critical care total mrcs part b

CRITICAL CARE TOTAL

1. Head injury with extradural, flail chest after falling of a bridge, acidosis & sepsis.

2. COPD with RESP failure post op. Metallic valve on warfarin and correction of anti-coagulation before emergency surgery. NB these stations go very quickly so don't hang about, often the last question is worth the most marks so make sure you complete everything

3. TURP syndrome, management of hyponatraemia & pulm oedema, plus different types of shock.

4. CT Abdo/pelvis could not work out what was going on? perf or gallstones?,5. Blood pressure control and Epidurals6. All about pathology and management of abdominal fistulas. Fairly easy just need to

know some basics.7. Car accident - ABC, CT scan interpretation (showing a splenic rupture), ABG (I

think), splenic rupture management.8. hypothermia - definition, how to prevent it pre-op and during the operation. Very

simple station.9. Burns, ARDS, HDU/ICU monitoring (referring)10. Bowel Obstruction and Trauma11. Pancreatitis12. Trauma

1) Burns – see example

2) Hypothermia – how categorise? why cold in theatre? Risks assoc with massive blood transfusion? Qs on blood products. Interpret blood results – clotting, Hb.

3) CVP – draw Starlings law, describe features on CXR (lines, ?ARDS features), Qs on fluid challenge and response of CVP. Risks of line insertion

4) Sepsis and Hypotension - Elderly lady with diverticular abscess has a systolic of 90mmHg what is your initial management? Definition of SIRS, shock etc. Broad principles of management of sepsis.

5) ECG/cardiac issues - Patient has had MI 6m ago, what is the risk of re-infarct if surgery done <3m post MI? Interpret ECG (ST elevation!) what does it show? How do you interpret an ECG? What to do with patient on clopidogrel post-stenting. What are alternatives to clopidogrel? Who would you discuss this patient with?

6) acute pancreatitis – asking various questions such as what scoring systems, ct scan image shown – asked what it showed, gave some ABG data and asked regarding interpretation of this.

7) Post-op hypotension - a scenario of patient coming back from theatre after THR, was hypotensive and hypothermic, asked various questions regarding fluid management, causes of hypotension, escalation of care to HDU. ETC.

8) Trauma - young man comes on following RTA. How will you institute initial management? (ABCDE etc.). He is hypotensive, tachycardic - what degree of shock is he in? You order a CXR - what does it show? (haemopneumothorax). how will you manage this? (chest drain). you then get a CT abdo pelvis. what does it show? (liver laceration). how can you manage this? (operative/conservative). in what setting should the patient be managed in? (ITU)

Critical care manned- tough station. You are called to see a patient whose signs are suggestive of cardiogenic shock or epidural complication or SIRS *No idea how I fared in this one!

Critical care unmanned- small bowel loops on plain abdominal radiograph+ SIRS on bloods, causes of above presentation & management.

Critical care- cholecystitis (CT), heart block (ECG), resp failure (ABG, CXR)

Polytrauma patient – interpret chest X-ray and blood gas. Suggest pathology and estimate blood loss. Think this was haemothorax as was supine chest film. Basically not a great question

Manned scenario – asked about significant blood loss. Presented with blood results – emerging DIC. Asked about types of transfusion and complications of transfusion. Also asked about hypothermia, ecg signs and definition.

Respiratory blood gas to interpret

Chat with two examiners about a patient with AAA rupture, Talked about hypothermia, definitions, management, complications etc. Moved on to talk about coagulation disorders in AAA rupture and the blood products you would give. Questions over too quickly and then sat around waiting for bell to go!

Unmanned station with interpretation of images - very poor image printed on laminated A4 card of a CT abdomen. Not entirely sure what the results showed!

Station 4 - Critical care - Patient following laparotomy (small bowel volvulus) has bowel contents leaking through abdominal wound, but well systemically. Previously had radiotherapy for Ca cervix. How would you assess the patient, given biochemistry results showing renal failure, as well as low K+, Na+ and Mg2+, questions about fluid management, electrolyte replacement and TPN

Station 5 - Critical care (unmanned) - Questions about hypothermia and its management in perioperative period

Critical care/Physiology – Trauma – young man hit by a car – asked about ATLS assessment and questions about all this, then asked to interpret a CXR with small right pneumothorax, rib fractures and surgical emphysema, then asked to look at a CT abdo – liver laceration and questions about management etc.

Critical care/physiology – Burns – ATLS assessment and questions – especially airway signs of soot and singe etc. Then given a diagram and asked about assessing %BSA burnt. Then asked about parkland formula for fluids and management. Then patient transferred to ITU becomes unwell – shown a CXR bilat pulmonary infiltrates and asked about ARDS and management.

Critical care/ Physiology – Sepsis – Patient with diverticulitis and signs of septic shock. Ccrisp style assessment and questions along the way and then questions around the management of sepsis.

1. Info outside station; 72 year old man, TURP this afternoon. The procedure was prolonged and he lost a lot of blood. You are surgical SHO on call and asked to see him as he is tachycardic, looks pale and is struggling to breath. Bloods; Hb 7.7, Na 121, WCC 7.8

a. What is most likely diagnosisb. Why?c. What else is relevant?d. What do you want to do?e. Where should this patient be treated?f. Explain method of action of osmotic diuretics.

Caseso Burns

Fluids Resuscitation Atls priniciples Ards – 4 components ! Calculation of %

o Fluids post op Causes Fluid compartments Question about vasopressin cant remember what it was about but adh was

the answer Discussion a fluid balance chart

o Pancreatitis Causes Ct scan and x-ray (chest – ali picture) Management

o TURP syndrome Cause Treatment Principles of management of pulmonary oedema

Diuretics and mode of actions, what part of the tubule they work ono PE

History, differential, management

Management station; pt septic 4 days post anterior resection, sounds like they’ve had a leak, distended and tender abdo, talked about sirs criteria, investigations, management, hdu level care, abx, pt was confused too, asked who we had to talk to, so said family

Pain management, given some obs; hypertensive and tachycardic, dissussed that this was likely due to pain, mentioned need to exclude important causes of pain eg. Infection and bleeding, then about appropriate analgesia, pt was post laparotomy so opioids, pca and epidural, asked about types of pca; looking for epidural and opioids, then asked about drugs for epidural; local, asked if local could be given iv; said no but ran out of time

Management station; pt mismanaged with IVI during theatre; 7 litres in, < 1 litre out! Said clearly overloaded, but needs assessing to be sure, Urine output seemed to be dropping off, was a bit confused by this but said could be a renal cause; i.e drugs. Then was asked about what do about mismanagement, said investigate, audit then guidelines

CRITICAL CARE SCENARIO

Fistula Scenario of a lady who has had extensive abdominal surgery with an enterocutaneous fistula.

o What predisposes to fistula formation? (Cancer, IBD, infection, ischaemia, distal obstruction, malnourished, age).

o What are the complications of fistula? (electrolyte loss, hypovolemia, infection, acidosis, malnourished, excoriation around wound!).

o Factors preventing closure ( persisting disease, discontinuity of bowel, distal obstruction, cancer).

o What should you look for in fistula pt? (dehydration, sepsis, cachexia, RR). o Bloods shown Low K, Na, High Cr and Ur, low Mg ( dehydrated with renal failure).o Management of fistula (SNAP)o Indications for surgery (persistence, abscess).o How do you measure nutritional requirements? ( Obs, weights, albumin, electrolytes)o What fluids to give this patient – how fast, etc, Nutritiono TPN and complications

Epiduralo Block for pneumonectomy now post-op increased RR and reduced BP and UO,

numbness in arms o What is an epidural? o Why is temp sensation better than pain or touch in testing for it? (Pain and temp

go in spinothalamic tract, using cryospray better to pt)Which fibres involved? (C fibres in ST tract).

o Consequences of high T3,4 block? (Sympathetic chain fibres cardiac are at this level). How does block interfere with resp? (blocks sympathetic line to cardiac and resp receptors).

o How do you tell if the hypotension is due to epidural (CVP response to 250mls, stop the epidural, fluids, UO). What else can you give? (Vasoconstrictors) Why is

UO low? (Hypoperfusion of kidney). What is first step of management? (ABC and fluids).

Hypothermia and coagulopathyo Definition: <35C, what factors contribute?(age, surroundings, convection,

radiation, conduction), who is at risk? (old, immunosurpressed, hypothyroid, burnt, malnourished, intoxicated. How is it controlled (Hypothalamus etc). Response: Shivering, vasoconstrict, increased RR, acidosis, high lactate. What happens to CVS (reduced CO below 28 degs). Extreme shivering: high Creat Kinase, K rise, myoglobinurea. Electrolytes: high K and lactate. How to treat: warm fluids, theatre, and cover pt, intraperitoneal lavage.

o Show you bloods low Hb, WCC, Plt, high APTT. Answer, pt needs blood, and

platelets, d/w haematologists re platelets and FFP, judge response with temp, BP, RR, UO, CVP!

o The patient then requires massive transfusion - complications of transfusion.

o Thermoregulation in theatre- NICE guidelines

AAA repair complications: emboli distally, compartment syndrome in abdomen, bleeds!

Shock SIRS Sepsis

o Surviving sepsis 6hr and 24hr bundleso Scenario – Lady post anterior resection – 5/7 post op. Septic, Talk about management and

investigations, SIRS and its management, blood results and investigationso anastamotic leak;o RUQ pain and pyrexiao CT showing gallstones. What other bloods would u like ( Clotting is the only one they

haven’t given you!). On admission? (ABx and fluids). What procedure do they need? ( Lap Chole)

o Neutropenic sepsis o Sepsis - GD perforation, diverticular perf or abscess. Initial management, who to d/w?

Imaginf req? Correct Tx? Ix req? ABG interpret and explanation; next move (ABCs, Ix, ?source) DDs? Management strategy? Haemodyn instabil despite ventilation, ?action? (O, PEEP, fluids, inotropes, further CT, op)

Trauma Hypovolemia

o Decceleration injury: Car Vs mano Shock define, outline management in HDU, and estimate blood loss. What are the

indicators for a CVP line other than fluid management? (drugs, mixed venous gas, and bloods, Abx, haemofiltartion, K). Normal CVP in adults is?(2-8cm of H2O above LEFT ATRIUM). What are you measuring? (LV end diastolic filling pressure). Draw a graph of LVEDP and stroke Volume essentially starlings law and curve! What is starling law? How in practice do you do a CVP? (250mls

boluses and response of BP and CVP with previous). Draw the graph from kanani about CVP response! Look at CXR ( name, point to central line, there will be either ARDS, pneumo, contusions, heart failure!) CVP line complications (infection, misplaced line, feed into chest cavity). How do you decrease risk of infection? (Wash hands, gown, drape and gloves, clean it). Nice guidelines under USS!!

Compartment syndrome(abdominal) + Crush injury Initial mx? o Initial management: ATLS.

o Who do you inform? (consultant, anaesthetist, and family). In theatre they are

doing fasciotomy, o How do you detect and treat hyperkalemia?

o Gases (show acidosis, and low albumin and Ca++why?)

o In HDU urine goes red why? (test it for blood, for myoglobin).

o Starts bleeding a lot what are the non surgical causes (DIC, pre-existing

coagulopathy, hypothermia)o ATLS management of liver laceration

TURP Syndrome Confused post TURP, hypotensive and tachy. TURP Syndorme, why glycine used. What is glycine. Use of osmotic diuretic. Differnetial- blood loss, pneumonia, PE, Citrate levels( on Warfarin, Bendro, Dox, and AVR 2yrs ago, high BP, HR normal, with pic of

bladder)Burnso Burns management calculating fluid replacement

Respiratory failureo Type 1 resp failure post op pt. o Investigations to delineate cause. ABG interpretation. o Treatmento NIV, mechanical ventilationo ARDs managemento Pneumothorax and flail chest: Initial management, ABG interpret – TII resp fail, expl

pic & management,Ix req, interpret CT

Small Bowel Obstructiono 65 with defunc ileostomy, IHD, RF, SOB, and low UO. Tachy, BP and temp okay.

Reduced air entry R base + creps. AXR and clinically distended. Drug prescribing in bowel obstruction

o What do you hear? ( Hyperactute bowel sounds/nothing). What additional radiological investigation to you want? (CT). With dilated loops and increased WCC what other diagnoses? ( Ileus, collection, Iscahemic bowel!!). Would serum lactate go up in dead bowel immediately? (No). Electrolyte disturbance (Hypokalemia and natremia). CXR, showing consolidation/asp pneumonia.What abx? (Taz, metronidazole, aumentin...not all of them). Why are cephalosporins 2nd line? ( C diff).

What factors influence your decision to go to theatre? ( acidosis, fluid balance, premorbid state, pt choice). Where should they go? (level 2, HDU)

o Clinical diagnosis of ileus and obstruction

Ischaemic gutGastric outflow obstruction

o Acid urine, electrolyte disturbancePancreatitis

o Data interpretation of basically pancreatitis – bloods, Ct resulto Score pancreatitis, Management and prognosis

Crohn’so 27 with diarrhoea: How do you assess? (Ba Enema, is there obstruction, look at bowel

wall, it will show skip lesions of strictures, crohns). o Why get irreg bowel habbit in Crohns ( failure to reabsorb, and colonic disease). 3

complications of crohns (fistula, stricture, abscesses, malabsorption, anaemia, cachexia). Resected terminal ileum and illeocaecal valve still got diahrroea (c.diff, infection, malabsorption).

o Why does she have macrocytosis 9 months later (doesn’t have a terminal ileum!!) Comes

to and e with vomiting and jaundice ( gallstones, no terminal ileum). What do you want? (bloods clotting and amylase).

o CT – gallstones why? And what kind (cholesterol, and oxalate renal stones too).

Pre-op assessmento Arrythmiaso pre-op patient with heart block, how to manage, comment on ECG o Why is aortic stenosis fatal? (fixed CO, LVH and increased O2 demand) What does the

ECG show? (L axis, 60 degs) CXR (ext wires on it). Problems with anaesthetico Dox action on bladder (relaxes neck). Muscarinic on bladder (contracts). o SEs of Bendro (hypernatremia, and Hypokalemia)

o Myocardial infarction

o Percentage increased risk of a further MI if undergoing surgery 3 months post MI (1

mark) and then 6 months post MI (1 mark). mechanism of action of clopidogrel with reference to prostaglandin and the fibrinolytic pathway. Also when to stop aspirin pre surgery and then when to stop aspirin and clopidogrel together pre op. Risks of stopping aspirin and clopidogrel with stents in situ

ECG’s o Rate, rhythm, and axis how do you do it? ( will be either infarct, tall T waves in crush

injury, heart block!) o P-R interval, qrs duration

o What do you do next? (ABC + chase underlying cause).

o What do they need before theatre (rate control and anti-coag!)

Renal failureo Classify (pre, intra,post).o What bedside test could you do to find which one (urine osmolality and urinary

Na). Where is Na resorbed (prox tubule). o Furosemide works in loop of henle, and spironolactone in DCT(hyperkalaemia &

renal failure) – how to treat + dose of insulin

o Treament of renal failure with raised CVP- RRT or diureticso Rhabdomyolysis 2ndry to crush injury- blood tests

CXR:o What is your system for assessing CXR? Whats the abnormality? (either

NG/Tracheostomy with ECG leads). Whats the patient at risk of? ( Asp Pneumonia). What should you do? (Take it out, gases, repeat CXR and new NG). How do you check NG (end tidal CO2, xray, listen, aspirate!!)

o CXR – Pneumothorax (needle decompress & chest drain)o CXR - Aspiration pneumonia (ABC, bronchoscopy & suction) + BorHaeve’so CXR – Pneumoperitoneum (ABC & theatre)o CXR - Pleural effusions (aspirate +/- drain)o CXR - Cardiac failureo CT – ruptured AAA or pancreatic pseudocysto AXR – SBOo CXR – misplaced NG, reasons to suspect, identify, how to check correct posn (end tidal

CO2) + types of nutrition

Acute care

1. 1 day post-op patient on epidural and develops respiratory depression; interpret ABG ; resp acidosis; how is CO2 transported in blood; dissolved; carboxyhaem and HC03-; what is reversible equation; what is chloride shift; management opioids overdose;

2. ASA 3 cardiology patient post hernia sudden onset respiratory failure; aABG hypoix and low C02; pulmonary oedema on CXR; Mx discussion of heart failure

6. Critical care

got scenario about pt with entero-cutaneous fistula with some biochem results

lots of qs about problems assoc with fistula, types, local and systemic factors affecting healing etc – basically know everything about them

11. Critical care

trauma pt fell off scaffolding sustained tib-fib fracture

has painful leg, ARF, blood in his urine

was asked what else it could be – rhambdo, compartment syndrome, trauma to kidneys.

The guy just looked at me blankly so didn’t know if was barking up wrong tree. Asked about mannitol for treatment and alkalinsation, was confused, but so was everyone else so who knows what they wanted!

17. Critical care – CVP – about waveforms and measuring CVP. Insertion of CVP and complications, how you do it, different places.

Critical care: essentially the same station described by Amel. I was quizzed on TURP syndrome. As I managed to get through all the questions, the anaesetists quizzed me further on pharmacology of furosemide, and Mannitol, the mechanism of action. They also asked about the indication for intubation in a patient (all covered in Kanani's critical care vivas).

Critical care: scenario of a patient who was trapped under collapsed building. Discussion was around ATLS management of trauma, rhabdomyolysis, hyperkalaemia(potassium from muscle getting into the circulation).

Critical care 3. Scenario of a patient who had a reversal of ileostomy 3 days ago, now has abdo distension, spiking temperatures. Asked about bowel obstruction, and anastomotic leak. Differentiating true obstruction from pseudo obstruction (no bowel sounds in pseudo, and tinkling In true obstruction).

1. Critical care: scenario of post operative pt with epidural anesthesia bradycardiac and hypotensivewhat is the cause, complication of epidural, ttt of complication types of medication used

2. Critical care: haemorrhagic shock in pt with splenic rupture, classes, ttt, resuscitation

3. Critical care; Hypothermia, definition, ttt, prevention, causes

Applied Surgical Science 1 – Interpret blood results of lady who’s had previous lap chole 7 years ago for pancreatitis, now come in with rigors, cholestatic blood picture, raised CRP. Deranged clotting.

Talk through blood results (cholestatic picture, deranged clotting). Why? What could explain these results? What do you think is going on? Why is ALP raised? Where is ALP produced/secreted? When would you get high AST and ALT? When would you get high AST specifically? Where in the cell is GGT found? What is happening with the clotting and why? Talk me through the extrinsic pathway. Which factors? How does Vit K work? What does bile do? Why in this scenario is clotting affected? (He kept trying to guide me to the answer but my neurones just wouldn’t connect at the time! Should be that bile flow blocked so unable to absorb Vit K hence deranged clotting.) What can you do to correct the clotting abnormality. What do they screen for in FFP? Particular in a young patient, what would you be worried about that they cannot screen for in FFP. (Correct answer was prion disease, he told me the answer and I just nodded to agree!) How would you investigate this patient? (Said US abdo and potentially MRCP) Results of US show ‘normal liver, dilated intra and extrahep ducts’ – what does it mean?

Applied Surgical Science 2 – Pt due for anterior resection (not specified what for and whether elective/emergency). Had an MI 3 months ago, which he had PCI and drug-eluting stent for. Now on aspirin, clopidogrel and statin.

How do you read an ECG? Interpret ECG (shows previous anterior infarct and borderline LAD). What is the % risk of having a peri-op MI within 3 months of the last MI? (Said 10-25% but drops to 5% by 6 months. So would depend on the indication for surgery and whether it can be postponed till months after MI.) Comment on his meds and impact on upcoming op (clopidogrel for stent, will need stopping before op). How does clopidogrel work? How long would effects last for? If it is an emergency, how would you reverse it immediately? (Said platelet transfusion.) What else could you do? (I was a bit stuck.) Then asked if I knew any IV anti-platelet drugs I could give (I just said sorry I don’t know!) And he said, don’t worry I didn’t either!!

Critical care – Patient undergoing ruptured AAA repair, has lost 4L of blood. In theatre now and temp of 35 degs. Showed blood results – Hb 6.5, Plts 51 x109, high APTT, PT and low fibrinogen.

Define hypothermia. What could be the cause of hypothermia in this patient, and why? What is transfused blood deficient in? What problems could a massive transfusion like in this case cause? (Fluid overload, hyperkalaemia, hypocalcaemia, DIC, ABO incompatibility, anaphylaxis) As you’ve already pointed out, he is in DIC. What else would may you need to give him? (Platelets, FFP) Name me an anti-platelet agent and tell me how it works. Who else would you discuss this with? (Anaesthetist in theatre and haematologist)

critical care - burn patient. ITU management.critical care - gastric outlet syndrome, hypochloraemic hyponatraemic metabolic alkalosis

1. Critical care – elderly patient with IHD who started feeling SOB after central line insertion and fluid resuscitation. The answer was NOT fluid overload/pulmonary oedema. It was pneumothorax as a complication of the central line insertion. Then questions on complications, how you would insert one, how you would remove one (head down to prevent air embolism). Very easy station

2. Critical care – duodenal ulcer perforation. Management. Causes of duodenal ulcers. Then steps of digestion and release of enzymes. Which enzymes. What is the role of gastrin. Phases of gastric acid release – advice - use Wikipedia. I did and am pretty sure I did well ;)

Station 2 – Critical Care

Central and CVP lineso Indications other than fluidso Complications of insertiono Relationship between EDV and pressure – draw this i.e. Frank Starling Curveo Are you aware of any guidelines for insertion? Whom are these written by?


Obvious history of Perf DU.

Management – surgical options for management e.g. oversew, omental patch. Difference between management between DU and PU.

What else would you do for a gastric ulcer intraoperatively? i.e. biopsy. Oversew small gastric ulcer, omental patch for large one.

What else would you do intraoperatively? Remember to peritoneal lavage and washout. NCEPOD Classifications – very brief- and where would you class this patient? Post op treatment i.e. medications. H.Pylori eradication. What drugs would you give? PPI/H2 receptor antagonists. How do they work and what cells

do they act on? How do NSAIDs work and how do they increase risk of ulceration – details of COX pathways

and where different NSAIDs act. Then detailed questions of gastric physiology – phases of gastric acid secretion . What

hormones are involved and which cells they act upon and where they are released from.


Ascending cholangitis – you are not given the diagnosis. Given LFTs – going off raised AST, ALT and GGT. Bil 125 Pyrexial and rigors. Physiology of bilirubin metabolism. What does conjugated mean? What conjugated to? How

is urobilinogen formed? Types of jaundice. Type and function of bile salts. What else do they do other than reduce pH of duodenum.

What are bile salts formed from and how? What stimulates its release? Enterohepatic circulation. Management of ascending cholangitis. Differential diagnosis What is INR, what does it stand for? What is it a ratio of? How does warfarin work? How

does heparin work?

Physiology and critical care:

1) Given a sheet to read: clinical scenario on sheet describes patient with perforated peptic ulcer (hx of recent NSAIDS, abdo pain and collapse). Asked to define how to class what is an emergency; urgent; urgent elective; routine elective operation? And what is this patients` category? Asked about clinical management surgical and medical (triple therapy and what are the mechanism of NSAIDS ie what enzymes are affected and PG physiology and what are the pharm mechs of PPIs) and also asked about the physiology of GI tract hormone and acid secretions. (2 examiners)

2) I cant remember my 2nd case well. It was again a sheet with a clinical scenario: with lots of biochemistry and haematology for interpretation. Asked to classify hyponatraemia! Also asked to explain why in this case of alkalosis (?) , the patient is still excreting acid urine and other aspects of renal physiology etc .

3) Critical care: history of pt with melaena and past history of CHF and IHD. Failed insertion of CVP and so resuscitated empirically only via p-line. Also pt getting more and more SOB. Asked what would you do? Then asked what are the NICE recommendations for landmarks for insertion of CVPs. Then shown a CXR relating to the case. Asked how I would normally assess a CXR and then asked for any diagnosis on CXR (large pneumothorax!) Then asked if it was a tension or not? And why.

6. Physiology: old lady postop, RR4, PCO2 9, Ph 7.24, low PO2, + several boluses of morphine.

Q`s How CO2 is carried to the lungs, (asks for the formula

H2O+ CO2 H2CO3 H+ + HCO3-

The Carbonic Anhydrase, and where this reaction happens. Etc Etc

7. And then this dreadful station of Nutrition 54 kg man with Crohns had Ileoceacal resection then leaks the fistulae.

Daily Dietary requirements, Calculate Proteins, Lipid Carbs, etc ect

8. Post lobectomy patient with Epidural BP 90/50, HR 40

U/o 10 mls/hr

Why? How would you Asses, DD? Treat, Indications of Para vertebral, side effects etc ect How does it work, how would you decide about the level, and how would you find if paravertebral is working? (Cold spray)

1) Surgical sciences. 60 y/o lady with pancreatitis. Given blood test results.Why does amylase have limited sensitivity?

What is a pseudocyst? How could you detect it clinically?

Name some prognostic scoring systems. What are there parameters? Why are they paramenters?

Why is this lady hypocalcaemic? What is the pathophysiological process?

Do you know any radiological scoring systems?

2) Surgical sciences. 30 y/o with Crohn's. Point out the features of small bowel obstruction on a plain abdominal film.

Aetiology of small bowel obstruction.

Baseline nutritional requirements and those in critical illness.

What is the respiratory quotient? Compostion of supplementary feeds

Routes of feeding. Complications with parenteral feeding.

Complications with central line insertion.

3) Surgical sciences. 40 y/o post left lower lobectomy. Epidural catheter in-situ. Hypotensive and bradycardic.

Initial assessment and management- general assessment and measures, plus epidural specific assessment and management.

Pathophysiology of neurogenic shock.

Sympathetic pathways.

Sensory pathways in spinal cord.

Station 6 - critical careExtremely easy station and very friendly examiner. Various questions on chest XR, abdo XR, and basic management of post op patient with chest infection.

Station 12 – critical careWhat are the layers of adrenal gland, what hormones does it produce, controle of these hormones, what are the post op difficulties expected in a patient with longterm steroids

Station 15 – critical careI was shown thyroid function tests and was asked to interpret. Questions on hypothyroidism. Pathophysiology, management. What drugs can cause hypothyroidism. Clinical signs

Critical Care 1:

Patient had lobectomy and is in HDU with T3/4 epidural and is now hypotensive/bradycardic. What are the possible causes? How would you manage the patient? How would you assess the epidural level? Why does a high epidural cause hypotension and bradycardia?

Critical Care 2:

Elderly gentleman admitted with worsening confusion and anorexia. Found to have 1500mls retention and in AKI + hyperkalaemia. Why do you think this is? How would you manage high K? What does his ECG show? Talk through the ethical implications of escalating care? Who would you involve?

Critical Care 3:

You are in the pre-assessment clinic and note an ESM in a patient. What could this be? What are the symptoms of aortic stenosis? Why would patients get this? What are the complications of aortic stenosis? What are the complications of thiazide diuretics?

1. Patient with previous episode of pancreatitis, presents with peritonitis and signs of shock. CT scan of pseudocyst, name the structures in the scan. What is peritonitis, what are the signs, why

is this patient worsening in terms of BP/HR despite resuscitation (Talked about vasodilation, reduced pre-load, and reduced SV as a result)? Sympathetic activation? What single blood test would you do (Amylase, lipase)? Why is she hypocalcaemic (low albumin and fat necrosis due to proteolytic activity causing formation of free fatty acids which precipitates with calcium). Why would you get hypocalcaemia in renal failure (unexcreted phosphate binds to calcium). CXR of ARDS – talk me through the CXR (apart from saying bilateral pulmonary infiltrates, need to say I would check, pt details, rotation, adequacy, inspiration). What is ARDS? Why does this patient need to go to ICU? What are your management options?

2. Complicated AAA, temp 35. What is hypothermia? Treatment of hypothermia? What are the contributing factors for heat loss in this patient (I said conduction, evaporation and I couldn’t think of any more). Bloods with DIC picture, why has this patient got this picture? How would you manage this patient? What are the complications of massive transfusion in this patient? What is Packed RBCs deficient in? What drugs do you know which affect platelet function? How does it work? What is the process of homeostasis (vasoconstriction, platelet aggregation and activation of the clotting cascade). So in this patient how are each of these parameters affected (vasoconstriction affected due to anaesthetic drugs, platelet aggregation affected due to lack of them, activation of clotting cascade affected due to inactivation of clotting factors as a result of hypothermia)? What are the immediate complications in this patient having an AAA repair (basal atelectasis, renal, mesenteric, spinal ischaemia, peripheral embolisation)? Who would need to get involved in this patients care (ITU, anaesthetics, medics [I said nephrologists when asked which medics])?

3. Hypothyroidism. Interpret blood results. Causes of hypothyroidism (iatrogenic, dietary, amiodarone, hypopituitary) . Tell me about the negative feedback and stimulation of thyroid hormones. What are the features of hypothyroidism. This patient is not compliant with her treatment, what are the difficulties in doing a laparotomy on her? Any anaesthetics risks? How would you ensure she is compliant?

4. Critical Care- trauma Scenario- adult stuck in a kitchen fire (I think) for at least 30mins. Burns to ant+post trunk, I think face and circumferential to upper limb. Soot around mouth. Think the patient was only on 2L of O2 in the scenario. ABCD. Got stuck on airway for a bit that I was pretty insistent was potentially threatened in view of mechanism of injury, soot around lips, 02 demands etc. Fluid resuscitation parkland formula. Then scenario was moved on several days to ITU – ARDS. Then ran out of time

5. Critical care / Surgical Sciences: Scenario was gastric outlet obstruction. Frosty examiner. To my horror launched into the natraemia’s early on, classification, causes. Explanation of the hypochloriaemic metabolic alkalosis of GO obstruction. Very specific questions around subsequent acidic urine production wanted exact

mechanism.

10. Critical care scenario: some patient with rubbish access the ITU reg had tried and failed to get a central line in then penumothorax clinically and on cxr. Management. Examiner was distinctly unpleasant, interrupted constantly. Questions on differential from CXR anatomical land marks for central line insertion, which side is more difficult, positioning of patient.

1. Burns patient - Standard ABCDE approach, Parkland formula, criteria for referral a burns specialist unit, Where would you manage this patient?? criteria for ward/HDU/ITU care.

1. Critical care - Gastric outlet obstruction. I was prepared for it but examiner was harsh and it was still one of the most difficult station. hyponatraemic, hypochloraemic hypokalaemic metabolic alkalosis. why? and why acidic urine? why hypokalaemic? what happens in the kidney? what is the ideal fluid? NaCl + K supplement what else would you do? fluid resuscitation ng tube catheter. why high urea and creatinine? acute kidney injury due to dehydration

2. Critical care - insertion of internal jugular line. What are the landmarks? what position of the patient? head down. why? reduce risk of air embolism. CXR - large pneumothorax. talk me through how you interpret a CXR. what are the types of pneumothorax. simple, traumatic, tension, open. what are the immediate complications of internal jugular line? bleeding air embolism arrhythmia damage to vessels and nerves. what is the guideline to internal jugular line insertion? USS guidance (nice guidelines)

3. Critical care - Burns and ARDS. calculate percentage of burns. how would you assess A and B of this patient. How would you assess his circulation. Fluid - what formula? parkland formula. 4ml/kg/%burn, half given within first 8 hours. if colloid? vernon mount formula. 0.5ml/kg/%burn given in 4/4/4/6/6/12. 4 cardinal signs of ARDS. Where and how would you manage this patient. ICU as need level 3 care. prone ventilation, PEEP, small tidal volume and careful fluid resuscitation.

HISTORIES/COMMUNICATION

Panic attack/anxiety in pre-op patient for lap cholecystectomy

Knee pain (post trauma)

See wife of unwell patient because consultant cannot attend as in emergency theatres

Speak to ICU consultant about lady who has suspected perforation who has acute kidney failure, hypokalaemia etc. Need to listen carefully to instructions given over the phone as consultant will ask you to repeat them.

CRITICAL CARE

Adrenalectomy - names the parts of the adrenal gland, which hormones are produced and the effects of adrenalectomy

> Physiology> 1. Obs chart. Talk about criteria for SIRS. What fluid I'd give to a hypotensive patient. What type of shock they were likely to have. Then shown blood results with low K and asked which fluid now etc etc.> > 2. Another station looking at obs charts! Kept asking what should be done at different points on the obs chart. Wasn't really clear where the examiner wa going with it - think they just wanted that youd get critical care involved as patient was likely to need BP-support. Asked for 'the formula for BP' think he wanted BP = CO x PVR. Ran out of time but I gather he went on to ask about inotropes versus pressors.> > 3. Discussion about a patient with low GCS. What their GCS would be with various descriptions. Asked about sending a patient with low GCS down to CT - was it safe etc. Then progressed to show picture of PTX. Told it was a spontaneous one. Asked to describe insertion of ICD. Said a surgical or Seldinger technique could be used- examiner was very excited to hear about Seldinger technique!

> Physiology> 1. Obs chart. Talk about criteria for SIRS. What fluid I'd give to a hypotensive patient. What type of shock they were likely to have. Then shown blood results with low K and asked which fluid now etc etc.> > 2. Another station looking at obs charts! Kept asking what should be done at different points on the obs chart. Wasn't really clear where the examiner wa going with it - think they just wanted that youd get critical care involved as patient was likely to need BP-support. Asked for 'the formula for BP' think he wanted BP = CO x PVR. Ran out of time but I gather he went on to ask about inotropes versus pressors.> > 3. Discussion about a patient with low GCS. What their GCS would be with various descriptions. Asked about sending a patient with low GCS down to CT - was it safe etc. Then progressed to show picture of PTX. Told it was a spontaneous one. Asked to describe insertion of ICD. Said a surgical or Seldinger technique could be used- examiner was very excited to hear about Seldinger technique!

Physiology

Core temperature changes and its control

Hypothyroidism and its causes

Critical care

Nutrition and TPN

Crohns and large bowel obstruction

6. Physiology- TURP Syndrome

Patient post TURP- confused, hypotensive.

Asked possible causes- hypovolaemia TURP syndrome

Given bloods with low sodium. Asked causes of hyponatraemia in general and then why low in this patient.

Asked reasons for hypotension.

How would you manage.

Name diuretics and mechanism of action, and which would you use in TURP.

8. Physiology

Scenario- jaundice, given blood results very high ALP, high GGT and bilirubin, Pretty normal ALT and AST.

Asked definition- obstructive picture. Why. Causes of hyperbilirubinaemia, how you would classify and examples of each.

Bilirubin metabolism.

Causes of painless jaundice with obstructive picture.

Risk factors for gallstone disease

Mechanisms of development of gall stones.

Causes of abnormal clotting in obstructive picture- talked about why deranged clotting

Role of vit K etc

Also- what make sup gall stones, why do they and how to they form.

Beginning of scenario ok- last questions were hard.

10. Physiology

8 days post bowel op. B/G IHD, HTN and COPD.

Shown AXR with dilated loops of small bowel.

Asked differentials- ileus, obstruction.

Causes of bowel obstruction.

Obs deteriorated- pyrexial, hypotensive, low sats.

Anastomotic leak, intra-ob sepsis

Asked what would consider before taking him to theatre.

18. scenario discussion on a patient who had become septic and started vomiting 5 days post op - discussion on post op sepsis, bowel obstruction/ ileus.




7. Critical care- Pancreatitis

Diagnosis, scoring and initial management, types of imaging and why. Asked to score patient. Why low calcium? Why high BM?

9. Critical Care- Aortic Stenosis

Pathophysiology, causes, symptoms, management, investigation of and whether it should delay procedure, then went on to talk about infective endocarditis and NICE guidance on prophylactic Abx. Showed ECG- LVH

Station 1 : discussion with itu reg asking about need for pre-op advice and post op bed in itu. Case was an elderly lady presented with acute abdomen pain ? Perforation. A

Asked about types of shock..-septic. Why is it septic. What if no bed available? Who would u call for advice? Write down advice cause he will ask u to repeat it. Give case of facts.

Stn 2 : pancreatitis and ards. What is the ex, what would u do. Talk about Glasgow score, what is its severity for? Explain inflammation process. Explain why ards develop. What is ards? How to treat? Look at ct. Interpret level, main organs noted.

Stn 8 : physiology. Anastomotic leak. Unwell. Shock. What can u do? Sirs criteria. What is it? What are the management options. What one Ivx I want to do - CT.

Stn 10 : physiology. Rhabdomyelisis. What is it? Why got loin pain? Why get AKI. What can u do...I ref,rained from mentioning furosemide and mannitol and bicarb but this is what he wanted actually. Why does urinary alkalinisation help? What is main worry - compartment syn, what is it. How to diagnose. How to treat?




7. Critical care- Pancreatitis

Diagnosis, scoring and initial management, types of imaging and why. Asked to score patient. Why low calcium? Why high BM?

9. Critical Care- Aortic Stenosis

Pathophysiology, causes, symptoms, management, investigation of and whether it should delay procedure, then went on to talk about infective endocarditis and NICE guidance on prophylactic Abx. Showed ECG- LVH

6. Physiology- TURP Syndrome

Patient post TURP- confused, hypotensive.

Asked possible causes- hypovolaemia TURP syndrome

Given bloods with low sodium. Asked causes of hyponatraemia in general and then why low in this patient.

Asked reasons for hypotension.

How would you manage.

Name diuretics and mechanism of action, and which would you use in TURP.

8. Physiology

Scenario- jaundice, given blood results very high ALP, high GGT and bilirubin, Pretty normal ALT and AST.

Asked definition- obstructive picture. Why. Causes of hyperbilirubinaemia, how you would classify and examples of each.

Bilirubin metabolism.

Causes of painless jaundice with obstructive picture.

Risk factors for gallstone disease

Mechanisms of development of gall stones.

Causes of abnormal clotting in obstructive picture- talked about why deranged clotting

Role of vit K etc

Also- what make sup gall stones, why do they and how to they form.

Beginning of scenario ok- last questions were hard.

16. discussion of a patient who had become confused and hypotensiove following a TURP - discussion on post TURP syndrome, causes of hyponatraemia, management, discussion on mechanisms of action of various diuretics (furosemide, mannitol)

17. discussion on jaundice - causes, investigation. then went on to talk about the synthesis, excertion and resorption of bile, function of bile. Discussed fat soluble vitamins and why patients with liver pathology become coagulapathic.

18. scenario discussion on a patient who had become septic and started vomiting 5 days post op - discussion on post op sepsis, bowel obstruction/ ileus.

critical care total mrcs part b

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