Hospital Medicine — MCQs

Hospital Medicine Indian Medical PG Practice Questions and MCQs

Question 21: Which of the following is the preferred route of access for total parenteral nutrition in a patient who requires it for less than 14 days and has no other indication for the use of a central catheter?

A. Internal jugular vein
B. External jugular vein
C. PICC line
D. Peripheral vein (Correct Answer)

Explanation: ***Peripheral vein*** - For short-term (less than 14 days) **total parenteral nutrition (TPN)** without other central line indications, **peripheral access (PPN)** is often preferred due to lower risk and ease of insertion. - Peripheral veins are suitable for lower osmolarity solutions and pose fewer risks of **pneumothorax**, **hemothorax**, or **central line-associated bloodstream infections (CLABSIs)** compared to central lines. *Internal jugular vein* - This is a common site for **central venous access** and is used for long-term TPN or in critical care settings, not typically for short-term peripheral needs. - Insertion carries risks such as **pneumothorax**, **arterial puncture**, and **infection**, which are usually avoided if less invasive options suffice. *External jugular vein* - While easier to access than the internal jugular, it is still a **central venous access** site and is generally reserved for situations warranting central access. - It carries similar risks to other central lines, albeit slightly lower than the internal jugular for certain complications, but is not the first choice for short-term, low-risk TPN. *PICC line* - A **Peripherally Inserted Central Catheter (PICC) line** is used for **long-term intravenous access** (weeks to months) due to its placement in a central vein, making it unsuitable for a patient requiring TPN for less than 14 days. - While inserted peripherally, the tip resides in a central vein, carrying the risks associated with central access and requiring specialized insertion and care, making it an over-complication for short-term use.

Question 22: Which of the following is NOT a feature of SIRS?

A. Heart rate >90/min
B. Temperature <36°C or >38°C
C. Blood pressure <90/60 mmHg (Correct Answer)
D. WBC >12,000 or <4,000/mm³

Explanation: ***Blood pressure <90/60 mmHg*** - While hypotension can be a feature of **sepsis** or **septic shock**, it is **not** one of the specific diagnostic criteria for **Systemic Inflammatory Response Syndrome (SIRS)** itself. - SIRS criteria are focused on inflammatory responses like altered temperature, heart rate, respiratory rate, and white blood cell count, **before** the development of organ dysfunction or shock [1]. *WBC >12,000 or <4,000/mm³* - This is a **classic criterion for SIRS**, indicating an acute inflammatory response with either an elevated or depressed **white blood cell count** [1], [3]. - A differential count showing **>10% immature neutrophils (bands)** also meets this criterion, even if the total count is normal. *Temperature <36°C or >38°C* - This is a **key SIRS criterion**, reflecting the body's dysregulated thermoregulation in response to systemic inflammation [1]. - Both **fever (>38°C)** and **hypothermia (<36°C)** are indicative of SIRS [2]. *Heart rate >90/min* - **Tachycardia** is another specific and common **SIRS criterion**, indicating the body's physiological stress response to inflammation [1]. - An elevated **heart rate (HR)** is a compensatory mechanism to increase cardiac output during systemic stress.

Question 23: TRALI occurs within how many hours of transfusion?

A. 6 hours (Correct Answer)
B. 48 hours
C. 72 hours
D. 12 hours

Explanation: ***6 hours*** - **Transfusion-related acute lung injury (TRALI)** is defined as new acute lung injury occurring during or within **6 hours** after the completion of a blood transfusion [1]. - It is a severe and potentially life-threatening transfusion reaction characterized by **acute respiratory distress**, **hypoxemia**, and **bilateral pulmonary infiltrates** on chest imaging [1]. *48 hours* - While other transfusion reactions or complications may manifest within 48 hours, TRALI has a more **acute onset**, typically within the first 6 hours. - A pulmonary event occurring between 6 and 48 hours post-transfusion might be considered **delayed TRALI** or another diagnosis like **transfusion-associated circulatory overload (TACO)**, but the classic definition refers to the 6-hour window. *72 hours* - Reactions occurring 72 hours after transfusion are generally considered **delayed transfusion reactions**, which include conditions like **delayed hemolytic transfusion reactions** or **post-transfusion purpura**. - This timeframe is too long for the typical presentation of TRALI, which is characterized by rapid onset. *12 hours* - Although 12 hours falls within an acute window, the most commonly accepted and diagnostically crucial timeframe for TRALI is **within 6 hours** of transfusion. - A reaction occurring between 6 and 12 hours would still be considered suspiciously TRALI, but the strict definition emphasizes the earlier onset.

Question 24: What is the PRIMARY evidence-based intervention for preventing catheter-associated urinary tract infections (CAUTIs)?

A. Use of face mask during catheter insertion
B. Prophylactic antibiotics are effective
C. Early catheter removal when clinically appropriate
D. Closed drainage technique to minimize bacterial entry (Correct Answer)

Explanation: ***Closed drainage technique to minimize bacterial entry*** - Maintaining a **closed drainage system** prevents the entry of bacteria into the urinary tract, which is a primary cause of CAUTIs. - This technique involves ensuring the connection between the catheter and the drainage bag remains sealed at all times, minimizing **environmental contamination**. *Prophylactic antibiotics are effective* - **Prophylactic antibiotics** are generally not recommended for routine CAUTI prevention due to concerns about **antibiotic resistance** and limited evidence of effectiveness [1]. - Their use is typically reserved for specific high-risk procedures or patient populations. *Use of face mask during catheter insertion* - While maintaining **asepsis** during catheter insertion is crucial, the use of a face mask specifically addresses **respiratory droplet transmission**, which is not the primary route of bacterial entry into the urinary system during catheterization. - **Sterile gloves** and a **sterile field** are more directly relevant for preventing contamination during insertion [1]. *Early catheter removal when clinically appropriate* - While **early catheter removal** is a critical strategy for CAUTI prevention by reducing dwell time, the question asks for the *primary* evidence-based intervention [1]. A **closed drainage system** directly addresses the mechanism of bacterial entry while the catheter is in place. - Reducing catheter duration minimizes risk, but the closed system ensures safety during the necessary period of catheterization.

Question 25: Which of the following is a complication of total parenteral nutrition?

A. Hyperglycemia (Correct Answer)
B. Hyperkalemia
C. Hyperglycemia and Hyperkalemia
D. Hyperosmolar dehydration

Explanation: ***Hyperglycemia*** - Total parenteral nutrition (TPN) solutions contain a high concentration of **dextrose** (glucose), which can lead to elevated blood glucose levels, especially in patients with pre-existing metabolic issues or high infusion rates. - The sudden and continuous infusion of carbohydrates can overwhelm the body's **insulin response**, resulting in hyperglycemia [3]. *Hyperkalemia* - **Hypokalemia**, rather than hyperkalemia, is a more common electrolyte disturbance associated with TPN due to intracellular shifts of potassium with glucose metabolism [2]. - While TPN solutions do contain potassium, hyperkalemia is generally rare unless there is significant renal impairment or excessive potassium supplementation. *Hyperglycemia and Hyperkalemia* - While **hyperglycemia** is a common complication, **hyperkalemia** is not; in fact, hypokalemia is a more frequent concern linked to the significant glucose load in TPN. - This option incorrectly pairs a common complication with one that is rare and generally only seen in specific circumstances. *Hyperosmolar dehydration* - This condition, also known as **hyperosmolar hyperglycemic state (HHS)**, is a severe complication that can arise from uncontrolled hyperglycemia, where high glucose levels lead to osmotic diuresis and severe dehydration [1]. - While hyperglycemia is a precursor to hyperosmolar dehydration, the direct complication of TPN administration itself is the hyperglycemia.

Question 26: In total parenteral nutrition, which of the following parameters is not routinely measured daily?

A. Electrolyte
B. Fluid intake and output
C. Magnesium
D. Liver function tests (LFTs) (Correct Answer)

Explanation: ***Liver function tests (LFTs)*** - **LFTs** are typically monitored periodically (e.g., weekly or bi-weekly) in patients on TPN, not daily, unless there are specific concerns about liver dysfunction [1]. - Daily monitoring is generally not required because changes in liver function due to TPN are usually insidious and not acutely life-threatening in hours. *Electrolyte* - **Electrolytes** (e.g., sodium, potassium, chloride) are crucial for cellular function and fluid balance [2]. They can fluctuate rapidly with TPN administration and patient's clinical status. - Daily measurement ensures prompt correction of imbalances to prevent serious complications like **cardiac arrhythmias** or neurological disturbances [2]. *Fluid intake and output* - **Fluid intake and output** are essential for assessing **hydration status** and preventing fluid overload or dehydration, which can change rapidly [2]. - Daily monitoring helps guide adjustments to fluid administration in TPN and other intravenous fluids. *Magnesium* - **Magnesium** is an important electrolyte involved in numerous enzymatic reactions and neuromuscular function, and its levels can be significantly affected by TPN [2]. - Daily or frequent monitoring is often necessary, especially in the initial phases of TPN or in patients with pre-existing deficiencies, to prevent complications such as **cardiac arrhythmias** or **weakness** [2].

Question 27: 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 28: Which of the following is NOT a standard management option for fat embolism?

A. Heparin administration
B. Low Molecular Weight Dextran
C. Oxygen therapy
D. Surgical intervention (Correct Answer)

Explanation: ***Surgical intervention*** - **Fat embolism syndrome (FES)** is a medical emergency primarily managed with **supportive care**, not surgery. - Surgical intervention is only indicated for the **initial injury**, such as stabilizing long bone fractures, which helps prevent fat emboli, but not for treating an already established FES [1]. *Oxygen therapy* - **Oxygen therapy** is a crucial component of FES management, as the syndrome often leads to **hypoxemia** due to lung involvement. - It helps maintain adequate **tissue oxygenation** and can be administered via nasal cannula, face mask, or mechanical ventilation in severe cases. *Heparin administration* - **Heparin administration** was historically used with the rationale of preventing thrombus formation and potentially breaking down fat globules. - However, its effectiveness is **unproven**, and it carries risks such as bleeding, so it is generally **not recommended** for FES. *Low Molecular Weight Dextran* - **Low Molecular Weight Dextran** has been investigated for its potential to improve blood flow, reduce fat globule aggregation, and expand plasma volume in FES. - While some studies showed promising results, it is **not a universally accepted standard treatment** due to conflicting evidence and potential side effects.

Question 29: Which of the following statements about aspiration pneumonia is true?

A. Severity is influenced by the pH of aspiration fluid.
B. Incidence increases during induction of anesthesia.
C. Severity is influenced by the volume of aspiration.
D. Both volume and pH of aspiration fluid influence severity. (Correct Answer)

Explanation: ***Both volume and pH of aspiration fluid influence severity.*** - The **severity** of aspiration pneumonia and pneumonitis is directly related to both the **volume** of aspirated material and its **pH** (acidity). - A larger volume and more acidic (lower pH) aspirate cause greater **lung injury** and inflammation. *Severity is influenced by the pH of aspiration fluid.* - While **pH** is a significant factor, it is not the sole determinant of severity. - Highly acidic aspirates (e.g., gastric acid) lead to severe chemical pneumonitis, but the **volume** also plays a critical role in the extent of lung damage. *Incidence increases during induction of anesthesia.* - The **risk** of aspiration is indeed higher during **induction of anesthesia** due to loss of protective airway reflexes. - However, this statement refers to the incidence of aspiration, not the **severity** of the resulting pneumonia. *Severity is influenced by the volume of aspiration.* - **Volume** is a crucial factor, with larger volumes causing more widespread and severe lung injury. - However, the **pH** of the aspirated material also significantly impacts the chemical damage to the bronchi and alveoli, making it an equally important determinant of severity.

Question 30: All of the following are selective indications for the use of hypotonic solutions, except:

A. Burns (Correct Answer)
B. Free water deficit
C. Hypernatremia
D. Maintenance fluid therapy in stable patients

Explanation: ***Burns*** - **Hypotonic solutions** are generally *not* indicated for burn patients because these patients typically lose large amounts of **isotonic fluid** through damaged skin. [1] - The primary goal in burn resuscitation is to replace lost plasma volume with **isotonic crystalloids** (e.g., Lactated Ringer's) to prevent **hypovolemic shock**. [1] *Hypernatremia* - **Hypernatremia** is a condition of excess sodium relative to water, meaning the body has a **water deficit**. [1] - **Hypotonic solutions** are used to gradually lower serum sodium by providing **free water** to dilute the excess sodium. *Free water deficit* - A **free water deficit** indicates a lack of pure water relative to solutes, leading to increased plasma osmolality. [2] - **Hypotonic solutions** are specifically designed to provide **free water** to correct this deficit and restore proper fluid balance. *Maintenance fluid therapy in stable patients* - For stable patients requiring maintenance fluids, **hypotonic solutions** (e.g., D5W with 0.45% NS) are often used to cover obligatory fluid losses and provide adequate water without causing **sodium overload**. [1] - In such cases, the goal is to prevent dehydration and electrolyte imbalances over time, which often requires a balance of electrolytes and **free water**. [1]

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