december 2008final frca viva

8/10/2019 December 2008Final FRCA Viva

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University Hospitals Coventry & Warwickshire NHS Trust: Dr C Mendonca

Final FRCA viva: December 2008

Set 1

Clinical Long Case:

Elderly women for laparotomy perf bowel, with large neck

swelling, presumed goitre. Has inspiritory stridor.

Discuss ECG !"#, C$% perf, cardiomegaly, mediastinalmass# and other in&estigations recommended. "luid

resuscitation, how to do fluid challenge etc. 'ethod of

!"(),

%eason for polycythaemia. Discuss airway management.

Critical incident fast !". *ost+op management of airway.

hort cases:

-. -yr old with "/ in eye, full stomach.

0. Epidural trouble+shooting ie called to ward, post !*

resection, epidural not working#. Discuss sensory1motor

block aspects. *ain scales and pain assessment.2. Can3t remember

ciences:

-. !natomy of )45

0. )ndications and complications of central &enous access

2. !dult and children daily fluid and electrolyte

re6uirements, how much 7a8 in different fluids

9. *aediatric fluids, discuss causes and conse6uences of

hyponatraemia, )!DH etc

. (ygen deli&ery + different facemasks how much ;(0,

5enturi effect, eamples

<. (ygen sampling, draw and eplain fuel cell and

paramagnetic old &ersion#. =rite down actual reaction

e6uations *b, Gold, (H+, electrons etc#

>. Cholinesterase + what different types are there. ?hen

acetylcholinesterase inhibitors. =anted lots of detail

about syptoms and treatment of organophosophorus

poisoning.

@. uamethonium apnoea + wanted rational behind dibucaine

number 6uite detailed#. How long the apnoea lasts for the

&arious genotypes

Set 2

L(7G C!E @?H DECE'/E% 0AA@ #

>< yr lady admitted 2< hrs ago with abdominal pain,nausea ,&omiting.he has been

resuscitated with i.&.fluids and nasogastric aspiration.

2- yrs ago she had a sub+total thyroidectomy but the disease has recurred and she has a

diffuse goitre.?hyroid function tests performed 0 yrs ago was normal.he is normally on A.0

mg digoin and 2AAmg aspirin.

(1E

*ulse @1min irregularly irregular /* -2A1 mmHg

1




welling in the neck

?he surgeon wants to perform a laparotomy for caecal perforation.

)75E?)G!?)(7

ECG : !" rate >+@

C$% : !* &iew B large mass in the neck, lung fields relati&ely clear minimal pleural

effusions Heart looked enlarged cannot comment as !* &iew #

/)(CHE')?% normal# : 7a -2 mmol1l F 2. mmol1l rea @.A mmol1l Creatinine

-A@ umol1l

"/C : Hb -. g1dl

*C5 raised

=CC ->. $ -A1 L

IE?)(7

ummarise the case

Comment on cr findings

)s she ade6uately resuscitated no+raised hb and pc& #Do you want to take her to theatre

How will you pre+optimise her

=hat other in& do you want ct scan, )DL,nasendoscopy ,thyroid function tests #

How would you manage the airway ) settled on awake fibreoptic as the safest option #

!fter securing the airway the choice of induction agent,muscle relaant and maintenance

agent and why

)n addition to c&p and art line what else would ) like to monitor said cardiac output with

Doppler1 lidco#

=hat is lidco and how does it work &ery briefly+nothing in too much detail #

=hat else to monitor urine output,peripheral perfusion,core+peripheral temp gradient #

)ntra+op pt de&elops !" with rate of -<A and haemodynamic compromise+what would you

do i said ideally DC cardio&ersion but need to rule out thrombus or anticoagulate+ruled

out in this case ...remember pt is only on digoin without any anticoagulation and is in

chronic !" normallyJfrom history #

o what would you do amiadarone and dose #

=hat could be the reason for !"

Causes of !" in general.

!fter the surgery what factors would decide if ) would etubate the patient.

*ros and cons of etubating &1s period of &entilation post+op.

'ethods of pain relief couldnKt complete B bell rang #

H(%? C!E

-# > % (LD =)?H !(%?)C ?E7() "(% ?H% .

igns and symtoms of !.

Eamination findings.

)n&estigations to assess se&erity of !.

Grading of se&erity on &al&e area and mean gradient.

Cardiologist says doesnKt need &al&e replacement. !ims of anaesthetic management.

How would you anaesthetise him

0# - % (LD =)?H *E7E?%!?)7G EE )74% =)?H "LL ?('!CH.

=hat are the main concerns.Effect of su on )(* B by how much does it increase it




How can you pre&ent it

=hat other option is a&ailable + delay surgery till fasted.

urgeon says cant wait+ how will you anaesthetise ) chose modified rapid se6uence using

propofol,rocuronium and alfentanil to pre&ent pressor response+ eaminer seemed ok with it

.#

=hat are your aims in management usual stuff like pre&ent factors increasingiop,maintain normocarbia, ade6uate analgesia , prophylactic anti+emetics, etubation when

fully awake #

How else can you anaesthetise+ didnKt understand what the eaminer was looking

for.thankfully mo&ed to net short case.

2# *!?)E7? H!D *%(C?(C(LEC?(' E!%L)E% ?H) '(%7)7G.E*)D%!L )7+

)?.L!?E% )7 ?HE E5E7)7G 7%E (7 ?HE =!%D C!LL ( ( !%E

(7+C!LL # !7D ! E*)D%!L 7(? =(%F)7G !7D *? )7 *!)7.

How will you go about managing this.

How do you assess the block

=hat do you look for in the anaesthetic notes=hat do you look for at epidural site catheter slipped out, fluid around site#

=hat are the options a&ailable couldnKt completeJbell rang to the rescue#

(&erall felt both the eaminers were friendly and put me at ease . generally looking

for common sense approach to problems than actual factual details. Helps &ery much

to ha&e a calm mind and to think before answering. easier said than done #

G((D LCF ?( E5E%/(D .

Set 3

CL)7)C!L:

<2 ear old lady with malignant melanoma on her back. "or wide local ecision and aillary

clearance in prone position. he had chronic cough and has been treated 2 in the last year

with antibiotics for recurrent chest infections. he has had a pre&ious % mastectomy for

breast cancer @ years ago. he also has a recent history of palpitations.

Drugs: enalapril

(1E: =t 9kg Ht ft

/* -<A1-A

H% @A

(n eamination heart sounds normal. Chest bilaterally wheeMy with widespread crackles.

C$%: %LL consolidation and ) thought# effusion.

ECG: % but ectopics. L5H. 7ormal ais. 7o I wa&es.

)ncluded:

8E:

7a -2>

F 9.

-A

C ->

!




*"?s: "E51"5C ratio <9; *ost nebulised salbutamol <>;

%educed "E5-

%educed "5C: (bstructi&e.

ummarise this case briefly.

=hat do you think about her C$%, ECG B went through both.L5H B likely cause.

*"?s B re&ersibility1 causes: C(*D, bronchitis

%enal impairment and likely causes B !CE) and hypertensi&e nephropathy.

*re optimisation N other in&estigations History, "/C, !/G, E ?ol, C? chest#

=hat about her hypertension B what risk in&ol&ed B would you proceed

How would you anaesthetise her =hat techni6ues 'onitoring ) said reinforced tube,

positioning, eye padding, free abdomen.

*roblems with prone and what mode of &entilation and what pressures would ) set &entilator

!bdominal compartment syndrome.

=hat problems might the surgeons cause you ) said methylene blue and rib resection. ?hen

problems with meth blue*ain relief ) said *C! 'orphine as proimity to surgical site1 infection risk with epidural.

'entioned D5? prophylais and then asked about guidelines B 7)CE and their

recommendations.

*ost+op she is etubated and goes to reco&eryO she becomes hypoic and wheeMy B take me

through your management. !/C, ensure no != obstruction N gi&e oygen. Listen to chest B

gi&e /0 agonists. Etc etc

?hen differentials: main thing they wanted: post+op atelectasis with 51I mismatch.

How would ) manage: ) said resp supprt 7)5, C*!*, and physio.

H(%? cases:

-. Dural puncture: what do you do N how do you manage ) put spinal catheter and

mentioned eplicit risk and precautions needed. ?hen eplain and reassure woman.

Late management and differentials.

/ld patch N risks and ; resolution.

0. <Ayr old man with se&ere cardiac history: 0 stents for knee arthroscopy.

How would you manage

!ssessment, what in&estigations. tarted with history, ECG, C*E?. howed me ECG:

)nferior I wa&es and lateral deep ? in&ersion. 7omal ais but L5H.*ost+') risk B asked for ; risk of peri+op ') B mentioned guidelines !CC.

=hat anaesthetic B ) said regional ideal: Lumbar pleus block or femoral1 sciatic.

=hat complications of L! blocks in general.

2. @ yr old boy B found in ditch. Comes to !NE with open fractured tib1fib. =hat do you

do

!/C B C spine control. !*L. !ssessments of conscious le&el B GC and !5*.

igns of H) N indications for C? head B guidelines again !!G/), 7)CE.

%aised )C* and management B risks and what to a&oid B time to draw - graph but no

time for much detail. C**.

C)E7CE &i&a:

"




-. !natomy: *hrenic ner&e.

=here and by what could it be damaged along its course. ?ake me through each le&el

N mechanism.

Course neck and thora, diaphragmB after eplaining course asked specifically where

does it lie in the chest.*hrenic ner&e damange B how would you tell =hat would happen "%C,

paradoical mo&. =hy might this be bad and whom particularly at risk.

?ests to confirm B end insp C$%. =hat else 'ade up sniffing while &isualising with

0. )ndications for renal replacement. pecifics about uraemia, when and what le&el %%?

indicated.

F and what le&el.

'ethods of renal replacement and ad&1disad& of each. HD, H", *D. *hysical

principles.

%isks in&ol&ed: catheter related and procedure related. pecifics of anticoagulation.'ortality benefit and do ) know of any trials. Cytokines.

2. 5ery strangely phrased I: cenario and end of operation, after using 5EC, there is no

?(".

Causes of no ?(" stimulation+ /asically wanted what prolongs blockade, but &ery

unclear at -st Drugs, electrolytes, 7' disease, neuropathy N e6uipment factors

!ll 7' monitoring, types, mechanism B ?9:?- ratio, stimului types, current etc.

9. =hat groups of patients are at risk if you donKt humidify != gases N why Groups.

hort+term N longterm damage and se6uelae. ?ypes of humidification. *assi&e H'E

N latent heat &aporisation. !cti&e: 'entioned /ernoulli principle N then bell

rang.

Set 4

LONG CASE ( 8! DECE"#ER 2008 $

>< yr lady admitted 2< hrs ago with abdominal pain,nausea ,&omiting.he has been

resuscitated with i.&.fluids and nasogastric aspiration.

2- yrs ago she had a sub+total thyroidectomy but the disease has recurred and she has a

diffuse goitre.?hyroid function tests performed 0 yrs ago was normal.he is normally on A.0

mg digoin and 2AAmg aspirin.

(1E*ulse @1min irregularly irregular

/* -2A1 mmHg

welling in the neck

?he surgeon wants to perform a laparotomy for caecal perforation.

%N&ES%GA%ONS

ECG : !" rate >+@

C'R : !* &iew B large mass in the neck,lung fields relati&ely clear minimal pleural

effusions

Heart looked enlarged cannot comment as !* &iew #

#%OC!E"%SR (n)rmal$ : 7a -2 mmol1l F 2. mmol1l rea @.A mmol1l Creatinine

-A@ umol1lF#C : Hb -. g1dl

#




*C5 raised

=CC ->. $ -A1 L

*+ES%ONS

ummarise the case

Comment on cr findings)s she ade6uately resuscitated no+raised hb and pc& #

Do you want to take her to theatre

How will you pre+optimise her

=hat other in& do you want ct scan, )DL,nasendoscopy ,thyroid function tests #

How would you manage the airway ) settled on awake fibreoptic as the safest option #

!fter securing the airway the choice of induction agent,muscle relaant and maintenance

agent and why

)n addition to c&p and art line what else would ) like to monitor said cardiac output with

Doppler1 lidco#

=hat is lidco and how does it work &ery briefly+nothing in too much detail #

=hat else to monitor urine output,peripheral perfusion,core+peripheral temp gradient #)ntra+op pt de&elops !" with rate of -<A and haemodynamic compromise+what would you

do i said ideally DC cardio&ersion but need to rule out thrombus or anticoagulate+ruled

out in this case ...remember pt is only on digoin without any anticoagulation and is in

chronic !" normallyJfrom history #

o what would you do amiadarone and dose #

=hat could be the reason for !"

Causes of !" in general.

!fter the surgery what factors would decide if ) would etubate the patient.

*ros and cons of etubating &1s period of &entilation post+op.

'ethods of pain relief couldnKt complete B bell rang #

S!OR CASES

1$ ,- R OLD .%! AOR%C SENOS%S FOR !R /

igns and symtoms of !.

Eamination findings.

)n&estigations to assess se&erity of !.

Grading of se&erity on &al&e area and mean gradient.

Cardiologist says doesnKt need &al&e replacement. !ims of anaesthetic management.

How would you anaesthetise him

2$ 1- R OLD .%! ENERA%NG EE %N+R .%! F+LL SO"AC!/=hat are the main concerns.

Effect of su on )(* B by how much does it increase it

How can you pre&ent it

=hat other option is a&ailable + delay surgery till fasted.

urgeon says cant wait+ how will you anaesthetise ) chose modified rapid se6uence using

propofol,rocuronium and alfentanil to pre&ent pressor response+ eaminer seemed ok with it

.#

=hat are your aims in management usual stuff like pre&ent factors increasing

iop,maintain normocarbia, ade6uate analgesia , prophylactic anti+emetics, etubation when

fully awake #

How else can you anaesthetise+ didnKt understand what the eaminer was lookingfor.thankfully mo&ed to net short case.

$




2$ A%EN !AD ROCOCOLECO" EARL%ER !%S

"ORN%NG/E%D+RAL %NS%+/LAER %N !E E&EN%NG N+RSE ON !E

.ARD CALLS O+ ( O+ ARE ONCALL $ AND SAS E%D+RAL NO

.OR%NG AND %N A%N/

How will you go about managing this.How do you assess the block

=hat do you look for in the anaesthetic notes

=hat do you look for at epidural site catheter slipped out, fluid around site#

=hat are the options a&ailable couldnKt completeJbell rang to the rescue#

(&erall felt both the eaminers were friendly and put me at ease . generally looking

for common sense approach to problems than actual factual details. Helps &ery much

to ha&e a calm mind and to think before answering. easier said than done #

G((D LCF ?( E5E%/(D .

#AS%C SC%ENCE &%&A ( 8 ! DECE"#ER 2008 $

ANAO")ndications for central &enous cannulation.

!natomy of )45 and /CL!5)!7 5E)7 Bin 6uite some depth.

Complications of central &enous cannulation.

'ethods of cannulating.

*ros and cons of ultrasound and landmark techni6ues.

!S%OLOG

"luid re6uirements of < yr old child.

7a and F re6uirements.

=hat type of fluids and why

=hat is stress response to surgery

=hy do children need glucose containing fluids

=hat are the problems of gi&ing only glucose

Effects of hyponatremia .

!AR"ACOLOG

=hat is acetylcholinesterase

=here is it found how does it work

=hat is pseudocholinesterase (ther name for it

=here is it found

=hat other drugs apart from su does it metabolise

7atural cause of decreased pseudocholinesterase production

Genetic &ariability ,dibucaine no and fluoride no .!S%CS

'ethods of o0 deli&ery to pt .

"ied performance and &ariable systems.

*rinciple of &enturi+mask.

! bit about Hudson mask and o0 tents.

'easurement of o0 + fuel cell , paramagnetic analyser.

!gain felt eaminers were &ery friendly. )n this &i&a you need a bit of luck to get

asked about what you know well. ?hat builds up the initial confidence and the rest of

the &i&a can go well.

(ther candidates got asked about anatomy of phrenic ner&e, renal replacementtherapies, humidity and methods of humidification and muscle relaants .

%




?H!7F G(D )? !LL (5E% . ! ( ')GH? H!5E GEED ) *!ED.

Set -

Long Case.

2Aish old man

-2A FG 'allampatti 2*oorly controlled epileptic refractory to 6uad drug therapy

Feppra

CarbamaMepine

0 benModiaMepines

)n&esigations

C$%

5agal ner&e stimulator

leep studies

(!

*olycythaemiaLung function tests

*E"% P

7o re&ersibility gi&en

*resentes with ruptured globe following fall on to radiator, no recollection of e&ents.

Discuss management and in&estigations

hort Cases

tridor in child

Laproscopic surgery

*hysiological changes

Complications

$+ray case

?/ B right upper lobe collapse

7eeds urgent surgery for bleeding ectopic

Hypotensi&e%esusiti&e laparotomy

HD post op

?/ implications side room etc




/asic sciences

*harmacology

'echanisms B detailed# of ecretion by kidney

!ffect of renal failure on pharmacokinetics

*hysics

?emperatures measurement

Causes of hyperthermia

*hysiology of pregenancy

'anagement of pregnant lady with appendicitis

!natomy

ympathetic ner&ous system

Set 'y Iuestions:

Long case: >0 yr Fnown lung tumor. Comes to !NE with se&ere pain in the neck. with !

murmer.

Cspice lateral &iew. C0 mass with !1! subluation. ECG Lt ais and borderline L5H

0Decho ! gradient 2mmhg.

discussion went to c+spine fiation and awake fibreoptic and anaesthetic management. and

neurological complication and eamination.

short cases.

- 4eho&ah3s witness.

0 preeclamtic. anaesthesia for C1 pros and cons of G!1pinal and periop management

2. *t who had a tracheostomy 9 days ago starts bleeding from tracheostomy site. how would

you manage. causes of bleeding at 9 days. ?he tracheostomy gets dislodged when taking the

patient to theatre in the corridor how would you manage.

basic science &i&a.

5agus ner&e transection at Qugular foraman. unilateral and bilateral. they were only interested

in airway problems anatomy, ner&e supply etc. discussion also included thyroidectomy. and

complications.

/eta receptors e&erything and / blockers. %ecent publications regarding b blocker uses,,

recommendations. plenun system and uses in anaesthetics. other than &aporisers.

late allergy. how long does late last in the theatre in general eponential decay etc

Set ,

- ! 0 years old lady is brought to !NE unconscious after an o&erdose of drugs.

How will you assess her

How do you assess consciousness

!t what le&el of GC would you intubate her

he had alcohol and *aracetamol, how will you manage her airway N breathing is fine#

=hen will you gi&e her 7 acetyl cysteine=hat is the route of administration

'




)n which solution is it prepared

=hich organs are affected by *aracetamol toicity

=hat is the pathophysiology of hepatic toicity

)f the )7% is high what would you do

0 ! 9 year old male patient for a testicular operation wants an epidural for the operation. He

was &ery groggy with his last G! and donot want G!.

=hat will you say to him

=hat risks of pinal1epidural would you eplain to him

)nner&ation of testies

%isk of pain in regional anaesthetic in teticular surgery

2 ! man with *acemaker for an electi&e surgery.

%outine &i&a bookcase*acemaker code

*reop check

Diathermy

Electrical safety

Clinical ciences 5i&a

- !natomy of nose

)ndications of nasal intubation.

%isks of nasal intubation.

How can you anaesthetise nose

How much lignocaine can be used

How much lignocaine is there in a puff

0 Hyperbaric (ygen

'echanism of action

)ndications

Carbon monoide poisoining O Criteria for H(?

Le&els of C( normal1 abnormal*athophysiology of C( poisoning

ymptoms

Contraindications

2 uamethonium

'echanism of action

'yalgia B reason

How can you pre&ent myalgia

'etabolism of u

*seudocholinesterase deficiency B genetic &ariability(ther causes

1(




?ypes of alleles

Dibucaine number

9 "oetal circulation

Draw N eplain.

Changes at birth.=hich drug is used to cause ductus arteriosus closure in babies

=hich drug is used to reduce pulmonary hypertension

=hat is tetralogy of "allot

=hat will the anaesthetic considerations in management of ?("

Set 8

L)n5 ca6e:

@A yr old lady for laparoscopic repair of hiatus hernia with a history of nausea and &omitting

for some time. !naemic Hb + normocytic#, !lbumin + 00, Low magnesium and calcium,significant ischemic changes on her ECG and a large homogenous opacity continuous with

her heart shadow and diaphragm in the left lower Mone on the Chest ray. he was on

digoin and a diuretic and was diagnosed with !trial fibrillation in the past.

Iuestions

ummarise

Discussion on in&estigations and results:

what could be the reasons for low calcium and magnesium would you correct it pre+op

what could be the reasons for anemia would you correct it

=hat could be the reasons for low albumin in her would you correct it

=hat are the changes in ECG what is your diagnosis I wa&es in L0 and !&", and

etensi&e ? wa&e changes in all leads#

=hat do you think is the cause for the shadow =hat are the differentials How would

you confirm.

=hat other in&estigations do you want and why

How long will you wait before anaesthetising her

=hat anaesthetic techni6ue

=hat pain management

=hat other post operati&e mangement HD1)?

=ill she need )?, if so why

?hen we spoke on 7utrition in the )?, ad&antages1disad&antages and differences betweenenteral and parenteral nutrition.

hort case:

*ost tonsillectomy bleed..... standard 6uestions relating to assessment of blood loss,

resuscitation and management.

!trial flutter and its management.

!natomy:

-. !natomy of trachea and how the anatomy affects an aspirated foreign body in an adult.

etent, relations + both intra and etra thoracic, bronchopulmonary segments. management

of anaesthesia for a foreign body.

11




0. Cigarrette smoking and its effects: 7icotine, Carbon monoide, carcinogens, changes to

the cilia, C(*D etc etc. =hat are the effects of stopping smoking How long would you

ad&ise a chronic smoker to stop smoking before anaesthesia

2. *harmacology: Effects of drugs on )C*: started off from induction agents to all other drugs

that we use in theatre.

9. Laser: How is laser produced and all the standard 6uestions from the basic sciences &i&a book.

.

Set 7

Clinical l)n5 ca6e

0@ year old primi gra&ida, > hours after an emergency LC needs a laparotomy massi&e

**H. he is tachycardic, /* unrecordable, pale and anious. Lab results show se&ere

anaemia, coagulopathy, pre renal dysfunction. /lood transfusion is in progress

Discussion was based on resuscitation, blood products, factor >!, and anaesthesia inhaemodyanmically unstable patient.

"ew 6uestions

=hat Hb are you happy with

=hat induction agent, why

*roblems with massi&e transfusion

=hat are the ways to control **H Esp atonic **H

%isk factors for atonic **H

terine tonics

urgical ways to control bleeding

ystemic problems with massi&e transfusion

*ost op complications

howed an ray of ards what could this be if it de&elops within -0 hours )? admission

?%!L)1o&erloadRdiscussion on trail

*ost op renal failure: how to manage

Clinical short cases

-. howed an ECG of !" with &entricular rate of A, old inferior wall ') , L!D

>A year old male for cystoscopy

clinical correlation How to optimise, wwhen would you anaesthetise hock or chemical

cardio&ertion Different scenarios.

Causes of !"

Drugs used

)ntraoperati&e fast !", how to manage

0. @A ' k1o C(*D with acute eacerbation

causes of deterioration!ny iatrogenic causes (0 therapy , its mechanism

1




How to assess the patient, in&estigations

?reatment

=hats blue bloater and pink puffers

=ho is suitable for 7)5 =hat are the contraindications

=hen would you think of &entilating

*roblems with weaning2. )5D for Hickman line insertion

=hat are the perioperati&e problems 5ascular access1infections1

)ssues of pain control

5iral diseases he can ha&e

this patient has aids, and you get a needle stick inQury

what is the protocol

basic science &i&a

-. Carotid endarterectomy

!naesthetic options ad&antages, disaad&.uperficial c pleus block how to perform, why not deep

=hat are the complications of deep block

=hat are the monitors used

Haws is cerebral function monitored in awake patients

0

Differences in neonatal resp physiology and their anaesthetic implications

Congenital diaphragmatic hernias, pathophysiology , how to optimise, &entilatory strategy

2. !t the end of a long operation in which there was a blood loss of litres the wound edges

are ooMyRwhat the mechanism is

Discussion on cell based coagulation, replacement of factors, what when how much to gi&e

what are the test used to assess coagulation, bed side tests ?EG in detail

9. !rterial blood pressure trace =hat info can you gather from the trace

=hat happens to the position of dicrotic notch in raised s&r ) said it would be shifted

proimally on the down slopeRhe seemed to agree

How does a line monitor work

=hat are the sources of error resonance, damping

Set 10

L)n5 ca6e

! 02 year old female who has deli&ered > hrs ago LC + continuing to pass clots on

syntocinon infusion, large baby weight + 9. kgs failure to progress prolonged labour . he is

recie&ing bloods. urgeons want to take her up for eploratory laparotomy

pale anious H% +-9A1min /* unrecordable

Hb + pre LC -2.0 g1l post 0. 1l

*latelets pre 2>2 post >2

1!




D Dimer + < &ery high#

"ibrinogen + 7ormal

Can you summarise the case

=hat is going on in your mind as you go to see her

=hat is the first thing you do apparently speed up the infusion#

=hat are the causes for her bleeding

=hat is your management

=hat are the doses of syntocinon, ergometrine and carboprost

=here will you take her post op

own $ ray + !%D 1 ?%!L)

=hat is your post op management

hort cases:

-. ECG + !" Causes, coming in for cystoscopy at induction /* crashes what drug would you

use

0. )5 drug abuser + precautions, difficulties , needle stick inQury, incidence of H)5 positi&ity

after needle stick, post eposure prophylais

2. Elderly male C(*D called by chest physician how will you asess when will you manage

conser&ati&ely Iuality of life

Clinical 5i&a:

-. )ntra arterial pressure monitoring + indications, damping , resonance, what parameters are

deri&ed, draw a trace, complications of arterial puncture,

0. G! 5ersus L! carotid endarterectomy + how do you do deep and superficial cer&ical

pleus block, complications Local &ersus G!

2. compare and contrast neonatal &ersus adult physiology

Clinical long case

0@ year old primi gra&ida, > hours after an emergency LC needs a laparotomy massi&e

**H. he is tachycardic, /* unrecordable, pale and anious. Lab results show se&ereanaemia, coagulopathy, pre renal dysfunction. /lood transfusion is in progress

1"




Discussion was based on resuscitation, blood products, factor >!, and anaesthesia in

haemodyanmically unstable patient.

"ew 6uestions

=hat Hb are you happy with

=hat induction agent, why

*roblems with massi&e transfusion

=hat are the ways to control **H Esp atonic **H

%isk factors for atonic **H

terine tonics

urgical ways to control bleeding

ystemic problems with massi&e transfusion

*ost op complications

howed an ray of ards what could this be if it de&elops within -0 hours )? admission?%!L)1o&erloadRdiscussion on trail

*ost op renal failure: how to manage

Clinical short cases

-. howed an ECG of !" with &entricular rate of A, old inferior wall ') , L!D

>A year old male for cystoscopy

clinical correlation How to optimise, wwhen would you anaesthetise hock or chemical

cardio&ertion Different scenarios.

Causes of !"

Drugs used

)ntraoperati&e fast !", how to manage

0. @A ' k1o C(*D with acute eacerbation

causes of deterioration

!ny iatrogenic causes (0 therapy , its mechanism

How to assess the patient, in&estigations

?reatment

=hats blue bloater and pink puffers=ho is suitable for 7)5 =hat are the contraindications

=hen would you think of &entilating

*roblems with weaning

2. )5D for Hickman line insertion

=hat are the perioperati&e problems 5ascular access1infections1

)ssues of pain control

5iral diseases he can ha&e

this patient has aids, and you get a needle stick inQury

what is the protocol

basic science &i&a

1#




-. Carotid endarterectomy

!naesthetic options ad&antages, disaad&.

uperficial c pleus block how to perform, why not deep

=hat are the complications of deep block

=hat are the monitors usedHaws is cerebral function monitored in awake patients

0

Differences in neonatal resp physiology and their anaesthetic implications

Congenital diaphragmatic hernias, pathophysiology , how to optimise, &entilatory strategy

2. !t the end of a long operation in which there was a blood loss of litres the wound edges

are ooMyRwhat the mechanism is

Discussion on cell based coagulation, replacement of factors, what when how much to gi&e

what are the test used to assess coagulation, bed side tests ?EG in detail

9. !rterial blood pressure trace =hat info can you gather from the trace

=hat happens to the position of dicrotic notch in raised s&r ) said it would be shifted

proimally on the down slopeRhe seemed to agree

How does a line monitor work

=hat are the sources of error resonance, damping

Long Case

0@ female, primi. 7ow > hours *ost LC for failure to progress#

he had oytocin drips for hours before deli&ary.

Deli&ered 9.@ kg male baby. he looks nwell, pale,

H% +-9A, /* not recordable, Carotid pulse present

*osted for urgent laprotomy

*re LC 7ow

H/ -2< 0@

*L!? 0AA @0

*? + -@

!*?? + ><

")/%)7(GE7 -.@%est bloods (k

ummary. !sked to go through blood results. =hat it is+ severe haemorrhagic shock.

Causes

=hy !tony suggested in this case 'anagement ABC, BLOOD, O NEGATIVE,

BIMANUAL, INFORM VARIOU !ROFEIONAL, ENIOR, ITU e"c..

(ther blood products 'onitors =hen happy to )nduce for laprotomy =hat drugs for

induction+ I sai# $e"ami%e. To i"&

)n )? Chest $ray B sho's (&) o#ema a%# e"" e%#o*ro%chia) . =hy pul odema How to treat

pul odema here =hat (ther generic measures in )? =hy D5? and G) prophylais

needed in this patient =hat are the measures of organ perfusion

=hen she is etubated, what pain management

1$




=hen can she breast feed

hort Case+ Clinical

-. >A '!LE for day case ?%/?. H?7, plays golf

ECG+ read through it =hats callibration I" 'as AF. Fea"&res o% ECG

Causes +e 'a%"e# I+D+TNVALVULAR DIEAE AND T+-ROTOICOI/=hat to do *atient has no symptoms *ost pone -es01 s(eak "o car#io)ogis"

!fter few days, !" sorted. )ntrop+ sudden H*(?E7)(7 Causes

7ot in !". =hats inotrope of choice

0. oung male1)5D1!)D1for Hickmans line

)ssues why infection in )5D

*roblems+ Nee#)e s"ick i%2&r3+ =hats risk of !)D infection "actors go&erning the rate

How compared to Hbs!g FIRT AID H(= The%1occ hea)"h. *os" e4(os&re (ro(h3)a4is1

what drugs

Clinical cience 5i&a1) carotid enarterectomy +L! describe how =hat dermatomes blocked Complications

of block !d& and disad& of L!. )f needs G! , what maQor issues How monitor C/"

under G! =H!? problem post op )ncidence of stroke I" seems caro"i# s"e%osis

ca&ses 567 o8 a)) "he "roke i% a%3 (o(&)a"io%. I g&esse# i" "o (er8ec"io%

) %espiratory *hysiology of neonate How diff than adults Chest wall, ribs, capacities,

diaphragm, al&eoli, etc. How control different ai# a*o&" chemorec("or )ess

se%se"ive000

airway differences 9a%"e# o*)iga"e %ose1*rea"hers.

Cong Diaghpramatic hernia, what is it =hats problem )ncidence *resentation *rinciples

of 'anagement of anaesthesia

!) *rolonged operation, post op ooMing from canula site+ Causes. 9a%"e# DIC,

h3(o"hermia, Liver #amage, h3(oca)cemia, se(sis, #r&gs )ike %sai#, he(ari%

)n&estigations /riefly each and which part of coagulation pathway tested

!sked about ?EG. How the test is done. Draw a normal and one abnormal trace

=hat blood products can be gi&en to correct coag problems =hat drugs, and how they

work

?ransfusion triggers for plat, cryo, rbc, factor @ concentrates

") )!/*+ indications Complications. Draw a pulse trace =hat all information

9a%"e# a )o" o8 s"&88 here..for stroke &olume, clearly indicate which part of area under the cur&e : &("o #iacro"ic %o"ch;.

=hat is transducer *roblems with them

Long case

<2 year old female is posted for electi&e procedure of ecision of malignant melanoma and

grafting.

he is a hypertensi&e on treatment with enalapril -A mg od

he has been a smoker for 2A years and in the last year has been treated for chest infections

with antibiotics 9 to times.

(n eamination pulse >A per minute regular. /lood pressure ->A1-Ahe has wide spread wheeMe and crackles at the bases on auscultation

1%




)n&estigations

/iochemistry

odium -2

*otassium 9.

rea -ACreatinine -2A

7o other blood in&estigations like "/C were pro&ided

! set of spirometry results which showed a "E5 -1 "%C of <0; and <>; post

bronchodilator therapy

!n ECG which showed a few &entricular premature complees and a L5H by &oltage criteria

! chest +ray which showed a loss of air shadowing in the rt base 8 right costophreinc angle

obliteration. )t showed a cardiomegaly

Iuestions

?ell me about your case

?ell me about the blood tests. !re the results standard or are they adQusted to the patientKscharacteristics age se etc#

?ell me about the ECG

?ell me about the ray

=hat about the spirometry results !re these results adQusted to patient characteristics )s the

impro&ement after bronchodilator therapy significant

) had mentioned in&estigations and optimisation in my summary. He then said lets say your

patient is optimised and now ready for surgery .=hat is your anaesthetic plan.

) mentioned preop &isit and premedication

=hy premed )s it your normal practice =hy particularly in this patient then

) went on to checking machine drawing drugs etc..EtcR He said it is all done talk thro your

anaesthetic

!fter ) mentioned arterial line B=hy arterial line !nd induction and intubation with

reinforced endotracheal tube, we mo&ed on to prone positioning

How will you physically do the positioning 7umber of people, how will you turn, how will

you position head, protect eyes and ner&es

*ostoperati&ely the patient de&elops wheeMing and hypoia in *!C. How will you

manage

=ould you send this patient to HD 1 )?

/ellR.

hort casesou ha&e done a dural puncture with a -< gauge needle in obstetrics. How will you proceed

) mentioned our hospital protocol of subarachnoid catheter. =hat drug will you gi&e How

long will it act for =hat will you tell the midwi&es

)s there anything else you can do ?ry another space. =hat are the ad&antages and

disad&antages of catheter and trying another space

=hat will you do during follow up

)f she has head ache how will you diagnose a post dural puncture headache from other

causes

How will you treat+ conser&ati&e and then blood patch

How will you do a blood patch

=hat filter will you use to inQect the blood ) said ) ha&e seen 0 of my consultants performing blood patch and we did not use a filter.

1




0. 9 year old weighing -A> kilogrammes , hypertensi&e is coming in for a knee arthroscopy

ECG gi&en showed t wa&e in&ersion in lead- , a5L and 52, 59, 5, 5<. ?here were I

wa&es in Lead 0 and a5"

?he 6uestions which followed were a bit &ague

?ell me about ECG=hat do your findings indicate ) said )HD.

=ould you do any further in&estigations =hat else you can ask ) said eercise tolerance in

history.

=ould you do this as a day case ) said you mentioned only the weight ) need to find out the

/'). )f obese ) would not do this as day case because of the co morbidities.

2. @ year old boy %?! with fracture tibia and fibula. "ound in a pool of mud. nconscious.

)n ! N E. (rthopaedicians want to fi the fracture. How will you proceed

) said the !?L approach. )t has all been done by the !NE staff.

) said if airway is not secured ) need to make sure the child is safe from that point. He said

GC is <. ) intubated the child with manual in line stabilisation=hat will you do net /reathing and CirculationR)t has all been done.

!nything else apart from GC. ) mentioned look for signs of significant head inQury+ skull

fractures, bleeding from nose, ears and papillary signs. ?his child has une6ual pupils..=hat

do une6ual pupils signify

nconscious, o ) will do C? head.

=hile taking back to )? blood pressure increases and pulse rate drops.. =hat will you do

=hat is this sign called

) said sign of worsening increased )C* =hat measure will you take

!fter mentioning e&erything ) said neurosurgical opinion.

#a6ic Science6

!natomy.

?ell me about the phrenic ner&e. ) started with ner&e roots an then the course till the

diaphragm. =hich sided phrenic ner&e is longer and why. =here does it lie in the thoracic

inlet

?ell me about the causes for phrenic ner&e palsy and paralysis. =hich anaesthetic procedures

in particular.

How will the patient present clinically. How will you diagnose. =hat will you see in dynamic

fluoroscopy

How will you treat this condition ) said symptomatic and phrenic ner&e pacing*hysiology.

%enal replacement therapy

=hat are the indications for renal replacement therapy

How will you do these in the )?

?alk through the principles of C55H" and C55HD"

Draw a diagram and show me from the patient end to machine end

=hat factors will act in the micro fibres+++ molecular siMe and negati&e charges

=hat are the complications

*harmacology

ou ha&e gi&en a 20 year old patient @ mgs of &ecuronium during induction. )ts - hour sincethen and the operation is done. /ut there are no twitches on ?(". How will you proceed

1'




) said ) will look for causesJtechnical factors ++++fault in neuromuscular monitor. =hat

faults can occur+ electrode not applied properly+ what ner&es will you use to test, where will

you place electrodes

/attery+ how will you know if the battery is low

*atient factors+ li&er failure, renal failure

Hypothermia Electrolyte abnormalitiesJshe asked me list all of them which ) did

Drugs+ =hat drugs

How does 5ecuronium get metabolised and ecreted

=hat else can you test apart from ?(" in these situations 'entioned *ost tetanic countJ

Eplain . How many twitches will signify re&ersal

)n ?(" what figure you look for to etubate

How are the &arious muscle group susceptible to muscle relaants+ &ocal cords, small

muscles of the hand and diaphragmatic. =hat is the significance during re&ersal

*hysics

Humidification=hy do we humidify inspired gases

How will you humidify inspired gases !d&antages, disad&antages and risks of each

=hat is relati&e humidity and absolute humidity

=hat is the humidity in upper airway

How does H'E work =hat is its efficiency

HaMards of humidifying inspired gases

) had mentioned about &enturi in nebulisation techni6ue. ?ell me how that works. Draw a

diagram to eplain

/ellR

"rom the =ednesday+

Long case+ **H management of#, how would you anaesthetise the patient for laparotomy

which induction agent, %) etc#, patient then mo&ed to )C post+op: shown C$% of !%D

what are the causes of !L)1!%D, what &entilation strategies do you know..#

Clinical short cases+ -# !" 0# C(*D 2# 7eedlestick

Clinical sciences: !natomy was femoral ner&e 2 in -, lumbar pleus#, Diabetes and )nsulin

did ) know about inhaled insulin ?urned out neither had the eaminer, pathophysiology

and management of DF!#, Diathermy and the complications of it.

F%NAL FRCA E'A" *+ES%ONS (8t

Dec 2008$

L)n5 ca6e:

Euthyroid big goitre for emergency laparotomy. $%C with retrosternal etension. ECG with

!", on antithyroid drugs, digoin N aspirin, /* -A1A, septic on in&

• ummarise the case

• Go through the in&estigations

• 'ore about Hb, hematocrit

• =hat more in&estigations you want

• =hat would to look for in fibreoptic nasoendoscopy

• =hat would the C? neck and thora tell you

• =hat does the ECG suggest

(




• =hat are the causes of !"

• How does Digoin work

• =here, why and how will you optimise

• =here will you put central line ) said femoralRwhat are the disad&antages#

• (ther monitoring

• =hat are the ad& and disad&antages of oesophageal Doppler

• =ill you put epidural in this one

• How will you anaesthetise

• ?ell me how will you do awake fibreoptic intubation wanted topic anesthesia in

detail#

• De&elops tachycardia postopRdifferential diagnosis

?he long case was pretty straight forward. ) Qust thought the eaminer was dragging me to the

answers he wanted to tick on his paper. Good for me, but it distracted me initially. =hen )

was describing something in a systematic way or classifying e.g causes of !"# he would stop

me in the middle and ask direct 6uestion regarding a particular DD. ) got scared initially andthought that ) am not answering fluently. ) think it was not true. He Qust wanted to get to the

bottom of the list !!*. ) then decided to answer ShisK way ?rying to guess whatKs on his

mind )t worked

S)rt Ca6e6:

!ortic stenosis for electi&e hip replacement

• =hat are causes of aortic stenosis

• 2 classical symptoms of ! ) said angina, syncope and dint remember the 2 rd one

breathlessness, ) think# o ) said palpitations

• He went through pathophysiology of each

• Desperately wanted the e6uation: Coronary perfusion pressure T 'ean aortic pr B

L5ED* ) realised a bit late

• 'ore in&estigations

• ) said 0D Echo: He asked how will it help. ) said to know the se&erity of !. =hen )

went to describe the grades and the numbers, he stopped me and said SitKs okK He

seemed &ery happy with the answer.

• How would knowing the se&erity help you. He wanted mild, moderate se&ere and the

decision ) said ) will discuss the necessity of the op. wheather he needs to ha&e it at

all. ince it is an electi&e op, mild+ go ahead, se&ere+ repair1 replace the &al&e first,

'oderate+ weigh the risk benefit# He seemed satisfied.

- yr old, full stomach with penetrating eye inQury

• =hat are the issues

• =hat is paediatric age group

• How will you go about this case

• =hat precautions would you take wanted antacids, antiemetics, anticholinergics,

minimise pressor response#

• ) said %ocuronium - mg1kg. He asked me if ) personally think it works as good as the

su. ince ) had said %oc, ) stood by my decision and said SyesK He was reluctant to

accept and wanted a SnoK /ut ) said it is an e&idence based decision He again askedme Smy personal opinionK ) again said, ) think it works Qust as good

1




*oorly working epidural following !* resection on the ward

• How will you go about it ) said, going throK notes, anaesthetic charts, eamination of

the patient, assessment of block, check the epidural pump, catheter etc#

• =hat else didnKt know what to sayRbut e&entually found out he specificallywanted me to say that ) will ask for the nature, site and duration of the pain#

• =hen ) said that, he said patient suffers from chronic backache

• He also specifically wanted me to say that ) will find out if the insertion of the

epidural catheter was difficult and wheather it ga&e analgesia in the reco&ery

) felt a bit inade6uate disorganised after answering this &i&a e&en though ) knew it all. ?he

eaminer asked me again the same things in detail, ) thought ) had already answered

#a6ic Science6

•

?ell me about cholinestarases ) had -A seconds of Sblack outK period# ?hen ) tried towork outR.anticholinesterases, anticholinergicsR.oh ) said, cholinesterases are

E7U'E

• he smiled and agreed he asked me if ) know any types. ) said !cetyl and

*seudocholinesterase Drew a diagram of 7' Qunction to show !chesterase in

present in the synaptic clefts DidnKt want blank gaps in my &i&a. ) thought drawing

something would help 'ay be she ll ask me something related to 7'4...he

didnKt#

• (ther names for pseudoR) said !typical 1 *lasma 1 /utyryl

• he was particularly happy with SbutyrylK and asked me if ) think its Qust one enMyme

or group of enMymesR) said group of course#

• Do you know subtypes RRR7o• ?ell me the drugs metabolised by *seudo. !re they all metabolised by the same

enMyme

• ?ell me the causes of low serum cholinestarases

• =hat is Dibucaine number

• =hat is normal

• =hat does the number @A mean

• Concentration of Dibucaine used in this test

• =hat is fluride number

• 5arious abnormal genotypes possible ) wrote down homogenous and heterogenous

normal, atypical, silent and flurideRbut also wanted the combinations amongstthemsel&es which ) forgot to mention uch as hetero fluoride and atypical + Ef:Ea#

• =here does !cetylcholine attach on the acetyl cholinesterase enMyme ) drew a

beautiful diagram he was happy#

• ?ypes of anticholinesterases 2 types+ competiti&e, non+competiti&e, irre&ersible#

• Eample of each

• Duration of action of 7eostigmine

• ?reatment of (*C poisoning =anted protection of health care workers since poison

can tra&erse the skin and mucous membranes#

• 'echanism of action of *ralidoime

• How do you measure oygen bell went off Qust after ) answered#

Clinical 6cience6




• )ndications of central &enous canulation

• !natomy of internal Qugular &ein

• !natomy of subcla&ian &ein wanted scalene anterior muscle in particular ) drew it

but didnKt label itRso he pointed at it and asked Swhat structure is thisK#

• Complications of central &enous canulation

• < yrs old child+ calculate maintenance fluid re6uirements

• =hy is it important to calculate

• =hat fluid would you gi&e

• =hat are you worried about =anted me to say hypo7a#

• =hy

?he eaminers were pleasant ecept for the short cases eaminer He was really aggressi&e

/ut it was a great eperience o&erall. Honestly, ) had not thought of many 6uestions and their

answers before despite them being pretty ob&ious and ) think you ha&e to think and apply

your knowledge when you are actually answering. ?he 6uestions may appear more or lessfamiliar and basic now, but they appear SnewK there ) suppose it is because of the way they

are asked. ) would suggest people to keep your mind as stable and open as you can and be

assured that if you ha&e done decent reading and hard work for this eam, it will get through

to the eaminers

12t December 2008

)9 Saner6

Clinical &iva

Long Case

@Ayr old frail lady presenting for electi&e laparoscopic hiatus hernia repair

%ecent admission 2 months ago with chest pain, not relie&ed with G?7 spray. "ast !" found

ECG B treated with digoin.

*'H

Di&erticulitis

Hypertension

DH

!CE)**)

Digoin

Eamination

reduced air entry left base

%% -<. ?emp 2<., H% A, /* -<A1@A

)

Hb , normocytic

%aised =CC and C%*

!lbumin 00, other L"?s normal. Low 'g08, Ca08

!




8E normal

ECG: !", rate A. global ? wa&e in&ersion, L!D, poor % wa&e progression

C$%: poor film# but air space shadowing left lower1middle Mone hiatus hernia

Iuestions

/loods B likely causes or raised C%*1=CC, Hb not much discussion about this#, lowalbumin B causes, effects

Discuss ECG + causes of ? wa&e changes ischaemia digoin effects

Causes of !"

Differentiating cardiac from oesophageal chest pain

C$% + large hiatus hernia seen collapse1consolidation

(ptimisation and further in&estigations

*remedication

!naesthetic management plan and post op plans

Effects of laparoscopic surgery B C51%esp1%enal1G) etc

*atient drops sats and hypotensi&e in reco&ery B possible causes, management

R..management of suspected tension pneumothora

hort Cases

-. (besity B ga&e height and weight of female patient morbidly obese# discussion on

/'), systemic effects of obesity and complications

0. /leeding tonsil in yr old B calculation of blood loss, &ital signs, problems,

management of induction, drug doses, tube siMes etc

2. hown ECG of 9:- atrial flutter rate controlled# B what drugs may patient be on

?his patient has end stage renal failure awaiting renal transplant + worrying,

managment

Clinical Science6 &iva

Anat)m9

Clinical presentation of foreign body aspiration. )f patient stable, how would you

anaesthetise Lead onto anatomy of trachea B length, position, diameter, number of rings,relations, tracheobronchial tree

96ic6

Lasers B acronym, types and clinical uses, mechanism of action, characteristics of light,

protection of patient and staff in theatre and potential haMards, laser tubes, low "i(0 and why.

!lternati&es to intubation. %isks of Qet &entilation.

96i)l)59

moking B physiological effects B C51%esp1C71carbon monoide1immune function

which components affected#. ?ime frames for cessation. )mplications for anaesthesia

armac)l)59

"




%aised )C* B 'onro Felly doctrine1 graphs1 how to control raised )C* in theatre. Effects on

)C* 8mechanisms# of inhalational agents which is worst#, nitrous oide, induction agents

thiopentone, ketamine#, muscle relaants, mannitol

Clinical

L)n5 Ca6e:Deatails pro&ided for the candidate

> yr old

*'H: Diabetes, Hiatus hernia, Hypertension

'edications: Diuretics, !CE inhibitors, omepraMole

/ooked for a thoracotomy for isolated neoplasm in Lung few weeks later

!dmitted in !N E yesterday with se&ere pain in neck

Eamination:

/*, *ulse normal

%honchi in both lung fieldsEQection systolic murmur o&er left sternal edge

%espiratory rate : 01minute

)n&estigations:

ECG: Left ais De&iation

%ight /undle branch block

I wa&es

!/G: on 0-; oygen

*(0 B , *C(0 + 9, *h >.9, HC(2+ 09

*"?s

*E"% B reduced

"E51"5C B >A;

Echocardiography

EQection fraction >A;

?hickened aortic &al&e, gradient across &al&e 2@ mmHG

(ther findings normal

$+ray C pine

)nade6uate film C>1?- not &isible#

C-1C0 subluation

Iuestions on:

#




!ll in&estigations, how do you diagnose Left ais de&iation, grading of !ortic stenosis,

grading of "E51"5C

=hat other in&estigations will you do

How to assess se&erity of aortic stenosis

Causes of neck pain in this patient

How can lung tumours present?echni6ue of G! B awake fibreoptic intubation

How do you anaesthetise airway for awake fibreoptic intubation

=hat monitoring B pinal cord monitoring

=hat methods of pain relief

Criteria for etubation B *hrenic ner&e inQury

=here manage post op

S)rt Ca6e6

1/ e)va ;itne66

Iuestions asked:

=hy as an anaesthetist you would worry

Iuestions on preop optimisation, consent issues, Gillick competence

Classes N 'echanisms of action of anti platelet drugs

) reeclam<6ia : 2< week primigra&ida /* -<A1A, *ulse, -091min

Iuestions asked:

=hat problems the abo&e patient poses

How do you diagnose preeclampsia

How is different from pregnancy induced hypertension

How can you control her blood pressure better

=hat in&estigations will you do

'echanism of action of magnesium and doses

=hat monitoring will you do and how would you anaesthetise her

%isks of G! in this patient

!) *atient had trace)6t)m9 days ago, you are called to ward to see him, and he is

bleeding profusely from the tracheostomy siteIuestions asked:

How will you proceed

=hen will you take him to theatre


Final FRCA &iva =>e6ti)n6:

Clinical

L)n5 Ca6e:

Deatails pro&ided for the candidate

> yr old

$




*'H: Diabetes, Hiatus hernia, Hypertension

'edications: Diuretics, !CE inhibitors, omepraMole

/ooked for a thoracotomy for isolated neoplasm in Lung few weeks later

!dmitted in !N E yesterday with se&ere pain in neck

Eamination:/*, *ulse normal

%honchi in both lung fields

EQection systolic murmur o&er left sternal edge

%espiratory rate : 01minute

)n&estigations:

ECG: Left ais De&iation

%ight /undle branch block

I wa&es

!/G: on 0-; oygen

*(0 B , *C(0 + 9, *h >.9, HC(2+ 09

*"?s

*E"% B reduced

"E51"5C B >A;

Echocardiography

EQection fraction >A;

?hickened aortic &al&e, gradient across &al&e 2@ mmHG

(ther findings normal

$+ray C pine

)nade6uate film C>1?- not &isible#

C-1C0 subluation

Iuestions on:

!ll in&estigations, how do you diagnose Left ais de&iation, grading of !ortic stenosis,

grading of "E51"5C

=hat other in&estigations will you do

How to assess se&erity of aortic stenosis

Causes of neck pain in this patient

How can lung tumours present

?echni6ue of G! B awake fibreoptic intubation

How do you anaesthetise airway for awake fibreoptic intubation

=hat monitoring B pinal cord monitoring=hat methods of pain relief

%




Criteria for etubation B *hrenic ner&e inQury

=here manage post op

S)rt Ca6e6

1/ e)va ;itne66

Iuestions asked:

=hy as an anaesthetist you would worry

Iuestions on preop optimisation, consent issues, Gillick competence

Classes N 'echanisms of action of anti platelet drugs

) reeclam<6ia : 2< week primigra&ida /* -<A1A, *ulse, -091min

Iuestions asked:=hat problems the abo&e patient poses

How do you diagnose preeclampsia

How is different from pregnancy induced hypertension

How can you control her blood pressure better

=hat in&estigations will you do

'echanism of action of magnesium and doses

=hat monitoring will you do and how would you anaesthetise her

%isks of G! in this patient

!) *atient had trace)6t)m9 days ago, you are called to ward to see him, and he is

bleeding profusely from the tracheostomy site

Iuestions asked:

How will you proceed

=hen will you take him to theatre


Clinical Science

Anat)m9: 7er&e supply of laryn

'uscles of laryn

7er&e inQuries and effects on &ocal cords

Causes of stridor post thyroidectomy

96i)l)59: 7on in&asi&e &entilation

C*!* N /i*!* B physiology behind their use

Complications of non in&asi&e &entilation

)ndications N contraindications for non in&asi&e &entilation

!l&eolar gas e6uation, how does C(0 effect oygenation

armac)l)59: *ros N Cons of beta blockers

'echanisms of action

Classification of beta blockers )ndications, contraindications N complications




96ic6: =hat do you understand by plenum principle

!pplications of plenum principle in anaesthesia

Diagram of &aporiser

How does /air Hugger work

?heatre &entilation systems )n a patient with late allergy how do you decide how many hours you

should lea&e theatre closed before using to make sure it is free from late omething to

do with time constants#

Long case

<>", rheumatic fe&er as child, cardiac surgery 09 years agoO ')s, C5!, E? -AAm with frame.

"allen o&er, V7(" B needs !ustin 'oore. Ht foot, =t <kg

Drugs B spironolactone, lisinopril, bumetanide, D"--@, warfarin

ECG B L///

C$% B two metallic &al&es, small effusions, big heart

8E B rea -<, Creat -9A

"/C B normocytic, normochromic anaemia, =CC 2, )7% 2.<

Discussions B list problems. ?alk through all in&estigations and possible cause. How to

SoptimiseK. =hat anaesthetic.

hort cases

-. Causes of weakness in long stay )C patients

0. -<" with DownKs syndrome for dental work. )ssues with DownKs. How to anaesthetise.

2. 02" for urgent C+section. Categories of section. History 1 eam 1 what anaesthetic for cat 0

section.

Science?

!natomy

WDraw the efferent cardiac sympatheticsX B Y) didnKt do anything for a few seconds as )

thought she hadnKt asked me the whole 6uestionZ. E&entually got onto the dener&ated heart

after )Kd repeatedly drawn a medulla and the &agus ner&e B problems with the dener&ated

heart.

*hysiologyickle cell anaemia. ?alked about it. *roblems. 'olecular stuffO Hb!1Hb. ?ourni6uets.

Echange transfusionsR

*harmacology

W?ell me about post+hepatic neuralgiaX B Y"elt there wasnKt much point carrying on at this

stageZ. ymptoms, treatment. Got onto action of amitriptyline, carbamaMepine. W)K&e think

weK&e had enough of this topic, lets mo&e onto to something else shall weX B Ywas that a hint

) was that badZ

Clinical measurement

Cardiac output monitoring. ome time talking about Lidco couldnKt for the life of meremember what role lithium had in this pulse contour analysis#, ?(Ds wa&eform and &arious

'




bits it measures and calculates#, *icco B luckily the bell went as the little knowledge )K&e e&er

had about *icco had &anished.

Long Case

@ yr old man presents with a - day history of lower abdo pain and &omiting. *re&ious hea&y

alcohol intake and still consuming alcohol.

!lso smoker 0A1day.

urgeons would like to take him for an emergency laparotomy as soon as possible.

(1E B *ainful lump in the right groin. H% B -Abpm /* B -201@A !pyreial

'eds B 7il

!llergies B 7il

/loods:

Hb -9.>

*lt 22A

=CC -0.>

7a -0@

F .-

r -A

Cr @9

L"?Ks + 7ormal

Clotting B 7ormal

C$% B !* erect. Hyperepanded. 7ormal heart siMe. hadowing left upper Mone (ld

scarring from ?/ *leural pla6ue. /ullae both upper lobes.

ECG B "ast !" [-Abpm. )n&erted ? wa&es inferior leads and I wa&es anterior leads.

Iuestions:

ummarise the case

=hat could be the causes of the lump in the groin

Comment on the blood results. =hat are causes of hyponatraemia

=hat about the L"?Ks and clotting being normal =hat do you usually see in patients with

ecess alcohol intake

Comment on the C$%. =hat could be causes for shadowing in the left upper Mone

Comment on the ECG.

=hat are your pre+op considerations How would you fluid resuscitate =hat are your end

points

=hat other in&estigations would you like

How would you manage the !"

How are you going to anaesthetise him

*roKs and cons of epidural.

)ntra+op udden low /* to <A systolic. =hat are the differentials

)f it was a tension pneumothora how would you manage it*ost op oliguria B causes and management.

!(




Clinical hort Cases

-. - year old afro Caribbean male for emergency appendicectomy. icklede test positi&e.=hat does this result mean =hatKs the difference between sickle trait and disease

=hat le&els of *(0 they sickle. =hy donKt the %/CKs sickle in the &enous circulation if *(0

there is .2Fpa

=hat about ?halassaemia Difference between alpha and beta, homoMygous and

heteroMygous. Complications seen in patients with ?halassaemia.

0. - year old male asked to re&iew in !NE for after %?!. GC -2 and linear fracture on

kull +ray. Compound fracture to right lower leg which surgeons would like to take to

theatre.

)ndications for C? head )mage anything else also Clearing the C+pine?ransferring patient to C? B reasons to intubate first how would you do this#, monitoring

'anagement of head inQury.

urgeons want to take him to theatre for his leg how would you manage this GC still -2 but

C? brain is normal#.

2. 0 year old lady asked to re&iew about ha&ing awareness post G! for c+section.

How would you manage this

=hat would you look for on the anaesthetic chart 'onitoring, drugs, timing, blood loss

etc..# %easons for awareness in obstetrics )ncidence

)s awareness always a problem

(ther high risk areas for awareness.

*re&enting awareness use of /)#.

/asic sciences

-. !natomy B /lood supply to the brain. Draw the Circle of =illis. =hat part does each

artery supply Commonest sites for !neurysms Causes of aneurysms ?ypical

presenting symptoms of !H. 'anagement of cerebral &asospasm.

0. Glucocorticoids + =here are they made How released much1day Effects of Cortisol

in the body. H*! ais. Cortisol and stress response to surgery. ?ypical signs of a patient on long term steroids. %eplacement therapy of patients on steroids coming for

surgery. How do you perform a short synacthen test

2. 'agnesium B =here is it found in the body Effects Le&els ses wanted lots of

uses# Effects of toicity.

9. Defibrillator B Difference between synchroniMed and unsynchroniMed DC shock.

Difference between mono and biphasic defibrillators. How does a defibrillator work

Draw a diagram.

L(7G C!E

0@ yr old primi with prolonged labour and @ hrs of synto infusion B normal &aginal deli&ery.

> hours after this, obstetricians want to take to theatre for laparatomy.

(1E*ale, anious lady

!1




H%+ -91min

/* unrecordable

Carotid pulses palpable

ao0 not recordable

(ne unit of blood transfusion ongoing

Hb+ 0.@Coag profile: D)C picture

NE s : pre renal picture

Iuestions:

-. ummarise

0. Comment on blood in&estigations

2. *lan and immediate action

9. How much of blood to organise

. !naesthetic techni6ue and management

<. *ost op care

>. Causes of obst hemorrhage

@. Details of blood products and what each contains. 'edical management of obst bleeding

-A. D)C pathogenesis

H(%? C!E

-. !"

ECG shown and asked to describe the findings

'anagement of acute !" B algorithm

Causes of !"

!naesthetic implications+ "ast !" intra op and management

0. C(*D pathogenesis

Emphysema and chronic bronchitis B difference

Called to assess a patient in the ward with resp failure B causes and management

2. )5 drug addict and known H)5 8 for Hickman line insertion

!naesthetic implications

7urse sustains needle stick inQury B how would you manage

/!)C C)E7CE

-. Carotid endarterectomy: G! &s L! O anatomy of cer&ical pleusO how to perform

blocks and complications

0. 7eonatal physiology and management of cong diaphragmatic hernia

2. ?ests of clotting : ooMing from wound edges after a surgery in&ol&ing l of blood loss

) later realised that all 6uestions in this section from royal college book#

9. )!/* B indicationsO complicationsO damping and resonanace

?hursday --th Dec.

!




Long Case:

>9yr old =est !frican =oman presenting for Cer&ical Laminectomy. Cer&ical pine changes

below C2. *'H of Hypertension and Diabetes.

Drugs: )nsulin, !tenolol, Ca ch blocker, !CE, *raMocin, !spirin, Dypridamole.

Eamination:/* -A1@A

ystolic murmur radiating to carotids

'otor changes: Legs A1, !rms 21.

)n&estigations:

Hb -- + no indices gi&en, plts and =CC normal

7! and F normal, Cr about -A, r about 0A

ECG -st degree H/. no other abnormailty

C$% Enlarged heart

Iuestions:ummary

=hat do you think about her /* control + ) eplained multipharmacy implied resistant

hypertension

Conse6uences of Hypertension

)nterpretation of murmur + !. ymptoms and signs of !.

How would ) further pre+assess this patient

!ssessment of diabetes + systems approach

%un through each in&estigation in turn:

Classification of !naemias + 'C51'CH

)n&estigation of ickle Cell disease1trait

Causes of %enal "ailure

ECG interpretation + causes of Heart block + related to /eat blocker1Ca ch blocker

*hysiology of sinus arrhythmia

=ould ) be happy to proceed with this ECG + yes

How further get this patient ready for theatre + he was looking for: get in night before, sliding

scale, -st on list

How would ) anaesthetise 1 intra+op with temp, cell sa&er, neuro+phys monitoring

Effect of C5 disturbance 1 arrhythmia on !

*ost op Care + HD

*ost op analgesia + no *C! gi&en arm weakness

hort Cases:

-. *acemakers: )ndications, classification, what is the commonest type DDD#. =hy no

longer 55). /enefit of DDD !5 pacing better than 5 pacing alone + more physiological#

pre+assessment, intra+op management, any anaesthetic drugs affect pacemaker function su,

&olatiles#. =hy is the pacemaker positioned where it is.

0. *t had !naesthetic 0 yrs ago and now presents for hydrocele repair wanting epidural +

discuss. "airly basic. ) said spinal, what le&el, what risks for spinal. could G! be better now

than 0 years ago. =hat risks do ) warn people about G!. o, was ) going to do this as a G!

or spinal. ) said yes. =as ) going to let the patient make up his own mind + ) said yes. Could

he ha&e spinal as daycase + ) said yes.

!!




2. =oman found at home drowsy after suspected o&erdose + @Ag paracetamol.

'anagement + !/C 1 !5*

%easons she could be drowsy + other substances

(ther in&estigations incl Head C?

How would ) intubate. 'anagement of head inQured patient.

!/G findings. %easons for 'et !cidosis + related to !nion gap.?reatment of paracetamol o&erdose + would ) treat before 9 hour le&el if good history for

paracetamol o&erdose + ) said yes

=hy 7+ acetyl cysteine. *athophysiology of paracetamol poisoning

/asic cience:

-. !7!?(' !natomy of the nose + ) may aswell ha&e got up and walked out for the

duration of this 6uestion. !pparently there is no nasal artery

Did e&entually get onto the functions of the nose, reasons for nasal airway 1 intubation, how

to anaesthetise, L! toicity

0. *H)(L(G. Changes to the foetal circulation at birth.

=asn3t interested in me Qust eplaining the anatomy of the foetal circulation

D! changes, *5% changes, D5 changes, changes due to clamping of mbilical cord on

5%,

=hat is ?etralogy of fallot

How would ) anaesthetise a -@ month old with tetralogy of fallot 5% and *5% changes#.

"actors affecting *5%.

2. *H!%'!C(L(G. uamethonium + draw it, what is it, where does it work on 7'4.

Does it work pre+synaptically + ) said no which is why you don3t get fade on ?("....they

seemed to like that.

ide effects of su. Containdications.

=ho gets muscle pains. How to reduce incidence of muscle pains + ) said benMo, pre+

curarisation.....they wanted another one but ) didn3t know.

u apnoea + congenital and ac6uired. no 6uestioning on Dibucaine but others in the same

group had in depth 6uestioning on that.

(ptions to anaesthetise -- yr old for !pp with su apnoea + !"() 1 'od %) with %oc.

*roblem with roc + long block + 6uick few 63s on structure of sugammade + does it work for

atracurium

9. Hyperbaric oygen

)ndications for use ) said infection + clostr. perfringens and cerebral abscess, C(Hb

poisoning, Deompression sickness, Low (0 carrying capacity eg. Qeho&as witness who has

bled#

(ygen content e6uation

How does it affect Carboyhaemoglobin....why does it help. )ndications for use in Carbon

monoide poisoning.

=here is nearest Hyperbaric chamber to you

*roblems with Hyperbaric (ygen + oygen toicity pulmonary, C7 + /ert effect#

*roblems with !naesthetising someone in a hyperbaric chamber. =hat is it like in a

hyperbaric chamber

!"




) passed despite knowing absolutely nothing about the anatomy of the nose......guess it goes

to show they don3t fail you for not knowing something like that if you know the important

stuff

?hanks for the help on the courses. )n&aluable.

%egards,

Final FRCA &iva December 2008

%mran ")amma

L)n5 ca6e

*ost+partum haemorrhage

0@yr old primip presents for emergency laparotomy > hours after emergency caesarean

section for failure to progress. he had been on a syntocinon infusion for > hours, 9.2@kg

foetus deli&ered, large post+partum haemorrhage. terine clots e&acuated since deli&ery.

!t presentation B pale, &ery anious

H% -9Abpm, unrecordable /*, pulse oimetry not picking up trace. Carotid pulse palpable.

/loods before LC normal ranges gi&en#

Hb -2

*latelets 02

(ther bloods unremarkable

/loods after LC

Hb 0.@

*latelets @9

*? -

!*?% -.@

"ibrinogen -.>

F

7o other in&estigations produced at this point although C$% showing bilateral infiltrates

consistent with !%D pro&ided during the &i&a

Iuestions on:How would you resuscitate this patient

Definitions of massi&e post+partum haemorrhage.

Classification of hypo&olaemic shock

*eri+operati&e management.

=ould you place an arterial line if you could not feel a radial artery pulse

Drugs affecting uterine tone.

*ost+operati&e management on )?

hown C$% B epected to comment on ade6uacy, positions of lines, tube, patchy airspace

opacification

Discussion about !%D B definition, clinical presentation, causes, )? management.

!#




S)rt ca6e6

!trial fibrillation

!sked to interpret ECG showing atrial fibrillation with fast &entricular response.

!sked about signs of compromise, peri+operati&e management, would you anaesthetise a

patient with fast !", what would you do if it occurred intra+operati&ely in association with

profound hypotension. How would you anaesthetise for an electi&e cardio&ersion.

C(*D

%eferred a C(*D patient on the medical ward by the medical registrar for respiratory failure.

Describe how you would assess this patient.

)ndications for intubation and &entilation.

'edical management for respiratory failure.

)nterim measures before intensi&e care.

)ndications and contra+indications of non+in&asi&e &entilation

H)51!)D

How would you anaesthetise a patient with known !)D for Hickman line placement.Discussed assessment, &iral load, CD9 count and implications, possible treatments they may

be taking.

)ndications for Hickman line placement.

ni&ersal precautions.

7eedlestick inQury protocol. %isks of transmission of H)5.

creening for other blood+borne &iruses.

=hat is post+eposure prophylais

Science &iva

"emoral ner&e

Describe anatomy B wanted detail of course from lumbar pleus, anterior1posterior di&isions

to terminal branches, motor and sensory supply

"emoral ner&e block B techni6ue, indications, contra+indications, local anaesthetic choice and

dose.

2+in+- block B ner&es blocked or not blocked#

'anagement of local anaesthetic toicity.

Head inQury

econdary brain insult B causes.

Cerebral blood flow graph B C(0, (0, '!*.)C* B definition, normal range, monitors, causes of raised )C*, management of raised )C*.

'anagement of head inQury on the intensi&e care unit.

7)% spectroscopy B how does it work

?ranscranial Doppler B basic information on how it works wanted, which artery used

Diabetic ketoacidosis

*athophysiology

Fetone body synthesis, acetone, acetoacetic acid, beta+hydroybutyric acid

tilisation of ketone bodies by brain, heart and tissues

Clinical presentations and management of DF!

ynthesis and actions of insulin, particularly with respect to ion shifts

!$




=hat happens if hypernatraemia corrected rapidly + interested in fluid shifts, cerebral

oedema.

urgical diathermy

=hat is it, how does it work

)nterested in current density, fre6uency, current, risk of electrocution/ipolar1unipolar comparison

Effect on pacemakers1)CDs

Diathermy plates, what happens if they are loosely applied

)solating capacitor

?he eaminers were friendly and helpful. ?hey did not seem to mind too much if the precise

detail of basic science was not there, ) felt they were much more interested in clinical

competence. ) found it difficult to distinguish between my basic and clinical science &i&a.

=hilst the preparation for the "inal + in particular for the !Is + is more stressful, ) ha&e no

doubt that the actual eam is easier than the *rimary.

L)n5 ca6e:

! 0@ year old lady who deli&ered > hours ago needs emergency laparotomy. Her current Hb

is 0@. /* <A19A. *eripheral pulse not felt. Carotid pulse felt. he is currently being transfused.

Her in&estigation results:

/efore laparotomy /efore deli&ery

Hb

=CC

"ibrinogen

*latelets

*?

!*?? 7a

F

rea

Creatinine

D+dimer

0@

-9

low normal

@A

-@

<A

-9A

high normal

high normal

ele&ated

-2

-9

high normal

-A

normal

normal

normal

normal

normal

normal

*>e6ti)n6:

-. ummarise the case

!%




0. =hat are the abnormalities in the in&estigations

2. =hy rea and creatinine high normal

9. =hat is the abnormality in the coagulation profile

. =hat would you do

<. =hom will you inform

>. =hat would you ask in the blood bank @. =ould you transfuse platelets with the platelet of @A#

. =hat do you need in the theatre

-A. How will you induce

--. =hat induction agents

-0. =hat muscle relaants

-2. =hy pancuroneum

-9. =hat are the medical management

-. =hat are the surgical options

-<. =hats the finding in ray bilateral diffuse infiltration #

->. =hat are the causes

-@. How will you manage in the )? cardiac output monitoring#-. (ther routine management

S)rt ca6e6:

1/ ECG: irre5>lar b>t % ;a6 able t) 6ee < ;ave6/

Iuestions about !"

!": causes and management

=arfarin+ when will you stop

DC cardi&ersion B when will u do

2/ COD

Causes for acute eacerbation of C(*D

"indings in emphysema and chronic bronchitis

'edical management

)? management

3/ !%&r>5 aict

=hat are the problems

=hat are the precautions

How will you a&oid needle stick inQury=hat will you do if it happens

=hat drugs for prophylais

"ollow+up

#a6ic 6cience

1/ Fem)ral Nerve

Detailed anatomy

'otor and sensory supply

How will u do the block2 in - block

!




Lateral cutaneous ner&e of thigh anatomy and block

L! toicity+ management

)ntralipid doses

2/ !ea in@>r9 ;it elevate %C

)? management=hat parameters u will aim for

How C/" controlled + graphs

=hat is Qugular &enous oygen saturation

=hat are the implications

*harmacological management

(ther monitors

3/ Diaterm9

Draw diathermy circuit

!ll in detail about monopolar and bipolar diathermy=hat are the problems

How will you pre&ent

*acemaker B how it interferes

How will u manage a patient with pacemaker

=hat is the problem with defib and pacemaker

4/ %n6>lin an DA

=hat is )nsulin

Half+life

=hat is DF!

how ketone bodies produced

=hat are the problems

How will you correct hyperglycaemia

Hypokalaemia management

!cidosis management

Long case:

0@ yo primip with **H re6uiring an emergency laparotomy.

> hours post Em LC for failure to progress despite syntocinin infusion#.

he had been back for an E%C*e&acuated large clots#and was on a syntocinin infusion.o1e: *ale, anious

7)/* unrecordable, H% -9A, A0 sats not picking up

Carotid pulse palpable

/loods: Hb 0,@g1dl, *lts , !*?? >@, ?? etended, "ibrinogen -.@

=hat would you do

'assi&e Haemorrhage protocol cons obs, cons ananethist, haematology, porters, oda#

-AA; A0 !/C

0 large bore )5 cannulae

=hat fluid would you gi&e her /lood + if her blood not a&ail immediately would gi&e A

negati&e bloodwhen would you be happy to take her to theatre what parameters /* recordable, radial

!'




pulse#

(ther monitoring + urinary catheter, arterial line not C5* now as coagulopathic#

How would you anaesthetise

*reop + %anitidine )5, /lood in theatre le&el ) warmer,etc

7aCitrate pre A0 %) with criciod

=hat drugs titrated dose of thiopentone small# and u=hay thiopentone because that is what ) am used to + they were happy

ou ha&e blood pouring in and suddenly you get another drop in /* + what would you do

Check screen + H% rhythm ....

what would you gi&e phenylepherine How much A+-AAmcg =hy alpha agonist use

in obstetrics better than ephedrine mied alpha beta# they were happy

=hat drugs can you gi&e to contract the uterus

synntocinin + how much + units then an infusion of 9Aunits19 hrs

syntometrine + =hat is that syntocinin units and ergometrine AAmcg what are the Es

H?7 -AA; 785

carbaprost *G"0alpha E3s n8& and what else oh bronchospasm

ok patient sur&i&ed and in itu

hown an C$% < hours post admission#+ what are the maQor abnormalities %

endobronchial intubation, bilateral fluffy shadowing .. Good

DD: !%D yes too early#

pulmonary odema from fluid o&erload#

?%!L) .... good =hen is onset of ?%!L) within < hours of blood transfusion. Good

hort Cases:

-. Elderly man for cystoscopy for haematuria

ECG + !" with I wa&es in inferior leads + what would be cause of them + old infarct

=hat are causes of !" + )HD, !'), Cardiomyopathy, H?7, ?hyrotoicosis, !lcohol

How about if a patient is really unwell ... oh sepsis

=hat drugs would he be on: bblocker post !') and rate controll#, digoin

=hat are the problems with !" !trial thrombus + emboli to cause C5!, distal

ischaemia

o what other drugs may he be on aspirin if low risk, warfarin if high risk

=ould you proceed with case if these were new findings on ECG 7o, an electi&e case

=hat further ) ECH( what would you be looking for E" what else atrial

thrombus what else what is a common cause of !" that you failed to mention earlier

mitral &al&e disease + i would look at siMe of &al&es normal 9+<cm0 and gradient, dopplerflow for '%

)f it was old findings and he was on warfarin with an )7% 0 would you stop his

coagulation preop

) said ) would liase with the surgeon + if they were happy for a 6uick cystoscopy ) was

happy to proceed with stopping + they said good better not to go messinfg around with

anticoagulation.

0. !sked to re&iew a patient on the ward with C(*D with acute eacerbation

=hat could be the cause of acute eacerbation:

) said pneumonia, pleural effusion infection or other cause#, certain drugs histamine

releasing .. etc ?hey said what else ,...what do emphysematous patients get .. bulla .. ahh a

"(




pneumothora ,, good

=hat is the difference between Chronic bronchitis and emphysema

How do you assess a patient with C(*D eacerbation on the ward

How do you treat ) forgot to say oygen but when asked said ) would limit the

amount intially with a &enturi mask and increment upwards as /? guidelines on

emergency oygen therapy. they seemed happy.

2. ou are asked to anaesthetise a young man )5D and H)5 for Hickman line insertion.

=hat are the problems:

*roblems to do with H)5 and problems to do with )5D

'ainly concentrated on problems to do with )5D some candidates it was the other

way round#

?alked about difficulty with )5 access + may need to do a gas induction, problems with

compliance, risk of infection for staff + =hat can be done to minimise risk of infection

Last on list, disposable e6uipement, notify staff, uni&ersal precautions, double scrub,

mask and eyewear.

ou sustain a needlestick inQury + what would you do according to hospital protocol .....

/!)C C)E7CE:

-. Ha&e you e&er seen a carotid endarectomy under L!

=hat are the ad&antages and disad&antages

How do you perform a block + superficial and deep cer&ical pleus block eplianed.

aid there is a recent editorial in the /4! which states there is no difference in outcome

between the two and that as the deep cer&ical block is associted with lots more

complications + superficial block better. !lso mentioned the G!L! study which is going

to show no difference in outcome between C!E under L! or G!.

0. !sked to tell the difference between adult and neonatal respiratory system.

/roke it down into anatomical differences and physiological differences.

"airly basic 6uestion.

!sked about "%C is it smaller well it is 2Amls1kg so yes !nd why is that important +

because it is (ygen reser&oir + therefore there is less (0 stores and as babies ha&e a

higher resting A0 consumption they desaturate more 6uickly. Good

2. ) think it may be in the college book.

omething like + you are in (? at the end of a maQor operation with large blood loss and

massi&e transfusion and the surgeon tells you the patient is 6uite ooMy. =hat is possiblecauses:

V dilutional: blood transfusion without clotting factors

V D)C: complication of massi&e transfusion or sepsis

V ) also said !/( incompatibility + they said yes but it was ob&ious it was not what

they were after

(ther complications of massi&e blood transfusion ....

=hat tests would you do + send fbc does that assess clotting function it does assess

platelet number#, ok what else + )7%, !**? what is normal !*?? # =hat do both those

tests assess : etrinsic and intrinsic pathway etc%eally wanted &ery little detail

"1




=hat other tests ?EG + Do you know anything about it Es + starting describing it

and they start they didnt want that much detail.

!sked what clotting products would gi&e + much much and at what triggers.

) said ""* -ml1kg if )7% \-., *latelets if ] A, Cryoprecipitate if "ibrinogen ] -.Ag1

dl

?hen asked what drugs you could gi&e if still bleeding: !ntifibrinolytics: traneamic acid and aproptinin but now unlicensed#

=hat else

7(5( > + well if your haematologist lets you

9. Draw an arterial line trace

=hat information does it tell you: /*, D/*, '!*, contractility, 5 area under graph

up to diacrotic notch#, 5%,

changes depending on where it is in body. !lso show arrhythmias

!sked about components of )!/* kit + &ery brief descriptions

?alk about catheter, fluid column, transducer strain gauge# and wheatstone bridge

didnt want me to draw it# !sked indications for using art line

!sked complications

-. Long case: <A yrs old lady for fracture neck of femur. *re&ious history of aortic and mitral

&al&e replacement 0A yrs ago on warfarin, poor eercise tolerance 0 yards, on diuretics,

digoin and lisinopril s1o heart failure on eamination#, ECG : Qunctional rhythm.

?hey asked about preoptimiMation. what in&estigation they told me on Echo eQection

fraction of 0; #

he had Hb of -A. =ould you transfuse her 7a was -2A. )s it normal what was the cause of

low 7a

HD for preoptimiMation Cardiac output monitoring How would to anaesthetise ) said G!

with femoral ner&e block.

hort cases

- Down3s syndrome

0.Critical care polyneuropathy

2.Category ! LC spinal &s G!#

/asic ciences

-. ympathetic supply of heart starting from brain. Differences between normal anddener&ated heart. How would u manage a patient with heart transplant coming for non

cardiac surgery.

0. sickle cell disease

2. post herpetic neuralgia. treatment and meachanism of action of all drugs.

9. cardiac output monitoring: LiDC(, (esophageal doppler

long case:

>< female,acute surgical abdo,for laparotomyon fast !",/') 2A

"




inspiratory stridor

high wcc

pmh: thyroidectomy,hypertension

cr:thyroid with retrosternal etension,tracheal de&iation,5Csyndrome

short cases:

-.failed epiduarl in the ward for a pancolectemy

0.se&ere ! for ?F%

2.full stomach 8 penetrating eye inQury

basic sciences:

fluid repalcement and daily electrolyte re6 in paed , new 7*! issue,which fluids and

details

oygen deli&ery de&ices, &ariable and fied orifice de&ices

anatomy of the internal Qugular and subcla&ian&eins 8 air embolism

short cases:

-. Qeho&ahs witness

0. pre eclampsia

2. bleeding trachy site and management thereafter

long case

> y1o man with lung ca awaiting lobectomy. presents with acute neck pain.

pmh + htn, hiatus hernia

dh + candesartan, ranitidine, bdM

ecg + nad

pft + nad

c spine + subluation of c-+0

echo + as

summary

diagnosis of neck pain

echo findings + management of as

management of neck + immobilisation, theatre, awake fibreoptic intubation, proning,etubation, analgesia, hdu

december 2008final frca viva

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