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LONG CASE 1
67-year-old female presenting for urgent parotidectomy/neck dissection for malignancy. PMH: COPD, HTN, chronic
smoker, peripheral vascular disease (fem-fem bypass 3 yrs ago) exercise tolerance 50 yards. Medications -
Aspirin, Simvastatin, Bendrofluazide, Ramipril, Salbutamol, Becotide, Thyroxine.
Investigations
− FBC - Hb 16g/dL, otherwise normal, normal WCC and plt
− U&E’s - Creatinine 89, otherwise normal.
− Glu 6.5
− CXR - hyperinflation, narrow heart, flattened diaphragm
− ECG - Sinus Tachy, LAD, inferior T wave inversion
− PFT’s - Severe obstructive defect, some reversibility, markedly reduced TLCo (29%)
− ABG - pO2 8, HCO3 25, pH 7.45, CO2 normal Type I RF
• Summarise.
• Why is this lady polycythaemic?
• What is DLCO and causes?
• How do you assess this perioperative risks?
• What is exercise test?
• What other Ix would you want? talked about echo, shuttle walk, CPEX, TFTs
• Which drugs to continue on day of surgery?
• How would you optimise respiratory function? steroids and dose, antibiotics, physio etc
• Do you predict a difficult airway? They said not usually!
• How would you anaesthetise her? which drugs and type of ETT.
• What does RAE stand for?
• What nerve would the surgeons monitor? Talked about facial nerve assessment and remi v NMB.
• Where should she go postop?
• What factors are important postop in this patient? Talked about respiratory function, anticoagulation
(mechanical and pharmacological).
• ENT surgeon doesn’t want Heparin, what are the alternatives?
• How would you extubate?
• She deteriorates post-op in recovery, differential diagnosis?
• What is stridor?
• What is the course of phrenic and recurrent laryngeal nerve? What other nerves could be affected by surgery?
• Needs to return to theatre for expanding haematoma, anaesthetic management? Airway swelling on HDU. How
do you manage this?....releasing clips, ABC What methods available for re-intubation? Which would you choose.
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Final SOE Questions December 2014 - Thanks to candidates from our courses
LONG CASE 2
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Final SOE Questions December 2014 - Thanks to candidates from our courses
LONG CASE 3
You have been asked to see (in ED) a 50 something female involved in an RTC. Driver of car vs lorry. There was a
prolonged period of entrapment. There is a pelvic fracture and femur on X-ray, CT head/neck is normal and a FAST
scan shows free fluid in the abdomen. She complains of pain in the right side of her chest.
No medical history is available.
O/E GCS 15, RR is 40 with evidence of paradoxical movement of the right side of her chest. SpO2 is 98% on 15L of O2
via a non rebreathe mask. BP is 90 systolic, HR 105ish.
Weight ~100Kg
Investigations
− FBC Hb 11.5, WCC raised (think around 18), Plt Normal
− U&Es Normal
− Glucose 11
− ABG pH 7.28 PO2 ~24kPa PCO2 ~4.8 (No lactate provided) BE -10
− CXR AP, ~3 #ribs on right, subcutaneous emphysema on right, chest drain in situ R side, # of one rib left
side, bra clip visible.
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Final SOE Questions December 2014 - Thanks to candidates from our courses
LONG CASE 4
33y male, globe rupture after falling on a radiator. He has poorly controlled epilepsy (1-2 seizures per day) since
childhood but says his fall was not as a result of a fit.
DH- carbamazepine, levetiracetam, some others that I can't remember!
On examination height 167cm, weight kg, BMI 44.9
Capped upper incisors, MP 3, full beard
Investigations:
− CXR showing: obese, Vagal nerve stimulator
− ABG showing: pH normal range, pO2 8.9, pCO2 6.8, high bicarbonate, HB 170
− Sleep studies showing: AHI 77, 170 desaturations period hour, average says 85%
− PFTs showing normal fev1/fvc, PEFR 55% predicted (although footnote at the bottom mentioned technique
was poor), reduced vital capacity and residual volume
• Summarise case
• Talk through respiratory investigations
• Significance of sleep apnoea - any scoring systems you know of?
• Significance of his epilepsy and anti epileptic drugs
• Is this emergency surgery- globe has already ruptured so do you still need to take precautions to reduce the risk
of evisceration?
• What makes you say his airway is difficult?
• How would you manage his airway, what do you mean by ramped/adequate preoxygenation, what equipment
would you have on your difficult airway trolley?
• What ventilator settings would you use, wanted PEEP
• What analgesia would you use?
• How would you extubate him? Where would you send him post op? There are no HDU beds, what would you
do?
• He becomes confused in recovery, how do you manage?
• What about VTE prophylaxis
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Final SOE Questions December 2014 - Thanks to candidates from our courses
LONG CASE 5
78 male admitted with acute ischaemic lower limb. Radiological management attempted and failed. Listed for fem-
pop bypass. Also had an episode of chest pain lasting 20 mins, relieved by GTN
PMH: CABG 20 years ago, PVD, L3-5 spinal decompression but chronic back pain, takes GTN regularly for chest pain
Medications: ACE inhibitor, beta-blocker, oral nitrates, diuretic, MST (high dose), aspirin, statin
BP 135/70, HR60, chest clear, ECG LAD, ?RBBB, no CXR given, weight 75kg, ht 1.75m
Investigations:
− ECG – L axis deviation, LBBB, inferior q waves., slow AF?
− ECHO – moderate LV dysfunction, mild TR, EF 50%, no LVH
− Angio (from 2 years ago) – patent grafted vessels, complete occlusion of original vessels.
− Bloods - Hb 117 (normochromic, normocytic anaemia) U+Es normal, creat was 96 eGFR 64. Clotting normal.
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Final SOE Questions December 2014 - Thanks to candidates from our courses
LONG CASE 6
Patient with known hypothyroidism, with a history of fatigue and malaise. Presents with a history of vomiting and
severe abdominal pain, and jaundice. Surgeons want to perform an urgent laparoscopy and exploration of the biliary
tree. She is normally on levothyroxine but she has been unable to take it. She has no other medical problems.
BMI 46.
BP 103/60, Hr 60
Temp 38.1
Investigations
− FBC – anaemia, elevated WBCs
− Coag – Prolonged PT, normal APTT, INR 3.1
− U&E – normal urea, creat, TSH in 200, Free T4 unrecordable. Abnormal ALT and ALP.
− ECG – sinus bradycardia, with artefact interference in lead V3.
− TSH raised, T4 undetectable
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Final SOE Questions December 2014 - Thanks to candidates from our courses
LNOG CASE 7
4 year old child with cerebral palsy, poorly controlled epilepsy and recurrent LRTI over last year.
For nissen fundoplication.
• Why is he on hyoscine
• What weight would I expect a 4yr old to be – why is he underweight
• Why hyponatraemic – casues and treatment options
• Would you anaesthetize him today
• How would you optomise him
• How would you put him to sleep – durug doses/tube sizes in this child as he is small
• Options for analgesia – talked about caudals in particular
• Intra op hypoxia – causes and management
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Final SOE Questions December 2014 - Thanks to candidates from our courses
SHORT CASES
2. SAH
• 55 yr old, sudden onset occipital headache and nausea.
• Likely diagnosis?
• Other causes of Sudden onset headache.
• She is for clipping of aneurysm, GCS 7.
• How do you manage this? Talked about intubation, arterial line.
• Complications during procedure specifically those that are vasculature related?
• Talked about vasospasm - presentation, treatment.
• Rebleeding.
• They mentioned dislodged coil.
7. 19 yrs old Afro Caribbean Sickledex test positive, for urgent appendicectomy
• Pathophysiology of sickle cell disease
• Other abnormal hbs, difference between them
• Management of sickle cell disease and trait
• Confirmatory tests
• Anaesthetic management
• Will a sickle dex test tell you whether the patient is sickle trait or sickle disease? How can you tell the
difference?
• What happens if a patient has sickle cell trait and thalassemia, is this better than sickle cell disease or worse?
• Why do they develop pe/dvt?
• What else could this diagnosis be aside from appendicitis?
• How would you anaesthetise this patient?
8. 65 yrs old, severe, stable COPD, Knee arthroscopy, wants a spinal anaesthetic
• What are the criteria for day surgery?
• Does having severe COPD mean you cannot have day surgery?
• Shown a CXR: What does the CXR show?
• My interpretation – hyperinflated lung fields, opacity left upper lobe
• What could the opacity be?
• What makes you say hyperinflated? What are the criteria?
• The patient wants a spinal for her arthroscopy, are you going to do it?
• What medication would you use for a day case spinal anaesthetic?
• How would you perform a spinal anaesthetic?
• If you can’t pass the needle at L3/4, would you go L1/2? Why not?
9. 25 year old cystic fibrosis, awaiting lung transplant, laceration right antecubital fossa: median nerve and
brachial artery repair.
• What is cystic fibrosis?
• How common is it? What is it’s incidence?
• What multi-system effects does it have?
• What are the issues associated with anaesthetizing patients with cystic fibrosis?
• What are the anaesthetic options for this procedure?
• Axillary block – describe your axillary block?
• Why wouldn’t you perform an interscalene block?
• Analgesia options
• Oxytocic drugs
• How will you extubate her?
• Say you had excluded all differentials and she's just drowsy, how would you manage her for section now?
• What would you do if her blood pressure was low?
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Final SOE Questions December 2014 - Thanks to candidates from our courses
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Final SOE Questions December 2014 - Thanks to candidates from our courses
Anatomy
3. T10
• What do you understand by the level T10?
• Shown CT scan at T10 following a barium swallow. Identify the structures (stomach, liver, spleen, diaphragm)
• There was free air on the CT. What could be the cause?
• Went on to management of the patient with perforated viscus for surgery.
5. Paravertebral block
• Can you draw the paravertebral space?
• Then shown diagram of paravertebral space, asked to name structures
• What are the indications for paravertebral block?
• Compare and contrast paravertebral block versus thoracic epidural?
• What are the complications of thoracic epidural
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Final SOE Questions December 2014 - Thanks to candidates from our courses
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Final SOE Questions December 2014 - Thanks to candidates from our courses
PHYSIOLOGY
3. Thyroid
• What signs/symptoms might you see in a patient with hypothyroidism who is on the wrong dose of
thyroxine? Wanted hypo and hyper.
• What condition would you see in a neonate with hypothyroidism?
• How does thyroid hormone work, how does it act at receptors?
• What are the problems with surgery/ anaesthesia in hyper- and hypo- thyroidism?
• What cardiac problems in hypothyroidism?
4. 02 toxicity
• What are the problems associated with high FiO2?
• What percentage of oxygen is safe and for how long?
• Which patients at risk?
• Recommended maximum times at different fi02s
• What effects does it have on babies? Who at most risk? - premature
• How is neonatal retinopathy minimized?
• Which systems does it affect?
• Why does oxygen toxicity occur?
• What is the molecular process?
• Are there any drugs that can cause O2 toxicity?
• When is a high level of oxygen good?
5. Carbon monoxide
• Harmful effects on body of smoking - Tar, carcinogens, carbon monoxide.
• When to stop smoking, will it be useful if stopped a day before
• How does carbon monoxide affect anaesthesia? What are the effects on the oxygen-haemooglobin
dissociation curve?
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Final SOE Questions December 2014 - Thanks to candidates from our courses
6. Starvation
• Describe the physiology of starvation
• Then ng feeding, benefits, components, how does this change in a critically ill pt.
• TPN – complications and benefits
• How does the body meet demands in first 24 hours?
• What happens after 24 hours?
• Where are ketones produced?
• How many calories does the body need?
• What electrolytes and how much is needed?
• Then talked about patients in hospital, asked why we need to focus on nutrition?
7. Immunity
• Types
• How do B cells work?
• What types of T cells are there?
• Where do you find these cells?
• Immunoglobulins - different types, sizes of them.
• How do you we use them therapeutically?
• Antigens - where are they found? How do they work?
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Final SOE Questions December 2014 - Thanks to candidates from our courses
PHARMACOLOGY
1. Parkinsons disease
• Signs
• Pathophysiology of Parkinsons?
• What drugs are there to treat it?
• How do they work?
• Classify into different types plus example from each type.
• Dopamine synthesis and metabolism.
• Anaesthetic management of patients with Parkinsons.
• Any drugs that should be avoided?
2. TIVA
• Why is TIVA suitable for daycase?
• What procedures might be used for in the day-case setting? (wanted shared airway, bronchoscopy)
• What are the advantages of TIVA?
• What Pharmacockinetic properties of Propofol make it suitable for TIVA?
• What is the context sensitive half life?
• What is the elimination half life of propofol?
• Why then does a patient wake up when you switch off the propofol? (Essentially 3 compartment model,
constants, volumes etc explanation of what happens to various concentrations during an infusion maintain
steady state and when switched off)
• What models are you aware of and how do they differ?
• Which gives bigger dose- Marsh or Schneider?
• What about targeting effect site?
• Which compartment most closely resembles brain in three compartment model?
3. Remifentanil
• What situations is Remifentanil used for?
• How is it given? What dose?
• What receptors does it act on?
• How is it metabolised?
• What pharmacokinetic model?
• What information does the model require?
• What are the advantages/ disadvantages of remifentanil?
• Why is it useful in neurosurgery (as well as it being titratable to stimulus)?
4. Bioavailability
• What are the different ways we can administer drugs?
• What are the options if someone has had bowel surgery and you want to avoid oral route?
• What is bioavailability?
• Can you draw me the graph explaining it?
• What factors affect bioavailability?
• What is first pass metabolism?
• What factors affect this?
• What drugs do you know that undergo significant first pass metabolism? High and low first pass?
• Alternative routes than oral administration of medication – wanted list.
• Focused on transdermal delivery
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Final SOE Questions December 2014 - Thanks to candidates from our courses
5. Suxamethonium
• Mechanism of action
• P’kinetics and P’dynamics
• Diffn b/w acetylcholinesterases and psedocholinesterases
• Can you tell me the side effects of suxamethonium
• Which patient groups would you avoid using it?
• What is the mechanism of anaphylaxis to suxamthenonium?
• What is the structure of suxamethonium?
• Why does it cause bradycardia?
• Why does it cause hyperkalaemia?
• What happens when you give repeated doses?
• What do you tell patients regarding myalgia and avoiding severe myalgia? Which patients are most at risk?
6. Anticoagulants
• Asked how warfarin works, what is it?
• How can we reverse INR?
• Discuss alternative anticoagulants
• How do we monitor factor Xa and direct thrombin anticoagulants
• Uses in medicine
• Describe clotting cascade
• Timeframe after stopping common drugs and time when it's safe to perform blocks
7. Opioid Tolerance
• Problems with chronic abuse eg IVDU. Co-existing medical problems, nutrition, iv access.
• What is tolerance? How does it affect periop management?
• Mechanism of tolerance of opioids?
• Problems with opioids - withdrawal, and again tolerance, hyperalgesia
• How do opioids work?
• Management of patient - talked of multimodal approach, NMDA antagonists (where are these receptors)
• Benefits of PCA in these patients. Background on PCA in these patients?
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Final SOE Questions December 2014 - Thanks to candidates from our courses
PHYSICS
1. Theatre pollution.
• What causes it?
• What makes it more likely to occur?
• How can it be prevented?
• Which anaesthetists are most at risk from anaesthetic gas pollution?
• Which staff most at risk?
• Name of standards
• How does theatre ventilation work?
• Methods of scavenging.
3. RRT
• What types of renal replacement therapies are there?
• What are the advantages / disadvantages of peritoneal dialysis?
• What method is used most commonly in critical care? Why?
• What are the physical principles underlying CVVH, dialysis?
• What are the indications for CVVH on ICU?
• What complications can occur?
• Alternatives to heparin?
• Principles behind arteriovenous techniques?
• Complications occurring at dialysis- fistula related.
4. TEG
• What bedside tests are you aware of? Bm, ABG, TEG, ACT
• What is TEG?
• How does it work? In detail
• What is added to help make the blood clot?
• What are the benefits of it?
• What other tests for clotting are there?
• Shown TEG diagram - explain the different points and what they represent?
• Shown 4 different TEG graphs and asked about the abnormalities and possible causes
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Final SOE Questions December 2014 - Thanks to candidates from our courses
5. CPEX
• Asked about METs
• Asked why investigations I do for elderly patients. I mentioned bloods, ECG, CXR, echo.
• They asked what information an echo provides.
• Asked what other things we can do: 6 min shuttle walk and CPEX, dobutamine stress test.
• Asked to explain what CPEX is and what variables we monitor, and what information it provided.
• Then shown a 9 plot and asked to explain what it shows. I talked about anaerobic threshold.
• They asked why CPEX was useful and how easy it is to perform.
• How is the flow measured, what do the values mean for VO2max and AT
• How is oxygen measured in cpex?
• Why is cpex beneficiao in oesophagectomy patients
6. Humidity
• Who is it especially important in? - mentioned old and very young, trache, ICU, long op.
• Why?
• Absolute and relative definitions, values at alveoli and room temp.
• Methods of humidification - HME, how does it work, what does 70% efficiency mean, problems with them,
explain low resistance.
• Nebulisers - mentioned venturi effect and they asked if there were any other principles.
• How water bath, problems, electrical safety.
• Would low flow circle system ensure adequate HME humidification? What else helps in circuit, started to
talk about soda lime.
• Problems with over humidification, which patients are more susceptible?
7. Delirium
• What is delirium?
• Can you classify delirium?
• What tools do we have to assess delirium?
• I said CAM-ICU, they asked for others…:
• I said GCS wasn’t designed for delirium assessment, but that it could be use to asesss change in level of
consciousness, they asked me to explain GCS
• Any others?
• I said AMT or MMSE, Abreviated Mental test Score – what is in this, what score suggests a problem?
• What is RASS? What scale is used? What do we aim for on ITU?
• What are the components of CAM-ICU?
• Who is at risk of delirium?
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