Trigger

You an anaesthetics resident working in a major tertiary hospital. Your first patient for the day is Alex, a 35 year old man who is booked for an emergency laparascopic appendicectomy. Your consultant has asked you to meet Alex in his holding bay and conduct a pre-anaesthetic assessment.

Tasks

1. Take a targeted history from Alex.
2. Demonstrate a targeted clinical examination including an airway assessment.
3. Outline any investigations you would like to order.
4. Assess Alex’s suitability for theatre this afternoon.

Please note the following…

• You do not need to confirm his diagnosis of acute appendicitis.
• Written findings will be provided at the end of your examination.
• You do not need to consent Alex for anaesthesia.

Actor’s Script

You are Alex, a well 35 year old gentleman who is scheduled to have a laparoscopic appendicectomy this afternoon.

Airway Questions

• No loose teeth or dental work
• You do not wear a denture

HOPC

• Not currently in any pain (nurses on the ward gave you medication already)

PMHx

1. Asthma
   • Currently on Symbicort 1 puff BD
   • Using Ventolin once every few weeks
   • No hospitalisations for asthma ever
   • No history of reactions to NSAIDs
2. Depression
   • Taking escitalopram 10mg mane
   • Known to your GP, nil other providers

Regular Medications

• Escitalopram 10mg mane
• Symbicort 1 puff BD

Anaesthetic History

1. GA for right total knee replacement two years ago
   • Vomited for the entire day after surgery
   • Can’t recall any other issues
2. GA for tonsillectomy in childhood
   • Can’t remember any details

Family History

• No family members have had issues with anaesthesia

Social History

• Smoking: previously smoked about one pack per day, but quit two years ago
• Alcohol: social drinker
• Drugs: previously used cannabis, but haven’t used in over ten years
• Employment: bricklayer

Resources

Examination Findings

General

• BMI ~30
• No increased in work of breathing
• Speaking in full sentences

Airway

• Normal neck circumference
• Bearded
• Normal jaw opening
• Normal jaw protrusion
• Normal thyromental distance
• Mallampati 2

Breathing

• Vesicular breathing sounds posteriorly
• Equal symmetrical expansion of upper and lower thorax

Circulation

• Regular peripheral pulses
• ~75 bpm

Airway Example

Marking Key

Introduction

• Introduces name and role to patient
• Washes hands
• Identifies patient

History

• Confirms operation and mode of anaesthetic
• Asks about recent illnesses
• Explores PMHx
• Explored past anaesthetic history AND asks for complications
• Regarding asthma: confirms stability, severity, risk factors, complications, treatments
• Assesses METs (flights of stairs)

Examination

Provide Mallampati photo and ask the candidate which one they are.

• Correctly identifies Mallampati 2 airway

Investigations

Discussion

Examiner’s Questions

1. What are the risk factors for post-operative nausea and vomiting?
   • Candidate lists at least four of the following…
   • Non-smoker
   • Female sex
   • History of PONV
   • Inner ear surgery
2. Briefly explain the Mallampati classifications of the airway.
   • Candidate is able to accurately describe the four following Mallampati classes…
   • Class I: soft palate, uvula, fauces, pillars
   • Class II: soft palate, most of the uvula, fauces
   • Class III: soft palate, base of uvula
   • Class IV: hard palate only

Global Score