Preoperative and Postoperative Care Practice Questions

Q: Four days after undergoing subtotal gastrectomy for stomach cancer, a 58-year-old woman complains of right leg and thigh pain, swelling, redness, and tenderness on examination. Deep vein thrombosis is suspected. What is the initial test to establish the diagnosis?

Venous duplex ultrasound. **Explanation:** The clinical presentation of unilateral leg pain, swelling, redness, and tenderness in a post-operative patient (especially after major abdominal surgery like gastrectomy) is highly suggestive of **Deep Vein Thrombosis (DVT)**. **1. Why Venous Duplex Ultrasound is correct:** Venous duplex ultrasound (combining B-mode imaging and Doppler) is the **initial and preferred diagnostic test** for suspected DVT. It is non-invasive, highly sensitive (>95%), and specific for proximal DVT. The primary diagnostic criterion is the **lack of compressibility** of the vein under the ultrasound probe. It has replaced more invasive or less accurate tests in standard clinical practice. **2. Why the other options are incorrect:** * **Venography (Option A):** Historically the "Gold Standard," it involves injecting contrast into the venous system. It is now rarely used because it is invasive, carries a risk of contrast-induced nephropathy/allergy, and may actually trigger thrombosis. * **Impedance Plethysmography (Option C):** This measures changes in electrical resistance to detect blood flow obstruction. It is less sensitive than ultrasound, especially for non-occlusive or calf thrombi, and is largely obsolete. * **Radio-labeled Fibrinogen (Option D):** This test detects active fibrin deposition. It is time-consuming (takes 24–72 hours), involves radiation, and is no longer used in acute clinical settings. **Clinical Pearls for NEET-PG:** * **Virchow’s Triad:** Stasis, endothelial injury, and hypercoagulability (all present in post-op cancer patients). * **Wells Score:** Used to determine the pre-test probability of DVT before ordering imaging. * **D-dimer:** Has a high **negative predictive value**; it is used to rule out DVT in low-risk patients but is often non-specifically elevated in post-operative patients. * **Gold Standard:** Contrast Venography (though Duplex US is the "Initial/Best" test).

Q: A 65-year-old man undergoes a low anterior resection for rectal cancer. On the fifth day in hospital, his physical examination shows a temperature of 39°C (102°F), blood pressure of 150/90 mm Hg, pulse of 110 beats per minute and regular, and respiratory rate of 28 breaths per minute. A computed tomography (CT) scan of the abdomen reveals an abscess in the pelvis. Which of the following most accurately describes his present condition?

Sepsis. ### Explanation The patient is presenting with a postoperative complication (pelvic abscess) following a major abdominal surgery. To identify the correct stage of the inflammatory response, we must apply the **SIRS and Sepsis criteria**. **1. Why Sepsis is Correct:** Sepsis is defined as **SIRS + a documented or suspected source of infection**. This patient meets the SIRS criteria by having: * **Temperature:** 39°C (>38°C) * **Heart Rate:** 110 bpm (>90 bpm) * **Respiratory Rate:** 28 breaths/min (>20 breaths/min) Additionally, the CT scan confirms a **pelvic abscess**, providing a definitive source of infection. Therefore, SIRS + Infection = **Sepsis**. **2. Why the Other Options are Incorrect:** * **SIRS (Systemic Inflammatory Response Syndrome):** This is a non-specific clinical response to a variety of insults (trauma, burns, pancreatitis). While the patient has SIRS, the presence of a confirmed infection (abscess) upgrades the diagnosis to Sepsis. * **Severe Sepsis:** Historically defined as sepsis associated with **organ dysfunction** (e.g., oliguria, altered mental status, lactic acidosis) or hypotension that responds to fluids. This patient’s BP is 150/90 mm Hg, and no organ failure is mentioned. * **Septic Shock:** Defined as sepsis with **persistent hypotension** (MAP 38°C or 90; RR >20 or PaCO2 12,000 or 10% bands). * **qSOFA Score:** In modern practice (Sepsis-3), the qSOFA (Quick SOFA) is used bedside: RR ≥22, Altered Mentation (GCS <15), and Systolic BP ≤100 mmHg. * **Post-op Fever Timeline:** Fever on Day 5 ("Walking") is classically associated with Wound infection or deep-seated abscesses (like in this case).

Q: A patient with meningioma and an inflammatory edematous lesion is scheduled for surgery. Which of the following represents a mistake in the junior resident's pre-operative notes?

Discontinue steroids. **Explanation:** The correct answer is **A. Discontinue steroids**. In neurosurgery, specifically for tumors like meningiomas associated with "inflammatory edematous lesions" (peritumoral edema), steroids (typically Dexamethasone) are a cornerstone of preoperative management. They stabilize the blood-brain barrier and reduce vasogenic edema, thereby lowering intracranial pressure (ICP) and improving the surgical field. Discontinuing them preoperatively would be a clinical mistake as it could lead to neurological deterioration or herniation. **Analysis of other options:** * **B. Wash head with shampoo:** This is a standard preoperative protocol to reduce the microbial load on the scalp, minimizing the risk of Surgical Site Infections (SSI). * **C. Check antibiotic sensitivity:** Preoperative prophylaxis is mandatory in neurosurgery. Ensuring the patient is not allergic and that the chosen antibiotic is appropriate is a vital safety step. * **D. Continue antiepileptic drugs (AEDs):** Patients with intracranial tumors are at high risk for seizures. AEDs must be continued perioperatively (often switched to IV formulations) to prevent intraoperative or postoperative status epilepticus. **Clinical Pearls for NEET-PG:** * **Steroid of Choice:** Dexamethasone is preferred in neurosurgery due to its high potency, long half-life, and minimal mineralocorticoid (salt-retaining) activity. * **Vasogenic vs. Cytotoxic Edema:** Steroids are highly effective for **vasogenic edema** (seen in tumors/abscesses) but have little to no role in **cytotoxic edema** (seen in acute ischemic stroke). * **Pre-op Fasting (ASA Guidelines):** 2 hours for clear liquids, 6 hours for a light meal, and 8 hours for fatty foods.

Q: What is the standard of care regarding vaccination in patients who have undergone splenectomy, excluding which of the following?

Typhoid vaccine. **Explanation:** The spleen plays a critical role in the immune system by filtering blood-borne pathogens and producing opsonins (like tuftsin and properdin). Patients who have undergone a splenectomy are at a lifelong risk of **Overwhelming Post-Splenectomy Infection (OPSI)**, primarily caused by **encapsulated bacteria**. **1. Why Typhoid vaccine is the correct answer:** The standard post-splenectomy vaccination protocol targets organisms that require splenic opsonization for clearance. *Salmonella typhi* (the cause of Typhoid) is an intracellular pathogen, and while it is encapsulated, it is not among the primary triad of organisms responsible for OPSI. Therefore, the Typhoid vaccine is not a standard or mandatory requirement for post-splenectomy care unless indicated by travel to endemic areas. **2. Why the other options are incorrect:** The "Big Three" encapsulated organisms that cause 80% of OPSI cases are: * **Streptococcus pneumoniae (Option C):** The most common cause of OPSI. Vaccination is mandatory. * **Haemophilus influenzae type b (Option A):** A significant cause of sepsis in asplenic patients, especially children. * **Neisseria meningitidis (Option B):** Asplenic patients have a significantly higher risk of meningococcal sepsis and meningitis. **Clinical Pearls for NEET-PG:** * **Timing is Key:** For elective splenectomy, vaccinate **2 weeks before** surgery. For emergency splenectomy, vaccinate **2 weeks after** surgery (to avoid the "stunning" effect of surgery on the immune system). * **Annual Requirement:** Patients should also receive the **annual Influenza vaccine**, as viral infections can predispose them to secondary bacterial pneumonia. * **Prophylaxis:** In addition to vaccines, lifelong prophylactic antibiotics (usually Penicillin V) are often recommended, especially for children under 5 or for the first 2 years post-surgery.

Q: The surgeon should be particularly concerned about which coagulation function in patients receiving anti-inflammatory or analgesic medications?

Bleeding time. **Explanation:** The correct answer is **Bleeding Time (D)**. **Why it is correct:** Anti-inflammatory and analgesic medications, specifically **Non-Steroidal Anti-inflammatory Drugs (NSAIDs)** like Aspirin, Ibuprofen, and Ketorolac, primarily affect **platelet function**. Aspirin irreversibly inhibits the enzyme cyclooxygenase-1 (COX-1), preventing the synthesis of Thromboxane A2, which is essential for platelet aggregation. Other NSAIDs cause reversible inhibition. Since the **Bleeding Time (BT)** is the primary clinical test used to assess the vascular phase and platelet plug formation (primary hemostasis), it is the parameter most affected by these drugs. **Why the other options are incorrect:** * **APTT (Activated Partial Thromboplastin Time):** This measures the integrity of the **intrinsic** and common coagulation pathways. It is used to monitor Heparin therapy, not NSAID use. * **PT (Prothrombin Time):** This measures the **extrinsic** and common pathways. It is used to monitor Warfarin therapy and liver synthetic function. * **Reptilase Time:** This measures the conversion of fibrinogen to fibrin. It is unaffected by heparin and is used to detect dysfibrinogenemia or contamination. **Clinical Pearls for NEET-PG:** * **Aspirin:** Should ideally be stopped **7–10 days** before major surgery (the lifespan of a platelet). * **NSAIDs (Non-selective):** Should typically be stopped **2–3 days** (approx. 5 half-lives) before surgery. * **Selective COX-2 Inhibitors (e.g., Celecoxib):** These do **not** affect platelet aggregation or bleeding time and can often be continued perioperatively. * **Normal Bleeding Time (Ivy’s Method):** 2–9 minutes.

Q: What is the purpose of the device shown below?

Pneumatic compression stockings for DVT prevention. ***Pneumatic compression stockings for DVT prevention*** - These devices provide **sequential compression** to the legs, promoting **venous return** and reducing **venous stasis**, which is a major risk factor for DVT formation. - They work by **intermittent inflation and deflation** of air chambers, mimicking the muscle pump action to prevent blood pooling in deep veins. *Hypothermia treatment* - Hypothermia treatment involves **cooling blankets** or **ice packs** to lower body temperature, not compression devices. - These devices focus on **temperature regulation** rather than **circulatory enhancement** for thrombosis prevention. *Cellulitis management* - Cellulitis treatment primarily involves **antibiotics** and **elevation** of the affected limb, not mechanical compression. - While compression may be used for **edema control**, it's not the primary purpose of pneumatic compression devices shown. *Varicose veins treatment* - Varicose vein treatment typically involves **sclerotherapy**, **laser ablation**, or **surgical stripping** of affected superficial veins. - While **static compression stockings** may help with varicose veins, **pneumatic compression** is specifically designed for **DVT prevention** in immobilized patients.

Question 1

Four days after undergoing subtotal gastrectomy for stomach cancer, a 58-year-old woman complains of right leg and thigh pain, swelling, redness, and tenderness on examination. Deep vein thrombosis is suspected. What is the initial test to establish the diagnosis?

Accepted Answer

Venous duplex ultrasound

Answer

Venography

Answer

Impedance plethysmography

Answer

Radio-labeled fibrinogen

Question 2

What is true regarding a subphrenic abscess?

Accepted Answer

It is most commonly seen following biliary tract surgery.

Answer

A subphrenic abscess is most common following stomach surgery.

Answer

As the subphrenic space is surrounded by the falciform ligament and other hepatic ligament anteriorly, the subphrenic space is best approached through the bed and 12th rib.

Answer

It occurs most commonly following hepatic abscess rupture.

Question 3

A significant increase in energy expenditure, approximately 100% over normal or two times greater than normal, is typically observed in patients with which of the following conditions?

Accepted Answer

Severe thermal burns involving more than 30% of the total body surface area (BSA)

Answer

Pyloric obstruction due to a chronic duodenal ulcer

Answer

Fracture of the femur

Answer

Perforated diverticulitis of the colon

Question 4

A postoperative patient presents with peritonitis and massive contamination due to a duodenal leak. What is the management of choice?

Accepted Answer

Total parenteral nutrition

Answer

Four quadrant peritoneal lavage

Answer

Duodenojejunostomy

Answer

Duodenostomy with feeding jejunostomy

Question 5

What is the most important consideration in a patient with borderline pulmonary function undergoing lung resection?

Accepted Answer

Elevated pulmonary artery pressure

Answer

The amount of nonfunctioning lung tissue to be removed

Answer

The amount of functioning lung tissue to be removed

Answer

Experience of the surgical team

Question 6

A 65-year-old man undergoes a low anterior resection for rectal cancer. On the fifth day in hospital, his physical examination shows a temperature of 39°C (102°F), blood pressure of 150/90 mm Hg, pulse of 110 beats per minute and regular, and respiratory rate of 28 breaths per minute. A computed tomography (CT) scan of the abdomen reveals an abscess in the pelvis. Which of the following most accurately describes his present condition?

Accepted Answer

Sepsis

Answer

Systemic inflammatory response syndrome (SIRS)

Answer

Severe sepsis

Answer

Septic shock

Question 7

A patient with meningioma and an inflammatory edematous lesion is scheduled for surgery. Which of the following represents a mistake in the junior resident's pre-operative notes?

Accepted Answer

Discontinue steroids

Answer

Wash head with shampoo

Answer

Check antibiotic sensitivity

Answer

Continue antiepileptic drugs

Question 8

What is the standard of care regarding vaccination in patients who have undergone splenectomy, excluding which of the following?

Accepted Answer

Typhoid vaccine

Answer

Haemophilus influenzae type b

Answer

Meningococcal vaccine

Answer

Pneumococcal vaccine

Question 9

The surgeon should be particularly concerned about which coagulation function in patients receiving anti-inflammatory or analgesic medications?

Accepted Answer

Bleeding time

Answer

APTT

Answer

PT

Answer

Reptilase time

Question 10

What is the purpose of the device shown below?

Accepted Answer

Pneumatic compression stockings for DVT prevention

Answer

Hypothermia treatment

Answer

Cellulitis management

Answer

Varicose veins treatment

Preoperative and Postoperative Care — MCQs

Preoperative and Postoperative Care — MCQs

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