ANZCA Final Exam Resources

Past Questions

Anaesthetic Vivas

Past Vivas

Past Vivas

Title

Exam

Background

Categories

Pass Rate

Status

Viva 1

A 10-year-old girl has been added to your dental list today at a tertiary hospital. She is scheduled for dental extractions and treatment under general anaesthesia.

Medical history

Rheumatic mitral valvular disease

Medications

Frusemide 30 mg BD

Spironolactone 25 mg once daily

Allergies

Nil known

Observations on admission

Height 150 cm

Weight 35 kg

BMI 15 kg/m2

HR 117 bpm

BP 95/60 mmHg

SpO2 96% on room air

In your preoperative review of this patient with her mother, what information on history and examination will you seek?

71.0%

Viva 2

It is 11:00 pm and you are on-call at your major metropolitan hospital. The first-year anaesthetic registrar telephones you at home and asks you to attend for a case that has been booked with a surgical urgency of one hour. The patient is a 55-year-old woman who has been booked for a T7 – L3 debridement and laminectomy for spontaneous epidural abscess.

Observations:

Heart Rate: 130 - 140 bpm, atrial fibrillation

Blood Pressure: 110/60 mmHg on noradrenaline (norepinephrine) infusion running at 0.25 mcg / kg / min (14.5 mcg / min based on estimated lean body weight)

SpO2: 90% on high-flow nasal oxygen 40 L/min

Respiratory Rate: 25 breaths per minute

Temperature: 38.5 °C

GCS: 11 (E2 V4 M5)

Weight: 130 kg

Height: 155 cm

BMI: 57

Past Medical History:

Guillain-Barré Syndrome 20 years previously with ICU admission and mechanical ventilation via tracheostomy (since closed)

Current smoking, 40-pack-year history

Type 2 diabetes mellitus (on insulin)

Hypertension

The registrar is concerned that the patient may require urgent intubation due to a falling level of consciousness. You are 20 minutes away from the hospital.

How would you approach the management of this situation?

66.0%

Viva 3

You are the duty anaesthetist at a major hospital. You receive a call from the emergency physician to advise of a 20-year-old woman en route to the hospital with an anterior chest wall stab wound.

The paramedics report that on their arrival, the patient was hypoxic and agitated. A 15 cm hunting knife was found nearby. The patient was intubated following administration of diazepam 10 mg and rocuronium 100 mg intravenously. She had bilateral thoracostomies.

The patient has a known intravenous substance use disorder with heroin.

The last set of vital signs recorded by the paramedics are as follows:

BP 70/55 mmHg

HR 130 bpm

SpO2 92% on FiO2 0.9

RR 15 breaths per minute, ventilated

What are your main considerations as you head down to the Emergency Department?

70.0%

Viva 4

You are the emergency theatre anaesthetist in a tertiary level hospital.

A 68-year-old man with end-stage renal disease is booked for debridement and washout of an infected brachiocephalic arteriovenous fistula (AVF) +/- fistuloplasty. He has missed his scheduled haemodialysis today due to 48 hours of progressive swelling and redness in his arm and intermittent chills. A peri-fistular collection is confirmed on ultrasound.

Medications

Amlodipine-Valsartan 5 mg/ 160 mg once daily

Calcium Carbonate 500 mg TDS

Epoetin alfa 6000 units SCI 3x weekly

Frusemide 160 mg once daily

Hydralazine 25 mg BD

Metoprolol 50 mg BD

Prazosin 1 mg nocte

Observations

Weight 115 kg / Height 1.82 metres /BMI 35 kg/m2

HR 80 bpm

BP 105/47 mmHg

RR 18 breaths per minute

SpO2 96% on room air

Temperature 37.5°C

GCS 15 - lethargic but lucid

Examination Findings

Heart sounds dual

JVP +2 cm

Breath sounds bilateral and vesicular

Bilateral +1 pedal oedema

Outline your clinical priorities in the preoperative assessment of this patient

70.0%

Viva 5

You are the anaesthetist for a gynaecology list in a standalone day surgical unit. The next patient is a 15-year-old girl presenting for termination of pregnancy.

She weighs 60 kg and is not on any regular medications. She denies any comorbidities.

She has attended alone due to parental objection to abortion. She is 11 weeks pregnant confirmed on ultrasound and therefore unsuitable for medical termination.

Describe the elements necessary for informed consent in this patient

78.0%

Viva 6

You are the anaesthetist at a tertiary referral centre. You have been asked to urgently review a 40-year-old woman in the emergency department who has presented with neck swelling and shortness of breath.

She is distressed and anxious.

Medications

Nil regular

Allergies

Nil known drug allergies

Observations

SpO2 98% on room air

RR 20 breaths per minute

HR 120 bpm

BP 130/70 mmHg

Temperature 37°C

Investigations

Full Blood Count:

Results within normal limits

Urea and Electrolytes:

Results within normal limits

Thyroid function tests:

TSH <0.1 mIU/mL (0.5–5 mIU/mL)

Free T4 30 pmol/L (9–19 pmol/L)

Free T3 9.0 pmol/L (3–6.5 pmol/L)

What are the key issues that you would address in your assessment?

73.0%

Viva 7

A 77-year-old man is booked for a posterior-approach left total hip joint arthroplasty (performed in the lateral position) on your list in a private hospital next week. You have taken over the list on behalf of an unwell colleague who provides their preoperative notes.

Medical History

Hypertension

Fibromyalgia

Obstructive sleep apnoea on nocturnal CPAP

Gastro-oesophageal reflux disease

Left total knee arthroplasty completed under spinal anaesthesia two years ago

Height 170 cm, Weight 130 kg, BMI 45 kg/m2

Medications

Amlodipine 10 mg once daily

Enalapril 20 mg once daily

Hydrochlorothiazide 50 mg once daily

Omeprazole 20 mg nocte

Naltrexone 4.5 mg once daily

Semaglutide 0.5mg SCI weekly

He has an unfilled prescription from his general practitioner for rivaroxaban 20 mg PO daily.

Allergies

Nil known drug allergies

An ECG has been performed and is attached below. A transthoracic echocardiogram will be performed prior to surgery.

⁠

What are your concerns about this patient’s presenting cardiac rhythm?

64.0%

Viva 8

You are the consultant in the high-risk obstetric clinic. Your first patient is a 38-year-old woman, G3P2, who is 25 weeks pregnant. She has had two previous lower uterine segment caesarean sections under regional anaesthesia.

Her BMI is 55 kg/m2 (height 174 cm, weight 167 kg). She was diagnosed with severe obstructive sleep apnoea one year ago and has used nocturnal CPAP since with improvement in her symptoms.

Medical History

Mild-moderate pulmonary hypertension

Congestive cardiac failure

Cardiorenal syndrome (GFR 41 mL/min)

Obstructive sleep apnoea on nocturnal CPAP

Medications

Aspirin 100 mg once daily

Spironolactone 50 mg mane

Frusemide 40 mg mane, 20 mg nocte

Labetalol 150 mg TDS

Nifedipine SR 30 mg nocte

Enoxaparin 100 mg SC once daily

Observations

HR 90 bpm

BP 130/80 mmHg

RR 22 breaths per minute

SpO2 96% on room air

She has been referred to your tertiary hospital for management of this pregnancy and planned delivery via repeat lower uterine segment caesarean section

⁠

What are the key concerns in assessing this woman for planned LSCS?

79.0%

Viva 9

You are called to the Emergency Department as part of the trauma team in a tertiary paediatric hospital.

The paramedics are en route and 5 minutes out from arrival.

You are told that a 2.5-year-old boy is being brought in following a motor vehicle accident. The handover reports obvious left facial and chest injuries as well as deformity and swelling of the left upper arm and thigh.

His observations as communicated by the paramedics are

HR 160 bpm

BP 70 mmHg systolic

RR 40 breaths per minute

SpO2 91% on 6L/min via Hudson mask

He responds to voice.

As the anaesthetist in the team, how you will prepare for the child’s arrival?

86.0%

Viva 10

You are the anaesthetist covering the intensive care unit and operating theatre in a small regional hospital. The emergency physician asks for your assistance with transferring a patient to radiology.

The patient is a 25-year-old man who was found wandering in a worksite.

He was agitated and confused, and an ambulance was called. In the ambulance, the patient initially complained of a headache, then become drowsy.

The emergency physician has requested a CT brain but is unable to transfer the patient due to clinical workload.

Medical History

Type 1 diabetes mellitus

Depression

Medications

Insulin pump 70 units Novorapid by subcutaneous infusion every 24 hours

Venlafaxine 150 mg daily

The observations recorded by the paramedics are as follows:

BP 140/85 mmHg

HR 84 bpm sinus rhythm

SpO2 99% on room air

RR 20 breaths per minute

Eye opening: open to voice

Best verbal response: mumbling words inappropriately

Best motor response: localising to pain

How will you assess this patient prior to transfer to radiology?

82.0%

Viva 11

You are requested to attend a trauma call in the emergency department of a tertiary hospital.

Paramedics have transferred a 38 year old man with a stab injury to his neck inflicted during an assault an hour ago.

His GCS is 15 (E4 V5 M6) and has the following initial observations:

Heart rate 95/min

BP 140/90 mmHg

Resp rate 18/min

SpO2 96% on oxygen at 6 LPM via a Hudson mask

A stab wound can be seen about 2 cm above the right clavicle. He has a 20-gauge cannula in his right antecubital vein and is currently receiving a litre of Hartmann’s solution. His Hb is 125 g/L on admission.

He does not have any prior medical conditions or allergies and does not take any medications.

⁠

On initial assessment, what clinical features will you focus on?

67.0%

Viva 12

You are tasked with reviewing a 50-year-old male in the preadmission clinic, who is scheduled for a transjugular intrahepatic portosystemic shunt (TIPS) procedure in one week.

Past medical history

Cirrhosis secondary to non-alcoholic steatohepatitis leading to previous variceal bleeding and recurrent ascites.

Type 2 diabetes mellitus.

Medications

Frusemide 40mg once daily

Lactulose 10ml three times daily

Metformin 1g once daily

Pantoprazole 40 mg once daily

Propranolol 10 mg twice daily

Rifaximin 550mg twice daily

Vital signs

Height 160cm

Weight 80 kg

BMI 31 kg/m2

BP 105/ 65 mmHg

HR 85 bpm

SpO2 95% on room air

Temp 36.5 o C

Under what circumstances may a TIPS be unsuitable for a patient with liver failure?

68.0%

Viva 13

You are reviewing a 55 Yrs old patient presenting for an elective release of perioral and anterior neck contracture scars 12 months following a burn injury involving 60% of her body surface area. The surgical plan will also involve a free flap to the anterior neck as well as perioral scar release.

Her medications are

Salbutamol MDI 100mcg 2 puffs QID PRN

Salmeterol/Fluticasone MDI 250/25mcg 2 puffs BD

For cultural reasons the patient has requested an all female team for her care in the operating theatre. How will you address her request for an all female team?

71.0%

Viva 14

You are the duty anaesthetist for a regional hospital. The general surgeons have booked a 69-year-old male for an urgent ureteric stent insertion at 1900 hrs.

Medical history

Hypertension

Type 2 Diabetes mellitus

Obstructive Sleep Apnoea on CPAP

Bronchial asthma

Currently smokes 10 cigarettes/day with a 50-pack year history

Drinks alcohol socially

Medications

Ramipril 5 mg daily

Empagliflozin 10 mg daily

Gliclazide XR 60 mg daily

Salbutamol inhalers 100 mcg 1-2 puffs q4h PRN

Vitals

Pulse rate 110 bpm

BP – 99/62 mm Hg

SpO2 94% on room air

Temperature 37.8 C

Patient’s body weight is 108 kilograms, height 167 cm

Calculated BMI is 38.7 kg/m2

ECG – sinus tachycardia 110 bpm

CT KUB – right sided hydronephrosis with a 12 mm calculus at the vesicoureteric junction

What further information would you like to determine the urgency of this case?

66.0%

Viva 15

A 17-year-old boy presents to pre-admission clinic in your tertiary referral centre. He requires assessment prior to a T2- L4 posterior spinal fusion for kyphoscoliosis with a 50 degree curvature.

He has a cervico-thoracic syrinx and had a foramen magnum decompression at 3 years of age for progressive lower limb weakness.

He is particularly apprehensive about the surgery and is worried about post-operative pain.

Height 168 cm, Weight 95 kg, BMI 33.6 kg/m2

What do you consider to be the most important features that need to be addressed during the preoperative assessment?

90.0%

Viva 16

You are called to review patient in recovery post elective LUSCS under neuraxial anaesthesia. The patient is increasingly short of breath and has ongoing oxygen requirement and the nursing staff are concerned about sending her back to the ward.

The lower uterine segment caesarean section (LUSCS) was performed at 36weeks gestation for intrauterine growth restriction (IUGR). A healthy infant was delivered 2 hours ago.

Biometrics:

Age 28 years

Weight 88kg

Height 160cm

BMI 34.4

Past obstetric and medical history:

G3P0

Systemic Lupus Erythematosus

Medications:

Clexane 40mg od (ceased yesterday)

Aspirin 100mg

Hydroxychloroquine 200mg od

Nil Known Drug allergies

Outline your initial management.

81.0%

Viva 1

You have been scheduled to an MRI list at a paediatric hospital. The first patient on the list is an 8-year-old girl for MRI brain and a lumbar puncture.

The girl has autism spectrum disorder. She has a mild speech delay but communicates well. Six months ago she had an episode of venous sinus thrombosis with raised intracranial pressure secondary to mastoiditis.

The indication for the MRI and lumbar puncture is worsening headache with intermittent low grade fever (highest temperature 37.8°C) over the past two weeks.

She weighs 25 kg.

She is admitted to the paediatric ward the day before the procedure and you are asked to perform a preoperative assessment.

What information do you seek during your preoperative visit?

80.0%

Viva 2

You are required to anaesthetise a 75-year-old woman undergoing a posterior C1 – 2 fusion after a low-velocity mechanical fall at home yesterday evening. Her only injury is a mildly displaced type II dens fracture which has resulted in posterior neck pain and mild left hand weakness. She is currently immobilised in a hard cervical collar.

She weighs 52 kg and is 155 cm tall. Her observations are within normal limits.

Her relevant active comorbidity is osteoporosis managed with a bisphosphonate. She lives alone and is independent in her activities of daily living.

A colleague has performed a preoperative review. The airway comments are:

Thin face with minimal cheek tissue

Mallampati 2, mouth opening 3 cm

Thyromental distance 3 cm

Upper partial plate (removable), lower natural dentition

Neck extension not assessed

Previous GA in 2020: Grade II, MAC 3. No comment on bag mask ventilation

What additional information would complete your airway assessment?

79.1%

Viva 3

An 18-year-old man was brought to the Emergency Department of your major hospital via ambulance after suffering a seizure at university this afternoon. A CT brain has been performed which reveals the suspicion of an arteriovenous malformation (AVM) with associated haemorrhage. There is also a 15 mm diameter cerebral aneurysm that appears intact.

The patient requires digital subtraction angiography of his cerebral vessels and you are asked to provide anaesthetic support for this procedure.

Describe the focus of your assessment of this patient.

69.1%

Viva 4

You are working in a large hospital when you are called by a surgeon regarding a 51-year-old woman who is in the Emergency Department. She requires an urgent laparotomy following a single stab wound to the abdomen after an assault at home.

Immediate history:

Arrived to hospital via ambulance within 30 minutes of injury

Since arrival to ED:

primary survey (no obvious other injuries)

IV access and blood tests taken

1000 mL Normal Saline and analgesia administered

FAST scan reveals free air and fluid

Observations:

Airway patent. GCS 15

SpO2 95% on 6L/min oxygen via Hudson mask

BP 80 mmHg systolic

HR 38 bpm

Dressing on anterior abdomen with some blood leaking through

Medical History:

Height – 153 cm

Weight – 90 kg

BMI 38.4 kg/m2

Type 2 diabetes mellitus, poorly compliant with prescribed treatment

Mild chronic renal impairment

Recent syncopal episodes and referred to cardiology – awaiting appointment

Smoker – 20 cigarettes per day

Medications:

Perindopril 4 mg once daily

Metformin 500 mg twice daily

Glipizide 5 mg twice daily

Atorvastatin 20 mg once daily

Initial blood test results and a 12-lead ECG are displayed below.

How will you assess this patient’s volume status before theatre?

79.1%

Viva 5

A 35-year-old woman with a history of myasthenia gravis was recently assessed for worsening symptoms. She was found to have an anterior mediastinal mass consistent with a thymoma.

She is booked for a VATS thymectomy due to difficult medical control of her symptoms and recent development of bulbar dysfunction as well as some clinical evidence of mass effect from the thymoma.

You are assessing the patient in the Preadmission Clinic a week prior to her scheduled surgery.

Medications:

Pyridostigmine 180 mg qid

Prednisolone 15 mg mane

What are the important elements in the assessment of this patient?

73.6%

Viva 6

You are working in the preadmission clinic. An 86-year-old woman is booked for a laparoscopic ultra-low anterior resection for rectal cancer on your list in three weeks’ time.

She lives alone at home and can comfortably walk 100 metres on the flat.

Medical history:

Hypertension

Transient ischaemic attack two years ago

Ex-smoker – 60 pack-year history

Chronic renal impairment

Medications:

Perindopril 4 mg daily

Aspirin 100 mg daily

Observations:

BP 160/85 mmHg

HR 82 bpm, regular

SpO2 94% on room air

Height 1.70 m

Weight 51 kg

BMI 17.6 kg/m2

A CT abdomen shows a large low rectal cancer and a single nodule in the liver.

The surgeon has asked you to provide an opinion on this patient’s perioperative risk. How would you assess this?

82.7%

Viva 7

You are the anaesthetist on call overnight in a regional hospital.

You are called to the Birth Suite at 2 am to review a 19-year-old woman who has just been brought in by ambulance in labour with sudden onset of shortness of breath within the last 6 to 12 hours.

The woman is G1 P0 and is 32 weeks gestation by dates. She has not had any antenatal care during the pregnancy.

The cardiotocogram (CTG) is normal.

The patient denies any prior medical history. She weighs 65 kg and has a BMI of 23 kg/m2.

The midwife informs you that the patient’s oxygen saturation is 94% on 15 L/min oxygen via non-rebreather mask.

The obstetric registrar and your anaesthetic registrar are currently performing a Category 2 caesarean section in the emergency theatre.

How will you approach this situation?

80.0%

Viva 8

You have been contacted by a vascular surgeon to inform you of an upcoming case at your metropolitan hospital.

The patient is a 50-year-old previously well man who had a ten-day ICU admission for severe sepsis due to COVID-19 pneumonitis with Streptococcus pneumoniae superinfection, for which he was intubated and ventilated as well as treated with inotropes and vasopressors.

He was extubated one week ago and vasopressor support was weaned. He is currently on a medical ward.

He requires bilateral below-elbow amputations and a right below-knee amputation for vasopressor-induced irreversible ischaemia associated with intractable pain.

He has a resolving lung injury and remains on oxygen at 3 L/minute via nasal prongs.

Current observations:

SpO2 89% on room air

SpO2 95% on oxygen 3L/minute

Weight 80 kg (premorbid weight 85 kg)

Height 179 cm

BMI 25 kg/m2 (premorbid BMI 26.5)

Medications:

Ampicillin 1 g QID

Paracetamol 1 g QID

Pregabalin 50 mg TDS

Oxycodone/naloxone 20 mg/10 mg BD

Oxycodone infusion – 4 mg per hour intravenously

(Note - ketamine was trialled and removed due to nightmares and dysphoria)

The surgeon anticipates a surgical time of eight hours and will involve the use of bilateral upper limb tourniquets and skin grafting.

What factors would influence your decision regarding the timing of surgery?

79.1%

Viva 9

A 2-year-old boy has presented for left VATS and decortication for an empyema after a chest infection. He has been on the ward in your tertiary referral centre for three days receiving antibiotics.

There is no significant past medical history and he has normal developmental milestones.

Vital signs:

HR 130 bpm

BP 95/52 mmHg

respiratory rate 28 bpm

temperature 37.5oC

weight 12 kg

He has been discussed at a multidisciplinary meeting and has been deemed suitable for surgery.

His chest X-ray is presented here.

How would you assess this patient preoperatively?

76.4%

Viva 10

You are in working in the preadmission clinic, assessing a 40-year-old man who is booked for transsphenoidal resection of pituitary adenoma on your neurosurgical list next week.

Medical history:

Acromegaly

Obstructive sleep apnoea

Cardiomyopathy

Hypertension

Medications:

Candesartan 16 mg mane, recently increased from 8 mg mane

Frusemide 80 mg bd

Metoprolol 47.5 mg bd

Octreotide 40 mg monthly by intramuscular injection

Cabergoline 1.5 mg weekly

There are no known drug allergies.

Vital signs:

Height 185 cm

Weight 125 kg

BMI 36.5 kg/m2

HR 80 bpm

BP 145/70 mmHg

SpO2 96% on room air

His only previous anaesthetic was for adenotonsillectomy as a child.

What information will you seek on history to address your key concerns about this patient?

86.4%

Viva 11

A 40-year-old woman is booked on your list tomorrow for posterior fossa craniotomy and resection of medulloblastoma. She presents with a three-week history of worsening headache, ataxia and dysarthria.

She has a medical history of mild intellectual impairment, obesity (BMI 35) and an unrepaired Ebstein’s congenital cardiac anomaly.

The last cardiology review that is recorded in the hospital medical record was ten years ago and revealed the following:

Moderate tricuspid regurgitation (posterior and septal leaflets adherent)

Some right ventricular enlargement

Atrial septal defect

No evidence of tachyarrhythmias

The neurosurgeon wishes to perform the surgery with the patient prone with reverse Trendelenberg (head-up) positioning. A sagittal image of the patient’s brain MRI is displayed.

What specific information do you seek in your history and examination?

72.7%

Viva 12

You are part of the trauma team at a metropolitan hospital. You are notified that a 67-year-old woman is being brought in by road ambulance after a motor vehicle accident.

She was the driver and sole occupant of a car that veered off a country road and down an embankment. The extraction was complicated, and it is now three hours since her initial injuries.

On arrival, her airway is patent, and her cervical spine is immobilised. She has two 16G IV cannulas in situ.

Paramedics hand over that she is confused and has weakness in her left arm and leg.

Prehospital eFAST is positive, with free fluid in the pelvis. She has an open fractured right tibia and fibula.

Vital signs:

HR 105 bpm (atrial fibrillation)

BP 220/110 mmHg

RR 24 breaths/minute

Sp02 98% (6 L/minute oxygen via mask)

What are your priorities when evaluating her neurological status?

62.7%

Viva 13

You are the anaesthetist on call in a tertiary hospital. It is after-hours and you are still on site.

You are called to the Cardiac Catheterisation Laboratory to assist with the care of a 73-year-old man who is undergoing an urgent coronary angiogram after presenting to the emergency department an hour earlier with an ST-segment elevation myocardial infarct. His management was expedited as a “code STEMI”.

You are informed that he was initially stable and neurologically intact on arrival to hospital but is now hypotensive with a blood pressure of 73/48 mmHg, and is agitated and moving around.

What information do you seek on arrival at the Cardiac Catheterisation Laboratory?

77.3%

Viva 14

You are the anaesthetist covering the weekday morning emergency list in a tertiary metropolitan hospital. The emergency medicine physician on duty calls to inform you about a 55-year-old man who has presented with haematemesis. The only known past medical history is significant alcohol intake and his current medications are unknown.

He is currently in the Emergency Department.

His observations at the time of the call are:

HR 100 bpm

NIBP 90/60 mmHg

SpO2 96% on oxygen 6 L/min via Hudson mask

Height 1.7 m

Weight 72 kg

BMI 24.9kg/m2

His blood test results are as displayed.

He has a 20G IV cannula in his left basilic vein and is receiving 1 L crystalloid.

The gastroenterologist plans to perform an emergency endoscopy.

What will you prioritise in your initial assessment and management of this patient?

80.9%

Viva 15

You are the on-call anaesthetist working at a regional hospital on a Saturday evening.

You are requested to attend the Emergency Department as part of a Trauma Call activation.

The ambulance service has pre-notified of the imminent arrival of a 25-year-old woman who is 32 weeks pregnant. She was the restrained driver in a car involved in a high-speed collision with a large tree at an estimated speed of 90 km/h.

Pre-notification information from paramedics:

Maintaining her airway

SpO2 stable at 96% on oxygen via a non-rebreathing mask

RR 22 breaths per minute and stable

PR 115 beats per minute and stable

BP 105/60 mmHg and stable

GCS 15 and stable

Complaining of severe abdominal pain

Significant bruising across lower and left upper quadrant of abdomen

The patient is estimated to be 15 minutes away and you have been requested to be the Team Leader at the Trauma Call.

How would you prepare for the patient’s arrival?

80.0%

Viva 16

You are in the preadmission clinic reviewing a 38-year-old woman with breast cancer whom you will anaesthetise for bilateral mastectomy and immediate deep inferior epigastric perforator (DIEP) flap reconstruction in two weeks’ time.

Medical History:

Type 2 diabetes mellitus – diagnosed two years ago

Antiphospholipid syndrome – diagnosed three months ago after first episode of lower limb deep vein thrombosis with pulmonary embolism

Medications:

Rivaroxaban 20 mg daily

Metformin 500 mg twice daily

Empagliflozin 10 mg daily

Semaglutide 2 mg weekly (subcutaneously)

Examination

Weight 80 kg

Height 160 cm

BMI 31 kg/m2

Examination is otherwise unremarkable

Investigations

Full blood examination – normal, with haemoglobin 125 g/dL (120 – 160 g/dL)

Electrolytes, urea and creatinine – normal

Coagulation studies – normal

HbA1c

5.8% (normal value < 6%)

40 (normal value < 42 mmol/mol)

ECG – sinus rhythm

What advice would you give the patient regarding her medications in preparation for surgery?

80.9%

Viva 1

You are the anaesthetist on-call in a tertiary hospital. The vascular surgeon calls you to advise that an 82-year-old man with a contained rupture of an abdominal aortic aneurysm has just arrived in the emergency department, transferred from a secondary centre.

The surgeon advises that the aneurysm is not suitable for an endovascular technique and the patient requires an urgent open repair. You immediately attend the emergency department.

What is your initial assessment of this patient?

72.2%

Viva 2

You are the anaesthetist in the pre-assessment clinic of a day surgery hospital.

You are reviewing an 86-year-old man who has been booked for a wide local excision of a left temple squamous cell carcinoma (SCC) and rotational flap under local anaesthetic and sedation.

Medical History

Dementia (moderate) – lives in hostel

Atrial fibrillation (stable)

Hypertension (stable)

Medications

Dabigatran 110 mg twice daily

Diltiazem 180 mg mane

He has been brought to the clinic by his son, his enduring guardian, who is very concerned about the possibility for conversion to a general anaesthetic. The patient had a general anaesthetic for removal of an SCC on his leg last year and experienced postoperative delirium requiring a three-day hospital stay.

His observations and results of blood tests are included below.

Weight 65 kg

Body mass index 23 kg/m2

Heart rate 75 beats per minute

Blood pressure 140/80 mmHg

Respiratory rate 15 breaths per minute

SpO2 97 % on room air

⁠

What issues would you address during the preoperative visit?

84.4%

Viva 3

You are anaesthetising for an ophthalmology list at a standalone day-surgery unit with two operating theatres.

Your first patient is a 55-year-old man with a rapidly-progressive posterior subcapsular cataract in the right eye for a cataract extraction and intraocular lens insertion.

Medical history

Type 2 diabetes mellitus

oral hypoglycaemics

HbA1c 6.8% (51 mmol/mol)

no known end-organ disease other than cataracts

Highly myopic, blind in left eye after previous macular retinal detachment at age 51 years

Medications

Metformin 1 g twice daily

Allergies:

Nil

Examination is unremarkable, with body mass index of 24 kg/m2. Preoperative investigations have been reviewed and are normal. The patient is fasted and has been considered appropriate for day surgery.

What are your considerations when evaluating your options for anaesthesia for this patient’s cataract surgery?

75.6%

Viva 4

You are the visiting anaesthetist in a small rural town where you work once a month with a visiting urologist. You receive a telephone call from a nurse in the Emergency Department asking if you could come and assist the GP anaesthetist.

The ambulance service have just brought in a 25-year-old man who fell from the roof of a farm shed, where he had been sitting and drinking with friends. The GP anaesthetist intubated the patient on arrival to hospital because of reduced Glasgow Coma Scale (GCS) score and is requesting your assistance with ongoing management.

Describe your initial response to this request.

75.6%

Viva 5

A 70-year-old man presents on the day of surgery for an elective L2–L5 posterior lumbar intervertebral fusion (PLIF), with a plan for intraoperative neurophysiological monitoring.

Medical History

Back pain

Hypertension

Type 2 diabetes mellitus

Paroxysmal atrial fibrillation

Smoker

Medications

Sotalol 80 mg twice daily

Enalapril 10 mg twice daily

Metformin 500 mg twice daily

Paracetamol 667 mg three times daily

Meloxicam 15 mg daily

Gabapentin 600 mg three times daily

Tramadol 100 mg three times daily PRN

Vital Statistics

Height 1.80 m

Weight 101 kg

Body Mass Index (BMI) 31 kg/m2

Preoperative blood test results are included below. An electrocardiogram (ECG) was performed this morning on admission to hospital and is attached.

⁠

What further history would you seek from this patient before proceeding with his anaesthesia?

64.4%

Viva 6

You are working in a standalone day surgery facility.

A 2-year-old boy weighing 15 kg presents for the combined procedures of release of bilateral hand syndactyly and open orchidopexy for a unilateral undescended testis.

He has had a clear runny nose for the past three days, which his parents attribute to teething. A COVID-19 rapid antigen test performed this morning returned a negative result.

How will you decide whether to proceed with surgery or defer until a later date?

82.2%

Viva 7

You are the duty anaesthetist in a tertiary hospital. You receive a telephone call from the obstetric consultant working in the antenatal clinic today. She is with a 24-year-old woman who is currently 35/40 in her first pregnancy. The woman has been booked for a caesarean section in a week’s time for intrauterine growth retardation.

Medical history

Severe scoliosis – corrective posterior fusion surgery at 16 years of age

Height 1.45 m

Weight 42 kg

Body mass index 20 kg/m2

What are the important issues to consider in your assessment of this patient?

85.6%

Viva 8

You are the anaesthetist on evening duty at your tertiary-level hospital. You receive a call from the emergency medicine physician who requests your assistance with the management of a 50-year-old man who experienced a choking episode while eating a sausage for lunch.

The patient is thought to have aspirated a piece of the sausage and is somewhat distressed. The patient has a history of brittle asthma and chronic obstructive pulmonary disease with a 60 pack-year history of smoking. He has known tracheal stenosis for which he receives regular tracheal dilations.

Medications

Fluticasone 250 mcg via metered-dose inhaler (MDI) 2 puffs twice daily

Salmeterol 50 mcg via metered-dose inhaler (MDI) 2 puffs twice daily

Salbutamol 100 mcg via metered-dose inhaler (MDI) 2 puffs twice daily

The emergency medicine physician would like to transfer the patient straight to theatre.

How will you assess his suitability for urgent transfer to theatre?

74.4%

Viva 9

You are the anaesthetist allocated to the emergency theatre at a tertiary hospital.

You attend the holding bay to assess your next patient, who is a 30-year-old woman booked for an open repair of a right common femoral artery pseudoaneurysm. She has a history of substance use disorder and the injury is a result of self-injection.

The 18-gauge intravenous cannula inserted under ultrasound guidance in the emergency department is no longer patent. There is a radial arterial line in-situ.

Prehospital and emergency department management has included:

Ketamine 50 mg intravenously

Fentanyl 100 mcg (in aliquots) intravenously

Hartmann’s solution one litre intravenously

The patient’s biometric data and results of an arterial blood gas are included below.

Biometric data

Height 1.70 m

Weight 50 kg

Body mass index 17.3 kg/m2

Body surface area 1.51 m2

Ideal body weight 61 kg

Arterial blood gas (FiO2 0.44, Temperature 38.0°C)

⁠

Outline how the history of substance use disorder influences your assessment of the patient.

69.8%

Viva 10

You are the weekend on-call anaesthetist at a tertiary regional hospital.

A 45-year-old man has been transferred to your emergency department for management of a femoral fracture after he fell last night. He received a femoral nerve block and splint at the referral hospital before being transferred to your facility.

The surgeons are worried about increasing swelling and gross deformity of his thigh and would like to place a femoral nail as soon as possible.

The patient has a past history of chronic back pain that was associated with OxyContin misuse. The OxyContin was converted to buprenorphine after a spinal fusion four months ago.

He had breakfast six hours ago.

Medications

Buprenorphine 18 mg sublingual once daily

Pantoprazole 40 mg once daily

Observations

Heart rate 100 beats per minute

Blood pressure 110/85 mmHg

SpO2 95% on room air

Respiratory rate 16 breaths per minute

Weight 160 kg

Height 1.86 m

Body mass index 45 kg/m2

How would the previous opioid misuse and current buprenorphine use affect your approach to the management of this patient?

81.4%

Viva 11

You are working in a standalone psychiatry hospital covering a colleague’s electroconvulsive therapy (ECT) list.

The first patient is a 53-year-old anaesthetist colleague with severe depression who has been booked for ECT titration (first ECT treatment). You review her in her room prior to the start of the ECT list. She is visibly upset.

Medical history

Type 2 diabetes mellitus

Hypertension

Paroxysmal atrial fibrillation

Medications

Candesartan 16 mg daily

Rivaroxaban 10 mg daily

Venlafaxine 75 mg daily

What are the requirements to safely proceed with ECT in this standalone facility?

73.3%

Viva 12

You are the on-call anaesthetist attending a trauma call in a major trauma centre.

A 30-year-old male driver was brought to the hospital by paramedics after a high-speed collision with a tree. A laryngeal mask airway was inserted en route due a fall in his level of consciousness. There is extensive bruising over his right chest and a prominent seatbelt sign.

He has polycystic kidney disease and attends the hospital for regular haemodialysis through an arteriovenous (AV) fistula in his left arm. He is otherwise well and has no known allergies.

How does end-stage renal failure affect the trauma management of this patient?

59.3%

Viva 13

You are called to the neurosurgical theatre by your provisional fellow who requests your assistance. They have anaesthetised a 36-year-old woman for a craniotomy and open clipping of a saccular middle cerebral artery aneurysm.

The patient was admitted with a sudden onset of headache two days prior and was diagnosed with a World Federation of Neurosurgical Societies (WFNS) grade I subarachnoid haemorrhage.

Medical History

Hypertension

Asthma

Medications

Nimodipine 60 mg four-hourly

Irbesartan 150 mg daily

Salmeterol/Fluticasone 250/25 mcg via metered-dose inhaler (MDI) daily

Salbutamol 100 mcg via metered-dose inhaler (MDI) PRN

Allergies

Morphine (rash)

When you attend the theatre, you discover that the patient was induced, intubated and anaesthetised uneventfully. She is currently being maintained on total intravenous anaesthesia, with target-controlled infusions of remifentanil and propofol. The patient has an arterial line and a central venous catheter in situ. Surgery is underway.

The provisional fellow is concerned that the patient has developed high airway pressures and a heart rate of 120 beats per minute.

What is your approach to this situation?

68.6%

Viva 14

A 12-year-old boy with an intellectual disability presents for dental restoration and extractions at your tertiary paediatric hospital.

His parents report that he is fearful of needles and has been worried about the surgery and anaesthetic.

Weight 133 kg

Height 1.60 m

Body mass index 52 kg/m2

What specific concerns would you seek to clarify on history.

73.3%

Viva 15

You are the anaesthetist in the obstetric anaesthesia clinic in a tertiary hospital.

You are asked to assess a 28-year-old woman with paraplegia in her first pregnancy. She is 34 weeks pregnant and is booked for an elective caesarean section at term.

The referral states:

Paraplegia following a horse riding accident aged 16 years IVF conception/pregnancy

Medications

Amitriptyline 50 mg daily

Cranberry capsules

Folic acid

Iron supplements

Baclofen – discontinued with pregnancy

What specific information on history and examination will help you develop an anaesthetic management plan for this patient?

81.4%

Viva 16

You are providing anaesthesia for an elective ENT list. A 63-year-old man with a laryngeal squamous cell carcinoma is booked for a salvage laryngectomy, and neck dissection with a free flap reconstruction.

The patient was seen ten days ago in the preadmission clinic. He was documented to have chronic obstructive airway disease only, with no known cardiovascular disease.

His observations this morning were:

Heart rate 86 beats per minute

Blood pressure 128/75 mmHg

SpO2 95% on room air

Body mass index 18 kg/m2

Medications

Salbutamol 100 mcg via metered-dose inhaler (MDI) PRN

Salmeterol/fluticasone (50/250 mcg) via metered-dose inhaler (MDI) 2 puffs twice daily

In addition to the routine examination, please describe how you will assess this patient’s airway.

72.4%

Viva 1

A 50-year-old man presents to the Emergency Department of your tertiary centre two hours after the onset of swelling in the face and lips.

Medications:

Ramipril 5 mg once daily

Rosuvastatin 10 mg once daily

Allergies: Shellfish

As the duty anaesthetist, you have been telephoned by the Emergency Medicine physician and asked to assist with airway management. How will you respond to the request?

56.7%

Viva 2

You are the anaesthetist for an upper limb orthopaedic list. The next patient on your list is a 55-year-old man for a left arthroscopic acromioplasty and rotator cuff repair in the beach chair position. The expected duration of surgery is 2.5 hours.

Medical history:

Currently well, generally active

Hypertension

Obesity (body mass index 35 kg/m2)

Smoker 10/day

No known allergies

Observations:

Height 178 cm

Weight 110 kg

Heart rate 65 beats per minute

Blood pressure 125/75 mmHg

Medications:

Irbesartan 150 mg mane

Discuss your plan for this patient’s perioperative analgesia.

78.3%

Viva 3

You are reviewing a 10-year-old child on the day of surgery who has been scheduled for bilateral proximal femoral derotation osteotomies and tendon transfers with a left pelvic osteotomy. The child has a history of cerebral palsy, epilepsy, autism spectrum disorder and intellectual disability, attending a school for children with disability in year 3. They have had previous surgery on the right hip and can mobilise short distances with a frame but they use a wheelchair when out of the house.

Weight 25 kg.

Medications:

Baclofen 2.5 mg TDS

Gabapentin 30 mg nocte

Omeprazole 5 mg daily

Sodium valproate 250 mg BD

Describe your key points of discussion with the parents of this child.

77.5%

Viva 4

An 88-year-old woman is scheduled for an elective transcatheter aortic valve implantation (TAVI). Her aortic stenosis has been under surveillance since she underwent two-vessel coronary bypass grafting nine years ago. She has experienced worsening exertional dyspnoea (NYHA III) and orthopnoea over the past six months and had an admission for heart failure last month that responded to diuretics.

She is an ex-smoker (30 pack-year history) with moderate chronic obstructive pulmonary disease. Her current FEV1 is 1.2 litres (56% predicted). She had one admission for a respiratory illness in 2021 when she experienced COVID-19 pneumonitis.

Medications:

Amlodipine 5 mg mane

Aspirin 100 mg mane

Pantoprazole 20 mg mane

Ramipril 5 mg mane

Symbicort Turbuhaler (budesonide/formoterol) 200/6 mcg 2 puffs inhaled bd

Salbutamol inhaled prn

Biometrics:

Height 178 cm

Weight 58 kg

Body mass index 18.3 kg/m2

Body surface area 1.73 m2

What further information do you require on history?

79.2%

Viva 5

You are the anaesthetist in a regional hospital assigned to the morning emergency list. Your next patient is a 45-year-old man admitted the previous evening with haematuria and flank pain from a renal stone. He is booked for cystoscopy, laser litholapaxy and JJ stent insertion.

Past Medical History:

Hypertension

Type 2 diabetes mellitus

Ryanodine receptor mutation

Medications:

Metformin 500 mg BD

Ramipril 5 mg mane

CT Abdomen and Pelvis report conclusion:

The appearance of the left kidney is in keeping with obstructive uropathy and superimposed pyelonephritis.

What discussion points will you highlight in your pre-anaesthesia consultation with this patient?

69.2%

Viva 6

You are working in the MRI suite of a major regional hospital providing general anaesthesia.

Your next patient is a 35 year-old woman with sensorineural hearing loss for a brain MRI. She requires anaesthesia because of severe anxiety and claustrophobia. Her completed Patient Health Questionnaire is attached.

She received oral diazepam 10 mg one hour ago as premedication. She is calm and mildly sedated in the anaesthesia room adjacent to the MRI scanner.

Outline your preoperative assessment of this patient.

77.5%

Viva 7

You are called by the obstetrics registrar to insert an epidural catheter in a patient with preeclampsia for blood pressure management and labour analgesia. The patient is a 30-year-old primiparous woman who is at 35+5 weeks gestation. She has gestational diabetes (diet-controlled) and her only medication is low-dose aspirin for a family history of hypertension.

How will you assess this patient?

82.5%

Viva 8

You are the anaesthetist on-call for trauma in a major tertiary hospital. You have been asked to attend the Emergency Department for a 48-year-old man brought in by paramedics with stab wounds following a pub fight in a regional town two hours away.

He has no previous medical conditions and no known allergies.

You notice that he is obese. He is irritable but is obeying commands. He has a cut and bruising over his left eye. There are wounds on his abdomen covered by blood- soaked gauze packs, and further wounds on his leg, with a tourniquet on his upper thigh.

His observations are:

Heart rate 125 bpm Blood pressure 110/68 mmHg Respiratory rate 26 breaths per minute SpO2 96% on 10LO2/min via Hudson mask

The ED physician tells you that an eFAST scan is positive. The surgeon asks if you are able to go straight to theatre for exploratory laparotomy.

Would you prioritise Computed Tomography (CT) scanning for this patient before going to the operating theatre?

85.8%

Viva 9

As the duty anaesthetist, you receive a phone call from the emergency department physician at your regional hospital, requesting help with an incoming trauma patient. A 35-year-old male incarcerated person is being transferred by paramedics following an assault two hours ago whilst he was having his meal. He was kicked and punched in both the face and chest and there was an attempted strangulation.

You are informed over the phone that the patient has difficulty breathing and has bruising and swelling to the front of his neck but otherwise appears stable.

He has no allergies and is not on any medications. He smokes 10-15 cigarettes a day and has no significant medical history.

What actions will you take prior to the patient’s arrival?

73.9%

Viva 10

You are reviewing a 72-year-old woman in the anaesthetic bay of a metropolitan hospital. She is scheduled for an elective left total hip replacement and was previously assessed in the pre-anaesthetic clinic two months ago. Two years prior she underwent a right total knee replacement, which was complicated by a 48-hour High Dependency Admission as she was “slow to wake up” and required supplemental oxygen therapy.

Medical history:

Hypertension Obesity (body mass index 41 kg/m2)

Medications:

Atorvastatin 20 mg daily Candesartan/hydrochlorothiazide 16/12.5 mg daily

Outline the areas of focus in your preoperative assessment of this patient.

79.5%

Viva 11

You are the on-duty anaesthetist in a large regional centre with a paediatric surgical service. You are called to assist in the Emergency Department with the management of an otherwise healthy 2-year-old girl who has ingested drain cleaner (sodium hydroxide) at home about two hours ago. There are concerns about likely aspiration or inhalational injury from vapours.

The Emergency Medicine specialist tells you that the girl was brought in to hospital by her mother after she found the child sitting on the kitchen floor with a pile of drain cleaner crystals next to her and crystals on her hands and inside her mouth. The mother was unable to quantify the amount ingested. The girl vomited once on the way to hospital and is currently drooling and distressed in her mother’s arms.

What are the important issues to consider in the assessment of this child?

70.5%

Viva 12

You are working in the preadmission clinic, reviewing your patients for a respiratory medicine bronchoscopy list in a week’s time. Your next patient is a 74-year-old man who has been scheduled for an elective bronchoscopic lung volume reduction procedure by insertion of endobronchial valves.

Medical history:

Emphysematous chronic obstructive airways disease - home oxygen 1L/min, 18 hours per day

Ex-smoker – ceased 5 years ago, 60+ pack-year smoking history

Osteoarthritis

Peripheral vascular disease

Atrial fibrillation

Medications:

Ipratropium bromide MDI (21 mcg/puff) 2 puffs bd

Seretide Inhaler (fluticasone/salmeterol 25/250 mcg) 2 puffs bd

Salbutamol (100 mcg/puff) 2 puffs prn

Paracetamol 1 g tds

Rivaroxaban 15 mg daily

The respiratory physician will perform the procedure in the bronchoscopy suite of your major tertiary hospital and has requested the case be performed under general anaesthesia with spontaneous ventilation. The patient has a planned admission for two days post-procedure to monitor for any complications.

What further information about the procedure would you seek from the respiratory physician?

78.4%

Viva 13

You are an anaesthetist at a tertiary hospital working in the pre-anaesthetic clinic. You review a 74-year-old man who is booked for robotic assisted partial nephrectomy for a 5 cm right upper pole renal cell cancer.

Medical History:

Obesity

Controlled hypertension

Type 2 diabetes mellitus

Obstructive sleep apnoea (treated with CPAP)

Hypercholesterolaemia

Medications:

Amlodipine 10 mg daily

Aspirin 100 mg daily

Atorvastatin 40 mg daily

Empagliflozin 10 mg daily

Metformin 1000 mg twice daily

Perindopril 8 mg daily

Biometrics:

Height 183 cm

Weight 144 kg

BMI 43 kg/m2

How would you assess this patient for their partial nephrectomy?

92.0%

Viva 14

You are on-call from home for a private hospital that has Intensive Care and Interventional Radiological facilities. You receive a call from the Upper GI surgeon you regularly work with regarding a patient you anaesthetised ten days prior. The patient is a 72-year-old man who had a laparoscopic distal pancreatectomy to remove a pancreatic mass found incidentally.

Medical history:

Hypertension

Hypercholesterolaemia

Obesity (weight 108 kg, body mass index 34 kg/m2)

Medications:

Irbesartan 150 mg daily

Rosuvastatin 20 mg daily

The patient’s surgery and recovery were uneventful and he was discharged home on day four postoperatively. The patient’s anaesthetic, including airway management, was also uneventful.

The surgeon is calling you because the patient has just gone to radiology for coiling of a possible bleeding vessel and the surgeon wants to give you a “heads up” in case the patient needs to go to the operating theatre.

What further information would you like from the surgeon?

80.7%

Viva 15

A 28-year-old primigravida currently at 24 weeks gestation attends your high-risk obstetric clinic with her partner. She has recently been diagnosed with myotonic dystrophy and is under the care of a neurologist at your hospital. Her presenting symptoms were progressive muscle weakness and difficulty swallowing over a period of two years. She has had three hospital admissions for aspiration pneumonia, none of which required intensive care unit admission. The pregnancy has been confirmed with an early first trimester ultrasound scan and has been uneventful to date.

Observations:

Height 1.62 m

Weight 65 kg

Pulse rate 90 beats per minute

Blood pressure 100/60 mmHg

Respiratory rate 20 breaths per minute

SpO2 96% on room air

Airway examination:

Thyromental distance less than 5 cm

Mallampati class III

Inter-incisor distance greater than 4.5 cm

Good neck extension

Normal jaw protrusion

Cardiovascular examination:

Normal heart sounds with no additional sounds

No signs of heart failure

Neurologic examination:

Proximal muscle weakness

Presence of persistent grip with handshake

Mild scoliosis with curvature to left

Medications:

Bisoprolol 2.5 mg mane

Frusemide 20 mg mane

A recent transthoracic echocardiogram shows mild biventricular and biatrial dilation; left ventricular ejection fraction 45%; and pulmonary artery systolic pressure of 25 mmHg.

She would like to discuss options for labour analgesia. What would you recommend as the best option for her?

80.7%

Viva 16

You are urgently directed to Resuscitation in a metropolitan Major Trauma Centre. A 24-year-old driver was in a motor vehicle accident between his car and a lorry carrying 12-cm diameter pine logs, with a log penetrating the windshield and impaling his right thorax. The time since injury is 25 minutes. He is fully conscious and in severe pain.

His initial observations are:

Heart rate 128 bpm

Blood pressure 88/68 mmHg

Respiratory rate 28 breaths per minute

What further information do you require?

78.4%

Viva 1

You are the on-call anaesthetist at a private hospital. One of your regular colorectal surgeons has asked you to assess a 65-year-old man for an urgent laparoscopic high anterior resection for an obstructing tumour of his sigmoid colon. The surgeon would like to proceed later today and has booked an intensive care bed postoperatively in preparation.

Past medical history:

Hypertension

Ischaemic heart disease – percutaneous coronary intervention (PCI) six months prior after an acute coronary syndrome (ACS). A drug-eluting stent was placed in the left anterior descending coronary artery

Most recent echocardiogram at time of stent insertion – unremarkable with no regional wall motion abnormalities

Medications:

aspirin 100 mg daily

atorvastatin 40 mg daily

clopidogrel 75 mg daily

oxycodone 5 mg PRN

telmisartan 40 mg daily

The surgeon has asked for your advice regarding the perioperative management of his coronary stent and antiplatelet therapy. What is your advice?

71.0%

Viva 2

A 35-year-old primiparous woman is referred to your high risk obstetric clinic at 28 weeks gestation as she is a Jehovah’s Witness.

Medications:

pregnancy multivitamin

iron supplement

She has no known allergies.

Height 175 cm

Weight 83 kg

BMI 27 kg/m2

Outline your assessment of this patient.

91.0%

Viva 3

You are currently providing anaesthesia for the transoesophageal echocardiogram and cardioversion list. The cardiology registrar informs you that he has added a 65-year-old man to the end of the list. The patient presented to the emergency department two hours ago with severe shortness of breath. He has a history of multiple admissions to the Coronary Care Unit for management for his cardiac amyloid disease.

Medications on admission:

atorvastatin 40 mg daily

bisoprolol 2.5 mg daily

furosemide (frusemide) 40 mg twice daily

potassium chloride 1500 mg twice daily

prednisone 10 mg daily

rivaroxaban 20 mg daily

spironolactone 25 mg daily

⁠

What are the key issues concerning your management of this patient?

76.0%

Viva 4

On your morning vascular list today is a 78-year-old woman who has been scheduled for an elective carotid endarterectomy. She has been extensively reviewed in the preanaesthesia clinic. Her underlying cardiovascular disease is considered mild, stable and optimised. Her renal function is normal.

The patient has provided consent to receive either general anaesthesia or regional anaesthesia with conscious sedation. The surgeon has requested regional anaesthesia with conscious sedation.

Today’s observations:

SpO2 – 97% (room air)

HR 80 bpm, regular

BP 160/90 mmHg

RR 14 breaths/min

Height 166 cm

Weight 88 kg

BMI 31.9 kg/m2

Outline the key points you would explore before proceeding with a regional technique.

71.0%

Viva 5

You arrive at a trauma call in a regional hospital just as the emergency doctor has intubated the patient. As a self-inflating bag is being connected, a team member announces that they cannot feel a pulse.

You are told the patient is a 25-year-old male who fell approximately three metres as a result of collapsed scaffolding and has just been intubated because of increasing restlessness and a falling GCS (Glasgow Coma Scale).

You agree to lead the ongoing resuscitation.

The bedside monitor shows:

ECG HR: 120 bpm

Last recorded SBP: 90 mmHg

Blood pressure monitor is cycling and not recording a pressure

Pulse oximeter: 'searching'

How will you manage the resuscitation?

81.0%

Viva 6

You review a 42-year-old woman in the preanaesthesia clinic who is booked for left mastectomy and axillary clearance for breast cancer.

She has a history of nausea with opioid analgesics and experienced severe postoperative nausea and vomiting after a previous hysteroscopic fibroid resection.

What is your plan for anaesthesia and postoperative analgesia?

79.0%

Viva 7

It is the weekend and you are the anaesthetist on-duty at a remote regional hospital. You receive a request from the Emergency Department (ED) registrar to assist in the management of an 8-year-old boy who has hit a tree whilst mountain biking.

The boy has an open mid-shaft fracture of the femur and the ED staff have been unable to secure intravenous access.

Past Medical History:

asthma

attention-deficit/hyperactivity disorder

Medications:

methylphenidate 20mg daily

salbutamol 100 mcg prn

fluticasone 100 mcg daily

What major issues are you going to consider in the management of this child?

87.0%

Viva 8

A 55-year-old woman is admitted from the emergency department for management of severe low back pain. She has a history of chronic back pain and had an epidural steroid injection one week ago which has not improved her symptoms.

She weighs 87 kg, BMI 31 kg/m2.

Current medications:

empagliflozin 10 mg daily

buprenorphine patch 15 mcg/hr transdermally

fluoxetine 20 mg daily

gabapentin 300 mg twice daily

metformin 1 g twice daily

paracetamol 500mg + codeine phosphate 30 mg, 1-2 tabs 4-hourly PRN

perindopril 10 mg daily

As a member of the acute pain service, you are asked to see her and advise on the best management of her pain.

How will you assess her?

80.0%

Viva 9

You are an anaesthetist at a metropolitan private hospital. A 22-year-old woman requires surgery for an acute abdomen. She is day 4 post-laparoscopic sleeve gastrectomy that was performed for obesity. The ICU specialist has called you with her blood results.

sodium 140 (135 – 145 mmol/L)

potassium 3.0 (3.5 – 5.5 mmol/L)

chloride 112 (95 – 110 mmol/L)

bicarbonate 16 (20 – 32 mmol/L)

urea 8.7 (3.5 – 8.5 mmol/L)

creatinine 90 (60 – 110 µmol/L)

urate 0.41 (0.20 – 0.50 mmol/L)

calcium 2.10 (2.15 – 2.55 mmol/L)

phosphate 0.80 (0.80 – 1.50 mmol/L)

magnesium 0.58 (0.65 – 1.00 mmol/L)

glucose 14.2 (3.6 – 6.0 mmol/L)

Usual medications:

empagliflozin 10 mg daily

escitalopram 20 mg daily

lansoprazole 30 mg bd

metformin 500 mg bd

vitamin D 1000 IU daily

Outline your preoperative assessment and preparation of this patient for surgery.

78.0%

Viva 10

You are the obstetric anaesthetist on duty at a major public hospital. A 22-year-old primigravida is undergoing an induction of labour at 37 weeks gestation for fetal intrauterine growth restriction. Her BMI is 17 kg/m2.

Her medical history includes previous oxycodone substance use disorder, for which she takes Suboxone (buprenorphine-naloxone 32 mg/8 mg sublingually every second day). She has no other medical or obstetric history.

She had an epidural catheter inserted in early labour by a colleague for analgesia. Although she has difficult venous access, an ultrasound-guided 18-gauge cannula was successfully sited in her cubital fossa.

The morning handover indicates that the patient has required two clinician epidural top-ups overnight due to unsatisfactory analgesia. There is now reduced fetal heart rate variability on cardiotocogram (CTG) and the obstetric team would like to place a fetal scalp electrode. The patient is refusing this intervention due to persisting discomfort. The obstetric team requests your assistance to improve her analgesia.

What are your initial priorities in the management of her pain?

88.0%

Viva 11

A 63-year-old woman is booked for a pulmonary vein isolation for atrial fibrillation today. She is scheduled to be the first case on your afternoon list in the cardiac catheter laboratory.

She describes episodic palpitations lasting 30 to 40 minutes up to five times a day with associated fatigue and exertional limitation.

Past medical history:

Ischaemic heart disease – drug-eluting stent (DES) to proximal LAD 12 weeks ago for stable angina symptoms

Hypertension

Type 2 diabetes mellitus

Obstructive sleep apnoea requiring nocturnal CPAP

Elevated BMI (41 kg/m2)

Chronic kidney disease - baseline eGFR 65 mL/min/1.73m2

Current medications:

apixaban 5 mg bd

aspirin 100 mg daily

clopidogrel 75 mg daily

dapagliflozin 5 mg daily

bisoprolol 2.5 mg bd

insulin glargine 20 units nocte subcutaneously

irbesartan/hydrochlorothiazide 150 mg/12.5 mg daily

pantoprazole 40 mg daily

rosuvastatin 10 mg nocte

An ECG has been taken this morning. Her blood pressure is 118/79 mmHg and SpO2 98% (room air).

⁠

What additional information would you like to obtain from the patient prior to commencing anaesthesia?

70.0%

Viva 12

You are seeing a 58-year-old man in preadmission clinic prior to elective open abdominal aortic aneurysm repair.

He is known to have hypertension, hypercholesterolaemia and aortic regurgitation. He stopped smoking when his aneurysm was diagnosed 6 years ago.

He lives independently in his own home with his wife.

He uses a stationary exercise bike three times per week for 20 minutes and enjoys gardening.

Current medications:

amlodipine 5 mg daily

aspirin (enteric-coated) 100 mg daily

enalapril 10 mg daily

simvastatin 20 mg daily

How will you evaluate this man for the proposed procedure?

69.0%

Viva 13

A 62-year-old woman has just arrived by ambulance to your burns centre emergency department and you have been called to assist as part of the trauma team. She was caught in a house fire where she was trapped indoors for ten minutes before firefighters were able to free her. Forty-five minutes have lapsed since rescue.

Past medical history:

Smoking 40 pack-year history

Mechanical mitral valve replacement

Chronic kidney disease

Medications:

warfarin 5 mg daily

Examination findings:

Approximate weight 70 kg

SpO2 99% (oxygen via Hudson mask at 10 L/min)

HR 120 bpm (sinus rhythm)

BP 100/70 mmHg

RR 21/min, shallow breathing and coughing intermittently

Chest auscultation: mild diffuse wheeze.

Her burn injuries have been documented by the paramedic in the diagram overleaf (hashed areas). The burnt skin is a blotchy red or dark pink colour and has large blisters. Capillary refill is sluggish (> 2 seconds) and there is loss of sensation in some areas.

She is confused about the events, visibly distressed and in pain. She has been administered 10 mg of morphine intravenously.

⁠

How do you assess her burn injuries?

66.0%

Viva 14

You are asked to review a 40-year-old man in the emergency department who has trismus secondary to a dental abscess. He has severe intellectual impairment and is nonverbal. His caregiver is with him.

The maxillofacial surgeon wishes to bring him to theatre urgently to remove a lower molar tooth and incise and drain his submandibular abscess.

⁠

How will you assess this man’s airway?

76.0%

Viva 15

A 2-year-old girl weighing 13 kg presents for bilateral strabismus (squint) surgery at a stand-alone day surgery facility.

She was born at 34 weeks gestation weighing 2.2 kg.

How will you establish she is suitable for day surgery?

81.0%

Viva 16

You are an anaesthetist working in a major hospital which includes neurosurgery.

You are currently in the preanaesthetic assessment clinic reviewing a 52-year-old man for his suitability to undergo awake craniotomy for tumour resection.

He presented with a headache and right-sided weakness two weeks ago.

Since diagnosis, his oral medications are:

dexamethasone 4 mg TDS

levetiracetam 500 mg BD

Weight 110 kg, height 182 cm (BMI 33kg/m2).

⁠

What does this scan show and how will you assess this patient’s suitability for awake craniotomy?

78.0%

Viva 1

A 30-year old man booked for an emergency laparoscopic cholecystectomy for a gangrenous gallbladder. He has a past medical history of juvenile idiopathic arthritis (formerly juvenile rheumatoid arthritis).

He appears unwell and is vomiting.

Vital signs

Blood pressure 100/60 mmHg

Heart rate 120 bpm

SpO2 93% (room air)

Respiratory rate 20 per minute

T 38.5°C

Based on the provided history and findings, describe your initial assessment of this patient.

76.5%

Viva 2

You are on-call at a tertiary hospital and receive a theatre booking from a surgeon at 23:00 hours for an urgent endoscopic retrograde cholangiopancreatography (ERCP).

The patient is a 30-year-old male (weight 60 kg) who presented with a three-day history of vomiting and jaundice and has been diagnosed with ascending cholangitis due to choledocholithiasis.

He is febrile at 38.5°C and tachycardic at 110 bpm.

His past medical history includes stage III testicular cancer diagnosed 12 years ago, for which he underwent radical orchidectomy followed by 18 months of chemotherapy with bleomycin and cisplastin.

During his latest surveillance review with oncology he was sent for some further investigations to assess progressive shortness of breath. His pulmonary function tests and chest X-ray are shown below.

⁠

What further information would you like to obtain?

83.7%

Viva 3

You are the on-call consultant in a regional hospital. The anaesthesia registrar calls you at 22:30 hours reporting that there is a 14-month-old child in the emergency department with a foreign body in the mid-oesophagus visible on chest X-ray. There is an ENT consultant available to take the child to theatre.

⁠

How would you assess the urgency of this case?

77.6%

Viva 4

You are the anaesthetist on-call in a large regional hospital. You have been asked to provide epidural analgesia to a 32-year-old parturient (gravida 1, para 0, 41+1 weeks gestation) after commencement of induction of labour for prolonged pregnancy.

The midwife informs you that the patient moved from Mongolia two years ago and is not fluent in English, although her husband in fluent in English. She has had an unremarkable antenatal course.

Her past medical history includes mild asthma (no regular treatment required).

When you attend the patient, she is noted to be in established labour with some distress due to contraction pain. She is 148 cm tall and weighs 55 kg.

How will you obtain consent for this patient’s labour epidural?

90.8%

Viva 5

A 76-year-old man with infected pacing wires has been scheduled for removal of his entire pacing system under general anaesthesia. The procedure is to be performed in a hybrid theatre in the cardiology department.

Current medications

aspirin 100 mg daily

atorvastatin 40 mg daily

flucloxacillin 2g qid IV

perindopril 1 mg daily

His chest X-ray is displayed.

Considering your clinical assessment of this man, what are your main areas of concern?

65.3%

Viva 6

You are the duty anaesthetist in a small regional hospital and have been called urgently to assist the anaesthesia registrar in the emergency theatre.

The registrar is anaesthetising a previously well 25-year-old man (75 kg, ASA I) who is undergoing open reduction and internal fixation of a fractured tibia and fibula sustained in a skiing accident two days ago. The registrar has noted progressive desaturation and increasing tachycardia over last 15 minutes. The surgeons have deflated the torniquet and are closing the wound.

⁠

What will you do when you enter the operating room?

80.6%

Viva 7

You are the anaesthetist on-call in a major trauma centre. The orthopaedic registrar has booked a 45-year-old woman for an urgent C3 – C7 decompression and fusion for C5/6 bilateral facet joint fracture-dislocations. She has an incomplete spinal cord injury.

The patient sustained the injury jumping off a cliff in an act of deliberate self-harm. She has had a prolonged extraction time due to difficult terrain.

Past medical history

anxiety and depression with multiple previous suicide attempts

polysubstance use disorder with previous intravenous drug use

Medications

clonazepam 0.5 – 1.0 mg PRN for anxiety

methadone 100mg mane

quetiapine 300mg nocte

⁠

Please comment on her chest X-ray.

77.6%

Viva 8

A 75-year-old woman presented to the emergency department following a fall in which she sustained a fractured right hip. She has no other injuries and is cognitively intact. She has been scheduled for a right hemiarthroplasty as the first case on the operating list tomorrow morning.

Past medical history

Polymyalgia rheumatica

Chronic alcohol consumption (60 g per day)

Previous deep vein thrombosis with pulmonary embolism

Chronic kidney disease

Height: 162cm Weight: 61kg

Medications

Fluoxetine 40 mg mane

Perindopril/indapamide 5 mg/1.25 mg mane

Prednisolone 15 mg mane

Rivaroxaban 15 mg mane

Rosuvastatin 20 mg mane

Blood test results on admission to the emergency department:

Haemoglobin 82 g/L (115-160)

Platelets 117 x10^9/L (150-450)

Na+ 127 mmol/L (135 - 145)

K+ 4.2 mmol/L (3.5 - 5.5)

Cl- 103 mmol/L (95 - 110)

HCO3- 20 mmol/L (20 - 32)

Urea 12 mmol/L (2.5 - 7.0)

Creatinine 145 mmol/L (45 - 95)

eGFR 30 mL/min/1.73m2 (>90)

Albumin 26 g/L (33 - 46)

A cardiac rhythm strip was printed in the Emergency Department, as shown below:

⁠

How will you assess if this patient is suitable for surgery tomorrow morning?

81.6%

Viva 9

You are running the emergency theatre in a regional hospital on a Sunday morning when you receive a phone call from the emergency department (ED) consultant.

A 23-year-old man with an intellectual disability has presented with a productive cough and haemoptysis after a choking episode the previous evening whilst eating dinner.

The ED consultant asks you to provide assistance with sedation for a CT chest due to the patient’s non-compliance with lying still.

What would you like to know from the ED consultant when she calls you?

72.2%

Viva 10

A 74-year-old woman presents to the preanaesthesia clinic for review ahead of a laparoscopic right hemicolectomy for colorectal cancer. She is a smoker and has a background of longstanding bronchial carcinoid tumours.

How would you assess this woman?

75.6%

Viva 11

You have been asked to take over an elective list at a tertiary paediatric hospital as the regular anaesthetist is delayed in the postanaesthesia care unit by a postoperative airway event.

The next patient is a five-year-old First Nations boy (weight 28 kg) from a regional centre who is accompanied by his grandmother who is his legal guardian. He is booked for adenotonsillectomy for the management of obstructive sleep apnoea. His surgery was previously cancelled three months ago. The anaesthetist had just administered ketamine and midazolam premedication to this child when he was called away.

What further information do you require to proceed with this case.

74.4%

Viva 12

You are the anaesthetist covering the obstetric theatre at a large regional hospital. A 30-year-old primiparous woman at 38 weeks gestation is booked for a category 2 caesarean section for a non- reassuring cardiotocograph (CTG).

The patient has pre-eclampsia with a blood pressure of 160/100 mmHg while on antihypertensive treatment. She is not currently in labour. She is morbidly obese with a BMI of 58 (height 168 cm, weight 164 kg).

When you review the patient, she tells you that she is needle-phobic and wants to “be asleep” for the procedure.

Current medications

Labetalol 40 mg q30 min IV

Magnesium 1g / hour IV

Methyldopa 500 mg PO QID

Nifedipine IR 10 mg PO

There are no known drug allergies.

How will you approach this situation?

74.4%

Viva 13

A 28-year-old male is booked on your list for resection of a large right-sided posterior mediastinal tumour. This was diagnosed after he presented with increased breathlessness and cough. He has no other significant comorbidities.

⁠

How will you assess this patient preoperatively?

76.7%

Viva 14

You are the on-call consultant anaesthetist at a small regional hospital. At 09:00 hours on a Saturday morning you receive a call from the surgical registrar regarding a 69-year-old man who presented to the emergency department with a 24-hour history of worsening abdominal pain. An erect chest X-ray demonstrates free gas under the diaphragm.

The surgical registrar would like to bring the patient to theatre for a laparotomy.

Past medical history

Current smoker – 50 pack-years

Ischaemic heart disease – non-obstructive, medical management

Abdominal aortic aneurysm – 4 cm diameter, currently under surveillance

Medications

Aspirin 100 mg daily

Atenolol 50 mg daily

Ibuprofen 400 mg tds PRN

Perindopril 5 mg daily

Rosuvastatin 20 mg daily

Height 175 cm

Weight 80 kg

BMI 26.1 kg/m2

(ideal body weight 70 kg)

Outline how you would respond to this request.

80.0%

Viva 15

As the duty anaesthetist in a tertiary hospital, you are asked to attend the emergency department for the impending arrival of a 38-year-old male who has been struck on the head while working on a building site. On arrival with the paramedics he is unconscious with a laryngeal mask airway in situ. He has a compression bandage applied to his head and severe right periorbital and midface swelling

The initial observations from the paramedics are as follows:

Heart rate 76 bpm

Blood Pressure 167/90 mmHg

SpO2 90% spontaneous ventilating on a T-piece with oxygen at 15 L/min

Respiratory rate 28/min

Left pupil size 4 and non-reactive

Right pupil size 2 and sluggishly reactive

What are your priorities in the management of this patient?

75.6%

Viva 16

You are seeing a 72-year-old man in the preanaesthesia clinic of your tertiary hospital. He is booked for a wide local excision of a sarcoma of the right latissimus dorsi muscle in ten days time.

The surgeon requests that he is positioned in the left lateral decubitus position. The surgery is anticipated to take two to three hours.

Past medical history

Coronary artery stent

Type 2 diabetes mellitus

Hypertension

Transient ischaemic attack two years ago

Medications

Clopidogrel 75 mg daily

Metformin 500 mg twice daily

Perindopril 8 mg daily

Rosuvastatin 20 mg daily

Observations performed in clinic

Blood pressure 165/95 mmHg

Heart rate 85 bpm

SpO2 98% on room air

Random blood glucose 8.5 mmol/L

Height 1.78m Weight 95 kg BMI 30

How will you assess this patient’s cardiovascular system?

73.3%

Viva 1

You review a 67-year-old man in the Preadmission Clinic (PAC) for a left hemihepatectomy via a roof-top incision for metastatic colon cancer.

He underwent a right hemicolectomy four months ago for primary cancer resection. The procedure was complicated by an extended stay in hospital due to suboptimal pain management.

Past medical history:

Hypertension

Lower limb peripheral neuropathy secondary to chemotherapy

Ex-smoker with 30 pack-year history

Medications & allergies

perindopril 5 mg daily

amitriptyline 25 mg nocte

Nil known allergies

Observations in PAC

BP - 160/85 mmHg

HR- 75 bpm

SpO2 - 98% on room air

weight - 65 kg

height - 180 cm

BMI – 20 kg/m2

Liver function test results:

⁠

All other blood results are normal.

Outline your concerns regarding the patient’s fitness for surgery.

69.9%

Viva 2

You are on call at the Children’s Hospital. At 1730 hours you are asked to review a 7-year-old girl with Down syndrome in the Emergency Department (ED) who sustained a supracondylar fracture of the left humerus whilst playing on a trampoline at a birthday party. She is booked on the emergency list for closed reduction and percutaneous pinning of the fracture.

On your arrival in ED you are informed that the girl has received intranasal fentanyl 50 mcg following one unsuccessful attempt to gain IV access.

The dose of fentanyl was based on a weight of 31 kg which had been documented in the girl’s case notes at a recent outpatient clinic appointment.

How will you approach your anaesthetic assessment of this girl?

86.0%

Viva 3

You attend the subacute Coronary Care Unit to review a 52-year-old man with a six week history of increasing dyspnoea who has been scheduled for revision aortic valve replacement +/- mitral annuloplasty tomorrow.

His past history includes a bioprosthetic aortic valve replacement eight years ago.

On admission his echocardiogram showed severe aortic regurgitation and moderate mitral regurgitation, with an estimated left ventricular ejection fraction of 35% and a moderately dilated left ventricle.

His only regular medication prior to this admission was aspirin 100 mg daily, but during this admission he has been commenced on:

furosemide (frusemide) 80 mg bd orally

perindopril 6 mg mane orally

dobutamine infusion 2.5 mcg/kg/min intravenously.

When you attend the ward you find him walking around with his IV pole.

He weighs 80 kg.

Outline how you would determine if this patient is optimised for his surgery.

73.1%

Viva 4

A 32-year-old woman attends the obstetric anaesthetic assessment clinic, having been referred by the obstetric registrar.

She is 24 weeks into her first pregnancy, and has a history of multiple sclerosis. She uses a walking stick. Her other medical history includes anxiety.

There are no other relevant obstetric, medical or anaesthetic issues. She had an uneventful general anaesthetic for an appendicectomy at this hospital last year for which you have the anaesthetic record. There were no airway issues.

She takes escitalopram and has monthly ocrelizumab infusions, which have been withheld in pregnancy. She has no allergies.

She wishes to discuss analgesia in labour and anaesthesia should a caesarean or other operative intervention be required.

What further information do you require to address the patient’s concerns?

83.9%

Viva 5

Your next patient on the emergency list is a 24-year-old man scheduled for a laparoscopic appendicectomy. His only past medical history is that of occasional self-limiting palpitations on exertion. He has been sick for three days with severe abdominal pain, nausea and vomiting.

He weighs 70 kg.

His vital signs are:

temperature 38.5° C

heart rate 106 bpm

blood pressure 100/71 mmHg

The surgeon suspects a perforated appendix.

He has an electrocardiogram (ECG) in his notes.

⁠

Please describe this ECG

76.3%

Viva 6

You are assessing a patient on the neurosurgical ward who is booked on your list tomorrow for coiling of cerebral aneurysms in the hospital’s interventional radiology suite.

The 56-year-old woman presented earlier in the day with a two day history of severe headache, vomiting and malaise that was unresponsive to paracetamol. There has been no change to her level of consciousness or focal neurological deficits.

Cranial CT revealed five intracerebral aneurysms, the largest in the anterior communicating artery. There is evidence of diffuse subarachnoid haemorrhage, Fisher grade 2.

Her vital signs are:

blood pressure 145/75 mmHg MAP 88 mmHg

pulse 85/min sinus rhythm

Past medical history

Polycystic kidney disease

renal transplant 10 years ago

end-stage renal disease treated with haemodialysis for two years prior to transplantation

Hypertension

Medications

atorvastatin 20mg daily

enalapril 5mg BD

mycophenolate 1g BD

prednisone 5mg daily

tacrolimus 5mg BD

trimethoprim / sulphamethoxazole one tab BD

What specific information do you require about this patient’s medical problems to ensure optimisation for the coiling procedure?

72.0%

Viva 7

A 50-year-old woman has been transferred to your tertiary referral centre for a total thyroidectomy for a massive goitre with associated recent voice change.

You review her on the ward as she is booked on your list for the following day.

Medications:

carbimazole 15 mg bd

propranolol 40 mg bd

rosuvastatin 10 mg daily

Weight 120 kg

Height 165 cm

BMI 44 kg/m2

⁠

How will you assess her airway preoperatively?

83.9%

Viva 8

You are the on-call anaesthetist for a regional base hospital. It is 2030 hours and you have just arrived in the carpark to review a patient for tomorrow’s elective operating list, when you receive a request for assistance from the ED consultant. He is busy resuscitating a sick patient and cannot attend a new category 1 trauma patient that has just arrived by ambulance.

The new arrival is a 45-year-old man who has been assaulted at a local hotel. He has been struck in the neck with a broken beer bottle and was found by paramedics lying on the floor of the public bar. They noticed profuse bleeding from an anterior neck wound before applying some gauze.

He is restless, irritable and combative.

How are you going to manage this situation?

73.1%

Viva 9

A 45-year-old man presents to your Preadmission Clinic for a review ahead of an open left adrenalectomy for phaeochromocytoma in four weeks time.

He currently takes the following medications:

Bio Magnesium supplements 2 capsules daily

dapagliflozin 10 mg mane

enalapril 40 mg mane

frusemide 20 mg mane

metoprolol 100 mg BD

How would you assess a patient with a phaeochromocytoma who is to undergo surgical resection?

81.2%

Viva 10

You are the duty anaesthetist in a regional hospital. You are called to the Emergency Department by the surgical registrar to review an 8-year-old boy who has been booked for an urgent appendicectomy.

The child has been previously well and presents with a three day history of abdominal pain and vomiting.

An ultrasound has been performed which suggests appendicitis. The surgical registrar would like to operate as soon as possible as he thinks the child is showing signs of sepsis.

Initial information on booking:

weight 25 kg

pulse 150 bpm

BP 80/40 mmHg

RR 45 bpm

temp 37.3° C

FBC:

Hb 120 g/L (110- 155)

WCC 17 x109 /L (4-11.0)

Plt 250 x109/L (140-400)

Electrolytes and renal function:

Na 133 mmol/L (133-144)

K 3.5 mmol/L (3.6-5.3)

Cl 104 mmol/L (97-110)

Bicarbonate 8 mmol/L (22-29)

Urea 5.0 mmol/L (2.7-7.8)

Creatinine 35 µmol/L (20-44)

What specific features would you look for in the assessment of this child?

81.2%

Viva 11

You are seeing a 64-year-old man in the Preadmission Clinic who is booked for a left lower lobectomy for non-small cell carcinoma.

He is on your list in two weeks’ time.

Past Medical History:

hypertension

type II diabetes mellitus

paroxysmal atrial fibrillation

Medications

perindopril 2mg bd

rivaroxaban 20 mg daily

metoprolol 50mg bd

empagliflozin 10mg daily

He currently smokes 1 packet cigarettes per day and has a 42 pack-year history.

Height - 177cm Weight - 74 kg BMI 23.6 kg/m2

His chest CT scan is displayed below.

⁠

How will you assess this patient’s suitability to undergo a lobectomy?

82.5%

Viva 12

You are asked to provide analgesia for a 26-year-old woman who presented in labour to your regional hospital on a weekday. She has a three month history of shortness of breath on minimal exertion. She has not presented for any antenatal care during the pregnancy and the shortness of breath has not been investigated. Otherwise she has had an uneventful pregnancy.

Her observations are:

Pulse 110/min

BP 110/80 mmHg

Respiratory rate 24/min

SpO2 95%

Height 170 cm

Weight 75 kg

How will you assess this patient?

83.8%

Viva 13

A 47-year-old woman with acromegaly attends your preoperative assessment clinic one week prior to undergoing a transsphenoidal hypophysectomy for pituitary adenoma. She has a history of hypertension and type II diabetes mellitus. She is a heavy smoker, has a hoarse voice and reports a recent hospital admission for investigation of shortness of breath on exertion.

Medications:

lisinopril 20 mg daily

metformin 1000 mg nocte

metoprolol 100 mg mane

octreotide 75 mcg subcutaneously x 3 daily

What features of the history will help you determine the severity of her condition?

86.2%

Viva 14

You are reviewing a 44-year-old man for revision ventriculoperitoneal shunt for congenital aqueductal stenosis which was first diagnosed at age 13. This operation will be his fourth revision. He is an inpatient on the neurosurgical ward.

His current medications are:

dexamethasone 4 mg bd orally

omeprazole 20 mg mane orally

levetiracetam (Keppra) 250 mg bd orally

⁠

Please comment on the CT scan and explain what specific information you would like in your assessment of this patient.

88.8%

Viva 15

You are working in the day surgery unit of a large regional hospital and allocated to a gynaecology list with a registrar. The next patient on the list is a 23-year-old woman booked for a hysteroscopic myomectomy.

Past Medical History

Menorrhagia secondary to uterine fibroids

Anxiety

Medications

Ferrous sulphate

Fluoxetine

Past Surgical History

Hysteroscopic myomectomy 2019

What additional information would you like to obtain to assist in formulating an anaesthetic plan?

78.8%

Viva 16

You are the on-site anaesthetist in a large regional centre and have been called to the Emergency Department to assist with the management of an 70 year-old woman who was brought in by ambulance ten minutes ago after falling down the stairs at home.

The patient lives independently and was discovered at the base of the stairs by her visiting daughter this morning after having fallen down the stairs last night. The patient was unable to reach the telephone to call for help and was not wearing her personal alarm button.

The patient is sitting up on a trolley and appears short of breath.

Observations:

HR - 113 bpm

BP – 148/92 mmHg non-invasively

SpO2 - 92 % on oxygen 15 l/min via non-rebreather mask

GCS - 12 (E3 V4 M5)

Past medical history:

atrial fibrillation

chronic back pain

Regular medications:

apixaban 2.5 mg bd

buprenorphine transdermal patch 15mcg/hour

digoxin 125 mcg daily

perindopril 2 mg daily

Describe your initial assessment and management of this patient.

83.8%

Viva 1

A 47-year-old male is brought into the emergency department of a tertiary hospital where you are the anaesthetist on call.

He has sustained abdominal gunshot wounds about 2 hours ago with only minor revealed bleeding obvious. He is diaphoretic and agitated requiring restraint. Your help is required to assist keeping him still enough for larger bore intravenous access (he currently has a 20 gauge cannula) and CT angiogram. He is believed to have recently used methamphetamine.

Observations

⁠

He has a background of illicit drug use and a known methamphetamine induced cardiomyopathy (ejection fraction 20-30% on recent echocardiogram). He has extremely poor dentition (“Meth Mouth”).

Medications

⁠

How would you assess his volume status for anaesthetic intervention prior to imaging?

71.0%

Viva 2

You are called to the Emergency Department at 12pm to assess a 75-year-old female with an acute anterior cerebral circulation ischaemic stroke. She has facial paresis, arm weakness and abnormal speech.

Her past history includes atrial fibrillation, type 2 diabetes and hypertension.

Her medications are:

Table

⁠

The onset of symptoms was 2 hours prior to admission. Her GCS is 15 and she is compliant with instructions. She has been scheduled for urgent clot retrieval.

What will you do when you arrive in the Emergency Department?

88.0%

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Viva 1

You are the duty anaesthetist in a teaching hospital.

The anaesthetist in the emergency theatre is a senior registrar. His next patient is an obese 56-year-old man for laparoscopic cholecystectomy, following a recent episode of pancreatitis.

As you pass the anaesthetic holding area the registrar is finishing his preoperative assessment of the patient.

You notice that the patient has a hoarse voice and appears somewhat short of breath.

How will you proceed?

75.0%

Viva 2

Your junior anaesthetic registrar calls you from the emergency department where he has just assessed a 20-year-old woman who requires an urgent laparoscopic appendicectomy.

He states that the patient says she was a blue baby and had several complex cardiac operations when she was a child.

Her current medications are:

aspirin 100 mg daily

enalapril 5 mg daily

digoxin 250 µg daily

frusemide 80 mg daily

She has no allergies.

Here are schematic representations of a normal cardiac circulation and the patient’s current Fontan circulation.

What further information would you like?

71.2%

Viva 3

Following a fall, a 78-year-old man needs a dynamic hip screw for an intertrochanteric fracture.

His past history includes:

Ischaemic heart disease

STEMI in 2014 followed by coronary stenting for double vessel disease

latest LVEF 23% with severe segmental left ventricular impairment and stage C heart failure

NYHA III

Peripheral vascular disease

open abdominal aortic aneurysm repair in 2010

right leg claudication

Hypertension

Poorly controlled gastro-oesophageal reflux

His current medications:

aspirin 100 mg mane

quinapril 20 mg mane

frusemide 40 mg bd

metoprolol 25 mg bd

spironolactone 25 mg bd

omeprazole 20 mg mane

His recent blood tests show: (reference range)

Haemoglobin 110 g/l (130–170)

Platelets 95 x109 /l (150–450)

Albumin 29 g/l (35–55)

What are the important preoperative issues in this patient?

63.7%

Viva 4

You are the on-call consultant anaesthetist and currently at home.

At 7 pm you receive a call from your first year trainee anaesthetic registrar who is attending a referral in the emergency department.

The patient is a 36-year-old G3P2 pregnant woman, with vaginal bleeding at 33 weeks gestation.

Her previous deliveries were by elective caesarean section.

An ultrasound scan at 28 weeks apparently showed a low lying placenta, but she has not had further follow-up.

What further information do you need and how will you advise the registrar?

86.2%

Viva 5

You are the on-call consultant anaesthetist at a large regional hospital.

The anaesthetic registrar rings to inform you of a 24-year-old man booked for knee washout for septic arthritis.

The patient has been unwell for one week with fever, rigors and chills. His left knee has been painful and swollen for three days.

He initially presented to a peripheral hospital 12 hours earlier. After cultures were taken and antibiotics commenced he was transferred for further orthopaedic assessment and management.

His only relevant past history is recreational intravenous drug abuse.

The patient has arrived in the anaesthetic bay and looks unwell.

His vital signs are:

Heart rate 115 /minute

Blood pressure 80/40 mmHg

SpO2 90% (on room air)

Temperature 38.6 C

How will you respond to the registrar’s phone call?

73.8%

Viva 6

You are on the pain round with the acute pain nurse when you attend an emergency buzzer call on the ward.

An elderly patient has collapsed in the bathroom and is unconscious.

You are the most senior doctor in attendance.

How will you manage this situation?

71.2%

Viva 7

You receive a trauma call to the emergency department of the regional hospital where you are working.

The paramedics have brought in a 30-year-old male who fell from a quad bike while intoxicated. He was dragged some distance before the quad bike rolled onto his legs, pinning him.

On arrival in the emergency department, he is conscious, screaming and has mangling injuries to his lower limbs. Bilateral arterial tourniquets are in situ. He has tyre marks across his abdomen and an open abdominal wound contaminated with dirt and grass.

Outline your priorities in the initial management of this patient.

75.0%

Viva 8

You are the on-call consultant anaesthetist, working on-site at a large regional hospital with a paediatric surgical service.

The surgical registrar phones and asks you to review a four-year-old boy on the children’s ward who has an acute abdomen, for which his consultant would like to book urgent surgery.

The boy has no significant past medical, family or social history.

Describe your initial management.

77.5%

Viva 9

You are the duty anaesthetist at a regional centre, and are urgently called to the emergency department.

Following a drunken fight over dinner, a 38-year-old man has been stabbed in the neck with a kitchen knife, which is still deeply embedded.

He is being cooperative with the emergency department staff.

How will you respond?

73.3%

Viva 10

A 26-year-old man is booked for an urgent laparotomy by the general surgeons.

He was admitted to hospital five days earlier with an acute spinal injury and his surgeons are concerned that he has infarcted bowel.

What are your main concerns and what will you do to explore these concerns?

81.3%

Viva 11

A 46-year-old woman is attending the pre-admission clinic prior to a left total hip replacement for severe osteoarthritis.

She has longstanding schizophrenia with associated intellectual impairment and lives in supported accommodation.

She suffers from behavioural problems including screaming and hair pulling, and is requiring increasing analgesia and sedative medication.

She is 163 cm tall and weighs 125 kg, with body mass index of 47.

Her current medications:

oxycodone 5 mg qid

chlorpromazine 200 mg bd

haloperidol 5 mg bd

diazepam 5 mg qid

Her carer states that eight years earlier, whilst the patient was having her gallbladder out, there was “difficulty placing a breathing tube”.

What particular issues do you anticipate in this patient?

80.0%

Viva 12

You are the consultant covering labour ward at a regional hospital, where the anaesthetist is notified of all high-risk admissions.

You have been called to see Mrs Smith, a 36-year-old primigravida at 38 weeks gestation, who was admitted one hour earlier with severe pre-eclampsia.

Her blood pressure on arrival was 200/100 mmHg.

She was commenced on oral labetalol by her obstetrician, who was then called away to an emergency caesarean section.

When you enter her room with the midwife, you find Mrs Smith semiconscious on the floor, leaning against her bed.

What is your immediate management of this situation?

85.3%

Viva 13

You are called to the cardiac catheter lab to provide assistance with a 54-year-old man.

On arrival you find the patient is agitated and has severe central chest pain.

The cardiology professor wants you to “put the patient to sleep” immediately.

This is the patient’s 12 lead ECG.

What does this ECG show? How will you manage this situation?

78.7%

Viva 14

A 64-year-old woman is booked for frameless stereotactic craniotomy and debulking of a temporal lesion, to be done within 24 hours, following presentation with a generalised seizure.

Her past medical history includes longstanding bronchiectasis and recently diagnosed pulmonary hypertension.

Her current medications:

fluticasone/salmeterol inhaler bd

frusemide 40 mg daily

bosentan 125 mg bd

ciprofloxacin (just completed two week course)

dexamethasone 4 mg qid (for the past 24 hours)

phenytoin 300 mg daily (for the past 24 hours)

Her MRI scan is shown here.

How will you assess her fitness to undergo this procedure?

88.0%

Viva 15

You are the on-call consultant anaesthetist in a tertiary hospital.

You are called to the emergency department to assist in the management of a 52-year-old male pedestrian hit by a car.

Preliminary information from the ambulance service is as follows:

Four fractured limbs, pelvic binding, open leg fractures.

Cervical collar in situ.

Intubated for low Glasgow Coma Scale (GCS) score.

Past history of cirrhosis and portal hypertension.

What will you do before the patient arrives?

81.3%

Viva 16

You are called by the emergency department staff of a children’s hospital.

A six-year-old girl is being brought by ambulance following a fall from a horse.

She was not wearing a helmet.

In the ambulance, her eyes are shut, she is moaning and not responding to pain. Her pupils are reacting sluggishly to light, but they are equal and not dilated.

How will you prepare for her arrival in the emergency department?

74.7%

Viva 1

You are the on-call consultant anaesthetist on Sunday morning at a district general hospital. You receive a telephone call from the emergency department registrar, who says:

“We have a man down here with an injury to his face from an angle grinder. We’re worried about his airway. He’s bleeding profusely and we need you straight away.”

You are currently anaesthetising an ASA physical status 3 patient for laparotomy, with a first year trainee anaesthetic registrar.

What will you do?

82.0%

Viva 2

You are the anaesthetist for the emergency list. The gastroenterology registrar has contacted you to book a patient for endoscopic retrograde cholangiopancreatography.

The patient is a 38-yr-old pregnant woman at 35 weeks' gestation, who has presented to the emergency department with acute ascending cholangitis.

Her vital signs are:

2015.1 Viva 2 Vital Signs

⁠

Her full blood count shows:

2015.1 Viva 2 FBC

⁠

What other condition may have a similar clinical presentation in this patient and how would you exclude this?

77.0%

Viva 3

You are the senior duty anaesthetist in a major metropolitan hospital. You receive a call from the emergency department regarding a four-year-old girl, who has presented with post-tonsillectomy haemorrhage. Her initial surgery was performed in a private hospital seven days earlier.

Her vital signs are:

2015.1 Viva 3 Vital Signs

⁠

Describe your initial assessment and management in the emergency department.

80.0%

Viva 4

An 86-year-old woman is admitted for repair of a fractured neck of femur following a fall.

Her surgery has been postponed for several days because of lack of theatre time.

You are seeing the patient for the first time in the holding bay of theatre.

She has a past history of hypertension and congestive cardiac failure. Her regular medications are metoprolol 25 mg daily and frusemide 40 mg daily.

How will you proceed?

84.0%

Viva 5

You are in the pre-anaesthesia assessment clinic.

This 54-year-old truck driver is scheduled for excision of a posterior fossa meningioma in a few weeks' time.

His height is 175 cm and weight 140 kg (body mass index 46).

His comorbidities include type 2 diabetes, hypertension and chronic back pain.

His current medications are:

metformin 1 g tds

quinapril 20 mg bd

oxycodone (sustained release) 20 mg bd

paracetamol 1 g qid

His observations are:

Blood pressure 145/85 mmHg

Heart rate 90 /minute (sinus rhythm)

SpO2 95% (on room air)

What are the important preoperative issues in this man?

89.0%

Viva 6

It is 0900 hours on Saturday morning; you are working in a large regional hospital and respond to a trauma call to the emergency department.

A young man has sustained injuries from an accident when his motorbike hit a tree. He was initially found confused at the scene by a passing motorist.

On arrival in the emergency department he is uncooperative and smells of alcohol. He has obvious large lacerations to his head and lower limbs.

His observations are:

Blood pressure 90/50 mmHg

Heart rate 120 /minute

Respiratory rate 22 /minute

SpO2 95%

Temperature 35.3°C

How will you approach this uncooperative patient?

83.0%

Viva 7

You arrive in the emergency department to assist with the management of an acutely unwell 76-year-old man, who has re-presented to hospital a week after thoracoscopy and talc pleurodesis for a non-resolving left-sided malignant pleural effusion.

Two years ago he was diagnosed with lung cancer, which was treated with chemotherapy and radiotherapy. Twelve months ago he developed atrial fibrillation and also suffered a mild left cerebrovascular accident, with no residual deficit.

He has more recently been referred to the Palliative Care team who have commenced him on pregabalin and tramadol because he is intolerant to morphine, fentanyl and oxycodone.

His current medications are:

digoxin 0.125 mg daily

warfarin 4 mg daily

pregabalin 150 mg bd

tramadol (sustained release) 150 mg bd

His vital signs are:

Blood pressure 83/41 mmHg

Heart rate 125 /minute

Respiratory rate 26 /minute

SpO2 93% (O2 6 l/minute via Hudson mask)

Temperature 36.1°C

Please comment on his chest X-ray and how it will influence your initial management.

77.0%

Viva 8

You are called by the emergency department registrar to help with the management of a 33-year-old man who has just presented, shouting about extreme pain in his left hand.

He is on the methadone maintenance program and has accidently injected a solution made with crushed oxycodone tablets into his brachial artery.

His hand is pale with mottled fingertips.

He is restless, agitated, and behaving in a threatening manner to the staff, who have been unable to perform any interventions.

Describe how you would approach this patient, and your thoughts on initial pain management.

79.0%

Viva 9

It is 1100 hours on Saturday morning and you are working in a large metropolitan hospital. You have just finished a case when you are phoned by the registrar in the high dependency unit.

An 84-year-old man who underwent neck dissection for melanoma two days ago is now in respiratory distress. A large right-sided neck swelling has developed over the last two hours.

His SpO2 is 97% on 15 l/minute of oxygen; his blood pressure is 140/80 mmHg and his heart rate is 95 /minute.

He has a background history of atrial fibrillation and transient ischaemic attacks, for which he takes dabigatran, 110 mg twice daily, as his only medication.

Dabigatran was ceased two days preoperatively and recommenced orally three hours ago. He was bridged with enoxaparin; the last dose of enoxaparin 1.5 mg/kg was 12 hours ago.

You have two minutes to consider the case as you proceed to the high dependency unit.

What further key information do you want to obtain once you get to the bedside?

72.1%

Viva 10

A pregnant woman at 36 weeks' gestation presents in respiratory distress to the emergency department of your hospital.

The obstetrician asks you to review the patient as her condition is rapidly deteriorating and he wants to deliver the baby.

How will you assess this patient?

81.4%

Viva 11

It is 1100 hours on Monday morning, and you are the anaesthetist for the emergency list at a large regional hospital.

The paediatric surgical registrar has booked a 12-year-old boy for drainage of a large pleural effusion. He thinks the effusion is secondary to pneumonia and tells you that the child looks unwell.

The interventional radiologist will insert the chest drain, under ultrasound guidance, in the radiology suite.

You send your anaesthetic registrar to the emergency department to assess the child.

You are able to view the child’s chest X-ray on the radiology information system.

Having seen this chest X-ray, what information will you require from the anaesthetic registrar?

70.9%

Viva 12

A 56-year-old woman with a body mass index of 45 and known metastatic ovarian cancer has presented to the emergency department of a peripheral hospital with severe pain in her right thigh following a seemingly trivial injury.

You have been asked to assist with her pain management.

The X-ray of her lower limb is shown.

Her usual medications are:

morphine (sustained release) 60 mg tds

tramadol 100 mg qid

morphine syrup 30 mg q4h prn (for breakthrough pain)

How will you manage this patient?

79.1%

Viva 13

After taking your patient to the post-anaesthesia care unit (PACU), you are asked by nursing staff to review another patient.

He is a 28-year-old man who has had a left craniotomy for excision of a tumour. The nurse has been unable to contact the anaesthetist who was involved with the case.

The patient has been in the PACU for one hour. In the last ten minutes he has become increasingly restless, agitated, and hypertensive.

His blood pressure, measured from a radial arterial line, is 200/100 mmHg.

Outline your initial assessment and treatment in the PACU.

89.5%

Viva 14

You are the anaesthetist on trauma call at a tertiary hospital.

The retrieval service has just brought a 26-year-old man to the emergency department following an industrial blast injury.

He has sustained burns to his anterior chest, abdomen, and legs.

He is already intubated.

His vital signs are:

Blood pressure 80/45 mmHg

Heart rate 110 /minute

SpO2 80% (FiO2 1.0)

Temperature 36.5°C

Describe your initial management of this patient.

82.6%

Viva 15

You are the on-call consultant anaesthetist in a tertiary referral hospital and are called to the emergency department.

A previously fit and well 70 kg 16-year-old girl has presented with acute shortness of breath. She has been generally unwell for three months, with a cough, increasing breathlessness, and occasional fevers.

She takes no regular medication.

Her observations are:

Blood pressure 100/70 mmHg

Heart rate 140 /minute

SpO2 92% (room air)

Respiratory rate 40 /minute

On entering the emergency department you see her chest X-ray on the viewing screen.

What does the chest X-ray show, and how will you assess this patient?

73.3%

Viva 16

You are in the pre-anaesthesia assessment clinic.

A 72-year-old man is scheduled for excision of a dorsal right forearm squamous cell carcinoma with a large rotation flap closure.

It is expected to take two to three hours, and is planned for next week.

His past history includes severe chronic obstructive pulmonary disease, asthma, and chronic renal impairment.

The patient does not speak English and an interpreter is present.

Please comment on his chest X-ray, shown here.

75.6%

⁠

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