the examination series
Second edition
examination ANAESTHESIA
A GUIDE TO THE F INAL FANZC A EXAMINATION
Christopher Chri stopher Tho
and Christoph
Butler
Examination Anaesthesia
Examination Anaesthesia
Examination Anaesthesia A Guide to the Final FANZCA Examination 2nd edition Christopher Thomas BMedSc MBBS FANZCA
Christopher Butler MBBS FANZCA MPH&TM Cer tDHM PGDipEcho
Elsevier Australia. ACN 001 002 357 (a division o Reed International Books Australia Pty Ltd) ower 1, 475 Victoria Avenue, Chatswood, NSW 2067
© 2011 Elsevier Australia Tis publication is copyright. Except as expressly provided in the Copyright Act 1968 and the Copyright Amendment (Digital Agenda) Act 2000, no part o this publication may be reproduced, stored in any retrieval system or transmitted by any means (including electronic, mechanical, microcopying, photocopying, recording or otherwise) without prior written permission rom the publisher. Every attempt has been made to trace and acknowledge copyright, but in some cases this may not have been possible. Te publisher apologises or any accidental inringement and would welcome any inormation to redress the situation. Tis publication has been careully reviewed and checked to ensure that the content is as accurate and current as possible at time o publication. We would recommend, however, that the reader veriy any procedures, treatments, drug dosages or legal content described in this book. Neither the author, the contributors, nor the publisher assume any liability or injury and/or damage to persons or property arising rom any error in or omission rom this publication. National Library o Australia Cataloguing-in-Publication Data _____________________________________________________________________________ o come
_____________________________________________________________________________ Publisher: Sophie Kaliniecki Developmental Editor: Neli Bryant Publishing Services Manager: Helena Klijn Project Coordinator: Natalre Hamad Edited by Margaret rudgeon Prooread by im Learner Cover design by Stan Lamond Internal design adapted by Lamond Art o Design Index by ypeset by NQ Printed in China by BA
Dedication o: Janet, John and Nick Butler Jo Potts Abigail and George Tomas
Foreword Assessment o knowledge in a ormal summative examination is a daunting and threatening process or the learner. Tis is urther magni�ed when the stakes are high, as with the �nal examination o the Australian and New Zealand College o Anaesthetists (ANZCA). Te exam requires the candidates to consider many aspects o lie and social structure beyond just acquiring and using knowledge and gaining expertise. Perormance at the test requires the candidate to possess knowledge, as well as understand the nature and process o the examination. Tere is a relative paucity o inormation on this process and most is passed down by previous candidates. Tis book provides the required inormation and gives guidance on how to prepare or what appears to be a mammoth task or the learner. It will help candidates manage the stress and the emotional rollercoaster o studying or the exam by providing valuable hints and examples. Tis second edition concentrates solely on the anaesthetic exam, thus eliminating any conusion between the anaesthetic and intensive care exams. I recommend this book to all ANZCA trainees and International Medical Graduate Specialists in anaesthesia preparing or the �nal exam. It will also prove useul or educators who take time to teach and prepare potential candidates, as well as those organising courses related to the examination. Associate Professor Kersi araporewalla MBBS, FFA RACS, FANZCA, M Clin Ed (UNSW) Discipline of Anaesthesiology and Critical Care, University of Queensland Director of Education and Research, Royal Brisbane and Women’s Hospital
Contents Acknowledgement Foreword Preface List of abbreviations Chapter 1 Overview of the FANZCA final examination FANZCA training scheme Format of the final examination Timing and location The written examination Multiple choice paper Short answer paper The clinical examination Chapter 2 Preparation for the final examination Resources The college website Curriculum Past papers Professional documents Final examination preparation resource Textbooks Journals Resuscitation guidelines Courses Preparation strategies Philosophy Timing Study groups Looking after yourself Coping with failure Chapter 3 The written examination Overview Performances strategies Multiple choice questions (MCQ) Short answer questions (SAQ) Written examination topics Airway management Ambulatory anaesthesia Anaesthetic equipment Applied anatomy Applied physiology and pharmacology Crisis management
xv vii xiii xvii 1 1 2 2 3 3 4 5 9 9 9 10 10 11 12 12 16 17 17 19 19 20 20 21 21 23 23 23 24 25 26 26 26 27 27 28 28
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Contents
Obstetric anaesthesia Paediatric and neonatal anaesthesia Pain management Perioperative medicine Regional anaesthesia Remote location anaesthesia Statistics and research Transfusion medicine Trauma anaesthesia Vascular anaesthesia Welfare, consent and quality assurance issues Chapter 4 The medical vivas Overview Performance strategies Patient assessment stations 1. The patient with aortic valve stenosis 2. The patient with ischaemic heart disease 3. The patient with hypertension 4. The patient with a permanent pacemaker/implantable defibrillator 5. The patient with peripheral vascular disease 6. The patient with chronic obstructive pulmonary disease 7. The patient with pulmonary fibrosis 8. The patient with diabetes 9. The patient with thyroid disease 10. The patient with pituitary disease 11. The patient with morbid obesity/obstructive sleep apnoea 12. The patient with a spinal injury 13. The patient with muscular dystrophy 14. The patient with multiple sclerosis 15. The patient with myasthenia gravis 16. The patient with chronic renal impairment 17. The patient with chronic liver disease 18. The patient with an organ transplant 19. The patient with rheumatoid arthritis 20. The patient with ankylosing spondylitis 21. The patient with trisomy 21 Chapter 5 The anaesthesia vivas Overview Performance strategies The viva Anaesthesia viva topics Airway Blood transfusion/coagulation Burns Cardiothoracic anaesthesia Co-existing disease
30 30 31 31 32 33 33 33 33 34 34 35 35 35 37 37 39 41 43 46 48 50 52 54 55 57 59 61 63 64 65 67 69 71 73 74 77 77 77 78 82 82 83 84 84 84
Contents
Emergency/crisis situations ENT/maxillofacial/thyroid surgery Equipment/environment General surgery Intensive care Neurosurgical anaesthesia Obstetrics and gynaecology Orthopaedics Paediatric anaesthesia Pain management Regional anaesthesia Remote locations Trauma Vascular surgery Welfare and professional issues Chapter 6 Data interpretation for the ANZCA examination Overview 1. Electrocardiography 2. Chest radiography 3. Neck radiography Neck trauma Flexion/extension views 4. Computed tomography (CT) Head and neck CT Chest CT Abdominal CT 5. Magnetic resonance imaging (MRI) Basic physics Types of magnetic resonance image 6. Echocardiography How to interpret the report Which numbers matter and what do they mean? Summary 7. Arterial blood gas analysis Overview Ancillary calculations 8. Coagulation studies Overview Prothrombin time (PT) Activated partial thromboplastin time (aPTT) Platelet count Fibrinogen Platelet function Thromboelastography (TEG) Activated coagulation (clotting) time (ACT) 9. Full blood count examination Haemoglobin White cell count
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88 89 90 90 90 90 91 93 94 95 96 96 97 98 98 100 100 101 119 138 138 142 143 143 146 149 150 150 150 155 155 156 158 166 166 166 169 169 170 170 170 171 171 172 173 175 176 177
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Contents
10. Urea and electrolytes Overview Sodium (Na+ ) Potassium (K+ ) Chloride (Cl– ) Bicarbonate (HCO3– ) Calcium (Ca+ ) Urea and creatinine 11. Respiratory function tests Spirometry Reversibility of airway obstruction Flow–volume loops DLCO diffusion studies 12. Sleep studies The sleep study Interpretation of the sleep study Answers to data interpretation cases Electrocardiography Chest radiography Echocardiography Arterial blood gas analysis Coagulation studies Chapter 7 Useful reference and review articles Overview Airway management and spinal injury Allergy and anaphylaxis Anaesthesia and co-existing disease Anaesthesia and specific situations Cardiac anaesthesia Cardiovascular risk and myocardial protection in anaesthesia Coagulation and anaesthesia Complications and consent in anaesthesia Endocrine disease and anaesthesia Intensive care topics Monitoring and equipment in anaesthesia Muscle disorders and anaesthesia Neuroanaesthesia Obstetric anaesthesia Ophthalmic anaesthesia Orthopaedic anaesthesia Paediatric anaesthesia Pain management Pharmacology and anaesthesia Regional anaesthesia Remote locations and anaesthesia Thoracic anaesthesia Transfusion medicine
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Preface Te concept o a guide to approaching a ellowship examination in a medical specialty is not a new one. For as long as examinations have existed, tips and tricks have been passed down rom one generation o candidates to the next. Te Australian and New Zealand College o Anaesthetists’ �nal ellowship examination is no exception, and much o the inspiration or this book comes rom others who have attempted to ease the pain o past examination candidates, most notably Dr Gabriel Maran, whose remembered preparation and exam experiences rom the late 1990s ormed the ‘Gabe Files’, still accessible online. Many other skilled mentors throughout Australasia and the Paci�c region have provided invaluable guidance and encouragement or each new generation o anaesthetists approaching the last major hurdle that leads to the FANZCA �nish line. Examination Intensive Care and Anaesthesia was written in 2006, and contained the �rst incarnation o the volume you now hold. It was the brainchild o Carole Foot and Nikki Blackwell o intensive care ame, who co-opted one o the current authors to provide chapters and inormation relevant to anaesthesia. Te preace o that book contained the prophetic statement: ‘As intensive care continues to develop its own identity … the concept o a combined guide to the examination process or intensivists and anaesthetists will become outmoded.’ On 1 January 2010 the College o Intensive Care Medicine was established as an independent entity. By the time this book has been published Examination Intensive Care will also be in production. Te ormat o the ANZCA �nal examination has evolved in the last ew years, and this update to the exam guide aims to keep pace with those developments. Te ormat, venues, relative weighting and timing o examination components have changed; these are re�ected in the overview to the �nal examination presented in Chapter 1. Useul resources, including new developments on the college website, and strategies or restructuring lie around exam preparation are provided in Chapter 2. Separate chapters based on the major components o the written and clinical exams aim to provide both perormance strategies and real examples o the types o questions encountered in the examination. o this end, the last 5 years o written short-answer questions and viva topics have been dissected and sorted under major topic headings. Examples o the types o cases encountered in the medical vivas are given, along with a structured approach to history-taking and examination o such patients, and topics or discussion that candidates might expect in the actual exam. Despite the culling o the data interpretation viva rom the examination ormat, the ability to interpret common investigations remains a rigorously evaluated attribute through all phases o the examination. Te data interpretation section in Chapter 6 aims to provide a structured approach to such investigations, with clinically relevant examples similar to those encountered in the exam. Finally, a selection o useul reerences and reviews is provided to serve as the nucleus or candidates’ own research and sel-directed study. Tose looking or the universal panacea to the �nal exam will not �nd all the answers in this book. Candidates will, however, �nd advice on how to discover the answers more efficiently or themselves, which is in�nitely more useul. Te biggest enemy
xiv
Preface
when preparing or the �nal examination is the inability to effectively manage one’s time. It is hoped that the inormation provided in this volume will both consolidate knowledge and save candidates some o that most precious resource. We wish candidates all the best in their endeavours. Chris Tomas Chris Butler April 2010
Acknowledgements Many thanks to Dr Andy Potter, Staff Specialist, Cairns Base Hospital, or his efforts in compiling and categorising many o the review articles presented in Chapter 7. We also wish to thank the ollowing specialists or their invaluable expertise and insightul input in reviewing the manuscript: Dr Jim McClean, Staff Specialist, Te Ipswich Hospital Dr Sharon Maconachie, Staff Specialist, Te ownsville Hospital We are grateul to many trainees o recent years or sharing their experiences and insights into the FANZCA training and examination process. Finally, we wish to acknowledge the efforts o the editorial team at Elsevier in obtaining the relevant permissions rom external sources or many o the radiological images which appear in Chapter 6, ‘Data interpretation or the ANZCA examination’.
Disclaimer Te authors have taken considerable care in ensuring the accuracy o the inormation contained in this book. However, the reader is advised to check all inormation careully beore using it to make management decisions in clinical practice. Te authors take no responsibility or any errors (including those o omission) that may be contained herein, nor or any misortune bealling any individual as the result o action taken using inormation in this book. Please note that the opinions expressed in this book are entirely those o the authors, and are in no way intended to re�ect or represent those o the Australian and New Zealand College o Anaesthetists; its Joint Faculties past or present; Court o Examiners; Special Interest Groups; subcommittees; other trainees or ellows. Every attempt has been made to trace and acknowledge copyright, but in some cases this may not have been possible. Apology is made or any accidental inringement, and inormation enabling us to redress the situation is welcomed.
List of abbreviations
A-a AAA ABG ACE AC ADH ADP AF AG AHA AHI AICD AIDS ANZCA AP aP ARDS AS ASA ASD ALS A-v A-V AVA BIS BMI BNP BP BPEG BSL BPS
Alveolar–arterial Abdominal aortic aneurysm Arterial blood gas Angiotensin converting enzyme Activated coagulation (clotting) time Antidiuretic hormone Adenosine diphosphate Atrial �brillation Anion gap American Heart Association Apnoea Hypopnoea Index Automatic implanted cardioverter de�brillator Acquired immune de�ciency syndrome Australian and New Zealand College o Anaesthetists Antero-posterior Activated partial thromboplastin time Acute (adult) respiratory distress syndrome Aortic stenosis American Society o Anesthesiologists Atrial septal deect Advanced trauma lie support Arterio-venous Atrio-ventricular Aortic valve area Bispectral index Body mass index ype B natriuretic peptide Blood pressure British Pacing Electrophysiology Group Blood sugar (glucose) level Body temperature and pressure saturated with
CABG CAD CCF CEA CK CNS CO2 COPD COX CPAP CPR Cr CRPS CSF C CR CVC CXR DC DDAVP DIC DKA DLCO DL ECG EC EDH EDA EEG EF EMAC EMG EMLA EMS
Coronary artery bypass graf Coronary artery disease Congestive cardiac ailure Carotid endarterectomy Creatine kinase Central nervous system Carbon dioxide Chronic obstructive pulmonary disease Cyclo-oxygenase Continuous positive airway pressure Cardiopulmonary resuscitation Creatinine Complex regional pain syndrome Cerebrospinal �uid Computed tomography Cardiothoracic ratio Central venous catheter Chest X-ray Direct current Desmopressin Disseminated intravascular coagulation Diabetic ketoacidosis Diffusion capacity or carbon monoxide Double-lumen tube Electrocardiograph Electroconvulsive therapy Extradural haematoma Ethylenediaminetetraacetic acid Electroencephalogram Ejection raction Effective Management o Anaesthetic Crises Electromyogram Eutectic mixture o local anaesthetics Early Management o
xx
List of abbreviations
EN EOG EPS ERCP ECO2 E FANZCA FBC FEF25–75% FESS FEV1 FiO2 FOI FS FVC GA GCS GFR
Ear, Nose and Troat (Otorhinolaryngology) Electrooculogram Electrophysiological study Endoscopic retrograde cholangiopancreatography End-tidal carbon dioxide Endotracheal tube
LMA LSCS
Fellowship o the Australian and New Zealand College o Anaesthetists Full blood count Forced expiratory �ow in middle hal o orced vital capacity Functional endoscopic sinus surgery Forced expiratory volume in one second Fraction o inspired oxygen Fibre-optic intubation Fractional shortening Forced vital capacity
LVO
General anaesthesia Glasgow coma score Glomerular �ltration rate
LV LVF LVIDd LVIDs
MA MCV MCQ MI MRI MS MV MVA NASPE NCA NEXUS NIDDM
Hb HbA1c HCO3 HIV HOCM HONK H IABP ICP ICU IHD INR
Haemoglobin Glycosylated haemoglobin Bicarbonate Human Immunode�ciency virus Hypertrophic obstructive cardiomyopathy Hyperosmolar non-ketotic coma Hypertension
IV IVS
Intra-aortic balloon pump Intracranial pressure Intensive care unit Ischaemic heart disease International normalised ratio Intravenous Interventricular septum
JVP
Jugular venous pressure
NN NOF NSAID NSEMI NYHA O2 OCP OP ORIF
Laryngeal mask airway Lower (uterine) segment Caesarean section Lef ventricle Lef ventricular ailure Diastolic diameter o lef ventricle Systolic diameter o lef ventricle Lef ventricular out�ow tract Maximum amplitude Mean corpuscular volume Multiple choice question Myocardial inarct Magnetic resonance imaging Multiple sclerosis Mitral valve Motor vehicle accident North American Society o Pacing and Electrophysiology Nurse controlled analgesia National Emergency XRadiography Utilization Study Non-insulin dependent diabetes mellitus Number needed to treat Neck o emur Non-steroidal antiin�ammatory drug Non st-elevation myocardia inarct New York Heart Association
OSA O
Oxygen Oral contraceptive pill Occipito posterior Open reduction and internal �xation Obstructive sleep apnoea Operating theatre
PA PAC PACU PCA
Postero-anterior Pulmonary artery catheter Post-anaesthesia care unit Patient-controlled
List of abbreviations
pCO2
xxi
SDH SIADH
PVD
Partial pressure o carbon dioxide Patent ductus arteriosus Post dural puncture headache Peak expiratory �ow Percutaneous endoscopic gastrostomy Platelet unction analyser Pulmonary hypertension Peripherally inserted central catheter Peak inspiratory �ow Prevocational medical education and training Partial pressure o oxygen Postoperative nausea and vomiting Postpartum haemorrhage Permanent pacemaker Pulse rate Proessional standards Prothrombin time Pulmonary thromboembolism Peripheral vascular disease
Qc
Corrected Q interval
V
esla ri-iodothyronine Tyroxine Tromboelastograph ransient ischaemic attack otal lung capacity ransoesphageal echocardiography issue plasminogen activator Tyroid stimulating hormone ransthoracic echocardiography ransurethral resection o prostate ricuspid valve
RA RDI
Right atrium Respiratory disturbance index Respiratory effort related arousal Rapid eye movement Respiratory unction tests Rotational thromboelastography Residual volume Right ventricle Right ventricular systolic pressure reatment
U&E UK
Urea and electrolytes Urokinase
VAE VF VSD V VI
Venous air embolism Ventricular �brillation Ventricular septal deect Ventricular tachycardia Velocity-time integral
WCC WPW
White cell count Wolff-Parkinson-White
XR
X-ray
PDA PDPH PEF PEG PFA PH PICC PIF PME pO2 PONV PPH PPM PR PS P PE
RERA REM RF ROEM RV RV RVSP Rx SAH SaO2 SAQ
Subarachnoid haemorrhage Oxygen saturation Short answer question
SK SSS SEMI SV 3 4 EG IA LC OE tPA SH E URP
Subdural haematoma Syndrome o inappropriate antidiuretic hormone secretion Streptokinase Sick sinus syndrome S-elevation myocardial inarct Supraventricular tachycardia
Chapter 4
The medical vivas The worst time to have a heart attack is during a game of charades. DEMETRI MARTIN
Overview Te medical vivas take place the day afer the written examination, and consist o two 18-minute examination stations involving a clinical encounter with a real patient. Te medical vivas evaluate candidates’ ability to perorm an appropriate preoperative assessment. Tey must take a relevant history, perorm a ocused examination eliciting physical signs and review investigation results, allowing them to enter into a discussion o the pathophysiology and unctional reserve o the patient in relation to the risks o anaesthesia. Marks in this component o the exam are allocated or the appropriateness o the history-taking and whether key symptoms are elicited. Candidates are expected to listen to the patient and also respond to their non-verbal cues. In the examination stage, candidates are marked on an examination technique which is sequential and logical, and which elicits key signs. Proessionalism is also judged, and candidates are expected to show patients respect, with concern or their comort and modesty. Finally, an organised and effi cient presentation o �ndings is expected; candidates must show good knowledge o the medical condition present and its implications or anaesthesia. Te medical viva seems to have changed subtly in its emphasis over the years. In the past it was purely medical history and examination without much anaesthesia �avour, but it is now more likely to include discussions about the anaesthesia implications o the condition. Te candidate should be prepared or this. You are generally not expected to examine speci�c anaesthesia areas o interest, such as the airway, unless it is a speci�c problem with the condition. For example, the case o a patient with aortic stenosis undergoing cardiovascular examination would probably not require comment about their airway, whereas that o a patient with rheumatoid arthritis probably would.
Performance strategies Many candidates �nd this component o the examination the most stressul, in both its preparation and its execution. In essence, this is what trainees spend
32
Examination anaesthesia
there is signi�cant time pressure in the patient evaluation stations, and many candidates worry about being rushed and missing critical historical inormation or examination signs, evoking memories o difficult medical short cases perormed in undergraduate examinations. Tis pressure has been relieved somewhat in recent years with the extension o the viva time to 18 minutes. Speci�c preparation or this section o the examination is ofen neglected as candidates concentrate on the sections o the written examination. One o the most common criticisms o candidates is that their interrogation and examination techniques lack polish. Part o the reason or this is that most o us become used to a non-physician-like patient assessment which is not directed at a single organ system. We take signi�cant and calculated shortcuts, ofen dictated by the time pressure o a large room o patients at a busy outpatient clinic. It is unusual or an anaesthetist to examine individual organ systems in turn. It is thereore important to speci�cally practise or this part o the examination. Where possible, perorm a single-system examination on preoperative patients to reresh any long-orgotten techniques and sequences. It is important to have a smooth examination technique or cardiovascular, respiratory, neurological and endocrine systems, and examination o the abdomen. Enlist the help o colleagues to �nd patients you can practise upon. Subject yoursel to the scrutiny o your physician and intensivist colleagues in examination conditions as ofen as you can. extbooks on physical examination, such as those by alley and O’Connor (see Chapter 2 or details), are essential revision. Te only equipment you will need to bring with you to the medical vivas is a stethoscope. Beore the day o the exam it is worth checking the patency o your stethoscope rom the diaphragm to the earpieces, especially i it has lain idle or a period o time. Also remember to wash your hands beore and afer seeing each patient. Tis is commonsense, good hygiene and displays an appropriate degree o proessionalism. During the two-minute perusal time beore the viva commences, write down the name and age o the patient, which will be provided on the door. A limited clinical history (which may include a list o medications) is ofen provided beore you enter the room, and may offer some clues as to the clinical scenario to be encountered. It is important to concentrate on the instructions that have been provided very careully, as your enquiries and examination will be directed towards a speci�c system or component thereo. Candidates tend to employ one o two techniques in the medical vivas. Te �rst and most common o these is to perorm the history-taking and examination sequentially. Te advantage o this approach is that it may be more amiliar and comortable or candidates. Te second approach is to take the history and perorm the examination simultaneously. Tis method is more effi cient and allows or more inormation to be gleaned in the small amount o time allowed. It is technically more demanding, however, and trainees who plan to use this method will need to practise it many times. Tey must also be wary o missing important clues rom the history or examination because o the distraction o perorming both together. Te examiners’ reports in the past have been scathing o candidates who have not shown good interpersonal skills with patients. You must always be riendly and polite, and listen careully to what the patient has to say. Be respectul o their modesty during the examination process, and under no circumstances do anything
4
• The medical vivas
33
beore leaving them or the discussion. On rare occasions the viva examinations will enlist the use o inpatients who are very unwell, and whose condition may deteriorate during the exam itsel. I your patient should become unwell/collapse/ lose consciousness/arrest, then immediately discard the trappings o pretence o the examination and alert the examiner to the situation. Do what you can to help given the resources available to you. Remember you have only eight or nine minutes to carry out your history and examination, so you must be ocused in your approach. Always remember to ask about previous anaesthesias and a list o medications (i not provided earlier), and always try to ascertain the unctional status o the patient and whether or not they are ully optimised. Patients are not instructed to withhold any inormation, and are ofen quite good at providing you with a succinct, relevant summary o their condition. It is perectly acceptable to ask a patient what diagnosis they have been given, or what they have been led to understand about their condition. In your examination o the patient it is important not to imagine signs that you think should be present. For example, a well-managed patient with a history o lef ventricular ailure may have a clear chest on auscultation. When the discussion period commences, begin with a concise summary o the patient’s history, unctional reserve and examination �ndings, and, where possible, the relevance o these to any proposed anaesthesia and/or surgery. Te examiners will then discuss management aspects o the case, or may provide you with the opportunity to ask or and review any investigations you think relevant. It is inevitable that such investigations will appear at this point; the majority o these will be electrocardiographs, chest X-rays, arterial blood gases, spirometry and haematology results. You can also expect to see cervical spine and abdominal plain �lms, C scans and MRI scans; echocardiographical, pulmonary artery catheter and sleep study data occasionally appear. You should have a systematic technique or reviewing ECGs and CXRs. Begin by outlining the process o your technique as you go. Afer doing this the �rst time, the examiner may ask you to simply comment on any obvious abnormality on subsequent results. Commonly encountered investigations are discussed urther in Chapter 6. Always be prepared to comment on the implications o any �ndings and their relevance to anaesthesia. It should be reassuring to candidates that the pass rate or the medical viva component o the examination is very high, usually similar to that o the anaesthesia vivas. Again, the useulness o practice cannot be overemphasised. Some sample medical viva cases are presented here to give you an indication o the type o ocused history and examination that may be required in the examination. opics or discussion are also provided.
Patient assessment stations 1. The patient with aortic valve stenosis Possible clinical scenario
Mrs I E, 64, is due to undergo elective emoral hernia repair. She presents with worsening shortness o breath when climbing stairs. Please take a relevant history
34
Examination anaesthesia
Appropriate thoughts
Beore you enter the room you should be ocused on either a cardiac or respiratory cause to explain the symptom outlined here. Ischaemic and/or valvular heart disease, or chronic lung disease, need to be uncovered early in the encounter to allow or a thorough directed history and examination. First impressions
• Note whether the patient appears to be an inpatient (hospital pyjamas,
wheelchair, oxygen) or an outpatient. Tis may provide clues as to the severity o the underlying disorder. • Is the patient dyspnoeic at rest? Histor y
• Patients with aortic stenosis will usually be able to tell you the diagnosis or
some variant thereo (‘a squeaky, very exciting Antarctic valve’ was told to one recent candidate). • Te classic triad o symptoms are angina, exertional dyspnoea and exertional syncope. • Ask about the time-rame o evolution o symptoms (ofen latent period >30 years) and speed o progression recently. • Is there a history o rheumatic ever? I so, you need to consider the possibility o co-existing mitral valve disease. I not, other causes are calci�cation o a bicuspid valve and degenerative calci�c stenosis (common in the elderly). • Assess the patient’s exercise tolerance and unctional reserve. • Is there evidence o ventricular ailure? Ask about orthopnoea, paroxysmal nocturnal dyspnoea and ankle swelling. • Ask about other risk actors or coronary artery disease. • What treatment options have been undertaken or planned? • Obtain a list o medications, other medical conditions and allergies. Physical examination
Position the patient at 45 degrees or cardiovascular examination and ask or the blood pressure (the examiners may make you take it yoursel). • Assess pulses or: – rate and rhythm – slow uptake or plateau carotid pulse – collapsing pulse (i concomitant signi�cant aortic incompetence) – radio-radial and radioemoral delay • Assess jugular venous pressure (JVP) • Examine the praecordium or: – previous cardiac surgical scars – displaced apex beat – hyperdynamic apex beat – aortic thrill (a sign o severity). • Auscultate the chest: – Listen to the loudness o heart sounds and splitting – Is there a ourth heart sound? Is there an ejection systolic murmur loudest in the second intercostal space
4
• The medical vivas
35
– Listen careully or an early diastolic murmur in expiration with patient sitting orward (aortic regurgitation will ofen be present to some degree). – Louder grade o murmur, later timing o peak intensity and sof or absent second heart sounds have been suggested as indicators o severity; such signs may be subtle and do not necessarily differentiate moderate and severe disease. • Perorm dynamic manoeuvres: – Leg raise or squat increases preload and makes the murmur louder. – Valsalva (decreased preload) and hand grip (increased aferload) should, in theory, make the murmur sofer. • Check lung �elds or crepitations, and the lower limbs or oedema. Useful statements
‘Mrs E gives a history o angina and dyspnoea afer climbing two �ights o stairs, which has been associated with syncope on two occasions. Combined with the presence o a slow upstroke carotid pulse and mid-systolic murmur radiating to the neck, I believe she has signi�cant aortic valve stenosis, which is most likely due to a calci�ed aortic valve. I would seek to investigate this urther beore embarking on the planned elective surgery.’ Investigations
• Echocardiography: check valve area, derived gradients across valve (mean and
peak), which depend or their accuracy on the contractile state o the ventricle; check lef and right ventricular unction • Chest X-ray: look or post-stenotic aortic dilatation, lef ventricular hypertrophy • ECG: check voltage criteria or lef ventricular hypertrophy, lef ventricular strain • Cardiac catheterisation: assess measurement o pressure gradients, look or concomitant coronary artery disease (i surgery planned). Topics for discussion
• Classi�cation o severity o aortic stenosis based on valve area, transvalvular
pressure gradient • NYHA classi�cation o perioperative risk: should surgery be cancelled? • Options or treatment o aortic stenosis: when is surgery indicated? • Options or anaesthesia or non-cardiac surgery • Antibiotic prophylaxis • Central neuraxial blockade and aortic stenosis • Haemodynamic goals during non-cardiac surgery and how to achieve these • Role or invasive monitoring: what are particular problems with pulmonary artery catheterisation? • What are your priorities in the event o this patient sustaining a cardiac arrest? • Te ventricular pressure/volume relationship in aortic stenosis. 2. The patient with ischaemic heart disease Possible clinical scenario
Mrs R C, aged 72, is due or right total hip replacement in 3 months’ time. She has
36
Examination anaesthesia
Appropriate thoughts
Acute-on-chronic myocardial ischaemia is the most likely cause or these symptoms. It is important to gain an impression o the severity o the disease when assessing the patient. In this situation it is also possible that the patient has suffered a myocardial inarct. First impressions
• Is the patient an inpatient? Look or oxygen, intravenous therapy and/or drugs. • Is she dyspnoeic at rest? • Look or obvious bruising rom venepuncture/arterial sites, which may indicate thrombolysis. Is there any obvious oedema?
Histor y
• Determine the nature o the chest pain and whether it is typical o myocardial
ischaemia. • Always keep gastro-oesophageal re�ux in mind as a differential diagnosis. • What precipitated the admission to hospital? • Has the patient had unstable angina (recent onset, worsening o previous angina, or symptoms at rest) or a myocardial inarct? • Is there any history o dyspnoea, orthopnoea or paroxysmal nocturnal dyspnoea? • What treatment did she receive (e.g. thrombolysis, cardiac catheterisation, stenting, stress test, echocardiography) and were there any complications (e.g. arrhythmias, ailure, bleeding problems)? Has this resulted in a reduction in symptoms? • Assess the patientʼs unctional reserve (metabolic equivalents are useul): walking distance on the �at and uphill/on stairs. Assess other limitations to normal activities o daily living. • Ask about cardiac risk actors and any efforts to control these: – diabetes – lipid pro�le – hypertension – smoking – amily history – OCP/menopause – obesity. • Obtain a list o all medications and any allergies. Physical examination
Position the patient at 45 degrees or cardiovascular examination. • ake note o any intravenous therapy they may be receiving. • Ask to measure the blood pressure. • Feel the pulse or rate and rhythm. • Feel or radio-radial and radioemoral delay. • Examine the mouth or cyanosis. • Assess the JVP or height and character and eel and auscultate the carotid pulses. • Inspect the praecordium or surgical scars, visible apex beat and pacemakers. Assess the location and character o the apex beat and any praecordial thrills
4
• The medical vivas
37
• Auscultate or:
– �rst and second heart sounds – heart murmurs, especially inarct related VSD or mitral regurgitation – crepitations at the lung bases. • Assess or the presence o peripheral oedema. In a well-managed patient there may be surprisingly little to �nd on clinical examination. Do not manuacture signs that are not present. Useful statements
‘Mrs C is currently an inpatient, having been admitted with unstable angina 1 week ago, with central chest pain radiating to her lef arm at rest. She has a history o 15 years o stable angina, which had been treated with aspirin, beta blockers and calcium channel blockers. She underwent coronary angioplasty and stenting with resolution o her symptoms. She can currently walk 200 m on the �at beore onset o dyspnoea.’ Investigations
• ECG (baseline and acute event i possible): comment on any arrhythmias,
evidence o ischaemia or inarction. I inarct, S segment elevation myocardial inarction (SEMI) or non-SEMI? • Echocardiography • Chest X-ray: signs o cardiomegaly, acute ventricular ailure • Cardiac catheterisation data. Topics for discussion
• Cyclo-oxygenase (COX)-2 inhibitors and myocardial ischaemia • Intraoperative monitoring or elective surgery • Bene�ts o general vs regional techniques in patients with minimal cardiac reserve • Justiy your choice o anaesthesia or hip replacement surgery • Intraoperative monitoring or myocardial ischaemia; use o transoesophageal
echocardiography (OE) • Role o B-type natriuretic peptide in diagnosis and prognosis o myocardial injury • reatment o intraoperative ischaemia • iming o post-inarct elective surgery • iming o cardiac surgery; bene�ts o stenting versus coronary artery bypass grafing • Management o patients with bare metal/drug-eluting stents, platelet inhibitors and elective surgery. 3. The patient with hypertension Possible clinical scenario
Mr O , 45, was due or elective varicose vein ligation, but cancelled because o high blood pressure. Please conduct a relevant history and examination. Appropriate thoughts
On rare occasions the examiners may give you very speci�c inormation to ocus your attention. In this case you should be considering causes o hypertension
38
Examination anaesthesia
o co-existent cardiorespiratory disease, and the effect o hypertension on other organ systems. First impressions
• Are characteristic eatures o a secondary cause o hypertension present? A
spot diagnosis o Cushing’s syndrome, acromegaly or myxoedema may lead to a modi�cation o your approach. • I the patient is an inpatient, this may be related to the investigation or treatment o hypertension, and again might raise suspicions o a secondary cause (e.g. renal artery stenosis, Conn’s syndrome or phaeochromocytoma). Histor y
• Ask when the diagnosis o hypertension was made, and approximate readings in recent times. How high have readings been in the past? • Is the patient aware o a diagnosis associated with their hypertension? – adrenal tumour – renal disease or renal artery stenosis – aortic coarctation – acromegaly – myxoedema – obstructive sleep apnoea. • Ask about actors that contribute to essential hypertension: – alcohol – obesity – cigarette smoking – poor diet and exercise patterns. • What treatment has the patient received or their hypertension and how successul has it been? • Have there been any complications rom the hypertension? – peripheral vascular disease – visual problems – strokes.
Physical examination
• Measure the patient’s blood pressure lying and standing. Ask or measurements
in each arm. Readings >140/>90 mmHg indicate the presence o hypertension. • Careully eel the peripheral pulses. It is appropriate to test or radio-radial delay and radioemoral delay. • Palpate and auscultate the carotid pulses. Ask to examine the undi (you may be told the results o undoscopic examination). • Examine the chest and listen or murmurs, a ourth heart sound and evidence o lef ventricular ailure. • Examine the abdomen or surgical scars, and eel or aortic aneurysms and renal masses, auscultate or renal bruits. Useful statements
‘Mr is a 45-year-old gentleman who presented 6 months ago or elective surgery which was cancelled because o a blood pressure reading o 220/110 mmHg. He had suffered headaches and blurred vision or a month beore this. Prior to this he
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was in excellent health and received yearly check-ups with no problems recorded. Tis history suggests a secondary cause o his hypertension, and Mr con�rms that urther investigation resulted in a diagnosis o Conn’s syndrome or which he underwent laparoscopic right adrenalectomy last week. He is on no current medication. ‘Examination today reveals a blood pressure o 110/70 mmHg in both arms with no postural drop. Cardiovascular system examination is otherwise unremarkable. Abdominal examination shows normal healing o laparoscopic port scars and no other abnormality.’ Investigations
• Urea and electrolytes: preoperative values or the classical eatures o Conn’s
syndrome (note that Cushing’s syndrome can also cause hypokalaemia), renal disease • BSL and lipid pro�le • ECG: voltage criteria or lef ventricular hypertrophy • Urinalysis or blood, protein and collection or catecholamines • Chest X-ray • Other imaging studies based on clinical suspicion (adrenal tumours, renal artery stenosis). Topics for discussion
• Causes o secondary hypertension • Treshold or cancelling elective surgery and urther management o hypertensive patients; what are the likely intraoperative problems to be expected? • Classes o antihypertensive drugs • Perioperative management o patients with phaeochromocytoma • Causes and management o hypertensive crises.
4. The patient with a permanent pacemaker/implantable defibrillator Possible clinical scenario
Mr A, aged 75, presents or transurethral resection o the prostate. He has had recent attacks o dizziness and palpitations. Please take a history and conduct a cardiovascular examination. Appropriate thoughts
While concomitant cerebrovascular disease is a possibility, the likely ocus o this case is cardiovascular, speci�cally cardiac arrhythmias and/or valvular lesions. First impressions
• Is the patient an inpatient? Tis may suggest a recurring or chronic cause with recent management with which the patient may be amiliar. • It is unlikely the examiners will recruit an unwell inpatient with an unstable lie-threatening arrhythmia. A well-looking, happy outpatient may re�ect successul treatment.
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Examination anaesthesia
Histor y
A succinct history may well provide you with most o the inormation you need. • Outline the time-rame o the presenting symptoms. – Was there any associated chest pain? – How ofen and under what circumstances (e.g. exertion) did the symptoms occur? – Can the patient tap out the palpitations; were they rapid/regular/irregular? – What exactly did the dizziness entail? • Rapid irregular palpitations suggest atrial �brillation. • Regular palpitations suggest supraventricular or ventricular tachycardia. • Heart block and sick sinus syndrome are less likely in the presence o palpitations. • Detail any history o previous heart disease, especially ischaemia or prior cardiac surgery. • Determine i there is a amily history o cardiac disease or arrhythmias (e.g. hypertrophic obstructive cardiomyopathy, congenital long Q syndromes). • Ask or details o treatment received: – Was treatment in the emergency department or subsequently as an inpatient? – Were physical manoeuvres (e.g. carotid sinus massage) employed? – Were any drugs used? (Patients may remember treatment with adenosine.) – Has the patient undergone cardiac catheterisation, electrophysiology studies or cardioversion? • Te presence o a pacemaker suggests an underlying bradyarrhythmia or biventricular ailure. Te presence o an automatic implanted cardioverter– de�brillator (AICD) suggests V, VF or prolonged Q syndrome. • For pacemakers and AICDs, ask when they were put in and i there have been any problems since. Does the patient carry a pacemaker card with the programming details? • How ofen is the device tested and when was this last done? • Are symptoms entirely controlled? How ofen does the DC shock go off? • Ask about unctional reserve pre- and post-treatment. Obtain a list o all medications. Physical examination
• Perorm your normal cardiovascular examination, ocusing speci�cally on the pulse rate, rhythm and character. • Note the presence o scars, indicating previous surgery, and the presence o a pacemaker or AICD device.
Useful statements
‘Mr A is an elderly gentleman who presented 6 months ago with dizziness and rapid regular palpitations on a background o ischaemic heart disease treated with CABG 5 years ago. Tese symptoms occurred on moderate exertion and on one occasion included a syncopal event, resulting in his hospitalisation and admission to coronary care, where he was treated with intravenous therapy and underwent subsequent cardiac catheterisation and electrophysiological studies. He was �tted with an AICD device and has experienced DC shocks on our occasions since. His exercise tolerance has improved and he can walk
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shows him to be in sinus rhythm, 84 beats per minute, with an obvious implanted device in the lef sub-clavicular area. Cardiovascular examination was otherwise unremarkable. I suspect that Mr A was suffering episodes o V, and that he has a device with overdrive pacing and DC cardioversion acilities. I would seek urther elucidation rom his cardiologist beore embarking on elective surgery.’ Investigations
• ECG: ask or this pre-treatment i possible: Q, SV, V, heart block and its variations, atrial �brillation • Serum electrolytes: potassium, magnesium • Echocardiography • Chest X-ray: position o the device and location o electrodes • Catheterisation data/EPS data • Ask or a report o the most recent check o the device.
Topics for discussion
• ypes o pacemaker/de�brillator and their classi�cation (see ables 4.1 and
4.2) • Use o biventricular pacing in the treatment o cardiac ailure • Hazards o using magnets with implanted cardiac devices • Indications or pacemaker insertion • Indications or AICD insertion • Management o elective surgery and pacemakers: diathermy, disabling unctions • What contingency plans would you have in place i the device ailed?
The North American Society of Pacing and Electrophysiology (NASPE) and British Pacing and Electrophysiology Group (BPEG) Generic Pacemaker Coding System TABLE 4.1
Letter position
I
II
III
IV
V
Category
Chamber paced
Chamber sensed
Response to sensing
Rate modulation
Multisite pacing
Letters
O = none
O = none
O = none
O = none
O = none
A = atrium
A = atrium
T = triggered
R = rate modulation
A = atrium
V = ventricle
V = ventricle
I = inhibited
V = ventricle
D = dual (T+I)
D = dual
D = dual
D = dual
Source: AD Bernstein, AJ Camm, RD Fletcher, et al. The NASPE⁄BPEG generic pacemaker code for
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Examination anaesthesia
The North American Society of Pacing and Electrophysiology (NASPE) and British Pacing and Electrophysiology Group (BPEG) Defibrillator Coding System TABLE 4.2
Letter position
I
II
III
IV
Category
Chamber shocked
Antitachycardia pacing chamber
Antitachycardia detection
Pacing chamber
Letters
O = none
O = none
E = electrogram
O = none
A = atrium
A = atrium
H = haemodynamic
A = atrium
V = ventricle
V = ventricle
V = ventricle
D = dual
D = dual
D = dual
Source: AD Bernstein, JC Daubert, RD Fletcher et al. The revised NASPE⁄BPEG generic code for antibradycardia, adaptive rate, and multisite pacing. Pacing and Clinical Electrophysiology 2002; 25:260–4.
5. The patient with peripheral vascular disease Possible clinical scenario
Mr E , 65, has suffered worsening leg pain or a number o years. Please take a history and conduct an appropriate cardiovascular examination. Appropriate thoughts
• You should be alerted to a possible vascular cause, although rom the given history it is possible the patient suffers rom a chronic pain syndrome. • It is important to assess risk actors and co-morbidities. • Functional assessment o vascular patients is critically important.
First impressions
• Is the patient an inpatient? Tere may be evidence o recent limb or abdominal surgery. • Are there any obvious previous limb amputations?
Histor y
• A history o the site, nature and progression o limb pain is important. Patients with peripheral vascular disease can typically walk a �xed distance beore needing to rest rom claudication. Tis distance may shorten over time until pain is present even at rest. • Concomitant eatures may include limb swelling, ulceration and gangrene. • Note that a very active patient with mild disease may suffer more discomort than a sedentary patient with more severe disease. • Ask about risk actors or atherosclerosis: hyperlipidaemia, obesity, smoking, age, diabetes and hypertension. Note that peripheral vascular disease may also encompass aneurysmal disease caused by rarer conditions such as Maran’s and Ehlers-Danlos syndromes. • Atherosclerosis may affect the entire vascular tree, so it is important to ask about symptoms o cerebrovascular insuffi ciency, renal dysunction and ischaemic heart disease. Te limitation o unctional capacity rom claudication may mask symptoms o coronary artery disease (which is signi�cant in up to 75% o
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Physical examination
• Examine the legs looking or skin integrity, asymmetry, pallor and capillary
re�ll. Examine all peripheral pulses on both sides. • Measure the blood pressure (or ask or the results) in both arms and both legs. Te ankle/brachial index is the highest systolic blood pressure rom the dorsalis pedis or posterior tibial artery divided by the systolic blood pressure measured at the brachial artery; a value o <0.6 may indicate severe lower limb ischaemia. • Examine the heart and lung �elds or valve lesions, signs o congestive heart ailure and evidence o chronic lung disease rom smoking. • Palpate and auscultate the carotid arteries or a thrill or bruit. • Palpate the abdomen or the presence o an aortic aneurysm. Useful statements
‘Mr is currently an inpatient being treated or a wound inection ollowing rightsided emoro-popliteal bypass grafing 8 days ago. His risk actors or peripheral vascular disease include a 40-pack-year history o cigarette smoking, raised cholesterol and systemic hypertension. He has suffered intermittent claudication or 5 years, with the claudication distance being steady at 200 m walking on the �at, until this year when the distance dramatically decreased to around 25 m. He also reports suffering pain at rest that wakes him rom sleep. He also has a history o stable angina or which he is on medical treatment, including betablocker therapy. His surgery was conducted with general anaesthesia and was unremarkable rom the patientʼs perspective. ‘On examination his surgical wounds are covered, with a hospital request to keep them so. Tere is no sign o obvious surrounding inection. Both dorsalis pedis pulses are palpable and strong. I cannot eel a lef posterior tibial pulse, but it is present on the right side. Capillary re�ll is sluggish in both eet. Brachial blood pressure is 150/80; the calculated preoperative right ankle:brachial index rom the inormation given to me is 0.5, a possible indication o severe lower limb ischaemia. Heart sounds are normal and other peripheral pulses are present. Auscultation o the carotid arteries reveals no bruits.’ Investigations
• Te unctional severity o claudication can be assessed using the Rutherord
Standard exercise protocol (treadmill walking or 5 minutes at 3 km/h up a 2% incline) • Limb imaging investigations include Doppler ultrasound, magnetic resonance angiography and dye angiography • Preoperative testing prior to revascularisation should include respiratory unction tests, ECG, chest X-ray, baseline bloods and echocardiography i aortic disease or symptomatic coronary artery disease • In this patient, postoperative ull blood count and wound microbiology, culture and sensitivities, and possibly blood cultures would also be o interest. Topics for discussion
• Regional anaesthesia and management o anticoagulation • Institution o beta-blocker therapy to decrease cardiac risk • echniques o regional anaesthesia or carotid endarterectomy Management o aortic cross-clamping
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Examination anaesthesia
6. The patient with chronic obstructive pulmonary disease Possible clinical scenario
Mr I is a 54-year-old man with wheeze and shortness o breath on exertion. He is scheduled or semi-elective laparoscopic hernia repair. Please take a history and examine his respiratory system. Appropriate thoughts
Tis combination o symptoms may steer your thinking to respiratory rather t han cardiac pathophysiology, although it is important to remember that the two ofen co-exist. I so, you should seek to determine the contribution o each to the underlying problem. Likely respiratory causes might be chronic bronchitis, emphysema, asthma, bronchiectasis and lung carcinoma, all o which can be elucidated on history and examination. Consider the possible implications o any underlying pathology on the proposed surgery. First impressions
• Is the patient dyspnoeic or cyanosed at rest? • Are they using supplemental oxygen? • Is the patient cachectic, nicotine-stained or obviously clubbed? • You may not be able to see inside a sputum cup as you walk in, but its presence may give you a clue to a diagnosis (a polystyrene cup in the room may also contain the examiner’s coffee).
Histor y
• Ask speci�cally about the duration and severity o presenting symptoms. • Ask also about cough and sputum production, and any other symptoms that may be present. • What is the diagnosis o the patient’s problem? • Are there any precipitants or actors which worsen the condition? • Is the patient using home oxygen? How many hours a day? • Determine any restriction on unction and reserve: – metabolic equivalent exercise tolerated – walking distance on �at and uphill/stairs – limitations to normal activities o daily living. • Determine underlying causes: – duration and magnitude o cigarette smoking – occupational exposure (e.g. asbestos) – inections (e.g. tuberculosis) – genetic illnesses (alpha-1-anti-trypsin de�ciency). • Elucidate current treatment o the patientʼs symptoms: – home oxygen – bronchodilators – antibiotics – steroid therapy – physiotherapy recent admissions to hospital, including intensive care/ventilation episodes.
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Physical examination
It is easiest to examine the respiratory system with the patient sitting up. • Examine the patient peripherally or cyanosis and clubbing (which will usually indicate co-existent disease, e.g. carcinoma, �brosis or chronic inection). Warm peripheries and a bounding pulse may indicate carbon dioxide retention. Pulsus paradoxus may be present. • Consider the patient’s pattern o breathing, respiratory rate and effort, including the use o accessory muscles, intercostal recession and tracheal tug. • Is the patient centrally cyanosed? • Ask the patient to breathe in deeply and breathe out as rapidly and completely as possible. Look or wheeze and prolonged expiration time beyond a ew seconds. • Posterior chest: – examine or overin�ation, scars – palpate or reduced expansion – percussing the chest may be o use i you suspect the possibility o localised inection or a pleural effusion – auscultate the chest to evaluate breath sounds in terms o quality and symmetry, and any adventitious sounds (crepitations and wheezes), and whether these change with coughing. • Anterior chest: – inspection – chest expansion – percussion – auscultation. Position the patient at 45 degrees and palpate the apex beat and look or a parasternal heave suggestive o right ventricular hypertrophy. Listen or a loud pulmonary component o the second heart sound. In a patient whose air�ow limitation is not severe, or extremely well-managed, there may be ew clinical signs present on the day o the examination. Useful statements
‘Mr is a middle-aged gentleman who has moderately severe chronic obstructive pulmonary disease, secondary to a 20-pack-year history o cigarette smoking, which is ongoing. He has recently been hospitalised or 1 week ollowing an inective exacerbation o his condition. He suffers unctional limitation rom his condition and is unable to walk up more than one �ight o stairs or 400 m on level ground without resting. He currently uses nebulised salbutamol approximately our times a day at home. On examination he is cachectic with nicotine-staining o his �ngers and is peripherally cyanosed. He is not centrally cyanosed. Tere is limited chest wall expansion and reduced breath sounds globally, with expiratory wheeze present especially in the lower lung zones. His condition is not optimised or the proposed surgery and I would seek urther investigations and instigate a management strategy prior to considering him or general anaesthesia.’ Investigations
• Pulse oximetry on room air is a useul test
Spirometry: restrictive/obstructive changes and effect o bronchodilators
46
Examination anaesthesia
carbon monoxide (DLCO) is reduced in emphysema, peak �ow rates, �ow– volume loops • Chest X-ray: look or hyperin�ation, inection • ABG on room air: respiratory ailure i pO2 <50 mmHg, or pCO2>50 mmHg • Full blood count: look or polycythaemia, increased Hb • ECG: evidence o right ventricular hypertrophy, concomitant ischaemic heart disease. Topics for discussion
• Strategies or optimisation o chronic airways limitation prior to surgery: role o outpatient clinics, respiratory physicians, exercise regimens and physiotherapy • Smoking cessation and anaesthesia: timing and consequences • Pneumoperitoneum and pulmonary consequences • Surgery or severe emphysema: criteria or suitability and preoperative evaluation • Choice o laparoscopic versus open surgical technique in this patient • Strategies or intraoperative ventilation • Management o the patient who ails extubation at the end o surgery.
7. The patient with pulmonary fibrosis Possible clinical scenario
Mr is a 68-year-old ormer roo�ng worker who has been admitted to hospital with worsening shortness o breath. He is normally on home oxygen. Please take a brie history and examine his respiratory system. Appropriate thoughts
From the history and examination request a pulmonary disease is likely, keeping in mind the possibility o concomitant right-sided cardiac disease/cor pulmonale. Perhaps a clue to the diagnosis lies in the occupational history. First impressions
• Dyspnoea, cyanosis and oxygen therapy are all likely, and the patient may have obvious clubbing. • Cachexia may be a sign o underlying malignancy.
Histor y
• Where the diagnosis is known this will usually be orthcoming, especially in
the case o occupational industrial dust disease. Determine the nature, severity and duration o exposure. • Ask about age o onset o the disease and symptom progression, concentrating on unctional limitations/exercise tolerance. • Is there any history o smoking? • Have systemic illnesses causing chronic lung disease been excluded, e.g. rheumatoid arthritis, systemic lupus, ankylosing spondylitis, scleroderma, polyarteritis, sarcoidosis, other autoimmune disease? Is there any history o pulmonary inection, e.g. tuberculosis, viral inection,
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• ake a medication history (bleomycin, nitrourantoin, amiodarone, methotrexate among others can cause interstitial lung disease). • Discuss current treatment. • Patients suffering rom asbestosis are at increased risk o pleural plaque ormation, bronchial carcinoma (especially i smokers) and malignant mesothelioma.
Physical examination
• Look or clubbing, central and peripheral cyanosis. • Determine respiratory rate, look or use o accessory muscles. • Percussion note may be dull over areas o pleural thickening/effusion/
mesothelioma. • Auscultate or �ne inspiratory crepitations and wheeze. • Look or signs o pulmonary hypertension/right ventricular hypertrophy (parasternal heave, loud pulmonary component o second heart sound). Useful statements
‘Mr is a gentleman with respiratory impairment rom known severe pulmonary �brosis o 6 years. Tis is believed to be due to occupational asbestos exposure; he worked or more than 20 years in a grinding room o untreated boards with no respiratory protection or clothing decontamination acility. He has been on home oxygen therapy 12 hours per day or 3 years. He is unable to walk across the room without becoming short o breath. He was a heavy cigarette smoker between the ages o 15 and 35, afer which time he quit. He was admitted to hospital 5 days ago with worsening shortness o breath and haemoptysis. He is due or a C-guided biopsy o a lesion detected on chest X-ray and C scanning, which his attending doctors ear may be malignant. ‘On examination he is receiving oxygen via nasal prongs at 4 L/min. He was happy to attempt to talk while on room air, but rapidly became short o breath, unable to speak in sentences and dramatically centrally cyanosed, at which point we paused or him to put the oxygen back on. He is obviously clubbed and cachectic. His respiratory rate is 24 per minute. Chest auscultation reveals widespread, �ne inspiratory crackles throughout both lung �elds. He has no palpable cervical lymphadenopathy. Tere is no parasternal heave and heart sounds were normal.’ Investigations
• Respiratory unction tests will typically show a restrictive pattern and reduced DLCO • Chest X-ray may show pulmonary in�ltrates, enlarged right ventricle, pleural plaques, pleural effusion, carcinoma • Arterial blood gases • ECG – evidence o right-sided hypertrophy/strain, right axis deviation, P pulmonale.
Topics for discussion
• Differential diagnosis o pulmonary in�ltrates/�brosis • What is the role o preoperative echocardiography should such a patient present or emergency repair o an incarcerated hernia? What anaesthesia techniques would you employ in that circumstance, and
48
Examination anaesthesia
8. The patient with diabetes Possible clinical scenario
Mr F R, 43, has recently undergone debridement o lower leg ulcers. Please take a brie history and examine the patient as you see �t. Appropriate thoughts
• Te history given in the scenario should lead you to a consideration o a patient with either peripheral vascular disease, diabetes mellitus, or both. • Remember that diabetic patients are always available, so they commonly make an appearance in the medical vivas. • Early questioning on the nature o the ulcers and surgery should point you in the right direction.
First impressions
Clues may be present as to the severity o any co-morbidities. • Is the patient unwell and wheelchair-bound or an obvious outpatient? • Are there any previous limb amputations? • A general impression o the patient’s weight may also be useul. Histor y
• Ask about the cause o the ulcers and any previous episodes o ulceration/
debridement. • Determine whether the patient has type I or type II diabetes, and at what age it was diagnosed. • Record the patient’s hypoglycaemic regimen, including dietary control, oral hypoglycaemics and insulin: what type, how much and when? • Determine the adequacy o control: how ofen is BSL measured and what is the pattern o results; has HbA1c been measured, and i so what was the result? • Have there been any symptoms o hyperglycaemia (admissions with DKA, ongoing polyuria and thirst with weight loss) or episodes o hypoglycaemia (dizziness, loss o consciousness, sweats, seizures): i so, under what circumstances? Importantly, determine the presence or absence o major co-morbidities: • Cardiovascular: – ischaemic heart disease (including silent ischaemic episodes) – exercise tolerance – claudication – transient ischaemic attacks/stroke – hypertension. • Nervous system: – peripheral neuropathy – autonomic neuropathy (ainting when standing, dizziness, erectile dysunction). • Vision: – lens and retinal disease. • Renal system: – dysuria/nocturia – oedema renal dysunction or ailure.
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Physical examination
You may be directed towards a speci�c system. • Ask or the patient’s weight, BSL and blood pressure, standing and supine. (You may be invited to measure the blood pressure.) • Position the patient or cardiovascular examination. • Assess peripheral circulation: – temperature – capillary re�ll o peripheries – peripheral pulses: carotid, radial, emoral, popliteal, dorsalis pedis and posterior tibial. • Inspect skin or ulceration and inection. • est sensation or peripheral neuropathy. • Postural hypotension (all o >30/20 mmHg on standing rom supine position) may be an indicator o autonomic neuropathy, as may tachycardia at rest. • Examination o the eyes is useul, including assessment o visual acuity, lens opaci�cation and undoscopy or haemorrhages, exudates and vessel prolieration. Ask to perorm undoscopy – the examiners may tell you the relevant �ndings. • Examine the chest or co-existing cardiac disease (e.g. cardiomegaly) and auscultate the lung �elds. • Assess the patient’s airway as you normally would (long-standing poor control may lead to a ‘stiff joint syndrome’ and increased incidence o intubation diffi culties). Useful statements
‘Mr R has long-standing type II diabetes which is well controlled on his current oral hypoglycaemics, as evidenced by tight BSL control and reportedly low HbA1c. He does, however, have several end-organ complications o his disease, including autonomic neuropathy (as evidenced by a resting heart rate o 110 beats per minute and a postural drop in lying to standing blood pressure rom 140/90 mmHg to 100/50 mmHg), peripheral neuropathy, absent peripheral pulses to palpation below the knee and vascular compromise resulting in ulceration and inection o his eet.’ Investigations
• Full blood count, random and asting blood glucose, HbA1c, urea and electrolytes • Urinalysis or glucose and protein • Chest X-ray • ECG: look or signs o ischaemia, Q variability.
Topics for discussion
• Perioperative management o BSL/oral drugs and insulin • Classi�cation o types o insulin • Advantages/disadvantages o spinal vs general anaesthesia or lower limb
debridement • How to construct a sliding scale o insulin; advantages/disadvantages o subcutaneous versus intravenous scales • Mechanism o action o: sulphonylureas, metormin, alpha-glucosidase inhibitors, thiazolidinediones • Importance o intraoperative patient positioning Diagnosis and management o diabetic ketoacidosis
50
Examination anaesthesia
9. The patient with thyroid disease Possible clinical scenario
Mrs S I, 57, has had recent weight loss. Please take a history and examine her head and neck. Appropriate thoughts
Hyperthyroidism is the most likely explanation or the presenting symptom and examination request. Keep other possible causes (e.g. malignancy) in mind. First impressions
• Does the patient have the characteristic acies o thyrotoxicosis? Is there an obvious goitre? • Is there a glass o water nearby (suggesting sipping by patient during previous examination)?
Histor y
• Ask about the history o weight loss: how much and over what time period? • Does the patient have a diagnosis or their condition? How long has this been
present? • I you suspect hyperthyroidism as a cause, ask about other symptoms: – anxiety – palpitations – tremor – heat intolerance – atigue – eye problems – sweating – diarrhoea, vomiting. • I a goitre is present, ask about airway symptoms: – positional dyspnoea (suggesting retrosternal extension) – dysphagia – stridor – engorgement o head and neck veins; epistaxis – hoarseness/stridor (recurrent laryngeal nerve involvement). • What treatment is the patient receiving? • Ask about any associated diseases, previous operations and current treatment. Physical examination
• Examine the eyes or lid retraction, lid lag, exophthalmos and conjunctivitis
(which suggest Graves’ disease). • Inspect the neck and any possible thyroid swelling by getting the patient to take sips o water (a thyroid mass will rise with the larynx). See i you can see an inerior border to the mass. • Look or prominent veins in the neck and upper chest. • Palpate the neck rom in ront and behind, eeling the size and consistency o any swelling.
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• Listen over the neck or a possible bruit, and ask the patient to raise their
arms over their head, looking or congestion in the superior caval distribution (Pemberton’s sign). • While in the vicinity, assess the patient’s airway as you normally would.
Useful statements
‘Mrs I is currently an inpatient, undergoing investigation or signs and symptoms o hyperthyroidism. She has an 8-week history o 10 kg weight loss, palpitations, heat intolerance and dry eyes, with easy atiguability causing absence rom work. On examination she has a pronounced thyroid stare, exophthalmos and conjunctivitis, and a smooth diffuse swelling in the neck consistent with an enlarged thyroid. Tere are no signs o retrosternal extension, recurrent laryngeal nerve involvement or thoracic inlet obstruction. Tese �ndings are most consistent with a diagnosis o Graves’ disease.’ Investigations
• Tyroid unction tests: thyroid stimulating hormone (SH), tri-iodothyronine
(3), thyroxine (4), ree concentration 4, 3 resin uptake, radioactive iodine scan • C scan • ECG. Topics for discussion
• Differential diagnosis o hyperthyroidism • Pharmacological management o hyperthyroidism: carbimazole, propylthiouracil, beta-blockers • Maniestations and treatment o thyroid storm • Anaesthesia technique or thyroidectomy • Diagnosis and management o postoperative hypocalcaemia • Management o postoperative haematoma.
10. The patient with pituitary disease Possible clinical scenario
Mr A E is a 55-year-old man who presented with headaches and visual disturbance or investigation, and is now booked on your elective neurosurgical list. Please take a history and examine the patient’s visual �eld with the equipment provided, along with any other examination as you see �t. Appropriate thoughts
Te combination o presenting problems should suggest intracranial pathology somewhere along the visual pathway rom the optic nerve to the occipital cortex. Te possibility o a lesion near the optic chiasm should trigger some memories. First impressions
• Patients with acromegaly secondary to a growth hormone secreting pituitary
adenoma have characteristic acies with a large supraorbital ridge producing rontal ‘bossing’, a large, square, prognathic jaw, macroglossia and ofen widely
52
Examination anaesthesia
• Te voice may be hoarse rom laryngeal tissue growth. • Hands and eet (the peripheral or acral components) are typically broad and spade-like, such that the acromegalic handshake is encompassing, moist and doughy.
Histor y
• Onset o bony and sof tissue changes is insidious and can go unnoticed or
considerable time. Patients ofen cease to wear rings, and their shoe size ofen increases. • Headache and visual disturbances are common presenting complaints. • Paraesthesiae and arthralgias are common; up to 50% o patients may have carpal tunnel syndrome. • Tere is a strong association with obstructive sleep apnoea; ask about: snoring, gasping, atigue, irritability, daytime somnolence. (See subsequent scenario.) • Patients may have cardiomyopathy and symptoms o lef ventricular dysunction. • Tere is a tenuous association between acromegaly and colonic polyps and carcinoma. • Ask about medications taken (octreotide, bromocriptine, cabergoline) and any side effects (orthostatic hypotension may occur with dopamine analogues such as bromocriptine). • Is any radiotherapy planned? (Surgery is ofen a �rst-line option.) • Ask about symptoms o diabetes. (Glucose intolerance is common.) Physical examination
• Physical eatures, as described above, may lead to an immediate diagnosis. • Spend some time evaluating the airway, as acromegalic eatures may predispose
the patient to diffi culties with bag and mask ventilation, and intubation. • Te classic visual �eld deect is a bitemporal hemianopia (central optic nerve �bres decussate at the optic chiasm near the sella), but a wide variety o �eld deects may be encountered. • It is prudent to conduct a cardiovascular examination looking or signs o congestive cardiac ailure and hypertension. Tere is an increased risk o vascular and ischaemic heart disease and stroke. • Examine the abdomen or organomegaly. • Multinodular goitre may be present. Useful statements
‘Mr E was diagnosed with acromegaly 7 weeks ago afer presenting to his GP with headaches and reporting two traffi c accidents where he sideswiped parked cars he did not see. A visiting relative also noticed a change in his appearance. On re�ection, Mr E concedes noticing his shoe size has increased rom 9 to 11 over a period o many months. He also reports suffering arthritic pains in most joints, and symptoms o snoring and daytime somnolence suggestive o sleep apnoea. ‘On examination he has characteristic acies and hands o acromegaly. He has a large tongue, splayed teeth, an inter-incisor distance o 2 cm and a Mallampati score o 3 on airway examination. Visual �eld examination reveals a bitemporal hemianopia more extensive in the lef visual �eld. Tere are no signs o respiratory or cardiac disease.
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Investigations
• Te diagnosis is usually con�rmed by an increased assay o insulin-like growth actor IGF-1; prolactin levels may also be increased. Diagnosis can also be con�rmed by ailure o growth hormone suppression by glucose tolerance test. • Other baseline tests o anterior pituitary unction include assays o cortisol, thyroxine and gonadal hormones. • While skull X-ray may show an enlarged sella, magnetic resonance imaging is the modality o choice. Pituitary adenomas appear hypodense on 1-weighted images and show less enhancement with gadolinium than surrounding tissue. • Preoperative testing should include blood glucose measurement, ECG and echocardiography when concomitant cardiac disease is suspected.
Topics for discussion
• Management o a potentially difficult airway • Complications o surgery: CSF rhinorrhoea, diabetes insipidus; how are they managed? • Patient positioning or surgery: neurosurgical requirements, peripheral nerve protection.
11. The patient with morbid obesity/obstructive sleep apnoea Possible clinical scenario
Mr L E, who is 40 years o age, recently underwent a laparoscopic gastric-banding operation. Please assess him as you see �t. Appropriate thoughts
• Anticipate the obese patient. • Consider the possible complications o obesity and how they may impact upon
anaesthesia management. • A patient scheduled or weight-reduction surgery will ofen talk happily and openly about their condition, but a degree o sensitivity is still required. First impressions
• You will rapidly orm an impression as to the magnitude o the patient’s obesity. • Tere may be evidence o concomitant disease (e.g. hypothyroidism or dyspnoea at rest). • I the patient is an inpatient it is unlikely to be because o the recent surgery unless there were complications. (patients are normally discharged around day 2.)
Histor y
• Determine the patient’s weight and height and calculate their body mass index (kg/m2). • Ask about any recent weight loss or gain, and over what time period changes have occurred, including any other therapies attempted prior to surgery. • How has the patient’s size impacted on their daily living and work? Ask the patient i he was made aware o any problems with the operation or
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Examination anaesthesia
• Ask about co-morbidities linked to obesity, speci�cally:
– hypertension – hyperlipidaemia – type II diabetes – coronary artery disease – hypothyroidism – stroke – congestive cardiac ailure – dysrhythmias – re�ux – obstructive sleep apnoea. • Patients with obstructive sleep apnoea may report a constellation o symptoms, including: – snoring – apnoea – choking – gasping – requent awakening – daytime sleepiness – atigue – irritability – deects in attention and memory – depression. • Ask about how the diagnosis was made (usually on polysomnography) and whether the patient uses a continuous positive airway pressure (CPAP) device, and i so, how this has helped. • Assess how the sleep apnoea has impacted on the patient’s liestyle, work and amily.
Physical examination
• Determine the BMI, i you have not worked it out already. • Te airway should be careully assessed, including mouth opening and
Mallampati score, and any limitation o neck movement. Neck circumerence has been proposed as an indicator o difficult intubation. • Assess the blood pressure and perorm cardiovascular examination, in particular looking or evidence o right ventricular hypertrophy and pulmonary hypertension. • Listen to the lung �elds. • Examine the abdomen including the recent surgical scars. Feel or hepatomegaly (which may be difficult). Locate the subcutaneous reservoir or the gastric band, looking or signs o inection at the site. Investigations
• Pulse oximetry on room air may be a good indicator o underlying pulmonary
pathology • Spirometry – assess or restrictive lung deect • ABG – especially i low oxygen saturation on room air • ECG – may show right-sided cardiac complications (right ventricular hypertrophy, right axis deviation) o sleep apnoea, lef ventricular hypertrophy, arrhythmias
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• Chest X-ray – look or advanced cardiac disease. • Echocardiography – look or ventricular hypertrophy, contractility, pulmonary pressure (may need transoesophageal echo or adequate study). • Polysomnography results.
Useful statements
‘Mr E is a 40-year-old gentleman who has suffered rom obesity or at least 20 years. He underwent laparoscopic gastric banding 2 weeks ago, prior to which he weighed 170 kg, which in conjunction with his height o 170 cm gives him a body mass index o 59. He has lost 10 kg since the surgery and appears well motivated. As well as his problem o morbid obesity, he was diagnosed with obstructive sleep apnoea 2 years ago, underwent sleep studies and has been using nocturnal CPAP, which has relieved his symptoms o snoring, daytime somnolence and atigue. On examination o his airway I note that he has good neck movement in all directions, a Mallampati score o 3 with a normal thyromental distance and inter-incisor distance. His blood pressure is normal, and there were no signs o pulmonary hypertension or right-sided cardiac ailure.’ Topics for discussion
• Metabolic syndrome • Obesity hypoventilation syndrome • Risk o re�ux and aspiration; use o histamine receptor and proton blockers • Intravenous access in obese patients • Suitability o obese patients or day surgery • Preoperative bene�ts o CPAP or obstructive sleep apnoea/obesity hypoventilation syndrome • Pharmacokinetics in obesity • Patient positioning • Airway management • Monitoring • Problems o pneumoperitoneum in this patient • Analgesia and obstructive sleep apnoea.
12. The patient with a spinal injury Possible clinical scenario
Mrs I H is wheelchair-bound and due to undergo check rigid cystoscopy. Please conduct a history and relevant neurological examination. Appropriate thoughts
You should be alert to the possibility o central nervous system or neuromuscular disease. First impressions
• Does the patient move any limbs spontaneously? • Does the patient have a tracheostomy in situ or portable ventilator? (Tis may give a clue as to the height o the lesion.)
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Examination anaesthesia
Histor y
• A history o trauma is common in the spinally injured patient. • Ask how long ago the injury occurred, and or how long the patient was initially hospitalised. • Ask about initial treatment, including surgery. • Patients are ofen very knowledgeable about the level o their lesion and the associated sensorimotor de�cits. • Did the injury result in complete spinal cord transection? • For thoracic lesions and above, ask about autonomic symptoms triggered by everyday activities, surgery, and other events. • Ask about chronic complications rom the injury: – chronic pain – skeletal muscle spasms – pressure area care problems – pulmonary and urinary tract inections – thermoregulatory disorders – anaemia. • What limitations does the level o injury place on the patientʼs liestyle, and how have they adapted to this? • Obtain details o previous surgery and anaesthesias, and whether there were any associated problems. • Obtain a list o current medications and any allergies which may be present (e.g. latex).
Physical examination
• You should attempt to correlate physical signs with the level o the injury. • Remember that there will be lower motor neurone signs at the level o the lesion: – weakness – wasting – loss o tone – reduced re�exes – asciculation. • Tere will be upper motor neurone signs below the level o the lesion: – paralysis, wasting – increased tone and clonus – hyperre�exia – extensor plantar response. • Tere will be complete sensory loss below the level o the lesion. • Bradycardia and heart block will usually not occur unless the lesion is above 4. • Systematic examination is best carried out with the patient supine, and should include: – inspection or asciculations and muscle wasting – test tone at knees, hips and ankles; test or clonus – test power in upper and lower limbs, i any present – test lower limb re�exes: knee jerk, ankle jerk, plantar re�ex – determine sensory level, comparing lef and right; time will probably preclude testing o multiple modalities (touch, pain, temperature, vibration and proprioception). I time permits, assess the patient’s airway and listen to the praecordium and
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Useful statements
‘Mrs H is a young woman who sustained a mid-thoracic spinal injury in a diving accident 6 years ago, leaving her paraplegic with a loss o bladder and bowel unction. Despite this, she maintains a rigorous liestyle and has had no cardiac or respiratory compromise. Complications o the injury have included relapsing urinary tract inections, and two episodes o autonomic hyperre�exia associated with catheterisation. On examination there is paralysis and wasting wa sting o both lower limbs with signi�cant muscle spasm, increased tone, hyperre�exia o knee and ankle jerks with clonus demonstrated at the right ankle ank le on hyperextension. Tere is an extensor plantar response. ‘Tere is sensory loss below 5 dermatomal level.’ Invest Inv estigat igations ions
• Radiological investigation o the injury: X-rays, C scan s can • Spirometry • ECG or high thoracic lesions elec trolytes • Full blood count, urea and electrolytes • Urine microscopy and culture.
Topics for discussion
• Pathophysiology o autonomic hyperre�exia: what actors increase the likelihood? • Preven Prevention tion and treatment o autonomic hyperre�exia • Muscle relaxants in spinal injuries, acute and chronic • Central neuraxial blockade or surgery Controversies es in neuroprotection or acute ac ute spinal cord injury • Controversi • Airway management o the patient with a suspected cervical cer vical injury • Controversi Controversies es in radiological diagnosis d iagnosis o spinal injuries.
13. The patient with muscular dystrophy Possible Poss ible clin clinica icall scen s cenar ario io
Mr K A is a 19-year-old man with weakness. He is con�ned to a wheelchair. wheelchair. Please take a brie history and conduct a neurological examination o his upper limbs. Appropr Appr opriat iate e thoug t houghts hts
Some causes o weakness in a male patient o this age include muscular dystroph dystrophyy, myasthenia (although unusual to be wheelchair-bound with treatment), myotonic dystrophy dystrophy, cerebral palsy and motor neurone disease. diseas e. (O the t he muscular dystrophies, Becker has similar eatures to Duchenne, but is usually u sually less severe, is o later onset, and is less progressive. Fascioscapulohumeral dystrophy is nearly as common as Duchenne, but less than 20% will require a wheelchair beore the age o 40.) First Fir st impr impress essions ions
• Examination patients may be present with a carer, who can provide much useul history history.. Tere may be obvious muscle wasting.
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Examination anaesthesia
• Patients with myotonic dystrophy have characteristic acies, baldness and visual problems. problems.
Histor Hist or y
• Patien Patients ts should be able to give you a diagnosis. • Ask about onset o symptom symptoms, s, symptom progression and unctional limitations. cardiorespiratory iratory problems? • Does the patient have any cardioresp • Are there any problems with speech, swallowing or oesophageal re�ux? • Have there been any recent anaesthesias, operations or intensive care admissions? • Is anyone else in the amily affected? (Sketching a brie amily tree may give clues to the genetic inheritance, and hence diagnosis; be aware though that cases may be the result o spontaneous gene mutation.)
Physica Phys icall examin exa minati ation on
Patients ts with muscular dystrophy usually have severe proximal weakness. Deep D eep • Patien
tendon re�exes tend to be preserved proportional to the amount o remaining muscle mass. Sensation is usually not affected. • Further examination in consideration or surgery would include cardiovascular examination (patients ofen develop cardiom c ardiomyopathy yopathy and may have mitral valve prolapse) and respiratory respiratory examination (pneumonia and respiratory ailure are common terminal events). Useful statements
‘Mr A is a young man who suffers rom Duchenne muscular dystrophy. dystrophy. He has been a recent inpatient with lef-sided pneumonia, rom which he has now recovered. His condition was diagnosed at the age o 3, and he has been wheelchair-bound since the age o 11. Progression seems to have been rapid in the last year, with worsening weakness, reduced unctional mobility and increased requency o respiratoryy inections. respirator inect ions. He has difficulty swallowi s wallowing ng and has a PEG in situ. While he is still cared or by his parents at home, he is currently being considered or ull-time nursing care in a palliative care centre. ‘On examination there is severe muscle wasting o all muscle groups, and obvious kyphoscoliosis. Tere is marked weakness o all upper limb muscle groups, reduced grip strength, demonstrably present but reduced biceps, triceps and supinator re�exes, and no loss o sensation to light touch.’ Invest Inv estigat igations ions
dystrophyy. • Creatine kinase is always high in patients with Duchenne muscular dystroph • Routine preoperative screening would include respiratory unction testing, chest X-ray and ECG. • Echocardiograph Echocardiographyy may be extremely useul i surgery is planned.
Topics for discussion
• Genetic inheritance o the t he different muscular dystrophies • Use o depolarising and non-depolarising relaxants, volatile agents, including dosage Pre-medication tion i surgery is planned • Pre-medica What is your anaesthesia technique or this patient i appendicitis is
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14. The patient with multiple sclerosis Possible Poss ible clin clinica icall scen s cenar ario io
Mrs O W is a 29-year-old woman who presented several years ago with w ith transient right hemiparesis. Please take a history o her illness and examine her cranial nerves. Appropr Appr opriat iate e thoug t houghts hts
• Te history suggests a central nervous system disorder, and the patient is too
young to be suffering rom an atherosclerotic cause (unless it was a severe amilial hyperlipidaemia). hyperlipidaemia). Other possible causes include hemiplegic migraine, paradoxical emboli or multiple sclerosis. • Focus on taking a thorough history and demonstrating a good cranial nerve examination technique until the nature o the problem becomes more obvious. Patients Patien ts with multiple sclerosis are usually very well inormed about their disease. First Fir st impr impress essions ions
• Between exacerbations some patients may appear completely well with near
complete recovery o symptoms. Others may suffer a more progressive orm o the disease without distinct episodes.
Histor Hist or y
• Diagnosis o multiple sclerosis requires separate episodes o central nervous
system events. • Ask about onset and offset o symptoms, which may include limb paresis, parasthesiae, ataxia, vertigo, visual disturbance, seizures and pseudobulbar palsy. • Ask i there are any precipitating actors or attacks (stress, extremes o temperature, temperatur e, intercurrent illnesses, exercise). • Discuss how the illness impacts on unctions unc tions o daily living. • Ask about past and current treatments (which may include carbamazepine, steroids, intereron and some cytotoxics, and rarely plasmapheresis; bacloen and dantrolene may relieve muscle spasm). • Urina Urinary ry retention and urgency are common. Physica Phys icall examin exa minati ation on
• Even with the constraints o the examination ormat there should be time to
perorm a thorough cranial nerve examination. • Note that signs can be extremely variable; there may be loss o visual acuity with central/hemianopic �eld deects, internuclear ophthalmoplegia ophthalmoplegia (weakness o adduction in one eye and nystagmus in the other), acial weakness and swallowing disorders. In general, cranial nerve signs occur less requently than long tract signs. • Further CNS examination may reveal sensory deects, especially to vibration, cerebellar signs (such as ataxia or intention tremor) and variable patterns o spastic motor weakness. Useful statements
‘Mrs W �rst presented 3 years ago with a sudden all at home and weakness o her right arm and leg, which resolved afer several days. Investigations or
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Examination anaesthesia
an episode o dizziness, reduced co-ordination and diffi culty maintaining her balance, and was admitted to hospital, at which point a diagnosis o multiple sclerosis was made. Tese symptoms also resolved afer 2 weeks. Since that time she has also suffered rom blurred and double vision, which is always present, but �uctuates in severity. She has no other unctional limitations at present but has chosen to stop driving. She is currently taking 5 mg prednisone per day. ‘On examination o her cranial nerves there are no visual �eld deects to gross testing. Eye movements are preserved, but there is sustained nystagmus in her right eye on rightward gaze, which may represent either internuclear ophthalmoplegia or cerebellar disease. Her tongue deviates to the right on protrusion, but there is no wasting or asciculation. Tis may represent a right hypoglossal nerve lesion. Tere are no other obvious cranial nerve abnormalities.’ Investigations
• MRI is the imaging modality o choice and may show demyelinated plaques. • CSF analysis may show leukocytosis, IgG bands and myelin basic protein.
Topics for discussion
• Autonomic instability and general anaesthesia • Importance o temperature monitoring during anaesthesia • Does general anaesthesia affect the course o the disease? • Would you be prepared to administer an epidural in labour or this patient?
15. The patient with myasthenia gravis Possible clinical scenario
Mrs U S, 35, has a history o difficulty swallowing and atigue on exertion. Please take a history and examine her upper limbs, and other areas as you see �t. Appropriate thoughts
• Te given history suggests a neuromuscular problem. • With myasthenia it is important to assess the severity o the illness, current
treatment, and anticipate questions related to the conduct o anaesthesia in such a patient.
First impressions
• Limb girdle and bulbar involvement suggests more severe disease; a degree o
ptosis may be evident, and the quality o the patient ʼs voice may deteriorate afer a ew minutes; all o these may depend on the timing and effectiveness o current treatment. • A characteristic myasthenic ‘snarl’ may be evident on smiling. Histor y
• Ask about duration and severity o symptoms, especially limb weakness
and chewing or swallowing difficulty (which predict the need or intra- and postoperative airway protection). • Ocular symptoms o ptosis and diplopia are common. Is there signi�cant respiratory impairment?
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• Previous anaesthesia history is o great importance. • What treatment has been undertaken? Tymectomy, immunosuppressives,
immunoglobulin, plasmapheresis may have been tried. Symptomatic control is usually with pyridostigmine; daily dosage >700 mg is a predictor o the need or postoperative ventilation.
Physical examination
• est or easy atiguability o the upper limbs (holding above the head); power
will be globally reduced. • Re�exes in the upper limb should be preserved and there is no sensory loss. • Ask the patient to keep gazing upward, which may reveal weakness o the eyelid and oculomotor muscles. Useful statements
‘Mrs S �rst reported symptoms o weakness and atigue 4 years ago, and was unable to undertake her regular gym training sessions. A diagnosis o myasthenia gravis was made, and she has been on medical therapy since. Her limb weakness improved, but in the last ew months has deteriorated. Diplopia became a more signi�cant problem and she was unable to leave her house. Swallowing difficulties with solid ood appeared at the same time, and she has had two urgent gastroscopies to retrieve ood boluses since then. Tere have been no reported respiratory problems, but she does not walk urther than 200 m due to atigue. Her current dose o pyridostigmine is 600 mg per day, and her symptoms noticeably worsen afer one missed dose. She is currently being investigated and worked up or thymoma removal. ‘On examination, I noticed that her voice became husky afer a ew minutes speaking. She has obvious ptosis. Upper limb examination reveals easy muscle atiguability, with overhead arm lif unable to be sustained or greater than 20 seconds. Grip strength is initially normal , but ades afer about 10 seconds. Re�exes are normal and there is no sensory de�cit to light touch.’ Investigations
• Diagnostic tests may include assay o antibodies against acetylcholine receptors,
electromyography and edrophonium challenge. • Investigations or thymoma will usually include chest X-ray and MRI scanning. • Preoperatively spirometry is very useul; patients with markedly reduced vital capacity are more likely to require postoperative ventilatory support. Topics for discussion
• How would you anaesthetise this patient or emergency laparotomy? • Management o anticholinesterase therapy in the perioperative period • Under what circumstances could the patient be extubated at the end o surgery? • Differentiation o myasthenic crisis rom cholinergic crisis.
16. The patient with chronic renal impairment Possible clinical scenario
Mrs E N, 49, presents because o a blocked A-V �stula. Please take a history and
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Examination anaesthesia
Appropriate thoughts
• You should have guessed by now that the patient is likely to have renal ailure. • It is important to elucidate the cause, any complications and current treatment.
First impressions
• Is the patient an inpatient? Is there a vascath or peritoneal dialysis device in situ? • You may gain an impression o the patient ʼs overall hydration state.
Histor y
• Ask when renal ailure was diagnosed and what led to the diagnosis. Does the
patient know the underlying cause or renal disease? – glomerulonephritis (primary, or as part o another disease, e.g. lupus) – analgesic nephropathy – diabetic nephropathy – hypertensive nephrosclerosis – ureteric re�ux – polycystic kidney disease. • Ask about progression o the disease and its treatment, including �uid restriction, dialysis (peritoneal and haemodialysis), transplantation (previous or pending) and other medical treatments (e.g. or hypertension). • Have there been any major complications o the disease or its treatment? – hypertension, anaemia, uraemia, cardiac ailure, gout, acute �uid overload – dialysis access problems, blocked or inected shunts, peritonitis – transplant problems:rejection, inection, complications o immunosuppression. • Discuss unctional limitations on the patient’s activity, and how the dialysis impacts on their lie. • Ask about concomitant medical conditions, medications, problems with previous surgery and anaesthesia and allergies. Physical examination
• Make an assessment o the hydration o the patient. Is she clinically anaemic? • Measure the blood pressure, and ask or the patient’s ideal body weight. • Examine any dialysis access points, including �stulae or patency, thrombosis
or inection, indwelling central venous access lines and peritoneal access points. • Examine the chest and listen or a pericardial rub or evidence o cardiac ailure. Listen to the lung �elds. • Examine the abdomen or scars o previous surgery (dialysis, transplants). Palpate or organomegaly and ascites. • Examine the legs or oedema, bruising and peripheral neuropathy. Useful statements
‘Mrs N has a 12-year history o chronic renal impairment caused by membranous glomerulonephritis or which she has been receiving intermittent haemodialysis three times a week or 6 years via an arteriovenous �stula ashioned on her lef wrist. Prior to that she had received peritoneal dialysis, which was discontinued due to several serious peritoneal inections. Four days ago it was noted that her A-V �stula was completely thrombosed. She is currently an inpatient receiving haemodialysis via a vascath placed in her right subclavian vein, pending new A-V
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not on the waiting list or a renal transplant because o her own personal cultural belies. On examination she is normotensive and her hydration appears normal, consistent with her dialysis last night.’ Investigations
• Urea, creatinine and serum electrolytes, creatinine clearance and plasma creatinine/urea ratio • Chest X-ray – look or acute pericarditis, position o vascath • Full blood count • ECG • ABG – look or metabolic acidosis.
Topics for discussion
• iming o dialysis and elective surgery, perioperative �uid management • Complications and mortality rom dialysis • Electrolyte disturbances and their emergency treatment • Anaesthesia techniques or A-V �stula ormation: general versus regional • Management o coagulation problems in renal ailure • Pharmacology o anaesthesia agents in renal ailure.
17. The patient with chronic liver disease Possible clinical scenario
Mr E X, aged 63, has been eeling unwell or many weeks. Please take a history and conduct an abdominal examination. Appropriate thoughts
Te directed examination suggests the possibility o abdominal organomegaly. First impressions
• Is the patient jaundiced? • Is the patient malnourished? • Other immediate clues to chronic liver disease may include tattoos (a s ource o viral inection) or pigmentation (haemochromatosis).
Histor y
• Ask the patient i they know the nature o their underlying condition. A
diagnosis o cirrhosis is commonly caused by either chronic alcohol abuse or viral inection, although the differential diagnosis is large. • What caused the patient to seek treatment? Common presenting complaints include: – weakness and atigue – jaundice – abdominal pain or swelling (ascites) – altered mental state – pruritis. • Ask about the duration o liver disease, including the ollowing: alcohol intake
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Examination anaesthesia
– overseas travel – drugs, e.g. isoniazid. • Have there been any complications? – haematemesis rom bleeding varices, melaena – ascites – encephalopathy – cholecystitis – pancreatitis. • What treatment has the patient received (including investigations)? – liver biopsy – ascitic tap – protein and �uid restriction – gastroscopy and injection o varices, portocaval shunt. • Enquire about restrictions on activity, and social impact o the disease. Physical examination
You may be again directed by the examiner to start examination at the abdomen. Te patient should be lying supine, with one pillow. • As you approach the abdomen, you may notice other stigmata o chronic liver disease: – palmar erythema – bruising – spider naevi – yellow sclerae – etor – gynaecomastia. • Inspect the abdomen: – masses – distension – bruising – scars. • Palpate all our quadrants: – hepatomegaly: massive, �rm, tender, irregular, pulsatile – splenomegaly (consider rolling patient onto right side as well) – kidneys. • Percuss: – approximate liver span – ascites: roll and test or shifing dullness. • Auscultation: – bruits – riction rubs – presence o bowel sounds. • Assess or the presence o hepatic encephalopathy: – asterixis/�ap – constructional apraxia. Useful statements
‘Mr X is currently an inpatient and gives his presenting problem as cirrhosis. He is a histori On urthe tionin he orts essi alcohol pti o
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likely cause o his disease. He has undergone recent gastroscopy or haematemesis. He is unaware o any current medical treatments. On examination he is malnourished with several stigmata o chronic liver disease, including scleral jaundice, many spider naevi on his arms and trunk, palmar erythema and many large bruises. Examination o his abdomen reveals generalised distension. Both liver and spleen were palpable and both were signi�cantly enlarged. I suspect the presence o ascites as evidenced by shifing dullness to percussion. Te most likely diagnosis in this gentleman is cirrhosis caused by alcoholic hepatitis, and complicated by portal hypertension.’ Investigations
• Full blood count • Urea and electrolytes, serum ammonia • ransaminases, bilirubin, albumin, blood glucose • Coagulation studies • Ascitic �uid cytology, microscopy, culture and biochemistry • Liver biopsy.
Topics for discussion
• Anaesthesia implications o chronic liver disease • Child–Pugh classi�cation o severity o liver disease • Indications/contraindications or liver transplantation • Differential diagnosis o hepatosplenomegaly • Causes o acute hepatitis • Risks o needle stick injury or hepatitis viruses • Anaesthesia implications o chronic alcoholism.
18. The patient with an organ transplant Possible clinical scenario
Mrs Q F, 36, presents or routine check-up afer major surgery. Please take a history and examine her cardiovascular system. Appropriate thoughts
Tere are ew clues to go on here, unless the major surgery was on her cardiovascular system … First impressions
• Unless major complications have intervened, the majority o patients with a
solid organ transplant regain the unction o the previously diseased organ. • It is likely that the patient will appear �t and well, but this may depend on how long ago the operation took place. Te patient may appear Cushingoid rom steroid therapy. Histor y
• Most patients will be very well inormed about the nature o their previous
disease and treatment, and the diagnosis will quickly become obvious. • Ask about the cause o previous cardiac ailure (in this age group usually due to cardiomyopathy) and symptoms the patient was experiencing prior to
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Examination anaesthesia
• Ask about the patient’s surgery: when and where, and whether there were
any complications (the most common o these are rejection and inection). Coronary vascular disease and malignancy may be problems in later years, as may hyperlipidaemia and hypertension. • Determine the patient’s current exercise tolerance and unctional reserve. • Are they able to work? • Ask about current medications, especially anti-hypertensives, cholesterollowering medication and immunosuppressants – have there been any adverse reactions rom these? • Ask about routine check-ups, including cardiac catheterisation and biopsies. • Ask about any other co-existent diseases, previous anaesthesia problems and allergies.
Physical examination
• Perorm your usual cardiovascular examination. • Ask or the patient’s weight and blood pressure. • Te transplanted heart lacks parasympathetic innervation, the resting
heart rate is usually around 90 beats per minute, and sinus arrhythmia is lost. • A small percentage o patients require a permanent pacemaker because o postoperative bradycardias. • A median sternotomy scar will be present, as may scars over the right internal jugular vein (rom endocardial biopsies). • Listen or normal heart sounds and clear lung �elds. Useful statements
‘Mrs F presents or routine cardiac catheterisation 3 years afer successul heart transplantation. She suffered rom severe cardiomyopathy prior to this, with rapid deterioration in unctional status over 2 years. At the time o her operation she was bed-bound, suffered rom severe orthopnoea and had an exercise tolerance o 10 metres on the �at. Te operation proceeded uneventully and there were no immediate postoperative complications. She has suffered some basal cell carcinomas on her skin since the operation, but ew other problems with immunosuppression. She is working ull-time and can walk or several kilometres a day.’ Investigations
• ECG: look or a second P wave (native + donor atrium; usually disappears), RBBB common • Cardiac catheterisation data • Echocardiography: look or intramural thrombi, ventricular unction • Full blood count and serum electrolytes • Chest X-ray.
Topics for discussion
• Management o anaesthesia or elective surgery • Inection prophylaxis • Detection o postoperative ischaemia
What signs and symptoms might alert you to the possibility o rejection?
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Note that many candidates will sit the clinical examination in a major or capital city where transplant candidates (pre- and post-surgery) are readily available or participation in the medical vivas. Te inormation presented above can be used in a �rst principles extrapolation or lung, kidney and liver transplants, i.e. cause and consequences o previous organ dysunction, perioperative management and complications (including complications o immunosuppression), post-transplant unction. You should be able to assess these patients as though they were appearing on your list or elective surgery, even i you are rom a centre where transplant patients are a rarity. 19. The patient with rheumatoid arthritis Possible clinical scenario
Mrs S A, aged 49, presents or metacarpophalangeal joint replacement o her hands. Please take a history and conduct a relevant examination. Appropriate thoughts
• Te operation should alert you to a possible diagnosis. • Tink o the articular and extra-articular maniestations o rheumatoid arthritis that may be o relevance to anaesthesia.
First impressions
• A diagnosis o rheumatoid arthritis may be obvious on �rst inspection. • Does the patient look Cushingoid rom steroid use?
Histor y
• Determine i rheumatoid arthritis is the patient’s main medical problem. • Ask when the diagnosis was made and what symptoms, initially led to the diagnosis. • Disease progression is important. Ask which joints are mainly affected, and speci�cally ask about the neck and jaw. • Ask speci�cally about upper limb neurological symptoms which may indicate nerve or spinal cord compression. • Is the disease currently active? What unctional impairment is present and in which joints? How does this impact on activities o daily living? • Ask about past and present drug treatment. • Have there been any problems related to pharmacological therapy? • Obtain a list o all medications. • Ask about previous anaesthesia problems and document any allergies. • Remember non-articular symptoms o the disease: – dry or in�amed eyes – Raynaud’s phenomenon – peripheral neuropathy – dyspnoea rom anaemia or pleural effusion/�brosis – chest pain typical o pericarditis – renal problems.
Physical examination
It may be useul to describe the articular changes seen in rheumatoid arthritis to
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Examination anaesthesia
• Upper limbs:
– swan-neck and boutonnière deormities o the �ngers – Z deormity o the thumb – ulnar deviation and palmar subluxation at the wrist – vasculitis may be evident in the nail-beds – look or muscle wasting on the palmar surace o the hands – evidence o previous surgery – rheumatoid nodules, i present. • Feel and move any affected joints or swelling and range o movement and tenderness (be gentle). • est the patient’s grip strength and hand unction (ask the patient to undo and redo a button). • Head and neck: – Look at the patient’s posture and test the range o movement o the neck in all planes – Look or temporomandibular joint involvement (swelling and tenderness to palpation, clicking and grating with jaw opening) – Examine the eyes or redness and dryness and nodular scleritis – Listen or hoarseness, which may indicate cricoarytenoid involvement. • Chest: – Listen to the heart or murmurs and pericardial rub – Listen to lung �elds or signs o effusion or crepitations due to pulmonary �brosis. • Abdomen: – Look or splenomegaly i time permits (in Felty’s syndrome, associated with neutropenia).
Investigations
• Serology: note that rheumatoid actor is neither particularly speci�c nor
sensitive; urea and electrolytes or renal unction • X-rays o affected joints: look or joint erosion, destruction and swelling • C-spine X-ray: when examining lexion and extension ilms lo ok or atlantoaxial subluxation (seen as separation o anterior margin o o dontoid process rom posterior margin anterior arch o atlas >3–4 mm). I separation is severe, the odontoid process may protrude into oramen magnum and put pressure on spinal cord or impair blood low through vertebral arteries. he odontoid may be eroded. Subluxation o other cervical vertebrae may occur. • Echocardiography: look or pericardial effusion • ECG: look or acute pericarditis, conduction deects rom nodules • Chest X-ray: look or thoracic maniestations o the disease • FBC: check or anaemia, thrombocytopaenia • Spirometry: look or a restrictive lung deect. Useful statements
‘Mrs A presents or her third metacarpophalangeal joint replacement operation. She has had rheumatoid arthritis or 15 years, and maniests severe changes o a symmetric polyarthropathy to the joints in her hands and wrists, which severely limit her unctional activity. She has had no problems with her cervical spine or
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• The medical vivas
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which are only partially effective in relieving her symptoms. Examination o her neck and airway is unremarkable.’ Topics for discussion
• Diagnosis o cervical spine, temporomandibular joint, laryngeal involvement • Complications o pharmacological therapy: aspirin, NSAID, steroids, methotrexate, penicillamine, gold, azathioprine, cyclosporin
• Perioperative glucocorticoid supplementation • Airway management or distal limb surgery • Extra-articular maniestations o the disease • Intraoperative positioning and monitoring diffi culties. 20. The patient with ankylosing spondylitis Possible clinical sc enario
Mr L O, 29, requires insertion o lower jaw prosthetic dental implants under general anaesthesia. He has a long history o back and hip pain. Please take a brie history and examine his airway and axial skeleton. Appropriate thoughts
• Te given history suggests orthopaedic injury or arthritides. Te examination request raises the possibility o spondylitis. • Perhaps the impending surgery is or dental trauma rom diffi cult intubation?
First impressions
• Ankylosis o the spine may lead to an unusually stiff posture. • Kyphosis may be obvious.
Histor y
• aking a brie dental history may be appropriate in this case. • Ask about onset, severity and progression o back and hip pain. Patients usually
complain o back pain radiating to the sacro-iliac joints and hips, which is worse at night and improves afer movement. • endon and ligament in�ammation is common, especially endoachilles, costochondritis. • Ask about visual symptoms – uveitis/iritis is common and may be severe. • Ask about cardiovascular and renal disease; there are associations with aortitis, aortic regurgitation, pulmonary �brosis and amyloid deposits. • Ask about previous anaesthesia or airway difficulties. • Speci�c problems include temporomandibular joint dysunction, cervical usion, atlanto-axial subluxation, risk o occult cervical racture with minimal trauma, cricoarytenoid arthritis; neuraxial block may be impossible (paramedian spinal may be best option); patient positioning may be diffi cult; limited chest expansion may be present. • Ask about unctional limitations and current treatment. Physical examination
• Care should be spent assessing the airway or eatures listed above. • Observe any kyphosis o the spine and assess degree o movement o all parts o the spine.
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Examination anaesthesia
• Feel or speci�c tenderness in the spine and sacro-iliac joints; assess hip range o motion. • Examine the chest (thoracic expansion speci�cally) and auscultate the heart and lungs.
Useful statements
‘Mr O is a young man who suffered dental trauma rom a difficult intubation while undergoing appendicectomy 7 months ago. He carries a letter and Medic Alert bracelet detailing this; the main problems seem to have been with jaw opening and limited neck movement. He was diagnosed with ankylosing spondylitis as a teenager, which affects his entire spine and his sacro-iliac joints. He has no history o cardiac disease, but suffers rom uveitis. On examination there is �xed kyphosis o the thoracic spine and loss o lumbar lordosis. Tere is markedly reduced neck �exion and extension with some preservation o rotation. Tere is tenderness over both sacro-iliac joints and reduced hip �exion. My main concern is airway management or the impending surgery.’ Investigations
• Preoperative respiratory unction testing and echocardiography may be indicated i evidence o extra-articular disease is present. • Neck and spine X-rays will outline extent o disease. • FBE may show normochromic anaemia.
Topics for discussion
• echnique o intubation • What do you do i awake �bre-optic intubation ails? • Te patient returns 1 year later or repair o ruptured Achilles tendon. What other problems do you anticipate?
21. The patient with trisomy 21 Possible clinical sc enario
Mr O is 24 and due to undergo dental examination under anaesthesia. He is present with a carer. Please take a history and conduct a brie examination. Appropriate thoughts
• Patients with risomy 21 (Down Syndrome) will occasionally appear in the
medical vivas. Tey will ofen be present with a relative or carer, who may provide the bulk o relevant history. It is important to have a gentle, kind approach. • You should be considering systemic maniestations o the condition. First impressions
Te diagnosis can be made rom the characteristic acies. Histor y
While many patients with risomy 21 have intellectual impairment, there is a wide variation in cognitive abilities in this group o patients. You may be asked to direct your questions to the carer present.
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• Ask about complications and associations o the syndrome that have been
encountered in the past: – congenital heart disease (especially endocardial cushion deects/VSD/patent ductus/tetralogy o Fallot), corrective surgery, cyanotic episodes, pulmonary hypertension – eye problems: strabismus, cataracts – hypothyroidism – central or obstructive sleep apnoea, susceptibility to respiratory inection – joint problems, including cervical instability – epilepsy – hearing problems – immunosuppression and increased risk o malignancy, e.g. leukaemia. • Ask about the patient’s current level o unctioning at home and in the community. • Ask about previous operations and anaesthesias and any problems encountered. • Obtain a list o medications and ask about any allergies.
Physical examination
• Some time should be spent ocusing on aspects o the patient’s airway. Particular problems include: – macroglossia – micrognathia – short, broad neck – atlanto-axial instability in about 15% o patients: usually asymptomatic – subglottic stenosis less common in adults – generalised joint laxity, including temporomandibular joint – high arched palate. • Examine the cardiovascular system, in particular looking or evidence o previous surgery and any cardiac murmurs that may be present. • Look or evidence o pulmonary hypertension or right ventricular hypertrophy.
Useful statements
‘Mr O is a young man born with risomy 21. He has a history o a small ventric ular septal deect, which has required no urther treatment. Other maniestations o the condition include epilepsy, which is currently well controlled on sodium valproate, and moderate intellectual impairment. Tere has been no problem with operations or anaesthesia in the past. On examination, many characteristic eatures o risomy 21 are present. My concerns relating to management o his airway include macroglossia and micrognathia with reduced neck movement in all directions. Cardiac auscultation reveals a loud pansystolic murmur throughout the praecordium consistent with a ventricular septal deect. I would seek urther inormation beore embarking on the proposed surgery.’ Investigations
• Previous anaesthesia records may provide much useul inormation • Echocardiography • ECG • Tyroid unction tests • Cervical spine X-rays.
