Primary FRCA OSCE Viva Questions May 2009 FRCA O… · Primary FRCA OSCE Viva Questions May 2009...

Primary FRCA OSCE Viva Questions May 2009Set 1, OSCES

Station 4. Electrical safety, picture showing patient connected to the ECG monitor with bed, machine earthed, asked what was wrong (multiple earth), how to correct it there was a sign wit=n exclamation mark within it asked to identify what it was. Showed a page full of electrical signs and asked to identify any to I identified CF & BF

Station 5 Resuscitation station patient for crash section, my colleague had just toped him up with 20mls of 0.5% Bupivaicaine. patient went into Pea Rate < 40Asked about the protocol of management of Non shockable rhythm, what are 4H’s & 4T’s,management of local anaesthetic toxicity , intralipid & doses

Station 6 Resus scenario with Rhythm Strip for fine VF Detailed question about monophasic and Biphasic difference in power, Adrenaline strength used in cardiac arrest, Amiodarone strength used

Station7 History station patient for elective lap cholecstectomy on htn and medication

Station 8 Pulse oximetry, wavelength, isobestic point (asked to point it out on the graph and values), causes of error in pulse oximetry (any two), any two other physiological parameters we can measure from pulse oximetry.

Station 9 Patient post inguinal repair aspirated intraperatively has been intubated and ventilated, now in ICU. Asked to examine the patient. SaO2 <80% on 100% O2. Asked what would be the caused of low saturation. Use ABC approach to assess the patient. No breath sound son auscultation bilaterally but chest was moving bilaterally. I did not understand the significance of it. Shown a blood gas which showed metabolic acidosis and severe hypoxia. Asked about shunting and above what % of shunting 100 % O2 does not help.

Station 10 CXR – Features consistent with mitralisation of right atrium Asked whether any other valvular heart disease would occur along with this. Causes of the disease.

University Hospitals Coventry & Warwickshire NHS TrustAcknowledgement: many thanks to the candidates of April 2009 OSCE viva course Page 1

Primary FRCA OSCE Viva Questions May 2009Station 11 Equipment station. Best position for bag masks ventilation. Required to show manoeuvres on mannequin. Showed a nasopharyngeal tube to list the complications of use of this tube.

Station 12 Anatomy station. Spinal tract. Exactly same question as primary FRCA Royal college book.

Station 13 History from a lady 40ish posted for hysterectomy. Had a previous history of surgery which was complicated by DVT, PE. Second surgery had discomfort because of the face mask. Smoker and profession school teacher.

Station 14 Follow on station from previous history taking station. What was her haemoglobin? (Did not know). What was the complication of previous surgery? How was it treated? How many cigarettes does she smoke per day? What was her profession?

Station 15 Unmanned station CXR – findings hiatus hernia. Would you premedicate this patient with H2- receptor antagonists? Would you insert a nasogastric tube in this patient pre-operatively? Is the right hemi diaphragm raised? (No).

Station 16 Equipment station. Airway devices. Asked to check devices on the table. ET tube (cuff was leaking); in the connector there was an obstruction. What are the equipments you would use for difficult intubations? Asked questions about ambo bag.

Station 17 Humidity. Asked difference between absolute and relative humidity. Picture to identify hair hygrometer, Renault’s hygrometer and Wet and dry hygrometer. Showed a graph and asked to calculate relative humidity from that. Asked about dew point.

Station 18 neuromuscular monitoring station , asked about the point you would use to set up the neuromuscular monitoring asked about different modalities of monitoring , single twitch, Tetanic, post tetanic potentation asked about the position of the electrodes on the foot and what movement you would elicit( did not answer that)

Station 18 base of skull , asked about cribiform fossa and 4 structures passing through it , asked about orbital nerve block and how you would perform it asked about the complication of this block other that retrorbital haemmorage (did not Know the answer)

Station19 D/w daughter about father who has been taken to theatre for leaking AAA and your registrar is in theatre


Primary FRCA OSCE Viva Questions May 2009Station20 Cvs examination precordail examination and examination of the pulse asked about AF and the characteristic of pulse you would get.

VIVA 1

Physiology

Define Hypoxia and the causes of Hypoxia, asked to write the formula for oxygen carrying capacity of the blood. Oxygen haemoglobin dissociation curve and name the three main points asked what will happen to the curve in hyper metabolic state ,increase in oxygen extraction and movement of the curve downward( in the beginning I went to the wrong path of leftward shift but was bought back by the examiner)

Immunology what do you understand? I classified them to acquired and inherited and in acquired mentioned skin, respiratory tract,GIT and tears acquired mentioned T& B lymphocytes asked about the immunoglobulin and the order in which it is inherited(i did not answer that question)

Starling forced & values difference in arterial and venous forces what is the difference of values in pulmonary circulation and why is it physiologically important, to prevent pulmonary oedema

Pharmacology VIVA

Compare the action on the CXVS of Isoflurane, SEvoflurane and Desflurane, then asked to compare isoflurane and sevoflurane generally forget about the metabolic products then that asked about it in detail where particularly interested in compound A

Pharmacokinetics Dose Response curve, Log Dose response curve with antagonist competitive and non competitive partial antagonist

Digoxin Mechanism of action in dseatail digoxin toxicity and how to manage it particularly interested in haemo dialysis and at what serum concentration you would consider haemodialysis (did not know the answer)

Clinical VIVA

19 year old found collapsed in night club now in A/E resus

ABCDE approach asked about the possible causes asked in details about the different drugs and their overdose symptoms


Primary FRCA OSCE Viva Questions May 2009 Asked about the signs of chronic alcohol abuse

Drugs of abuse and their s/E

Cocaine _coronary vasospasm

Amphetamine -electrolyte disturbance,

All of them cause electrolyte disturbance

Patient intubated and ventilated in CT scan develops Cushing signs management of raised intracranial pressure, principles, carbondioxde, Blood pressure, hypoxia, pharmacological methods of management of raised ICP, mannitol asked about the dose (did not know)

Physics VIVA

Gas laws

Asked how long can we supply a patient at 4L/min from a 5litre cylinder? I said I will not be able to calculate the value without knowing the pressure in the cylinder then he gave me a value after getting the volume in the cylinder using Boyles law he did not even want me to calculate the time!!!!!

Asked about Charles law, Avogadro’s hypothesis, Daltons law and grahams law

ECG

CM5 lead what did that mean and how would you place the electrodes, why we would use it, the degree of diminution of the value of the RMP from the heart to the ECG did not know the answer but the examiner guided with the answer asked the RMP of heart -90mv, the potential on the electrolyte1mvper 10mm so there for the diminution was approximately 90 times asked to draw the eithoven triangle and axes

Resuscitation equipment and ambu bag in detail none return valve Reuben valve mushroom valve, (drew them)

LMA different sizes and what weights were used

Set 2

SOE1 – Physiology/Pharmacology


Primary FRCA OSCE Viva Questions May 2009pH – definition, buffers, compensatory mechanisms

Pituitary gland – anatomy, hormones, ADH and osmolarity regulation in detail

Ion channels – Nerst Equation, Gibbs-Donnan, Goldman Field equation

Anticholinesterase - classification, side effects, organophosphate poisoning. Started with NMJ.

Drug interaction in anaesthetics – general classification and then details on reversible/irreversible antagonism, dose-response curves

SOE2 – Clinical and Physics

‘Sux problem’ in patient requiring rapid sequence induction. General history, examination and investigations. Differential diagnosis of ‘problem’ – apnoea, anaphylaxis or MH. RSI with rocuronium was my suggestion.

Flow, rotameter, Hagen-P equation, difference between laminar and turbulent

Effects of altitude on PAO2 and vaporisers

Pressure – units, measurements

OSCE

Anatomy – orbit, nerves, peribulbar blocks. Facial fractures.

Anatomy – spinal cord and tracts. Exactly as in college primary guide book

Simulation/resus – PEA arrest in pregnant woman. I thought this was a bit haphazard as the mannequin still had a pulse even when they insisted that there wasn’t a blood pressure.

Equipment – humidity and definitions. Methods of measurement. More detail about Regnaults Hygrometer and interpretation of humidity curves.

Equipment/Hazards – electrical symbols (nothing simple but still in the books). Definition of earth and equipotential.

Clinical skills – NMB monitoring. Where to place electrodes on wrist and lower limb. Pattern of response for TOF. Differentiation between depolarising and non-depolarising blockade.

Clinical examination – CVS in particular the arterial pulses.


Primary FRCA OSCE Viva Questions May 2009Machine – check equipment needed for RSI. Scope and ETT were faulty. Short discussion on CICV scenario.

History – patient about to undergo AV fistula formation. Previous awareness under anaesthesia.

Communication – AAA rupture as per course.

History/Communication – 2 part station. TAH in patient with heavy periods. Hb check. Previous problems with GA – awareness during emergency C. Section and traumatic experience as child from face mask.

Radiology – I think it was coarctation of aorta. The questions were leading that way but unconvinced by actual x-ray.

Radiology – Large hiatus hernia.

Simulation/Resus – ITU patient, intubated and ventilated as aspirated during induction. Low sats. Tube too far in and developing ARDS. PEEP suggested.

Resus – talk with examiner about the management of VF. Very straight forward.

Clinical skills – maintainging airway. Head position in adult and paeds. Nasopharyngeal airway.

Set 3

Pharmacology / physiologydraw the arterial wave from, explain how if differs from aorta to radial arterydraw a pressure volume loop and explain how it changes with increased contractilityexplain the ventilatory response to hypercapnia when rebreathingexplain the ventilatory response to hypoxiatell me some of the functions of the liverexplain liver blood flowdraw the structure of the liver lobule and explain ittell me about commonly used iv induction agentstell me about thiopentone, can you draw it?, what are structure activity relationships,tell me about ketaminetell me about classes of drugs used in asthmawhat variants are there in metabolism of anaesthetic drugs - sux apnea and porphyria


Primary FRCA OSCE Viva Questions May 2009 clinical - a 65 year old man needs a laparotomy for a perforated viscus, INR is 5 because of warfarin for DVT, biochemically dehydratedwhat are your concernswhat are you going to dodiscuss how to correct his coaghow will you anaesthetise himcritical incident - HR goes up tp 145, hypotensive - causes, how do you treat itphysicsidentify these electrical symbols - electrical componentswhat factors influence electrical resistanvewhat is ohms law, what is powerseveringhaus electrode, calibration graphfeatures and faults of a syringe driver pump OSCE16 - XR of aortic coarctation15- check equipment for RSI and failed intubation routine14- questions on humidity13 - qs on nerve stimulator and patterns of block12 - qs on skull anatomy, eye block11- qs on electrical safety and symbols10- communication - aortic aneurysm relative9 - resus - pregnant woman, LA toxicity8- resus - ALS algorithm7 - history - previous awareness (CRF, new AV fistula)6 - critical incident SIM man - endobronchial intubation5 - paediatric resuscitation - differences between paeds airway and adult4 - XR - lateral chest with hiatus hernia3- hx - take hx from female for hysterectomy2- present hx / questions on hx gained1 - spinal cord anaomy and tracts

Set 4

Primary FRCA Questions MAY 2009

Physiology viva:


Primary FRCA OSCE Viva Questions May 20091) Frank –starlings law; cardiac cycle; pressure volume loops- with afterload and

preload, along with definitions.2) Alveolar gas equation and its significance.3) Hormones and HPA, negative feedback mechanism

Pharmacology Viva;

1) Receptors and ligands, Types of receptors, steroids.2) NDMR, MOA and metabolism, Hoffmans and ester hydrolysis.3) Steroids and administration during surgery.

Physics:

1) Calibration ( 2 point, 3point) where used in practice.2) Magnets- where used in practice( spoke about paramagnetic analysers and MRI)

Asked in details about MRI.3) Ventilators and its classification

Clinical:

75 yr old obese lady, on the list for strangulated umbilical hernia, is also a heavy smoker and type 2 diabetic on metformin. Discuss in regard to obesity.

OSCE:

1) Simman : tracheostomy out reinsertion not possible—went through DAS Guidelines2) History on an asian female with thalassemia.3) Vertebrae: axis –where does the vertebral artery lie.Denticulate ligament. Odontoid

peg to be identified.Borders of the epidural space, where spinal cord ends in adults and kids.

4) Art line set up with flaws to be identified.5) Bains Breathing system chaeck6) Intraosseus insertion.7) Cardiac angiography identify LCA- Circumflex and LAD.8) Counselling mum as child with sux apnea.9) Bradyarrthymias to be managed.10) Tachyarrthymias management with defib use11) Identify clarkes electrode and its parts.12) Xray :seemed to be ARDS, so managed it as such13) Pulmonary angiogram of a pt with burns- showed a pneumothorax14) History taking of a pt for laprotomy and the next station was for the questions


Primary FRCA OSCE Viva Questions May 200915) Laser tube with questions on safety with lasers16) Explain the suitability of a pt. for GA or SA who has preeclampsia.17) Axillary approach of brachial blockade

Set 5

OSCE- Communication: talk to a daughter of a man admitted for urgent AAA repair- History taking: Woman in her 5os for AV-fistula- History taking, two-step station: woman in her 40s for abdo hysterectomy- Resusc: PEA in preganant woman after a 20 ml 0.5% bupi epidural top up- Resusc: Collapse on the ward: VF- SIMMAN: low SpO2: recognise R endotracheal intubation- Physical examination: Pulse and heart examination- Equipment: check RSI equipment: various faults: leaking tube cuff, broken McGill, pieces of plastic in the connection. Add which other equipment will be needed: drugs, IV, fluids, suction, GEB, tipping trolley.- Skills: demonstrate bag-mask ventilation on a manikin and various questions about ambu bags, cricoid pressure, etc- Standard questions about pulsoxymeter- Neurostimulator: recognise various patterns, quastions about voltages, location of the electrodes on the wrist and ankle- Station on electrical safety and symbols- Anatomy: orbit with structures passing through optic canal, superior issure, lamina cribrosa, etc.- Anatomy: spinal cord: very similar to the one in the college book.- Chest X-ray: coarctation of the aorta- Chest X-Ray: hiaus hernia (Left lateral view) can't remember the last 4... VIVAs Physiology- Definition and classification of hypoxia, HB sissociation curve, CaO2, etc- Capillary bed hydrostatic/oncotic pressures in the systemic cirulation differences in the renal and pulmonary bed circulation- Immune system: classification, role of te different white cells, hypersensitivity reactions type I-V Pharmacology:


Primary FRCA OSCE Viva Questions May 2009- compare Sevo and Des- agonist antagonist curves- all about Digoxine Physics- Gas laws and their application to anaesthetics- ECG- Bag-valve mask: components, materials, differences btw paediatric and adult models. Clinical:- 19y old man fallen down the stairs in a night club at 2 am, brought to AE, discussion about intracranial haemorrage, raised ICP, monitoring and transfer, mannitol, RSI...

Set 6

OSCE

1.Called to ITU @ 2:00 am doe desaturating 70 yr old gentleman; Tracheostomy tube out( inserted only 48 hrs ago) known difficult intubation.

2.X-ray – pulmonary oedema

3.Axillary block on actor n follow on questions

4.History station

5. Follow on questions

6.CT chest on inhalational injury.

7.Bains circiut check

8. O2 electrodes – pictures n questions

9.Intra ossious needle insertion

10. Sux apnoea – communication to mother( mum was really bored n kept looking out of the window!!)

11.ALS scenario – shockable ECG

12.ECG rhytmn strip – SVT n questions

13. Arterial line set up n faults

14.History station


Primary FRCA OSCE Viva Questions May 200915.Anatomy station –Vertebras 100 s of them – C1 n C2 as well(had not seen them since MBBS days)

16.Anatomy of heart- Angiogram n questions

17. Examine a pregnant lady for GA/ regional. You can ask for any results and equipment u to aid ur examination.

VIVA – PHYSIO- PHARMAC

PHYSIO-

1. Adrenoreceptors. Differences b/n Adrenaline n Noradrenaline

2. Structure of sarcomere both relaxed n contracted with all the lines. Excitation-contraction coupling

3. Starvation n all the cycles(krebs)

PHARMAC-

1. Diuretics

2. Local anaesthetics

3. Dose-response n log dose response curves

PHYSICS-

1. Pressure n invasive arterial setup n principles

2. Pulse oximetry n graphs( wanted graph of absorbance against time)

3. Ventilators n graphs of flow/time n pressure/time

CLINICAL-

45 yr old for elective Abdominal hysterectomy with 2 finger mouth opening. Outline anaesthetic management.

Set 7

SOE1Physiology:arterial pressure trace, what can you tell from it? Draw the pressure volume loop for the LV, what happens in failure?The liver blood supply and metabolism


Primary FRCA OSCE Viva Questions May 2009What happens to minute volume when rebreathing CO2, draw a graph with MV and time. What effects would this have on the patient?Pharmacology:IV induction agents. Draw thio or propofol and discuss differences generallyHow do different people handle drugs differently?Drugs used in asthma - how do they work? SOE 2Clinical:62 year old man, emergency laparotomy for perforated viscus, on warfarin for previous PE 6 months ago, INR 5.8 mild ARFManagement, fluid managment, management of INR and subsequent anticoagulationPatient becomes tachycardic and hypotensive on tablePhysicsIdentify electrical symbols. When do we use resistors? Principles around resistors, pressure transducers. Electrical safety, how do we get electricityCapacitors, when do we use them, defibrillator.pumps, drip counters, problems and safety around pumps (awful) OSCEExamine the arterial pulse and the praecordiumBase of skull, orbit and peribulbar blocksDiagram regarding electrical safety, identify symbols, say why patient doesn't get electrocuted by ECGprinciples behind pulse ox - the question straight from the college bookTake a history from a woman having an AV fistula formed with previous history of awarenessResus 1: pregnant lady in PEA, probably IV LA injectedResus 2: discuss ALS guidelines, questions on algorithmCheck equipment needed for RSI. Holes in cuff, no bougie, magills didn't openSim man - tube in right main bronchus, questions on shuntCross section of spinal cord, questions straight out of college book


Primary FRCA OSCE Viva Questions May 2009Humidity, questions on hygrometersHistory from woman for TAH with awareness - straight from college book tooX ray 1: probably co arctation of aortaX ray 2: lateral chest showing hiatus hernia and further questions on thisAirway adjuncts, NPA, emergency airwaysCommunication: daughter of 82 year old man having emergency AAA repair

Set 8

Physiology viva

1 Write down the normal values for CVP, HR, BP, CO. What happens to these values if 20% haemorrhage occurs? What are the physiological responses to 20% blood loss if left untreated? What neural and hormonal responses occur? Tell me more detail about the hormonal responses that occur?

2 Write a table comparing the concentrations of various intracellular and extracellular ions. What are the functions of magnesium? What are the functions of phosphate?

3 What is compliance? Draw a diagram representing lung compliance (pressure-volume curve of lung). What are static and dynamic compliance, why do they differ? What are the components of total compliance of the respiratory system? Name some causes of altered compliance of the lung. What happens to compliance in paediatric respiratory distress syndrome?! What is surfactant? What is Laplace’s law?

Phamacology viva

1 What are the factors affecting uptake of inhaled agents? Draw a graph showing how low and high minute ventilation affect uptake. What is the blood-gas solubility coefficient?

2 Define volume of distribution. Why factors influence the differences in Vd of a drug. Give a couple of examples of drugs with high Vd and low Vd. Define clearance. How are Vd and clearance related?

3 What are the mechanisms by which drugs affect gastric pH? Name some examples of each type of drug. Draw a gastric parietal cell and show the receptors these drugs act on. What exactly happens at the receptors (H+ proton pump and histamine H2 receptor)?


Primary FRCA OSCE Viva Questions May 2009Clinical scenario

30 year old primip with epidural in situ for labour pain relief is handed over to you. You are informed that she is failing to progress and will need C-section.

1 How would you assess this woman for C-section. What would you check with the obs registrar? What different categories of urgency are there for C-section. What category does this fall into? How would you top up her epidural for LSCS?

2 During the section, after baby has been delivered, she starts to complain of severe abdominal pain. How would you manage this? She declines GA, what would you do?

3 You go and see this lady 24 hours later. What would you tell her? Specifically, what would you say regarding pain relief for future pregnancies? What complications from her epidural would you be looking out for at this stage. What might be the causes of residual weakness? How would you assess her? What else might she complain of? What is the cause of post-dural puncture headache? How would you manage PDPH?

Everyone came out of this asking what the critical incident had been. It wasn’t your standard, ‘ABC, 100% O2, I would call for help, alert my consultant etc’. It was much more like a discussion regarding what the options are for managing pain during LSCS if GA is refused. Discusion was regarding opiates (IV and epidural), use of local anaesthetics, what might the surgeons be doing, would you use midazolam.

Physics viva

1 What are the causes of heat loss from a patient in theatre, and in what proportion do these occur? What is radiant heat loss? What form of energy is this? What is convective heat loss? Why does this occur and how can it be minimised? What is evaporative heat loss? Where does this occur from? What is the latent heat of vaporisation? Why does it cause heat loss? What is conductive heat loss? Why is so much heat lost from the head and face? What methods are there to limit heat loss during surgery?

2 With regard to blood pressure monitoring, what do you understand by static response and dynamic response? (I asked around about this later – no candidate I spoke to felt they knew the answer to it, most mentioned static and dynamic measurement of lung compliance.) The examiner then drew axis for a pressure time curve and drew a rectangle (as if a flush was going through an art line): What is the pressure of the pressurised bag in a art line system? What happens after the flush is released? I then went on to draw the response seen under different damping conditions. What is Fourier analysis? What is the fundamental


Primary FRCA OSCE Viva Questions May 2009frequency? What are harmonics? How many harmonics are necessary to formulate most biological signals?

3 Picture shown of 3 different ET tubes. What are all of these? (normal Cuffed ETT, South-facing RAE tube and uncuffed paediatric tube). Take me through all the markings on the normal ETT. What length would you ask your ODP to cut the tube to? What does RAE stand for? What is this? (Murphy eye). What is it for? What is different about the paediatric tube? Why no cuff? What age child is this tube for (it was a size 4 tube)? What else is unusual about the tube? (8mm connectors)

Set 9

SCE- Communication: talk to a daughter of a man admitted for urgent AAA repair- History taking: Woman in her 5os for AV-fistula- History taking, two-step station: woman in her 40s for abdo hysterectomy- Resusc: PEA in preganant woman after a 20 ml 0.5% bupi epidural top up- Resusc: Collapse on the ward: VF- SIMMAN: low SpO2: recognise R endotracheal intubation- Physical examination: Pulse and heart examination- Equipment: check RSI equipment: various faults: leaking tube cuff, broken McGill, pieces of plastic in the connection. Add which other equipment will be needed: drugs, IV, fluids, suction, GEB, tipping trolley.- Skills: demonstrate bag-mask ventilation on a manikin and various questions about ambu bags, cricoid pressure, etc- Standard questions about pulsoxymeter- Neurostimulator: recognise various patterns, quastions about voltages, location of the electrodes on the wrist and ankle- Station on electrical safety and symbols- Anatomy: orbit with structures passing through optic canal, superior issure, lamina cribrosa, etc.- Anatomy: spinal cord: very similar to the one in the college book.- Chest X-ray: coarctation of the aorta- Chest X-Ray: hiaus hernia (Left lateral view) can't remember the last 4... VIVAs Physiology- Definition and classification of hypoxia, HB sissociation curve, CaO2, etc


Primary FRCA OSCE Viva Questions May 2009- Capillary bed hydrostatic/oncotic pressures in the systemic cirulation differences in the renal and pulmonary bed circulation- Immune system: classification, role of te different white cells, hypersensitivity reactions type I-V Pharmacology:- compare Sevo and Des- agonist antagonist curves- all about Digoxine Physics- Gas laws and their application to anaesthetics- ECG- Bag-valve mask: components, materials, differences btw paediatric and adult models. Clinical:- 19y old man fallen down the stairs in a night club at 2 am, brought to AE, discussion about intracranial haemorrage, raised ICP, monitoring and transfer, mannitol, RSI...

Set 9

SOE

Pharmacology:-Define MAC. Types of MAC. Factors governing MAC.-Define Bioavailiblity. How do you measure it. Factors goverrening it.-What types of classification of anti-arrythmics are you aware of? Draw a Cardiac action potential and show action of each of the clases of Vaughn Williams classification.-Discuss Indications, MOA, & S/E of Amiodarone

Physiology:-Draw pressure changes in the Right ventricle durinng crdiac cycle. -Superimpose Pressure changes in Left ventrile on an arterial trace.-Show how an ECG relates to the graph showing the Pressure changes in Left ventrile during the cardiac cycle.-How is CO2 carried in the body? Show how Co2 in transported at tissue level and at lungs. What is the Bohr effect? What is the Haldane effect?-Draw CO2 dissociation curve. Show the Haldane effect.

Physics:-What types of Laryngoscopy blades are you aware of? Indictions for each type.-How do you assess flow in Gases and Fluids? Ficks principle.


Primary FRCA OSCE Viva Questions May 2009-What does Laser stand for? How is it produced? Types of Lasers ad their indications. Precautions during laser surgery.

Clinical:6yr boy for an Elective Tonsillectomy for recurrent snorring at night. PMHx-Asthma on regular inhalers. Recent cold 6 days ago.-How would you assses. Points of concern.-ow would you asses the severity of OSA & asthma. Implitions of the same on your anaesthetic.-What are the indications for intubtion ? What type of tube, ventiltor support ?-Pain relief. Concerns for opiate use for the samme-Critical incident:Post-op hypoxia.-Mgm of bleeding post-op tonsillectomy.

OSCE:

1> Nerve stimulator: Where would you place the electrodes. Desribe features on graphs of - Single stimilus, TOF, Post-tetanic stimulation.2> Anatomy: Cribriform plate. Le forts fracture classification. Orbit and eye blocks. Superior orbital fissure and optic canal contents. Describe peri-bulbar block and its complications.3> History taking of a lady due for laproscopic cholecystectomy. Asthmatic.4> Cardiac arrest in labour post Bupivacaine epidural top-up.5> Examine Radial artery and auscultate precordium.6> ECG: VF. Treatment options.7> Electrical safety. Equipotential. Classification of instuments based on their design and maximum leakage current.8> Communication: Speak to daughter of a 82yr. old patient brought in with a ruptutred Abdominal Aortic Aneurysm.9> Simulation: Hypoxia in a patient on the ITU admitted following routine Appendicectomy who aspirated post-op. Endobronchial intubation.10> CXR: Coarctation of aorta (Very suttle rib notching noted)11> History taking: Lady booked for TAH. (55yr old teacher. PMHx-Anaemia,Migraine,PMHx:PE (Rx- IV and then some oral tablets given), Awareness during Emergency LSCS for foetal distress, Face-mask phobia. Smoker. Allergic to Penicillin. GP had taken bloods for Hb recently)12> Follow-on from the Hx station.13> Airway mantainence on a manequin. Position, airway adjuncts with their s/e. QuestionS on Cricoid pressure during RSI.


Primary FRCA OSCE Viva Questions May 200914> Anatomy: Spinal cord, label parts on a diagram of spinal cord cross-section, blood supply, CSF production.15> CXR: Lateral CXR with hiatal hernia16> Anaethetic instruments needed for RSI (Suction, Bougie, Blades(Light not working), Magill forcep(did not open), tube connector(FB within), HME)17> Physics: Humidity (Define Absolute and Relative Humidity, what are the units. Describe Hair Hygrometer & Regnaults hygrometer. Shown a graph and asked how will you calculate Absolute and Relative Humidity from it)

Set 11

Physiology:starvationMuscle striated/cardiacbwta agonists - fx of norad and adrenaline on heart rate/BP Physics:Pressure - gauge/atmosphericManometerVentilator classificastion - time/flow/pressure cycled and xtics Pharm:local anaesthetics - action - pka, etc, toxicityNephron and actions of diureticsLog dose response curves - agonist/antag etc ClinTAH and reduced mouth opening: Mxregional vs GA? fibreoptic? inhalationalClin incident - laryngospam in recovery - Mx

Set12

Cardiac cycle

Given arterial trace unlabelled.


Primary FRCA OSCE Viva Questions May 2009Asked to label axes, put values and explain trace.

Asked to superimpose LV pressure curve, and explain valvular openings/closures.

Then was asked to add RV pressure curve explain difference (lower pressure).

Add CVP trace, explain.

Add 2 ECG’s.

Heart sounds position on above.

Monosynaptic reflex/Muscle spindle

Define monosynaptic reflex (I defined and explained with diagram-went down well),

Asked about muscle spindles- definition, role, afferents efferent fibres types,

Role of monosynaptic reflex!???

Any other influence! Cortex. What happens if you do knee jerk with tight fists- reflex augmented!

CO2 transport in blood

How is CO2 transported in blood, give % for all 3 ways!

Role of carbonic anhydrase,

Draw a red cell and explain how CO2 is transported here.

What is a buffer?

Tell me the qualities of an ideal buffer.

Set 13Pharmacology Viva

MAC/Volatiles


Primary FRCA OSCE Viva Questions May 2009Define MAC (MAC50),

Give values for volatiles you use, including N20,

What other MAC do you know- I did not know the answer to that.

How does potency relate to MAC (graph),

What factors influence MAC, then asked me about neonates vs bigger kids- lower/higher MAC.

Bioavailability

Define Bioavailability, graph.

Factors that influence Bioavailability (list)!

Routes of drug administration.

Most important factor affecting Bioavailability- First Pass metabolism (gut wall-examples-GTN, liver). Factors that influence 1st pass metabolism at liver.

Factors that affect diffusion across membranes!

Antiarrhythmics

Classify antiarrhythmics- Vaughan Williams, very keen to know what ion channels they act on (Na, K, Ca).

Draw me a quick (Ha Ha) cardiac action potential and show me the ion flux.

Where does Amiodarone work?

Amiodarone side effects.

Clinical VIVA

6 year old for tonsillectomy, asthma on Becotide, URTI finished 1/52 ago (parents statement)

How would you assess above pt? (Very pleased I said I would have in mind patient risk factors, anaesthetic risk factors and surgical risk factors).


Primary FRCA OSCE Viva Questions May 2009Cancel or not in view of URTI! I stated is a difficult decision, I would look for ongoing sepsis and cancel if present, if no signs I would ask the opinion of a senior colleague. Was told… Fair enough.

How do you assess URTI’s?

How do you assess asthma?

How would you induce this child? Iv vs inhalational, one or both parents present?

Critical Incident! Hypoxia in recovery! Approach, causes, treatment!

Where would you discharge this patient to?

How much would this patient weigh. What size tube what tube cuffed vs uncuffed. Would the surgeon influence your decision?

What analgesia (including doses per Kg)

How would you extubate?

Physics viva

LASERS

How do lasers work? I’ve drown the diagram whilst talking.

Beam characteristics.

What types of lasers do you know? Classify, explain the differences between them.

Safety measures!

Measurement of FLOW

How do we measure flow?

Describe flow meter. I knew this well so they did not interrupt me.


Primary FRCA OSCE Viva Questions May 2009How does Wright respirometer work?

How do pneumotachographs work? Basic principles!

She then asked me about the USS way of measuring flow which I did not know.

Laryngoscopes

Examples, once I told them they asked me to identify them on a photo (just MAC and McCoy). We then talked about use of short handle one.

Identify image (fibroscope).

Identify components. How does it work, how many optic glass fibres……

How do you clean it? Do you autoclave it? (NO) Asked me about the substance used to clean it…didn’t know.

LMA types

How do you sterilise them?

Describe Igel LMA (I brought the subject up)

Set 13

My OSCEs included - testing a Bain's circuit, checking an arterial line, Chest Xray of bronchiectasis, pictures to discuss of polargraphic, Clarke and paramagnetic O2 analysers. Intraossius infusions, management of bradycardia, tracheostomy that had fallen out of a patient who was a grade four intubation, lumbar anatomy, axillary nerve block, examining a patient to ascertain whether she would be suitable for a GA or RA for LSCS, OSCE - NSAIDs, ACEi, intraplueral pressure changes in IPPV and spont ventilation, thyroid hormone, muscle spindles, withdrawl reflex, nociceptive pathway.University Hospitals Coventry & Warwickshire NHS TrustAcknowledgement: many thanks to the candidates of April 2009 OSCE viva course Page 22

Primary FRCA OSCE Viva Questions May 2009OSCE- appendicectomy on a 25yr old diabetic with a temp of 38.5 and a blood glucose of 25. Fluid warmers, ph and Hion concentrations relationships - graph of log pH and concentration H+, power as watts and generation of heat by power.

Set 14

Bain circuit checkqs on oxygen measurement2 history stationsManninkin on VFSTATION ON ARRYTHMIAS SVTCommunication for Sux apnoeascenario of tracheostomy falling out in ITU on ManninkinQs on Needle stick injuryIntrosseus needle insertionanatomy coronary circulationVertebra anatomyExam of pregnant patient for GA/Epidural /spinalCXR -pulmonary edemaCT chest of pneumothorax Viva physio/pharm Intracellelar ionslung complianceVd and ClearancePPI Physics/clinical Epidural topup for LSCS and then into PDPH managementStatic and dynamic compliance in BP ..... I have not heard or seen about thisHeat loss and prevention

Set15

PHYSIOLOGY


Primary FRCA OSCE Viva Questions May 20091) Can you draw and compare the graphs of how HR and Systolic and Diastolic BP changes with Adrenaline and Noradrenaline infusions.2) Adrenergic receptors in details3) Physiology of starvation in detail.....Wanted to know about the exact steps at which Amino acids and glycerol enter the gluconeogesis pathway.4) drw a sarcomere. Excitation contraction coupling Pharmacology1) Local anaesthetics structure and comparison.How do PPbinding etc alter the activity2) Dose response Curves3)Cant remember the third one Physics1)what is pressure. what are SI units. compare the various units. Showed picture of a barometer and manometer. Asked to compare. Then asked what relative pressure is....and how it is different from Gauge pressure?!2)Classify ventilators. Principle of Oxylog and compare various graphs for flow and pressure generators as well as for various cyclings!3) Spectrophotometry. Easy OSCE1) Needle stick injurywhat will u do. what are seroconversion rates. Post exposure prophylaxis2)Simman....tachycardia algorithms....eventually needed defibrillation3) Simman.....Bradycardia algorithm!!4) Another arrythmia station...PSVT5) History taking....asian lady with thallasemia....also cough and fever following visit to bangladesh.6) Simman....very tough.....Tracheostomised man ..known difficult intubation. recent tracheostomy. now tube out ....cant intubate cant ventilate.last minute I occluded the trachi with gauge and saw the chest moving....phew!!7)Axillary block. What nerves blocked. what spared. qustions on nerve stimulator8) Chest Xray: Pulm edema i think9)Ct chest: loculated pneumothorax I thinkvague questions of fluid replacement ..patient had a burn?!10) Bains circuit check11)Pictures of electrodes...clark, fuel cell to label12) History folllow on....guy ahd all the diseases under the sun....and the examiner asked me....how did his brother die!!13) intraosseous...demonstartion and questions14) Cardiac angiogram and standard questions15) sux apnoea....communication with Mum

Set 16


Primary FRCA OSCE Viva Questions May 2009Pharmacology Viva: Discuss the main advantages of using desflurane and sevoflurane over isoflurane - was wanting blood/gas coefficients - definition/values for each agent and why onset of anaesthesia was faster with low coefficients.Wash-in curves for the above agents, factors affecting shape of curves, effect of nitrous oxide.Digoxin - draw structure of it.......hhmmm (apparently a steroid nucleus); mechanism of action. Draw action potential traces of pacemaker and normal myocyte cells and explain digoxin effect on trace.Dose response curves and definitions of affinity/efficacy/potency/inverse agonist. Physiology Viva: Define hypoxia. What are the different types of hypoxia that you know. Draw the oxygen dissociation curve and explain what hapens to the arterial and venous points with the different types of hypoxia.Immunity - define, types of. How many types of hypersensitivity do you know. What is the immunological basis for each of them. Give a clinical example of delayed hypersensitivity reaction.Starling's forces at a normal capillary bed, alveolar capillary and renal glomerulus. Clinical Viva: Scenario: 19 year old male, fall down stairs in a nightclub. Brought in by ambulance crew with confusion and agitation.Viva followed a discussion on the possible differential diagnoses of the presentation. Focus on management of intra-cranial injury - use of AVPU score over GCS. When would I consider intubation for a trip to the CT scanner?How to prepare for a RSI.Development of Cushing's reflex during CT scanning - how would you proceed.What do you need to prepare for an inter-hospital


Primary FRCA OSCE Viva Questions May 2009transfer.Which IV fluids would you use and why? Physics Viva: How do you calculate how much oxygen is left in an oxygen cylinder? Same for nitrous oxide.Ideal gas laws.Mechanism of action of Ambu bag valve/mushroom valve. OSCE Stations. Schematic diagram of plenum vaporiser - questions on function/safety features.ECG - fast AF - what else could it be/how would you check? What investigations would you like to perform. When would you electrically cardiovert this patient? How man joules would you use. When would you not cardiovert the patient. What pharmacologicaloptions are there for rate control and cardioversion?History-taking - mastectomy/breast reconstruction in a patient post chemo for breast ca.History-taking & follow-on questions Re: hx - 21 year old type 1 DM for tonsillectomy with features of OSAS. Lots of marks for thorough diabetic history.Resusc 1 - called to ED for collapsed 33yr old female just diagnosed with ectopic - asystole algorithm.Resusc 2 - called by junior SHO for a patient who is developing anaphylactic shock post ceftriaxone.Anatomy - underside of diaphragm, labelling key parts, distinguishing levels of entry of IVC/oesophagus/aorta. Diaphragmatic sensory/motor innervation.Anatomy - sacrum - identifying sacral cornua/sacrococcygeal membrane....describe how to perfom a caudal block in a 5yr old for orchidopexy - where does dural sac end in a 5yr old, how big is the caudal sac in this age group, what quantity of LA would you use, describe angle of entry of needle.Equpiment - LMAs - demonstrate selection/preparation/insertion/checking of LMA. 2 contraindications to LMA other than full stomach and


Primary FRCA OSCE Viva Questions May 2009pregnancy.Equipment - anaesthetic machine check - absent blanking yokes where cylinders absent, oxygen analyser not working, vaporiser not filled.Equipment - schematic diagrams of null deflection paramagnetic analysers/Clark electrode and galvanic fuel cell and questions pertaining to each system.Anaesthetic hazards - photograph on patient's elbow lying on a metal edge - risk of ulnar nerve injury, clinical symptoms, examination findings and treatment. Another photograph with arm abducted to 90 degrees against a metal bar - questions about circumflex nerve injury.Communication - discuss the pros and cons of PCA vs epidural forpost-operative analgesia in a female undergoing elective TAH. The woman was worried about N&V with a PCA which her friend had experienced. He had also had experience of an epidural for labour analgesia. Eventually plumped for an epidural.CXR 1 - single lead pacemaker - questions on classifying pacemaker, use of diathermy.CXR 2 - CTPA with filling defects bilaterally.

Set 16OSCE

1. Base of skull a. Orbital fissures and optic canal b. Cribriform plate c. Types of facial fracture

2. Electrical safetya. Diagram with ECG and CVP attached to patient b. Details of currents that cause macro and microshockc. Details of how macro and micro shock can be prevented. d. Equipotential earth.e. Various safety symbols to identify e. AP, APG, CF etcf. Discussion of pulse oximetry

3. Nerve stimulatora. Placement of electrodes and nerves that can be stimulatedb. Currents and frequency of stimulationc. Diagram with TOF, Tetanic, PTC patterns for depolarising and non

depolarising block.4. Communication skills

a. Talking to daughter of patient in theatre with a ruptured AAA5. Resus:


Primary FRCA OSCE Viva Questions May 2009a. Pregnant (term) lady for c-section-. Another junior has topped up epidural and

patient has become unstable. Likely IA injection of epidural injection. Descended into a PEA arrest Various points:

i. To connect oxygen to ambu bagii. Remember to ask for wedge

iii. Remember to ask surgeons to remove babyiv. Grilled about intralipid (inc. doses)

6. History station 1:a. Observed, marked history by examiner in room (may have been one of the

trial stations?) b. I think it was for a lap chole-. Allergic to penicillin.

7. History station 2:a. Total abdominal hysterectomy with prev GAb. Points quizzed on:

i. Occupationii. How she was treated for PE post c-section

iii. Dentitioniv. Allergiesv. Whether she was anaemic, whether it had been checked by the GP,

when and what the value was. Was she symptomatic8. Cross section spine and columns (ascending and descending)9. Equipment check prior to RSI

a. No battery in laryngoscopeb. Filter had condensation within it suggesting previous use.c. Magills not opening properlyd. Tube cuff with hole in it.e. Catheter mount had a foreign body hidden within it.f. Asked what other equipment I would want

10. Humiditya. Definitionsb. Diagrams of wet and dry bulbs, regnaults hygrometer and hair.c. Asked discuss how Regnaults worksd. Asked about importance of humidity in theatre.

11. Critical incident scenario (simulator)a. Patient on ITU with aspiration. Need to take over from F1 who has called you

because of desaturation.b. Go through scenario- ETT endobronchial.c. Asked about differential and other ways of treating aspiration (bronchoscopy

and suction)

12. Airway managementa. Asked to demonstrate ideal position for bag valve ventilation (nb. Pillow

present at side of room)b. Asked how position, equipment and technique would differ for a child.c. Asked to insufflate 5 breaths. d. Asked about a nasopharyngeal tube and contraindications.


Primary FRCA OSCE Viva Questions May 200913. X-rays:

a. Coaractationb. Hiatus Hernia

PHYSIOLOGY/ PHARM VIVA

1. Coronary circulation and determinants of it2. Autoregulation graph3. Factors that alter MRO24. Factors that affect flux across the placenta. 5. Body fluid compartments6. How body responds to 500ml of blood loss.

7. IV induction agents and classification8. Asked to draw thiopentone and propofol9. Asked how the various IV induction agents are presented10. Short discussion on importance of ionization11. Asked in detail about hypoglycaemic drugs and how they work and side effects

(Metformin, sulphonylureas, thiozolidindiones, acarbose and insulin)

CLINICAL/ PHYSICS

1. 72 year old admitted with cholecystitis 2 days ago. Now septic with abdominal pain presumed from a perforated gall bladder. Jaundiced

a. initial discussion on causes of jaundice and sequellae of liver failure. b. Then movement onto assessment, optimization, intraop and post op

management. 2. Identification of electrical signal symbols (eg. Resistors, inductor) 3. Identification of defibrillator circuit4. Discussion of supraglottic airway devices (LMA, ILMA, Proseal LMA) and

combitube. 5. Picture of BP cuff and discussion about cuff sizes and sources of error 6. Discussion about cuff pressures.

Set17OSCE MAY 2009

1. CT thorax scan on pt with burn injuries and needing appendicectomy. T/F questions.

2. Check Bains circuit and questions.

3. O2 electrodes – Clarke, Polargraphic and Paramagnetic with diagram and questions.


Primary FRCA OSCE Viva Questions May 20094. Insertion of intraosseous needle. Demonstrate how to do it + questions

5. Communication – Sux apnoea

6. Examination – Pregnant pt – suitability for GA or Regional technique with any investigations

7. Anatomy – Coronary circulation – from Royal college book

8. Resus – Bradyarrythmia and performing a synchronised shock

9. Safety – check A-line set up

10. Needlestick injury with question on what to do, rates of transmission

11. Resus – mx SVT and cardioversion with rhythm strip

12. History – elective hysterectomy

13. Simulation station – ITU pt desaturating due to obstructed trachy

14. Radiology – CXR ? Pulmonary oedema – T/F questions

15. Anatomy – Axillary nerve block – position pt then questions

16. Anatomy – Spine – thoracic with ligament attachments etc

17. History follow on station

VIVA MAY 2009

Physiology

Normal ranges for CO, HR, CVP, SV

What happens to above with IPPV

What happens if lose 20% blood volume

Lung compliance – definition and value

Difference between static and dynamic compliance

Draw lung compliance curve and explain


Primary FRCA OSCE Viva Questions May 2009What are the main intracellular and extracellular ions with figures for each

Mg – what happens with hypomagnesaemia – signs and symptoms

Pharmacology

What pt factors influence the uptake of volatiles

Draw the uptake curve for volatile agents and explain

Explain the 2nd gas effect with N2O

What is Vd – definition

What influences Vd

Give egs of drugs with large and small Vd.

Why are they large and small

Tell me about drugs that influence gastric acid

Why do we use sodium citrate for obstetric patients

Draw the Parietal cell and explain where ranitidine and omeprazole work

Clinical

Obstetric pt with epidural in situ. Now needs a C-section.

What would you do

What are the options for C-section

How urgent do you need to do this – classification of urgency


Primary FRCA OSCE Viva Questions May 2009Towards the end of the procedure she develops pain

What could this be due to – ie differential diagnosis

What are the options

What can the surgeon do

What are you as the anaesthetist most at risk of – ie litigation

What are the complications of a regional technique

Post dural headache and management

Nerve damage

Physics

How do pt’s lose heat during a GA

What is the amount lost by radiation and how can it be minimised, via convection and how is it minimised, evaporation and how is it minimised.

Describe drift – static and dynamic

How do we minimise it – 2 point calibration and graph

Where do we take the 2 points

How do you design a machine to measure arterial bp directly – 1st harmonic being HR etc

Equipment – photo of 3 types of ETT – describe one in detail.

Discussion about cuff pressures and advantages/disadvantages of low/high pressure cuff and markings on the tubes.

Physiology VIVA

1. Starvation: how does the body adapt. How long does a person survive? What is the cause of death? What are the hormonal changes?


Primary FRCA OSCE Viva Questions May 20092. Muscle physiology: excitation contraction coupling. Structure of sarcomere.

Difference between cardiac and skeletal muscle.

Pharmacology VIVA

1. G-protein receptors: Types with examples. MOA. Response to stimulation of α, β and dopaminergic receptors

2. Dose response curve: Describe log D-R curve. Importance of semilog. scale. Changes in the presence of partial agonist, competitive and non competitive antagonist. Effect of tramadol on morphine D-R curve

3. Diuretics: Classify. Explain countercurrent mechanism. Describe MOA of furosemide and the side effects.

Physics VIVA

1. Pulse oxymeter: principles, working, draw isobestic point diagram

2. Pressure: methods of measurement. Method of measuring atmospheric pressure. Picture of a U-tube filled with mercury with the mercury level different in the two limbs – asked to describe the device?????

3. Ventilators: classify. Difference between Manley’s and Nuffield ventilators with regards to peak pressure and volumes delivered.

Clinical VIVA

1. Patient with 2 finger mouth opening for abdominal hysterectomy. She wants a general anaesthetic only. How will you manage her?

2. Patient in recovery. Recently extubated. Develops stridors. Differential diagnosis and management.

OSCEs

1. COMMUNICATION: explain awake fibreoptic intubation to an anxious patient with previous difficult intubation.


Primary FRCA OSCE Viva Questions May 20092. SKILL: cardioversion in a patient with AF. Demonstrate on a biphasic defibrillator

3. EXAMINATION: CVS. Concentrate on radial pulse and precordium

4. ALS: ECG rhythm strip showing asystole. Describe algorhythm for asystole (not a simulator station)

5. HISTORY: patient for lap chole with past history of suxamethonium apnoea

6. SIMULATOR: can’t intubate - can’t ventilate a patient after RSI. Lock jaw. Ends with needle cricothyrodotomy

7. SKILL: BP taking with anaeroid BP machine. Questions related to cuff size, errors etc

8. CXR: Mitral stenosis

9. CXR: cervical spondylitis

10. FOLLOW ON STATION: 20yr male for CT brain under GA. History of poorly controlled asthma, migraine.

11. MACHINE CHECK: with identification of faults

12. EQUIPTMENT: pH electrode

13. SKILL: epidural. Demonstrate on mannequin

14. SKULL: trigeminal nerve. Describe nuclei, identify openings in skull base for the different branches. Causes of trigeminal neuralgia

15. ANATOMY: trachea


Primary FRCA OSCE Viva Questions May 200916. EQUIPTMENT: assemble and check Bain’s circuit.

17. EQUIPTMENT: laser tube. Difference between laser and ordinary tube. How does the protective eyewear work? Name different types of laser.

.


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