Anaesthesiology 💉

A female patient, approximately 38 years old, underwent an appendectomy under spinal anaesthesia. While recovering in the postoperative room, she experiences a severe, pulsating headache accompanied by neck tension whenever she attempts to sit up or raise her head from a lying position. The pain subsides when she lowers her head back down. She also reports nausea and sensitivity to light. Her vital signs are as follows: temperature of 36.8°C, blood pressure of 94/65 mmHg, respiratory rate of 14 breaths/minute, and pulse rate of 93 beats/minute. There is no abdominal pain or guarding observed. Intravenous fluids and simple analgesics were administered to alleviate the pain. What would be the most appropriate next step in managing this condition?

A 67-year-old man presents at the Accident and Emergency department with acute onset of breathlessness. He has a smoking history equivalent to 20 pack years and has previously been diagnosed with chronic obstructive pulmonary disease (COPD). On examination, he is not running a temperature, his heart rate is 110 beats per minute, his respiratory rate is 28 breaths per minute, his blood pressure is 110/70 mmHg, and his oxygen saturation (SpO2) level is 80%. Respiratory examination reveals the use of accessory muscles of respiration and bilateral wheezing. He is immediately started on oxygen with FiO2 24% via Venturi face mask, along with nebulised salbutamol, ipratropium, and IV hydrocortisone 100mg. After initial treatment, the SpO2 is 82%. An arterial blood gas (ABG) analysis is performed and the results are as follows:

– pH: 7.30 (normal range: 7.35-7.45)

– PaO2: 7 kPa (normal range: 10-14 kPa)

– PaCO2: 6.5 kPa (normal range: 4.7-6.0 kPa)

– Bicarbonate: 25 mmol/L (normal range: 22-26 mmol/L)

A chest X-ray is performed, which shows bilateral hyperinflated lungs. What is the next appropriate treatment for this patient?

A 48-year-old woman undergoes an open hysterectomy to address her fibroids. Postoperatively, she receives morphine for pain relief. Four hours after the procedure, she experiences drowsiness and difficulty in being awakened. The patient has an indwelling catheter, and her urine output is measured at 20 ml/hour. Her vital signs include a temperature of 37.1°C, heart rate of 78 beats per minute, respiratory rate of 8 breaths per minute, blood pressure of 110/70 mmHg, and oxygen saturation of 96%. There are no signs of abdominal distension. What is the MOST LIKELY cause for her symptoms?

A 33-year-old female who is 17 weeks pregnant arrives at the Emergency Department. She has a history of epilepsy and is currently on medication for it, although she has been non-adherent and missed taking her medication for the past 4 days. Earlier this morning, she experienced a tonic-clonic seizure that lasted for 4 minutes and was transported to the hospital by ambulance. She has established IV access. While awaiting medical attention, she begins to have another generalized tonic-clonic seizure. Which of the following is the MOST appropriate course of action?

A 43-year-old man was admitted to the hospital ward, and Hartmann solution was administered through a peripheral intravenous cannula. After thirty minutes, his upper limb became swollen, soft to the touch, and cool. He reported pain at the puncture site, but there was no discoloration of the skin. What is the most appropriate course of action?

A 42-year-old man recently underwent open inguinal hernia repair a few hours ago. He started experiencing a headache a few hours after the surgery. The headache worsens when he is upright and improves upon lying down. The procedure was performed under spinal anesthesia. Upon examination, the patient is afebrile, with a heart rate of 87 beats per minute, blood pressure of 130/70 mmHg, and SpO2 level of 96%. He has a history of hypertension and ischemic heart disease and is currently on medications for both conditions. The patient was advised to lie down in his preferred position, and paracetamol was administered, which provided some relief from the headache. He is able to tolerate oral fluids. What is the MOST appropriate next step?

A 22-year-old man was brought to the Accident & Emergency department by paramedics following a suicide attempt by jumping from an overpass. The paramedics noted obvious deformities in both of his lower extremities. Upon arrival, he was in pain but had normal vital signs. X-rays revealed bilateral mid-shaft femur fractures and a left tibial shaft fracture. The patient underwent open reduction surgery and was placed in bilateral distal femoral traction with a left long-leg splint. The day after surgery, his condition deteriorated rapidly, with a decreased level of consciousness and the following recorded observations:

Heart rate: 140 beats per minute

Oxygen saturation: 80% on room air

Temperature: 38.2°C

An arterial blood gas (ABG) test was performed with the following results:

pH: 7.47 (normal range: 7.35-7.45)

pCO2: 3.8 kPa (normal range: 4.7-6.0 kPa)

pO2: 7.3 kPa (normal range: 10-14 kPa)

Intubation improved his hypoxemia, and an ECG showed sinus tachycardia. What is the MOST likely cause of the deterioration of his condition after surgery?

A 30-year-old man who was rescued from a burning building arrives at the Emergency Department in an unconscious state. There are no apparent burns or external injuries observed. The patient’s heart rate is 135 beats per minute, and his blood pressure measures 85/55 mmHg. What is the MOST SUITABLE course of action?

A man in his early 60s was brought to the Emergency Department following a road traffic accident. The patient’s blood pressure is recorded as 80/40 mmHg, respiratory rate is 39 breaths/minute, and oxygen saturation is 88%. He presents with bruises on his chest, asymmetrical chest wall movement, labored breathing, accessory muscle use, and fluctuating levels of consciousness. What is the MOST appropriate initial course of action?

A 26-year-old individual who is a heroin addict was discovered unconscious on the floor of their kitchen. It was determined that the gas stove in the kitchen was left turned on. Paramedics brought the individual to the hospital, where they have regained consciousness but remain confused and disoriented. The person’s skin appears flushed, and their pupils are dilated and equal on both sides. Their blood pressure is 120/70 mmHg, and their heart rate is 90 beats per minute. What is the MOST appropriate course of action?

A 49 year-old man had a colectomy with an ileostomy 3 days ago as part of the management of his ulcerative colitis. He complains of nausea and has started vomiting over the past 4 hours. He looks drowsy. Due to his pain, he has been taking intravenous morphine. He has a temperature of 37.7°C, heart rate of 80 beats/minute and a respiratory rate of 6 breaths/minute. On examination, he has decreased bowel sounds. He has generalised abdominal tenderness with distention. Blood test have been requested which show the following:

Haemoglobin 142 g/L (130-180)

White cell count 10 x 10″/L (4-11)

Platelets 320 x 109/L (150-400)

Sodium 141 mmol/L (135-145)

Potassium 3.5 mmol/L (3.5-5)

Calcium 2.42 mmol/l (2.1-2.6)

Urea 3 mmol/L (2.0-7)

Creatinine 92 μmol/L (70-150)

eGFR >90 mL/min

CRP 38 mg/L (<10)

What is the SINGLE most likely reason for his presentation?

An anesthesiologist initiated the induction of anesthesia and intubated a patient scheduled for a laparoscopic cholecystectomy. Shortly after intubation, the following readings were observed:

– SpO2: 81% on 100% oxygen

– Capnography ETCO2: 0%

What would be the most appropriate course of action?

A 50-year-old man with breathing difficulties and confusion is brought to the Emergency Department by paramedics. He has a medical history of COPD and regularly uses salbutamol inhalers and triple therapy consisting of beclometasone, formoterol, and tiotropium. Upon assessment in the A&E department, his Glasgow Coma scale is reported as 11 out of 15. His body temperature is measured at 38.1°C, heart rate at 106 beats per minute, respiratory rate at 9 breaths per minute, and oxygen saturation at 83%. Oxygen therapy has been initiated through a venturi face mask at 40%. Breath sounds are diminished. An arterial blood gas analysis yields the following results:

– pH: 7.10 (normal range: 7.35-7.45)

– PaO2: 8 kPa (normal range: 10-14)

– PaCO2: 12 kPa (normal range: 4.7-6.0)

– Bicarbonate: 30 mmol/l (normal range: 22-26)

Which of the following management options is the MOST appropriate?

A 24-year-old man arrives at the Emergency Department after experiencing a generalized tonic-clonic seizure that has lasted for the past 30 minutes. His airways have been secured, and his oxygen saturation (SpO2) is currently at 98%. A capillary glucose test shows a reading of 4.4 mmol/L. The patient already has intravenous access and has received two doses of intravenous lorazepam, but the seizures persist. According to his partner, he takes sodium valproate for his epilepsy. What is the MOST appropriate management option in this case?

A 70-year-old woman is experiencing sudden shortness of breath that has developed over the past 24 hours. Two weeks ago, she underwent intramedullary nailing for a right femur fracture and has been bedridden since then. She has a medical history of metastatic breast cancer. Presently, her temperature is 37.1°C, heart rate is 125 beats per minute, blood pressure is 110/80 mmHg, respiratory rate is 30 breaths per minute, and oxygen saturation is 81% on room air. An ECG reveals sinus tachycardia. An arterial blood gas (ABG) test was performed, and the results are as follows:

– pH: 7.46 (normal range: 7.35-7.45)

– pCO2: 3.8 kPa (normal range: 4.7-6.0 kPa)

– pO2: 7.3 kPa (normal range: 10-14 kPa)

What is the MOST likely diagnosis in this case?

A 28-year-old woman undergoes elective surgery under general anesthesia. The induction and maintenance agents used are propofol, sevoflurane, and remifentanil. After initial assisted ventilation during induction, she is switched to an intermittent positive pressure ventilation (IPPV) circuit. Following this, her heart rate and blood pressure rapidly decrease to 45 beats per minute and 75/35 mmHg, respectively. She has an ongoing infusion of Hartmann’s solution. The anesthetist administers successive IV boluses of ephedrine hydrochloride, resulting in normalization of her vital signs. However, she remains unconscious. What is the MOST likely diagnosis?

A 55-year-old man is being evaluated in the pre-operative clinic for an upcoming open rotator cuff surgery under general anesthesia. His medical history includes hypertension, hypercholesterolemia, hiatus hernia, and asthma. His regular medications consist of amlodipine, lisinopril, atorvastatin, beclomethasone inhalers, and omeprazole. Which of the following medications would be MOST appropriate to omit on the day of surgery?

A 34-year-old female patient has undergone a successful cholecystectomy and is currently receiving intravenous morphine for postoperative pain management. Shortly after receiving her second dose of morphine, the nurse observes that she has become unresponsive. Examination of her pupils reveals bilateral symmetrical miosis. She has a respiratory rate of 6 breaths per minute, with reduced chest movements. Air entry is equal, and there are no abnormal sounds upon auscultation. No other abnormalities are found during a systems examination. What is the MOST appropriate next step in management?

A 30-year-old patient is brought to the emergency department following a road traffic accident. The patient presents with multiple bruises on the chest and an area of paradoxical rib movement. A chest X-ray reveals a right-sided pulmonary contusion. The patient’s vital signs include a pulse rate of 129 beats per minute, blood pressure of 100/70 mmHg, and respiratory rate of 33 breaths per minute. Additionally, the patient experiences severe chest pain and dyspnea. What is the BEST single management option for this patient’s condition?

An 18-year-old female presents to the Emergency Department with a generalized tonic-clonic seizure that has lasted for 20 minutes according to eyewitness accounts. High-flow oxygen is administered, and her oxygen saturation (SpO2) is currently at 97%. She has already received two doses of rectal diazepam, but the seizures have not ceased. What is the MOST appropriate single management option in this case?

A 10-year-old boy is brought to the Emergency Department unconscious after falling down a flight of stairs while playing with his brother. The incident occurred half an hour ago, and he has not regained consciousness since. The nurse has connected him to a monitor, which shows a heart rate of 90 beats per minute, blood pressure of 126/70 mmHg, and respiratory rate of 11 breaths per minute. What is the SINGLE most appropriate initial management?

A 53-year-old woman is being evaluated for surgery under general anesthesia. She is currently taking metformin for type 2 diabetes mellitus, candesartan and amlodipine for hypertension, and levothyroxine for hypothyroidism. Recently, she started taking omeprazole for gastritis. Her blood tests indicate an estimated glomerular filtration rate (eGFR) of 90 mL/min (>90). Which medication should be discontinued before the surgery?

An 81-year-old woman has undergone a successful open reduction and internal fixation of her femur. Following the procedure, the nurse notices that she has become unresponsive with agonal respiration. The nurse maintains her airway using a jaw-thrust maneuver and initiates oxygen administration via a face mask. The patient has a respiratory rate of 8 breaths per minute with reduced chest movements, equal air entry, and no adventitious sounds on auscultation. Her blood pressure is 110/70 mmHg, heart rate is 60 beats per minute, and oxygen saturation is 96% on 15 liters of oxygen. An arterial blood gas analysis shows the following results:

– Hemoglobin: 111 g/L (115-160)

– pH: 7.25 (7.35-7.45)

– PaO2: 8.5 kPa (10-14)

– PaCO2: 7.8 kPa (4.7-6.0)

– Bicarbonate: 23 mmol/L (22-26)

What is the MOST appropriate next management step?

A 36-year-old man who was rescued from a burning building arrives at the Emergency Department with symptoms of headache, vertigo, nausea, vomiting, confusion, and weakness. Upon arrival, he appears drowsy and less responsive compared to when he was initially found. There are no visible burns or external injuries on him, and he does not smoke. His vital signs show a temperature of 36.7°C, heart rate of 104 beats per minute, blood pressure of 100/64 mmHg, respiratory rate of 28 breaths per minute, and oxygen saturation of 100% on room air. Further tests, including arterial blood gas analysis, reveal the following results:

– pH: 7.25 (normal range: 7.35-7.45)

– PaO2: 4 kPa (normal range: 10-14)

– PaCO2: 9.0 kPa (normal range: 4.3-6.0)

– Bicarbonate: 16 mmol/L (normal range: 22-26)

– Lactate: 7 mmol/L (normal range: 2-4)

– Base excess: -4 mmol/L (normal range: ±2)

– Carboxyhemoglobin: 12% (normal range: < 2%)

Which of the following is the most appropriate management option?

A 72-year-old woman collapses in front of her son and is unable to stand, showing weakness on her right side. The son calls the paramedics, and upon arrival at the A&E, the woman has a Glasgow Coma Scale (GCS) score of 13/15 and exhibits right-sided weakness. Within an hour, her GCS drops to 8/15, and she becomes increasingly agitated. Which of the following is the most appropriate next course of action?

A 31-year-old woman experiences a gradual onset headache spanning from the back to the front of her head, occurring 48 hours after undergoing a caesarean section due to a failed induction of labor. The headache is felt on both sides and worsens when she stands but improves when she lies down. She also reports feeling nauseous but denies any visual disturbances. Her vital signs show a temperature of 36.7°C, heart rate of 70 beats per minute, blood pressure of 110/70 mmHg, respiratory rate of 15 breaths per minute, and oxygen saturation of 99%. Urinalysis reveals trace protein and 1+ blood. What is the most likely diagnosis?

A 45-year-old man with a history of epilepsy is brought to the hospital by ambulance due to an ongoing generalized tonic-clonic seizure that lasted for 40 minutes. On arrival, his Glasgow Coma Scale (GCS) is 7. He exhibits noisy breathing and appears cyanosed. He starts seizing again, and he has intravenous access. What is the most appropriate initial management?

A 10-year-old child who has been rescued from a house fire is brought to the hospital by ambulance. The child has soot in their mouth and is experiencing difficulty breathing. What is the most appropriate management in this situation?

A 33-year-old man involved in a road traffic accident is admitted to the intensive care unit with multiple injuries to his abdomen, pelvis, and thighs. Imaging reveals a right femoral shaft fracture. He is intubated and scheduled for open reduction and internal fixation of the femur. A few hours after admission, his oxygen saturation drops from 99% to 90% and his blood pressure decreases from 120/80 mmHg to 80/40 mmHg. Upon examination, decreased air entry is noted on the left side of his chest, and higher ventilator pressures are required to achieve the target tidal volume. What is the most likely diagnosis in this case?

A 40-year-old man is brought to the Emergency Department after experiencing a seizure at a family gathering. His seizure has been ongoing for the past 35 minutes, and he has not regained consciousness during this time. Recognizing this as a case of status epilepticus, intravenous lorazepam was administered without effect. The decision is made to start the patient on phenytoin. The patient weighs 100 kg and requires a dose of 20 mg/kg of phenytoin at a rate of 50 mg/min. What is the duration of time over which phenytoin must be administered?

A 31-year-old man is knocked down during a fight in the waiting room of the Emergency Department and is now unconscious and unresponsive. What is the most important first action to take in this situation?

A 58-year-old man who is scheduled for an elective inguinal hernia repair is currently taking 10 mg of oral prednisolone daily to manage his symptoms of polymyalgia rheumatica. He has been on this dose for the past 4 weeks. What is the most appropriate advice regarding his prednisolone?

A 44-year-old man is found unconscious in a burning building and is brought to the Emergency Department by paramedics after being rescued by the fire department. He shows no evidence of burns or external injuries. His heart rate is 115 beats per minute, respiratory rate is 25 breaths per minute, and blood pressure is 105/75 mmHg. His oxygen saturation is 96% on room air, and he is confused. Vesicular breath sounds are present, and his airways are patent. What is the most appropriate management in this case?

A 39-year-old woman is scheduled for an elective lumpectomy under general anesthesia for suspected breast cancer. Her surgery is scheduled for 11 am. She had her breakfast, including a milky coffee, at 7 am and continued with clear fluids until 10 am. What is the most appropriate action in this situation?

A 33-year-old woman undergoing a laparoscopy for the investigation of endometriosis experiences a drop in blood pressure and heart rate shortly after insufflation of carbon dioxide for pneumoperitoneum. Her blood pressure decreases from 120/70 mmHg to 80/45 mmHg, and her heart rate drops from 70 beats per minute to 35 beats per minute. Her peripheral oxygen saturation (SpO2) remains at 98%. What is the most appropriate next step in this situation?

A 24-year-old man arrives at the emergency department with partial thickness burns all over his body from a house fire. He exhibits a persistent cough, stridor, deep neck burns, carbonaceous sputum, and soot in the mouth, along with edema of the oropharynx. What is the most appropriate management in this case?