CRITICAL CARE TOTAL

1. Head injury with extradural, flail chest after falling of a bridge, acidosis & sepsis.
2. COPD with RESP failure post op. Metallic valve on warfarin and correction of anticoagulation before emergency surgery. NB these stations go very quickly so don't
hang about, often the last question is worth the most marks so make sure you
complete everything
3. TURP syndrome, management of hyponatraemia & pulm oedema, plus different types
of shock.
4. CT Abdo/pelvis could not work out what was going on? perf or gallstones?,
5. Blood pressure control and Epidurals
6. All about pathology and management of abdominal fistulas. Fairly easy just need to
know some basics.
7. Car accident - ABC, CT scan interpretation (showing a splenic rupture), ABG (I
think), splenic rupture management.
8. hypothermia - definition, how to prevent it pre-op and during the operation. Very
simple station.
9. Burns, ARDS, HDU/ICU monitoring (referring)
10. Bowel Obstruction and Trauma
11. Pancreatitis
12. Trauma

1) Burns see example

2) Hypothermia how categorise? why cold in theatre? Risks assoc with massive blood
transfusion? Qs on blood products. Interpret blood results clotting, Hb.
3) CVP draw Starlings law, describe features on CXR (lines, ?ARDS features), Qs on
fluid challenge and response of CVP. Risks of line insertion
4) Sepsis and Hypotension - Elderly lady with diverticular abscess has a systolic of 90mmHg
what is your initial management? Definition of SIRS, shock etc. Broad principles of
management of sepsis.

5) ECG/cardiac issues - Patient has had MI 6m ago, what is the risk of re-infarct if surgery done
<3m post MI? Interpret ECG (ST elevation!) what does it show? How do you interpret an
ECG? What to do with patient on clopidogrel post-stenting. What are alternatives to
clopidogrel? Who would you discuss this patient with?

6) acute pancreatitis asking various questions such as what scoring systems, ct scan
image shown asked what it showed, gave some ABG data and asked regarding
interpretation of this.

7) Post-op hypotension - a scenario of patient coming back from theatre after THR, was
hypotensive and hypothermic, asked various questions regarding fluid management,
causes of hypotension, escalation of care to HDU. ETC.
8) Trauma - young man comes on following RTA. How will you institute initial
management? (ABCDE etc.). He is hypotensive, tachycardic - what degree of shock is
he in? You order a CXR - what does it show? (haemopneumothorax). how will you
manage this? (chest drain). you then get a CT abdo pelvis. what does it show? (liver
laceration). how can you manage this? (operative/conservative). in what setting
should the patient be managed in? (ITU)

Critical care manned- tough station. You are called to see a patient whose signs are
suggestive of cardiogenic shock or epidural complication or SIRS *No idea how I fared in
this one!
Critical care unmanned- small bowel loops on plain abdominal radiograph+ SIRS on
bloods, causes of above presentation & management.
Critical care- cholecystitis (CT), heart block (ECG), resp failure (ABG, CXR)
Polytrauma patient interpret chest X-ray and blood gas. Suggest pathology and estimate
blood loss. Think this was haemothorax as was supine chest film. Basically not a great
question
Manned scenario asked about significant blood loss. Presented with blood results
emerging DIC. Asked about types of transfusion and complications of transfusion. Also
asked about hypothermia, ecg signs and definition.
Respiratory blood gas to interpret

Chat with two examiners about a patient with AAA rupture, Talked about hypothermia,
definitions, management, complications etc. Moved on to talk about coagulation
disorders in AAA rupture and the blood products you would give. Questions over too
quickly and then sat around waiting for bell to go!
Unmanned station with interpretation of images - very poor image printed on laminated A4
card of a CT abdomen. Not entirely sure what the results showed!

Station 4 - Critical care - Patient following laparotomy (small bowel volvulus) has
bowel contents leaking through abdominal wound, but well systemically.
Previously had radiotherapy for Ca cervix. How would you assess the patient,
given biochemistry results showing renal failure, as well as low K+, Na+ and
Mg2+, questions about fluid management, electrolyte replacement and TPN
Station 5 - Critical care (unmanned) - Questions about hypothermia and its
management in perioperative period

Critical care/Physiology Trauma young man hit by a car

asked about ATLS assessment and questions about all this, then
asked to interpret a CXR with small right pneumothorax, rib
fractures and surgical emphysema, then asked to look at a CT abdo
liver laceration and questions about management etc.
Critical care/physiology Burns ATLS assessment and
questions especially airway signs of soot and singe etc. Then given
a diagram and asked about assessing %BSA burnt. Then asked
about parkland formula for fluids and management. Then patient
transferred to ITU becomes unwell shown a CXR bilat pulmonary
infiltrates and asked about ARDS and management.
Critical care/ Physiology Sepsis Patient with diverticulitis and
signs of septic shock. Ccrisp style assessment and questions along
the way and then questions around the management of sepsis.

1. Info outside station; 72 year old man, TURP this afternoon. The procedure
was prolonged and he lost a lot of blood. You are surgical SHO on call and
asked to see him as he is tachycardic, looks pale and is struggling to
breath. Bloods; Hb 7.7, Na 121, WCC 7.8
a. What is most likely diagnosis
b. Why?
c. What else is relevant?
d. What do you want to do?
e. Where should this patient be treated?
f. Explain method of action of osmotic diuretics.

Cases
o Burns

o Fluids

Fluids
Resuscitation
Atls priniciples
Ards 4 components !
Calculation of %

post op
Causes
Fluid compartments
Question about vasopressin cant remember what it was
about but adh was the answer
Discussion a fluid balance chart
Pancreatitis
Causes
Ct scan and x-ray (chest ali picture)
Management
TURP syndrome
Cause
Treatment
Principles of management of pulmonary oedema

PE

Diuretics and mode of actions, what part of the tubule

they work on

History, differential, management

Management station; pt septic 4 days post anterior resection, sounds like theyve had
a leak, distended and tender abdo, talked about sirs criteria, investigations,
management, hdu level care, abx, pt was confused too, asked who we had to talk to,
so said family
Pain management, given some obs; hypertensive and tachycardic, dissussed that this
was likely due to pain, mentioned need to exclude important causes of pain eg.
Infection and bleeding, then about appropriate analgesia, pt was post laparotomy so
opioids, pca and epidural, asked about types of pca; looking for epidural and opioids,
then asked about drugs for epidural; local, asked if local could be given iv; said no but
ran out of time

Management station; pt mismanaged with IVI during theatre; 7 litres in, < 1 litre
out! Said clearly overloaded, but needs assessing to be sure, Urine output
seemed to be dropping off, was a bit confused by this but said could be a renal
cause; i.e drugs. Then was asked about what do about mismanagement, said
investigate, audit then guidelines

CRITICAL CARE SCENARIO

Fistula
Scenario of a lady who has had extensive abdominal surgery with an enterocutaneous fistula.
o What predisposes to fistula formation? (Cancer, IBD, infection, ischaemia, distal
obstruction, malnourished, age).
o What are the complications of fistula? (electrolyte loss, hypovolemia, infection, acidosis,
malnourished, excoriation around wound!).
o Factors preventing closure ( persisting disease, discontinuity of bowel, distal obstruction,
cancer).
o What should you look for in fistula pt? (dehydration, sepsis, cachexia, RR).
o Bloods shown Low K, Na, High Cr and Ur, low Mg ( dehydrated with renal failure).
o Management of fistula (SNAP)
o Indications for surgery (persistence, abscess).
o How do you measure nutritional requirements? ( Obs, weights, albumin, electrolytes)
o What fluids to give this patient how fast, etc, Nutrition
o TPN and complications

Epidural
o Block for pneumonectomy now post-op increased RR and reduced BP and UO,
numbness in arms
o What is an epidural?
o Why is temp sensation better than pain or touch in testing for it? (Pain and temp
go in spinothalamic tract, using cryospray better to pt)Which fibres involved? (C
fibres in ST tract).

o Consequences of high T3,4 block? (Sympathetic chain fibres cardiac are at this
level). How does block interfere with resp? (blocks sympathetic line to cardiac
and resp receptors).
o How do you tell if the hypotension is due to epidural (CVP response to 250mls,
stop the epidural, fluids, UO). What else can you give? (Vasoconstrictors) Why is
UO low? (Hypoperfusion of kidney). What is first step of management? (ABC
and fluids).
Hypothermia and coagulopathy
o Definition: <35C, what factors contribute?(age, surroundings, convection,
radiation, conduction), who is at risk? (old, immunosurpressed, hypothyroid,
burnt, malnourished, intoxicated. How is it controlled (Hypothalamus etc).
Response: Shivering, vasoconstrict, increased RR, acidosis, high lactate. What
happens to CVS (reduced CO below 28 degs). Extreme shivering: high Creat
Kinase, K rise, myoglobinurea. Electrolytes: high K and lactate. How to treat:
warm fluids, theatre, and cover pt, intraperitoneal lavage.
o Show you bloods low Hb, WCC, Plt, high APTT. Answer, pt needs blood, and
platelets, d/w haematologists re platelets and FFP, judge response with temp, BP,
RR, UO, CVP!
o The patient then requires massive transfusion - complications of transfusion.
o Thermoregulation in theatre- NICE guidelines
AAA repair complications: emboli distally, compartment syndrome in abdomen,
bleeds!

Shock
SIRS
Sepsis
o Surviving sepsis 6hr and 24hr bundles
o Scenario Lady post anterior resection 5/7 post op. Septic, Talk about management and
investigations, SIRS and its management, blood results and investigations
o anastamotic leak;
o RUQ pain and pyrexia
o CT showing gallstones. What other bloods would u like ( Clotting is the only one they
havent given you!). On admission? (ABx and fluids). What procedure do they need?
( Lap Chole)
o Neutropenic sepsis
o Sepsis - GD perforation, diverticular perf or abscess. Initial management, who to d/w?
Imaginf req? Correct Tx? Ix req? ABG interpret and explanation; next move (ABCs, Ix, ?
source) DDs? Management strategy? Haemodyn instabil despite ventilation, ?action? (O,
PEEP, fluids, inotropes, further CT, op)

Trauma
Hypovolemia
o Decceleration injury: Car Vs man

o Shock define, outline management in HDU, and estimate blood loss. What are the
indicators for a CVP line other than fluid management? (drugs, mixed venous gas,

and bloods, Abx, haemofiltartion, K). Normal CVP in adults is?(2-8cm of H2O
above LEFT ATRIUM). What are you measuring? (LV end diastolic filling
pressure). Draw a graph of LVEDP and stroke Volume essentially starlings law
and curve! What is starling law? How in practice do you do a CVP? (250mls
boluses and response of BP and CVP with previous). Draw the graph from kanani
about CVP response! Look at CXR ( name, point to central line, there will be
either ARDS, pneumo, contusions, heart failure!) CVP line complications
(infection, misplaced line, feed into chest cavity). How do you decrease risk of
infection? (Wash hands, gown, drape and gloves, clean it). Nice guidelines under
USS!!
Compartment syndrome(abdominal) + Crush injury Initial mx?
o Initial management: ATLS.
o Who do you inform? (consultant, anaesthetist, and family). In theatre they are
doing fasciotomy,
o How do you detect and treat hyperkalemia?
o Gases (show acidosis, and low albumin and Ca++why?)
o In HDU urine goes red why? (test it for blood, for myoglobin).
o Starts bleeding a lot what are the non surgical causes (DIC, pre-existing
coagulopathy, hypothermia)
o ATLS management of liver laceration
TURP Syndrome
Confused post TURP, hypotensive and tachy.
TURP Syndorme, why glycine used. What is glycine. Use of osmotic diuretic.
Differnetial- blood loss, pneumonia, PE,
Citrate levels( on Warfarin, Bendro, Dox, and AVR 2yrs ago, high BP, HR normal, with pic of
bladder)
Burns
o Burns management calculating fluid replacement

Respiratory failure
o Type 1 resp failure post op pt.
o Investigations to delineate cause. ABG interpretation.
o Treatment
o NIV, mechanical ventilation
o ARDs management
o Pneumothorax and flail chest: Initial management, ABG interpret TII resp fail, expl
pic & management,Ix req, interpret CT
Small Bowel Obstruction
o 65 with defunc ileostomy, IHD, RF, SOB, and low UO. Tachy, BP and temp okay.
Reduced air entry R base + creps. AXR and clinically distended. Drug prescribing in
bowel obstruction
o What do you hear? ( Hyperactute bowel sounds/nothing). What additional radiological
investigation to you want? (CT). With dilated loops and increased WCC what other
diagnoses? ( Ileus, collection, Iscahemic bowel!!). Would serum lactate go up in dead

bowel immediately? (No). Electrolyte disturbance (Hypokalemia and natremia). CXR,

showing consolidation/asp pneumonia.What abx? (Taz, metronidazole, aumentin...not
all of them). Why are cephalosporins 2nd line? ( C diff). What factors influence your
decision to go to theatre? ( acidosis, fluid balance, premorbid state, pt choice). Where
should they go? (level 2, HDU)
o Clinical diagnosis of ileus and obstruction
Ischaemic gut
Gastric outflow obstruction
o Acid urine, electrolyte disturbance
Pancreatitis
o Data interpretation of basically pancreatitis bloods, Ct result
o Score pancreatitis, Management and prognosis
Crohns
o 27 with diarrhoea: How do you assess? (Ba Enema, is there obstruction, look at bowel
wall, it will show skip lesions of strictures, crohns).
o Why get irreg bowel habbit in Crohns ( failure to reabsorb, and colonic disease). 3
complications of crohns (fistula, stricture, abscesses, malabsorption, anaemia, cachexia).
Resected terminal ileum and illeocaecal valve still got diahrroea (c.diff, infection,
malabsorption).
o Why does she have macrocytosis 9 months later (doesnt have a terminal ileum!!) Comes
to and e with vomiting and jaundice ( gallstones, no terminal ileum). What do you want?
(bloods clotting and amylase).
o CT gallstones why? And what kind (cholesterol, and oxalate renal stones too).

Pre-op assessment
o Arrythmias
o
o
o
o
o
o

pre-op patient with heart block, how to manage, comment on ECG

Why is aortic stenosis fatal? (fixed CO, LVH and increased O2 demand) What does the
ECG show? (L axis, 60 degs) CXR (ext wires on it). Problems with anaesthetic
Dox action on bladder (relaxes neck). Muscarinic on bladder (contracts).
SEs of Bendro (hypernatremia, and Hypokalemia)
Myocardial infarction
Percentage increased risk of a further MI if undergoing surgery 3 months post MI (1
mark) and then 6 months post MI (1 mark). mechanism of action of clopidogrel with
reference to prostaglandin and the fibrinolytic pathway. Also when to stop aspirin pre
surgery and then when to stop aspirin and clopidogrel together pre op. Risks of stopping
aspirin and clopidogrel with stents in situ

ECGs
o Rate, rhythm, and axis how do you do it? ( will be either infarct, tall T waves in crush
injury, heart block!)
o P-R interval, qrs duration
o What do you do next? (ABC + chase underlying cause).
o What do they need before theatre (rate control and anti-coag!)

Renal failure
o Classify (pre, intra,post).

o What bedside test could you do to find which one (urine osmolality and urinary
Na). Where is Na resorbed (prox tubule).
o Furosemide works in loop of henle, and spironolactone in DCT(hyperkalaemia &
renal failure) how to treat + dose of insulin
o Treament of renal failure with raised CVP- RRT or diuretics
o Rhabdomyolysis 2ndry to crush injury- blood tests
CXR:
o What is your system for assessing CXR? Whats the abnormality? (either
NG/Tracheostomy with ECG leads). Whats the patient at risk of? ( Asp Pneumonia).
What should you do? (Take it out, gases, repeat CXR and new NG). How do you check
NG (end tidal CO2, xray, listen, aspirate!!)
o CXR Pneumothorax (needle decompress & chest drain)
o CXR - Aspiration pneumonia (ABC, bronchoscopy & suction) + BorHaeves
o CXR Pneumoperitoneum (ABC & theatre)
o CXR - Pleural effusions (aspirate +/- drain)
o CXR - Cardiac failure
o CT ruptured AAA or pancreatic pseudocyst
o AXR SBO
o CXR misplaced NG, reasons to suspect, identify, how to check correct posn (end tidal
CO2) + types of nutrition

Acute care
1. 1 day post-op patient on epidural and develops respiratory depression;
interpret ABG ; resp acidosis; how is CO2 transported in blood; dissolved;
carboxyhaem and HC03-; what is reversible equation; what is chloride shift;
management opioids overdose;
2. ASA 3 cardiology patient post hernia sudden onset respiratory failure; aABG
hypoix and low C02; pulmonary oedema on CXR; Mx discussion of heart failure

6. Critical care
got scenario about pt with entero-cutaneous fistula with some biochem results
lots of qs about problems assoc with fistula, types, local and systemic factors
affecting healing etc basically know everything about them

11. Critical care

trauma pt fell off scaffolding sustained tib-fib fracture
has painful leg, ARF, blood in his urine
was asked what else it could be rhambdo, compartment syndrome, trauma to
kidneys.
The guy just looked at me blankly so didnt know if was barking up wrong tree.
Asked about mannitol for treatment and alkalinsation, was confused, but so was
everyone else so who knows what they wanted!

17. Critical care CVP about waveforms and measuring CVP. Insertion of CVP
and complications, how you do it, different places.
Critical care: essentially the same station described by Amel. I was quizzed on
TURP syndrome. As I managed to get through all the questions, the anaesetists
quizzed me further on pharmacology of furosemide, and Mannitol, the
mechanism of action. They also asked about the indication for intubation in a
patient (all covered in Kanani's critical care vivas).
Critical care: scenario of a patient who was trapped under collapsed building.
Discussion was around ATLS management of trauma, rhabdomyolysis,
hyperkalaemia(potassium from muscle getting into the circulation).
Critical care 3. Scenario of a patient who had a reversal of ileostomy 3 days ago,
now has abdo distension, spiking temperatures. Asked about bowel obstruction,
and anastomotic leak. Differentiating true obstruction from pseudo obstruction
(no bowel sounds in pseudo, and tinkling In true obstruction).

1. Critical care: scenario of post operative pt with epidural anesthesia

bradycardiac and hypotensivewhat is the cause, complication of
epidural, ttt of complication types of medication used
2. Critical care: haemorrhagic shock in pt with splenic rupture,
classes, ttt, resuscitation
3. Critical care; Hypothermia, definition, ttt, prevention, causes
Applied Surgical Science 1 Interpret blood results of lady whos had previous
lap chole 7 years ago for pancreatitis, now come in with rigors, cholestatic blood
picture, raised CRP. Deranged clotting.
Talk through blood results (cholestatic picture, deranged clotting). Why? What
could explain these results? What do you think is going on? Why is ALP raised?
Where is ALP produced/secreted? When would you get high AST and ALT? When
would you get high AST specifically? Where in the cell is GGT found? What is
happening with the clotting and why? Talk me through the extrinsic pathway.
Which factors? How does Vit K work? What does bile do? Why in this scenario is
clotting affected? (He kept trying to guide me to the answer but my neurones
just wouldnt connect at the time! Should be that bile flow blocked so unable to
absorb Vit K hence deranged clotting.) What can you do to correct the clotting
abnormality. What do they screen for in FFP? Particular in a young patient, what
would you be worried about that they cannot screen for in FFP. (Correct answer
was prion disease, he told me the answer and I just nodded to agree!) How

would you investigate this patient? (Said US abdo and potentially MRCP) Results
of US show normal liver, dilated intra and extrahep ducts what does it mean?
Applied Surgical Science 2 Pt due for anterior resection (not specified what
for and whether elective/emergency). Had an MI 3 months ago, which he had
PCI and drug-eluting stent for. Now on aspirin, clopidogrel and statin.
How do you read an ECG? Interpret ECG (shows previous anterior infarct and
borderline LAD). What is the % risk of having a peri-op MI within 3 months of the
last MI? (Said 10-25% but drops to 5% by 6 months. So would depend on the
indication for surgery and whether it can be postponed till months after MI.)
Comment on his meds and impact on upcoming op (clopidogrel for stent, will
need stopping before op). How does clopidogrel work? How long would effects
last for? If it is an emergency, how would you reverse it immediately? (Said
platelet transfusion.) What else could you do? (I was a bit stuck.) Then asked if I
knew any IV anti-platelet drugs I could give (I just said sorry I dont know!) And
he said, dont worry I didnt either!!
Critical care Patient undergoing ruptured AAA repair, has lost 4L of blood. In
theatre now and temp of 35 degs. Showed blood results Hb 6.5, Plts 51 x10 9,
high APTT, PT and low fibrinogen.
Define hypothermia. What could be the cause of hypothermia in this patient,
and why? What is transfused blood deficient in? What problems could a massive
transfusion like in this case cause? (Fluid overload, hyperkalaemia,
hypocalcaemia, DIC, ABO incompatibility, anaphylaxis) As youve already
pointed out, he is in DIC. What else would may you need to give him? (Platelets,
FFP) Name me an anti-platelet agent and tell me how it works. Who else would
you discuss this with? (Anaesthetist in theatre and haematologist)

critical care - burn patient. ITU management.

critical care - gastric outlet syndrome, hypochloraemic hyponatraemic metabolic
alkalosis
1. Critical care elderly patient with IHD who started feeling SOB after
central line insertion and fluid resuscitation. The answer was NOT fluid
overload/pulmonary oedema. It was pneumothorax as a complication of
the central line insertion. Then questions on complications, how you
would insert one, how you would remove one (head down to prevent air
embolism). Very easy station

2. Critical care duodenal ulcer perforation. Management. Causes of

duodenal ulcers. Then steps of digestion and release of enzymes. Which
enzymes. What is the role of gastrin. Phases of gastric acid release
advice - use Wikipedia. I did and am pretty sure I did well ;)

Station 2 Critical Care

Central and CVP lines

o Indications other than fluids
o Complications of insertion
o Relationship between EDV and pressure draw this i.e. Frank
Starling Curve
o Are you aware of any guidelines for insertion? Whom are these
written by?

Station 14 Critical Care

Obvious history of Perf DU.

Management surgical options for management e.g. oversew, omental
patch. Difference between management between DU and PU.
What else would you do for a gastric ulcer intraoperatively? i.e. biopsy.
Oversew small gastric ulcer, omental patch for large one.
What else would you do intraoperatively? Remember to peritoneal lavage
and washout.
NCEPOD Classifications very brief- and where would you class this
patient?
Post op treatment i.e. medications.
H.Pylori eradication.
What drugs would you give? PPI/H2 receptor antagonists. How do they
work and what cells do they act on?
How do NSAIDs work and how do they increase risk of ulceration details
of COX pathways and where different NSAIDs act.
Then detailed questions of gastric physiology phases of gastric acid
secretion . What hormones are involved and which cells they act upon and
where they are released from.

Station 18 Critical Care

Ascending cholangitis you are not given the diagnosis.

Given LFTs going off raised AST, ALT and GGT. Bil 125
Pyrexial and rigors.
Physiology of bilirubin metabolism. What does conjugated mean? What
conjugated to? How is urobilinogen formed?
Types of jaundice.
Type and function of bile salts. What else do they do other than reduce pH
of duodenum. What are bile salts formed from and how? What stimulates
its release?
Enterohepatic circulation.
Management of ascending cholangitis.
Differential diagnosis
What is INR, what does it stand for? What is it a ratio of? How does
warfarin work? How does heparin work?

Physiology and critical care:

1) Given a sheet to read: clinical scenario on sheet describes patient with
perforated peptic ulcer (hx of recent NSAIDS, abdo pain and collapse).
Asked to define how to class what is an emergency; urgent; urgent
elective; routine elective operation? And what is this patients` category?
Asked about clinical management surgical and medical (triple therapy and
what are the mechanism of NSAIDS ie what enzymes are affected and PG
physiology and what are the pharm mechs of PPIs) and also asked about
the physiology of GI tract hormone and acid secretions. (2 examiners)
2) I cant remember my 2nd case well. It was again a sheet with a clinical
scenario: with lots of biochemistry and haematology for interpretation.
Asked to classify hyponatraemia! Also asked to explain why in this case of
alkalosis (?) , the patient is still excreting acid urine and other aspects of
renal physiology etc .
3) Critical care: history of pt with melaena and past history of CHF and IHD.
Failed insertion of CVP and so resuscitated empirically only via p-line. Also
pt getting more and more SOB. Asked what would you do? Then asked
what are the NICE recommendations for landmarks for insertion of CVPs.
Then shown a CXR relating to the case. Asked how I would normally assess
a CXR and then asked for any diagnosis on CXR (large pneumothorax!)
Then asked if it was a tension or not? And why.

6. Physiology: old lady postop, RR4, PCO2 9, Ph 7.24, low PO2, + several boluses
of morphine.
Q`s How CO2 is carried to the lungs, (asks for the formula
H2O+ CO2 H2CO3 H+ + HCO3The Carbonic Anhydrase, and where this reaction happens. Etc Etc

7. And then this dreadful station of Nutrition 54 kg man with Crohns had
Ileoceacal resection then leaks the fistulae.
Daily Dietary requirements, Calculate Proteins, Lipid Carbs, etc ect

8. Post lobectomy patient with Epidural BP 90/50, HR 40

U/o 10 mls/hr
Why? How would you Asses, DD? Treat, Indications of Para vertebral, side effects
etc ect How does it work, how would you decide about the level, and how would
you find if paravertebral is working? (Cold spray)

1) Surgical sciences. 60 y/o lady with pancreatitis. Given blood test results.
Why does amylase have limited sensitivity?

What is a pseudocyst? How could you detect it clinically?

Name some prognostic scoring systems. What are there parameters? Why are
they paramenters?
Why is this lady hypocalcaemic? What is the pathophysiological process?
Do you know any radiological scoring systems?
2) Surgical sciences. 30 y/o with Crohn's.
Point out the features of small bowel obstruction on a plain abdominal film.
Aetiology of small bowel obstruction.
Baseline nutritional requirements and those in critical illness.
What is the respiratory quotient? Compostion of supplementary feeds
Routes of feeding. Complications with parenteral feeding.
Complications with central line insertion.
3) Surgical sciences. 40 y/o post left lower lobectomy. Epidural catheter insitu. Hypotensive and bradycardic.
Initial assessment and management- general assessment and measures, plus
epidural specific assessment and management.
Pathophysiology of neurogenic shock.
Sympathetic pathways.
Sensory pathways in spinal cord.

Station 6 critical care

Extremely easy station and very friendly examiner. Various questions on chest XR, abdo XR, and
basic management of post op patient with chest infection.
Station 12 critical care
What are the layers of adrenal gland, what hormones does it produce, controle of these
hormones, what are the post op difficulties expected in a patient with longterm steroids

Station 15 critical care

I was shown thyroid function tests and was asked to interpret. Questions on hypothyroidism.
Pathophysiology, management. What drugs can cause hypothyroidism. Clinical signs

Critical Care 1:
Patient had lobectomy and is in HDU with T3/4 epidural and is now hypotensive/bradycardic.
What are the possible causes? How would you manage the patient? How would you assess
the epidural level? Why does a high epidural cause hypotension and bradycardia?

Critical Care 2:
Elderly gentleman admitted with worsening confusion and anorexia. Found to have 1500mls
retention and in AKI + hyperkalaemia. Why do you think this is? How would you manage
high K? What does his ECG show? Talk through the ethical implications of escalating care?
Who would you involve?

Critical Care 3:
You are in the pre-assessment clinic and note an ESM in a patient. What could this be?
What are the symptoms of aortic stenosis? Why would patients get this? What are the
complications of aortic stenosis? What are the complications of thiazide diuretics?

1. Patient with previous episode of pancreatitis, presents with peritonitis and

signs of shock. CT scan of pseudocyst, name the structures in the scan. What
is peritonitis, what are the signs, why is this patient worsening in terms of
BP/HR despite resuscitation (Talked about vasodilation, reduced pre-load, and
reduced SV as a result)? Sympathetic activation? What single blood test
would you do (Amylase, lipase)? Why is she hypocalcaemic (low albumin and
fat necrosis due to proteolytic activity causing formation of free fatty acids
which precipitates with calcium). Why would you get hypocalcaemia in renal
failure (unexcreted phosphate binds to calcium). CXR of ARDS talk me
through the CXR (apart from saying bilateral pulmonary infiltrates, need to
say I would check, pt details, rotation, adequacy, inspiration). What is ARDS?
Why does this patient need to go to ICU? What are your management
options?

2. Complicated AAA, temp 35. What is hypothermia? Treatment of hypothermia?

What are the contributing factors for heat loss in this patient (I said
conduction, evaporation and I couldnt think of any more). Bloods with DIC
picture, why has this patient got this picture? How would you manage this
patient? What are the complications of massive transfusion in this patient?
What is Packed RBCs deficient in? What drugs do you know which affect
platelet function? How does it work? What is the process of homeostasis
(vasoconstriction, platelet aggregation and activation of the clotting cascade).
So in this patient how are each of these parameters affected (vasoconstriction
affected due to anaesthetic drugs, platelet aggregation affected due to lack of
them, activation of clotting cascade affected due to inactivation of clotting
factors as a result of hypothermia)? What are the immediate complications in
this patient having an AAA repair (basal atelectasis, renal, mesenteric, spinal
ischaemia, peripheral embolisation)? Who would need to get involved in this
patients care (ITU, anaesthetics, medics [I said nephrologists when asked
which medics])?

3. Hypothyroidism. Interpret blood results. Causes of hypothyroidism (iatrogenic,

dietary, amiodarone, hypopituitary) . Tell me about the negative feedback and
stimulation of thyroid hormones. What are the features of hypothyroidism.
This patient is not compliant with her treatment, what are the difficulties in
doing a laparotomy on her? Any anaesthetics risks? How would you ensure
she is compliant?

4. Critical Care- trauma Scenario- adult stuck in a kitchen fire (I think)

for at least 30mins. Burns to ant+post trunk, I think face and
circumferential to upper limb. Soot around mouth. Think the patient
was only on 2L of O2 in the scenario. ABCD. Got stuck on airway for
a bit that I was pretty insistent was potentially threatened in view of
mechanism of injury, soot around lips, 02 demands etc. Fluid
resuscitation parkland formula. Then scenario was moved on several
days to ITU ARDS. Then ran out of time
5. Critical care / Surgical Sciences: Scenario was gastric outlet
obstruction. Frosty examiner. To my horror launched into the
natraemias early on, classification, causes. Explanation of the
hypochloriaemic metabolic alkalosis of GO obstruction. Very specific
questions around subsequent acidic urine production wanted exact
mechanism.
10. Critical care scenario: some patient with rubbish access the ITU reg had tried
and failed to get a central line in then penumothorax clinically and on cxr.
Management. Examiner was distinctly unpleasant, interrupted constantly.
Questions on differential from CXR anatomical land marks for central line
insertion, which side is more difficult, positioning of patient.
1. Burns patient - Standard ABCDE approach, Parkland formula, criteria for
referral a burns specialist unit, Where would you manage this patient?? criteria
for ward/HDU/ITU care.
1. Critical care - Gastric outlet obstruction. I was prepared for it but examiner was harsh
and it was still one of the most difficult station. hyponatraemic, hypochloraemic
hypokalaemic metabolic alkalosis. why? and why acidic urine? why hypokalaemic?
what happens in the kidney? what is the ideal fluid? NaCl + K supplement what else
would you do? fluid resuscitation ng tube catheter. why high urea and creatinine?
acute kidney injury due to dehydration
2. Critical care - insertion of internal jugular line. What are the landmarks? what position
of the patient? head down. why? reduce risk of air embolism. CXR - large
pneumothorax. talk me through how you interpret a CXR. what are the types of
pneumothorax. simple, traumatic, tension, open. what are the immediate
complications of internal jugular line? bleeding air embolism arrhythmia damage to

vessels and nerves. what is the guideline to internal jugular line insertion? USS
guidance (nice guidelines)
3. Critical care - Burns and ARDS. calculate percentage of burns. how would you assess
A and B of this patient. How would you assess his circulation. Fluid - what formula?
parkland formula. 4ml/kg/%burn, half given within first 8 hours. if colloid? vernon
mount formula. 0.5ml/kg/%burn given in 4/4/4/6/6/12. 4 cardinal signs of ARDS.
Where and how would you manage this patient. ICU as need level 3 care. prone
ventilation, PEEP, small tidal volume and careful fluid resuscitation.

HISTORIES/COMMUNICATION
Panic attack/anxiety in pre-op patient for lap cholecystectomy
Knee pain (post trauma)
See wife of unwell patient because consultant cannot attend as in emergency theatres
Speak to ICU consultant about lady who has suspected perforation who has acute kidney
failure, hypokalaemia etc. Need to listen carefully to instructions given over the phone as
consultant will ask you to repeat them.
CRITICAL CARE
Adrenalectomy - names the parts of the adrenal gland, which hormones are produced
and the effects of adrenalectomy

> Physiology
> 1. Obs chart. Talk about criteria for SIRS. What fluid I'd give to a
hypotensive patient. What type of shock they were likely to have. Then
shown blood results with low K and asked which fluid now etc etc.
>
> 2. Another station looking at obs charts! Kept asking what should be
done at different points on the obs chart. Wasn't really clear where the
examiner wa going with it - think they just wanted that youd get critical
care involved as patient was likely to need BP-support. Asked for 'the
formula for BP' think he wanted BP = CO x PVR. Ran out of time but I
gather he went on to ask about inotropes versus pressors.
>
> 3. Discussion about a patient with low GCS. What their GCS would be
with various descriptions. Asked about sending a patient with low GCS
down to CT - was it safe etc. Then progressed to show picture of PTX. Told
it was a spontaneous one. Asked to describe insertion of ICD. Said a
surgical or Seldinger technique could be used- examiner was very excited
to hear about Seldinger technique!

> Physiology
> 1. Obs chart. Talk about criteria for SIRS. What fluid I'd give to a
hypotensive patient. What type of shock they were likely to have. Then
shown blood results with low K and asked which fluid now etc etc.
>
> 2. Another station looking at obs charts! Kept asking what should be
done at different points on the obs chart. Wasn't really clear where the
examiner wa going with it - think they just wanted that youd get critical
care involved as patient was likely to need BP-support. Asked for 'the
formula for BP' think he wanted BP = CO x PVR. Ran out of time but I
gather he went on to ask about inotropes versus pressors.
>
> 3. Discussion about a patient with low GCS. What their GCS would be
with various descriptions. Asked about sending a patient with low GCS
down to CT - was it safe etc. Then progressed to show picture of PTX. Told
it was a spontaneous one. Asked to describe insertion of ICD. Said a
surgical or Seldinger technique could be used- examiner was very excited
to hear about Seldinger technique!
Physiology
Core temperature changes and its control
Hypothyroidism and its causes
Critical care
Nutrition and TPN
Crohns and large bowel obstruction

6. Physiology- TURP Syndrome

Patient post TURP- confused, hypotensive.
Asked possible causes- hypovolaemia TURP syndrome
Given bloods with low sodium. Asked causes of hyponatraemia in general and then why
low in this patient.
Asked reasons for hypotension.
How would you manage.
Name diuretics and mechanism of action, and which would you use in TURP.

8. Physiology
Scenario- jaundice, given blood results very high ALP, high GGT and bilirubin, Pretty
normal ALT and AST.
Asked definition- obstructive picture. Why. Causes of hyperbilirubinaemia, how you would
classify and examples of each.

Bilirubin metabolism.
Causes of painless jaundice with obstructive picture.
Risk factors for gallstone disease
Mechanisms of development of gall stones.
Causes of abnormal clotting in obstructive picture- talked about why deranged clotting
Role of vit K etc
Also- what make sup gall stones, why do they and how to they form.
Beginning of scenario ok- last questions were hard.

10. Physiology
8 days post bowel op. B/G IHD, HTN and COPD.
Shown AXR with dilated loops of small bowel.
Asked differentials- ileus, obstruction.
Causes of bowel obstruction.
Obs deteriorated- pyrexial, hypotensive, low sats.
Anastomotic leak, intra-ob sepsis
Asked what would consider before taking him to theatre.

18. scenario discussion on a patient who had become

septic and started vomiting 5 days post op - discussion
on post op sepsis, bowel obstruction/ ileus.

Critical care/Physiology Trauma young man hit by a car asked

about ATLS assessment and questions about all this, then asked to
interpret a CXR with small right pneumothorax, rib fractures and surgical
emphysema, then asked to look at a CT abdo liver laceration and
questions about management etc.
Critical care/physiology Burns ATLS assessment and questions
especially airway signs of soot and singe etc. Then given a diagram and
asked about assessing %BSA burnt. Then asked about parkland formula for
fluids and management. Then patient transferred to ITU becomes unwell
shown a CXR bilat pulmonary infiltrates and asked about ARDS and
management.
Critical care/ Physiology Sepsis Patient with diverticulitis and signs
of septic shock. Ccrisp style assessment and questions along the way and
then questions around the management of sepsis.

7. Critical care- Pancreatitis

Diagnosis, scoring and initial management, types of imaging and why. Asked to
score patient. Why low calcium? Why high BM?

9. Critical Care- Aortic Stenosis

Pathophysiology, causes, symptoms, management, investigation of and whether
it should delay procedure, then went on to talk about infective endocarditis and
NICE guidance on prophylactic Abx. Showed ECG- LVH

Station 1 : discussion with itu reg asking about need for pre-op advice and post op bed in
itu. Case was an elderly lady presented with acute abdomen pain ? Perforation. A
Asked about types of shock..-septic. Why is it septic. What if no bed available? Who
would u call for advice? Write down advice cause he will ask u to repeat it. Give case of
facts.

Stn 2 : pancreatitis and ards. What is the ex, what would u do. Talk about Glasgow score,
what is its severity for? Explain inflammation process. Explain why ards develop. What is
ards? How to treat? Look at ct. Interpret level, main organs noted.

Stn 8 : physiology. Anastomotic leak. Unwell. Shock. What can u do? Sirs criteria. What is
it? What are the management options. What one Ivx I want to do - CT.

Stn 10 : physiology. Rhabdomyelisis. What is it? Why got loin pain? Why get AKI. What
can u do...I ref,rained from mentioning furosemide and mannitol and bicarb but this is
what he wanted actually. Why does urinary alkalinisation help? What is main worry compartment syn, what is it. How to diagnose. How to treat?

Critical care/Physiology Trauma young man hit by a car asked

about ATLS assessment and questions about all this, then asked to
interpret a CXR with small right pneumothorax, rib fractures and surgical
emphysema, then asked to look at a CT abdo liver laceration and
questions about management etc.
Critical care/physiology Burns ATLS assessment and questions
especially airway signs of soot and singe etc. Then given a diagram and
asked about assessing %BSA burnt. Then asked about parkland formula for
fluids and management. Then patient transferred to ITU becomes unwell
shown a CXR bilat pulmonary infiltrates and asked about ARDS and
management.
Critical care/ Physiology Sepsis Patient with diverticulitis and signs
of septic shock. Ccrisp style assessment and questions along the way and
then questions around the management of sepsis.

7. Critical care- Pancreatitis

Diagnosis, scoring and initial management, types of imaging and why. Asked to

score patient. Why low calcium? Why high BM?

9. Critical Care- Aortic Stenosis

Pathophysiology, causes, symptoms, management, investigation of and whether
it should delay procedure, then went on to talk about infective endocarditis and
NICE guidance on prophylactic Abx. Showed ECG- LVH

6. Physiology- TURP Syndrome

Patient post TURP- confused, hypotensive.
Asked possible causes- hypovolaemia TURP syndrome
Given bloods with low sodium. Asked causes of hyponatraemia in general and then why
low in this patient.
Asked reasons for hypotension.
How would you manage.
Name diuretics and mechanism of action, and which would you use in TURP.

8. Physiology
Scenario- jaundice, given blood results very high ALP, high GGT and bilirubin, Pretty
normal ALT and AST.
Asked definition- obstructive picture. Why. Causes of hyperbilirubinaemia, how you would
classify and examples of each.
Bilirubin metabolism.
Causes of painless jaundice with obstructive picture.
Risk factors for gallstone disease
Mechanisms of development of gall stones.
Causes of abnormal clotting in obstructive picture- talked about why deranged clotting
Role of vit K etc
Also- what make sup gall stones, why do they and how to they form.
Beginning of scenario ok- last questions were hard.

16. discussion of a patient who had become confused

and hypotensiove following a TURP - discussion on post
TURP syndrome, causes of hyponatraemia,
management, discussion on mechanisms of action of
various diuretics (furosemide, mannitol)

17. discussion on jaundice - causes, investigation. then

went on to talk about the synthesis, excertion and
resorption of bile, function of bile. Discussed fat soluble
vitamins and why patients with liver pathology become
coagulapathic.
18. scenario discussion on a patient who had become
septic and started vomiting 5 days post op - discussion
on post op sepsis, bowel obstruction/ ileus.