Risk Assessment and Stratification — MCQs

10 questions

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

In the immediate post operative period the common cause of respiratory insufficiency could be because of the following, except -

Most sensitive method of monitoring cardiovascular ischemia in the perioperative period is -

Which of the following is the LEAST significant risk factor for postoperative pulmonary complications?

What does the MELD diagnostic score predict in patients awaiting liver transplantation?

All of the following are indicators of adequacy of pre-operative resuscitation except

In a patient with cirrhosis, which finding indicates worst prognosis according to Child-Pugh score?

Blood loss during major surgery is best estimated by:

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?

Q10

Consider the following statements: Poor prognostic indicators in advanced germ cell tumours show 1. primary sites in mediastinum 2. non-pulmonary metastasis 3. lactate dehydrogenase more than 10 times of normal value Which of the statements given above are correct?

Risk Assessment and Stratification Indian Medical PG Practice Questions and MCQs

Question 1: 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 2: In the immediate post operative period the common cause of respiratory insufficiency could be because of the following, except -

A. Mild Hypovolemia (Correct Answer)
B. Residual effect of muscle relaxant
C. Overdose of narcotic analgesic
D. Myocardial infarction

Explanation: ***Mild Hypovolemia*** - While significant **hypovolemia** can lead to systemic complications, *mild hypovolemia* itself does not directly cause *respiratory insufficiency* in the immediate postoperative period without other complicating factors. - Hypovolemia primarily affects **cardiovascular stability** and tissue perfusion, not directly the mechanics or drive of respiration unless it progresses to **shock**. *Residual effect of muscle relaxant* - **Residual neuromuscular blockade** can lead to *diaphragmatic weakness* and impaired accessory muscle function, causing insufficient ventilation and respiratory distress. - This is a common cause of *postoperative respiratory insufficiency*, especially if reversal agents are inadequate or not administered. *Overdose of narcotic analgesic* - **Narcotic overdose** depresses the *respiratory drive* in the brainstem, leading to decreased respiratory rate and depth, which can result in **hypoventilation** and *respiratory insufficiency*. - This is a significant concern in the immediate postoperative period due to pain management requirements. *Myocardial infarction* - A *myocardial infarction* can lead to **cardiogenic pulmonary edema** due to impaired cardiac function, resulting in fluid accumulation in the lungs and *respiratory insufficiency*. - Postoperative myocardial infarction is a serious complication that directly impacts respiratory function through its effect on **pulmonary hemodynamics**.

Question 3: 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 4: Which of the following is the LEAST significant risk factor for postoperative pulmonary complications?

A. Age >70
B. Patient with 7 pack years of smoking
C. Upper abdominal surgery
D. BMI>30 (Correct Answer)

Explanation: ***BMI>30*** - While **obesity (BMI >30)** is associated with some surgical risks, it is generally considered a less significant independent risk factor for postoperative pulmonary complications compared to other factors like age, smoking, and surgical site. - The impact of obesity on pulmonary function is complex and varies depending on the type of surgery and presence of comorbid conditions like **sleep apnea**. *Age >70* - **Advanced age (>70)** is a significant independent risk factor due to decreased physiological reserve, reduced pulmonary function (e.g., decreased lung elasticity, impaired cough reflex), and increased prevalence of comorbidities. - Older patients are more susceptible to **atelectasis**, **pneumonia**, and **respiratory failure** postoperatively. *Patient with 7 pack years of smoking* - Even a relatively low cumulative smoking history of **7 pack-years** can impair mucociliary clearance, increase bronchial secretions, and cause airway inflammation, significantly increasing the risk of pulmonary complications. - Smoking compromises lung function and increases the risk of **bronchospasm** and infection. *Upper abdominal surgery* - **Upper abdominal surgery** is a significant risk factor because incisions close to the diaphragm interfere with diaphragmatic movement, leading to reduced lung volumes, impaired cough, and increased risk of **atelectasis** and **pneumonia**. - Pain from the incision further restricts deep breaths and coughing, contributing to pulmonary complications.

Question 5: What does the MELD diagnostic score predict in patients awaiting liver transplantation?

A. Higher score - less mortality risk
B. Predicts mortality risk for a 60 day period
C. It is a 4 to 60 scale
D. Predicts mortality in patients waiting for liver transplant (Correct Answer)

Explanation: ***Predicts mortality in patients waiting for liver transplant*** - The **Model for End-Stage Liver Disease (MELD)** score was developed to predict **mortality risk** in patients with severe liver disease [1]. - It is crucial for **prioritizing patients** on the liver transplant waiting list, ensuring those with the greatest immediate need receive organs first. *Higher score - less mortality risk* - A **higher MELD score** indicates **more severe liver disease** and a **higher risk of mortality**, not less [1]. - The scoring system is designed to identify patients who are most critically ill and therefore have a greater need for transplantation [1]. *Predicts mortality risk for a 60 day period* - The MELD score was originally developed to predict **3-month (90-day) mortality** in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) procedures. - While it's used for short-term prediction, 60 days is not the standard predictive period. *It is a 4 to 60 scale* - The MELD score typically ranges from **6 to 40**, although extreme clinical conditions can lead to scores outside this range in rare cases. - A score of 4 would be unusually low and not reflective of the calculated range based on its components.

Question 6: 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 7: In a patient with cirrhosis, which finding indicates worst prognosis according to Child-Pugh score?

A. PT prolonged by 4 seconds
B. Grade 3 encephalopathy (Correct Answer)
C. Serum albumin 2.8 g/dL
D. Moderate ascites

Explanation: ***Grade 3 encephalopathy*** - According to the **Child-Pugh score**, **grade 3 or 4 encephalopathy** is assigned the highest score (3 points) in the encephalopathy category, indicating the severest form and poorest prognosis [1]. - Higher grades of encephalopathy reflect significant **neurological dysfunction** due to impaired liver detoxification [1]. *PT prolonged by 4 seconds* - A **prothrombin time (PT)** prolongation of 4-6 seconds beyond control receives 2 points, while PT prolonged >6 seconds beyond control receives 3 points in the Child-Pugh score [1]. - While significant, a 4-second prolongation (2 points) is less severe than grade 3 encephalopathy (3 points). *Serum albumin 2.8 g/dL* - A **serum albumin level** between 2.8 and 3.5 g/dL receives 2 points in the Child-Pugh score [1]. - This value indicates moderate liver dysfunction but is not the highest score achievable within the Child-Pugh system. *Moderate ascites* - **Moderate ascites** that is responsive to diuretics receives 2 points in the Child-Pugh score [1]. - **Refractory ascites** receives 3 points, but "moderate ascites" alone typically implies a milder form with a better prognosis than grade 3 encephalopathy due to its lower score [1].

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: 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 10: Consider the following statements: Poor prognostic indicators in advanced germ cell tumours show 1. primary sites in mediastinum 2. non-pulmonary metastasis 3. lactate dehydrogenase more than 10 times of normal value Which of the statements given above are correct?

A. 1 and 2 only
B. 2 and 3 only
C. 1, 2 and 3 (Correct Answer)
D. 1 and 3 only

Explanation: ***1, 2 and 3*** - **All three statements** represent poor prognostic indicators in advanced germ cell tumors, as defined by the **International Germ Cell Cancer Collaborative Group (IGCCCG)** classification. - A primary site in the **mediastinum**, the presence of **non-pulmonary visceral metastases**, and **LDH levels >10 times the upper limit of normal** are all independent factors associated with a worse prognosis. *1 and 2 only* - This option is incorrect because it excludes a critically important poor prognostic indicator: **markedly elevated lactate dehydrogenase (LDH)**. - While mediastinal primary and non-pulmonary metastases are poor prognostic factors, high LDH further defines the **poor risk group**. [1] *2 and 3 only* - This option is incorrect as it omits the significance of a **mediastinal primary site** as a poor prognostic factor in advanced germ cell tumors. - **Mediastinal germ cell tumors** are known to have a worse prognosis compared to testicular primaries, even in the absence of other poor risk factors. *1 and 3 only* - This option is incorrect because it fails to include **non-pulmonary metastases** as a distinct poor prognostic factor for advanced germ cell tumors. - The presence of metastases to sites like the **liver, brain, or bone** significantly worsens the prognosis compared to lung-only metastases.

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