December 2008final FRCA Viva

University Hospitals Coventry & Warwickshire NHS Trust: Dr C Mendonca
Final FRCA viva: December 2008

Set 1
Clinical Long Case:
Elderly women for laparotomy perf bowel, with large neck
swelling, presumed goitre. Has inspiritory stridor.
Discuss ECG (AF), CXR (perf, cardiomegaly, mediastinal
mass) and other investigations recommended. Fluid
resuscitation, how to do fluid challenge etc. Method of
AFOI,
Reason for polycythaemia. Discuss airway management.
Critical incident fast AF. Post-op management of airway.
Short cases:
1. 15yr old with FB in eye, full stomach.
2. Epidural trouble-shooting (ie called to ward, post AP
resection, epidural not working). Discuss sensory/motor
block aspects. Pain scales and pain assessment.
3. Can't remember
Sciences:
1. Anatomy of IJV
2. Indications and complications of central venous access
3. Adult and children daily fluid and electrolyte
requirements, how much Na+ in different fluids
4. Paediatric fluids, discuss causes and consequences of
hyponatraemia, SIADH etc
5. Oxygen delivery - different facemasks how much %O2,
Venturi effect, examples
6. Oxygen sampling, draw and explain fuel cell and
paramagnetic (old version). Write down actual reaction
equations (Pb, Gold, OH-, electrons etc)
7. Cholinesterase - what different types are there. Then
acetylcholinesterase inhibitors. Wanted lots of detail
about syptoms and treatment of organophosophorus
poisoning.
8. Suxamethonium apnoea - wanted rational behind dibucaine
number (quite detailed). How long the apnoea lasts for the
various genotypes
Set 2
LONG CASE ( 8TH DECEMBER 2008 )
76 yr lady admitted 36 hrs ago with abdominal pain,nausea ,vomiting.She has been
resuscitated with i.v.fluids and nasogastric aspiration.
31 yrs ago she had a sub-total thyroidectomy but the disease has recurred and she has a
diffuse goitre.Thyroid function tests performed 2 yrs ago was normal.She is normally on 0.25
mg digoxin and 300mg aspirin.
O/E
Pulse 85/min irregularly irregular
BP 130/55 mmHg
1
Swelling in the neck

The surgeon wants to perform a laparotomy for caecal perforation.
INVESTIGATIONS
ECG : AF rate 75-85
CXR : AP view large mass in the neck, lung fields relatively clear ? minimal pleural
effusions
Heart looked enlarged( cannot comment as AP view )
BIOCHEMISTRY (normal) : Na 139 mmol/l K 3.9 mmol/l Urea 8.0 mmol/l Creatinine
108 umol/l
FBC : Hb 15.9 g/dl
PCV raised
WCC 17.9 X 10^9/ L
QUESTIONS
Summarise the case
Comment on cxr findings
Is she adequately resuscitated ? ( no-raised hb and pcv )
Do you want to take her to theatre?
How will you pre-optimise her?
What other inv do you want? ( ct scan, IDL,nasendoscopy ,thyroid function tests )
How would you manage the airway ? (I settled on awake fibreoptic as the safest option )
After securing the airway the choice of induction agent,muscle relaxant and maintenance
agent and why?
In addition to cvp and art line what else would I like to monitor? ( said cardiac output with
Doppler/ lidco)
What is lidco and how does it work? ( very briefly-nothing in too much detail )
What else to monitor ? ( urine output,peripheral perfusion,core-peripheral temp gradient )
Intra-op pt develops AF with rate of 160 and haemodynamic compromise-what would you
do? ( i said ideally DC cardioversion but need to rule out thrombus or anticoagulate-ruled
out in this case ...remember pt is only on digoxin without any anticoagulation and is in
chronic AF normallyfrom history )
So what would you do? ( amiadarone and dose )
What could be the reason for AF ?
Causes of AF in general.
After the surgery what factors would decide if I would extubate the patient.
Pros and cons of extubating v/s period of ventilation post-op.
Methods of pain relief ( couldnt complete bell rang! )
SHORT CASES
1) 75 YR OLD WITH AORTIC STENOSIS FOR THR .
Signs and symtoms of AS.
Examination findings.
Investigations to assess severity of AS.
Grading of severity on valve area and mean gradient.
Cardiologist says doesnt need valve replacement. Aims of anaesthetic management.
How would you anaesthetise him?
2) 15 YR OLD WITH PENETRATING EYE INJURY WITH FULL STOMACH.
What are the main concerns.
Effect of sux on IOP by how much does it increase it?
2
How can you prevent it ?

What other option is available - delay surgery till fasted.
Surgeon says cant wait- how will you anaesthetise ( I chose modified rapid sequence using
propofol,rocuronium and alfentanil to prevent pressor response- examiner seemed ok with it
.)
What are your aims in management ? ( usual stuff like prevent factors increasing
iop,maintain normocarbia, adequate analgesia , prophylactic anti-emetics, extubation when
fully awake )
How else can you anaesthetise- didnt understand what the examiner was looking
for.thankfully moved to next short case.
3) PATIENT HAD PROCTOCOLECTOMY EARLIER THIS MORNING.EPIDURAL INSITU.LATER IN THE EVENING NURSE ON THE WARD CALLS YOU ( YOU ARE
ON-CALL ) AND SAYS EPIDURAL NOT WORKING AND PT IN PAIN.
How will you go about managing this.
How do you assess the block?
What do you look for in the anaesthetic notes?
What do you look for at epidural site? ( catheter slipped out, fluid around site)
What are the options available? ( couldnt completebell rang to the rescue)
Overall felt both the examiners were friendly and put me at ease . generally looking
for common sense approach to problems than actual factual details. Helps very much
to have a calm mind and to think before answering. ( easier said than done! )
GOOD LUCK TO EVERYBODY .
Set 3
CLINICAL:
63 Year old lady with malignant melanoma on her back. For wide local excision and axillary
clearance in prone position. She had chronic cough and has been treated 3x in the last year
with antibiotics for recurrent chest infections. She has had a previous R mastectomy for
breast cancer 8 years ago. She also has a recent history of palpitations.
Drugs: enalapril
O/E: Wt 54kg Ht 5 ft 5
BP 160/105
HR 80
On examination heart sounds normal. Chest bilaterally wheezy with widespread crackles.
CXR: RLL consolidation and (I thought) effusion.
ECG: SR but ectopics. LVH. Normal axis. No Q waves.
Included:
U+E:
Na 137
K 4.5
U 10
C 157
PFTs: FEV/FVC ratio 64% Post nebulised salbutamol 67%

Reduced FEV1
Reduced FVC: Obstructive.
Summarise this case briefly.
What do you think about her CXR, ECG went through both.
LVH likely cause.
PFTs reversibility/ causes: COPD, bronchitis
Renal impairment and likely causes ACEI and hypertensive nephropathy.
Pre optimisation & other investigations (History, FBC, ABG, Ex Tol, ?CT chest)
What about her hypertension what risk involved would you proceed?
How would you anaesthetise her? What techniques? Monitoring? I said reinforced tube,
positioning, eye padding, free abdomen.
Problems with prone and what mode of ventilation and what pressures would I set ventilator?
Abdominal compartment syndrome.
What problems might the surgeons cause you? I said methylene blue and rib resection. Then
problems with meth blue?
Pain relief? I said PCA Morphine as proximity to surgical site/ infection risk with epidural.
Mentioned DVT prophylaxis and then asked about guidelines NICE and their
recommendations.
Post-op she is extubated and goes to recovery; she becomes hypoxic and wheezy take me
through your management. ABC, ensure no AW obstruction & give oxygen. Listen to chest
give B2 agonists. Etc etc
Then differentials: main thing they wanted: post-op atelectasis with V/Q mismatch.
How would I manage: I said resp supprt NIV, CPAP, and physio.
SHORT cases:
1. Dural puncture: what do you do & how do you manage? I put spinal catheter and
mentioned explicit risk and precautions needed. Then explain and reassure woman.
Late management and differentials.
Bld patch & risks and % resolution.
2. 60yr old man with severe cardiac history: 2 stents for knee arthroscopy.
How would you manage?
Assessment, what investigations. Started with history, ECG, CPET. Showed me ECG:
Inferior Q waves and lateral deep T inversion. Nomal axis but LVH.
Post-MI risk asked for % risk of peri-op MI mentioned guidelines ACC.
What anaesthetic I said regional ideal: Lumbar plexus block or femoral/ sciatic.
What complications of LA blocks in general.
3. 8 yr old boy found in ditch. Comes to A&E with open fractured tib/fib. What do you
do?
ABC C spine control. APLS. Assessments of conscious level GCS and AVPU.
Signs of HI & indications for CT head guidelines again AAGBI, NICE.
Raised ICP and management risks and what to avoid time to draw 1 graph but no
time for much detail. CPP.
SCIENCE viva:
4
1. Anatomy: Phrenic nerve.

Where and by what could it be damaged along its course. Take me through each level
& mechanism.
Course neck and thorax, diaphragm after explaining course asked specifically where
does it lie in the chest.
Phrenic nerve damange how would you tell? What would happen? FRC,
paradoxical mov. Why might this be bad and whom particularly at risk.
Tests to confirm end insp CXR. What else? Made up sniffing while visualising with
US!
2. Indications for renal replacement. Specifics about uraemia, when and what level RRT
indicated.
K and what level.
Methods of renal replacement and adv/disadv of each. HD, HF, PD. Physical
principles.
Risks involved: catheter related and procedure related. Specifics of anticoagulation.
Mortality benefit and do I know of any trials. Cytokines.
3. Very strangely phrased Q: Scenario and end of operation, after using VEC, there is no
TOF.
Causes of no TOF stimulation- Basically wanted what prolongs blockade, but very
unclear at 1st! Drugs, electrolytes, NM disease, neuropathy & equipment factors
All NM monitoring, types, mechanism T4:T1 ratio, stimului types, current etc.
4. What groups of patients are at risk if you dont humidify AW gases & why? Groups.
Short-term & longterm damage and sequelae. Types of humidification. Passive HME
& latent heat vaporisation. Active: Mentioned Bernoulli principle & USS then bell
rang.
Set 4
LONG CASE ( 8TH DECEMBER 2008 )
76 yr lady admitted 36 hrs ago with abdominal pain,nausea ,vomiting.She has been
resuscitated with i.v.fluids and nasogastric aspiration.
31 yrs ago she had a sub-total thyroidectomy but the disease has recurred and she has a
diffuse goitre.Thyroid function tests performed 2 yrs ago was normal.She is normally on 0.25
mg digoxin and 300mg aspirin.
O/E
Pulse 85/min irregularly irregular
BP 130/55 mmHg
Swelling in the neck
The surgeon wants to perform a laparotomy for caecal perforation.
INVESTIGATIONS
ECG : AF rate 75-85
CXR : AP view large mass in the neck,lung fields relatively clear ? minimal pleural
effusions
Heart looked enlarged( cannot comment as AP view )
BIOCHEMISTRY (normal) : Na 139 mmol/l K 3.9 mmol/l Urea 8.0 mmol/l Creatinine
108 umol/l
FBC : Hb 15.9 g/dl
5
PCV raised
WCC 17.9 X 10^9/ L
QUESTIONS
Summarise the case
Comment on cxr findings
Is she adequately resuscitated ? ( no-raised hb and pcv )
Do you want to take her to theatre?
How will you pre-optimise her?
What other inv do you want? ( ct scan, IDL,nasendoscopy ,thyroid function tests )
How would you manage the airway ? (I settled on awake fibreoptic as the safest option )
After securing the airway the choice of induction agent,muscle relaxant and maintenance
agent and why?
In addition to cvp and art line what else would I like to monitor? ( said cardiac output with
Doppler/ lidco)
What is lidco and how does it work? ( very briefly-nothing in too much detail )
What else to monitor ? ( urine output,peripheral perfusion,core-peripheral temp gradient )
Intra-op pt develops AF with rate of 160 and haemodynamic compromise-what would you
do? ( i said ideally DC cardioversion but need to rule out thrombus or anticoagulate-ruled
out in this case ...remember pt is only on digoxin without any anticoagulation and is in
chronic AF normallyfrom history )
So what would you do? ( amiadarone and dose )
What could be the reason for AF ?
Causes of AF in general.
After the surgery what factors would decide if I would extubate the patient.
Pros and cons of extubating v/s period of ventilation post-op.
Methods of pain relief ( couldnt complete bell rang! )
SHORT CASES
1) 75 YR OLD WITH AORTIC STENOSIS FOR THR .
Signs and symtoms of AS.
Examination findings.
Investigations to assess severity of AS.
Grading of severity on valve area and mean gradient.
Cardiologist says doesnt need valve replacement. Aims of anaesthetic management.
How would you anaesthetise him?
2) 15 YR OLD WITH PENETRATING EYE INJURY WITH FULL STOMACH.
What are the main concerns.
Effect of sux on IOP by how much does it increase it?
How can you prevent it ?
What other option is available - delay surgery till fasted.
Surgeon says cant wait- how will you anaesthetise ( I chose modified rapid sequence using
propofol,rocuronium and alfentanil to prevent pressor response- examiner seemed ok with it
.)
What are your aims in management ? ( usual stuff like prevent factors increasing
iop,maintain normocarbia, adequate analgesia , prophylactic anti-emetics, extubation when
fully awake )
How else can you anaesthetise- didnt understand what the examiner was looking
for.thankfully moved to next short case.
6
3) PATIENT HAD PROCTOCOLECTOMY EARLIER THIS

MORNING.EPIDURAL IN-SITU.LATER IN THE EVENING NURSE ON THE
WARD CALLS YOU ( YOU ARE ON-CALL ) AND SAYS EPIDURAL NOT
WORKING AND PT IN PAIN.
How will you go about managing this.
How do you assess the block?
What do you look for in the anaesthetic notes?
What do you look for at epidural site? ( catheter slipped out, fluid around site)
What are the options available? ( couldnt completebell rang to the rescue)
Overall felt both the examiners were friendly and put me at ease . generally looking
for common sense approach to problems than actual factual details. Helps very much
to have a calm mind and to think before answering. ( easier said than done! )
GOOD LUCK TO EVERYBODY .
BASIC SCIENCE VIVA ( 8 TH DECEMBER 2008 )
ANATOMY
Indications for central venous cannulation.
Anatomy of IJV and SUBCLAVIAN VEIN in quite some depth.
Complications of central venous cannulation.
Methods of cannulating.
Pros and cons of ultrasound and landmark techniques.
PHYSIOLOGY
Fluid requirements of 6 yr old child.
Na and K requirements.
What type of fluids and why?
What is stress response to surgery ?
Why do children need glucose containing fluids ?
What are the problems of giving only glucose?
Effects of hyponatremia .
PHARMACOLOGY
What is acetylcholinesterase ?
Where is it found ? how does it work ?
What is pseudocholinesterase? Other name for it ?
Where is it found ?
What other drugs apart from sux does it metabolise?
Natural cause of decreased pseudocholinesterase production ?
Genetic variability ,dibucaine no and fluoride no .
PHYSICS
Methods of o2 delivery to pt .
Fixed performance and variable systems.
Principle of venturi-mask.
A bit about Hudson mask and o2 tents.
Measurement of o2 - fuel cell , paramagnetic analyser.
Again felt examiners were very friendly. In this viva you need a bit of luck to get
asked about what you know well. That builds up the initial confidence and the rest of
the viva can go well.
Other candidates got asked about anatomy of phrenic nerve, renal replacement
therapies, humidity and methods of humidification and muscle relaxants .
7
THANK GOD ITS ALL OVER . AS YOU MIGHT HAVE GUESSED I PASSED.
Set 5
Long Case.
30ish old man
130 KG Mallampatti 3
Poorly controlled epileptic refractory to quad drug therapy
Keppra
Carbamazepine
2 benzodiazepines
Invesigations
CXR
Vagal nerve stimulator
Sleep studies
OSA
Polycythaemia
Lung function tests
PEFR
No reversibility given
Presentes with ruptured globe following fall on to radiator, no recollection of events.
Discuss management and investigations
Short Cases
Stridor in child
Laproscopic surgery
Physiological changes
Complications
X-ray case
TB right upper lobe collapse
Needs urgent surgery for bleeding ectopic
Hypotensive
Resusitive laparotomy
HDU post op
TB implications side room etc
Basic sciences
Pharmacology
Mechanisms (detailed) of excretion by kidney
Affect of renal failure on pharmacokinetics
Physics
Temperatures measurement
Causes of hyperthermia
Physiology of pregenancy
Management of pregnant lady with appendicitis
Anatomy
Sympathetic nervous system
Set 6
My Questions:
Long case: 72 yr Known lung tumor. Comes to A&E with severe pain in the neck. with AS
murmer.
Cspice lateral view. C2 mass with A/A subluxation. ECG Lt axis and borderline LVH
2Decho AS gradient 35mmhg.
discussion went to c-spine fixation and awake fibreoptic and anaesthetic management. and
neurological complication and examination.
short cases.
1 Jehovah's witness.
2 preeclamtic. anaesthesia for C/S pros and cons of GA/Spinal and periop management
3. Pt who had a tracheostomy 4 days ago starts bleeding from tracheostomy site. how would
you manage. causes of bleeding at 4 days. The tracheostomy gets dislodged when taking the
patient to theatre in the corridor how would you manage.
basic science viva.
Vagus nerve transection at jugular foraman. unilateral and bilateral. they were only interested
in airway problems anatomy, nerve supply etc. discussion also included thyroidectomy. and
complications.
Beta receptors everything and B blockers. Recent publications regarding b blocker uses,,
recommendations.
plenun system and uses in anaesthetics. other than vaporisers.
latex allergy. how long does latex last in the theatre in general exponential decay etc
Set 7
1 A 25 years old lady is brought to A&E unconscious after an overdose of drugs.
How will you assess her?
How do you assess consciousness?
At what level of GCS would you intubate her?
She had alcohol and Paracetamol, how will you manage her ( airway & breathing is fine)?
When will you give her N acetyl cysteine?
What is the route of administration?
9
In which solution is it prepared?

Which organs are affected by Paracetamol toxicity?
What is the pathophysiology of hepatic toxicity?
If the INR is high what would you do?
2 A 45 year old male patient for a testicular operation wants an epidural for the operation. He
was very groggy with his last GA and donot want GA.
What will you say to him?
What risks of Spinal/epidural would you explain to him?
Innervation of testies?
Risk of pain in regional anaesthetic in teticular surgery?
3 A man with Pacemaker for an elective surgery.
Routine viva bookcase
Pacemaker code
Preop check
Diathermy
Electrical safety
Clinical Sciences Viva
1 Anatomy of nose
Indications of nasal intubation.
Risks of nasal intubation.
How can you anaesthetise nose?
How much lignocaine can be used?
How much lignocaine is there in a puff?
2 Hyperbaric Oxygen
Mechanism of action
Indications
Carbon monoxide poisoining ; Criteria for HOT
Levels of CO normal/ abnormal
Pathophysiology of CO poisoning
Symptoms
Contraindications
3 Suxamethonium
Mechanism of action
Myalgia reason
How can you prevent myalgia?
Metabolism of Sux
Pseudocholinesterase deficiency genetic variability
Other causes
10
Types of alleles
Dibucaine number
4 Foetal circulation
Draw & explain.
Changes at birth.
Which drug is used to cause ductus arteriosus closure in babies?
Which drug is used to reduce pulmonary hypertension?
What is tetralogy of Fallot?
What will the anaesthetic considerations in management of TOF?
Set 8
Long case:
80 yr old lady for laparoscopic repair of hiatus hernia with a history of nausea and vomitting
for some time. Anaemic (Hb - 9 normocytic), Albumin - 22, Low magnesium and calcium,
significant ischemic changes on her ECG and a large homogenous opacity continuous with
her heart shadow and diaphragm in the left lower zone on the Chest x ray. She was on
digoxin and a diuretic and was diagnosed with Atrial fibrillation in the past.
Questions
Summarise
Discussion on investigations and results:
what could be the reasons for low calcium and magnesium? would you correct it pre-op
what could be the reasons for anemia? would you correct it
What could be the reasons for low albumin in her? would you correct it
What are the changes in ECG? what is your diagnosis ( Q waves in L2 and AvF, and
extensive T wave changes in all leads)
What do you think is the cause for the shadow? What are the differentials? How would
you confirm.
What other investigations do you want and why?
How long will you wait before anaesthetising her?
What anaesthetic technique?
What pain management?
What other post operative mangement? HDU/ITU
Will she need ITU, if so why?
Then we spoke on Nutrition in the ITU, advantages/disadvantages and differences between
enteral and parenteral nutrition.
Short case:
Post tonsillectomy bleed..... standard questions relating to assessment of blood loss,
resuscitation and management.
Atrial flutter and its management.
Anatomy:
1. Anatomy of trachea and how the anatomy affects an aspirated foreign body in an adult.
( extent, relations - both intra and extra thoracic, bronchopulmonary segments. management
of anaesthesia for a foreign body.
11
2. Cigarrette smoking and its effects: Nicotine, Carbon monoxide, carcinogens, changes to
the cilia, COPD etc etc. What are the effects of stopping smoking? How long would you
advise a chronic smoker to stop smoking before anaesthesia
3. Pharmacology: Effects of drugs on ICP: started off from induction agents to all other drugs
that we use in theatre.
4. Laser: How is laser produced? and all the standard questions from the basic sciences viva
book.
.
Set 9
Clinical long case
28 year old primi gravida, 7 hours after an emergency LSCS needs a laparotomy massive
PPH. She is tachycardic, BP unrecordable, pale and anxious. Lab results show severe
anaemia, coagulopathy, pre renal dysfunction. Blood transfusion is in progress
Discussion was based on resuscitation, blood products, factor 7A, and anaesthesia in
haemodyanmically unstable patient.
Few questions
What Hb are you happy with?
What induction agent, why?
Problems with massive transfusion?
What are the ways to control PPH? Esp atonic PPH
Risk factors for atonic PPH
Uterine tonics?
Surgical ways to control bleeding?
Systemic problems with massive transfusion?
Post op complications?
Showed an xray of ards what could this be if it develops within 12 hours ITU admission?
TRALI/overloaddiscussion on trail
Post op renal failure: how to manage
Clinical short cases
1. Showed an ECG of AF with ventricular rate of 90, old inferior wall MI , LAD
70 year old male for cystoscopy
clinical correlation? How to optimise, wwhen would you anaesthetise? Shock or chemical
cardiovertion? Different scenarios.
Causes of AF?
Drugs used?
Intraoperative fast AF, how to manage
2. 80 M k/o COPD with acute exacerbation
causes of deterioration?
Any iatrogenic causes? O2 therapy , its mechanism
12
How to assess the patient, investigations?

Treatment
Whats blue bloater and pink puffers?
Who is suitable for NIV? What are the contraindications?
When would you think of ventilating?
Problems with weaning
3. IVDU for Hickman line insertion
What are the perioperative problems? Vascular access/infections/
Issues of pain control
Viral diseases he can have?
this patient has aids, and you get a needle stick injury
what is the protocol
basic science viva
1. Carotid endarterectomy
Anaesthetic options advantages, disaadv.
Superficial c plexus block how to perform, why not deep?
What are the complications of deep block
What are the monitors used
Haws is cerebral function monitored in awake patients
2
Differences in neonatal resp physiology and their anaesthetic implications
Congenital diaphragmatic hernias, pathophysiology , how to optimise, ventilatory strategy
3. At the end of a long operation in which there was a blood loss of 5 litres the wound edges
are oozywhat the mechanism is
Discussion on cell based coagulation, replacement of factors, what when how much to give
what are the test used to assess coagulation, bed side tests? TEG in detail
4. Arterial blood pressure trace? What info can you gather from the trace?
What happens to the position of dicrotic notch in raised svr? I said it would be shifted
proximally on the down slopehe seemed to agree
How does a line monitor work?
What are the sources of error resonance, damping
Set 10
Long case
A 23 year old female who has delivered 7 hrs ago LSCS - continuing to pass clots on
syntocinon infusion, large baby weight - 4.5 kgs failure to progress prolonged labour . She is
recieving bloods. Surgeons want to take her up for exploratory laparotomy
pale anxious HR -140/min BP unrecordable
Hb - pre LSCS 13.2 g/l post 2.5 9/l
Platelets pre 373 post 73
13
D Dimer - 6 ( very high)

Fibrinogen - Normal
Can you summarise the case ?
What is going on in your mind as you go to see her ?
What is the first thing you do ? ( apparently speed up the infusion)
What are the causes for her bleeding ?
What is your management ?
What are the doses of syntocinon, ergometrine and carboprost ?
Where will you take her post op ?
Sown X ray - ? ARDS / TRALI
What is your post op management ?
Short cases:
1. ECG - AF Causes, coming in for cystoscopy at induction BP crashes what drug would you
use ?
2. IV drug abuser - precautions, difficulties , needle stick injury, incidence of HIV positivity
after needle stick, post exposure prophylaxis
3. Elderly male COPD called by chest physician how will you asess ? when will you manage
conservatively ? Quality of life
Clinical Viva:
1. Intra arterial pressure monitoring - indications, damping , resonance, what parameters are
derived, draw a trace, complications of arterial puncture,
2. GA Versus LA carotid endarterectomy - how do you do deep and superficial cervical
plexus block, complications Local versus GA
3. compare and contrast neonatal versus adult physiology
Clinical long case
28 year old primi gravida, 7 hours after an emergency LSCS needs a laparotomy massive
PPH. She is tachycardic, BP unrecordable, pale and anxious. Lab results show severe
anaemia, coagulopathy, pre renal dysfunction. Blood transfusion is in progress
14
Discussion was based on resuscitation, blood products, factor 7A, and anaesthesia in
haemodyanmically unstable patient.
Few questions
What Hb are you happy with?
What induction agent, why?
Problems with massive transfusion?
What are the ways to control PPH? Esp atonic PPH
Risk factors for atonic PPH
Uterine tonics?
Surgical ways to control bleeding?
Systemic problems with massive transfusion?
Post op complications?
Showed an xray of ards what could this be if it develops within 12 hours ITU admission?
TRALI/overloaddiscussion on trail
Post op renal failure: how to manage
Clinical short cases
1. Showed an ECG of AF with ventricular rate of 90, old inferior wall MI , LAD
70 year old male for cystoscopy
clinical correlation? How to optimise, wwhen would you anaesthetise? Shock or chemical
cardiovertion? Different scenarios.
Causes of AF?
Drugs used?
Intraoperative fast AF, how to manage
2. 80 M k/o COPD with acute exacerbation
causes of deterioration?
Any iatrogenic causes? O2 therapy , its mechanism
How to assess the patient, investigations?
Treatment
Whats blue bloater and pink puffers?
Who is suitable for NIV? What are the contraindications?
When would you think of ventilating?
Problems with weaning
3. IVDU for Hickman line insertion
What are the perioperative problems? Vascular access/infections/
Issues of pain control
Viral diseases he can have?
this patient has aids, and you get a needle stick injury
what is the protocol
basic science viva
15
1. Carotid endarterectomy
Anaesthetic options advantages, disaadv.
Superficial c plexus block how to perform, why not deep?
What are the complications of deep block
What are the monitors used
Haws is cerebral function monitored in awake patients
2
Differences in neonatal resp physiology and their anaesthetic implications
Congenital diaphragmatic hernias, pathophysiology , how to optimise, ventilatory strategy
3. At the end of a long operation in which there was a blood loss of 5 litres the wound edges
are oozywhat the mechanism is
Discussion on cell based coagulation, replacement of factors, what when how much to give
what are the test used to assess coagulation, bed side tests? TEG in detail
4. Arterial blood pressure trace? What info can you gather from the trace?
What happens to the position of dicrotic notch in raised svr? I said it would be shifted
proximally on the down slopehe seemed to agree
How does a line monitor work?
What are the sources of error resonance, damping
Long Case
28 female, primi. Now 7 hours Post LSCS (for failure to progress)
She had oxytocin drips for 5 hours before delivary.
Delivered 4.8 kg male baby. She looks Unwell, pale,
HR -140, BP not recordable, Carotid pulse present
Posted for urgent laprotomy
Pre LSCS
Now
HB
136
28
PLAT
200
82
PT
18
APTT
76
FIBRINOGEN
Rest bloods Ok
1.8
Summary. Asked to go through blood results. What it is?- severe haemorrhagic shock.
Causes?
Why Atony suggested in this case? Management? ABC, BLOOD, O NEGATIVE,
BIMANUAL, INFORM VARIOUS PROFESSIONALS, SENIORS, ITU etc..
Other blood products? Monitors? When happy to Induce for laprotomy? What drugs for
induction- I said Ketamine. To itu
In ITU Chest Xray shows pul odema and ett endobronchial. Why pul odema? How to treat
pul odema here? What Other generic measures in ITU? Why DVT and GI prophylaxis
needed in this patient? What are the measures of organ perfusion?
When she is extubated, what pain management?
16
When can she breast feed?

Short Case- Clinical
1. 70 MALE for day case TURBT. HTN, plays golf
ECG- read through it? Whats callibration? It was AF. Features on ECG
Causes? He wanted IHD/HTN/VALVULAR DISEASE AND THYROTOXICOSIS]
What to do? Patient has no symptoms? Post pone? Yes?- speak to cardiologist
After few days, AF sorted. Introp- sudden HYPOTENSION? Causes?
Not in AF. Whats inotrope of choice?
2. Young male/IVDU/AIDS/for Hickmans line
Issues?? why infection in IVDU?
Problems- Needle stick injury- Whats risk of AIDS infection? Factors governing the rate?
How compared to HbsAg? FIRST AID HOW? Then-occ health. Post exposure prophylaxiswhat drugs?
Clinical Science Viva
1. carotid enarterectomy -LA describe how? What dermatomes blocked? Complications
of block? Adv and disadv of LA. If needs GA , what major issues? How monitor CBF
under GA? WHAT problem post op? Incidence of stroke? It seems carotid stenosis
causes 20% of all the Stroke in any population. I guessed it to perfection
2. Respiratory Physiology of neonate? How diff than adults? Chest wall, ribs, capacities,
diaphragm, alveoli, etc. How control different? Said about chemorecptor less
sensetive???
airway differences? Wanted obligate nose-breathers.
Cong Diaghpramatic hernia, what is it? Whats problem? Incidence? Presentation? Principles
of Management of anaesthesia?
3. Prolonged operation, post op oozing from canula site- Causes. Wanted DIC,
hypothermia, Liver damage, hypocalcemia, sepsis, drugs like nsaid, heparin

Investigations? Briefly each and which part of coagulation pathway tested?
Asked about TEG. How the test is done. Draw a normal and one abnormal trace?
What blood products can be given to correct coag problems? What drugs, and how they
work?
Transfusion triggers for plat, cryo, rbc, factor 8 concentrates?
4. IABP- indications? Complications.? Draw a pulse trace? What all information?
Wanted a lot of stuff here..
for stroke volume, clearly indicate which part of area under the curve( upto diacrotic notch).
What is transducer? Problems with them?
Long case
63 year old female is posted for elective procedure of excision of malignant melanoma and
grafting.
She is a hypertensive on treatment with enalapril 10 mg od
She has been a smoker for 30 years and in the last year has been treated for chest infections
with antibiotics 4 to 5 times.
On examination pulse 70 per minute regular. Blood pressure 170/105
She has wide spread wheeze and crackles at the bases on auscultation
17
Investigations
Biochemistry
Sodium 135
Potassium 4.5
Urea 10
Creatinine 130
No other blood investigations like FBC were provided
A set of spirometry results which showed a FEV 1/ FRC of 62% and 67% post
bronchodilator therapy
An ECG which showed a few ventricular premature complexes and a LVH by voltage criteria
A chest x-ray which showed a loss of air shadowing in the rt base + right costophreinc angle
obliteration. It showed a cardiomegaly
Questions
Tell me about your case
Tell me about the blood tests. Are the results standard or are they adjusted to the patients
characteristics (age sex etc)?
Tell me about the ECG
Tell me about the x ray
What about the spirometry results? Are these results adjusted to patient characteristics? Is the
improvement after bronchodilator therapy significant?
I had mentioned investigations and optimisation in my summary. He then said lets say your
patient is optimised and now ready for surgery .What is your anaesthetic plan.
I mentioned preop visit and premedication
Why premed? Is it your normal practice? Why particularly in this patient then?
I went on to checking machine drawing drugs etc..Etc He said it is all done talk thro your
anaesthetic
After I mentioned arterial line Why arterial line? And induction and intubation with
reinforced endotracheal tube, we moved on to prone positioning
How will you physically do the positioning? Number of people, how will you turn, how will
you position head, protect eyes and nerves
Postoperatively the patient develops wheezing and hypoxia in PACU. How will you
manage?
Would you send this patient to HDU / ITU?
Bell.
Short cases
You have done a dural puncture with a 16 gauge needle in obstetrics. How will you proceed?
I mentioned our hospital protocol of subarachnoid catheter. What drug will you give? How
long will it act for? What will you tell the midwives?
Is there anything else you can do? Try another space. What are the advantages and
disadvantages of catheter and trying another space?
What will you do during follow up?
If she has head ache how will you diagnose a post dural puncture headache from other
causes?
How will you treat- conservative and then blood patch
How will you do a blood patch?
What filter will you use to inject the blood? I said I have seen 2 of my consultants performing
blood patch and we did not use a filter.
18
2. 54 year old weighing 107 kilogrammes , hypertensive is coming in for a knee arthroscopy
ECG given showed t wave inversion in lead1 , aVL and V3, V4, V5, V6. There were Q
waves in Lead 2 and aVF
The questions which followed were a bit vague
Tell me about ECG
What do your findings indicate? I said IHD.
Would you do any further investigations? What else you can ask? I said exercise tolerance in
history.
Would you do this as a day case? I said you mentioned only the weight I need to find out the
BMI. If obese I would not do this as day case because of the co morbidities.
3. 8 year old boy RTA with fracture tibia and fibula. Found in a pool of mud. Unconscious.
In A & E. Orthopaedicians want to fix the fracture. How will you proceed?
I said the ATLS approach. It has all been done by the A&E staff.
I said if airway is not secured I need to make sure the child is safe from that point. He said
GCS is 6. I intubated the child with manual in line stabilisation
What will you do next? Breathing and CirculationIt has all been done.
Anything else apart from GCS. I mentioned look for signs of significant head injury- skull
fractures, bleeding from nose, ears and papillary signs. This child has unequal pupils..What
do unequal pupils signify?
Unconscious, So I will do CT head.
While taking back to ITU blood pressure increases and pulse rate drops.. What will you do?
What is this sign called?
I said sign of worsening increased ICP? What measure will you take?
After mentioning everything I said neurosurgical opinion.
Basic Sciences
Anatomy.
Tell me about the phrenic nerve. I started with nerve roots an then the course till the
diaphragm. Which sided phrenic nerve is longer and why. Where does it lie in the thoracic
inlet?
Tell me about the causes for phrenic nerve palsy and paralysis. Which anaesthetic procedures
in particular.
How will the patient present clinically. How will you diagnose. What will you see in dynamic
fluoroscopy?
How will you treat this condition? I said symptomatic and phrenic nerve pacing
Physiology.
Renal replacement therapy
What are the indications for renal replacement therapy?
How will you do these in the ITU?
Talk through the principles of CVVHF and CVVHDF
Draw a diagram and show me from the patient end to machine end
What factors will act in the micro fibres--- molecular size and negative charges
What are the complications?
Pharmacology
You have given a 32 year old patient 8 mgs of vecuronium during induction. Its 1 hour since
then and the operation is done. But there are no twitches on TOF. How will you proceed?
19
I said I will look for causestechnical factors ----fault in neuromuscular monitor. What
faults can occur- electrode not applied properly- what nerves will you use to test, where will
you place electrodes
Battery- how will you know if the battery is low
Patient factors- liver failure, renal failure
Hypothermia
Electrolyte abnormalitiesshe asked me list all of them which I did
Drugs- What drugs
How does Vecuronium get metabolised and excreted?
What else can you test apart from TOF in these situations? Mentioned Post tetanic count
Explain? . How many twitches will signify reversal?
In TOF what figure you look for to extubate?
How are the various muscle group susceptible to muscle relaxants- vocal cords, small
muscles of the hand and diaphragmatic. What is the significance during reversal?
Physics
Humidification
Why do we humidify inspired gases?
How will you humidify inspired gases? Advantages, disadvantages and risks of each
What is relative humidity and absolute humidity?
What is the humidity in upper airway?
How does HME work? What is its efficiency?
Hazards of humidifying inspired gases
I had mentioned about venturi in nebulisation technique. Tell me how that works. Draw a
diagram to explain
Bell
From the WednesdayLong case- PPH (management of), how would you anaesthetise the patient for laparotomy
(which induction agent, RSI etc), patient then moved to ICU post-op: shown CXR of ARDS
(what are the causes of ALI/ARDS, what ventilation strategies do you know..?)
Clinical short cases- 1) AF 2) COPD 3) Needlestick
Clinical sciences: Anatomy was femoral nerve (3 in 1, lumbar plexus), Diabetes and Insulin
(did I know about inhaled insulin? Turned out neither had the examiner!, pathophysiology
and management of DKA), Diathermy and the complications of it.
FINAL FRCA EXAM QUESTIONS (8th Dec 2008)
Long case:
Euthyroid big goitre for emergency laparotomy. XRC with retrosternal extension. ECG with
AF, on antithyroid drugs, digoxin & aspirin, BP 150/90, septic on inv
Summarise the case

Go through the investigations
More about Hb, hematocrit
What more investigations you want
What would to look for in fibreoptic nasoendoscopy
What would the CT neck and thorax tell you
What does the ECG suggest
20
What are the causes of AF

How does Digoxin work
Where, why and how will you optimise
Where will you put central line? (I said femoralwhat are the disadvantages)
Other monitoring
What are the adv and disadvantages of oesophageal Doppler
Will you put epidural in this one?
How will you anaesthetise
Tell me how will you do awake fibreoptic intubation (wanted topic anesthesia in
detail)
Develops tachycardia postopdifferential diagnosis?
The long case was pretty straight forward. I just thought the examiner was dragging me to the
answers he wanted to tick on his paper. Good for me, but it distracted me initially. When I
was describing something in a systematic way or classifying (e.g causes of AF) he would stop
me in the middle and ask direct question regarding a particular DD. I got scared initially and
thought that I am not answering fluently. I think it was not true. He just wanted to get to the
bottom of the list ASAP. I then decided to answer his way! Trying to guess whats on his
mind! It worked!!
Short Cases:
Aortic stenosis for elective hip replacement
What are causes of aortic stenosis

3 classical symptoms of AS (I said angina, syncope and dint remember the 3rd one
(breathlessness, I think)! So I said palpitations!
He went through pathophysiology of each
Desperately wanted the equation: Coronary perfusion pressure = Mean aortic pr
LVEDP!! I realised a bit late!
More investigations
I said 2D Echo: He asked how will it help. I said to know the severity of AS. When I
went to describe the grades and the numbers, he stopped me and said its ok! He
seemed very happy with the answer.
How would knowing the severity help you. He wanted mild, moderate severe and the
decision (I said I will discuss the necessity of the op. wheather he needs to have it at
all. Since it is an elective op, mild- go ahead, severe- repair/ replace the valve first,
Moderate- weigh the risk benefit!) He seemed satisfied.
15 yr old, full stomach with penetrating eye injury
What are the issues

What is paediatric age group
How will you go about this case
What precautions would you take (wanted antacids, antiemetics, anticholinergics?,
minimise pressor response)
I said Rocuronium 1 mg/kg. He asked me if I personally think it works as good as the
sux. Since I had said Roc, I stood by my decision and said yes!! He was reluctant to
accept and wanted a no! But I said it is an evidence based decision! He again asked
me my personal opinion!! I again said, I think it works just as good!
21
Poorly working epidural following AP resection on the ward
How will you go about it (I said, going thro notes, anaesthetic charts, examination of
the patient, assessment of block, check the epidural pump, catheter etc)
What else? (didnt know what to saybut eventually found out he specifically
wanted me to say that I will ask for the nature, site and duration of the pain)
When I said that, he said patient suffers from chronic backache!
He also specifically wanted me to say that I will find out if the insertion of the
epidural catheter was difficult and wheather it gave analgesia in the recovery!
I felt a bit inadequate disorganised after answering this viva even though I knew it all. The
examiner asked me again the same things in detail, I thought I had already answered!
Basic Sciences
Tell me about cholinestarases (I had 10 seconds of black out period!) Then I tried to
work out.anticholinesterases, anticholinergics.oh! I said, cholinesterases are
ENZYMES!
She smiled and agreed! She asked me if I know any types. I said Acetyl and
Pseudocholinesterase (Drew a diagram of NM junction to show Achesterase in
present in the synaptic clefts! Didnt want blank gaps in my viva. I thought drawing
something would help! May be she ll ask me something related to NMJ!!...She
didnt!)
Other names for pseudoI said Atypical / Plasma / Butyryl
She was particularly happy with butyryl and asked me if I think its just one enzyme
or group of enzymesI said group (of course)!!
Do you know subtypes? No!!
Tell me the drugs metabolised by Pseudo. Are they all metabolised by the same
enzyme?
Tell me the causes of low serum cholinestarases
What is Dibucaine number
What is normal
What does the number 80 mean?
Concentration of Dibucaine used in this test?
What is fluride number?
Various abnormal genotypes possible? (I wrote down homogenous and heterogenous
normal, atypical, silent and fluridebut also wanted the combinations amongst
themselves which I forgot to mention! Such as hetero fluoride and atypical - Ef:Ea)
Where does Acetylcholine attach on the acetyl cholinesterase enzyme (I drew a
beautiful diagram!! She was happy)
Types of anticholinesterases (3 types- competitive, non-competitive, irreversible)
Example of each
Duration of action of Neostigmine
Treatment of OPC poisoning (Wanted protection of health care workers since poison
can traverse the skin and mucous membranes)
Mechanism of action of Pralidoxime
How do you measure oxygen (bell went off just after I answered!)
Clinical sciences
22
Indications of central venous canulation

Anatomy of internal jugular vein
Anatomy of subclavian vein (wanted scalene anterior muscle in particular! I drew it
but didnt label itso he pointed at it and asked what structure is this!)
Complications of central venous canulation
6 yrs old child- calculate maintenance fluid requirements
Why is it important to calculate
What fluid would you give
What are you worried about (Wanted me to say hypoNa)
Why
The examiners were pleasant except for the short cases examiner! He was really aggressive!
But it was a great experience overall. Honestly, I had not thought of many questions and their
answers before despite them being pretty obvious and I think you have to think and apply
your knowledge when you are actually answering. The questions may appear more or less
familiar and basic now, but they appear new there! I suppose it is because of the way they
are asked. I would suggest people to keep your mind as stable and open as you can and be
assured that if you have done decent reading and hard work for this exam, it will get through
to the examiners
12th December 2008
Joy Sanders
Clinical Viva
Long Case
80yr old frail lady presenting for elective laparoscopic hiatus hernia repair
Recent admission 3 months ago with chest pain, not relieved with GTN spray. Fast AF found
ECG treated with digoxin.
PMHx
Diverticulitis
Hypertension
DHx
ACEI
PPI
Digoxin
Examination
?reduced air entry left base
RR 16. Temp 36.9, HR 90, BP 160/80
Ix
Hb 9, normocytic
Raised WCC and CRP
Albumin 22, other LFTs normal. Low Mg2+, Ca2+
23
U+E normal
ECG: AF, rate 90. global T wave inversion, LAD, poor R wave progression
CXR: (poor film!) but air space shadowing left lower/middle zone ?hiatus hernia
Questions
Bloods likely causes or raised CRP/WCC, Hb (not much discussion about this), low
albumin causes, effects
Discuss ECG - ?causes of T wave changes ?ischaemia ?digoxin effects
Causes of AF
Differentiating cardiac from oesophageal chest pain
CXR - ?large hiatus hernia seen ?collapse/consolidation
Optimisation and further investigations
Premedication
Anaesthetic management plan and post op plans
Effects of laparoscopic surgery CVS/Resp/Renal/GI etc
Patient drops sats and hypotensive in recovery possible causes, management
..management of suspected tension pneumothorax
Short Cases
1. Obesity gave height and weight of female patient (morbidly obese) discussion on
BMI, systemic effects of obesity and complications
2. Bleeding tonsil in 5 yr old calculation of blood loss, vital signs, problems,
management of induction, drug doses, tube sizes etc
3. Shown ECG of 4:1 atrial flutter (rate controlled) what drugs may patient be on?
This patient has end stage renal failure awaiting renal transplant - ?worrying, ?
managment
Clinical Sciences Viva

Anatomy
Clinical presentation of foreign body aspiration. If patient stable, how would you
anaesthetise? Lead onto anatomy of trachea length, position, diameter, number of rings,
relations, tracheobronchial tree
Physics
Lasers acronym, types and clinical uses, mechanism of action, characteristics of light,
protection of patient and staff in theatre and potential hazards, laser tubes, low FiO2 and why.
Alternatives to intubation. Risks of jet ventilation.
Physiology
Smoking physiological effects CVS/Resp/CNS/carbon monoxide/immune function
(which components affected). Time frames for cessation. Implications for anaesthesia
Pharmacology
24
Raised ICP Monro Kelly doctrine/ graphs/ how to control raised ICP in theatre. Effects on
ICP (+mechanisms) of inhalational agents (which is worst?), nitrous oxide, induction agents
(thiopentone, ketamine), muscle relaxants, mannitol
Clinical
Long Case:
Deatails provided for the candidate
75 yr old
PMH: Diabetes, Hiatus hernia, Hypertension
Medications: Diuretics, ACE inhibitors, omeprazole
Booked for a thoracotomy for isolated neoplasm in Lung few weeks later
Admitted in A& E yesterday with severe pain in neck
Examination:
BP, Pulse normal
Rhonchi in both lung fields
Ejection systolic murmur over left sternal edge
Respiratory rate : 25/minute
Investigations:
ECG: Left axis Deviation
Right Bundle branch block
Q waves ?
ABG: on 21% oxygen
PO2 9, PCO2 - 4, Ph 7.45, HCO3- 24
PFTs
PEFR reduced
FEV/FVC 70%
Echocardiography
Ejection fraction 70%
Thickened aortic valve, gradient across valve 38 mmHG
Other findings normal
X-ray C Spine
Inadequate film ( C7/T1 not visible)
C1/C2 subluxation
Questions on:
25
All investigations, how do you diagnose Left axis deviation, grading of Aortic stenosis,
grading of FEV/FVC
What other investigations will you do?
How to assess severity of aortic stenosis
Causes of neck pain in this patient
How can lung tumours present
Technique of GA awake fibreoptic intubation
How do you anaesthetise airway for awake fibreoptic intubation
What monitoring ? Spinal cord monitoring
What methods of pain relief
Criteria for extubation Phrenic nerve injury ?
Where manage post op?
Short Cases
1. Jehovah witness
Questions asked:
Why as an anaesthetist you would worry
Questions on preop optimisation, consent issues, Gillick competence
Classes & Mechanisms of action of anti platelet drugs
2.
Preeclampsia : 36 week primigravida BP 160/90, Pulse, 124/min
Questions asked:
What problems the above patient poses
How do you diagnose preeclampsia?
How is different from pregnancy induced hypertension
How can you control her blood pressure better?
What investigations will you do?
Mechanism of action of magnesium and doses
What monitoring will you do and how would you anaesthetise her?
Risks of GA in this patient
Patient had tracheostomy 5 days ago, you are called to ward to see him, and he is
bleeding profusely from the tracheostomy site
Questions asked:
How will you proceed?
When will you take him to theatre?
Final FRCA Viva questions:
3.
Clinical
Long Case:
Deatails provided for the candidate
75 yr old
26
PMH: Diabetes, Hiatus hernia, Hypertension

Medications: Diuretics, ACE inhibitors, omeprazole
Booked for a thoracotomy for isolated neoplasm in Lung few weeks later
Admitted in A& E yesterday with severe pain in neck
Examination:
BP, Pulse normal
Rhonchi in both lung fields
Ejection systolic murmur over left sternal edge
Respiratory rate : 25/minute
Investigations:
ECG: Left axis Deviation
Right Bundle branch block
Q waves ?
ABG: on 21% oxygen
PO2 9, PCO2 - 4, Ph 7.45, HCO3- 24
PFTs
PEFR reduced
FEV/FVC 70%
Echocardiography
Ejection fraction 70%
Thickened aortic valve, gradient across valve 38 mmHG
Other findings normal
X-ray C Spine
Inadequate film ( C7/T1 not visible)
C1/C2 subluxation
Questions on:
All investigations, how do you diagnose Left axis deviation, grading of Aortic stenosis,
grading of FEV/FVC
What other investigations will you do?
How to assess severity of aortic stenosis
Causes of neck pain in this patient
How can lung tumours present
Technique of GA awake fibreoptic intubation
How do you anaesthetise airway for awake fibreoptic intubation
What monitoring ? Spinal cord monitoring
What methods of pain relief
27
Criteria for extubation Phrenic nerve injury ?

Where manage post op?
Short Cases
1. Jehovah witness
Questions asked:
Why as an anaesthetist you would worry
Questions on preop optimisation, consent issues, Gillick competence
Classes & Mechanisms of action of anti platelet drugs
2.
Preeclampsia : 36 week primigravida BP 160/90, Pulse, 124/min
Questions asked:
What problems the above patient poses
How do you diagnose preeclampsia?
How is different from pregnancy induced hypertension
How can you control her blood pressure better?
What investigations will you do?
Mechanism of action of magnesium and doses
What monitoring will you do and how would you anaesthetise her?
Risks of GA in this patient
Patient had tracheostomy 5 days ago, you are called to ward to see him, and he is
bleeding profusely from the tracheostomy site
Questions asked:
How will you proceed?
When will you take him to theatre?
3.
Clinical Science
Anatomy: Nerve supply of larynx
Muscles of larynx
Nerve injuries and effects on vocal cords
Causes of stridor post thyroidectomy
Physiology: Non invasive ventilation
CPAP & BiPAP physiology behind their use
Complications of non invasive ventilation
Indications & contraindications for non invasive ventilation
Alveolar gas equation, how does CO2 effect oxygenation
Pharmacology: Pros & Cons of beta blockers
Mechanisms of action
Classification of beta blockers
Indications, contraindications & complications
28
Physics:
What do you understand by plenum principle?

Applications of plenum principle in anaesthesia
Diagram of vaporiser
How does Bair Hugger work?
Theatre ventilation systems
In a patient with latex allergy how do you decide how many hours you
should leave theatre closed before using to make sure it is free from latex? (Something to
do with time constants!)
Long case
67F, rheumatic fever as child, cardiac surgery 24 years ago; MIs, CVA, ET 100m with frame.
Fallen over, #NOF needs Austin Moore. Ht 5 foot, Wt 96kg
Drugs spironolactone, lisinopril, bumetanide, DF118, warfarin
ECG LBBB
CXR two metallic valves, small effusions, big heart
U+E Urea 16, Creat 140
FBC normocytic, normochromic anaemia, WCC 3, INR 3.6
Discussions list problems. Talk through all investigations and possible cause. How to
optimise. What anaesthetic.
Short cases
1. Causes of weakness in long stay ICU patients!
2. 16F with Downs syndrome for dental work. Issues with Downs. How to anaesthetise.
3. 23F for urgent C-section. Categories of section. History / exam / what anaesthetic for cat 2
section.
Science
Anatomy
Draw the efferent cardiac sympathetics [I didnt do anything for a few seconds as I
thought she hadnt asked me the whole question]. Eventually got onto the denervated heart
after Id repeatedly drawn a medulla and the vagus nerve problems with the denervated
heart.
Physiology
Sickle cell anaemia. Talked about it. Problems. Molecular stuff; HbA/HbS. Tourniquets.
Exchange transfusions
Pharmacology
Tell me about post-hepatic neuralgia [Felt there wasnt much point carrying on at this
stage]. Symptoms, treatment. Got onto action of amitriptyline, carbamazepine. Ive think
weve had enough of this topic, lets move onto to something else shall we? [was that a hint
I was that bad?]
Clinical measurement
Cardiac output monitoring. Some time talking about Lidco (couldnt for the life of me
remember what role lithium had in this pulse contour analysis), TODs (waveform and various
29
bits it measures and calculates), Picco luckily the bell went as the little knowledge Ive ever
had about Picco had vanished.
Long Case
58 yr old man presents with a 1 day history of lower abdo pain and vomiting. Previous heavy
alcohol intake and ? still consuming alcohol.
Also smoker 20/day.
Surgeons would like to take him for an emergency laparotomy as soon as possible.
O/E Painful lump in the right groin. HR 150bpm BP 132/80 Apyrexial
Meds Nil
Allergies Nil
Bloods:
Hb 14.7
Plt 330
WCC 12.7
Na 128
K 5.1
Ur 10
Cr 84
LFTs - Normal
Clotting Normal
CXR AP erect. Hyperexpanded. Normal heart size. Shadowing left upper zone ? Old
scarring from TB ? Pleural plaque. Bullae both upper lobes.
ECG Fast AF ~150bpm. Inverted T waves inferior leads and Q waves anterior leads.
Questions:
Summarise the case
What could be the causes of the lump in the groin?
Comment on the blood results. What are causes of hyponatraemia?
What about the LFTs and clotting being normal? What do you usually see in patients with
excess alcohol intake?
Comment on the CXR. What could be causes for shadowing in the left upper zone?
Comment on the ECG.
What are your pre-op considerations? How would you fluid resuscitate? What are your end
points?
What other investigations would you like?
How would you manage the AF?
How are you going to anaesthetise him?
Pros and cons of epidural.
Intra-op Sudden low BP to 60 systolic. What are the differentials?
If it was a tension pneumothorax how would you manage it?
Post op oliguria causes and management.
30
Clinical Short Cases

1. 19 year old afro Caribbean male for emergency appendicectomy. Sickledex test positive.
What does this result mean? Whats the difference between sickle trait and disease?
What levels of PO2 they sickle. Why dont the RBCs sickle in the venous circulation if PO2
there is 5.3Kpa?
What about Thalassaemia? Difference between alpha and beta, homozygous and
heterozygous. Complications seen in patients with Thalassaemia.
2. 19 year old male asked to review in A&E for after RTA. GCS 13 and linear fracture on
Skull x-ray. Compound fracture to right lower leg which surgeons would like to take to
theatre.
Indications for CT head? Image anything else also? Clearing the C-Spine?
Transferring patient to CT reasons to intubate first (how would you do this?), monitoring?
Management of head injury.
Surgeons want to take him to theatre for his leg how would you manage this (GCS still 13 but
CT brain is normal).
3. 25 year old lady asked to review about having awareness post GA for c-section.
How would you manage this?
What would you look for on the anaesthetic chart? (Monitoring, drugs, timing, blood loss
etc..) Reasons for awareness in obstetrics? Incidence?
Is awareness always a problem?
Other high risk areas for awareness.
Preventing awareness (use of BIS).
Basic sciences
1. Anatomy Blood supply to the brain. Draw the Circle of Willis. What part does each
artery supply? Commonest sites for Aneurysms? Causes of aneurysms? Typical
presenting symptoms of SAH. Management of cerebral vasospasm.
2. Glucocorticoids - Where are they made? How released much/day? Effects of Cortisol
in the body. HPA axis. Cortisol and stress response to surgery. Typical signs of a
patient on long term steroids. Replacement therapy of patients on steroids coming for
surgery. How do you perform a short synacthen test?
3. Magnesium Where is it found in the body? Effects? Levels? Uses (wanted lots of
uses)? Effects of toxicity.
4. Defibrillator Difference between synchronized and unsynchronized DC shock.
Difference between mono and biphasic defibrillators. How does a defibrillator work?
Draw a diagram.
LONG CASE
28 yr old primi with prolonged labour and 8 hrs of synto infusion normal vaginal delivery.
7 hours after this, obstetricians want to take to theatre for laparatomy.
O/E
Pale, anxious lady
31
HR- 145/min
BP unrecordable
Carotid pulses palpable
Sao2 not recordable
One unit of blood transfusion ongoing
Hb- 2.8
Coag profile: DIC picture
U&E s : pre renal picture
Questions:
1. Summarise
2. Comment on blood investigations
3. Plan and immediate action
4. How much of blood to organise
5. Anaesthetic technique and management
6. Post op care
7. Causes of obst hemorrhage
8. Details of blood products and what each contains
9. Medical management of obst bleeding
10. DIC pathogenesis
SHORT CASES
1. AF
ECG shown and asked to describe the findings
Management of acute AF algorithm
Causes of AF
Anaesthetic implications- Fast AF intra op and management
2. COPD pathogenesis
Emphysema and chronic bronchitis difference
Called to assess a patient in the ward with resp failure causes and management
3. IV drug addict and known HIV + for Hickman line insertion
Anaesthetic implications
Nurse sustains needle stick injury how would you manage
BASIC SCIENCE
1. Carotid endarterectomy: GA vs LA ; anatomy of cervical plexus; how to perform
blocks and complications
2. Neonatal physiology and management of cong diaphragmatic hernia
3. Tests of clotting : oozing from wound edges after a surgery involving 5 l of blood loss
( I later realised that all questions in this section from royal college book)
4. IABP indications; complications; damping and resonanace
Thursday 11th Dec.
32
Long Case:
74yr old West African Woman presenting for Cervical Laminectomy. Cervical Spine changes
below C3. PMH of Hypertension and Diabetes.
Drugs: Insulin, Atenolol, Ca ch blocker, ACE, Prazocin, Aspirin, Dypridamole.
Examination:
BP 150/80
Systolic murmur radiating to carotids
Motor changes: Legs 0/5, Arms 3/5.
Investigations:
Hb 11 - no indices given, plts and WCC normal
NA and K normal, Cr about 190, Ur about 20
ECG 1st degree HB. no other abnormailty
CXR Enlarged heart
Questions:
Summary
What do you think about her BP control - I explained multipharmacy implied resistant
hypertension
Consequences of Hypertension
Interpretation of murmur - AS. Symptoms and signs of AS.
How would I further pre-assess this patient
Assessment of diabetes - systems approach
Run through each investigation in turn:
Classification of Anaemias - MCV/MCH
Investigation of Sickle Cell disease/trait
Causes of Renal Failure
ECG interpretation - causes of Heart block - related to Beat blocker/Ca ch blocker?
Physiology of sinus arrhythmia
Would I be happy to proceed with this ECG - yes
How further get this patient ready for theatre - he was looking for: get in night before, sliding
scale, 1st on list
How would I anaesthetise / intra-op with temp, cell saver, ?neuro-phys monitoring
Effect of CVS disturbance / arrhythmia on AS
Post op Care - HDU
Post op analgesia - no PCA given arm weakness
Short Cases:
1. Pacemakers: Indications, classification, what is the commonest type (DDD). Why no
longer VVI. Benefit of DDD (AV pacing better than V pacing alone - more physiological)
pre-assessment, intra-op management, any anaesthetic drugs affect pacemaker function (sux,
volatiles). Why is the pacemaker positioned where it is.
2. Pt had Anaesthetic 25 yrs ago and now presents for hydrocele repair wanting epidural discuss. Fairly basic. I said spinal, what level, what risks for spinal. ?could GA be better now
than 25 years ago. What risks do I warn people about GA. So, was I going to do this as a GA
or spinal. I said yes. Was I going to let the patient make up his own mind - I said yes. Could
he have spinal as daycase - I said yes.
33
3. Woman found at home drowsy after suspected overdose - 80g paracetamol.

Management - ABC / AVPU
Reasons she could be drowsy - other substances
Other investigations incl Head CT
How would I intubate. Management of head injured patient.
ABG findings. Reasons for Met Acidosis - related to Anion gap.
Treatment of paracetamol overdose - would I treat before 4 hour level if good history for
paracetamol overdose - I said yes
Why N- acetyl cysteine. Pathophysiology of paracetamol poisoning
Basic Science:
1. ANATOMY Anatomy of the nose - I may aswell have got up and walked out for the
duration of this question. Apparently there is no nasal artery!
Did eventually get onto the functions of the nose, reasons for nasal airway / intubation, how
to anaesthetise, LA toxicity
2. PHYSIOLOGY. Changes to the foetal circulation at birth.
Wasn't interested in me just explaining the anatomy of the foetal circulation
DA changes, PVR changes, DV changes, changes due to clamping of Umbilical cord on
SVR,
What is Tetralogy of fallot?
How would I anaesthetise a 18 month old with tetralogy of fallot (SVR and PVR changes).
Factors affecting PVR.
3. PHARMACOLOGY. Suxamethonium - draw it, what is it, where does it work on NMJ.
Does it work pre-synaptically - I said no which is why you don't get fade on TOF....they
seemed to like that.
Side effects of sux. Containdications.
Who gets muscle pains. How to reduce incidence of muscle pains - I said benzo, precurarisation.....they wanted another one but I didn't know.
Sux apnoea - congenital and acquired. no questioning on Dibucaine but others in the same
group had in depth questioning on that.
Options to anaesthetise 11 yr old for Appx with sux apnoea - AFOI / Mod RSI with Roc.
Problem with roc - long block - quick few q's on structure of sugammadex - does it work for
atracurium!
4. Hyperbaric oxygen
Indications for use (I said infection - clostr. perfringens and cerebral abscess, COHb
poisoning, Deompression sickness, Low O2 carrying capacity eg. jehovas witness who has
bled)
Oxygen content equation
How does it affect Carboxyhaemoglobin....why does it help. Indications for use in Carbon
monoxide poisoning.
Where is nearest Hyperbaric chamber to you?
Problems with Hyperbaric Oxygen - oxygen toxicity (pulmonary, CNS - Bert effect)
Problems with Anaesthetising someone in a hyperbaric chamber. What is it like in a
hyperbaric chamber?
34
I passed despite knowing absolutely nothing about the anatomy of the nose......guess it goes
to show they don't fail you for not knowing something like that if you know the important
stuff!
Thanks for the help on the courses. Invaluable.
Regards,
Final FRCA Viva December 2008
Imran Mohammad
Long case
Post-partum haemorrhage
28yr old primip presents for emergency laparotomy 7 hours after emergency caesarean
section for failure to progress. She had been on a syntocinon infusion for 7 hours, 4.38kg
foetus delivered, large post-partum haemorrhage. Uterine clots evacuated since delivery.
At presentation pale, very anxious
HR 140bpm, unrecordable BP, pulse oximetry not picking up trace. Carotid pulse palpable.
Bloods before LSCS (normal ranges given)
Hb 13
Platelets 235
Other bloods unremarkable
Bloods after LSCS
Hb 2.8
Platelets 84
PT 19
APTR 1.8
Fibrinogen 1.7
K5
No other investigations produced at this point although CXR showing bilateral infiltrates
consistent with ARDS provided during the viva
Questions on:
How would you resuscitate this patient?
Definitions of massive post-partum haemorrhage.
Classification of hypovolaemic shock
Peri-operative management.
Would you place an arterial line if you could not feel a radial artery pulse?
Drugs affecting uterine tone.
Post-operative management on ITU
Shown CXR expected to comment on adequacy, positions of lines, tube, patchy airspace
opacification
Discussion about ARDS definition, clinical presentation, causes, ITU management.
35
Short cases
Atrial fibrillation
Asked to interpret ECG showing atrial fibrillation with fast ventricular response.
Asked about signs of compromise, peri-operative management, would you anaesthetise a
patient with fast AF, what would you do if it occurred intra-operatively in association with
profound hypotension. How would you anaesthetise for an elective cardioversion.
COPD
Referred a COPD patient on the medical ward by the medical registrar for respiratory failure.
Describe how you would assess this patient.
Indications for intubation and ventilation.
Medical management for respiratory failure.
Interim measures before intensive care.
Indications and contra-indications of non-invasive ventilation
HIV/AIDS
How would you anaesthetise a patient with known AIDS for Hickman line placement.
Discussed assessment, viral load, CD4 count and implications, possible treatments they may
be taking.
Indications for Hickman line placement.
Universal precautions.
Needlestick injury protocol. Risks of transmission of HIV.
Screening for other blood-borne viruses.
What is post-exposure prophylaxis?
Science Viva
Femoral nerve
Describe anatomy wanted detail of course from lumbar plexus, anterior/posterior divisions
to terminal branches, motor and sensory supply
Femoral nerve block technique, indications, contra-indications, local anaesthetic choice and
dose.
3-in-1 block nerves blocked (or not blocked!)
Management of local anaesthetic toxicity.
Head injury
Secondary brain insult causes.
Cerebral blood flow graph CO2, O2, MAP.
ICP definition, normal range, monitors, causes of raised ICP, management of raised ICP.
Management of head injury on the intensive care unit.
NIR spectroscopy how does it work
Transcranial Doppler basic information on how it works wanted, which artery used?
Diabetic ketoacidosis
Pathophysiology
Ketone body synthesis, acetone, acetoacetic acid, beta-hydroxybutyric acid
Utilisation of ketone bodies by brain, heart and tissues
Clinical presentations and management of DKA
Synthesis and actions of insulin, particularly with respect to ion shifts
36
What happens if hypernatraemia corrected rapidly - interested in fluid shifts, cerebral

oedema.
Surgical diathermy
What is it, how does it work?
Interested in current density, frequency, current, risk of electrocution
Bipolar/unipolar comparison
Effect on pacemakers/ICDs
Diathermy plates, what happens if they are loosely applied
Isolating capacitor
The examiners were friendly and helpful. They did not seem to mind too much if the precise
detail of basic science was not there, I felt they were much more interested in clinical
competence. I found it difficult to distinguish between my basic and clinical science viva.
Whilst the preparation for the Final - in particular for the SAQs - is more stressful, I have no
doubt that the actual exam is easier than the Primary.
Long case:
A 28 year old lady who delivered 7 hours ago needs emergency laparotomy. Her current Hb
is 28. BP 60/40. Peripheral pulse not felt. Carotid pulse felt. She is currently being transfused.
Her investigation results:
Hb
Before laparotomy
28
Before delivery
13
WCC
14
14
Fibrinogen low normal
high normal
Platelets
80
150
PT
18
normal
APTT
Na
K
Urea
Creatinine
60
normal
140
5
high normal
high normal
normal
normal
normal
normal
D-dimer
elevated
Questions:
1. Summarise the case
37
2. What are the abnormalities in the investigations

3. Why Urea and creatinine high normal
4. What is the abnormality in the coagulation profile
5. What would you do
6. Whom will you inform
7. What would you ask in the blood bank
8. Would you transfuse platelets (with the platelet of 80)
9. What do you need in the theatre
10. How will you induce
11. What induction agents
12. What muscle relaxants
13. Why pancuroneum
14. What are the medical management
15. What are the surgical options
16. Whats the finding in xray (bilateral diffuse infiltration )
17. What are the causes
18. How will you manage in the ITU (cardiac output monitoring)
19. Other routine management
Short cases:
1. ECG: irregular but I was able to see p waves.
Questions about AF
AF: causes and management
Warfarin- when will you stop
DC cardiversion when will u do
2. COPD
Causes for acute exacerbation of COPD
Findings in emphysema and chronic bronchitis
Medical management
ITU management
3. HIV-drug addict
What are the problems?
What are the precautions?
How will you avoid needle stick injury?
What will you do if it happens?
What drugs for prophylaxis
Follow-up
Basic science
1. Femoral Nerve
Detailed anatomy
Motor and sensory supply
How will u do the block?
3 in 1 block
38
Lateral cutaneous nerve of thigh anatomy and block

LA toxicity- management
Intralipid doses
2. Head injury with elevated ICP
ITU management
What parameters u will aim for?
How CBF controlled - graphs
What is jugular venous oxygen saturation?
What are the implications?
Pharmacological management
Other monitors?
3. Diathermy
Draw diathermy circuit
All in detail about monopolar and bipolar diathermy
How will you prevent
Pacemaker how it interferes
How will u manage a patient with pacemaker?
What is the problem with defib and pacemaker
4. Insulin and DKA
What is Insulin?
Half-life
What is DKA
how ketone bodies produced?
How will you correct hyperglycaemia?
Hypokalaemia management
Acidosis management
Long case:
28 yo primip with PPH requiring an emergency laparotomy.
7 hours post Em LSCS for failure to progress (despite syntocinin infusion).
She had been back for an ERCP(evacuated large clots)and was on a syntocinin infusion.
o/e: Pale, anxious
NIBP unrecordable, HR 140, 02 sats not picking up
Carotid pulse palpable
Bloods: Hb 2,8g/dl, Plts 95, APTT 78, TT extended, Fibrinogen 1.8
What would you do?
Massive Haemorrhage protocol (cons obs, cons ananethist, haematology, porters, oda)
100% 02 ABC
2 large bore IV cannulae
What fluid would you give her? Blood - if her blood not avail immediately? would give 0
negative blood
when would you be happy to take her to theatre? what parameters? (BP recordable, radial
39
pulse)
Other monitoring - urinary catheter, arterial line (not CVP now as coagulopathic)
How would you anaesthetise?
Preop - Ranitidine IV, Blood in theatre level I warmer,etc
NaCitrate pre 02 RSI with criciod
What drugs? titrated dose of thiopentone (small) and Sux
Whay thiopentone? because that is what I am used to - they were happy
You have blood pouring in and suddenly you get another drop in BP - what would you do
Check screen - HR rhythm ....
what would you give ? phenylepherine How much ? 50-100mcg Why? alpha agonist use
in obstetrics (better than ephedrine mixed alpha beta) they were happy
What drugs can you give to contract the uterus?
synntocinin - how much - 5 units then an infusion of 40units/4 hrs
syntometrine - What is that? syntocinin 5units and ergometrine 500mcg what are the SEs?
HTN 100% N+V
carbaprost PGF2alpha SE's n+v and what else ? oh bronchospasm
ok patient survived and in itu
Shown an CXR (6 hours post admission)- what are the major abnormalities? R
endobronchial intubation, bilateral fluffy shadowing .. Good
DDx: ARDS (yes too early)
pulmonary odema (from fluid overload)
TRALI .... good When is onset of TRALI? within 6 hours of blood transfusion. Good
Short Cases:
1. Elderly man for cystoscopy for haematuria
ECG - AF with Q waves in inferior leads - what would be cause of them - old infarct
What are causes of AF - IHD, AMI, Cardiomyopathy, HTN, Thyrotoxicosis, Alcohol
How about if a patient is really unwell ... oh sepsis
What drugs would he be on: bblocker (post AMI and rate controll), digoxin
What are the problems with AF? Atrial thrombus - emboli to cause CVA, distal
ischaemia
So what other drugs may he be on? aspirin if low risk, warfarin if high risk
Would you proceed with case if these were new findings on ECG? No, an elective case
What further Ix ? ECHO what would you be looking for ? EF what else? atrial
thrombus what else? what is a common cause of AF that you failed to mention earlier?
mitral valve disease - i would look at size of valves normal 4-6cm2 and gradient, doppler
flow for MR
If it was old findings and he was on warfarin with an INR 2 would you stop his
coagulation preop?
I said I would liase with the surgeon - if they were happy for a quick cystoscopy I was
happy to proceed with stopping - they said good better not to go messinfg around with
anticoagulation.
2. Asked to review a patient on the ward with COPD with acute exacerbation
What could be the cause of acute exacerbation:
I said pneumonia, pleural effusion (infection or other cause), certain drugs (histamine
releasing .. etc
They said what else ,...what do emphysematous patients get .. bulla .. ahh a
40
pneumothorax ,, good
What is the difference between Chronic bronchitis and emphysema ?
How do you assess a patient with COPD exacerbation on the ward?
How do you treat ?? I forgot to say oxygen!!! but when asked said I would limit the
amount intially with a venturi mask and increment upwards as BTS guidelines on
emergency oxygen therapy. they seemed happy.
3. You are asked to anaesthetise a young man IVDU and HIV for Hickman line insertion.
What are the problems:
Problems to do with HIV and problems to do with IVDU
Mainly concentrated on problems to do with IVDU (some candidates it was the other
way round)
Talked about difficulty with IV access - may need to do a gas induction, problems with
compliance, risk of infection for staff - What can be done to minimise risk of infection?
Last on list, disposable equipement, notify staff, universal precautions, double scrub,
mask and eyewear.
You sustain a needlestick injury - what would you do according to hospital protocol .....
BASIC SCIENCES:
1. Have you ever seen a carotid endarectomy under LA ?
What are the advantages and disadvantages?
How do you perform a block - superficial and deep cervical plexus block explianed.
Said there is a recent editorial in the BJA which states there is no difference in outcome
between the two and that as the deep cervical block is associted with lots more
complications - superficial block better. Also mentioned the GALA study which is going
to show no difference in outcome between CAE under LA or GA.
2. Asked to tell the difference between adult and neonatal respiratory system.
Broke it down into anatomical differences and physiological differences.
Fairly basic question.
Asked about FRC is it smaller ? well it is 30mls/kg so yes And why is that important because it is Oxygen reservoir - therefore there is less O2 stores and as babies have a
higher resting 02 consumption they desaturate more quickly. Good
3. I think it may be in the college book.
Something like - you are in OT at the end of a major operation with large blood loss and
massive transfusion and the surgeon tells you the patient is quite oozy. What is possible
causes:
# dilutional: blood transfusion without clotting factors
# DIC: complication of massive transfusion or sepsis
# I also said ABO incompatibility - they said yes but it was obvious it was not what
they were after
Other complications of massive blood transfusion ....
What tests would you do - send fbc (does that assess clotting function ? it does assess
platelet number), ok what else - INR, APPT (what is normal APTT ?) What do both those
tests assess : extrinsic and intrinsic pathway etc
Really wanted very little detail
41
What other tests ?? TEG - Do you know anything about it ? YEs - starting describing it
and they start they didnt want that much detail.
Asked what clotting products would give - much much and at what triggers.
I said FFP 15ml/kg if INR >1.5, Platelets if < 50, Cryoprecipitate if Fibrinogen < 1.0g/
dl
Then asked what drugs you could give if still bleeding:
Antifibrinolytics: tranexamic acid and aproptinin (but now unlicensed)
What else
NOVO 7 - well if your haematologist lets you
4. Draw an arterial line trace
What information does it tell you: SBP, DBP, MAP, contractility, SV (area under graph
up to diacrotic notch), SVR,
changes depending on where it is in body. Also show arrhythmias
Asked about components of IABP kit - very brief descriptions
Talk about catheter, fluid column, transducer (strain gauge) and wheatstone bridge
(didnt want me to draw it)
Asked indications for using art line ?
Asked complications
1. Long case: 60 yrs old lady for fracture neck of femur. Previous history of aortic and mitral
valve replacement 20 yrs ago on warfarin, poor exercise tolerance 25 yards, on diuretics,
digoxin and lisinopril (s/o heart failure on examination), ECG : junctional rhythm.
They asked about preoptimization. what investigation ?( they told me on Echo ejection
fraction of 25% )
She had Hb of 10. Would you transfuse her? Na was 130. Is it normal? what was the cause of
low Na?
HDU for preoptimization? Cardiac output monitoring? How would to anaesthetise? I said GA
with femoral nerve block.
Short cases
1 Down's syndrome
2.Critical care polyneuropathy
3.Category A LSCS (spinal vs GA)
Basic Sciences
1. Sympathetic supply of heart starting from brain. Differences between normal and
denervated heart. How would u manage a patient with heart transplant coming for non
cardiac surgery.
2. sickle cell disease
3. post herpetic neuralgia. treatment and meachanism of action of all drugs.
4. cardiac output monitoring: LiDCO, Oesophageal doppler
long case:
76 female,acute surgical abdo,for laparotomy
on fast AF,BMI 30
42
inspiratory stridor
high wcc
pmhx: thyroidectomy,hypertension
cxr:thyroid with retrosternal extension,tracheal deviation,SVCsyndrome
short cases:
1.failed epiduarl in the ward for a pancolectemy
2.severe AS for TKR
3.full stomach + penetrating eye injury
basic sciences:
fluid repalcement and daily electrolyte req in paed , new NPSA issue,which fluids and
details
oxygen delivery devices, variable and fixed orifice devices
anatomy of the internal jugular and subclavianveins + air embolism
short cases:
1. jehovahs witness
2. pre eclampsia
3. bleeding trachy site and management thereafter
long case
75 y/o man with lung ca awaiting lobectomy. presents with acute neck pain.
pmh - htn, hiatus hernia
dh - candesartan, ranitidine, bdz
ecg - nad
pft - nad
c spine - subluxation of c1-2
echo - as
summary
diagnosis of neck pain
echo findings - management of as
management of neck - immobilisation, theatre, awake fibreoptic intubation, proning,
extubation, analgesia, hdu
43

December 2008final FRCA Viva

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University Hospitals Coventry & Warwickshire NHS Trust: Dr C Mendonca

Final FRCA viva: December 2008

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PFTs: FEV/FVC ratio 64% Post nebulised salbutamol 67%

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3) PATIENT HAD PROCTOCOLECTOMY EARLIER THIS

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In which solution is it prepared?

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How to assess the patient, investigations?

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D Dimer - 6 ( very high)

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When can she breast feed?

hypothermia, Liver damage, hypocalcemia, sepsis, drugs like nsaid, heparin

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Summarise the case

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15 yr old, full stomach with penetrating eye injury

What are the issues

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Indications of central venous canulation

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Clinical Sciences Viva

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Preeclampsia : 36 week primigravida BP 160/90, Pulse, 124/min

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PMH: Diabetes, Hiatus hernia, Hypertension

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Criteria for extubation Phrenic nerve injury ?

Preeclampsia : 36 week primigravida BP 160/90, Pulse, 124/min

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What do you understand by plenum principle?

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Clinical Short Cases

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3. Woman found at home drowsy after suspected overdose - 80g paracetamol.

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