Pulmonary Risk Assessment — MCQs
Type 3 respiratory failure occurs due to ?
A 40F with progressive exertional dyspnea and cyanosis. Physical examination reveals digital clubbing and a loud P2 heart sound. Most appropriate next step in diagnosis?
What type of respiratory failure is most commonly observed in post-operative patients?
Most sensitive method of monitoring cardiovascular ischemia in the perioperative period is -
Among the following conditions, laparoscopy carries the highest risk in patients with:
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?
In an emphysematous patient with bullous lesions, which is the best investigation to measure lung volumes?
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?
What is the relative risk of developing pulmonary embolism in users of oral contraceptives as per the information given below?
In clinical assessment of an elderly patient, 'the get up and go test' is used to evaluate which of the following?
Pulmonary Risk Assessment Indian Medical PG Practice Questions and MCQs
Question 1: Type 3 respiratory failure occurs due to ?
- A. Post-operative atelectasis (Correct Answer)
- B. Kyphoscoliosis
- C. Flail chest
- D. Pulmonary fibrosis
Explanation: ***Post-operative atelectasis*** - **Type 3 respiratory failure**, also known as **perioperative respiratory failure**, is characterized by hypoxemia occurring typically after surgery. - **Atelectasis**, the collapse of lung tissue, is a common cause of hypoxemia in the post-operative period due to shallow breathing, pain, and anesthesia affecting lung volumes. *Kyphoscoliosis* - This condition leads to a **restrictive lung disease** due to chest wall deformity, causing chronic respiratory failure. [1] - It more typically results in **Type 2 respiratory failure** (hypercapnic) due to impaired ventilation over time. [1] *Flail chest* - Flail chest is a severe chest wall injury causing paradoxical movement, leading to **acute respiratory failure**. - It is often associated with **Type 1 (hypoxemic)** or **Type 2 (hypercapnic)** respiratory failure due to trauma-induced lung injury and impaired mechanics. *Pulmonary fibrosis* - This is a progressive interstitial lung disease causing **restrictive ventilatory defect** and impaired gas exchange. - It leads to chronic **Type 1 respiratory failure** (hypoxemic) as the lung tissue becomes stiff and scarred.
Question 2: A 40F with progressive exertional dyspnea and cyanosis. Physical examination reveals digital clubbing and a loud P2 heart sound. Most appropriate next step in diagnosis?
- A. Echocardiography (Correct Answer)
- B. Pulmonary function test
- C. Chest X-ray
- D. Electrocardiogram
Explanation: ***Echocardiography*** - The presence of **exertional dyspnea**, **cyanosis**, **digital clubbing**, and a **loud P2 heart sound** strongly suggests pulmonary hypertension [1]. - An **echocardiogram** is crucial for directly visualizing the heart chambers and great vessels, allowing for the estimation of **pulmonary artery pressures** and assessing right ventricular function, which is key in diagnosing and evaluating **pulmonary hypertension** [1]. *Pulmonary function test* - While pulmonary function tests (PFTs) assess lung mechanics and volumes, they primarily help diagnose **obstructive** or **restrictive lung diseases**. - PFTs do not directly measure **pulmonary artery pressures** or assess cardiac structure, which are central to the patient's presentation. *Chest X-ray* - A chest X-ray can show signs of **pulmonary hypertension** such as **enlarged pulmonary arteries** or **cardiomegaly** [1], [2]. - However, it provides limited information regarding cardiac function and **pulmonary artery pressures** and is less specific than an echocardiogram for initial diagnosis [1]. *Electrocardiogram* - An ECG can detect signs of **right ventricular hypertrophy** or **right axis deviation**, which may be present in **pulmonary hypertension** [2]. - However, it offers no direct information on **pulmonary artery pressures** or structural abnormalities of the heart chambers.
Question 3: What type of respiratory failure is most commonly observed in post-operative patients?
- A. Hypercapnic respiratory failure
- B. Mixed respiratory failure
- C. Perioperative respiratory failure
- D. Hypoxemic respiratory failure (Correct Answer)
Explanation: ***Hypoxemic respiratory failure*** - **Hypoxemic respiratory failure** (Type I) is characterized by a **PaO2 less than 60 mmHg** with a normal or low PaCO2, often due to **V/Q mismatch** and **shunt**. - Post-operative patients frequently develop **atelectasis**, **pneumonia**, or **pulmonary edema**, leading to impaired gas exchange and reduced oxygenation. - This is the **most commonly observed type** in the immediate post-operative period. *Hypercapnic respiratory failure* - **Hypercapnic respiratory failure** (Type II) is primarily due to **alveolar hypoventilation**, resulting in a **PaCO2 greater than 50 mmHg**. - While it can occur post-operatively, it is less common than hypoxemic failure and is typically seen with significant **sedation**, **neuromuscular blockade**, or severe **obstructive lung disease**. *Mixed respiratory failure* - **Mixed respiratory failure** involves both **hypoxemia** and **hypercapnia**, indicating severe impairment in both oxygenation and ventilation. - Although it can occur in severe post-operative complications, it is not the *most commonly observed initial presentation* compared to isolated hypoxemia. *Perioperative respiratory failure* - **Perioperative respiratory failure** (Type III) occurs specifically in the surgical setting and involves atelectasis from changes in chest wall mechanics. - While this occurs in the post-operative context, the term is less commonly used, and the **underlying mechanism is primarily hypoxemic** in nature.
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: Among the following conditions, laparoscopy carries the highest risk in patients with:
- A. COPD (Correct Answer)
- B. Diabetes
- C. Hypertension
- D. Obesity
Explanation: ***COPD*** - **COPD** patients have severely compromised respiratory function, and the **pneumoperitoneum** from CO2 insufflation causes **diaphragmatic splinting** and reduced lung compliance, leading to dangerous **CO2 retention** and respiratory failure. - The increased **intra-abdominal pressure** significantly impairs ventilation in patients who already have limited respiratory reserve, making laparoscopy extremely high-risk. *Diabetes* - While diabetes increases risks of **poor wound healing** and **infection**, these complications are not specifically worse with laparoscopy compared to open surgery. - **Perioperative glucose management** can effectively control diabetes-related risks, and laparoscopy may actually offer benefits like smaller incisions. *Hypertension* - **Hypertension** requires careful **blood pressure monitoring** during surgery but doesn't pose risks unique to laparoscopic procedures. - Well-controlled hypertension with appropriate **antihypertensive medications** allows for safe laparoscopic surgery. *Obesity* - **Obesity** makes laparoscopy technically challenging due to **thick abdominal walls** and need for higher insufflation pressures. - However, laparoscopy is often **preferred over open surgery** in obese patients due to reduced wound complications and faster recovery.
Question 6: 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 7: In an emphysematous patient with bullous lesions, which is the best investigation to measure lung volumes?
- A. Body plethysmography (Correct Answer)
- B. Helium dilution
- C. Trans diaphragmatic pressure
- D. DLCO
Explanation: ***Body plethysmography*** - This method measures **total lung capacity (TLC)** by applying **Boyle's Law** and is not significantly affected by **trapped air** in bullae. - It directly measures changes in volume and pressure within a sealed chamber, providing accurate lung volumes even in the presence of **non-communicating air spaces**. *Helium dilution* - The **helium dilution technique** underestimates lung volumes in conditions with **trapped air** or poorly communicating air spaces, such as **bullae**, because helium cannot diffuse into these areas. - This method relies on the equilibration of a known amount of helium throughout the lungs, which is unreliable when significant parts of the lung are not ventilated. *Trans diaphragmatic pressure* - **Transdiaphragmatic pressure (Pdi)** is primarily used to assess **diaphragmatic strength and function**, not for measuring static lung volumes. - It involves measuring the pressure difference between the gastric and esophageal balloons and is unrelated to **total lung capacity** or **residual volume**. *DLCO* - **Diffusing capacity of the lung for carbon monoxide (DLCO)** measures the efficiency of gas transfer from the alveoli to the red blood cells, not lung volumes. - While it is a valuable test in emphysema (typically reduced), it does not provide information about the **absolute volumes of the lung**.
Question 8: 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?
- A. Coronary angiography, Thallium scan
- B. ECG, CBC, Coronary angiography
- C. ECG, CBC, Stress echocardiography (Correct Answer)
- D. ECG, CBC, Stress echocardiography, coronary angiography
Explanation: **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.
Question 9: What is the relative risk of developing pulmonary embolism in users of oral contraceptives as per the information given below?
- A. 4.80 (Correct Answer)
- B. 0.24
- C. 0.48
- D. 2.40
Explanation: ***4.80*** - **Relative Risk (RR)** = Risk in exposed / Risk in unexposed - From the table provided: - **OC users (exposed):** 120 developed PE out of 200 women → Risk = 120/200 = 0.60 - **Non-OC users (unexposed):** 10 developed PE out of 80 women → Risk = 10/80 = 0.125 - **RR = 0.60 / 0.125 = 4.8** - This indicates OC users have **4.8 times higher risk** of developing pulmonary embolism compared to non-users - This significant association aligns with known **thrombogenic effects** of estrogen-containing oral contraceptives - **Clinical relevance:** Highlights importance of screening for VTE risk factors before prescribing OCs *0.24* - This value would result from incorrect calculation or misinterpretation of table values - Does not represent any valid epidemiological measure from the given data *0.48* - This is simply the decimal misplacement of 4.8 divided by 10 - Results from calculation error, not proper relative risk computation *2.40* - This is exactly half of the correct answer (4.8/2) - May result from using wrong numerator or denominator values - Does not represent the correct relative risk calculation
Question 10: In clinical assessment of an elderly patient, 'the get up and go test' is used to evaluate which of the following?
- A. Gait and balance (Correct Answer)
- B. Cognition
- C. Urinary incontinence
- D. Driving ability
Explanation: Gait and balance - The **Timed Up and Go (TUG) test** is a widely used clinical tool designed to assess a person's **mobility**, **balance**, and **fall risk**. [2] - It measures the time taken for an individual to rise from a chair, walk 3 meters, turn, walk back, and sit down again. *Cognition* - While physical and cognitive functions are related, the TUG test does not directly assess **cognitive abilities** like memory, executive function, or language. - Cognitive assessment typically involves tools such as the **Mini-Mental State Examination (MMSE)** or **Montreal Cognitive Assessment (MoCA)**. [1] *Urinary incontinence* - The TUG test does not evaluate **urinary function** or the presence of incontinence. - Assessment of urinary incontinence involves patient history, bladder diaries, and physical examination. *Driving ability* - Although mobility and balance are important for driving, the TUG test alone is not a direct measure of **driving ability**. - Driving assessments are more comprehensive, often involving on-road tests and specialized cognitive and visual evaluations.
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