Details generously supplied by Kelly Bratkovic (NSW), June 2005.
Comments: "Opening scenario in bold. My responses are in italics so that may change
things a bit. I have probably forgotten some questions! Also, for some
perspective, just remember that I didnt know the answer to all these questions
and I still passed!"
43 yo woman with shortness of breath. Take a relevant history and examine her
cardiovascular system.
Mitral regurgitation on auscultation.
Presented findings.
Questions were regarding
- aetiology of MR
- what investigations
- shown ECG and TTE report, asked questions.
A 71 yo woman with a long history of valvular heart disease.
Take a relevant history and examine her cardiovascular system.
Aortic Stenosis on auscultation.
Presented findings.
Questions were regarding:
Investigations
CXR
Flow volume loop, pre- and post- bronchodilator =>COPD
Thromboelastograph
ABG/ECU => High anion gap metabolic acidosis
An obese 60yo man for laparoscopic gastric banding. He has a history of obstructive sleep apnoea.
BP today is 170/105
What concerns do you have with respect to his BP?
Anaesthetic risks labile BP intra-op
End organ disease CVS, renal, CNS
Aetiology
Aetiology of hypertension
What do you do now?
Recheck BP, correct cuff size
Will you proceed?
How would you assess his OSA?
History, examination, investigations (discussed echo)
Treatment CPAP
How does his OSA effect your management?
Post-operative care
Analgesia
He wants to go home day 1. Would you let him?
He has difficult venous access. What are your options?
CVC IJV, device to help you (ultrasound)
Anatomy
Gas induction why / why not?
During the case, there is an abrupt rise in end-tidal pCO2.
Management
Aetiology (rapid v slow rise in CO2)
8 yo girl with cystic fibrosis. Current URTI, unwell, sats 91%. Booked for a
Portacath.
What is cystic fibrosis?
Anaesthetic implications?
Anaesthetic Plan patient assessment, consent, induction etc.
Gas induction any concerns re nitrous oxide?
Justify airway choice
End of case, sudden rise in airway pressure.
How do you insert a chest drain?
What size would you use?
A 27 yo male is stabbed in a fight at pub, (picture drawn showing injuries to left side sternum,
left upper thorax). Hew is intoxicated and unco-operative. Noted to be hypotensive and tachypnoeic
Outline your initial management.
EMST guidelines, etc
Diagnose tension pneumothorax. Outline management.
Discuss fluid resuscitation. Choice of fluid. What are your end-points?
Diagnose pericardial tamponade.
Discuss management.
Complications of needle thoracocentesis.
BP still low differential diagnosis?
FAST scan what do you look for?
DPL
Would you go to CT?
How would you transfer patient to OT (includes lift)?
(I said I would intubate, he said fine, but in the scenario you dont)
For laparotomy, no one present who knows how to do cricoid pressure. What would you do?
Formally describe technique for applying cricoid pressure.
Anaesthetic management of pericardial tamponade.
A 55 yo woman scheduled for a vaginal hysterectomy.
She has a long history of multiple sclerosis. Current medications are Interferon and Paroxetine.
There is also a history of severe PONV.
What are your anaesthetic options?
Discussed regional (spinal, epidural in MS) and general.
How do you assess her risk for PONV?
Scoring systems. Can you quantify her risk?
If she has a GA, how do you minimise her risk of PONV? (Pre, intra and post op)
RA what do you administer?
What do you tell her about MS and anaesthesia?
Called to assess her in recovery re PONV, outline your approach.
Later recovery says she is shaky, sweaty and anxious. Your management?
(I didnt give her a 5-HT3 receptor antagonist because of this risk)
Suspect serotonin syndrome what drugs should be avoided? Treatment?
Two days later, gynaecologist informs you that she has foot-drop. What do you
do?
Assessment hx. Ex, consider referral.
Differential diagnosis peroneal n injury (lithotomy), complication of spinal,
MS related.
Distinguish between these.
UMN vs LMN lesions.
Anatomy of common peroneal nerve, sensory supply.
Sciatic nerve.
A 4 year old male with Downs syndrome scheduled for As and Ts in the Day Surgery Unit.
History is that he snores
Current URTI.
The patient is needle phobic and unco-operative.
On examination you hear a systolic murmur. How do you assess the significance of
the murmur?
Hx, Ex, Ix, case notes, call GP.
Child saw a cardiologist a year ago, diagnosed with an insignificant VSD. How would
you proceed?
Admit to a tertiary centre, overnight admission.
Why admit overnight?
Bleeding, oedema.
How would you assess his snoring?
Airway problems in Down syndrome?
Your anaesthetic plan?
Concerns regarding use of N2O?
Discuss halothane vs sevoflurane.
Child extremely unco-operative your approach?
What are the problems with premed? Particularly with OSA?
What do you give, dose, routes?
After gas induction, he desaturates with an obstructed airway. Your management?
Sats 50%, HR 60 Give sux and atropine route, dose
Further management.
A 35 yo woman is booked for a laparoscopy for a ruptured ectopic pregnancy at 15/40.
-PMHx asthma
-Meds salbutomol MDI, herbal supplements, folate.
What will you ask the gynaecologist?
Patients current haemodynamic status, location, treatment (IV access,
cross-match etc)
Query the diagnosis (15/40 is late presentation of an ectopic)
Further details regarding co-morbidities
Check that operating theatres informed and prepared.
What will you ask the patient?
Routine anaesthetic history, detailed asthma history, herbal ingredients.
What problems are associated with garlic, gingko?
What is your anaesthetic plan?
Note increased airway pressures management, differential diagnosis, mechanism
of PTx with laparoscopy?
Respiratory and haemodynamic changes associated with laparoscopy and
Trendelenberg position?
Note low BP Management?
Convert to open, bleeding, transfuse 8 units.
Shown coags (incr INR, APTT, dec plt, fibrinogen)
Rx? Ddx? (DIC v Tx complication)
Other mx oxytocics, Factor VIIa
Shown ABG (low pa02 on Fi02 1.0)
Shown CXR
Ddx (overload, ARDS, TRALI)
Ventilatory mx of ARDS
Post-op mx
30 yo man
-MVA with compound #tib/fib
-IVDU methadone 80mg od, oxycodone 20mg bd, diazepam 5mg tds
Undergoes ORIF under epidural block. What do you ask nursing staff to do in
recovery?
Handover
Routine obs
Sedation score, Pain score, Motor and sensory level.
What sensory level do you want?
What problems can occur with epidurals?
What do you give in your epidural and why?
Other possible additives? (clonidine, neostigmine)
Do you want an IDC?
Called to recovery as epidural "not working" what is your approach?
Review pt in person if possible, ABC, history from nurses, check drugs
appropriately admin, check block with ice, bolus given.
There is no response to the LA bolus What is your plan now?
Re-insert epidural
This has a good effect and the patient is discharged to ward. Eight hours post-op, the patient is agitated on
the ward.
Your approach?
See the patient. Assess vitals, pain, urinary retention, electrolytes, withdrawal (drug, alcohol)
Ddx discussed were fat emboli, hyponatraemia, withdrawal.
Epidural has "fallen out", pt in pain options?
Check anticoagulation recent Clexane given. Opt for PCA.
Asked to calculate appropriate dose regime; discuss NSAID, paracetamol,
ketamine.
Still in pain, what other choices?
Sciatic nerve block
Describe approach.
I chose lateral popliteal.
Catheter options, Drug choices.
71 yo man with history of type 2 diabetes (on metformin).
Gastroenterologist wants to do an ERCP. You are new to the hospital. What will
you ask him?
Patient status and location. Indication for ERCP, his technique (ie prone?),
where is ERCP done, what facilities are available?
What facilities do you want?
ANZCA guidelines ..etc..
How do you assess the patient?
He is septic, in ICU. Shown coags (incr INR, APTT)
Causes?
Mx of coagulopathy?
Fluid mx?
Plan for ERCP?
I said GA with ETT in OT. In viva I was directed to the Endoscopy suite and told to plan for sedation
in semi-prone position.
Sats drop to 75%, Mx?
Desat again in recovery. Mx?
Ddx?
What Ix do you want? Shown ABG, CXR (APO)
Causes of APO? How to differentiate between them? Mx?
An 83 year old man has a supracondylar fracture of the arm.
Past medical history: CCF, Emphysema (Resp function tests shown) and lots of medications.
You decide on a regional technique. Justify your choice.
I discussed and described infraclavicular approach to brachial plexus blockade.
Compare this to other approaches (axillary, interscalene, supraclavicular).
Discussed anatomy and complications.
For the viva, you perform an interscalene block. Describe your approach.
How do you use a Peripheral Nerve Stimulator?
What other options are there for locating the brachial plexus? (Paraesthesia, skin stimulation,
ultrasound).
What local anaesthetic agent would you use?
Compare Ropivicaine, Bupivicaine and Laevobupivicaine. Discuss problems with studies.
Toxicity and mechanism of toxicity.
30 min into case, the patient desaturates. How would you manage this?
Differential diagnosis?
(phrenic n, block, Pneumothorax, CCF, excessive sedation, airway obstruction)
Ix II available
(Shown an ABG) Describe.
2 days post-op, the patient is complaining of a pain in his forearm. How would you approach this?
Assessment compartment syndrome, CRPS.
Management of "burning pain"
Discuss Amitriptylline, Gabapentin (doses, adverse effects).
Draw the brachial plexus.