Preoperative and Postoperative Care Practice Questions

Q: A female patient with steroid-resistant ITP underwent laparoscopic splenectomy. On postoperative day 3, she developed a fever. Which of the following is the most likely cause?

Left lower lobe consolidation. **Explanation:** Postoperative fever is categorized by the timing of its onset. In the early postoperative period (Days 1–3), pulmonary complications are the most common cause. **1. Why Option A is correct:** Following a splenectomy, especially via the laparoscopic route, the left diaphragm is often irritated or manipulated. This leads to splinting (reduced movement of the diaphragm due to pain) and shallow breathing, resulting in **atelectasis** or **consolidation** of the left lower lobe. On postoperative day 3, pulmonary issues (the "Wind" in the 5 W's of post-op fever) are the most frequent etiology. **2. Why the other options are incorrect:** * **Surgical Site Infection (B):** Typically presents between postoperative days 5 and 7 ("Wound"). It is unlikely to manifest as early as day 3 unless caused by *Clostridium* or *Group A Strep*. * **Intra-abdominal collection (C):** While a subphrenic abscess is a known complication of splenectomy, it usually presents later (Day 5–10) with a swinging pyrexia. * **Urinary Tract Infection (D):** UTIs ("Water") usually occur between days 3 and 5, often related to catheterization, but pulmonary causes remain statistically more likely on day 3 post-upper abdominal surgery. **Clinical Pearls for NEET-PG:** * **The 5 W’s of Post-op Fever:** **W**ind (Atelectasis/Pneumonia, Days 1-2), **W**ater (UTI, Days 3-5), **W**alking (DVT/PE, Days 4-6), **W**ound (Infection, Days 5-7), **W**onder drugs (Drug fever/IV lines, Day 7+). * **Splenectomy Specifics:** Left-sided pleural effusion or basal atelectasis is a classic "hidden" source of fever post-splenectomy. * **OPSI:** Overwhelming Post-Splenectomy Infection is a late, life-threatening complication, most commonly due to *Streptococcus pneumoniae*.

Q: What is the most common electrolyte imbalance that causes paralytic ileus?

Hypokalemia. **Explanation:** **Hypokalemia (Option C)** is the most common electrolyte abnormality leading to paralytic ileus. Potassium is essential for maintaining the resting membrane potential of smooth muscle cells. Low extracellular potassium levels cause hyperpolarization of these membranes, making it significantly harder for smooth muscle cells in the gastrointestinal tract to reach the threshold required for an action potential. This results in decreased or absent peristalsis, leading to the clinical presentation of abdominal distension, absent bowel sounds, and inability to pass flatus. **Analysis of Incorrect Options:** * **Hyponatremia (Option A):** While severe hyponatremia can cause neurological symptoms like confusion or seizures, it does not directly impair intestinal smooth muscle contractility. * **Hypernatremia (Option B):** Typically presents with signs of dehydration and CNS irritability rather than gastrointestinal paralysis. * **Hyperkalemia (Option D):** High potassium levels increase cell excitability and are more closely associated with life-threatening cardiac arrhythmias (e.g., peaked T-waves) rather than ileus. **Clinical Pearls for NEET-PG:** * **The "Big Three" of Ileus:** The most common causes of postoperative ileus are **Surgical Handling** of the bowel, **Opioid Analgesics**, and **Hypokalemia**. * **Management:** The first step in managing suspected paralytic ileus is checking the serum electrolyte panel and correcting any deficits, particularly potassium and magnesium. * **Associated Electrolyte:** **Hypomagnesemia** often coexists with hypokalemia and can also contribute to refractory ileus; potassium cannot be effectively corrected until magnesium levels are normalized. * **Radiology:** X-ray typically shows uniform dilatation of both the small and large bowels with gas present in the rectum (unlike mechanical obstruction).

Q: Complications of hemithyroidectomy include all of the following, except?

Hypocalcemia. **Explanation:** The correct answer is **Hypocalcemia**. **1. Why Hypocalcemia is the correct answer:** Hypocalcemia occurs due to accidental removal or devascularization of the parathyroid glands. There are four parathyroid glands (two on each side). In a **hemithyroidectomy**, only one lobe of the thyroid is removed, leaving the two contralateral parathyroid glands intact. These remaining glands are sufficient to maintain normal calcium homeostasis. Therefore, clinically significant hypocalcemia is a complication of total or subtotal thyroidectomy, but not hemithyroidectomy. **2. Analysis of incorrect options:** * **Wound Hematoma:** This is a potential complication of *any* neck surgery. A tension hematoma can cause life-threatening airway obstruction and requires immediate bedside evacuation. * **Recurrent Laryngeal Nerve (RLN) Palsy:** The RLN runs in the tracheoesophageal groove on both sides. Even in a unilateral procedure, the nerve on the operative side is at risk during dissection, leading to hoarseness of voice. * **External Branch of Superior Laryngeal Nerve (EBSLN) Palsy:** This nerve lies close to the superior thyroid artery. Damage during ligation of the superior pole vessels (on the operative side) results in loss of high-pitched voice and vocal fatigue. **NEET-PG High-Yield Pearls:** * **Most common cause of hypocalcemia post-thyroidectomy:** Accidental injury to parathyroid glands or their blood supply (Inferior Thyroid Artery). * **Chvostek’s and Trousseau’s signs:** Clinical indicators of latent tetany due to hypocalcemia. * **Nerve most commonly injured:** EBSLN (due to its proximity to the superior thyroid artery). * **Nerve injury causing "Bovine Cough":** Unilateral RLN palsy. * **Emergency Management:** For post-op respiratory distress due to hematoma, the first step is to **open the wound sutures at the bedside** to relieve pressure.

Q: On the 7th postoperative day after laparoscopic cholecystectomy, a patient developed upper abdominal pain and a 10 cm x 8 cm collection. What is the recommended initial treatment?

Percutaneous drainage. ### Explanation The patient presents with a localized fluid collection (likely a biloma or hematoma) on the 7th postoperative day following a laparoscopic cholecystectomy. In a hemodynamically stable patient with a localized collection, the management follows the principle of **"Step-up Approach."** **1. Why Percutaneous Drainage (Option B) is Correct:** Percutaneous drainage (usually ultrasound or CT-guided) is the **initial treatment of choice**. It serves two purposes: * **Therapeutic:** It decompresses the collection, relieves pain, and prevents sepsis. * **Diagnostic:** Analysis of the fluid (bilirubin levels, culture) helps differentiate between a biloma, seroma, or abscess. Once the collection is drained and the patient is stabilized, further imaging like **MRCP or ERCP** is performed to identify the source (e.g., a cystic duct leak or a minor bile duct injury). **2. Why Other Options are Incorrect:** * **Option A & C (Laparotomy/Surgical Exploration):** Immediate surgery is contraindicated in a stable patient with a localized collection. Early re-operation in an inflamed, "friable" abdomen increases the risk of further biliary injury and morbidity. Surgery is reserved for patients with generalized peritonitis or those who fail minimally invasive management. * **Option D:** Since surgical options are not the first-line treatment, "All of the above" is incorrect. **Clinical Pearls for NEET-PG:** * **Most common cause of post-cholecystectomy biloma:** Leak from the **Cystic duct stump** or the **Duct of Luschka**. * **Gold standard for diagnosing the site of bile leak:** ERCP (which is also therapeutic as stenting lowers intraductal pressure, allowing the leak to heal). * **Timing:** Post-laparoscopic bile duct injuries typically present between day 3 and day 7. * **Initial Investigation of choice:** Ultrasound (to detect collection); **Most accurate investigation:** MRCP/ERCP.

Question 1

A female patient with steroid-resistant ITP underwent laparoscopic splenectomy. On postoperative day 3, she developed a fever. Which of the following is the most likely cause?

Accepted Answer

Left lower lobe consolidation

Answer

Surgical site infection

Answer

Intra-abdominal collection

Answer

Urine specimen showing pyuria

Question 2

What is the commonest symptom observed post-operatively?

Accepted Answer

None of the above

Answer

Depression

Answer

Psychosis

Answer

Euphoria

Question 3

A patient with pyloric stenosis secondary to peptic ulcer complains of profuse vomiting, and has Na+ of 125 meq/L, K+ of 2.3 meq/L, and Cl- of 85 meq/L. Which intravenous fluid should be administered?

Accepted Answer

Normal saline

Answer

Half normal saline

Answer

Potassium bolus

Answer

Hypertonic saline

Question 4

A postoperative cardiac surgery patient developed sudden hypotension, raised Central Venous Pressure (CVP), and pulsus paradoxus at the 4th postoperative hour. What is the most probable diagnosis?

Accepted Answer

Cardiac tamponade

Answer

Excessive mediastinal bleeding

Answer

Ventricular dysfunction

Answer

Congestive cardiac failure

Question 5

What is the most common electrolyte imbalance that causes paralytic ileus?

Accepted Answer

Hypokalemia

Answer

Hyponatremia

Answer

Hypernatremia

Answer

Hyperkalemia

Question 6

Complications of hemithyroidectomy include all of the following, except?

Accepted Answer

Hypocalcemia

Answer

Wound hematoma

Answer

Recurrent laryngeal nerve palsy

Answer

External branch of superior laryngeal nerve palsy

Question 7

A patient requires total parenteral nutrition for more than a month via a central venous catheter. Which of the following is NOT a standard management practice?

Accepted Answer

Change the central venous catheter tube every two weeks routinely.

Answer

Liver function tests and blood urea nitrogen must be done weekly.

Answer

Electrolytes must be checked every 2-3 days.

Answer

Sudden glucose intolerance is an early sign of sepsis.

Question 8

On the 7th postoperative day after laparoscopic cholecystectomy, a patient developed upper abdominal pain and a 10 cm x 8 cm collection. What is the recommended initial treatment?

Accepted Answer

Percutaneous drainage

Answer

Immediate laparotomy

Answer

Laparotomy and surgical exploration of the bile duct with T-tube insertion

Answer

All of the above

Question 9

A 55-year-old woman undergoes elective cholecystectomy. On postoperative day 6, she has mild abdominal discomfort and bloating. She has received antibiotics, morphine for pain, and metoclopramide for nausea. She has not passed flatus or stools since the surgery. On auscultation, bowel sounds are hypoactive. An abdominal x-ray is ordered. What is the most possible cause for her symptoms?

Accepted Answer

Prolonged postoperative ileus

Answer

Impaction of a gallstone in the ileum

Answer

Adhesions following the surgery

Answer

Absence of bile storage reservoir

Question 10

Which of the following intravenous fluids should not be administered in the first 24 hours after surgery?

Accepted Answer

0.9% NaCl solution

Answer

5% dextrose

Answer

Lactated Ringer's solution

Answer

Darrow's solution

Preoperative and Postoperative Care — MCQs

Preoperative and Postoperative Care — MCQs

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