Australian and New Zealand College of Anaesthetists

Final Fellowship Examination Report – May 2014

General Comments
Candidates should be aware that whilst the exam is not held at the absolute end of their
training, the standard expected across all aspects of the exam is that of someone ready to
commence independent specialist practice; it functionally is an exit exam.

As all aspects of the curriculum are examinable, trainees are advised their best chance of
success is to sit the exam when their clinical experience / exposure matches their theoretical
knowledge.

Candidates and trainees are also reminded that memorising questions from the exam, in
particular the MCQ paper, and posting them on the “black bank” would be a breach of their
training agreement with the College and of ANZCA intellectual policy.

The mark allocation for the examination is as follows:

Performance
Section FANZCA Vivas only
assessment
MCQ 20
SAQ 20 20 (25%)
Medical Clinical 12 12 (15%) 12 (20%)
Anaesthesia vivas 48 48 (60%) 48 (80%)
Total 100 80 (100%) 60 (100%)

The pass rates for candidates presenting for the Final Fellowship in March-May 2014 are
presented below:

Category MCQ SAQ Medical Viva Overall

No. sitting 206 206 206 190 159
ANZCA Trainees
% pass 75.1% 58.3% 81.6% 86.3% 77.2%

No. sitting 7 7 7 6 2
IMGS – Full FFE
% pass 85.7% 0% 28.6% 33.3% 28.6%

IMGS – Performance No. sitting 6 6 6 1

Assessment % pass 0% 50.0% 33.3% 16.7%

No. sitting 7 7 3
IMGS – No written
% pass 42.9% 28.6% 28.6%

No. sitting 213 219 226 170 164

Total
% pass 75.1% 53.1% 77.9% 81.3% 72.3%

Multiple Choice Questions

Of the candidates who sat multiple choice questions (MCQ) section 75.1% passed.

The above histogram shows the distribution of candidates overall scores in the MCQ paper.

Each question is of the one best answer type; no marks are deducted for incorrect answers.

The table below outlines the number of questions in each subject category (noting that an
individual question may have more than one subject). Only subjects represented in four or
more questions are listed. The subject spread in the MCQ paper varies from exam to exam,
as it is partly determined by the content of the short answer and viva sections of the exam, to
ensure that an appropriately wide range of subjects is covered by the whole examination.

Topic Number of questions Percentage (%)

PA Paediatrics 13 8.67

PO Cardiovascular disorders 12 8.00

AM Airway Management 10 6.67

SQ Equipment 10 6.67

PO Neurological, Neuromuscular 9 6.00

GS Monitoring 7 4.67

GS Pharmacology 7 4.67

OB Obstetrics 7 4.67

PM Acute Pain 6 4.00

PO Haematol/ oncology, anticoa 6 4.00

RT Periop Crises 6 4.00

RT Trauma 6 4.00

TS Thoracics 6 4.00

CS Cardiac surgery 5 3.33

PO Metabolic & Endocrine 5 3.33

PO Respiratory disorders 5 3.33

RA Regional Anaesthesia 5 3.33

RA Regional Anatomy 5 3.33

SQ Safety 5 3.33

SQ Scientific Enquiry 5 3.33

GG GI Surg 4 2.67

NS Neurosurgery 4 2.67

PO Gastrointestinal disorders 4 2.67

PO Perioperative Investigation 4 2.67

RT Arrest Resuscitation 4 2.67

RT Shock/Haemorrhage 4 2.67

Short Answer Questions

Of the candidates who sat this short answer question paper (SAQ) section, 53.1%
passed.

The average mark per question was 5.04/10.

The above histogram shows the distribution of overall marks of candidates that took the SAQ
component of the exam.

All questions are worth equal marks. The SAQ section tests a combination of knowledge
[content] and reasoning skills, above that tested by the MCQ section. The material covered is
mapped to the curriculum.

It is recognised that preparation and performance for this section is demanding. Candidates
are advised that practicing answering SAQ questions under exam conditions is a valuable
method of preparation for this section of the exam. For this exam the SAQ paper was taken in
the morning of the “written” day.

Of all the sections of the exam, the SAQ shows the best correlation with each other section of
the examination and the examination overall.
Responses that specifically answer the specific question asked require less time to write.

Writing must be legible and abbreviations should be avoided unless explained in the body of
an answer.

Logical, well-organised, clearly expressed answers that reflect safe practice, defensible
judgment and evidence-based practice attract higher marks.

The examiners acknowledge that there is often a great deal that the candidates can offer in
response to some of the short answer questions. Part of the challenge of this section is to
manage time and rank information that is included.

SAQ Topic % Pass

1 Advantages/disadvantages of paediatric circle system vs Jackson-Rees 23.3%
modification of Ayres T-piece
2 Anaesthetic implications of Arrhythmia ablation procedure 55.3%
3 Quality improvement programe to address late OR starts 65.8%
4 Chronic AF on warfarin for elective surgery 60.3%
5 Elective bariatric surgery; airway and hypoxia management/prevention 87.2%
6 Chest pain in PACU post fem-pop bypass 57.1%
7 CVC insertion – sepsis prevention 43.4%
8 Mid thoracic epidural – relevant anatomy and postop leg weakness 71.2%
9 Pneumoperitoneum: pathophysiology of effects and management to 96.8%
avoid.
10 Steps to ensure safe storage, handling and administration of blood once 55.7%
in the OR
11 Use of vasoconstrictors in myocutaneous free flap surgery 61.6%
12 Shoulder surgery in the beachchair position – problems and 44.3%
management
13 Acromegaly and pituitary surgery 77.2%
14 Ventilator acquired pneumonia in ICU patients 28.%
15 C5-6 quadriplegia – anaesthetic management for urological procedure 75.3%

Question 1

Outline the advantages and disadvantages of using the paediatric circle system and the
Jackson-Rees modification of Ayre’s T-piece (Mapleson F) for anaesthesia in a 15 kg child.

23.3% of candidates passed this question.

Key components of an answer for this question required candidates to

Demonstrate adequate understanding of each system.

Should mention:
Resistance – valves
Dead space
Fresh gas flows

Better candidate will mention: Humidification, scavenging, weight/bulk, provide more detailed
understanding / explanation and point out there is less difference between contemporary
systems.

Question 2

An otherwise well 35-year-old woman is scheduled for ablation of an accessory atrio-

ventricular pathway in the Cardiac Electrophysiology laboratory.

What are the implications for anaesthesia and how would you manage them?

55.3% of candidates passed this section.

Key components of an answer for this question related to providing an understanding of the
main problems and an approach to prevention and management. As a minimum, mention of
likely duration of procedure, location [isolated] and possible intra- and post-procedural life
threatening complications was expected.

Question 3

Operating theatres starting late have been identified as a problem in your hospital.

How would you design and implement a quality improvement program to assess and improve
operating theatre starting times in your hospital?

65.8% of candidates passed this section.

Key components of an answer for this question related to demonstrating the important steps
in such a program – planning, implementation, review and standard setting with relevance to
late start times.

Question 4

A patient with chronic atrial fibrillation on warfarin is scheduled for elective surgery.

Outline how you decide if bridging therapy is needed? (70%)

Describe how you would bridge anticoagulation if necessary. (30%)

60.3% of candidates passed this question.

As a minimum, candidates were expected to be able to demonstrate understanding of

balancing risk of thrombosis versus bleeding, therefore should:
1. Mention patient and surgical factors:
Under patient factors
 AF in the absence of other co-morbidities is low risk for bridging (AHA/ACC
guidelines)
 CHADS2
Under surgical factors – mention high / intermediate / low risks

2. Principles of Bridging
Cease warfarin 5 days pre-op
Usually bridge with LMWH – mention dose range from prophylactic to therapeutic
If using therapeutic dose – cease 24 hours pre-operatively
If using prophylactic dose – cease 12 hours pre-operatively

Question 5

A 40 year-old male is scheduled for elective bariatric surgery.

For this patient:

List the important features of history and examination that may identify a potentially difficult
airway. (30%)

How could you modify your anaesthetic technique to minimise hypoxia at induction. (70%)

87.2% of candidates passed this question.

As a minimum, answers should mention:

- historical issues like previous anaesthetic problems, symptoms suggestive of OSA,
neck circumference and mallampati score

- The role of awake intubation if concerned, positioning and preoxygenation [ET

O2>80] better candidates will say ETO2>90 is specific for bariatric surgery?

Question 6

A patient is complaining of central chest pain in the post anaesthesia care unit (PACU)
following femoro-popliteal artery bypass surgery.

Outline the diagnostic criteria for acute myocardial ischaemia on an ECG? (30%)

Describe your management of acute myocardial ischemia in PACU in this patient. (70%)

57.1% of candidates passed this question.

Key components of an answer for this question related to:

- a description of ECG changes of ischaemia and NOT infarction

- a description of immediate “standard management” of infarction as well as managing
issues specific to this patient [setting of vascular surgery, heparinisation, “normal” BP etc]

Question 7

You are inserting a central venous line (CVL) as part of your anaesthetic management for a
laparotomy.

Outline the perioperative measures you should consider to minimise central venous line
sepsis.    

43.4% of candidates passed this question.

 
Key components of an answer for this question related to covering the following:
- mention of risks/benefits, of using a central line at all
- discussion of aseptic technique
- following agreed protocols for the insertion procedure
- complying with hand hygiene recommendations
- use of adequate skin antiseptic
- choosing the best CVC insertion site
- use of adequate port disinfection priori to use
- education of medical and nursing staff
- removal of CVC as soon as it is not needed.

Question 8

A patient has a mid-thoracic epidural inserted preoperatively prior to anaesthesia for open
AAA repair.

Describe the relevant anatomy including surface landmarks for insertion of a mid-thoracic
epidural. Use of diagram(s) may be helpful.
50%

List reasons for persistent leg weakness 4 hours after emergence from anaesthesia in this
case.
50%

71.2% of candidates passed this question.

Key components of a basic answer for this question related to:

- demonstrate recognition of surface landmarks relating to thoracic spinal cord levels

- outlining layers between skin and epidural space
- mention of contents of the epidural space
- reasons for leg weakness included
o spinal cord injury related to epidural – haematoma / trauma
o persistent nerve blockade
o spinal cord ischaemia

Question 9

An otherwise well patient presents for a laparoscopic right hemicolectomy.

What are the issues related to the carbon dioxide pneumoperitoneum?

How would your intra operative management address these issues?

96.8% of candidates passed this question.

Key components of a basic answer for this question:

- Required the candidate to show an understanding of the deleterious pathophysiology

– especially the cardiovascular and respiratory systems including perfusion and
autonomic effects, as well as ventilation pulmonary / chest mechanics; and
demonstrate an understanding of strategies to improve circulation and ventilation
parameters.
- Better responses included discussion of other systems and positioning effects and
had more detail in measures to address issues.

Question 10

Outline the steps to ensure the safe storage, handling and administration of blood to a patient
once the packed red blood cells (RBC’s) have arrived in the theatre suite.

55.7% of candidates passed this question.

Key components of an answer for this question related to:

Processes to ensure the right patient received the right pack of the right product and that it
was stored safely. Aspects of administration including filtering and non mixing of infusions.

Question 11

Outline the physiological determinants of blood flow through a myocutaneous free flap? (50%)

Evaluate the use of vasoconstrictors for support of blood pressure following reanastamosis of
a myocutaneous free flap? (50%)

61.6% of candidates passed this question.

Key components of an answer for this question related to:

1. mention of the physiological determinants

 perfusion pressure and resistance to flow – with some understanding of Ohms law
2. acknowledging that vasoconstrictors had a role to play but should be considered after
other parameters had been optimised.

Question 12

A patient is scheduled on your list for arthroscopic shoulder surgery. The surgery is to be
performed in the beach chair position.

List the problems associated with this position and describe how you could minimise them.

44.3% of candidates passed this question.

Key components of an answer for this question:

- This required mention of issues related to placing the patient in the position including
eye protection, head positioning to avoid traction on the nerve plexi as well as
pressure care.
- It required some detail in the discussion of the risks of orthostatic hypotension and
subsequent cerebral, myocardial hypoperfusion, and measures to monitor for and
minimize such effects.

Question 13

A 53 year-old man with acromegaly presents for a transphenoidal resection of his pituitary
tumour.

Outline the features of acromegaly. (50%)

How does this diagnosis influence your anaesthetic management? (50%)

77.2% of candidates passed this question.

Key components of a basic answer for this question:

Needed to relate acromegaly to and excess of growth hormone, to show understanding of the
facial and airway features of acromegaly and reconition of associated systemic problems –
diabetes and hypertension. There needed to be a sensible discussion of airway management
and post op complications and the need for hormone supplementation.

Question 14

A patient’s arterial blood gases include

pH 7.1
pCO2 27 mmHg
HCO3 <15

A. What is the acid-base status of this patient and briefly justify your differential diagnosis list.

B. Describe how other biochemical parameters would help identify the cause

59.4% of candidates passed this question.

Key components of an answer for this question are:

Identifying that the patient has a metabolic acidosis with some degree respiratory
compensation.
Providing a list of differential aetiologies with some justification
- DKA
- Hyperosmolar non-ketotic syndrome
- Raised anion gap acidosis
- Normal anion gap acidosis
Discuss what and how other parameters contribute to identifying the cause
- glucose / ketones
- electrolytes
- renal function
- lactate

Question 15

Define persistent post surgical pain

Outline the interventions that are efficacious in reducing the transition of acute post surgical
pain to persistent post surgical pain

85.8% of candidates passed this question.

Key components of an answer for this question:

- A definition of PPSP
- Must develop after surgical procedure
- Pain of at least 2 months duration
- Other causes have been excluded
- The possibility that the pain is from a preexisting condition has been excluded

10


- Should identify some of the common factors including surgical technique, commonly
used medications such as regional blockade, ketamine, clonidine, gabapentinoids,
TCAs, using concept of preventive analgesia and mention psychological preparation.

11


Medical Clinical Vivas

77.9% of candidates passed this section of the examination.

The medical vivas attempt to test the ability of a candidate to assess a specified medical
condition. It does not address other issues, which may be routine during a pre-anaesthetic
consultation, such as anaesthetic history or difficulty of intubation, when unrelated to the
patient's condition. Candidates are expected to take a history, elicit physical signs and from
these, determine the functional status of the system to which they are directed. They are
expected to be able to interpret ECG's, CXR's, blood results, Pulmonary Function Tests and
other investigations, which are relevant to the progress of the condition or its complications.
An understanding of the management of acute medical emergencies is expected, and
candidates should be able to discuss options for medical optimization of the relevant medical
condition.

Marks are allocated for

- an appropriate history and examination which explore risk factors, degrees of severity,
progression, response to therapy and long-term management (where appropriate) for
a disease state
- physical examination should elicit key signs and follow an efficient, logical sequence
- an organised presentation of findings which synthesises and interprets history,
examination and investigations
- professionalism in dealing with patients

The following is a list of some of the primary medical conditions of patients used for this exam.
Different scenarios were used to introduce the organ system chosen for the focus of the viva.

Cardiovascular system
- Valvular heart disease
- Post cardiac transplantation
- Heart failure
- Atrial fibrillation/flutter
- Ischaemic heart disease
- Pulmonary hypertension
- Marfan’s Syndrome
- Congenital heart disease
- Hypertrophic obstructive cardiomyopathy
- Other cardiomyopathy

Respiratory system
- Chronic obstructive pulmonary disease
- Asthma
- Pulmonary fibrosis
- Fibrosing alveolitis
- Post lung transplantation
- Bronchiectasis
- Obstructive sleep apnoea
- Cystic Fibrosis

Nervous Sytem / Musculoskeletal

- Peripheral neuropathy
- Guillain-Barre
- Spinal cord AV malformation with neuropathic pain
- Ankylosing spondylitis

12


- Rheumatoid arthritis
- Acromegaly
- Myotonic dystrophy
- Scleroderma
- Myasthenia
- Cranial nerve pathology

Other
- Liver cirrhosis
- Chronic renal failure
- Haemochromatosis
- Diabetes and its complications

13


Anaesthesia Vivas

Of candidates who presented for the anaesthetic vivas, 81.3% passed this section.

The aim of this section of the examination is to assess the ability to

- Apply principles of acceptable, safe practice and demonstrate sound clinical
judgment.
- Plan and prioritise clinical actions and to anticipate their sequelae.
- Demonstrate organizational and communication skill.

Marks are awarded for

- showing sound judgement in decision making
- demonstrating adaptability to changing clinical situations
- applying basic scientific principles to clinical practice and the ability to organise and
express thoughts clearly.

Evolving clinical scenarios are used in this section of the exam.

The introductory scenarios and initial questions are listed below.

VIVA 1

The neurosurgeon contacts you at 0600 to inform you that a 75-year-old man is booked for an
occipital craniotomy today for evacuation of haematoma and resection of tumour. The patient
was admitted overnight following a grand mal seizure. The patient was given a loading dose
of Phenytoin 750 mg IV at the time. The patient is now intubated and ventilated.

Previous medical history: Paroxysmal atrial fibrillation, ischaemic heart disease (bare metal
stent 2011), type II diabetes, transient ischaemic attack 2012 & hypertension.

Current medications:
Dabigatran 150 mg bd
Metformin 500 mg bd
Candesartan 8 mg mane
Amiodarone 150 mg mane
Aspirin 150 mg mane
Phenytoin 100 mg tds; (last dose of dabigatran given @ 0800 the day before)

Investigations available:
Urea & electrolytes: Na 139 meq/l, K 4.2 meq/l, Cr 125; Cr clearance 50 ml/min/m2
FBC: Hb 110 plt 200

Q. How would you (i) assess and (ii) manage this patient’s anticoagulation in the
perioperative period?

VIVA 2

During the Acute Pain ward round you are asked to review a 68-year-old man. He is day 3
following a laparoscopic right hemicolectomy for cancer.
On Day 1 he was managing well on oral analgesia, however late on post op Day 2 he
developed increasing abdominal pain.

14


He was seen yesterday evening by the anaesthesia registrar who charted a morphine PCA
(1mg bolus and 5 minute lockout).
He is now drowsy but more comfortable, but he still finds moving or coughing very painful.
His past medical history is of hypertension for which he takes Lisinopril, his pre operative BP
was 150/85mmHg.

Q. How would you assess this patient’s pain?

VIVA 3

You are called by the obstetrician to see a 28 year-old woman who has presented following
an intra-uterine fetal death at 31 weeks gestation. The obstetrician wants to begin an
induction of labour as soon as possible and the patient is asking about analgesia for labour.

Q. Which specific elements of the patient’s history, examination and

investigations will help you in the anaesthetic management of this patient?

VIVA 4

You are called by the emergency department to assist in the management of a 62-year-old
woman who has an isolated chest injury after a fall at home. She has sustained multiple right
sided rib fractures. She has received 15 mg of intravenous morphine in the emergency
department.

Her comorbidities include Chronic obstructive airways disease and ischaemic heart disease.

Her medications are aspirin, perindopril, salbutamol and budesonide.

The emergency physician asks for your advice with regard to her ongoing pain management.

Q. How will you assess the adequacy of her pain management?

VIVA 5

A 75-year-old sedentary man with a history of aortic stenosis is re-booked for cardiac
catheterization prior to aortic valve surgery.

The cardiologist has requested an anaesthetist to assist as the procedure was cancelled the
day before because the patient was agitated and unable to keep still.

The patient stopped smoking 2 weeks ago and rarely goes to the doctor.
His known current medications are:
Aspirin 100mg daily
Esomeprazole 40mg bd

Q. How will you manage this patient for his cardiac catheterization?

15


VIVA 6

You are the anaesthetist for the emergency list and your next case is a 50-year-old man with
a diagnosis of nasopharyngeal carcinoma who has been undergoing radio and chemotherapy
for his cancer. Over the last few weeks he has been having recurrent epsiodes of epistaxis
and was brought to hospital last night after having a large epistaxis that has been controlled
using a Foley’s catheter in the nasopharynx.

The patient is in your anaesthetic room and the surgeon wants to perform urgent examination
under anaesthesia and cautery of his nose.

The following results are available (on wall and on desk):

Hb: 99 g/L (135 – 180)

MCV: 80 fl (80 – 120)
MCHC: 260 g/L (300 – 360)
WCC: 2.3 x109/L (3.4 – 11.0)
Plt: 97 x109/L (140 – 450)

INR: 1.4

Q. How will you proceed?

VIVA 7

A 45-year-old male patient with Amyotrophic Lateral Sclerosis (Motor Neuron Disease) has
sustained a fracture dislocation of the ankle. How would you assess the severity of this
patient’s neuromuscular disease?

Q. How would you assess the severity of this patient’s neuromuscular disease?

VIVA 8

You are the consultant anaesthetist on duty for emergency cases.

You are called to the operating theatre lobby to find a four-year-old boy accompanied by
emergency department staff and a neurosurgeon. The child has come directly from the CT
scanner.
The scan shows a large left subdural haematoma with midline shift.
The surgeon wishes to evacuate the haematoma as soon as possible.
The patient weighs 18 kg, is in a hard collar, is not intubated and has one peripheral cannula.

Q. Outline your immediate management of this situation.

VIVA 9

A 78-year-old woman is brought into the Emergency Department by ambulance having

collapsed at home.

16


On arrival she has a Glasgow Coma Score of 5 with a left sided hemiparesis.

She is intubated in the emergency department.

An urgent non-contrast CT is suggestive of a ruptured aneurysm.

The aneurysm is unsuitable for coiling.

Below is her CT scan.

Q. What clinical and radiological features may indicate a poor prognosis in this
patient?

VIVA 10

A 48-year-old lady presents for a Left Mastectomy and Axillary Clearance for a biopsy proven
triple negative intraductal adenocarcinoma with palpable lymph nodes.
She weighs 99kg and is 155cm tall (BMI 41). She has a lifelong history of asthma and
smokes 20 cigarettes a day. Her past history includes a Motor Vehicle Accident 10 years ago
where she sustained pelvic fractures and chronic hip pain.

Her current medications are:

Prednisone 5mg mane

17


Serotide MA 2 puffs bd
Ventolin 5 mg nebulized bd
Baclofen 20mg tds
Gabapentin 900mg/day
Movicol bd
Oxycodone 5mg qid
Esomeprazole 40 mg mane

Spirometry from 6 weeks ago:

Predicted Pre Bronchodilator Post Bronchodilator

FEV1 2.55 1.53 (60%) 1.85 (72%)
FVC 3.15 2.52 (77%) 2.69 (85%)
FEV1/FVC 80% 60% 69%

Q. She arrives on the morning of surgery and your registrar rings you to tell you
that she is wheezing. What is your response?

VIVA 11

You are asked to provide a labour epidural for a 32-year-old woman, who is at full term in her
first pregnancy. As you arrive the midwife informs you that the woman has had breathing
difficulties for the last five minutes and is now difficult to rouse.

Q. How would you assess and manage this situation?

VIVA 12

You are the Consultant Anaesthetist on duty, including responsibility for the Intensive Care
Unit (ICU).

In the evening, you receive a telephone call from the Emergency Department (ED) requesting
your presence (your registrar is already occupied elsewhere).

A 46-year-old man has been brought in by friends, having collapsed after feeling unwell for a
few days. He now appears confused and is vomiting.

Q. Before you make your way to the ED, what key information do you need over
the phone?

VIVA 13

A 79-year-old woman with a painful ulcer on her right heel is scheduled for an angiogram and
possible angioplasty or stenting of her posterior tibial artery next week. She presents to pre-
anaesthetic clinic for assessment.

The procedure would take about 60 minutes.

18


She is very anxious but does not wish to have a general anaesthetic.

She stopped smoking 6 months ago.

She has a BMI of 35.

Her medications are

Gliclazide 120 mg mane

Metformin 1g mane
candesartan 16mg/
hydrochlorthiazide12.5mg 16/12.5 mg mane
digoxin 62.5 mcg mane
paracetamol 1330mg tds
oxycodone slow release 10mg bd
frusemide 80 mg mane
potassium chloride 1200mg mane
aspirin 100mg mane
esomeprazole 40mg bd

She has no known drug allergies.

Q. Please comment on her ECG below.

19


VIVA 14

You are called to attend a 60-year-old man who has presented to your Emergency
Department with breathing difficulty that has worsened over the last four hours. He has
known carcinoma of the tongue and had been scheduled for hemiglossectomy and radical
neck dissection in one week’s time. His only known past history is heavy alcohol
consumption and 40 pack-years of cigarette smoking.

Q. Describe your airway management plan.

VIVA 15

You are reviewing a patient on the day of surgery, due to have a total knee replacement.

In the preadmission clinic, he was noted to have a history of hypertension, treated with
perindopril 10mg od; he is otherwise asymptomatic.

On examination, you hear a harsh ejection systolic murmur, which had not been noted
previously.

Q. What are the key features you would look for on the history in this patient?

VIVA 16

You are the on-call anaesthetist in a peripheral metropolitan hospital.

The emergency department consultant asks for your assistance with intravenous access and
blood collection in a ten-day-old girl, who has been brought in by her parents with a history of
not feeding and being unwell.

When you see the child she is listless and difficult to rouse, and is making grunting noises
with respiration.

Q. How will you assess this child?

Dr Mark Buckland
Chair, Final Examination Sub-Committee

20