Peri-operative Care

A 30-year-old man is admitted electively for a right inguinal hernia repair under local anesthesia. He is otherwise healthy, with no significant medical history. He mentions that his grandfather died from a pulmonary embolism. Considering his planned surgery and personal history, what is the most appropriate form of thromboprophylaxis?

A 65-year-old man is admitted to the surgical ward following an elective bowel resection. Postoperatively, he develops hypotension, and the nursing staff initiates intravenous fluid resuscitation. Over the next 24 hours, his renal function deteriorates, and blood tests show worsening metabolic acidosis with elevated serum chloride levels. Reviewing his fluid administration record reveals significant intravenous fluid infusion. Which intravenous fluid, commonly used perioperatively, most likely contributed to his elevated chloride levels?

A 70-year-old woman is admitted to the hospital following prolonged episodes of vomiting and diarrhea. Laboratory tests indicate dehydration with electrolyte abnormalities. Which of the following laboratory findings would NOT typically be associated with dehydration?

A 30-year-old male patient undergoes elective right inguinal hernia repair under local anesthesia. Postoperatively, the surgical resident notices the patient becoming agitated, tachycardic (heart rate 105 bpm), and hypertensive (blood pressure 170/100 mmHg). Clinical examination indicates fluid overload. Laboratory results reveal significant hyponatremia (Na 120 mmol/L). What is the most likely cause of his symptoms?

A 30-year-old man is scheduled for elective right inguinal hernia repair under general anesthesia. He is otherwise fit and healthy with no significant medical history. Which of the following is considered appropriate standard practice immediately before surgery as part of enhanced recovery protocols?

A 63-year-old man is recovering from an open extended right hemicolectomy performed for carcinoma of the colonic splenic flexure. Two days postoperatively, he develops persistent pyrexia. Which of the following is the LEAST likely cause of his fever?

A 52-year-old man presents to the emergency department with severe central chest pain lasting for one hour. On examination, there is a systolic murmur suggestive of mitral regurgitation. An ECG demonstrates ST elevation prominently in leads V1 to V6, with no ST elevation observed in the inferior leads (II, III, and aVF). What is the most likely diagnosis?

A 26-year-old woman with Crohn’s disease presents to the colorectal surgery clinic with severe perianal disease, including multiple anal fistulae. Acute sepsis has been managed surgically, and seton drains are currently in place. Despite standard medical management, her symptoms persist. Which biological therapy is most appropriate for managing her severe perianal Crohn’s disease?

A 65-year-old man presents with abdominal discomfort and early satiety. Imaging identifies a large gastrointestinal tumor, deemed locally unresectable due to its size and location. Biopsy confirms a gastrointestinal stromal tumor (GIST), positive for KIT (CD117). Which of the following medications is most appropriate for this patient’s treatment?

A 68-year-old man with hypertension and coronary artery disease is scheduled for elective abdominal surgery. He has been on regular medication, including beta blockers and statins. Preoperative evaluation reveals hypoalbuminemia, and elevated brain natriuretic peptide (BNP). During the preoperative review, the surgical team considers the implications of these findings on his surgical outcomes. Which of the following statements is incorrect in managing this patient’s perioperative care?

A 65-year-old man with longstanding insulin-dependent diabetes mellitus is scheduled for elective surgery requiring general anesthesia. He will be fasting for approximately 24 hours perioperatively. The surgical team is reviewing perioperative management plans, including appropriate intravenous fluids and glucose monitoring. Which of the following statements regarding his perioperative management is incorrect?

A 40-year-old man undergoes elective orthopedic surgery on his right lower limb. A pneumatic tourniquet is applied to minimize intraoperative bleeding. The surgical team discusses precautions and potential complications associated with tourniquet use. Which of the following statements regarding tourniquet use in surgery is incorrect?

A surgeon is preparing to perform a minor surgical procedure under local anesthesia using lignocaine. During the preoperative assessment, the surgeon considers various factors that might influence the effectiveness of lignocaine. Which of the following conditions would most likely attenuate the action of lignocaine?

A 32-year-old woman with a history of invasive ductal carcinoma of the breast underwent a wide local excision and axillary node clearance, which revealed five positive lymph nodes. The tumor was estrogen receptor (ER) negative, HER2 positive, and exhibited vascular invasion. She now presents with a lesion in the left lobe of her liver that is suspicious for metastatic disease. Which of the following agents is most likely to be beneficial in her treatment?

A 67-year-old man with a history of hypertension, type 2 diabetes, and peripheral arterial disease presents with worsening claudication, now limiting his ability to walk more than 50 meters. Doppler ultrasound and angiography confirm significant stenosis of the superficial femoral artery, and he is scheduled for a femoro-popliteal bypass graft.
During the preoperative discussion, the surgical team considers anticoagulation strategies to prevent intraoperative thrombosis. The anesthetist notes that the patient is on aspirin but has not been receiving therapeutic anticoagulation. As the surgical team prepares to cross-clamp the femoral artery, what is the most appropriate heparin regimen?

A 24-year-old man is scheduled for excision of a sebaceous cyst from his scalp under local anesthesia. The surgical team discusses the choice of local anesthetic to ensure effective analgesia while minimizing bleeding. Which of the following agents is the most appropriate for this procedure?

A 58-year-old man with type 2 diabetes is scheduled for elective colorectal surgery. As part of his preoperative assessment, the anesthesiologist reviews his fluid management plan. Which of the following statements regarding preoperative fluid management is FALSE?

A 19-year-old man undergoes excision of a skin lesion from his back. At his 4-month postoperative review, the surgeon notes that the scar has begun to contract. Which of the following cell types is primarily responsible for this process?

A 52-year-old man presents to the emergency department with severe central chest pain and vomiting. He reports drinking a bottle of vodka earlier in the evening. On examination, mild crepitus is palpable in the epigastric region. What is the most likely diagnosis?

A 45-year-old man is scheduled to undergo an elective right hemicolectomy. As part of his preoperative care, the anesthetist discusses fluid management strategies to optimize recovery and minimize postoperative complications. What is the most appropriate fluid management option for this patient?

A 32-year-old man with newly diagnosed acute myeloid leukemia (AML) requires venous access for chemotherapy, which will involve multiple cycles over several months. The oncologist requests a durable and reliable venous access device for administering chemotherapy and obtaining frequent blood samples. Which of the following is the most appropriate option?

A 43-year-old woman with a metallic heart valve undergoes an elective paraumbilical hernia repair. Due to her metallic valve, she is placed on unfractionated heparin perioperatively for anticoagulation. Given that her renal function is normal, which of the following is the most appropriate method to monitor the therapeutic efficacy of her anticoagulation?

A 35-year-old man requires local anesthesia for a minor surgical procedure. His medical history includes arrhythmia currently managed with flecainide and a known diagnosis of protein C deficiency. The surgeon considers potential contraindications before administering lignocaine. Which of the following is NOT a contraindication to the use of lignocaine for local anesthesia?

A 50-year-old woman with a history of chronic liver disease and jaundice is admitted for elective abdominal surgery. The surgeon is concerned about potential factors that may impair postoperative wound healing. Which of the following conditions is associated with poor wound healing?

A 73-year-old man develops sudden-onset, severe chest pain described as tearing in nature. On auscultation, a loud diastolic murmur is noted. His blood pressure is significantly elevated. The attending physician suspects an acute vascular emergency. Which of the following investigations is most likely to be helpful in demonstrating the cause?

A 6-year-old child requires long-term intravenous drug therapy for a rare genetic disorder. The parents express concerns as the child has been frequently pulling at their current Hickman line. They request an alternative that would be more secure and require less frequent maintenance. What is the best option for long-term venous access?

A 45-year-old man presents to the surgical clinic with concerns about wound healing following cancer treatment. He has a history of zinc deficiency, previous radiotherapy, and recent chemotherapy. The clinician discusses potential risk factors for delayed healing and wound complications. Which of the following associations is incorrect?

A 60-year-old woman is admitted to the hospital for a total abdominal hysterectomy due to a large fibroid uterus causing pressure symptoms. During the procedure, the anesthetist decides to administer an intravenous fluid that is electrolyte-rich to optimize intravascular volume and maintain electrolyte balance. Which of the following intravenous fluids most closely matches this requirement?

A 55-year-old man is found collapsed outside a nightclub where he and his friends have been drinking heavily. His friends explain that before collapsing, he complained of severe, tearing chest pain. Emergency responders find him conscious but in distress, with signs of subcutaneous emphysema on examination. Which of the following investigations is most likely to be indicated?

An 80-year-old woman is evaluated in the preoperative clinic before undergoing elective hip replacement surgery. Routine cardiac assessment reveals severe aortic stenosis. The anesthetist is concerned about her intraoperative risk. What is the main perioperative concern in this patient?

A 65-year-old male presents to the emergency department with sudden onset, severe chest pain described as tearing and radiating to his back. On examination, he is tachycardic with a blood pressure of 160/90 mmHg and has a soft, diastolic murmur heard best along the left sternal border. A chest X-ray reveals a widened mediastinum. ECG shows ST elevation in leads II, III, and aVF.
Which of the following is the most likely diagnosis?

A 65-year-old male is being taken off the cardiopulmonary bypass machine following a successful aortic valve replacement. Prior to decannulation and surgical closure of the chest, it is noted that his coagulation times remain prolonged due to the anticoagulation used during the procedure.
What is the most appropriate drug to administer to correct his clotting before proceeding?

A 62-year-old male with a history of a mechanical aortic valve is scheduled for elective cholecystectomy. He has been maintained on intravenous unfractionated heparin perioperatively to manage anticoagulation. To minimize bleeding risks and ensure a safe surgical procedure, a normal coagulation state must be achieved before the operation begins.
What is the most appropriate perioperative anticoagulation management strategy?

A 55-year-old male with type 2 diabetes mellitus is scheduled for an elective laparoscopic cholecystectomy. He has well-controlled blood glucose on oral antidiabetic agents and no history of ketoacidosis. His last blood glucose reading in the preoperative clinic was 7.2 mmol/L (130 mg/dL).
Which of the following statements about perioperative diabetes management is false?

A 54-year-old male undergoing a complex pancreaticoduodenectomy has a left-sided central venous catheter inserted prior to induction of anesthesia. After successful intubation, the patient begins to exhibit worsening oxygenation and increasing hemodynamic instability. Auscultation reveals decreased breath sounds on the left side, and the peak airway pressures on the ventilator are rising.
What is the most likely underlying explanation for the patient’s hypoxia and instability?

A 20-year-old male is scheduled for removal of an ingrown toenail on his left big toe. The procedure is expected to be straightforward, and local anesthesia will be administered using a ring block.
Which of the following local anesthetic preparations would be the most appropriate for this patient?

A 54-year-old woman is undergoing parathyroidectomy for primary hyperparathyroidism. The surgeon plans to use a technique that may help in identifying the parathyroid glands intraoperatively.
Which of the following agents is most likely to assist in identifying the parathyroid glands during the operation?

A 72-year-old male with sepsis is being managed in the intensive care unit. He requires intravenous fluid resuscitation. You are reviewing the fluid options available.
Which of the following is not classified as an intravenous colloid?

A 32-year-old man presents to the emergency department after a high-speed motorcycle accident. He has a large wound on his left forearm where the skin and subcutaneous tissue have been sheared off, revealing underlying muscle. Examination reveals that the overlying skin has a pale, mottled appearance and moves abnormally relative to the deeper structures.
Which of the following is not typically associated with this type of degloving injury?

A 70-year-old male with a history of progressive angina is found to have a critical lesion in the proximal left anterior descending (LAD) coronary artery. A decision is made to perform coronary artery bypass grafting (CABG).
Which of the following is the most suitable conduit for bypassing the LAD lesion?

A 25-year-old male presents to the emergency department with a painful, fluctuant swelling near the anal verge. He is diagnosed with a perianal abscess, which is treated with incision and drainage under general anesthesia. The resulting perineal wound is approximately 3cm by 3cm.
Which of the following is the best management option for this wound?

A 22-year-old African woman underwent a laparotomy for a ruptured appendix. Eight months later, she presents for a routine follow-up. On examination, the abdominal incision site shows a raised, shiny, firm scar that extends beyond the original incision boundaries.
Which of the following is the most likely underlying process?

A 60-year-old man is scheduled for a flexible sigmoidoscopy due to recurrent episodes of bright red rectal bleeding. He has no significant medical history and is currently asymptomatic.
What is the most appropriate preparation?

A 30-year-old patient presents with a raised, firm scar that extends beyond the original wound margins on the upper chest. The patient recalls the wound was initially minor, caused by a small scratch. Examination confirms the diagnosis of a keloid scar.
Which of the following statements about keloid scars is untrue?

A 60-year-old male with a history of multiple abdominal surgeries presents with adhesional small bowel obstruction. He has been managed conservatively with nasogastric drainage for several days. His current blood test results are as follows:
Test Result Normal Range
Sodium 131 mmol/L 135 – 145 mmol/L
Potassium 3.3 mmol/L 3.5 – 5.0 mmol/L
Urea 7.8 mmol/L 2.5 – 7.1 mmol/LCreatinine: 92 µmol/L
What is the most appropriate intravenous fluid prescription?

A 40-year-old patient is scheduled for a minor surgical procedure under local anesthesia. The anesthetist plans to use an amino amide-type local anesthetic to minimize the risk of side effects and provide stable anesthetic properties.
Which of the following local anesthetics is not an amino amide type?

A physician is preparing to perform a skin biopsy under local anesthesia using lignocaine. The patient asks how the local anesthetic works to prevent pain.
Which of the following best explains lignocaine’s mechanism of action?

A 65-year-old man with normal renal function and iron deficiency anemia is scheduled for a diagnostic colonoscopy. He has been taking ferrous sulfate daily as part of his anemia management.
What preparatory regimen should be considered?

A 75-year-old woman sustains a distal radius fracture after a fall. A Bier’s block is planned to facilitate closed reduction of the fracture.
Which of the following agents is the most appropriate choice for this procedure?

A 4-year-old child arrives at the emergency department after a motor vehicle accident. The child is hypotensive, tachycardic, and unresponsive to initial fluid resuscitation attempts. Multiple attempts at intravenous cannulation have failed.
What is the best course of action?

A 25-year-old man is reviewed 10 days after undergoing a laparotomy for a perforated appendix. The wound appears to be healing well with no signs of infection or dehiscence.
Which of the following processes is least likely to be occurring in the wound at this stage?

A 2×2 cm split-thickness skin graft is placed on a healthy granulating wound. After one week, a bluish-white edge appears around the graft and spreads gradually at about 1 mm per day.
What is this bluish-white margin?

A 78-year-old man is admitted for an abdomino-perineal excision of the rectum due to a low rectal cancer. His comorbidities include well-controlled diabetes, and his renal function is within normal limits.
What is the most appropriate form of thromboprophylaxis?

A 60-year-old patient is receiving low molecular weight heparin (LMWH) for venous thromboembolism prophylaxis following a major abdominal surgery. The medical team is discussing the pharmacological properties of LMWH.
Which of the following statements about low molecular weight heparins is false?

A 54-year-old woman undergoing laparotomy is given atropine as part of her premedication. During the procedure, the anesthetist notes the patient’s physiological responses to the medication.
Which of the following is least likely to occur as a result of atropine administration?

A 52-year-old male with a history of chronic alcoholism presents to the emergency department with acute abdominal pain radiating to the back, nausea, and vomiting. The pain began suddenly after a binge drinking episode two days ago. On examination, his heart rate is 115 bpm, blood pressure is 95/60 mmHg, and respiratory rate is 24 breaths per minute. He appears dry and confused, with reduced urine output over the past 24 hours.
Blood tests reveal the following:
Test Patient Value Normal Range Interpretation
Sodium 137 mmol/L 135 – 145 mmol/L ✅ Normal
Potassium 4.3 mmol/L 3.5 – 5.0 mmol/L ✅ Normal
Urea 6.5 mmol/L 2.5 – 7.8 mmol/L ✅ Normal
Creatinine 95 µmol/L 60 – 110 µmol/L (male) ✅ Normal
Amylase 1,200 IU/L 30 – 110 IU/L ❌ High → Suggests pancreatitis
Lipase 1,500 IU/L 23 – 300 IU/L ❌ High → More specific for pancreatitis
Arterial pH 7.35 7.35 – 7.45 ✅ Low-normal
pCO₂ (partial CO₂) 35 mmHg 35 – 45 mmHg ✅ Normal
HCO₃ (Bicarbonate) 21 mmol/L 22 – 26 mmol/L ❌ Slightly low → Metabolic component
Lactate 2.5 mmol/L 0.5 – 2.2 mmol/L ❌ Mildly elevated → Suggests hypoperfusion or stress

Imaging confirms severe acute pancreatitis with evidence of peripancreatic fluid collections. The patient is admitted to the high-dependency unit for closer monitoring. Despite initial fluid boluses with 0.9% saline, his hemodynamic parameters remain borderline, and his urine output has not improved. The medical team decides to change the fluid strategy.
Which intravenous fluid is most appropriate at this time?

A 65-year-old male with stable angina and a known 90% stenosis of the left anterior descending artery undergoes coronary artery bypass grafting (CABG). The surgeon uses a combination of the left internal mammary artery (LIMA) and a saphenous vein graft for revascularization. The patient recovers well postoperatively and is discharged on antiplatelet therapy, statins, and lifestyle modifications.
Which of the following statements about coronary artery bypass graft surgery is true?

A 34-year-old male patient with acute myeloid leukemia is admitted for chemotherapy. His platelet count drops to 8,000/μL, and he is noted to have multiple petechiae and minor mucosal bleeding. The hematology team decides to administer a platelet transfusion. Due to an emergency situation, ABO-compatible platelets are not immediately available.
Which of the following blood products can be safely administered to a non-ABO-matched recipient?

A 5-year-old boy undergoes elective closure of a loop colostomy. He has no significant comorbidities and is expected to mobilize quickly after surgery.
What thromboprophylaxis should be used?