Viva Stems Flashcards
(15 cards)
A 10-year-old girl has been added to your dental list today at a tertiary hospital. She is
scheduled for dental extractions and treatment under general
anaesthesia.
Medical history
Rheumatic mitral valvular disease
Medications
Frusemide 30 mg BD
Spironolactone 25 mg once daily
Allergies
Nil known
Observations on admission
Height 150 cm
Weight 35 kg
BMI 15 kg/m 2
HR 117 bpm
BP 95/60 mmHg
SpO 2 96% on room air
In your preoperative review of this patient with her mother, what information
on history and examination will you seek?
It is 11:00 pm and you are on-call at your major metropolitan hospital. The first-year
anaesthetic registrar telephones you at home and asks you to attend for a case that has
been booked with a surgical urgency of one hour. The patient is a 55-year-old woman
who has been booked for a T7 – L3 debridement and laminectomy for spontaneous
epidural abscess.
Observations:
Heart Rate: 130 - 140 bpm, atrial fibrillation
Blood Pressure: 110/60 mmHg on noradrenaline (norepinephrine) infusion running at
0.25 mcg / kg / min (14.5 mcg / min based on estimated lean body weight)
SpO2: 90% on high-flow nasal oxygen 40 L/min
Respiratory Rate: 25 breaths per minute
Temperature: 38.5 °C
GCS: 11 (E2 V4 M5)
Weight: 130 kg
Height: 155 cm
BMI: 57
Past Medical History:
Guillain-Barré Syndrome 20 years previously with ICU admission and mechanical
ventilation via tracheostomy (since closed)
Current smoking, 40-pack-year history
Type 2 diabetes mellitus (on insulin)
Hypertension
The registrar is concerned that the patient may require urgent intubation due to a falling
level of consciousness. You are 20 minutes away from the hospital.
How would you approach the management of this situation?
You are the duty anaesthetist at a major hospital. You receive a call from the emergency
physician to advise of a 20-year-old woman en route to the hospital with an anterior
chest wall stab wound.
The paramedics report that on their arrival, the patient was hypoxic and agitated. A 15
cm hunting knife was found nearby. The patient was intubated following administration
of diazepam 10 mg and rocuronium 100 mg intravenously. She had bilateral
thoracostomies.
The patient has a known intravenous substance use disorder with heroin.
The last set of vital signs recorded by the paramedics are as follows:
BP 70/55 mmHg
HR 130 bpm
SpO 2 92% on FiO2 0.9
RR 15 breaths per minute, ventilated
What are your main considerations as you head down to the Emergency Department?
You are the emergency theatre anaesthetist in a tertiary level hospital.
A 68-year-old man with end-stage renal disease is booked for debridement and washout
of an infected brachiocephalic arteriovenous fistula (AVF) +/- fistuloplasty. He has
missed his scheduled haemodialysis today due to
48 hours of progressive swelling and redness in his arm and intermittent chills. A peri-
fistular collection is confirmed on ultrasound.
Medications
Amlodipine-Valsartan 5 mg/ 160 mg once daily
Calcium Carbonate 500 mg TDS
Epoetin alfa 6000 units SCI 3x weekly
Frusemide 160 mg once daily
Hydralazine 25 mg BD
Metoprolol 50 mg BD
Prazosin 1 mg nocte
Observations
Weight 115 kg / Height 1.82 metres /BMI 35 kg/m 2
HR 80 bpm
BP 105/47 mmHg
RR 18 breaths per minute
SpO 2 96% on room air
Temperature 37.5°C
GCS 15 - lethargic but lucid
Examination Findings
Heart sounds dual
JVP +2 cm
Breath sounds bilateral and vesicular
Bilateral +1 pedal oedema
Outline your clinical priorities in the preoperative assessment of this patient.
You are the anaesthetist for a gynaecology list in a standalone day surgical unit. The
next patient is a 15-year-old girl presenting for termination of pregnancy.
She weighs 60 kg and is not on any regular medications. She denies any comorbidities.
She has attended alone due to parental objection to abortion. She is 11 weeks pregnant
confirmed on ultrasound and therefore unsuitable for medical termination.
Describe the elements necessary for informed consent in this patien
You are the anaesthetist at a tertiary referral centre. You have been asked to urgently
review a 40-year-old woman in the emergency department who has presented with neck
swelling and shortness of breath.
She is distressed and anxious.
Medications
Nil regular
Allergies
Nil known drug allergies
Observations
SpO 2 98% on room air
RR 20 breaths per minute
HR 120 bpm
BP 130/70 mmHg
Temperature 37°C
Investigations
Full Blood Count:
Results within normal limits
Urea and Electrolytes:
Results within normal limits
Thyroid function tests:
TSH <0.1 mIU/mL (0.5–5 mIU/mL)
Free T4 30 pmol/L (9–19 pmol/L)
Free T3 9.0 pmol/L (3–6.5 pmol/L)
What are the key issues that you would address in your assessment?
A 77-year-old man is booked for a posterior-approach left total hip joint arthroplasty
(performed in the lateral position) on your list in a private hospital next week. You have
taken over the list on behalf of an unwell colleague who provides their preoperative
notes.
Medical History
Hypertension
Fibromyalgia
Obstructive sleep apnoea on nocturnal CPAP
Gastro-oesophageal reflux disease
Left total knee arthroplasty completed under spinal anaesthesia two years ago
Height 170 cm, Weight 130 kg, BMI 45 kg/m 2
Medications
Amlodipine 10 mg once daily
Enalapril 20 mg once daily
Hydrochlorothiazide 50 mg once daily
Omeprazole 20 mg nocte
Naltrexone 4.5 mg once daily
Semaglutide 0.5mg SCI weekly
He has an unfilled prescription from his general practitioner for rivaroxaban 20 mg PO
daily.
Allergies
Nil known drug allergies
An ECG has been performed and is attached below. A transthoracic echocardiogram will
be performed prior to surgery
ECG showing - A flutter
What are your concerns about this patient’s presenting cardiac rhythm?
You are the consultant in the high-risk obstetric clinic. Your first patient is a 38-year-old
woman, G3P2, who is 25 weeks pregnant. She has had two previous lower uterine
segment caesarean sections under regional anaesthesia.
Her BMI is 55 kg/m 2 (height 174 cm, weight 167 kg). She was diagnosed with severe
obstructive sleep apnoea one year ago and has used nocturnal CPAP since with
improvement in her symptoms.
Medical History
Mild-moderate pulmonary hypertension
Congestive cardiac failure
Cardiorenal syndrome (GFR 41 mL/min)
Obstructive sleep apnoea on nocturnal CPAP
Medications
Aspirin 100 mg once daily
Spironolactone 50 mg mane
Frusemide 40 mg mane, 20 mg nocte
Labetalol 150 mg TDS
Nifedipine SR 30 mg nocte
Enoxaparin 100 mg SC once daily
Observations
HR 90 bpm
BP 130/80 mmHg
RR 22 breaths per minute
SpO 2 96% on room air
She has been referred to your tertiary hospital for management of this pregnancy and
planned delivery via repeat lower uterine segment caesarean section
What are the key concerns in assessing this woman for planned LSCS?
You are called to the Emergency Department as part of the trauma team in a tertiary
paediatric hospital.
The paramedics are en route and 5 minutes out from arrival.
You are told that a 2.5-year-old boy is being brought in following a motor vehicle
accident. The handover reports obvious left facial and chest injuries as well as deformity
and swelling of the left upper arm and thigh.
His observations as communicated by the paramedics are
HR 160 bpm
BP 70 mmHg systolic
RR 40 breaths per minute
SpO 2 91% on 6L/min via Hudson mask
He responds to voice.
As the anaesthetist in the team, how you will prepare for the child’s arrival?
You are the anaesthetist covering the intensive care unit and operating theatre in a small
regional hospital. The emergency physician asks for your assistance with transferring a
patient to radiology.
The patient is a 25-year-old man who was found wandering in a worksite.
He was agitated and confused, and an ambulance was called. In the ambulance, the patient
initially complained of a headache, then become drowsy.
The emergency physician has requested a CT brain but is unable to transfer the patient
due to clinical workload.
Medical History
Type 1 diabetes mellitus
Depression
Medications
Insulin pump 70 units Novorapid by subcutaneous infusion every 24 hours
Venlafaxine 150 mg daily
The observations recorded by the paramedics are as follows:
BP 140/85 mmHg
HR 84 bpm sinus rhythm
SpO2 99% on room air
RR 20 breaths per minute
Eye opening: open to voice
Best verbal response: mumbling words inappropriately
Best motor response: localising to pain
How will you assess this patient prior to transfer to radiology?
Page 42 of 52
VIVA 11 - Pass Rate 67%
You are requested to attend a trauma call in the emergency department of a tertiary
hospital.
Paramedics have transferred a 38 year old man with a stab injury to his neck inflicted
during an assault an hour ago.
His GCS is 15 (E4 V5 M6) and has the following initial observations:
Heart rate 95/min
BP 140/90 mmHg
Resp rate 18/min
SpO 2 96% on oxygen at 6 LPM via a Hudson mask
A stab wound can be seen about 2 cm above the right clavicle. He has a 20-gauge
cannula in his right antecubital vein and is currently receiving a litre of Hartmann’s
solution. His Hb is 125 g/L on admission.
He does not have any prior medical conditions or allergies and does not take any
medications.
On initial assessment, what clinical features will you focus on?
You are tasked with reviewing a 50-year-old male in the preadmission clinic, who is
scheduled for a transjugular intrahepatic portosystemic shunt (TIPS) procedure in one
week.
Past medical history
Cirrhosis secondary to non-alcoholic steatohepatitis leading to previous variceal bleeding
and recurrent ascites.
Type 2 diabetes mellitus.
Medications
Frusemide 40mg once daily
Lactulose 10ml three times daily
Metformin 1g once daily
Pantoprazole 40 mg once daily
Propranolol 10 mg twice daily
Rifaximin 550mg twice daily
Vital signs
Height 160cm
Weight 80 kg
BMI 31 kg/m 2
BP 105/ 65 mmHg
HR 85 bpm
SpO 2 95% on room air
Temp 36.5 o C
Under what circumstances may a TIPS be unsuitable for a patient with liver failure?
Page 48 of 52
Viva 14 - Pass Rate 66%
You are the duty anaesthetist for a regional hospital. The general surgeons have booked
a 69-year-old male for an urgent ureteric stent insertion at 1900 hrs.
Medical history
Hypertension
Type 2 Diabetes mellitus
Obstructive Sleep Apnoea on CPAP
Bronchial asthma
Currently smokes 10 cigarettes/day with a 50-pack year history
Drinks alcohol socially
Medications
Ramipril 5 mg daily
Empagliflozin 10 mg daily
Gliclazide XR 60 mg daily
Salbutamol inhalers 100 mcg 1-2 puffs q4h PRN
Vitals
Pulse rate 110 bpm
BP – 99/62 mm Hg
SpO2 94% on room air
Temperature 37.8 C
Patient’s body weight is 108 kilograms, height 167 cm
Calculated BMI is 38.7 kg/m2
ECG – sinus tachycardia 110 bpm
CT KUB – right sided hydronephrosis with a 12 mm calculus at the vesicoureteric
junction
What further information would you like to determine the urgency of this case?
A 17-year-old boy presents to pre-admission clinic in your tertiary referral centre. He
requires assessment prior to a T2- L4 posterior spinal fusion for kyphoscoliosis with a
50 degree curvature.
He has a cervico-thoracic syrinx and had a foramen magnum decompression at 3 years
of age for progressive lower limb weakness.
He is particularly apprehensive about the surgery and is worried about post-operative
pain.
Height 168 cm, Weight 95 kg, BMI 33.6 kg/m 2
What do you consider to be the most important features that need to be addressed
during the preoperative assessment?
You are called to review patient in recovery post elective LUSCS under neuraxial
anaesthesia. The patient is increasingly short of breath and has ongoing oxygen
requirement and the nursing staff are concerned about sending her back to the ward.
The lower uterine segment caesarean section (LUSCS) was performed at 36weeks
gestation for intrauterine growth restriction (IUGR). A healthy infant was delivered 2
hours ago.
Biometrics:
Age 28 years
Weight 88kg
Height 160cm
BMI 34.4
Past obstetric and medical history:
G3P0
Systemic Lupus Erythematosus
Medications:
Clexane 40mg od (ceased yesterday)
Aspirin 100mg
Hydroxychloroquine 200mg od
Nil Known Drug allergies
Outline your initial management.
