Postoperative bleeding — MCQs

A 40-year-old Caucasian male presents to the emergency room after being shot in the arm in a hunting accident. His shirt is soaked through with blood. He has a blood pressure of 65/40, a heart rate of 122, and his skin is pale, cool to the touch, and moist. This patient is most likely experiencing all of the following EXCEPT:

A 28-year-old man presents for severe abdominal pain and is diagnosed with appendicitis. He is taken for emergent appendectomy. During the procedure, the patient has massive and persistent bleeding requiring a blood transfusion. The preoperative laboratory studies showed a normal bleeding time, normal prothrombin time (PT), an INR of 1.0, and a normal platelet count. Postoperatively, when the patient is told about the complications during the surgery, he recalls that he forgot to mention that he has a family history of an unknown bleeding disorder. The postoperative laboratory tests reveal a prolonged partial thromboplastin time (PTT). Which of the following is the most likely diagnosis in this patient?

A 71-year-old woman is brought to the emergency department following a syncopal episode. Earlier in the day, the patient had multiple bowel movements that filled the toilet bowl with copious amounts of bright red blood. Minutes later, she felt dizzy and lightheaded and collapsed into her daughter's arms. The patient has a medical history of diabetes mellitus and hypertension. Her temperature is 99.0°F (37.2°C), blood pressure is 155/94 mmHg, pulse is 82/min, respirations are 15/min, and oxygen saturation is 99% on room air. The patient's exam is notable for fecal occult blood positivity on rectal exam; however, the patient is no longer having bloody bowel movements. The patient's lungs are clear to auscultation and her abdomen is soft and nontender. Labs are ordered as seen below. Hemoglobin: 7.1 g/dL Hematocrit: 25% Leukocyte count: 5,300/mm^3 with normal differential Platelet count: 182,500/mm^3 Two large bore IV's are placed and the patient is given normal saline. What is the best next step in management?

A 12-year-old boy is brought to the emergency department after a motor vehicle collision. He was being carpooled to school by an intoxicated driver and was involved in a high velocity head-on collision. The patient is otherwise healthy and has no past medical history. His temperature is 99.2°F (37.3°C), blood pressure is 80/45 mmHg, pulse is 172/min, respirations are 36/min, and oxygen saturation is 100% on room air. A FAST exam demonstrates free fluid in Morrison pouch. The patient’s parents arrive and state that they are Jehovah’s witnesses. They state they will not accept blood products for their son but will allow him to go to the operating room to stop the bleeding. Due to poor understanding and a language barrier, the parents are also refusing IV fluids as they are concerned that this may violate their religion. The child is able to verbalize that he agrees with his parents and does not want any treatment. Which of the following is the best next treatment for this patient?

A 38-year-old male is brought to the emergency department by ambulance after a motor vehicle collision. He is found to have a broken femur and multiple soft tissue injuries and is admitted to the hospital. During the hospital course, he is found to have lower extremity swelling, redness, and pain, so he is given an infusion of a medication. The intravenous medication is discontinued in favor of an oral medication in preparation for discharge; however, the patient leaves against medical advice prior to receiving the full set of instructions. The next day, the patient is found to have black lesions on his trunk and his leg. The protein involved in this patient's underlying abnormality most likely affects the function of which of the following factors?

A 22-year-old woman in the intensive care unit has had persistent oozing from the margins of wounds for 2 hours that is not controlled by pressure bandages. She was admitted to the hospital 13 hours ago following a high-speed motor vehicle collision. Initial focused assessment with sonography for trauma was negative. An x-ray survey showed opacification of the right lung field and fractures of multiple ribs, the tibia, fibula, calcaneus, right acetabulum, and bilateral pubic rami. Laboratory studies showed a hemoglobin concentration of 14.8 g/dL, leukocyte count of 10,300/mm3, platelet count of 175,000/mm3, and blood glucose concentration of 77 mg/dL. Infusion of 0.9% saline was begun. Multiple lacerations on the forehead and extremities were sutured, and fractures were stabilized. Repeat laboratory studies now show a hemoglobin concentration of 12.4 g/dL, platelet count of 102,000/mm3, prothrombin time of 26 seconds (INR=1.8), and activated partial thromboplastin time of 63 seconds. Which of the following is the next best step in management?

A 27-year-old man is brought to the emergency department by emergency medical services. The patient was an unrestrained passenger in a head-on collision that occurred 15 minutes ago and is currently unresponsive. His temperature is 99.5°F (37.5°C), blood pressure is 60/33 mmHg, pulse is 180/min, respirations are 17/min, and oxygen saturation is 95% on room air. A FAST exam demonstrates fluid in Morrison’s pouch. Laboratory values are drawn upon presentation to the ED and sent off. The patient is started on IV fluids and an initial trauma survey is started. Twenty minutes later, his blood pressure is 95/65 mmHg, and his pulse is 110/min. The patient is further stabilized and is scheduled for emergency surgery. Which of the following best represents this patient’s most likely initial laboratory values?

Two hours after undergoing a left femoral artery embolectomy, an obese 63-year-old woman has severe pain, numbness, and tingling of the left leg. The surgery was without complication and peripheral pulses were weakly palpable postprocedure. She has type 2 diabetes mellitus, peripheral artery disease, hypertension, and hypercholesterolemia. Prior to admission, her medications included insulin, enalapril, carvedilol, aspirin, and rosuvastatin. She appears uncomfortable. Her temperature is 37.1°C (99.3°F), pulse is 98/min, and blood pressure is 132/90 mm Hg. Examination shows a left groin surgical incision. The left lower extremity is swollen, stiff, and tender on palpation. Dorsiflexion of her left foot causes severe pain in her calf. Femoral pulses are palpated bilaterally. Pedal pulses are weaker on the left side as compared to the right side. Laboratory studies show: Hemoglobin 12.1 Leukocyte count 11,300/mm3 Platelet count 189,000/mm3 Serum Glucose 222 mg/dL Creatinine 1.1 mg/dL Urinalysis is within normal limits. Which of the following is the most likely cause of these findings?

Three days after undergoing coronary artery bypass surgery, a 72-year-old man has severe right upper quadrant pain, fever, nausea, and vomiting. He has type 2 diabetes mellitus, benign prostatic hyperplasia, peripheral vascular disease, and chronic mesenteric ischemia. He had smoked one pack of cigarettes daily for 30 years but quit 10 years ago. He drinks 8 cans of beer a week. His preoperative medications include metformin, aspirin, simvastatin, and finasteride. His temperature is 38.9°C (102°F), pulse is 102/min, respirations are 18/min, and blood pressure is 110/60 mmHg. Auscultation of the lungs shows bilateral inspiratory crackles. Cardiac examination shows no murmurs, rubs or gallops. Abdominal examination shows soft abdomen with tenderness and sudden inspiratory arrest upon palpation in the right upper quadrant. There is no rebound tenderness or guarding. Laboratory studies show the following: Hemoglobin 13.1 g/dL Hematocrit 42% Leukocyte count 15,700/mm3 Segmented neutrophils 65% Bands 10% Lymphocytes 20% Monocytes 3% Eosinophils 1% Basophils 0.5% AST 40 U/L ALT 100 U/L Alkaline phosphatase 85 U/L Total bilirubin 1.5 mg/dL Direct 0.9 mg/dL Amylase 90 U/L Abdominal ultrasonography shows a distended gallbladder, thickened gallbladder wall with pericholecystic fluid, and no stones. Which of the following is the most appropriate next step in management?

A 31-year-old woman is brought to the emergency department 25 minutes after sustaining a gunshot wound to the neck. She did not lose consciousness. On arrival, she has severe neck pain. She appears anxious. Her temperature is 37°C (98.6°F), pulse is 105/min, respirations are 25/min, and blood pressure is 100/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. She is oriented to person, place, and time. Examination shows a bullet entrance wound in the right posterior cervical region of the neck. There is no exit wound. Carotid pulses are palpable bilaterally. There are no carotid bruits. Sensation to pinprick and light touch is normal. The lungs are clear to auscultation. Cardiac examination shows no murmurs, rubs, or gallops. In addition to intravenous fluid resuscitation, which of the following is the most appropriate next step in the management of this patient?