Three days after being admitted to the hospital because of a fall from the roof of a two-story building, a 27-year-old man is being monitored in the intensive care unit. On arrival, the patient was somnolent and not oriented to person, place, or time. A CT scan of the head showed an epidural hemorrhage that was 45 cm3 in size and a midline shift of 7 mm. Emergency surgery was performed with craniotomy and hematoma evacuation on the day of admission. Perioperatively, a bleeding vessel was identified and ligated. Postoperatively, the patient was transferred to the intensive care unit and placed on a ventilator. His temperature is 37°C (98.6°F), pulse is 67/min, and blood pressure is 117/78 mm Hg. The ventilator is set at a FiO2 of 55%, tidal volume of 520 mL, and positive end-expiratory pressure of 5.0 cm H2O. In addition to intravenous administration of fluids, which of the following is the most appropriate next step in managing this patient's nutrition?
Q2
A 65-year-old woman comes to the physician because of progressive weight loss for 3 months. Physical examination shows jaundice and a nontender, palpable gallbladder. A CT scan of the abdomen shows an ill-defined mass in the pancreatic head. She is scheduled for surgery to resect the pancreatic head, distal stomach, duodenum, early jejunum, gallbladder, and common bile duct and anastomose the jejunum to the remaining stomach, pancreas, and bile duct. Following surgery, this patient is at the greatest risk for which of the following?
Q3
A 55-year-old woman is brought to the emergency department due to sudden onset retrosternal chest pain. An ECG shows ST-segment elevation. A diagnosis of myocardial infarction is made and later confirmed by elevated levels of troponin I. The patient is sent to the cardiac catheter laboratory where she undergoes percutaneous catheterization. She has 2 occluded vessels in the heart and undergoes a percutaneous coronary intervention to place 2 stents in her coronary arteries. Blood flow is successfully restored in the affected arteries. The patient complains of flank pain on post-procedure evaluation a few hours later. A significant drop in hematocrit is observed, as well as a drop in her blood pressure to 90/60 mm Hg. Physical examination reveals extensive ecchymoses in the flanks and loin as seen in the provided image. Which of the following conditions is this patient most likely experiencing?
Q4
Twelve days after undergoing total pancreatectomy for chronic pancreatitis, a 62-year-old woman notices oozing from her abdominal wound. She first noticed fluid draining 8 hours ago. Her postoperative course has been complicated by persistent hypotension requiring intravenous fluids and decreased ability to tolerate food. She has type 1 diabetes mellitus and glaucoma. The patient smoked one pack of cigarettes daily for 30 years, but quit 2 years ago. She drank a pint of vodka every day starting at age 20 and quit when she was 35 years old. Her current medications include subcutaneous insulin and timolol eye drops. She appears comfortable. Her temperature is 37°C (98.6°F), pulse is 95/min, and blood pressure is 104/78 mm Hg. The abdomen is soft and mildly tender to palpation. There is a 12-cm vertical wound beginning in the epigastrium and extending caudally. 25 mL of a viscous, dark green substance is draining from the middle of the wound. There is a small amount of dried fluid on the patient's hospital gown. The wound edges are nonerythematous. There is no pus draining from the wound. Laboratory studies show:
Hematocrit 38%
Leukocyte count 8,000/mm3
Serum
Na+ 135 mEq/L
Cl- 100 mEq/L
K+ 3.4 mEq/L
HCO3- 23 mEq/L
Urea nitrogen 13 mg/dL
Creatinine 1.1 mg/dL
Glucose 190 mg/dL
Which of the following is the most appropriate next step in management?
Q5
Three hours after undergoing open proctocolectomy for ulcerative colitis, a 42-year-old male complains of abdominal pain. The pain is localized to the periumbilical and hypogastric regions. A total of 20 mL of urine has drained from his urinary catheter since the end of the procedure. Temperature is 37.2°C (98.9°F), pulse is 92/min, respirations are 12/min, and blood pressure is 110/72 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 99%. Physical examination shows a 20 cm vertical midline incision and an ileostomy in the right lower quadrant. There is no fluid drainage from the surgical wounds. The urinary catheter flushes easily and is without obstruction. Cardiopulmonary examination shows no abnormalities. Serum studies show a blood urea nitrogen of 30 mg/dL and a creatinine of 1.3 mg/dL. Which of the following is the most appropriate next step in management?
Q6
One and a half hours after undergoing an elective cardiac catheterization, a 53-year-old woman has right flank and back pain. She has hypertension, hypercholesterolemia, and type 2 diabetes mellitus. She had an 80% stenosis in the left anterior descending artery and 2 stents were placed. Intravenous unfractionated heparin was used prior to the procedure. Prior to admission, her medications were enalapril, simvastatin, and metformin. Her temperature is 37.3°C (99.1°F), pulse is 102/min, and blood pressure is 109/75 mm Hg. Examination shows a tender lower abdomen; there is no guarding or rigidity. There is right suprainguinal fullness and tenderness. There is no bleeding or discharge from the femoral access site. Cardiac examination shows no murmurs, rubs, or gallops. Femoral and pedal pulses are palpable bilaterally. 0.9% saline infusion is begun. A complete blood count shows a hematocrit of 36%, leukocyte count of 8,400/mm3, and a platelet count of 230,000/mm3. Which of the following is the most appropriate next step in management?
Q7
A 45-year-old man undergoes elective vasectomy for permanent contraception. The procedure is performed under local anesthesia. There are no intra-operative complications and he is discharged home with ibuprofen for post-operative pain. This patient is at increased risk for which of the following complications?
Q8
Ten days after undergoing emergent colectomy for a ruptured bowel that she sustained in a motor vehicle accident, a 59-year-old woman has abdominal pain. During the procedure, she was transfused 3 units of packed red blood cells. She is currently receiving total parenteral nutrition. Her temperature is 38.9°C (102.0°F), pulse is 115/min, and blood pressure is 100/60 mm Hg. Examination shows tenderness to palpation in the right upper quadrant of the abdomen. Bowel sounds are hypoactive. Serum studies show:
Aspartate aminotransferase 142 U/L
Alanine aminotransferase 86 U/L
Alkaline phosphatase 153 U/L
Total bilirubin 1.5 mg/dL
Direct bilirubin 1.0 mg/dL
Amylase 20 U/L
Which of the following is the most likely diagnosis?
Q9
A 28-year-old man comes to the physician because of increasing shortness of breath, abdominal fullness, and pedal edema for 3 months. Four months ago, he was diagnosed with pulmonary tuberculosis and is currently receiving therapy with isoniazid, rifampin, pyrazinamide, and ethambutol. His temperature is 37°C (98.6°F), pulse is 100/min, respirations are 20/min and blood pressure is 96/70 mm Hg. Examination shows 2+ pretibial edema bilaterally. There is jugular venous distention. The jugular venous pressure rises with inspiration. Breath sounds are decreased at lung base bilaterally. Cardiac examination reveals an early diastolic sound over the left sternal border. The abdomen is distended and shifting dullness test is positive. An ECG shows low-amplitude QRS complexes. Chest x-ray shows small pleural effusions bilaterally and calcifications over the left cardiac silhouette. Echocardiography shows a 40% decrease in the velocity of peak diastolic blood flow across the mitral valve during inspiration. A cardiac catheterization shows elevated right ventricular diastolic pressure with characteristic dip-and-plateau waveform. Which of the following is the most appropriate next step in management?
Q10
A 55-year-old woman is being managed on the surgical floor after having a total abdominal hysterectomy as a definitive treatment for endometriosis. On day 1 after the operation, the patient complains of fevers. She has no other complaints other than aches and pains from lying in bed as she has not moved since the procedure. She is currently receiving ondansetron, acetaminophen, and morphine. Her temperature is 101°F (38.3°C), blood pressure is 127/68 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 94% on room air. Her abdominal exam is within normal limits and cardiopulmonary exam is only notable for mild crackles. Which of the following is the most likely etiology of this patient’s fever?
Post-op care US Medical PG Practice Questions and MCQs
Question 1: Three days after being admitted to the hospital because of a fall from the roof of a two-story building, a 27-year-old man is being monitored in the intensive care unit. On arrival, the patient was somnolent and not oriented to person, place, or time. A CT scan of the head showed an epidural hemorrhage that was 45 cm3 in size and a midline shift of 7 mm. Emergency surgery was performed with craniotomy and hematoma evacuation on the day of admission. Perioperatively, a bleeding vessel was identified and ligated. Postoperatively, the patient was transferred to the intensive care unit and placed on a ventilator. His temperature is 37°C (98.6°F), pulse is 67/min, and blood pressure is 117/78 mm Hg. The ventilator is set at a FiO2 of 55%, tidal volume of 520 mL, and positive end-expiratory pressure of 5.0 cm H2O. In addition to intravenous administration of fluids, which of the following is the most appropriate next step in managing this patient's nutrition?
A. Enteral feeding via nasogastric tube (Correct Answer)
B. Oral feeding
C. Keep patient NPO
D. Total parenteral nutrition
E. Enteral feeding using a percutaneous endoscopic gastrostomy (PEG) tube
Explanation: ***Enteral feeding via nasogastric tube***
- This patient has been **somnolent** and on a ventilator for 3 days after a significant head injury, indicating a prolonged period without oral intake and an inability to protect his airway for oral feeding. **Early enteral nutrition** via a nasogastric tube is preferred in critically ill patients, especially those with head injuries, as it helps maintain gut integrity and reduces complications compared to parenteral nutrition.
- The patient's **hemodynamic stability** (blood pressure and pulse are within a reasonable range for a ventilated patient) suggests he can tolerate enteral feeding, and there are no signs of gut ischemia or ileus that would contraindicate it.
*Enteral feeding using a percutaneous endoscopic gastrostomy (PEG) tube*
- While a PEG tube provides enteral nutrition, it is typically reserved for patients requiring **long-term enteral support** (usually more than 4-6 weeks) or those who cannot tolerate a nasogastric tube.
- Given that it has only been 3 days post-injury, a **less invasive method** like a nasogastric tube is initially preferred.
*Oral feeding*
- The patient is described as **somnolent** and on a ventilator, meaning he is not awake enough or able to protect his airway to safely receive oral feeding.
- Attempting oral feeding in this state carries a high risk of **aspiration pneumonia**.
*Keep patient NPO*
- Keeping the patient NPO (nil per os) for an extended period in critical illness is associated with several negative outcomes, including **gut mucosal atrophy, increased infection risk**, and poorer clinical outcomes.
- After 3 days, initiating nutritional support is crucial to prevent these complications.
*Total parenteral nutrition*
- **Total parenteral nutrition (TPN)** is generally considered a last resort when the gastrointestinal tract is non-functional or enteral feeding is contraindicated.
- TPN is associated with a **higher risk of complications**, such as central line infections, liver dysfunction, and metabolic disturbances, compared to enteral feeding.
Question 2: A 65-year-old woman comes to the physician because of progressive weight loss for 3 months. Physical examination shows jaundice and a nontender, palpable gallbladder. A CT scan of the abdomen shows an ill-defined mass in the pancreatic head. She is scheduled for surgery to resect the pancreatic head, distal stomach, duodenum, early jejunum, gallbladder, and common bile duct and anastomose the jejunum to the remaining stomach, pancreas, and bile duct. Following surgery, this patient is at the greatest risk for which of the following?
A. Wide-based gait
B. Calcium oxalate kidney stones
C. Microcytic anemia (Correct Answer)
D. Increased bile production
E. Hypercoagulable state
Explanation: ***Microcytic anemia***
- The surgical procedure described is a **Whipple procedure**, which involves partial gastrectomy and duodenectomy. This significant alteration to the upper GI tract can lead to **iron malabsorption**, as iron is primarily absorbed in the duodenum and proximal jejunum, and gastric acid is crucial for converting dietary iron to its absorbable ferrous form.
- **Iron deficiency** is the most common cause of **microcytic anemia**, characterized by small, pale red blood cells, due to impaired hemoglobin synthesis as a result of insufficient iron availability for the heme component.
*Wide-based gait*
- A **wide-based gait** is typically associated with **ataxia** or conditions affecting cerebellar function or proprioception, which are not direct complications of a Whipple procedure.
- While nutritional deficiencies can occur post-surgery, a wide-based gait specifically points to neurological impairment rather than postsurgical metabolic issues.
*Calcium oxalate kidney stones*
- **Calcium oxalate kidney stones** are often associated with conditions causing **hypercalciuria** or malabsorption of fat, which leads to increased oxalate absorption in the colon. While fat malabsorption can occur after a Whipple due to pancreatic insufficiency, dietary oxalate intake and hydration status are generally more significant determinants of stone formation.
- The surgery itself does not directly increase the risk for calcium oxalate kidney stones more than other listed complications.
*Increased bile production*
- A Whipple procedure involves the removal of the **gallbladder** and rerouting of the **bile duct** directly into the jejunum. This does not lead to increased bile production, but rather a different regulation and flow of bile.
- In fact, the absence of the gallbladder means there is no storage for bile, leading to a continuous, unregulated flow of bile into the small intestine, potentially contributing to maldigestion or diarrhea, but not "increased production."
*Hypercoagulable state*
- While surgery, including a Whipple procedure, can transiently increase the risk of a **hypercoagulable state** (e.g., deep vein thrombosis, pulmonary embolism) in the immediate postoperative period due to immobility and tissue injury, this risk is generally mitigated with prophylactic anticoagulation.
- The question asks about the **greatest risk** post-surgery, and long-term complications related to altered anatomy and malabsorption, such as microcytic anemia, are more direct and sustained consequences unique to the extent of the resection.
Question 3: A 55-year-old woman is brought to the emergency department due to sudden onset retrosternal chest pain. An ECG shows ST-segment elevation. A diagnosis of myocardial infarction is made and later confirmed by elevated levels of troponin I. The patient is sent to the cardiac catheter laboratory where she undergoes percutaneous catheterization. She has 2 occluded vessels in the heart and undergoes a percutaneous coronary intervention to place 2 stents in her coronary arteries. Blood flow is successfully restored in the affected arteries. The patient complains of flank pain on post-procedure evaluation a few hours later. A significant drop in hematocrit is observed, as well as a drop in her blood pressure to 90/60 mm Hg. Physical examination reveals extensive ecchymoses in the flanks and loin as seen in the provided image. Which of the following conditions is this patient most likely experiencing?
A. Retroperitoneal hemorrhage (Correct Answer)
B. Fat embolism
C. Adrenal hemorrhage
D. Patent ductus arteriosus
E. Ventricular septal defect
Explanation: ***Retroperitoneal hemorrhage***
- The sudden onset of **flank pain**, significant drop in **hematocrit** and **blood pressure**, and the presence of **extensive ecchymoses in the flanks and loin (Grey Turner's sign)** following a cardiac catheterization via femoral artery access are highly suggestive of a **retroperitoneal hemorrhage**.
- **Retroperitoneal hemorrhage** is a known complication of femoral artery puncture, where the puncture site bleeds into the retroperitoneal space, causing symptoms like pain, hypovolemia, and the characteristic flank ecchymoses.
- This is an acute post-procedural complication that requires immediate recognition and management.
*Fat embolism*
- Fat embolism syndrome typically presents with a **triad of respiratory distress**, **neurological symptoms**, and a **petechial rash**, which are not described in this patient.
- While it can occur after trauma or orthopedic procedures, it is not a direct complication of cardiac catheterization and stent placement in this manner.
*Adrenal hemorrhage*
- Adrenal hemorrhage can cause flank pain and hypovolemia, but it is typically associated with **severe stress, sepsis, or anticoagulant use**, and usually presents with symptoms of **adrenal insufficiency**.
- The context of a recent femoral artery puncture and the characteristic ecchymoses point away from isolated adrenal hemorrhage as the primary cause.
*Patent ductus arteriosus*
- **Patent ductus arteriosus (PDA)** is a congenital heart defect characterized by a persistent connection between the aorta and pulmonary artery, leading to a **left-to-right shunt**. It is *not* an acute complication of cardiac catheterization in an adult.
- Symptoms of PDA in adults typically include **dyspnea, fatigue, and a continuous murmur**, none of which are presented in this acute post-procedural scenario.
*Ventricular septal defect*
- A **ventricular septal defect (VSD)** is a **hole in the septum** separating the ventricles, often congenital, and can cause a shunt and heart failure. It is *not* an acute complication of cardiac catheterization and stent placement.
- A VSD would typically present with a **loud harsh holosystolic murmur** and signs of heart failure (if significant), which are not discussed in this acute post-procedure presentation following a chest pain event.
Question 4: Twelve days after undergoing total pancreatectomy for chronic pancreatitis, a 62-year-old woman notices oozing from her abdominal wound. She first noticed fluid draining 8 hours ago. Her postoperative course has been complicated by persistent hypotension requiring intravenous fluids and decreased ability to tolerate food. She has type 1 diabetes mellitus and glaucoma. The patient smoked one pack of cigarettes daily for 30 years, but quit 2 years ago. She drank a pint of vodka every day starting at age 20 and quit when she was 35 years old. Her current medications include subcutaneous insulin and timolol eye drops. She appears comfortable. Her temperature is 37°C (98.6°F), pulse is 95/min, and blood pressure is 104/78 mm Hg. The abdomen is soft and mildly tender to palpation. There is a 12-cm vertical wound beginning in the epigastrium and extending caudally. 25 mL of a viscous, dark green substance is draining from the middle of the wound. There is a small amount of dried fluid on the patient's hospital gown. The wound edges are nonerythematous. There is no pus draining from the wound. Laboratory studies show:
Hematocrit 38%
Leukocyte count 8,000/mm3
Serum
Na+ 135 mEq/L
Cl- 100 mEq/L
K+ 3.4 mEq/L
HCO3- 23 mEq/L
Urea nitrogen 13 mg/dL
Creatinine 1.1 mg/dL
Glucose 190 mg/dL
Which of the following is the most appropriate next step in management?
A. Intravenous antibiotic therapy
B. Surgical exploration of the abdomen
C. Total parenteral nutrition and ostomy pouch (Correct Answer)
D. Wound debridement and irrigation
E. Oral food intake and intravenous fluid administration
Explanation: ***Total parenteral nutrition and ostomy pouch***
- The patient, having undergone total pancreatectomy, is experiencing an **enterocutaneous fistula** from an anastomotic leak (e.g., gastrojejunostomy or choledochojejunostomy), presenting as viscid, dark green drainage from the wound.
- An **ostomy pouch** will protect the skin from digestive enzymes and allow quantification of output, while **total parenteral nutrition (TPN)** provides bowel rest, promoting spontaneous healing of the fistula.
- This conservative approach is appropriate given the patient's **hemodynamic stability** and **absence of signs of sepsis or peritonitis**.
*Intravenous antibiotic therapy*
- While infection is a concern, there are **no clear signs of systemic infection** (e.g., fever, leukocytosis, erythema, purulent drainage) in this patient.
- **Antibiotics alone** would not address the underlying anatomical leak and its resulting drainage.
*Surgical exploration of the abdomen*
- **Surgical exploration** is typically reserved for cases with signs of **sepsis**, **peritonitis**, **uncontrolled leak**, or failure of conservative management.
- Given the patient is hemodynamically stable without signs of severe infection or acute abdomen, a **conservative approach** is preferred initially.
*Wound debridement and irrigation*
- **Wound care** is important, but debridement and irrigation alone will **not stop the internal leakage** of enteric content from the gastrointestinal tract.
- The primary issue is an internal fistula, not a localized wound infection requiring debridement.
*Oral food intake and intravenous fluid administration*
- **Oral food intake** would exacerbate the fistula by stimulating digestive secretions and increasing enteric output, hindering natural healing.
- While **intravenous fluids** are used for hydration and electrolyte balance, they do not address the fistula, and **bowel rest is crucial** for spontaneous closure.
Question 5: Three hours after undergoing open proctocolectomy for ulcerative colitis, a 42-year-old male complains of abdominal pain. The pain is localized to the periumbilical and hypogastric regions. A total of 20 mL of urine has drained from his urinary catheter since the end of the procedure. Temperature is 37.2°C (98.9°F), pulse is 92/min, respirations are 12/min, and blood pressure is 110/72 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 99%. Physical examination shows a 20 cm vertical midline incision and an ileostomy in the right lower quadrant. There is no fluid drainage from the surgical wounds. The urinary catheter flushes easily and is without obstruction. Cardiopulmonary examination shows no abnormalities. Serum studies show a blood urea nitrogen of 30 mg/dL and a creatinine of 1.3 mg/dL. Which of the following is the most appropriate next step in management?
A. Administer tamsulosin
B. Administer intravenous furosemide
C. Obtain an abdominal CT
D. Start ciprofloxacin
E. Administer intravenous fluids (Correct Answer)
Explanation: ***Administer intravenous fluids***
- The patient's **oliguria** (20 mL urine over 3 hours, ~7 mL/hour) post-surgery, elevated **BUN (30 mg/dL)**, and **creatinine (1.3 mg/dL)** with a **BUN:Cr ratio >20:1** suggest **prerenal acute kidney injury** due to **hypovolemia**.
- Post-operative fluid losses from **third-spacing**, blood loss, and insensible losses commonly cause hypovolemia after major abdominal surgery.
- **Intravenous fluids** are the most appropriate initial step to restore intravascular volume and improve renal perfusion.
*Administer tamsulosin*
- **Tamsulosin** is an alpha-blocker used to relax smooth muscle in the prostate and bladder neck, primarily for **urinary retention** due to benign prostatic hyperplasia.
- This patient's oliguria is due to **prerenal azotemia** from hypovolemia, not prostatic obstruction, and the catheter flushes easily without obstruction.
*Administer intravenous furosemide*
- **Furosemide** is a loop diuretic that increases urine output, but administering it in the context of **prerenal acute kidney injury** can worsen hypovolemia and further compromise renal function.
- Diuretics are generally contraindicated in oliguria due to hypovolemia and should only be considered after volume resuscitation.
*Obtain an abdominal CT*
- While an abdominal CT can diagnose surgical complications, there are no immediate signs of a surgical emergency like **anastomotic leak** or **bowel obstruction**.
- Addressing the likely **hypovolemia** is more urgent and should precede further imaging in this scenario.
*Start ciprofloxacin*
- The patient does not show signs of infection, such as fever or localized signs of bacterial peritonitis, making **antibiotics** like ciprofloxacin inappropriate as the initial management step.
- The elevated BUN and creatinine are more indicative of volume depletion than infection.
Question 6: One and a half hours after undergoing an elective cardiac catheterization, a 53-year-old woman has right flank and back pain. She has hypertension, hypercholesterolemia, and type 2 diabetes mellitus. She had an 80% stenosis in the left anterior descending artery and 2 stents were placed. Intravenous unfractionated heparin was used prior to the procedure. Prior to admission, her medications were enalapril, simvastatin, and metformin. Her temperature is 37.3°C (99.1°F), pulse is 102/min, and blood pressure is 109/75 mm Hg. Examination shows a tender lower abdomen; there is no guarding or rigidity. There is right suprainguinal fullness and tenderness. There is no bleeding or discharge from the femoral access site. Cardiac examination shows no murmurs, rubs, or gallops. Femoral and pedal pulses are palpable bilaterally. 0.9% saline infusion is begun. A complete blood count shows a hematocrit of 36%, leukocyte count of 8,400/mm3, and a platelet count of 230,000/mm3. Which of the following is the most appropriate next step in management?
A. X-ray of the abdomen
B. Obtain an ECG
C. CT scan of the abdomen and pelvis (Correct Answer)
D. Administer protamine sulfate
E. Administer intravenous atropine
Explanation: ***CT scan of the abdomen and pelvis***
- The patient's symptoms of **right flank and back pain**, along with **right suprainguinal fullness and tenderness** following cardiac catheterization with **anticoagulation**, are highly suggestive of a **retroperitoneal hemorrhage**.
- A **CT scan of the abdomen and pelvis** is the most appropriate diagnostic tool to confirm the presence, size, and location of the retroperitoneal bleed.
*X-ray of the abdomen*
- An **X-ray of the abdomen** is generally not useful for diagnosing soft tissue conditions like retroperitoneal hemorrhage.
- It would be primarily used for detecting **ureteral stones** or **bowel obstruction**, which are not the primary concerns with this presentation.
*Obtain an ECG*
- While an **ECG** is important in cardiac patients, the current symptoms of flank pain, back pain, and suprainguinal fullness are not typical signs of an acute cardiac event.
- The patient just underwent a successful cardiac catheterization and stent placement, making **ischemia** less likely to be the immediate cause of these specific symptoms.
*Administer protamine sulfate*
- **Protamine sulfate** is used to reverse the effects of **unfractionated heparin**, which was used prior to the procedure.
- While a retroperitoneal hemorrhage is suspected, reversal of heparin without definitive diagnosis and assessment of the bleeding severity could be premature and might increase the risk of **thrombosis** in a patient with recent stent placement.
*Administer intravenous atropine*
- **Intravenous atropine** is used to treat **bradycardia**.
- The patient's pulse is 102/min, indicating **tachycardia**, not bradycardia, making atropine an inappropriate treatment.
Question 7: A 45-year-old man undergoes elective vasectomy for permanent contraception. The procedure is performed under local anesthesia. There are no intra-operative complications and he is discharged home with ibuprofen for post-operative pain. This patient is at increased risk for which of the following complications?
A. Prostatitis
B. Seminoma
C. Testicular torsion
D. Sperm granuloma (Correct Answer)
E. Inguinal hernia
Explanation: **Sperm granuloma**
- A **sperm granuloma** can occur after vasectomy due to the extravasation of sperm from the severed vas deferens, leading to a foreign body granulomatous reaction.
- This complication presents as a **palpable, tender nodule** at the vasectomy site and is a relatively common long-term issue.
*Prostatitis*
- **Prostatitis** is an inflammation of the prostate gland, and there is no direct mechanistic link or increased risk following a vasectomy.
- It is typically caused by bacterial infection or non-infectious inflammatory processes, unrelated to the **vas deferens** ligation.
*Seminoma*
- **Seminoma** is a type of testicular germ cell tumor, and extensive research has shown no increased risk of developing testicular cancer after vasectomy.
- The procedure does not alter the cellular processes or environment within the testicles that predispose to germ cell tumor formation.
*Testicular torsion*
- **Testicular torsion** is a urological emergency involving the twisting of the spermatic cord, which cuts off blood supply to the testis.
- This condition is not associated with vasectomy; it typically occurs due to an anatomical abnormality (e.g., **bell-clapper deformity**) or trauma.
*Inguinal hernia*
- An **inguinal hernia** is a protrusion of abdominal contents through a weakness in the abdominal wall, specifically in the inguinal canal.
- Vasectomy is a superficial procedure that does not involve manipulating or weakening the abdominal wall in a way that would increase the risk of an inguinal hernia.
Question 8: Ten days after undergoing emergent colectomy for a ruptured bowel that she sustained in a motor vehicle accident, a 59-year-old woman has abdominal pain. During the procedure, she was transfused 3 units of packed red blood cells. She is currently receiving total parenteral nutrition. Her temperature is 38.9°C (102.0°F), pulse is 115/min, and blood pressure is 100/60 mm Hg. Examination shows tenderness to palpation in the right upper quadrant of the abdomen. Bowel sounds are hypoactive. Serum studies show:
Aspartate aminotransferase 142 U/L
Alanine aminotransferase 86 U/L
Alkaline phosphatase 153 U/L
Total bilirubin 1.5 mg/dL
Direct bilirubin 1.0 mg/dL
Amylase 20 U/L
Which of the following is the most likely diagnosis?
A. Hemolytic transfusion reaction
B. Acalculous cholecystitis (Correct Answer)
C. Acute cholecystitis (calculous)
D. Small bowel obstruction
E. Acute pancreatitis
Explanation: ***Acalculous cholecystitis***
- This patient's clinical picture of **fever**, **RUQ tenderness**, **leukocytosis**, and mildly elevated liver enzymes in the setting of recent **major surgery**, **trauma**, and **total parenteral nutrition (TPN)** is highly suggestive of **acalculous cholecystitis**.
- **Acalculous cholecystitis** often occurs in critically ill patients due to gallbladder stasis, ischemia, and inflammation, usually without the presence of stones.
*Hemolytic transfusion reaction*
- While the patient received blood transfusions, a **hemolytic transfusion reaction** typically presents with fever, chills, flank pain, and **hemoglobinuria**, none of which are explicitly mentioned.
- Liver enzyme elevations can occur, but the significant RUQ tenderness and absence of signs of hemolysis make it less likely.
*Acute cholecystitis (calculous)*
- **Acute cholecystitis with gallstones** typically presents with similar symptoms to acalculous cholecystitis (pain, fever), but requires the presence of gallstones causing obstruction.
- The clinical context of critical illness, recent surgery, and TPN use points more towards acalculous inflammation rather than stone-related disease.
*Small bowel obstruction*
- **Small bowel obstruction** would present with more pronounced **abdominal distention**, **vomiting**, and often **high-pitched bowel sounds** followed by absent sounds, which is not the primary picture here.
- Although bowel sounds are hypoactive, the focal RUQ tenderness and liver enzyme changes are not typical of a primary small bowel obstruction.
*Acute pancreatitis*
- **Acute pancreatitis** is usually characterized by **severe epigastric pain** radiating to the back, and significantly elevated **amylase** and **lipase** levels.
- The patient's amylase is normal, and lipase is not mentioned but usually tracks with amylase in pancreatitis.
Question 9: A 28-year-old man comes to the physician because of increasing shortness of breath, abdominal fullness, and pedal edema for 3 months. Four months ago, he was diagnosed with pulmonary tuberculosis and is currently receiving therapy with isoniazid, rifampin, pyrazinamide, and ethambutol. His temperature is 37°C (98.6°F), pulse is 100/min, respirations are 20/min and blood pressure is 96/70 mm Hg. Examination shows 2+ pretibial edema bilaterally. There is jugular venous distention. The jugular venous pressure rises with inspiration. Breath sounds are decreased at lung base bilaterally. Cardiac examination reveals an early diastolic sound over the left sternal border. The abdomen is distended and shifting dullness test is positive. An ECG shows low-amplitude QRS complexes. Chest x-ray shows small pleural effusions bilaterally and calcifications over the left cardiac silhouette. Echocardiography shows a 40% decrease in the velocity of peak diastolic blood flow across the mitral valve during inspiration. A cardiac catheterization shows elevated right ventricular diastolic pressure with characteristic dip-and-plateau waveform. Which of the following is the most appropriate next step in management?
A. Colchicine therapy
B. Heart transplantation
C. Implantable cardioverter defibrillator
D. Pericardiectomy (Correct Answer)
E. Metoprolol therapy
Explanation: ***Pericardiectomy***
- The patient's symptoms (shortness of breath, edema, ascites, elevated JVP with Kussmaul sign, early diastolic sound, low voltage ECG, calcified pericardium on CXR, and inspiratory decrease in mitral inflow velocity) are classic for **constrictive pericarditis**, often a complication of **tuberculosis**.
- **Pericardiectomy** is the definitive treatment for constrictive pericarditis, involving surgical removal of the thickened, fibrotic pericardium to relieve the heart from external compression.
*Colchicine therapy*
- **Colchicine** is primarily used in the management of **acute pericarditis** or recurrent pericarditis to reduce inflammation.
- It is not effective for **constrictive pericarditis**, where the pathology involves fixed fibrous thickening rather than active inflammation.
*Heart transplantation*
- **Heart transplantation** is a treatment option for **end-stage heart failure** refractory to other medical or surgical interventions.
- While constrictive pericarditis can lead to heart failure symptoms, it is a mechanical issue with the pericardium, and relieving this constriction via pericardiectomy is the primary treatment, not replacing the heart.
*Implantable cardioverter defibrillator*
- An **ICD** is indicated for patients at high risk of sudden cardiac death due to **ventricular arrhythmias** or severe left ventricular dysfunction.
- It does not address the underlying mechanical restriction of **constrictive pericarditis** and would not improve the patient's symptoms related to cardiac filling.
*Metoprolol therapy*
- **Metoprolol**, a beta-blocker, is used to reduce heart rate, blood pressure, and myocardial oxygen demand in conditions like **heart failure with reduced ejection fraction**, angina, or arrhythmias.
- It is generally **contraindicated** or used with extreme caution in **constrictive pericarditis** because further slowing the heart rate can worsen cardiac output in a heart already constrained by a rigid pericardium, and it does not resolve the mechanical constriction.
Question 10: A 55-year-old woman is being managed on the surgical floor after having a total abdominal hysterectomy as a definitive treatment for endometriosis. On day 1 after the operation, the patient complains of fevers. She has no other complaints other than aches and pains from lying in bed as she has not moved since the procedure. She is currently receiving ondansetron, acetaminophen, and morphine. Her temperature is 101°F (38.3°C), blood pressure is 127/68 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 94% on room air. Her abdominal exam is within normal limits and cardiopulmonary exam is only notable for mild crackles. Which of the following is the most likely etiology of this patient’s fever?
A. Deep vein thrombosis
B. Abscess formation
C. Inflammatory stimulus of surgery (Correct Answer)
D. Urinary tract infection
E. Wound infection
Explanation: ***Inflammatory stimulus of surgery***
- Postoperative fever occurring within the first 24-48 hours after surgery, especially a major abdominal procedure, is most commonly due to the **systemic inflammatory response** to tissue trauma and stress from the surgery itself.
- The temperature of 101°F (38.3°C) is a common reactive fever. In this timeframe, **atelectasis** (part of the inflammatory response to surgery) is the classic cause, supported by the patient's **immobility since surgery** and **mild crackles** on exam.
- The patient has no other specific signs of infection, making this the most likely cause.
*Deep vein thrombosis*
- While DVT is a concern post-surgery, it typically presents with **leg pain, swelling, and tenderness**, not primarily as fever alone on day 1.
- A fever from DVT would usually indicate a more advanced complication like pulmonary embolism, which is inconsistent with the mild crackles and stable oxygen saturation.
*Abscess formation*
- Abscesses usually take several days to form and present with significant fevers, localized pain, and possibly purulent drainage, not typically within the first **24 hours post-op**.
- The abdominal exam is noted as within normal limits, making an abscess unlikely at this early stage.
*Urinary tract infection*
- UTIs are common post-op, especially with catheterization, but typically present with **dysuria, frequency, urgency**, and sometimes suprapubic pain, which are absent here.
- While fever can be a symptom, the lack of urinary complaints makes it a less likely primary diagnosis on day 1.
*Wound infection*
- Wound infections rarely develop within the first **24-48 hours** post-surgery, as bacteria require time to proliferate and cause inflammatory signs.
- Typical signs include **erythema, warmth, tenderness, and purulent drainage** at the incision site, which are not mentioned.
