DA(SA)_Past_Papers 3

8/22/2019 DA(SA)_Past_Papers 3

1/18

PAPER 1

1 One of your general surgery patients is a 60-year-old, 60 kg male with a septicgangrenous foot for an urgent above knee amputation.The patient is known withhypertension and type 2 diabetes on oral medication.He complains of reflux.Vitals: HR 110/min, BP 160/90mmHg, Temperature 38.5CSide room: Blood Glucose: 22mmol/L, Urine dipstix: glucose +, ketones+Special investigations:Full blood count: Hb 11g /dl, White cell count 15, Platelets 65x109

Urea & Electrolytes: Urea 11, Creatinine 140a) Discuss your pre-operative approach to this case.

i) History.ii) Examination.iii) Discuss the above special investigations as well as any additional ones

you will request (with reasoning behind the request).iv) Optimisation end points.v) Premedication instructions once optimal. (40)

b) Discuss your intra-operative plani) Theatre preparation.ii) Anaesthetic plan including drug choices with doses and monitor use.

(30)c) List the main points of your postoperative care plan for this patient. (10)d) On day 3 post-operatively the ward sister informs you that the patient has

developed dyspnoea (shortness of breath).Discuss your differential diagnosis,diagnostic tests as well as treatment you will initiate. (20)

[100]

1 Een van die pasinte op u algemene chirurgie lys is 60-jarige 60 kg, man met septiese gangrenuese voet vir dringende boknie-amputasie. Die pasint is bekendmet hipertensie en tipe 2 diabetes op orale medikasie.Hy kla ook van refluks.Vitale tekens: Hartspoed 110/min, Bloeddruk 160/90mmHg, Temperatuur 38.5CSykamerondersoeke: Bloedglukose 22mmol/L, uriendoopstokkie: glukose +,

ketone +Spesiale ondersoeke:Volbloedtelling: Hemoglobien 11 g/dl, Witseltelling: 15, Plaatjies 65 x10 9

Ureum & Elektroliete: Ureum 11, Kreatinien 140a) Bespreek u preoperatiewe benadering tot hierdie geval.

i) Geskiedenis.ii) Ondersoek.iii) Bespreek die bogenoemde spesiale ondersoeke asook enige

addisionele ondersoeke wat jy sal aanvra (met redes vir dieondersoeke).

iv) Optimalisasie-eindpunte.v) Premedikasie-instruksies wanneer die pasint geoptimaliseer is. (40)

b) Bespreek u intra-operatiewe plani) Teatervoorbereiding.ii) Narkoseplan, insluitend die middelkeuse en dosisse asook die

monitering gebruik. (30)c) Lys die hoofpunte van u postoperatiewesorg plan vir hierdie pasint. (10)d) Die pasint ontwikkel dispnee (hy is kortasem) op dag 3 postoperatief.

Bespreek differensiele diagnose, diagnostiese toetse asook diebehandeling wat u sal inisieer. (20)

[100]


2/18

2.1 Pharmacologya) Explain the mechanism of action of muscle relaxants. (5)b) What is up-regulation of receptors, name one clinical condition that leads to

up-regulation and what is the response to muscle relaxants in this condition. (5)

2.2 Explain the following termsa) Precurarisation. (2)b) Priming. (2)c) Hoffmann Elimination. (2)d) Sugammadex. (2)e) Phase 1 versus Phase 2 blockade. (2)

2.3 Tabulate the muscarinic side effects of Choline Esterase Inhibitors. (5)

2.4 Physicsa) Draw a picture of the preferred arrangement of the main components of a

circle system. (5)b) Explain the implication of using a circle system. (2)c) What are the advantages of using the circle system? (3)

2.5 a) What pressure does the central venous line (CVP) measure? (1)b) Name 5 different sites for placing a central venous line. (5)c) What is the position of a correctly placed central venous line? (1)d) How do you confirm central venous line placement? (3)e) Draw the CVP-waveform in relation to the ECG. (5)

2.6 Physiologya) What is the normal cerebral blood flow? (3)b) What factors are important in the regulation of cerebral blood flow? (12)

2.7 a) Draw and label the oxygen haemoglobin dissociation curve of a normal adult.

(4)b) List the factors that cause a shift to the right. (4)c) What is meant by the term P50? (1)d) What is the normal P50 value for ADULTS? (1)

2.8 Special investigationsa) What ECG changes are seen in hyperkalaemia? (5)b) You are given the following arterial blood gas result

pH 7.27PaO2 4.44 kPa (33,39 mmHg)PaCO2 12.98 kPa (97,61 mmHg)HCO3 (bicarb) 44 mmol/l

ABE 11.4 mmol/lSBE 15.8 mmol/lSat 55.1%Hb 18.2 g/dlYour interpretation please. (10)


3/18

2.9 A 25-year-old lady is brought to casualty after having been found unconscious in herflat. Her electrolyte and arterial blood gas results are as follows

Sodium 133 mmol/lPotassium 2.6 mmol/lChloride 100 mmol/lBicarbonate 14 mmol/lGlucose 8.3 mmol/lUrea 12.7 mmol/lCreatinine 100pH 7.48paCO2 2.53 kPa (19.03 mmHg)paO2 12.8 kPa (96.26 mmHg)

Your interpretation and possible diagnosis. (10)[100]

2.1 Farmakologiea) Verduidelik die werkings meganisme van spierverslappers. (5)b) Wat is opregulasie van reseptore, noem een kliniese toestand wat tot

opregulasie lei en wat sal die respons met spierverslappers wees in hierdietoestand? (5)

2.2 Verduidelik die volgende termea) Prekurariseer. (2)b) "Priming. (2)c) Hoffmann-eliminasie. (2)d) Sugammadex. (2)e) Fase 1 en Fase 2-blok. (2)

2.3 Tabuleer die muskariene newe-effekte van cholienesterase-inhibeerders. (5)

2.4 Fisikaa) Teken die sirkelsisteem en dui die hoofkomponente aan in die aangewese

samestelling. (5)b) Wat is die implikasie van die gebruik van sirkelsisteem? (2)c) Watter voordele spruit uit die gebruik van die sirkelsisteem? (3)

2.5) a) Watter druk word deur die sentraalveneuse lyn (CVP) gemeet? (1)b) Noem 5 verskillende toegange vir die plasing van sentraalveneuse lyn. (5)c) Wat is die posisie van korrek geposisioneerde sentraalveneuse lyn? (1)d) Hoe kan u die posisie van die sentraalveneuse lyn bevestig? (3)e) Teken die CVP-kurwe in verhouding tot die EKG. (5)

2.6 Fisiologiea) Wat is die normale serebrale bloedvloei? (3)

b) Watter faktore is belangrik in die regulering van serebrale bloedvloei? (12)

2.7 a) Teken en benoem die suurstof-hemoglobiendissosiasiekurwe van normalevolwassene. (4)

b) Lys die faktore wat verskuiwing na regs veroorsaak. (4)c) Wat word met die term P50 bedoel? (1)d) Wat is die normale P50 waarde vir VOLWASSENES? (1)


4/18

2.8 Spesiale Ondersoekea) Watter EKG-veranderinge word gesien met hiperkalemie? (5)b) U kry die volgende arteriele bloedgasuitslag:

pH 7.27PaO2 4.44 kPa (33,39 mmHg)PaCO2 12.98 kPa (97,61 mmHg)HCO3(bicarb) 44 mmol/lABE 11.4 mmol/lSBE 15.8 mmol/lsat 55.1%Hb 18.2 g/dl

Wat is u interpretasie hiervan? (10)

2.9 25-Jarige dame word na ongevalle gebring nadat sy bewusteloos in haar woonstelgevind is. Haar elektroliet en arteriele bloedgasuitslae is soos volg

Natrium 133 mmol/lKalium 2.6 mmol/lChloried 100 mmol/lBikarbonaat 14 mmol/lGlukose 8.3 mmol/l

Ureum 12.7 mmol/lKreatinien 100pH 7.48paCO2 2.53 kPa (19.03 mmHg)paO2 12.8 kPa (96,26 mmHg)

Wat is u interpretasie hiervan en wat is die moontlike diagnose? (10)[100]


5/18

1.1 A 25-year-old patient presents for a partial thyroidectomy. Intra-operatively shedevelops a sinus tachycardia (HR 130 bpm) and hypertension (BP 170/105).a) Discuss the regulation of thyroid hormones. (3)b) What is the standard laboratory evaluation of thyroid function? (2)c) List 5 symptoms and 5 signs of hypothyroidism. (5)d) List 5 symptoms and 5 signs of hyperthyroidism. (5)e) What are the pre-operative considerations of a patient with thyroid disease?

(5)f) What are the postoperative considerations of a patient with thyroid disease?

(5)

1.2 A 30-year-old carpenter sustained an open eye injury while working. He had recentlyeaten lunch.a) List 10 factors known to increase intra ocular pressure. (10)b) What are the factors to consider when delaying surgery in this patient? (5)c) What drugs would you use when anaesthetising this patient? Justify your

choices. (10)

1.3 A 26-year-old lady is booked for an emergency Cervical Cerclage at 18 weeksgestation. On history and examination she confirms that she is a known cardiacpatient with mitral valve incompetence, but has defaulted on follow-up.Discuss your management of the case regardinga) The pathophysiological changes to the cardiovascular system caused by the

valve lesion. (5)b) The specific information you need to decide on the severity of the valve

lesion. (3)c) What are the cardiovascular goals when anaesthetising a patient with mitral

valve incompetence? (5)d) Your planned anaesthetic management. Motivate your decisions. (10)e) What antibiotic prophylaxis will you consider for this patient? Motivate your

answer. (2)

1.4 You have to do a Dental list in a day-case clinic. The last child on this morning list isHIV positive.a) What is relevant in the pre-op history and physical examination? (5)b) Explain how you will perform an inhalation induction. (5)c) During the inhalation induction you struggle to ventilate the child. He severely

desaturates down to 85%. What is your differential diagnosis andmanagement? (10)

d) What cases are appropriate to be done as Day Case Surgery? (5)[100]

1.1 25-Jarige pasint ondergaan gedeeltelike tireodektomie. Intra-operatiefontwikkel sy sinus tagikardie (HS 130 spm) en, hipertensie (BD 170/105).a) Bespreek die regulering van tiroid hormone. (3)b) Wat is die standaard laboratoriumevaluasie van tiroedfunksie? (2)c) Lys 5 simptome en 5 tekens van hipotireose. (5)d) Lys 5 simptome en 5 tekens van hipertireose. (5)e) Wat is die pre-operatiewe oorwegings in pasint met slildklierssiekte? (5)f) Wat is die postoperatiewe oorwegings in pasint met skildkliersiekte? (5)


6/18

1.2 30-Jarige skrynwerker doen oop oogwond op by die werk. Hy het onlangs

middagete genuttig.a) Lys 10 faktore wat verhoogde inta-okulere druk kan veroorsaak. (10)b) Wat is die faktore om te oorweeg indien chirurgie in hierdie pasint uitgestel

word? (5)c) Watter middels sal u gebruik vir die narkose van hierdie pasint? Regverdig u

keuses. (10)

1.3 26-Jarige vrou is bespreek vir nood servikale cerclage op 18 wekeswangerskap. Die geskiedenis en ondersoek bevestig dat sy bekende kardialepasint is met mitraalinkompetensie. Sy het egter nagelaat met opvolg.

Bespreek u hantering van hierdie geval met betrekking tota) Die patofisiologiese veranderinge in die kardiovaskulere stelsel veroorsaak deur

die klepletsel. (5)b) Die spesifieke informasie wat u benodig om die ernstigheidsgraad van die

klepletsel te besluit. (3)c) Wat is die kardiovaskulere mikpunte wanneer pasint met

mitraalinkompetensie narkose ontvang? (5)

d) Wat is u beplande narkose-hantering? Motiveer u besluite. (10)e) Watter antibiotiese profilakse sal u oorweeg vir hierdie pasint? Motiveer uantwoord. (2)

1.4 U doen tandheelkundelys in dagkliniek. Die laaste kind op die oggendlys is MIVpositief.a) Wat is relevant in die pre-operatiewe geskiedenis en fisiese ondersoek? (5)b) Verduidelik hoe u inhalasie-induksie sal doen. (5)c) Gedurende die inhalasie-induksie sukkel u om die kind te ventileer. Hy

desatureer erg tot 85% Wat is u differensiele diagnose en hantering? (10)d) Watter gevalle is geskik vir dag-gevalchirurgie? (5)

[100]

2.1 Post-operative nausea and vomiting (PONV)a) Name 3 groups of drugs commonly associated as a cause of post-operative

nausea and vomiting (PONV). (1)b) List 3 surgical procedures commonly associated with PONV. (1)c) Name 4 patient factors which increase the likelihood of PONV occurring. (2)

2.2 Induction agentsa) How long may an ampoule of propofol remain open before it must be

discarded? Why? (1)b) Name 2 induction agents which can be used as anticonvulsants. (1)c) What is the intravenous induction dose of Etomidate? (1)

d) What effect does Etomidate have on the endocrine system? (1)e) What determines the duration of action of SodiumThiopentone? (1)

2.3 Local Anaestheticsa) Classify local anaesthetics. (2)b) Why is adrenaline added to local anaesthetics? (1)c) Why is bicarbonate of soda added to local anaesthetics? (1)d) What is the maximum dose of bupivacaine? (1)


7/18

2.4 Spinal anaesthetic

a) What is the minimum monitoring required for spinal anaesthesia? (1)b) Why is using a small diameter pencil point needle the preferred technique? (1)c) List four absolute contraindications to neuraxial blockade. (2)d) You plan to do a spinal anaesthetic for a patient on prophylactic Clexane.

When would you advise the surgeon to give the last dose before theatre? ()

2.5 Blood Pressure measurementa) Name the two methods of blood pressure measurement. (1)b) How does blood pressure cuff width influence blood pressure readings? (1)c) How does one determine the correct blood pressure cuff size? (1)d) Why is the blood pressure reading taken on the lower limb normally higher

than that taken on the upper limb? (2)

2.6 Temperaturea) Name four anatomical sites at which temperature can be monitored

intraoperatively. (2)b) List four complications of hypothermia. (2)c) List 2 measures which can be taken in theatre to prevent heat loss? (1)

2.7 Capnographya) Draw a normal capnograph demonstrating the phases of expiration. (3)b) Draw the capnograph of a patient with severe obstructive pulmonary

disease. (2)

2.8 Downs syndromea) A five-year-old Downs syndrome child is booked for dental extractions. What

associated abnormalities would concern you regardingi) The airway. (2)ii) The cardiac system. (2)iii) The gastrointestinal system. (1)

2.9 Intra-operative complicationFollowing the administration of 2g of Cefazolin, a patient becomes hypotensive andtachycardic.a) What is the most likely diagnosis? (1)b) Besides tachycardia & hypotension, name 2 other signs you may find? (1)c) Briefly describe your management of this patient. (3)

2.10 Emergency drugsName one drug you would use in the following situations. Give appropriate doses.a) Severe bradycardia resulting in hypotension. (1)b) Asystolic arrest. (1)

c) Respiratory depression following opioid administration. (1)d) Respiratory depression following midazolam administration. (1)e) Malignant hyperthermia. (1)

2.11 Blood Transfusiona) What is the average blood volume of a 60kg male patient? (1)b) List four complications of massive blood transfusion. (2)c) Give two alternative strategies for management of blood loss during surgery.

(2)


8/18

2.12 A patient with a T6 spinal cord transection presents 6 months after the injury fordebridement of a bedsore.a) Is this patient at risk for autonomic hyperreflexia? ()b) Below which spinal cord level is it less likely to occur? ()c) What are the signs and symptoms of autonomic hyperreflexia? (2)d) Briefly explain how autonomic hyperreflexia occurs. (2)

2.13 You are asked to anaesthetise a patient with a closed head injury (GCS = 13, nolocalizing signs) for an emergency laparotomy.List five aspects of anaesthetic management which you should pay particularattention to in this case and state why it is important. (5)

2.14 Halothane, Isoflurane and Desfluranea) Which has a preservative? What is the preservative? (1)b) Which undergoes the least metabolism? Indicate what percentage of this

agent is normally metabolised. (1)c) Which has the lowest boiling point and of what significance is this? (1)

d) Which has the highest blood-gas partition coefficient at 37o

C? ()e) Give the MAC value for each agent. (1)

2.15 The settings on a mechanical ventilator used for a 70 kg patient are as followsRespiratory rate = 10 breaths min-1Inspiration: Expiration ratio (I:E ratio) =1:2Inspiratory gas flow = 30 l min-1

a) Calculate the tidal volume delivered to the patient. (2)b) Calculate the Inspiratory time. (1)c) Is the tidal volume appropriate? What is an appropriate tidal volume in ml/kg?

(1)d) What would be an appropriate minute volume for this patient? (1)

2.16 Tabulate a safe and an unsafe drug for patients with renal failure for each of thefollowing

a) Induction agents. (1)b) Muscle relaxants. (1)c) Analgesics. (1)d) Volatile agents. (1)e) Antibiotics. (1)

2.17 Regarding lower oesophageal sphincter tonea) Name 5 drugs/factors that increase lower oesophageal sphincter tone. (2 )b) Name 5 drugs/factors that decrease lower oesophageal sphincter tone. (2 )

2.18 Following a balanced general anaesthetic for an appedicectomy, a young patient isextubated and taken to the recovery room. You are called to see him as he is

hypertensive and unable to maintain adequate oxygen saturation on a 40% oxygenmask.a) Name four possible anaesthetic related causes for this respiratory

insufficiency (2)b) Name four possible common causes of hypertension in this patient. (2)c) What would be your immediate management for this respiratory insufficiency?

(1)


9/18

2.19 Post-operative analgesiaa) Write a post-operative script for analgesia for a 5-year-old patient who has

had bilateral tibial osteotomies with a caudal block and general anaesthesia.Indicate drug dosages. (2)

b) Write a post-operative script for analgesia for a 56-year-old patient postlaparotomy for open cholecystectomy. Indicate drug dosages. (2 )

2.20 Briefly mention the factors affecting the function of an anaesthesia vaporizer andhow these are minimised in a modern vaporiser. (5)

[100]

2.1 Post-operatiewe naarheid en braking (PONB)a) Noem 3 middelgroepe dikwels geassosieer met PONB. (1)b) Lys 3 chirurgiese prosedures dikwels geassosieer met PONB. (1)c) Noem 4 pasientfaktore wat die waarskynlikheid van PONB verhoog. (2)

2.2 Induksiemiddelsa) Hoe lank mag Propofolampule oop wees voordat dit weggegooi moet word?

Waarom? (1)b) Noem 2 induksiemiddels wat as antikonvulsante gebruik kan word. (1)

c) Wat is die intraveneuse induksiedosering van Etomidaat? (1)d) Watter effek het Etomidaat op die endokrienstelsel? (1)e) Wat bepaal die duur van werking van Natriumtiopentoon? (1)

2.3 Lokaalverdowersa) Klassifiseer die lokaalverdowers. (2)b) Waarom word adrenalien by lokaalverdowers gevoeg? (1)c) Waarom word natriumbikarbonaat by lokaalverdowers gevoeg? (1)d) Wat is die maksimum dosis van bupivakaien? (1)

2.4 Spinaalnarkosea) Wat is die minimum monitering benodig tydens spinaalnarkose? (1)

b) Waarom word baie dun potloodpuntnaald verkies? (1)c) Lys 4 absolute kontra-indikasies vir neuraksiale blokkade. (2)d) U beplan spinaalnarkose vir n pasint op profilaktiese Clexane. Wanneer

moet die chirurg die laaste dosering pre-operatief toedien? ()

2.5 Bloeddrukmetinga) Noem die twee metodes van bloeddrukmeting. (1)b) Hoe beinvloed die wydte van die bloeddrukband die bloeddruklesing? (1)c) Hoe bepaal u die korrekte bloeddrukbandwydte? (1)d) Hoekom is die bloeddruklesing geneem op die been gewoonlik hoer as op die

arm? (2)

2.6 Temperatuura) Noem vier anatomiese liggings waar temperatuur intra-operatief gemeet kan

word. (2)b) Lys vier komplikasies van hipotermie. (2)c) Lys twee metodes wat in teater gebruik kan word om hitteverlies te bekamp.

(1)

2.7 Kapnograafa) Teken normale kapnogram en dui die fases van ekspirasie aan. (3)b) Teken die kapnogram van pasint met erge obstruktiewe lugwegsiekte. (2)


10/18

2.8 Downsindroom

Vyfjarige kind met Downsindroom is bespreek vir tandekstraksies. Wattergeassosieerde afwykings sou u bekommer met betrekking tota) Die lugweg. (2)b) Die kardiale stelsel. (2)c) Die gastro-intestinale stelsel. (1)

2.9 Intraoperatiewe komplikasie.Na die administrasie van 2g Kefasolien ontwikkel n pasint hipotensie en tagikardie.a) Wat is die mees waarskynlike diagnose? (1)b) Noem twee ander tekens wat u mag vind behalwe tagikardie en hipotensie (1)c) Bespreek kortliks u hantering van hierdie pasient. (3)

2.10 NoodmiddelsNoem een middel wat u in die volgende situasies sou gebruik. Gee geskiktedoserings.a) Erge bradikardie wat tot hipotensie lei. (1)b) Asistoliese kardiale arres. (1)c) Respiratoriese onderdrukking na opiaattoediening. (1)

d) Respiratoriese onderdrukking na midazolam toediening. (1)e) Maligne hipertermie. (1)

2.11 Bloedoortappinga) Wat is die gemiddelde bloedvolume van n 60 kg manlike pasint? (1)b) Lys vier komplikasies van n massiewe bloedoortapping. (2)c) Gee twee alternatiewe strategiee vir die hantering van bloedverlies tydens

chirurgie. (2)

2.12 Pasint met T6 spinaalkoordtranseksie presenteer 6 maande na die besering virdebridement van bedseer.a) Het hierdie pasint n risiko om outonome hiperrefleksie te ontwikkel? ()

b) Onder watter spinaalkoordvlak is dit minder waarskynlik om outonomehiperrefleksie te ontwikkel? ()

c) Wat is die simptome en tekens van outonome hiperrefleksie? (2)d) Verduidelik kortliks hoe outonome hiperrefleksie ontstaan. (2)

2.13 Jy word gevra om narkose toe te dien aan pasint met hoofbesering (GCS = 13,geen lokaliserende tekens nie) wat presenteer vir noodlaparotomie.Lys vyf belangrike aspekte van jou narkosehantering waaraan jy spesiale aandagmoet gee by hierdie geval. (5)

2.14 Halotaan, Isofluraan, Desfluraana) Watter een het preserveermiddel? Wat is die middel? (1)

b) Watter een ondergaan die minste metabolisme? Gee aanduiding van diepersentasie van hierdie middel wat normaalweg gemetaboliseer word. (1)

c) Watter een het die laagste kookpunt en van watter belang is dit? (1)

d) Watter een het die hoogste bloed-gasskeidingsyfer by 37o

C? ()e) Gee die MAK-waarde (MAC) vir elk. (1)


11/18

2.15 Die stellings van meganiese ventilator vir 70 kg pasint is soos volg:Asemhalingstempo=10 per minuutInspirasie: Ekspirasie-verhouding (I:E Ratio) = 1:2Inspiratoriese gasvloei= 30 liter per minuuta) Bereken die getyvolume gelewer aan die pasint. (2)b) Bereken die inspiratoriese tyd. (1)c) Is die getyvolume toepaslik? Wat is toepaslike getyvolume in ml/kg? (1)d) Wat is toepaslike minuutvolume vir hierdie pasint? (1)

2.16 Tabuleer een veilige en een gevaarlike middel vir elk van die volgende in pasintmet nierversaking.a) Induksiemiddels. (1)b) Spierverslappers. (1)c) Analgetika. (1)d) Vlugtige narkosemiddels. (1)e) Antibiotika. (1)

2.17 Met betrekking tot laer esofageale sfinktertonusa) Noem 5 middels of faktore wat laer esofageale sfinktertonus vermeeder.(2 )b) Noem 5 middels of faktore wat laer esofageale sfinktertonus verminder. (2 )

2.18 Na gebalanseerde narkose vir appendisektomie word jong pasint ge- ekstubeer en na die herstelkamer geneem. U word geroep want hy is hipertensief en

kan nie voldoende suurstofsaturasie handhaaf met n 40% suurstofmasker nie.a) Noem vier moontlike narkose-verwante oorsake van hierdie respiratoriese

ontoereikendheid. (2)b) Noem vier moontlike algemene oorsake van hipertensie in hierdie pasient. (2)c) Wat sou u onmiddelike hantering van hierdie respiratoriese ontoereikendheid

wees? (1)

2.19 Post-operatiewe analgesiea) Skryf post-operatiewe voorskrif neer vir analgesie vir n 5-jarige pasint wat

bilaterale tibiale osteotomiee ondergaan het onder algemene narkose met kaudale blok. Dui die middeldoserings aan. (2 )

b) Skryf post-operatiewe voorskrif neer vir analgesie vir 56-jarige pasint wat laparotomie vir oop cholesistektomie ondergaan het. Dui diemiddeldoserings aan. (2 )

2.20 Noem kortliks die faktore wat die funksie van narkose-verdamper benvloed en duiaan hoe dit in moderne verdamper tot die minimum beperk word. (5)

[100]


12/18

PAPER 2

1.1 A 25-year-old patient presents for a partial thyroidectomy. Intra-operatively shedevelops a sinus tachycardia (HR 130 bpm) and hypertension (BP 170/105).a) Discuss the regulation of thyroid hormones. (3)b) What is the standard laboratory evaluation of thyroid function? (2)c) List 5 symptoms and 5 signs of hypothyroidism. (5)d) List 5 symptoms and 5 signs of hyperthyroidism. (5)e) What are the pre-operative considerations of a patient with thyroid disease?

(5)f) What are the postoperative considerations of a patient with thyroid disease?

(5)

1.2 A 30-year-old carpenter sustained an open eye injury while working. He had recentlyeaten lunch.a) List 10 factors known to increase intra ocular pressure. (10)b) What are the factors to consider when delaying surgery in this patient? (5)c) What drugs would you use when anaesthetising this patient? Justify your

choices. (10)

1.3 A 26-year-old lady is booked for an emergency Cervical Cerclage at 18 weeksgestation. On history and examination she confirms that she is a known cardiacpatient with mitral valve incompetence, but has defaulted on follow-up.Discuss your management of the case regardingf) The pathophysiological changes to the cardiovascular system caused by the

valve lesion. (5)g) The specific information you need to decide on the severity of the valve

lesion. (3)h) What are the cardiovascular goals when anaesthetising a patient with mitral

valve incompetence? (5)i) Your planned anaesthetic management. Motivate your decisions. (10)j) What antibiotic prophylaxis will you consider for this patient? Motivate your

answer. (2)

1.4 You have to do a Dental list in a day-case clinic. The last child on this morning list isHIV positive.e) What is relevant in the pre-op history and physical examination? (5)f) Explain how you will perform an inhalation induction. (5)g) During the inhalation induction you struggle to ventilate the child. He severely

desaturates down to 85%. What is your differential diagnosis andmanagement? (10)

h) What cases are appropriate to be done as Day Case Surgery? (5)[100]

1.1 25-Jarige pasint ondergaan gedeeltelike tireodektomie. Intra-operatiefontwikkel sy sinus tagikardie (HS 130 spm) en, hipertensie (BD 170/105).a) Bespreek die regulering van tiroid hormone. (3)b) Wat is die standaard laboratoriumevaluasie van tiroedfunksie? (2)c) Lys 5 simptome en 5 tekens van hipotireose. (5)d) Lys 5 simptome en 5 tekens van hipertireose. (5)e) Wat is die pre-operatiewe oorwegings in pasint met slildklierssiekte? (5)f) Wat is die postoperatiewe oorwegings in pasint met skildkliersiekte? (5)


13/18

1.2 30-Jarige skrynwerker doen oop oogwond op by die werk. Hy het onlangsmiddagete genuttig.a) Lys 10 faktore wat verhoogde inta-okulere druk kan veroorsaak. (10)b) Wat is die faktore om te oorweeg indien chirurgie in hierdie pasint uitgestel

word? (5)c) Watter middels sal u gebruik vir die narkose van hierdie pasint? Regverdig u

keuses. (10)

1.3 26-Jarige vrou is bespreek vir nood servikale cerclage op 18 wekeswangerskap. Die geskiedenis en ondersoek bevestig dat sy bekende kardialepasint is met mitraalinkompetensie. Sy het egter nagelaat met opvolg.

Bespreek u hantering van hierdie geval met betrekking totf) Die patofisiologiese veranderinge in die kardiovaskulere stelsel veroorsaak deur

die klepletsel. (5)g) Die spesifieke informasie wat u benodig om die ernstigheidsgraad van die

klepletsel te besluit. (3)h) Wat is die kardiovaskulere mikpunte wanneer pasint met

mitraalinkompetensie narkose ontvang? (5)i) Wat is u beplande narkose-hantering? Motiveer u besluite. (10)j) Watter antibiotiese profilakse sal u oorweeg vir hierdie pasint? Motiveer u

antwoord. (2)

1.4 U doen tandheelkundelys in dagkliniek. Die laaste kind op die oggendlys is MIVpositief.e) Wat is relevant in die pre-operatiewe geskiedenis en fisiese ondersoek? (5)f) Verduidelik hoe u inhalasie-induksie sal doen. (5)g) Gedurende die inhalasie-induksie sukkel u om die kind te ventileer. Hy

desatureer erg tot 85% Wat is u differensiele diagnose en hantering? (10)h) Watter gevalle is geskik vir dag-gevalchirurgie? (5)

[100]

2.1 Post-operative nausea and vomiting (PONV)a) Name 3 groups of drugs commonly associated as a cause of post-operative

nausea and vomiting (PONV). (1)b) List 3 surgical procedures commonly associated with PONV. (1)c) Name 4 patient factors which increase the likelihood of PONV occurring. (2)

2.2 Induction agentsa) How long may an ampoule of propofol remain open before it must be

discarded? Why? (1)b) Name 2 induction agents which can be used as anticonvulsants. (1)

c) What is the intravenous induction dose of Etomidate? (1)d) What effect does Etomidate have on the endocrine system? (1)e) What determines the duration of action of SodiumThiopentone? (1)

2.3 Local Anaestheticsa) Classify local anaesthetics. (2)b) Why is adrenaline added to local anaesthetics? (1)c) Why is bicarbonate of soda added to local anaesthetics? (1)d) What is the maximum dose of bupivacaine? (1)


14/18

2.4 Spinal anaesthetica) What is the minimum monitoring required for spinal anaesthesia? (1)b) Why is using a small diameter pencil point needle the preferred technique? (1)c) List four absolute contraindications to neuraxial blockade. (2)d) You plan to do a spinal anaesthetic for a patient on prophylactic Clexane.

When would you advise the surgeon to give the last dose before theatre? ()

2.5 Blood Pressure measurementa) Name the two methods of blood pressure measurement. (1)b) How does blood pressure cuff width influence blood pressure readings? (1)c) How does one determine the correct blood pressure cuff size? (1)d) Why is the blood pressure reading taken on the lower limb normally higher

than that taken on the upper limb? (2)

2.6 Temperaturea) Name four anatomical sites at which temperature can be monitored

intraoperatively. (2)

b) List four complications of hypothermia. (2)c) List 2 measures which can be taken in theatre to prevent heat loss? (1)

2.7 Capnographya) Draw a normal capnograph demonstrating the phases of expiration. (3)b) Draw the capnograph of a patient with severe obstructive pulmonary

disease. (2)

2.8 Downs syndromea) A five-year-old Downs syndrome child is booked for dental extractions. What

associated abnormalities would concern you regardingi) The airway. (2)

ii) The cardiac system. (2)iii) The gastrointestinal system. (1)

2.9 Intra-operative complicationFollowing the administration of 2g of Cefazolin, a patient becomes hypotensive andtachycardic.a) What is the most likely diagnosis? (1)b) Besides tachycardia & hypotension, name 2 other signs you may find? (1)c) Briefly describe your management of this patient. (3)

2.10 Emergency drugsName one drug you would use in the following situations. Give appropriate doses.

a) Severe bradycardia resulting in hypotension. (1)b) Asystolic arrest. (1)c) Respiratory depression following opioid administration. (1)d) Respiratory depression following midazolam administration. (1)e) Malignant hyperthermia. (1)

2.11 Blood Transfusiona) What is the average blood volume of a 60kg male patient? (1)b) List four complications of massive blood transfusion. (2)c) Give two alternative strategies for management of blood loss during surgery.

(2)


15/18

2.12 A patient with a T6 spinal cord transection presents 6 months after the injury for

debridement of a bedsore.a) Is this patient at risk for autonomic hyperreflexia? ()b) Below which spinal cord level is it less likely to occur? ()c) What are the signs and symptoms of autonomic hyperreflexia? (2)d) Briefly explain how autonomic hyperreflexia occurs. (2)

2.13 You are asked to anaesthetise a patient with a closed head injury (GCS = 13, nolocalizing signs) for an emergency laparotomy.List five aspects of anaesthetic management which you should pay particularattention to in this case and state why it is important. (5)

2.14 Halothane, Isoflurane and Desfluranea) Which has a preservative? What is the preservative? (1)b) Which undergoes the least metabolism? Indicate what percentage of this

agent is normally metabolised. (1)c) Which has the lowest boiling point and of what significance is this? (1)

d) Which has the highest blood-gas partition coefficient at 37o

C? ()e) Give the MAC value for each agent. (1)

2.15 The settings on a mechanical ventilator used for a 70 kg patient are as followsRespiratory rate = 10 breaths min-1Inspiration: Expiration ratio (I:E ratio) =1:2Inspiratory gas flow = 30 l min-1

a) Calculate the tidal volume delivered to the patient. (2)b) Calculate the Inspiratory time. (1)c) Is the tidal volume appropriate? What is an appropriate tidal volume in ml/kg?

(1)d) What would be an appropriate minute volume for this patient? (1)

2.16 Tabulate a safe and an unsafe drug for patients with renal failure for each of the

followinga) Induction agents. (1)b) Muscle relaxants. (1)c) Analgesics. (1)d) Volatile agents. (1)e) Antibiotics. (1)

2.17 Regarding lower oesophageal sphincter tonea) Name 5 drugs/factors that increase lower oesophageal sphincter tone. (2 )b) Name 5 drugs/factors that decrease lower oesophageal sphincter tone. (2 )

2.18 Following a balanced general anaesthetic for an appedicectomy, a young patient is

extubated and taken to the recovery room. You are called to see him as he ishypertensive and unable to maintain adequate oxygen saturation on a 40% oxygenmask.a) Name four possible anaesthetic related causes for this respiratory

insufficiency (2)b) Name four possible common causes of hypertension in this patient. (2)c) What would be your immediate management for this respiratory insufficiency?

(1)


16/18

2.19 Post-operative analgesiaa) Write a post-operative script for analgesia for a 5-year-old patient who has

had bilateral tibial osteotomies with a caudal block and general anaesthesia.Indicate drug dosages. (2)

b) Write a post-operative script for analgesia for a 56-year-old patient postlaparotomy for open cholecystectomy. Indicate drug dosages. (2 )

2.20 Briefly mention the factors affecting the function of an anaesthesia vaporizer andhow these are minimised in a modern vaporiser. (5)

[100]

2.1 Post-operatiewe naarheid en braking (PONB)a) Noem 3 middelgroepe dikwels geassosieer met PONB. (1)b) Lys 3 chirurgiese prosedures dikwels geassosieer met PONB. (1)c) Noem 4 pasientfaktore wat die waarskynlikheid van PONB verhoog. (2)

2.2 Induksiemiddelsa) Hoe lank mag Propofolampule oop wees voordat dit weggegooi moet word?

Waarom? (1)b) Noem 2 induksiemiddels wat as antikonvulsante gebruik kan word. (1)

c) Wat is die intraveneuse induksiedosering van Etomidaat? (1)d) Watter effek het Etomidaat op die endokrienstelsel? (1)e) Wat bepaal die duur van werking van Natriumtiopentoon? (1)

2.3 Lokaalverdowersa) Klassifiseer die lokaalverdowers. (2)b) Waarom word adrenalien by lokaalverdowers gevoeg? (1)c) Waarom word natriumbikarbonaat by lokaalverdowers gevoeg? (1)d) Wat is die maksimum dosis van bupivakaien? (1)

2.4 Spinaalnarkosea) Wat is die minimum monitering benodig tydens spinaalnarkose? (1)

b) Waarom word baie dun potloodpuntnaald verkies? (1)c) Lys 4 absolute kontra-indikasies vir neuraksiale blokkade. (2)d) U beplan spinaalnarkose vir n pasint op profilaktiese Clexane. Wanneer

moet die chirurg die laaste dosering pre-operatief toedien? ()

2.5 Bloeddrukmetinga) Noem die twee metodes van bloeddrukmeting. (1)b) Hoe beinvloed die wydte van die bloeddrukband die bloeddruklesing? (1)c) Hoe bepaal u die korrekte bloeddrukbandwydte? (1)d) Hoekom is die bloeddruklesing geneem op die been gewoonlik hoer as op die

arm? (2)

2.6 Temperatuura) Noem vier anatomiese liggings waar temperatuur intra-operatief gemeet kan

word. (2)b) Lys vier komplikasies van hipotermie. (2)c) Lys twee metodes wat in teater gebruik kan word om hitteverlies te bekamp.

(1)

2.7 Kapnograafa) Teken normale kapnogram en dui die fases van ekspirasie aan. (3)b) Teken die kapnogram van pasint met erge obstruktiewe lugwegsiekte. (2)


17/18

2.8 Downsindroom

Vyfjarige kind met Downsindroom is bespreek vir tandekstraksies. Wattergeassosieerde afwykings sou u bekommer met betrekking tota) Die lugweg. (2)b) Die kardiale stelsel. (2)c) Die gastro-intestinale stelsel. (1)

2.9 Intraoperatiewe komplikasie.Na die administrasie van 2g Kefasolien ontwikkel n pasint hipotensie en tagikardie.a) Wat is die mees waarskynlike diagnose? (1)b) Noem twee ander tekens wat u mag vind behalwe tagikardie en hipotensie (1)c) Bespreek kortliks u hantering van hierdie pasient. (3)

2.10 NoodmiddelsNoem een middel wat u in die volgende situasies sou gebruik. Gee geskiktedoserings.a) Erge bradikardie wat tot hipotensie lei. (1)b) Asistoliese kardiale arres. (1)c) Respiratoriese onderdrukking na opiaattoediening. (1)

d) Respiratoriese onderdrukking na midazolam toediening. (1)e) Maligne hipertermie. (1)

2.11 Bloedoortappinga) Wat is die gemiddelde bloedvolume van n 60 kg manlike pasint? (1)b) Lys vier komplikasies van n massiewe bloedoortapping. (2)c) Gee twee alternatiewe strategiee vir die hantering van bloedverlies tydens

chirurgie. (2)

2.12 Pasint met T6 spinaalkoordtranseksie presenteer 6 maande na die besering virdebridement van bedseer.a) Het hierdie pasint n risiko om outonome hiperrefleksie te ontwikkel? ()

b) Onder watter spinaalkoordvlak is dit minder waarskynlik om outonomehiperrefleksie te ontwikkel? ()

c) Wat is die simptome en tekens van outonome hiperrefleksie? (2)d) Verduidelik kortliks hoe outonome hiperrefleksie ontstaan. (2)

2.13 Jy word gevra om narkose toe te dien aan pasint met hoofbesering (GCS = 13,geen lokaliserende tekens nie) wat presenteer vir noodlaparotomie.Lys vyf belangrike aspekte van jou narkosehantering waaraan jy spesiale aandagmoet gee by hierdie geval. (5)

2.14 Halotaan, Isofluraan, Desfluraana) Watter een het preserveermiddel? Wat is die middel? (1)

b) Watter een ondergaan die minste metabolisme? Gee aanduiding van diepersentasie van hierdie middel wat normaalweg gemetaboliseer word. (1)

c) Watter een het die laagste kookpunt en van watter belang is dit? (1)

d) Watter een het die hoogste bloed-gasskeidingsyfer by 37o

C? ()e) Gee die MAK-waarde (MAC) vir elk. (1)


18/18

2.15 Die stellings van meganiese ventilator vir 70 kg pasint is soos volg:Asemhalingstempo=10 per minuutInspirasie: Ekspirasie-verhouding (I:E Ratio) = 1:2Inspiratoriese gasvloei= 30 liter per minuuta) Bereken die getyvolume gelewer aan die pasint. (2)b) Bereken die inspiratoriese tyd. (1)c) Is die getyvolume toepaslik? Wat is toepaslike getyvolume in ml/kg? (1)d) Wat is toepaslike minuutvolume vir hierdie pasint? (1)

2.16 Tabuleer een veilige en een gevaarlike middel vir elk van die volgende in pasintmet nierversaking.a) Induksiemiddels. (1)b) Spierverslappers. (1)c) Analgetika. (1)d) Vlugtige narkosemiddels. (1)e) Antibiotika. (1)

2.17 Met betrekking tot laer esofageale sfinktertonusa) Noem 5 middels of faktore wat laer esofageale sfinktertonus vermeeder.(2 )b) Noem 5 middels of faktore wat laer esofageale sfinktertonus verminder. (2 )

2.18 Na gebalanseerde narkose vir appendisektomie word jong pasint ge- ekstubeer en na die herstelkamer geneem. U word geroep want hy is hipertensief en

kan nie voldoende suurstofsaturasie handhaaf met n 40% suurstofmasker nie.a) Noem vier moontlike narkose-verwante oorsake van hierdie respiratoriese

ontoereikendheid. (2)b) Noem vier moontlike algemene oorsake van hipertensie in hierdie pasient. (2)c) Wat sou u onmiddelike hantering van hierdie respiratoriese ontoereikendheid

wees? (1)

2.19 Post-operatiewe analgesiea) Skryf post-operatiewe voorskrif neer vir analgesie vir n 5-jarige pasint wat

bilaterale tibiale osteotomiee ondergaan het onder algemene narkose met kaudale blok. Dui die middeldoserings aan. (2 )

b) Skryf post-operatiewe voorskrif neer vir analgesie vir 56-jarige pasint wat laparotomie vir oop cholesistektomie ondergaan het. Dui diemiddeldoserings aan. (2 )

2.20 Noem kortliks die faktore wat die funksie van narkose-verdamper benvloed en duiaan hoe dit in moderne verdamper tot die minimum beperk word. (5)

[100]

DA(SA)_Past_Papers 3

Documents

Transcript of DA(SA)_Past_Papers 3