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Primary OSCE 59

Created: 18/11/2011
1. Anaesthetic machine check
You are asked to carry out a check on an old machine (cylinders only). The O2 analyser is not working properly (reads 100% with O2 but 0% in air) and there is a leak from the vaporiser (no O ring). Discuss oxygen failure warning devices.

2. Statistics
You are given two graphs showing the cumulative frequency of weight among boys in two populations, A and B. A had a normal distribution and B was right skewed. You are asked questions about the 95% confidence interval in A, and about the type of statistics used in B, and to carry out a paired student t test to compare samples of 20 from the two populations.

3. ECG
You are asked to interpret an ECG showing left bundle branch block (LBBB), in a 60-year-old preoperative man with mild shortness of breath on exertion (SOBOE), and to answer some questions about it.
- Does the patient need a preoperative pacemaker?
- Has this patient had a myocardial infarction previously?

4. Data interpretation
A patient presents with tachycardia, a PO2 of 7 kPa, PCO2 of 5.5 kPa, PH 7.5 and a respiratory rate of 35 bpm. The FEV1/FVC ratio is 0.25%.

Answer the following True/False questions:
(i) The blood gas results indicate an anxiety attack.
(ii) The normal pCO2 is reassuring.
(iii) The patient may have a pneumothorax.
(iv) Deteriorating blood gases will determine the need for ventilatory support.
(v) The patient should be admitted to an acute medical ward for observation overnight.

5. Anatomy
Describe the anatomy of the spinal cord.
- What is the normal volume and pressure of cerebrospinal fluid?
- Describe the blood supply to the spinal cord.
. – You are shown a cross-section of the spinal cord; identify the tracts.
- What happens in anterior artery thrombosis?

6. Communication
An 80-year-old man is due to undergo emergency surgery for ruptured abdominal aortic aneurysm. You need to tell his daughter what is happening. She last saw him yesterday, when he was fine, and has no idea what has happened or how serious the situation is.

7. Equipment
You are shown a picture of a CO2 electrode and a pH electrode and asked to identify them.
- Which would you choose to measure CO2?
- Label the various parts of the CO2 electrode and explain how it works.
- What other methods do you know for measuring CO2?

8.Clinical anaesthesia
You are called to the ward for a cardiac arrest in a patient 3 hours after laparoscopic cholecystectomy. Cardiopulmonary resuscitation is in progress on your arrival.
- Talk through the process with the examiner.
- Describe the ‘SAFE’ approach.
- The monitor shows pulseless electrical activity (PEA). List the possible causes of PEA.

9. Examination
Carry out an examination of the pulse/praecordium and auscultate the heart in a healthy volunteer.
- Discuss the different types of pulse character and rhythm and their causes, and RR/RF delay and their causes.

10. Anatomy
Describe the anatomy of heart: blood supply, chordae tendineae, sinus of valsalva etc.
- You are asked to identify on an angiogram the left main stem and left anterior descending artery and the area it supplies.

11. History taking
You are asked to take a history from a 70-year-old man presenting for removal of a suspicious mole below his shoulder blade. He has previously undergone general surgery and also cataract surgery under local anaesthetic, but has no significant history of problems with general anaesthetic or local anaesthetic. He had a pacemaker fitted for fainting episodes >5 years ago; this is checked yearly, most recently about two months ago, with no problems found. He has been on angiotensin-converting enzyme inhibitors and aspirin 75 mg since his fainting episodes. He has no allergies. His operation may possibly include SSG.

12. Simulator manikin
A healthy patient has undergone a successful rapid sequence induction for appendectomy, and is on standard drugs + antibiotics. You are with a new SHO and have to talk them through what happens. The patient’s SpO2 has decreased, heart rate increased and blood pressure decreased. He is easy to ventilate, but there is some wheeze.
- Demonstrate how you would manage the patient.

13. ECG
- Discuss the use of three-lead ECG monitoring in the operating theatre.
- Describe the position of the electrodes.
- CM5 configuration: which lead is not involved?
- Discuss the advantages and disadvantages of unipolar versus bipolar diathermy leads.
- Discuss diagnostic versus monitoring mode, and interference.

14. Equipment
You are shown a diagram of a patient with an ECG and some other equipment and are asked questions about micro-shock, differential earth voltages and current leak.
- You are shown a sheet of electrical symbols, and asked to choose three and identify them.

15. Simulator manikin
What are the indications and contraindications of cricoid pressure?
- Why is the cricoid used?
- When should the cricoid pressure be removed?
- Demonstrate the application of cricoid pressure on a simulator manikin.
- How much pressure should be applied?
- What is the weight equivalent to Newtons in kg.

16. History taking
Take a history from a woman presenting for abdominal hysterectomy. She has had menorrhagia for several years and is fatigued with anaemia. She does not know her haemoglobin level, but has been taking iron. She has experienced previous awareness during intubation for Caesarian section. As a child, she also experienced an unpleasant induction for tonsillectomy.

17. X-ray
You are shown a preoperative chest X-ray from a chachectic tachypnoiec patient who keeps pigeons. You are asked questions about the restrictive versus obstructive pattern of lung disease, the need for postoperative ventilatory support and the need for postural drainage

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