Preoperative and Postoperative Care Practice Questions

Q: Which of the following are the common complications associated with enteral nutrition in postoperative patients ? 1. Tube malposition, displacement 2. Diarrhoea, constipation 3. Predisposition to systemic sepsis 4. Electrolytic imbalance Select the correct answer using the code given below :

1, 2 and 3. ***1, 2 and 3*** - **Tube malposition/displacement** is a common mechanical complication (10-15% incidence), which can lead to ineffective feeding or aspiration into the respiratory tract. - **Diarrhoea and constipation** are frequent gastrointestinal complications (10-20% incidence), occurring due to formula intolerance, rapid infusion rates, or altered gut motility in postoperative patients. - **Predisposition to systemic sepsis**: While enteral nutrition itself has lower infection risk than parenteral nutrition, complications like **aspiration pneumonia** (from tube malposition), **contaminated formula**, and **prolonged ileus** can predispose to severe infections and sepsis in postoperative patients. This is particularly relevant when enteral feeding is improperly managed. *1, 2 and 4* - This combination includes **electrolyte imbalances** (hypokalemia, hypophosphatemia, hypomagnesemia), which are indeed common metabolic complications requiring monitoring. - However, in the context of postoperative patients, the infection risk (sepsis) from aspiration and feeding-related complications is considered a more significant acute complication than electrolyte disturbances, which are generally manageable with proper monitoring and formula adjustment. *1, 3 and 4* - This option incorrectly excludes **diarrhoea and constipation**, which are among the **most common complications** of enteral nutrition, occurring in 10-20% of patients. - GI complications are a primary reason for enteral feeding intolerance and cannot be omitted. *2, 3 and 4* - This option incorrectly omits **tube malposition/displacement**, which is the most important **mechanical complication** directly related to the enteral feeding method. - Without proper tube placement verification, feeding cannot be safely administered, making this a critical complication to recognize.

Q: A young 28-year-old male was operated for duodenal ulcer perforation peritonitis. After having recovered well for five days, he developed high fever with chills and symptoms of toxemia. He developed right shoulder tip pain and intractable hiccoughs. The most likely diagnosis is :

Subphrenic abscess. ***Subphrenic abscess*** - The development of **high fever with chills**, **toxemia**, **right shoulder tip pain**, and **intractable hiccups** following a duodenal ulcer perforation repair strongly suggests a subphrenic abscess. - **Diaphragmatic irritation** by the abscess causes referred shoulder pain (due to phrenic nerve irritation) and hiccups. *Right lobe liver abscess* - While a liver abscess can cause fever and chills, **shoulder tip pain** and **hiccups** are less typical compared to a subphrenic abscess, unless the abscess is very superficial and irritating the diaphragm. - A liver abscess often presents with **right upper quadrant pain** and hepatomegaly, which are not mentioned. *Surgical site infection* - A surgical site infection would typically manifest with **localized pain**, **redness**, **swelling**, and possibly **pus discharge** at the incision site, rather than referred shoulder pain or intractable hiccups. - While it can cause fever and toxemia, the specific constellation of symptoms points away from a superficial wound infection. *Postoperative peritonitis* - Postoperative peritonitis would present with more generalized **abdominal pain**, **distension**, **tenderness**, and potentially signs of evolving **sepsis** or **organ dysfunction**. - While it can cause fever and toxemia, the distinct symptoms of **shoulder tip pain** and **hiccups** are less characteristic of diffuse peritonitis.

Q: A malnourished 60-year-old man underwent emergency surgery for Strangulated Sigmoid Volvulus. After resection of the sigmoid colon, a colostomy was fashioned. The postoperative period was stormy and he developed a painful calf swelling in right lower limb. The most probable diagnosis is :

Deep vein thrombosis. ***Deep vein thrombosis*** - Postoperative patients, especially those undergoing **abdominal surgery** and those with **malnutrition**, are at high risk for **deep vein thrombosis (DVT)** due to Virchow's triad (venous stasis, endothelial injury, hypercoagulability). - A **painful calf swelling** is a classic symptom of DVT, indicating clot formation within the deep veins of the leg. *Myocardial failure due to fluid overload* - While fluid overload can occur post-surgery, it typically leads to **generalized edema**, shortness of breath, and signs of cardiac dysfunction, not isolated painful calf swelling. - The primary presentation here is a localized, painful swelling, which is less consistent with systemic cardiac issues. *Oedema of renal failure* - **Renal failure** can cause **edema**, but it tends to be **pitting, bilateral, and generalized**, often affecting the ankles and sacral areas. - It would not typically present as a painful, unilateral calf swelling without other signs of kidney dysfunction. *Hypoproteinaemia* - **Hypoproteinaemia**, common in **malnourished** individuals, can cause **generalized non-pitting edema** due to decreased oncotic pressure, not specifically a painful calf swelling. - It would manifest as widespread edema rather than a localized, painful swelling indicative of a thrombotic event.

Q: Preoperative investigations done prior to surgery depend upon which of the following? 1. Type of surgery 2. Patient origin 3. Patient comorbidities 4. Experience of surgeon

1. Type of surgery. ***1. Type of surgery*** - The **type of surgery** is a primary determinant of preoperative investigations, as it defines the baseline assessment needed based on the procedure's complexity, invasiveness, and physiological stress. - Minor surgeries (e.g., superficial excisions) typically require minimal investigations, while major surgeries (e.g., cardiac, neurosurgery) mandate comprehensive cardiovascular, pulmonary, and hematological workups. - **Clinical Note:** In practice, preoperative investigations depend on BOTH the surgery type AND patient comorbidities working together, but this question likely seeks the most fundamental starting point. *3. Patient comorbidities* - **Patient comorbidities** are undeniably crucial in determining the extent and nature of preoperative investigations. - A patient with diabetes, hypertension, or cardiac disease requires additional specific investigations regardless of the surgery type. - However, the surgery type establishes the baseline framework, which is then modified based on comorbidities. *2. Patient origin* - **Patient origin** (geographical location, ethnicity) is generally not a direct determinant of preoperative investigation protocols. - While certain populations may have higher prevalence of specific conditions, investigations are based on individual patient assessment, not origin. *4. Experience of surgeon* - The **experience of the surgeon** does not alter the medical necessity or standard protocols for preoperative investigations. - Patient safety standards and investigation requirements remain consistent regardless of surgical expertise level.

Q: The following statements are correct about burst abdomen (abdominal dehiscence) except

Second dehiscence is very common. ***Second dehiscence is very common*** - This statement is incorrect. While **dehiscence** can recur, it is not considered "very common" after proper surgical repair and addressing risk factors. - The overall incidence of **abdominal dehiscence** ranges from 0.5% to 3%, and subsequent dehiscence, though possible, is less frequent than the initial event due to stricter prophylactic measures and more careful wound closure techniques. *Manage with nasogastric aspiration and intravenous fluids* - This is a crucial initial step for managing **burst abdomen**, as it helps to decompress the gastrointestinal tract and prevent vomiting. - **Intravenous fluids** are essential for maintaining hydration and electrolyte balance, especially if the patient is experiencing fluid loss through the exposed wound. *Cover the wound with sterile towel and perform emergency surgery* - Covering the exposed viscera with a **sterile, saline-soaked towel** is vital to prevent desiccation, infection, and further injury to the bowel. - **Emergency surgery** is necessary to debride the wound, inspect the abdominal contents, and perform a secure secondary closure of the abdominal wall layers. *Peak incidence is between 6th and 8th post operative day* - This timeframe is consistent with the typical healing progression of surgical wounds, where the tensile strength of the wound is still relatively low before collagen deposition is complete. - Factors like **infection**, **increased intra-abdominal pressure**, and poor nutritional status can contribute to wound breakdown during this critical period.

Q: The earliest clinical sign of an impending burst abdomen is:

Serous wound discharge. ***Serous wound discharge*** - The appearance of **serosanguinous (pinkish-yellow) fluid** leaking from the wound is often the earliest and most reliable sign. - This discharge indicates separation of fascial edges before complete dehiscence, as it can pass through small gaps in the compromised closure. *Tachycardia and high-grade fever* - These are systemic signs of **infection or sepsis**, which can predispose to wound dehiscence but are not typically the earliest direct local sign of an impending burst abdomen itself. - While infection increases risk, the direct physical sign of fascial disruption often precedes clear signs of systemic infection or is present without high fever. *Pus discharge from the wound* - **Pus discharge** signifies a localized wound infection (abscess or cellulitis) and can contribute to wound breakdown, but it is not the *earliest* sign of **fascial dehiscence** specifically. - Serous discharge indicates mechanical separation, whereas purulent discharge indicates infection, which can lead to dehiscence but is a different process. *Erythema of the wound* - **Erythema** (redness) around the wound typically indicates localized **inflammation or infection** (cellulitis). - While inflammation can compromise wound healing and increase the risk of dehiscence, it is generally not the first specific sign of impending fascial disruption.

Q: Which one of the following statements regarding the composition of common crystalloid solutions is correct ?

Hartmann’s solution contains 111 meq/L of Cl. ***Hartmann’s solution contains 111 meq/L of Cl*** - **Hartmann's solution** (Lactated Ringer's) typically contains **111 mmol/L** (or meq/L) of chloride. - Its electrolyte composition aims to mimic plasma more closely than normal saline, with **lower chloride content** to reduce the risk of hyperchloremic acidosis. *Hartmann’s solution contains 111 meq/L of Na* - Hartmann's solution contains approximately **130 meq/L of Na**, not 111 meq/L. - The sodium concentration is higher than 111 meq/L to maintain **isotonicity** and match plasma osmolality. *Normal saline contains 130 meq/L of Cl* - **Normal saline (0.9% NaCl)** contains **154 meq/L of Cl**, which is significantly higher than 130 meq/L. - Its high chloride content can lead to **hyperchloremic metabolic acidosis** if administered in large volumes. *Normal saline contains 100 meq/L of Na* - **Normal saline (0.9% NaCl)** contains **154 meq/L of Na**, not 100 meq/L [1]. - This higher sodium concentration contributes to its **isotonicity** with plasma [1].

Q: Which of the following statements regarding the composition of common crystalloid solutions is correct ?

Normal saline contains 154 mEq/L of Na+. ***Normal saline contains 154 mEq/L of Na+*** - Normal saline (0.9% NaCl) contains **154 mEq/L of both Na+ and Cl-**, making this statement factually correct. - This makes normal saline **hypernatremic and hyperchloremic** compared to plasma (which has ~140 mEq/L Na+ and ~103 mEq/L Cl-). - Normal saline is useful for correcting **hyponatremia** and for significant volume expansion, but large volumes can cause **hyperchloremic metabolic acidosis**. *Hartmann's solution contains 140 mEq/L of Na+* - Hartmann's solution (Lactated Ringer's) actually contains approximately **130 mEq/L of Na+**, not 140 mEq/L. - The sodium content is designed to be closer to that of **plasma**, making it a more physiologically balanced solution. *Hartmann's solution contains 120 mEq/L of Cl-* - Hartmann's solution contains approximately **109-110 mEq/L of Cl-**, not 120 mEq/L. - This **lower chloride content** compared to normal saline, along with the presence of lactate (28 mEq/L), contributes to a reduced risk of hyperchloremic metabolic acidosis. - The lactate is metabolized to bicarbonate, providing a mild alkalinizing effect. *Normal saline contains 140 mEq/L of Cl-* - Normal saline contains **154 mEq/L of Cl-**, not 140 mEq/L. - Its high chloride content can lead to **hyperchloremic metabolic acidosis** with large-volume administration.

Q: A 60 year old lady underwent total abdominal hysterectomy. On the 3rd post operative day she suddenly became breathless while returning from washroom. Her blood pressure recorded was 80/50 mm of Hg. The most probable diagnosis is

Thromboembolism. ***Thromboembolism*** - Sudden onset **breathlessness** and **hypotension** in a postoperative patient are classic signs of a **pulmonary embolism (PE)**, a severe form of thromboembolism. - Surgical procedures, especially pelvic surgeries like hysterectomy, are **risk factors** for deep vein thrombosis (DVT) which can lead to PE. *Postural hypotension* - While it can cause lightheadedness or dizziness upon standing, it typically doesn't present as sudden, severe **breathlessness** and sustained **hypotension**. - Its onset is directly related to a change in position, and the patient's symptoms are more severe than usually seen with postural changes. *Transient ischaemic attack* - A TIA involves **neurological deficits** such as weakness, speech disturbance, or visual changes, which are temporary. - It does not present with sudden **breathlessness** or profound **hypotension**. *Secondary haemorrhage* - This would typically manifest as signs of **blood loss**, such as fresh bleeding from the surgical site or distended abdomen, along with features of hypovolemic shock. - While hypotension would be present, the primary symptom would not be sudden **breathlessness**.

Question 1

Which of the following are the common complications associated with enteral nutrition in postoperative patients ?

1. Tube malposition, displacement
2. Diarrhoea, constipation
3. Predisposition to systemic sepsis
4. Electrolytic imbalance

Select the correct answer using the code given below :

Accepted Answer

1, 2 and 3

Answer

1, 2 and 4

Answer

1, 3 and 4

Answer

2, 3 and 4

Question 2

A young 28-year-old male was operated for duodenal ulcer perforation peritonitis. After having recovered well for five days, he developed high fever with chills and symptoms of toxemia. He developed right shoulder tip pain and intractable hiccoughs. The most likely diagnosis is :

Accepted Answer

Subphrenic abscess

Answer

Right lobe liver abscess

Answer

Surgical site infection

Answer

Postoperative peritonitis

Question 3

A malnourished 60-year-old man underwent emergency surgery for Strangulated Sigmoid Volvulus. After resection of the sigmoid colon, a colostomy was fashioned. The postoperative period was stormy and he developed a painful calf swelling in right lower limb. The most probable diagnosis is :

Accepted Answer

Deep vein thrombosis

Answer

Myocardial failure due to fluid overload

Answer

Oedema of renal failure

Answer

Hypoproteinaemia

Question 4

Preoperative investigations done prior to surgery depend upon which of the following?

1. Type of surgery
2. Patient origin
3. Patient comorbidities
4. Experience of surgeon

Accepted Answer

1. Type of surgery

Answer

4. Experience of surgeon

Answer

2. Patient origin

Answer

3. Patient comorbidities

Question 5

The following statements are correct about burst abdomen (abdominal dehiscence) except

Accepted Answer

Second dehiscence is very common

Answer

Manage with nasogastric aspiration and intravenous fluids

Answer

Cover the wound with sterile towel and perform emergency surgery

Answer

Peak incidence is between 6th and 8th post operative day

Question 6

The earliest clinical sign of an impending burst abdomen is:

Accepted Answer

Serous wound discharge

Answer

Tachycardia and high grade fever

Answer

Pus discharge from the wound

Answer

Erythema of the wound

Question 7

Risk Scoring System which can be used postoperatively is:

Accepted Answer

POSSUM 
Physiologic and Operative Severity Score for Enumeration of Mortality and Morbidity

Answer

ASA 
American Society of Anaesthesiologist

Answer

MET 
Metabolic Equivalent Task

Answer

RCRI 
Revised Cardiac Risk Index

Question 8

Which one of the following statements regarding the composition of common crystalloid solutions is correct ?

Accepted Answer

Hartmann’s solution contains 111 meq/L of Cl

Answer

Hartmann’s solution contains 111 meq/L of Na

Answer

Normal saline contains 130 meq/L of Cl

Answer

Normal saline contains 100 meq/L of Na

Question 9

Which of the following statements regarding the composition of common crystalloid solutions is correct ?

Accepted Answer

Normal saline contains 154 mEq/L of Na+

Answer

Hartmann's solution contains 120 mEq/L of Cl-

Answer

Hartmann's solution contains 140 mEq/L of Na+

Answer

Normal saline contains 140 mEq/L of Cl-

Question 10

A 60 year old lady underwent total abdominal hysterectomy. On the 3rd post operative day she suddenly became breathless while returning from washroom. Her blood pressure recorded was 80/50 mm of Hg. The most probable diagnosis is

Accepted Answer

Thromboembolism

Answer

Postural hypotension

Answer

Transient ischaemic attack

Answer

Secondary haemorrhage

Preoperative and Postoperative Care — MCQs

Preoperative and Postoperative Care — MCQs

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