2009, Paper 2 Vivas

Vivas in Order of Appearance
Viva 1

A 30 year old man  has  been  admitted to hospital  with  severe  multiple  injuries following a motor vehicle accident.

On day 2, his intracranial pressure has stabilised  and his head CT shows scattered punctate haemorrhage with subarachnoid blood, with no mass lesion requiring evacuation.   His pelvic fracture and  right tibial/fibula fracture have been managed  with external fixation and  a left leg femoral fracture has undergone open reduction and internal fixation.

He has been in good health, but had a DVT 3 years ago and is not on any regular medication.

Outline your approach to prophylaxis for venous thrombo-embolism in this patient.

The other questions focussed on priniciples of DVT prophylaxis, use of various agents in a variety of clinical situations, HITTS and management of DVT prophylaxis in TBI.

(Haematology and Oncology) - Pass rate ; highest mark .

Viva 2

You are reviewing an intubated and ventilated 35 year old 4 days following traumatic subarachnoid haemorrhage.  Overnight he has developed a temperature of 39.3 and has developed a new tachycardia of 130 beats/minute and has been commenced on noradrenaline for a low blood pressure (90 mm Hg systolic).

What could be the causes of fever in this man?

The rest of the viva focussed on evaluation of sepsis in a critically ill patient, interpretation of CSF results and biomarkers of sepsis.

(Infectious Disease Antibiotics and Sepsis) - Pass rate ; highest mark .

Viva 3

Aortic dissection: diagnosis and management

(Cardiothoracic Intensive Care) - Pass rate ; highest mark .

Viva 4

A 26 year old lady presents from home confused with a low-grade fever. Her blood pressure is
160/100. She has no gross motor deficits. Ten days ago she had an emergency termination of pregnancy for an intrauterine death that was complicated  by disseminated intravascular coagulation.  She was 32 weeks gestation and had been on labetalol for a pregnancy-induced hypertension. Her discharge medications included paracetamol, tramadol and a selective serotonin reuptake inhibitor. She has a 6-year history of uncomplicated Hepatitis  C.

What would you include in your differential diagnosis for her confusion and temperature?

The rest of the viva focussed on the evaluation and management of encephalopathy and DIC in the pregnant patient. .

Areas of weakness identified by examiners:

(Pregnancy, Obstetrics and Gynaecology) - Pass rate ; highest mark .

Viva 5

A 68 year old man had both legs trapped under a heavy concrete slab for 4 hours. He has just been admitted to the ICU, 8 hours post injury, following adequate resuscitation and definitive operative wound debridement. His observations are that he is, fully conscious, his blood pressure is 110/70 mmHg, pulse 86 beats/min  and respiratory rate 24 breaths/min. He is anuric, and has been for the past 3 hours.

Relevant blood results at that time are:

 

Venous biochemistry

Test

Value

Normal Range

Sodium

138 mmol/L

135 -145

Potassium*

7.1 mmol/L

3.5 - 4.5

Chloride

100 mmol/L

95 -105

Bicarbonate*

11 mmol/L

22 - 26

(Renal Failure and Dialysis) - Pass rate ; highest mark .

Viva 6

You are the Intensivist  on call, working with a new ICU Registrar who is in the first year of Advanced Training. This is your first shift with this trainee but your colleagues have found him/her to be competent. A 72-year-old lady, Mrs May Brown, has been admitted following a Medical Emergency Team call to the ward. On arrival of the MET team, May was deemed to be close to respiratory arrest and she was intubated by the ICU Registrar. Intubation was followed by cardiac arrest. After 10 minutes of unsuccessful resuscitation, a senior nurse questioned  the position of the endotracheal tube and it was discovered to be in the oesophagus. The tube was re-positioned correctly and after a further 10 minutes of resuscitation, return of spontaneous circulation was achieved and May was transferred to the ICU. She is currently requiring ventilation with Fi02 1.0, she is haemodynamically unstable  on an adrenaline
infusion at 1 mcg/kg/min and she has myoclonic jerks.

The ICU Registrar has been waiting for you to arrive to talk to you.

Areas of weakness identified by examiners:

(Communication and Ethics) - Pass rate ; highest mark .

Viva 7

Radiology station:  6 radiographs were shown including  chest X-rays, and  CT scans of head, chest and abdomen.

Areas of weakness identified by examiners:

•    Failure to identifiy common pathologies
•    Diagnosing PE on a CT chest where contrast had not been given.
•    Candidates did not always use the information given to them about each Xray eg CT abdomen post rectal contrast

Candidates did not recognise significant free intraperitoneal air on abdo CT.

(Radiology) - Pass rate ; highest mark .

Viva 8

Procedure station was about management of an obstructed airway.

Areas of weakness identified by examiners: 
•    Inability to clearly describe anatomical relationships

(Airway Management) - Pass rate ; highest mark .

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