Postoperative Care ( Platinum ) – EMQ

Option List:

A. C5-T1
B. C5-C6
C. L1-L2
D. S1-S2
E. S1-S4
F. L1-L4
G. C8-T1
H. L4-S3
I. T12-L1
J. L2-L3
K. C1-C6
L. C4-C8
M. S2-S4
N. T8-T12
0. L2-L4
For each of the following situations, please select most appropriate nerve root from list each option may be use d once more than once or none at all

1. Mrs. Saida. Is primiparous fully dilated and pushing for 2 hours, she si not on any analgesia she agrees for operative delivery with pudendal block

2. Mrs.Saly, 55-year-old Undergoes radical hysterectomy with pelvic lymph node dissection. surgery was prolonged for 4hours as her BMI was 45Kg/m2
Postoperative period she complains of Paraesthesia over mons, pubis, femoral triangle none of the motor function is affected.

3. Ms. Sara, 33 yer I’d presenting with severe spasmodic dysmenorrhoea . On ultrasound 5x4cm endometriosis cyst in left ovary she underwent excision of cyst followed by which  she presents with sensory loss in the upper medial   Part of left thigh and she is unable to adduct her  left thigh  during examination

4. Mrs. Briganza underwent total laparoscopies hysterectomy for multiple fibroid uterus  .
Surgery was done in steep Trendelenburg position to get better view. She was provided with shoulder braces to prevent her from fall,
Postop follow up she presented with claw hand where forearm is supinated and wrist and finger are flexed.

For each scenario described below choose the SINGLE most appropriate image for the woman who developed thrombosis in postoperative period from the above list of options . Each option may be used once, more than once, or not at all.

Option List:

A. Image B
B. Image C
C. Image A
D. Image A&C
E. Image D
F. Image B&C
G. Image A& D
H. Image A&B.
I. Image B&D
J. Image C&D
K. None of the above

5. Mrs. Laurie , 55 year old underwent TAH with BSO for Stage 1 endometrial cancer . On 7th day post op she has come back with swelling of right lower limb complains of pain in legs .in examination right leg is warmer than left and right leg circumference is also increased .suspecting deep vein thrombosis

6. Mrs. Lenie, 32 year old ,wome had developed acute dyspnoea after 5 th day of emergency cesarean section
Her BMIis 32
She has undergone emergency cesarean section under GA , as spinal failed
Confirmed pulmonary embolism

7. Ms.  Lisa, 44 year old complains of noticeable swelling of your entire leg.
tenderness on  examination abnormal swelling that stays swollen,  pitting oedema and low-grade fever. Investigation confirmed she has right femoral vein thrombosis .

Option List:

A. Ovarian hyperstimulation syndrome
B. Pneumonia
C. Bowel Injury
D. Megacolon
E. Ureteric Injury
F. Bladder injury
G. pulmonaryEmbolism
H. Opioid over dose.
I. vault infection
J. vesico Vaginal fistula
K. subphrenic abscess
L. paralytcileus .
M. Oligivesyndrome .
N. sepsis
O. Small bowel obstruction.
P. Vessel injury

8.Ms. Rachel , 35years,after laparotomy , presented few days later feeling unwell.she complains of fever with chills and rigors.
She complains of left hypochondrial pain radiated to the left shoulder.
On examination -
Febrile
stony dull percussion other wise no other finding

9. Ms. Zubaida , presented 7 days after hysterectomy she came with tender abdomen,  severe left loin pain and haematuria.

10. Mrs. Tessily , known diabetic underwent laparotomy for  twisted ovarian cyst .she is on patient controlled analgesia developed sudden onset of breathlessness . On examination -pinpoint pupils, Respiratory rate -10bpm .pulse -100 bpm
Blood pressure is 90/60mm of Hg

11.Mrs. Irena, history of primary subfertilty is undergoing IVF treatment .she is here for retrieval of oocytes. After 4hours of procedure feels giddy , uncomfortable on examination -pulse 130 bpm . Blood pressure is 90/50mm of Hg .Abdomen ; -slightly distended .

Option LIst:

A. Proceed with laparotomy
B. call surgeon colleague
C. IV 10 ml 10% calcium gluconate over 2 to 5 minutes
D. Third and fourth degree perineal tear
E. Alert team, IV antibiotics and observe.
F. Continue planned procedure.
G. Postpartum Haemorrhage
H. Arrange for diagnostic laparoscopy
I. 10 IU fast-acting insulin (Actrapid) added to 50 ml of 50%
K. Arrange for a CXR looking for air under diaphragm
L. Visualize the primary trocar site from a secondary port.

For each scenario provided below, choose the most appropriate immediate intervention for different complications of surgical procedures.Each option may be used once, more than once, or not at all.

12. You see a 60 year-old patient who had an abdominal hysterectomy for stage 1 endometrial cancer 3 days ago. She has vomiting and complains of muscle weakness, palpitations and paraesthesia, and she is oliguric. An ECG shows loss of P-waves, tall T waves , wide QRS complexes her K+ level is 7.5 mmol/L.

13. You are performing a hysteroscopy and endometrial biopsy on a 58 year-oldpara 4, allcesarean section, who presents with postmenopausal bleeding and TVS shows 10 mm-thick endometrium. Because of cervical resistance, with difficulty you manage to dilate the cervix with 3.5mm dilator but there is sudden loss of resistance. You suspect uterine perforation, introduce a 5-mm hysteroscope and recognize a hole on the anterior uterine wall.

14. You perform laparoscopy for a 27-year-old para 2 for chocolate cyst of 5x6x6.5cm. She has had two previous caesarean sections. You use closed-entry technique and insulate the abdomen to 25 mm Hg before inserting the primary trocar in the umbilicus. After introducing the laparoscope you suspect bowel loop adherent at primary trocar site, you suspect you might have damaged bowel

Option List:

A. Acute renal failure
B. Allergic reaction
C. Bowel perforation
D. Pnuemonia
E. Cerebrovascular accident
F. Deep vein thrombosis
G. Delirium tremens
H. Intra-abdominal haemorrhage
I. Myocardial infarction
J. Paralytic ileus
K. Pulmonary atelectasis
L. Pulmonary embolism
M. Small bowel obstruction
N. Subcutaneous haematoma
O. Sub rectushaematoma
P. Septic shock
Q. Urinary tract infection
R. Vaginal vault haematoma

Choose the single most likely diagnosis in postoperative period from the option list above. Each answer may be used once, more than once or not at all.

15. A 75-year-old woman, with a BMI of 24 and who is a non-smoker, had a laparotomy through a mid-line surgical incision for an ovarian malignancy 3 days ago and the tumour was deemed to be inoperable. She has developed some central and right-sided chest pain and is feeling unwell and breathless and has become restless.
On examination: abdomen is soft and non-tender;wound satisfactory; chest dull to percussion both bases and poor air entry with some crepitations that clear with coughing.
On examination -
Pulse rate is 96 bpm
BP is 110/60 mmHg
Temperature is 38.7°C
Respiratory rate is 21 breaths/min

16. A 25-year-old woman underwent an uncomplicated laparoscopy and dye test to investigate primary subfertility. There was some minimalstage endometriosis, which was diathermised, and the fallopian tubes were patent. Eight hours after the operation the woman is experiencing a lot of pain requiring opiate analgesia. The abdomen is very tender around the secondary port site in the left iliac fossa; is slightly distended; oozing blood-stain fluid, despite a pressure dressing.

Observations:
Pulse rate is 110 bpm
BP is 140/75 mmHg
Temperature is 36.5°C
Respiratory rate is 18 breaths/min .

17. A 42-year-old woman had undergone emergency cesarean section for fetal distress in the afternoon the day before and is seen on the Day 1 ward round. She looks pale and feels unwell and faint and complains of difficulty getting her breath and pains in her chest and shoulders. There is no vaginal bleeding and the urine catheter sample is clear, but she has passed only 100 ml overnight, despite receiving more than a litre of normal saline overnight. The abdomen is slightly distended and tender,bowel sounds are present.
Observations:
Pulse rate is 105 bpm
BP is 120/50 mmHg;
Temperature is 36.7°C;
Respiratory rate is 25 breaths/min

18.A 70-year-old woman, Para1Living 1 with a BMI of 34 and type 2 diabetes and who is a smoker (15 cigarettes a day) had an uncomplicated laparoscopic hysterectomy and bilateral salpingo-oophorectomy two days ago to treat endometrial cancer. She has developed some central and right-sided chest pain and is feeling unwell and breathless and has become restless.
On examination:
she looks pale and moderately distressed;
Abdomen is soft and non-tender;
Wounds satisfactory;
Chest percussion and breath sounds are normal;
Lower limbs normal and mobile.
Observations:
Pulse rate is 102 bpm;
BP is 140/750 mmHg;
Temperature is 36.7°C;
Respiratory rate is 22 breaths/min

19. A 48-year-old woman had an abdominal total hysterectomy and bilateral salpingo-oophorectomy to remove an ovarian tumour and is seen on the ward round on day 2. She had a poor night with abdominal pain and bloating and has just started vomiting.
On examination:
She looks distressed with pain. The abdomen is distended with minimal bowel sounds and generalised tenderness;
Temperature is 36.8°C;
Pulse rate is 100 bpm;
BP is 120/65 mmHg;
Respiratory rate is 14 breaths/min; BMI is 36

Option List:

A. IV 10 ml 10% calcium gluconate over 2 to 5 minutes.
B. Proceed with diagnostic laparoscopy.
C. Alert team, IV antibiotics and observe.
D. Proceed with laparotomy.
E. Stop any drugs that contain potassium.
F. Call the general surgeon.
G. 10 IU fast-acting insulin (Actrapid) added to 50 ml of 50%  dextrose infused IV over 20 minutes.
H. Insert another port for better visualisation.
I. Arrange for a CXR looking for air under diaphragm.
J. Reinsert the primary port in Palmer’s point
K. Visualize the primary trocar site from a secondary port.

For each of the following clinical scenarios, select the single most likelyimmediate management of the various surgical complications from the option list above. Each option may be used once, more than once or not at all.

20. You see a 75-year-old patient who had an abdominal hysterectomy 2 days previously. She complains of muscle weakness, palpitations and paraesthesia, and she is oliguric. An ECG shows loss of P-waves, wide QRS complexes and peaked -waves. The K+ level is 6.3 mmol/L.What is the most appropriate immediate intervention?

21. You are performing a hysteroscopy and endometrial biopsy on a 65-year-old para 3 who presents with postmenopausal bleeding and a 9-mm-thick endometrium. You manage to dilate the cervix but there is sudden loss of resistance. You suspect uterine perforation, introduce a 5-mm hysteroscope and recognize a hole on the anterior uterine wall.
What is the most appropriate immediate intervention?

22. You perform laparoscopy for a 27-year-old para 2 with a 6 × 5 × 7 cm left ovarian dermoid cyst. She has had two previous caesarean sections. You use closed-entry technique and insulate the abdomen to 25 mm Hg before inserting the primary trocar in the umbilicus. After introducing the laparoscope you suspect that a loop of bowel is adherent to the anterior abdominal wall at the primary port site.What is your most appropriate next step?

Option List:

A. Infection
B. Haemorrhage
C. Death
D. Third and fourth degree perineal tear
E. Cephalhematoma
F. Uterine perforation
G. Postpartum Haemorrhage
H. Need for repeat evacuation
I. Bleeding for 2 weeks
J. Retinal Haemorrhage
K. Retinal Haemorrhage
L. aneonatal jaundice

For each option provided below, choose the possible complication of different surgical procedures which you need to explain to obtain valid, informed consent. Each option may be used once, more than once, or not at all.

23. Mrs. Adams, 38 weeks pregnant is here for planning her delivery. This is her second pregnancy. First one was Emergency caesarean section done at full dilatation for fetal distress. She is asking what the commonest problem she can encounter if she chooses to have a repeat caesarean section is

24. Ms. Tina, 20 years old is suffering from chronic pelvic pain, not been benefited from any treatment, and she is posted diagnostic laparoscopy. What is a complication which is very rare that can happen during this procedure.

25. Ms. Rebecca / 24-year-old In her pregnancy now 38 weeks admitted in active labour, she has been fully dilated for 3hours 30minutes under epidural analgesia, the station is +3 , left occipital anterior, absent membranes, when discussed for operative delivery she is keen on ventouse delivery, wants to know very common complication to her.