End of year Case-Based Oral Exam For First Year Residents

Aim: To determine how strong the residents are in:

Preoperative Evaluation (focused history, PE and appropriate labs and clearance)

Risk Assessment (identify modifiable risks and institute appropriate management)

Preoperative Preparation (anticipate potential problems and devise plans to address these problems to
prevent complications)

Formulation of a Comprehensive Anesthesia Plan (Intraoperative and Postoperative)

Obtaining Informed Consent

Crisis Management

Note: Maximum of 20 mins per station. No extension. At the end of oral exam, debriefing/feedback from
examinees and examiners follow

Case 1: Elderly patient with Intestinal Obstruction for E Exlap

82 year old male ht 158cm wt 55kg. No known co-morbid illness. No allergies. Non-smoker, not an
alcoholic beverage drinker. History of L inguinal mass. No previous surgery.

Question: What else do you want to find out in the patient’s history?

HPI: 3 days ago developed severe abdominal pain and bloatedness. 2 days ago had loss of appetite and
multiple episodes of vomiting, unable to take anything per orem. 1 day ago noted to be weak, lethargic,
distended abdomen and vomited fecaloid material. Persistence of symptoms prompted consult and
subsequent admission

Question: What will you look for or focus on in the patient’s PE?

PE: Vital signs BP: 80/50 mmHg, HR 120s-130s/min, RR 26/min, Temp 36C. Drowsy, opens eyes to
moderately vigorous stimulation, not oriented, does not follow commands. Sunken eyeballs. Pale
palpebral conjunctivae. Dry buccal mucosa. Edentulous, adequate thyromental distance, good mouth
opening. Hyperdynamic precordium. Clear breath sounds. Weak peripheral pulses.
Question: What laboratory tests or diagnostic procedures will you request?

Labs: Hgb 128 hct 0.35 WBC 18 platelet 226. BUN 21. Crea 1.28. Na- 125. K 2.7. PT 13 sec, INR 1.1, aPTT
32sec, PTPA 87%

Diagnostics: CXR, 12 L ECG, 2 DE findings are within normal limits

Impression: Intestinal Obstruction probably due to strangulated hernia for E Ex-lap

Question: What is your anesthesia plan and how will you explain it to the patient?

Points of Discussion:

1- Preop evaluation: ASA classification, identify and modify risks – fluids and electrolytes (signs and
symptoms of dehydration, importance of electrolyte correction), risk for aspiration, risk for AKI,
consider sepsis
2- Preop preparation: Put NGT to decompress stomach. Monitor and replace GI losses. Optimize
fluids (compute for fluid deficit, hydrate patient, enumerate endpoints of adequate hydration)
and electrolytes (correct hyponatremia, hypokalemia). Start appropriate antibiotics. Get blood
culture. Consider vasopressor if perfusion does not improve with fluid hydration
3- Anesthesia plan: GETA-RSI (conduct of RSI, choice of drugs), Maintain adequate muscle
relaxation during surgery. Monitors (SpO2, ECG, NIBP, ETCO2, Temp, TOF). Intraop fluid
management – fluid maintenance, fluid replacement. Monitor hydration – hourly uo, waveform
analysis. Keep patient warm – warm IV fluids, use forced air warmer. Reserve blood. Plan for
postop pain management. Plan for post-op repeat labs. Plan for delayed extubation and
postoperative SICU admission

Crisis Management Part 1: Patient was brought to the SICU intubated and then hooked to mechanical
ventilator.

Challenge: 1-Give ventilator settings. 2- Criteria for extubation

Crisis Management Part 2: After 2hrs, patient woke up, ventilator support was weaned. An hour later,
patient was extubated. In the SICU, the bedside nurse reported that the patient displayed aggression
and was combative i.e tries to pull out NGT, IV lines etc, kicks and screams, tries to get out of bed,
calls/asks for her parents

Challenge: 1- Define postoperative delirium, risk factors, prevention and treatment