FANZCA Final Exam Viva Practice
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Mitral Valve Disease and End Stage Renal Failure
You are reviewing a 69-year-old man in preadmission clinic. He is booked for a femoral nail exchange in 3 weeks secondary to osteomyelitis and fracture non-union. Post procedure he will be considered for mitral valve surgery. Past Medical History End stage renal failure secondary to diabetic nephropathy Rheumatic mitral valve disease Bioprosthetic aortic valve replacement Hypertension Type 2 diabetes mellitus Osteoporosis Medications Frusemide 500 mg once daily Amlodipine 10 mg once daily Metoprolol 50 mg once daily Aspirin 100 mg once daily Long-acting insulin 40 IU nocte Calcium carbonate 1500 mg with meals Calcitriol 0.25 mcg once daily Epoetin alfa 10,000 IU three times per week Phenoxymethylpenicillin 500 mg twice daily Vital Signs Height 1.74 m Weight 97 kg (dry weight 95 kg) BMI 36 kg/m2 BP 183/89 mmHg HR 77 bpm SpO2 95% on room air Temp 36.8°C
Myotonic Dystrophy with AICD for Shoulder Surgery
You are reviewing a 43-year-old man in preadmission clinic. He has been referred for assessment prior to left arthroscopic shoulder surgery in 2 weeks. Past Medical History Myotonic dystrophy Type 1 (Classical) AICD in situ Medications Tapentadol IR 50 mg prn Gabapentin 150 mg twice daily Vital Signs Height 1.88 m Weight 95 kg BMI 26.9 kg/m2 BP 145/87 mmHg HR 60 bpm SpO2 95% on room air Temp 36.8°C
Failed Intubation in Obese Patient with Achalasia
You are the duty anaesthetist at a busy tertiary hospital. Your provisional fellow calls you for urgent assistance with an airway emergency. They have performed a rapid sequence induction and attempted to intubate a 22-year-old man for a Per-Oral Endoscopic Myotomy (POEM) procedure for type 2 achalasia in the main theatres. Intubation was attempted with a videolaryngoscope and hyperangulated blade. The percentage of glottic opening visible was 10% and they were unable to pass the endotracheal tube or a gum elastic bougie. They were then unable to bag-mask ventilate the patient but successfully placed a second generation supraglottic airway. Ventilation has been restored, and green tinged fluid has been noted in the gastric port. Current observations are: HR 95 bpm BP 97/56 mmHg SpO2 90% on FiO2 1.0 ETCO2 41 mmHg (5.47 kPa) TV 400 mL with a small air leak Weight 169 kg Height 199 cm BMI 42 kg/m2 Past Medical History Type 2 achalasia Class III obesity Attention deficit hyperactivity disorder Mild developmental delay Severe anxiety Medication Lisdexamfetamine 70 mg once daily Melatonin 4 mg nocte Diazepam 10 mg was given orally preoperatively Allergies Nil known
Multiply Injured Obese Intoxicated Trauma Patient
You are the anaesthetist on call at a trauma centre and you are asked to assist with the management of a 72-year-old male pedestrian who has been involved in a motor vehicle accident (MVA). He was struck by an oncoming car travelling at 60 km/hour. He has extensive pelvic and lower limb injuries and is conscious but confused, pulling his oxygen mask off. You notice he smells strongly of alcohol. Observations HR 128 bpm BP 89/48 mmHg RR 16 breaths per minute SpO2 92% on room air Estimated weight > 120 kg, estimated BMI >45 kg/m2 GCS 12 (E3 V4 M5) Investigations BSL 11.7 mmol/L Point of care haemoglobin 87 g/L Treatment pre-hospital 18G IV access in situ (difficult intravenous access on scene) 1000 mL normal saline given intravenously Cervical collar and pelvic binder placed Treatment on arrival Primary survey underway 1 unit O negative packed red blood cells in progress
Paediatric E-Scooter Trauma with Head Injury
You are the duty anaesthetist at a tertiary paediatric centre. A 6-year-old boy is being brought in following a collision with a car while he was playing on a friend's e-scooter. You arrive in the emergency department as the child is brought in and notice bruising to his head and chest. The paramedics have managed to obtain 22G IV access and have administered some IV analgesia, dosing to an estimated weight of 20 kg. His parents are on their way. Initial observations are: HR 130 bpm BP 100/50 mmHg RR 36 breaths per min SpO2 92% on 4 L/min via a Hudson mask GCS 13 (E3, V5 – screaming, M5 – flailing around)
Cerebral Palsy Patient for CT-Guided Renal Biopsy
You are providing anaesthesia in the interventional radiology suite of your major hospital. On the list is a 22-year-old woman who requires a CT-guided biopsy of a left renal mass that was discovered incidentally on abdominal imaging. The patient was admitted today for the procedure and is accompanied by her parents who are her legal guardians and carers. A postoperative bed has been booked for the patient. Medical History Severe cerebral palsy - spastic quadriplegia - moderate intellectual disability Recurrent aspiration pneumonia - severe gastro-oesophageal reflux - oropharyngeal dysphagia - gastrostomy feeding tube (feeds ceased for six hours) Anxiety - distress with medical procedures Epilepsy Medications Baclofen 10 mg tds Levetiracetam 1000 mg bd Pantoprazole 40 mg once daily Allergies Nil known Observations height 155 cm estimated weight 40 kg estimated (BMI approx. 16.6 kg/m2) HR 90 bpm BP 95/55 mmHg SpO2 96% on room air Preoperative Investigations Blood test results are normal Blood Group and Hold has been conducted
Tachycardia in Labouring Patient with Epidural
You are the on-call anaesthetist at a tertiary obstetric hospital and part of the medical emergency team (MET). A MET call has been activated for a 42-year-old woman in her first pregnancy (G1P0) undergoing induction of labour with an epidural in situ. You are the first person to arrive at the bedside. On arrival, the patient looks comfortable from the end of the bed. The midwife informs you that the MET call is for tachycardia.
Opioid-Tolerant Trauma Patient with Rib Fractures
You are the consultant covering acute pain and you are asked to assist with the analgesic management of a 50-year-old man in the emergency department who has been brought in after a motor vehicle accident. He has been stabilised and has the following injuries: Segmental rib fractures bilaterally with anterolateral flail segments, right rib fractures 4 – 7, left rib fractures 5 – 7, associated mild bilateral pulmonary contusions Non-displaced fracture right femoral shaft, non-displaced left medial malleolar ankle fracture, right radius and ulnar non-displaced fractures He is mildly confused and agitated. He has been commenced on high flow nasal oxygen at 50 L/min FiO2 0.5, and intravenous infusions of ketamine 10 mg/hour and morphine 10 mg/hour. Medical History L 1 – 2 lumbar laminectomy with redo surgery and L 2 – 5 discectomy Anxiety/depression Chronic back pain Current smoker 15 pack-year history Medications Morphine 8 mg/24 hours via implanted continuous intrathecal infusion pump Medical cannabis daily Citalopram 20 mg once daily Observations HR 110 bpm BP 150/85 mmHg RR 30 breaths per minute SpO2 92% on HFNP 50 L/min FiO2 0.5 Weight 110 kg height 178 cm BMI 35 kg/m2
Elderly Hip Fracture with Pulmonary Hypertension and Advance Directive
Your regular orthopaedic surgeon informs you they have added a trauma patient to their elective list tomorrow. The patient is an 82-year-old woman requiring a total hip replacement for a sub-capital neck of femur fracture from a mechanical fall. The patient lives in a granny flat attached to her daughter's home. She tripped on her bedroom door stopper. Her past medical history includes: Chronic obstructive airway disease - 50 pack years of smoking cigarettes, ceased 6 months ago Atrial fibrillation diagnosed 2 years ago - recent echocardiogram shows RVSP 65 mmHg Medications Formoterol 12 mcg every 6 hours, as required Indacaterol/glycopyrronium 110/50 mcg once daily Apixaban 2.5 mg bd Digoxin 62.5 mcg once daily Furosemide 20 mg once daily Spironolactone 50 mg once daily Escitalopram 10 mg once daily Current observations HR 112 bpm BP 89/60 mmHg SpO2 94% on room air RR 20 breaths per min Weight 60 kg Height 155 cm BMI 25 kg/m2 VAS pain score 8 out of 10 (after 2.5 mg oxycodone IR 30 min ago) The patient and family wish to discuss her anaesthetic risks.
Obstructive Jaundice with Recent Coronary Stent for ERCP
A 65-year-old man attends pre-assessment clinic prior to a scheduled endoscopic retrograde cholangio-pancreaticogram (ERCP) in ten days, with a plan for surgery in a few weeks. Medical History Obstructive jaundice secondary to a periampullary carcinoma - Discovered due to weight loss (12 kg over 3 months) and pruritus - Imaging confirms the tumour is resectable Hypertension Coronary artery disease - Inferior myocardial infarction with drug-eluting stent inserted 5 months ago. Observations Weight 69 kg Height 188 cm Body Mass Index 19 kg/m2 Medications Aspirin 100 mg once daily Clopidogrel 75 mg once daily Enalapril 5 mg once daily Atorvastatin 40 mg once daily Esomeprazole 20 mg once daily Liver Function Tests result reference range albumin 29 L (32–45 g/L) total bilirubin 150 H (<20 µmol/L) AST 16 (0-40 U/L) ALP 328 H (30–150 U/L) ALT 14 (0-35 U/L) Gamma GT 800 H (0-35 U/L)
Obese OSA Patient with Carotid Stenosis for Bimaxillary Osteotomy
The first patient on your elective maxillo-facial operative list in a tertiary hospital is a 55-year-old man for a bimaxillary osteotomy for treatment of his obstructive sleep apnoea. He has a BMI of 47, is an ex-smoker with hypertension and type 2 diabetes mellitus. He has not been to the pre-admission clinic but shows you a recent ultrasound report demonstrating 70% stenosis of his left carotid artery. Medications Rosuvastatin 20 mg once daily Candesartan 16 mg once daily Metformin 500 mg bd Gliclazide 60 mg MR once daily
Multitrauma ICU Patient with Raised ICP for Thoracotomy
You are asked to urgently review a 45-year-old man in the intensive care unit (ICU) who requires a left thoracotomy for ongoing bleeding from a chest drain. The patient was involved in a high-speed motor vehicle accident twelve hours ago. He had an uncomplicated intubation in the emergency department on arrival and is now ventilated in the ICU after surgical management. His injuries and surgical management to date includes: Closed head injury - External ventricular drain (EVD) in situ. - Intermittent spikes in intracranial pressure measurements while in the intensive care unit. Bilateral rib fractures and lung contusions with bilateral chest drains in situ. External fixation of left femoral and tibial fractures. External fixation of pelvic fractures. When you arrive in the intensive care unit to review the patient, his observations are: HR 115 bpm BP 80/45 mmHg, unsupported SpO2 89% on FiO2 1.0
Obese Paediatric Patient with Difficult IV Access for Appendicectomy
You are asked to attend the paediatric emergency department at your tertiary referral centre to assist with IV access in a 9-year-old boy with abdominal pain who the emergency registrar has been unable to cannulate. The child can speak English, but the parents speak no English and require an interpreter. Observations HR 122 bpm BP 105/60 mmHg RR 26 breaths per min SpO2 97% on room air Weight 49 kg Height 122 cm BMI 32.9 kg/m2 (>95th centile for age)
Hypotension After TAVI with Subsequent Stroke
You are the duty anaesthetist and respond to an urgent call from the cardiac anaesthetic fellow who requires assistance in the cardiac catheter lab. Upon your arrival, the fellow briefs you that they have just completed a transcatheter aortic valve implantation (TAVI) under sedation on an 88-year-old woman weighing 56 kg. The procedure itself was uncomplicated. However, following transfer across to the coronary care bed, the patient's blood pressure has dropped to 80/40 mmHg as measured on the arterial line.
Suboptimal Labour Epidural Progressing to Emergency Caesarean
You are the consultant anaesthetist covering labour ward. A 24-year-old woman in her first pregnancy (G1P0) had an epidural inserted by your registrar four hours ago. Your registrar is now attending to another patient, and the midwife phones you to ask if you can attend and assess the effectiveness of epidural pain relief as the patient is still complaining of pain. The midwife tells you the epidural was difficult to insert, requiring multiple attempts from your registrar.
Ruptured AAA with Concurrent Chest Pain for Endovascular Repair
You are called to the emergency department to assess a 60-year-old woman who requires urgent transfer to the interventional suite for an endovascular repair of a ruptured abdominal aortic aneurysm (AAA). That morning, she developed acute abdominal and chest pain, vomited and then lost consciousness. She had regained consciousness by the time emergency services arrived. During transfer to hospital, she was still complaining of chest and abdominal pain, and on arrival she received an urgent chest and abdominal CT scan. Her CT scan showed a contained rupture of an infra-renal AAA amenable to endovascular repair. Her current observations are: HR 110 bpm BP 85/45 mmHg SaO2 92% on room air Weight 85 kg Height 165 cm BMI 31.2 kg/m2
Heart Failure with Reduced EF for Total Shoulder Replacement
You are reviewing the online pre-anaesthesia documents and health questionnaire of a 75-year-old man who is scheduled to have a left total shoulder replacement on your list at a private hospital in two days' time. A health summary from his general practitioner provides medical information as follows: Medical history Hypertension Hyperlipidaemia Ischaemic heart disease – two coronary stents inserted 2 years ago Heart failure with reduced ejection fraction - cardiology review six months ago - echocardiogram: LVEF 32%, mild mitral regurgitation, bi-atrial enlargement Medications Clopidogrel 75 mg once daily Bisoprolol 5 mg once daily Dapagliflozin 5 mg once daily Spironolactone 25 mg bd Atorvastatin 10 mg once daily Sacubitril/valsartan 97 mg/103 mg bd GTN sublingual spray PRN On the online health questionnaire, the man has indicated an exercise capacity of one flight of stairs. He writes that he has had worsening shortness of breath and increasing leg swelling over the past few months.
Pulmonary Hypertension and Cognitive Decline for Colorectal Cancer Resection
You are the anaesthetist participating in a multidisciplinary team (MDT) meeting at the high-risk surgical clinic. The other members of the team are the colorectal surgeon, geriatrician, oncologist, stoma nurse and the social worker. You are meeting to discuss a 75-year-old woman who is being planned for a laparoscopic right ultralow anterior resection +/- open +/- colostomy for sigmoid colon adenocarcinoma. Medical History Cognitive decline Idiopathic pulmonary hypertension Tricuspid regurgitation - planned for percutaneous tricuspid valve repair Allergies Nil known Medications Donepezil 5mg once daily Enalapril 2.5mg bd Spironolactone 50mg once daily Physical Examination Weight 50 kg Height 166 cm BMI 18 kg/m2 Investigations Echocardiogram report attached Mild iron deficiency anaemia, stable Chronic kidney disease stage 2, stable Other investigations including ECG within normal limits
Cirrhosis and Hepatocellular Carcinoma for Dental Clearance
You are asked to review a 58-year-old woman in preadmission clinic. She has been referred for assessment prior to dental clearance with extractions in two weeks. Past Medical History Cirrhosis secondary to non-alcoholic fatty liver disease Hepatocellular carcinoma Type 2 diabetes mellitus Medications Carvedilol 6.25 mg daily Furosemide 80 mg daily Lactulose 30 mL three times daily Metformin 1 g daily Pantoprazole 40 mg daily Rifaximin 550 mg twice daily Spironolactone 200 mg daily Vital Signs Height 1.60 m Weight 82 kg BMI 32 kg/m2 HR 68 bpm BP 105/62 mmHg SpO2 92% on room air Temp 36.7 degrees C
Double Lung Transplant for Cystic Fibrosis Requiring Fundoplication
A 51-year-old lady presents to the preadmission clinic for assessment prior to a laparoscopic fundoplication. Past Medical History Double lung transplant 2 years ago Cystic fibrosis Gastroesophageal reflux Hypertension Medications Azathioprine 100mg three times a day Azithromycin 250mg once daily, three times a week Calcium 3g once daily Creon 50,000 units per meal Telmisartan 40mg nocte Pantoprazole 40mg twice daily Prednisolone 5mg once daily Tacrolimus 4mg XL once daily Trimethoprim/sulfamethoxazole 160/800mg once daily, three times a week Vitamin D 1000 IU once daily Vital Signs Height 1.54 m Weight 71 kg BMI 30 kg/m2 BP 158/81 mmHg HR 90 bpm SpO2 94% on room air Temp 36.5 degrees C
Hypotensive Anaesthesia for FESS with LMA Management
You are taking over a functional endoscopic sinus surgery (FESS) case from a colleague in a private hospital because the morning list is running over time and the colleague needs to leave. The handover given is that the patient is a 50-year-old man undergoing a FESS with mechanical positive pressure ventilation (PPV) using a flexible laryngeal mask airway (LMA). Anaesthesia is being maintained with target-controlled infusions of propofol and remifentanil. Observations have been stable with a targeted mean arterial pressure (MAP) of 65 mmHg after the surgeon requested hypotensive anaesthesia. Medical History Obstructive sleep apnoea on nocturnal CPAP Hypertension, preoperative BP 130/63 mmHg (MAP 85 mmHg) Smoker 10 cigarettes/day with a 20-pack-year history Medications Amlodipine 5 mg once daily Allergy Nil known drug allergy Observations HR 70 bpm BP 100/47 mmHg (MAP 65 mmHg) SpO2 98% on FiO2 40% Temp 36.5°C Weight 90 kg Height 177 cm BMI 29 kg/m2
Rheumatic Mitral Stenosis in Pregnancy
You are the anaesthetist in the multidisciplinary high risk obstetric clinic at a tertiary referral hospital. You are reviewing a 29-year-old woman with rheumatic mitral stenosis who is 20 weeks pregnant with her first child. (G1P0) Medications Bisoprolol 2.5 mg once daily Enoxaparin 80 mg SCI bd (previously on warfarin) Her echocardiogram done earlier in the day is available for review. Transthoracic Echocardiogram Report Height (cm) 165 Weight (kg) 80 BSA (m2) 1.9 Heart Rate 80 bpm Rhythm Sinus LV: LVIDd 4.9 cm (3.9-5.3 cm), LVIDs 3.3 cm (2.3-3.8 cm), EF 55% (> 55%) RV: Mildly dilated, normal systolic function LA: 70 mL/m2 (<35ml/m2), Spontaneous echo contrast RA: 35 mL/m2 (<27ml/m2) AV: Trileaflet valve with normal morphology, No evidence of aortic regurgitation MV: Thickened leaflets. Doming of the anterior leaflet. Restriction of the posterior leaflet. Mean gradient 9 mmHg. MVA 1.5 cm2 TV: Normal morphology, Estimated PASP 40 mmHg
Multi-Trauma Cyclist with Aortic Dissection
You have been delegated as resuscitation team leader in the emergency department of a major hospital. You are asked to manage the initial treatment of a 70-year-old male cyclist who collided with a motor vehicle at high speed. He is a recreational cyclist who rides about 25 km two or three times per week. Medications Metoprolol tartrate 50 mg bd On arrival, he is hypotensive with systolic BP 75 mmHg. He is receiving oxygen at 6L/min by Hudson mask. The ambulance paramedic shows you a bicycle helmet which is split in half.
Emergency Hernia Repair in Severe Cardiorespiratory Disease
You are the anaesthetist in the emergency theatre at a tertiary hospital. Your first case is a planned open right inguinal hernia repair in a 73-year-old man who presented overnight with an incarcerated hernia. Conservative management has failed. The surgeon wishes to proceed urgently to prevent strangulation. Medical History Severe smoking related COPD with type II respiratory failure ABG on room air: pH 7.32 (7.35-7.45), pCO2 49 mmHg (35-45 mmHg), pO2 81 mmHg (80-100 mmHg), HCO3- 29 mmol/L (22-26 mEq/L) Coronary artery disease - right coronary artery 80% stenosis Valvular heart disease - severe mitral regurgitation - severe tricuspid regurgitation - normal left ventricular ejection fraction - mild right ventricular systolic dysfunction Pulmonary hypertension - right ventricular systolic pressure (RVSP) 60 mmHg Paroxysmal atrial fibrillation Stage 2 chronic kidney disease - GFR 65 ml/minute, creatinine 100 micromoles/litre Medications Amiodarone 200 mg once daily Digoxin 62.5 mcg once daily Frusemide 20 mg once daily Metoprolol 25 mg bd Rivaroxaban 15 mg once daily Rosuvastatin 40 mg once daily Tiotropium inhaler 18 mcg once daily
Duchenne Muscular Dystrophy with Femur Fracture
You are the anaesthetist on call in a tertiary metropolitan hospital. You are notified that the next patient on the emergency list is a 14-year-old boy with a history of Duchenne muscular dystrophy. He has a compound displaced midshaft fracture of his femur after a mechanical fall down several stairs at home yesterday. He is scheduled for insertion of an intramedullary (IM) nail by the orthopaedic team. Medical History Duchenne muscular dystrophy - Under the care of a regular neurologist - One inpatient admission for a lower respiratory tract infection six months ago - Self-ambulant around the home but uses a wheelchair for longer distances - Gastrostomy tube for nocturnal enteral feeding due to dysphagia and poor nutritional state Medications Prednisolone 2.5 mg once daily Observations HR 102 bpm BP 110/64 mmHg SpO2 96% on room air Temp 36.8°C RR 28 breaths per minute Weight 38 kg Height 160 cm BMI 14.8 kg/m2
Laparoscopic Splenectomy for ITP with Type 1 Diabetes
You are the anaesthetist rostered to the pre-admission clinic at a metropolitan teaching hospital. The next patient to be seen is a 46-year-old woman booked for a laparoscopic splenectomy for severe, chronic immune thrombocytopenic purpura (ITP). Medical History Type 1 diabetes mellitus Immune thrombocytopenic purpura Medications Insulin pump 60 units Novorapid by subcutaneous infusion every 24 hours Prednisolone 25 mg once daily Rituximab 100 mg IV weekly (completed 1 week prior) Observations Weight 85 kg, Height 161 cm, BMI 33 kg/m2 Surgery is planned in one week's time, and you will be the anaesthetist for this list.
Ruptured Cerebral Aneurysm with Cocaine Toxicity
A 25-year-old man presents in the evening to the emergency department of your tertiary metropolitan hospital. He is a singer who collapsed on stage whilst performing. He initially complained of a severe headache and chest pain. On arrival, he appears confused, is slurring his words, and has weakness in his left arm with neck stiffness. Observations HR 98 bpm BP 170/110 mmHg SpO2 93% on room air Temp 37.6°C GCS 13 (E4 V4 M5) An urgent cerebral CT angiogram has been performed and an image from the CT is displayed. The neurosurgical team wishes to urgently perform a craniotomy and clip a presumed ruptured right middle cerebral artery aneurysm.
Pelvic Fracture in Chronic Pain Patient with Anxiety
You are asked to review a 43-year-old woman who fell from her horse 24 hours ago and sustained an isolated displaced pelvic fracture. She was transferred in a stable condition from a regional hospital and is booked for anterior intrapelvic fixation in the emergency theatre tomorrow. Medical History Gastro-oesophageal reflux disease Severe anxiety Longstanding lower back pain and coccygeal pain Medications Amitriptyline 20 mg nocte Duloxetine 60 mg once daily Medicinal cannabis (sublingual CBD oil) 40 mg nocte Meloxicam 15 mg once daily Oxycodone SR 40 mg bd Oxycodone IR as required, up to 40mg daily Pantoprazole 40 mg once daily Tramadol SR 150 mg bd Observations Weight 60 kg Height 165 cm BMI 22 kg/m2 The patient is not mobile and has severe pain, which she states has been poorly managed. She has significant anxiety related to her impending procedure. You are asked to see her on the ward to assist with the management of her pain which is causing significant behavioural issues.
Thyroidectomy for Amiodarone-Induced Thyrotoxicosis with CRT-D
You are reviewing in the clinic a 60-year-old man listed next week for a total thyroidectomy for amiodarone induced thyrotoxicosis. Past medical history: Ischaemic cardiomyopathy Cardiac resynchronisation therapy with implantable defibrillator (CRT-D) placed two months ago Type II Diabetes Obesity – 110kg, 174cm. Neck circumference 44cm Hypercholesterolaemia Gastro-oesophageal reflux disease Drugs: Aspirin 100mg once daily Bisoprolol 2.5mg once daily Sacubitril / Valsartan 97/103 mg twice daily Spironolactone 25mg once daily Frusemide 40mg once daily Rosuvastatin 40mg once daily Metformin XR 1g twice daily Dapagliflozin 10mg once daily Semaglutide 1mg weekly sub cut Esomeprazole 40mg once daily CRT-D report: attached Echo summary report: attached Echocardiogram Summary (performed day before clinic) Severe ischemic cardiomyopathy with global LV dysfunction (EF 25%) Dilated LV with extensive wall motion abnormalities, consistent with prior infarcts LA moderately dilated; RA mildly dilated Mild-moderate functional MR due to LV remodelling Mild TR. Aortic valve normal structure, no stenosis or regurgitation Biventricular pacing active, with evidence of improved mechanical synchrony Mild pulmonary hypertension (RSVP 40mmHg) and mildly dilated RV with reduced function IVC: normal diameter, normal respiratory collapse Pacemaker report Date of Evaluation: 12th May, 2025 Device Model: Medtronic Claria MRI Quad CRT-D Implant Date: March 27th, 2025 Indication for CRT-D: Severe ischemic cardiomyopathy (LVEF 20%), NYHA Class III heart failure, history of ventricular arrhythmias Device Type: Cardiac Resynchronization Therapy with Defibrillator (CRT-D) Leads & Positioning: Right Atrium (RA): Lead in right atrial appendage Right Ventricle (RV): Lead in RV apex (shock lead) Left Ventricle (LV): Lead via coronary sinus to lateral/posterolateral vein Intrinsic Rhythm & Pacing Dependence Underlying Rhythm: Normal sinus rhythm (NSR) Atrial Pacing (AP): 1% (Minimal pacing, appropriate sinus node function) Ventricular Pacing (VP): 96% biventricular pacing (Effective CRT delivery) Biventricular Pacing Capture: >95% (Adequate resynchronization)
Category 1 Caesarean Section in IV Substance User
You are the anaesthetist on site at a tertiary obstetric hospital. The obstetric registrar has called a category 1 lower uterine segment caesarean section (LSCS) for a 35-year-old woman, G6P5, at 31+6 weeks gestation, who presented to the hospital with possible decreased fetal movements. The patient has not had any antenatal care during the pregnancy. She has a known intravenous substance user disorder with polysubstance use. Obstetric History 3 previous LSCS (one with general anaesthesia, two with neuraxial anaesthesia) 2 spontaneous vaginal deliveries Medical History Current smoker, 10-pack-year history Asthma since childhood Medications Suboxone (buprenorphine/naloxone) 12 mg once daily Observations HR 85 bpm BP 100/80 mmHg SpO2 96% on room air
Speedboat Propeller Injury with Drowning and Tourniquet
You have been asked to attend a trauma call in the emergency department of a tertiary hospital. The pre-arrival notification states that a 32-year-old man has been run over by a speedboat while swimming in the sea with an obvious lower limb injury due to the propeller. On extricating the patient from the water, significant coughing and vomiting of sea water was noted by first responders. The estimated time of arrival is 1630 hours (two hours post-injury). The patient's observations en route are: Temp 32°C HR 90 bpm BP 85/46 mmHg SpO2 91% on oxygen at 10 L/min via face mask GCS 10 (E2 V2 M6) A tourniquet was placed on the upper thigh at 1430 hours as the paramedics were unable to control the blood loss with pressure and 1 L of normal saline has been commenced. A point-of-care haemoglobin is measured as 6.3 g/dL.
Rigid Bronchoscopy and Mediastinoscopy in Severe COPD
You are a staff anaesthetist at a major metropolitan hospital. You have been asked to review a patient who is on your list in seven days' time. He is a 73-year-old man who was admitted five days ago with an exacerbation of chronic obstructive pulmonary disease (COPD) secondary to a viral illness. During his admission a CT chest was performed that showed a mediastinal mass, which now requires a tissue diagnosis. The location of the lesion is not amenable to a CT guided biopsy, and a flexible bronchoscopy failed to yield a specimen for diagnosis. He has been booked by a cardiothoracic surgeon for a rigid bronchoscopy and mediastinoscopy. Medical History Severe chronic obstructive pulmonary disease Type 2 diabetes mellitus Hypertension Ischaemic heart disease, medically managed. Medications Aspirin 100 mg once daily Prednisolone 30 mg once daily (day 5 of 5 – day course) Ramipril 5 mg once daily Rosuvastatin 20 mg once daily Sitagliptin/ metformin 50 mg/1000 mg once daily Tiotropium-olodaterol inhaler one puff bd
Paediatric Trauma in 2-Year-Old with Supracondylar Fracture
You are the on-call anaesthetist at a general regional hospital. You are called to the emergency department to attend a trauma involving a 2-year-old girl. On entering the resuscitation room in the emergency department, you see a crying and slightly drowsy child with an obvious arm deformity. You establish this was an unwitnessed accident. The mother explains she last saw her daughter riding her scooter in the driveway. A short time later, she found her crying and distressed under a parked car and called emergency services. The child has just arrived by ambulance. She has received fentanyl 1 mcg/kg, and crystalloid 10ml/kg intravenously en route. Observations HR 180 bpm BP 82/40 mmHg RR 35 breaths per minute SpO2 96% on room air
Undiagnosed Phaeochromocytoma with Intraoperative Hypertension
You are in between cases in a private hospital list when you are asked to urgently help in the theatre next door. You attend to see a middle-aged male patient being hand ventilated via an endotracheal tube by an experienced anaesthetist. The surgeon is scrubbed but the operation has not started. The anaesthetic monitor is alarming. Your colleague asks for help to control the hypertension.
Acute Ischaemic Stroke with Competing Emergencies
You are the on-call anaesthetist on site at a tertiary referral hospital. In the evening you are made aware of a patient with an acute ischaemic stroke secondary to right middle cerebral artery occlusion. They are expected to arrive in the angiography suite in approximately ten minutes for endovascular clot retrieval. Operating theatre staff inform you that they have just received notification of an impending category 1 lower uterine segment caesarean section (LSCS), and a trauma patient currently in the CT scanner. You have an advanced trainee and a basic trainee registrar on site. Limited information is available regarding the stroke patient: He is an 80-year-old man who lives alone and was found by support services slumped in a chair at home. He was last known to be well approximately six hours earlier. His fasting status is unknown. Medical History Type 2 diabetes mellitus Hypertension Dyslipidaemia Paroxysmal atrial fibrillation At this stage, his medications are unknown. He has no known allergies.
Chronic Pelvic Pain with Opioid Burden and Serotonin Toxicity Risk
You receive a referral from the gynaecology registrar during your shift in the acute pain service. The patient is a 22-year-old woman with chronic pelvic pain. She had seven presentations to the emergency department with severe abdominal pain over the past few months. Her most recent pelvic ultrasound is normal and she had two negative diagnostic laparoscopies last month. During this admission she was on an intravenous ketamine infusion at a rate of 10 mg/hour for three days. The infusion was ceased a few hours ago. She also received intermittent doses of oral tramadol 100 mg four times daily and oxycodone 10 mg four hourly. She has been referred to the chronic pain service but has not yet been seen. Medical History Asthma Depression Medications Celecoxib 200 mg bd Clonazepam 1 mg once daily Clonidine 50 mcg qid Oxycodone/naloxone 40 mg/20 mg bd Paracetamol 1 g qid Salbutamol Inhaler as required Thyroxine 75 mcg once daily Venlafaxine 75 mg bd Observations Weight 65 kg Height 168 cm BMI 23 kg/m2 The gynaecology team is requesting a discharge analgesia plan for this patient.
Valvular Heart Disease and Pacemaker for Cholecystectomy
You are asked to review an 82-year-old man in preadmission clinic. He has been referred for assessment prior to a laparoscopic cholecystectomy in 2 weeks' time. He has had 2 recent admissions with cholecystitis which have required intravenous antibiotics. Past Medical History Valvular heart disease Sick sinus syndrome with a pacemaker Hypertension Stage III chronic kidney disease Medications Apixaban 2.5mg twice daily Metoprolol 50mg twice daily Telmisartan 40mg nocte Ezetimibe/atorvastatin 10mg/80mg mane Vital Signs Height 1.76 m Weight 75 kg BMI 24 kg/m2 BP 176/92 mmHg HR 62 bpm SpO2 96% on room air Temp 36.4 oC
Parkinson's Disease for Hip Arthroplasty
You have been asked to review a 78-year-old woman who is scheduled to undergo left hip arthroplasty in two months' time for the management of osteoarthritic pain. She lives in a residential aged care facility. She enters your rooms using a 4-wheel walker escorted by her daughter. Medical History Parkinson's disease diagnosed ten years prior Gastroesophageal reflux Osteoarthritis Hypertension She has never smoked and does not drink alcohol Medications Stalevo (levodopa 200 mg/carbidopa 50 mg /entacapone 200 mg) four times daily Rasagiline 1 mg mane Baclofen 30 mg mane and 40 mg nocte Quetiapine 12.5 mg nocte Escitalopram 10 mg nocte Telmisartan 40 mg nocte Esomeprazole 20 mg bd Paracetamol 665 mg, 2 tablets bd Movicol 2 sachets nocte Vital Signs HR 85 bpm BP 110/70 mmHg RR 18 bpm SpO2 94% in room air Temperature 36.7°C Height 167 cm Weight 55 kg BMI 19.7 kg/m2
Paediatric MRI and Lumbar Puncture with Autism
You have been scheduled to an MRI list at a paediatric hospital. The first patient on the list is an 8-year-old girl for MRI brain and a lumbar puncture. The girl has autism spectrum disorder. She has a mild speech delay but communicates well. Six months ago she had an episode of venous sinus thrombosis with raised intracranial pressure secondary to mastoiditis. The indication for the MRI and lumbar puncture is worsening headache with intermittent low grade fever (highest temperature 37.8°C) over the past two weeks. She weighs 25 kg. She is admitted to the paediatric ward the day before the procedure and you are asked to perform a preoperative assessment.
Unstable Cervical Spine Posterior Fusion
You are required to anaesthetise a 75-year-old woman undergoing a posterior C1 – 2 fusion after a low-velocity mechanical fall at home yesterday evening. Her only injury is a mildly displaced type II dens fracture which has resulted in posterior neck pain and mild left hand weakness. She is currently immobilised in a hard cervical collar. She weighs 52 kg and is 155 cm tall. Her observations are within normal limits. Her relevant active comorbidity is osteoporosis managed with a bisphosphonate. She lives alone and is independent in her activities of daily living. A colleague has performed a preoperative review. The airway comments are: Thin face with minimal cheek tissue Mallampati 2, mouth opening 3 cm Thyromental distance 3 cm Upper partial plate (removable), lower natural dentition Neck extension not assessed Previous GA in 2020: Grade II, MAC 3. No comment on bag mask ventilation
Cerebral AVM with Haemorrhage and Aneurysm
An 18-year-old man was brought to the Emergency Department of your major hospital via ambulance after suffering a seizure at university this afternoon. A CT brain has been performed which reveals the suspicion of an arteriovenous malformation (AVM) with associated haemorrhage. There is also a 15 mm diameter cerebral aneurysm that appears intact. The patient requires digital subtraction angiography of his cerebral vessels and you are asked to provide anaesthetic support for this procedure.
Abdominal Stab Wound with Bradycardia
You are working in a large hospital when you are called by a surgeon regarding a 51-year-old woman who is in the Emergency Department. She requires an urgent laparotomy following a single stab wound to the abdomen after an assault at home. Immediate history: Arrived to hospital via ambulance within 30 minutes of injury Since arrival to ED: · primary survey (no obvious other injuries) · IV access and blood tests taken · 1000 mL Normal Saline and analgesia administered · FAST scan reveals free air and fluid Observations: Airway patent. GCS 15 SpO2 95% on 6L/min oxygen via Hudson mask BP 80 mmHg systolic HR 38 bpm Dressing on anterior abdomen with some blood leaking through Medical History: Height – 153 cm Weight – 90 kg BMI 38.4 kg/m2 Type 2 diabetes mellitus, poorly compliant with prescribed treatment Mild chronic renal impairment Recent syncopal episodes and referred to cardiology – awaiting appointment Smoker – 20 cigarettes per day Medications: Perindopril 4 mg once daily Metformin 500 mg twice daily Glipizide 5 mg twice daily Atorvastatin 20 mg once daily Initial blood test results and a 12-lead ECG are displayed below.
Myasthenia Gravis VATS Thymectomy with Anterior Mediastinal Mass
A 35-year-old woman with a history of myasthenia gravis was recently assessed for worsening symptoms. She was found to have an anterior mediastinal mass consistent with a thymoma. She is booked for a VATS thymectomy due to difficult medical control of her symptoms and recent development of bulbar dysfunction as well as some clinical evidence of mass effect from the thymoma. You are assessing the patient in the Preadmission Clinic a week prior to her scheduled surgery. Medications: Pyridostigmine 180 mg qid Prednisolone 15 mg mane
Elderly Frail Patient for Laparoscopic Anterior Resection
You are working in the preadmission clinic. An 86-year-old woman is booked for a laparoscopic ultra-low anterior resection for rectal cancer on your list in three weeks' time. She lives alone at home and can comfortably walk 100 metres on the flat. Medical history: Hypertension Transient ischaemic attack two years ago Ex-smoker – 60 pack-year history Chronic renal impairment Medications: Perindopril 4 mg daily Aspirin 100 mg daily Observations: BP 160/85 mmHg HR 82 bpm, regular SpO2 94% on room air Height 1.70 m Weight 51 kg BMI 17.6 kg/m2 A CT abdomen shows a large low rectal cancer and a single nodule in the liver. The surgeon has asked you to provide an opinion on this patient's perioperative risk.
Pre-eclampsia and Pulmonary Oedema in Preterm Labour
You are the anaesthetist on call overnight in a regional hospital. You are called to the Birth Suite at 2 am to review a 19-year-old woman who has just been brought in by ambulance in labour with sudden onset of shortness of breath within the last 6 to 12 hours. The woman is G1 P0 and is 32 weeks gestation by dates. She has not had any antenatal care during the pregnancy. The cardiotocogram (CTG) is normal. The patient denies any prior medical history. She weighs 65 kg and has a BMI of 23 kg/m2. The midwife informs you that the patient's oxygen saturation is 94% on 15 L/min oxygen via non-rebreather mask. The obstetric registrar and your anaesthetic registrar are currently performing a Category 2 caesarean section in the emergency theatre.
Post-ICU Triple Amputation for Vasopressor-Induced Ischaemia
You have been contacted by a vascular surgeon to inform you of an upcoming case at your metropolitan hospital. The patient is a 50-year-old previously well man who had a ten-day ICU admission for severe sepsis due to COVID-19 pneumonitis with Streptococcus pneumoniae superinfection, for which he was intubated and ventilated as well as treated with inotropes and vasopressors. He was extubated one week ago and vasopressor support was weaned. He is currently on a medical ward. He requires bilateral below-elbow amputations and a right below-knee amputation for vasopressor-induced irreversible ischaemia associated with intractable pain. He has a resolving lung injury and remains on oxygen at 3 L/minute via nasal prongs. Current observations: SpO2 89% on room air SpO2 95% on oxygen 3L/minute Weight 80 kg (premorbid weight 85 kg) Height 179 cm BMI 25 kg/m2 (premorbid BMI 26.5) Medications: Ampicillin 1 g QID Paracetamol 1 g QID Pregabalin 50 mg TDS Oxycodone/naloxone 20 mg/10 mg BD Oxycodone infusion – 4 mg per hour intravenously (Note - ketamine was trialled and removed due to nightmares and dysphoria) The surgeon anticipates a surgical time of eight hours and will involve the use of bilateral upper limb tourniquets and skin grafting.
Paediatric VATS Decortication for Empyema
A 2-year-old boy has presented for left VATS and decortication for an empyema after a chest infection. He has been on the ward in your tertiary referral centre for three days receiving antibiotics. There is no significant past medical history and he has normal developmental milestones. Vital signs: HR 130 bpm BP 95/52 mmHg respiratory rate 28 bpm temperature 37.5oC weight 12 kg He has been discussed at a multidisciplinary meeting and has been deemed suitable for surgery. His chest X-ray is presented here.
Acromegaly for Transsphenoidal Pituitary Resection
You are in working in the preadmission clinic, assessing a 40-year-old man who is booked for transsphenoidal resection of pituitary adenoma on your neurosurgical list next week. Medical history: Acromegaly Obstructive sleep apnoea Cardiomyopathy Hypertension Medications: Candesartan 16 mg mane, recently increased from 8 mg mane Frusemide 80 mg bd Metoprolol 47.5 mg bd Octreotide 40 mg monthly by intramuscular injection Cabergoline 1.5 mg weekly There are no known drug allergies. Vital signs: Height 185 cm Weight 125 kg BMI 36.5 kg/m2 HR 80 bpm BP 145/70 mmHg SpO2 96% on room air His only previous anaesthetic was for adenotonsillectomy as a child.
Posterior Fossa Craniotomy with Ebstein's Anomaly
A 40-year-old woman is booked on your list tomorrow for posterior fossa craniotomy and resection of medulloblastoma. She presents with a three-week history of worsening headache, ataxia and dysarthria. She has a medical history of mild intellectual impairment, obesity (BMI 35) and an unrepaired Ebstein's congenital cardiac anomaly. The last cardiology review that is recorded in the hospital medical record was ten years ago and revealed the following: Moderate tricuspid regurgitation (posterior and septal leaflets adherent) Some right ventricular enlargement Atrial septal defect No evidence of tachyarrhythmias The neurosurgeon wishes to perform the surgery with the patient prone with reverse Trendelenberg (head-up) positioning. A sagittal image of the patient's brain MRI is displayed.
Motor Vehicle Accident with Acute Stroke and Trauma
You are part of the trauma team at a metropolitan hospital. You are notified that a 67-year-old woman is being brought in by road ambulance after a motor vehicle accident. She was the driver and sole occupant of a car that veered off a country road and down an embankment. The extraction was complicated, and it is now three hours since her initial injuries. On arrival, her airway is patent, and her cervical spine is immobilised. She has two 16G IV cannulas in situ. Paramedics hand over that she is confused and has weakness in her left arm and leg. Prehospital eFAST is positive, with free fluid in the pelvis. She has an open fractured right tibia and fibula. Vital signs: HR 105 bpm (atrial fibrillation) BP 220/110 mmHg RR 24 breaths/minute Sp02 98% (6 L/minute oxygen via mask)
STEMI with Cardiogenic Shock and Emergency CABG
You are the anaesthetist on call in a tertiary hospital. It is after-hours and you are still on site. You are called to the Cardiac Catheterisation Laboratory to assist with the care of a 73-year-old man who is undergoing an urgent coronary angiogram after presenting to the emergency department an hour earlier with an ST-segment elevation myocardial infarct. His management was expedited as a "code STEMI". You are informed that he was initially stable and neurologically intact on arrival to hospital but is now hypotensive with a blood pressure of 73/48 mmHg, and is agitated and moving around.
Upper GI Haemorrhage with Variceal Bleeding
You are the anaesthetist covering the weekday morning emergency list in a tertiary metropolitan hospital. The emergency medicine physician on duty calls to inform you about a 55-year-old man who has presented with haematemesis. The only known past medical history is significant alcohol intake and his current medications are unknown. He is currently in the Emergency Department. His observations at the time of the call are: HR 100 bpm NIBP 90/60 mmHg SpO2 96% on oxygen 6 L/min via Hudson mask Height 1.7 m Weight 72 kg BMI 24.9kg/m2 His blood test results are as displayed. He has a 20G IV cannula in his left basilic vein and is receiving 1 L crystalloid. The gastroenterologist plans to perform an emergency endoscopy.
Obstetric Trauma at Regional Hospital
You are the on-call anaesthetist working at a regional hospital on a Saturday evening. You are requested to attend the Emergency Department as part of a Trauma Call activation. The ambulance service has pre-notified of the imminent arrival of a 25-year-old woman who is 32 weeks pregnant. She was the restrained driver in a car involved in a high-speed collision with a large tree at an estimated speed of 90 km/h. Pre-notification information from paramedics: Maintaining her airway SpO2 stable at 96% on oxygen via a non-rebreathing mask RR 22 breaths per minute and stable PR 115 beats per minute and stable BP 105/60 mmHg and stable GCS 15 and stable Complaining of severe abdominal pain Significant bruising across lower and left upper quadrant of abdomen The patient is estimated to be 15 minutes away and you have been requested to be the Team Leader at the Trauma Call.
Bilateral Mastectomy and DIEP Flap Reconstruction
You are in the preadmission clinic reviewing a 38-year-old woman with breast cancer whom you will anaesthetise for bilateral mastectomy and immediate deep inferior epigastric perforator (DIEP) flap reconstruction in two weeks' time. Medical History: Type 2 diabetes mellitus – diagnosed two years ago Antiphospholipid syndrome – diagnosed three months ago after first episode of lower limb deep vein thrombosis with pulmonary embolism Medications: Rivaroxaban 20 mg daily Metformin 500 mg twice daily Empagliflozin 10 mg daily Semaglutide 2 mg weekly (subcutaneously) Examination Weight 80 kg Height 160 cm BMI 31 kg/m2 Examination is otherwise unremarkable Investigations Full blood examination – normal, with haemoglobin 125 g/dL (120 – 160 g/dL) Electrolytes, urea and creatinine – normal Coagulation studies – normal HbA1c - 5.8% (normal value < 6%) - 40 (normal value < 42 mmol/mol) ECG – sinus rhythm
Rheumatoid Arthritis for Total Hip Replacement
You are in the preadmission assessment clinic. A 77-year-old woman with joint pain presents for assessment prior to an elective right total hip replacement. Past Medical History Hypertension Paroxysmal atrial fibrillation Peripheral vascular disease (bilateral femoral arterial stents inserted in 2018) Rheumatoid arthritis Medications Amlodipine 5 mg once daily Metoprolol 50 mg twice a day Digoxin 125 mcg once daily Apixaban 5 mg twice a day Clopidogrel 75 mg daily Methotrexate 50 mg weekly Quinapril 20 mg once daily Buprenorphine 10 mg patch (10 mcg/hr) Observations Height 145 cm Weight 44.5 kg Body Mass Index 21 kg/m2 She ambulates with a single stick forearm frame and needs help with daily activities such as washing, ironing and cleaning. Photograph of patient's hands showing musculoskeletal changes associated with RA Available investigations: C-spine X ray ECG Biochemistry Full blood count Spirometry
Syncope Assessment for Lumbar Fusion
You are in the preadmission clinic. A 76-year-old man presents for a multilevel lumbar posterior fusion procedure for severe spinal canal stenosis. He lives on and maintains a rural property (25 acres). He is undergoing investigation for dizzy spells. Medications Empagliflozin 25 mg daily Metformin 850 mg twice a day Rosuvastatin 10 mg daily Candesartan 16 mg daily Escitalopram 20 mg daily Mirtazapine 7.5 mg daily Tamsulosin Hydrochloride 400 mcg daily Temazepam 10 mg daily Observations Height 176 cm Weight 85 kg Body Mass Index 27.4 kg/m2 Available investigations: ECG Full blood count Biochemistry
Pulmonary Hypertension for Bariatric Surgery
You are in the preadmission clinic. Your next patient is a 34-year-old female booked for a laparoscopic sleeve gastrectomy to manage her obesity. Her surgery is scheduled in 6 weeks. Medications Ambrisentan 5 mg daily Sildenafil 100 mg three times a day Atenolol 50 mg daily Irbesartan 75 mg daily Escitalopram 30 mg daily Quetiapine 150 mg daily Levothyroxine 100 mcg daily Vital Signs Height 152 cm Weight 127 kg Body Mass Index 55 kg/m2 Blood pressure 135/75 mmHg Heart rate 87 beats per minute SpO2 94% on room air Available investigations: ECG ECHO and RHC Spirometry 6-minute walk test CXR ABG
Sarcoidosis with Liver Cirrhosis for Variceal Banding
You are asked to review a 70-year-old gentleman in the preadmission clinic. He has been referred for assessment prior to a gastroscopy for variceal banding in four weeks' time. Past Medical History Cirrhosis secondary to sarcoidosis Medications Ferrous sulfate/ascorbic acid 325 mg/500 mg daily Propranolol 10 mg twice a day Pantoprazole 40 mg daily Ursodeoxycholic acid 30 mg daily Observations Height 180 cm Weight 65 kg Body Mass Index 20 kg/m2 Blood pressure 110/80 mmHg Heart rate 80 beats per minute SpO2 95% on room air Temperature 36.5 oC Available investigations: CXR ECG Iron studies Liver function tests
Ruptured Abdominal Aortic Aneurysm Open Repair
You are the anaesthetist on-call in a tertiary hospital. The vascular surgeon calls you to advise that an 82-year-old man with a contained rupture of an abdominal aortic aneurysm has just arrived in the emergency department, transferred from a secondary centre. The surgeon advises that the aneurysm is not suitable for an endovascular technique and the patient requires an urgent open repair. You immediately attend the emergency department.
Elderly Dementia Patient for Skin Cancer Excision
You are the anaesthetist in the pre-assessment clinic of a day surgery hospital. You are reviewing an 86-year-old man who has been booked for a wide local excision of a left temple squamous cell carcinoma (SCC) and rotational flap under local anaesthetic and sedation. Medical History Dementia (moderate) – lives in hostel Atrial fibrillation (stable) Hypertension (stable) Medications Dabigatran 110 mg twice daily Diltiazem 180 mg mane He has been brought to the clinic by his son, his enduring guardian, who is very concerned about the possibility for conversion to a general anaesthetic. The patient had a general anaesthetic for removal of an SCC on his leg last year and experienced postoperative delirium requiring a three-day hospital stay. His observations and results of blood tests are included below. Weight 65 kg Body mass index 23 kg/m2 Heart rate 75 beats per minute Blood pressure 140/80 mmHg Respiratory rate 15 breaths per minute SpO2 97% on room air Haemoglobin 120 g/L (115-160) White cell count 7.0 x10^9/L (4.0-11.0) Platelet count 300 x10^9/L (150-400) Sodium 136 mmol/L (135-145) Potassium 3.5 mmol/L (3.5-5.2) Urea 4.0 mmol/L (3.0-8.0) Creatinine 70 µmol/L (45-90)
Cataract Surgery in Only Seeing Eye
You are anaesthetising for an ophthalmology list at a standalone day-surgery unit with two operating theatres. Your first patient is a 55-year-old man with a rapidly-progressive posterior subcapsular cataract in the right eye for a cataract extraction and intraocular lens insertion. Medical history Type 2 diabetes mellitus - oral hypoglycaemics - HbA1c 6.8% (51 mmol/mol) - no known end-organ disease other than cataracts Highly myopic, blind in left eye after previous macular retinal detachment at age 51 years Medications Metformin 1 g twice daily Allergies: Nil Examination is unremarkable, with body mass index of 24 kg/m2. Preoperative investigations have been reviewed and are normal. The patient is fasted and has been considered appropriate for day surgery.
Rural Trauma with Fall from Height
You are the visiting anaesthetist in a small rural town where you work once a month with a visiting urologist. You receive a telephone call from a nurse in the Emergency Department asking if you could come and assist the GP anaesthetist. The ambulance service have just brought in a 25-year-old man who fell from the roof of a farm shed, where he had been sitting and drinking with friends. The GP anaesthetist intubated the patient on arrival to hospital because of reduced Glasgow Coma Scale (GCS) score and is requesting your assistance with ongoing management.
Posterior Lumbar Fusion with Prolonged QT
A 70-year-old man presents on the day of surgery for an elective L2-L5 posterior lumbar intervertebral fusion (PLIF), with a plan for intraoperative neurophysiological monitoring. Medical History Back pain Hypertension Type 2 diabetes mellitus Paroxysmal atrial fibrillation Smoker Medications Sotalol 80 mg twice daily Enalapril 10 mg twice daily Metformin 500 mg twice daily Paracetamol 667 mg three times daily Meloxicam 15 mg daily Gabapentin 600 mg three times daily Tramadol 100 mg three times daily PRN Vital Statistics Height 1.80 m Weight 101 kg Body Mass Index (BMI) 31 kg/m2 Preoperative blood test results are included below. An electrocardiogram (ECG) was performed this morning on admission to hospital and is attached. Full blood count test results: Haemoglobin 148 g/L (115-160) White cell count 5.2 x10^9/L (4.0-11.0) Platelet count 398 x10^9/L (150-400) Biochemistry test results: Sodium 138 mmol/L (135-145) Potassium 4.2 mmol/L (3.5-5.2) Bicarbonate 26 mmol/L (22-32) Urea 6.1 mmol/L (3.0-8.0) Creatinine 89 µmol/L (45-90) eGFR 69 mL/min/m2 (>80)
Paediatric Day Surgery with URTI
You are working in a standalone day surgery facility. A 2-year-old boy weighing 15 kg presents for the combined procedures of release of bilateral hand syndactyly and open orchidopexy for a unilateral undescended testis. He has had a clear runny nose for the past three days, which his parents attribute to teething. A COVID-19 rapid antigen test performed this morning returned a negative result.
Caesarean Section with Severe Scoliosis
You are the duty anaesthetist in a tertiary hospital. You receive a telephone call from the obstetric consultant working in the antenatal clinic today. She is with a 24-year-old woman who is currently 35/40 in her first pregnancy. The woman has been booked for a caesarean section in a week's time for intrauterine growth retardation. Medical history Severe scoliosis – corrective posterior fusion surgery at 16 years of age Height 1.45 m Weight 42 kg Body mass index 20 kg/m2
Foreign Body Aspiration with Tracheal Stenosis
You are the anaesthetist on evening duty at your tertiary-level hospital. You receive a call from the emergency medicine physician who requests your assistance with the management of a 50-year-old man who experienced a choking episode while eating a sausage for lunch. The patient is thought to have aspirated a piece of the sausage and is somewhat distressed. The patient has a history of brittle asthma and chronic obstructive pulmonary disease with a 60 pack-year history of smoking. He has known tracheal stenosis for which he receives regular tracheal dilations. Medications Fluticasone 250 mcg via metered-dose inhaler (MDI) 2 puffs twice daily Salmeterol 50 mcg via metered-dose inhaler (MDI) 2 puffs twice daily Salbutamol 100 mcg via metered-dose inhaler (MDI) 2 puffs twice daily The emergency medicine physician would like to transfer the patient straight to theatre.
Femoral Artery Pseudoaneurysm in IV Drug User
You are the anaesthetist allocated to the emergency theatre at a tertiary hospital. You attend the holding bay to assess your next patient, who is a 30-year-old woman booked for an open repair of a right common femoral artery pseudoaneurysm. She has a history of substance use disorder and the injury is a result of self-injection. The 18-gauge intravenous cannula inserted under ultrasound guidance in the emergency department is no longer patent. There is a radial arterial line in-situ. Prehospital and emergency department management has included: Ketamine 50 mg intravenously Fentanyl 100 mcg (in aliquots) intravenously Hartmann's solution one litre intravenously The patient's biometric data and results of an arterial blood gas are included below. Biometric data Height 1.70 m Weight 50 kg Body mass index 17.3 kg/m2 Body surface area 1.51 m2 Ideal body weight 61 kg Arterial blood gas (FiO2 0.44, Temperature 38.0°C) pH 7.30 (7.35-7.45) pCO2 32 mmHg (35-45) pO2 120 mmHg (80-100) Bicarbonate 15.2 mmol/L (21-28) Base excess -9.9 mmol/L (-3.0-3.0) Lactate 3.5 mmol/L (<1.3) Haemoglobin 108 g/L (115-160) Na+ 131 mmol/L (137-147) K+ 5.7 mmol/L (3.5-5.0) Ca2+ 0.75 mmol/L (0.85-1.25) Cl- 108 mmol/L (96-109) Glucose 6.4 mmol/L (3.0-7.7)
Femoral Fracture in Patient on Buprenorphine
You are the weekend on-call anaesthetist at a tertiary regional hospital. A 45-year-old man has been transferred to your emergency department for management of a femoral fracture after he fell last night. He received a femoral nerve block and splint at the referral hospital before being transferred to your facility. The surgeons are worried about increasing swelling and gross deformity of his thigh and would like to place a femoral nail as soon as possible. The patient has a past history of chronic back pain that was associated with OxyContin misuse. The OxyContin was converted to buprenorphine after a spinal fusion four months ago. He had breakfast six hours ago. Medications Buprenorphine 18 mg sublingual once daily Pantoprazole 40 mg once daily Observations Heart rate 100 beats per minute Blood pressure 110/85 mmHg SpO2 95% on room air Respiratory rate 16 breaths per minute Weight 160 kg Height 1.86 m Body mass index 45 kg/m2
ECT in Standalone Psychiatry Hospital
You are working in a standalone psychiatry hospital covering a colleague's electroconvulsive therapy (ECT) list. The first patient is a 53-year-old anaesthetist colleague with severe depression who has been booked for ECT titration (first ECT treatment). You review her in her room prior to the start of the ECT list. She is visibly upset. Medical history Type 2 diabetes mellitus Hypertension Paroxysmal atrial fibrillation Medications Candesartan 16 mg daily Rivaroxaban 10 mg daily Venlafaxine 75 mg daily
Multi-Trauma with End-Stage Renal Failure
You are the on-call anaesthetist attending a trauma call in a major trauma centre. A 30-year-old male driver was brought to the hospital by paramedics after a high-speed collision with a tree. A laryngeal mask airway was inserted en route due a fall in his level of consciousness. There is extensive bruising over his right chest and a prominent seatbelt sign. He has polycystic kidney disease and attends the hospital for regular haemodialysis through an arteriovenous (AV) fistula in his left arm. He is otherwise well and has no known allergies.
Subarachnoid Haemorrhage Craniotomy with Anaphylaxis
You are called to the neurosurgical theatre by your provisional fellow who requests your assistance. They have anaesthetised a 36-year-old woman for a craniotomy and open clipping of a saccular middle cerebral artery aneurysm. The patient was admitted with a sudden onset of headache two days prior and was diagnosed with a World Federation of Neurosurgical Societies (WFNS) grade I subarachnoid haemorrhage. Medical History Hypertension Asthma Medications Nimodipine 60 mg four-hourly Irbesartan 150 mg daily Salmeterol/Fluticasone 250/25 mcg via metered-dose inhaler (MDI) daily Salbutamol 100 mcg via metered-dose inhaler (MDI) PRN Allergies Morphine (rash) When you attend the theatre, you discover that the patient was induced, intubated and anaesthetised uneventfully. She is currently being maintained on total intravenous anaesthesia, with target-controlled infusions of remifentanil and propofol. The patient has an arterial line and a central venous catheter in situ. Surgery is underway. The provisional fellow is concerned that the patient has developed high airway pressures and a heart rate of 120 beats per minute.
Obese Paediatric Dental Surgery
A 12-year-old boy with an intellectual disability presents for dental restoration and extractions at your tertiary paediatric hospital. His parents report that he is fearful of needles and has been worried about the surgery and anaesthetic. Weight 133 kg Height 1.60 m Body mass index 52 kg/m2
Caesarean Section in Paraplegic Patient
You are the anaesthetist in the obstetric anaesthesia clinic in a tertiary hospital. You are asked to assess a 28-year-old woman with paraplegia in her first pregnancy. She is 34 weeks pregnant and is booked for an elective caesarean section at term. The referral states: Paraplegia following a horse riding accident aged 16 years IVF conception/pregnancy Medications Amitriptyline 50 mg daily Cranberry capsules Folic acid Iron supplements Baclofen – discontinued with pregnancy
Salvage Laryngectomy and Free Flap Reconstruction
You are providing anaesthesia for an elective ENT list. A 63-year-old man with a laryngeal squamous cell carcinoma is booked for a salvage laryngectomy, and neck dissection with a free flap reconstruction. The patient was seen ten days ago in the preadmission clinic. He was documented to have chronic obstructive airway disease only, with no known cardiovascular disease. His observations this morning were: Heart rate 86 beats per minute Blood pressure 128/75 mmHg SpO2 95% on room air Body mass index 18 kg/m2 Medications Salbutamol 100 mcg via metered-dose inhaler (MDI) PRN Salmeterol/fluticasone (50/250 mcg) via metered-dose inhaler (MDI) 2 puffs twice daily
Trisomy 21 for Hemithyroidectomy
You are in the Preadmission Assessment Clinic. A 40-year-old woman with trisomy 21 (Down Syndrome) presents to the clinic with her mother for assessment prior to an elective left hemithyroidectomy. Past Medical History 1. Trisomy 21 2. Left eye surgery under GA (2020) 3. Multinodular goitre 4. Hypothyroidism Medications Cholecalciferol 25mcg daily Levothyroxine 150 mcg daily Pantoprazole 40 mg daily Investigations included: TFTs ECG CXR CT neck and chest Echo Sleep studies Biochemistry
COPD Assessment for Laparoscopic Cholecystectomy
You are reviewing a 68-year-old man in the preadmission clinic. He is scheduled to undergo a laparoscopic cholecystectomy for recurrent cholecystitis and a recent episode of cholangitis requiring hospital admission. Medications: aclidinium/formoterol (eformoterol) 340/12 mcg inhaled twice daily amlodipine 5 mg daily candesartan/hydrochlorothiazide 32/12.5 mg daily cholecalciferol 25 mcg daily paracetamol 1 g four times daily salbutamol 200 mcg inhaled 4 times a day as required Investigations included Spirometry ABG ECG 6MWT CXR
Angioedema and Difficult Airway Management
A 50-year-old man presents to the Emergency Department of your tertiary centre two hours after the onset of swelling in the face and lips. Medications: Ramipril 5 mg once daily Rosuvastatin 10 mg once daily Allergies: Shellfish As the duty anaesthetist, you have been telephoned by the Emergency Medicine physician and asked to assist with airway management.
Shoulder Surgery in Beach Chair Position
You are the anaesthetist for an upper limb orthopaedic list. The next patient on your list is a 55-year-old man for a left arthroscopic acromioplasty and rotator cuff repair in the beach chair position. The expected duration of surgery is 2.5 hours. Medical history: Currently well, generally active Hypertension Obesity (body mass index 35 kg/m2) Smoker 10/day No known allergies Observations: Height 178 cm Weight 110 kg Heart rate 65 beats per minute Blood pressure 125/75 mmHg Medications: Irbesartan 150 mg mane
Paediatric Cerebral Palsy for Bilateral Hip Surgery
You are reviewing a 10-year-old child on the day of surgery who has been scheduled for bilateral proximal femoral derotation osteotomies and tendon transfers with a left pelvic osteotomy. The child has a history of cerebral palsy, epilepsy, autism spectrum disorder and intellectual disability, attending a school for children with disability in year 3. They have had previous surgery on the right hip and can mobilise short distances with a frame but they use a wheelchair when out of the house. Weight 25 kg. Medications: Baclofen 2.5 mg TDS Gabapentin 30 mg nocte Omeprazole 5 mg daily Sodium valproate 250 mg BD
TAVI in Elderly Patient with COPD
An 88-year-old woman is scheduled for an elective transcatheter aortic valve implantation (TAVI). Her aortic stenosis has been under surveillance since she underwent two-vessel coronary bypass grafting nine years ago. She has experienced worsening exertional dyspnoea (NYHA III) and orthopnoea over the past six months and had an admission for heart failure last month that responded to diuretics. She is an ex-smoker (30 pack-year history) with moderate chronic obstructive pulmonary disease. Her current FEV1 is 1.2 litres (56% predicted). She had one admission for a respiratory illness in 2021 when she experienced COVID-19 pneumonitis. Medications: Amlodipine 5 mg mane Aspirin 100 mg mane Pantoprazole 20 mg mane Ramipril 5 mg mane Symbicort Turbuhaler (budesonide/formoterol) 200/6 mcg 2 puffs inhaled bd Salbutamol inhaled prn Biometrics: Height 178 cm Weight 58 kg Body mass index 18.3 kg/m2 Body surface area 1.73 m2
Malignant Hyperthermia Susceptibility and Renal Stone Surgery
You are the anaesthetist in a regional hospital assigned to the morning emergency list. Your next patient is a 45-year-old man admitted the previous evening with haematuria and flank pain from a renal stone. He is booked for cystoscopy, laser litholapaxy and JJ stent insertion. Past Medical History: Hypertension Type 2 diabetes mellitus Ryanodine receptor mutation Medications: Metformin 500 mg BD Ramipril 5 mg mane CT Abdomen and Pelvis report conclusion: The appearance of the left kidney is in keeping with obstructive uropathy and superimposed pyelonephritis.
Anaesthesia in the MRI Suite
You are working in the MRI suite of a major regional hospital providing general anaesthesia. Your next patient is a 35 year-old woman with sensorineural hearing loss for a brain MRI. She requires anaesthesia because of severe anxiety and claustrophobia. Her completed Patient Health Questionnaire is attached. She received oral diazepam 10 mg one hour ago as premedication. She is calm and mildly sedated in the anaesthesia room adjacent to the MRI scanner.
Preeclampsia and Labour Epidural
You are called by the obstetrics registrar to insert an epidural catheter in a patient with preeclampsia for blood pressure management and labour analgesia. The patient is a 30-year-old primiparous woman who is at 35+5 weeks gestation. She has gestational diabetes (diet-controlled) and her only medication is low-dose aspirin for a family history of hypertension.
Trauma with Stab Wounds and Haemorrhage
You are the anaesthetist on-call for trauma in a major tertiary hospital. You have been asked to attend the Emergency Department for a 48-year-old man brought in by paramedics with stab wounds following a pub fight in a regional town two hours away. He has no previous medical conditions and no known allergies. You notice that he is obese. He is irritable but is obeying commands. He has a cut and bruising over his left eye. There are wounds on his abdomen covered by blood-soaked gauze packs, and further wounds on his leg, with a tourniquet on his upper thigh. His observations are: Heart rate 125 bpm Blood pressure 110/68 mmHg Respiratory rate 26 breaths per minute SpO2 96% on 10L O2/min via Hudson mask The ED physician tells you that an eFAST scan is positive. The surgeon asks if you are able to go straight to theatre for exploratory laparotomy.
Airway Trauma from Assault
As the duty anaesthetist, you receive a phone call from the emergency department physician at your regional hospital, requesting help with an incoming trauma patient. A 35-year-old male incarcerated person is being transferred by paramedics following an assault two hours ago whilst he was having his meal. He was kicked and punched in both the face and chest and there was an attempted strangulation. You are informed over the phone that the patient has difficulty breathing and has bruising and swelling to the front of his neck but otherwise appears stable. He has no allergies and is not on any medications. He smokes 10-15 cigarettes a day and has no significant medical history.
Suspected OSA for Total Hip Replacement
You are reviewing a 72-year-old woman in the anaesthetic bay of a metropolitan hospital. She is scheduled for an elective left total hip replacement and was previously assessed in the pre-anaesthetic clinic two months ago. Two years prior she underwent a right total knee replacement, which was complicated by a 48-hour High Dependency Admission as she was "slow to wake up" and required supplemental oxygen therapy. Medical history: Hypertension Obesity (body mass index 41 kg/m2) Medications: Atorvastatin 20 mg daily Candesartan/hydrochlorothiazide 16/12.5 mg daily
Paediatric Caustic Ingestion
You are the on-duty anaesthetist in a large regional centre with a paediatric surgical service. You are called to assist in the Emergency Department with the management of an otherwise healthy 2-year-old girl who has ingested drain cleaner (sodium hydroxide) at home about two hours ago. There are concerns about likely aspiration or inhalational injury from vapours. The Emergency Medicine specialist tells you that the girl was brought in to hospital by her mother after she found the child sitting on the kitchen floor with a pile of drain cleaner crystals next to her and crystals on her hands and inside her mouth. The mother was unable to quantify the amount ingested. The girl vomited once on the way to hospital and is currently drooling and distressed in her mother's arms.
Endobronchial Valve Insertion in Severe COPD
You are working in the preadmission clinic, reviewing your patients for a respiratory medicine bronchoscopy list in a week's time. Your next patient is a 74-year-old man who has been scheduled for an elective bronchoscopic lung volume reduction procedure by insertion of endobronchial valves. Medical history: Emphysematous chronic obstructive airways disease - home oxygen 1L/min, 18 hours per day Ex-smoker – ceased 5 years ago, 60+ pack-year smoking history Osteoarthritis Peripheral vascular disease Atrial fibrillation Medications: Ipratropium bromide MDI (21 mcg/puff) 2 puffs bd Seretide Inhaler (fluticasone/salmeterol 25/250 mcg) 2 puffs bd Salbutamol (100 mcg/puff) 2 puffs prn Paracetamol 1 g tds Rivaroxaban 15 mg daily The respiratory physician will perform the procedure in the bronchoscopy suite of your major tertiary hospital and has requested the case be performed under general anaesthesia with spontaneous ventilation. The patient has a planned admission for two days post-procedure to monitor for any complications.
Robotic Partial Nephrectomy in Obese Patient
You are an anaesthetist at a tertiary hospital working in the pre-anaesthetic clinic. You review a 74-year-old man who is booked for robotic assisted partial nephrectomy for a 5 cm right upper pole renal cell cancer. Medical History: Obesity Controlled hypertension Type 2 diabetes mellitus Obstructive sleep apnoea (treated with CPAP) Hypercholesterolaemia Medications: Amlodipine 10 mg daily Aspirin 100 mg daily Atorvastatin 40 mg daily Empagliflozin 10 mg daily Metformin 1000 mg twice daily Perindopril 8 mg daily Biometrics: Height 183 cm Weight 144 kg BMI 43 kg/m2
Post-Pancreatectomy Bleeding in Interventional Radiology
You are on-call from home for a private hospital that has Intensive Care and Interventional Radiological facilities. You receive a call from the Upper GI surgeon you regularly work with regarding a patient you anaesthetised ten days prior. The patient is a 72-year-old man who had a laparoscopic distal pancreatectomy to remove a pancreatic mass found incidentally. Medical history: Hypertension Hypercholesterolaemia Obesity (weight 108 kg, body mass index 34 kg/m2) Medications: Irbesartan 150 mg daily Rosuvastatin 20 mg daily The patient's surgery and recovery were uneventful and he was discharged home on day four postoperatively. The patient's anaesthetic, including airway management, was also uneventful. The surgeon is calling you because the patient has just gone to radiology for coiling of a possible bleeding vessel and the surgeon wants to give you a "heads up" in case the patient needs to go to the operating theatre.
Myotonic Dystrophy in Pregnancy
A 28-year-old primigravida currently at 24 weeks gestation attends your high-risk obstetric clinic with her partner. She has recently been diagnosed with myotonic dystrophy and is under the care of a neurologist at your hospital. Her presenting symptoms were progressive muscle weakness and difficulty swallowing over a period of two years. She has had three hospital admissions for aspiration pneumonia, none of which required intensive care unit admission. The pregnancy has been confirmed with an early first trimester ultrasound scan and has been uneventful to date. Observations: Height 1.62 m Weight 65 kg Pulse rate 90 beats per minute Blood pressure 100/60 mmHg Respiratory rate 20 breaths per minute SpO2 96% on room air Airway examination: Thyromental distance less than 5 cm Mallampati class III Inter-incisor distance greater than 4.5 cm Good neck extension Normal jaw protrusion Cardiovascular examination: Normal heart sounds with no additional sounds No signs of heart failure Neurologic examination: Proximal muscle weakness Presence of persistent grip with handshake Mild scoliosis with curvature to left Medications: Bisoprolol 2.5 mg mane Frusemide 20 mg mane A recent transthoracic echocardiogram shows mild biventricular and biatrial dilation; left ventricular ejection fraction 45%; and pulmonary artery systolic pressure of 25 mmHg.
Penetrating Chest Trauma with Impalement
You are urgently directed to Resuscitation in a metropolitan Major Trauma Centre. A 24-year-old driver was in a motor vehicle accident between his car and a lorry carrying 12-cm diameter pine logs, with a log penetrating the windshield and impaling his right thorax. The time since injury is 25 minutes. He is fully conscious and in severe pain. His initial observations are: Heart rate 128 bpm Blood pressure 88/68 mmHg Respiratory rate 28 breaths per minute
Cirrhosis for Gastroscopy and Colonoscopy
You are asked to assess a 60 year old woman with cirrhosis in the preadmission clinic prior to her booked gastroscopy and colonoscopy next week. Medications: Bisoprolol 2.5mg bd Thyroxine 100microg mane Vildagliptin 50mg daily Furosemide 40mg mane Spironolactone 25mg mane Lactulose 30mL daily Rifaximin 550mg bd Investigations included: Biochemistry Haematology Coagulation tests
Chronic Lung Disease for Hemicolectomy
A 59 year-old woman presents to your Pre-anaesthetic Assessment Clinic prior to an elective hemicolectomy for bowel cancer. She has a chronic lung condition. Her long-term medications are: Atorvastatin 20 mg once daily Azithromycin 250 mg once daily Darbepoetin 80 mg weekly Escitalopram 10 mg daily Lercanidipine 10 mg daily Prednisolone 5 mg daily Sulfamethoxazole 800 mg/trimethoprim 160 mg 3 times weekly Investigations included: ABG PFTs Biochemistry FBC Fe studies
End-Stage Renal Failure on Peritoneal Dialysis
You are asked to assess a 55 year old man with end-stage renal failure who currently uses peritoneal dialysis. You are seeing him in the pre-admission clinic prior to day surgery for dental extractions next week. Medications: Novorapid insulin 6U with breakfast, 8U with dinner Gliclazide modified release 60mg bd Linagliptin 5mg mane Paracetamol 1g qid Darbepoetin 40 mcg fortnightly Frusemide 250mg mane Metoprolol 25mg mane Pravastatin 10mg daily Aspirin 100mg mane Kidney vital vitamin – 1 mane Lanthanum carbonate (phosphate binder) – 1 tds Investigations included: FBC Fe studies Biochemistry ECG Echocardiogram report Cardiac angiogram report Dipyridamole stress echo report
Corrected Tetralogy of Fallot for Hernia Repair
You are in the preadmission clinic reviewing a 25-year-old man who has been scheduled for an open repair of a large right inguinal hernia in eight weeks' time. Your hospital has an intensive care unit but there is no facility for cardiac surgery. He was born with Tetralogy of Fallot (TOF) which consisted of: 1. Ventricular septal defect (VSD) 2. Right ventricular (RV) outflow tract obstruction (RVOTO) 3. RV hypertrophy (RVH) 4. An overriding aorta and a hypoplastic left pulmonary artery. At 3 months of age he had a Blalock shunt as a temporary measure (supplying blood to the hypoplastic pulmonary artery) and at 3 years of age his TOF was fully repaired. He takes no regular medications. He works part-time at the local supermarket and sometimes gets short of breath on exertion. Investigations included: ECG Echocardiogram and stress echo reports
Urgent Laparoscopic Anterior Resection with Recent Coronary Stent
You are the on-call anaesthetist at a private hospital. One of your regular colorectal surgeons has asked you to assess a 65-year-old man for an urgent laparoscopic high anterior resection for an obstructing tumour of his sigmoid colon. The surgeon would like to proceed later today and has booked an intensive care bed postoperatively in preparation. Past medical history: Hypertension Ischaemic heart disease – percutaneous coronary intervention (PCI) six months prior after an acute coronary syndrome (ACS). A drug-eluting stent was placed in the left anterior descending coronary artery. Most recent echocardiogram at time of stent insertion – unremarkable with no regional wall motion abnormalities. Medications: aspirin 100 mg daily atorvastatin 40 mg daily clopidogrel 75 mg daily oxycodone 5 mg PRN telmisartan 40 mg daily
Jehovah's Witness Obstetric Patient
A 35-year-old primiparous woman is referred to your high risk obstetric clinic at 28 weeks gestation as she is a Jehovah's Witness. Medications: pregnancy multivitamin iron supplement She has no known allergies. Height 175 cm Weight 83 kg BMI 27 kg/m2
Cardioversion with Cardiac Amyloidosis
You are currently providing anaesthesia for the transoesophageal echocardiogram and cardioversion list. The cardiology registrar informs you that he has added a 65-year-old man to the end of the list. The patient presented to the emergency department two hours ago with severe shortness of breath. He has a history of multiple admissions to the Coronary Care Unit for management of his cardiac amyloid disease. Medications on admission: atorvastatin 40 mg daily bisoprolol 2.5 mg daily furosemide (frusemide) 40 mg twice daily potassium chloride 1500 mg twice daily prednisone 10 mg daily rivaroxaban 20 mg daily spironolactone 25 mg daily
Carotid Endarterectomy under Regional Anaesthesia
On your morning vascular list today is a 78-year-old woman who has been scheduled for an elective carotid endarterectomy. She has been extensively reviewed in the preanaesthesia clinic. Her underlying cardiovascular disease is considered mild, stable and optimised. Her renal function is normal. The patient has provided consent to receive either general anaesthesia or regional anaesthesia with conscious sedation. The surgeon has requested regional anaesthesia with conscious sedation. Today's observations: SpO2 – 97% (room air) HR 80 bpm, regular BP 160/90 mmHg RR 14 breaths/min Height 166 cm Weight 88 kg BMI 31.9 kg/m2
Trauma Resuscitation with PEA Arrest
You arrive at a trauma call in a regional hospital just as the emergency doctor has intubated the patient. As a self-inflating bag is being connected, a team member announces that they cannot feel a pulse. You are told the patient is a 25-year-old male who fell approximately three metres as a result of collapsed scaffolding and has just been intubated because of increasing restlessness and a falling GCS (Glasgow Coma Scale). The bedside monitor shows: ECG HR: 120 bpm Last recorded SBP: 90 mmHg Blood pressure monitor is cycling and not recording a pressure Pulse oximeter: 'searching'
Mastectomy with Severe PONV History
You review a 42-year-old woman in the preanaesthesia clinic who is booked for left mastectomy and axillary clearance for breast cancer. She has a history of nausea with opioid analgesics and experienced severe postoperative nausea and vomiting after a previous hysteroscopic fibroid resection.
Paediatric Trauma with Open Femur Fracture
It is the weekend and you are the anaesthetist on-duty at a remote regional hospital. You receive a request from the Emergency Department (ED) registrar to assist in the management of an 8-year-old boy who has hit a tree whilst mountain biking. The boy has an open mid-shaft fracture of the femur and the ED staff have been unable to secure intravenous access. Past Medical History: asthma attention-deficit/hyperactivity disorder Medications: methylphenidate 20mg daily salbutamol 100 mcg prn fluticasone 100 mcg daily
Epidural Abscess in Chronic Pain Patient
A 55-year-old woman is admitted from the emergency department for management of severe low back pain. She has a history of chronic back pain and had an epidural steroid injection one week ago which has not improved her symptoms. She weighs 87 kg, BMI 31 kg/m2. Current medications: empagliflozin 10 mg daily buprenorphine patch 15 mcg/hr transdermally fluoxetine 20 mg daily gabapentin 300 mg twice daily metformin 1 g twice daily paracetamol 500mg + codeine phosphate 30 mg, 1-2 tabs 4-hourly PRN perindopril 10 mg daily
Post-Bariatric Surgery Acute Abdomen
You are an anaesthetist at a metropolitan private hospital. A 22-year-old woman requires surgery for an acute abdomen. She is day 4 post-laparoscopic sleeve gastrectomy that was performed for obesity. The ICU specialist has called you with her blood results. Results: sodium 140 (135–145 mmol/L) potassium 3.0 (3.5–5.5 mmol/L) chloride 112 (95–110 mmol/L) bicarbonate 16 (20–32 mmol/L) urea 8.7 (3.5–8.5 mmol/L) creatinine 90 (60–110 µmol/L) urate 0.41 (0.20–0.50 mmol/L) calcium 2.10 (2.15–2.55 mmol/L) phosphate 0.80 (0.80–1.50 mmol/L) magnesium 0.58 (0.65–1.00 mmol/L) glucose 14.2 (3.6–6.0 mmol/L) Usual medications: empagliflozin 10 mg daily escitalopram 20 mg daily lansoprazole 30 mg bd metformin 500 mg bd vitamin D 1000 IU daily
Obstetric Epidural Management with Opioid Use Disorder
You are the obstetric anaesthetist on duty at a major public hospital. A 22-year-old primigravida is undergoing an induction of labour at 37 weeks gestation for fetal intrauterine growth restriction. Her BMI is 17 kg/m2. Her medical history includes previous oxycodone substance use disorder, for which she takes Suboxone (buprenorphine-naloxone 32 mg/8 mg sublingually every second day). She has no other medical or obstetric history. She had an epidural catheter inserted in early labour by a colleague for analgesia. Although she has difficult venous access, an ultrasound-guided 18-gauge cannula was successfully sited in her cubital fossa. The morning handover indicates that the patient has required two clinician epidural top-ups overnight due to unsatisfactory analgesia. There is now reduced fetal heart rate variability on cardiotocogram (CTG) and the obstetric team would like to place a fetal scalp electrode. The patient is refusing this intervention due to persisting discomfort. The obstetric team requests your assistance to improve her analgesia.
Pulmonary Vein Isolation with Recent Coronary Stent
A 63-year-old woman is booked for a pulmonary vein isolation for atrial fibrillation today. She is scheduled to be the first case on your afternoon list in the cardiac catheter laboratory. She describes episodic palpitations lasting 30 to 40 minutes up to five times a day with associated fatigue and exertional limitation. Past medical history: Ischaemic heart disease – drug-eluting stent (DES) to proximal LAD 12 weeks ago for stable angina symptoms Hypertension Type 2 diabetes mellitus Obstructive sleep apnoea requiring nocturnal CPAP Elevated BMI (41 kg/m2) Chronic kidney disease - baseline eGFR 65 mL/min/1.73m2 Current medications: apixaban 5 mg bd aspirin 100 mg daily clopidogrel 75 mg daily dapagliflozin 5 mg daily bisoprolol 2.5 mg bd insulin glargine 20 units nocte subcutaneously irbesartan/hydrochlorothiazide 150 mg/12.5 mg daily pantoprazole 40 mg daily rosuvastatin 10 mg nocte An ECG has been taken this morning. Her blood pressure is 118/79 mmHg and SpO2 98% (room air).
Open Abdominal Aortic Aneurysm Repair with Aortic Regurgitation
You are seeing a 58-year-old man in preadmission clinic prior to elective open abdominal aortic aneurysm repair. He is known to have hypertension, hypercholesterolaemia and aortic regurgitation. He stopped smoking when his aneurysm was diagnosed 6 years ago. He lives independently in his own home with his wife. He uses a stationary exercise bike three times per week for 20 minutes and enjoys gardening. Current medications: amlodipine 5 mg daily aspirin (enteric-coated) 100 mg daily enalapril 10 mg daily simvastatin 20 mg daily
Major Burns with Mechanical Mitral Valve
A 62-year-old woman has just arrived by ambulance to your burns centre emergency department and you have been called to assist as part of the trauma team. She was caught in a house fire where she was trapped indoors for ten minutes before firefighters were able to free her. Forty-five minutes have lapsed since rescue. Past medical history: Smoking 40 pack-year history Mechanical mitral valve replacement Chronic kidney disease Medications: warfarin 5 mg daily Examination findings: Approximate weight 70 kg SpO2 99% (oxygen via Hudson mask at 10 L/min) HR 120 bpm (sinus rhythm) BP 100/70 mmHg RR 21/min, shallow breathing and coughing intermittently Chest auscultation: mild diffuse wheeze. Her burn injuries have been documented by the paramedic in the diagram (hashed areas). The burnt skin is a blotchy red or dark pink colour and has large blisters. Capillary refill is sluggish (> 2 seconds) and there is loss of sensation in some areas. She is confused about the events, visibly distressed and in pain. She has been administered 10 mg of morphine intravenously.
Dental Abscess with Trismus and Intellectual Impairment
You are asked to review a 40-year-old man in the emergency department who has trismus secondary to a dental abscess. He has severe intellectual impairment and is nonverbal. His caregiver is with him. The maxillofacial surgeon wishes to bring him to theatre urgently to remove a lower molar tooth and incise and drain his submandibular abscess.
Paediatric Strabismus Surgery at Day Surgery
A 2-year-old girl weighing 13 kg presents for bilateral strabismus (squint) surgery at a stand-alone day surgery facility. She was born at 34 weeks gestation weighing 2.2 kg.
Awake Craniotomy for Tumour Resection
You are an anaesthetist working in a major hospital which includes neurosurgery. You are currently in the preanaesthetic assessment clinic reviewing a 52-year-old man for his suitability to undergo awake craniotomy for tumour resection. He presented with a headache and right-sided weakness two weeks ago. Since diagnosis, his oral medications are: dexamethasone 4 mg TDS levetiracetam 500 mg BD Weight 110 kg, height 182 cm (BMI 33 kg/m2).
Systemic Sclerosis for Lithotripsy
You are in the preadmission anaesthesia clinic. A 57 year old male presents to the clinic prior to extracorporeal shockwave lithotripsy for a staghorn calculus. His past medical history includes systemic sclerosis. Medications listed are: Prednisone 2.5 mg daily Mycophenolate 3g daily Insulin Humalog 16 units three times daily and Lantus 25 units at night Apixaban 5mg twice daily Irbesartan 300mg daily Vitamin D 1000 IU daily Magnesium 500mg twice daily Artificial tears prn Investigations included: Pulmonary function tests CXR Full blood picture Urea and electrolytes 6 minute walk test
Cardiac Disease for Total Knee Replacement
You are reviewing a 71 year old male in the pre-anaesthetic clinic. He is scheduled for a total knee replacement in 2 weeks. Current medications: Frusemide 20mg daily Rivaroxaban 20mg daily Digoxin 125mcg daily Bisoprolol 10mg twice daily Sacubitril/valsartan 97/103mg twice daily Rosuvastatin 10mg daily Ezetimibe 10mg daily Investigations included: CXR ECG Iron studies Biochemistry Complete blood picture
Emergency Cholecystectomy with Juvenile Idiopathic Arthritis
A 30-year old man booked for an emergency laparoscopic cholecystectomy for a gangrenous gallbladder. He has a past medical history of juvenile idiopathic arthritis (formerly juvenile rheumatoid arthritis). He appears unwell and is vomiting. Vital signs Blood pressure 100/60 mmHg Heart rate 120 bpm SpO2 93% (room air) Respiratory rate 20 per minute T 38.5°C
Urgent ERCP with Bleomycin Lung Toxicity
You are on-call at a tertiary hospital and receive a theatre booking from a surgeon at 23:00 hours for an urgent endoscopic retrograde cholangiopancreatography (ERCP). The patient is a 30-year-old male (weight 60 kg) who presented with a three-day history of vomiting and jaundice and has been diagnosed with ascending cholangitis due to choledocholithiasis. He is febrile at 38.5°C and tachycardic at 110 bpm. His past medical history includes stage III testicular cancer diagnosed 12 years ago, for which he underwent radical orchidectomy followed by 18 months of chemotherapy with bleomycin and cisplatin. During his latest surveillance review with oncology he was sent for some further investigations to assess progressive shortness of breath. His pulmonary function tests and chest X-ray are provided. Pulmonary Function Test results show a restrictive pattern with significantly reduced gas transfer capacity (TLCO 26% predicted, KCO 39% predicted).
Paediatric Oesophageal Foreign Body
You are the on-call consultant in a regional hospital. The anaesthesia registrar calls you at 22:30 hours reporting that there is a 14-month-old child in the emergency department with a foreign body in the mid-oesophagus visible on chest X-ray. There is an ENT consultant available to take the child to theatre.
Labour Epidural with Language Barrier
You are the anaesthetist on-call in a large regional hospital. You have been asked to provide epidural analgesia to a 32-year-old parturient (gravida 1, para 0, 41+1 weeks gestation) after commencement of induction of labour for prolonged pregnancy. The midwife informs you that the patient moved from Mongolia two years ago and is not fluent in English, although her husband is fluent in English. She has had an unremarkable antenatal course. Her past medical history includes mild asthma (no regular treatment required). When you attend the patient, she is noted to be in established labour with some distress due to contraction pain. She is 148 cm tall and weighs 55 kg.
Infected Pacing Wire Removal
A 76-year-old man with infected pacing wires has been scheduled for removal of his entire pacing system under general anaesthesia. The procedure is to be performed in a hybrid theatre in the cardiology department. Current medications aspirin 100 mg daily atorvastatin 40 mg daily flucloxacillin 2g qid IV perindopril 1 mg daily His chest X-ray is displayed.
Intraoperative Pulmonary Embolism
You are the duty anaesthetist in a small regional hospital and have been called urgently to assist the anaesthesia registrar in the emergency theatre. The registrar is anaesthetising a previously well 25-year-old man (75 kg, ASA I) who is undergoing open reduction and internal fixation of a fractured tibia and fibula sustained in a skiing accident two days ago. The registrar has noted progressive desaturation and increasing tachycardia over the last 15 minutes. The surgeons have deflated the tourniquet and are closing the wound.
Cervical Spine Injury with Self-Harm and Polysubstance Use
You are the anaesthetist on-call in a major trauma centre. The orthopaedic registrar has booked a 45-year-old woman for an urgent C3–C7 decompression and fusion for C5/6 bilateral facet joint fracture-dislocations. She has an incomplete spinal cord injury. The patient sustained the injury jumping off a cliff in an act of deliberate self-harm. She has had a prolonged extraction time due to difficult terrain. Past medical history anxiety and depression with multiple previous suicide attempts polysubstance use disorder with previous intravenous drug use Medications clonazepam 0.5–1.0 mg PRN for anxiety methadone 100mg mane quetiapine 300mg nocte
Fractured Hip with Multiple Comorbidities
A 75-year-old woman presented to the emergency department following a fall in which she sustained a fractured right hip. She has no other injuries and is cognitively intact. She has been scheduled for a right hemiarthroplasty as the first case on the operating list tomorrow morning. Past medical history Polymyalgia rheumatica Chronic alcohol consumption (60 g per day) Previous deep vein thrombosis with pulmonary embolism Chronic kidney disease Height: 162cm Weight: 61kg Medications Fluoxetine 40 mg mane Perindopril/indapamide 5 mg/1.25 mg mane Prednisolone 15 mg mane Rivaroxaban 15 mg mane Rosuvastatin 20 mg mane Blood test results on admission to the emergency department: Haemoglobin 82 g/L (115-160) Platelets 117 x10^9/L (150-450) Na+ 127 mmol/L (135-145) K+ 4.2 mmol/L (3.5-5.5) Cl- 103 mmol/L (95-110) HCO3- 20 mmol/L (20-32) Urea 12 mmol/L (2.5-7.0) Creatinine 145 mmol/L (45-95) eGFR 30 mL/min/1.73m2 (>90) Albumin 26 g/L (33-46) A cardiac rhythm strip was printed in the Emergency Department.
Intellectual Disability with Foreign Body Aspiration
You are running the emergency theatre in a regional hospital on a Sunday morning when you receive a phone call from the emergency department (ED) consultant. A 23-year-old man with an intellectual disability has presented with a productive cough and haemoptysis after a choking episode the previous evening whilst eating dinner. The ED consultant asks you to provide assistance with sedation for a CT chest due to the patient's non-compliance with lying still.
Carcinoid Syndrome for Laparoscopic Hemicolectomy
A 74-year-old woman presents to the preanaesthesia clinic for review ahead of a laparoscopic right hemicolectomy for colorectal cancer. She is a smoker and has a background of longstanding bronchial carcinoid tumours.
Paediatric Adenotonsillectomy for OSA
You have been asked to take over an elective list at a tertiary paediatric hospital as the regular anaesthetist is delayed in the postanaesthesia care unit by a postoperative airway event. The next patient is a five-year-old First Nations boy (weight 28 kg) from a regional centre who is accompanied by his grandmother who is his legal guardian. He is booked for adenotonsillectomy for the management of obstructive sleep apnoea. His surgery was previously cancelled three months ago. The anaesthetist had just administered ketamine and midazolam premedication to this child when he was called away.
Morbidly Obese Pre-eclamptic for Caesarean Section
You are the anaesthetist covering the obstetric theatre at a large regional hospital. A 30-year-old primiparous woman at 38 weeks gestation is booked for a category 2 caesarean section for a non-reassuring cardiotocograph (CTG). The patient has pre-eclampsia with a blood pressure of 160/100 mmHg while on antihypertensive treatment. She is not currently in labour. She is morbidly obese with a BMI of 58 (height 168 cm, weight 164 kg). When you review the patient, she tells you that she is needle-phobic and wants to "be asleep" for the procedure. Current medications Labetalol 40 mg q30 min IV Magnesium 1g/hour IV Methyldopa 500 mg PO QID Nifedipine IR 10 mg PO There are no known drug allergies.
Posterior Mediastinal Tumour Resection
A 28-year-old male is booked on your list for resection of a large right-sided posterior mediastinal tumour. This was diagnosed after he presented with increased breathlessness and cough. He has no other significant comorbidities.
Emergency Laparotomy in Elderly Smoker
You are the on-call consultant anaesthetist at a small regional hospital. At 09:00 hours on a Saturday morning you receive a call from the surgical registrar regarding a 69-year-old man who presented to the emergency department with a 24-hour history of worsening abdominal pain. An erect chest X-ray demonstrates free gas under the diaphragm. The surgical registrar would like to bring the patient to theatre for a laparotomy. Past medical history Current smoker – 50 pack-years Ischaemic heart disease – non-obstructive, medical management Abdominal aortic aneurysm – 4 cm diameter, currently under surveillance Medications Aspirin 100 mg daily Atenolol 50 mg daily Ibuprofen 400 mg tds PRN Perindopril 5 mg daily Rosuvastatin 20 mg daily Height 175 cm Weight 80 kg BMI 26.1 kg/m2 (ideal body weight 70 kg)
Traumatic Brain Injury with Midface Swelling
As the duty anaesthetist in a tertiary hospital, you are asked to attend the emergency department for the impending arrival of a 38-year-old male who has been struck on the head while working on a building site. On arrival with the paramedics he is unconscious with a laryngeal mask airway in situ. He has a compression bandage applied to his head and severe right periorbital and midface swelling. The initial observations from the paramedics are as follows: Heart rate 76 bpm Blood Pressure 167/90 mmHg SpO2 90% spontaneous ventilating on a T-piece with oxygen at 15 L/min Respiratory rate 28/min Left pupil size 4 and non-reactive Right pupil size 2 and sluggishly reactive
Sarcoma Excision with Cardiovascular Disease
You are seeing a 72-year-old man in the preanaesthesia clinic of your tertiary hospital. He is booked for a wide local excision of a sarcoma of the right latissimus dorsi muscle in ten days time. The surgeon requests that he is positioned in the left lateral decubitus position. The surgery is anticipated to take two to three hours. Past medical history Coronary artery stent Type 2 diabetes mellitus Hypertension Transient ischaemic attack two years ago Medications Clopidogrel 75 mg daily Metformin 500 mg twice daily Perindopril 8 mg daily Rosuvastatin 20 mg daily Observations performed in clinic Blood pressure 165/95 mmHg Heart rate 85 bpm SpO2 98% on room air Random blood glucose 8.5 mmol/L Height 1.78m Weight 95 kg BMI 30
Left Hemihepatectomy with Liver Metastases
You review a 67-year-old man in the Preadmission Clinic (PAC) for a left hemihepatectomy via a roof-top incision for metastatic colon cancer. He underwent a right hemicolectomy four months ago for primary cancer resection. The procedure was complicated by an extended stay in hospital due to suboptimal pain management. Past medical history: - Hypertension - Lower limb peripheral neuropathy secondary to chemotherapy - Ex-smoker with 30 pack-year history Medications & allergies: - perindopril 5 mg daily - amitriptyline 25 mg nocte - Nil known allergies Observations in PAC: BP - 160/85 mmHg, HR - 75 bpm, SpO2 - 98% on room air, weight - 65 kg, height - 180 cm, BMI - 20 kg/m2 Liver function test results: Bilirubin 50 (3-17 umol/L), AST 40 (5-35 IU/L), ALT 38 (5-35 IU/L), ALP 560 (30-300 IU/L), GGT 110 (11-51 IU/L), Albumin 35 (35-50 g/L), INR 1.1 (0.8-1.2) All other blood results are normal.
Paediatric Supracondylar Fracture with Down Syndrome
You are on call at the Children's Hospital. At 1730 hours you are asked to review a 7-year-old girl with Down syndrome in the Emergency Department (ED) who sustained a supracondylar fracture of the left humerus whilst playing on a trampoline at a birthday party. She is booked on the emergency list for closed reduction and percutaneous pinning of the fracture. On your arrival in ED you are informed that the girl has received intranasal fentanyl 50 mcg following one unsuccessful attempt to gain IV access. The dose of fentanyl was based on a weight of 31 kg which had been documented in the girl's case notes at a recent outpatient clinic appointment.
Redo Aortic Valve Replacement with Heart Failure
You attend the subacute Coronary Care Unit to review a 52-year-old man with a six week history of increasing dyspnoea who has been scheduled for revision aortic valve replacement +/- mitral annuloplasty tomorrow. His past history includes a bioprosthetic aortic valve replacement eight years ago. On admission his echocardiogram showed severe aortic regurgitation and moderate mitral regurgitation, with an estimated left ventricular ejection fraction of 35% and a moderately dilated left ventricle. His only regular medication prior to this admission was aspirin 100 mg daily, but during this admission he has been commenced on: - furosemide (frusemide) 80 mg bd orally - perindopril 6 mg mane orally - dobutamine infusion 2.5 mcg/kg/min intravenously When you attend the ward you find him walking around with his IV pole. He weighs 80 kg.
Multiple Sclerosis in Pregnancy
A 32-year-old woman attends the obstetric anaesthetic assessment clinic, having been referred by the obstetric registrar. She is 24 weeks into her first pregnancy, and has a history of multiple sclerosis. She uses a walking stick. Her other medical history includes anxiety. There are no other relevant obstetric, medical or anaesthetic issues. She had an uneventful general anaesthetic for an appendicectomy at this hospital last year for which you have the anaesthetic record. There were no airway issues. She takes escitalopram and has monthly ocrelizumab infusions, which have been withheld in pregnancy. She has no allergies. She wishes to discuss analgesia in labour and anaesthesia should a caesarean or other operative intervention be required.
Laparoscopic Appendicectomy with WPW Syndrome
Your next patient on the emergency list is a 24-year-old man scheduled for a laparoscopic appendicectomy. His only past medical history is that of occasional self-limiting palpitations on exertion. He has been sick for three days with severe abdominal pain, nausea and vomiting. He weighs 70 kg. His vital signs are: - temperature 38.5 degrees C - heart rate 106 bpm - blood pressure 100/71 mmHg The surgeon suspects a perforated appendix. He has an electrocardiogram (ECG) in his notes.
Subarachnoid Haemorrhage with Polycystic Kidney Disease
You are assessing a patient on the neurosurgical ward who is booked on your list tomorrow for coiling of cerebral aneurysms in the hospital's interventional radiology suite. The 56-year-old woman presented earlier in the day with a two day history of severe headache, vomiting and malaise that was unresponsive to paracetamol. There has been no change to her level of consciousness or focal neurological deficits. Cranial CT revealed five intracerebral aneurysms, the largest in the anterior communicating artery. There is evidence of diffuse subarachnoid haemorrhage, Fisher grade 2. Her vital signs are: - blood pressure 145/75 mmHg (MAP 88 mmHg) - pulse 85/min sinus rhythm Past medical history: Polycystic kidney disease - renal transplant 10 years ago - end-stage renal disease treated with haemodialysis for two years prior to transplantation Hypertension Medications: - atorvastatin 20mg daily - enalapril 5mg BD - mycophenolate 1g BD - prednisone 5mg daily - tacrolimus 5mg BD - trimethoprim/sulphamethoxazole one tab BD
Total Thyroidectomy for Massive Goitre
A 50-year-old woman has been transferred to your tertiary referral centre for a total thyroidectomy for a massive goitre with associated recent voice change. You review her on the ward as she is booked on your list for the following day. Medications: - carbimazole 15 mg bd - propranolol 40 mg bd - rosuvastatin 10 mg daily Weight 120 kg, Height 165 cm, BMI 44 kg/m2
Penetrating Neck Trauma at Regional Hospital
You are the on-call anaesthetist for a regional base hospital. It is 2030 hours and you have just arrived in the carpark to review a patient for tomorrow's elective operating list, when you receive a request for assistance from the ED consultant. He is busy resuscitating a sick patient and cannot attend a new category 1 trauma patient that has just arrived by ambulance. The new arrival is a 45-year-old man who has been assaulted at a local hotel. He has been struck in the neck with a broken beer bottle and was found by paramedics lying on the floor of the public bar. They noticed profuse bleeding from an anterior neck wound before applying some gauze. He is restless, irritable and combative.
Phaeochromocytoma for Open Adrenalectomy
A 45-year-old man presents to your Preadmission Clinic for a review ahead of an open left adrenalectomy for phaeochromocytoma in four weeks time. He currently takes the following medications: - Bio Magnesium supplements 2 capsules daily - dapagliflozin 10 mg mane - enalapril 40 mg mane - frusemide 20 mg mane - metoprolol 100 mg BD
Paediatric Appendicitis with New Diagnosis of DKA
You are the duty anaesthetist in a regional hospital. You are called to the Emergency Department by the surgical registrar to review an 8-year-old boy who has been booked for an urgent appendicectomy. The child has been previously well and presents with a three day history of abdominal pain and vomiting. An ultrasound has been performed which suggests appendicitis. The surgical registrar would like to operate as soon as possible as he thinks the child is showing signs of sepsis. Initial information on booking: weight 25 kg, pulse 150 bpm, BP 80/40 mmHg, RR 45 bpm, temp 37.3 degrees C FBC: Hb 120 g/L (110-155), WCC 17 x10^9/L (4-11.0), Plt 250 x10^9/L (140-400) Electrolytes: Na 133 mmol/L (133-144), K 3.5 mmol/L (3.6-5.3), Cl 104 mmol/L (97-110), Bicarbonate 8 mmol/L (22-29), Urea 5.0 mmol/L (2.7-7.8), Creatinine 35 micromol/L (20-44)
Left Lower Lobectomy for Lung Cancer
You are seeing a 64-year-old man in the Preadmission Clinic who is booked for a left lower lobectomy for non-small cell carcinoma. He is on your list in two weeks' time. Past Medical History: - hypertension - type II diabetes mellitus - paroxysmal atrial fibrillation Medications: - perindopril 2mg bd - rivaroxaban 20 mg daily - metoprolol 50mg bd - empagliflozin 10mg daily He currently smokes 1 packet cigarettes per day and has a 42 pack-year history. Height - 177cm, Weight - 74 kg, BMI 23.6 kg/m2 His chest CT scan is displayed below.
Undiagnosed Mitral Stenosis in Labour
You are asked to provide analgesia for a 26-year-old woman who presented in labour to your regional hospital on a weekday. She has a three month history of shortness of breath on minimal exertion. She has not presented for any antenatal care during the pregnancy and the shortness of breath has not been investigated. Otherwise she has had an uneventful pregnancy. Her observations are: Pulse 110/min, BP 110/80 mmHg, Respiratory rate 24/min, SpO2 95%, Height 170 cm, Weight 75 kg
Acromegaly for Transsphenoidal Hypophysectomy
A 47-year-old woman with acromegaly attends your preoperative assessment clinic one week prior to undergoing a transsphenoidal hypophysectomy for pituitary adenoma. She has a history of hypertension and type II diabetes mellitus. She is a heavy smoker, has a hoarse voice and reports a recent hospital admission for investigation of shortness of breath on exertion. Medications: - lisinopril 20 mg daily - metformin 1000 mg nocte - metoprolol 100 mg mane - octreotide 75 mcg subcutaneously x 3 daily
VP Shunt Revision with Hydrocephalus
You are reviewing a 44-year-old man for revision ventriculoperitoneal shunt for congenital aqueductal stenosis which was first diagnosed at age 13. This operation will be his fourth revision. He is an inpatient on the neurosurgical ward. His current medications are: - dexamethasone 4 mg bd orally - omeprazole 20 mg mane orally - levetiracetam (Keppra) 250 mg bd orally Please comment on the CT scan and explain what specific information you would like in your assessment of this patient.
Hysteroscopic Myomectomy with Fluid Overload and Tracheal Injury
You are working in the day surgery unit of a large regional hospital and allocated to a gynaecology list with a registrar. The next patient on the list is a 23-year-old woman booked for a hysteroscopic myomectomy. Past Medical History: - Menorrhagia secondary to uterine fibroids - Anxiety Medications: - Ferrous sulphate - Fluoxetine Past Surgical History: - Hysteroscopic myomectomy 2019
Elderly Fall with Flail Chest and Rhabdomyolysis
You are the on-site anaesthetist in a large regional centre and have been called to the Emergency Department to assist with the management of a 70-year-old woman who was brought in by ambulance ten minutes ago after falling down the stairs at home. The patient lives independently and was discovered at the base of the stairs by her visiting daughter this morning after having fallen down the stairs last night. The patient was unable to reach the telephone to call for help and was not wearing her personal alarm button. The patient is sitting up on a trolley and appears short of breath. Observations: HR - 113 bpm, BP - 148/92 mmHg non-invasively, SpO2 - 92% on oxygen 15 l/min via non-rebreather mask, GCS - 12 (E3 V4 M5) Past medical history: - atrial fibrillation - chronic back pain Regular medications: - apixaban 2.5 mg bd - buprenorphine transdermal patch 15mcg/hour - digoxin 125 mcg daily - perindopril 2 mg daily
Cystic Fibrosis for Laparoscopic Cholecystectomy
A 30-year-old man with cystic fibrosis presents to the anaesthetic pre-assessment clinic for assessment prior to an elective laparoscopic cholecystectomy. Medications: - Cholecalciferol 1.25 mg, monthly - Vitabdeck 2 tabs, daily - Nebulised tobramycin 300 mg, bd - Nebulised pulmozyme 2.5 mg, mane - Nebulised hypertonic saline 5 mL, daily - Azithromycin 500 mg, x3/week - Creon Forte 15/day, daily - Ensure Plus 1 bottle tds - Alendronate 70 mg, weekly - Omeprazole 20 mg, daily - Seretide 125/25 2 puffs, bd - Novorapid insulin 2-3 units - Salbutamol 2-6 puffs, PRN - Ferrous fumarate 200 mg, daily - Calogen 30 mL bd
Abdominal Gunshot Wounds with Cardiomyopathy
A 47-year-old male is brought into the emergency department of a tertiary hospital where you are the anaesthetist on call. He has sustained abdominal gunshot wounds about 2 hours ago with only minor revealed bleeding obvious. He is diaphoretic and agitated requiring restraint. Your help is required to assist keeping him still enough for larger bore intravenous access (he currently has a 20 gauge cannula) and CT angiogram. He is believed to have recently used methamphetamine. BP 100/56 HR 70bpm SaO2 96% He has a background of illicit drug use and a known methamphetamine induced cardiomyopathy (ejection fraction 20-30% on recent echocardiogram). He has extremely poor dentition ("Meth Mouth"). Medications: - telmisartan 40mg daily - carvedilol 25mg (slow release) daily - frusemide (furosemide) 20mg daily
Acute Ischaemic Stroke for Clot Retrieval
You are called to the Emergency Department at 12pm to assess a 75-year-old female with an acute anterior cerebral circulation ischaemic stroke. She has facial paresis, arm weakness and abnormal speech. Her past history includes atrial fibrillation, type 2 diabetes and hypertension. Her medications are: - irbesartan 150 mg daily - dabigatran 150 mg bd - dapagliflozin 10 mg daily The onset of symptoms was 2 hours prior to admission. Her GCS is 15 and she is compliant with instructions. She has been scheduled for urgent clot retrieval.
Subglottic Stenosis with New AF on ECG
You are midway through an ENT list at a large metropolitan private hospital. The nurse in the admissions unit brings in an ECG for you to review, along with a GP Health Summary. The patient is scheduled for balloon dilatation of subglottic stenosis later on the list.
Elderly Septic Diabetic Foot Debridement with Dementia
You are a consultant anaesthetist at a metropolitan tertiary hospital. On the day's emergency list is an 82-year-old man for the debridement of his right forefoot. He is a current inpatient having been admitted from home, unwell with sepsis, the previous day. From the intern admission note you see that he has a significant past medical history including: - Hypertension - CCF - medically managed - Chronic renal impairment - eGFR 42 mL/min/1.73m2 - Aortic stenosis managed by TAVI in 2019 and complicated by CVA with mild residual dysphasia - Dual antiplatelet therapy - Progressive dementia - still lives at home with support from his family and aged care service providers who visit daily You go to the ward to pre-operatively assess him. He is the patriarch of a large family and his son (who has medical power of attorney) is in attendance.
End-Stage Renal Failure with Pulmonary Hypertension
A 55-year-old male has been added to your general surgical list for the laparoscopic insertion of a peritoneal dialysis catheter. Their past medical history is of end stage renal failure, chronic obstructive pulmonary disease and hypertension. His medications include: - amlodipine 10 mg po daily - frusemide 120 mg po mane - fluticasone/salmeterol inhaler two doses bd He has had worsening shortness of breath on exertion over the past month. He tells you that at his last consultation with his respiratory physician he was told that he has "high blood pressure in his lungs".
Paediatric MRI with Developmental Delay
You are reviewing a child in the pre-anaesthetic clinic of a tertiary paediatric centre. He is a 20 kg 23-month-old boy with moderate global developmental delay and seizure activity on EEG. You are booked to anaesthetise him for an MRI brain scan the following day.
Motorcycle Trauma with Facial Burns and Airway Concerns
You are called to the emergency room of a level 1 trauma centre as part of a trauma team call. A convoy of 15 motorcyclists was struck by a truck. There was a fire at the scene and 2 people have died on site. Your centre is receiving 3 patients. You are assigned as the airway doctor for 1 of the patients arriving by road ambulance. Additional information provided by paramedics: He is a 48-year-old male, weight 123 kg and height around 174 cm. He was wearing an open-faced helmet, removed at the scene. He has a partially singed beard with bruising and swelling of his midface. He is vocalising with no obvious stridor or hoarseness.
Labour Epidural with Gestational Thrombocytopenia
You have been asked to put in an epidural in a G1 P0 woman who has presented in spontaneous labour at 38 weeks' gestation. She has a normal body habitus. She has no significant past medical history. Her antenatal history is unremarkable other than stable gestational thrombocytopaenia. An FBE was performed at 36 weeks gestation. Hb 129 g/L (115-165) WCC 11 x 10^9/L (4-11) Plt 88 x 10^9/L (150-400) When you enter the room, she is in obvious pain and states "Just put the epidural in!"
Obese Asthmatic Parturient for Labour Epidural
A 28-year-old female, 39/40 pregnant, presents to a tertiary referral hospital in early labour post induction for fetal macrosomia. Her history is significant for morbid obesity (BMI 44) and labile severe asthma. You have been consulted for a labour epidural.
Post-Coronary Angiography Hypotension and Cardiogenic Shock
You are the duty anesthetist for your cardiovascular theatres. You are called to the cardiac catheter lab recovery where they have a hypotensive patient following coronary angiography. The medical emergency team (MET) have been called. The patient is a 55-year-old 85 kg male. He has no allergies or anaesthetic issues. He has a new presentation of heart failure and is being assessed for coronary artery disease. His pre procedure echocardiogram showed a mildly dilated left ventricle with moderate dysfunction and an ejection fraction of 40%. On entering the recovery room you notice a number of people around the patient with more arriving.
Motor Vehicle Accident with Blunt Cardiac Injury
You are the day time anaesthetist on for trauma calls at a major trauma hospital. You have been asked to attend a trauma call in the Emergency Department for a 68-year-old woman after a motor vehicle accident earlier today. The patient was driving on the highway and her car crashed into a tree. She has a past history of hypertension, previous TIA and previous DVT. Currently she is alert and talking with a GCS of 15. Her BP is 130/80, HR 110bpm and SO2 95% on 6L via Hudson mask. This is her Chest X-ray on admission.
ECT Titration with Cardiac Complications
You are doing an ECT list at a private stand-alone facility. Your 2nd patient of the morning is a 55-year-old male having his first ECT titration for schizophrenia with bipolar disorder. He has a history of hypertension, hypercholesterolaemia, and is a current smoker. His medications are as follows: - amlodipine - lithium - olanzapine - rosuvastatin
Paediatric Tonsillectomy with ADHD and High Airway Pressure
It is 0700 hrs and you are the anaesthetist rostered to a morning ENT list in a tertiary referral hospital. The first case is a three-year-old boy for tonsillectomy. The referral states he has attention deficit hyperactivity disorder (ADHD), asthma and had bilateral grommets inserted one year previously. He presents with his mother. His current medications are: - dexamphetamine - clonidine - budesonide - salbutamol
Laryngeal Papillomatosis with Mobitz II Heart Block
A 65-year-old female with long standing laryngeal papillomatosis, presents for laser ablation. She has dyspnoea and hoarseness that has worsened significantly in the last month. She is on no medications. Below is her preoperative ECG.
Bilateral Total Knee Replacement in Obese Diabetic Patient
You are in pre-assessment clinic reviewing a 68-year-old female. She is booked for bilateral total knee joint replacement surgery. Her initial details and medications have been documented by the clinic nurse: Height 162 cm Weight 100 kg Body Mass Index 38.1 kg/m2 Medications: - insulin via pump - fentanyl patch 12 mcg/hr TD q72hrly - pregabalin 150 mg PO BD - paracetamol 667 mg PO TDS - quinapril/hydrochlorthiazide 10 mg/12.5 mg PO daily - atorvastatin 40 mg PO daily - aspirin 100 mg PO daily (stopped by surgeon 2 days ago) - clopidogrel 75 mg PO daily (stopped by surgeon 2 days ago) - pantoprazole 40 mg PO daily Allergies: penicillin (rash)
Peritonsillar Abscess with Trismus
As the duty anaesthetist receiving emergency bookings, you take a phone call from the ENT registrar, who is in the Emergency Department with a 26-year-old man requiring urgent surgical drainage of a suspected peritonsillar abscess. The registrar reports that the patient is very distressed, refuses to lie flat and cannot open his mouth more than 1.5cm.
Dislodged Tracheostomy in Supraglottitis Patient
A 56-year-old man with supraglottitis required a tracheostomy under local anaesthetic on presentation to hospital three days ago. Since that time, he has been in the Intensive Care Unit receiving antibiotics and dexamethasone. Overnight the anaesthetic registrar was asked to see the man regarding some minor neck swelling. This was managed conservatively. This morning the man has been restless and has completely dislodged his tracheostomy. You are called as the duty anaesthetist to assist the junior ICU registrar. As you arrive into the ICU bay this is how the patient appears: He is moving around the bed trying to get himself comfortable. His observations as they appear on the ICU monitor are: RR 26 SaO2 90% on Oxygen 10l/min BP 100/52 mmHg HR 125 bpm
Elderly High-Risk Patient for Emergency Hernia Repair
You are the anaesthetist for the emergency theatre at a tertiary hospital. The surgeons have booked an 81-year-old male patient for repair of an incarcerated upper abdominal incisional hernia. You review him in the Emergency department. 81-year-old male Examination: On 2L/min oxygen, tachypnoeic Pulse rate 120 bpm BP 105/65 Past medical history: - CABG / MVR (St Jude mechanical valve) 2002 - Chronic obstructive pulmonary disease with bullous disease - home oxygen 18 hours per day - Bowel cancer - laparotomy 2018 Medications: - metoprolol 50 mg daily - digoxin 62.5 microg daily - irbesartan / hydrochlorothiazide (150/12.5mg) daily - warfarin 5mg daily (INR target 2.5-3.5) - tiotropium 2.5microg daily (Spiriva) - fluticasone / salmeterol (250/25microg) 2 puffs twice daily (Seretide) - salbutamol inhaler prn
Obstetric Emergency with Seizure and Haemorrhage
You are the consultant covering labour ward and have been phoned on the obstetric emergency phone to attend the delivery suite as part of the obstetric emergency team in a large tertiary hospital. The patient is a previously well 30-year-old primigravida (38/40) having an induction of labour for prolonged premature rupture of membranes. Her husband had alerted the delivery suite staff that she had become unconscious and was having a seizure. She has an 18 gauge cannula insitu and was recently started on patient controlled epidural analgesia. The obstetrician, neonatal team and midwives are present when you arrive. The seizure has terminated. She is not responsive. Her observations on your arrival are: HR 76 bpm BP 92/55 SaO2 86% on oxygen 6l/min
Paediatric Dental GA with Aspirated Tooth
A 12-year-old boy has been a late addition to your dental list today at a small private hospital. He is scheduled for removal of three carious teeth under general anaesthesia. Past medical history: - attention-deficit hyperactivity disorder (ADHD) - adenotonsillectomy aged 6 years Medications: - methylphenidate (controlled release) 60 mg mane, not taken today Allergies: Nil known Observations on admission: - Height 152 cm - Weight 45 kg - Temperature 36.6 degrees Celsius - Pulse rate 96 bpm - Blood pressure 106/62 mmHg - SaO2 99% (room air)
Post-TAVI Patient for Pacemaker Insertion
You are assessing an 80-year-old man in the coronary care unit just prior to a planned permanent pacemaker insertion for persistent bradyarrhythmias. The cardiologist has requested anaesthesia assistance as the patient has been having difficulty lying flat due to back pain. He had an elective proximal right coronary artery stent seven days ago, and a TAVI performed under general anaesthesia five days ago, for treatment of his coronary artery disease and severe aortic stenosis.
Sepsis with Metabolic Acidosis at Rural Hospital
You are the anaesthetist covering the Intensive Care Unit and operating theatres for a rural hospital on a weekend. You are asked to assist in the management of a 55-year-old female brought in by ambulance to the Emergency Department with nausea, vomiting, rigors and fever. Medications: - rivaroxaban - sotalol Vital Signs: HR 108, BP 90/40, RR 18, Temp 38.8, SaO2 96% room air, Weight 80 kg Venous Blood Gas (room air): FiO2 0.21, pH 7.31, PCO2 30 (4), PO2 45 (6), Hb 150, K 4.8, Na 144, Ca 1.1, Cl 105, HCO3 15, Base excess -10, Lactate 3.6
Elderly Spinal Surgery with New Atrial Fibrillation
You are the anaesthetist in the Anaesthetic Assessment Clinic. The spinal surgeon has referred an 82-year-old woman for an anaesthetic assessment. The proposed surgery is L4/5 spinal decompression and instrumented fusion for lumbar spinal stenosis. The surgeon's booking notes state: - hypertension - diabetes mellitus - myocardial infarction 10 years ago Medications: - aspirin - metformin - quinapril - vildagliptin This is today's ECG.
Major Trauma with Polytrauma and Transfusion Reaction
You are the emergency anaesthetist working in a major hospital. You receive a call alerting you to the arrival of a patient in ten minutes. The ambulance service is bringing a 27-year-old male who has fallen from a height of 5-10m. He is reported to have: GCS 7 SBP 80 mm/hg HR 125 bpm Oxygen saturation 89% on Oxygen 6l/min Pupils fixed at 4mm En route the ambulance performed a right-sided needle thoracostomy. The patient has IV access x2, a pelvic binder and cervical collar and has not been intubated. Theatre will not be available for at least 45 minutes.
Pregnant Trauma Patient
A 25-year-old woman has been brought into hospital by ambulance after being struck by a falling branch in a storm. You are advised that she is obviously pregnant and is in a confused state. You are asked to attend the emergency department as part of the trauma call team.
Dislodged Tracheostomy in Obese ICU Patient
You are the duty consultant anaesthetist at a tertiary hospital. You are called to come immediately to the intensive care unit (ICU) to help other medical staff struggling with the airway management of a patient with a tracheostomy. On arrival you see: - the ICU consultant attempting to insert a laryngeal mask airway (LMA) - an ear, nose and throat (ENT) surgical registrar attempting to replace the tracheostomy tube - oxygen saturation SpO2 86% - heart rate 122 beats per minute - blood pressure 195 / 115 mmHg The ICU consultant tells you this is a 55-year-old man weighing 165kg who has community-acquired pneumonia. The patient had a surgical tracheostomy three days ago. The tracheostomy tube has now become dislodged while turning the patient.
Obese Paediatric Adenotonsillectomy
A 6-year-old child is scheduled for adenotonsillectomy in a regional hospital. You are seeing him for the first time on the morning of surgery. He is 35kg and on no medications.
Elderly Hip Fracture with Capacity Assessment
You are asked to see an 84-year-old woman in the acute orthopaedic ward. She was admitted earlier in the afternoon with a peri-prosthetic femoral fracture after a mechanical fall at home. She had a right total hip replacement five years ago for osteoarthritis. She is scheduled for revision total hip arthroplasty tomorrow morning. She has a history of cardiac failure, type 2 diabetes, hypertension and atrial fibrillation. Medications: - rivaroxaban 15 mg daily - atenolol 50 mg daily - metformin 500 mg twice daily - perindopril 5 mg daily At your pre-operative consult she is distressed, in pain and difficult to engage.
Morbidly Obese Patient for Prone Spinal Surgery
A 58-year-old man presents to the preadmission clinic prior to thoracic decompression and sural nerve biopsy to be done in the prone position. His history includes progressive lower limb and truncal weakness. Progression has occurred over the last four months and he is now wheelchair-bound. Weight 152kg, body mass index 48 kg/m2 His past medical history includes: - obstructive sleep apnoea - on continuous positive airway pressure (CPAP) therapy - hypertension Current medications: - candesartan 8mg daily - enoxaparin 40mg subcutaneous injection daily - pregabalin 150mg bd
Obstetric Emergency with Abnormal CTG
As the on-call anaesthetist in a general hospital you are asked by a midwife to place an epidural for a labouring patient in the delivery suite. The patient is 42 years old, G6P0, and has had three in vitro fertilisation (IVF) attempts. She is 38 weeks' pregnant and labour was induced because of reduced fetal movements. When you go to assess the patient, the midwife shows you the following baseline cardiotocogram (CTG). The obstetrician and your anaesthetic registrar are not immediately available because they are in theatre with another case. Here is the CTG. Please interpret it. What would you do?
Thoracotomy for Empyema in Scleroderma Patient
A 45-year-old female inpatient at your tertiary hospital was admitted with increasing shortness of breath. Her imaging and investigations confirmed a right sided empyema. Her surgeon indicated that it is complex and not amenable to percutaneous drainage so has booked her on your list for a right thoracotomy and decortication. Past medical history: - systemic sclerosis (scleroderma) - interstitial lung disease (pulmonary fibrosis) - Raynaud's phenomenon - gastroesophageal reflux Current medications: - omeprazole 40mg mane - mycophenolate 1g bd - amlodipine 10mg mane - ceftriaxone 1g intravenously bd - metronidazole 500mg intravenously bd
Obese Patient with Proximal Humerus Fracture and LA Toxicity
A 47-year-old man is on your list today for an open reduction and internal fixation of a right proximal humerus fracture. His injury was sustained in a motorbike accident three days ago. Following his accident he was assessed in the emergency department and then discharged home. Medications: - Metformin 1g bd - Atorvastatin 40mg daily - Perindopril 8mg daily - Paracetamol 1g q4h PRN (last three days) - Oxycodone 10mg q4h PRN (last three days) Weight 146kg, height 180cm, body mass index 45 kg/m2 Heart rate 78 beats per minute Blood pressure 148/86 mmHg SpO2 96% on air Respiratory rate 16 breaths per minute On initial inspection he has a full beard, a graze on the right side of his face, and bruising on the right side of his chest and right hip. His right arm is in a collar and cuff sling.
Paediatric Trauma at Regional Hospital
You are the on-duty anaesthetist at a large regional hospital which provides general paediatric services. A 5-year-old boy has been knocked off his scooter in the driveway by his mother's four-wheel drive (4WD) car. He is en route to the hospital by road ambulance, and the estimated time of arrival is in ten minutes. You have been called to the emergency department to assist in his resuscitation.
Bilateral Femoral Fractures with Fat Embolism Syndrome
You have commenced your shift this morning as the in-charge consultant anaesthetist in a regional hospital where you are also responsible for the intensive care unit (ICU). In the ICU, there is a 40-year-old man with isolated bilateral femoral fractures who was admitted 20 hours ago and has been booked for surgery later today. He is otherwise well with no co-morbidities or other injuries. You have been asked to review the patient as his pain is poorly controlled despite having been prescribed an intravenous morphine patient-controlled analgesia regimen. Your nursing staff also tell you that the patient is becoming increasingly confused.
Paediatric ENT with URTI and Laryngospasm
A 4-year-old girl presents on your ear, nose and throat (ENT) list at a small regional hospital for elective bilateral myringotomies and insertion of grommets. She has a history of recurrent middle ear infections and has also been diagnosed with asthma and atopic dermatitis. She is allergic to peanuts. On the preoperative-assessment questionnaire her mother has stated that the child currently has a runny nose and a cough. The girl's medications are: - fluticasone 100-200 mcg daily (via metered-dose inhaler plus spacer) - salbutamol 200-400 mcg PRN (via metered-dose inhaler plus spacer)
Ulcerative Colitis Patient for Proctocolectomy
You have been asked to assess a 26-year-old woman with ulcerative colitis for an inpatient semi-urgent laparoscopic-assisted total proctocolectomy with ileoanal anastomosis. Medications: - mesalazine 2g orally bd - prednisolone 40mg orally daily - infliximab 300mg intravenously fortnightly Investigations: - sodium 135 mmol/L (135-145), potassium 4.0 mmol/L (3.5-5.2), creatinine 75 micromol/L (<105) - haemoglobin 105 g/L (115-155), MCV 71 fL (80-100), MCH 23 pg (27.5-33.2) - white cell count 6.4 x10^3/microL (3.5-9.8), platelets 400 x10^3/microL (150-450) - iron 8 micromol/L (5.0-30), transferrin 3.2 g/L (2.0-3.2), transferrin saturation 12% (10-45%), ferritin 40 ng/mL (20-250) - CRP 150 mg/L (<5), albumin 30 g/L (38-52)
Open Eye Injury in Intoxicated Patient
You are at home and the junior night anaesthetic registrar rings you at 0200 to let you know about a case which has just been booked. There is an 18-year-old man with a right open eye injury which the ophthalmology team want to explore within the next six hours. Your registrar tells you he has just started an appendicectomy. He hasn't done any eye cases before and would like to know what he should do. The history from the ophthalmology registrar is that the patient had been out drinking, has allegedly been assaulted, fell to the ground and has a large facial swelling and an open eye injury and is alert. He has taken a photo. The patient is uncooperative but the registrar doesn't think there are any other injuries and the patient is otherwise well. Your registrar would like to do the case after the appendicectomy.
Pregnant Patient with Drug Use and Endocarditis History
A 22-year-old woman who is 32 weeks pregnant presents to the High Risk Obstetric Anaesthesia Clinic for assessment and delivery planning. She has a history of: - illicit drug use and is currently using methamphetamine - previous bacterial endocarditis
TEVAR with Spinal Cord Injury Risk
You are asked to review a 76-year-old man for planned thoracic endovascular aortic repair (TEVAR) on your list in seven days' time. His aneurysm includes the origin of the left subclavian artery and extends distally to the renal arteries. He has a background of hypertension, type 2 diabetes mellitus and a transient ischaemic attack (TIA). He has a body mass index of 32 kg/m2 and has a 24 pack-year history of smoking, having ceased smoking when he suffered the TIA four months ago. His medications include: - clopidogrel 75mg daily - rosuvastatin 10mg daily - perindopril 4mg mane - metoprolol 25mg bd - metformin 1000mg bd
Post-ACDF Neck Haematoma with Airway Obstruction
You are called to assess a 40-year-old woman in the surgical ward while working as the evening on-call anaesthetist. The patient has had an anterior cervical discectomy and fusion (ACDF) for cervical radicular symptoms caused by C5/6 disc prolapse. The operation was completed six hours ago with 500mL of blood loss. You have been asked to review the patient because of increasing neck pain. Medications: - paracetamol 1g orally q6h - ibuprofen 400 mg orally q8h - pregabalin 75 mg orally q12h - oxycodone-with-naloxone controlled-release 20/10 mg orally q12h - oxycodone 5 to 10mg orally q4h