therefore, pituitary surgery generally does not affect **aldosterone secretion**, and replacement is typically not required unless the adrenal glands themselves are compromised [1][2]. *Estradiol* - **Estradiol** production by the ovaries is stimulated by **follicle-stimulating hormone (FSH)** and **luteinizing hormone (LH)**, which are pituitary hormones. - Pituitary surgery can disrupt the production of FSH and LH, leading to **secondary hypogonadism** and requiring estrogen replacement, especially in pre-menopausal women [2]. *Glucocorticoids* - The adrenal glands produce **glucocorticoids** (e.g., cortisol) under the stimulation of **adrenocorticotropic hormone (ACTH)** from the pituitary [1]. - Damage to the pituitary during surgery can reduce ACTH secretion, leading to **secondary adrenal insufficiency** and necessitating **glucocorticoid replacement** [1]. *L-Thyroxine* - The thyroid gland produces **thyroid hormones** (T3 and T4) under the influence of **thyroid-stimulating hormone (TSH)**, a pituitary hormone [1]. - Post-hypophysectomy, a patient may develop **secondary hypothyroidism** due to impaired TSH production, requiring **L-thyroxine replacement** [1].
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