2015 Paper 3 Flashcards
- Which chamber abnormalities of the heart can be diagnosed from this ECG?
- Give the electrocardiographic features on the ECG that support each of your diagnoses. (4)
- Briefly explain the electrophysiological basis of the ECG changes of each chamber abnormality.
(4)
a.
○ Left ventricular hypertrophy
○ Left ventricular strain pattern
○ Left axis deviation
b)
○ LVH
•Sokolov-Lyoncriteria: S wave depth in V1 + tallest R wave height in V5-V6 > 35 mm :
= +/- 50mm in this ECG
•R wave in lead I + S wave in lead III > 25 mm
= +/- 30
•R wave in V5 or V6 plus S wave in V1 > 35 mm
= +/- 53mm
○ LV strain
• ST segment depression and T wave inversion in the left-sided leads = I VL V5 V6
○ Left Axis Deviation
= QRS axis less than -30°.
Question 3
Concerning capnography during anaesthesia:
a) Name the two principal types of dead space. (2)
b) Briefly explain the causes of the 4 phases of the trace above. (4)
c) Why may phase III of the normal capnogram have a slight up-slope? (2)
d) Explain under what circumstances phase IV can occur. (2)
a) Physiologic & anatomic dead space
b)
• Phase I (inspiratory baseline) reflects inspired gas, which is normally devoid of carbon dioxide.
Phase II (expiratory upstroke) is the transition between VDana, which does not participate in gas exchange, and alveolar gas from the respiratory bronchioles and alveoli.
Phase III is the alveolar plateau. Traditionally, PCO2of the last alveolar gas sampled at the airway opening is called the PETCO2.
Phase 0 is the inspiratory downstroke, the beginning of the next inspiration
c) The alpha angle can be used to assess the ventilation/perfusion of the lung. V/Q mismatches will have an alpha angle greater than 90 degrees.
d) an additional phase IV (terminal upstroke before phase 0) may be seen in pregnancy
Question 4
Concerning renal function:
Patient 1
Urine: Na+ = 5 mmol/L, Cr = 1000 mmol/L.
Plasma: Na+ = 140 mmol/L, Cr = 200 mmol/L.
Patient 2
Urine: Na+ = 5 mmol/L, Cr = 140 mmol/L.
Plasma: Na+ = 140 mmol/L, Cr = 196 mmol/L.
a) What is evaluated by the fractional excretion of sodium? In the above two patients with oliguria, calculate the fractional excretion of sodium. (5)
b) What are the diagnostic implications of the fractional excretion of sodium in each of the above
cases? (3)
c) Explain whether fractional excretion of sodium a reliable indication of the cause of oliguria. (2)
a) By definition, FENa is the ratio between the quantity of Na excreted in the urine relative to the amount filtered at the glomerulus. Measuring urine sodium concentration alone is not sufficient, as the sodium concentration in urine varies with water reabsorption. It is necessary to plug in the serum and urinary creatinine into the calculation, in order to calculate the amount of fluid and sodium that is filtered through to glomerulus.
○ Prerenal AKI can be due to intrarenal vasoconstriction, systemic vasodilation, and volume depletion. These patients will try to compensate and retain sodium and usually have a FENa of less than 1%. If any of the above insults continue and become intense, the blood supply to the renal tubules is severely reduced leading to acute tubular necrosis. Once the tubules are damaged, they lose their ability to reabsorb sodium, and the FENa will usually be greater than 2–3%.
○ FENa is often used in the setting of acute renal failure to help distinguish
between prerenal (decreased renal perfusion) and intrinsic renal (ATN due to renal hypoperfusion) causes. In general, a FENa of <1% suggests prerenal
disease, between 1 and 2% is indeterminate, and >2% suggests ATN. There are some exceptions to this, but overall, the specificity of this test is >80%.
There are limitations to FENa.
• The threshold used to distinguish prerenal and intrinsic renal disease may vary; there are other causes of low FENa and salt-wasting conditions (like diuresis) affect urinary sodium levels.
Calculations : Patient 1 =0.7% Patient 2= 5%
b) Patients 1 prerenal, 2 ATN
c)
•There may be an overlap between prerenal and intrinsic renal failure, especially in cases where the condition producing prerenal disease becomes severe enough to produce a significant drop in blood pressure. If the drop in blood pressure is severe enough, it can produce damage to the renal tubules. In such cases, both prerenal disease and ATN may be present, making the FENa result difficult to interpret.
• In addition, urinary sodium levels can become quite variable from hour to hour with acute renal failure, especially during the early stages of the disorder. So a single measurement of FENa can give a misleading answer. This limitation can usually be circumvented by measuring FENa several times over a period of several hours, until the measurement stabilizes.
• In people with chronic underlying kidney disease (such as chronic glomerulonephritis), a superimposed acute prerenal condition can result in an elevated value of FENa, which can mislead doctors to think that ATN has occurred. So interpreting FENa in the setting of chronic kidney disease must be done with caution.
Finally, it is not possible to reliably interpret the FENa measurement in people taking diuretic therapy, which increases urinary sodium levels.
• The threshold used to distinguish prerenal and
intrinsic renal disease may vary; there are other causes of low FENa and salt-
wasting conditions (like diuresis) affect urinary sodium levels.
Question 5
Concerning the following haematological values:
WBC 10 x 109/L.
RBC 6 x 1012/L.
Hb 19 g/dL.
Platelet count 370 x 109/L.
a) Give a short classification for the abnormality in the blood results above, with an example of each. (6)
b) Would you accept this patient for elective surgery? (2)
c) Explain why this patient may be centrally cyanosed without being hypoxaemic. (2)
a)
•Primary Polycythemia (Polycythemia Vera) The criterion or the diagnosis of primary polycythemia, also known as “Polycythemia Vera” (PV), involves an elevated hemoglobin level (>18.5 g/dL in men; >16.5 g/dL in women) and either the presence o a JAK2 mutation or two o the ollowing: hypercellularity o the bone marrow, a subnormal serum erythropoietin (EPO) level, or endogenous erythroid colony ormation
•Secondary Polycythemia most commonly arises as a result of hypoxia or from excess EPO production
•Relative Polycythemia results rom a reduction of plasma volume, is typically due to dehydration. Diuretic use precipitates the dehydration with excessive sweating, or inadequate oral intake.
b) Patients with polycythemia vera are at risk or periopera-
tive hypercoagulability and hemorrhage. In order to reduce
the risk o thrombohemorrhagic complications, Hct reduc-
tion to 45% be ore surgery is recommended. Additionally,
thrombocytosis should be decreased to less than 400,000 platelets/mm3 prior to surgical intervention to prevent complications. In the case that bleeding occurs, both cryoprecipitate and desmopressin improve vWF levels. Nonetheless, patients should be advised to withhold rom aspirin use or at least 7 days prior to surgery.
When the red blood cell count reaches a critical number, the flowability of the blood decreases leading to restricted blood circulation. This causes a blue coloration of the skin (cyanosis).
C. Elevated amount of deoxygenated hemoglobin
Question 6
Concerning the following chest radiograph:
a) What are the most important radiological signs? (3
b) What are possible causes? (3)
c) What technique should be used for tracheal intubation? (4)
- Airfluid level in the right upper lobe
Elevated right hemidiaphragm - Infection: pneumonia, abscess
Bulae
Tumor - One lung ventilation with DLT/BB/EBI, isolation of the lungs to prevent cross contamination.
Question 7
Concerning the following spirometry:
a) What pathology could one expect in a patient with this flow volume loop? How would one distinguish between the two main causes? (4)
b) Briefly describe how the test for diffusing capacity is performed. (6)
a) Expiratory airflow limitation secondary to chronic obtructive airway disease, emphysema or asthma .Instead of the almost linear decrease in expiratory flow, there is a “scooping” of the loop soon after the PEFR. This scooping represents the decreased amount of flow secondary to difficulty in expelling the volume of gases left in the distal airways.
A post Bronchodilation spirometry with significant reversibility of the obstruction as marked by FEV1 increase 12%/200ml
b) A frequently used test is thesingle-breath method, in which a single inspiration of a dilute mixture of carbon monoxide is made and the rate of disappearance of carbon monoxide from the alveolar gas during a 10-second breathhold is calculated. This is usually done by measuring the inspired and expired concentrations of carbon monoxide with an infrared analyzer. The alveolar concentration of carbon monoxide is not constant during the breath- holding period, but allowance can be made for that. Helium is also added to the inspired gas to give a measurement of lung volume by dilution. The normal value of the diffusing capacity for carbon monoxide at rest is about 25 ml·min−1·mm Hg−1, and it increases to two or three times this value on exercise because of recruitment and distension of pulmonary capillaries .
Question 8
Concerning anaesthesia for lung resection:
a) What is this test? (2)
b) What additional information on the patient’s exercise capacity would be useful to determine suitability for a right upper lobectomy? (4)
c) What additional lung function test results would be useful to determine suitability for a right upper lobectomy? (4)Preoperative pulmonary evaluation for lung resection Preety Mittal Roy
Article: Preoperative pulmonary evaluation for lung resection Preety Mittal Roy
a) Lung scintigraphy
b)
c)% PPO FEV1 or
DLCO less than 30%, SCT less than 22 m, or SWT less
than 400 metre are indications of cardiopulmonary exercise
test (CPET).
•CPET quantifies objectively the functional capacity of a subject to respond to the increased metabolic demands of major surgery, most commonly using three measures: peak _ VO2, anaerobic threshold (AT) and ventilatory equivalent for carbon dioxide ( _VE/ _VCO2), all of which define the limits of an individual’s physiological reserve.
• Values more than 20ml/kg/min is suggestive of a favorable
prognosis,[12,13] and patients with VO2max less than
10 ml/kg/min are very high risk candidates for pulmonary
resection.[
• AT less than 11 ml/kg/min
and 8 ml/kg/min is indicative of poor and very poor postoperative outcome, respectively
• Oxygen pulse Values more than 80% of the predicted is considered normal.Low values of oxygen pulse is suggestive of poor left ventricular function
The arterial blood gas below was obtained from a patient recovering from ARDS, 2 hours post extubation, on a 40% Venturi mask:
pH 7.51.
PO2 8.2 kPa.
PCO2 4.8 kPa.
Standard bicarbonate 32 mmol/L.
a) What is the pathophysiological explanation for the PaO2? (2)
b) How can you explain the bicarbonate value? (1)
c) How is shunt calculated? (3)
d) What causes of hypoxaemia are likely in this patient? (2)
e) How could the patient’s respiratory status be improved? (2)
a) This patient has a high A-a gradient of 188mmHg which suggest the possibility of a difusion impairment or ventilation/perfusion mismatch (R-L shunt differential) and the cause of low PaO²
b) HCO3 BUFFER SYSTEM
Hypercapneic patients with ARDS commonly develop a metabolic alkalosis (e.g. bicarbonate level of 30-35 mM), evenwithoutany exogenous bicarbonate administration. This occurs for two reasons. First, these patients are often diuresed, leading to a contraction alkalosis. Second, when exposed to hypercapnia, the patient’s kidneys will naturally retain bicarbonate in efforts to increase the pH.
c)Qs= CcO²-CaO², QT = CcO²-CvO²
d) VQ mismatch , r- left shunt, hypoventilation
e) addition of non invasive PEEP CPAP/BIPAP/HFNO2
A patient suffers blunt abdominal trauma and requires several laparotomies, leading to small- and large bowel resection, liver packing and parenteral nutrition.
Blood results (in mmol/L) are as follows:
Na 135 mmol/L; K 2.8 mmol/L; Cl 98 mmol/L; Standard bicarbonate 32 mmol/L.
Urea 5 mmol/L; Creatinine 105 µmol/L.
Mg 0.54 mmol/L; Ca 2.15 mmol/L; PO4 0.36 mmol/L; Albumin 22 g/L.
a) What is the corrected calcium level? (2)
b) What further investigation is required to determine the significance of the K level? (1)
c) What is the significance of the reduced PO4 level in the clinical setting and the likely consequences of commencing parenteral nutrition without correction? (4
d) What electrolyte supplementation would you provide in this patient? (3)
a) corrected calcium = measured calcium + 0.8×(4,0-albumin)
b) ? ECG
c) Refeeding syndrome
d) Calcium, MgSO4, k+
A 67-year-old man is undergoing transurethral resection of the prostate under spinal anaesthesia. At the end of the procedure the patient is found to be confused.
Interpret the following blood results:
Na 121 mmol/L; Cl 101 mmol/L; K 3.6 mmol/L; Glucose 4.5 mmol/L.
pH 7.35; PaO2 12.5 kPa; PaCO2 5.0 kPa; Standard bicarbonate 26 mmol/L.
a) What are 2 likely causes for this acute condition? (2)
b) What clinical signs may be associated with this condition, and which other causes of confusion must be excluded? (4)
c) How would you manage this patient? (4)
○ TURP syndrome is a complication characterised by symptoms of Hyponatraemia, ( headache,confusion, anxiety, dyspnoea, arrhythmias, hypotension, convulsion, coma, death) secondary to absorption of irrigation fluid by disrupted sinuses of prostate venous plexus typically 10-30mls/min. This results in water toxicity that causes hypoosmotic Hyponatraemia.
○ glycine present in irrigation fluid is a inhibitory neurotransmitter and toxicity presents as nausea, headache, malaise, weakness, hypertension,visual disturbance, myocardial depression. It’s metabolites glycoxylic acid and ammonia in access may alter level of consciousness.
1. Severe Hyponatraemia
2. Glycine toxicity:
Resuscitation
○ Attend to ABCs and address life threats:O2 +/- intubation (or airway protection)and ventilationinvasive monitoring
Specific Treatment:
• fluid overload: frusemide 40mg IV
• seizures: benzodiazepines +/- other anti-epileptics; consider magnesium (stabilises NMDA receptors)
• hyponatraemia:hypertonic saline is only indicated for neurological manifestations if measured serum osmolality is < 260 mOsmol/kgaim to raise Na+ by no more than 10-12 mmol/24 hours)a rapid increase in plasma sodium is not concerning (this often happens with glycine metabolism), unlessthere is a sudden change in osmolality (measured osmolality usually changes little as the hyponatremia resolves)severe cases may require renal replacement therapytreat acute pulmonary oedema and dysrhythmias as requiredtreat hypocalcaemia
• Treat underlying cause
stop surgery as soon as possible coagulate bleeding points stop IV fluid monitor Hb
Disposition admission to HDU/ ICU (features may worsen due to ongoing absorption of irrigation fluid)
a) Describe the most prominent features in this chest radiograph. (2)
b) What is the most likely cause of the condition? (2)
c) What additional investigations are necessary? (2)
d) What treatment can be employed before embarking on elective surgery in order to facilitate the procedure? (2
e) What are the options for securing the airway? (2)
a) Positive cervicothoracic sign
1. Anterior-Superior mediastinal mass
2. Tracheal deviation to the right
3. Tracheal narrowing
b)
1. Retrosternal goitre
2. Thymus pathology
c) CT :
1. Degree of obstruction
2. Level of obstruction
According to one study, the most important CT features in determining the necessity of sternotomy for goiter excision are the presence of an ectopic goiter, total thyroid gland volume and goiter extension below the tracheal carina
• Lateral xray :
• flow volume loop : fixed obstructive picture
d) Radiotherapy + Chemotherapy + steroids
1. Propylthyuracil
2. Carbimazole
3. Radioactive iodine
e)
1. Awake FOI with placement of armoured ETT below the narrowest part of trachea.
2. Gas induction with maintenance of spontaneous ventilation
3. Rigid bronchoscopy
4. Rescue airway not trachy therefore have:
5. Cardiac bypass on standby
A 21-year-old woman is brought to theatre for an exploratory laparotomy. On examination she is found to be confused, tachycardic and sweaty. She is not on chronic medication and does not take recreational drugs.
Investigations reveal:
pH 7.23; PaO2 12.6 kPa breathing room air; PaCO2 3.7 kPa; HCO3 10 mmol/L.
Na 126 mmol/L; K 5 mmol/L; Cl 95 mmol/L; Blood glucose 18 mmol/L.
a) What is your diagnosis? (1)
b) What is the anion gap in this patient? (2
c) Briefly describe your management. (4)
d) Name 3 additional causes of an abnormal anion gap. (3)
Blood gas interpretation
• High anion gap metabolic acidosis -
• Delta gap is high therefore there is concurrent metabolic alkalosis
• winter’s formula measured pCO2 higher than calculated therefore Respiratory acidosis present
b) Anion gap is 26
c) M- Methanol
U- Uremia
D- DKA
P- Paraldehyde
I- Infection or INH
L- Lactic acid
E- Ethanol, ethylene glycol
S- Salicylate
Question 14
a) Draw a normal thrombelastograph (TEG) trace and name 5 variables that can be examined. (5)
b) What coagulation state is represented in each image below? (5)
Variables assessed
• R value = reaction time (s) time of latency from start of test to initial fibrin formation(amplitude of 2mm) initiation phase dependent on clotting factors
• K = kinetics (s)time taken to achieve a certain level of clot strength (amplitude of 20mm) amplification phase dependent on fibrinogen
• alpha = angle (slope of line between R and K) measures the speed at which fibrin build up and cross-linking takes place, hence assesses the rate of clot formation“thrombin burst” / propagation phase dependent on fibrinogen
• TMA = time to maximum amplitude(s)MA = maximum amplitude (mm)represents the ultimate strength of the fibrin clot; i.e. overall stability of the clotdependent on platelets (80%) and fibrin (20%) interacting via GPIIb/IIIaA30 or LY30 = amplitude at 30 minutespercentage decrease in amplitude at 30 minutes post-MAfibrinolysis phaseCLT = clot lysis time (s)
Question 15
With respect to monitoring neuromuscular blockade:
a) Which monitoring method is employed in this diagram? (3)
b) What are the benefits of this method in assessing neuromuscular blockade? (3)
c) What is meant by the post-tetanic count? What is the clinical application of this measurement?
(4)
a) Double burst stimulation
• DBS consists of two short bursts of 50-Hz tetanic stimulation separated by 750 ms. The duration of each square wave impulse in the brst is 0.2 ms. The most commonly used is DBS with three impulses in each of the two tetanic bursts. In the absence of neuromuscular blockade, the response to DBS is two short muscle contractions of equal strength. In non depolarizing block, the second response is weaker than the first.
b) DBS allows for detection of small amounts of residual blockade during emergence and in the postoperative period. The DBS response is more easily felt than TOF making it a superior option. As with all modalities of testing, the frequency and duration should be kept constant for the entire operative time
Question 16
The following patient presents for a hysterectomy: Her preoperative history includes syncopal episodes, palpitations and increased shortness of breath. Her echocardiography report appears below:
a) Point out the importantinformation on this echocardiography report. (4)
b) How was the ejection fraction calculated? (1)
c) What is the pressure gradient across a normal aortic valve? (1)
d) What are the major considerations should hypotension develop during induction of anaesthesia? (4)
a)
○ Critical aortic stenosis
• Valve area
• Pressure gradient
• Jet velocity
b) EDV-ESV/EDV×100
c) <5mmHg
d)• aim mean arterial pressure of > 70mmhg
• give small increment of PEP
• Avoid bradycardia cardiac output is SVXHR, with a narrowed valve maintaining hr is critical and tachycardia to preserve edv and myocardial perfusion maintenance
• treat arrhythmia aggressively as atrial kick helps mainten CO
Question 17
After induction of a child for a tonsillectomy the following 12 lead ECG is taken after observing
abnormalities on the ECG monitor in theatre:
a) What abnormalities do you observe on the ECG? (3)
b) What is your diagnosis? (2)
c) What can be the cause in this scenario? (5)
a)
• Wide QRS complexes
• Dominant s wave v1-4
• RS pattern in v5
• appropriatediscordancemanifesting as ST depression in leads V5-6, as well as mild ST elevation in leads V2-3.
b) Aortic stenosis
Ischaemic heart diseaseHypertension
Dilated cardiomyopathy
Anterior MI
Lenègre-Lev disease: primary degenerative disease (fibrosis) of the conducting system
Hyperkalaemia
Digoxin toxicity
Question 19
This 30-year-old, critically ill patient is receiving ventilatory support with intermittent positive pressure
ventilation, under close cardiovascular monitoring:
a) What is demonstrated by this graph? (1)
b) What is measured at points a, b, c, d? How do you interpret the values shown at points e and
f? (6)
c) What important additional information can be obtained from this monitor? (2)
d) What is the important limitation of this technique? (1)
Question 20
a) How would you describe this x-ray? (2)
b) Identify the numbered structures i - iv. (8)
Question 2
A 65-year-old diabetic patient presents for elective surgery with the following ECG:
a) Describe the prominent abnormalities on this ECG. (3)
b) What pathology could cause this ECG pattern? (4)
c) How would you manage this patient? (3)
Life in fast lane
a.
• Sinus bradycardia HR 47b/min preceeded by s wave
•Narrow QRS complex
• T wave inversion lead 1,V1/2} Biphasic/3/4
b. Wellens Syndrome is aclinical syndromecharacterised bybiphasicordeeply inverted T waves in V2-3,plus a history of recent chest pain now resolved. It is highly specific for critical stenosis of the left anterior descending artery (LAD)
c.Due to the critical LAD stenosis, these patients usually require invasive therapy, do poorly with medical management, and may suffer MI or cardiac arrest if inappropriately stress tested
Question 1
Describe the components of this capnogram of a mechanically ventilated patient, and explain all
possible reasons that may account for each of its components.10
- Above baseline start
• Exhausted sodalime
• Use of non circle system circuits with inappropriately low flows resulting in rebreathing
•incompetent unidirectional inspiratory or expiratory valv
• Accidental administration of carbon dioxide
•Channelin of gas within the CO2 absorber - Abnormal inhalation limb with small elevation
• Rebreathing of expired air.
Question 4
A 67-year-old type II diabetic, hypertensive on hydrochlorothyiazide and enalapril, has a 25 pack-year smoking history. He has defaulted treatment for prostatic cancer after having an
orchidectomy 12 months previously. He now presents with a gangrenous leg requiring amputation
but is tachypnoeic (Respiratory rate = 24 breaths per minute) and he is using accessory respiratory muscles
a) List what you would consider to be differential diagnoses for the increased respiratory rate given the patient’s history and respiratory findings.
b) What does this chest x-ray suggest is the most likely cause for the patients dyspnoea and give your reasons?
c) What single further investigation would help you discriminate between cardiac and respiratory causes and describe how would it help?
Differential includes:
• Cardiac
• Metastatic + mediastinal mass or pleural effusion
• Primary lung CA + mediastinal mass or pleural effusion
• COPD
• Pneumonia
• Pulmonary embolism
b) Features on CXR:
• Erect (no mobile identification and scapulae out of the chest) so CTR able to be assessed
• CTR <50% but difficult to assess with hyperinflation
• No features of pulmonary oedema
• No upper lobe venous diversion
• Lung fields clear (no pneumonia, primary, metastatic or mediastinal masses accounting for
dyspnoea)
• Most likely cause is COPD but could have cardiac cause
c) Differential either COPD or cardiac failure (not seen on CXR) and transthoracic echo would be able
to exclude a cardiac cause if good ejection fraction and normal architecture.
With respect to the graphic above
a) Name the pattern of lung disorder seen is this patient and briefly explain your answer. (4)
b) How do you grade severity of this type of lung disorder and how would you obtain the
information you would need to grade it in this patient? (4)
c) List 4 potential causes for this type of pattern. (2)
Question 8
a) Classify the causes of post-operative hepatic dysfunction and give two examples of each
type.
(6)
b) In the table below, what are the expected results in the following conditions?
(4)
KEY: (↓= decreased; ↑= increased; N=normal or unchanged)
Question 10
a) Complete the table below of the laboratory diagnosis of coma in the mentioned conditions (5
b) Giving reasons, briefly describe the derangements in serum potassium, serum sodium and
serum phosphate values of a patient presenting with a DKA. (5)
Question 11
With respect to the electrocardiograph (ECG) below
a) What are the abnormal features of this ECG? (3)
b) What is the diagnosis? (1)
c) How would you manage this abnormality further? (6)
QRS duration > 120ms
Dominant S wave in V1
Broad monophasic R wave in lateral leads (I, aVL, V5-6)
Absence of Q waves in lateral leads
Prolonged R wave peak time > 60ms in leads V5-6
Question 12
With respect to the assessment of fluid responsiveness, tabulate 5 (five) minimally invasive
cardiac output measuring techniques, and their limitations. [10]
Question 13
With respect to this normal pressure-volume loop in the left ventricle (LV) of the heart in one
heartbeat, answer the questions below
a) What do the following represent: H, G and E? (1.5)
b) Superimpose the pressure volume loop you would expect in a patient with Aortic stenosis on
the image above. (2.5)
c) Giving reasons, list three conditions which greatly increase the LV afterload. (6)
In the above image, what do the following refer to on a normal Thromboelastogram and give
examples of abnormalities or conditions which may change their values
a) R-time.
b) K-time.
c) Alpha-angle.
d) Maximal amplitude.
e) Amplitude 60 minutes after maximum.
Question 15
With respect to the electrocardiograph (ECG) below, answer the following questions
a) What are the abnormal features of this ECG? (4)
b) What is the diagnosis? (1)
c) How would you manage this patient if they became acutely hypotensive? (5)
Question 16
The lung function test above is from a 26-year-old female requiring a left upper lobectomy
following haemoptysis due to pulmonary tuberculosis
a) How would you assess cardiopulmonary reserve in this patient? (5)
b) Calculate the predicted post-operative FEV1 for the patient and comment on suitability for
resection based on your answer. (5)
Question 18
The meta-analysis below shows the primary mortality outcome of studies investigating early goal directed therapy (EGDT) in septic shock patients.
a) What is an odds ratio? (3)
b) In which study/ies did EGDT lead to an improved odds of mortality ? (1)
c) What is a confidence interval (CI)? (2)
d) What CI was used here and how is it calculated? (1)
e) Comment on the confidence intervals of the studies above? (2)
f) Comment on the heterogeneity of this meta-analysis. (1)
Question 19
Below are 2 ultrasound images. Answer the following questionsa) Label the image (1.5)
EO (muscle 1)
IO (muscle 2)
TA(muscle 3
c) Which nerve distribution is blocked with this technique? (1)
d) List 4 surgical procedures where it has shown to be effective.
e) List 2 strategies to optimise block success.
f) List 2 complications associated with this block.
g) List 2 analgesic alternatives to this block (excluding neuraxial analgesia). (1)
a) Identify the patterns of peripheral nerve stimulation below and one clinical application of each
(6)
b) Which modality is most useful in detecting a phase II block from depolarising muscle
relaxant? Draw the expected pattern of response to stimulation.
(2)
b) Which modality is most useful in detecting a phase II block from depolarising muscle
relaxant? Draw the expected pattern of response to stimulation.
(2)
