4 | Anesthesia Key

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)

Reproduced from Diagnosis and Treatment in Internal Medicine, Patrick Davey and David Sprigings, Figure 111.1. Copyright Oxford University Press, 2011. Reproduced with permission of the Licensor through PLSclear.

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

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

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

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

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

1.———————

2.———————

3.———————

4.———————

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

1.———————

2.———————

3.———————

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.

A. List the general (4 marks) and specific (4 marks) anaesthetic issues.

General considerations

1.———————

2.———————

3.———————

4.———————

Specific to this procedure

1.———————

2.———————

3.———————

4.———————

B. How would you manage profound bradycardia during surgical traction? (3 marks)

1.———————

2.———————

3.———————

C. For each of these 3 common postoperative problems, complete the table with the relevant management strategies (9 marks)

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.

A. Outline your immediate management (4 marks)

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B. Outline your secondary management (3 marks)

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C. The patient’s blood pressure remains at 75/42mmHg. You administer a further fluid bolus. What other secondary agents would you consider to treat the refractory hypotension? (2 marks)

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D. In the NAP6 study what are the 3 most common causative agents of perioperative anaphylaxis? (3 marks)

————————

E. Complete the following table with the different hypersensitivity reactions (8 marks)

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).

A. Detail the current criteria for the diagnosis of ARDS (8 marks)

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B. Describe the pathophysiology of ARDS (4 marks)

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C. Complete the table to describe each of the 3 phases of ARDS (3 marks)

Phase	Pathophysiological description
Acute/exudative (1 mark)	———————-
Proliferative/subacute (1 mark)	———————-
Chronic/fibrotic (1 mark)	———————-

D. What specific strategies can be used in the management of ARDS to optimize ventilation and oxygenation? (3 marks)

1.———————

2.———————

3.———————

E. List 2 beneficial effects of the prone position in severe ARDS? (2 marks)

1.———————

2.———————

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).

A. Give 5 characteristics of the pain that supports a diagnosis of TN? (5 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

B. Give 4 differential diagnoses (4 marks)

1.———————

2.———————

3.———————

4.———————

C. What other conditions is TN associated with? (3 marks)

1.———————

2.———————

3.———————

D. What drugs would you use to treat TN? (3 marks)

1.———————

2.———————

3.———————

E. What non-pharmacological treatments are available for TN? (3 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

F. If left untreated, what is the natural prognosis of the condition? (1 mark)

G. What is the incidence of TN in the UK? Please select your answer (1 mark)

1 in 1,000 1 in 10,000 1 in 100,000

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.

A. What class of obesity is this patient in? (1 mark)

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B. Briefly describe the specific preoperative concerns which must be considered in this patient? (5 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

C. Define the following terms considered when administering anaesthetic drugs to obese patients (4 marks)

Total body weight (TBW) (1 mark)	———————-
Ideal body weight (IBW) (1 mark)	———————-
Lean body weight (LBW) (1 mark)	———————-
Adjusted Body Weight (ABW) (1 mark)	———————-

D. What are the principles of delivering safe general anaesthesia for this patient assuming risk of sleep disordered breathing? (5 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

E. What local anaesthesia based analgesic options may be considered for this case? (4 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

F. What anatomical landmark indicates an ideal ramped position before induction of general anaesthesia? (1 mark)

Question 7

A. Please detail the 5 levels of the evidence hierarchy (5 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

B. Give 4 types of bias you must be aware of, and state how can they be avoided when carrying out research? (8 marks)

1.———————

2.———————

3.———————

4.———————

C. How can results be misleading despite a double blind RCT? (2 marks)

D. What aspects should you pay particular attention to when appraising a paper? (5 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

Total 20 marks

Question 8

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

A. What specifically is bimaxillary surgery? (1 mark).

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B. What are the common indications for this surgery which are relevant to the anaesthetist? (2 marks)

1.———————

2.———————

C. What are the main airway considerations for this case? (3 marks)

1.———————

2.———————

3.———————

D. Following successful intubation you insert a throat pack.

Describe 5 steps that are taken to ensure the throat pack is not retained in error following completion of surgery and anaesthesia? (5 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

E. What techniques can be used to minimize bleeding during this operation? (2 marks)

1.———————

2.———————

3.———————

4.———————

F. The patient has intramedullary fixation (IMF) with elastics in place at cessation of surgery.

What measures are taken to ensure airway safety during emergence from anaesthesia and in the early postoperative period for this situation? (7 marks)

	Airway safety measures
Emergence (4 marks)	1.——————— 2.——————— 3.——————— 4.———————
Postoperative (3 marks)	1.——————— 2.——————— 3.———————

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.

A. Name 4 nerves that need to be blocked to provide analgesia for rotator cuff repair? (4 marks)

1.———————

2.———————

3.———————

4.———————

B. What are the benefits of the interscalene approach to the brachial plexus in this case? (4 marks)

1.———————

2.———————

3.———————

4.———————

C. Complete the table by listing 6 possible neurological side effects/complications of an interscalene block (6 marks). Give one feature that is a hallmark of each complication you list (6 marks)

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.

A. Classify obesity using World Health Organization (WHO) definition of BMI (3 marks)

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B. List 5 risks associated with obesity during pregnancy (5 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

C. List 6 physiological changes that occur in the respiratory system and airway due to obesity? (6 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

6.———————

D. Outline your initial management of this patient on the labour ward (6 marks)

————————

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.

A. Describe the pathophysiology of autonomic dysreflexia (ADR)? (3 marks)

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B. What 3 features of a spinal cord injury are usually associated with development of severe ADR? (3 marks)

1.———————

2.———————

3.———————

C. What is the most common precipitant of an episode of ADR in this patient group? (1 mark)

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D. What are the clinical manifestations which aid recognition of an episode of ADR? (6 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

6.———————

E. List the main anaesthetic techniques which can be considered for elective colostomy formation in this patient (4 marks)

1.———————

2.———————

3.———————

4.———————

F. The patient develops an episode of ADR in HDU 24 hours postoperatively. Briefly describe the management steps (3 marks)

1.———————

2.———————

3.———————

Total 20 marks

Question 12

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

A. List the patient factors which may require this procedure to be performed under general anaesthesia (3 marks)

1.———————

2.———————

3.———————

B. The patient has no significant medical history. She has not had her blood pressure checked within the last year. She is found to have a blood pressure of 169/94 on a single reading in the preoperative assessment clinic. What actions are appropriate regarding her raised blood pressure? (3 marks)

1.———————

2.———————

3.———————

C. The patient is asking whether general anaesthesia is safe for her.

Briefly describe 3 different modalities which can be used to help inform patients of risk during the consent process? (3 marks)

1.———————

2.———————

3.———————

D. The patient wishes to proceed with the procedure under general anaesthesia and supplemental block performed asleep.

List 4 principles of general anaesthesia for intraocular eye surgery (4 marks)

1.———————

2.———————

3.———————

4.———————

E. Describe a single eye block by completing the following table (3 marks)

Block (1 mark)	Eye position for block (1 mark)	Needle insertion point (1 mark)
——————–	——————–	——————–

F. List 4 of the complications specific to eye blocks? (4 marks)

1.———————

2.———————

3.———————

4.———————

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