Sunday, December 2, 2007

Short Cases

Difficult to classify them in topics but useful as a list to print out:

Discuss the anaesthetic management of a 3-year-old child who has inhaled a peanut.

Describe the ECG pattern of a 2:1 block.
- What are the causes of 2:1 block?
- What problems are associated with this condition?
- Discuss the perioperative management and types of pacing.

A 19-year-old presenting for surgery is found to be positive for sickle cell disease. How would this affect your anaesthetic management?
- Discuss sickle cell disease

How does a pulse oximeter work?

Describe the anatomy of the femoral nerve.
- What are the indications for blockade?
- Describe the methods of blockade.

What are the causes and effects of hypercapnia postoperatively?

Compare and contrast sevoflurane and desflurane.

You are asked to interpret a chest X-ray showing tension pneumothorax.
- could the chest X-ray give any indication of the cause?

Discuss the differential diagnosis of subacute lower limb weakness.
- Discuss the diagnosis and management of Guillan barre in the intensive care unit.

A 20-year-old Down’s syndrome patient with a mental capability of a 5-year-old child is admitted with a white, pulseless lower limb. He also has patent ductus arteriosus with Eisenmenger’s syndrome. Discuss your detailed management.

74yo Ruptured aortic aneurysm while in the ward

What will you do now? How do you resuscitate circulation?

What will you do?

How much blood will you request. How much will you resuscitate? How do you proceed?

Where will you anaesthetise? Take me through the process?

What induction agent will you use? Difference between Ketamine and Etomidate? What monitoring will you use?

Do you need arterial line to start the case. How do you monitor clotting?

What is the principal of thrombo elastogram

When do you expect problems

How do you treat intra operative hypertension

26y Thoroscopic Sympathectomy for hyperhydrosis

What do you see in the CXR- Pneumothorax

What else do you see- Subcutaneous emphysema

How to detect pneumothorax on the table? What do you do immediately? How do you insert chest drain? Where do you insert? Do you apply suction?

25yo Mytonica Dystrophica

What are features? Mode of inheritance? Onset? What are the problems for anaesthetists?

What is the principal of anaesthetic management? What is pathology associated

Failed needle thoracocentesis for tension pneumothorax XRC

diagnosis, reasons for failure, what would you do next?

IVDU for operation

Prone position- all routine questions


A 8 year old boy who had an emergency appendicectomy is not breathing at the end of the procedure

What is ur differential diagnosis?

How would you proceed?

What would u use first – naloxone or nerve stimulator? Why?

What patterns of nerve stimulation will u use? Why?

What if there is no response to TOF?

What is the difference between TOF,DBS and tetanus?

The last dose of muscle relaxant was given 60 min ago and there is no response to TOF or DBS. What are the things you will consider?

What is sux apnea?

How will u manage it?

Are there any methods to hasten recovery? Would u use them?

Where will you recover the patient?

The patient is now fully recovered. How will u confirm ur diagnosis?

What is dibucaine no?

What atypical variants of sux gene do you know?


What are the principles of management?

What will they accept and not accept?

What is ur target Hb preoperatively? How will u achieve it? Other than iron, erythropoeitin what else would you use?

What steps can u use to minimise blood loss?

What is ur post op management?

When would u consider hyperbaric oxygen therapy?

If you have a 13 year old boy, how will u proceed?

If the child is Gillick competent and refuses blood transfusion what will u do?


spine X ray showing atlanto axial subluxation. ? compression of C3 and posterior fixation of C3-5

Tell me ur findings

This is the C spine X ray of a 66 female with rheumatoid arthritis who has intermittent stridor

How will u differentiate between asthma and stridor?

When is stridor predominant- inspiration or expiration? Why?

Are the C spine findings significant?

How would you secure the airway in this lady?

What are the problems of awake fibreooptic in this lady?

Would you consider gas induction?

Which gas would you use? Why?

1. Discuss infantile pyloric stenosis:
– What is the age distribution/sex distribution/population group most commonly affected?
– What is the pathology?
– What are the signs and symptoms?
– How would you assess a 10 week old child with pyloric stenosis?
– How would you assess the degree of dehydration?
– What are the biochemical abnormalities?
– At what stage would you be prepared to proceed with the anaesthetic?
– How would you anaesthetise the child?
– How would you ventilate the child intraoperatively (mode, rate etc)?
– How would you provide analgesia?
– what postoperative problems might you encounter?

2. You are presented with an intravenous drug abuser:
– What are the problems you might encounter?
– What precautions would you take?
– What would you do in the case of a needle stick injury?
– What measures would you take if blood spills onto the floor and the anaesthetic machine?
– How would you anaesthetise a patient who has injected himself in the femoral artery and is scheduled to have a debridement of his leg?
– What would be your choice of anaesthetic, and what problems might you encounter?
– How would you manage postoperative analgesia if the patient is a heroin addict?

3. A patient who is a known epileptic, taking phenytoin, presents for abscess drainage in his abdomen. You are shown his ECG (2:1 block).
– Is the ECG normal? If not, what is the problem? How is the action potential affected?
– How does phenytoin cause this problem? What does it do to the action potential?
– What investigations would you perform? (measure phenytoin levels/electrolytes)
– Would you anaesthetise the patient?
– What would you do if it were an emergency?
– What problems might you encounter, and what precautions would you take?

What is trigeminal neuralgia?
– What treatments can be given?
– Describe the anatomy of trigeminal ganglion block.
– What dose/volume of glycerol should be given?
– How would you perform a microvascular decompression?

A 23 year old female with severe asthma presents for elective nasal polypectomy. She is currently on inhaled and oral steroids and large doses of inhaled salbutamol. You are shown her ECG (shows atrial flutter with 3:1 block).

– Describe the features of the ECG.
– How is the axis calculated?
– Why might the patient be in atrial flutter?
– How do beta-2 agonists work (beyond the G protein level)?
– How would you treat her, and when would you anaesthetise her?

A 25 year old female presents for thymectomy for myasthenia gravis.

1. What is myasthenia gravis?
2. Tell me as much as you know about it
3. How is it diagnosed? (include EMG)
4. What is edrophonium?
5. How does it work?
6. What dose should be used?
7. What are the symptoms?
8. How would you anaesthetise her?

A 16 year old girl with Down syndrome presents for dental conservation as a day case.

1. Outline the problems you might encounter.
2. What are the specific problems associated with Down syndrome?
3. What premedication would you give and why?
4. What anaesthetic would you give and why?

A 13 year old child presents with Guillain Barré syndrome. He has a history of 10 days of malaise, fatigue and weakness.

– What are the treatment options? (discuss plasmaphoresis versus intravenous immunoglobulin)
– You are shown his chest X-ray; describe the features. (discuss pneumomediastinum)

A patient with end-stage renal failure presents for interval appendicectomy
– Discuss the management pre-, intra- and postoperatively

A patient presents with a C2 fracture/dislocation.
– Discuss the anaesthetic management for the repair of acute cervical fracture.

A patient with a 1-month history of anaphylaxis during general anaesthesia now presents for an evacuation of retained products of conception procedure (ERPC).
– Discuss the anaesthetic management of this patient.
– Discuss the investigations for anaphylaxis postoperatively.

A 23 year old woman with Down syndrome presents with a pale, painful right leg.

1. What is the likely diagnosis?
2. What is Eisenmenger's syndrome?
3. What are the problems with anaesthetising a Down syndrome patient?
4. What would the surgeon want to do?
5. What type of anaesthesia would you choose?

You are shown the chest X-ray of a 26 year old female who has undergone a thoracic sympathectomy by the transaxillary approach. This shows:
– An endotracheal tube in situ (flexometallic)
– Pneumomediastinum (air around the heart and great vessels)
– A globular cardiac silhouette

1. What is likely to be the diagnosis?
2. How would you manage the patient?

A patient presents with interpleural block.

1. What are the indications?
2. Describe the procedure you would perform, in terms of the site, position and type of needle, and the catheter used. What would be the relation of the needle to the rib, which space would you choose?
3. What would be your choice of anaesthetic?
4. What volume of anaesthetic would you administer? What rate of infusion would you choose?
5. What complications might you encounter?

Your Examiner describes a patient in the accident and emergency department with features of a tension pneumothorax.

1. How would you treat the patient?
2. Draw the arrangement of a chest drain bottle.
3. How far does the tube go in the water and why is this?
4. Why is the bottle so large?
5. How long should the tubing be?
6. Why should the drain not be lifted above the patient?
7. Draw the arrangement of bottles used to drain a haemothorax and suction.
8. What would you do if the drain stops swinging/bubbling?

A 21 year old primiparous Afro-Caribbean woman presents with an unbooked pregnancy of 31 weeks’ gestation. She is admitted onto the labour ward with foetal distress and her blood test results are:
– Sickledex positive
– Haemoglobin: 9.2 g/dL
– Mean cell volume: 60 fL

1. What problems might you encounter?
2. What is fL the abbreviation for?
3. How would you interpret the blood test results?
4. What are the important things to consider in sickle cell disease?
5. How would you anaesthetise the patient for an immediate emergency Caesarean section?

Eight hours later you are called to see the patient on the ward. She is complaining of pleuritic chest pain and has a raised respiratory rate and a tachycardia. Her oxygen saturation (SpO2) is 89% and her haemoglobin is now 6.5 g/dL ,with a reticulocyte count of 16%.

What do these signs and symptoms suggest to you, and how would you manage the patient?

You are asked to anaesthetise a fit 3 year old boy for a circumcision as a day case.
1. Is this an appropriate patient for day case surgery?
2. Would you anaesthetise a 1 year old child as a day case?
3. What is your lower cut-off age for day case surgery?
4. What premedication would you give?
5. What anaesthetic would you give and why?
6. How would you administer analgesia?
7. How exactly would you perform the local block that you have chosen?
8. How would you anaesthetise this 3 year old child for a circumcision?
9. Under what circumstances would you consider deferring the operation?
10. What kinds of regional blocks might you consider?
11. How would you perform a penile block/caudal?
12. What would be your choice of local anaesthetic and how much would you use?
13. What postoperative analgesia would you prescribe, and at what dose?

A young man presents to the accident and emergency department with an acute onset of dyspnoea. 1. What course of action would you take?
2. What are the likely causes of this presentation?
3. How would you differentiate between a flail chest and a pneumothorax?
4. Describe how a chest drain is inserted.
5. How far beneath the water must the tube be placed?
6. What is the significance of the depth of the under-water seal?

What are the indications for a lumbar sympathectomy?
How would you perform this procedure?
What are the contraindications to a lumbar sympathectomy?
What substances would you inject and at what doses?
What strength of alcohol might you use?

What do you understand by the term 'total intravenous anaesthesia'?
What sort of patients would be suitable for such a technique, and for what sort of procedures?
Which agents would you use?
What is the half-life of propofol?
What are its advantages and disadvantages?

What are the different reasons for being called to recovery?
What are the causes of low blood pressure in recovery
How would you approach the problem?

Discuss the management of acute severe asthma

Discuss the causes and prevention of secondary brain insult

You are presented with an 80-year-old woman with diabetes mellitus and a touch of indigestion on climbing stairs.
Describe her preoperative assessment and perioperative management for cataract surgery.

Describe the control of blood pressure, both in the immediate and long term.

Discuss the management of a 45-year-old female presenting with a perforated appendix and a blood glucose level of 23 mmol/L. She has been unwell for a week, and the surgeons want to take her to theatre as quickly as possible.

How would you manage an unanticipated difficult airway? Compare your management to the situation where a difficulty is expected.

How would you manage an elderly patient presenting for a quick excision biopsy of a lump in his throat? You notice that he is quite hoarse when you see him.

How would you manage a primiparous woman, presenting for a Caesarean section, who is short of breath at rest? You notice that her booking blood pressure was at least 20 mmHg lower than its present value.

What neurosurgical complications do you know of? Select one complication and describe how you would manage it.

A 10-week-old female infant weighing 3.5 kg is scheduled for inguinal hernia repair. She was delivered prematurely at 34 weeks. List the risk factors and state how these can be minimised.

Discuss the perioperative management of a young patient undergoing removal of a phaeochromocytoma.

How would you manage a patient with 45% burns and smoke inhalation postoperatively on the intensive care unit?

A 50-year-old male presents for an open cholecystectomy. He is a known epileptic.
- What are the anaesthetic problems?
- Describe the classifications of epilepsy.
- What drugs are used in the management of the various forms of epilepsy?
- What are the side-effects associated with these drugs?
- What are the implications of anaesthetic drugs for this patient?
- How would you anaesthetise an epileptic patient?

You are shown an ECG; read this systematically.
The diagnosis in this case is of inferior lateral myocardial infarction
(MI) (how would you calculate the axis?). The patient in question is a 55-year-old male who had an MI 4 years ago. He did not have any chest pain at that time.
- What drugs is the patient likely to be on?
- How would you assess this patient?
- What are the symptoms of congestive cardiac failure?
- Differentiate between right heart / left heart symptoms
- Discuss beta blockade.

A 50-year-old woman presents 4 weeks after receiving an epidural steroid injection for chronic back pain. She is now experiencing severe back pain and perineal numbness.
- How would you proceed?
- What are the likely causes of her discomfort?
- What are the markers of infection?
- What further investigations would you carry out?

A female patient has had an anaphylactic reaction. You have dealt with the initial crisis.
- What further action would you take?
- Who should perform the skin prick testing?
- If the same patient were to present for appendicectomy before these test have been carried out, how would you manage this?
- What is the evidence for premedicating with an antihistamine in these circumstances?
- Which induction agent is least likely to cause anaphylaxis?
- How would you recognise anaphylaxis if the patient is anaesthetised?
- If this patient were to present for a leg operation (e.g. for debridement) rather than an appendicectomy, how would you anaesthetise her?

A 36-year-old female with a history of ulcerative colitis presents with toxic megacolon.
- What are the problems you might encounter?
- What investigations would you request?
- What drugs are such patients commonly taking?
- What problems might be caused by these drugs?
- How would you anaesthetise this patient?
- What drugs would you avoid in this type of patient?
- What are the pros and cons of epidural analgesia in such a patient?

A patient presents for a day case laparoscopy.
- How would you provide antiemesis?
- Why is this important?
- Discuss your anaesthetic technique.
- Which volatile anaesthetic is most likely to cause emesis?
- How would you guarantee that emesis is avoided?
- List some antiemetic agents. Where do they act?

You see a 24-year-old woman with antenatal haemorrhage while in labour.
Discuss the causes and management.

You are presented with a case of acromegaly. Discuss the problems of airway management, postoperative care and other associated issues.

You see a patient who has undergone a laparoscopic cholecystectomy. Discuss the issues regarding the use of pneumoperitoneum.

Discuss the causes and physiology of pneumothorax.

Discuss the mechanisms of action of the different classes of anti-hypertensive agents. What are their respective side-effects?

Describe the metabolic pathway of bilirubin and how this can lead to jaundice.
What investigations would you carry out?
Discuss the pathophysiology of pre- and post-hepatic causes of jaundice.

Discuss laminar/turbulent flow and its clinical relevance to anaesthesia.

You are anaesthetising a child for circumcision.
- Discuss how you would carry out a penile block, including details of the method, doses used and nerve roots to be blocked.
- Discuss how you would carry out a caudal block, including the method, doses used , postoperative analgesia and route of administration of analgesia.

How would you assess the severity of a burn?
- Discuss timing of intubation.
- Discuss the method of intubation you would use.

You are to perform a laparoscopic cholycystectomy on a man with right bundle branch block on ECG.
-Interpret the patient’s ECG.
-What is the significance of this condition to his current surgery?
- Discuss the cardiovascular changes that occur with a pneumoperitoneum.

Discuss the following aspects of lasers:
- Their mechanisms of action
- The various types
- Safety issues
- Precautions

Discuss the anatomy of the sciatic nerve, including: Nerve roots, course, branches
- Discuss the following blocks, including use of the nerve stimulator:
- Femoral nerve block
- Three-in-one block
- Obturator nerve block

Discuss the following:
- Drug tolerance
- Drug dependence
- Opiate dependence (including how to deal with intravenous drug addicts)
- Opiate withdrawal

Concerning the pulmonary artery catheter:
- Draw a trace
- Discuss the uses
- Discuss measurements and causes of inaccuracies
- Cardiac output measurement

While administering an epidural for analgesia in a woman in labour with a 16-gauge Tuohy needle, a dural tap occurs.
- What are the reasons for a patient developing a headache after a dural tap?
- What percentage of patients will develop a postdural puncture headache (PDPH)?
- What are the risk factors which predispose to PDPH?
- What would be your further management?
- Would you administer another epidural or insert a spinal catheter?
- What are the advantages and disadvantages of these two techniques?
- Are there any other problems associated with the spinal catheter?
- How would you diagnose Cauda equina syndrome?
- What are the characteristics of PDPH?
- How is it treated?
- Can you use caffeine therapy in a woman who is breast-feeding?
- Would you use an epidural blood patch?
- At what stage would you administer this?
- How is this administered?
- Will you repeat it?
- How would you advise the woman about her future pregnancy?
- Is a future epidural likely to be as good/bad as this one?

How would you anticipate a difficult intubation?
- Describe the Mallampati classification.
- ? Sensitivity and specificity of MPC and others like Patils, Callders, Wilsons
- What equipment would you keep ready in the operating theatre?
- What types of blades would you have ready?
- How would you manage a patient who can be ventilated but cannot be intubated?

A patient in the recovery room, who has undergone a hysterectomy, is confused.
- What is your differential diagnosis and management?
- What are the usual causes for this (including drugs)?
- The patient is hypotensive and tachycardic; how would you manage this?
- Her ECG shows supraventricular tachycardia. How will you manage this?

For the treatment of a fractured wrist, discuss the use of Biers block, brachial plexus block, haematoma block and general anaesthesia with rapid sequence induction.

A patient presents for flexible laryngoscopy; discuss preoperative assessment, microlaryngeal tubes, laser tubes, rigid scopes and maintenance of anaesthesia.

Discuss the anaesthetic management of a 3-year-old child who has inhaled a peanut.

Describe the ECG pattern of a 2:1 block.
- What are the causes of 2:1 block?
- What problems are associated with this condition?
- Discuss the perioperative management and types of pacing.

A 19-year-old presenting for surgery is found to be positive for sickle cell disease. How would this affect your anaesthetic management?
- Discuss sickle cell disease

How does a pulse oximeter work?

Describe the anatomy of the femoral nerve.
- What are the indications for blockade?
- Describe the methods of blockade.

What are the causes and effects of hypercapnia postoperatively?

Compare and contrast sevoflurane and desflurane.

An 8 year old girl fails to breathe after appendicectomy.
- What are the possible causes?
- How could you tell if this was due to muscle relaxants?
- What might you see with a nerve stimulator?
- What is a phase 1 block?
- What is a phase 2 block?
- What type of drug is dibucaine?
- What are normal and abnormal dibucaine numbers?
- Discuss the genetics of suxamethonium apnoea.
- For how long would this patient be apnoeic?
- How would you treat the patient?

You are shown an X-ray of a fractured mandible.
- Present the X-ray.
- Surgeons tell you to take the patient to the operating theatre within the hour. What will you do?
- What would make this case an emergency?
- How would you anaesthetise the patient?
- What are the Difficult Airway Society guidelines with respect to gas induction?
- How would you go about this procedure?
- What might be your major concerns?
- What antiemetics would you use?

A 23-year-old primigravida requires emergency lower segmental caesarean section (LSCS).
- It is a grade 1 category section, what would you do?
- What are the different grades of LSCS?
- Discuss the advantages and disadvantages of general anaesthesia versus spinal anaesthesia.
- Discuss the preoperative assessment en route to theatre with the patient in the left lateral position and receiving oxygen
- Discuss appropriate premedication
- Discuss the techniques for rapid sequence induction of anaesthesia.
- Discuss spinal anaesthesia and the doses that are used.
- Why is thiopentone used for rapid sequence induction?
- Which volatile anesthetics do you use and why?
- What is you opinion of the use of desflurane?

What are the safety features of the modern anaesthetic work station?
- Describe what you know about vaporisers.
- Discuss the use of plenum and draw-over vaporisers. Have you ever used a draw-over vaporiser?
- Discuss the Interlink 25, hypoxic guards, and Richie whistles.

Draw a cross-section of the spine at C6.

How do antiemetics work?
- What receptor types are found at each area?
- Where are the CRTZ, and the VC?
- What antiemetics do you use?
- Describe the mechanism of action of dexamethasone.

What is the stress response?


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