FRCA viva questions from 2011 exam

Final FRCA viva questions from June 2011 exam
Some general feedback for the day for any future candidates:
During the exam, as all candidates take the exam in small booths all in the same room, the
noise levels can be quite high and during pauses to think, it is possible to hear candidates in
the next booth answering their questions! Don't let this put you off! It can be quite
distracting but you really do need to ignore any other conversations.
Some of the radiographs are on computer screens now, and will be shown as such during
the 10 minute prep as well as on paper too. In the examiners booth, the CXR was on a
computer screen not on paper.
Practice the timing for your 10 minute preparation for your long case with a watch you can
wear to the exam. Where I was sat, you couldn't see a clock and so couldn't work out how
much of the 10 minutes had elapsed. Consequently, even though I had always been well
under the 10 mins prep time in my practices, on the day I just ran out of time.
The examiners may move you on quickly and sometimes want quite 'punchy' answers.
Don't let this upset you, go with where they are directing you and be flexible in your
approach with your answer structure. But in general, start broad, classify and work towards
the details.
The examiners may really push you and come across quite mean! In my science viva, I
thought I was doing badly and nearly felt defeated but picked myself up and pushed on. At
the end, when I'd passed and was chatting to the examiner with a glass of wine in hand he
said he knew I'd passed and was pushing me to get to the minutiae, and all along I thought
I was failing! You will be a bad judge of how you're doing so keep going, don't get
defeated or angry!
Set1
21 year old 32 weeks pregnant lady presents to Ante natal ward with chest pain and
breathlessness on exertion and rest, she did not receive her antennal appointment as she
was worries that they will advise her to terminate her pregnancy as they did 2 years back,
so she has not been seeing anyone since 3 years, she is known to have a bicuspid Valve(
Aortic Valve)
ECG T wave inversion in Lead III and V1 rest all ecg Normal
ECHO - Peak gradient 78 mm of Hg and mean 38mm of Hg
Ejection Fraction 60%, Valve area 1 cm2
Good systolic functions
Calcifications on the cusps
X ray- No cardiomegaly but interstitial oedema present characteristic bat winged
appearance with prominent hilum . (Pulmonary HTN)
Bloods- Hb 11
Coventry collection: Many thanks to the candidates form June 2011 Course
1
Questions i was asked

Summrise
Investigations
Why she is breathless- AS and preg fixed CO state, details of cardiac changes in preg
affecting AS
Managemant She should have a elective LSCS. Examiners happy with answer not to
keep her in DGH , transfer her where facility exists for Valve replacement.
Now in tertiary centre How would you anaesthetise her.
In this i Answered as we tend to answer like , consent , monitoring , invasive , blood loss ,
temp , urine output .
GA/ RA . why not Spinal and what are advantages of CSE
What monitorning
Drugs Thio and eximers asked any other drug ( Etimidate ) with TAP Block . Multimodal
analgesia
Now she Bleeds Management Ergometrine avoid Oxytocin as it causes Hypotension
and decreases SVR which is not good for her , also prostaglandins like PGF2a and PGE2
Where will she be after words post op (HDU/ITU) depending on how operation goes.
Management on ITU . FLATHUG
What about Breast feeding opoids and Benzodiazepine .
Short Cases
1.ECT What is ECT, How is it helpful , how does it works ,
Q-What are key in preop management
Answer-Full history, lots of comorbidities , HTN , IHD , COPD , Poor historiens ,
Aspiration risk. Allergies , prev anaesthetic charts imp
Q- Drugs like litium how does it affect Anaesthetic drugs
Q- what changes does ECT prod
A- On saying parasympathetic and Symp , they showed me a ECG where initial
aystole and then tachycardia .
B- I answered making sure that leads are not disconnected and feel for pulse if needed
use glycopyrolate and then atropine.
Q how would u anaesthetise her , what precautions will u take ?

A- Good pre op work up , as done in Isolated conditions if any risk factors i would do it
where help can arrive and if no risk factors , Machine check , drugs ready , AAGBI
monitoring, trained assistant , Sr help around,and standard....................
Short case 2
Pre-assement calls you that a lady has arrived for elective cholecystectomy and
mentions that lady says she suffers with Sickle cell Anaemia and nurse knows nothing
about the disease what will be your advise .
Initially i answered- to do basic check up take blood pressure and bloods for
electrophoresis or Sickeldex test and ECG then it clicked to me that there will be more
to the questions and i answered that i will ask the nurse to wait and i will down myself
2

and see the lady ... my examiner almost jumped from her chair ... very happy , more
they were happy more confidence i was getting that things are moving in the right
directions , KEEP SMILING ( it covers many things as we all think so many things and
so many things going in our minds )
Then questions started
What is SCA
Implications
Different haemoglobins
Systems like in college book
Crises Different types, i made a Pneumonic (VASH) Vaso , Aplastic, Sequestration ,
Haemolytic.
Usual precipitants
Why stones pigment stones and also crises may mimick surgical emergency
Later she developed Acute chest Syndrome
Short Question 3.
Basic Sciences
Anatomy of pherenic nerve.
Relations in the neck, thorax , and insetions on the diaphragm
When does it get damaged
What happens when it get damaged
Which is longer
Diaphgarm
Muscular and tendinious part
Supply (sensory , motor )
Openings
Thyroid hormones
Synthesis
Mechanism of actions
Effects
Hypo/ hyperthyroidism
Treatment
Effects of anaesthetisings hypothyroid/ hyperthyroidism
Treatment of thyroid storm
Hypo/Hyper glycemia
Causes and effects of both hypo and hyper glycemia( Classify)
When on valve is hypoglycaemia
How do you control stress resp leading to hypoglycaemia ,answer Insulin sliding
scale
Why not tight control
Which paper
what effects on surgical outcome poor wound healing, dehiscence
drugs for oral hypoglycemics mech of action
-Physics----Scoliosis

What are the key concern in this case
What are the effects of scoliosis on body systems (Classify )
Restrictive diease , CVS , one lung ventilation . what will you see on PFT , Reduced
FVC but normal FEV1 therefore ratio increased
Associations of Scoliosis Muscular Dystrophies
Diff positions and effects ( lateral approach and prone approach )
What all can be damaged Spinal cord ischemia
Why spinal cord ischemias , how does it happen and what can be done to minimise it .
THEN QUESTION CAME ON PHYSICS
SSEP
How do you monitor
Which one is better
SSEP/MEP effects of NDMR /DMR on each of them
Any other
Epidural MEP.
Set 2
Clinical: Long case
55year old male 174cm, 74Kg. 1 day history of lower abdo pain and vomiting for
emergency laparotomy. Smokes 20 day. Has Hx of alcohol excess unknown if still abuses
it. Nil meds.
Apyrexial HR 150 good BP. Bloods: Na 128 K 5.1 normal u&Es and normal LFTs FBC
white cell counto f 12.4, neutrophilia. ECG AF rate 150, CXR LUZ changes ? old and
RMZ changes.
Discuss differentials: they wanted incarcetated hernia
Discuss how you would opitimis/ when he needs surgery and why
what montioing and why and what would you us e the art line for//tests/ picco etc
Discuss mx of AF and what route you would take/ anticoagulant etc
Anaesthetic Mx and whether you would do epidural or not.
Critical incident: profound hypotension 1 hour into surgery
would you extubate him at end?
Short cases:
1.Young child for circumcision. Discuss analgesia...just like the Bricker book
2. 12 Year old for Cholesteatoma surgery. What is cholesteatoma, what makes the tumour,
which nerve is at risk, what are the special anaesthetic implications, how would you
anaesthetise and what would you explain to pt: ponv/head bandage.
3.65yr old for carotid endarterectomy, shows you ecg with LBBB, 1st degree HB and
borderline LAD...not sure if it was LAD or not! Discussed anaesthetic implications. Risk
benefits of GA vs LA, Monitoring, how you proceed with each type of surgery.
Basic Science
Anat:
Pleural anatomy, what is in pleural space. How can it be breached. Discussed effusions,
transudate vs exudate analysis, pnumothorax causes and treatment. Anatomy of chest drain
insertion rather than technique specifically.
Physiology:
Alcoholic liver disease pt and why they get admitted to ICU. Then in depth discussion of
all of the systems involved
Measurement:
Breathing circuits. Indications for how you choose which type of circuit you will use.
Circle system, advantages and disadvantages, volumes, substances that build up, where
valves are, what happens if exp valve jams open in spont breathing patient.
Pharmacology
Immunosuppressants in patient post renal transplant. Why the renal function of the graft
may fail, what function you expect a graft to have and will renal function return to normal.
Classes of mmunomodulator and side effects.
Set 3
1. Long case
65/M, smoker, alcoholic, one day H/O abdo pain
O/E HR 150/min, BP 135/70, ht/wt normal, bibasilar crackles
Bloods WCC 12, Na 128, K 5.1, rest wnl
CXR, changes of pulm oedema, L m/z opacity, ECG - A fib
Questions
summarize
key issues
pre op optimisation
when to operate
SIRS
comment on bloods
how to treat blood abnormalities
what invasive monitoring, details of oesopahgeal doppler
CXR changes - pulm oedema findings
ECG - Mx of A fib
intraop Mx, post op HDU Mx
Short cases
1. 3 yr old male child for circumcision
Q's - entire viva only on pain Mx, including penile/ caudal block techniques

2. 65/M for carotid end arterectomy with ECG of trifascicular block
Describe ECG, pre/intra op Mx of CEA, GALA trial, adv/disadv of RA/GA in this case
3.3 yr old male child for cholesteatoma
details of cholesteatoma(fortunately I remembered from my USMLE reading but a lot of
people said they did not have a clue
pre op issues, complications of cholestatoma
intra/ post op Mx, what will u explain to mother about post op problems
Basic science viva
1. Anatomy of pleura
Pneumothorax
chest drain insertion
2. Alcoholic patient in ICU, physiology of liver injury and sequelae in alcoholic liver
disease, child pugh, encephalopathy, hepatorenal syndrome, varices, etc.(too many detailed
questions asked with unwillingness to move on until answered fully)
3. renal transplant patient for day care procedure
indications of transplant
problems with transplant patients
classification, S/E and anaesthetic effects of immuno suppressants(absolute details, knew it
well, so was OK but lot of people felt it was harsh)
4. anaesthetic breathing circuits, details of Bains and circle systems
Long Case:
42 year old with manic depression for dental clearance. History of multiple ECT
treatments. Lives alone, heavy smoker. On chlorpromazine, flupenthixol, lithium and
amlodipine.
Renal failure and HTN, under nephrologist.
Ix: LVH on ECG, cardiomegaly on CXR, polycythaemia, obstructive PFTs, lithium level
upper limit normal.
Asked regards pre op issues (esp lithium).
Intraop Mx.
Post op slow waking, obstruction airway. ?causes and mx.
Short cases:
1) Dural puncture siting labour epidural: options (risks/benefits), PDPH risk and
subsequent Mx.
2) CXR showing NGT off to left, discussed ways to establish NG position. Enteral feeding
on ICU risks and benefits. Nutritional status in critically ill. Requirements of various
components.
3) 2year old with stridor: differential and Mx
6

Sciences:
1) Cross sectional anatomy of T10 level, moved on to CT (meant to show anastamotic
leak). Discussed functional liver anatomy.
2) Na+: body regulation, importance, hyponatraemia differential and management.
3) Reasons anaesthetist might prescribe anti-hypertensives, BTS guidelines on HTN,
hypotensive anaesthesia, options infusion therapy to drop BP, focus on nitrates and SNP,
CN toxicity and Mx, brief discussion on phaeo.
4) Laser: physics, clinical mx
Set 4
Long Case:
58 year old lady for elective aneurysm repair . 2 week history of hemiparesis.
Known Hypertensive and chronic smoker with COAD.
H/O Complete heart block with Pacemaker insitu.
PFT : Moderate obstructive lung disease.
CXR : Pacemaker.
Short cases:
1) Awareness
2) Downs syndrome with Eisenmenger's disease for fracture NOF
3) Sepsis
Clinical sciences:
1) Anatomy : Blood supply of spinal cord.
2) Physics: Osmosis
3) Pharmac: VTE Guidelines and anticoagulants
4) Physio : Burns / CO & Cyanide poisoning.
Set 5
Long Case: Urgent AAA repair
Short cases:
1) Bleeding tonsil
2) T2 Spine fracture with autonomic hyperreflexia
3) Lobectomy with PFT of COAD
Clinical Science:
1)Anatomy : Mediastinum
2)Physics : MRI
3)Pedicle graft - Hagen Posieulle Law

4)Pharmac : Antibiotics
Ser 6
Long case
RA pt for cervical laminectomy with neurology.
Previous MI
Frail with fixed flexion deformities
61 kg
Drugs include atenolol, amlodipine, statin, perdnisolone, azathioprine, lansoprazole and
aspirin
Hb 9
Mcv 96
Na 133
Urea 12
Creat 124
CXR reticulonodular shadowing
Summary?
Went through Ix and ECG ( prev MI)
Why anaemic?
Why hyponatraemic?
Can he be optimised pre op?
How would you anaesthetise this pt?
Airway mx with RA?
Prone - issues ?
Post op?
Develops SVT in HDU
Management ?
Short cases
1. Ruptured AAA in a and e - pacemaker/hypotensive
Periop mx?
2. Obs: SOB / collapse post SVD with epidural.
Causes?
Mx?
3. ECG - complete heart block
Management pre op?
Management if it occurred intra op?
Science viva
1. Eye pain post non eye surgery
( no idea )
2. Adverse effects and benefits of oxygen therapy
3. Latex allergy - types of hypersensitivity. Mx of latex allergy case and presentation of
anaphylaxis
4. Blood pressure measurement
Set 7
Clinical Viva
Long Case
78 yr-old man. For free flap graft of infraorbital defect secondary to radiotherapy for
Maxillary squamous cell carcinoma.
PMH
Severe Ischaemic heart disease
Diet-controlled DM
DHx
Ramipril 2.5mg
Carvedilol 12.5mg (?)
Furosemide 40mg
Simvastatin 40mg
NKDAs
O/E
Chest Clear
No murmurs
Investigations
Full Blood Count - Normocytic anaemia (Hb 11.0)
U+Es
Urea + Creatinine raised, Urea 10, Creatinine 140 (Approx)
Fasting Glucose 11.0
ECG
SR 80, LBBB
Coronary Angiography
85% stenosis to proximal LAD, 85% stenosis LCx, 80% Stenosis to RCA
EF 40%
Reduced motion of anterior wall

Questions
How would you assess cardiovascular status / risk?
When would you perform surgery?
Would you refer for coronary intervention?
How would you anaesthetise?
Would you wake at the end of surgery?
The patient develops chest pain with ST elevation, 12 hours post-op
How would you manage?
Short Cases
25 yr old, Isolated head injury
Management principles for transfer to neurosurgical centre.
Shown CT with Extradural Haematoma.
60 yr old (?) Post-op thoracic Aortic Aneurysm repair

Had CSE sited pre-op
Now 6 hours post-op with sensory and motor loss in lower limbs.
Epidural infusion stopped 2 hours ago
Differential diagnosis
How would you assess?
Principles of Spinal cord perfusion pressure. (i.e. should maintain adequate MAP to
prevent secondary injury, + discussed possibility of CSF drainage)
16yr old with Learning difficulties for dental corrective surgery (due to last 1 - 2 hours)
What are the issues with this case?
What is capacity?
Consent issues in adolescents.
How would you anaesthetise this case?
Clinical Science
Radial Artery Cannulation
Allens Test
Anatomy of radial artery
Describe the path of blood from the heart to the radial artery.
Abnormal Haemoglobins
Abnormal Erythrocytes (Mentioned hereditary spherocytosis, G6PD)
Life cycle of normal erythrocyte
Pathophysiology of Haemolysis
10

Magnesium
Indications
Causes of Hypomagnesaemia
Causes and Management of Hypermagnesemia
A Marathon runner is brought to A+E with a temperature of 40.5 degrees
How can we measure temperature?
Set 8
1. Long case
23 year old lady with 32 weeks pregnant, got admitted to the delivery suite with giddiness,
chest pain and tiredness. Smoker
Investigation - Hb 11.0
CXR - seems to be normal
Echo - AV area 1.0cm2, peak pressure gradient 70 mm Hg, mean 35 mm Hg.
Summary?
What is the problem?
Grading of AS - different methods? area grades pressure gradient classification.
Signs and symptoms of AS?
Changes in pregnancy?
Effects of AS? especially CVS?
Anaesthesia options? Goals? - graded epidural / GA
1. Sickle cell anaemia?
Different types? Physiological effects?
Anaesthesia goals/concerns?
2. 45 year old lady for ECT. She is taking lithium.
What is ECT? Diseases?
Physiological effects?
Systemic effects?
ECG strip at ECT?
Problems associated with Lithium?
3. 22 year old man with fracture mandible for surgery. Brought to hospital from pub.
Concerns in this patient - haed injury, c spine, alcohol, drugs
Problems associated with fracture mandible surgery? shared airway, nasal intubation,
difficult intubation
1. Thyroid hormones - physiological effects, systemic effects
2. Perioperative sugar control - hypoglycaemia and hperglycaemia
3. Phrenic nerve anatomy - details
nerve supply, causes of nerve injury
11

4. Scoliosis surgey - concerns and problems.
Long surgery, blood loss, nerve injury, spinal cord injury
SSEP - principles
Set 9
Clinical
Long Case
Middle aged gentleman for emergency laparotomy with one day history of abdo pain and
vomiting. He has a mass in right groin.
Past history of alcohol and long term smoker.
Bloods essentially normal except:
MCV raised
Low sodium
Mildly raised urea
CXR - Chronic fibrotic changes throughout with apical scarring in left upper zone
ECG - Fast AF
Summarise the case
What would be your differential? - strangulated hernia, ischaemic bowel, cancer, appendix
mass (in the groin!? - I said you cant rule it out if it was retroperitoneal - they were happy)
Describe the X-ray and ECG - I said I want to repeat the ECG as it wasnt a great trace but
I said I would treat - with what? I mentioned beta blockers would not be beneficial in a
respiratory patient and digoxin in sepsis has poor results so I would treat with a loading
dose of amiodarone of 300mg into a large antecubital vein in a HDU environment or
certainly with ECG monitoring and BP measurement. Where would I do this? Either on the
ward or in my recovery if the ward staff were not available.
What other investigations would you want - ABG and PEFR
Do you want an ECHO?? - I said firstly I would ask more about his exercise tolerance in
my history in order to gain a functional status and consider this if his exercise tolerance
was limited or if on auscultation I heard a murmur - however I wont delay surgery for it as
it wont change my management - they were really happy with this as I think everyone was
saying just get an ECHO when there was no real clinical indication.
Anything pre-op?
- I said get the chest physios to come and show him exercises to do and consider pre-op
nebs
How will you anaesthetise?
RSI, Routine stuff, No plan for epidural as WCC high and SIRS - MASTER trial
mentioned and they were happy with my analgesic plan of TAP blocks and PCA
Art line, no CVP, Catheter - aim 0.5ml/kg/hr, consider CVP line intra-op on the table if
hameodynamically unstable but BP had NEVER been a problem.
Post-op - HDU, DVT Gastric prophylaxis and feeding
Relatively straight forward!
Short cases
Young boy for circumcision - methods of pain relief including anatomy - which one would
12

you choose for day case and why. Indications for discharge from Day surgery
Elderly male for carotid endarterectomy shown ECG LBBB with 1st degree HB - would
you anaesthetise? I said not without further history and examination and a referral to the
cardiologists - if there was an associated LAD this would be trifascicular block and an
increase risk of periop complete heart block. Brief discusiion of GALA trial - what do I do
and why
12 year old for middle ear surgery - choleasteatoma - diabetic.
What is a cholesteatoma
What are the issues here - child/shared airway/long case/micro surgery requiring minimal
blood loss for surgical field/facial nerve monitoring
What would you do?
Pre-op assess/Exam etc
Remi infusion - intubate on remi and avoid NDMR completely - have I done this before yes - describe!
What sort of tube - South RAE or reinforced ETT NOT AN LMA at all - why- want to
control CO2 and long operation !
Basic Sciences
Tell me about the anatomy of the pleura
- what is it? boundaries, what does it cover
- innervation
- how can it be damaged?
exudates/transudates/blood/air
- how do you insert a chest drain?
- what is the recommendation regarding ultrasound of the chest before insertion
How do end-stage liver patients present to intensive care
- bleeding - upper GI - varices, ulcer disease, portal hypertension
- ascites and spontaneous bacterial peritonitis
- encephalopathy
- physiological changes - I just said things in a very systematic way for each system and
they let me talk for pretty much all of the time and were nodding their heads so I just
carried on until they told me to stop - I related everything I mentioned to anaesthesia and
poor prognostic indicators etc. so tried to show I had experience of these type of patients
and also the fact that sometimes if they are end-stage the decision may be to allow natural
death and supportive palliative care - they actually like that!
You have a patient presenting for elective surgery who has had a renal transplant. What
drugs do these patients take and how will this affect your anaesthetic?
- firstly discussed necessity of surgery
- drugs - steroids - in depth! including replacement and equivalent doses perioperatively
- cyclosporin - how it works - t cell associated and what it does - pharmacodynamics
- any newer agents you have heard of - tacrolimus - less side effects
13

Breathing systems - mapleson classification
What determines what circuit you use - children versus adults, circumstances A&E/CT/Theatre/Resus
Circle system - draw and explain. VIC and VOC
Set 10
Long Case
Elderly man with PMH Rheumatoid Arthritis and 2 previous MIs, last one 3 years ago.
Had cervical cord compression on MRI and had symptoms - weakness and wasting in the
upper limbs. Due for posterior cervical laminectomy. Had anaemia. Average weight.
ECG showed ECG evidence of previous MI. CXR apparently showed some bullae.
Questions
Possible causes of the anaemia
ECG changes - cause
How I would anaesthetise the patient
Talked about prone positioning and problems associated with this
Other problems associated with RA
What would you do with post op pain relief
Short Cases
1 Ruptured AAA in A&E
How would you initially manage and resuscitate this patient
How would you induce the patient
Post op management
Causes of a post op acidosis
Abdominal compartment syndrome
2 Complete heart block in a patient attending for pre op - would you anaesthetise him.
What would you do.
Now patient develops heart block intraop - what would you do.
Talked about different ways of pacing
3 Patient on labour ward with an epidural has just delivered. Now complaining of SOB
What is your differential
What would you do
Talked about amniotic fluid embolus
Anatomy
Talked about a patient post op complaining of eye pain (non ocular surgery)
What would you do - how would you examine. Causes of eye pain and causes of eye
damage intra op.
Pathways involved in the pupillary light relexes
How does a stellate ganglion block affect the eye.
Physiology
Oxygen toxicity - how does it affect the body
Limits of oxygen therapy
14

Who is prone to oxygen toxicity
Mechanism of oxygen toxicity
Pharmacology (?)
Latex allergy - who is prone
What types of hypersensitivity are encountered intraop
How to treat anaphylaxis
Basic Science
Non invasive BP - how is it measured - mechanisms
Finepres
Set 11
Long Case:
Elderly lady with history of COPD; FEV1 of 0.8 and obstructive lung defect presents with
intracranial bleed. 2 weeks later she is booked for elective aneurysm clipping that is not
ameenable to Endovascular repair.
She has a cardiac pacemaker for complete heart block.
Investigations included CXR which showed hyperexpanded lungs, was asked to
demonstrate this; pacemaker with atrial and ventricular leads; was asked to explain this.
ECG showed paced rhythm with ventricular pacing spikes; was asked why no atrial pacing
spike; explained this could be related to sensing.
Was asked the significance of Spirometry what does it mean?
How would you deal with a pacemaker pre/intra and post operatively?
What other investigations would you like? FBC; Coag: U&E etc
Then was asked about introperative management:
TIVA technique with reasoning; avoidance of pressor response; elements of maintaining
CPP; seemed very happy with this
Was asked how to manage intraoperative cerebral oedema; started basic upto
pharmacological
Post operative: would I extubate?
what would govern my decision?
Post operative confusion; what is the differential?
How would I manage?
All was reasonable; managed to score 10/12

Short cases:
Awareness; Standard quest as previously asked ;no problems
Seemed very concerned with medicolegal aspects
Eisenmengers Syndrome
Again standard question; wanted very detailed pathphysiology; questioned mode of
15

reversal of the shunt
Anaesthetic managment would you consider a regional?
Not the smoothest answer despite knowing the topic well!
Sepsis
Again standard question
Definitions/management/targets all fine was very happy; even asked about eveidence in the
literature - no problem
Basic Science
Anatomy of the Spinal Cord Blood Supply
Questons regarding orgins etc plus wanted veous drainage. Not too bad.
Pathophysiology nonthermal burn injury
Talked about Carbon monxide poisoning and cynanide toxicity. Mode of pathophysiology
etc managment.
Examiner seemed more than happy.
NICE guideance on VTE prophylaxis
Wanted quite a lot of detail relating to the guideline; mode of action of antiplatelet and
heparin agents.
Osmolality - not the smoothest.
Wanted the equation; could not really remember followed by a discussion on
hyponatraemia causes; managment.
Set 12
67 year old man for a flap repair of maxilla defect second to previous SCC. Given an ECG
(LAD, SR, Q waves), an Angio (triple vessel disease), his U&Es (Chronic renal failure)
and FBC. PMH: HTN, IHD, DM
Questions:
Summarise the case
What do you think of his blood results?
How can you assess his cardiac function?
What about the Angio? What could be done to optimise him for surgery (Angioplasty,
CABG)
How would you anaesthetise him?
What are the important factors for flap surgery? How do you keep the flap warm in
theatre? - warming & Humidifying the theatre environment
Short cases
A: 16 year old with learning difficulties for dental clearance
How would you asses?
Parental/guardian issues
If no relative/friend - involvement of IMCA - relevance of MHCA.
How would you anaesthetise
16

B: 27 year old with head injury requiring transfer to neurocritical care setting.
How would you assess and prepare for transfer - talked about clearing/protecting c - spine.
Ensuring no other non-neurosurgical life threatening issues, readiness for transfer, how
much oxygen do you require (including the amount of oxygen required to power oxylog),
communication between hospitals, how do you manage a blown pupil in the ambulance
(dose of mannitol). I had to ask to see the scan.
C: 70 yo post AAA repair. Had epidural in situ. not able to feel or more legs.
How would you assess?
What are the causes of this?
What investigations are required?
Talked about spinal cord perfusion pressure and protection during the time waiting for scan
and transfer for surgery. So talked about increasing MAP and decreasing ICP by doing a
spinal to take off CSF. Normal coagulation. Risks and benefits of this.
Science viva wasn't very scientific.
1- Anatomy: Discuss the radial artery. What is best practice for placing radial arterial lines:
were aiming for things like: labelling, sterile transparent membrane coverings, aseptic
technique on insertion etc.
Complications of arterial lines - early and late.
Anatomy of radial artery and the blood supply to the hand.
"Tell me about abnormal red blood cells"
Talked about sickle cell disease, thalassaemia, haemolytic anaemia. How do you diagnoses
haemolytic anaemia.
2 - Pharmacology
Tell me about magnesium
3 - Heat stroke
37 year old man with a temperature of 42 in A&E - how do you manage him.
How does an oesophageal doppler work? What therapeutic strategies do you have to cool
him
Set 13
Long case
Middle aged man, smoker, previous alcoholic with abdominal mass and vomiting for
urgent laparotomy.
ECG - poor quality trace (typical ward ECG, all over the place!) but in fast AF
CXR - wide spread fibrotic change, ?bulla LUZ but examiner led me away from that idea,
consolodation and some lesions that were suspicious of neoplasm (patient also had
hyponatraemia ?SIADH secondary to lung cancer)
Hyponatraemia and dehydration on U&Es
Leucocytosis, LFTS etc WNL.
Questions for long case
AF - are they optomised (no), what considerations (duration of AF and need to
17

anticoagulate before cardioversion, better to rate control in this case), what can you use and
what will you use (digoxin)
Benefit of NG tube
Classes of shock
Risks and benefits of epidural (sepsis- abdo or chest or both but laparotomy, MASTER
trial)
How to GA (RSI and lines +/- epi)
Intraop tachycardia and hypotension causes and management
On ICU post op with low UO, causes and management
Short cases:
1. Analgesia for circumcision - WHO analgesic ladder (doses in mg/kg), topical LA, penile
block and caudal block and asked how to do them. Armitage formula for caudal bearing in
mind max dose of LA.
2. Showed me an ECG and wanted it describing, LBBB (looked, but it wasn't trifasicular)
in a patient for CEA. LA vs GA arguement for CEA and options for LA. Mentioned GALA
trial too.
3. 12 year old for excision of cholesteatoma!! Asked what it was (no idea), examiner
mentioned it was middle ear surgery (surgical seive and mentioned benign or malignant
tumour). Mentioned that in the 'real world' would discuss surgical needs with surgeon, and
ask anaesthetic Cons colleague what anaesthetic implications there were (any associated
common syndromes, effects on systems or need for special anaesthetic technique etc),
examiner smiled and nodded and seemed happy with a sensible approach! Also PONV and
facial nerve stimulator. Child was also an IDDM on an insulin pump. Wanted details of
how an insulin pump worked, what type of insulin it contained and what you would do preop (stop and put on sliding scale or leave in situ).
Science viva
Anatomy - of the pleura (boundaries and visceral/parietal) and PTX and pleural effusions
(transudate and exudate and how to classify by protein and LDH levels), what else can
collect in the pleural space? How to insert a ICD.
Physiology - acute liver failure and triggers for admission to ICU. Discusses variceal bleed
and treatment, portal hypertension, ascites and SBP, cerebral odema and encephalopathy.
Physics - paediatric breathing systems (inc E, F and circle) and why we can't use the
standard ones. Why we use an Ayres T piece. Problems with circle systems and
advantages. Resistance and work of breathing in paeds.
Pharmacology - Immunosuppressants! Wanted classifications and mechanism of actions,
side effects etc.
Set 14
Clinical long case:
55 year old woman listed for elective neurosurgery following hemiparesis 2 weeks ago and
scan showing two aneurysms in anterior circulation.
SOB at 50-100 yrds, PPM for CHB,
Investigations showed: Bloods (within normal limits from memory - or atleast not grossly
deranged - maybe some renal impairment)
PFTs: FEV1/FVC of 40%
CXR: Hyperexpanded and Dual chamber PPM
18

ECG: Paced
ABG showed mildly raised PCO2 and Low pO2 on air
General discussion about the case and issues.
Asked about PFT's and would I do the case given COPD and ABG's - discussion re: risk
stratification
Details of how I would proceed with anaesthetic. Could I use Isoflurane?
Level of monitoring (art line pre-induction)
Post op seizure /differential and treatment of it.
SHORT CASES:
Awareness - risk factors, management of
Lady with sepsis following admission with cholecystitis - from your previous que bank!
Downs syndrome with Eisenmengers listed for DHS - Not interested in issues re: Downs.
wanted to know about Congenital heart disease, causes of cyanotic heart disease,
principles of conduct of anaesthesia.
CLINICAL SCIENCE:
Spinal cord blood supply and avoidance of ischaemia.
House fire and physiology of Carbon monoxide/cyanide poisoning
Osmolality and measurement and causes of derangement
Anticoagulants/Antiplatelets and recent NICE guidance
Set 15
Long case
72 yr old for aaa repair recently has got discoloured toes (may be embolic) on paracetamol
1g for toe pain .he is a smoker.
bloods normal u & e,fbc n ,
ecg fast af lad,
echo biatrial enlargement
lv and rv normal
exercise tolrance limited by arthritis
Fast AF management,causes,what drugs would u use why
cardiac assessment for non cardiac surgery
investigations thalliumscan dipyramidol scan
echo
TOE would you anaesthetise for TOE
Dobutamine stress echo
Induction lines drugs gtn,mannitol,vasopressors and inotropes blood products pre op
epidural
clamp onand off physiology
PERI OP RENAL PROTECTION what is the role of mannitol in renal protection
19

Post op Teg Fibinolysis trace
Antifibrinolytics would you use and why
all about aprotinin dose /problems
BELL RANG
SHORT CASES
1.POST TONSILLECTOMY BLEEDING USUAL QUESTIONS FELT EASY how do u
assess bleeding in children,paediatric anaesthesia airway edema why surgery and
instrumentation,shock,full stomch,induction,rsi/inhalational why maintanance,how will u
extubate post op
2.Assessment of suitability for lobectomy pt with squamous cell ca lung for lobectomy
went it to details of lung function how will u do TLCO,FEV FVC OBSTRUCTIVE
/RESTRICTIVE
PEFR 25-75
FEF
How do you measure TF TLCO,NORMAL VALUES
SIX MIN WALK TEST
ALGORTHIM IN cepd article
PREDICTED POST OP FEV1/FVC
HOW DO U CALCULATE THE FORMULA
CPEXTESTING AT AND VO2 MAX
3.SPINAL CORD INJURY 2YEARS AFTER COMING FOR BLADDER STONE

REOVAL
DO WE NEED ANAESTHETIC, PROBLEMS,
AUTONOMIC DYSREFLEXIA
WHY WOULD YOU UINTUBATE RSI/GASTRICSTASIS ,WHEEL CHAIR BOUND
,OTHER OPTIONS
POST OP ISSUES
BASIC SCIENCES
1.MEDIASTINUM ANATOMY SHOWED THE PICTURE OF MEDIASTINUM
IDENTIFY THE STRUCTURES
GRVESSELS HEART BORDER
OESOPHAGUS COURSE
DIAPHRAGM,OPENINGS,INNERVATION,ETC
2.Free flap surgery principles
what is free flap,
20

problems,
flow requirements
laminar flow
formula laminar,turbulant,reynolds number
3.AntibiotiCs prophylaxis
all the questions from reCent guidelines
vague and poorly framed questions
4.MRI
PRINCIPLES
PROBLEMS
ECG LEAD PROBLEMS,If non ferrous lead how does it detect signals, contra indications
for MRI
USUAL QUESTIONS.
Set 17
Long Case:
A 60 year old women presents for an oesophagogastrectomy for cancer. She has a past
medical history of scleroderma & Raynouds disease. Mouth opening is 2 fingers. She has
significant acid reflux. Recently she has been complaining of shortness of breath on
exertion. She had an appendicectomy 5 years ago.
dhx:
Prednisolone (no dose given)
Sildenafil
Enalapril
Lanzoprazole
Prostacyclin
Bloods:
Urea-10 Creat-130
Rest of bloods ok
CXR: cardiomegaly (? I think it was meant to show enlarged right heart for right sided
failure secondary to lung disease)
ECG: LV Strain and Left Axis Deviation (Axis was -30ish)
Pulmonary Fn Tests: Restrictive Defect with low transfer of CO
Questions:
1. Summarise the key points
2. What is sildenafil for?
3. What is prostacyclin for?
4. Talk through the abnormal investigations
5. What is TLCO on the PFTs?
6. Anything you can do to optimise her pre-op? In particular her poor lung function-was
happy when I said she was on treatment and there wasn't much you can do because it's
21

pulmonary fibrosis.
7. How will you anaesthetise her? I said: Need to fully assess airway as mouth opening 2
fingers. If no worse than when had previous RSI then proceed with RSI otherwise AFO
intubation. Needed a rapid sequence but lung isolation. Art line as well as standard
monitoring. Have a DLT and SLT ready-if easy, put a DLT down, if not then a SLT with
bronchial blocker or change to DLT.
8. How do you check a DLT position?
9. Where does she need to go post op?
10. What criteria do you use to decide whether to extubate or not i.e. HDU or ITU? I said
take ABG at end an if pO2>10 on FiO2 <.40 then extubate.
11. What post op pain relief would could you have? Wanted to discuss epidural vs
paravertebral vs intercoastal vs pca
Short Cases:
1. A 30yr old woman with past history of PONV presents on your day case list for Gynae
laparoscopy. She asks, is it going to happen again? What are the risk factors for PONV?
What can you do to minimise it in this patient? What drugs can you give-name one from
each class.
2. A 20yr old boy presents sudden onset SOB following trauma. You are called to resus he
is tachycardic and tachynoeic and bp is ok. What does his X-ray show? His X-ray (shown
on a screen) is a large simple pneumothorax. Point to the outline of the lung! What is you
management? Aspirate then drain. Describe how you put a drain in-site and actual
procedure. After it's in what do you connect it to? How deep is the water? Why that deep?
Do you put suction on? If you needed to take him to theatre with this what else can you do
to help? They wanted you to say, limit the pressure, that's all.
3. A 70yr old man presents for a microlarygoscopy who has a hoarse voice. What's the
differential diagnosis of his hoarse voice? What are the potential problems of the
anaesthetic?
Basic Sciences
1. Anatomy: what are the indications for cannulating the femoral vein? Describe the
venous drainage of the leg. Describe the relations of the femoral vein at the groin. What are
the complications of cannulating the femoral vein?
2. Physiology: describe the physiological changes of old age and how they affect your
anaesthetic management
3. Pharmacology: what drugs may a patient with metastatic disease be taking? And how do
they affect your anaesthetic management? I talked about analgesics, antiemetics, steroids,
chemotherapeutic agents
4. Physics: describe the normal capnograph (was shown on a computer screen). Describe
these abnormal capnographs-breathing, re-breathing (raised Et CO2), reducing EtCO2.
22

How do you measure EtCO2? sidesteam vs main stream. Wavelength of CO2 absorbance
from Infrared spectrum
Set 16
Long case
59 yr old female scheduled for craniotomy, had hemiparesis secondary to intracerebral
bleed 2/52 ago.
PMHx resp disease with ex tolerance 50-100 yards, hypertension, diagnosed CHB 2 years
ago and has pacemaker
Meds:
Nimodipine 60mg qds, perindopril 4mg, becotide, tiotropium, salbutamol, fluoxetine, PPI
and a statin
Pfts:
FEV1 0.84, FVC 2.7, VC 2.8, FEV1/VC ratio 33%
ABG (on air) ph 7.38; PO2 9.4kPa (asked if this was hypoxic or not);PaCO2 6.1 HCO3 28;
BE 1
CXR -= pacemaker and hyperexpanded lungs
ECG paced rhythm
Questions:
1. Summarise case
2. Comment on PFTs, ECG and ABG
3. Comment on CXR (was there something in the lung fields)
4. How would you anaesthetise?
5. Critical incident post op:
a. Fitting your management
b. Ct head
Short Cases:
1. Awareness as per the blue book, 30yr old patient who you anaesthetised 2 months
ago complains of awareness and GP refers her to you
a. Definitions?
b. Causes?
c. What would you do?
d. Who would you inform?
2. 50yr old male downs syndrome patient with eisenmengers syndrome
a. What is eisenmengers? how would you anaesthetise? What drugs?
3. 30yr female admitted 2/7 ago with acute cholecystitis, you get a call from outreach
she is hypotensive sys bp 70 and tachy 160.
a. What are you going to advise
b. Whats the most likely cause
c. Define severe sepsis (I then talked about sirs, sepsis, severe sepsis and
septic shock)
d. What would be your management
23

Clinical science viva
Anatomy: Arterial supply and venous drainage of spinal cord
What problems?
Spinal perfusion
How would you monitor it? What symptoms?
How could you improve spinal perfusion?
Venous drainage
What problems might occur?
Which group is particularly at risk
Epidural haematoma
Risk factors?
Presentation?
Physiology: Carbon monoxide poisoning and Cyanide poisoning
Mechanisms, treatments
Pharmacology - Anticoagulation
1. NICE guidelines for VTE prophylaxis
2. Risk factors
3. Different drugs and where they act
Clinical Measurement/Physics: Osmalarity and Osmolality
Formula to calculate
Why might you have a reduced osm?
What will it cause?
On same day other group got asked:

Clinical :
Alcoholic man with acute abdomen
Sciences:
Anatomy of pleura
Renal transplant pharmacology
Set 17
73y man scheduled for an urgent AAA. He has a 6.1cm aneurysm and has recently
developed a black middle toe on the right foot. He has bilateral OA of both hips which are
severely spondylosed. He has no other significant medical history, but has recently been
diagnosed with an irregular pulse. He stopped smoking 10 years ago.
He takes 1g Paracetamol qds.
O/E: Afebrile, BP 140/70. HR 112bpm irreg irreg. Normal chest and heart sounds
Biochemistry: Na 136, K 5.1, Urea 5.0, Creat 67 Glc 5.6
Haematology: Hgb 15, WCC 11.1 Plts 278
ECG: Atrial Fibrillation 80-150bpm, one ectopic
Echo: Good LV function, mod dilated RA and LA
Summarise the case
Go through each of the investigations in turn Biochemistry normal
24

Haematology WCC upper border normal (though I said it was all essentially
normal so he asked about the WCC so I said at 0.1raised is essentially normal)
ECG AF Echo dilated LA probably accounting for AF and no thrombus
So how would you proceed with this case?
More history (he said what Cardiovascular and Respiratory and how to
differentiate between these)
What other investigations would you need?
CXR and ABG/Spirometry if chest was bad, and some functional cardiac testing as
poor mobility and these are usually vasculopaths.
What do you mean by functional cardiac testing?
These range from exercise ECG which would not be possible in this case to
pharmacological stress methods.
What methods are these?
Dobutamine stress test so how do you carry this out I said inject Dobutamine
and watch the heart function with an echo. Ok, good any other tests? DipyridamoleThallium scan how does this work dilation of the arterioles with Dipyridamole and
then watch for cold/hot spots. Ok, any other test? CPEX test but would be challenging
in him with the bike so would opt to use a hand bike.
Tell me about CPEX testing Ran through airy room, standard monitoring and
airway gases, resus equipment, exercise bike/hand bike, metabolic cart (his eyes glazed
over then), pneumotachograph. Measurement of Vo2/VCO2 ratio and AT. That of
11ml/kg/min being the defining number for good post op recovery.
What drugs would you have him on?
Statin, didnt need any hypertension or diabetic control but I would consider rate
control and need to consider why hes not on Warfarin as per the NICE guidelines.
If he was on a NSAID would that bother you with putting in an epidural?
No
So how would you carry out the anaesthetic if youd had all of the investigations
and optimized fully?
Started simply with equipment (cell salvage, invasive monitoring), bair hugger
over upper half why warming? said all patients should be warm as per NICE
guidelines and also coagulation reasons. Drugs, awake epidural. He then asked me how
Id put it in said consent, iv access, trained assistant, monitoring, sitting, full asepsis
and he moved me on! Invasive monitoring.
So you said cell salvage how does that work
Dedicated suction to a reservoir, washed (with what said Im not sure I presume
saline he said yes!) centrifuged and then the packed cells are collected through a filter
20-40nm. What are the cells suspended in - said wasnt too sure.
Ok youre half way through the case and the surgeon releases the clamp and
theres a large amount of bleeding what do you do?
Surgical and anaesthetic things. Start with anaesthetic: give blood that I would have
in theatre ready for an AAA, coagulation factors.
25

Ok what factors. I said FFP 15u/kg for APTR or PT below 1.5 but as per the massive
haemorrhage AAGBI guidelines more if there is micro vascular oozing, and consider
cryoprecipitate if fibrinogen under 1g/dl. Also think of tranexamic acid 1g as an
antifibrinolytic. But the tests for APTT and Pt might take a while to come back so need
to treat pre-emptively
What about platelet levels? Aim above 75 as per AAGBI guidelines
But what would you do first get the surgeon to put the clamp back on. He smiled!
What other near bedside tests are there that may guide you?
TEG
So what does the TEG tell you?
Platelet function, but gives no indication of actual numbers
Then puts up a normal TEG on the screen (said normal TEG on the icon!) so asked me
to run through it.
Little hazy here but said it looks globally normal as has the characteristic port
glass shape, short R time (what does that measure time to initial fibrin) then angle,
then the MA speed of clot strength
Showed abnormal TEG essentially similar at the start but shorter and was a
characteristic picture of fibrinolysis
SHORT CASES:
5 yr old bleeding tonsil.
Essentially straight out of any viva book problems, assessment, fluid resuscitation,
blood loss estimation, whats circulating volume of child? Said 70ml/kg. So what
would his be? Some rapid fire maths said estimate weight of 18kg. Then thought
never multiply 70 by 18 so I said Id presume 20kg for now and said 1.4l. She seemed
happy. technique for anaesthetising RSI vs Inhalational (but what would you do RSI),
equipment, ENT surgeon, ant emetics, pain relief.
67yr old female presenting with right lower lobe carcinoma and needs a lobectomy.
Handed a set of pulmonary function tests. Had to go through each one in turn and say
what they were and what their significance was.
FEV1 (forced expiratory flow in 1s) 1.4
FVC reduced
FEV1/FVC 58% - obstructive
FEF 25-75. What is it? Guessed at forced expiatory flow. What does it measure? Small
airways. So its lowered by what: Emphysema, Fibrosis, and Anaemia
TLCO Transfer factor for CO. What does this show surface area of the lung. How do
they measure it. Get patient to breathe in CO. Breathe in CO examiner looked
26

horrified, threw me a bit as I was a bit taken by surprise but anyway stuck to my guns
and said yes, but not a lethal amount. So how much I dont know but certainly below
10%! yes I think that would be a safe bet!
So how would you asses this ladys fitness for surgery?
Cardiovascular and respiratory parameters
Respiratory ones?
BTS guidelines: FEV1 should be more than 1.5 for the lobectomy and this is low so
would need to estimate post op. Ok how do you do this well could V/Q scan. Any
other quicker way?
Lung broken down into bronchopulmonary segment. Right well if youve lost the
lower lobe on the right what does that leave you with. Again maths in a stress situation
so I said well there are 3,2,5 on the right side, so that would be five from the 10. She
laughed and pointed out there are two lungs so did they both have the same number of
segments. Oops! Theres 9 on the left so leave 5/19 (thankfully didnt have to work that
out as a number!)
And cardiovascular? CPEX would be gold standard seemed happy with that and
moved on.
43 yr old male spinal cord transaction 2 yrs ago at T2 presents for renal stone surgery.
What are the issues. Essentially straight out of a viva book.
Several systems: resp lost intercostals, so diaphragmatic, poor cough,
Cardiovascular bradycardia, postural hypotension
Autonomic Hyperreflexia tell me about this, what happens, what causes it
Thermal control
Pressure sores
DVT
Recurrent UTIs
Hard veins
Bell went. The clinical long case was quite weird really. 2 very stern looking examiners
who were very business like, difficult to get any rapport going at all- We all came out
thinking it was too easy and straight forwards, with not much meat to the question at
all. They jumped around quite a bit so keeping your train of thought was difficult.
Short cases very fair 2 straight out of the viva books (so no complaints). The
pulmonary function tests were more iffy, but again they are all in the books and the
pre-op resp carcinoma is also in the books. So, on the whole pretty fair.
Clinical Sciences
Anatomy: On the computer screen in the booth a picture of the thorax and neck with
the veins and arteries of the mediastinum.
27

Tell me about the mediastinum. I said it was an area of the neck and thorax split in to
4: superior, middle, anterior and posterior.
What structures do each contain and can you point them out. Said thymus in the
neck in the superior ok, what about the vasculature. Went through each in turn
which, as there was a picture on the screen was really straight forwards. They wanted
the Aorta, brachiocephalic, subclavian, common carotids. Then jugular, subclavian,
brachiocephalic, SVC. Wheres the pulmonary veins, pulmonary artery, where would
the ductus venosus run, wheres the thoracic duct ( I said on the left side but I cant
actually see it on this screen as it should be draining into Left subclavain he had a
look and agreed it wasnt there!) Name some nerves that traverse through the
neck/chest and abdomen vagus. Where does it lie in the neck T-O groove. Where
does the oesphagus start and how long is it.
Why is the oesophagus important to anaesthetists?
Mode of feeding so placement of NG
Mode of monitoring: Doppler/ TOE/temp
Inadvertent injury: bougie, trache
Air into stomach esp in children/LMA regurg risk
Inadvertent intubation
Then he looked as if we had covered what he wanted to so took a few seconds looking
at the paper before asking How would you anaesthetize for food bolus removal ?
Checked it was definitely in the oesophagus. Yes. So history, examination and
investigations. Yes theyre all ok. Well If the airway wasnt difficult would do iv
induction and intubate. Care needed as it will be a shared airway, and need to make
sure patient is fully paralysed if they are going to use a rigid scope.
Physiology: Free flap surgery
What different types of flaps are there, and whats the differences between them
blood supply pedicle flap vs free flap.
How do you look after a patient with Free flap.
Maintain good oxygenation, MAP but with careful use of vasoconstrictors as these
decrease flow to the flap and actually want to modify the rheology of the blood
haematocrit as per the Pouiselles equation (at which case he switched off), so talked
about keeping warm, vasodilator drugs, leeches,
Pharmacology:
Antibiotics who would you use antibiotics for pre-operatively?
Essentially a run through of the surgical site infections guidelines about antibiotics.
Talked about patient factors and surgical factors (clean, clean-contaminated,
contaminated, dirty.. and wanted examples of these) , implants, at risk patients
diabetics, immunocompromised, IE prophylaxis. Wound dressings. Patient and staff
education. Taylor therapy to potential pathogens. Wanted examples of what to use for
bowel surgery: need anaerobic cover metronidazole, and orthopaedic? At my hospital
we give gentamycin and Flucloxacillin to cover staphylococci. Ok what about MRSA?
Talked about colonization vs infection. Then education of patients and staff.
Handwashing. Aprons and gloves, isolation. Use of specific antibiotics as per
28

sensitivities what would you use. Vancomycin. If they had renal failure what would
you use would speak to the microbiologist for advise of sensitivities and what the
hospital policy was, but could consider Linezolid!
Physics:
Straight out of a viva book: tell me about the problems of anaesthetizing a patient in an
MRI scanner.
Problems with isolated area, magnetism, noise, equipment and monitoring, condition
why needing MRI scan often children.
Basically a run through how it affects all these in turn lots of time on monitoring and
equipment, whos contraindicated pacemaker 5 gauss (though now can get MRI safe),
aneurysm clips. Infusion pumps 30Gauss. Different monitoring. Mentioned ear plugs
would you use in an anaesthetized patient. Said yes as anaesthetic doesnt affect
pressure wave (had no idea though!). Quenching, missiles from ferrous material. Then
how does MRI work in the last minute of the viva. So got to alignment of the atoms
and then apply magnet and the bell went!
Again I thought an extremely fair viva. All the topics were pretty straightforward.
Many found the mediastinum question threw them as it is not in the books however
there was the picture on the screen and pointing out the aorta etc shouldnt be too
difficult to work out on your feet. Examiners were much more interactive in this exam
and it was more like a chat between us three as opposed to an actual viva- actually
enjoyed it by the end. However the questions clearly suited me.
Other vivas I heard about on the day for the long case: Scleroderma and CREST
syndrome in the long case. Short cases femoral triangle, pleural anatomy and chest
drains, osmosis/osmolarity, chemotherapy drugs for renal transplantation and the
indications for transplant and side effects of the drugs.
Interestingly when talking to the examiners afterwards I said I thought that had I got
the science viva with pleura/chemotherapy/osmolarity it would have been much harder
however 70% of candidates passed the exam that day. 57% passed with the questions
we had which is interesting as I thought they were more middle of the road questions.
The Monday cohort had a 50% candidate pass- so I am glad I didnt sit then!
Set 19
57 male, scheduled for emergency laparotomy
24 hour history of abdominal pain & vomiting.
Red mass in right groin
Nil PMH
Smokes 20 / day
Previous alcohol excess, unclear about current intake
29

HR 150
BP 137/86
Reduced air entry at both bases, with bilateral crepitations
ECG Fast AF
CXR Bilateral pulmonary oedema, sail sign & RUL scarring
Bloods
Na 128
K 5.1
U+Es normal
LFTs normal
Hb 14.6
WCC 12.9
Plts 306
Summarise the case

Differential diagnosis
Explain ECG & CXR findings
Pre-op optimisation where, how?
Goal directed fluid therapy
How long willing to wait given likelihood of strangulated hernia?
Management of fast AF chemical vs electrical cardioversion, importance of
knowing old or new AF.
Profound hypotension intraop causes & management
When would you extubate? On table or not?
Post op analgesia epidural vs PCA & TAP blocks
Develops hypoxia post op in HDU, CXR shows basal atelectasis, how would you
manage?
Short Cases
8 year old boy for circumcision methods of analgesia
Simple analgesics
Local anaesthetic (instillagel)
Caudal vs penile block
Anatomy of caudal space, how performed, complication & doses
How a penile block is performed
57 year old male pre-op assessment clinic for CEA
30

Shown ECG Rate 66bpm, SR, normal axis, 1st degree heart block & LBBB
What further information would you want to obtain
Would you be happy to anaesthetise?
What further investigations?
Biggest concern? (recent silent MI)
How would you anaesthetise cervical plexus block vs GA
Advantages & disadvantages of each
GALA trial
12 year old boy for cholesteatoma
What is a cholesteatoma
How long is the operation?
What are the considerations?
Hypotensive anaesthesia (I only had time to discuss increased volatile conc & remi
before being moved on)
What nerves may be damaged?
How are they monitored?
How does this affect the anaesthetic technique?
Basic Sciences
Anatomy of the pleura
Describe the anatomy of the pleural space
Why is it important to anaesthetists?
What accumulates in it?
Why does the lung collapse in pneumothorax?
Pleural effusion types (transudates & exudates protein content & causes)
Chest drain insertion where? How?
Physiology Alcoholic Liver Disease
Pathophysiology of ALD
Relevance to anaesthetists
Problems
o Protein synthesis (protein binding)
o Clotting factor synthesis
o Hypoglycaemia
Blood result derangements
Encephalopathy definition & presentation
Hepato-renal syndrome (implications)
31

Pharmacology Immunosuppressants
Assessment of the post renal transplant patient for theatre
Cause of their renal failure
Function of the transplanted kidney
Difficult vascular access
Types of immunosuppressants
Azathioprine / ciclosporin how do they work?
Steroids how do they work?
What will you do in your anaesthetic?
HPA axis & supplementation
Conversion doses
Long term problems GVHD, nephrotoxicity of immunospressants
Physics & Equipment Breathing systems
How do you choose which one to choose?
Which ones do I regularly ues?
What would you use for MRI / for children?
Efficiency of the Bain for SV / IPPV?
Circle system draw it adv / disadv
Components of soda lime
Set 20
74 year old male for elective C3/4 C4/5 decompression. PMH: RA, prev MI x2 over two
years ago, has had PCI.
Presents as generally frail, weak upper limbs and lower limbs, with altered sensation in
upper arms.
On statin, B blocker, azathioprine, prednisolone, lansoprazole, aspirin
Bloods
Normocytic anaemia, low Na 133
CXR
? increase fibrotic lung markings
ECG
? partial LBBB, evidence of lateral ischaemia
Questions:
Why normocytic anaemia?

Why anaemic?
Why Na low?
Comment on ECG:
32

What other investigations would you like?
How would you anesthetise?
Problems with intubation ?AFOI
Problems with proneing
Where would you send him post op?
Would you extubate him? I said yes totally forgot about potential for phrenic nerve
involvement!!!
80 year old chap presents to pre assessment clinic for SCC removal on his forehead. He
complains of dizzy spells.
They show you his ECG
It was CHB but I messed that up and said it was trifascicular block
80 year old chap comes to A/E with abdo pain, CT confirms AAA his BP is 60/40, HR 85,
he is conscious.
What are you going to do? Stay in A\E or take to theatre?
What fluids , how much?
Consent issues
You get to theatre, how are you going to induce him?
What agent are you going to use?
Multiparous lady has given birth normally and has an epidural in situ. You are asked to see
her as she is complaining of shortness of breath.
What are you going to do?
ABC, Hx and examination etc
DD
? high epidural, ?AFE ? CVS vs Respiratory
Management of AFE
Science Viva
Pt wakes up with sore eye post op
Causes, reasons, what are you going to do.
Examine eye, possible findings on exam.
What are you going to do if it is abrasion?
Eye signs in anaesthesia and critical care?
Talk about light reflex, afferent and efferent pathways.
Talk about nerve supply to eye muscles
Talk about SNS and PNS supply to eye
33

Oxygen toxicity
What happens if you give someone too much O2.
Symptoms of toxicity, how much is too much?
CNS and respiratory symptoms
Who gets O2 toxicity
What is the mechanism behind O toxicity????
Anaphylaxis
Latex sensitivity, type of reactions Type 1 vs type 4
Mechanism of reactions.
Symptoms and signs of reaction
Who gets latex reactions
How would you know under GA?
Management of anaphylaxis, ABC etc
BP measurement
How do we measure NIBP?
Explain syphgomanometer and korotkoff sounds
Explain mechanism
Other types of Non invasive measurement. Eg Finapres
How does it work? What else does it tell us (PCA)
Why dont we use Finapres?
Set 21
Long Case
1. 76 Yrs male H/o 12 months weakness of arms now progressing to legs having C34, C4-5 cervical laminectomy.
PMH: MI *2 , 3 yrs ago Dec& Jan
Rheumatoid arthritis for 10 years
On Examination:
BP 145/60 mmHg, HR 60/min
FBC: Hb 10g%, Plt 136, others normal
U&E: Na 133 , K 4.5, U 9.0, Creatine 80
ECG: Q in L1 , aVL, V4-6, T inversion Q in L1, aVL, V4-6
CXR: Trachea deviated to Right due to? Aortic unfolding
DH: Azathioprine, B blocker, statin, Aspirin
Summarise the case
What Hx would you ask
Comment on FBC and U&E
34

Causes of low sodium
Causes of high urea
Describe chest x-ray, Features in RA
Describe ECG
What other investigations?
Airway examination and findings in RA
Goals for anaesthetising
Intraoperative: Monitors
GA options: AFOI, GA with manual in line stabilisation
Induction drugs
How to anaesthetise airway
Maintenance
Pain management intraop
Post op pain management( cant use PCA morphine due weakness of arms)
Post op goes to ( ECG shown Atrial flutter ) management
Bell rang!!!!!!
Short Cases
1. 80 years male, who is reasonably independent, diagnosed with confirmed
Ruptured aortic aneurysm is with surgeon. BP 60/40 mmHg, Just arousable, HR
120/min, H/O pacemaker, working well.
How would you manage
What resuscitation fluid would you give
What other instructions would you give to your team ?
How would you manage pain?
Investigations?
How would you induce and where?
What monitors will you use
Do you need a line and cvp pre induction?
2. 30 yrs had normal vaginal delivery, epidural in situ for delivery. In 20 min post
delivery Pt. becomes short of breath
Differential diagnosis for SOB
They were expecting huge list
Can she have PET post delivery? I said yes
They wanted Drug induced Pulmonary embolism
Mechanism of pulmonary edema in pre eclampsia( leaky capillary and
decreased oncotic pressure)
Mechanism of ergo metrine
3. You see a pt. for pre assessment with complete heart block( had to diagnose
with ecg) for elective surgery( dont remember)
How would you approach?
What is your immediate managent?
35

PPM for future
Other ways of treating CHB( drugs)
Causes of CHB
BASIC SCIENCES
1. Pt. C/o pain in one eye after non ocular surgery
What is your differential diagnosis?
Causes of pain in eye?
What drugs are used to treat glaucoma?
What drugs precipitate glaucoma?
How would you examine eye and what INVT would you do?
Tell me the pupillary light reflex pathway in detail
Tell the corneal reflex pathway in detail
2. Oxygen Toxicity
What are the ways of oxygen toxicity?
How does it affect various system
Where would you use 100% ( not hyperbaric) O2?
% FiO2 and duration of treatment relation (safely)
How does it cause retrolental fibroplasia ?
Who are prone to get retrolental fibroplasia apart from prematurity?
Group of patients who will deteriorate with 100 % O2
3. NIBP
What are the ways of measuring NIBP non invasively?
How does the sphygmomanometer work?
Causes of erroneous reading?
Is mercury open to atmosphere or closed?
Korotkoff sounds describe
Von Recklinghausen oscillotometer- How does it work?
Draw the Oscillations for MAP, SBP
Can you show for DBP
DINAMAP Principles
Causes of erroneous readings
Finapress:
Principles
4. Pt. has H/O allergy to Latex.
What is Latex?
What types of hypersensitivity reaction it causes?
Which other types of hypersensitivity reaction do you see during
anaesthesia?
How would you manage Pt. with latex allergy under anaesthesia?
What substances in theatres and anaesthetic room has latex?
Where would you anaesthetise?
Where would you shift pt post treatment?
Who would you refer later?
36

Set 22
Long case:
72 years, h/o hip arthritis with reduced mobility presenting with 6.2 cm AAA. 2/52 of right
leg discoloration and 1/52 of black right big toe.
Now in AF ~122, BP: 135/75.
Drug Hx: Paracetamol
CXR: nil
ECG: AF; ECHO: Good LV function. Dilated LA, RV, RA. Mildly impaired RV function.
Valves- normal.
Bloods: Normal FBC, K 5.4, urea 9, normal creatinine
Quest: summary, preop optimise. Is this case emergency? What drug for rate control? Is
high Potassium alarming? Comment on ECG, ECHO.
Anaesthesia- your technique? Intraop monitoring? Shown a TEG with fibinolysis...what
Mx?
Short cases:
1. 5 years post-tonsillectomy bleed. Standard questions.
2. 78 years with FEV1 1.48L, FEV25-75: 50% of predicted. Lowish Diffusion
capacity. Posted for pneumonectomy. Risks? Suitability for lobectomy?
3. 30+ young man 2years after T5 complete transection of sp cord now listed for renal
stone retrieval. Risks? Conduct of anaes? Intraop brady....why? how do you
manage?
Anatomy:
Mediastinum: boundaries? Structures from neck to thorax? Trace major vessels and
thoracic duct on the image? Oesophagus- anatomy- relevance to anaesthetists.
Physiology:
Physiological goals for a flap plastic neck surgery? Free vs pedicle? Post-op goals? If low
perfusion, how do you manage?
Pharmacology:
Antibiotic prophylaxis: indications/ types of surgeries routinely given/ commonly used
drugs/ timing/ disadvantages. It is part of .......campaign? what are the other points in this
campaign?
Physics:
MRI- standard questions- challenges to anaesthetists/ principles of monitoring, equipment/
what is MRI/ contra-indications
Set 23
CLINICAL VIVA
Long Case
History
Elderly man with neurological symtoms of upper limbs for 12 months, scheduled for C3/4
and C4/5 posterior decompression.
History of RA, 2 previous MI 3 years ago and has a stent insitu
Drugs: azathioprine, atenolol, ISMN, aspirin, ACEI
37

No allergies
Examination:
Height 169cm, weight 61kg, BP 140/80
Thinning of skin and fixed flexion deformities
Investigations:
FBC: Hb 9.1 normochromic normocytic anaemia, platelets 136, WCC 7, low lymphocyte
count
Biochem: Na 133, ur 13 and creat 125
CXR no obvious abnormality
ECG: SR 80. Q waves I and v5/6 with TWI in same leads
Questions:
Summarise case
Comment on FBC and biochem. Discuss possible causes of then derangements.
Comment on ECG, possible causes, consistent with previous infarct? Significance of Q
waves
Comment on CXR: what possible changes might you expect on see. Asked about changes
seen with RA/CCF
Then asked about anaesthetic technique. Discussed Fibreoptic intubation. Other options for
intubation. What tube would I use.
Then intra op management prone position discussed issues with positioning,
physiological changes, which nerves can be at risk
Then post op management analgesia.
Critical incident shown ECG - ? flutter /? SVT. Causes and management.
Short cases
1) Elderly man with ruptured triple AAA management (standard questions)
2) Shown ECG with CHB asked about managgment and them about management of
patient with pacemaker
3) Pregnant lady postpartum with SOB asked about differential diagnosis, then asked
about features of amniotic fluid embolism and features and management of PET with
pulmonary oedema.
SCIENCE VIVA
1) Asked about abnormalities of the pupil, what happens when light shone in pupil
(follow impulse to brain and back)
2) Oxygen toxicity when it occurs, what happens, why it occurs, how free radicals
cause harm. why premature infants get retinopathy/retrolental fibroplasia. How
much oxygen and for how long.
38

3) Latex allergy which patients, management of patient with latex allergy. Types of
hypersensitivity reaction. What occurs with each/what reacts with what (seemed to
ask for quiet some detail) Recognition of anaphylaxis and management
4) Methods of measuring BP non invasively. Sources of inaccuracy. Just managed to
get on to talk about Finapres.
Set 24
Clinical sciences
Anatomy
How do you get pain in the eye?
How do u get pain in eye intra operative and post operatively?
How do u get pain in the eye with non operative surgery?
What is the nerve supply to eye?
What is the anatomy of the sns to the eye?
What is the ganglion associated with this
What eye nerves are tested in bsdt
What is the efferent pathway of the PLR
How does one get blindness in the eye with pressure
What drugs act on the ans to the eye
Which drugs cause miosis and mydriasis
Physiology
Oxygen
How do u get problems with oxygen
Wanted thorough details on adults and children including mechanisms
Which age groups most susceptible
Wanted quite specific details
Im not sure I provided them
Pharmacology
Latex allergy
Medications used in this
Types of reaction
Testing
Patient on table symptoms ad signs of anaphylaxis
What to do
Drugs doses
Short cases
1
AAA in resus shocked gcs 6/15
Management
How to control BP
39

To intubate or not. Where
Do in theatre?
Renal failure how to reduce renal failure
Post op metabolic acidosis
Causes
Management
What to tell relatives about bowel ischemia
What other stuff to prepare for
I said blood loss, vasopressors
lines maybe post induction
Cell salvage. Urinary Catheter cvp
2
Sob post partum multiple aged epidural in situ
Causes if sob
Wanted a long list
Wanted preeclampsia and effects of epidural
Little about amniotic fluid bolus
Wanted to know about drugs. How they cause fluid overload
3
Third degree heart block
What to do pre op
What to do intraop
Drugs used
How to cardiovert
Long case
76 cervical cord compression for posterior laminectomy
Rheumatoid
Azothioprine
Na 133
Renal impairment
Halo
Fibrotic lung disease
ECG - anterolateral ischaemia
Anaemia thrombocytopenia
Summarise
Main problems
Bloods
ECG
Cxr
Management plan
Post op location
Post op analgesia
Components of prone
Why
Abdominal compression
40

Bleeding
Why post op hdu Itu
Set 25
Long Case
76 yr male paraesthesia and weakness in arms for posterior cervical decompression C2/3
+ C3/4
PMH 2x MI with primary PCI to LCA, Rheumatoid arthritis
DH atenolol, amlodipine, ISMN, statin, aspirin, prednisolone 7.5mg od, azathiopine,
lasnoprazole, codydramol NKDA
Examination deformities of arms and skin, cachectic (weight 60kg)
Bloods Na 133, Cr 124, Ur 9.8 Hb 9.1 MCV normal, WCC 7.29 Plt 136
ECG sinus rhythm, normal axis rate 75, borderline 1st degree heart block
CXR unremarkable
QUESTIONS
- summary
- how would you anaesthetise him
- talk through the normal chest x-ray
- discuss his MI and problems associated with this intraoperatively
- how would you further investigate his cardiac history
- what cardiac meds would you continue and why, which ones would you stop, are
there any he is not on you would like to stop and why!
- other investigations ie/ pulmonary functiontests
- discussion about risks related to rheumatoid arthritis and airway, then c spine and
airway
- steroid and azathiopine effects and whether I would replace steroids
- issues with prone position padding, physiology
- post operatively he has SVT management
Short Cases
70yr, PPM for complete heart block, ruptured AAA
-
immediate management in A&E - who available / who would you inform /

resuscitation bp aims and why / consent / discussion about why heart rate not
useful parameter in this case
in theatre anaesthetic management, lines
physiology of problems in AAA repairs including cross clamp and letting it off, use
of GTN / noradrenaline in relation to cross clamping / site of cross clamp / mannitol
and frusemide for renal protection and evidence for this
41

Preop assessment, Complete heart block, rate 40
- how would you manage this immediately / long term
- different types of pacing available
- what would you do if this happened intraoperatively (drugs / pacing)
- guidelines for preop insertion of pacing wires
Primip, epidural for labour, just delivered, sudden onset SOB
- causes
- ergometrine and effects of drug
- high block and identification
- amniotic fluid embolism pathophysiology
Science Viva
Anatomy - EYE
- causes of unilateral red eye post non-opthalmic surgery
- anatomy of papillary reaction
- effect of drugs on the pupil
- clinical conditions cause pupil abnormalities
Physiology OXYGEN TOXICITY
- disadvantages of high flow oxygen
- exact mechanism of neonatal retinal problems / length of oxygen treatment required
/ concentration of oxygen required
- COPD patients and hypoxic drive
- Pathophysiology in lungs of oxygen toxicity
- Oxygen and carbon monoxide poising (brief they moved me off this fast)
- Neurological effects of oxygen toxicity
- Cellular mechanism of oxygen toxicity
Pharmacology
- Types of latex allergy
- Types of allergy, how each is mediated
- Anaphylactoid vs anaphylaxis
- People at risk of anaphylaxis to latex
- How you plan your list around latex allergy
- ?premed
- Management of anaphylaxis
Physics
- different methods of measuring non invasive blood pressure
- DINAMAP, principles behind how it works, diagram of oscillations with MAP and
diastolic BP on
- Sphig / stethoscope and how it works, turbulent flow
- Finipress
- Causes for error in DINAMAP
Set 25
Long case
29-year-old male for dental clearance. Recent referral to nephrologist for renal impairment.
42

PMH:
Manic depression
Obesity
Renal impairment
HTN
Smoking
DH:
Lithium
Fluphenthixole
Amlodipine
Chlorpromazine
O/E
BMI 35-40 bp 130/90 bilateral wheeze
FBC: Hb 16.5 High PCV
Bichemistry: Cr 135 Ur 8.5 Lithium 1.0 (upper limit of normal)
ECG: SR with signs of right atrial hypertrophy
CXR: Clear
PFTs: Obstructive ventilatory defect with reversibility
Questions
Summarise the case
How do you know the renal impairment is chronic?
What does his ECG show?
What does his CXR show?
What do you think about his PFTs?
What would explain the ECG and PFT findings?
What are the anaesthetic implications of lithium?
Does anything need to be done about his lithium?
How would you anaesthetise him?
Are you sure a GA is the best option for him?
How about a throat pack?
Talked about safety concerns with a throat pack
Develops airway obstruction in recovery
How would you manage it?
What are the possible causes?
What is the likely cause in this patient and how is it best managed?
Airway obstruction resolves and now the patient is insisting he wants to go home
How would you manage this?
Would you involve anyone else?
43

Would you get him to sign anything?
Short cases
1) PDPH
How do you diagnose PDPH?
What would you do if you perform a dural-tap whilst placing an epidural catheter?
What are the advantages and disadvantages of your approach?
How would you manage a PDPH?
Regarding epidural blood patch:
What would you explain to the patient?
How would you perform it?
What is the optimum time to perform it?
Would you perform it in the first 24 hours?
If not why?
2) Paediatricians request your help with a 2-year-old with stridor
How would you approach this situation?
What are the possible causes?
Interested in inhalational injury
Patient deteriorates and requires intubation
How would you manage this?
Who would you want present?
1) Shown CXR of NG tube sitting in left lung
What is this?
How do you check the position of an NG tube?
What would you do with this one?
What are the nutritional requirements of a normal person (Kcal, carbohydrate, fat, protein,
electrolytes)?
How does this change with critical illness?
What are the complications of enteral feeding?
What does enteral feed contain and what is the base solution?
Science
1) Anatomy
What do you understand by the term T10?
Shown a diagram of a cross section of abdomen/thorax at T10 and asked to name as many
structures as possible.
Shown a CT slice at level of T10 with peritoneal free air and asked to identify structures
What is the diagnosis?
44

Asked about macroscopic anatomy of the liver
What is the blood supply?
Where do the portal vein and hepatic artery meet?
1) Physiology
Define hyponatraemia
What are the causes of hyponatraemia?
How is sodium regulated by the body?
What are the clinical features of hyponatraemia?
What is TURP syndrome?
How would you manage it?
Why are we seeing less of it recently?
1) Pharmacology
Name some drugs we use to reduce the arterial blood pressure
In what clinical situations would you use them?
How does GTN act?
Does it act more on the venous or arterial system?
What would you do if asked to reduce the blood pressure during middle ear surgery?
What is the mechanism of action of sodium nitroprusside?
What are the problems associated with its use?
Is cyanide toxicity common?
How do you treat it?
1) Physics
Tell me about the different types of lasers you are aware of
In what situations are the different types used?
How is laser generated?
What safety precautions would you take when using laser for upper airway surgery?
What would you do if the surgeon said a laser resistant tube would impair his vision?
What are the problems with transglottic jet ventilation?
Are there any other options other than transglottic jet ventilation?
What is the name of the tracheal catheter that can be used?
Set 26
Clinical long case
Lady with CREST syndrome (didnt say CREST, said Reynauds and Scleroderma, but she
had oesophageal disease and mildly elevated Ca2+ on bloods), symptomatic reflux disease,
presenting for oesophagectomy for oesophageal Ca. Exactly like case on Coventry course
same clinical details. Same issues: needs RSI but limited mouth opening and DoubleLumen Tube (I talked about awake FOI and then tube exchange or using bronchial blocker
not sure they were that impressed). Asked which sided DLT and why.
Also, she had pulmonary hypertension Right ventricular bump on CXR and increased
lung vascularity. ECG showed left axis deviation (?). Was taking Sildenafil and Iloprost.
We had a brief discussion about diagnosis (above signs), further investigations (Echo),
45

causes (2ry to pulmonary complications of connective tissue disease and its treatments)
Anaesthetic implications (avoid hypoxia, ??role for pulmonary artery catheter),
pharmacology of Sildenafil and Iloprost.
Clinical short cases

1) Young lady for laparoscopic sterilization. Had PONV with previous operations.
- What will you tell her (in lay language)
- Why is she at risk (discussion of risk factors: Patient, surgical and anaesthetic)
- What can you do to decrease risk (non-pharmacological Vs pharmacological)
- Tell me about pharmacological which receptors can you block (+example), how
does ondansetron work, whats the incidence of PONV, how is this affected by
ondansetron (I happened to know of one study in gynae patients where incidence
reduced from about 50% to about 26% with addition of Ondansetron). Any side
effects or contra-indications
- So whats youre plan with this lady?
2) Trauma call to a young man (no further details given). CXR showed a pneumothorax
- Discussion of simple versus tension pneumothorax (clinical signs on tension
pneumo)
- Treatment of pneumothorax
- Talk me through putting in a chest drain. Which type? Which site?
- Treatment differences with tension pneumothorax
- Treatment differences with spontaneous pneumothorax (BTS guidelines)
- He also has a dislocated shoulder on the other side and the trauma surgeon asks you
to give him a quick GA so he can reduce it [High risk case, needs transfer to
theatre and GA in safe environment. Avoid N2O. Wanted to hear that IPPV can
convert a simple pneumothorax to a tension. LMA +SV not fasted. Avoid
brachial plexus blocks phrenic nerve block (interscalene) or pneumothorax
(infraclavicular/subcoracoid) on other side to existing pneumothorax would be
disastrous.]
3) 70yo man for ENT microlaryngoscopy for hoarse voice
- discussion of causes Direct vocal chord pathology, extrinsic airway compression
or nerve lesion.
- Which nerves involved? Describe motor nerve supply to larynx and effect of partial
and complete lesions.
- What are the issues anaesthetizing this man [Patient factors (commonly smokers
with other pathologies, particularly respiratory and vardiovascular, ?airway
difficulties) and surgical factors (shared airway, head end distant from anaesthetic
machine, need for airway that allows surgery]
- Any other investigations (flexible nasendoscopy, CT)? What do you want to know
from nasendoscopy (cord movement)
- Whats your plan? Discussion of benefits of microlaryngoscopy tube Vs Huntsakir
jet ventilator (definitive airway with airway protection. Difficult for posterior
comissure pathology)
- The surgeon now says he wants to use the laser. What are the implications [staff
(warning signs, goggles) and patient
46

- What would you do? What would you have done if youd known beforehand you
would use laser (metal tube, saline-filled cuff etc)
- What would you do in an airway fire? [Bell rang!]
Clinical Science Viva

Anatomy
- Venous drainage of the lower limb. They wanted this in detail course of long and
short saphenous, point of insertion to femoral, distinction between deep and
superficial veins, where does the popliteal vein arise, where does the popliteal vein
become the femoral?
- Where does femoral vein lie in femoral triangle. Describe borders and floor of
femoral triangle.
- Indications for cannulation of femoral vein
Physiology
Discussion of physiology of ageing, going through each system and its relevance to
anaesthetics. Wanted reasonable detail and typical figures (eg for closing volume, rate of
decline of GFR)
Pharmacology
- What drugs are used in the treatment of malignancy?
- Symptom control. Spent a couple of minutes discussing analgesia. Emphasis on
opiates, especially alternative routes of delivery (transdermal, sublingual, sub-cut in
terminal care). Typical doses (point seemed to be that they can have very high
opiate requirements). Brief mention of alternatives (gabapentin/pregabalin,
amitriptylline, SSRIs. SNRIs like duloxetine) and very brief mention of nerve
blocks/celiac plexus blocks
- Other symptoms: anti-emetics (not in any detail), steroids (very briefly how do they
act on the cell), anxiolytics and antisialogogues in end-of-life care.
- Treatment Classify chemotherapeutic agents [I said purine analogues like 5-FU,
direct cytotoxics like vincristine or bleomycin, recombinant antibodies like
herceptin, and drugs that affect gonadotrophin axis, like aromatase inhibitors or
GnRH analogues]
- What are the important side effects? [general nausea, anorexia, electrolyte
disturbance, hair loss, friable skin, pancytopaenia and specific cardiomyopathy
with vincristine, lung fibrosis with bleomycin]. He asked me whether lung fibrosis
was worse with neomycin or bleomycin. At that point I thought I must have passed!
Physics and equipment
Capnography:
- talk me through a normal capnograph. They had a screen there with a capnograph
on it.
- Where does exhalation start
- Talk me through these capnographs:
o re-breathing/exhausted soda-lime/insufficient flows in mapleson A or D
o MH/Hypoventilation/sympathetic activation/sepsis
47

o Curare cleft
o MI/PE/oesophageal intubation (if at induction)
- How is capnograph generated? How is CO2 sensed?
- Side-stream Vs In-line
- Infra-red absorption. Wavelength, interference from N20 and collision broadening.
Other gases that can be measured with IR
- Other ways of measuring CO2 (not in any detail)
Set 27
Long Case:
76 yr old man with motor and sensory weakness in his upper limbs for last 12 months
presenting for posterior cervical laminecetomy of c3-4 and c4-5.
PMH: RA
Previous 2 MI 3 yrs ago. With stenting done. SOB on climbing stairs.
LONG list of drugs: beta blockers, aspirin, antihypertensives, disease modifying drugs,
analgesia
ECG: q wave inversion/ t wave inversion
CXR: apparently some round lesions that i did not see
Hyponatraemia/ raised urea
Anaemia
Questions:
Go through investigations ( causes of all abnormalities )
Any other investigations ( CT/ nasal endoscopy/ ECHO)
What are you worried about? Problems with RA and prone positioning
What do you need to do to optimise him? ( not much i thought, just thorough assessment of
airway/ cvs)
How would you do the anaesthetic? I said fOB did not ask me any further qs re this.
Post op management/ analgesia
Critical incident: Atrial flutter and management and the new aF guidelines
Short cases:
1. 80 yr old ruptured AAA with PPM. Syandard
2. Ecg: CHB and management. Wanted to know a lot of isoprenaline ( whats in the
bottle/ new formulation / dose etc)
3. 32 yr old multip in postnatal ward with epidural (!!) now has SOB. Management.
Felt this was woolly- not quite sure what they were getting to. Never got a
diagnosis so kept my management generic.
Clinical sciences:
1.causes of unilateral painful eye in non ocular surgery?!!! Wanted acute glaucoma!!.
Pathway for brainstem death testing. And all the eye examinations to do with BSD.
2. hazards of oxygen ( both equipment / physiological)
3, allergy/ anaphylaxis- management of latex, types of hypersensitivity reactions
4.NIBP- automated version/ penaz; reason why foot bp would be higher than arm;
problems with each method
48

I felt the questions were sometimes asked in a roundabout manner and had to ask them to
clarify. Also in some of the questions, wasnt sure what they were getting at but just kept
telling them all i know! In the short cases, i just imagined what i would do if i was actually
there and that helped a lot. In fact that is what one of the examiners asked. Overall I did
feel a bit rushed but keep your cool and think positive.
73 year old retired gentleman is posted for urgent AAA repair. CT abdomen shows 6.7cm
AAA. He is having pain in his left leg for the past 3 weeks. He is having discoloration of
his left leg and a black toe for the past 1 week. He is also having severe hip osteoarthritis
limiting his exercise tolerance. He has stopped smoking 10 years ago. He is not known to
have any other significant past medical history.
Medication
Paracetamol
Investigations:
FBC
-results within normal limits
U& Es Potassium 5.1 mmol/L

Sodium 140 mmol/L
Urea 16
Creatinine Normal
LFT within normal limits
INR 1.0
ECG AF
Echocardiogram
Normal LV systolic function

Mild left ventricular hypertrophy
Moderate dilatation of left atrium
Moderate dilatation of RA and RV
Valves Normal
Questions:
What are the main concerns in this patient?
What could be the cause for the emboli? Any other causes?
What are going to do now?
Pre-op assessment :
How will you assess this patients cardiorespiratory status?
went through all the investigations
WBC 11.5 does that concern you?
49

What does the ECG show? How will you treat it in this patient?What is the NICE guideline
for the treatment of AF? (Beta Blocker)#
Do you want to do any other investigations ?
What about exercise tolerance tests?
Tell me about Cpex
Where is the aneurysm? Does it matter? How will you prevent renal failure? What drugs
can be used and why they are used?
Anaesthetic management:
Preparation- Communication Drugs Equipments
Communication with whom?
What drugs?
What equipments?
Monitoring what is your plan for monitoring this patient?
Thoracic epidural will you do it awake or asleep? Pros and cons
Induction drugs
Maintenance
Critical incident:
The surgeon releases the clamp and there is a massive haemorrhage from the proximal
anastamosis. What will you do now?
(Ask surgeon to clamp the aorta)
ABC
Fluids crystalloids or colloids
Blood O ve/group specific/cross match how long does it take to get it?
Clotting products FFP/Cryoppt -will you wait for the clotting results?
Showed me a TEG one is normal and another one which showed fibrinolysis
What will you do if you get this for your patient? Cryoppt- Any drugs? Tranexamic
acid.Asked about the trial?
Anything else you want to consider in management of massive haemorrhage? Temperature
management.
Short cases
1) 5 year old post tonsillectomy bleeding- typical questions
2) Pre-operative assessment of a lady with squamous cell carcinoma.h/o smoking
+.She is going to have right lower lobectomy.
Lung function tests
50

FEV1
FVC
FEV1/FVC
Results showed obstructive picture? Does that surprise you?
FEF 25-75%
Predicted post-operative FEV1 How will you calculate for this patient?
TLCO How is it measured.(asked me in detail.)
3) Anaesthetic management of patients with high spinal cord injury coming for other
operations.
What are anaesthetic implications?
What is autonomic dysreflexia? Signs and symptoms
This patient comes for removal of bladder stones. What is your plan of anaesthetic?
This patient develops severe hypertension? How will you manage it? He develops
bradycardia also with hypertension? How will you manage it?
Clinical Sciences
Anatomy
What is mediastinum?
Showed me a picture and asked me to identify the major blood vessels and the
thoracic duct
Name the structures that travels through the whole mediastinum
Anatomy of oesophagus
What are the anatomical abnormalities of oesophagus that increase the risk of
aspiration?
Foeign body oesophagus anaesthetic management
Physiology
What are your anaesthetic concerns when a patient comes for a head and neck
cancer surgery?
Flap surgery types of flap/difference between the two types of flap
Anaesthetic principles of free flap surgery
Do you know anything about reccurence of malignancy after surgery?Does it
increase or decrease?How can you modify it
Pharmacology
Do you give antibiotics for surgical prohylaxis?When you will give it? Why do you
want to give it before induction?
In what type of surgeries will you give prophylactic antibiotics?
Are you aware of any NICE guidelines?
SSI guidelines
What are the common possible flora in a hospital setting? What antibiotics will you
give to cover these flora?
51

What is MRSA? What will you do if you find a patient colonised with MRSA preoperatively?What antibiotics will you give if the patient has been infected with
MRSA.
Set 28
Clinical viva
Long case
Elderly gentleman, presented for cervical spine decompression, symptoatic. history of 2 MI
several years ago since them stented and now asymptomatic. Has history of rheumatoid
arthritis.
On aspirin, antihypertensive drugs and azothrioprin and prednisolone ECG shows old
ischaemic CXR - was not clear but some round ? Nodules in left middle area
Questioned related to areas of concern.
IHD, Cervical instability - how to intubate Steroid replacement Invasive lines Patient had a
SVT during anaesthesia - how to treat
Short case 1
Obstetric case - post partum NVD, sudden onset SOB Differential diagnosis Management
Investigations
Short case 2
Leaking AAA in A&E How to resuscitate How to prepare When and how to induce How
to anaesthetize
Short case 3
Complete heart block How to diagnose Causes Treatment of CHB
Basic science viva

Anatomy- eyes
Initially started clinically, differential diagnosis for painful eye following non eye surgery
Then asked about how to examine eye. Direct and consensual reflex of eye SNS and PNS
tracts to eye
Physiology- oxygen toxicity
Wanted quite a lot of details Details of NPSA guidelines regarding oxygen Signs and
symptoms of toxicity Those at risk Exact mechanism in detail- free radicals not enough !
Pharmacology- latex allergy
How to anaesthetise Types of hypersensitivity Difference between anaphylaxis and
anaphylactoid How to treat anaphylaxis
Physics - NIBP monitoring
ways to measure BP non invasively Kortakoff sounds Wave form of how DINAMAP
measures Other types - ? Finger probe, how it works ?
52
Set 29
Long case:
Vascular surgeon in your hospital wishes to take a 73 year old retired physicist for urgent
AAA repair. U/S Scan aneurysm size 6.1cm. For the last 3 weeks he has swollen Rt lower
limb with dusky skin. Last week he developed a gangrenous Rt toe which is now necrosed.
He has an irregularly irregular heart rate. He has stopped smoking 10 years ago. He has
embolised his Rt toe from his aneurysm. He has no other significant medical history. Heart
sounds normal. Chest clear. He has Rt hip dysplasia, impaired mobility and ankylosis of Rt
hip. He is on paracetamol 1 gm qds.
Investigations:
ECG : AF, rate around 130/mt, no other ischaemic changes.
FBC: Hb -11.1 gm/dl
RBC -4.5
Plt 280
Wcc 8.5
MCV, MCH and MCHC Normal
Biochem: Na 142,
K 5.1,
Urea 8.1,
Creatinine 103,
Bil -17,
AST Normal,
Alk phos Normal
Echo : Good LV function
Good rv function, RV mod dilated
RA & LA Mod dilated
AV, MV, TV, PV Normal
What are your concerns about this patient?
Surgeon wishes to take him to theatre straight away .Do you take him to theatre now?
Does he need to be on any other drugs?
I said Aspirin, statins, warfarin/heparin for AF but needs surgery .
How does statins work ---- plaque stabilisation, reduces cholesterol
Rate control of AF With what drugs B- blockers
53

Discussed about how I would assess his cardiac risk CPEX but could not do on bicycle
because of his hips. Then examiner asked how else could you do I said he could use his
hands and work until he reaches anaerobic threshold.
Also mentioned Dobutamine stress test, Dipyridamole Thallium Scan.
Examiner asked what you will look for when u do Dobutamine stress test.
Thought block and muddled up with Thallium scan, but they moved forward?
Intraop: How would u anaesthetise this patient?
I started with anaesthetic equipment, oda examiner stopped and asked what principles of
anaesthetising?
What monitoring? Technique and what drugs?
What problems do you expect intraop?
You have compromised perfusion to kidneys?
I said vasopressors, Increase MAP, increase perfusion
What other methods?
Mentioned Mannitol, N-acetyl cysteine
Dose of mannitol?
Why do we do all this for kidneys?
To prevent renal failure
You mentioned about coagulation problems. This patient is loosing quiet a lot of blood
intraop surgeons unable to control bleeding. What will you do now?
I will meed to transfuse the patient depending on condition. I said for this patient I would
have crossmatched 6 units blood already and it should be ready.
I also mentioned that I will send further blood samples to assess his clotting status and Hb.
I mentioned I will alert blood bank.
He asked me who else would you alert?
Haematologist as he may need clotting products and platelets sometimes take longer to
process.
What are my targets with blood and clotting products?
Postop:
Showed a normal TEG and an abnormal TEG trace.
Asked me what I would do showing me abnormal TEG
Problem with Fibrinolysis
What would you give this patient?
Tranexamic acid.
Asked about Tranexamic acid studies?
I said many studies but people use in different doses depending on different specialities .
Eg. Cardiac upto 6 gm. Ortho -1gm.
Bleeding still not controlled. What else would you use /
Mentioned aprotinin, Factor 7a
When would you extubate this patient? What are your criteria for extubation?
I said patient should not be acidotic?
What PH do you consider to be acidotic?
Bell rang
Short case 1:
Called by a surgeon as 5year old child bleeding 4 hours after Aden tonsillectomy.
54

How would you assess this child? How would you assess his blood loss? Calculation of
blood volume?
What are the problems?
How would you anaesthetise?
What problems would surgeons have?
How would you manage intraoperatively?
When would you extubate and how?
Short case 2:
64yr old woman/ Rt lower lobe lung mass coming for bronchoscopy +/- proceed to
Thoracotomy?
They gave Pulmonary function tests. Discussed just about pulmonary function tests in this
case. They did not ask even about double lumen tubes or one lung ventilation.
Just pulmonary function tests.
I donot remember all values but the PFT showed Restrictive pattern.
Asked about DLCO and how you do the test and what you are looking for etc.
Why are these tests important to do in this patient/
What is the significance?
I told some values for lobectomy and pneumonectomy.
Examiner asked where do all these numbers come from?
Short case 3:
26yr/M had spinal cord injury at T2, had repeated urinary catheterisation before, now
coming for a bladder stone removal.
How would you anaesthetise this patient? Do you need to anaesthetise him?
What problems do you expect?
How do they present when the surgeon proceeds?
I mentioned about autonomic symptoms.
What other problems do you expect?
I mentioned pressure areas, thromboprophylaxis
Drug problems
I said no sux as risk of hyperkalaemia and cardiac arrest.
Examiner asked what other drugs could cause problems.
Asked about temp regulation as I missed this before.
Clinical Sciences viva:
Anatomy:
What is Mediastinum?
Boundaries and relations
Showed picture of heart and great vessels. Asked me to identify vascular structures?
Asked where ductus arteriosus would be in fetus. How blood flow would be in a fetus in
ductus
What are the structures which travel all the way down from thorax to below diaphragm?
I said vagus, thoracic duct, azygos vein.
Examiner wanted oesophagus
What is oesophagus?
Extension, blood supply, lymphatic drainage, nerve supply?
Problems anaesthetising patient with an oesophageal foreign body?
55

What is anaesthetic importance of Oesophagus?
Physiology:
A man coming for head and neck surgey with some tumour.
What are anaesthetic considerations with this man?
Mentioned airway problems.
Examiner asked what other problems?
Mentioned smoking and associated comorbidities
What do you understand by flap?
Types of flaps?
What are the problems with different types of flaps? Which flap is better? Why?
What factors affect flap survival? What is important for flap survival?
I mentioned maintaining blood pressure, perfusion, vasodilatation, decreased viscosity
Examiner asked whether there is any formula
I said Hagen poiseulle formula for laminar flow.
What wpuld you do as an anaesthetist for increasing chance of survival of a flap?
Are there any drugs you could give?
Pharmacolgy:
What are antibiotics?
When do you use antibiotics for a patient who is having a surgery?
Are you aware of any guidelines about antibiotics during surgery?
I mentioned about NICE guidelines and endocarditis prophylaxis
Examiner asked me whether there are any other guidelines.
Said that it is a pharmacology question and can you talk on basis of half lives
I mentioned about dosing
Which antibiotics for what surgery?
How would you determine?
What other precautions would you take to avoid infection apart from giving antibiotics?
Mentioned about sterile technique
Examiner prompted glucose - I said hyperglycaemia increases risk of infection
Then also mentioned about hypothermia and delayed wound healing.
Physics:
What is MRI?
What problems would you encounter in MRI?
Broad classification of types of problems- I said remote location, patient factors and
equipment factors.
Detailed about each
Asked about Resus trolley I said should be outside the MRI room and patient should be
wheeled out.
Earths magnetic field and MRIS magnetic field?
Principles of MRI?
How does it work?
56

FRCA viva questions from 2011 exam

Diunggah oleh

Informasi Dokumen

Deskripsi Asli:

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

FRCA viva questions from 2011 exam

Diunggah oleh

Hak Cipta:

Format Tersedia

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Questions i was asked

Q how would u anaesthetise her , what precautions will u take ?

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

60 yr old (?) Post-op thoracic Aortic Aneurysm repair

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

All was reasonable; managed to score 10/12

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

3.SPINAL CORD INJURY 2YEARS AFTER COMING FOR BLADDER STONE

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

On same day other group got asked:

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Summarise the case

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Why normocytic anaemia?

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

immediate management in A&E - who available / who would you inform /

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

Clinical short cases

Final FRCA viva questions from June 2011 exam

Clinical Science Viva

Final FRCA viva questions from June 2011 exam

Final FRCA viva questions from June 2011 exam

-results within normal limits

U& Es Potassium 5.1 mmol/L