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You are in Home >> Exams >> Primary FRCA >> OSCE and SOE

Primary OSCE 10

Created: 7/9/2004

1. History taking
Take a history from a man, 68 years old, scheduled for laparotomy and hemicolectomy tomorrow. History reveals bronchitis, ischaemic heart disease, gastrointestinal bleed, history of transfusion 6 months previously (anaemia); patient is taking ibuprofen for arthritis, and is also on inhalers, diuretics and cardiac drugs.

2. History taking
Take a history from an elderly man coming for hernia repair tomorrow. History reveals hypertension and ischaemic heart disease; patient is on nifedepine and aspirin. Angina increasing in frequency, but patient is responding well to glyevryl trinitrate  sprays. No symptoms of heart failure.

- Answer questions about the anatomy of antecubital fossa
- Demonstrate Biceps tendon
- Position of Brachial artery: how does it run in the cubital fossa (course)?
- What structure lies above brachial artery?
- Demonstrate position of radial nerve in cubital fossa
- What test do you do to find the integrity of superficial and deep palmar arches?
- Demonstrate how you would perform this test (Modified Allen’s Test)
- Describe landmarks to block median nerve at wrist
- Where do you block ulnar nerve at wrist?
- Which muscle lies closer to ulnar nerve at this point?

4. Anatomy of the heart
- Arterial supply of AV node: in what % of patients is this the case?

You are shown a photograph of 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?
- What do these patients need?
- What is the nerve supply of AV node?
- What is the course of the vagus nerve, either left or right (origin, course, innervation)?

5. Communication
Explain a failed intubation drill to the operating department assistant who has started her training recently. On questioning, she has never seen a general anaesthetic being given and does not know what intubation is!! 

Explain briefly about general anaesthesia and intubation and then about failed intubation drill 

6. Examination
Examine the respiratory system (detailed airway examination not needed) of a 25-year-old young man with cough and chest infection. On examination, he looks a bit short of breath, with an increased respiratory rate.  

Carry out a systematic examination of the respiratory system . 

Machine check
Basic anaesthetic machine with the following faults:
- No marks for absent pipelines
- Oxygen analyser: no battery
- Two empty vaporisers on back bar - isoflurane and enflurane vaporisers
- No interlock mechanism. ‘O’ ring missing from the enflurane vaporiser
- Could not pressurise the system with enflurane vaporiser turned on.

Resusciate a pregnant woman found collapsed

Ventricular fibrillation scenario algorithm

- Fill in the chart

You are shown two groups of data: GpA and Gp B, with 6 values in each; SD and ‘n’ given for both.

Answer 10 true/false questions, including questions concerning:
- What is the mode mean and median?
- Is this a normal distribution?
- Does population in Gp B have SEM greater than 1 SD?
- Calculation of SEM

10. Data interpretation
ECG: 60-year-old man, admitted with sudden onset of chest pain and confusion.
Called for urgent cardioversion. Blood pressure: 80/40 mmHg. ECG revealed ventricular tachycardia.

Answer 10 true/false questions, including:
- Patient is in sinus rhythm
- Patient has ventricular rate of 200/min
- There is evidence of left axis deviation
- There is evidence of inferior wall myocardial infarction
- QRS duration > 0.12 seconds
- Propofol 2 mg/kg is the drug of choice for cardioversion
- Inhalation induction with sevoflurane likely to get delayed
- Acute myocardial infarction is a possibility
- Arterial line should be inserted before cardioversion 

11. E
You are shown a photograph of a pulse oximeter monitor

- What details can be obtained from this monitor? (pulse rate, SpO2, waveform and signal strength)

You are shown a picture of an oxygen dissociation curve, with marked points A and B

- What is point A? (90% saturation = 60 mmHg)
- What is point B?
- What is P50? What are its uses? (to identify various Hb, position of ODC)

You are shown another chart containing two curves

- You are asked to identify them (ODCs of Myoglobin and hemoglobin)

You are shown a chart of absorption characteristics of oxy- and deoxyhaemoglobin

- Identify the wavelengths used in the pulse oximeter
- Why are there two wavelengths? Why is ther only a pulsatile component?
- What are the points marked at around 800 nm? (isobestic point)
- What do you obtain with light absorption at that point? (total haemoglobin)

You are shown another chart

- Where do you see this type of trace commonly? (blood pressure cuff going up on the same side, probe dislodged and corrected)
- What are the various sources of error in pulse oximeter?

12. Blood pressure measurement

- Take the blood pressure from the model and answer questions:
- What is the blood pressure?
- Which phase is systolic blood pressure concerned with?
- Which phase is diastolic blood pressure concerned with?
- What is the formula for mean arterial pressure?
- Why is this formula used?
- What changes occur in elderly patients?
- What differences you expect between men and women?
- Is the difference the same throughout life?
- What is the size of the blood pressure cuff?
- What is the problem of using a small sized cuff?

13. Anaesthetic hazards
You are shown a photo of a patient lying on the bed connected to a central venous pressure monitor and other electronic monitors which are connected to earth. There are electrical symbols displayed here and there.

- What is the magnitude of current required for microshock?
- Are all items of equipment working correctly?
- Is the patient not touching any metal?
- Why does electrocution not occur?
- What do the symbols mean? (isolated circuit, earth potential)
- Is earth potential the same at all the places?
- How can you make them equal?
- What is the maximum allowed difference between earth potential and mains voltage of 240 V?
- Select any two symbols from the card and explain what they represent

14. Data interpretation
A 65-year-old man, who has had a road traffic accident, presented drowsy to Accident and Emergency, then became unconscious. His CT scan was shown on the screen.

Answer 10 true/false questions, including:
- Air is seen in the frontal sinus
- Patient has blood collection in the left side
- Patient has temporal bone fracture in the right side
- No evidence of midline shift
- Normal left lateral ventricle

The CT scan shows extradural haematoma:
- Patient needs urgent evacuation of blood
- Prognosis very poor at this age
- Right-sided dilated pupil would be expected

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?
- Why is humidity important (give two reasons)?

You are shown three charts: Regnault's, wet and dry bulb thermometer, hair hygrometer

- Which is the hair hygrometer?
- What is the principle of Regnault’s hygrometer?

You are shown chart with relative humidity lines (100%, 50% etc) Y axis is water vapour g/m3 and X axis shows temperature.

- What is the absolute humidity if the dew point is at 30 degrees C

16. Data interpretation
A 65-year-old man is found unconscious in car with a hose from exhaust 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 10 true/false questions, including:
- Pulse oximetry will show 85% saturation
- Needs oxygen through Hudson mask at rate of 10 L/min
- Metabolic acidosis returns to normal when hypothermia is corrected
- PCO2 levels lower than actual because of hypothermia
- Hyperbaric is of no use if oxygen is given effectively
- Patient would require intubation
- Patient requires bicarbonate administration

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