Ebook Structured oral examination practice for the final FRCA: Part 1

OX F O RD SP EC I A LTY TRA IN IN G

Structured Oral Examination
Practice for the Final FRCA


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OX FO RD S PE C I A LT Y T R A I NI NG

Structured Oral
Examination Practice
for the Final FRCA
ED I T ED BY

Rakesh Tandon
Consultant Anaesthetist, Addenbrooke’s Hospital, Cambridge University Hospitals, Cambridge, UK

1


1

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Contents
List of abbreviations ix
List of contributors xiii
Introduction

xv

Chapter 1 1
Clinical anaesthesia 3
Long case: A case for craniotomy 3
Short cases 8
Questions 8
Answers 9
Clinical science 19
Questions 19
Answers 20
Chapter 2 29

Clinical anaesthesia 31
Long case: A case for total thyroidectomy
Short cases 35
Questions 35
Answers 37

31

Clinical science 41
Questions 41
Answers 42
Chapter 3 47
Clinical anaesthesia 49
Long case: A case for elective colectomy 49
Short cases 54
Questions 54
Answers 56
Clinical science 60
Questions 60
Answers 61
Chapter 4 67
Clinical anaesthesia 69
Long case: A patient with carcinoma of the sigmoid colon 69
Short cases 73

v


Contents

Questions 73
Answers 75
Clinical science 80
Questions 80
Answers 81
Chapter 5 87
Clinical anaesthesia 89
Long case: A patient for total hip replacement 89
Short cases 95
Questions 95
Answers 97
Clinical science 103
Questions 103
Answers 104
Chapter 6 111
Clinical anaesthesia 113
Long case: A patient with spinal stenosis 113
Short cases 119
Questions 119
Answers 121
Clinical science 126
Questions 126
Answers 127
Chapter 7 135
Clinical anaesthesia 137
Long case: A case of hiatus hernia 137
Short cases 142
Questions 142
Answers 144
Clinical science 150

Questions 150
Answers 151
Chapter 8

161

Clinical anaesthesia 163
Long case: A young boy with Guillain–Barré syndrome 163
Short cases 168
Questions 168
Answers 169

vi


Contents

Clinical science 176
Questions 176
Answers 177
Chapter 9

185

Clinical anaesthesia 187
Long case: A patient for elective open AAA repair 187
Short cases 192
Questions 192
Answers 193
Clinical science 200

Questions 200
Answers 201
Chapter 10 211
Clinical anaesthesia 213
Long case: A patient in Accident and Emergency 213
Short cases 219
Questions 219
Answers 220
Clinical science 225
Questions 225
Answers 226
Chapter 11 233
Clinical anaesthesia 235
Long case: A patient with multiple medical issues 235
Short cases 240
Questions 240
Answers 241
Clinical science 245
Questions 245
Answers 246
Chapter 12 253
Clinical anaesthesia 255
Long case: A patient for dental clearance as day-case procedure 255
Short cases 261
Questions 261
Answers 263

vii

Contents

Clinical science 269
Questions 269
Answers 270
Chapter 13 279
Clinical anaesthesia 281
Long case: A patient for major cancer surgery 281
Short cases 287
Questions 287
Answers 288
Clinical science 295
Questions 295
Answers 296
Chapter 14 305
Clinical anaesthesia 307
Long case: A patient with epilepsy on emergency operating list
Short cases 313
Questions 313
Answers 314

307

Clinical science 319
Questions 319
Answers 320
Chapter 15 327
A child with upper respiratory tract infection 329
Anaesthetic management of a patient with severe sepsis 331
Smoking and drinking alcohol and anaesthesia 334

Fast tracking in anaesthesia 336
What is ziconotide? 337
What is dabigatran? 338
What is sugammadex? 339
Applications of transdermal drug delivery

340

Role of cell salvage in anaesthesia 342
Sedation in children and young people: current recommendations 344
Failed spinal anaesthesia: mechanisms, management, and prevention 347
Ultrasound-guided or peripheral nerve stimulation for peripheral nerve blocks 349
Rapid sequence induction and intubation: current controversy 351
The current findings of The Centre for Maternal and Child Enquiries (CMACE) 354

viii


List of abbreviations
A&E
AAA
AAGBI
ABC
ABCDE
ABG
ACE
ACh
ACTH
AF
AL

ALI
ALP
APH
aPTT
ARDS
ARF
ASA
ATP
AVB
AVPU
AVPU

accident and emergency
abdominal aortic aneurysm
Association of Anaesthetists of Great Britain & Ireland
airway, breathing, circulation
airway, breathing, circulation, disability, exposure
arterial blood gas
angiotensin-converting enzyme
acetylcholine
adrenocorticotropic hormone
atrial fibrillation
axial length
acute lung injury
alkaline phosphatase
antepartum haemorrhage
activated partial thromboplastin time
acute respiratory distress syndrome
acute renal failure
American Society of Anesthesiologists

adenosine triphosphate
atrioventricular conduction block
alert, voice, pain, unresponsive (scale)
atrioventricular

BAL
BP
BTS

bronchoalveolar lavage
blood pressure
British Thoracic Society

cAMP
CBF
CHB
CMACE
CMRO2
CN
CNS
CO
CO2
COHb
COPD
CPAP
CPP
CPR
CRP
CSA
CSF

CT
CVP
CVS

cyclic adenosine monophosphate
cerebral blood flow
complete heart block
Centre for Maternal and Child Enquiries
cerebral metabolic requirement of O2
cranial nerve
central nervous system
carbon monoxide
carbon dioxide
carboxyhaemoglobin
chronic obstructive pulmonary disease
continuous positive airway pressure
cerebral perfusion pressure
cardiopulmonary resuscitation
C-reactive protein
central sleep apnoea
cerebrospinal fluid
computed tomography
central venous pressure
cardiovascular system

ix


List of abbreviations

DDAVP desmopressin acetate
dL
decilitre/s
DVT
deep vein thrombosis
EBM
ECG
ECMO
ECT
EEG
ELMS
ERC
ERV
ETCO2
ETT

evidence-based medicine
electrocardiogram
extracorporeal membrane oxygenation
electroconvulsive therapy
electroencephalogram
Eaton–Lambert myasthenic syndrome
European Resuscitation Council
expiratory reserve volume
end-tidal carbon dioxide
endotrachael tube

FDA
FEV1
FFP

FGF
FRC
FVC

Food and Drug Administration
forced expiratory volume in 1 second
fresh frozen plasma
fresh gas flow
functional residual capacity
forced vital capacity

GABA
GCS
GFR
GI
GIT
GP
GTN

gamma-aminobutyric acid
Glasgow Coma Scale
glomerular filtration rate
gastrointestinal
gastrointestinal tract
general practitioner
glyceryl trinitrate

Hb
HbA
HbF

HDU
HPA
HR

haemoglobin
adult haemoglobin
fetal haemoglobin
high dependency unit
hypothalamo–pitutary–adrenal
heart rate

IC
ICP
ICU
IHD
IM
IO
IRV
IU
IV
IVRA

inspiratory capacity
intracranial pressure
intensive care unit
ischaemic heart disease
intramuscular
intraosseous
inspiratory reserve volume
international units

intravenous
intravenous regional anaesthesia

J

joule/s

K

potassium

x


List of abbreviations

LMA
LMWH
LOC
LVH

laryngeal mask airway
low-molecular-weight heparin
loss of consciousness
left ventricular hypertrophy

MAC
MAP
mcg
MCV

ml
MLT
mmHg
MRI
ms
MTCT

minimum alveolar concentration
mean arterial pressure
microgram/s
mean cell volume
millilitre/s
microlaryngeal tube
millimetres of mercury
magnetic resonance imaging
millisecond/s
mother-to-child transmission

Na
Nd:YAG
NICE
NMBD
NSAID

sodium
neodymium-doped yttrium aluminium garnet
National Institute for Health and Clinical Excellence
neuromuscular blocking drug
non-steroidal anti-inflammatory drug

O2
OER
ORIF
OSA

oxygen
oxygen extraction ratio
open reduction and internal fixation
obstructive sleep apnoea

PCA
PCO2
PDA
PE
PEEP
PEFR
PFT
PO2
PONV
PR
PT
PTH

patient-controlled analgesia
carbon dioxide partial pressure
posterior descending artery
pulmonary embolism
positive end-expiratory pressure
peak expiratory flow rate
pulmonary function test

oxygen partial pressure
postoperative nausea and vomiting
per rectum
prothrombin time
parathyroid hormone

RAD
RAE
RBC
RCA
RCT
RCT
RSII
RV

right axis deviation
Ring, Adair, and Elwyn
red blood cell
right coronary artery
randomized controlled trial
randomized control trial
rapid sequence induction and intubation
residual volume

SAE
SAE

subarachnoid haemorrhage
sinoatrial

xi


List of abbreviations

sec
SIADH
SIRS
SVR
SVT

second/s
syndrome of inappropriate antidiuretic hormone secretion
systemic inflammatory response syndrome
systemic vascular resistance
subventricular tachycardia

T3
T4
TAP
TBSA
TIA
TIVA
TKR
TLC
TOE
TRH
TSH
TURP

triiodothyronine
thyroxine
transversus abdominis plane
total body surface area
transient ischaemic attack
total intravenous anaesthesia
total knee replacement
total lung capacity
trans-oesophageal echocardiography
thyrotropin-releasing hormone
thyroid-stimulating hormone
transurethral resection of prostate

U&E
URTI

urea and electrolytes
upper respiratory tract infection

V
VAP
VC
VF
VT
VTE

volt/s
ventilator-associated pneumonia
vital capacity
ventricular fibrillation

ventricular tachycardia
venous thromboembolism

WBC
WPW
Ω

white blood cell
Wolff–Parkinson–White
ohm/s

xii


List of contributors
Amr Abdelaal
Consultant Anaesthetist,
Cambridge University Hospitals NHS Foundation Trust
Sam Bass
Consultant Anaesthetist,
Cambridge University Hospitals NHS Foundation Trust
Ajit Bhat
Anaesthesia Registrar,
Cambridge University Hospitals NHS Foundation Trust
Nathaniel Broughton
Anaesthetic Registrar,
Cambridge University Hospitals NHS Foundation Trust
Ari Ercole
Clinical Lecturer in Anaesthesia,
Cambridge University Hospitals NHS Foundation Trust

Ravi Kare
Anaesthetic Registrar,
Cambridge University Hospitals NHS Foundation Trust
Lucy Pearmain
Anaesthesia Registrar,
Cambridge University Hospitals NHS Foundation Trust
Karim Shoukrey
Anaesthesia Registrar,
Cambridge University Hospitals NHS Foundation Trust
Claire Williams
Consultant Anaesthetist,
Cambridge University Hospitals NHS Foundation Trust
Imaging:
Penelope Moyle
Consultant Radiologist, Hinchingbrook and Cambridge University Hospitals

xiii


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Introduction
The format of the Structured Oral Examination (SOE) of The Royal College of Anaesthetists has
changed considerably since its inception in 1996. This book is based on the SOE as set out by the most
recent requirements and guidance from the Royal College of Anaesthetists, and as such it offers
updated and highly relevant content for anyone preparing for this examination.
We have produced this book after almost 8 years of experience in examination practice. The book
combines aspects of clinical anaesthesia as well as clinical sciences. The pattern of questions in this
book is designed to be like the real examination. In addition we have included some questions which

specifically focus on current issues and recent development in anaesthesia, to better equip the
examination candidate.
The book is structured to specifically follow the pattern of examination as set out by the Royal
College of Anaesthetists. The book is arranged in 15 chapters, with the first 14 chapters each
representing one complete examination. The clinical anaesthesia SOE consists of one long case with
the relevant laboratory results, X-ray, and ECG. This information is followed by a set of questions
based on the clinical scenario. The questions are answered individually with evidence-based answers.
The short cases are scenario-based with questions which are also followed by model answers. The
SOE for clinical sciences also follows a similar pattern as the examination covering applied aspects of
anatomy, physiology, pharmacology, physics, and clinical measurements. The questions are separated
by subject and answers are provided individually by topic.
A special feature of this book is the inclusion of X-rays which are individually reported by the
radiologist, and anatomy diagrams which are simplified and can be reproduced easily. The graphs are
simple to understand as well as simple to reproduce.
The last chapter in the book is called ‘Hot topics in anaesthesia’. This is specially written in view of
the changing and evolving role of anaesthetists, who are expected to deliver evidence-based practice
with full patient safety in mind. Moreover, recently there are new recommendations from the National
Audit Project of the Royal College of Anaesthetists, the National Patient Safety Agency, the Association
of Anaesthetists, and the Centre for Maternal and Child Enquiries. Such information as well as new
knowledge from scientific publications are quite topical for the examination, and are included in this
last chapter of the book.

Marking
Structured Oral Examination I
Clinical anaesthesia is of 50 minutes’ duration, comprising 10 minutes to view clinical material, 20 minutes
of questions on clinical material, and 20 minutes of questions on clinical anaesthesia unrelated to the
clinical material.

Structured Oral Examination II
Clinical science lasts for 30 minutes on the application of basic science to anaesthesia, intensive care

medicine, and pain management.

xv


Introduction

The marking system
The College uses a five-point closed-marking system in its examinations, the marks being:
2+
2
1+
1
0

Outstanding performance
Pass
Fail
Poor fail
Veto (if a candidate fails to answer a compulsory question
in the SAQ paper of the Final Fellowship of Royal College
of Anaesthetists examination)

To pass the oral examination the examinee requires a minimum score of 2 or 2+. The 2+ plus
examinee is a potential medal winner.

Structured Oral Examination I: Clinical anaesthesia
The SOE for clinical anaesthesia (SOE-I) lasts for 50 minutes, and comprises 10 minutes to view clinical
material, 20 minutes of questions on the clinical material, and 20 minutes of questions on clinical
anaesthesia unrelated to the clinical material as three short cases.

The aim of the clinical anaesthesia section of the examination is to test the ability to manage a real
scenario appropriately. This means assessing a patient in an orderly manner, carefully analysing and
interpreting the given investigations, presenting coherent justification for any further information that
may be required, planning the perioperative management, and perhaps most importantly,
communicating effectively.

Structured Oral Examination I: Long case
Preparation time 10 minutes:
‹Read the scenario carefully and prioritize important issues.
‹Go through the investigations.
‹Based on the clinical scenario, analyse and interpret the findings.
z Organize your thoughts. Divide your answer into three parts that are based around the
perioperative stages:
‹Preoperative stage: assessment and investigation.
‹Intraoperative stage:
„ Induction of anaesthesia and airway management plan.
„ Monitoring during surgery.
‹Postoperative stage:
„ Pain relief.
„ Recovery.
z How to ‘Summarize the long case’:
‹The opening sentence is quite important as this sets the tone of the viva. This should be well
prepared, short, and well structured.
‹It is important that you follow a simple rule of one to two sentences.
‹Important information you convey should include age and sex of the patient, your diagnosis,
planned procedure and the urgency of the case.
‹Outline the important issues particularly highlighting important preoperative morbidities.
z

xvi

Introduction

Long case investigations: analyse/interpret all the investigations available, formulate your
differential diagnosis or specific diagnosis, and provide the rationale for your conclusion. You
should make this response short and specific.
‹Chest X-ray: detailed discussion and differential diagnosis as appropriate.
‹Electrocardiograph (ECG) diagnosis based on findings.
‹Arterial blood gas analysis: systematic report with your inference.
‹Alveolar gas equation likely to be asked to explain the P(A–a)O difference.
2
‹Pulmonary function tests (PFTs): FVC (forced vital capacity) graph, flow–volume loops
(differentiating between obstructive and restrictive disease).
‹Echo: explain the information you seek and its effect on patient management.
‹Justify any further investigations you require.
z Anaesthetic management: for all the long case questions you will be asked about your plan
of anaesthetic management. There is no right or wrong answer per se—the important thing is
that you need to think and formulate a structure and technique with appropriate justification.
Patient safety is paramount and the answers should cover all aspects of patient safety.
z What anaesthetic monitoring? Monitoring is based on the Association of Anaesthetists of
Great Britain and Ireland recommendations:
‹ECG
‹NIBP and IBP, CVP catheter
‹Pulse oximetry
‹Capnography including inhalational agent
‹Urine output
‹Temperature, and
‹Neuromuscular junction monitoring
z

Structured Oral Examination I: Short cases
At the end of the first 20 minutes the examiners will change, and the second examiner will discuss
three short cases. These cases could include anything from a list of clinical issues with anaesthetic
problems or ECG or radiological image to begin a discussion. The discussion could be based on the
management of the situation based upon the findings.
On a regular basis in your day-to-day practice of anaesthesia you should incorporate certain routine
habits like interpreting the ECG and chest X-ray. This would certainly improve your practice of
communication skills as well as that of interpretation of results presented to you. There are certain
common situations in anaesthesia which can be practised on regular basis. An example is shown
below.
Phraseology to be used/opening gambits:
Patient with type 2 diabetes and a gangrenous leg requiring amputation.
‘My main concerns in this case would be the effect of diabetes on the various organ systems, the
perioperative control of blood glucose, and the urgency of the operation.’
z How do you manage a difficult airway?
‘Difficult airway is a serious problem in anaesthetic practice. I would like to discuss its definition,
prediction, and management of unexpected and anticipated situations.’
z

Structured Oral Examination II: Clinical science
The SOE in clinical science is intended to assess the examinee’s understanding of the applied basic
science to the practice of clinical anaesthesia, critical care, and chronic pain management. This part of
the examination takes 30 minutes and is divided into a 15-minute session with each of the two examiners.

xvii


Introduction

This is further divided into 7 minutes per topic with each examiner. All the candidates in the room are
asked the same question and these questions would not be repeated in SAQ.

Applied anatomy
The applied anatomy relevant to clinical anaesthesia practice is a fair subject to be examined.
The common clinical practice of anaesthesia of intravenous cannulation, regional anaesthesia,
and intubation all require the applied knowledge of clinical anatomy. The anatomy is best described
with a good line diagram and knowledge of relationships to adjacent structures. A typical question
could be, for instance, about the blood supply of the heart followed by the clinical application of the
applied knowledge. Types of anatomy question can be divided into a theoretical anatomy question or
a practical anatomy question. This means that a question about coronary circulation is an example of
a theoretical question but this knowledge is essential as we can alter the circulation. Similarly, cerebral
circulation and spinal circulation is purely a theoretical concept but it is in the management of the head
injury patient that one requires specific understanding of applied anatomy. The question on practical
anatomy will be simple to address if you have experience of femoral or brachial plexus nerve block,
or radial artery cannulation. The theoretical anatomy question has to be memorized for the examination
and the best method is to pick-up the questions which are relevant to anaesthesia and practice with
the help of line diagrams. The practical anatomy questions are the ones which can be practised every
day while you are performing the procedures. For instance, if you are performing the brachial plexus
block you can practise taking a colleague completely through each and every step of the block including
the nerves you are blocking with their roots. Once you get in the habit of doing this a few times you
will have sufficient knowledge and will not have to spend time reading it from a book. This means you
can revise applied anatomy for the final FRCA in your day-to-day practice of anaesthesia.
It is good practice to draw some line diagrams of common anatomical structures which we come
across in day-to-day practice. The anatomy diagram should be practised and memorized. This not only
improves the performance but also has the advantage of increasing one’s confidence too.

Applied physiology
The understanding of anaesthesia is very much dependent on the knowledge of physiology. A safe
practice of perioperative medicine, anaesthesia, critical care, and pain is only possible when there is

sound knowledge of physiology. The different aspects of applied physiology could be explored leading
into the clinical manifestation of the disease and its management. A thorough understanding of
cardiorespiratory physiology is essential.

Applied pharmacology
The practice of anaesthesia is not possible without the knowledge of applied pharmacology. The
examinees are expected to be familiar with the applied pharmacology of all the commonly used drugs.
This includes the application of pharmacodynamics and pharmacokinetics. Individual patients could be
on multiple drugs and it is important to consider potential drug interactions. There has to be an
understanding of geriatric changes along with effects of disease processes on anaesthetic drug
administration, especially in critical care and pain management.
The number of drugs used in anaesthesia as such is limited. The drugs include anaesthesia induction
agents, neuromuscular blockers, volatile analgesics, and local anaesthetic drugs. Hence, as an
anaesthetist, there should be complete knowledge of these topics. Apart from this, the receptor
functions and hormones as drugs are also quite important. The understanding of pharmacodynamics
and pharmacokinetics is also a fair examination topic.
The pharmacological exam question also covers the principles of applied statistics and clinical trials
which are common in the anaesthetic literature. Fundamental understanding of basic statistics and clinical
research is expected. The current practice recommendations for the National Health Service come
generally come from National Institute for Health and Clinical Excellence (NICE) guidelines which help

xviii


Introduction

you to deliver the best practice. The understanding of evidence-based medicine based on an understanding
of the hierarchy of evidence, including evidence from meta-analysis, would be quite topical.

Applied physics

The anaesthetic speciality has evolved over the years based on various physical principles, hence the
knowledge of these represent a basic expectation from the examinee. It is important to understand
the basic principles of the gas laws, and at the same time it is important to demonstrate that there is
essential clinical awareness and safety implication.

General guide to the Structured Oral Examination
The SOE viva for the final FRCA is intended to test the understanding of the safe practice of anaesthesia.
Once the written part is completed, there is a time gap prior to the oral examination. It is very difficult,
and potentially stressful for some, to get motivated into the full swing of revision needed for the oral
examination when the result is not posted for the preceding written examination. In many instances,
2 weeks down the line when one discovers the results of the written examination, panic sets in and
one wonders how best to utilize the limited time appropriately. This book will equip you and help you
to prepare and organize your answers. The knack of passing examinations of this kind is to possess
techniques which enable one to appear knowledgeable, confident, and safe.
The preparation for the clinical oral examination normally begins when an examinee is aware of the
results of the written examination. This preparation is very simple as the examination is based on the
day-to-day practice of any trainee. Once the written examination is passed it is clear that the knowledge
has been tested but the application of this knowledge for the broad understanding of clinical anaesthesia
is also required. The other skills which are required are assessment of the patient, interpretation of
investigations, prioritization, planning of the management plan, good judgement, and communication.
These skills can be gained with clinical experience and specific preparation.
Such skills can largely be achieved with the planning of day-to-day clinical work, particularly if you
get into a habit of considering your normal theatre list as problem-based learning. So when you go to
see your patient preoperatively take some more time and carefully assess the patient, and look at the
investigations with a view to interpreting the results, including the radiograph. Summarize the case
with important issues and possible options of management. Then request a senior colleague to go
through the case and provide you with feedback. In doing so, you develop the all important presentation
skills which represent another facet of the examination.
Similarly, during the module in critical care you could take the opportunity to work-up a patient fully
and make sure you present such cases during the ward rounds. Regular examination of laboratory

results, assessment of ECGs, chest X-ray and magnetic resonance imaging (MRI) should be part of
your routine practice. You should specifically learn how to interpret and present the ECG and chest
radiograph. The cornerstone of clinical practice is effective communication and if this is repeated
regularly and routinely, it will improve the performance during a formal examination.
The time you have spent as a trainee gaining real experience, when combined with the knowledge
you have attained will equip you to answer most of the questions. However, it is very important to
communicate the confidence of your knowledge that will be needed to impress the examiners.

Structured Oral Examinations require a different
approach to revision
Some of the techniques that are very useful in preparation are summarized below.
A general idea of the syllabus and important core topics.
Problem-based learning.
z Case-based discussion.
z
z

xix


Introduction

Regular practice and discussion.
Reflective learning.
z Organizing your answer.
z
z

The syllabus for the final fellowship examination is vast and can be both very daunting and a
considerable task, but this book will help you with specific skills to get through this with a level of

confidence.
The book can be used as an examination guide for a single candidate or a group of candidates using
a question and answer pattern. This will enable candidates to assess their knowledge and skills within
the time limit, and will provide thorough revision for the examination which will enable the trainee to
identify their strengths and weakness in areas of clinical knowledge, clinical skills, problem solving, and
organization.
We sincerely hope that the information provided in this book will be beneficial to candidates
preparing for the final fellowship examination.

xx


Chapter 1
Clinical anaesthesia
Long case: A case for craniotomy 3
Short cases 8
Questions 8
Answers 9
Short case 1: Morbid obesity 9
Short case 2: Patient retrieved from house fire 11
Short case 3: Septic shock 14
Clinical science
Questions 19
Answers 20
Anatomy: Trigeminal nerve 20
Physiology: Lung volumes 22
Pharmacology: Thiopentone 24
Physics and clinical measurements: Electricity 26

1

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Clinical anaesthesia
Long case: A case for craniotomy
A 38-year-old male patient presented to his GP with visual disturbance. A head CT scan demonstrated
a tumour in the occipital region. He had one episode of seizure after the CT scan and needs an urgent
craniotomy for biopsy of the occipital lesion. His past medical history includes neurofibromatosis. He
smokes about 20 cigarettes per day and consumes alcohol in moderate to large amounts.
Clinical examination

Temperature: 38.2°C; weight: 85 kg; height: 160 cm
Pulse: 78/min, regular; BP: 138/70 mmHg; respiratory rate: 12/min
Chest: bilateral decreased air entry at bases, vesicular breath sound, wheeze
and crackles are heard on auscultation
Cardiovascular system: normal heart sound with no murmurs
Central nervous system: no neurological deficit apart from visual field defects

Laboratory investigations

Hb
MCV
WBC
Platelets
CRP

16.0 g/dL
109 fL

14.0 × 109/L
351 × 109/L
110

Pulmonary function tests

Na
K
Urea
Creatinine
Glucose

142 mEq/L
3.7 mEq/L
6.6 mmol/L
107 μmol/L
5.2 mmol/L

Alkaline phos.

400 IU/L

Predicted
FEV1

1.5 L

FVC

2.3 L

2.6 L
3.5 L

FEV1/FVC

65%

74%

QUESTIONS
1. Summarize the key features of this case.
2. What do you think—is this case elective or emergency?
3. How can you say someone is alcoholic? What is the recommended maximum weekly alcohol
intake?
4. Comment on the mean corpuscular volume (MCV).
5. What are the causes of high MCV?
6. Comment on alkaline phosphatase and C-reactive protein (CRP).
7. Discuss the chest X-ray.
8. Read the ECG.
9. What are the causes for the raised ST?
10. What do you see from the flow–volume loop of this patient?
11. What is the differential diagnosis for the cause of seizure in this patient?
12. What is the cause of right inferior homonymous hemianopia?

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Structured Oral Examination Practice for the Final FRCA

13. What other investigations would you need?
14. Will you proceed with the case?

Figure 1.1 Chest X-ray.

T

79
I

aVR

C1

C4

II

aVL

C2

C5

III

aVF

C3

C6

II

Figure 1.2 ECG.

4