nbme1-1-33 - doc_vic

[ArchivalUser]

33. Four hours after undergoing a cesarean delivery at term followed by tubal ligation, a 37-year-old woman, gravida 2, para 2, has dizziness and confusion. The operation was uncomplicated, and blood loss is estimated to be 800 mL. Patient-controlled epidural analgesia has been moderately effective for pain. Her blood pressure now is 80/40 mm Hg, decreased from 120/72 mm Hg intraoperatively, and pulse is 152/min, increased from 96/min intraoperatively. Breath sounds are decreased bilaterally. No murmurs are heard. Abdominal examination shows distention and tenderness. Bowel sounds are absent. The incision is intact with no drainage. She is disoriented to person, place, and time. Her hematocrit is 23%; preoperative hematocrit was 35%. Which of the following is the most likely cause of the hemodynamic changes?

A
) Epidural-related hypotension

B
) Insufficient intraoperative fluid replacement

C
) Postoperative intra-abdominal hemorrhage

D
) Supine hypotensive syndrome

E
) Underestimated intraoperative blood loss

[ArchivalUser]

i think the an is E.

[ArchivalUser]

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[ArchivalUser]

hello doc...do u want to discuss nbme 1 ques ,only the confusing ones.....

[ArchivalUser]

c
keys:
1. dizziness and confusion
2. blood pressure is 80/40 mm Hg, decreased from 120/72 mm Hg intraoperatively
3. pulse is 152/min, increased from 96/min intraoperatively
4. Breath sounds are decreased bilaterally
5. Abdominal examination shows distention and tenderness. Bowel sounds are absent MOST IMPAORTANT KEY FOR THIS SCENARIO
6. hematocrit is 23%; preoperative hematocrit was 35%.

choice E wouldn't cause abdominal distention and tendernesss/////

[ArchivalUser]

someone explains why it's E, sounds reasonable to me.

E) Underestimated intraoperative blood loss. The short time course (4 hrs) suggests that is unlikely that this is a post-operative bleeding. In other words, if it's intraoperative bleeding only hypovolemic shock would be present without changes in the hematocrit. But since hematocrit decreased from 35 to 23%, it suggests that the bleeding began much earlier and possibly intraoperative fluid replacement further diluted the RBC mass. Possibly an atonic uterus is to blame that holds the excess of unaccounted blood as a big clot. My guess again.