4

Exam 4 questions


Exam 4 contains 12 selected Constructed Response Questions (CRQs) balanced across the intermediate curriculum, reflecting the Final Examination of the Diploma of Fellowship of the Royal College of Anaesthetists (FRCA) exam. We recommend attempting these questions under exam conditions. Please limit/contain your answer to/within the dotted lines given for each question.


Question 1


A 67-year-old patient is on the trauma list for emergency surgery for fractured neck of femur. He was fitted with a permanent pacemaker 5 years ago, after suffering blackouts. His pacemaker code is DDI.



A. Describe what each letter of this pacemaker code denotes? (3 marks)


————————


————————


————————



B. This is the patient’s electrocardiogram (ECG) on admission. What information about the pacemaker can be deduced from this? (3 marks)



C. You decide to change the pacemaker to fixed rate pacing.


What pacemaker code denotes fixed rate pacing? (1 mark)


————————


————————


————————



D. What is the major concern if this pacemaker is subject to electrical interference? (2 marks)


————————


————————


————————



E. What information do positions 4 and 5 of the pacemaker code denote? (2 marks)


————————


————————


————————



F. Describe what each position (1–4) of an implantable defibrillation device code denotes (4 marks)



G. How would you advise the theatre team in the safe use of monopolar diathermy? (3 marks)



H. State which anaesthetic technique you would use for this patient (1 mark) and why (1 mark)


————————


————————


————————



Total 20 marks


Question 2


A 4-year-old boy is listed for strabismus surgery as a day case.



























Post-op problem Management 1 (3 marks) Management 2 (3 marks) Management 3 (3 marks)
PONV      
Pain      
Recovery room distress      

Total 20 marks


Question 3


A 52-year-old woman is having a right nephrectomy. She has a past medical history of hypertension for which she takes atenolol. Induction and intubation with propofol and rocuronium were straightforward. You transfer her into theatre and administer prophylactic gentamicin. Twenty minutes later, as the abdomen is being prepped her blood pressure drops to 79/32, her heart rate is 132bpm, and her airway pressures increase. You suspect anaphylaxis.



























Type Description of immune response (4 marks) Example (4 marks)
1 —————— ——————
2 —————— ——————
3 —————— ——————
4 —————— ——————

Total 20 marks


Question 4


A 52-year-old man is ventilated in the intensive care unit (ICU). He presented 4 days ago with severe community acquired pneumonia. You now suspect he has acute respiratory distress syndrome (ARDS).



Total 20 marks


Question 5


A patient attends the chronic pain clinic with facial pain. Her GP has told her he thinks she has trigeminal neuralgia (TN).



Total 20 marks


Question 6


A 61-year-old woman with endometrial cancer is listed for total abdominal hysterectomy and bilateral salpingo-ophorectomy with pelvic lymphadenectomy. Her medical history is type 2 diabetes mellitus and asthma. Her medication is metformin, gliclazide, and salbutamol. She is a long-term smoker. Her body mass index (BMI) is 48Kg/m2.



Question 7



Total 20 marks


Question 8


You anaesthetise a 19-year-old woman for bimaxillary surgery. She has no significant past medical or drug history.
















Airway safety measures

Emergence


(4 marks)

1.———————

2.———————

3.———————

4.———————


Postoperative


(3 marks)

1.———————

2.———————

3.———————


Total 20 marks


Question 9


You assess a 24-year-old rugby player for repair of rotator cuff in his right shoulder. He weighs 110kg and is 185cm tall. He is right-handed.




























Complication (6 marks) Feature (6 marks)
1 1
2 2
3 3
4 4
5 5
6 6

Total 20 marks


Question 10


A 25-year-old woman presents to the labour ward in the early stages of labour. She is Para 1 + 0 at 38 weeks’ gestation. She has no significant past medical history. She weighs 140kg.



Total 20 marks


Question 11


A 34 year old man is listed for elective colostomy. He had a complete C6 spinal cord injury 10 years ago.



Total 20 marks


Question 12


An 86-year-old female requires preoperative assessment for vitreoretinal surgery.



Total 20 marks


Exam 4 answers


Many of the following questions contain more answers than there are marks allocated. This redundancy is intentional and is to ensure that a spread of possible answers by the candidate are recognized. 1 mark is awarded per correct point up to the maximum specified in each subsection.


Question 1


A 67-year-old patient is on the trauma list for emergency surgery for fractured neck of femur. He was fitted with a permanent pacemaker 5 years ago, after suffering blackouts. His pacemaker code is DDI.



A. Describe what each letter of this pacemaker code denotes? (3 marks)



(3)


B. This is the patient’s ECG on admission. What information about the pacemaker can be deduced from this? (3 marks)



OR



(3)


C. You decide to change the pacemaker to fixed rate pacing. What pacemaker code denotes fixed rate pacing? (1 mark)



(1)


D. What is the major concern if this pacemaker is subject to electrical interference? (2 marks)


Electrical interference from other sources may be interpreted by the pacemaker as intrinsic cardiac activity (1 mark) and any pacing will be inhibited (1 mark)


(2)


E. What information do positions 4 and 5 of the pacemaker code denote? (2 marks)



(2)


F. Describe what each position (1–4) of an implantable defibrillation device code denotes (4 marks)



(4)


G. How would you advise the theatre team in the safe use of monopolar diathermy? (3 marks)



(3)


H. State which anaesthetic technique you would use for this patient (1 mark) and why (1 mark)



OR



(2)


Total 20 marks


Further reading


P Diprose, JM Pierce; Anaesthesia for patients with pacemakers and similar devices. British Journal of Anaesthesia CEPD Reviews, Volume 1, Issue 6, 2001, Pages 166–70.


TV Salukhe, D Dob, R Sutton; Pacemakers and defibrillators: anaesthetic implications, BJA: British Journal of Anaesthesia, Volume 93, Issue 1, July 2004, Pages 95–104.


Question 2


A 4-year-old boy is listed for strabismus surgery as a day case.


Aug 27, 2021 | Posted by in ANESTHESIA | Comments Off on 4
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