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FCA(SA) Part II

THE COLLEGES OF MEDICINE OF SOUTH AFRICA

Incorporated Association not for gainReg No 1955/000003/08

Final Examination for the Fellowship of theCollege of Anaesthetists of South Africa

20 August 2012

Paper 1 (3 hours)

All questions are to be answered. Each question to be answered in a separate book (or books if more thanone is required for the one answer)

Al die vrae moet beantwoord word. Elke vraag moet in ’n aparte boek (of boeke indien meer as een nodig is

vir ’n vraag) geskryf word

1 a) What is meant by surgical site infection (SSI), and describe the factors thatplay a role in SSI. (30)b) Discuss the role of the anaesthesiologist in the prevention of surgical site

infection (SSI). (70)[100]

1 a) Wat beteken die term “chirurgiese lokus infeksie” en beskryf die faktore wat ’nrol speel in hierdie patologiese proses? (30)

b) Bespreek die rol wat die narkotiseur het om te speel in die voorkoming vanchirurgiese lokus infeksie. (70)

[100]

2 A 45-year-old woman with end-stage renal failure is scheduled for a living donorrenal transplant.a) Discuss the pathophysiological changes associated with chronic renal failure

which are of concern to the anaesthesiologist. (60)b) Describe your intra-operative management of this patient for renal transplant

surgery. (40)[100]

2 ’n 45-Jarige dame met eindstadium nierversaking, is geskeduleer vir die ontvang van’n lewende donor nier.

a) Bespreek die patofisiologiese veranderinge wat geassosieer is met chroniesenierversaking wat van belang is vir u as narkotiseur. (60)

b) Beskryf die intraoperatiewe hantering van hierdie pasiënt vir haarnieroorplanting chirurgie. (40)

[100]

3 With reference to neuropathic pain:a) List the major aetiological categories for this condition and give examples for

each category. (30)b) What are the symptoms of this condition? – explain terms that are specific to

pain descriptors. (15)

c) What are the signs you should look for? (10)d) Describe the screening tools and mention 2 that are in clinical use. (5)e) Discuss the treatment options for this condition. (40)

[100]

PTO/ Page 2 Question 3...



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3 Met verwysing na neuropatiese pyn:a) Lys die belangrike oorsaaklike kategorieë vir die toestand en gee ’n voorbeeld

in elke kategorie. (30)b) Wat is die simptome van die toestand? Verduidelik ook die terme wat

spesifiek is tot die pyn terminologie. (15)c) Wat is die kliniese tekens waarvoor u sou soek by so ’n pasiënt? (10)d) Bespreek die moontlike ondersoeke wat gedoen kan word om vir die toestand

te soek en noem twee wat huidig in kliniese gebruik is. (5)e) Bespreek die behandelings opsies vir die toestand. (40)

[100]

4 A one day old infant is presented to you for surgical repair of a lumbarmyelomeningocoele.a) Describe the anatomical defect present, and discuss the incidence and

associated problems. (10)b) Describe your pre-operative concerns, and the peri-operative management for

the repair of the myelomeningocoele. (90)

[100]

4 U word versoek om ’n een dag oue kindjie te hanteer vir die chirurgiese herstel van’n lumbale miëlomeningoseel.a) Beskryf die anatomiese defek van die toestand en bespreek die insidensie

sowel as die probleme geassosieer met die toestand. (10)b) Bespreek die aspekte waaraan u in die preoperatiewe fase aan aandag sal

gee sowel as die perioperatiewe hantering van die pasiënt vir die herstel vandie miëlomeningoseel. (90)



FCA(SA) Part II




21 August 2012

Paper 2 (3 hours)

All questions are to be answered. Each question to be answered in a separate book (or books if more thanone is required for the one answer)

Al die vrae moet beantwoord word. Elke vraag moet in ’n aparte boek (of boeke indien meer as een nodig isvir ’n vraag) geskryf word

1 a) What are the medical complications of alcohol abuse? (30)b) Discuss the peri-operative management of a patient with a history of chronic

alcohol abuse. (70)[100]

1 a) Wat is die mediese komplikasies geassosieer met alkoholmisbruik? (30)b) Bespreek u perioperatiewe hantering vir ’n pasiënt met ’n geskiedenis van

chroniese alkoholmisbruik. (70)[100]

2 A 3-year-old girl has a sterile brain abscess needing drainage. She was born with acyanotic congenital heart condition, is not growing well, and has been in and out ofhospital since birth.a) Discuss the pathophysiological consequences of cyanosis in cyanotic heart

disease. (10)b) List the possible cardiac lesions and possible previous interventions. (12)c) What associated abnormalities may be present? (4)d) Discuss the peri-operative risks and considerations. (24)e) Describe your peri-operative management of the patient. (40)f) Discuss the pathophysiological consequences of a left to right shunt. (10)

[100]

2 ’n Drie-jaar-oue dogtertjie met ’n steriele brein abses, word geskeduleer vir dreinasie

van die abses. Sy is gebore met ’n sianotiese kongenitale hartletsel en haar fisiesevordering is nie op standaard nie. Sy was al by herhaling toegelaat tot die hospitaal.a) Bespreek die patofisiologiese gevolge van sianose in ’n pasiënt met

sianotiese hartsiekte. (10)b) Lys die moontlike hartletsels verantwoordelik vir die toestand en noem die

moontlike voorheen korrektiewe prosedures wat gedoen was. (12)c) Watter geassosieerde abnormaliteite is soms ook teenwoordig? (4)d) Bespreek die perioperatiewe risiko en aspekte waaraan u sal aandag gee.(24)e) Bespreek u perioperatiewe hantering van hierdie pasiënt. (40)

f) Bespreek die patofisiologiese gevolge van ’n links na regs intrakardialeaftakking. (10)

[100]




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3 Regarding the anaesthetic management of a patient for carotid endarterectomy,discuss the following:a. List the indications for surgery in the treatment of carotid artery disease. (10)b. Discuss the rationale and options for monitoring intra-operative cerebral

ischaemia. (30)c. What are the pertinent aspects of the pre-operative assessment? (10)d. Discuss the choice of the anaesthetic technique. (30)e. Describe the post-operative management. (20)

[100]

3 Met verwysing na ’n pasiënt wie narkose moet ontvang vir ’n karotis

endarterektomie, bespreek die volgende:a) Lys die indikasies vir chirurgie in die behandeling van karotis arterie siekte.

(10)b) Bespreek die redes en die opsies vir die monitering van intraoperatiewe

serebrale isgemie. (30)

c) Watter aspekte is spesifiek van belang in u preoperatiewe evaluasie van diepasiënt? (10)d) Bespreek u keuse van ‘n narkose tegniek. (30)e) Bespreek u postoperatiewe hantering van hierdie pasiënt. (20)

[100]

4 With respect to Abdominal Compartment Syndrome:a) What is meant by the Abdominal Compartment Syndrome? (14)b) How is it diagnosed? (10)c) How is it graded? (6)d) What are the physiological effects of the Abdominal Compartment Syndrome?

(25)e) How may the patient with the syndrome present clinically? (5)f) How should the condition be managed (prevented and treated) by way of

i) Lowering intra-abdominal pressure without surgery? (5)ii) Organ Support? (12)iii) Surgery? (3)

g) What are the anaesthetic considerations in a patient scheduled for surgery forthe condition? (20)

[100]4 Met verwysing na Abdominale Kompartement Sindroom:

a) Wat word bedoel met die term “abdominale kompartement sindroom”? (14)

b) Hoe word dit gediagnoseer? 10)c) Hoe word die toestand gegradeer? (6)d) Wat is die fisiologiese effekte van die sindroom? (25)e) Hoe kan die pasiënt, met die sindroom, kliniese presenteer? (5)f) Hoe behoort die toestand hanteer word (voorkoming en behandeling) deur

middel vani) Verlaging van intra abdominale druk sonder chirurgie? (5)ii) Ondersteuning van organe? (12)iii) Chirurgie? (3)

g) Wat is die narkose oorwegings vir ’n pasiënt geskeduleer vir chirurgie vir dietoestand? (20)

[100]



FCA(SA) Part II

THE COLLEGES OF MEDICINE OF SOUTH AFRICAIncorporated Association not for gain

Reg No 1955/000003/08


22 August 2012

Paper 3 Picture booklet (3 hours)

All questions are to be answered. Al die vrae moet beantwoord word

CANDIDATE NUMBER……………………




-2-

Question 5 / Vraag 5

(Figure1) CT scan for Question 5Figuur 1 Hierdie rekenaartomografie skandering verwys na vraag 5


This ultrasound image shows a section of the abdominal wall.

Hierdie ultrasoniese beeld verwys na die abdominale wand.

(Figure 2) Ultrasound picture for Question 7(Figuur 2) Die ultrasonografiese prentjie is vir gebruik by vraag 7


1

2

3



-3-


(Figure 3) ECG trace for Question 9 a)(Figuur 3) Die EKG verwys na vraag 9 a)

(Figure 4) ECG trace for question 9 b)(Figuur 4) Hierdie EKG verwys na vraag 9 b)


Paper speed 25mm/sec



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(Figure 5) X ray picture for Question 12(Figuur 5) Die x-straal verwys na vraag 12


(Figure 7) Neck X ray picture for Question 14(Figuur 7) Die x-straal van die nek verwys na vraag 14

PTO/ Page 5 Question 15…



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(Figure 8) Haemodynamic snapshot for Question 15(Figuur 8) Hierdie hemodinamiese rekord verwys na vraag 15




-6-


(Figure 9) Echocardiograph for Question 17(Figuur 9) Hierdie eggokardiografiese beeld is vir gebruik saam met vraag 17


(Figure 10) ECG trace for Question 19(Figuur 10) Die EKG verwys na vraag 19 van die vraestel



FCA(SA) Part II


Reg No 1955/000003/08


22 August 2012

Paper 3 Data Interpretation (3 hours)



Question 1 – 3 / Vraag 1 - 3




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A 70-year-old patient has a pre-operative PaO2 of 10.5 kPa (78 mmHg) at sea level onroom air. Following a laparotomy, the PaO2 is 7.8 kPa (58 mmHg) and the PaCO2 is 6.5kPa (49 mmHg), on a 35% oxygen facemask, in the high care unit

’n 70 jaar oud pasiënt het ’n preoperatiewe PaO2 van 10.5kPa (78mmHg) by seevlak op

kamerlug. Na ’n laparotomie is die PaO2 7.8 kPa (58mmHg) en die PaCO2 6.5 kPa (49mmHg). Die pasiënt is op ’n 35% suurstof masker in die hoësorg eenheid.

a) What is your interpretation of these results? (2)a) Hoe interpreteer u hierdie resultate? (2) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

b) What are the most likely (pathophysiological) mechanisms for a low PaO2?(4)b) Wat is die mees waarskynlike (patofisiologiese) meganisme vir die verlaging in die

PaO2?(4)

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

c) What do you think is the most likely mechanism mentioned in b), for the low PaO2 and give reasons? (4)

c) Wat dink u is die mees waarskynlike meganisme soos genoem in 1 b) vir dieverlaging in die PaO2? Gee u redes. (4)

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

[10]

PTO/ Page 3 Question 2...-3-




The following blood results were obtained from a patientDie volgende bloedresultate is verkry by ’n pasiënt

Patient valuesDie pasiënt se waardes

Reference valuesVerwysingswaardes

Sodium / Natrium = 140 mmol/l 135-147 mmol/lPotassium / Kalium = 6.7 mmol/l 3.3-5.3 mmol/l

Urea / Ureum = 18 mmol/l 2.1-7.1 mmol/lCreatinine / Kreatinien = 250 µmol/l 49-90 mol/l

a) If this electrolyte abnormality is left untreated, what ECG changes will progressivelybe seen? (4)

a) Indien hierdie elektroliet abnormaliteit onbehandeld gelaat word, wat sal dieprogressiewe veranderings op die EKG wees wat u sal waarneem? (4)

___________________________________________________________________ ___________________________________________________________________

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

b) What are the (medical) treatment options of this electrolyte abnormality in a patientwho is haemodynamically stable? (4)

b) Wat is die (mediese) behandelings opsies beskikbaar om die elektrolietabnormaliteite in die pasiënt te behandel? Die pasiënt is hemodinamies nog stabiel. (4)

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

___________________________________________________________________

c) How would your treatment differ if this patient was haemodynamically unstable?(2)

c) Hoe sou u behandeling verskil indien die pasiënt hemodinamies onstabiel is?(2)

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

___________________________________________________________________ ___________________________________________________________________[10]




Question 3

The table below reflects water and electrolyte disturbances in neurosurgical patients.Complete the table. Where appropriate simply indicate high (↑), normal (N) or low (↓)

Die onderstaande tabel noteer die water en elektroliet abnormaliteite wat inneurochirurgiese pasiënte voorkom. Voltooi die tabel. Waar van toepassing, wys ‘nverhoging met (↑) normaal (N) of verlaging (↓). (10)

DiabetesInsipidus

Syndrome ofInappropriate Anti -DiureticHormoneOntoepaslikeantidiuretiesehormoonsekresie

Cerebral SaltWasting SyndromeSerebralesoutverliessindroom

PathophysiologyPatofisiologie

UrineUriene

Sodium / Natrium (normal / normaal =20meq/l)(↑or N or ↓)

Osmolality vs.serum osmolality(> or = or <)Osmolaliteitteenoor serum

osmolariteit(> of = of <)

SerumSerum

Sodium / Natrium (↑ or N or ↓)

Osmolality /Osmolaliteit (↑ or N or ↓)

IntravascularvolumeIntravaskulêre

volume

(↑ or N or ↓)

[10]



FCA(SA) Part II


Reg No 1955/000003/08


22 August 2012






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A 75-year-old man undergoes transurethral resection of the prostate under generalanaesthesia. In recovery he is confused, with a pulse of 60 beats/min and a blood pressureof 90/45 mmHg. His urea and electrolytes are as follows:

’n 75-Jarige man ondergaan ’n transuretrale reseksie van die prostaat onder algemenenarkose. In die herstelkamer is hy verward, sy pols is 60 slae/minuut en bloeddruk

90/45mmHg. Die ureum en die elektroliete is as volg:

Na 114 mmol/l Urea / Ureum 3.2 mmol/lK 3.1 mmol/l Creatinine / Kreatinien 148µmol/lCl 94 mmol/lBicarbonate / Bikarbonaat 21 mmol/l

a) What is the pathophysiology of this complication? (3)a) Wat is die patofisiologie van die komplikasie? (3)

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

b) Describe the treatment of this complication. (7)b) Beskryf u hantering van die komplikasie. (7)

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

[10]


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An adult male is found collapsed. In the emergency department he localises to pain with hisleft arm but no movement is elicited from his right side. He groans and his eyes remainclosed on painful stimulation. His left pupil is slightly dilated and the response to light issluggish.

’n Volwasse man word tot die noodeenheid toegelaat met die geskiedenis dat hyineengestort het. Hy lokaliseer pyn met sy linkerarm maar daar is geen beweging van die

regterarm nie. Hy kreun en sy oë bly toe selfs na pynlike stimulasie. Die linker pupil iseffens dilateerd en die respons tot lig stadig.

a) What does the CT scan show (Figure1)? (Please refer to picture booklet). (2)a) Wat wys die skandering (Figuur 1)? (Verwys asseblief na foto/figuur boek) (2) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

___________________________________________________________________

b) What is his Glasgow Coma Scale (show your calculation)? (2)b) Wat is die pasiënt se Glasgow Koma Skaal (Wys asb. u berekening)? (2) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

c) List the steps of your immediate management. (6)c) Lys die stappe wat onmiddellik gedoen moet word in die hantering van die

pasiënt. (6) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

[10]


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An adult female is scheduled for an elective subtotal thyroidectomy. She gives a history ofintolerance to heat, palpitations, lethargy and weight loss. She had failed radio-iodinetherapy 3 years ago. Her current medications are carbimazole 20 mg daily, the oralcontraceptive pill and methylcellulose eye drops. Blood results on admission were asfollows: (normal values in brackets).

’n Volwasse vroulike pasiënt is geskeduleer vir elektiewe subtotale tiroïdektomie. Sy gee ’ngeskiedenis dat sy hitte sleg verdra, ly aan hartkloppings , algemene moegheid engewigsverlies. Sy het radio aktiewe jodium terapie gehad drie jaar gelede wat as

onsuksesvol beskou is. Haar huidige medikasie is Karbimazool 20mg/dag, oralevoorbehoedmiddel en metielsellulose oogdruppels. Die bloed uitslae by toelating wys dievolgende: (normale reikwydte in hakies).

i) Hb 10.2 g/dl (11- 16 g/dl)ii) WBC 3.2 x 109 (4 - 11 x 109)iii) T4 30.7 (10 – 22 pmol/l)iv) FT3 10.5 (2.8 – 7.1 pmol/l)v) TSH 0.1 mU/l (0.34 – 4.6 mU/l)

a) What do the blood results show? (2)a) Hoe interpreteer u die bloedtoets hierbo opgesom? (2) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

b) What is the likely clinical diagnosis? (2)b) Wat is die mees waarskynlike kliniese diagnose? (2) ___________________________________________________________________

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

c) What is the most likely cause for her low haemoglobin? (2)c) Wat is die mees waarskynlike verduideliking vir die lae hemoglobien? (2) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

d) What peri-operative complications may this patient develop? (4)d) Watter perioperatiewe komplikasies kan hierdie pasiënt ontwikkel? (4) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

[10]




a) Name the anatomical structures labelled 1, 2 and 3 in (Figure 2). (Please referto picture booklet). (1.5)

a) Benoem die anatomiese strukture wat gemerk is as 1, 2 en 3 in (Figuur 2). (Verwysasseblief na foto/figuur boek). (1.5)

___________________________________________________________________

___________________________________________________________________ ___________________________________________________________________

b) What ultrasound probe is best suited for this view and where should it be placed?(2)

b) Watter ultrasoniese monitor kop is die mees geskikte tipe vir hierdie aansig en waarbehoort dit geplaas te word? (2)

___________________________________________________________________ ___________________________________________________________________

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

c) What ultrasound-guided block can be performed using this view, and what nervesare blocked? (2.5)

c) Watter ultrasonies gerigte senuweeblok kan gedoen word deur gebruik te maak vanhierdie spesifieke aansig? Watter senuwees word geblok? (2.5)

___________________________________________________________________ ___________________________________________________________________

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

d) For what procedures is it suitable? (2)d) Vir welke prosedures is hierdie blok geskik? (2) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

___________________________________________________________________ ___________________________________________________________________

e) List 4 complications of the block. (2)e) Lys 4 komplikasies van die blok. (2) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

[10]





A 2-day-old term neonate weighing 3 kg undergoes an emergency initial repair of a bladderexstrophy, during which the surgeon causes a significant haemorrhage. The baby has noother abnormalities detected pre-operatively. The duration of the anaesthetic is 280minutes.

’n 2-Dag-oue volterm neonaat, wie 3 kg weeg, ondergaan ’n aanvanklike nood herstel vanblaasekstrofie. Gedurende die prosedure veroorsaak die chirurg betekenisvolle bloeding.Die baba is andersins as normaal genoteer by die preoperatiewe ondersoek. Die totale

duur van die narkose was 280 minute.

a) What is the baby’s blood volume and at what stage would you consider a bloodtransfusion? (3)

a) Wat is die baba se bloedvolume en op watter stadium sal u oorweeg om ’nbloedtransfusie te begin? (3)

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

___________________________________________________________________

b) Within what parameters should you aim to keep the baby’s blood pressure and pulserate? (2)

b) Wat is die reikwydtes waarbinne u sal poog om die baba se bloeddruk en polsspoedte hou? (2)

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

c) What should the depth marking of the endotracheal tube at the nostril be? (1)c) By watter diepte, gemerk by die neusvleuel, behoort die endotrageale buis geplaas

te wees? (1) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

d) Which and how much crystalloid fluid would you use? (2)d) Watter tipe en hoeveel kristalloïede vog sou u gebruik? (2) ___________________________________________________________________

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

e) What doses of the Atracurium, Neostigmine and Glycopyrrolate would you use? (2)e) Wat is die doserings van Atrakurium, Neostigmien en Glikopirrolaat wat u sou

gebruik? (2) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________



FCA(SA) Part II


Reg No 1955/000003/08


22 August 2012








-2-

Question 12

A 63-year-old man presents for an emergency laparotomy. Attached is his pre-operativechest x-ray (Figure 5). (Please refer to picture booklet)’n 63 jarige man moet ’n nood laparotomie ondergaan. Die preoperatiewe x-straal is Figuur5 van u foto/figuur boek.

a) What is implanted and what is its indication? (2)a) Wat is in hierdie pasiënt ingesit en wat is die indikasie daarvoor? (2) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

b) Where is it positioned? (1)b) Waar is dit geposisioneer? (1) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

c) What are the intra-operative implications and how should you manage this deviceintra-operatively? (3)

c) Wat is die intraoperatiewe implikasies en hoe sou u hierdie apparaat intraoperatiefhanteer? (3)

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

d) What other medications may this patient be taking? (4)d) Op watter ander medikasie mag die pasiënt dalk wees? (4)

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

[10]


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Question 13

Figure 6 demonstrates a flow volume loop of a patient booked for elective surgery.

Figuur 6 wys ’n vloei-volume lus van ’n pasiënt wat geskeduleer is vir elektiewe chirurgie.

(Figure 6) Flow Volume loop

a) Interpret the flow volume loop in (Figure 6). (6)a) Interpreteer die vloei-volume lus (Figuur 6). (6) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

b) Would you accept the patient for elective surgery? Give reasons. (2)b) Sal u hierdie pasiënt aanvaar vir elektiewe chirurgie? Gee u redes. (2)

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

___________________________________________________________________

c) Indicate on the flow volume loop (Figure 6 above) which is the effort independentpart of expiration. (2)

c) Wys op die vloei-volume lus (Figuur 6 hierbo) watter deel is die poging onafhanklikedeel van ekspirasie. (2)

[10]PTO/ Page 4 Question 14...

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Question 14



An adult female presents to theatre for debridement of a compound fractured humerusfollowing a motor vehicle accident.

’n Volwasse vroulike pasiënt moet ’n debridement ondergaan van ’n gekompliseerdehumerus fraktuur. Sy was in ’n motorvoertuig ongeluk.

a) What is the most obvious finding on this lateral neck x-ray (Figure 7) that will alertyou to a potentially serious neck injury? (Please refer to picture booklet)

(1)

a) Wat is die mees opvallende bevinding op die laterale nek x-straal (Figuur 7) wat uaandag sal vestig op ’n potensiële ernstige nekbesering. (Verwys asseblief na diefoto/figuur boek). (1)

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

b) What other clinical signs will you look for indicating a potentially serious neck injury? (4)

b) Vir watter ander kliniese tekens sal u soek as aanduidend van ’n potensieël ernstigenekbesering? (4)

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

c) What other special investigations will you request relevant to the neck injury?(3)

c) Watter ander spesiaal ondersoek sal u vra (relevant tot die nekbesering)? (3) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

d) Is this an acceptable film to comment on and give reasons for your answer? (Figure7). (Please refer to picture booklet) (2)

d) Is die x-straal in (Figuur 7) ’n aanvaarbare ondersoek vir u om op kommentaar telewer? Gee redes vir u antwoord. (Verwys asseblief na die foto/figuur boek).

(2) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________



FCA(SA) Part II




22 August 2012


All questions are to be answered.

Al die vrae moet beantwoord word






-2-


A patient coming off bypass has the following snapshot (Figure 8). (Please refer to picturebooklet).

’n Pasiënt is so pas afgehaal van kardiopulmonêre omleiding. (Sien Figuur 8 van die

foto/figuur boek).

a) Describe the arterial waveform in (Figure 8). (Please refer to picture booklet).(2)

a) Beskryf die arteriële golfvorm (Figuur 8). (Verwys asseblief na die foto/figuurboek). (2)

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

___________________________________________________________________ ___________________________________________________________________

b) Describe the haemodynamic effects of what is seen in the arterial waveform in(Figure 8). (Please refer to picture booklet). (8)

b) Beskryf die hemodinamiese effek van wat u sien op die arteriële golfvorm in(Figuur 8). (Verwys asseblief na die foto/figuur boek). (8)

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

[10]




-3-


An adult black female is found unconscious. A blood test performed on admission showsthe following results:

’n Volwasse, swart vroulike pasiënt is bewusteloos gevind. ’n Bloedondersoek is gedoenby toelating en wys die volgende:

Plasma

Na+ - 133 mmol/l K+-2.5 mmol/l Cl-- 97 mmol/l

HCO3-- 8 mmol/l Urea/ Ureum -14.6mmol/l

Creatinine / Kreatinien -105 μmol/l

Glucose / Glukose - 38 g/dl

a) What is the most likely diagnosis in this patient? (1)a) Wat is die mees waarskynlike diagnose in die pasiënt? (1) ___________________________________________________________________ ___________________________________________________________________

___________________________________________________________________

b) Comment on this patient’s renal function and calculate the estimated glomerularfiltration rate. (3)

b) Gee kommentaar oor die pasiënt se nierfunksie en bereken die geskatte glomerulêrefiltrasiespoed. (3)

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

___________________________________________________________________

c) Calculate this patients expected potassium deficit and describe how you wouldreplace it. (3)

c) Bereken die pasiënt se kaliumtekort en verduidelik hoe u die kaliumtekort souvervang. (3)

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

___________________________________________________________________

d) Calculate the anion gap. (3)d) Bereken die anioon gaping. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

[10]

Note: where calculations are asked for , simply f ill in values in the formula.Nota: waar berekeninge gevra word, sit slegs die waardes in die vergelyking.

PTO/ Page 4 Question 17…-4-




An adult female patient presents for mitral valve replacement surgery and has this trans-esophageal echo picture (Figure 9). (Please refer to picture booklet).

’n Volwasse vroulike pasiënt presenteer vir ’n mitraalklepvervanging en haartransoesofageale eggobeeld verskyn in (Figuur 9). (Verwys asseblief na die foto/figuurboek).

a) What view is this in (Figure 9)? (Please refer to picture booklet) (1)a) Watter aansig is gebruik in (Figuur 9)? (Verwys asseblief na die foto/figuur

boek). (1) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

b) List at least three major structures seen in this picture (Figure 9). (Please refer topicture booklet). (3)b) Lys ten minste drie belangrike strukture sigbaar in hierdie beeld (Figuur 9). (Verwys

asseblief na die foto/figuur boek). (3) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

c) What are the obvious abnormalities in (Figure 9)? (Please refer to picture booklet). (3)

c) Wat is die opvallende abnormaliteite wat u opmerk in hierdie beeld (Figuur 9)?(Verwys asseblief na die foto/figuur boek). (3)

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

___________________________________________________________________

d) What is the coronary vascular supply to the areas marked 1-3 in (Figure 9)? (Pleaserefer to picture booklet). (3)

d) Wat is die koronêre bloedvoorsiening na die area gemerk 1–3 in (Figuur.9)?(Verwys asseblief na die foto/figuur boek). (3)

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

___________________________________________________________________ ___________________________________________________________________

[10]



FCA(SA) Part II


Reg No 1955/000003/08


22 August 2012






-2-




A patient is being assessed for elective closure of an abdomen left open after a laparotomyfor perforated duodenal ulcer. The patient has been on a ventilator for 5 days and is beingfed by nasogastric tube.Current settings in Synchronised Intermittent Mandatory Ventilation (SIMV) mode are

Inflation pressure: 24cmH2OPositive end expiratory pressure (PEEP): 12cmH2OPressure Support: 20cmH2OSet Respiratory rate: 12 breaths/minMeasured Respiratory rate: 18 breaths/min

The arterial blood gas results are as followsPh: 7.55 PO2: 14kPa (105mmHg) PCO2:5kPa (37.5 mmHg)Bicarbonate: 32mmol/lLactate: 1.2mmol/l

’n Pasiënt het voorheen ’n laparotomie gehad vir ’n geperforeerde duodenale ulkus. Na diechirurgie is die abdomen oop gelos en die pasiënt is nou geskeduleer vir ’n elektiewe

sluiting van die abdomen. Die pasiënt was op ’n ventilator vir vyf dae en word gevoed via ’nnasogastriese buis.Die ventilator stelling is gesinchroniseerde intermitterende verpligte ventilasie

Inflasiedruk: 24cmH2OPositiewe end ekspiratoriese druk: 12cmH2OInspiratoriese druk ondersteuning: 20cmH2OGestelde respiratoriese spoed: 12 asems/minuutGemete asemhalingspoed: 18 asems/minuut

Die arteriële bloedgas wys die volgendepH 7.55 PaO2:14kPa (105mmHg) PaCO2 5 kPa (37.5mmHg)Bikarbonaat: 32mmol/Laktaat 1.2mmol/l.

a) Explain these results. (8)a) Verduidelik die resultate. (8) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

b) Is the patient fit for the proposed operation? (2)b) Is die pasiënt geskik vir die beoogde prosedure? (2) ___________________________________________________________________ ___________________________________________________________________

___________________________________________________________________ ___________________________________________________________________[10]




Question 19

A 68-year-old poorly compliant hypertensive with a 40 pack-year smoking history presentsthree days after an uneventful laparoscopic cholecystectomy with an ECG as shown in(Figure 10). (Please refer to picture booklet).

His blood pressure is 150/90 mmHg, heart rate is 110 beats/min and N-Terminal Pro-BNPis 2800mmol/l.

’n 68-Jarige pasiënt wat bekend is met hipertensie en ’n 40 pak jare rook geskiedenis,presenteer drie dae na ’n roetine laparoskopiese cholesistektomie. Die verdere geskiedenisis dat die pasiënt nie instruksies of medikasie gereeld neem nie en ’n EKG is geneem(Figuur 10). (Verwys asseblief na die foto/figuur boek).

Sy bloeddruk is 150/90mmHg, hartspoed is 110 slae/minuut en NproBNP is 2800mmol/L.

a) Describe the abnormalities on this ECG trace (Figure 10). (Please refer topicture booklet). What is the diagnosis? (2)

a) Beskryf die abnormaliteite wat u oplet op die EKG (Figuur 10). (Verwysasseblief na die foto/figuur boek). Wat is die diagnose? (2)

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

b) Describe your initial management. (8)b) Beskryf u aanvanklike hantering. (8) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

[10]


-4-

Question 20



An endurance athlete presents to ICU with a change in mental status after a six hour, 80kmrace. The urea and electrolytes are as follows:

’n Langafstand atleet het ’n 80km wedloop voltooi. Ses uur na die wedloop presenteer hyby die intensiewe sorg eenheid met ’n verandering in sy bewussyn. Die ureum enelektroliete lyk as volg:

Na: 112mmol/l Cl: 94mmol/l

K: 3.4mmol/l Bicarbonate / Bikarbonaat: 18mmol/l

Urea / Ureum: 3.5mmol/l Creatinine / Kreatinien: 55 µmol/l

a) What is the diagnosis? (2)a) Wat is die diagnose? (2) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

___________________________________________________________________

b) Briefly outline your management. (8)b) Bespreek kortliks u hantering. (8) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

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FCA(SA) Part II


Reg No 1955/000003/08


22 August 2012








-2-


a) This is the ECG (Figure 3) of a 45-year-old man who is for elective endoscopicsurgery for chronic sinusitis. (Please refer to picture booklet).

a) Hierdie EKG (Figuur 3) is geneem van ’n 45 jarige oue man wie geskeduleer is virelektiewe endoskopiese chirurgie vir chroniese sinusitis. (Verwys asseblief nafoto/figuur boek).

i) List the abnormalities on this ECG (Figure 3). (Paper speed 25mm/s).(2)

i) Lys die abnormaliteite wat u oplet op die EKG (Figuur 3). (Die EKG isafgeneem teen 25mm/sekondes). (2)

____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

ii) What is the diagnosis and how would you confirm this diagnosis? (3)ii) Wat is die diagnose en hoe sal u te werk gaan om die diagnose te bevestig?

(3) ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

b) This is the ECG (Figure 4) of a slim 40-year-old man. He exercises regularly with noproblems. (Please refer to picture booklet).

b) Hierdie EKG (Figuur 4) is verkry by ’n skraal, 40 jarige man. Hy oefen gereeld enhet geen kliniese simptome nie. (Verwys asseblief na foto/figuur boek).

i) List the abnormalities on this ECG (Figure 4). (Paper speed 25mm/s).(2)

i) Lys die abnormaliteite wat u oplet op die EKG (Figuur 4). (Die EKG isafgeneem teen 25mm/sekondes). (2)

____________________________________________________________________ ____________________________________________________________________

____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

ii) What is the diagnosis and how would you confirm this diagnosis? (3)ii) Wat is die diagnose en hoe sou u te werk gaan om die diagnose te bevestig?

(3) ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________




Question 10

A 70-year-old lady has a haemoglobin value of 9.2g/dl and a MCV (mean corpuscularvolume) of 109 fL.

’n 70-Jarige dame het ’n hemoglobien van 9.2g/dL en ’n GKV (gemiddelde korpuskulêrevolume) van 109fL.

a) What are the causes of a raised MCV? (5)a) Wat is die oorsake van ’n verhoogde GKV? (5)

____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

b) What tests would you use to investigate these causes of a raised MCV? (5)b) Watter toetse sou u doen om die oorsake van die verhoogde GKV te ondersoek?

(5)

____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

[10]


-4-



Question 11

A 60-year-old man is referred to the pain clinic for treatment of low back pain. He has feltlethargic recently and has lost 6kg in weight in the last 3 months. Blood tests results are asfollows:

’n 60 Jarige manlike pasiënt word verwys na die pynkliniek vir hantering van lae rugpyn. Diepasiënt gee ‘n geskiedenis van algemene swakheid en moegheid van onlangse aankoms enhet 6kg gewig verloor in die laaste drie maande. Die bloed uitslae wys die volgende:

Hb 9g/dl, ESR 90mm/hr, Sodium 136mmol/l, Potassium 4.8mmol/l, Chloride 101mmol/l, Non-ionised Calcium (corrected) 3.1mmol/l, Total Protein 90g/l, Albumin 32g/l.

Hb 9g/dl, ESR 90mm/uur, Natrium 136mmol/l, Kalium 4.8mmol/l, Chloried 101mmol/l, Nie-ioniseerde kalsium (gekorrigeerd) 3.1mmol/l, Totale proteïen 90g/l, Albumien 32g/l

a) What serious condition does this patient need to be investigated for? (1)a) Vir watter ernstige toestand behoort hierdie pasiënt verder ondersoek te word?

(1) ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

b) Which particular electrolyte is raised in this patient? Give one way of correcting thiselectrolyte abnormality pre-operatively. (3)

b) Watter van die elektroliete hierbo genoem is verhoog? Gee een manier hoe om dieelektroliet abnormaliteite te korrigeer in die preoperatiewe fase. (3)

____________________________________________________________________ ____________________________________________________________________

____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

c) List further investigations for this patient and give reasons for your choices. (6)c) Lys verdere ondersoeke wat u sou aanvra op hierdie pasiënt en gee die redes vir u

keuses. (6) ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

[10]

fca(sa)_part_ii_past_papers 12

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