a 78 year old man is brought to your office in a w
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ABSITE - Preoperative Evaluation –
Questions and Answers 100% Correct
A 78-year-old man is brought to your office in a wheelchair. He says his abdominal wall hernia
has been getting bigger and wonders if he needs surgery. He looks thin and pale, but in no
distress. He is mildly hypertensive (150/90), had a CABG 3 years prior, and is on a statin and a
diuretic. He feels weak, his appetite is poor, and he lives in a skilled nursing facility. He has a
10x8 non- incarcerated midline incisional hernia. His postoperative risk is best determined by
which of the following?
A. Echocardiogram
B. Pulmonary function testing
C. Frailty index
D. Serum electrolytes
E. Abdominal CT scan - ANSWER - C.
Frailty has gained in importance as a predictor of post-operative outcomes, especially in the
geriatric population. The frailty index includes functional, nutritional and Charlson Comorbidity
Index. This patient had a moderate cardiac risk. His procedure is elective and a frailty
assessment would likely make him a significant risk.
A 56-year-old female is scheduled to undergo a total thyroidectomy for papillary carcinoma. She
is currently taking warfarin (Coumadin) 5 mg daily due to a femoral DVT 4 months ago. Her
current INR is 2.9. Regarding her anticoagulation regimen, what is the most appropriate course
of action before surgery?
A. Decrease Coumadin dose to 1 mg daily 7 days before surgery.
B. Decrease Coumadin dose to 1 mg daily 5 days before surgery.
C. Stop Coumadin 7 days before surgery.
D. Stop Coumadin 5 days before surgery.
E. Stop Coumadin 3 days before surgery. - ANSWER - D
The usual recommendation is to withhold warfarin starting 4 to 5 days preoperatively (if the INR
is between 2.0 and 3.0) to allow the INR to decrease to less than 1.5, which is a level
considered safe for surgical procedures and neuraxial blockade. Only if the INR is greater than
3.0 is it usually necessary to stop warfarin longer than 4 to 5 days. If the INR is higher than 1.8
, the day of surgery, a small dose of vitamin K (1 to 5 mg administrated orally or subcutaneously)
can reverse anticoagulation.
A 61-year-old male with pancreatic cancer presents for preoperative evaluation prior to
pancreaticoduodenectomy. He is unable to walk two city blocks. His history is significant for
GERD, hyperlipidemia and diabetes mellitus. Which of the following is an indication that this
patient should undergo a preoperative echocardiogram?
A. Inability to walk two blocks
B. History of diabetes mellitus
C. History of hyperlipidemia
D. Age over 60 years
E. High-risk surgical procedure - ANSWER - A
Echocardiography testing preoperatively should be used selectively in patients at high risk for
cardiac complications perioperatively. This includes patients who are unable to achieve four
metabolic equivalents (METs), defined as climbing two flights of stairs or walking four city
blocks. Achieving less than 4 METs indicates poor cardiac reserve, and echocardiogram is
indicated before intermediate or major risk surgery. Diabetes, hyperlipidemia, age, and the
operation risk are not reasons for preoperative echocardiography.
A 75-year-old man complains of severe rest pain in his right leg. He has no pulse in the femoral
artery or below with an ABI index of .2, but no gangrene. He has pulses in the left leg. His BP is
150/80 mmHg, pulse 60 bpm, RR 18 breaths/min. He is on clopidogrel (Plavix), a beta blocker,
and a statin. His EKG and echocardiogram show no acute changes and his ejection fraction is
60%. Which of the following medications should he receive the day of surgery?
A. Beta blocker alone
B. Clopidogrel and statin
C. Beta blocker and statin
D. Beta blocker, statin, and low molecular weight heparin
E. ACE inhibitor, aspirin, and statin - ANSWER - D
Beta blockers and statins have been demonstrated to lower cardiac risk and should be
continued perioperatively. Clopidogrel (Plavix) is difficult to reverse and should be discontinued
preoperatively if there is a risk of bleeding. He should also receive low molecular weight heparin
for prophylaxis. There is no clear indication to add aspirin.
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