FCA(SA) Part II

THE COLLEGES OF MEDICINE OF SOUTH AFRICA

Incorporated Association not for gain Reg No 1955/000003/08

Final Examination for the Fellowship of the

College of Anaesthetists of South Africa 31 August 2011 Paper 1 (3 hours)

All questions are to be answered. Each question to be answered in a separate book (or books if more than one is required for the one answer) Al die vrae moet beantwoord word. Elke vraag moet in n aparte boek (of boeke indien meer as een nodig is vir n vraag) geskryf word

With reference to the use of positive end-expiratory pressure (PEEP) in a ventilated adult patient in the intensive care unit, discuss the ways in which you would titrate PEEP with reference to the items numbered (a) to (f). Give the physiological background for your opinion concerning each item, showing the necessary calculations and/or figures, and explain how you would use the information to titrate PEEP a) Total body oxygen delivery. (5) b) Information derived from arterial and mixed venous blood gases, including applicable calculations. (40) c) Compliance of the lung. (20) d) The minimum inflexion point on the volume-pressure curve of the ventilator. (5) e) Dead space. (20) f) Pulmonary artery pressure. (10) [100] Bespreek die maniere waarop u positiewe eind-ekspiratoriese druk (PEED) sou titreer na aanleiding van die items hieronder genommer (a) tot (f) met verwysing na die gebruik van PEED in n geventileerde volwasse pasint in die intensiewe sorgeenheid. Gee die fisiologiese agtergrond vir u opinie by elke item, wys die nodige berekeninge en/of figure en verduidelik hoe u die inligting sal gebruik om PEED te titreer a) Heelligaam-suurstoflewering. (5) b) Inligting verkry uit arterile en gemeng-veneuse bloedgasse, insluitende toepaslikeberekeninge. (40) c) Vervormbaarheid van die long. (20) d) Die minimum infleksiepunt op die volume-drukkurwe van die ventilator. (5) e) Dooiespasie. (20) f) Pulmonale arteriedruk. (10) [100] You are asked to anaesthetise a twenty-five-year-old patient for a thoracotomy for a pleurectomy after development of a spontaneous pneumothorax. The patient is known to have Marfans syndrome a) List the expected clinical findings in this patient. (15) b) List your concerns regarding anaesthesia. (10)

c) d)

Outline your anaesthetic plan. (60) List the indications for, and complications of placement of a double lumen endotracheal tube. (15) [100]

U word versoek om narkose toe te dien aan n vyf-en-twintig-jarige pasint vir n torakotomie vir n pleurektomie na n spontane pneumotoraks. Die pasint is n bekende met Marfansindroom a) Lys die verwagte kliniese bevindings in die pasint. (15) b) Lys u probleme rakende narkose. (10) c) Omskryf u narkoseplan. (60) d) Lys die indikasies en komplikasies van die plasing van n dubbellumen endotrageale buis. (15) [100] a) Discuss the use of the arterial tourniquet during surgery, under the following headings i) Pathophysiological consequences. (40) ii) Tourniquet safe times and pressures. (10) Magnesium: an emerging drug in anaesthesia Write notes on magnesium and i) Analgesia. (10) ii) Obstetrics. (10) iii) Phaeochromocytoma. (5) iv) Neuroprotection. (10) v) Cardiac arrhythmias. (10) vi) Side effects. (5) [100] Bespreek die gebruik van die arterile toerniket gedurende chirurgie onder die volgende hoofde i) Patofisiologiese gevolge. (40) ii) Veilige toernikettye en drukke. (10) Magnesium: n Opkomende middel in narkose Skryf notas oor magnesium en i) Analgesie. (10) ii) Obstetrie. (10) iii) Feochromositoom. (5) iv) Neurobeskerming. (10) v) Kardiale disritmie. (10) vi) Newe-effekte. (5) [100]

b)

a)

b)

A 1,9 kg premature neonate with a ventriculoseptal defect and tracheooesophageal fistula is scheduled for the repair of the fistula a) Discuss the most important anaesthetic considerations in this neonate (40) b With regard to informed consent, how would you outline the potential risk to the parents, relevant to the surgery, anaesthetic and post-operative management? (10) c) Discuss the induction of anaesthesia and the possible strategies you may employ to ensure minimal stomach inflation during lung ventilation. (30) d) Outline possible causes of intraoperative desaturation and their prevention in this patient. (20)

[100] 4 n Prematuur 1,9 kg neonaat met n ventrikuloseptale defek en trageoesofageale fistel is geskeduleer vir herstel van die fistel a) Bespreek die belangrikste narkose-oorwegings by hierdie neonaat.(40) b) Betreffende ingeligde toestemming, beskryf hoe u die potensile risiko aan die ouers sal beskryf ten opsigte van die chirurgie, narkose en die postoperatiewe hantering? (10) c) Bespreek die induksie van narkose en die moontlike strategie wat u kan aanwend om minimale maaginsufflasie te verseker gedurende longventilasie. (30) d) Omskryf die moontlike oorsake van intraoperatiewe desaturasie en die voorkoming daarvan in hierdie pasint. (20) [100]

FCA(SA) Part II

THE COLLEGES OF MEDICINE OF SOUTH AFRICA

Incorporated Association not for gain Reg No 1955/000003/08

Final Examination for the Fellowship of the

College of Anaesthetists of South Africa 1 September 2011 Paper 2 (3 hours)

All questions are to be answered. Each question to be answered in a separate book (or books if more than one is required for the one answer) Al die vrae moet beantwoord word. Elke vraag moet in n aparte boek (of boeke indien meer as een nodig is vir n vraag) geskryf word

Describe anaesthesia for major liver resection under the following headings a) Preoperative assessment and risk stratification. (10) b) Appropriate anaesthesia techniques including perioperative monitoring (30) c) Fluid and transfusion management including coagulation support, blood conservation techniques, and monitoring. (50) d) Post-operative care including analgesic options. (10) [100] Bespreek narkose vir major lewerreseksie onder die volgende hoofde a) Preoperatiewe beoordeling en risikostratifikasie. (10) b) Toepaslike narkosetegnieke, insluitend perioperatiewe monitering. (30) c) Vloeistof en transfusiehantering, insluitend stollingsondersteuning, bloedkonserveringstegnieke en monitoring. (50) d) Post-operatiewe sorg insluitend pynverligtingsopsies. (10) [100] A 48-year-old female is presented for clipping of an anterior communicating cerebral artery aneurysm 3 days post subarachnoid haemorrhage. Discuss under the following headings a) Pre-operative assessment of this patient with reference to i) Classification and prognosis. (10) ii) Associated ECG abnormalities and their significance. (5) iii) Respiratory considerations. (10) b) The risk of cerebral vasospasm and its pathogenesis and management. (25) c) Intraoperative management with reference to i) Monitoring. (10) ii) Brain protection. (15) iii) Strategies to prevent rupture, and the anaesthetic management of an intraoperative rupture of the aneurysm. (25) [100] n 48-Jarige vrou presenteer vir klemming van n anterior kommunikerende serebrale arterie aneurisme 3 dae na n subarachnoidale bloeding. Bespreek onder die volgende hoofde a) Pre-operatiewe beoordeling van hierdie pasint met verwysing na

b) c)

i) Klassifikasie en prognose. (10) ii) Geassosieerde EKG-abnormaliteite en hul betekenis. (5) iii) Respiratoriese oorwegings. (10) Die risiko van serebrale vasospasma, en die patogenese en hantering daarvan. (25) Intraoperatiewe hantering met verwysing na i) Monitering. (10) ii) Breinbeskerming. (15) iii) Strategie om ruptuur te voorkom en die narkosehantering van n intraoperatiewe ruptuur van die aneurisme. (25) [100]

Discuss the paediatric patient with thermal burns under the following headings a) The pathophysiology of acute burns. (30) b) The initial resuscitation. (20) c) The management of the child with inhalational injury. (20) d) Anaesthetic management for acute burns surgery. (20) e) Briefly discuss anaesthetic considerations for reconstructive surgery (10) [100] Bespreek die pediatriese pasint met brandwonde onder die volgende hoofde a) Die patofisiologie van akute brandwonde. (30) b) Die inisile resussitasie. (20) c) Die hantering van die kind met inhalasiebrandwonde. (20) d) Narkosehantering van akute brandwondchirurgie. (20) e) Bespreek kortliks narkose-oorwegings by rekonstruktiewe chirurgie(10) [100] a) b) Briefly classify cardiomyopathies and give examples in each category. (25) A patient presents at 37 weeks gestation with dyspnoea and bilateral opacification on her chest radiograph. i) How would you establish the diagnosis? (30) ii) Discuss the pre-and intra-operative management of a patient with an established diagnosis of severe peripartum cardiomyopathy, who requires caesarean delivery. (45) [100] Klassifiseer kardiomiopatie kortliks en gee voorbeelde in elke kategorie. (25) n Pasint presenteer teen 37 weke gestasie met dispnee en bilaterale infiltrate op haar borskasfoto. i) Hoe sal u die diagnose bepaal? (30) ii) Bespreek die pre- en intra-operatiewe hantering van n pasint met n bevestigde diagnose van n erge peripartum kardiomiopatie en wat n keisersnit benodig. (45) [100]

a) b)

FCA(SA) Part II

THE COLLEGES OF MEDICINE OF SOUTH AFRICA

Incorporated Association not for gain Reg No 1955/000003/08

Final Examination for the Fellowship of the College of Anaesthetists of South Africa 2 September 2011 Paper 3 Data Interpretation - Pictures (3 hours)

All questions are to be answered. Each question to be answered in a separate book (or books if more than one is required for the one answer) Al die vrae moet beantwoord word. Elke vraag moet in n aparte boek (of boeke indien meer as een nodig is vir n vraag) geskryf word

CANDIDATE NUMBER
Question 3 / Vraag 3

Question 10 / Vraag 10 The picture below is a typical example of a somatosensory evoked potential (SSEP) obtained whilst monitoring the spinal cord during corrective spinal surgery. Die grafiek hieronder is n tipiese voorbeeld van n somatosensoriese uitgelokte potensiaal (SSEP) wat verkry is gedurende monitering van die spinaalkoord gedurende korrektiewe spinaalchirurgie.

Question 15 / Vraag 15 With reference to the x-ray below Met verwysing na die x-foto hieronder

Question 20 / Vraag 20

A routine preoperative ECG in an otherwise well 69-year-old gentleman is shown below n Roetine preoperatiewe EKG van n andersins gesonde 69-jarige man word hieronder vertoon

FCA(SA) Part II

THE COLLEGES OF MEDICINE OF SOUTH AFRICA

Incorporated Association not for gain Reg No 1955/000003/08

Final Examination for the Fellowship of the College of Anaesthetists of South Africa 2 September 2011 Paper 3 Data Interpretation (3 hours)

All questions are to be answered. Each question to be answered in a separate book (or books if more than one is required for the one answer) Al die vrae moet beantwoord word. Elke vraag moet in n aparte boek (of boeke indien meer as een nodig is vir n vraag) geskryf word

CANDIDATE NUMBER
Question 1 / Vraag 1 A 45-year-old female undergoes a transsphenoidal hypophysectomy for pituitary adenoma. 18-hours post operatively it is noted that she is passing copious volumes of urine (400 mL per hour). The laboratory results show: Urine SG <1.005, urine osmolality <200 mosmol/kg, serum sodium 145 meql/L and serum osmolality of 310 mosmol/Kg. n 45-Jarige vrou ondergaan n trans-sfenoiedale hipofisektomie vir n hipofiseadenoom. 18-ure postoperatief word daar opgemerk dat sy groot volumes urien passeer (400 mL per uur). Die laboratoriumresultate wys: Urien SG <1.005, urienosmolaliteit <200 mosmol/kg, serumnatrium 145 meql/L and serumosmolaliteit is 310 mosmol/Kg. a) a) What is the diagnosis? Wat is die diagnose? (1) (1)

b) b)

What is the natural history of this condition? Wat is die natuurlike verloop van die toestand?

(1) (1)

c) c)

What is the treatment of this condition? Wat is die behandeling van hierdie toestand?

(5) (5)

d) d)

What conditions other than that associated with pituitary resection may cause this abnormality? (3) Watter toestande mag hierdie abnormaliteit veroorsaak ander dan di geassosieerd met hipofise-chirurgie? (3)

[10] Question 2 / Vraag 2 A 4-month-old male child is admitted to a state hospital with a history of projectile vomiting of several days duration. The surgeon requests to take him to theatre immediately as an ICU bed has become available. The child is lethargic and the mother reports that the childs nappy has been dry for more than 12 hours. The following laboratory results are obtained: pH 7.50, PaCO2 49 mmHg, HCO3- 37 meq/L, Na+ 140 meq/L, K+ 2.9 meq/L, Cl- 87 meq/L n 4-Maande-oue seuntjie word opgeneem in n staatshospitaal met n geskiedenis van projektiele braking vir n paar dae. Die chirurg versoek om hom dadelik teater toe te neem omdat n ISE-bed beskikbaar geword het. Die kind is letargies en die moeder rapporteer dat die baba se doek droog is vir meer as 12 uur. Die volgende laboratoriumresultate is verkry: pH 7.50, PaCO2 49 mmHg, HCO3- 37 meq/L, Na+ 140 meq/L, K+ 2.9 meq/L, Cl- 87 meq/L a) a) What is the diagnosis? Wat is die diagnose? (1) (1)

b) b)

What is the acid-base disturbance? Wat is die suur-basisversteuring?

(1) (1)

c) c)

What is the explanation for these abnormal results? Wat is die verduideliking vir hierdie abnormale resultate?

(5) (5)

d) d)

Would you agree with the surgeon that the patient be taken to theatre immediately, and give a reason? (1) Stem u saam met die chirurg dat die pasint dadelik teater toe geneem moet word, en gee n rede? (1)

e) e)

What would be your course of action from presentation until the surgery? Wat sal u aksieplan wees vanaf presentering tot chirurgie?

(3) (3)

[10] Question 3 / Vraag 3 A 42-year-old previously healthy male patient presents with chest pain which is made worse by movement. An early diastolic murmur is noted in the aortic region. n 42-Jarige, voorheen gesonde man presenteer met borskaspyn wat vererger met beweging. n Vroe diastoliese geruis word gehoor oor die aorta-area. a) a) Describe the ECG. Beskryf die EKG. (4) (4)

b) b)

What is the ECG diagnosis? Wat is die EKG diagnose?

(1) (1)

c) c)

What are the possible aetiologies in this patient? Wat is die moontlike etiologie in hierdie pasint?

(5) (5)

[10] Question 4 / Vraag 4 A patient presents to hospital with the following scenario n Pasint presenteer by die hospitaal met die volgende beeld i) 60-Years of age with a history of binge alcohol consumption. i) 60-Jaar-oud met n geskiedenis van episodiese oormatige alkoholmisbruik. ii) Acute central abdominal pain, radiating to the back. ii) Akute, sentrale abdominale pyn wat versprei na die rug. iii) Serum values: iii) Serumwaardes: Na+ = 143 meq/L K+ = 5.1 meq/L Cl- = 98 meq/L Urea = 4.8 mmol/L Creatinine = 100 mol/L Amylase = 1200 U/L Calcium = 2.1 mmol/L Glucose = 15.2 mmol/L iv) Full blood count iv) Volbloedtelling Hb = 14 g/dL WCC = 14,000/mL Platelet count = 115 109/L v) Liver Enzyme Analysis v) Lewerensiemanalise AST = 130 IU/L ALT = 100 IU/L LDH = 1500 IU/L

a) a)

What is the likely diagnosis? Wat is waarskynlike diagnose?

(1) (1)

b) b)

Which of these factors indicates severe disease? Watter van hierdie faktore dui op ernstige siekte?

(3)

At 48 hours after admission the following is noted 48-Uur na opname word die volgende genoteer The patient has required 5 litres of Ringers Lactate, 1500 mL of hydroxyethyl starch and has received 2800 mL of other fluids with medication and parenteral nutrition. His urine output is 0.5 mL/kg/hour. Die pasint het 5 liters Ringerslaktaat benodig, 1500 mL hidroksie-etielstysel en het 2800 mL ander vloeistowwe ontvang saam met medikasie en parentrale voeding. Sy urienuitskeiding is 0,5 mL/kg/uur. Serum values Serumwaardes

Na+ = 135 meq/L K+ = 4.8 meq/L Cl- = 108 meq/L Urea = 7.6 mmol/L Creatinine = 160 mol/L Amylase = 800 U/L Calcium = 1.7 mmol/L

Full blood count Volbloedtelling Hb = 8 g/dL (no blood transfused) WCC = 15,000/mL Platelet count = 100 109/L Liver Enzyme Analysis Lewerensiemanalise AST = 132 IU/L ALT = 103 IU/L LDH = 1505 c) c) Which factors are suggestive of severe disease at this time? Watter faktore is op hierdie tydstip suggestief van ernstige siekte? (4) (4)

d) d)

What other test is strongly indicated to assess severity, and what results would suggest severe disease on this test? (2) Watter ander toets is sterk aangedui om die ernstigheidsgraad te beoordeel, en watter bevindinge sal op ernstige siekte dui met hierdie toets? (2)

[10] Question 5 / Vraag 5 a) a) Place the following signs of a fulminant malignant hyperthermia episode under general anaesthesia, in the time sequence in which they are likely to appear (5) Plaas die volgende tekens van n fulminerende maligne hipertermie episode tydens algemene narkose in die temporale volgorde waarin dit waarskynlik sal voorkom (5) - Rapid temperature rise. Vinnige temperatuurstyging. - Falling end-tidal oxygen content. Dalende endgety-suurstofinhoud. - Rising end-tidal CO2 content. Stygende endgety-CO2 inhoud. - Rapid rise in the temperature of the sodalime. Vinnige styging van die natronkalktemperatuur. - Sinus tachycardia. Sinustagikardie. - Ventricular arrhythmias. Ventrikulre disritmie. - Base excess > - 8 meq/L. Basisoormaat > -8 meq/L 1 2 3 4 5 6 7 b) b) List the differential diagnosis of this constellation of signs. Lys die differensile diagnose van hierdie groep tekens. (5) (5)

[10] Question 6 / Vraag 6 What are the causes of pulseless electrical activity in a cardiac arrest situation? Wat is die oorsake van polslose elektriese aktiwiteit tydens n kardiale arres? [10] [10]

Question 7 / Vraag 7 The following results are obtained from a thirty-year-old woman presenting for a laparoscopy for pelvic pain, complaining of tiredness and muscle weakness. The only other abnormality is a blood pressure of 195/120. Die volgende resultate is verkry van n dertigjarige vrou wat presenteer vir laparoskopie vir laeabdominale pyn. Sy kla van moegheid en spierswakheid. Die enigste ander abnormaliteit is n bloeddruk van 195/120. Na+ 137 meq/L, K+ 2.6 meq/L, urea 4.2 mmol/L, creatinine 99 mol/L, Hb 10 g/dL, platelet count 150 x 109 /mL. a) a) What is the likely diagnosis? Wat is waarskynlike diagnose? (1) (1)

b) b)

What is the underlying mechanism of this condition? Wat is die onderliggende meganisme van hierdie toestand?

(2) (2)

c) c)

What are the anaesthestic implications of this condition? Wat is die narkose-implikasies van hierdie toestand?

(3) (3)

d) d)

What is characteristic about the replacement of the deficient electrolyte? Wat is die tipies van die vervanging van die elektroliet wat tekort is?

(1) (1)

e) e)

What conditions may be associated with secondary hyperaldosteronism? Wat toestande mag geassosieer wees met sekondre hiperaldosteronisme?

(3) (3)

[10]

Question 8 / Vraag 8 The following results are obtained from a forty-year-old woman presenting for placement of bilateral nephrostomy catheters. She is known to suffer from stage 3 cervical carcinoma. Her blood pressure is 180/100, for which she receives a calcium antagonist: Na+ 130 meq/L, K+ 4.9 meq/L, urea 51 mmol/L, creatinine 532 mol/L, Hb 6.5 g/dL Die volgende resultate word verkry van n veertigjarige dame wat presenteer vir plasing van bilaterale nefrostomiekateters. Sy is bekend met stadium 3 servikskarsinoom. Haar bloeddruk is 180/100 waarvoor sy n kalsiumantagonis neem: Na+ 130 meq/L, K+ 4.9 meq/L, urea 51 mmol/L, creatinine 532 mol/L, Hb 6.5 g/dL a) a) What is the likely diagnosis? Wat is die waarskynlike diagnose? (1) (1)

b) b)

What are the anaesthetic implications of this condition? Wat is die narkose-implikasies van hierdie toestand?

(5) (5)

c) c)

What are the anaesthetic implications of positioning of this patient for the procedure? (4) Wat is die narkose-implikasies van die posisionering van hierdie pasint vir die proseduur? (4)

[10]

Question 9 / Vraag 9 The following results are obtained form a fifty six year old female patient, presenting for exploration of a neck mass: Die volgende resultate word verkry van n ses-en-vyftigjarige dame wat presenteer vir die eksplorasie van n nekmassa: Na+ 139 meq/L, K+ 4.8 meq/L, urea 7 mmol/L, creatinine 98 mol/L, Hb 13 g/dL, calcium 3.25 mmol/L, phosphate 0.70 meq/L. a) a) What is the likely diagnosis? Wat is die waarskynlike diagnose? (1) (1)

b) b)

What are the anaesthetic implications of this condition? Wat is die narkose-implikasies van hierdie toestand?

(6) (6)

c) c)

What complications might you need to address in the immediate post operative period? (3) Watter komplikasies mag u aandag benodig in die onmiddelike postoperatiewe periode? (3)

[10] Question 10 / Vraag 10 a) a) What part of the spinal cord does SSEP monitor? Watter deel van die spinaalkoord word gemonitor deur SSEP? (1) (1)

b) b)

How would the trace change with significant spinal cord ischaemia? Hoe sal die grafiek verander tydens betekenisvolle spinaalkoordisgemie?

(2) (2)

c) c)

What other factors can influence the SSEP during surgery? Watter ander faktore kan die SSEP gedurende chirurgie benvloed?

(4) (4)

d) d)

Which additional evoked potential can be used to monitor the spinal cord optimally? (1) Watter addisionele uitgelokte potensiaal kan gebruik word om die spinaalkoord optimaal te monitor? (1)

e) e)

How would this alter your anaesthetic technique? Hoe sal dit u narkosetegniek wysig?

(2) (2)

[10] Question 11 / Vraag 11

A 50-year-old patient is scheduled for removal of a floor of mouth tumour. He is otherwise well and asymptomatic. His blood results show a serum sodium of 120 meq/L. n 50-Jarige pasint is geskeduleer vir die verwydering van n mondvloertumor. Hy is andersins gesond en asimptomaties. Sy bloedresultate toon n serumnatrium van 120 meq/L. a) a) What is the most likely cause of the hyponatraemia? Wat is die waarskynlikste oorsaak van die hiponatremie? (1) (1)

b) b)

How would you manage this hyponatraemia? Hoe sal u hierdie hiponatremie hanteer?

(2) (2)

c) c)

What is Tumour Lysis Syndrome? Wat is Tumorlise-sindroom?

(4) (4)

d) d)

List 3 other paraneoplastic disturbances. Lys 3 ander paraneoplastiese versteurings.

(3) (3)

[10] Question 12 / Vraag 12 Concerning porphyria Betreffende porfirie a) a) Indicate the positions of the enzyme defects in Acute Intermittent Porphyria (AIP) and Variegate Porphyria (VP) on the pathway below. (2) Dui die posisies van die ensiemdefekte aan op die biosintetiese pad hieronder vir Akuut Intermitterende Porfirie (AIP) en Porfirie Variegata (VP). (2)

b) b)

What are the characteristic biochemical findings in AIP and VP? Wat is die karakteristieke biochemiese bevindinge in AIP en VP?

(2) (2)

c) c)

How may AIP and VP differ in their clinical presentation? Hoe kan AIP en VP verskil in hul kliniese beeld?

(1) (1)

d) d)

List in point form the key elements of management of an acute porphyric crisis. Lys puntsgewys die sleutelelemente in die hantering van n acute porfiriekrisis.

(5) (5)

[10] Question 13 / Vraag 13 With reference to the meta-analysis result below, which pertains to the incidence of sternal sepsis after cardiac surgery Met verwysing na die meta-analiseresultate hieronder wat handel oor die insidensie van sternale sepsis na kardiale chirurgie (Please note: DM = diabetes mellitus; NDM = non-diabetes mellitus)

Please explain the graphic notations which appear below the term risk ratio on the plot. Also explain what is meant by heterogeneity. Give your opinion on the conclusions which can be drawn from this particular diagram (Forest plot). (DM = diabetes mellitus, NDM = non-diabetes mellitus). Verduidelik asseblief die figuurinskrywings wat verskyn onder die term risk ratio op die grafiek. Verduidelik ook wat bedoel word met heterogeneity. Gee u opinie oor die gevolgtrekkinge wat gemaak kan word van hierdie spesifieke diagram (Forest plot). (DM = diabetes mellitus, NDM = non-diabetes mellitus).

[10] Question 14 / Vraag 14 Complete the table which compares the NYHA classification for exercise tolerance with more objective determinants of exercise tolerance. Give the value (or minimum and maximum) which would be equivalent to the NHA class. Voltooi die tabel wat die NYHA-klassifikasie vir oefeningstoleransie vergelyk met meer objektiewe bepalers van oefeningstoleransie. Gee die waarde (of minimum en maksimum) wat ekwivalent sal wees met die NYHA-klas. NYHA 1 VO2max METS EF

VO2max = maximum oxygen uptake (mL/kg/min); METS = metabolic equivalents; EF = ejection fraction. Question 15 / Vraag 15 a) a) What is the diagnosis? Wat is die diagnose?

[10]

b) b)

Note the reason(s) for your opinion. Gee die rede(s) vir u opinie.

[10] Question 16 / Vraag 16 a) a) Draw the left ventricular pressure volume curve for a patient with clinically significant mitral regurgitation. (6) Teken die linkerventrikel druk-volumekurwe vir n pasint met klinies betekenisvolle mitraalregurgitasie. (6)

b) b)

List the reasons for potential improvement of the symptoms of mitral regurgitation in pregnancy. (4) Lys die redes vir die potensile verbetering van mitraalregurgitasie-simptome tydens swangerskap. (4)

[10] Question 17 / Vraag 17 An adopted 12-year-old girl of African origin presents for cholecystectomy due to repeat episodes of gallstone colic. She appears well, but gives a history of repeated hospitalisation with abdominal pain, and had an abdominal organ removed 2 years previously, although her foster parents do not know why. Her full blood count and liver function tests are as follows n Aangenome, 12-jarige meisie van Afrika-oorsprong presenteer vir n cholesistektomie vanwe herhalende galsteenkoliek. Sy kom gesond voor maar gee n geskiedenis van herhalende hospitalisasies vir abdominale pyn en n abdominale orgaan is verwyder 2 jaar tevore, maar haar voogouers weet nie wat die rede was nie. Haar volbloedtelling en lewerfunksies is soos volg Hb 9.8 g/dL, MCV 82 fL, MCHC 27 g/dL, WBC 11.6 109/L, platelet count 468 109/L, reticulocyte count 12%, ALT 32 IU/L, alkaline phosphatase 67 IU/L, AST 41 IU/L, albumin 49 g/L, bilirubin (total) 53 mol/L.

a) a)

What do these results show? Wat wys hierdie resultate?

(2) (2)

b) b)

What is the underlying diagnosis? Wat is die onderliggende diagnose?

(1) (1)

c) c)

How might the diagnosis be confirmed? Hoe kan die diagnose bevestig word?

(1) (1)

d) d)

Which abdominal organ was removed 2 years previously, and why? Watter abdominale orgaan is 2 jaar tevore verwyder, en waarom?

(2) (2)

e) e)

What are the most important anaesthetic considerations for the planned surgery? (4) Wat is die belangrikste narkose-oorwegings vir die beplande chirurgie? (4)

[10] Question 18 / Vraag 18 Tabulate the differences between starches and gelatins. Tabuleer die verskille tussen die stysels en die gelatiene. [10] [10]

Question 19 / Vraag 19 a) a) Write down the Henderson-Hasselbalch equation. Skryf die Henderson-Hasselbachvergelyking neer. (2) (2)

b) b)

Define Stewarts Strong Ion Difference. Definieer Stewart se Sterk Ioonverskil (Strong Ion Difference).

(3) (3)

c) c)

Define the anion gap and its clinical use. Definieer die anioongaping en sy kliniese gebruik.

(2) (2)

d) d)

Briefly discuss the clinical relevance of a hyperchloraemic metabolic acidosis. (3) Bespreek kortliks die kliniese relevansie van n hiperchloremiese, metaboliese asidose.(3)

[10] Question 20 / Vraag 20 a) a) What is the abnormality? Wat is die abnormaliteit? (3) (3)

b) b)

What are the causes of axis deviation on an ECG? Wat is die oorsake van as-deviasie op n EKG?

(7) (7)

[10]