POSTGRADUATE INSTITUTE OF MEDICINE UNIVERSITY OF COLOMBO MP (ANAESTHESIOLOGY) FINAL EXAMINATION - MARCH Time : p.m p.m.

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1 POSTGRADUATE INSTITUTE OF MEDICINE UNIVERSITY OF COLOMBO MP (ANAESTHESIOLOGY) FINAL EXAMINATION - MARCH 2016 Date :- 10 th March 2016 LONG ESSAY QUESTIONS Answer any three questions. Answer each question in a separate book. Time : p.m p.m. 1. You are asked to assess a 70 year old female scheduled for emergency laparotomy for suspected large bowel obstruction. 1.1 What peri-operative risk factors will predict Acute Kidney Injury (AKI) in this patient? (30%) 1.2 Briefly describe the mechanisms that regulate glomerular filtration rate (GFR). (20%) 1.3 What measures can be taken to prevent AKI? (30%) 1.4 If this patient develops AKI in the post operative period, what is your plan of management? (20%) 2. A 25yr old patient is admitted to ETU with a history of head injury due to an assault with a wooden bar on the head. Pupils are equally reacting to light. His GCS is E=3, V=2, M=4 (9/15). 2.1 Outline the management of this patient in the ETU. (30%) 2.2 Describe briefly the pathophysiology of acute traumatic brain injury. (20%) 2.3 What are the predictors of poor outcome in head injury? (10%) 2.4 This patient was intubated and brought to the ICU, following insertion of an external ventricular drain (EVD) and ICP monitoring. Describe briefly the management in the ICU for the first 24 hours. (40%) Contd.../2-

2 2 3. A 28 year old primi-para with a body weight of 130kg, BMI of 45kg/m 2 with a POA of 39 weeks is admitted to the ward for a category IV caesarean section. There has been no record of any obstetric or other medical problems. Her blood pressure is 130/80mmHg and the heart rate is 80 beats per minute. 3.1 What are the advantages and disadvantages of a combined spinal epidural (CSE) vs a spinal alone for caesarean section in this patient? (30%) 3.2 Explain the place for supplementary oxygen to this patient during the caesarean section. (20%) 3.3 Outline giving reasons, the measures you would take if the multiparameter monitor indicates a BP of 80/50 mmhg and a heart rate of 50 beats/min on the operating table before CSE. (30%) 3.4 What postoperative complications may occur in this patient? How would you minimise them? (20%) 4. A neonate with duodenal atresia scheduled for an emergency laparotomy is. in the neonatal ICU. 4.1 List 5 other conditions which may require an emergency laparotomy in a neonate. (10%) 4.2 Outline the problems you would identify in this neonate. (30%) 4.3 List the investigations required prior to surgery. (10%) 4.4 Outline the pre-operative optimization of the neonate and the preparation for the surgical procedure. (20%) 4.5 Describe your intra operative management of this neonate. (30%)

3 POSTGRADUATE INSTITUTE OF MEDICINE UNIVERSITY OF COLOMBO MP (ANAESTHESIOLOGY) FINAL EXAMINATION - MARCH 2016 Date :- 11 th March 2016 Short Answer Questions Time :-1.00 p.m p.m. Candidates are required to answer all twelve questions. Candidates who fail to attempt any one 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 previously healthy, 50 year old patient is admitted for a laparotomy with a diagnosis of carcinoid tumour in the small bowel. He has got features of carcinoid syndrome with no evidence of liver metastases What is carcinoid syndrome? (15%) 1.2. How do you prepare this patient for laparotomy? (40%) 1.3. What are your concerns during anaesthesia? (45%) 2. A 70 year old gentleman was admitted to the surgical ward with severe epigastric pain radiating to the back. He has been diagnosed with Acute Pancreatitis How do you define acute severe pancreatitis? (10%) 2.2. On what criteria would you decide to admit this patient to the ICU? (35%) 2.3. In the ICU his Sp0 2 drops to <90%. What could contribute to this desaturation? (30%) 2.4. What other complications can this patient develop in the ICU? (25%) Contd.../2-

4 / 3.1. Categorise chronic back pain. (10%) 3.2. How would you clinically identify them? (30%) 3.3. Outline investigation of chronic back pain (20%) 3.4. State therapeutic strategies used in the management of chronic back pain. (40%) 4. A 70 year old patient is scheduled for reconstructive free flap surgery following unilateral block dissection of the neck for cancer surgery What are the patient factors which influence functional outcome? (60%) 4.2. Outline the post-operative goals. (40%) Explain how different modes of heat loss from a patient undergoing a laparotomy differ from a person working in the same environment (40%) 5.2. List the adverse clinical effects associated with perioperative hypothermia. (20%) 5.3. If a patient in the ICU develops a temperature of 40.5 C, what measures would you take to bring the temperature down to normal? (40%) 6.1. What are the indications for the use of LMA? (25%) 6.2. List the advantages and disadvantages of using the Classic LMA during anaesthesia. (50%) 6.3. Explain how the 2 nd generation LMAs would overcome some of the disadvantages of the Classic LMA. (25%) Clntd.../3-

5 PARTS 7. A 32 year old female presents to A & E with a 5 day history of fever with chills, cough and shortness of breath. Her past medical history is not significant except for a previous admission with a chest infection six weeks ago. Following examination, a provisional diagnosis of tricuspid valve endocarditis is made List groups of patients at risk of developing endocarditis? (30%) 7.2. What are the common organisms responsible for endocarditis? (10%) 7.3. What are the Duke's major criteria used in the diagnosis of endocarditis? (20%) 7.4. Outline your initial management of this patient. (40%) Describe the sensory and motor innervations below the knee. (30%) 8.2. What are the local and systemic complications following use of tourniquet? (30%) 8.3. What safety precautions do you take to minimize complications associated with tourniquets? (40%) 9. A 26 year old primipara with a POA of 34 weeks is complaining of headache and blurring of vision. She is conscious and rational and has a BP of 180/120 mmhg and a proteinuria of 3+. Her Hb is 8 g/dl, platelet count is 50,000/mm 3, INR is 1.7, SGOT is 120 IU/L and SGPT is 230 IU/L. Her BMI is 35kg/m 2. Airway assessment revealed a Mallampati Grade What is the most likely diagnosis? (05%) What other clinical features would support your diagnosis? (10%) 9.2. How will you stabilize her prior to an urgent delivery? (40%) 9.3. What are the advantages of giving spinal anaesthesia after correcting the coagulopathy? (25%) 9.4. List the post operative complications that may occur. (20%) Contd.../4-

6 4 10. A 5 year old girl weighing 12kg is admitted with fever, neck swelling and difficulty in swallowing. The pulse rate is 140 bpm, Sp0 2 on air 96%. She is diagnosed as having a retropharyngeal abscess. She is scheduled for intraoral drainage of the abscess Briefly describe the retropharyngeal space in relation to the important anatomical structures in the neck. (20%) Outline the complications of a retropharyngeal abscess. (40%) Outline how you would secure the airway. (40%) 11. A 58year old with acquired immunodeficiency syndrome(aids) on anti retro viral therapy is scheduled for an interval appendicectomy List the investigations you would request, giving reasons, prior to surgery. (50%) What special precautions would you take during the peri operative period? (50%) Name the common supratentorial tumours in the brain. (10%) Briefly describe the important pathophysiological changes seen in the brain due to such tumours. (25%) How would you preoperatively optimise a patient awaiting craniotomy for excision of a supra tentorial tumour? (25%) If cerebral oedema develops during surgery what are the measures that can be taken to control the brain swelling. (40%)