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Primary OSCE 26

Created: 27/5/2005
1. History taking
Take an anaesthetic history from a 68-year-old man who is scheduled for laparotomy and hemicolectomy the following day. (In this case, the history revealed bronchitis, ischaemic heart disease and a gastrointestinal bleed, with a history of transfusions for the past 6 months due to anaemia; the patient was taking ibuprofen for arthritis and was also using inhalers, diuretics and cardiac drugs).
2. History taking
Take an anaesthetic history from an elderly gentleman scheduled for hernia repair the following day. He has hypertension and ischaemic heart disease, and is taking nifedipine and aspirin. His angina is increasing in frequency, but responds well to glyceryl trinitrate sprays. There are no symptoms of heart failure.
3. Anatomy: the antecubital fossa and arm
- Demonstrate the biceps tendon.
 - Where is the brachial artery? Describe the course of this artery in relation to the antecubital fossa. 
- What structure lies above the brachial artery?
- Demonstrate the position of the radial nerve in the cubital fossa.
- What test would you perform to ascertain the integrity of superficial and deep palmar arches? 
- Demonstrate how you would perform a modified Allen's test.
- Describe how you would block the median nerve at the wrist.
- Describe how you would block the ulnar nerve at the wrist.
The cubital fossa : Anaesthesia UK

4. Anatomy: the heart
- What is the blood supply of the AV node?
-  You are presented with a coronary angiogram showing the left coronary artery. Identify the branch marked "A" (left anterior descending artery). What does it supply?
-  What is the significance of right coronary artery occlusion, and how should such patients be treated?
-  Describe the nerve supply of the AV node.
-  Describe the origin, course and innervation of the vagus nerve (either the left or right branch).
5. Communication
Explain the failure of an intubation drill to an operating department assistant who has only recently started their training.
6. Examination: respiratory system
Examine the respiratory system of a 25-year-old man with a cough and chest infection.
7. Equipment check
Carry out a check on a basic anaesthetic machine with the following faults:
 No marks for absent pipelines
 Oxygen analyser had no battery
 Two empty vaporisers (isoflurane and enflurane) on back bar
 No interlock mechanism. "O" ring missing in enflurane vaporiser
AAGBI Checklist for Anaesthetic Equipment 2004
8. Resuscitation
You are asked to resuscitate a pregnant woman who has collapsed. Fill in a ventricular fibrillation algorithm.

ALS algorithm 
Resuscitation Council UK Adult Advanced Life Support 
9. Statistics
- You are presented with two datasets - group A and group B - and asked a series of true/false questions.
-  Define the mode, mean and median.
-  What is a normal distribution?
-  Is it possible for the population in group B to have a standard error of the mean (SEM) greater than 1 standard deviation (SD)?
Mean, median and mode
The normal distribution
10. Data interpretation
You are presented with the ECG of a 60-year-old man who has been admitted with sudden onset of chest pain and confusion. His blood pressure is 80/40 mmHg. What does the ECG show, and how should he be treated? You are asked the following true/false questions:
- The patient is in sinus rhythm.
- He has a ventricular rate of 200 beats/min.
- There is evidence of left-axis deviation.
- There is evidence of inferior wall myocardial infarction.
- The QRS duration is >0.12 seconds.
- Propofol 2 mg/kg is the drug of choice for cardioversion.
- Inhalational induction with sevoflurane is likely to be delayed.
- Acute myocardial infarction is a possibility.
- An arterial line should be inserted before cardioversion.

11. Equipment
a) You are shown a photograph of a pulse oximeter monitor.
-  What details can be obtained from this monitor?
b) You are shown an oxygen dissociation curve, with two points, A and B, marked.
-  What does point A represent?
-  What does point B represent, and what are its uses?
c) You are shown oxygen dissociation curves for myoglobin and haemoglobin and asked to identify them.
d) You are shown a chart of the absorption characteristics of oxyhaemoglobion and deoxyhaemoglobin.
-  Identify the wavelengths used in the pulse oximeter.
-  Why are there two wavelengths?
-  Why is there only a pulsatile component? 
-  What is the point marked at around 800 nm?
-  What value do you obtain with light absorption at that point?
e) You are shown the chart below:

-  Where would you see this type of tracing commonly?
f) What are the various sources of error associated with a pulse oximeter?
Oxygen Dissociation Curve : Anaesthesia UK 
Principles of pulse oximetry : Anaesthesia UK 
12. Blood pressure measurement
Take the blood pressure of the model and answer the following questions:
- What is the blood pressure?
- Which phase of the cardiac cycle is represented by the systolic blood pressure?
- Which phase of the cardiac cycle is represented by the diastolic blood pressure?
- What is the formula for calculating mean arterial pressure?
- Why is this formula used?
- What changes occur in elderly patients?
- What differences would you expect between men and women?
- Is the difference the same throughout life?
- What is the correct size of the blood pressure cuff?
- What problem might arise from using a small sized cuff?
Cardiac cycle
13. Anaesthetic hazards
You are shown a photograph of a patient lying on the bed, connected to a central venous pressure monitor and other electronic monitors which are connected to earth. Answer the following questions:
- What is the magnitude of the current required for microshock?
- Assuming that all equipment is working correctly and that the patient is not touching any metal, why does electrocution not occur?
- What do the symbols mean?
- Is earth potential the same at all points on the equipment?
- How can they be made to be equal?
- What is the maximum allowed difference between earth potential and the mains voltage of 240 volts?
- Select any two symbols from the card and explain what they represent.
14. Data interpretation
You are presented with a 65-year-old man who has had a road traffic accident. On arrival at the accident and emergency department he was drowsy, then became unconscious. His CT scan is shown on the screen. Answer the following true/false questions:
- Air is seen in the frontal sinus.
- The patient has blood collection on the left side.
- The patient has a temporal bone fracture on the right side.
- There is no evidence of midline shift.
- The left lateral ventricle appears normal.
- An extradural haematoma can be seen (Extradural haematoma).
- Urgent evacuation of blood is needed.
- Prognosis is very poor at the patient's age.
- The right pupil would be expected to be dilated.
15. Humidity
- Define relative humidity.
- What is absolute humidity?
- What are the units of absolute humidity?
- What is the value of absolute humidity in the trachea?
- Give two reasons why humidity is important
- You are shown three charts; which chart is taken from a hair hygrometer?
- Explain the principle of Regnault's hygrometer.
- You are given a chart showing relative humidity lines (100%, 50% etc), with the Y axis denoting water vapour (in g/m3) and the X axis denoting temperature; if the dew point is at 30 degrees C, what is the absolute humidity?
Humidity : Anaesthesia UK
16. Data interpretation.
A 65-year-old man is found unconscious in a car, with a hose leading from the exhaust pipe into the car. The following are values obtained from initial investigations:
pH 7.1
Temperature 33.3 degrees C
pCO2 4.1 kPa
COHb 40%
pO2  9.2 kPa
Base excess 15 mmol/L

Answer the following true/false questions:
- The pulse oximetry will show 85% saturation.
- The patient should receive oxygen through a Hudson mask at a rate of 10 L/min.
- Metabolic acidosis will return to normal once hypothermia has been corrected.
- pCO2 level will be recorded as lower than the actual value because of hypothermia.
- Hyperbaric oxygen therapy will be of no use if oxygen is given effectively.
- The patient requires intubation.
- The patient requires bicarbonate administration.
Oxygen Dissociation Curve : Anaesthesia UK

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