Final FRCA exam viva questions June 2009: Set 2 Set 1 Clinical viva Long case Trauma,53 year old lady, no PMHx available, Multiple rib fractures with flail segment on the right chest, surgical emphysema on right side of chest # Rt femur BP 94/45, pulse 110, Crystalloid drip running, no ECG DPL ++ LOC 15/15 CT scan head and neck – normal FBC - ↓Hb, rest normal U&Es- Normal ABGs- Profound met acidosis, ↓HCO3-, ↓ pH, ↓BE, Normal PCO2, high PO2 on O2/ face mask Questions Present the case to me as if l am at home and you are the on call registrar on ITU asked to see the pt in A&E. What do you think is going on with this patient? Causes of Anaemia in this particular case Interpret CXR( was asked to just dwell on abnormalities) Causes of surgical emphysema What BP do you aim for in this patient during resuscitation? What is permissive hypotension in trauma resuscitation? How would you anaesthetise this patient? Why cricoid pressure? Short cases 1) 42 year old for direct laryngoscopy for vocal cord lesions She has got a few weeks history of stridor What are your concerns in the management of this patient booked on the ENT list? 2) 20 yr old Down’s Syndrome with eisenmenger’s syndrome for dental extraction Anaesthetic management including pre-, intra- and postop University Hospitals Coventry & Warwickshire NHS Trust Acknowledgement: many thanks to the candidates of June 2009 final FRCA viva course Page 1

Final FRCA exam viva questions June 2009: Set 2 What drugs to use and why? 3) Shown a CXR with a mass in the RT middle lobe DDx? Told patient ended up having a thoracotomy so asked about Postop analgesia for thoracotomy and thoracic epidural in detail including side effects and complications

SOE 2(Basic Sciences) 1. Anatomy of sacral canal in a 2 yr old Contents of sacral canal Volumes for different procedures and maximum doses Complications 2. Critical illness neuropathy Causes Management How do you confirm diagnosis Asked in detail how EMG works 3. What is awareness ? Different types Causes How do you monitor? Asked in detail about EEG and BIS 4. Antibiotic prophylaxis in perioperative period Rationale behind NICE guidelines on perioperative antibiotic prophylaxis Antibiotics given for Upper GIT surgery, lower GIT surgery, Dental and Urology procedures and what organisms they cover MRSA- what is it Prophylactic and therapeutic antibiotics used Problems with use of Vancomycin, teicoplanin

Set 2 Long Case: 55 year old Afrocaribbean lady with sickle cell trait, hypertension and obesity for thyroidectomy. FBC – microcytic anaemia TFTS – normal ECG – sinus tachy rate 120, nil else University Hospitals Coventry & Warwickshire NHS Trust Acknowledgement: many thanks to the candidates of June 2009 final FRCA viva course Page 2

Final FRCA exam viva questions June 2009: Set 2 CXR – large goitre causing tracheal deviation -Summarise -How will you manage this lady pre-intra-post op -Airway management discussion, causes of post-op stridor. Short Cases: 1. 19 year old man has been assaulted in a pub. He had a period of loss of consciousness. He presents for repair of fractured mandible. How will you manage this patient? What are the indications for CT head? 2. A 43 year old lady is referred back to you 6 weeks following a hysterectomy during which she remembers being awake. What will you do? Discussion about awareness – definition, incidence, risk factors, measurement. 3. A 78 year old patient is brought to hospital by ambulance. She was found at the bottom of her stairs. She is unconscious and hypothermic. How will you proceed? Differential diagnosis? How do you grade severity of hypothermia? Science Viva 1. Anatomy of the coronary arteries and what they supply. Anatomy of the conduction pathways of the heart. Long QT syndrome – definition, normal value, causes, consequences. 2. How will you manage hypoxia during one lung ventilation? 3. What implications does renal failure have on drugs? Started broad, then discussion on specific types of drugs – muscle relaxants, opioids, nephrotoxins. 4. Mapleson E circuit – discuss. When seriously ran out of things to say they moved on to anatomical differences in paeds vs adults. Set 3 Final FRCA questions LONG CASE A 68 year old male is scheduled for a T8-T10 decompression following a recent onset of weakness in his legs. Surgeons have planned a right thoracotomy approach. He underwent nephrectomy for renal cell carcinoma and a wedge decompression of his thoracic spine for spinal metastases 3 years ago, following which he was in the HDU for a while as he developed respiratory problems. He had severe hallucinations when he was on Moprhine PCA during his recovery. He prefers not to have the PCA again this time. He is a hypertensive, had a TIA a few years ago. He hasn’t smoked for the last 6 months (having smoked for more than 20 years). He is able to walk around but his activities have certainly reduced in the last few months. Medications Amlodipine 10mg, Bendroflumethiazide, Simvastatin, MST 10mg Clinical examination University Hospitals Coventry & Warwickshire NHS Trust Acknowledgement: many thanks to the candidates of June 2009 final FRCA viva course Page 3

Final FRCA exam viva questions June 2009: Set 2 HR – 60/min 160cm, wt -86kg BP- 130/80 mmHg BloodsABG: pH- 7..38 pO2 – 12.99 pCO2 – 4.6 BE - -5.5 fiO2 – 21% Hco3 -16.8 Gluc -17.1 Lact – 4.5

chest – few crackles B/L basal

Ht-

S1S2 heard, no murmurs U & Es: Na - 134 K – 4.3 Hco3 -28 Alk Phos -45 Bilirubin -7 Alb - 32 tot prot - 50 Urea – 25 Creatinine – 194

ECG – Prolonged PR interval, LAD, 60/min CXR – bibasal infiltrates, R lower lobe hilar infiltrates – small, circumscribed lesions (not very clear), L lower lobe collapse, consolidation (partial), L heart border not well visualised, flat diaphragms, faint metal shadow behind the heart (clip on the spine). Questions asked: •

Summarise the case

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What is wrong with his biochemistry?

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Why do you think glucose and lactate are elevated?

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What would you see if this were DKA?

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Interpret ABG

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Why are his urea, creatinine elevated?

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Interpret ECG

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What are the causes of 1 degree heart block?

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Why do you think this man has a first degree heart block?

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What changes would you see on the ECG if someone had a COAD?

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What are the CVS changes in a pt with COAD?

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Interpret CXR

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What are those infiltrates?

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What are the signs of collapse, consolidation? How would you differentiate?

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What are the lesions on the right lower lobe?

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Final FRCA exam viva questions June 2009: Set 2 •

What else do you see? ( artefact behind the heart)

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Lets assume that we don’t have much time for investigations, how would you optimise him?

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Advise to stop smoking – how do you think that would help?

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What other effects does smoking have? (long term smoking, CVS)

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What is your plan of anaesthesia for him?

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Why DLT?

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Which DLT would you prefer? Right or left – why?

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Explain in detail – how do you insert a DLT

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How would you check it?

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How would you initiate OLV?

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Hypoxia halfway through – how would you manage?

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Everything has been done including clamping pulmonary artery, hypoxia is still unsettled, what else can you do? Would you consider replacing it with SLT if there is unsettled hypoxia?

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What is your plan of postop analgesia?

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Why would you not consider doing an epidural or paravertebral prior to the surgery instead of asking the surgeon to do it?

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What problems would you face if you are going to do it?

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How would you manage him in HDU postop?

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What would you do if he needs more analgesia?

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Would you give him morphine PCA? Any other PCA?

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What would you tell him during PCA prescription?

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What other concerns would you have?

SHORT CASE 1. A 4 year old boy is scheduled for a squint surgery as a day case procedure

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Final FRCA exam viva questions June 2009: Set 2 •

What are the issues?

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What problems would you face pre, intra and post operatively?

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How common is MH amongst those who present for squint surgery?

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What other comorbidities are common?

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What is the most important complication intraoperatively?

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What would you tell the parents preoperatively?

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Any premedication?

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What is your plan of anaesthesia?

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Options for post op analgesia

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What can the surgeon do to help the post op analgesia?

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What measures would you take to reduce the incidence of PONV?

2. Tracheostomy •

Indications

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What is the most important complication doing a trachesotomy in a trauma patent?

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Why is it so important in ITU patients?

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Timing of tracheostomy in ITU patients

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Any criteria for tracheostomy in ITU patients? How do you decide who should have it?

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What are the benefits for the patient?

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What are the complications?

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What is the most important complication for which you get called for in the ward?

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What are the reasons for the obstruction?

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What would you do?

3. A 71 year old man for TURP surgery, he is a hypertensive, had 2 MIs last one being 8 months ago, COAD, smoker. He is on bendrofluazide, atenolol. He has limited exercise tolerance.

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Final FRCA exam viva questions June 2009: Set 2 •

How would you assess him?

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What would you ask regarding his MI?

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How would you assess functional capacity?

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COAD – what would you ask?

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What else would you want to know?

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What investigations do you want? Why?

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What is your plan of anaesthesia? Why?

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What are the advantages of SAB?

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What is the most important complication of SAB?

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How would you prevent it?

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What is the most important complication intraoperatively?

CLINICAL SCIENCES 1. Internal Jugular vein anatomy

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Explain in detail the anatomy of internal jugular vein

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Relations in the neck, lower neck

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Course of subclavian vein – left and right

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How would you insert a CVP line?

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Indications of a CVC insertion

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Do you always need USG? Where would you not use it?

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Surface landmarks for insertion

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Complications

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Catheter related blood stream infection – what factors influence it?

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How can you prevent it?

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Final FRCA exam viva questions June 2009: Set 2 2. Cerebral blood flow

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What factors influence CBFlow?

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How do they influence? (diagram expected)

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Pco2 influence on CBF – is that a direct effect or indirect effect?

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What is the perfusion pressure?

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What factors influence CPP?

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How is MAP, perfusion controlled in the brain?

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What factors affect autoregulation?

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Mechanism of autoregulation

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Immediate management of ICP

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How would you treat if it is due to elevated CSF pressure?

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How would you treat if it is due to increase in brain tissue volume?

3. PCA •

What features are seen on a PCA?

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Explain every feature and its importance – bolus dose, lockout interval, background infusion, hourly dose limit

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What other features are available?

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What security features are present?

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If you design your own PCA what features would you want on it?

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Final FRCA exam viva questions June 2009: Set 2 •

Whom would you not prescribe a PCA for?

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What would you tell the patient when you prescribe PCA? What would you tell the staff?

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What alarms are present on the PCA machine?

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What is the advantage of a PCA?

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Common cause for being called to the ward

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What else would you prescribe? Why?

4. Sterilisation and disinfection

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On a difficult airway trolley – which items are single use/ reusable?

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Single use items – what are the advantages?

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Problems with use of single use items

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How are the single use items sterilised during manufacture?

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What other radiation other than gamma can be used?

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Which items are reusable?

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How would you sterilise each one of them?

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Which items can you/ can you not autoclave?

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How does an autoclave work?

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What is the temperature/ pressure?

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How would you know if items are sterilised well or not?

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Explain about the indicator strip

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What is usually on the strip? (bacterial colonies etc)

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What other mechanisms are used for sterilisation?

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How do you clean fibreoptic scope?

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What are the concerns with reusable equipment?

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Final FRCA exam viva questions June 2009: Set 2 •

What are prions? What does it cause?

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What is the risk of transmission?

Set 4 1. Long Case (10 + 20 min.) 17 month old child, admitted via A&E, has eaten Bombay mix (peanuts) about 2 hours, was initially choking & blue but recovered and ate a banana later. Initially some creps left chest basally. Sats = 94% on air, grunting, playing on ward CXR shows hyperinflation of right lung and slight mediastinal shift to the left. -

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Summarise the case (Inhaled foreign body, some hypoxia on air, not compromised, issues: paediatric case, parents, risk of aspiration, possible chemical pneumonia) Explain the CXR (Ball-valve mechanism with hyperinflation of the lung, peanut/s seem to be in right main bronchus) Explain pathophysiology of the ball-valve mechanism (subatmospheric pressure during inspiration leads to opening of airways, during expiration closure of airways and hyperinflation of lung) Added breath sounds on the left explained as chemical pneumonia (from the oil of the peanuts) due to initial inhalation into left lung, then choking & coughing and movement of peanuts to the right lung/bronchi What Premedication would you give ? Atropine/Glycopyrrolate (to reduce secretion, but may lead to thickening of mucous) EMLA / Amethop (+ what it contains) Explain Anaesthetic Management See patient  A,B,C, consent parents, Bronchoscopy should be postponed because child not compromised, Premed., Anaesthetic equipment checked, trained assistant, senior anaesthetist (paediatric ?), Airway equipment, Anaesthetic & Emergency drugs Inhalational induction with spontaneous ventilation (Sevoflurane+Oxygen, deep anaesthetic required), I would avoid N2O (because of hyperinflated right lung), ventilation through bronchoscope possible, asked about different types of bronchoscopes (Storz, Negus) Prior to bronchoscopy spraying of pharynx and vocal cords with lidocaine (max. 3mg/kg, 1 puff=10mg) Post-op PRN paracetamol (not very painful) Possible sequelae of bronchoscopy (perforation, pneumothorax, tachycardia, bleeding …)

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Final FRCA exam viva questions June 2009: Set 2 Another set Clinical Long Case 17mo male currently on childrens ward. Was brought into accident and emergency by mother due to grunting. 2hrs earlier he was eating Bombay mix when had an episode of coughing and went blue. Shortly afterwards was recovered and was well enough to eat a banana and chocolate biscuit. PMH: Fit and well. No prev Gas. O/E Sats 94% on air CXR: looked quite normal ? slightly overexpanded R side 1) 2) 3) 4) 5) 6) 7)

Summarize the case What is the underlying pathology? – wanted ball valve mech Present the CXR How would you manage the case? Would you give any premed? ?dose of oral atropine How would you do a gas induction? Resp distress in recovery how would you manage? What is diff diagnosis?

Short cases: 1) 80yo male was eating lunch when developed severe pain and hunched over. Brought into A+E. BP 60/30. Surgeons believe ruptured AAA. How would you manage? How would you decide if he should have operation? ?scoring system – didn’t know of one How would you resuscitate? How would you anaesthetise? Epidural? 2) 70yo female on ITU for 7days with community acquired pneumonia. Develops weakness. What is the differential diagnosis? How would you diagnose critical illness neuropathy/myopathy. What is the cause? 3) 2yo post grommets in recovery. Agitated and distressed. How would you manage? ABC. What can cause agitation in recovery? SVT rate 300. How would you manage? ALS algorithm. Who else would you involve – wanted cardiologist/paediatrician. Dose of adenosine in child. Clinical Science Anatomy: Femoral triangle, boundaries, facial layers, how would you block? How does 3 in 1 block differ? University Hospitals Coventry & Warwickshire NHS Trust Acknowledgement: many thanks to the candidates of June 2009 final FRCA viva course Page 11

Final FRCA exam viva questions June 2009: Set 2 Physiology: Preoxygenation. What is it? How does it work? How long does it last for? What are the possible complications? pCO2 vs minute ventilation Pharmacology: Chronic opioids. Which groups of people are on long term opioids? What limits the upper dose of opioids in these pts? How can opioids be administered? How would you manage acute pain in these pts? Physics and Clinical measurement: Ultrasound – how does it work? What are it’s uses? Nice guidelines re central line insertion, regional block, epidural. How does Doppler work? Another set LONG CASE: 17 month old child- eaten ‘Bombay mix’- 2 hours ago- who had choking episode but subsequently ok Has eaten crisp and banana since episode. Presents to hospital- red faced, grunting, sats 94% on room air. Left sided harsh breath sounds No PMH Q: summarise case CXR- ? tracheal deviation to left? Possible LUL collapse/ consolidation. Q: Anaesthetic Mx Would you wait for fasting? How would you treat child in mean time Induction of child- Gas vs Iv RSI I said partial obstruction as ‘grunting’ I said- treat with oxygen, nebs, po Dex- watch carefully and wait for fasting- then with help- gas induction to keep spontaneously breathing.- Sevo/O2. then secure iv access. Use of Storz rigid bronchoscope- attach Ayre’s T piece to maintain O2 and sevo while ENT surgeon retrieved foreign body. If they were struggling-and child was desaturating- to paralyse and intubate- control airway. Q: Problems with ‘bombay mix’- they wanted to know about inflammatory response to ? Arachis oil? University Hospitals Coventry & Warwickshire NHS Trust Acknowledgement: many thanks to the candidates of June 2009 final FRCA viva course Page 12

Final FRCA exam viva questions June 2009: Set 2 Q: Where would you keep the child post op. I said PICU to observe as child could possibly have some respiratory complications.

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Final FRCA exam viva questions June 2009: Set 2 Short Cases (20 min.) 1. Ruptured AAA (80 years old, in A&E, BP=60/40, tachycardic, sweaty,clammy, drowsy) -

asked about initial management Severe hypovolaemic shock: A,B,C,D ; 2x large bore iv-cannuale, bloods (FBC, Clott, Fibrinogen, U&E’s, Cross-match blood), ABG including Hb, aggressive iv-fluids resuscitation (uncrossmatched blood, crystalloids, colloids), arterial line, inform senior anaesthetist/second pair of hands required, get op. theatre ready & surgeons scrubbed up, move to op. theatre asap to stop the bleeding, may arrest during induction of anaesthesia (so I would not intubate in A&E), speak to blood bank & haematologist (FFP, Cryo, Platelets required) - asked about endpoint of fluid resuscitation I said BP systolic of ~ 100 mmHg (to avoid increased haemorrhage) - Strategies to prevent renal failure Experienced surgeon, reduce time of aortic cross clamping, adequate hydration, osmotic diuresis with Mannitol (he wanted something else ?) - What would be his prognosis if he developed ischaemic bowel post-op I said I don’t know the percentage but that he would have a very high mortality and that I would tell the relatives that it is likely that he is not going to survive 2. 76 year old woman ventilated on ITU for 1 week due to severe sepsis, now generalised weakness -

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What is the differential diagnosis Critical illness polyneuromyopathy – yes Classified into CNS, Metabolic, Musculoskeletal, Drugs CNS – stroke, cerebral bleeding, spinal cord damage Metabolic – electrolyte derangement, sepsis (catabolism), parenteral nutrition Musculoskeletal – prolonged ventilation, Myasthenia gravis, Myasthenic syndrome, Drugs – muscle relaxants, steroids, Antibiotics, sedatives (they were happy with that) How is diagnosis of critical illness neuromyopathy made By exclusion of other diagnosis, EMG (neurophysiological studies) Management: Exclude CNS-damage, physiotherapy & mobilisation, adequate & enteral nutrition, correct electrolytes, avoid precipitating medication

3. 2-year old post-op grommets, distressed, unsettled in recovery with tachycardia (being shown ECG with HR= 250/min, SVT-narrow complexes) - asked about differential diagnosis

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Final FRCA exam viva questions June 2009: Set 2

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unfamiliar environment, absence of parents, post-op confusion, residual anaesthetic drugs, pain, hypothermia, drug side effects, hypoxia, hypercarbia, upper airway obstruction, sepsis … Hypotensive  compromised DC-Cardioversion with 4J/kg (approx. 40-50 J –they were happy with that) Find the cause and treat (dehydration, electrolytes, infection) What are the other treatment options if not compromised ? vasovagal manoeuvres, adenosine (I mentioned amiodarone, beta-blockers as well)

BASIC & CLINICAL SCIENCES 1. Anatomy – Femoral triangle - Draw a diagram - asked more specifically about floor I said psoas muscle & pectineus muscle, but he was looking for something else (muscle fascia) - What covers the femoral triangle I said fat tissue, subcut. Tissue, skin - asked about usefulness of anatomy of fem. Triangle for anaesthesia - Femoral nerve block, 3-in-1 block, Fascia iliaca block - Arterial cannulation (continuous BP, cardiac catheterisation), Femoral vein for CVC-line and Vascath-Haemofiltration - Femoral nerve block and 3-in-1 block – how does it work and how to perform & indications Spread of LA towards lumbar plexus (enhanced by distal compression) Nerve stimulator (o.3-0.5 mA) and 15-20ml 0.375% Chirocaine for femoral nerve block, about 30ml 0.375% for fascia iliaca block For THR, NOF-ORIF, anterior aspect of thigh (skin graft, burns, dressing Change), as well as analgesia for femoral bone fracture as well as knee operations/replacement - Been asked if I would do a femoral nerve block only for some operations I said: No. Only supplementary to either neuraxial block or GA for analgesia 2. Physiology – Pre-oxygenation -

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Who is at increased risk of hypoxia ? Patients with reduced FRC Phsiologically – children, elderly, pregnancy, high metabolic rate (sepsis, burns) etc. Pathologically – acute abdomen (bowel obstruction), anaemia/hypovolaemia, lung pathologies Describe how you pre-oxygenate a patient Purpose: to denitrogenate the lungs and fill the FRC with Oxygen Oxygen stores are: FRC, Oxygen bound to Hb and dissolved in blood I presented the equation for Oxygen-flux and calculated the additional time before hypoxia occurs when the FRC is filled with Oxygen (FRC of 2.5-3

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Final FRCA exam viva questions June 2009: Set 2 litres, Oxygen-uptake 3.5 ml/kg/min at rest for 70kg man 40 years) approx. +5-6 min. 3. Pharmacology – Long term intake of opioids (pain) -

Which patients need long term opiods Cancer pain Non-cancer pain (e.g. neuropathic pain) Drug abuser (including methadone) - What will be the opiod requirements peri-operatively ? Increased due to tolerance To be given regularly Breakthrough pain with higher dose or different agent (e.g. Oxycodone) - Asked about Oxycodone I told them the dose but was unable to say any more details - Tell me about morphine (pharmacokinetics, pharmacodynamics) Talked about side effects, bioavailability, metabolism (active metabolites) 4. Physics – Ultrasound -

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Uses in Anaesthetics For Regionals – nerve blocks, location of epidural space For Cannulation – int. jug. Vein, arterial etc. For diagnostic purposes (pleural effusions, FAST scan, Transthoracic echo, TOE, Doppler probe, DVT) Physiotherapy How does it work Ultrasound uses sound waves above human hearing (> 20.000 Hz) Piezoelectric crystall (generates and receives ultrasound waves), reflection and absorption of waves in tissue  image generation and 2D-picture on monitor What info do you get from TOE ? Heart-filling, wall motion abnormalities (hypokinesia, akinesia), ejection fraction (estimation), heart valves (pressure gradients, morphology, regurg., stenosis), Pericardial effusion Started talking about Doppler-effect before bell rang

Set 5 Long case Elective, 67 yr old male for elective open AAA repair, with (still) hypertension(160/90,on enlapril and diuretics) and IHD with recent episode of ? ACS,raised creatinine , Ex heavy smoker. Investigations provided(Abnormal ones…) Creat 180, WCC outside the refernce range. Low K(on diuretics). CXR Hyprluscency, cardiomegaly University Hospitals Coventry & Warwickshire NHS Trust Acknowledgement: many thanks to the candidates of June 2009 final FRCA viva course Page 16

Final FRCA exam viva questions June 2009: Set 2 ECG- Ant lat ischemic changes, Left axis deviation Questions. Summarise the case What are the main problems that worry you? How would you approach that? What additional investigation for IHD would you do? What you will look for in tread mill test? What you look for in echo? Any other investigation? What you want to know about recent ACS? What about the BP. would you treat it or will proceed with surgery? What grade is it? What are Grade 1 fundoscopic changes? What would be the reason for elevated creat. What medications would you prepare before the case and for what reasons? What are the concerns during the intra op period? What is the effect of x clamp? How would you manage hypotension after x clamp removal? What are analgesic options? When would you start? Where do you monitor the patient post op? short cases young woman wi previous PONV who was worried about more PONV after a lap steri. What are the risk factors for PONV? How would you manage this case? What anaesthetic techniques are better for this patient? What medications would u use,dose, action and when to give? Why ponv in female patients? hypertensive (ie pre-eclamptic Bp 150/105) woman for emerg LSCS for crap CTG (mostly based around assessment of pre-eclampsia) What is your diagnosis? What is PE? Why is it? What would u do in this case, will you proceed or treat the BP? How would you treat the BP? What is non-re assuring CTG? Timing, Anaesth technique, and reasons for it. 72yr old lady's PFT results as pre-op Ix for thoracotomy for lung Ca. What is obstructive defect, restrictive defect, Draw the NORMAL and Abnormal patterns. Anatomy Sympathetic/Para sympatheic Nerve supply of EYE? Lesions at different levels,signs and causes of it? University Hospitals Coventry & Warwickshire NHS Trust Acknowledgement: many thanks to the candidates of June 2009 final FRCA viva course Page 17

Final FRCA exam viva questions June 2009: Set 2 Difference between Hypermeatbolic state and starvation? Question were mainly based on Protoen/lipid metabolism Pulse Oximetry, technique, abnormal response, reason for abnormal response, Graph of oximetry curves. Neuropathic pain, defention, examples, types, signs, symptom and treatment? Treatment options Mechanism of action of Anti-depressent ,Anti-psychotics, and Anti-convulsants? Capsacin?

Set 6 Long case A similar case appears in one or other of the books: Obese 53 year old lady RTA prolonged extraction. No history in addition. C/O R hip and Chest Pain HR 100, BP 90/45, Wt 98 kg, ht 1.68m Investigations revealed Hb 11 PCV down to 35 (presumed blood loss and dilutional anaemia secondary to resuscitation with non blood fluids). Normal renal function but venous Bicarb of 19, BM 11.4, WCC 18.6 ABG with metabolic acidosis ph 7.26, BE -8.9, PO2 31 on Oxygen >21% on the form. Positive DPL CXR – Multiple rib # R side with Flail segment clear on the right, CD in situ, small apical pneumothorax, pulmonary contusion on same side. Rotated film, somewhat overpenetrated. CT head and neck reported as normal Questions: Summarise the history and examination findings. How would you manage this lady? – ATLS approach, immobilise the CSpine (distracting injury – so immobilise until can be cleared safely), Oxygen (said that I would ensure appropriate device not just >21% - there was obviously a mark for each of these two) Circulation – additional bloods, XM 6 U, resuscitate with crystalloid initially and then blood (some people asked to discuss the classification of shock – I had called it class 3 in the summary and they didn’t bother to ask me about it). Also monitor to look for evidence of cardiac contusion. D – Asked me about AVPU score, Pupils and GCS – detail on AVPU E – Exposure – note hip pain so complete top to toe examinations, maintain temperature, complete trauma series and log roll, check BM What do you make of the raised BM, WCC Stress response, fat lady may be diabetic – do I care about these values right now – no not really! How would you approach getting more history? – AMPLE (asked to expand on that), collateral and so on.

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Final FRCA exam viva questions June 2009: Set 2 What does the +ve DPL suggest? I felt it was going quite well so I suggested that it must mean that the CT scanner was broken! Quickly added that it was a diagnostic tool for intraperitoneal bleeding Resuscitation – where do you want to do this? Benefits and disadvantages of doing it in ICU, A&E, Theatre anaesthetic room. Analgesia in the interim Peri-op management – Running short of time so quickly through: Invasive monitoring, RSI with manual in line immobilisation, opioids, usual delivering a warmed, resuscitated, normoglycaemic patient to ITU – ventilated post op. What is the optimum post op Mx of flail chest? What are the pain control options for multiple rib #? Really very straightforward, nice examiners set the pace nicely. Short cases: 1.Hoarseness of voice in heavy smoker for direct Laryngoscopy by ENT differential diagnosis, problems of anaesthetising – (fished around for clues here and landed on management of the airway as the bit they wanted to talk about) management of anaesthesia, options for oxygenation and delivery of anaesthesia in these patients. 2. Heavy smoker again, chest pain, chronic cough, CXR of R lung lesion – differential Diagnosis and other questions to ask. Patient having lobectomy – choice of Tube (L sided DLT) vs Bronchial blocker, placement and confirmation, post op analgesia options ED vs Paravertebral block benefits and disadvantages 3. Down’s syndrome patient with eisenmengers for ischaemic leg – Discuss problems with Eisenmengers and Downs syndrome generally then possible causes for the embolic phenomena and why is this patient at high risk for thromboembolism (polycythaemia, R-L shunt, Dilated chambers with tendency to form clots and reduced movement due to severe hypoxia I think) Flew by – nothing too taxing – all questions that appear in one form or another in the books. Basic Sciences Pharmacology of Antibiotic prophylaxis – sounds dreadful but they carried me through without any problems. Discussion of mechanisms, groups who benefit (High risk patients, Specific Surgical groups and Special risk groups), Specific drugs for the organisms in question then a bit on MRSA and the development of Abx resistance, Tx regimen for MRSA topical and systemic – problems with Vancomycin. Then discussion of new NICE guidance on ABx prophylaxis in valve disease patients – is there any controversy that you are aware of with these guidelines? Anatomy for Caudal – straight out of the book – very easy, some people talked about the procedure – we didn’t just talked about complications and doses and spread of LA – Armitage regimen etc Critical Care Weakness – causes, diagnosis and the EMG – how is it done, what do they record and what are the differences between CIPN and CIM, got a bit bogged down in the actual vs perceived weakness in the context of Sedative agents – this wasted some time but didn’t upset them unduly Awareness monitoring – Risk factors for awareness – what does the college say on awareness – examiner got a bit upset when I suggested that TIVA was a risk factor I said that there is no RCT showing an increased risk but that the inability to monitor University Hospitals Coventry & Warwickshire NHS Trust Acknowledgement: many thanks to the candidates of June 2009 final FRCA viva course Page 19

Final FRCA exam viva questions June 2009: Set 2 true effect site concentration plus the method of administration must make for a theoretical increase in risk. Methods of monitoring - Confounders of the physiological parameters and how accurate they are. Mechanical methods and BIS monitoring – recent guidelines on the use of BIS. All in all a much easier viva than any I had before the exam. Examiners have clearly got to get certain points out so often don’t let you waste time taking systematic approaches and classifying broadly – this I think is an effort to get you through the question quickly and tick all the boxes. It can feel a bit disruptive to your rhythm however so don’t let it disturb you if you feel that you haven’t been allowed to expand on something – they’re leading you where the marks are! Long case A similar case appears in one or other of the books: Obese 53 year old lady RTA prolonged extraction. No history in addition. C/O R hip and Chest Pain HR 100, BP 90/45, Wt 98 kg, ht 1.68m Investigations revealed Hb 11 PCV down to 35 (presumed blood loss and dilutional anaemia secondary to resuscitation with non blood fluids). Normal renal function but venous Bicarb of 19, BM 11.4, WCC 18.6 ABG with metabolic acidosis ph 7.26, BE -8.9, PO2 31 on Oxygen >21% on the form. Positive DPL CXR – Multiple rib # R side with Flail segment clear on the right, CD in situ, small apical pneumothorax, pulmonary contusion on same side. Rotated film, somewhat overpenetrated. CT head and neck reported as normal Questions: Summarise the history and examination findings. How would you manage this lady? – ATLS approach, immobilise the CSpine (distracting injury – so immobilise until can be cleared safely), Oxygen (said that I would ensure appropriate device not just >21% - there was obviously a mark for each of these two) Circulation – additional bloods, XM 6 U, resuscitate with crystalloid initially and then blood (some people asked to discuss the classification of shock – I had called it class 3 in the summary and they didn’t bother to ask me about it). Also monitor to look for evidence of cardiac contusion. D – Asked me about AVPU score, Pupils and GCS – detail on AVPU E – Exposure – note hip pain so complete top to toe examinations, maintain temperature, complete trauma series and log roll, check BM What do you make of the raised BM, WCC Stress response, fat lady may be diabetic – do I care about these values right now – no not really! How would you approach getting more history? – AMPLE (asked to expand on that), collateral and so on. What does the +ve DPL suggest? I felt it was going quite well so I suggested that it must mean that the CT scanner was broken! Quickly added that it was a diagnostic tool for intraperitoneal bleeding University Hospitals Coventry & Warwickshire NHS Trust Acknowledgement: many thanks to the candidates of June 2009 final FRCA viva course Page 20

Final FRCA exam viva questions June 2009: Set 2 Resuscitation – where do you want to do this? Benefits and disadvantages of doing it in ICU, A&E, Theatre anaesthetic room. Analgesia in the interim Peri-op management – Running short of time so quickly through: Invasive monitoring, RSI with manual in line immobilisation, opioids, usual delivering a warmed, resuscitated, normoglycaemic patient to ITU – ventilated post op. What is the optimum post op Mx of flail chest? What are the pain control options for multiple rib #? Really very straightforward, nice examiners set the pace nicely. Short cases: 1.Hoarseness of voice in heavy smoker for direct Laryngoscopy by ENT differential diagnosis, problems of anaesthetising – (fished around for clues here and landed on management of the airway as the bit they wanted to talk about) management of anaesthesia, options for oxygenation and delivery of anaesthesia in these patients. 2. Heavy smoker again, chest pain, chronic cough, CXR of R lung lesion – differential Diagnosis and other questions to ask. Patient having lobectomy – choice of Tube (L sided DLT) vs Bronchial blocker, placement and confirmation, post op analgesia options ED vs Paravertebral block benefits and disadvantages 3. Down’s syndrome patient with eisenmengers for ischaemic leg – Discuss problems with Eisenmengers and Downs syndrome generally then possible causes for the embolic phenomena and why is this patient at high risk for thromboembolism (polycythaemia, R-L shunt, Dilated chambers with tendency to form clots and reduced movement due to severe hypoxia I think) Flew by – nothing too taxing – all questions that appear in one form or another in the books. Basic Sciences Pharmacology of Antibiotic prophylaxis – sounds dreadful but they carried me through without any problems. Discussion of mechanisms, groups who benefit (High risk patients, Specific Surgical groups and Special risk groups), Specific drugs for the organisms in question then a bit on MRSA and the development of Abx resistance, Tx regimen for MRSA topical and systemic – problems with Vancomycin. Then discussion of new NICE guidance on ABx prophylaxis in valve disease patients – is there any controversy that you are aware of with these guidelines? Anatomy for Caudal – straight out of the book – very easy, some people talked about the procedure – we didn’t just talked about complications and doses and spread of LA – Armitage regimen etc Critical Care Weakness – causes, diagnosis and the EMG – how is it done, what do they record and what are the differences between CIPN and CIM, got a bit bogged down in the actual vs perceived weakness in the context of Sedative agents – this wasted some time but didn’t upset them unduly Awareness monitoring – Risk factors for awareness – what does the college say on awareness – examiner got a bit upset when I suggested that TIVA was a risk factor I said that there is no RCT showing an increased risk but that the inability to monitor true effect site concentration plus the method of administration must make for a theoretical increase in risk. University Hospitals Coventry & Warwickshire NHS Trust Acknowledgement: many thanks to the candidates of June 2009 final FRCA viva course Page 21

Final FRCA exam viva questions June 2009: Set 2 Methods of monitoring - Confounders of the physiological parameters and how accurate they are. Mechanical methods and BIS monitoring – recent guidelines on the use of BIS. All in all a much easier viva than any I had before the exam. Examiners have clearly got to get certain points out so often don’t let you waste time taking systematic approaches and classifying broadly – this I think is an effort to get you through the question quickly and tick all the boxes. It can feel a bit disruptive to your rhythm however so don’t let it disturb you if you feel that you haven’t been allowed to expand on something – they’re leading you where the marks are!

Set 7 Clinical Long Case 28yrs old woman 4 days post delivery. 4th child. Uneventful delivery. Has become unwell over past 2 days. Despite having ERPC 8 hours ago has continued to deteriorate and is now needing an urgent hysterectomy. She has grown a Group A Streptococcus from blood cultures and is on Augmentin and Clindamycin and heparin BD O/E Drowsy (GCS 13/15). Temp 38.5C. BP 120/90. HR 120. RR 30 Investigations ECG – sinus tachycardia CXR – small left effusion. CVC line in situ Bloods – Hb 11.0, PCV 0.35, platelets 22, INR 1.1 Na 138, K 3.9, Ur 8, Cr 110 Raised Alk Phos and Bilirubin ABG – on FiO2 0.7 CPAP – PaO2 12, PaCO2 3.5, HCO3 17, BE -7, Lactate 1.8 Questions Based on going through investigations in detail esp the blood gas. Reasons for low platelets. Further pre-op management(i.e. haematologist, microbiologist, ITU, lines etc.) plus in detail how to interpret an ECG (e.g. working out rate, axis etc.) and CXR. Briefly discussed anaesthetic technique and intraoperative management. I said I would use cardiac output monitoring – therefore discussed oesophageal Doppler and what the different values represent What inotropes may be needed Quite extensive post-op Mx on ITU. Surviving Sepsis. Would I use steroids. Post-op analgesia SHORT CLINICAL 1) Paediatric bleeding tonsil – standard question looking at pre-op management, induction and intraop Mx 2) Head injury with low GCS and hard collar in place. Discussed how to clear the CSpine in this situation. Problems with keeping collar in place (esp. Keen to discuss University Hospitals Coventry & Warwickshire NHS Trust Acknowledgement: many thanks to the candidates of June 2009 final FRCA viva course Page 22

Final FRCA exam viva questions June 2009: Set 2 decreased CPP due to possible raised CVP). How to manage the patient when collar removed. MRI vs CT scan. Problems with monitoring in CT 3) Unbooked 30yr old presents for emergency C-section due to foetal distress. Sickledex positive. – had to spoke about pre-op management, why bother doing sickledex testing, types of abnormal sickle diseases (I had to list HbAS, HbSS, HbSC, Hb SThal and talk about the phenotypical picture of allof them.) Post op becomes SOB, hypoxic, pleuritic chest pain. – very brief discussion on diagnosis, acute chest syndrome, exchange transfusion. SCIENCE VIVA 1. Anatomy – cardiac circulation – arterial and venous in detail. Moved on to clinical discussion about a patient who developed a LAD occlusion – why they develop chest pain, how to manage an acute MI, contraindications to thrombolysis. How ECG changes evolve during the course of a MI from acute to chronic 2.

Physics – capnography. Principles, sidestream vs mainsteam. Draw the trace and explain various phases. Small discussion on alveolar time constants. Abnormal capnography traces esp. Interested in raised CO2. Best monitor – capnography or sats probe

3. Pharmacology. Started off as a clinical scenario. How to manage a patient with asthma presenting for surgery. Discussed pre-op investigations – pulmonary function tests and peak flow. ? need for CXR. How to grade severity of asthma. What determines bronchial tone. Parasympathetic vs. Sympathetic Nervous system. Local mediators. Discussion on histamine and it’s release. How would I modify my anaesthetic for an asthmatic. What drugs would i avoid. LMA or ETT. What type of asthmatics are sensitive to NSAIDS 4.Physiology Proning. What physiological changes occur in a healthy patient who is proned. Discussed in detail the various respiratory changes Why do we prone patients on ITU Problems with proning. How long do you prone them for (20 hours with 4 hour break) ARDS – definition. Different ventilator strategies. ARDSnetwork

Set 8 Long Case: 76 yr/F, scheduled for mastectomy and axillary node clearance for advanced cancer of breast; she is a known COPD with limited exercise tolerance and previous hospital University Hospitals Coventry & Warwickshire NHS Trust Acknowledgement: many thanks to the candidates of June 2009 final FRCA viva course Page 23

Final FRCA exam viva questions June 2009: Set 2 admissions for exacerbations; had aortic valve replacement 3 years ago; she had prednisolone two months ago for her COPD; Clinical findings: palpable liver, no creps, no oedema Medications- warfarin, beclomethasone/salbutamol/salmetorol/ipratropium inhalers and theophylline tabs, frusilax Blood: Hb 10.5, WCC 13.5 (granulocytosis), Normal MCV, INR 1.7 Biochem: normal electrolytes and slightly raised urea Blood gas: on air, po2 of 9.0 pco2 5.5 and rest normal PFT : Severe obstructive (FEV1/FVC of 33%) no info on post inhaler CXR: emphysematous, ?infection, Aortic valve ECG: 1 deg block 1. Summarise/main problems 2. Asked about investigations- brief discussion about all of them –not too probing- whats missing in PFT (post bronchodilator values), cause of anemia, raised urea in this patient 3. Some discussion about warfarin, what to do with it; if changing to heparin, when? Target INR 4. Is she fit to be anaesthetised-obviously not!! ; why not-severe COPD and possible infection, possible cardiac failure; need further investigations and optimisation; but balance the risk and benefit of delaying surgery for cancer and increased perioperative risk 5. What further investigations-Echo/CPET, what to look for in ECHO 6. Why do you say this COPD is severe- all possible treatment and ratio of 33% 7. What organizational arrangements you will make before planning for surgeryICU 8. Anaesthetic option- GA/ETT/IPPV with interpleural/paravertebral; i would avoid epidural 9. Post-op: sudden dyspnea in HDU, how will you approach, DD Short Cases: 1. Causes of secondary brain injury and how to minimise them; discussion on ICP reduction 2. 32 weeks pregnant with cord prolapsed-initial management-anaesthetic options-GA-Difficult intubation-LMA 3. ECG with LBBB- 40yr man- for knee arthroscopy as day case- he has travelled a long way and made lot of arrangements for this operation (??)University Hospitals Coventry & Warwickshire NHS Trust Acknowledgement: many thanks to the candidates of June 2009 final FRCA viva course Page 24

Final FRCA exam viva questions June 2009: Set 2 Need further investigation and examination- towards aortic stenosis-and then came back and said, assume he is clinically normal; would you anaesthetize; literally pushing me towards anesthetising him; but i denied till the very end; finally saying, at least ask a second opinion if not a cardiologist

Basic science:

Anatomy: 1. Indications for tracheostomy 2. When do you decide about tracheostomy for weaning in ICU 3. How will you do percutaneous trachy 4. Complications 5. Anaesthetising a patient with long term tracheostomy 6. Draw a diagram of C/S at C6 level (including whats behind the vertebra, of course!)-finally a question on anatomy Physiology: 1. Causes of hypoventilation 2. Why is hypoventilation bad 3. How will you manage a patient with hypoventilation 4. Led into alveolar gas equation and respiratory quotient and factors influencing the R, when will the pH2O significant (high altitude) Pharmac: 1. Types of shock 2. How will you manage each 3. Inotropes- how do they work; not happy with alph and beta receptors; they wanted cAMP and non cAMP agents (PDEi were included in the cAMP University Hospitals Coventry & Warwickshire NHS Trust Acknowledgement: many thanks to the candidates of June 2009 final FRCA viva course Page 25

Final FRCA exam viva questions June 2009: Set 2 category- they wanted Digoxin after all....Ah! then a discussion on digoxin mechanism of action ?Stats: (many found this question difficult) 1. Scoring systems used in ICU 2. GCS/sedation....not happy....APACHE...they were keen to discuss on this 3. How do they devise scoring systems 4. How do you calibrate 5. Whats is purpose of this 6. Disadvantages

Set 9 Long case 70 year old man had a AAA repaire 4 days ago . was extubated in theatres post operatively and then transferd to ICU. He suddenly developed shortnesss of breath and tachycardia. PMH – HTN , well controlled angina, TIA claudication, NIDDM, Labrynthitis Drug – Aldactone, NSAID+Misoprostol, Quinine , Omeprozole, Metapralol…….. O/E – Reduced air entry Right base ECG – pre. Op- Normal Post op –AF, wide QRS, ST depression V1-V5, Axis Normal CXR - Typical Bats wing( B/L pulmonary infiltration) ABG – 70% Fio2 PH 7.43 , PCO2 - 4.5 kpa, PO2-11kpa, BE -1.6 Bloods - Na , K, - Normal Urea – 14 Createnine – 138 Q. – Summerise Q - What is the cause Resoiratory , Cardiovascular, Abdominal Went on the wrong tract a bit saying right lower lobe collapse as there was a haziness at rt lower lobe + decreased air entry on Rt base on examination. Q- what else can it be looking at the CXR? Pulmonary oedema Q: What else? ARDS Q: Look at the ECG –what do you think? AF , Ischemia Q What is the cause of pul. Oedema University Hospitals Coventry & Warwickshire NHS Trust Acknowledgement: many thanks to the candidates of June 2009 final FRCA viva course Page 26

Final FRCA exam viva questions June 2009: Set 2 He wanted me to AF , and the ischemic pattern is due to AF( didn’t agree but said yes) Q: What is your management ? ABC Treat pul. Oedema Q: How? Diuretics Head up til Q: What else would be a better way to treat ? ???????????????????? Examiner said better to treat AF which will then sort pul. Oedema out Q:How do you treat AF Q: do you want to shock him Q: Why not Q; What else do you want to give him Anticoagulnts Q: What do you want to give and what is the dose Q; how to treat heart failure in ICU

Short cases 1. 5year old for circumcision - How do you manage his pain - What pharmacological methods - What are the doses - What route - Which rout is prefferd - What do you ned to do before giving PR - How whould you do a penile block - How much local - What else – local infiltration - What else – lignocain gel 2. 27 year old with h/o palpitation, coming for cystoscopy - what is the ECG -what is WPW -How do you treat what drus -What drugs to avoid -how would you anaesthetise for radiofrequency ablation -What inhalational agent would you use - can they get palpitation 3. Latex allergey - who is prone for latex allergy University Hospitals Coventry & Warwickshire NHS Trust Acknowledgement: many thanks to the candidates of June 2009 final FRCA viva course Page 27

Final FRCA exam viva questions June 2009: Set 2 -

why what do you do if you get someone with latex allergy What equipment are latex free in theatre Whould you anaesthetise in theatre or anaesthetic room Patient develops anaphylactic reaction . what do you do Crystalloid or colloid Why?

Basic sciences Anatomy -Tell me about the anatomy of the liver - what are the relations -Draw the micro structure what are portal traiad -How is the blod supply -How much is the total -how much of blood passes through hepatic artery /portal vein -which part causes ischemia most -what are the 3 zones -effect of anaesthesia on the liver Physiology -

What is the effect of transplanted heart How to manage such a patient coming for non cardiac surgery What is the physiology behind it What are the anti rejection drugs What are there side effects What is the side effects of cyclosprin

Pharmacology -Why do patients in ICU get gastric stress ulcers -who are more prone to it -What is the pathophysiology (knew absolutely nothing about this, started sweating at this point) -Tell me the treatment -what is the problem with H2 blockers Why don’t we want to use it any more - what does sucralfate do( new nothing again!) Physics - Tell me about electricity - What happens if you touch a live wire University Hospitals Coventry & Warwickshire NHS Trust Acknowledgement: many thanks to the candidates of June 2009 final FRCA viva course Page 28

Final FRCA exam viva questions June 2009: Set 2 -

Where do we use electricity in anaesthesia Draw diathermy and explain Where else? ( gone blank!) Examiner- we use it to resuscitate----ah! defib Draw and explain defebrillation Where else (blank again) Examiner – neuro use it ----------ah! ECT How much current For how long Tell me the physiological effects

Set10 70 year old male, Elective AAA repair, 4 days ago, electively ventilated post op and extubated after 24 hours. He has been on CPAP since then. You are called to see that patient in ITU with sudden onset of severe SOB. He has a past medical history of HT, IHD, NIDDM, Hiatus hernia, TIA. SOB on walking 50 yards. Bilateral basal creps. Pre op ECG: LAD Examination: dyspnoea, SaO2 90% on 70% oxygen. HR 150/min. BP 130/85 mmHg. Chest: Breath sounds decreased on the right side. Investigations: Normal Serum Na & K. Urea: 14; Creatinine: 190 ECG: AF CXR: Bilateral hilar shadows more on the Right base. ABG: PaO2: 11 KPa; PaCo2: 4.2KPa; Base excess: -2.0. FiO2 70% Questions: 1. Summary. 2. DD for the SOB. 3. DD for the CXR findings. 4. Discussion of ECG findings both pre op and post op. 5. Discussion about the ABG, DD for metabolic acidosis. causes of acidosis in this patient. Compensation- how and why? University Hospitals Coventry & Warwickshire NHS Trust Acknowledgement: many thanks to the candidates of June 2009 final FRCA viva course Page 29

Final FRCA exam viva questions June 2009: Set 2 6. Why respiratory alkalosis? Hypoxia stimulating peripheral chemoreceptors and alveolar fluid. 7. Discussion about raised urea & creatinine. (Disproportinate raise in the urea and creatinine) probable causes in this patient. 8. Management. 9. Treatment of Heart failure in this patient. Frusemide, GTN, ACE inhibitors. 10. Treatment of AF in this patient. No for beta blockers and digoxin in this patient. Amiodaraone with dose and duration of infusion.

Short cases. 1. ECG: WPW syndrome. 2. Analgesia for Circumcision in a 3 year old child. 3. Latex allergy. Clinical Science: Applied anatomy: Liver. Relations, gross, histology, blood flow, anaesthetic agents affecting the blood flow. Applied Physics: Electricity Microshock, how to prevent it? Diathermy, Defibrillators. Applied Physiology: Denervated Heart. Physiology and anaesthetic management. Applied Pharmacology: Stress Ulcer in ICU Causes of stress ulcer in ICU. Gastrin: Physiology of secretion and control of secretion. Prophylaxis against stress ulcer in ICU. Antacid prophylaxis. Enteral nutrition. fine bore NG tube. what is the advantage? translocation of bacteria, gram negative septicaemia. Evidence of SSD on preventing Hospital acquired pneumonia and sepsis. University Hospitals Coventry & Warwickshire NHS Trust Acknowledgement: many thanks to the candidates of June 2009 final FRCA viva course Page 30

Final FRCA exam viva questions June 2009: Set 2

Set 11 Long Case Information Female patient in her 70’s presenting for mastectomy and axillary node clearance. Background of COPD with several hospital admissions including one to HDU/ITU and currently on a reducing dose of steroids. Had AV replaced 10 years ago. Taking Warfarin, Prednisolone 2.5mg qds, steroid inhalers, salbutamol/ipratropium nebulisers, theophylline. Examination Normal BMI Hypertensive ( approx.180/100) Mild bibasal crepitations Bloods ABG; pH 7.46, PaO2 9.5, PaCO2 5.9, BE 2, HCO3- 29 FBC; Hb 10, Normochromic, normocytic. WCC 12 INR 1.3 Biochem Urea 12, Cr 130, otherwise normal CXR Relatively poor quality reproduction Hyperinflated lung fields Barely visible mechanical heart valve ECG Sinus Left axis deviation PFTs Severe obstructive defect (values approx) FEV1 0.98 Ratio 35% predicted University Hospitals Coventry & Warwickshire NHS Trust Acknowledgement: many thanks to the candidates of June 2009 final FRCA viva course Page 31

Final FRCA exam viva questions June 2009: Set 2

Questions • • • • • • •

• • • • • • •

Can you summarise this case please? How would you pre-optimise her (focussed on respiratory function) Can you comment on her CXR please What does her ECG show? What is the likely cause of her left axis deviation? What further investigations would you like? What is the likely cause of her anaemia? How would you anaesthetise her (went for a-line awake, LMA and spont ventilation, asked why this method, benefits/problems, how would you assess that ventilation was inadequate or obstructed, how would you manage thissaid PCV max 15-20cmH2O through LMA, if still inadequate intubate) What are the potential organisational problems with this case (focussed on anticoagulant management) What are the options for post op analgesia? What would you choose? (Went for tinterpleural catheter) How would you perform this? Would you give NSAID? (Said yes but limit to 2-3 doses) How would you manage postoperative respiratory distress? What are the indications/contraindication for NIV?

Short Cases 1) How is secondary brain injury prevented? 2) A previously well 32 year old, 32 week primigravida is being brought in by ambulance with umbillical cord prolapse. University Hospitals Coventry & Warwickshire NHS Trust Acknowledgement: many thanks to the candidates of June 2009 final FRCA viva course Page 32

Final FRCA exam viva questions June 2009: Set 2 How would you manage her initially? What monitoring is required? What would be your anaesthetic technique? (Discussed spinal if response to interim measures, GA if severe compromise and how each would be performed.) What else would you do for post op if GA? (Analgesia). 3) Shown an ECG This is a 65yr old gentleman presenting for arthroscopy as a day case, take me through the ECG. LBBB and left axis deviation therefore left anterior fasicular block. Why is the QRS prolonged? Can you draw the conduction pathway defect? What are the causes of LBBB? Would you anaesthetise this man today? (No) What would be your plan? (Further history, refer to cardiologist for investigation) What would you tell the patient and the surgeon?

University Hospitals Coventry & Warwickshire NHS Trust Acknowledgement: many thanks to the candidates of June 2009 final FRCA viva course Page 33