POSTGRADUATE INSTITUTE OF MEDICINE UNIVERSITY OF COLOMBO

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1 POSTGRADUATE INSTITUTE OF MEDICINE UNIVERSITY OF COLOMBO MD (ANAESTHESIOLOGY) FINAL EXAMINATION AUGUST 2013 Date : 2 nd August 2013 Time : 1.00 p.m p.m. Answer any three questions. Answer each question in a separate book. LONG ESSAY QUESTIONS 1. A 64 year old male with chronic obstructive pulmonary disease (COPD) is scheduled for a gastrectomy under general anaesthesia. He is found to have rhonchi on auscultation. FEV 1 is 40% of predicted and FEV 1 /FVC = <0.7. You are asked to evaluate this patient in the pre anaesthetic clinic List other investigations you need for the assessment of this patient. Give reasons. (20%) 1.2. How would you optimize him with regard to his COPD? (30%) 1.3 The patient is scheduled for surgery two weeks later. Outline your intra and post operative management of this patient. (50%) 2. A 45 year old previously healthy patient presents with acute intestinal obstruction. His blood pressure is 70/40 mmhg, pulse 120/minute, haematocrit (Hct) 45%, SpO 2 85% on air, ph Explain the reasons for the above findings. (25%) 2.2. How will you optimize this patient prior to surgery? (25%) 2.3. What special precautions would you take during induction? (10%) 2.4. If the patient regurgitates during induction what is your immediate management? (15%) 2.5. How would you ensure adequate oxygenation during the first 24 hours? (25%)

2 Discuss the pre operative assessment and risk stratification of a patient scheduled for cardiopulmonary bypass surgery. (60%) 3.2. What measures would you take during the bypass period to ensure a good outcome? (40%) What are the anatomical differences between the airway of an infant and that of an adult? How will these differences affect the airway management of an infant? (25%) 4.2. A one year old child is scheduled for repair of a cleft palate What problems would you anticipate in your pre-operative visit? (15%) Describe the intraoperative anaesthetic management of this child. (50%) List the post-operative complications. (10%)

3 POSTGRADUATE INSTITUTE OF MEDICINE UNIVERSITY OF COLOMBO MD (ANAESTHESIOLOGY) FINAL EXAMINATION AUGUST 2013 Date : 5 th August 2013 Time : 1.00 p.m p.m. Short Answer Questions Candidates are required to answer all twelve questions. Candidates who fail to attempt anyone question will not pass the examination. All questions carry equal marks. Answer each part in a separate book marked A and B. PART A 1. A 75 year old patient presents to the surgeons with episodes of abdominal pain, diarrhea and weight loss, accompanied by flushing episodes. A CT scan shows several gastro-intestinal mesenteric tumours and a diagnosis of carcinoid syndrome is made. it is resolved to carry out a laparotomy to remove the tumours. The patient s preoperative ECG shows atrial fibrillation What are the symptoms of carcinoid syndrome, and what mediators cause these symptoms? (35%) 1.2. What will you include in your pre-operative tests and preparation of this patient? (40%) 1.3. Which drugs or techniques will you avoid using in giving this patient an anaesthetic and why? (25%) Describe the acute effects of tobacco smoking on the cardiovascular and respiratory system? (40%) 2.2. List the peri-operative complications that are more common in regular smokers compared with non-smokers. (40%) 2.3. What advice would you give to a smoker attending a preoperative assessment clinic four weeks before an elective operation under general anaesthesia? (20%)

4 How would you identify delirium in the ICU? (25%) 3.2. What are the consequences of ICU delirium? (50%) 3.3. What precautions should be taken to prevent delirium in the ICU? (25%) 4. A patient presents with chronic back pain to the pain clinic What are the 3 categories to which chronic back pain is triaged clinically? (15%) 4.2. How would you differentiate and diagnose each category? (60%) 4.3. Outline your management of simple chronic back pain not necessitating surgery. (25%) 5. A 28 year old man was found trapped inside a burning building and brought to the hospital. On admission he was conscious but drowsy and in severe pain How would you assess the severity of the burns? (25%) 5.2. What are the indications to intubate this patient? (25%) 5.3. Describe your management in the first 24 hours. (50%) 6. A 56 year old lady is scheduled for a percutaneous nephrolithotripsy (PCNL) in the prone position List the problems associated with the prone position. (25%) 6.2. Briefly outline the other intraoperative problems indicating how you would detect and prevent them. (75%)

5 PART B 7. A 75 year old man, with a BMI of 36, is admitted for elective repair of an abdominal aortic aneurysm. He has controlled hypertension and currently asymptomatic ischaemic heart disease, which are treated with atenolol and ramipril. He had a myocardial infarction six months ago, at which time a coronary angiogram showed diffuse small vessel coronary artery disease; he was started on clopidogrel at this time, and this was stopped seven days ago. He has type II diabetes, treated with metformin and he is a non-smoker What are the preoperative investigations you would expect to have been carried out before agreeing to anaesthetize this patient? (20%) 7.2. What are the perioperative risks associated with obesity? (40%) 7.3. What criteria would you use to extubate him at the end of the surgery, rather than keeping him intubated and ventilated on ICU post-operatively? (40%) Outline the physical principles involved in capnography. (40%) 8.2. Draw and label a normal capnography wave form. (20%) 8.3. What are the various types of abnormal wave forms you might see in anaesthesia? (40%) Draw and label a diagram of the caudal epidural space in a child. (50%) 9.2. Outline how a caudal block is performed in a 5 year old child for intra and postoperative analgesia. (50%)

6 10. A 27 year old primi with a POA of 32/52 has presented with a severe headache and a blood pressure of 180/ What other features would you expect to find in this patient during your pre operative assessment to make a diagnosis of severe preeclampsia? (40%) Outline how you would optimize this patient prior to caesarean section. (60%) 11. A 45 year old patient is having a laparoscopic cholecystectomy under general anaesthesia. A few minutes after surgery has started the endtidal PCO 2 is noted to be 6.2 kpa What may be causing this raised end-tidal PCO 2? (20%) Describe the pathophysiological changes associated with laparoscopic surgery. (50%) What steps should be taken to prevent the PCO2 from rising further? (30%) How would you define awareness during general anaesthesia? (15%) What are the causes? (50%) How do you prevent it? (35%)