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LONG CASES
1. Patient for resection of lung mass
52 year old lady listed for resection of possible lung mass. Known to have COPD and Hiatus Hernia. Medications: Salmeterol
and Budesonide. PFTs FEV1 1.4 Pred 2.3, FVC reduced, FEV1/FVC reduced, DLCO reduced, FRC + TLC increased
76 male, admitted for laryngectomy for laryngeal carcinoma. Recently noticed stridor, sleeping upright in chair Severe COPD,
HTN Meds: amilodipine, inhalers, diuretic
• Summarise
• Talk through investigations
• How would you optimise?
• What other tests? Wanted nasoendoscopy. Then showed a picture showing tumour & tracheal narrowing. How would you
rate his airway obstruction
• How would you anaesthetise?
• How would change the ETT for a tracheostomy interoperatively
• Critical incident: on ITU, becomes hypoxic, agitated, tachycardic. What are the differentials? Showed ECG with ischaemic
changes. How would you manage acute cardiac event?
• Is he likely to have cardiac problems?
• What tests?
• Like a MUGA scan? Would you really do that?
• What about CPEX testing? Would you do that?
• Ok so you’ve pre-optimised him and he’s now in the anaesthetic room, what are you going to do? How are you going to
anaesthetise him?
• So how would you do it? He’s in your anaesthetic room.
• Would you give him Clopidogrel given recent operation?
Questions:
Rheumatoid arthritis , c3-c4 post stabilisation, AF, Thrombocytopenic, anaemic,CXR: lung fibrosis
The rheumatoid neck with unstable neurology
• The airway management options, including the process of an awake fibe-optic intubation.
• Ways by which the airway could be assessed and the effects of RA on the airway.
• The implications of coronary stents. Also the implications of anaesthetising a patient with ischaemic heart disease.
• The further investigations required (was asked to elaborate on lung function tests and what they might show in patient).
• How best to stabilise a c-spine perioperatively.
• The implications of the prone position in some detail but particularly focusing on how to manage the neck.
• Hyponatraemia and how to decide on potential differential diagnoses (eg: fluid status, urinary Na etc.).
• Then we discussed diuretics as a cause and their mechanism of action.
June 2013 Final FRCA SOE – Thanks to all our candidates
• Causes of anaemia, particularly focusing on RA-related anaemia (drugs, chronic disease etc.)
4. Patient with Gestational Diabetes presenting with DKA & infected hand wound
20 year old female, 30/40 pregnant. Diagnosed with DM., currently on long and short acting insulin. Very poorly controlled
DM, she claimed that she was using her father’s insulin as she had run out of her own insulin. She currently presents with
feeling generally unwell and swollen Right hand.
54-year-old man with 29 year history of severe depression scheduled for dental clearance on your list. Has required multiple ECT
sessions in the past. Medications – Lithium, Flupenthixol depot injection, chlorpromazine, amlodipine.
He is a chronic heavy smoker, hypertension, obese.
• Summarise case.
• Go through investigations and point out abnormalities.
• Why is he polycythaemic? Does this affect us as anaesthetists? Why?
• What are the effects of chronic smoking? How does this affect an anaesthetic?
• Lithium – why measure levels? What are the problems associated with lithium therapy? How might it affect your
anaesthetic? What are the signs and symptoms of toxicity?
• Why is he on amlodipine? Why not an ACE? Should he be on an ACE?
• What is flupenthixol?
• What does his spirometry show?
• Any investigations you would like to see that aren’t here?
• How would you preoptimise him prior to surgery?
• How do you assess his airway?
• Discussed possibility of OSA – asked a bit about this. How would it change your anaesthetic management?
• How will you obtain consent?
• How would you anaesthetise him? GA vs LA. ETT vs LMA. Nasal vs oral ETT. Intraoperative considerations. What else would
you want intraoperatively?
• Discussed throat packs. Asked is there any guidance on throat packs? Talked through guideline.
• Analgesia options. What exactly would you use?
• DVT prophylaxis guidance. What would you do for him?
• Post-operatively you are called to recovery. He is not saturating well and very slow to wake up. Differential diagnosis?
Causes? How would you manage him? Went through systems. Eventually got to throat pack retention.
• Are you happy for him to go home? Turns out he lives alone. You are called later as the patient wants to leave against your
advice. How would you manage him? Issues regarding self discharge – what paperwork are you aware of?
23 year old woman, 32 weeks pregnant attends A+E short of breath, chest pain and feeling dizzy. Background of bicuspid
aortic valve disease but has had no cardiology or antental input for fear of being told to have an abortion.
7) Aspirated peanut
Long case: 15 month old with an aspirated peanut and not starved. CXR showed hyperinflation on one side. SpO2 93% in air and
grunting.
58 year old male patient was admitted with one day history of abdominal pain and vomiting. On examination, there is a
swelling in the region of he right groin. The surgeons want to take him up for an emergency laparotomy. Patient had been a
chronic smoker and alcoholic.
• Summary
• Comment on haematology, biochemistry, ECG, CXR.
• What are the present issues?
• How will you manage them/ preop optimisation?
• How will you manage the AF?
• What other investigations would you want to have?
• Type of monitoring?
• At what HR would you be satisfied to induce anaesthesia?
• How would you induce anaesthesia? drugs/doses/ reasons for each.
• Intraoperativelythis patient develops sudden hypotension, What could be the causes of this and how will you manage the
situation?
• What would be your ventilation parameters and why?
• Towards the end of the surgery, what would be your criteria for extubating this patient or not to extubate?
• Postoperatively, where would you manage this patient?
• What analgesic options are available? asked about epidural and its benefits in such a patient?
• How will you manage the fluid balance of this patient?
• The patient is in the HDU, at 4 AM, the nurse informs you that the patient has started desaturating and is getting
tachypnoeic. How will you manage this?
• Also, if this patient started getting anuric in the HDU, how will you manage this ?
June 2013 Final FRCA SOE – Thanks to all our candidates
Short Cases
2. Collapsed Parturient: Collapsed labouring parturient after topping up with 20mls of 0.25% Bupivacaine causes?
• Differential diagnoses
• Initial management
• Told this was LA toxicity
• Mechanism of toxicity
• All aspects of resuscitation
• How would you deliver oxygen?
• How would you treat a seizure?
• Would you use intralipid to treat a seizure without cardiovascular collapse?
• What is the dosing regimen for intralipid?
3. Respiratory failure in COPD: Critical care outreach nurse calls you to see a 72 year old man on a respiratory ward who was
admitted with an exacerbation of COPD 3 weeks ago. Usual meds inhalers. Now breathless.
• Analysis of gases
• Initial management and assessment/investigations
• Treatment options
• What are the indications for non-invasive ventilation in COPD?
4. Neck stabbing: Young, Afro-Caribbean, high BMI male with a kitchen knife though his neck. Sitting up, GCS 15.
• How would you investigate him?
• X-ray showed knife through neck. No surgical emphysema.
• What are the anaesthetic concerns?
• How would you anaesthetise him?
• Patient refuses AFOI. What now?
5. Anaemia & hemicolectomy: Elderly lady with cardiac disease, OA, needing a right hemicolectomy for bowel Ca. Shown
blood results- microcytic anaemia.
• Causes of anaemia?
• How would you optimise?
• Timing of blood transfusion? Day before? Two days before? Why?
• How would you investigate her?
• Led onto CPEX testing. What equipment needed. How do you do it with arthritic knees? What results do you get and what
do they mean?
• Preoptimisation of blood: cell saver, haemodilution, hypotensive anaesthesia, Ferrinject, d/w haematology, would not
consider Epo Side effects of Ferrinject.
• What is enhanced recovery?
6. Management of IUD: Intrauterine death with signs of sepsis and DIC (shown blood results). How do you manage DIC.
• Analgesia options.
• Obstetricians decide to induce for NVD, what analgesia options. So regional technique is excluded due to DIC and sepsis,
PCA is feasible. What drugs would I use? Remifentanyl (pros and cons), Morphine, alfentanil, Pethidine and fentanyl…..
• What are the causes of intrauterine death?
• Would you put an epidural in this lady?
• How would you correct her clotting?
• She miscarried quite a few times before. Why? I mentioned the TORCH screen. Components please and clotting disorders
that would predispose to frequent IUDs.
9. Muscular dystrophy
• Muscular dystrophy and Duchen's
• What is the difference , how do u anaesthetise
• Congenita myotonica and was asked to compare with duchennes and classify congenital neurological conditions. Myotonic
dystrophy
• Incidence, pattern of inheritance, pathophysiology and clinical findings
• Effects on conduct of anaesthesia with particular focus on the effects of sux and opiates.
• Post-operative plan including criteria for post-op ventilation/NIV.
• Comparisons with muscular dystrophy.
• The current thinking about MH and Beckers.
10. Cord Prolapse: Pregnant 34/40 with cord prolapse on her way in via ambulance
• What do you do to prepare – theatres, seniors, obstetricians aware, drugs and look for notes
• What do you do when she is in – ABC, left side head down
• Going to theatre for emergency LSCS – management – options(GA vs Spinal)
• You decide for GA
• Pre-op - antacids
• Peri-op – discuss with Obs/Paeds if opioids used
• What is she at risk of
• What will you give her after the baby is delivered
• After delivery – what do you do – Analgesia
12. MH: 4 year old child for surgery. His Grandfather has MH
• What is the incidence of MH?
• What are the chances of his father having MH?
• What are the chances of the child having MH?
• They wanted to know which chromosome was affected and went through the molecular changes
• How is it diagnosed?
• I described genetic testing, Halothane/ caffeine test
• How does MH differ in children?
June 2013 Final FRCA SOE – Thanks to all our candidates
• He come for surgery, how would you proceed?
13. Patient with previous MI: Man present to your pre-assessment clinic for a laparoscopic inguinal hernia repair. He has a
history of previous MI and stents inserted 9 months ago. Tell me about his ECG at the time of his MI.
• Inferior MI. Bradycardia. 1st degree heart block.
• Why was he bradycardic?
• Which artery is affected?
• What drugs would this patient be on? How do statins work?
• What types of stents do you know about? What is the difference?
• What do drug eluting stents elute?
• What are the guidelines regarding surgery and stents?
• Shown second ECG from today.
• What does it show?
• 1st degree heart block. Q waves. RBBB.
• He has a good exercise tolerance and tells you he goes running a few times a week. Would you anaesthetise him? What else
would you want to know?
14. Unexpected mass on CXR: 72 year old lady with bunions presents for day surgery and you review CXR.
• Talk through CXR systematically.
• Would you anaesthetise her today?
• Differential diagnosis?
• What sorts of lung cancer do you know about?
• How might her lung cancer affect your anaesthetic?
• How would you proceed to work her up for surgery?
• What investigations would you want?
• How would you anaesthetise her?
• What sort of tube would you use? Why a left sided tube? How would you check its position? What are the options for
analgesia after a thoracotomy?
15. Dilated carotid: A renal patient has just had a neck haemodialysis catheter inserted and now has stridor and a swelling.
• How do you approach this patient?
• Who do you want to help you?
• What is stridor?
• How would you anaesthetise this patient?
• They asked what other considerations specific to this case you would want to think about.
• I said choose drugs that were suitable in renal failure. They said anything else? I looked blank and they said what about
coagulation problems in renal patients?
• They pushed me asking which exact pieces of difficult airway equipment would I want before starting. I said McCoy, bougie
and fibreoptic scope but they were looking for needle cricothyroidotomy kit. Why wouldn’t I do a gas induction?
16. Hip with cardiac history: 78 year old lady with severe IHD and previous MI is being assessed for Revision hip.
• How can you assess cardiac function?
• What are your perioperative considerations?
• How do you choose between a CSE/spinal/GA?
• What other considerations are there?
• What methods exist to reduce blood loss.
17. Day case with COPD: 50 for arthroscopy knee sever COPD and want spinal for day case
• What are criteria for day case surgery
• Showed an x ray for some one very hyper inflated lung and possible a shadow left upper lobe
• Are you gonna do her in day case?
• How much you give in spinal and what would you use and how you manage her.
19. Enucleation with cardiac history: 72 year old gentleman posted for enucleation of eye. He had a cardiac history 5 years ago,
following which a stent was put in. At this point, I was given an ECG to interpret. ( it showed 1st degree HB + old lateral wall
ischaemic changes).
June 2013 Final FRCA SOE – Thanks to all our candidates
• Asked about Drug eluting stents?
Basic Sciences
1) Limb ischaemia
• Symptoms and signs of acute limb ischaemia
• Assessment and management of lower limb ischaemia on ITU
• Anatomy of arterial supply of lower limb
• Arterial supply of lower limb.
• Causes of ischemia of lower limb
• Signs and symptoms
• Management of an ischaemic limb following removal of a picc line.
• Management of a patient for elective peripheral vascular surgery.
• GA versus regional technique – advantages, disadvantages.
3) Glycaemic control
• Perioperative issues with glycaemic control
• Reasons for hyper and hypoglycaemia
• Insulin – secretion, pharmacology, short and long acting
• Pharmacology of oral hypoglycaemics
• Oral Hypoglycemic drugs, mechanism of action
• Hypo and hyperglycaemia intra-operatively. Causes and management of each.
• Pharmacology of insulin.
5) Trigeminal nerve
• Anatomy Course of the trigeminal nerve.
• Symptoms of trigeminal neuralgia.
• Causes and treatment.
• Shown pictures of dermatomes of head.
• Asked to describe distribution of trigeminal nerve. Asked what occiput and back of neck supplied by.
• Complications of surgey / RF ablation.
6) Gastric emptying
• Physiology Gastric emptying. Causes of delay? Implications of delay?
• Incidence of aspiration? What determines the severity of aspiration?
• How to manage prior to anaesthesia?
• Starvation times for fluids, food and breast milk.
• What drugs do we use for gastric dysmotility?
• What is the guidance for starvation times?
• What about chewing gum?
June 2013 Final FRCA SOE – Thanks to all our candidates
7) Anticoagulants
• What drugs affecting coagulation do you know of?
• Tell me about heparin?
• What are the advantages and disadvantages of unfractionated heparin vs LMWH?
• What is warfarin? How does it act?
• What are the half-lives of different clotting factors?
• How would you treat someone with INR of 5.0 presenting for NOF?
• They didn’t seem interested much in beriplex or FFP but more in vitamin K and how it worked. Problems of giving vitamin K
to someone on warfarin.
• What is dibagatran?
9) Pain pathways
• Describe the pain pathway? What neurotransmitters? How is pain modulated (gate theory), what neurotransmitters and
what pathways.
• How to assess pain?
• Then take a Hx of pain
• Various scales to assess pain
• Magill questionnaire
• Mechanism of analgesia:NSAIDs, Paracetamol, Gabapentin, Local anaesthetics, Opioids, Ketamine, etc (wanted receptors or
mechanism)
11) Magnesium
• What is the role of Mg in the body?
• Where is it found?
• How is it stored on the extracellular space?
• When would you give Mg? / How and where?
14) Flaps
• Types of flaps in plastics (free vs pedicle).
• Causes of flap failure.
• Methods of maintaining flap perfusion including simple measures such as temperature regulation and avoiding pressure
and drugs (including those to avoid).
• Post-operative management.
• Use of dopexamine and how it works.
• Methods of maintaining adequate MAP without vasoconstricting.
16) Temperature
• The physics of temperature -electrical non electrical.
• What is heat? What is temperature.
• How can we cool patients, why cool. Evidence in neurosurgery,
• Temperature loss – causes under ga and their percentages.
• Temperature measurement including electrical : thermistor, thermocouple and resistance
18) Sodium
• How is sodium controlled in the body? What is normal? Intracellular and extracellular? How much do we need every day?
• How many bags of fluid is that? Talked about different composition of various fluids.
• What is hyponatraemia? What are the causes? What are the symptoms?
• What is SIADH? What are the causes?
• What is cerebral saltwasting syndrome?
• When would you be worried about hyponatraemia?
• How would you treat hyponatraemia? How fast would you replace it? What concentrations of hypertonic saline are there?
• What is the risk of treating it too quickly?
• What drugs can cause hyponatraemia?
19) AChE
• What is acetylcholinesterase? Whereabouts is it found? Tell me what happens at the neuromuscular junction.
• Where else is it found?
• What other cholinesterases do you know about?
• What drugs do they break down?
• Why do we have plasma cholinesterases in our body?
• What anticholinesterases can you tell me about?
• Can you tell me about how the different types work?
June 2013 Final FRCA SOE – Thanks to all our candidates
• What is the Tensilon test?
• What do you know about organophosphate poisoning? Who does it affect?
• What bond is formed? Is it reversible? What are the symptoms? How is it managed?
• What treatment do you know about?
27) TCI
• Asked about TIVA pump.
• Causes of light plane of anaesthesia in a patient who is on TCI propofol.
• Any means of monitoring a patient for awareness in this patient.?
• Any guidelines?
• Asked about different drug delivery models.
• Asked about 3 compartment model.
• Asked about effect site and plasma site concentrations?
• TIVA pharmacokinetics: Marsh and Schneider