1- PANCREATITIS

2- PREPARATORY STATION FOR CONVINCING A PT WITH SPLENIC HAEMATOMA TO STAY AT

THE HOSPITAL. DAMA
3- GIVING IN F O R M A T IO N » PT WITH SPLENIC HAEMATOMA INSISTING TO BE DISCHARGES
4- MALIGNANT MELANOMA LT ARM AND POST OPERATIVE COMPLICATIONS, AXILLARY VEIN
THROMBOSIS.
5- TESTICULAR TUMORS WITH METS. TYPES, MARKERS, AND HISTOLOGY REPORTS.
6- RHABDOMYOLYSIS, A PT WITH LOWER LIMB INJURY FOR 3-4 HOURS THEN BROUGH TO THE
HOSPITAL. FULL DISCUSSION ABOUT RHABDOMYOLYSIS.
7- PREPARATORY STATION: CALL ITU REG TO BOOK A BED FOR N OLD WOMEN W HO IS GOING
FOR LAPAROTOMY WITH RENAL IMPAREMENT, ELECTROLYTE DISTURBANCES.
8- CALL THE ITU REG.
9- CRITICAL CARE CASE,(SORRY I CANT REMEBER IT.)
10- PUTTING SUTURES. THE CHOICE OF MATERIAL ACCORDING TO INSTRUCTIONS .
11- ANATOMY: HEAD AND NECK, THYROID VESSELS, STRAP MUSCLES, NERVE SUPPLY.
12- ANATOMY: LUMBAR SPINES IN A MODEL. FORAMINA, CONTENTS, ANATOMY OF THE DISC,
DISC HERNIATION. MRI TO READ.
13- ANATOMY: LOWER LIMB. A SEMULATOR LYING DOWN KNEES AND BELOW BARE. MUSCLES,
MOVEMENTS, NERVE SUPPLY. KNEE AND ANKLE JERKS, HOW TO PERFORM AND WHAT IS THE
ROOT VALUE.
14- CVS EXAMINATION: A PT WITH MIDLINE STERNOTOMY, AND A LT LOWER PARA STERNAL
SCAR. A PROSTHETIC VALVE. GOING FOR HERNIAL REPAIRE. WHAT PRECAUTIONS
(WARFARIN)
15- HEAD AND CRANIAL NERVES EXAMINATION. DO OTOSCOPY. PT WITH HEAD INJURY AND LT
HEARING IMPAIREMENT. W HAT INVS TO DO?
16- KNEE JOINT EX
17- HX: EPIGASTRIC PAIN FOR 5 HOURS (DISCUSSION& DD)
18- HX: VASCULAR LEG.
19- BACK SWELLIN EXAMINATION :LIPOMA
20- GIVING LOCAL ANAS.
anatomy 1: mandible (bone), id. Condyle, tmj, articulate the mandible with the skull, ligaments, what happens
when opening the mouth, pterion. diploic veins, lateral x ray spine id. Odotoid process, post. Arch of atlas, type
of ligament bw axis and atlas, foramen spinosum, styloid process ligaments attached, stylomastoid foramed.
layers encounterd when making a burrhole. bell rang

Anatomy 2: thorax id. Rt. And It subclavian art., rt and It. Common carotid art. Rt and It recurrent vagi, parts of
thyroid blood supply and venous drainage, embryology of thyroid, thyroglossal cyst, id. Trunks of brachial
plexus, erb’palsy motor and sensory, klumbek’spalsy

Anatomy 3: boundaries of femoral triangle, id femoral art. And vein, femoral nerve and m. Supplied
by,susartorial canal snd boundaries, contents, surface anatomy of femoral art. surface anatomy of sfj,
boundaries of femoral ring , contents of femoral sheath

Path. 1: infective endocarditis def., organisms. 3hand signs, rheumatic fever. young patient with tv
endocarditits risk factors, failure of treatment complications, types of matching in heart transplantation,
complications of immunosupressive therapy

Path. 2: gangrene def, diff. Bw dry and w e t. asthersclerosis, risk factors, types of cell death, diff. Bw
mesothelioma and bronchogenic caricinoma. signficance of pleural plagues, risk factors of mesothelioma, bell
rang

Assccl: def hypothermia, risk factors . ways of heat loss, coagulopathy why. complications of massive
transfusion, die, treatment, who to involve in care (ruptured aaa)', organs to be ischemic if aaa ruptures, bell
rang

Asscc 2: ways of co2 transfer, draw eqution. wherer occus, chloride shift, respiratory acidosis, why, mechanis
morphine cause resp. Depression, when to treat resp. Acidosis and why, how to treat, why pao2 is still normal
depite on 60 % o2. why bicarbonate still low

Asscc3: ecg ( air under diaphragm) and ecg (a f). causes of air under diaphragm, causes of af. calcuate hr from
ecg. why diff from measured by the machine, why af. hoow to treat, bell rang

Cpe 1: examine cranial nerves in a patient with bitempral hemianopia (wtf..)

Cpe 2: examine back lipoma

Cpe 3: examine submandibular salivary gland swelling

Cpe 4: examine inguinoscrotal hernia

3 min discussions was so short for the no. Of questions

History 1: a woman with a 10 history of goiter recently turned to be toxic

History 2 : a woman referred from her gp by calcular cholecystits and on history taking discovers to be an ibs
.deceiving

Comm. 1: anxious mother about her 10 y old daughter going to have appendectomy , questions about
confirming diagnosis, how big is the scar, any harm to reproductive tubes

Comm. 2: phone cardiothoracic consultant to make a refer of polytrauma patient with aortic rupture, never lie if
you are not sure of any thing

Procedural 1: hand tie 2 rubber bands, deep tying in a hock, figure of eight a bleeding point
Q .: name of knot, why, other knots, how to protect deep structure when tying at depth, marerial of vicryl, how
much it keeps tensile strength, advantages of braided sutures, bell rang

Procedural 2: FNAC of cystic lesion suspicious to be a recurrence of malignant melanoma

Assistant offers you many types of syriges and needels to choose, offers local anathetics, 2slides to put on and
a cytospin container, patient asks is it mailignant, where to know pathology report
History: Progressive dysphagia 6mth with odynophagia, LOW 2 stones (= 201b), drinker. Likely
diagnosis and differentials? (Oesophageal cancer.) How to manage?

History/comms: Patient post op after gastrectomy for cancer, physically well and due for discharge
today but nurses think he is depressed. Interview patient and assess. Patient makes no eye contact
and gives m onosyllabic answers, looks down and shakes his head says "I don't know" to everything.
Asked why he is upset? Cancer m ay come back; There's nothing I can do. Asked if we can help in
anyway - no. Present your findings. W hat is the cause of his depression? Management plan? W ho
should see patient? W ould you discharge this patient today?

Comms: Patient referred from GP after dysphagia, barium swallow shows stricture likely benign,
counsel for OGD, biopsy and dilatation, in particular the risks. History also shows smoker of 40
sticks/day, drinker of 20units a week. Labs show bilirubin a bit high, low Hb 10.0. Is it m y fault? Is it
cancerous? W ill it go away if I just stop smoking? Can I go home today?

Comms: Interval cholecystectomy POD2. Op uneventful, 2 clips to CBD 2 clips to cystic artery, but
since yesterday worsening abdo pain with tachycardia, US shows free fluid in abdomen no CBD
dilatation. Labs show TW 18 and CRP 50, bilirubin raised (something like that). Your consultant thinks
there is bile leak from CBD injury, wants you to transfer to HPB consultant Prof Archibald Rose at
regional centre. His reg picks up. Reg not too happy that your labs are from yesterday and nothing
was done now you are calling at 4pm on a Friday. W hat do you think he has? W here is the source of
the bile leak? Do you have any evidence where it's coming from? Could you arrange ERCP to confirm
the source of the bile leak? Is it urgent? W ill you need to speak to anyone? (Bed manager)

Skills: Set IV plug on hypotensive trauma patient possible pelvic and lower limb fracture. Don't need to
wear gloves or gown. Insert into dum m y arm, blood splatters all over the shop, draw blood. Connect
the IV tubing (unfam iliar eguipment), secure plug with transpore tape (struggle cos blood all over the
place, no tegaderm). W hat blood tests would you send for? W rite fluid order. W hat else would you
do?

Skills: Given silk, vicryl, prolene. Hand-tie 2 rubber bands together with braided non-absorbable. Hand
tie deep hook in cylinder with braided absorbable. Overrun bleeder with figure of 8 using
monofilament non-absorbable and instrument tie. W ear gloves and throw away your sharps. W hat
knot did you use for your rubber bands? W hy did you use a square knot? W hat other knots could you
use? W hat are advantages of braided sutures? W hat is vicryl made of? How long does vicryl last?
W hat's the difficulty with deep tying and how to overcome it?

Examination: Indirect inguinal hernia with previous appendicectom y scar. W hy do you transilluminate?
Present your findings. How to differentiate from femoral hernia? Have you seen femoral hernias
above pubic tubercle? (Examiner has, they can extend above, but they are lateral). Is there any
relationship between open appendicectomy and hernia? How else can you test the ilioinguinal nerve?
(Sensation on lateral side of scrotum .) W hat types o f repair are there? W hen would laparoscopic
repair be favoured? (Bilateral hernia.) W hat types of anaesthesia? W hen would you use RA/local
anaesthesia?

Examination: Sm oker with claudication after 50-100m. Rather plump gentleman, difficult to palpate
pulses other than femoral and DP; not enough tim e to do Doppler and ABPI. How long must you wait
in Buerger’s test? W hat other examination would you do? (CVS.) W hat's the cause of his peripheral
arterial disease based on his history? (Smoking.) W hat tests can you do in clinic since you can't
palpate pulses? (Doppler.) W hat would you expect his ABPI to be? How to manage?

Examination: Neck lump, examine. Glass of water available but no tendon tapper. Examine and
present. W hat else do you want to examine? W hat’s your diagnosis? Graves disease. W hat
differentials? W hat tests to do? W hat management? If patient comes back with pain on swallowing
difficulty breathing few months later, does it change your management?

Examination: Post-op patient after colectomy or something, midline laparatomy wound covered up by
a dressing. (No need to take it off.) Tenderness at LUQ and LLQ radiating to left shoulder. T 39 deg,
PR 150, BP normal, TW 15 and CRP high. Examine and present. W hy is there shoulder pain? How to
manage?
Patho: 23yo lady just came back from Bangladesh, has anterior neck lump night sweats. W hat are
your top differentials? W hat two broad categories of tests can you do from the FNAC? (Microbiology,
cytology.) How do you label the specimen? (Category 3 hazard.) W hat tests for TB? W hat stains can
be done for TB? (Ziehl Neelsen or auramine.) How long to culture TB? W hat is the public health
concern? W hom to notify? W hat is the histological appearance of TB? W hat is a giant cell? W hat
other granulomatous diseases do you know of? (Leprosy, Crohn's, W egener’s, sarcoidosis.) W hat
type of protein deposition occurs? (Amyloid.) W hat other mycobacterium causes enlarged lymph
nodes abscesses in im m unosuppressed? (Prefers the term MAI rather than MAC.)

Patho (pilot station?): 40yo lady got pathological fracture of fem ur shaft while cycling. Examiner is a
poker-faced dude who just says 'T hank you" to all your answers. W hat is a pathological fracture?
W hat could be the causes? W hat 5 cancers classically metastasise to bone? Fixation done, how to
check what malignancy? Histo shows follicular cells, where is it from ? Cannot find anything wrong
with thyroid, where could the cancer be? Pathologist wants to confirm its from the thyroid, how? W hat
epithelial m alignancy of thyroid cannot be found on radionuclide scan and why?

Patho: Shows gross specimen of colon with millions of polyps. W hat is this? 23 year old, how to
manage? (Colectomy.) W hat is the chance of malignancy? W hat is inheritance of FAP? W hat type of
gene is APC? (Tumour suppressor.) W hat are some extraintestinal manifestations of FAP? (Desmoid
tumours, gastric fundal polyps, osteom a o f jaw .) Histo shows dysplastic polyp; what is dysplasia?
W hat does it imply? W hat lifestyle changes in general population to reduce risk of colon Ca? His
ulcers heal by secondary intention; what is secondary intention? W hat is an ulcer? Ulcer gets infected
with staphylococcus aureus; what are the features of staph aureus? (Gram positive cocci in clusters.)

Anat: Thorax and upper abdo prosections (specimens all hard as wax).
Posterior view coronal section of heart and mediastinum. W hat is this? (Pulmonary trunk.) W hat
structure here? (Pulmonary valve.) W hat branches does the pulm onary trunk have? Identify this.
(Papillary m uscles.) W hat structure are they attached to in this specimen? (Tricuspid valve.) W hat
connects them to atrioventricular valves? W hat is their function?
Saggital section thorax and mediastinum. Identify azygos vein. Name 2 tributaries or structures that
drain into the azygos vein. W here does azygos vein drain into? W hat is this? (Thoracic sympathetic
trunk.) W here do the preganglionic fibres that supply sympathetic trunk come from? W hat connects
the sympathetic trunk to the spinal nerves?
Anterior view of thorax and upper abdo. Identify the spleen. W hat is the blood supply? Describe
course of splenic artery. W hat structure must be preserved in splenectomy? W hat 2 other structures
does it supply? Identify this structure. (Duodenum .) How many parts does it have? W hich part does
ampulla of vater open into? W hich structures open into the duodenal papilllae? W hat do they drain?
W hat blood vessel runs posterior to D1?

Anat: Lower limb.

Anterior thigh - Identify femoral vein. W hat structure is medial? (Femoral canal.) W hat structures are
found in femoral sheath? Is femoral nerve inside femoral sheath? W hat structure is this? (Rectus
femoris.) W hat function? Point out ITB. W hat inserts into ITB? W hat does the ITB do when I'm
standing at attention?
Posterior gluteal region, reflected gluteus m aximus - W hat is this structure? (Gluteus medius.) Nerve
supply? W hat is its function when I'm marching?
Posterior thigh - Identify biceps femoris. How many heads? Nerve supply? Identify common peroneal
nerve. W hat muscles does it supply? W hat sensory supply? W hat happens in common peroneal
nerve transection? W hat is this? (Gastrocnemius.) Is it affected if I cut the common peroneal nerve? If
no traum a but got loss of dorsiflexion and numbness o f dorsum o f foot, where do I look for the lesion?

Anat: C-spine.
How many cervical vertebrae are there? How many cervical nerve roots are there? W hich vertebrae
are atypical? W hat are the atypical features?
Gives you bone - what is this vertebra? (C1 atlas.) Show me the features. W hat runs through foramen
transversarium? W hat level do they first enter?
On patient, landmark the hyoid bone. W hat level is it? W hat structure is found at C6? W hat part of Gl
tract is found at C6? W here does esophagus end? I feel downwards on the C-spine; what's the first
process I feel? W hy can't I feel the upper spinous processes? (Bifid and attached to nuchal ligament.)
Landmark the brachial plexus on this patient. W hat muscles does the brachial plexus run between?
Lat C spine X-ray and open mouth odontoid - Identify cervical vertebrae on lat x-ray. (Wants you to
count C1 down to C7.) W hat's this? (Body of C2.) W hat’s this? (Hyoid.) Apart from fracture, what other
signs of c-spine injury can be seen on lateral x-ray? (Abnormal alignment, prevertebral soft tissue
swelling.) How this view taken? (Open mouth odontoid.) W hat features can you see? (Odontoid
process, lateral masses of C1, C2 spinous process.) W hat ligaments are attached to odontoid
process?

Crit care: Lady vomiting, epigastric fullness. Labs show Na 125, K 1.9, Cl 59, pH 7.2 etc. W hat does
she have? W hy got hypochlorem ic alkalosis? W hy got hyponatremia? How to classify hyponatremia
and what examples? W hat are the complications o f hyponatremia? W hy got hypokalemia (the simple
answer)? (Loss in vom itus.) W hy got aciduria? W hat is the key element in these exchanges?
(Sodium.) How would you treat? W ho else should be involved in management? W hen would this lady
be fit for surgery?

Crit care: S/p lobectomy and epidural T3 T4 level, now has hypotension bradycardia S p 0 2 92%.
W hat causes of this clinical picture? W hat’s so good about epidural in this patient? W hy do we use
temperature sensation to check? How would you do it in real life? How to manage?

Crit care: Elderly gentlem an has abdo pain, looks confused. CXR showing free air under diaphragm,
ECG showing AF. W hat must you confirm on CXR and ECG? W hat is the problem with taking consent
from this dude? W hat do you call all this stuff about how patient must understand information be able
to repeat? W ho should make decision? W hat's the significant finding on this CXR? W hat is differential
diagnosis of perforated viscus? W hat pathologies in the large bowel could cause it? Tell me about this
ECG. (Irregularly irregular.) W hat is the rate? How com e different from m y automatic reading? W hat
are the causes of AF in a SURGICAL population? W hat broad principles to manage AF? If stable how
to manage? W hat 1st line drug? W hat dose?
1) P ulm onary em bolism
Nurse calls you for right sided chest pain, POD8 cholecystectomy.

Sees patient (actor) with oxygen mask.

Asked patient where the pain is and assured patient i will not hurt u, will stop immediately if pain.
Started with respiratory examination on the posterior chest - chest expansion, percussion, ascultation
Patient cringed in pain when taking deep breath - told patient to normal breaths
CVS examination - just ascultated aortic, pulmonary, tried to ask pt to lift up left breast to listen to mitral
but stopped by examiner
Tried to position patient to examine Abd but stopped by examiner
Went to the calves, squeeze left calf and patient nearly jumped
Shown vitals chart: HR100-130, RR 20-30, 92% on room air over the last 1hr

Qns
1) Present your findings - Pleuritic chest pain on deep inspiration with no wheeze/dullness to percussion
and patient speaking full sentences. Tender left calf.
2) Differential diagnosis - Pulmonary embolism from deep vein thrombosis
3) Investigation - FBC, coagulation profile, d-dimer, fibrinogen. Definitive: CT pulmonary angio
4) Mx - ABC, anticoagulate with IV heparin. If haemodynamically unstable, for embolectomy

2) Lipom a
Patient referred from GP for lump over the upper back.

Pt is hospital baju.
Asked pt whether the lump is painful. Assured pt i will not hurt u and will stop immediately if pain.
Pt says pain on flexion of neck to study.

Untie top of baju at the back.

10x15cm soft oval lump over the C7 vertebrae
No skin changes, deep to skin. But not attached to the back muscles.
Told examiner done before 6min mark

Qns
1) Present your findings - as above
2) Differential diagnosis - Lipoma most likely, Sebaceous cyst, Muscular haematoma. Neurofibroma
3) Invx - US lump
4) Mx - In view of functional symptoms and impairment, recommend operative removal
5) Complications and risks of surgery - GA, Surgery. Bleeding, infection, recurrence

3) Preop arrangem en t preset

1) 55yo Mrs Thompson with penicillin and iodine allergy has diverticular abscess for sigmoid colectomy
2) Mr Philip with IDDM, AF (warfarin but converted to LMWH) has MRSA left foot ulcer for BKA
3) Mr McPhee with pacemaker and severe COPD has strangulated hernia

Qn
1) Arrange the op in order (was prompted about strangulated hernia otherwise would have kept pt with
allergy first)
Strangulated hernia, then Sigmoid colectomy, then BKA
 2) Reasons for order
- strangulated hernia: emergency
- BKA: MRSA should be last
3) Important things to take note for each pt
- strangulated hernia: in view of severe COPD, should attempt RA rather than GA. in view of pacemaker,
should use bipolar
- what prophylactic antibiotics? cefazolin

- pencillin and iodine allergy: in view of iodine allergy, can use alcohol/chlorhexidine based antiseptic, in
view of pencillin allergy, can use clindamycin or vancomycin
- if you are not sure? consult the hospital bacteriogram and the infectious disease physicians

- BKA: IDDM, need sliding scale, warfarin, need to make sure INR<1.5 and LMWH stopped in the
morning. MRSA, vancomycin for prophylactic abx
- another abx: bactrim, clindamycin?
- if you are not sure, what can you do? refer to ID physician for antibiotics guidance.
- have you heard of ‘ tigermycin"? (some T drug which i didnt recognise)

4 ) U lcerative C o litis
Ulcerative colitis patient on surveillance.
What is UC? Inflammatory bowel dz
Pathophysiology. Just need to say unknown/idiopathic and u get the mark. Added that studies show
immunogenetics link (HLADR 2) but not needed (wasted m y time).
On histo, how to tell if it is Crohn’s? I said CD usually transmural, skipped lesions, fistula, stenosis but all were
not the Keyword that examiner wanted to score the marks
Why need to scope? Said bleeding... then keyword. Risk of CA.
Recent colono histo result: Tibular dysplasia in one part, adenocarcinoma in one part
Picture of cancer eroding through muscularis layer
Name one tumor staging classification and stage tumor. Duke’s. So tumor is Duke A.
Describe APC pathway. APC tumor suppressor gene damage leading to hyperproliferation. Mutation to
Oncogene KRAS leading to dysplasia. Loss of p53 causing adenocarcinoma.
Surgical Mx: Colectomy. Asked examiner which part CA is in colon. Examiner asked if I wanted to do partial
colectomy in a very shock manner. Got the hint and said total colectomy since patient has UC.

5) G allbladd er sepsis
Patient has gallbladder CA s/p op
What causes gallbladder CA? Chronic inflammation (gallstone, polyps..etc)
What kind of CA? Adenocarcinoma most common
First area that it spreads to? Said CBD, Liver. Examiner asked again. LN?
Post op had localised collection. W hat to do? I said Abx with drainage (open vs percutaneous). Examiner
asked if we give Abx for abscess? Told him drainage most impt as Abx do not penetrate abscess well.
Now there is pain, swelling over surgical site, septic. Why? Told him wound dehiscence. Need TRO
necrotising faciitis (since all of us knew from TYS that it will lead this way.)
What organisms? Staph Aureus, Strep pyogenes, Clostiridium perfigens (gas gangrene)
Patient started having bloody diarrhoea. Name 4 differentials. GE, IBD, Opsite bleeding, PMC.
Showed colonoscopy pic of PMC (as expected). W hat is this? PMC
Cause? Due to use of broad spectrum Abx (eg. Augmentin, clinda), normal flora destroyed. Overgrowth of
Clostridum difficule. Produce Enterotoxin A.B leading to PMC formation.
As we knew the questions, completed it in 6 mins. Examiner very surprised that the SG pple all did very well
for this station compared to the foreigners.

6) S u b m a nd ib ular gland ph ysica l exam ination

Was told to take short history and perform physical exam then discuss
Hx: Patient noticed swelling below tongue for few days, Swelling worsen and pain on ingesting of food. No
discharge,
No fever, No LOW, no LOA.
PE: no distinct lump felt. No LN palpable. Slight swelling over right floor of mouth on bimanual palpation. No
discharge from opening of Wharton's duct.
No tongue deviation, able to depress mandible
Differential? Sialolithiasis, Infection, tumor (benign vs malignant)
Investigation: Sialogram. Examiner asked for something non-invasive. XR KIV U/S
Management? Conservative. Some stones can pass out or can be milked out. If not, surgery.

7) H isto ry ta kin g - T hyroid

Middle aged lady, with longstanding history of goiter, but has sudden increase in R side
Has symptoms of hyperthyroidism - LOW, heat intolerance, anxiety, palpitations, tachycardia, diarrhea,
irregular menses
Also has symptoms of compression- dysphagia solids worse than liquids
Nil other family hx, nil hoarseness of voice, nil SOB

What investigation would you do on this patient ? U/S and FNAC

What other investigations would you do? Radioisotope scan
What are the possible causes of the sudden enlargement? - Benign (Toxic adenoma, part of MNG) Malignant
(Papillary follicular medullary, less likely anaplastic)
What are the possible treatments? Trick question. W ith compressive symptoms no choice but to op. Spoke
about hemi vs total thyroidectomy
What possible complications of the surgery would you advice this patient? Risk of RLN injury, hypocalcemia,
lifelong thyroxine replacement

8) Patho -E n te ro c u ta n e o u s fis tu la (N asty exam iner!)

What is a fistula? (Mug definition)
What are the risk factors for the formation of enterocutaneous fistula? Divided into patient, surgeon and other
factors
What are the factors that predispose non closure of a fistula? FRIENDS
If the patient is for conservative Tx, what would your management be? SNAP but no P
What other complications will the fistula have besides metabolic disturbances? Dehydration, wound infection
Why would the patient be acidotic? Where is Bicarb mainly produced from?

9) H isto ry - Pre op co n fu sio n

You are the MO on the ground, during pre op admission, informed by Nurse that patient was acting weirdly.
Due for surgery tomorrow, you are supposed to take consent. (For some non urgent benign surgery)

I Just did AMT scored 1/10 - patient had to purposely think before answering so he could answer wrongly
Don't forget to ask family for collaborative history - apparently AMS is longstanding
What test did you just do and why did you do it?
What are the causes of AMS in a patient like this?
Will he be able to give consent? Why? No! Coz based on cannot retain information, cannot make an informed
decision etc. (based on principles on Dr Exam)
Should the surgery proceed? Only if patient has lasting powers of attorney
Family does not have lasting power of attorney but wants surgery to proceed. Can they? No. Say will refer for
work up of AMS
If this was an emergency can the surgery proceed? Yes. with 2 consultants signatures, in the best interest of
the patient.

Anat

10 . T ru n k and th orax
- stab wound x 3: epigastrium, 2x thorax

- prosection of heart, mediastinum

- identify the right atrium, left ventricle, and pulmonary trunk

- identify the pulmonary valve. How many cusps are there in the valve?

- identify this triangular structure (auricle of right atrium)

- Name the structures that pass through the hilum of the lung? Which is the most anterior?

- what are the branches of the pulmonary trunk?

- what are the first 2 organs injured in a stab wound to the epigastrium?

- what demarcates the left and right lobes of the liver?

- what is the venous drainage of the liver?

- what branch of the celiac trunk supplies both the stomach and the liver?

- In what structure does it run to reach the porta hepatis?

- point out the quadrate lobe

- what are the boundaries of the quadrate lobe?

11 . Parotid gland
- prosection of parotid, base of skull, patient

- show me the surface landmark of the parotid gland on the patient

- show me the surface landmark of the parotid duct

- what are the differential diagnoses if the patient has a lump in the parotid gland?

- other than parotid gland, what else could the lump arise from?
- what are the structures that lie within the parotid gland?

- which parasympathetic ganglion supplies the parotid gland?

- which region of the body does the pre auricular lymph node drain?
- on the prosection, show me the parotid duct

- show me the branches of the facial nerve

- on the base of skull, show me where the facial nerve exits

- the patient goes for a lump excision and develops gustatory sweating (Frey’s syndrome). W hat is the nerve

involved?

12. S h oulde r girdle

- bones: clavicle, humerus, scapula

- prosection: chest wall, shoulder girdle

- MRI shoulder

- identify this bone (clavicle). Which side is it from? Name the parts of the clavicle

- identify this bone (scapula). Which side is it from? Name the parts of the scapula
- identify this bone (humerus). Which side is it from? Name the parts of the superior aspect of the bone.

Where is the surgical neck? W here is the anatomical neck?

- please articulate the scapula and humerus

- please articulate the clavicle and scapula

- what movements take place at the shoulder joint? Show me using the scapula and humerus

- what contributes to the stability of the shoulder joint?

- of these, which is the most important? (Rotator cuff)

- what are the components of the rotator cuff?

- identify these muscles please (points to supraspinatus, infraspinatus, teres minor, subscapularis). W hat

innervates them?

- identify this muscle (pec major). What innervates it?

- what is this structure? (Cephalic vein in arm piercing clavipectoral fascia)

- what is this structure? (Long head of biceps). From where does it originate? W hat attaches to the humerus

medially and laterally to it?

- what are these structures? (Long and lateral head of triceps). What innervates them?

- what passes through this space? (Quadrangular space)

- what does the axillary nerve supply?

- identify the structures you see on the MRI of the shoulder

13. (P rocedural s k ills ) T urkey leg

- scenario is pt young male who crashed into a glass window
- Debrtdement of giant turkey leg with a wound laden with pepper and pebbles
-1 assistant and 1 examiner
- given large syringe, NS, curette, scalpel (10 and ?14 blade), tooth forceps
- what instruments would you use
- asked what I would do -- went on to flush copiously, tried to refashion wound edges and pick out the pebbles
with the forceps while he watched
- what invx would I do - I said the usual blood invx and IV abx. Got prompted for xr when I forgot
- how would you know if a blood vessel was cut - said might see spurting if arterial injury, he seemed satisfied
with that
- what would you do if you saw a radial artery cut?
- what would you do if a nerve was cut
- what will you do with the wound

14. (P hysical exam) Pvd

This gentleman has calf pain on walking for 100m, please examine his lower limb vascular system
No ulcers present, small scar on medial aspect of left knee but unrelated
Did the normal exam, unable to feel any pulses other than femoral bilaterally
Buergers test unremarkable
The examiner stopped me before I went on to ABPI, no time anyway
- what do you think this patient had?
- what investigations would you do and in what order?
- how would you manage this patient? -- conservative vs surgical

15. (C om m unications) CTVS tra n s fe r

Young motorcyclist involved in RTA. wearing full leathers and helmet at time of injury
Quite a few pages of info from patients notes
- documented by reg that ST 1 should call for transfer to CTVS before going to see the patient
- noted in patients bag an appointment card for a diabetic clinic this coming Tuesday
- patient GCS 14, PR 120, HR 100/80, T 37, complaining of right sides chest pain, 4L crystalloids given so far,
requested 6 units of blood for standby
- noted left thigh swollen, no open wounds, ?fracture - no Thomas' traction yet
- CXR: widened mediastinum, bilat pleural effusions
- AXR: psoas shadow not seen, dilated small bowel loops
- Left femur XR: shaft fracture
- CT not available for next 3 hours as it is being serviced
- registrar also documented insertion of chest tube on the right. Swinging fluid with 200mls of blood stained
fluid
- Hb 8. otherwise FBC normal, UECr/LFT normal, CRP raised very minimally
- pH 7.32, P a02 10kPa, PaC 02 6.0kPa, H C 03 19
Wanted to give SBAR but examiner kept interrupting to ask questions
- what is the issue?
- will you do CT scan?
- what will you do for his C-spine?
- what are you going to do for his leg?
- is there any abdominal issue?
- what are you going to do about the blood pressure?
- why should you not increase the BP? - prevent further bleeding
- what are his blood abnormalities?
- why do you say metab acidosis?
- who will accompany the patient?

16. A cute p a n cre atitis (C ritical Care)

Guy went out partying, drank alcohol, has epigastric pain radiating to back. Showed some bloods outside the
station for you to read in 1 minute before entering. Basically amylase 2100, and out of Glasgow score,
glucose, albumin, calcium, urea, total whites were deranged
- what is the diagnosis, differentials
- what in the investigations led you to your diagnosis (amylase)
- name me one scoring system for severity, no need the values, just components
- for your scoring system, what is the time interval to do the tests?
- causes of normal amylase in pancreatitis? (too early, too late)
- how do you manage the pain? opioids
- why cannot give NSAIDS? (afraid of renal injury)
- what other option if opioids not enough? (epidural)
- what is pseudocyst?
- w hy is calcium low?
- complications of pseudocyst?
- what in blood results leads you to suspect pseudocyst? (amylase)
- is amylase a marker of severity? (no)
- where would you manage the patient? (ITU)
Just give one-word/short answers to allow examiner to tick the box and move on. They are not interested in
anything else that is not on their marking scheme.

17. Pre-op a o rtic ste no sis (C ritica l Care)

Patient planned for elective transurethral resection of bladder tumour was found to have aortic stenosis.
- what is the pathophysiology of aortic stenosis?
- what are the symptoms of aortic stenosis
- what are the signs of aortic stenosis, where do you hear the murmur
- what are the complications of aortic stenosis
- read this ECG, what does it show? (LVH)
- how do you calculate the heart rate from the ECG? (just nice about 60 bpm)
- would you still let him go for op? what would you do? (contact consultant, contact anaesthesia, refer CVM,
explain to patient, call OT to cancel listing, MDT, etc)
- if cancel the op, what are you worried about? (that is is a cancer and it should be done the sooner the better)
- what investigation would you do for him? (2DE)
- need antibiotics for him? (yes, NICE guidelines)
For Critical Care stations, like stations like Pathology and Anatomy, it was clear that they were just looking for
that one-word answer so that they can tick off that checkbox in the marking scheme. It is an OSCE after
all, and if you mention that one word they want, they will have to give you the mark. It helps to observe
the examiner’s body language so that you know how much or how little to talk and not waste time.

18. A n g ry p atie nt w hose operation g o t cancelled again (C om m unications)

Previously arthroscopy cancelled. Symptomatic. Now here for arthroscopy again. Op cancelled due to
emergency case. Patient frustrated.

Went in preparation bay to find a stack of about 10+ pages of notes ranging from patient details to patient's
GP letter to blood results.
- take note of all the dates, as they may not run in order
- you have 9 minutes to write down on the papers provided all the information that you will need, before going
to the next station to talk to the patient
The story: this guy has left knee pain, and his GP has assessed him to have possible meniscal tear. Wrote
referral to Ortho. Ortho assessed him, recommended him for arthroscopy for diagnosis KIV repair. Op
was scheduled last month, but got cancelled due to some reason. Also noted CRP at that time to be high,
possibly related to sinusitis. Rescheduled for operation. GP wrote another letter urging Ortho to expedite
operation, as his work as postman is affected, and he has been putting on weight. Also, he is in pain.
Knee xray shows joint space narrowing. However, this operation will have to be postponed again as
consultant has to attend to E-trauma.
- it helps to write a numbered list of the issues you need to address with the patient. 1) his knee pain - he
would tell you his ibuprofen has been causing him gastric pain, give him alternatives 2) weight loss -
swimming, physio, etc with analgesia cover 3) work as postman - offer to write to employer to explain
situation and cover with MC 4) sinusitis - must get GP to sort it out to prevent operation being cancelled a
3rd time 5) offer avenue to complain - PALS 6) offer to talk to wife 7) assure him his operation will be
placed on priority list, etc etc
- it helps to just keep quiet and let him talk, so that you can understand his issues that need addressing. Of
course with the usual cues of listening in conversations like nodding etc
1. Communication skills. The wife of a man admitted with ascites, which has shown malignant
cells, is waiting to talk to the consultant to is busy. CT scan broken in hospital. Explain the
situation to her. Angry wife.
2. Practical station. Catheterise patient with severe abdo pain and no urine output. No urine from
catheter. Obs show tachycardia and low BP. ?causes for no urine output.
3. Pathology. Gallbladder malignancy - differentials, most common type, where does it initially
spread. Wound infection post resection. Not improving with antibiotics, ?necrotising fasciitis -
what are the 3 commonest organisms. Bloody diarrhoea - pseudomembranous colitis, what
causes the pseudomembrane?
4. Pathology. Haematemesis in chronic alcoholic. ?causes, ?commonest site and why. Know
treatments. Know what sengsten Blakemore tube is and how it is positioned/used. Causes of
thrombocytopenia, and macrocytic anaemia. Would the haematologist advise platelet
transfusion?
5. Practical. Identify pneumothorax on chest xray. Insert chest drain. What size of tube?
Complications - short and long term? If water not bubbling ?causes
6. History taking. Diarrhoea, and upset patient (wanted to see consultant). Inflammatory bowel
disease - investigation, management.
7. History taking. Back pain for 5 years. Differentials, and treatment.
8. Anatomy. Cranial foramen - foramen spinosum. Pterion - what bones make it up, what is
damaged on fracture of this area. TMJ - type of joint, name areas of mandible, what muscles
move mandible. Mastoid process.
9. Anatomy. Thyroid and blood supply. RLN and Superior laryngeal nerve - what do they
supply? Where does RLN run? Vagus nerve course.
10. Anatomy. Bones of foot, tendons of anterior foot, pulses, how do they supply foot? Arches of
foot.
11. Pathology. Pituitary adenoma, blood abnormalities, chronic peptic ulcer, CLO test, where is
ectopic thyroid found? UTIs.
12. Pneumothorax secondary to attempt at central line insertion. Surface markings of
IJV. Complications of central line insertion. How to reduce infections - sterile technique etc.
13. Examination. Examine cranial nerves - bitemporal hemianopia, causes, treatment,
investigation.
14. Examination. Cardiovascular, aortic stenosis, do BP. Pre-op assessment - what investigations?
15. Examination. Abdominal, right upper quadrant pain, pyrexial, tachycardia. Differentials,
investigation, management.
16. Critical care. Poor urine output 12 hours post op abdominoperineal resection. Renin-
angiotensin-aldosterone system, how does ADH work?
17. Communication. Discuss trauma patient with vascular compromise to left leg after bike accident
on phone to consultant.
18. Examination. Arterial examination of lower limb including Doppler, pulses and sensation.
19. Critical care. Post op analgesia. PCA benefits and drawbacks. Normal dosage. Side effects of
morpine.
Examiners on the whole are nice, they don't stress you out unnecessarily. Som e will
literally force the answer out o f you by leading you to it, others just stare at you in
silence.

Thankfully my dept bosses were very

nice and allowed me to take both study leave and A L together. Although I did promise
to buy loads o f goodies for them.

But I digress.

The structure o f the exam is as follows - the group is divided into 2, h alf will take 8
(not including the 2 prep stations) and the other half will take 10 stations,
you have 1 min to read the stem, some stems are ridiculously short, ie this young lady
who fell o ff a horse. Then there will be another bell and you will enter the room.

Each station is 9 min long, after 6 min someone will shout 3 M IN U TES
REM AINING. So for the PE stations, after 6 min they will stop you from doing the
PE and start bombarding you with questions,
after which a bell will ring and you run to the next station.

Sometimes, you may find that you end w-ith extra time, which can either be very good
or very bad. If you think you've done well for the station, you can just sit in silence or
try to talk rubbish with the examiners. Som e are really nice. Or if you mucked up
earlier, try asking them if you can go back to the previous questions.

note - this account may be overly detailed with many other nonsense details. Sorry,
too psyched to sleep.

l.A P S
Rugby player who got tackled, had a hyperextension injury o f his cervical spine.

Basically it was about cervical spine anatomy.

how many cervical vertebrae, cervical nerve roots
which are the atypical vertebrae
C l and C2 - what is this - odontoid, lamina, pedicle, transverse foramen, etcetc
what ligaments are at the atlanto-axial joint that contribute to its stability
which level is the hyoid (c3)
Demonstrate on this patient, (om g there w as a patient. I thought it was another
examiner.)
which is the most prominent cervical vertebrae
why are the others non palpable
what is this x ray and what does it show (swimmers view, shows odontoid)
shown lateral and ap C-spine. what are you looking out for (i think it was normal,
went on the describe all 4 lines etc)

Had som e time at the end, happily told the examiner that I liked this question a lot cos
I used to play rugby. And so did he! Things like this are a good portend, (hopefully
anyway)

2. CSI prep Reading station

Repeated question, patient POD 3 lap chole now with ? bile leak. Abdo pain with
jaundice, bloods given TW CRP bil high. Fluid collection noted. The consultant was
very good, all he wrote in the entry was to transfer to HPB centre. Your job is to call
some superbigshot Prof about the transfer and the current management plan.

For the reading stations, you are given a small stack o f case notes, lab results, scan
results, and you have 9 minutes to process them (which is honestly a luxury).
So use this time to SB A R properly, and try to anticipate w'hat possible qns they will
ask. - differentials, management, why need to transfer and cannot manage at the
current hospital etc.

3. CSI
The phone to call the Prof was in the middle o f the room. I took about 1 min before
figuring out how the phone worked.
The speaker on the other line had a Sean Connery-ish accent, was rather hard to hear
him. So I ju st verbal diarrhoeaed my pre-prepared script.
Just go with the normal SB A R and it was no problem.
Possible dx - bile leak from dam age to C B D , clip slippage, retained stone.
Hardly asked me any questions at all and had lots o f time left over, to well, stone.
Management usual - IV drip, N B M , roc/flagyl, arrange for M RCP (ER C P centre
closed), PFO bloods

was expecting a question on Calot's triangle. None!

4. A SSC C

repeated qn
Old lady with vomiting x 1/52, epigastric discomfort and distension.
Labs show hyponatremia, hypocl, hypokalemia, high bicarbonate
Crt, Urea high.

another repeated question, hooray!

C auses o f hyponatremia - classify by volume status,

why is the chloride low - vomiting
why is the Crt and U high - dehydration, AKI
why is the K low
Patient has paradoxical aciduria, why.
likely diagnosis (pyloric stenosis)
Management
Who would you like to seek help from, (renal? God?)

This is undoubtedly everyone's favourite question. Not going to type out everything
cos it has been repeated pretty much every year. :P

5.A SSC C
Elderly patient with perf DU and peritonitis
C X R with air under diaphragm
ECG - A F

Questions in this station were quite strange, first question he asked me was what do
you do FIR ST when you see a C X R or ECG (check name, number, date? very
ambiguous)
What does the C X R show - air under diaphragm, Riglers
where are the possible perforations - DU, PU, appe, caecum, sigm oid etc
what does the ECG show, why is the HR on the ECG and the HR on the BP cuff
different - said something about the A F causing a smaller volume pulse, BP puff
cannot read.
C auses o f AF
- classify by cardiac, pulmonary, septic, others
M ost likely cause o f A F in this patient
Management o f A F
- my first plan was to refer CVM . Got a scowl in return, cannot refer so quickly
apparently. G S so much pride)
- treat underlying cause
- went by A C L S principles
- rate/rhythm control, how? side effects o f beta blockers and C C B S (cb i could not
remember)

6. CSI prep reading station

another repeated question.
Guy with dysphagia for a few months, GP done a barium swallow for pt, shows
possible benign stricturing. Counsel patient for OGD KIV dilatation.

7. CSI station

the patient was quite chill, did not interrupt me at all and let me go on full steam.
Indications, procedure, risks etc.
Had a lot o f extra time and was worried if I left something out. Thankfully the pt said
I covered most.

8. ASP

Picture o f a resected colon wall with multiple polyps. In my excitement I said UC

almost immediately before the examiner could say anything, (it looked rather
pseudopolypy with friable mucosa) Thankfully he was very nice and told me to look
again. Intensely. And that the patient is 22 years old and has a family history o f
colorectal CA.

GAAH. Flip table time.

Sooooo what does this patient have - FAP

inheritence pattern
what is dysplasia, what is tumour grade
what is Duke classification, what is the score in this patient i f there is no LN
involvement.
what other staging do you know. I ju st said TM N he did not press on for specifics,
what kind o f polyps are the most malignant
what will this patient need in the future
in a person with no FAP, what can protect this patient against getting ca

Extra-colonic manifestations o f FAP which I definitely read but could not remember
at all. My brain decided to abandon me here.

was all prepared to recite the APC M YC beta-cathenin K-ras p53 song about the
tumour carcinogenesis but he did not ask th at:(

9. ASP

young lady went overseas for 6 months, now with neck lump in anterior triangle. Also
has LOW

also a repeated question but did horribly in it

differentials - TB vs hodgkin
what forms the giant cell
what investigations - FNAC
what other pathological investigations - no idea, was staring at the examiner blankly,
hoping that the answer will magically pop up on his head. A las this was not meant to
be.
what TWO community concerns o f T B infection - community spread and ????
other assorted questions ranging from W TF to W TFF (what the Hying f)

had a whole lot o f extra time somehow. The examiner w as nice and actually went
back to the questions I could not answer.
Left the station sadly

1 0 .A SS C C

this patient with a right lower lung lobe lobectomy, epidural was given at about T4-6
level. HR low, BP low, right U L swelling, urine output lOml/hr in last 6 hours,
saturation low.

The moment I read the word epidural I knew this question would be disastrous.
W TFFFFFF question is this seriously! where is the bum s qn with A R D S! or the
pancreatitis one!

differentials
- axillary vein thrombosis with ? PE
- ? inhibition o f sympathetic outflow

Cause o f the low urine output - poor preload/renal perfusion?

cause o f respi failure - sympathetic inhibition?
cause o f bradycardia - sympathetic inhibition?? (can't be the sam e answer right)

At this point I was just praying at this to end

How to manage this patient - finally something that can be smoked, refer anesthesia
for aid in titrating analgesia, IV fluid resus, nasal prong, urine output the usual
shebang.

A whole lot o f other questions which I did not remember due to the trauma o f this
station. Tried multiple times to give puppy dog eyes to the examiner. I do not think
this works. Especially if you are a guy.

left the station feeling utterly confused. Anesthesia question yo!

B R EA K !
mandatory break for us, examiners and other staff involved in the exam. Not bad
actually they provided refreshments.
As I had no appetite for breakfast, lunch and the previous night dinner, this was a
welcome break.

11. CPE - patient with stoma ? parastomal hernia?

Male with transverse RIF/suprapubic scar (never seen any scar like this before),
colostomy bag in LIF. Had APR previously according to the stem. Was draining
brown stool, examiner told me to assum e that bag is empty with no output for past
few hours.
felt a ? parastomal hernia.

Took too long with the exam as I was figuring out W TFF w as going on. Kept
palpating the stoma bag hoping it would talk to me. But it didn't.
Rambled on about the possible complications o f stoma.
Did not reach invx or management.

most o f my group could not get it too. Sigh.

Anyway, in stoma exam s, they do not expect you to remove the stoma and inspect the
sprout. They will just tell you the findings.

12.C SH

repeated question - patient with gastrectomy POD 5 now feeling sad.

apparently patient not sleeping well due to change in external environment,

for the hx stations - ICE if have time!
Concerns - worried about what is the outcome from here
- guilty that he was operated on first???? he started talking about som e sm all girl who
did not go for op.
- he has no family to look after him.

spent most o f the remaining time sayanging the patient + + T L C + + , was all ready to
offer ice cream/money etc until the bell rang.

examiner asked organic vs non organic causes o f depression??

refer social care nurse, MSW, rule out other sources o f depression

13.C SH

Patient with lx episode o f haematememis, dyaphagia for 6/12 progressively

worsening, LOW
Straightforward Ca esophagus history,
investigations and management per usual.
for the management, they did not even ask that kind o f operation to be done. All I said
was something along the lines o f an en-bloc resection o f entire tumour with adequate
margins, with the removal o f the corresponding lvmph nodes and lvmphovascular
supply, and they nodded happily and cut me o ff there. This w as one o f my fall back
statements to use in G S M B B S when I didn't know what was going on.

Seen and practised case many times during final M B B S, so no issues. Had time to talk
rubbish with the patient for a while. He said he was tired cos he was talking for the
whole day lol. Offered me a sweet which I declined.

14. APS
Stem w as about one line about this patient with chest pain. I have no idea how this
links to the below question about trunk and abdomen anatomy but yea.

My examiner for this station was cool, he looked a bit like Magneto (the Sir Ian
Mckellen one).

So anyways, identify som e structures.

Heart, pulmonary artery, vein
azygous vein
sympathetic chain from T1 to L2, what is the sym chain and what connects it to the
spinal cord.
blood supply o f pancreas and spleen
where is the spleen located

other random anatomy things which you really should know.

15. APS
stem was this lady was riding a horse and fell off. now with multiple injuries over the
lower limb.
basically just an excuse to whack you on questions about the LL

anatomy o f lower limb

identify gluteus max, med, mini, tensor fascia lata, ITB
nerve supple o f glut med
basis o f trendenlenburg gait/sign
identify rectus femoris, insertion to where
pointed to rubbery thing around fibula head - common peroneal nerve
what happens in a palsy o f this
which compartments does it supply
where is the sensory loss
patient cannot extend the big toe at all. where are the other possible lesions,

easy question.
16. Procedural skills - IV line insertion
lady with RTA, vitals quite stable, ju st insert IV line and what lluid management you
want to give
the IV line was very funny, unlike any o f those in any hospitals, bloody stiff', difficult
to draw back (even the TTSH ones were easier to use!)
by the time it was my turn the cubital fossa w as already very macerated. Tried re-
cannulating that region, no flashback, tried a few more times before examiner sighed
and said pretend there is a flashback.
and then the tegederm could not be peeled off! stiff tegederm also, since when is there
tegederm that is stiff!
Examiner frowned! I also frowned!
questions were to prescribe an appropriate fluid regiment on the PAPER imr. Have not
seen one o f these ancient things since KTPH ?

anyway, the potassium regiment is lOmmol in 500mls. NO T lOOmls.

felt that I screwed up this potentially free marks station monstrously.

17. procedural skills - suturing in 3 separate scenarios

several sutures which are not labelled given to you in a box. prolene3, vicryl2, silk3,
and some transparent thing that never seen before (not ethilon or monocryl)

1. use a non absorbable, braided suture and hand tie around 2 elastic bands
- silk
- difference between surgeons and square knot. What knot did you use just now.

2. use an absorbable, braided suture and hand tie around a hook in a cylinder.
-vicryl
- very the tricky, I thought the hook w as attached firmly to the base o f the cylinder, to
my horror it started to move with applied excessive force. Turns out it is magnetic.
Luckily examiner didn't see this :P
- what is vicryl? polyglactin

3. use a non absorbable, monofilament suture and overtie a bleeding vessel

- prolene!
- figure o f 8 knot, somehow on the artificial skin my figure o f 8 looked like a 3. How
that happened I also have no idea.

for this station, practise practise practise! No two ways about it. Go and kope some
silk from OT i f they don't need it and just practice hand tying during trauma rounds or
M and M. Or on the 12 hour flight to London instead o f watching lego movie.

18. CPE - parotid lump

Go by the Andre Tan PE and it was fine - look feel move, cervical LN , facial nerve,
examine mouth and duct, offer bimanual palpation
lcm lump felt at the angle o f the mandible
differentials and invx

had lots o f extra time again. Patient started reading vanity fair when my turn was
done.

straightforward case

19. CPE - L L vascular exam

this old chap with vascular claudication, examine.

same thing, go by the Andre Tan PE.
look - DM dermopathy, loss o f hair, no ulcers
feel - cold peripheries, pulses. Only fems were palpable.
move - Buerger was positive at like 5 degrees, first time seeing something like that
too.
they provided a doppler and a steth/BP cuff which they cunningly hid near the bed.
Doppler the PT and DP, absent! popliteal was biphasic. Fem tri. learn to identify the
sound o f the waveforms as I was asked that.
wanted to do ABPI but ran out o f time.
diagnosis - PVD likely from DM/smoking/Berger
management - conservative/medical/surgical

20. CPE - LIF tenderness post colectomy

this young lady POD 5 left colectomy, now with LIF tenderness, fever, TW CRP
raised.

so just do an abdo exam

signs were LIF, lumbar pain, had laparatomy scar with dressing intact, was not
allowed to remove the dressing.

diagnosis - ? anastomotic leak, perf viscus

management - usual. N B M , IV drip, hourly urine output, IV roc/flagyl, tell consultant
lalala

Some final tips

1. for most o f us, we would be taking this exam about 1 or 2 years after our M B B S.
And yes, you would have realized that your pre M B B S knowledge has been gone with
the wind. Even more frighteningly, the emphasis on anatomy, pathology and critical
care (which requires an understanding o f physiology) is rather high. Hence it is
important to STU D Y Y Y . Every senior would have a recommended text to use, these
were mine.
anat - Simon Overstall. Small green book which is easy to
read. Referred to Harold Ellis and Netters for the things they did not have.
C C / physio - this section was probably the weakest for me as I did not have an
anesthesia posting before this. Went through Kanani and Cracking . And
prayed that TTSH A and E knowledge would help me.
Pathology - Andre Tan is actually quite comprehensive in this. Wanted to at least read
through baby Robbins again but did not have enough time.
PE - Andre Tan and Orthobots. Awesome books.
Communications - also relied on M B B S templates.

2. PE stations - practise on whoever you can find, but I feel that it is more important
to practise presentation. Like what a very big shot p ro f (E L ) said when we were
students - PE once, but present 5!

3. The anticipation for the exam is much worse than the exam itself. Once the exam
starts just go with it. By the second station you won't be nervous anymore. By the
time you hit the break it’s ju st another clinic session for you.

4. Beneficial postings - obviously G S or anesthesia would help tremendously. Ortho

(where I w as at prior to exam) was also useful in that I could practise my PEs on
clinic patients; limbs and spine anatomy also became a non issue (unlike a few o f my
friends doing G S at that time). Personally, the best posting to at least have beforehand
would be anesthesia/SICU (crit care would be no problem).

5. Arranging tutorials - Prof Raj tutorials are legendarily good, and essential before
taking the exam. There will be at least 3 stations in which the specimens would be
from a cadaver. Enough said.
Having a core group to study and practise O SC Es with is also very important,
especially when practising presentations and PEs.

6. Questions are usually quite directed. Don't know ju st say don't know and move on.
The era in which they ask you to talk about lentiginous maligna melanomas for 5
mins is over.

7. M O ST IMPORTANTLY - PAST Y EA R Q UESTIO N S.

About 60% o f my past year questions were repeated. Hence i f you are really out o f
time (like me as I had almost no time to study), these would save you. Repeatedly.

8. Enjoy London when you are done :D.

all the best guys!
 1. A nat pathology - FAP ( repeat)

Shows picture o f num erous colonic polyps

Diagnosis
Surgical options
Ulcer def
PUS d ef
Extracolonic m anifestations
APC gene is a tu m o u r suppressor gene
W hy m ust take o u t in 22yo? Adenoma-dysplasia sequence
Inheritance pa ttern - AD

2. A nat pathology - TB (repeat)

Stem: Indian lady w ith a n te rio r triangle lum p + LOW

Differentials-
S ta in s -

3. A nat Pathology - Cervical spine (repeat)

Cervical spine xr, m odel spine, as w e ll as actress around

4. A nat pathology - Thorax and abdomen

Iden tify tricuspid valve, chordate tendinae, papillary muscle, pulm onary artery and vein
Name azygos vein and trib u ta rie s (2)
Spleen supply, ribs, structures to be w ary when splenectomy - pancreas tail
Duodenum - how m any parts, gastroduodenal artery behind duodenum
Referred pain mechanism

5. A nat pathology - Lower lim b (repeat o f lady fallen o f horse)

6. Critical Care - EPIDURAL ANAESTHESIA, pt post lo b e c to m y , c/o dyspnea, sats 90%, oliguria
10ml over 6h

Killed m ost people mainly. Cannot read the exam iner, sigh. Very hard to clarify w hat he is asking.
Then m y basic science not th a t all good, shucks man.
D ifferentials - should have spammed cause o f SOB, AKI
Advantages- sleep v no s le e p , CVS, respi effect?
W hy test pain tem pe ra tu re and n o t dorsal colum n in checking levels (BS abt th ick th in fibres, I
obviously did n o t know w hat I was talking about lol)
W hy m igh t epidural be dangerous at T4? (BS som ething a bout transaxial line)
W hat w ould you do if suspect overanaes/toxicity, how to check
Level o f block depends o n ___ (dose, duration, position)

7. Critical Care - Gastric o u tle t obstruction (repeat)

Standard UEC disorder hypo Na, Hypo K, Hypo Cl, m etabolic alkalosis
W hy bicarbonate increased?
W hy paradoxical aciduria?
W hat o th e r adjuncts you wanna consider - NBM,IV fluid, NGT, catheter
W ho do you wanna call? Renal? Internal medicine? Fk, dunno w ho to call... cannot manage yourself
meh?
 8. Crit Care - ischemic colitis, p e rf viscus, CXR : free air under diaphragm, AF elderly, c/o ado
pain

Com m on causes - m etabolic - low K, low Mg, low Ca, th yroid,

infection, traum a, sepsis, stress - I also stress w hy I no AF
underlying heart disease

Q. W hat you w ould do to optim ise fo r o p - ATLS, fluid, iv am iodarone/bisoprolol

9. PE - ischemic lim b w ith claudication

Pt got m urm ur, MR damn loud. But exam iner d id n 't look impressed.
Some a trophic skin changes - d r y , loss o f hair, nail. No ulcers. Feel all the pulse
G ot Doppler by bedside - but no tim e
Q. w ha t o th e r inx - assess severity ABPI, contrast angio, assess risk factors, LDL, BP, DM, IHD

10. PE - poor stom a o u tp u t in pt s/p APER ( already m entioned APER, can o ffe r to exam iner its
likely an end colostom y, and perineum w ill have scar.)

Pt got Kocher incision, m idline lap, Suprapubic cath, incisional hernia, stoma - end colostom y LIF
Q. W hy got NO o u tp u t - OBSTRUCTION, ILEUS (op was 18 mo ago, say Adhesion pis), recurrence o f
tu m o u r
Q. MX - w h a t scan - CT A P , PET? no tim e

11. PE - C olectom y POD 1 LHC pain

Actress - fake pe rito n itic signs - rebound, guarding, cross tenderness, g o t TEDS on
stem not specified, so ju s t do cursory chest and abdo exam, and inspect plug site
g o t MEWS (HD chart) - T 38, HR tachy, BP dropping, ECG tachy

Q. DDx
Q. M x - nbm , iv drip, abx, analgesia, CT AP , prep fo r drainage, o r repair ( not sure if its abscess or
anastom otic leak. POD 1 leh.

12. PE - Parotid lump

Pt got lum p, no facial nerve involvem ent

Q. D iffe re n tia ls -in c lu d e m alignant

Q. M x - U S , FNAC

13. H istory - DEPRESSION - pt w eary teary, post gastrectom y - alm ost tim e to dc, and ctsp re pt
n o t w anting to go hom e

Let th e pt ta lk about how sad he is. 'I got tim e , take yo u r tim e /

Q. do you th in k is depression
Q. W hat w ould you do. But I th in k exam iner failed me, ju st to ld me answer - you w ill reassure him.
:S)

I got the story he not sleeping w ell, w orried about recurrence, fo llo w up, w hy his op was put on a
Saturday, is it th a t his case not im portant. Lol. Yeah I lo at him . And reassure him
Then present like a MSE ?? and th en th e exam iner ask w hat is it? He w ill insist it's depression (but o ff
th e to p o f m y head, bloody DSM criteria say m ust be m ore than few m onths right, so now only a few
days duration post op, ITS ACUTE ADJUSTMENT DISORDER)

14. H isto ry-D ysp h a g ia

Pt pub ow ner, drinks, tells you got v o m it blood x l/7 . But actually dysphagia x6/12 , solid>liquid, LoW
+, DRINK 5u /d, Smoke since teenager, no fhx, takes nsaids fo r hip replacem ent pain
D iffe re n tia ls-e so p h a g e a l adenocarcinoma (from barretts esophagus), benign stricture, PUD (lol,
during hx taking, I to ld p t it is likely PUD?!? then th e exam iner come round and ask whats m y top
differentials, I had to backpaddle like shid.) this exam iner is cfm laughing executioner type !! still say
w ell done a t th e end. Confirm GG

15. Skills - IV cannula

Pt got in to some accident, HD unstable, do usual pt details, chat a b it on allergy, needle phobia, w hy
put needle
Later she w ill say wanna go hom e to n ig h t during your firs t a tte m p t, b u t generally cooperative
I to o distracted to read th e stem properly, I th in k she was HD unstable needed large am ount o f fluid,
no touch technique and alcohol w ipe, norm al gloves, no need clean petri dish too. aim median
cubital, but previous candidates made a hole else w here, and I fo llo w suit, only got on 2nd try,
anyhow plaster the tegaderm too.
Q. W hat flu id , how much, how fast?

16. Skills - Knot tie (repeat)

handtie rubberband w ith non absorb braided(silk knot 3x), handtie deep cavity hook absorb braided
Vicryl- knot3x)- advice - w ear SMALL GLOVES. Their m edium size very big
underrun vessel w ith fig ure o f 8 knot w ith non absorb m ono fil - prolene knot 6x

Q. p ro pe rty o f each one, tensile strength, w hy tie m ore knot

17. Comm- Phone call to tra n sfe r bile leak case (repeat)

Q. W hy bile leak - clips slipped, CBD injury, interval stones

Q. W hat to do - nbm , iv fluid , abx, w ha t else w hat else? The stem says no ERCP available, so I d id n 't
say, quite silly, th e y ju st w an t to hear you say it. plan decompress - ERCP not available on site ( LOL I
o ffe r octreotide) wah exam iner te ll me not medical exam here lol. A nw o ffe r MRCP/PTC

18. Comm- endoscopy dila ta tion biopsy consent

Case file stem : guy had dysphagia, m iddle age, smoker, ETOH use +, w ent on to have Ba swallow,
looks benign so here at clinic to be consented fo r OGD, D ilatation and BIOPSY.

Tests show : ALP raised, Bil slightly, Hb LOW. NCNC pic.

Risk/ In d ica tio n / asked if w ill be done under GA hm.. I dunno maybe coz m ore painful?
The stem d id n 't say but a b it w eird thinks there is m ore than meets th e eye.
1. Critical care
45 yr old chronic alcoholic, p /w h aem atem esis, low BP, tachycardic
a. Differential - o eso p h ageal v arices
b. FBC picture sh o w s low Hb an d platelets
i. R eason s for low platelets - DIVC, liver dysfunction
ii. If you call h aem atologist, will you a sk for p latelets?
c. Sen gstaken Blakem ore tube
i. D escribe u sage
ii. 3 p o rts - w hat a re they for and w here do the balloon sits
iii. W hat is the m odification - p ort an terio r to o eso p h agu s? If
there is no m odification, w hat do you do? (in sert NGT)
iv. p ro blem s asso c iate d
2. Pathology
Elderly lady with b /g g astric ulcer, now p /w h aem atem esis, OGD done,
sh ow s peptic ulcer - biopsied. Pt now in clinic to trace rep o rt o f biopsy.
R eport o f biopsy - clo te st +ve. FBC sh ow s an aem ia, Ca raised . Pt taking
long term abx.
a. W hat is an ulcer - breech in epithelium
b. W hat is clo te st (cam py lobacter like organ ism )
c. Exact m echanism o f clo test
i. The b asis o f the te st is the ability o f H. p ylo ri to se crete the
u rease enzym e, which catalyzes the con version o f urea to
am m on ia and carbon dioxide. A b io psy o f m u cosa is taken
from the antrum o f the stom ach, an d is placed into a
m edium containing urea and an in dicator such a s phenol
red. The u rease produced by H. p ylo ri h ydrolyzes urea to
am m onia, w hich ra ise s the pH o f the m edium , and chan ges
the color o f the specim en from yellow (NEGATIVE) to red
(POSITIVE).
d. T reatm en t - triple th erapy (am oxicillin l g BD, klacid 5 0 0 m g BD,
PPI)
e. A nother reaso n for h em etem sis - hyperCa in creased gastrin
re lease -> in creased HC1 production
f. 2 com m on cau ses for h ypercalcaem ia - p arath yroid aden om a,
renal failure
g. show n pathology rep o rt with ch ief cells -> p arath yroid aden om a
h. w here are p arath yroid glan ds located
i. m an agem en t o f parath yroid - se stam ib i scan, parath yroidectom y
3. Pathology
50 yr old lady gone for elective lap chole -> converted to open, histo:
gallblad d er CA
a. com m on est histo o f gallb lad d er CA - adenoCA
b. com m on est cau se of g allb lad d er CA in UK - sto n e s causin g chronic
inflam m ation
c. site w h ere gallblad d er CA com m only sp re a d s to - liver segm en t V
d. POD 3 pt has pain at w ound site, red n ess, w hat do you su sp e c t
i. W ound site infection
 ii. Mgt: abx, take sw ab for c /s
iii. C om m onest o rgan ism - staph
e. Inflam m ation se en at w ound, no cellulitis, w hat else can you do???
f. W ound w o rsen s - d evelop s necrotizing fasciitis
i. Mgt - ABC, abx, debridem en t
ii. C om m onest o rgan ism s: staph , strep to coccu s, Clostridium
g. Pt d evelop s bloody d iarrh ea - show n picture of
p seu d o m em b ran o u s colitis
i. Why d o e s p seu d om em b ran e happen - biofilm form ation
(b ro ad sp ectru m abx -> norm al gut flora d estro y ed C diff
p ro du ces enterotoxin A& B -> d am ag e s bow el m u cosa ->
exudative fibrin deposition -> p seu d om em b ran es)
4. Clinical S k ills/P ro ced u re - urinary catheterization
a. 14Fr cath eter
b. com m on est ca u ses o f an u ria - blocked cath eter
c. com m on est ca u ses o f blocked cath eter - gel
d. if obstru ction - flush cath eter and a sp irate
e. flushed and asp irated , still no urine show n tem p eratu re and vitals
chart - con sid er hypovol sh ock
5. A n ato m y - th o ra x /u p p e r limb
a. Arch o f ao rta - brach ioceph alic trunk, left CCA, left subclavian
b. V agus nerve
i. P reganglionic p arasy m path etic fibres travel in it
c. R ecurrent laryngeal nerve
i. M uscles th at it su p p lies
d. Thyroid
i. P arts o f thyroid
ii. Blood su p p ly an d w here they a rise from
iii. V enous d rain age an d w here they drain into
iv. N erves a sso c ia te d with them
v. Em bryological origin of thyroid gland
e. Parathyroid glan ds
i. N um ber
ii. Location
iii. Why do in f thryoids go dow n into thym us
f. U pper lim b u pp er brachial plexus injury - erb 's palsy
i. Nerve ro o ts - C5,6
ii. A sked to sh ow u p p er roots
iii. V alues o f low er roots
1. K lum pe's palsy
2. W hat a re the m u scles that are going to be affected
6. A natom y - Skull and lateral C sp in e XR
a. T em poral m an d ibu lar joint
i. W hat join t is it: biarticu lar fibrocartilagin ous joint
ii. In a living p erson w hat do you find???
iii. M ovem ents o f the TMJ
iv. M uscles acting on joint
b. Show n pituitary fo ssa
c. Coronoid su tu re
 d. W hat is diploic veins
e. Foram en s on b a se o f skull - nam e them
i. Foram en sp in osu m - m iddle m eningeal artery
ii. Foram en ovale & nerve
iii. Stylom astoid foram en & nerve
f. Pterion - sign ifican ce and bon es that m ake it up
g. M uscles attach ed to styloid p ro ce ss
h. Show cervical v erteb rae on C spine xray
i. W hat is odontoid p ro ce ss
ii. W hat is the joint betw een odontoid an d atlas - pivot join t
A natom y - tib ia/fib u la, ankle
a. O rientate the tib ia/fib u la
b. Nam e each bone o f the foot
c. Su b talar join t - talo-navicular an d calcaneo-cuboid
d. Nam e bon es th at form m edial and lateral arch es o f foot
e. S u ste n ta c u lu m ta li (alternatively, the talar shelf], which gives
attach m en t to the plan tar calcaneo-navicular (sp rin g) ligam ent,
tibiocalcaneal ligam ent, and m edial talocalcan eal ligam ent.

talar articular surface

erosity
articular surface

Sustentaculum tali

G roove for
tendon o f flexor Fibular
hallucis longus (peroneal)
trochlea
M edial
Lateral
process of
tuberosity

P o s te rio r v ie w

f. M edial ankle collateral ligam ent

g. Lateral ankle collateral ligam ent
h. Which position is the ankle m ost stab le
i. M ovem ents o f ankle
j. Show ten don s and nam e m u scles o f all com partm en ts o f LL
k. L an dm arks o f d o rsalis ped is and p o ste rio r tibial artery
1. Blood su p ply o f foot
m. M uscles resp o n sib le for inversion o f foot & eversion o f foot
8. Critical care
Insertion o f central line pt becam e b reath less -> CXR sh o w s left sid ed
PTX
a. Initial M anagem ent: ABC, in sp e c t/p e rc u ss/p a lp a te , 0 2
b. Before looking a t CXR w hat to do - check pt identifiers, d ate etc.
c. How to look at CXR - check view, exposu re, rotation, well
in sp ired ?, etc.
d. T yp es o f pneum oth orax
e. M anagem ent - insertion o f chest tube
Clinical sk ills - chest tube insertion
a. select equipm en t - ch est tube (size 10)
b. m argins o f triangle o f safety
c. connect to u n d erw ater seal
d. com plication s o f chest tube insertion
10. Critical care
7 0 y r old m an 9h p o st laparotom y, c /o low er abdom in al pain. Vitals stable,
slightly tachycardic, apyrexic. Drug chart given.
a. How do you a s s e s s pain
b. How do you a s s e s s pt
c. Drug chart sh o w s IV p aracetam ol and IV diclofenac, s / c m orphine
with cinnarizine
d. WHO pain lad d er
e. Side effects o f m orphine
f. PCA - w hat is it
i. P roblem s - pt has to be alert and o rien tated to be able to
u se it
ii. M achine can b reak d ow n /ru n out o f battery
11. Exam ination * CVS exam ination with m urm ur o f m itral regurgitation
a. Check BP
b. A sked for d iagn osis
12. Exam ination - Ischaem ic limb
Pt p /w claudication
a. Do b u ergers, feel for p u lses, in spect etc.
b. Offer to do ABPI
c. Blood su p ply o f low er limb
13. Exam ination - abdom en, RHC pain
a. D ifferentials for RHC pain: cholecystitis, PUD, cholangitis, low er
lobe pneum onia, pancreatitis, renal pathology
b. B ed sid e te sts you can do to help in your d iag n o sis - blood tests,
UFEME, US abdom en
c. US sh o w s g allston es -> cholecystitis
d. Mgt o f cholecystitis - ab x (3 rd gen cep h alosporin + m etron idazole)
e. Surgical option s
14. Exam ination - elderly guy p /w headache, do cran ial n erves exam ination -
bitem poral hem inanopia
a. Differential: pituitary ad en om a
b. M anagem ent: CT brain/M RI, blood te st/h o rm o n e test,
su rg ical/m e d ical txt (brom ocrpitin e)
15. C om m unications (w ith p rep station)
21 yr old m ale RTA victim with LOC 15m in durin g incident. Reg in OT,
p lease call traum a consultant.
Pt GCS15 initially, lucid, vitals stab le initially, blood te st ok, has pain over
right UL (XR sh o w s m etacarp al #), open tibia # o ver left LL. FAST sh o w s
sm all am t o f free fluid in abdom en. Later left LL no distal pulses.
a. W hat is m ost urgent - open #
i. C om partm ent syn drom e
ii. A rterial dam age
b. W hat do you do
i. R ef to v ascu lar and ortho
ii. Im m obilize and reduce the fracture
iii. CT a b d o /p e lv is to rule out injury
iv. CT head
c. Plan for next 12hr
16. C om m unications - an gry p atien t (with p rep station)
Pt p /w abdom in al sw elling - ascites. Pt had tap done, show n m alignant
cells. Scheduled for CT scan but w as cancelled b ecau se scan m achine
broke down. Given options - either do US o r t / f to oth er h ospital for CT
scan. Wife has arrived and is an gry w an ts to s / t con sultan t but he is in
em ergen cy surgery. To s / t wife.
17. H istory taking
40 yr old lady with gen eralized back pain X 5 y rs
a. Red flags o f back pain
b. D ifferentials
c. W hat exam ination will you perform
18. H istory taking
25 yr old girl p /w diarrh ea, blood stain s
a. D ifferentials - inflam m atory bow el d isease, IBS, cancer
b. In vestigation s - FBC, UECr, Stool c /s, colonoscopy
c. F eatu res seen on colon oscopy
Anatom y Station s
1) T h orax & Neck
• B ran ch es o f ao rta arch
• A rterial su p p ly /V en o u s d rain age/ly m p h d rain age o f thyroid
• Nerve su p ply to thyroid
• V agu s/P h ren ic nerve
2) B ase o f Skull
• Optic canal
• Foram en R otu n du m /O v ale/Sp in osu m
• Boundary o f M iddle cran ial fo ssa
• Sp read o f infection through m iddle e a r cavity
• C avernous sin u s
• Sp read o f infection from face
3) Foot/A nkle
• Nam e bon es o f foot
• Deltoid ligam ent
• Which position is the ankle m ost stable
• Put tibia and fibula together
• T en d on s o f foot
• A rterial su pply o f foot
• Inversion - w hat m u sc les/n erv e
• A ctions o f ankle joint

Pathology
1) Skin lesion - M elanom a
• Risk factors
• W hat m acro sco p ic/m icro sco p ic featu res o f m alignant lesion
• H istology vs. Cytology
• Axillary vein th rom bosis - m an agem en t
2) A nterior Neck Lum p - TB lym phom a
• T ype o f lym phom a
• W hat inform ation n eeded on re q u est form
• G ranulom a - give 3 exam p les
• Giant cell o f Langhans - w hat a re they?
• Nam e one o th er M ycobacterium
• Culture m edium for M ycobacterium
• Rapid detection o f M ycobacterium

Critical Care
1) Burns M anagem ent
• Initial m an agem en t - ABCDE
• Calculation of TBSA
• Parkland form ula and type of fluid given
• Interpret CXR of ARDS
• W hat is ARDS
 • M anagem ent o f ARDS
• C om plications o f ARDS
2) Opioid O verdose
• How is C 02 tran sp o rted in blood
• W rite form ula for C 02 tran sp o rt in blood and carbonic an h y d rase which
p art o f form ula d oes it act on
• Interpret ABG - w hat ty p e o f R espirato ry failure
• W here d oes Opioid act on
• R espirato ry drive - ch em oreceptors
3) RTA - liver laceration /P n eu m o th o rax
• Initial m an agem en t at A & E -A B C D E
• T ype o f airw ay m an agem en t
• How you w ould m an agem en t "Circulation"
• T rau m a se rie s XRs
• Interpret CXR - su b cu tan eo u s em ph ysem a
• Interpret CTAP - liver laceration
• How w ould you m an age liver laceration

Sk ills/P rin cip les

1) Closing w ound
• P repare y ou r own tray - su tu re /in stru m en t
• A nsw er qn s from p atien t - painful? A ntibiotics? STO? Scar?
• T ype o f LA - m axim al sa fe d ose
2) R e-arrange OT list
• W arfarin m an agem en t
• DM m an agem en t
• COPD m an agem en t (pre-op)
• Penicillin allergy - w hat prophylactic an tibiotics for laparotom y
• Show on m annequin the extent o f cleaning for each op - laparotom y,
hernia, BKA
• T ype o f d iath erm y for each p atien t - pacem aker
• Show on m annequin the location o f electrode plate placem ent

Exam ination
1) C ard io vascu lar Exam ination
2) Knee Exam ination
3) Cranial N erve Exam ination
4) Hernia Exam ination

History
1) A bdom inal Pain
2) A sse ss m ental capacity for consent-taking

Com m unications
1) Phone consult - re q u est for post-op ICU bed
2) T alk to fam ily regard in g asc ite s

KEEP CALM & CARRY ON! All the Best!

I have trie d to keep the account as detailed as possible w ith all the exact questions. No problem
recalling cos PTSD haha.. Anyw ay fo r pointers: Tim ing is super tig h t. Need to speak quickly,
neverm ind about organisation like "I w ould like to divide m y investigations into bloods and
radiological. No points fo r th at.
I personally found saying "can i skip and come back later" fo r th e knowledge stations quite useful.

All th e best!

Station 1: Prep station, th en ta lk to p a tient -- Esophagoscopy, biopsy and dilatation

C om m unications -- explain the barium sw allow result to patient, address his concerns and talk about
the indications and specific risks o f dilatation.

Station 2: History taking

Lady comes in w ith 6/12 o f PR bleed and change in bow el habits
Examiner did n o t le t me get past the d ifferential diagnosis -- gave differentials o f malignancy, polyps,
d ive rticular disease, haem orrhoids. I th in k th e y w ere looking fo r IBD. Sigh.

Station 3: History taking

Guy comes w ith rig ht groin lum p -- likely hernia, sym ptom atic, affecting w ork
Drinking some to nic thingy. Had previous GU problem (th in k it's gonorrhea). Asked if he had slow
stream but d id n 't have (was w orrie d about urethral stricture)
Specific questions asked - how w ould you manage hernia? w h a t are your d /dx: said inguinal,
fem oral hernia, saphena varix (w hat else, w hat else), LN, fem oral aneurysm. Examiner satisfied.
How to repair hernia -- lap vs open.
W hich w ould you recom m end fo r him - open: unilateral
Are you w o rried bout the to n ic -- Yes, I w ould like to know if these are steroid containing
Good, so he goes hypotensive a fte r the op -- explain Addisonian crisis.
W hat is you r m anagem ent -- ABC, Fluids, hydrocortisone

Station 4: P a th o --G B C A
W hat is th e m ost com m on histology fo r GB CA?
W hat are the risk factors? W hat is th e m ost com m on risk fa cto r in th e UK?
W hat is th e com m on routes o f spread
Patient is staged and goes fo r op
Postoperatively, develops w ound infection on POD2. W hat is th e m ost likely offending organism?
If th e re is m inim al cellulitis, w h a t is yo ur m anagement?

Pt deteriorate s and you note th a t the w ound is necrotic

W hat is you r diagnosis? Nec fasc
W hat is y ou r tre a tm e n t fo r that? Broad spectrum antibiotics (i said fo rtu m , he seemed to agree),
fluids and debridem ent
W hat are some the organisms responsible? Name 3 ( i said Clostridium - which Clostridium.
C lostridium perfringens. Staphylococcus aureus.) W hat else? I w e n t the gam ut fro m Strep to every
o th e r bacteria, but no th a t was not the answer. I really th o u g h t strep was involved.
Postoperatively she recovers, but develops PR bleed. W hat are your 4 d /d x diagnoses?
- C d if f
- Ischemic bowel
- Stress ulcers
- ???? Really dunno. DIVC and coagulopathy is n o t correct.
Look at the colonoscopy picture -- w h at do you see?
Pseudomembranes
Can you te ll me w hat the exact mechanism o f how C d iff causes pseudomembranes? Exudative
fib rin deposition as th e bacteria secretes proteases to damage th e bow el mucosa.

Station 5 -
Patient s/p op, now BP high, desaturating and low urine o u tp u t, (asked to in te rp re t the vitals chart
and I/O chart w hich is not given p rio r in the stem).
Explained flu id overloaded cos net 5L + input.
W hat are yo ur expected physical exam findings?
W hat investigations w o uld you w a nt to do? W hat are your expected findings?
In te rp re t th is CXR: pulm onary edema ++, loss o f cardiophrenic angle, cardiomegaly.
How w ill you manage this pt?
Can you explain the patient's low urine o u tp u t? W hat is the m inim um urinary output?
W hat are some physiological causes fo r his low urine o u tp u t postop?
Explain w h a t are the flu ids th a t have been given. W hich are crystalloids, colloids.
W hat is th e Na requirem ents in a patient?
W hat are the K requirem ents in a patient?
Can you give a few suggestions on how this situation can be prevented o r detected earlier?
Put patient in HD?? (the exam iner laughed). Times up.
In retrospect -- maybe the answ er he was looking fo r was CVP line insertion postop.

Station 6 - Patho
Post to ta l th yroid e ctom y pt w ith low Ca. All o th e r bloods norm al
Explain how Ca is carried in th e body and which part is active (bound the album in, ionized fraction is
active)
W hich horm ones are involved in Ca regulation (name 3). W hat are th e ir actions? (exam iner asked
the exact mechanism o f how parathyroid horm one causes phosphate excretion in the kidneys, w tf.
Gave some dubious answer about DCT haha)
How is active v it D3 form ed?
W hat are the physiological roles o f Ca in th e body? Name 4. Cardiac, nervous, haemostasis and
bone.
Can you te ll me w hy this lady has hypothyroidism ? Inadvertant rem oval o f parathyroids.
W hat is a m ore com m on cause? Ischemia to parathyroid glands.
Examiner goes "Yes, precisely!" Sigh.
So w h at w ould you be w orried about in this lady? Tetany
And so? Respiratory em barassm ent
How does hypoCa cause SOB? Laryngospasm causing upper airway obstruction
W hat o th e r signs o f HypoCa do you know of? Chovsteks and Trousseaus sign.
Can you describe th em fo r me?
So w h at w ould you w a n t to do fo r her? Give Ca replacem ent -- IV Ca gluconate. W hat is th e exact
dose th a t you w ould give? and th e concentration? W hat w ould you ink up in the IMR? lO m ls 10% Ca
glue
W hat o th e r m anagem ent? Said A, B, C.. exam iner not interested. M o n ito rin g -- ECG, Sa02
m onitoring.
W hat else? Regular Ca m onitoring? Digoxin? HD? bell ring. Sigh.

Station 7 - Patho

Previously w ell 53 y r old adm itted fo r 1/52 duration o f b loody diarrhea. Suddenly stopped having
any m ore episodes o f diarrhea and now having abdo distension.
W hat are yo ur d /d x: Enterocolitis, IBD, colon CA. W hat else? C d iff
In te rp re t th e lab results: Na 128 K 3.1 Cr 109 U 9. Hb 8.7 (hypochrom ic, m icrocytic), TW 12 (raised).
PLT 666.
Explain all th e abnorm alities.
Do you th in k he has chronic o r acute anaemia? CHronic. Why? MCHC anaemia. W ould be NCNC in
acute hemorrhage.
W hy are the platelets high? Dehydration, acute bleed. These are right, but w hat else? Acute phase
response.
W hat do you see on th e AXR? T hum bprinting
Besides all these investigations, how else w ould you investigate this patient? (FBC, UECr, AXR done)
CRP, ESR, stool c/s + OCP, Stool C d iff, CEA, specific antibodies fo r Crohns and UC (Yes, but only a t a
late r date right?) How else w ill u investigate the patient? Colonoscopy at later date (doesn't seem
like the answer)
How w ill you m o n ito r this patient's progress? Clinically -- fever settles, diarrhea settles.
Investigations -- TW, CRP decreases.
W hat w ould you do fo r th is patient?
W hat are the indications fo r operative m anagement?
W hat surgery w ill you perform fo r him?

Station 8: History taking

Pt presents w ith R knee pain over m any yrs duration. Recently getting worse.
A /w pain th a t wakes him up fro m sleep. O therw ise very mechanical. I asked if he had any previous
m edical issues -- He denied. But, if you elicit enough history, then he w ill te ll u he had injured his
ligam ent before and had a w ashout done w hen he was younger. Affecting work.
Summarize y o u r findings
W hat is you r diagnosis?
W hat signs in th e PE w ill u be looking for?
W hat o th e r differentials? RA knee, g ou t flare, ligam entous instability. W hy do you say th a t
secondary OA is yo ur to p differential?
How to investigate? Xrays (skyline, w eight bearing AP/Lat), FBC, ESR, CRP.
W hat else? MRI knee, uric acid.
M anagement?

Station 9: Com m unications (Prep station and call your consultant)

Some damn long history., i th in k like 10 pages o f info. On to p o f th a t, your stem is like a FULL A4
sized page.
Anyway is POD 2 s/p R SMAC, patients daughter w ants to AOR because she doesn't w ant to travel to
and fro betw een the hospital and her ow n house. Environm ent is not ideal because her husband
and herself w ork as school teachers, and she stays w ith 2 teenage daughters. I th in k also g o t a dog.
She has convinced th e m o th e r to go hom e, although p rio r to this the m other was m ore keen to
recover in hospital before going back home.
4 pages o f labs are all norm al -- but note these are all preop

Call you r consultant to te ll her about th e situation.

Salient points -- 58 y r old Caucasia lady w ho is POD 2 R sentinel lym ph node biopsy, then continued
to perform SMAC. No intraop com plications, blood loss m inim al. Postop D1 w ell, POD 2 developed
SOB, m ild tachycardia HR 95 and BP holding 135/90. Drain o u tp u t 410mls (bloody) <- 30mls
(serous). Axilla is also puffy.
Use the standard SBAR fo rm a t, and update consultant as per how u w ould on a norm al ward round.
No biggie.
Form to sign fo r AOR, o ffe r to update the team 's prim ary consultant.
"Is there any policy in th e hospital th a t we can force her to stay in fo r tre a tm e n t? "
Hmm. I said if she is m entally com pe ten t can sign AOR and we can't keep her u n fortuna tely ( i dunno
w h e th e r this is right). Then she asked, so is the pt m entally com petent?
I said th a t i hadn't assessed form ally, b u t noted fro m the notes th a t it seemed th a t she was.

- half an hour break -

Station 10: Trauma activation

You have a m otorcyclist w ho is now GCS 3, cyanosed and not breathing. Has cardiac output.
Examiner and mannequin.
Gel and glove up.
Has no C collar on.
Testing ATLS.

- 1said w ould ask the nurse to hold the head or put sandbags
-Secure airw ay -- ja w th ru s t: sweep foreign bodies. W hat foreign bodies could these be? Patient's
vom itus, dentures, loose tee th etc.
-P atient is still cyanotic. W hat w ill yo ur next step be? Guedel airway.
-Sats still n o t picking up. Offered in tub atio n - "you mean you can intubate?" I said i w ill ask an A&E
colleague h a h a ." W ell, th a t is not w rong."
-But w hat else can you do?
Bag valve mask th e p atient. Show me.
- Now the sats have started to pick up., w h a t else do you w ant to do?
Put on th e C collar. "OK, show me."
- W hat if sats still not picking up. W hat w ill you do?
If upper airw ay obstruction., offered needle cricothyroidoto m y -> form al cricothyroidotom y. Asked
on how to do it.
And how long can a crico th yro id o to m y last?
Is it perm anent?
How to pe rform a tracheostom y?
And w hy is it perform ed at the level o f the 2nd and 3rd rings o f the trachea? I said lo w e r risk of
tracheal stenosis but th is is w rong :(.

Station 11: Procedural stations

- 1DC insertion.
- w ha t w ill you do if th e re is no urine -- aspirate the urine. If still no urine? flush and aspirate.
W hat is you r logic fo r flushing and aspirating?
- If still no urine and no good flo w -- w h at w ill you do? take o u t th e IDC
W hy? W hat are you r differentials? False passage, catheter tip in urethra instead o f bladder
- W hat else?
Not a true palpable bladder -- ie, a suprapubic mass
- W hat are the suprapubic mass d/dx? Pt was male. Malignancy fro m bladder, prostate, CLR CA,
pelvic collections, abscesses, m esenteric cysts.
Bell rang.

Station 12: Patho

- M edullary th y ro id CA: stains calcitonin +.
- asked you to fill up th e pathology report.
- W hat is it associated w ith? MEN2
- W hat are the o th e r features o f MEN 2?
- W hat is th e oncogene m u ta tion fo r MEN 2?
- W hat is th e m ode o f inheritence o f MEN 2?
- W hat w ould you like to exclude before operation? Phaeo.
W hy? Labile BP, dangerous.
- How do you do so? Urine VM A, M etanephrines. W hat else? I w ant a blood test.
- Explain in layman term s w ha t im m unohisto chemical staining is.

Station 13: PE
Subm andibular gland swelling -- erm . th e swelling was n o t easy to feel, it's only like 2cm, and quite
deep.
Questions asked: w h a t are you r differentials fo r the swelling?
W hat are the causes o f each differen tial? Enlarged cervical LN and subm andibular gland
enlargem ent
Asked how to d /d x b tw Subm andibular gland and enlarged cervical LN
So w hich is y o u r to p d iffe re ntia l and why?
W hat is th e m anagem ent o f this swelling?

Station 14: PE
Appendicitis
- How w ould you perform an appendicectom y?
Open vs laparoscopic
- w hat are the advantages o f lap? less scarring, can perform diagnostic lap
- w ha t w ill u be looking a t in the lap?
- How do you do the diagnostic lap and where do you insert the ports?

Station 15: PE
Pacemaker dude w ith aortic valve replacem ent

Station 16: PE
Thyroid

Station 17: A natom y (super rush fo r tim e!)

Hand. ALL ABOUT HAND.
Name all the bones o f the carpus and show them on the Xray given. (AP and Lat view)
Name all the m ovem ents o f the th u m b and dem onstrate it to me. Show me which muscles control
these m ovem ents and w ha t is th e ir innervation?
Show me th e median nerve d istrib u tio n o f the hand. They ask fo r th e extent o f th e dorsum also.
W hat muscles make up the th e n a r eminence.
W hat is th e nerve supply o f the na r eminence?
W hat are the boundaries o f the anatom ical snuffbox? Dem onstrate to me where is the anatomical
snuffbox. W hat is in the anatom ical snuffbox?
W hat is th e significance o f snuffbox tenderness?
W hy do you get AVN in scaphoid #?
How do you te s t fo r collateral circulation o f the hand?
Describe th e test fo r me.
Identify the superficial palm ar arch (on prosection). W hat is th e supply?
W hat are the roots o f the ulnar nerve? W hat does it supply in the hand?

Station 18: A natom y (also super rush fo r tim e)

Identify the pterion.
w h at are th e 4 bones th a t converge here and show them on th e skull.
w h at is its clinical significance
Identify this bone -- atlas
W hat part is this? A n te rio r tubercle o f atlas
Show me th e foram en lacerum
w h at is posterior cranial fossa form e d by?
Identify this part: petrous tem po ra l bone
Given lateral XRay o f skull -- show me th e sella turcica.
W hat is this: ethm oid sinus
On prosection: W h a t is this muscle -- tem poralis
W hat is its blood supply? Deep tem po ra l artery. W here is it from ? LOL.really dunno man.
W hat supplies th e scalp over the tem poralis muscle? Superficial tem poral artery. W here is it from ?
On prosection: This is th e o ptic chiasma. W hat nerve is this? O cculom otor nerve.
W hat are the autonom ic innervation to the pupil? W hat does sym pathetic do and w hat does
parasym pathetic do?
W hat do you get in raised ICP?
W hy?
W hat exact structure is CNIII pressed against? Show me on the prosection.
Station 19
There is a skeletal m odel and you are given a pointer.
- show me th e attachm ents and origins o f the ro ta to r cu ff muscles
- Show me th e spiral groove
- W hat nerve runs in it
- Id en tify the m edial epicondyle
- w ha t w ill u get in fractures there?
- show me on your hand w ha t is the area supplied by th e ulnar nerve (show both palm ar and
dorsum )
- W hat is th e principle fle xor o f the hip
- W here is th e insertion. Show me.
- W hat muscle has its origin at th e ASIS?
- W hat is its nerve supply?
- W hat nerve runs under th e inguinal ligament?
- W hat syndrom e happens if th is nerve is caught?
- show me th e origin and insertion o f the gluteus medius and m inim us
- show me th e origin and insertion o f the quadratus fem oris

THE END.

P.S. I had one "te s t" station w hich w asn't counted in the marks. M ost likely th e ATLS one?
1) Hx taking. Pt came fo r elective hip replacem ent. Nurses are concerned th a t p t is confused and the
consent is not valid. Please assess pt.
- did AM T scoring, offered MMSE. pt got 0 o u t o f 10 pts fo r AM T (they gave the pts details on a piece
o f paper)
- p t did not even know w hy she was in hospital (i did not bother gg on to ask pt if she knew the risks
o f op, o r th e alternatives available)
- discussed w ith exam iner: said th a t p t d e finitely not fit fo r op.
- offered to speak to pts daughter to see if confusion was acute or chronic
- to speak to d octo r w ho to o k the consent
- if acute, offered various ix fo r w orkup: hypocount, bloods, vitals, neuro exam
- if chronic, offered geriatric review kiv scan head
- to reschedule anothe r appt to assess fitness fo r consent as OA hip replacem ent was nonurgent
exam iners d id n t really ask any questions fo r this case, so i ju s t kept talking, frankly, im not sure
w h e th e r i headed in the right direction.

2) hx taking: pr bleed.
m iddle age lady, alternating bow el habits, fam ily hx o f cancer, pr bleed fo r 6/12
- conversation was to ta lly not guided by examiners, had to tim e my ow n history taking, move on to
d ifferentials and investigations, d id n t manage to move on to m anagem ent, on hindsight, shouldnt
have spent so much tim e on taking an extensive history.

3) prioritizing OT cases
- man w ith strangulated hernia, b /g o f severe copd, has pacemaker
- lady w ith perforated diverticular abscess fo r hartm anns o peration, has penicillin and iodine allergy
- man w ith LL ulcer fo r BKA. background DM on insulin and AF on w arfarin, mrsa positive

prioritizing should be in th e o rd e r above, based on urgency o f op.

- don t both er arguing w ith exam iners even if you feel th a t th e order should be otherw ise, just accept
it
questions:
- w hy the o rd e r above?
- how long w ill you expect each operation to last? how extensive w ill you clean and drape the pt?
- w hat to w o rry about fo r copd? (may not be suitable fo r ga)
- qns on m onopolar and bipolar diatherm y
- how to manage th e pacemaker
- w hat to give if has iodine allergy
- how to manage dm and af preop (scsi, stop clexane 12hrs before)
- w hen to give spinal or epidural anaesthesia

led on to m annequin on the bed

- w here w ill you place the diath erm y pad fo r m onopolar and bipolar (trick qn fo r the bipolar bit),
w hy th a t spot?
- if you have to use m onopolar fo r the pacemaker pt, w here w ill you place the pad?

4) physical exam ination: lady had a fall 2 days ago sec to alcohol intoxication, now has le ft sided
hearing loss, perform exam ination o f her hearing, and o th e r cranial nerves as necessary, no
otoscopy required.
- perform webers and rinnes
- did a fu ll CN exam ination anyway because there was tim e,
qns
- w hats the finding?
- all the causes fo r conductive hearing loss - ear wax, infection, hem otym panium sec to traum a
- w hich CN is the m ost im p o rta n t to exam ine together? CN7. exits to g e th e r at 1AM
- how w ill u fix the otoscope, how to perform otoscopy, how w ill u position the pts ear to make
otoscopy easier
showed picture o f hem otym panium
-w h a t is this?
- w ha t ix to do? cT brain, audiogram , ent review.

5) physical exam ination: indire ct inguinal hernia

- w here is the deep ring? w here is the inguinal ligam ent landmarks?
- w ha t are you r differential? exam iner looking fo r lipom a o f cord
- w h at ix w ill you do? i offered US o f contralateral side because i th o u g h t there m ight also be a
contralateral hernia
- lap o r open
- mesh repair o r prim ary repair? is it proven th a t one has b e tte r results than th e other?
- pt doesnt w a nt operation because his jo b requires heavy lifting, has no money, cannot take MC. i
offered to discharge pt w ith advice, b u t apparently exam iner was looking fo r a second tcu w ith pt to
le t p t reconsider
- how long m ust pt avoid heavy liftin g fo r a fte r hernia repair?

6) physical exam ination: CVS

- m itra l valve replacem ent, m id sterno tom y scar, audible m etallic click even at bedside, no o th e r
com plications
questions:
- whats the diagnosis?
- w hat are y o u r concerns fo r operation?
- on m ention o f anticoagulation, exam iner pulls o u t a ACC w arfarin chart o f pt. asked qns abt
w arfarin mechanism o f action, how to bridge w ith clexane, w hen to resume w arfarin
- w hat preop ix : ecg, 2DE
- NICE guidelines fo r IE prophylaxis
- pt presents w ith fever 5 days postop. w hat are ur concerns

7) physical exam ination: L knee pain

OA knee, exam ination largely unrem arkable except fo r m ild crepitus over knee joints
- expected to perform hip and ankle exam ination.
- expected to o ffe r neurovascular exam ination
- asked fo r derm atom es
- asked fo r differentials

8) com m s: call a consultant to discuss abt a case

expected to read through 'case notes' and piece the story to g e th e r w ith in ten mins prep station,
scenario was an elective le ft hem icolectom y fo r caecal tu m o r, w ith liver biopsy fo r suspected mets.
c u rre n tly postop D l, having persistent tachycardia 120 and hypotension SBP 90-100 post op, tem p
37.5. postop bloods unrem arkable except drop in Hb fro m 12 to 10, Cr 116, Urea 16. ECG norm al -
no MI/PE. CXR clear, p t docum ented as having benign abdom en, appears dehydrated. I/O in
negative 150mls balance, GW nurses said theres no urine o u tp u t in IDC. asked to call consultant on
call, as consultant incharge is on leave.

- asked w ho the consultant o f the case was (need to pick up this info in prep station, some
candidates d id n t realise leading to some confusion)
- asked to summarize the case
- asked 'so w h at do you th in k it is?' (offered dehydration, need to check w h e th e r catheter is blocked'
- asked fo r plans o f action, w h e th e r p t need to be brought dow n to H
- asked w h e th e r candidate feels th e consultant oncall needs to com e back (i said no, but w ill call him
again if p t does not respond to fluid resuscitation or th e repeat set o f bloods shows any worsening,
offered to proceed w ith CTPA if has desaturation, but w ill keep on clexane and TED stockings fo r
now)
- asked w h e th e r it is possibly an anastam otic leak? ( i offered th a t as p t is non toxic, its very unlikely,
b ut i'll do serial abdo exam, and let consultant know again if pt becomes peritonitic)

9) anat: Shoulder
- piece the calvicle scapula and humerus
- w hats the surgical and anatom ical neck
- parts o f th e scapula
- g reater and lesser tuberosity
- range o f m otio n o f shoulder jo in t
- factors affecting sta bility o f a shoulder jo in t
- w ha t does shouder jo in t need to do to com plete abduction? (internally rotate)
- muscle th a t stabilises shoulder jo in t
- id e n tify supraspinatus infraspinatus teres m inor and subscapularis. w hats the nerve supply
- id e n tify functional parts o f th e pec m ajor
- nerve ro o t supply o f pec m ajor
- actions o f deltoid
- axillary nerve dmg, w hats the consequence
- w here does the brachial plexus run? (posterior triangle o f neck)
- MRI shoulder photos

10) anat: C spine

- num ber o f cspine, num ber o f cspine nerve roots
- which are atypical cspine processes
- parts o f th e C2 spine ( lamina, dens, foram ina transversalis, verterbrae body, articulation areas)
- w here do nerves exits
- ligam ents betw een C l and C2
- shown xrays o f C spine (odontoid open m outh and lateral view ): id entify various parts o f various
bones on both views (C l C2 hyoid)
- in trau m atic rugby injury, w ha t are th e abnorm alities youll expect to see on th e xray besides
fractures? (soft tissue swelling, dislocation)

11) Anat: Abdom inal Aorta

- p oint o u t the aorta
- p oint o u t the IVC
- branches o f aorta (specifically w hich are the posterior branches, w hich branches supply th e Gl tra ct
and at w h a t level does it exit)
- which level does the aorta e n te r the abdom inal cavity
- which level does it bifurcate
- w hat structures overlie the aorta: duodenum 1 and 4, head o f pancreas, liver
- p oint o u t the trib u ta rie s o f th e IVC
- id e n tify th e le ft and rig ht gonadal vein (the le ft couldnt be seen actually, was hidden betw een all
th e o th e r structures)
- shown m esenteric angiogram, asked the id e n tify the branches
- shown CT angiogram o f AAA. asked to id entify it (saccular, infrarenal AAA)
- w ha t is a dissecting aneurysm
- w ha t is the pathogenesis
- w ha t are th e causes? w hich is th e m ost com m on cause w o rld w id e (hypertensive sec to
atherosclerosis sec to smoking)

12) Pathology: UC lady, on long te rm im m unosuppression

- w ha t is pathogenesis o f ulcerative colitis
- if it is crohns, w h a t w ill th e m icroscopic features be
- w ha t is a pro oncogene
- w hy w ill the patient require colonoscopic surveillance
- colono done shows TA w ith LGD and evidence o f invasive adenoCa. w hat surgery w ill you o ffe r the
patient? (tota l colectom y)
- id e n tify the duke or TNM staging (schematic diagram given, showing invasion into propria and 1/4
LN affected)
- if th e re was live r mets, how w ill it affect the TNM staging?
- how w ill you manage the patient preoperatively in view o f long te rm steroids
- questions on HPAA axis, how w ill the cortisol affect the adrenal gland? w ill it cause both th e cortex
and m edulla to atrophy?
- postoperatively, p t was found to be unconscious and hypotensive. ABG and bloods w ere norm al,
w h at is the cause? (addisonian crisis)
- whats the pathogenesis o f addisonian crisis
- how w ill it affe ct the glycem ic co ntrol o f the patient?

13) Pathology: Stem on man w ith aortic valve failure, w ith hx o f jo in t pains w hen young.
- w hat is the likely cause?
- how did rheum atic heart disease cause the aortic stenosis? (exam iner w anted answers on
infla m m a tion o f th e valve)
- if the pa tien t having fever now, w ha t is th e like cause?
- w hat are the com m on organisms in IE?
- w hat are th re e signs you find on th e hands in IE? w hat is the pathogenesis?
- w hat antibiotics w ill to you give? w hy is it hard to tre a t IE?
- if it occurs on the tricuspid valve in a younger person, w hat w ill you be w orried about?
- if the pt suddenly develops renal im pairm ent, w hats the cause?
- w hat blood te st w ill you use to m o n ito r progress o f disease?
- if the pt does not respond to antibiotics, w hat options are there? (i gave aortic valve replacem ent,
but i th in k exam iner was looking fo r heart transplant)
- w hat kind o f m atching do you need before transplant? (HLA antigen)
- w hat kind o f im m unologic reaction w ill occur if not m atched? w hat is th e consequence?
- how do you prevent transplant rejection?
- whats the consequence o f long te rm steroids? (looking fo r lym phom a/lukem ia as malignancy)

14) Counselling: Pt w ants to AOR. please advise pt

- preceded by a prep station, given in fo rm a tio n th a t pt suffered a splenic hem atom a a fte r an
accidental fall, seen on CT scan, sec to rib fractures, no evidence o f lung injury. Hb dropped by lg /d l,
bloods otherw ise stable. (Nothing much to prepare fo r this. Just sat around and stoned)
- counseling pt was easy, p t offered all the in fo rm a tio n required.
- explored pts concern: some story abt how p t has jo b in terview the next day. w hen offered to speak
to fam ily, said th a t he doesnt w an t w ife to know, and th a t she had breast cancer
- o ffe re d options to excuse pt fro m jo b interview .
- p t insisted on AOR in the end. advised p t to return by giving him w arning sym ptom s
Not much knowledge required at th is station. Pt kept th e conversation gg 90% o f the tim e.
 15) Procedural: Consultant was in the process o f excising a benign nevus on pts le ft thigh, but was
called away a fte r giving the LA.
- expected to check consent again (was hidden away at a corner in a room )
- pick the instrum ents you require, pick te stitch you w ant
- need to m ou nt yo ur ow n scalpel blade, procedure otherw ise quite straightforw ard
- stem offered chance to draw out margins if required, but i feel it just wastes tim e
- th e sponge used was quite s tiff and hard to close, a lo t o f the candidates ended up tearing through
the sponge, m yself included. M y advice is th a t since th e y probably dont judge yo u r suturing skills,
ju st th ro w very big bites to m inim ise the risk o f tearing through
- rem em ber to end o ff by th ro w in g your sharps, including th e scalpel blade tip
- quick advice on TCU plans and how to keep the w ould clean

16) Critical care: Pancreatitis

- w ha t is the likely diagnosis? (based on stem and blood results)
- w h at w ill cause a norm al amylase level in pancreatitis, does amylase correlate w ith severity of
pancreatitis?
- w h at causes th e hypocalcemia?
- w h at are th e consequences o f severe pancreatitis?
- w h at radiological investigations w ill you do? (ct scan and US HBS)
- w hat is a pancreatic pseudocyst?
- w hat are the sym ptom s to suggest a pancreatic pseudocyst?
- name tw o form s o f scoring, explain one o f them .
- w hat glasgow score breakdow n is? hat score w ill be considered as severe?
- w hat analgesia w ill you give the patient?
- w hat is the WHO analgesia ladder?
- is m orphines effect on the sphincter spasm real o r theoretical

17) Critical care: N u tritio n . Stem show p t w ith Crohns s/p ileocaecal valve resection
- w hat does xray show? (small bowel I/O)
- w hat is the likely cause? ( SB strictu re sec to Crohns)
- w hat are the feeding options? (parenteral vs non parenteral)
- w hat are types o f non parenteral feeding options?
- w hat are the com plications o f non parenteral feeding?
- w hat are constituents o f TPN? (i d id n t m ention w a te r )
- w hat is th e main source o f carbohydrate in TPN?
- w hat is th e consequence o f using glucose only as a th e main fo rm o f carbohydrate source?
- w hat are the com plications o f parenteral feeding?
- how do you give parenteral feeding?
- w hat are the indications fo r parenteral feeding?
- w ha t are the consequence o f bow el mucosa atrophy?

18) Critical care: Post low er lobectom y, pt now is hypotensive, bradycardic and desaturation, pt had
spinal anaesthesia at T4/T5, and had epidural catheter
- w ha t are yo ur differentials? (hem opneum othorax, paralysis o f diaphragm , paralysis o f intercostal
muscles)
- w ha t is th e m anagem ent plan? (fo r all the d iffe re n t scenarios, rem em ber to call consultant o f op as
w ell as anaesthetist to review)
- w ha t factors affe ct the epidural efficacy?
- w hy do you te s t fo r tem pe ra tu re sensation rather than pain?
- how do th e y test fo r te m pe ra tu re sensation in th e OT?
- how does epidural cause the hypotension and bradycardia?
probably m ore qns than this but i fo rg o t the rest.
Procedural skills:
1. TnS of superficial wound. Similar to previous years. Expected to finish steps from intro to
consent and patient advice when doing the tns. Did not require scrubbing.
- my friend and I only received questions regarding LA dose, with or without adrenaline and side
effects after. Bell rang before I could finish.

2. OT listing. Prioritize between:

A. COPD with strangulated hernia
B. divert abscess with penicillin and iodine allergy.
C. Mrsa dm foot for BKA.
Both of us did it in that order. Hernia first because emergency and best done without prior
contamination. Offered dm foot last case by doing spinal or RA.

Then examiner asked what pre op orders u want for each case. le. what anaesthesia, what
cleaning solution (choose between iodine and chlorhex) and where to place diathermy pads for
each case.

Do these two skill stations quickly, there really isn't much time.

Anatomy
3.head and neck with brachial plexus.
- identify aortic arch, vagus nerve and recurrent laryngeal nerve
- thyroid anatomy, blood supply and its origins/drainage ie where superior and inferior veins drain.
- brachial plexus: upper (erbs) and lower (klumpke) palsy and posterior cord (from which root levels
and what presentation)

4. Middle cranial fossa

- bones that make it up
- all foramina within it
- cavernous sinus and contents of medial and lateral wall
- optic canal: surrounding sheath of optic nerve and clinical significance. W hat other structure:
ophthalmic artery and it's significance.

5. Ankle and foot

- how to put a Tib and fib together- its superior and inferior articulations.
- identify sustentac tali
- bones that make up medial and lateral arch. Remember that lateral arch distally includes 4th
metatarsal too apart from just the 5th. Got this wrong.
- medial and lateral collateral ligaments. NOT the deltoid ligaments.
- identify extensor tendons in dorsum of foot from medial to lateral
- which muscles invert evert foot, most stable position of ankle..

Surgical pathology

6. Malignant melanoma
- standard questions, what is significant in full patho report- don't forget size! Br. Thickness etc..
- what is surgical treatment- complication of auxiliary vein thrombosis - PE - management of
complications

7. Enlarged lymph node. Exact tb and lymphoma repeat.

- most common lymphoma in young Caucasian lady
- impact of TB on community- give 2 major impacts
- what other patho test u will do of the lymph node besides histo/culture/stain...??
Crit care

8. Burns and ards. Calculate exact burn percentage based on rule of nines. Got a tick and nod
when given exact number.
- parklands formula
- recognition of type of burn
- choice of fluids
- recognition definition and management of ards

9. Multiple trauma
- cxr with pneumothorax, subcutaneous emphysema and rib fractures
- management according to atls protocol
- read ct coronal slice: liver laceration. Management

10. Respiratory acidosis in type 1 failure

- illustrate co2 and h20 equation in blood
- how is co2 transported in blood- 3 ways
- which part of blood does reaction occur
- explain metabolic compensation mechanism- kidneys and bicarb
- explain chloride shift

Hx and comms

11. Speak to reg for itu reservation of elderly patient going for exploratory lap
- see previous years. Mainly talk about ACLS and secondary resus of patient, not much about
transfer
- remember to be nice and offer to discuss with your consultant again and call back if reg refuses
transfer

12. Counsel angry patient whose husband scan is postponed and consultant too busy to talk to
them. Use dr exam comms section

13. Assess confused patient coming for elective op

-AMT
- plan for the patient: postpone op, involve family etc..

14. Hx taking for patient with gallstones

- questions include differentials, investigation and management

15. Cvs exam

- early diastolic murmur with collapsing pulse. AR with differentials of ms and ts.
- prep precautions for hernia repair. Spoke briefly about IE and anticoagulation

16. Cns exam

- apparently a standard pituitary adenoma station but flunked
- see past years

17. Huge indirect hernia

- standard station, hernia management, considerations in respi patient, patient advice post op

18. Knee examination

- limited rom of left knee 90-180
- differentials
- management: conservative, medical, surgical
Day2

Anatomy
1. Thorax and Abdomen
1. Identify Pulmonary Trunk
2. Identify Ascending Aorta
1. Branches of the Ascending Aorta : Right and Left Coronary Arteries
3. Identify Sympathetic Trunk
1. Source of Trunk : T1 to L2
4. Tributaries of the Azygos Vein : Inferior Phrenic Veins, Posterior Intercostal Veins,
Esophageal Veins (give 3)
5. Identify Papillary Muscle and Chordae Tendinae
1. Function : Prevent AV valve from prolapsing
6. Identify Spleen
1. Course of Splenic Artery
2. Structures Damaged during Splenectomy
2. Lower Limb
1. Identify Sciatic Nerve
1. Nerve roots
2. The bony landmarks from which it emerges : ischial tuberosity and greater trochanter
3. Variations of its normal course in the buttock
1. Normal: from under pyriformis
2. Can be over pyriformis or under gamellus superioris
2. Identify gluteus medius
1. Nerve supply
2. Action and consequence of weakness
3. Causes of weakness of gluteus medius
4. Describe tredelenburg test
3. Contents of the Popliteal Fossa
1. Identify Popliteal artery
2. Identify common peroneal and tibial nerve
4. Structures that may be damaged in a supracondylar fracture
5. Possible causes of a swelling in the posterior knee (popliteal fossa)
1. Skin; Subcutaneous; Vascular; Bony
1. W here does the lymph nodes in the popliteal fossa drain from? : from the lateral leg
and foot, following the course of the short saphenous vein
3. Genitourinary Tract
1. Identify bladder
2. Blood supply of the b la d d e r: vesical arteries via the internal iliac artery
3. Identify the internal iliac artery
4. W hat is the muscle of the bladder wall? : Detrusor muscle
1. Innervation of the Detrusor? : primarily parasympathetic via pelvic sphlanchnic nerves
5. Most common cancer of the bladder (give 2 ) : TCC and SCC
6. W hat is transitional epithelium
1. W here is transitional epithelium found
7. Orientate model of bladder/penis
1. Identify structures on the posteroinferior aspect of the bladder
8. Identify the ureters
1. How does the ureter enter the bladder?
2. Identify the opening of the ureters on the inner surface of the bladder
9. Relations of the peritoneum to the bladder: covers dome of bladder only
10. Layers encountered when doing suprapubic catheterization
Surgical Pathology
4. Rheumatic Heart Disease
* what is your diagnosis from the case vignette?: previous rheumatic fever with rheumatic heart
disease
* Pathophysiology of rheumatic heart disease
* W hat do you expect to see macroscopically?
* Post valve replacement; anticoagulant used
* W hat are the common anticoagulants you know of
* Their mechanism of action
- W hat factors are vitamin k dependent?
* Reversal of warfarin? Vitamin k
* If you need it reversed urgently? FFP
* How do you monitor warfarin? INR
- Now patient fever etc you suspect IE
* what signs do you look for in the hands?
* Pathophysiology of osiers nodes and janeway lesions
* W hy are patients with Rheumatic heart disease and or heart valve replacement more
susceptible to IE?
* W hat features are you looking for on 2D echo
- If you see right sided vegetations, what aspect of the history do you need to ask the patient?
IVDA
- Treatment of IE?
* If still does not resolve with long term IV antibiotics in this patient? Consider surgical revision

5. PUD/PTH
* review history and lab results, what do you think is the cause of this patient's PUD? H Pylori
(CLO test positive)
* Other contributory factors? Hypercalcemia
* W hat is CLO test?
- W hat is an ulcer?
* Treatment for H pylori positive PUD? Triple therapy. W hat does that consist of?
* Review labs, what is the cause of hypercalcemia in this patient? Primary hyperparathyroidism
* W hat is the most likely cause? Parathyroid Adenoma
- W hat investigations will you do? Bloods, Sestamibi scan
- You see a prominent spot on sestamibi, what would you do? Offer parathyroidectomy
- Where do you expect to find the parathyroid g la n d s?
- W h y can the in fe rio r para th yro id g lands be fo und n e a r / w ith th e thym u s?
- F rozen se ctio n re p o rt interpret: h y p e rtro p h y o f o n e parathyroid gland w ith p rim arily ch ie f
cells, oth e rs sh o w in volu tion
- W h a t is a fro ze n se ctio n ? H ow is the sp ecim e n fixe d in an FS?

Critical Care
6. Massive Transfusion (Patient in the ED with suspected leaking AAA, s/p emergent repair which
took quite long, now Post op Hb 6, temp 35)
* what is hypothermia? : temp <36
- In this case, what may have contributed to the hypothermia? Massive blood loss and
transfusion, resuscitation with unwarmed fluids, open surgery which was prolonged, wanted
more but I couldn't give
* W hat are the mechanisms by which you can lose heat? Conduction convection radiation
evaporation
* W hat are the complications of massive transfusion?
* W hat are the early complications of this surgery? Give at least 3
* How would you correct the coagulopathy? Platelets and FFP in 1:1:1 ratio, tranexamic acid
- Other questions but I forgot

7. Obstructive Jaundice
- read and interpret lab results: obstructive jaundice
* W hat is bilirubin conjugated to?
* W hat is urobilinogen?
* Explain the enterohepatic circulation of bile salts
- W hat is the function of bile salts in digestion of fat?
- W hat investigations would you do for this patient? Bloods, US HBS
* If us hbs shows stones, what would be your next step? Ercp
* If this patient has fever and pain, what would you be worried about? Ascending cholangitis
* Also other questions but forgot

8. Fluid Overload
* read and interpret anesthesia record and ward vitals
- W hat can you tell about the patient when he was discharged from anesthesia recovery? Still
hypertensive and tachycardic
* Comment on the fluid status of this patient: received 5 unit crystalloid and 2 unit colloid in 12 hrs,
poor urine output, likely over replaced, too much electrolytes (sodium) given as well (all
crystalloids were normal saline)
* Comment on the CXR: fluid overload with bilateral congestion in all lung fields and pleural
effusion
* Management of this condition? ABC, lasix, asked for another drug besides lasix
* How do you think you can prevent this poor management from occurring again? Report to
hospital incident reporting system, better training of junior staff

Procedural Skills
9. FNAC
- same old: greet intro explain reconfirm indication and consent, site and side
* Don't poke too far into the model some candidates actually poked the actor and caused her to
cry (gg)
* Handle sharps
* Fix specimen onto slide
* Put the rest into cytospin bottle
- Explain to patient follow up plan
- Patient asks if this is likely to be cancer (has previous history of melanoma in the same limb)

10. Suturing
- tie with non absorbable braided suture (hand tie); what are the type of knots you know? W hat
are the advantages of a braided suture?
- Tie a hook in a cavity with a absorbable braided suture (hand tie); what are the potential
complications when tying a knot in a cavity?
* Overrun a bleeding spot with a figure of 8 suture with a non absorbable monofilament
(instrument tie); why do you have to tie prolene so many times?

Clinical Examination
11. Respi/COPD
* elective hernia repair now for preop review, chronic smoker
* Noted mild clubbing, palmar erythema, hyperinflated chest with some scattered coarse creeps
but no rhonchi
- Ddx: COPD
- W hat are your operative considerations now? Need to refer Anes, Respiratory, manage COPD
first, advise smoking cessation, consider further investigations, cannot do laparoscopic hernia
repair

12. Arterial LL
* left foot previous 2nd rays, 4/5th toe dry gangrene, absent DP/TP, buerger's positive
* W hat else would you like to do? ABPI, Doppler of LL pulses, examine abdomen and CVS
* W hat are you looking for when examining the abdomen and CVS systems
- W hat is your diagnosis? Critical limb ischemia (patient c/o pain at rest when I asked before
examining + tissue loss)
- Basis of buerger's test?

13. LL Neuro
* back pain radiating down LL bilaterally complains of numbness examine LL neurologically
* Tenderness over L4/5 L5/S1 region with para vertebral spasm
* No other clear cut Neuro signs, sensation normal
- Differential diagnosis? Spinal stenosis vs. vascular claudication
- Pathophysiology of pain in spinal stenosis? Stenosis causing ischemia of the cord
* Investigation? MRI spine
* Management?

14. Hydrocele with Testicular Mass

* left hydrocele with enlarged testis
* W hat else would you like to examine? Abdomen
- Other differentials? Hernia, varicocele
* W hat investigation you'd do? US Scrotum
* US shows hydrocele and enlarged testis, differentials? Testicular tumor
* US only shows hydrocele, management? jaboulay

Communications
15. Comms; Angry Parent
* son bib father earlier with fall from height resulting in splenic rupture now in ot for splenectomy,
now speak to angry mother who just arrived
- W hy no consent from mother, what are the complications of splenectomy, deal with complaint
about incompetent husband, 'was he drunk???', future considerations of splenectomy
16. Comms; History Taking PE
- POD5 THR now SOB take history
- Took full SOB history; Acute onset SOB with haemoptysis and pleuritic chest pain
* Differentials? PE, Pneumonia, TRO ACS
* Investigations; ECG, CXR, Bloods, CT PA, V/Q Scan
* Management?; anticoagulants if stable, consider thrombolysis/embolectomy if not

17. Comms; Update trauma consultant over phone about trauma patient
- young gentleman RTA with right tib/fib open fracture now right LL pulseless and cold, FAST for
abdomen ?some collection but otherwise stable, left hand metacarpal fractures
- basically just update on issues, prioritize and give your plan

18. Comms; History for PR bleed

- PR bleeding (?malenic stools) x months
* W hat are your differentials
* How would you investigate
* Colono shows a sigmoid tumor, How would you proceed?
1. Anatomy r thigh...10 cm cut 10 cm.inf to.ing lig. W hat muscles severecL.arteries. R thigh
triangle...borders. Cont. R adductor canal...same. Femoral canal...nerve distrib to.thigh...sens and motor.
2. Anatomy r otitis.media...ways of pus to spread intracranially...base of skull q...optic.canal
content...locate trigem ganglion on skull...holes and nerves...meninges in optic
canal...clinical...papillooedema...ways to get inf from face in skull and symptoms.after...etc
3. SUTURE SKILLS..READ EACH TYPE OF SUTURE ADVANTAGES AND CHOICE Wise. Why
this.choice...etc
4. Anat. Chest and neck...oesophagus...level of oesoph...tachea dividing...ccarotid into ce an ci..parotid
and submandib...type of secretions...serous and mucus which one. Point r vagus in chest
5. Ccrit. AAA and intraop hypothermia...complications...ways of heat loss...coagulation affected? Why?
Stages of coag and why affected...anemic so needs massive transfusion...lost 4 l....complic. of massive
transfusion...what is missing from bank blood?
6. Path. Temporal artery bipsy...signiff...one simple blood test to proove. ESR. Treatment? One year
after...frac ofneck of femour....why? W orrie in operating this 74 yo lady? Addisonian? Coag? Immune
resp? Causes of osteoporosys in her....causes of neck of femur fract in 74 yo women..
7. Physio. Thyroid...hyper...dg...management. Clinical of Hypothy. Describe humoral feedBAck.loop.
Manage hyperthy? Surgery postop complications...early only. Quite diff station. Pt was anemic why?
Dunno...
8. Guy 32 with cryptorchidism excised...read path report...dg? Why? Test teratomA....diff dg? Ways of
spreading? Tumomarkers? Explain fam ily path result. In 3 simple lines.of
thought...cancer...testicular...incomplete resection...lymphatic spread. Post op? Mdt...scan...retroperit
lymph surgery...chimio...
9. Ccrit. Crohns pt with rhemi. Postop feeding options. Comparrison between ng nj tpn. Components.
Advantages...disadvantages. Complic of each. Lovely examinator.
10. Proc..l&d of r thigh abscess under.La. Consent. Allergy. Weight. Prepare.local. Instillate.
Incise....surprise...sebaceous cyst. Excise jacket. Incision why? Langer lines..post op arrangements?
Packing.options? Dressing? Community nurse management?
11. Examinations. Young alcoholic fell and had left temporal.trauma...now hearing loss.on left ear.
Examine. I did general skull exam and cn vii and viii nerves exam. Mentioned fundoscopy and
competecranial nerves. On otoscopy...picture of haemotympanus...base of skull fracture...conduction
hearing loss. Manage? Atls and neurosurg...ct scan.
12. Exam. R knee footy trauma...r.lat lig tear and med.meniscus tear.manage? Treatment?
13. Exam.postop I hemi. pt. In distress. Called to seel. Examine. General and abdoexam. Midline wound
ok. Lif peritonism. Why? Differential? Manage...ccrisp prot. Septic shock. Scans? Bllods. Bid cultures.
Lines fluid resus. Ct scan. Ecg shows Af. N rhythm.
14. Exam. Large neck to higher back.lipoma. Prev incision mark. Real patient! Examine. Diff dg.
Sarcoma? Mdt? Mri scan? Offer surgery if lipoma...have to exclude sarcoma.prior...
15. Comms. reffer 64 yo lady treated as mild.diverticulitis.and.found with sudden critical.limb ischaemia
after Af untreated...non anticoagulated to.vase tertiarycentrer.consultant over phone..ok station...mention
critical.limb ischaemia
16. Comms. D with 54 yo man about ogd and dilatation for amid oesophagussoft stricture.on baswallow.
Weight loss. Smoker. Discussed cancer possibility and perforation...dvt...etcas complic. Biopsy needed
so discuss follow up with results and possible plans in future...
17. Hx taking. 64 yo lady...no comorbid. Aw lap.chole...worried. Anxious with tighness over chest and
neck.lump.sensation last two weeks...no cardioresp spt..seemed anxious and stressed because of
procedure. Globus hystericus. Panic attack. Reassure
18. Hx taking. Young 32 yo male personal trainer...hx of rih lump on exercising...but also recent east
europe travel with unprotected sexand penile discarge afterwards...dg diff rih and plans with std and
lymphadenopathy. Rih surgery.
S kills-
-FNA skin cystic lesion, Hx o f excision fo r melanom a. Pt: is it a recurrence?
-M inim al flu id fro m 'cystic lesion' on aspiration, did all I could to smear on slides and te ll the
exam iner to cytospin the others.

S kills-
-Handtie to oppose rubber bands w ith nonabsorbable braided
-Handtie hook in 'cavity' w ith absorbable braided, w hat handtie m ethod you ju s t used (told
exam iner m y 'granny kn o t’ cause I feel th a t it holds be tte r, but alternatively I can surgeon's knot)
W hat to do so th a t you w ill n o t damage deep structures on tying knots?
-Stitch fake skin/sponge w ith nonabsorbable m onofilam en t. How m any throw s did you do?

Examination-
-Cranial nerves (anosmia), stem : NOT required to test visual acuity o r smell
-Turns o u t bitem poral hem ianopia
-Causes, Ix (bid, scans), Mx

Examination-
-Abdom inal pain (short Hx: T3N2 low rectal CA s/p APR years ago)
-Real pt w ith parastom al hernia over le ft side (pt: plz do not open the stoma bag, exam iner: plz do
n o t open his stom a bag... w h ile i poke poke th e shit on the stoma to see the mucosa)
-How to tre a t parastom al hernia, w h a t are principles o f repair, w hy mesh n o t encouraged here
-Need TRO recurrence, tu m o r m arker tre n d , colonoscope, CT scan
-W he the r w ill recom m end surgical resection (depends on staging if really recurrence)

Examination-
-Subm andibular swelling
-Asked the p t/a c to r w h e th e r g ot pain over swelling, he answered: no swelling wor..
-Examined, bim anual palpation, fren u lum checked, cervical nodes, nothing fe lt
-Examiner looked puzzled but proceed w ith DDX, Ix and M x (tricked me, keep asking w hat o th e r XR
w ill I ask fo r o th e r than sialography, but th e answer she w anted was CT SCAN)
-If painful, need TRO malignancy
-Need fu ll ENT exam ination if suspected lym phadenopathy

Examination-
-POD6 elective le ft hem icolectom y fo r CA, now abd pain, BNO ld a y (actor actually looked septic!)
-Given charts: rising tem p eratu re , rising PR, BP sliding dow n slowly, 0 2 requirem ents rising to
m aintain Sp02
-Given bids: TW raised, Hb norm al, CRP raised, Urea Creatinine on the rise
-Given ECG: AF
-Exam ination abdo le ft sided tenderness, localized guarding and rebound, otherw ise soft, no
generalized peritonism , not distended, BS present, radial pulse not in AF (haha.. exam iner ask to
ignore radial pulse), pt in TEDS stockings
-Anastom tic leak and M x (NBM, abx, drip, IDC, KIV NG tube if starts vom iting), CXR, CT AP w ith
contrast, CT PA (TRO PE as cause fo r AF and increasing 0 2 requirem ents)
C om m unication-
- l l y r old perforated appendicitis, severely dehydrated, resuscitating now w ith anaest/paeds on
board, consultant (M r Mann) com ing back to do th e surgery
-m o th e r concerned about surgery and risks
-apparently the father/hu sband, had esophagectom y 2yrs ago by M r M ann, post-op leak, and died
-actor very enthu w ith her tissue paper
-started blam ing herself fo r w orking extra-tim e and leaving kid to neighbour, th in k she could had
brought kid in earlier

C om m unication-
-RTA young man, w idened m ediastinum on CXR and bilateral hem othorax, right fe m u r #, GCS 14 BP
100/60 PR 102 Sp02 stable.
-Call CTS consultant fo r transfer
-Called misleading w ritte n phone num ber, nonstop blow ing history and presentation fo r lm in before
the girl on th e phone asked: 'Are u ok, th is is th e HR dept..' Ran o u t to seek help STAT
-CTS consultant: OK, can transfer, w ho w ill be accompanying p t ? I said, 'Me'.
C onsultant asked: 'You sure you OK? W hat if need to in tubate the pt? You com fortable?'
Naturally, I went, 'No problem, I can intubate the pt if necessary.'
The consultant, 'You sound very experienced!'
No shit... I im m e d ia te ly , 'I will ask anesthesia colleagues to come along with me .... '

Anatom y-
-Femoral triangle (some dum b butcher, cleaved his ow n thigh during w ork)
-Boundaries, contents, identify muscles and fem oral vessels
-Boundaries o f fem oral canal, w hat's the im portance (lymphatics)
-Branches o f fem oral nerve, Iden tify LI, L2, L3 dem atom es
-Look at th e provided LL angiogram, w hich one is SFA? W hat are the 3 branches?

Anatom y-
-M andible, muscles o f m astication
-Cspine lateral XR shown: id e n tify C l structure
-Skull, foram en ovale and structures, Stylom astoid foram en and structure (w hat happens if cut)
-How old w hen m astoid developes?
-Pterion and bones th a t fo rm it, w hy EDH w ith traum a
-Skull XR: id e n tify coronoid suture, w h a t condition gives lytic skull lesions? Point to p itu ita ry fossa

Anatom y-
-Prosection o f thorax to jaw
-Show: aortic arch, brachiocephalic a rt/L com m on carotid/L subclavian, vagus, recurrent laryngeal
-Thyroid and blood supply, nerves damaged, physiological response to thyroidectom y
-Em brylogy o f th yro id, fo rm a tio n o f thyroglossal cyst
-Parathyroids and PTH fun ction
-Brachial plexus, Erb and Klumpke's palsy

Critical care-
-Post-op given m orphine ++, now in respi failure, RR 5 /m in , ABG hypercarbia, Pa02 norm al (Fi02 0.6)
-Respi drive, M u receptors, Naloxone
-Central and peripheral chem oreceptors fo r respi control
-C02 transport, carbonic anhydrase, place o f conversion, Chloride shift
-W hy respi acidosis but bicarb still norm al? kidneys takes tim e to compensate
-Further Mx: to HD, close m o n ito r, KIV fu rth e r closes o f naloxone
Critical care-
-70+ presents w ith peritonism , confusion
-Given: CXR pneum operitoneum , ECG AF (need to say check name, 1C, tim e and date o f XR and ECG)
-Causes o f the above
-Consent in confused p atient, speak to fa m ily regarding pre-m orbid wishes regarding surgery, any
designated NOK
-Consultant sign consent

Critical care-
-Ruptured AAA, lost 4L, hypotherm ic, in OT now
-W hy hypotherm ia, how to prevent
-W hy coagulopatic
-DIC and blood products
-Im m ediated com plications o f massive transfusion
-W ho to involve in care o f pt? Hem atologist (they're in charge o f blood bank!)
Examiner wonted to go fo r early beer, so finished fast

History-
-Thyroid swelling 8yrs now enlarging
-Toxic sym ptom s
-Examiner: fu rth e r Ix

History-
-Abd pain, US a t GP: gallstones
-Also c/o alternating BO habits, m ore diarrhoea (pt volunteered related to stress), no o th e r red flags
-Prom pted and prom pted, the pt said husband lost job, now no $$
-Examiner: fu rth e r Ix

Pathology-
-Pt w ith aortic stenosis, Hx o f jo in t pains at young age
-Rh heart ds, now replaced m echanical valve
-W hy on w arfarin, mechanism o f action, how to m o n ito r
-N ow pt prolonged fever, IE; w ha t stigm ata on hands and w hat's the pathophysiology
-W hy abx n o t very effective, w h at micro-organism s, if tricuspid valve w h e th e r IVDU
-W hat surgery m ay be perform ed?

Pathology-
-Pt Hx o f DM, PVD, now came w ith black toe, shipyard w orker
-Risk factors o f PVD
-Dry gangrene vs w e t, w ha t determ ines level o f am putation
-Then p t returned w ith pleural effusion, said diagnostic pleural tap, examiner: m esotheliom a (w ork
exposure)
-Then re turned again w ith SOB, cough, LOW, said need TRO m alignancy

Examiners generally friendly, will keep prompting you until they hear the key word (to give you marks)
A n a to m y ( on M a g nifie d P h o to „& Bone., & liv in g p e rso n s fo r su rfa ce anatom y))

1- ID: appendix, caecum, ascending colon, how to know the caecum from the ascending colon( the
blind lower end),. Ovary Fallopian tubes.recto uterine pouch, it's alternative name( Douglas pouch),
interpretation of initial and localised pain i.e. Its afferent pathway( read this in Raftery book page 450
OSCE 2.1) ID : external & internal oblique muscle, origin& nerve supply , direction of the
muscles .which fleshy m uscle infront the deep inguinal ring. In appendicectomy we open the ex obliq
muscle in which direction???

2- Cx spine vertebrae ID c2 its feature, what pass in the foramen transversarum, from which vertebral
foramen it start to ascend, c7 W hat is its name, why can’t feel the other Cx vertebra, ligaments attach
to dense „ surface anatom y of brachial plexus, where is it on a living Show me, cricoid at which
verteb level, show me hyoid bone on a living person,,, from which part o f GIT c6 develop????? Plain
x-Ray w hat is this?=open mouth view , ID CX spine on lateral plain x Ray, all vertebrae?? ID
structures in the open mouth view(dense. Lateral mass of atlas spine o f axis and the teeth ??? Signs
of or features o f trauma??? Is this x Ray normal or not???

3-plain x- Ray showing supracondylar fr of distal humerus? ID, humerus, ulna,radius.& articulate them,
W hat is this?trochlea and trochlear notch,capitellum &. Radial head,,,, W HAT IS THIS( median nerve,
brachial artery, biceps tendone, radial nerve....what sensory and motor deficit in median nerve injury
at the elbow,why ulnar paradox at the wrist, how to test flexor digitoxin profundus tendons of little and
ring fingers,,

P a th o lo g y

4- Gastric carcinoma +Surgery done,,,, singet ring cells,,,,, what are the two major risk factors for
gastric cancer??? Explain the pathology report to the fam ily in 4 sentences,,, 7 or 10 days post
operative have. Axillarry vein thrombosis, what is in this patient predispose to
this???( hypercoagulation in malignancy, Age, major s u rg e ry), 6 months later cam e with ascitis &
liver functions deranged?? W hat the two pathological tests to do?? Ascitis tap, to see what?? CellS‘ “
& liver biopsy to see what?? Cells and liver architecture + accepted but I think there was something
else here.. W hat is the ttt for this patient now??? Two things???? I do not know??? Tried
chem otherapy & radiotherapy? But was wrong

5-Aortic stenosis,,, causes , how stenosis occurs in bicuspid aortic valve??? Said calcification but not
accepted this answer ( possibly due to lipid accumulation + calcification + inflammation. All cause
thickening, I'm not sure fo r this answer)...W hy bicuspid valve may cause sudden death?? Myocardial
infarction,, seems accepted??
Define infective endocarditis??? He wants to say infection of endocardial surface & valves with
microorganism( do not start the definition W ith inflammation))),, what is the commonest
microorganism??? =staphylococcus aureus???Blood test to diagnose??? =Blood culture?? W hat's it's
criteria??? How to treat???W hy ESR&CRP. Used to follow the response to ttt???= they are
inflammatory markers for the inflammation ? How infection reach to the valve??= blood,,,,,how to
treat??? W hy it is difficult to trea t?? ?,,,„,„A o rtic valve replacement done &patient develop weak arms
and some facial paralysis, why?= thrombosis & embolism to the brain...why thrombosis in the metallic
valve??? Define throm bosis??if infection happened in metallic valve why should be removed?? = to
eradicate the infection because valve is s foreign body....on examination o f thrombus after removing
the valve, a branching hyphae seen??? W hat does this means?= fungal infection ( e.g. Candida)??
Which drug is used for long term anticoagulantion??=W arfarin? Mechanism o f action?????

ASSCC
6-Burn, how to manage airways,& circulation???calculate amount of fluid? W hich type of fluid used? =
Hartm an’s so lutio n„If,Which formula used to calculate fluids?? Parkland formula?? If used saline
would you use the same formula?? Said yes( seems accepted)... Pt. developed tachypnea + SOB
explain???ARDS showed CXR.. Read this.... H o w to manage and where?

7-poly trauma ( pt came in RTA having pneumothorax & rigid abdomen). How to m anage?=A TLS ,...
How to confirm rupture organ? Said FAST Scan and CT .. W hat to see on FAST Scan? = fluid=
bleeding.. Read the scenario again?? You will do CT , I said ttt pneumothorax with needle in the 2nd
I.C.space +chest tube + if haemodynamic stability we can do C T „, If not. Go directly to urgent
laparotomy.(examiner now very h a p p y ).. Showed me CT Abdomen.. W hat do you see ( the abnormal)
= liver laceration( search for ct abdomen with liver lacerations on Google you will find it and c le a rly )))..
How to ttt it??? Said conservative if haemodynam ic stable but if not surgical with packing and control
bleeding via Pringle’s manover,,, I’m sorry I forgot something i can't rem em ber it. So sorry ..

8-Diverticular disease and septic shock ( ( I can't read the stem properly as a was running from one
corner of the exam to the other far one!!!!!) & unfortunately the stem wasn't available inside the room,,
I asked the examiner about it ju st to try to read better, but he. Refused,,, I complained at the end of
the e x a m .... Questions about septic shock and how to manage?? Showed me blood tests. And ABG
why septic shock,, read ABG? W hy???? Pt now have tachypnea?? showed x Ray.....(I cannot
remember)so sorry

S k ills

9- F N A C ,„, follow the instructions in the stem exactly?? Local anaesthesia was asked to do and
requested by the pt.,,, is it cancer?? W hen to know the results?? No more questions.. Speak while
aspirating or w ashing your hand like in practice.. The actor will say. It is painful while giving local
anaesthesia.. Like in practice.. I said I'm sorry for you?? There is one doctor examiner & a lay
examiner... Very hard to know the I impression about you????

10-suturing a wound model fixed on the thigh of an actor.... Chose your instruments and sutures.. You
will cut the stitches yourself no assistant.... Pt. asked How many stitches you will do??? I. Said from 3
to 4( This is from m y experience.. But I do not know the ideal answer for this exam) when to remove
sutures?it will be painful after anaesthesia fade out ? I said I will prescribe analgesia.,,,,you will give
me antibiotic??i Said yes(this answer is logic as it is wound outside the theatre..I.e clean
contam inated,so at least one dose of antibiotic)... Questions about type of anaesthesia to give& what
maxim dose???No more questions .

11- hydrocele: examine, presnt your finding , DD, investigations. Treatment.. A kind Egyptian
exam iner helped me to transilum inat the swelling.. Thanks so much for this good man

12-cerebellar examination. Posterior cranial fossa mass, as in no 11. In DD asked which brain
tumour,, I said gliom a( Astrocytom a)what else said meningioma,, asked from which site. I said from
tectorium cerebellum.. My feeling that there was something else more but he was little bit satisfied...
Investigations ?? CT and M R L W hat advantage and disadvantage for each?? MRI better soft tissue
visualisation...CT =radiation exposure he W as satisfied..bell range Q Q ©

13-Respiratory examination in COPD GUY with transvers scare at the lower part of the chest..
Chronic..preparing for elective hernia repair,, as usual.. Present. DD = COPD, Asthma, chest
in fe c tio n ,. lnvestigation?=CXR,spirom eter &respiratory function tests, bloods & ABG. Should
anaesthesia see this pt.? Said yes, W hy? Better to avoid general anaesthesia? How to prepare for
surgery??where to ttt postoperative? HDU OR ITU Why? = high risk of respiratory failure.

14-varicose veins,,, as usual.. Present your finding„D D = primary W , secondary ( abdominal mass
postthrombotic. DVT.investigation ?duplex scan, what you want to see from duplex scan?= deep
venous system patent or not+ incompetent perforators+ .... W hat to do for the pt( ttt) bell
r a n g e O © © © © © .. I lost some time while trying to ID the femoral artery then the saphenofemoral
junction , „ I
[10/27/2015, 11:39 PM] +20 102 504 0569: just heard the femoral a. And directly went to the
saphenofemoral junction & I found it, the exam iner noticed that .& he asked me did you heard the
femoral a I said I just heard it & bcause I know the exact anatomy for both the femoral a & the
saphenofemoral junction......I don't know his impression about th is © € l> © ^ S ) © ©

H is to ry

15- Bach pain,.. DD= functional pain , osteoarthritis. T u m o r s , T a lk a t iv e exam iner but kind.bell
range before investigation & ttt© @ € M I€ D

16-SOB after started preparing fo r surgery( anxious patient)...

17- Anxious mother( ruptured spleen of her son)

18- Phone call. Oliguria POD1.... Questions what do you think the cause is? how to know that he is
dehydrated? Decreased level of consciousness after how much of fluid loss???i do not know
s ir© @ © © W h a t will you do? Do you want me to come? Bell range... The fluid chart was not available
at the preparation time for this station.... And I didn't see it during the. Phone call except after the.
Examiner told m e ..© © © it was m y last station and my brain was coming down I was

Sleep well the night before the exam.. I tried to show m y mistakes ,so please try to avoid it.. Try to
confirm or correct m y answers..
Finally I Apologise fo r forgetting some questions, Because it was very difficult for me to sleep the
night before the exam. And I was fighting to be Alert. Please pray for me to
PASSSSSSSSSSSSSSSSSS .THANKS& Good luck.
 1) H istory taking - Unilateral Enlarged tonsil

Hx: U nilateral righ t sided tonsil enlargem ent fo r 5-6 m onths. A /w night sweats, LOW. No o th e r hx o f
note. No travel / contact hx. No sm oking hx. No fam ily hx.

Present y o u r hx
D ifferentials
Investigations

I fum bled on hx taking and the actor volunteered inform ation very readily. Nothing very special
about th is station.

2) H istory taking - Left sided groin swelling

Hx: Left sided groin mass x 1 week. Acute onset. No previous hx o f abscesses. PULSATILE. IVDA
(heroin) fre q u e n tly injects in to the fem oral. No o th e r com plications o f pseudoaneurysm. No signs o f
w idespread sepsis o r infective endocarditis. No w ithdraw al sym ptom s - last dose was a fe w hours
ago o r som ething

Present yo ur hx
D ifferentials
Investigations
M anagem ent o f pseudoaneurysm

Actress was very jitte ry through o u t the exam ination. Kept asking w h ether she can go home.
V olunteered the hx o f PULSATILE very readily. Otherwise p re tty straight forw ard. Quizzed on
investigations. I said U/S o f the lum p and arteriogram . Asked w hat type o f arteriogram , I said
fem oral artery. Dude nodded. Asked about management. Only managed to squeeze o u t stenting
before bell rang. History taking station very lim ited by tim e.

3) A natom y - Thorax anatom y

Stem: Patient stabbed in chest tw ice and ju s t under xiphoid sternum . Specimens o f heart, lung and
th o ra x cut transversely to show diaphragm

Iden tify right atrium , pulm onary trunk, aortic valve, right auricle
How m any cusps does pulm onary valve have
W hat does pulm onary tru n k divide into
Iden tify hilum o f lung
W hat is in th e hilum , id e ntify all th e com ponents
How m any pulm onary veins are there in each lung
W hich is m ost a n te rio r in hilum
W hat level is th e hilum at
W h at passes through central tendon o f diaphragm
W h at are th e bony attachm ents o f the diaphragm
W h at are th e ligam ents o f the diaphragm (I ju st said median arcuate ligam ent and he moved
on. D idn't get to say th e rest)
 Organs damaged by knife just under the xiphiod. (Answer he w anted was le ft lobe o f liver
and diaphragm. I said heart firs t but he kept pushing fo r liver and diaphragm)
How fa r does the le ft lobe o f th e liver extend to norm ally (he said YES! W hen I said le ft mid
clavicular line. A nyhow guess =S)
W hat divides le ft and righ t lobe o f liver.
W hat attaches liver to diaphragm (have to point on specimen.)
Iden tify quadrate lobe and name its boundaries.

This exam iner super nice. Some anatom ist he w rote some textbook and was telling me how he was
going to Singapore to give lectures at NTU and NUS. A pparently helped NTU set up th e ir anat
depa rtm e n t or something.

4) A n a to m y -U p p e r lim b

Stem is fall w ith swelling around elbow . Specimen o f upper lim b. (Veins were frigging colored in
bright red)

Iden tify bones o f upper lim b (hum erus, ulnar, radius)

O rientated them
W hich part o f the hum erus is involved in the elbow jo in t
W hich part o f ulnar and radius participates in th e elbow jo in t. Asked to id entify EXACTLY
w here is olecranon.
Showed Xray o f supracondylar fracture. W hat is this fracture
W hat are you w orried about?
How do you assess fo r this? (I said check brachial pulse. Asked if got any distal pulses. Also
said check fo r neurological d e ficit but he was n o t impressed. Kept asking fo r m ore but I
really dunno w ha t he was getting at)
Ask fo r cutaneous d istrib u tio n o f median nerve.
W hat happens if median nerve cut at elbow . State th e functional loss. (I d id n 't understand
p roperly so I said all the loss o f the various muscles and numbness. He was n o t impressed
until I said loss o f flexion o f fingers, abduction o f thum b and flexion o f w rist)
If you asked th e p a tien t to flex th e w rist, w hat w ould happen. (Basically ulnar deviation)
Asked about ulnar paradox

Probably got a fe w m ore qns w hich I cant rmb. D idn't feel to o good fo r this station

5) Procedure skill - IV cannulation

Stem: RTA victim . Presents at AnE. BP hypotensive, GCS 15, tachycardic. Please start IV infusion fo r
him.

Prepared equipm ent.

Checked patient id e n tity etc.
IV super easy to set, put on the prepared infusion. Infusion flow ed w ell, (apparently some
people d id n 't get the infusion to flow )
W rite fluid orders on paper IMR
How w ould I manage this p atie nt ( I said everything but analgesia. He kept asking me w hat
m ore w ould I do but I fo rg o t analgesia omg... bell rang)
 6) Procedure skill - Chest tube insertion

Given xray o f pneum othorax. Please p o in t o u t th e pneum othorax. (The xray was dam n blur... hardly
could make o u t th e pneum othorax)

Triangle o f safety fo r insertion.

W hat size chest tu b e w ill you insert
Inserted chest tu be w ith running com m entary. Attached to underw ate r seal
I said I w ould check its oscillating, under the patient and do a purse string. He said go ahead.
0_ 0 .
Com plications o f chest tu b e insertion

7) Physical exam ination - Vascular exam

Cant rm b stem

Signs th a t I got: Bilateral PVD skin changes. Hair loss, dry shiny skin. No ulcers / gangrene. Buerger's
positive. O ffered to com plete by doing ABPI, BP, fundoscopy, urine analysis. Guy just nodded.

Investigations
Managem ent

Straight forw ard.

8) Physical exam ination - S ubm andibular swelling

Stem: Guy presents w ith swelling and pain during eating. Swelling comes and goes.

Signs th a t I got: C ouldn't see / feel the swelling. Asked patient to point it out. He pointed to the
right. Did bim anual palpation. Checked parotid as well. Checked opening o f ducts. Asked patient to
stick o u t tongue and say ah as w ell. Also checked cervical lym phadenopathy. Normal patient
basically

D ifferentials
Investigations
Managem ent

Straight fo rw a rd sialolithiasis.

9) Physical exam ination - CVS (Aortic stenosis)

Stem is new m u rm u r picked up on pre op screening.

Signs th a t I got: Super loud ESM at aortic region. Signs o f cardiac failure (bibasal creps, peripheral
oedema, LVH, radiates to carotids) No m edications at side.

Diagnosis
 Pre op cardiac investigations
M anagem ent
If p a tien t is on w arfarin, w hen w ould you stop pre op
W hat w ould you do fo r a p atie nt on w arfarin going fo r op

Straight fo rw a rd repeat. He raised his eye brows when I said IV heparin fo r bridging and started
asking me w hy IV? So I explained to him S/C clexane used m ore com m only nowadays but I to ld him
the benefits o f using IV heparin over S/C and he ju st nodded. Also asked w hat is a MIBI scan.

10) Physical exam ination - Scrotal swelling

Signs th a t I got: Left sided swelling o f scrotum. Examination signs are basically hydrocele. But it does
n o t transillum inate. I also noted unilateral pittin g oedema on the le ft leg w ith some inguinal
lym phadenopathy. So I did a quick abdo exam as well.

D ifferentials (I said testicular m alignancy in view o f everything but also very quickly offered
hydrocele)
Investigations
Blood tests fo r testicular tu m o u r
M anagem ent fo r hydrocele

D idn't feel to o good fo r this station cause he asked me again if I fe lt inguinal lym ph nodes. M ost
people said hydrocele. =(

11 + 12) Prep station.

Stem: Guy is m oto rb ike rider. In RTA by h it and run. Was unconscious in itia lly but GCS 15 on arrival.
A dm itted. Ultrasound showed ?free flu id in paracolic gutter. Xrays showed le ft tibial + fibula fracture
open fracture. Noted by nurse to suddenly have a cold lim b + pulseless. Please inform traum a
consultant on call. Blood investigations on admission all norm al. Raised CRP and TW only

Basically SBAR and spammed him w ith all th e inform ation.

Asked me fo r m y plan o f management. ( I said CT brain, AP, send to op, start ABx
W hat can I do before sending to OT (he was looking fo r analgesia + traction)
W hat blood investigations w ill u send fo r
How w ill you fix his fracture (I said external fixation. He asked why)
W hat w ill you do fo r the w ound (I d id n 't really understand initially, b u t he w anted me to say
debridem ent o f necrotic tissue)

The phone sound quality is dam n bad. I had to always ask him to clarify again.

13) Critical care - Calcium homeostasis

Stem: Post th yro id e cto m y hypocalcemia. Given investigation: Calcium 1.8. P04 0.7. Everything else
ok

W hat is the cause fo r hypocalcemia

How is calcium transported in body
W hat is calcium used fo r
 3 horm ones involved in homeostasis
How is V it D form ed
W hat is V it D actions
W hat are th e actions o f parathyroid
W hat are clinical sym ptom s o f hypocalcemia
W hich muscle are you w orried about in hypocalcemia te ta n y (I really d id n 't get th e correct
answer fo r th is one. I said diaphragm, intercostals. He just shook his head. So I to ld him I
d id n 't know)
How to tre a t hypocalcema (Told him IV calcium gluconate. He asked fo r specific dose. I said
IV infusion over 10 mins 10 mis o f 10% calcium gluconate. He said he w ill accept that)

Straight forw a rd . Probably missed a few qns but nothing new.

14) Critical care - Acute pancreatitis w ith ARDS

- Shown CT scan w ith massive pseudocyst. Identify main organs. (Stomach was squished till it
became a line w ith a small black lining inside. Keep probing me till I said stomach lol)

M ain abnorm ality (pseudocyst. I said dilated ducts as w e ll and he asked me to point it
out.)
Told me patient is now hypocalcemic and hyperglycem ic. Explain w hy (I said
saponification o f calcium soap. He asked fo r one m ore reason. I shrugged.)
Showed me CXR w ith diffuse lung in filtra te s w ith pulm onary oedema
Patient is now tachypneic. WHY? (He w anted to hear abdo pain, splinting o f diaphragm
due to large cyst, ARDS, sym pathetic overdrive as patient is not stable)(He w anted all
the reasons before allow ing me to move on...)
W hat is this. ARDS and ra ttle o ff criteria
H o w to m anagem ent
Pathophysiology o f ARDS
W hat happens to lung compliance?

Probably some m ore qns about th e hypocalcemia and hyperglycemia, cant rm b. No qns on glasglow
scoring. Surprise surprise.

15+16) Prep station. Angry patient.

This is exactly th e same stem about ascites w ith m alignant cells and CT scanner broke down. Offered
US abdom en o r faraw ay hospital.

Nothing new here guys, move along.

17) Pathology: FAP

Stem: Colonoscopy done fo r some dude. Got CRC and many polyps

Diagnosis
W hat gene defect
W hat does APC gene do norm ally
Extraintestinal m anifestations
 Patient has a 2 year old son. W hat w ould you te ll th e m om
Genetic inheritance
W ha t surgery w ill you do fo r FAP
W ha t type o f polyps has highest m alignancy potential
Shown a diagram w ith tu m o u r invading past muscularis propria
W ha t is T staging and duke staging o f this. (Omg I d id n 't know the T staging lol.)
W ha t is dysplasia

I d o n 't recall anym ore qns on this. It was very short. I ended even before th e 6 m in bell rang. I kept
asking him anym ore, he said I answered everything except the T staging lol.

18) Pathology: TB

Stem: Indian girl trave l overseas again, come back w ith neck lum p

D ifferentials
W hat are th e com m onest type o f lym phom a (I ju st said non hodghkin. He said ok)
Investigations
W hich labs w ill you send the sputum to (he d id n 't w ant to hear all th a t rubbish a bout ZN
stain, aurom ine rhoam ine gel. He w anted to hear, m icrobiology lab, cytology lab.)
W hat o th e r investigations (TB PCR, m antoux, interferon gamma.)
W hat w ill you do once you collected the sputum sample (Put in biohazard bag, inform
CDC. I w asn't sure about th e UK equivalent, so I said I w ill inform the UK e q u iv a le n t o f
CDC and m inistry o f health. He laughed really loudly and asked how do we do it in
Singapore. I said online o r call)
W hat is the public health concern fo r TB diagnosis
W hat is contact tracing and w hat w ill you advice to the contacts.
W hat o th e r m ycobacterium do you know. (I said m ycobacterium avium. He said th a t is
not the fu ll name. W h at is the fu ll name. I co u ld n 't recall. Someone else said MAC and
he was happy w ith that.)
Given histology report: TB histo
W hat is a giant cell. Describe its m orphology
W hat is a granulom a
3 causes o f granulom atous inflam m ation. Foreign body and TB are not counted.
(C ouldn't get the last one. I said sarcoidosis, crohn's. I said A LOT OF things he just kept
shaking his head. Silicosis did n o t satisfy him)

19) Critcal Care - Enterocutaneous fistula

W hat is a fistula
W hat factors predispose to fo rm a tio n o f ECF
W h at factors prevent spontaneous closure o f ECF
W h at conservative m anagem ent can you do fo r ECF
W h at com plications o f ECF
W h at w ill make you bring the p atient in to the OT w ith in the firs t 24 hrs (He nodded and gave
approval w hen I said distal o bstruction, intraabdom inal sepsis. I said a lo t o f o th e r things but
he d id n 't let me go till I said those 2)
 W hat are signs o f intraabdom inal sepsis
Given blood results: Low Na, K,HC03
W hy low bicarb
W hat is the principle o f fluid m anagem ent in this patient
W hat are th e principles o f m anagem ent fo r ECF

This station had A LOT o f qns. I cant rm b th e rest cause it was really quick fire.

20) Anatom y: U pper lim b again....

Point o u t the acrom ion and coracoid process

W hat are ro ta to r c u ff muscles and origins and attachm ents
Point o u t spiral groove. W hat nerve runs in it
Point o u t medial epicondyle. W hat nerve. W hat are th e cutaneous deficits o f radial and
ulnar nerve.
W hy is grip strength w eaker if radial nerve is affected. (You cant grip things if you cant
extend the w rist)
W hat is the origin and attachm ent o f gluteus medius and its function. (He d id n 't let me go
w ith a vague pointing around th e iliac crest fo r th e origin lol.)
W hat is the origin and insertion o f th e quadratus fem oris ( =( I forgot)
W hat is the main flexo r o f the hip
Pointed to ASIS. W hat is th is and w hat muscle attaches here
W hat nerve is this. Lateral cutaneous nerve
W hat is the condition if this nerve is compressed.

Finished early again. Very obvious w hich qns I could answer and those I could not. This guy d id n 't
allow fo r any smoking.

Good luck folks! Tim e is short especially in the history taking and PE stations. Theory part is p retty
straight forw a rd . They ju st w a nt to hear keywords. If you give it to them , you w ill know cause they
w ill m ove on. The m arking sheet has the answers on it and some examiners w ere bored and just put
th e m arking sheet on the table and I could m ore o r less see if I scored th e m ark o r not.
Station 1 (CPS)
Excisional biopsy o f nevus
- Consultant w as about to perform ex bx of nevus over pt's thigh, but w as called aw ay for E-op. Already
cleaned, draped and LA infiltrated.
- Instructed to perform ex bx and close w ound w ith synthetic, non-absorbable sutures in interrupted
fashion.
- Introduced m yself and asked w hether pt w as ok with me perform ing procedure instead of consultant
- Consent re-taken and checked against w ritten consent (have to check against pt's w rist tag)
- You have to choose the instrum ents you w ant by placing them into sterile field (have to choose between
prolene and vicryl sutures)
- Perform an elliptical incision and excise as per usual
- Take big bites w hile closing to prevent tearing through foam
- Give pt advice on dressing and STO dates
- Give advice on estim ated histo result dates

Station 2 (critical care)

Pt with hypothyroidism , non-com pliant to m edications planned for elective surgery
- Blood results shown:
> FBC showed m acrocytic anemia
> fT4 low, TSH high
- Questions asked:
> Interpret TFT
> Explain HPT axis
> Clinical presentation of hypothyroidism
> W hy might pt be hypothyroid / why might pt be non-com pliant
> W hat are the perioperative concerns with hypothyroidism
> How w ould you enforce com pliance (s/t pt, fam ily, w ork w ith GP, etc.)

Station 3 (critical care)

Pt POD 5 post-ileostom y reversal with signs of sepsis: febrile, tachycardic. Also noted to have a right UL
patch on CXR. Dilated small bowel loops on AXR
- Questions asked:
> AXR show n: w hat is the diagnosis?
> W hat are the ddx for dilated SB loops on AXR? 10 vs ileus
> How to differentiate them ? Bowel sounds
> W hat are the possible causes for pt’s clinical presentation?
> How to treat? W hat antibiotics to give? W hy should not give cephalosporins? (apparently answ er was
because it causes C. diff...)
> W hen w ould you opt for surgical m anagem ent?

Station 4 (pathology)
Given clinical hx of pt with lum p over arm. Ex bx done, shown histo report of BCC with depth of invasion,
deep margin involvem ent
- Questions asked:
> W hat is BCC?
> Natural hx of BCC
> W hat are your concerns regarding the histo report?
> How w ould you m anage a pt with deep margin involvem ent?
> H o w to prevent recurrence of deep m argin involvem ent during re-operation?
Skin graft placed for pt and subsequently had graft failure
> Cause for graft failure? W ound infection
 > Com m on organism ? S. aureus
W ound c/s grew M RSA
> W hat is MRSA?
> How w ould you manage this pt with M RSA wound infection?
Subsequently pt developed axillary lymph nodes
> Concerns? Unlikely BCC (no LN mets)
> FNAC o f axillary LN done, show ed Reed-Sternberg cells. Diagnosis? HL

Station 5 (pathology)
Pt with sickle cell disease com ing in with brain tum or
- Questions asked:
> W hat is sickle cell disease?
> Surgical relevance? Gallstones, im m unocom prom ise, bone crises
> W hy are pts im m unocom prom ised? Autosplenectom y
> W hat is the most com m on prim ary brain tum or in elderly pt?
> Natural history of primary brain tum or?
> Brain biopsy showed squam ous cells with keratinisation. Relevance? Likely m etastatic SCC
> Possible primary sources of SCC?
Post-biopsy had wound infection
> Com m on organism ?
> W ound fluid show ed glucose 3.3. Relevance? CSF com m unication

Station 6 (IDC insertion)

Pt presented with lower abdo pain and NPU. Registrar thinks it is ARU , asked you to perform IDC.
Have to prepare IDC set yourself: place the catheter (with syringe for balloon), KY jelly, in sterile field
Explain to pt indication o f procedure
Perform an IDC insertion as per usual
However, no urine com ing out. Tried to aspirate and flush, but still no urine
- Causes for no urine?
- W hat will you do now? Don’t blow up balloon, remove IDC and look for other causes o f abdo pain and
NPU
M ostly self-directed station, exam iner didn't ask many questions

Station 7 (Anatom y)
Thorax and abdom en
- Pointed to follow ing structures, asked to identify:
> Pulm onary trunk
> Tricuspid valve. W hat are the structures connecting papillary m uscles to valve cusps? W hat is the
function of the chordae tendinae?
> Azygos vein. Tributaries of azygos vein
> Sym pathetic trunk. Contributory spinal cord levels to sym pathetic trunk
> Duodenum . How m any parts of duodenum ?
> W hat 2 ducts join and enter the duodenum ? W hich part o f the duodenum do they enter?
> Gallbladder fundus. Pathophysiology of radiation o f pain to shoulder tip in gallbladder pathology.

Station 8 (Anatom y)
Neck
- Asked to identify follow ing structures
> Thyroid and its lobes. W hy does the thyroid move up with swallowing?
> Strap muscles: w hich is sternothyroid, which is sternohyoid. Innvervation of infrahyoid strap muscles?
Nerve roots of ansa cervicalis?
> Om ohyoid
> Superior thyroid artery. W hat structure is closely related? W hat happens when this structure is injured?
 > W hat structure is closely related to bifurcation of ECA and ICA? W hat is the clinical significance of
injuring this structure?
> W hat is the landm ark used in an em ergency airway? Cricothyroid m em brane. Identify it.
> Identify cricothyroid muscle. W hat innervates this?

Station 9 (Anatom y)
Hand
- Shown X-ray o f hand
> Identify all the carpal bones
- Shown bony model of hand
> Point out the attachm ents of the flexor retinaculum
> W hat are the structures running through the carpal tunnel?
- Shown cadaveric hand. Asked to identify:
> Median nerve
> Ulnar nerve
> W hat is this structure? Ulnar artery
> How to test for sufficient ulnar artery supply to hand? Describe Allen's test.
> W here do the tendons o f FDS and FDP insert? Dem onstrate how to test for FDS
> W hat are the m ovem ents of the thum b? Dem onstrate on yourself
> W hat is the innervation o f all the m uscles m oving the thum b?

Station 10 (critical care)

Clincial scenario o f a pt com ing in with abdo pain, guarding and free air under diaphragm . Has PM Hx of
som e chronic pain issues on NSAIDs.
- Questions asked:
> W hat is the likely diagnosis?
> W hat is the pathophysiology o f PUD?
> W hat are the causes of increased gastric acid secretion?
> W hat are the different phases controlling gastric acid secretion?
> W hat m edications w ould this pt require in the long-term ?
> How do PPIs work?
> How urgently does this pt need to go to OT?
> How w ould you treat this pt surgically if it w as a PDU vs a PGU?

Station 11 (History taking)

Pt with long-standing goiter w ith increasing sw elling of neck lump. Has been experiencing sym ptom s of
thyrotoxicosis as well.
- W hat are the ddx for the pt?
- How w ould you investigate the pt?
- W hat are the features on US thyroid that you w ould be keen to know?
Didn't get further than investigations...

Station 12 (History taking)

Pt with 6/12 hx of PR bleed w ith significant fam hx o f colorectal cancer
- W hat are the ddx for the pt?
- How w ould you investigate?
- If confirm ed to be CRC, how else w ould you investigate?

Station 13 (Physical exam ination)

Pt with long-standing hx of sm oking and drinking presents with increasing breast size. He is getting
increasingly self-conscious. Perform the relevant physical exam inations.
Obese pt. Did a full breast exam ination, no lum ps felt in breasts or in axilla. Did an abdo exam ination
targeted tow ards looking for signs o f chronic liver disease. Forgot to check the genitalia. W anted to check
for visual fields but exam iner said to assum e normal.
- Questions asked:
> How w ould you like to com plete your exam ination? Check for testicular atrophy
> W hat is the likely diagnosis?
> W hat are the causes of gynaecom astia?
> How w ould you investigate the pt?
> How w ould you manage this pt?

Station 14 (Physical exam ination)

Young pt with visual problem s. Specifically told not to check for visual acuity, papillary reflex, corneal
reflex, gag reflex, jaw jerk.
Did a full CN exam ination, main finding of bitem poral hem ianopia.
- Questions asked:
> W hat are the causes of bitem poral hemianopia?
> How w ould you investigate this pt?
> How w ould you treat the pt?
> W hat is the pathophysiology behind bitem poral hem ianopia?

Station 15 (Physical exam ination)

Elderly pt w ith previous abdom inal surgery, now c/o painful lum p over incisional site.
Very frail old lady with a T shaped scare over lower abdom en. Had a lum p in RIF region that w as only
apparent after standing up (pt started in a supine position). Not incarcerated or strangulated. Bowel
sounds +
- Questions:
> W hat is the diagnosis?
> How w ould you manage this pt conservatively and surgically?
> W ould you offer this pt surgery?

Station 16 (Physical exam ination)

Obese pt w ith previous THR, now c/o contralateral hip pain. Perform full hip examination.
Pt had BILATERAL THR scars and bilateral TKR scars. Tried to do hip exam ination but pt w as tender over
entire hip. ROM restricted in all directions.
- Questions:
> W hat is the diagnosis? OA??? Prosthesis loosening??? Pt doesn't fit the description...
> How w ould you manage this pt?

Station 17 (Physical exam ination)

Pt com ing in for elective hernia surgery. Has a M VR (not told at start). Asked to perform full CVM exam.
Pt had midline sternotom y scar, no scars over LL. Loud m etallic S I. Not in heart failure.
- Questions:
> W hat are your perioperative concerns for this pt?
> Shown pt's INR trend, which was supratherapeutic. How w ould you m anage this?

Station 18 (Comm unications)

POD 1 post-left hem icolectom y for sigmoid adenocarcinom a w ith liver biopsy for suspicious liver nodule.
Intra-operatively had slipped clam p with blood loss. Now anuric, IDC already flushed. Hb slight drop, renal
panel shows AKI with raised Ur and Cr. Have to speak to on-call consultant regarding low urine output.
- Introduce yourself, pt's prim ary consultant and pt
- SBAR
- W hat are your differential diagnoses for the pt?
- Is there an anastom otic leak?
- How are you going to m anage the pt? Does he require HDU transfer? Does he require op now?
- If HDU is full, w ho are you going to speak to?
- Does the consultant need to com e and see him now?

Station 19 (Comm unications)

Young pt w ho w as in an RTA and suffered a large splenic hem atom a. Observed for 48h, rem ained well,
but planned by consultant for further observation KIV splenectom y if hem atom a ruptures. Pt w ants to
AOR discharge because he has an im portant interview the next day. Also facing financial difficulties
because of w ife's new diagnosis of cancer.
- Explored ICE with pt
- Offered alternatives of hom e leave, but cannot: interview in next town
- Offered w riting a memo or calling em ployer, but cannot: weekend currently, em ployer unforgiving in
previous cases
- Offered speaking to wife, but pt declined
- In the end agreed to let pt discharge, but with a m em o to seek m edical treatm ent as soon as he reaches
back home
- Also got pt to agree to have som eone accom pany him on the journey back
- Given abdo advice to w atch for signs and sym ptom s o f hem atom a rupture
- Asked pt to sign indem nity form
 Anat
1. Thyroid, vagus n, brachial plexus injury
- Plastic m odels o f neck (a n te rio r view ) and h ea rt
- Arch o f aorta, branches
- Id e n tify vagus nerve on neck m odel, w h a t n e u ro n s does it co n ta in in th o ra x

- Id e n tify RLN on h e a rt m odel, w h a t m uscles does it supp ly

- Parts o f th y ro id (lobes, isthm us)
- Blood su p p ly o f th y ro id
- Em bryological o rig in o f th y ro id gland
- W h a t physiological p ro b le m s a fte r to ta l th y ro id e c to m y (h y p o th y ro id is m and

h yp o p a ra th yro id ism )
- W here are th e p a ra th y ro id glands located
- W h a t is th e ir fu n c tio n , w h a t does PTH do
- Scenario o f p a tie n t in RTA w ith Erb's palsy - tru n k involved? From w h ich nerve roots?
Show u p p e r tru n k on neck m o d e l (co u ld n 't fin d it). W hat's th e p o sitio n o f th e u p p e r

lim b
- W hat's th e m o to r and sensory loss in p a tie n t w ith lo w e r tru n k (in trin sic m uscles o f
hand, num bn ess over m edial arm + fo re a rm )

2. Skull, TMJ, la te ral skull XR

- Id e n tify c o n d yla r process o f m a ndible
- Describe h o w and w h e re it a rticu la te s w ith skull
- D e m o n stra te a rtic u la tio n betw e en m a n d ib le and skull
- W hich m uscles depress m andible , w h ich m uscles m ove m a n d ib le fro m side to side

- On skull in fe rio r view, id e n tify stylo m a sto id fo ra m e n , w h ich nerve passes th ro u g h

- On in fe rio r view, id e n tify fo ra m e n ovale, fo ra m e n sp inosum and s tru ctu re s passing
th ro u g h
- Styloid process - w h a t m uscles a tta ch here

- Show w h e re p te rio n is, w h a t is significance o f area

- Lateral skull XR - id e n tify e th m o id sinus, p itu ita ry fossa, d iffe re n t s u tu re lines

3. Tib/fib, ankle
- A rtic u la te tib ia and fib u la (hand ed m e fib u la upside d ow n)

- Show how ankle m o rtise fits to g e th e r

- W h a t kind o f jo in t is distal tib -fib jo in t (syndesm otic?)
- Show (using ow n ankle) m o ve m e n t o f ankle jo in t p u re ly (dorsi and p la n ta r fle xio n )
- Show (using ow n ankle) m o ve m e n ts o f su b ta la r jo in t (in ve rsio n /e ve rsio n )
- W hich p o s itio n is ankle m o re stable in and w h y (d o rsifle xio n due to w id e r talus

a n te rio rly)
- Describe m ain c o m p o n e n t o f d e lto id lig a m e n t (th in k he w a n te d tibionavicula r? )
- Show w h e re lateral collateral ankle ligam ents a tta ch on skeleton
- Id e n tify su ste n ta cu lu m tali
- Id e n tify bones o f fo o t and m edial + la te ra l lo n g itu d in a l arches

- Tendons on a n te rio r o f fo o t
- Blood su p p ly o f fo o t (w anted details o f h o w PT sp lits in to m edial and lateral p la n ta r
a rte rie s to fo rm p la n ta r arch, w h e re DP pierces th ro u g h d o rsu m o f fo o t to p la n ta r
side, and w h ich p la n ta r a rte ry it jo in s w ith )

Physical exam

4. Cranial nerves - bitem poral hem ianopia

- S im ulated p a tie n t, p /w headache and a b n o rm a l vision
- C ranial nerves all n o rm a l except very cle ar b ite m p o ra l hem ia nopia

- Pen to rch , tu n in g fo rk, c o tto n w o o l p ro vid e d

- Asked fo r likely area w h e re p a th o lo g y occurs
- Possible causes o f lesion at o p tic chiasm
- W h a t else I w o u ld like to exam ine - w as lo okin g fo r th y ro id status, evidence o f
Cushing's, evidence o f acrom egaly, nipple discharge etc.
- Investigatio ns - did n o t w a n t all th e in d ivid u a l h o rm o n e s to be tested, was happy
w ith "h o rm o n e assays". MRI p itu ita ry - w h y n o t CT scan. A dvantages vs disadvantages
o f CT scan? (he was lo o kin g fo r a n o th e r disadvantage o f CT besides p o o re r so ft tissue
visualisation, need fo r constrast, ra d ia tio n ...n o t sure w h at)
- M a n a g e m e n t - Endocrine, su rg e ry - tra n s-sp h e n o id a l vs. tra n s fro n ta l

5. Right chest pain post-op - PE

- Q uestion was to th o ro u g h ly assess th is p a tie n t w ith POD 4 rig h t chest pain. N o t
h is to ry taking, b u t a llow ed to ask certa in q u e stio n s d u rin g e xa m in a tio n . Specifically
stated n o t to give ru n n in g co m m e n ta ry.

- S im ulated p a tie n t, using oxygen m ask w ith no connected oxygen, u n d e r blanket

- Did a sh o rte n e d respi and CVS exam - p ro b a b ly lost q u ite a lo t o f m arks fo r being a
b it disorganised and m issing p e rip h e ra l exam s. D id n 't do vocal resonance either.
- P atient had p le u ritic chest pain on in sp ira tio n .
- Palpated th e abdo, b u t p a tie n t had a large m id lin e la p a ro to m y dressing on w h ich we

w e re n 't a llow ed to rem ove. So n o t m uch abd o exam either.

- Removed th e bla n ke t fully, fe lt calves - le ft calf te n d e r
- Vitals c h a rt also given, p a tie n t had tachycardia, m ild d e sa tu ra tio n
- D iffe re n tia ls
- M a n a g e m e n t o f PE, w h e n is surgery indicated

6. Knee - LCL / meniscus injury

- Stem was p a tie n t p re se n tin g w ith rig h t knee pain a fte r tw is tin g knee d u rin g soccer
- S im ulated p a tie n t lying on bed, una ble to stand and w a lk due to pain
- +ve fin d in g s o f rig h t knee decreased ROM, la te ra l jo in t line tenderne ss, te nderne ss

over LCL and pain on stressing LCL. Also had positive M cM urray's w ith pain and a
CLICK w h e n d o in g it (no idea h o w th e p a tie n t w as clicking. M aybe som e clicker u n d e r
th e blanket).
- D iffe re n tia ls
- Investigatio ns and m a nag em e nt
- W h a t I'm lo o kin g fo r on XR, and on MRI

7. RHC tenderness - cholecystitis

- P atient p re se n tin g w ith D4 abd o pain
- S im ulated p a tie n t

- +ve fin d in g s o f RHC tenderne ss, no g u a rd in g /re b o u n d , M u rp h y's +ve

- Vitals c h a rt show ed high fe ve r w ith tachycardia and d ro p p in g BP
- D iffe re n tia ls
- Investigatio ns - a fte r bloods, said U/S HBS. W hat else? I said CT AP. W h a t o th e r
o p tio n s fo r im aging b ilia ry system . I said MRCP?

- M a n a g e m e n t - w h a t antibiotics?
- Likely a p p ro a ch fo r surgery
- O p tio n s fo r tim in g o f su rg e ry - early vs interval. I in itia lly said in te rva l in view o f
a lre a d y D4, th e n he said w h a t if it was o n ly D1 - 1said in m y experience m o stly early.
- W h a t if p a tie n t clinically im p ro v in g post-op, b u t LFTs w e re w o rse n in g . D ifferentials?

Practical stations
8. IDC in s e rtio n
- Stem o f p a tie n t needs IDC in s e rtio n due to ARU, no h is to ry o r PE needed. Prepare

y o u r IDC tro lle y and catheterise th e p a tie n t. M easure u rin e v o lu m e d rain ed.
- Two exam iners, one being y o u r assistant and one ta k in g th e sta tio n
- 1sta rte d o ff by g e ttin g th e p a tie n t's nam e, DOB, and b rie fly to ld him a b o u t IDC
in se rtio n
- W asn't allow ed to pre p a re m y ow n stu ff, th e e xa m in e r blocked m y vie w o f th e s tu ff

beh ind him and asked m e w h a t I'd like, he w o u ld get fo r me

- IDC set, 14F IDC, c o tto n balls, gauze, chlorhex, w ater, lignocaine, syringe, drapes,
gloves. No u rin e bag to connect.
- He in itia lly gave Aquagel in a tube, I asked him fo r som e in a syringe instead and he
obliged by s q u irtin g A quagel in to m y e m p ty syringe.

- 1also asked fo r a sponge h o ld e r to hold m y co tto n balls, he ro lle d his eyes and gave
me plastic forceps. Oh w ell.
- A fte r te stin g IDC, cleaning, d ra p in g and je lly-in g , IDC could on ly be inserted up to
halfw ay. I w a sn 't sure if it was m a n n e q u in issues o r if it was really supposed to be
blocked, so I was p u llin g th e penis up and d o w n and g e n tly a d ju s tin g th e IDC

- He e ven tua lly sm irke d a t m e and asked if I w as having p ro b le m s

- Likely cause o f o b s tru c tio n a t th is level - BPH
- If BPH, h o w w o u ld I try to hold penis so IDC m ay be able to go in? In itia lly said hold
penis d o w n w a rd s (p o in tin g to feet), b u t he said nope, hold it p o in tin g up (to ceiling)
- If una ble to insert, w h a t w o u ld I do? A tte m p t la rg e r IDC. W hy? Stiffer, easier to push

th ro u g h o b s tru c tio n .
- O th e r possible causes o f o b s tru c tio n
- Risks/ co m p lica tio n s o f IDC in se rtio n

9. Excision o f naevus
- Stem was p a tie n t has naveus on le ft thigh , review ed by y o u r co n su lta n t, deem ed
benign and planned fo r excision. H ow ever, ju s t before sta rtin g , c o n s u lta n t had to rush
o ff and asked you to take over. Lignocaine a lre a d y given, C&D done.
- Checked p a tie n t and conse nt (e xa m in e r was h id in g conse nt be h in d his back)
- Explained s itu a tio n to patie nt, p a tie n t agreeable fo r m e to excise

- Choose in s tru m e n ts you need, s u tu re yo u w a n t

- Tested anesthesia
- Elliptical excision o f naevus (big d o t o f ink on a fo a m pad), se n t fo r histo
- Closed w ith Prolene
- Take advantage o f silence w h ile yo u 're w o rk in g to ta lk to p a tie n t, o th e rw ise m ay ru n

o u t o f tim e
- Explain dressing changes, STO, h isto results w ill take a w h ile
- W hen I asked her if she had any que stions, p a tie n t had specific q u e stio n s a b o u t
histo - w o rrie d a b o u t skin Ca as m o th e r had it. Also asked w h a t else she shou ld look
o u t fo r - to ld h e r to w a tch o u t fo r evidence o f in fe ctio n

- Due to ta lk in g and w o rkin g , fin ish e d w ith q u ite a lo t o f tim e to spare

H is to r y a n d c o m m s

10. LBP, depression -?som atoform disorder

- P atient w ith h /o DDD 5 years ago, has w o rse n in g pain in lo w e r back fo r past few
m o n th s, a /w pain in neck, shoulders, arm s, legs. But no ra d ia tio n , all separate pain
- Red flags -ve
- S ym ptom s o f depression
- Social issues - $ pro b le m s, una ble to take care o f husband p ro p e rly w h o has COPD

- S um m arise h is to ry - gave a p ro b le m list w ith LBP, ?depression, social problem s.

- D iffe re n tia ls fo r LBP
- W h a t to exam ine fo r, p a rtic u la rly to rule o u t red flag co n d itio n s
- Investigatio ns - was in itia lly n o t ve ry h ap py w h en I o ffe re d MRI, a lth o u g h gave an

a m b ig u o u s Indian head shake w h e n I calm ly reasoned th a t h e r last MRI was 5 years

ago and h e r back pain had re ce n tly w orsen ed. H m m .
- M a n a g e m e n t - kind o f ran o u t o f tim e , so a fte r th e gong rang I could o n ly lam ely
b lu rt M u ltid is c ip lin a ry ! Analgesia! PSY! MSW! as I was escorted o u t o f th e station.

11. IBD
- Young p a tie n t (I th in k 25/F) re fe rre d fro m GP due to dia rrh e a
- 6-8 m o n th s o f loose w a te ry stools, g ra d u a lly increasing in fre q u e n cy
- Spots o f blood in stools, no fra n k bleed

- a /w RIF pain d u rin g stools

- a /w LOA + LOW (5+ kg)
- No a b d o bloating, no fever, no n a u se a /vo m itin g
- M enses norm al, no th y ro id sym p to m s
- PHx o f b ila te ra l knee pain fo r 1 year +, S/B GP to ld a rth ritis , on codeine and

ib u p ro fe n
- No FHx o f a u to im m u n e / colon p ro b le m s
- H airdresser, dia rrh e a a ffe ctin g w o rk because she needs to keep ru n n in g to to ile t
- W hen asked a b o u t concerns, ke p t asking if she's ta k in g to o m uch codeine, w h at's th e
safe dose o f codeine to take everyday, sh o u ld she sto p ta k in g th e codeine. A b it w e ird.

I kept reassuring h e r and te llin g h e r I w o u ld go th ro u g h her m eds la te r and review .

- D iffe re n tia ls - 1 o ffe re d IBD, IBS, m alignancy. Exam iner's eyes bugged o u t w h e n I said
m alignancy.
- Investigatio ns - e x a m in e r ke p t asking me "lo o kin g for?" a fte r every in vestigatio n, so
th is to o k a lo t o f tim e

- P ro m p te d m e w h a t o th e r basic te s t to do besides b lo o d s /im a g in g - sto o l tests.

- C olonoscopy - w h a t gross fin d in g s if th is is Crohn's. Was lo okin g fo r co b b lestone
appearance (w hich I d id n 't get, and was stuck on fo r th e rest o f th e station.)
- Person a fte r m e said co b b le sto n e appearance, and w e n t on to ta lk a b o u t m edical
m a n a g e m e n t o f th e p a tie n t (I was ea ve sd ro p p in g d u rin g m y rest station)

12. Update trau m a con re: open tib /fib fractu re in ED

- O ne prep sta tio n p rio r to th is one - given case notes, no vitals chart
- Case notes had m a n y e n trie s (typed o u t) fro m GS, ra d io lo g is t etc.
- Basically yo u n g guy, RTA, LOC, GCS 15 OA a t ED, vitals stable

- Fluid resus given, GXM done

- Blood results m o re o r less n o rm a l
- Right tib /fib ope n #, gross soilage, a n tib io tic s + ATT given
- S/B GS, abrasions on le ft flank, abd o soft, does n o t th in k needs CT AP b u t o rd e re d
U/S

- U/S - d iffic u lt exam , ?LHC free fluids, suggested CT AP

- Pulses in itia lly n o t m e n tio n e d , b u t nurses la te r n o ted fo o t g e ttin g co ld e r and paler,
d iffic u lt to feel pulses
- XRs show ed tib /fib #s, rig h t hand MC #s
- N ext s ta tio n was to call c o n s u lta n t re g a rd in g case.

- Asked - w h y are you calling me n o w (w ill need o v e rn ig h t surgery), w h y did GS ask fo r

U/S w h e n th e y fe lt abd o was n o rm a l (w anted to hea r a b o u t th e abrasions, possible
splenic in jury)
- Plan - NBM; C collar; reduce and s p lin t tib /fib - reassess pulses and neurology, KIV
w ith bedside d o p p le r - call vascular if necessary; u p d a te GS; CT brain, C spine, A/P;

CT LL ang iog ram if pulses still n o t w e ll fe lt (I d id n 't o ffe r th is a t first, he had to prise it
o u t o f me)
- People I m ay need to call e ith e r pre- o r in tra -o p - OT, anesthesia, GS, Vascular,
Plastics (again, he had to d rag th is o u t o f me)

13. CT s c a n n e r d o w n , t a lk to p a tie n t's w ife

- O ne prep sta tio n p rio r to th is one - case notes given
- P atient re fe rre d fro m GP fo r ascites
- P eritoneal ta p - m a lig n a n t cells on cytolog y
-T u m o u r m arkers sent, pen din g

- Planned fo r CT AP today, b u t CT broke dow n. Engineer se n t for, co m in g to m o rro w ,

CT w ill on ly be up n e xt w eek. R adiologist o ffe re d to do U/S a b d o to d a y
- C o n su lta n t was supposed to S/T w ife, b u t had to go to EOT.
- R egistrar w ro te in notes th a t if p a tie n t ve ry SOB, can co n sid e r th e ra p e u tic tap
- Task was to u p d a te p a tie n t's w ife
- A n gry w o m a n ++. M u st be ve ry tirin g fo r th e actress
- Aside fro m n o rm a l questions, w ife also asked a b o u t w h a t w e can do if p a tie n t still
very SOB - th e ra p e u tic ta p - asked h o w o fte n w e can do it, w h a t th e risks m ay be
- Was also a ng ry th a t reg to ld her all hope is lost
- Had th is fixed, unshakeable idea th a t all cancers are curable; I trie d to g e n tly

disabuse h e r o f th a t n o tio n
-Ju st stay calm folks, she ran o u t o f steam e ven tua lly
 Phvsio + critical care

14. Hem atem esis, esophageal varices

- Stem was p a tie n t w h o is a ch ro n ic alcoholic, p /w hem atem esis x3, BP d ro p p in g , HR
rising
- D iffe re n tia ls fo r th is p a tie n t
- Acute m a n a g e m e n t o f variceal bleed

- W hich varices are usually bleeding (GEJ)

- Causes o f th ro m b o c y to p e n ia in th is case - w a n te d q u ite a few answ ers. CLD
(hypersplenism ...? W anted at least 2 m o re I th ink); possible DIVC (he e ve n tu a lly said
th is an sw e r h im s e lf w h e n I d id n 't com e up w ith it)
- Shown a tu b e - 1th in k it was a M inne sota tu b e (4 lum ens), b u t he was h ap py enough

w ith Sengstaken B lakem ore, ju s t shrugged and nod ded w h e n I corre cted m y answ er
to M inne sota. Asked to explain h o w it w o rks. He looked a t m e in th e eyes, gra b b e d m y
w ris t and said "IN BROAD PRINCIPLES" (I gave him a 2 m in u te spiel anyw ay)
- Risks and co m p lica tio n s o f using Sengstaken B lakem ore tu b e

15. EDH
- Stem was p a tie n t h it head, in itia l LOC, th e n okay, th e n GCS d ro p p in g again
- Shown CT b rain w ith EDH and m id lin e s h ift
- W h a t are in d ica tio n s fo r d o in g CT b rain in tra u m a tic head injury? Was ve ry happy
w h en I m e n tio n e d C anadian CT head rules. W anted to hea r all th e crite ria .

- P a tho physiolog y o f lucid interval

- Layers passed th ro u g h w h e n d o in g a b u rrh o le o ve r th e p te rio n
- W hen I w o u ld co n sid e r in tu b a tin g th is p a tie n t (in a d d itio n to low GCS, airw ay, pC 02
co n tro l, also w a n te d to hear " if I need to tra n s p o rt th e p a tie n t to a n o th e r hospital")
- B enefits o f in tu b a tio n - a fte r I said decrease pC 02, he p ro m p te d m e "and th e o th e r

gas...?" W anted to hea r o xyg e n a tio n to p re ve n t HIE

16. PUD + parathyroid

- Stem o f 40/F w ith gastric ulcer on scope
- In cre d ib ly PMS-ey exam in er.
- W h a t is an ulcer - 1d id n 't g e t any m arks fo r "breach in a m ucosal surface". Go fin d
y o u r ow n best answ er
- Likely cause o f th is lady's ulcer based on in ve stig a tio n results (show ed CLO +ve)
-T re a tm e n t o f H pylori
- O th e r possible causes o f u lce ra tio n in her? (labs also show ed hypercalcem ia -

increased ga strin p ro d u c tio n )

- Likely causes o f hyperCa in th is p a tie n t - p a ra th y ro id adenom a, m alignancy
- W h a t is a p a ra th y ro id adenom a
- 2 tests to investigate - th in k she on ly w a n te d Sestam ibi and PTH assay
- H ow to m anage, w h a t s o rt o f surgery - was n o t h ap py w ith p a ra th y ro id e c to m y . Kept

saying "and...?" Shot m e a w ith e rin g stare w h e n I o ffe re d sub cu ta n e o u s p a ra th y ro id

im p la n ta tio n a t sam e setting. D o n 't kn o w w h a t she w a n te d .
- H isto re p o rt show ed one gland th a t was heavier th a n th e rest w ith p re d o m in a n tly
c h ie f cells, and th e o th e rs w ith p re d o m in a n tly o xyph il cells. Asked to in te rp re t

17 . Post-op pain
- Stem is p o st op a fte r m a jo r a b d o m in a l surgery, has severe pain, all sig nifica nt
pa th o lo g y excluded
- H ow to assess severity o f p a tie n t's pain
- W h a t does th is VAS m ean (show ed 0-10 VAS line w ith X so m e w h e re to th e rig h t o f

centre)
- If you saw th is d ru g chart, w h a t w o u ld you tell th e nurse? D rug ch a rt was strangely
fo rm a tte d , b u t seem ed to show th a t b o th PRN drugs and re g u la r d rugs h a d n 't been
given fo r a w hile.
- H ow to m anage th is p a tie n t's pain (w anted to hea r re fe r pain team on to p o f th e rest

o f th e answ ers)
- Adverse effects o f post-op o p ioids
- P roblem s caused by post-op pain
- H ow does PCA w o rk, and w h a t are its fe a tu re s

- C o m plica tions o f PCA - w a n te d to hear 4, w h ich I d id n 't m anage to give

18 . Post-op surgical site infection, pseudom em branous colitis

- Stem is p a tie n t s/p open cholecystecto m y
- W ou n d very w e t and oozy w ith green liq u id co m in g out? W hat do you suspect, w h a t

o rg a n ism do yo u th in k, and w h a t a n tib io tic s w o u ld you give?

- W h a t if w o u n d was d ry b u t had e ryth e m a and te n d e rn e ss a ro u n d w o u n d edges?
W hat do you suspect, w h a t organ ism do you th in k , w h a t a n tib io tic s w o u ld you give?
- W h a t if w o u n d had black edges, looked necrotic; w h a t are p ossibilitie s
- W anted to hear nec fasc. W h a t organ ism s cause this, w h a t is m a n a g e m e n t
- Post-op had b lo o d y d ia rrh e a - DDx? O ffered ischem ic colitis, C. d iff +

p se u d o m e m b ra n o u s colitis. W anted 2 m o re Ddx..l o ffe re d a n tib io tic related diarrhe a,

w h ich d id n 't g e t m e any m arks.
- Shown im age o f co lo n o w ith p se u d o m e m b ra n o u s colitis. W hat is this, h o w can you
tell. P a tho physiolog y o f p se u d o m e m b ra n o u s colitis.
Anatom y Stations:

1. Scenario o f young man falling o ff the horse, questions had nothing to do w ith the scenario.
There was a man lying on couch.
a. Surface makings o f Extensor Hallucis Longus, Dorsalis Pedis Artery
b. A ttachm ent o f Perroneus Longus and Peroneus Brevis
c. Action o f Tibialis A nterior and Tibialis Posterior together
d. Action o f all peroneus muscles together
e. Muscles o f dorsi flexion
f. Muscles o f Plantar Flexion
g. Name o f inward turning o f fo o t (Inversion)
h. Name o f outw ard turning of fo o t (Eversion)
i. Nerve root o f knee extension, flexion, Foot dorsiflexion and plantar flexion
j. Nerve root value o f plantar relex
k. Cutaneous supply o f dorsal surface o f fo o t and verntral surface o f foot.
2. Two lum bar Vertebrae on table
a. Which part o f vertebral columen they belong to
b. Arrange in anatomical position
c. M ovem ent on these vertebrae
d. Name different parts o f the vertebrae
e. Location o f anterior longitudinal, posterior longitudinal ligaments and ligamentum
flavum
f. Level o f spinal cord in new born and aduts
g. Contents of spinal canal below L2
h. Location o f paravertebral venous plexus
i. Clinical significance
j. Tumors metastasizing to vertebral column
3. Prosection o f neck
a. Identify different parts o f thyroid gland, om ohyoid muscle
b. Strap muscles in fro n t o f thyroid gland
c. Nerve supply o f strap muscles
d. Sympathetic Ganglia in relation to which thyroid artery
e. Muscle causing stretching o f vocal cords
f. Nerve supply o f th a t muscle
g. Name cartilages o f larynx

Surgical Pathology Stations:

4. Scenario o f biopsy o f mole on Right forearm, histopathology showing malignant melanoma

a. Feature to look fo r in pathology report o f malignant melanoma
b. Breslow classification and management
 c. A fte r treatm ent, presented w ith mass in axilla, w hat are possibilities
d. How to differentially diagnose (FNAC)
e. Had extensive surgery fo r axillary lump, presented w ith red swollen upper extrem ity,
w hat are possibilities
f. How to treat deep vein thrombosis
g. Complications
h. How to manage pulmonary throm boem bolis
5. Scenario o f 32 year old male w ith undescended testis, presented w ith abdominal lump
a. Risks associated w ith undescended testis
b. Gave pathology report, showing teratom a. W hat is teratom a
c. How to explain bone tissue in teratom a
d. Tum or markers o f testicular malignancies
e. Which factors o f Virchow's triad fo r DVT are positive in this patient
f. Why hypercoagulability in tum or
g. Name the factor th a t converts fibrin to fibrin polymers

Critical Care Scenarios:

6. 45 year old male, diagnosed and managed fo r acute pancreatitis tw o weeks back. Now presents
w ith tachycardia, tachypnea and shortness o f breath.
a. W hat are the possibilities
b. Show a picture o f CT scan, asks to identify different structures on CT film . (Liver, spleen,
pancreas, aorta, vertebrae)
c. Shows a blood report having hypocalcemia. Asks about cause o f hypocalcemia in acute
pancreatitis. (Wanted to listen at least two)
d. Shows X Ray Chest o f the patient, Asks fo r positive findings (Pulmonary infiltrats in all
zones bilaterally)
e. Asks mechanis o f ARDS
f. Diagnostic criteria o f ARDS
g. Etiologic factors o f pancreatitis, wanted to listen 5-6
h. Bell rings, could not com plete this station (I think so)
7. M iddle aged male, had low anterior resection 5 days back. Now having persistent fever,
tachycardia and difficulty breathing.
a. W hat are possibilities
b. Shows ABGs having picture o f metabolic acidosis. Asks about interpretation
c. Shows serum report having raised creatinine and potassium, asks about cause of
hyperkalemia in this patient
d. Show com plete blood count. Asks w hat is SIRS. Which o f SIRS factors are positive in this
patient. (All fo ur were positive)
e. How to manage

Physical Examinations:
 8. Examine Knee joints o f this patient. (Positive findings were scar marks 2cm on both knee,
crepitus positive, patellar tap positive on left) Likely had some ligament repair in past
a. Positive findings
b. D ifferential diagnosis
c. M anagement o f O steoarthritis
9. Examine Ear o f this patient and related nerves (Patient had RTA a day back)
a. Positive findings (Decreased air conduction o f left, W eber lateralized to left)
b. Further investigations (CT, Acoustometry)
c. Show picture o f otoscopy (Hemotympanum)
10. Young male planned fo r inguinal hernia. Examine heart fo r preoperative evaluation.
a. Had sternotom y scar
b. Click in m itral area (Had m itral valve replace)
c. Risks in surgery
d. Give warfarin chart. How to manage preoperatively and intraoperatively
11. M iddle aged male, lump on right flank. (Lipoma)
a. Examine lump and describe findings
b. D ifferential diagnosis
c. W ork Up (USG)
d. When to get MRI

History Stations

12. 25 female comes in ER w ith abdominal pain

a. Patient had epigastric pain, radiating to back. Vom iting
13. 30 male in clinic w ith leg pain
a. Inte rm itte n t claudication, was smoker
b. W hat specific clinical tests to do (Berger, ABPI)

Communication Skill Stations

14. Speaking to ICU registrer fo r potential need o f ventilator to a patient w ho had come in ER w ith
Duodenal perforation and emeregency operation was planned
a. Says no bed is available then w hat
b. Asks certain investigations to get done and then asks to repeat w hat he said
15. Councelling o f patient w ho wants to get LAMA, Had traum atic splenic laceration, being manged
conservatively
a. He ju st wanted to go LAMA come w hat may ©

Surgical Skills Stations:

16. Abscess o f thigh, Incision and Drainage

a. W hat sort o f dressing will you do
b. W ill you give antibiotics
c. W ill scar be there
17. Excisional biopsy o f mole
a. Why mattress suture
b. Apply m onofilam ent, non absorbable suture
c. W ill scar be there
d. W ill it cause pain
Applied Knowledge

Anatom y

1. HPB (Transpyloric plane anatom y prosection)

a. Name the m ajor structures in th e area
b. Explain fo rm a tio n o f the pancreas
c. Explain renal vessels
2. Brain
a. Name all the venous sinuses and how th e y run
b. Point to me w h at sinus is this (straight sinus)
c. Id en tify the ventricles and flo w o f CSF
d. MRI picture (Astocytom a): w hat are your differentials
3. Lower Lim b/Hip
a. Name all the nerves
b. Name all the muscles o f th e hip (the usual)
c. If have in ju ry here (gluteal region) w h a t can be injured
d. Name LL vessels
e. Something about fo o t drop and where the areas o f injury could be

Pathology

1. Necrosis (picture o f toe gangrene)

a. Define necrosis
b. Explain the cause and pathophysiology
c. Complications
d. T reatm ent options: Chop or d o n 't chop?
2. APKD (picture o f PKD)
a. W hat is th e pathology (cysts)
b. W hat o th e r differentials
c. Com plications o f the pathology
d. U nderw ent n e p h re c to m y -w h y ?
e. Had kidney transplant - explain th e d iffe re n t rejection reactions
f. Im m unosuppresion fo r a while, noted to now have malignancy - w hat kind
g. How to tre a t this com plication th e re a fte r (chemo)

Applied science/Critical Care

1. HPA Axis (RA patient on steroids/im m unom odullators)

a. Explain the axis and how it works
b. Symptoms if p a tien t is supressed
c. Relavence in surgery, how to prep patient fo r op things to w atch o u t fo r
i. Neck fo r RA
 ii. Steroids and to give stress dose how to calculate and convert pred/hydro cot
(m ust know)
d. Com plications o f long te rm steroid use
2. Gastric o u tle t obstru ction w ith m etabolic alkalosis (usual question)
a. Standard pathophysiology
b. Symptoms to watch o u t fo r
c. Symptoms o f NA changes
d. How to tre a t w hat to investigate
3. A o rtic stenosis (dulan examiner)
a. Explain com plications o f aortic stenosis
b. Causes
c. How it affects surgery (talk a bout fixed o u tflo w obstruction)
d. W hen to o ffe r surgery
e. So if p a tien t now has gastric cancer - do op straight o r do heart op firs t to optim ise if
th e surface area is x vs y (gives both a norm al and n o t norm al one) - m ust know
valve surface area lim it fo r surgery and transvalvular gradient
f. How to optim ise p rio r to surgery and things to consider
i. W arfarin if p atie nt w ent fo r m etallic valve
ii. Concern fo r spread if delay cancer surgery
iii. Concern fo r on table cardiac event if d o n 't do valve surgery (equivalent to
heart failure patient)

Applied Skills

Procedure skills

1. W ound closure
a. Show LA injection and how much to give
b. Explain choice o f suture and type o f closure
c. M ake sure stitch w ell th e y w ill use forceps to try to pry open your knots
d. Num ber o f knots im p o rta n t as well
e. Talk about tetanus and antibiotics requirem ents
2. l& D o fa b s c e s s
a. Principles o f lines o f langers (w here to incise)
b. Do w e give LA? Is LA useful in such a situation
c. M ake sure to irrigate and currete
d. Pack and explain to patient give ABX etc

Physical Examination

1. Respi (COPD)
a. Full respi exam ination as per MBBS
b. Features o f severity
c. Explain how COPD w ould im pact surgery
d. How to prep p a tie n t p rio r to surgery
2. Vascular (Arterial/PVD)
a. Full vascular exam (D oppler included and provided)
 b. Show me signs o f PVD
c. Explain how to grade severity
d. How to tre a t
e. Surgical options elaboration
3. Neuro (Bitem poral hem ianopia)
a. SP patient: not very good cause donno w hat she doing
b. Examine this patient's neurology ?loss o f vision
c. W hat and w here is the likely pathology
d. W hat o th e r signs are you looking fo r
e. T reatm ent
4. Abdom en (RHC pain/B iliary colic)
a. SP: good actor
b. RHC pain w ith m urphy positive
c. D ifferentials fo r pathology
d. Com plications o f disease
e. W hen to op: so if day 1 op? so if day 5 op?

History Taking

1. Vascular claudication (standard history)

a. Explain severity
b. Risk factors
c. Indications fo r in te rve ntion and w hen to intervene
d. A t present need surgery? (no need as fo ntaine n o t high enough yet, can do
exercisetherapy w ith medical tre a tm e n t)
2. M M SE/AM T
a. Patient 80 years old previously signed consent fo r hip replacem ent now unable to
te ll u tim e and location
b. Assess using history fitness fo r consent
c. Should p a tie n t go ahead w ith surgery?
d. He has no o th e r fa m ily now in the area, can th e do cto r just sign? Patient just outside
OT right now
e. M ust take FULL AMT and a tte m p t MMSE as much as possible (there are no aids
there fo r you to use)

Com m unication station

1. Call consultant in o th e r hospital fo r transfer

a. Your boss made a mistake did a lap chole now g ot CBD in ju ry need to transfer to
another hospital w ith a HPB surgeon fo r b e tte r m anagement
b. W hole list o f blood investigations th e re m ust te ll bout the cr (aki) as w ell as biliary
obstruction, raised TW and CRP
c. They use a cordless phone w ith intercom so no one else th e re w ith u do take your
tim e to look through the investigations and op notes
2. Consent taking fo r paeds patient fo r lap appendectom y
a. Consent fro m w ife but kid already in OT induction room
W ife insist on seeing kid firs t b u t cannot go in but need to take consent
M ade w orse because surgeon on call killed the husband last year in some crazy op
so once w ife finds o u t th e surgeon is M r xyz she w ill th ro w a f it and ask fo r another
surgeon (bu t th e re is no one else)
Speak slowly
1. [ASSCC] 2 cases
• CXR o f Lady who underwent bronchoscopy - Shows large left pneumothorax. No
mediastinal/tracheal deviation.
• What does the Xray show? W hat system do you use to look at Xrays?
• How do you manage this (pneumothorax)?
• Tell me how you w ould insert a chest drain
• She suddenly becomes more short o f breath and hypoxic. What is
happening? What do you do? Where to insert needle? Tension
pneumothorax. Needle thoracocentesis mid clav 2nd intercostal space.
• CT brain o f 80 yo woman who fell down (SDH). In A&E eyes open to pain, makes
incomprehensible sounds, and w ithdraw s to painful stimulus.
• What does it show? Lense shape hyperdense lesion. Right SDH.
Midline shift. Loss o f grey-w hite m atter
• What does loss o f grey-white m atter suggest?
• What is "GCS”, and what is her GCS?
• Who w ill you involve in her care?

2. [ASP] A natom y: Cadaveric specimen o f thorax and neck.

• *Points to specimen and asked to identify* - Brachiocephalic artery, aortic arch,
right common carotid, left common carotid, le ft subclavian. Thyroid gland,
superior tru n k o f brachial plexus.
• Show me the vagus nerve.
• Show me the recurrent larngeal nerve. What does it supply? W hat w ill patient
present w ith if damanged? What supplies cricothyroid muscle?
• Thyroid - How do you anatomically divide the thyroid? (2 lobes and isthumus,
occasional pyram idal) What is the blood supply (arterial and venous) o f thyroid
gland?
• Points and asked to identify superior tru n k o f brachial plexus. What roots do
these originate from? What position would the arm be if this is damaged (asked
to show the upper lim b position/deform ity of erbs palsy)?
• What m otor and sensory deficits w ill result from in fe rio r tru n k damage? i.e
Klumpke's palsy

3. [ASP] A natom y: Given a tibia, fibula foot skeleton, and cadaveric specimen o f leg/foot
• Please put the tibia and fibula in its correct orientation. Now place it on the foot
in the rig ht orientation - Have to put the tib and fib together and put it on the
talus o f the foot correctly.
• Name the bones o f the foot (and point on the skeleton)
• What bones make up the lateral longitudinal arch of foot?
• There are 4 ligaments that make up the medial collateral ligament o f the foot.
What are they and show me their attachments.
• What are the lateral ligaments o f the foot that attach to fibula?
• What type o f jo in t is the in fe rio r tib io fib u la r joint?
• *Points at doral foot tendons - Name these tendons: Tibialis anterior, Ext
hallucis longus, Ext digitorium , Peroneus tertius.
• Show me on yourself, w hat movements occur at the ankle joint? What
movements occurs at the subtalar joint?

4. [ASSCC] 34 weeks pregnant lady undergoing laparoscopic cholecystectomy for

gangrenous cholecystitis. She is in reverse trendelenburg position. BP drops from
107/60 to 85/56, HR 110.
• What are the benefits and risks fo r this patient undergoing this op?
• Who should be involved in her care? Anaesth, O&G, ?neonatologist (He wasn't
satisfied w ith 1st 2, wanted more) Where would she be m onitored post-
operatively? (Wasn’t happy w ith HD, Surgical ICU. I said O&G HD/ICU. Not sure
if it exists here)
• W hat is preload?
 • What mechanisms are involved in venous return? How would mechanical DVT
prophylaxis affect this?
• In this lady, how w ould you manage this drop in BP?

5. [CPSJ Primary survey - 24 M was h it by a car. Now in A&E. Patient is not responsive. Not
breathing. Appears cyanotic. Assume circulatory status is adequate. Manequin there. On
table they displayed different sizes o f C-spine collar, guedels, a bag & mask.
• Examiner stops you at Airw ay and breathing - Patient not breathing, what do
you do? Insert oropharyngeal airway, bag and mask (asked to do it). Suggested
intubation but need anaesth to do it. We are not qualified.
• W hy did you pick that size o f guedel? - Show me how you measure. Show me
how you insert. Show me your bag-&-mask technique (got to show that both
mannequin lungs were inflated adequately)
• Ok patient breathing now. What you do next? Secure C-spine, ensure adequate
ventilation. Show me how you’d insert C-spine collar. Examiner is the "nurse".
6. [ASSCCJ Acute pancreatitis. Lady, recurrent alcoholism w ith epigastric pain. Shown
bloods - LFTs, FBC. UECr, Ca/M g/P04. Amylase 2100.
• What's the diagnosis?
• W hat radiological investigations w ill you do? US HBS first, CT Abdo. What are
you looking for?
• How w ould you manage this patient?
• How w ould you manage her pain? WHO Pain ladder
• Name 2 scoring systems used to risk stratify patients?
• Pick one and tell me their components. How does the score relate to mortality?
(Asked to give a score and corresponding m ortality risk i.e score 0-2: 2%, 3-4:
15% m ortality, etc). I made the numbers up but she was happy I got the correct
gist o f it.
• W hat are the components o f pseudocyst? How long after w ill you suspect this?
How w ill they present?

7. [ASPJ A natom y - Shown cervical vertebrae, skull, Right lateral Cerebral angiogram and
cadaveric specimen o f neck.
• Asked to identify arteries on angiogram.
• Show me the path of the ICA on this skull, including which foramina it goes
through
• Asked to identify ECA on cadaver
• How to tell between upper and low er m otor neuron lesion on the face?
• What neuro deficits w ill patient have if MCA is occluded?
• What abnorm alities do you see on the angio? (aneurysms)
• W hat sort o f intra cranial haemorrhage w ill be associated w ith a ruptured berry
aneurysm?
• Other supply comes from vertebro-basillar system. Name the parts o f the brain
supplied by this.

8. [ASP] Lady w ith temporal a rteritis who underwent temporal artery biopsy.
• What histopath features w ould you see on biopsy specimen?
• Which artery is biopsied?
• W hat is usual treatment? steroids
• Lady subsequently needs a surgery. What are concerns fo r this lady undergoing
op? Taking steroids, need peri-op stress steroids if taking large doses for long
time.
• What side effects of steroids w ill you need to counsel patient about?
• Lady then has a fall and fractures her hip. What are the likely causes in this
situation?
• What is the pathophysiology o f osteoporosis? What are the causes o f
osteoporosis?

9. [A S P J Man h a s b ic u sp id v alv e , an d yo u h e a r a m u rm u r su g g e stiv e o f a o rtic ste n o sis.

 • What are the causes o f aortic stenosis ?
• Who w ould you involve in pre-op assessment? What investigations required?
• Patient eventually underwent metallic valve replacement. What are the peri-op
implications o f this? Discuss anti-coagulation
• What common anti-coagulant is norm ally used? W arfarin. How does warfarin
work? W hat are the vitam in K dependent vitamins?
• What is infective endocarditis? Name 2 common microorganisms associated
w ith IE.
• If it were a young man having right sided heart valve IE. What particular risk
factor w ill you be concerned about? IV drug use.
• What investigation w ould you do to identify vegetations.
• Antibiotics may not be effective against clearing vegetations. Why?
• Patient may eventually require removal of a rtificial valve. What is the principle
behind this? Examiner basically looking for “ removal o f septic focus".

10. [CPSJ Perform FNAC on a old lady w ith previously excised melanoma on right leg, now
presenting w ith new lump on right thigh.
• Perform FNAC, put on slides, smear and spray. Left overs fo r cytospin.
• No questions asked by examiner. Just perform procedure and interact w ith
patient only.

11. [CSI] Prep reading 9 min. Discuss case w ith Trauma consultant over phone - 21 yo med
student, car h it him w hile riding bicycle at 2330 hrs. LOC for unknown amt of time, but
was consciouss by the tim e ambulance arrived (~15m in). On arrival to A&E,
haemodynamically well. O/E Right hand swollen, abrasions left upper abdo, open
fracture left leg. Abdo soft, non tender. GCS 15. Xrays - Right hand MC fracture, Left
tib/Fib fracture. CXR normal. GS registrar saw - No need for emergency laparotomy for
now. Suggest US abdo. US abdo subsequently shows ?free fluid in left para-colic gutter.
At about 120am, left leg became pale, DP/PT pulses not palpable. Worsening pain.
Bloods given - Hb 11. UECr, LFTs, PT/PTT normal. Tetanus and Abx given in A&E. 2L
N.Saline given. GXM pending.
• Call trauma consultant to handover case
• Who do you want to get involved In this case? Plastics, ortho, GS.
• Any other investigations you want to perform?
• W hy you thin k he needs GS involvement? Why Plastics?

12. [CSI] Angry patient. Has severe knee OA planned for surgery. Postponed last tim e
because lack o f manpower. Now consultant has emergency op, so have to postponed
again. Patient not happy. Talk to him.

13. [CSHJ H is to ry OA knee. 60+ yo M w ith worsening left knee pain past 6 months. Was on
and o ff last few years but worse last 6 months, a /w swelling. Worse after walking. No
stiffness. No fevers. Was a professional footballer and had high impact in ju ry during a
game 30 yrs ago.
• What are you differentials
• What investigations?
• How you manage his OA?
• How w ould you help off-load his knee? Knee brace

14. [CSHJ H is to ry IBD. 30 yo F, w ith 6 months history o f loose stools w ith mucus, a /w RIF
pain not relieved w ith defecation. LOA/LOW 6 kg over 6 months. No PR
bleeding/malaena. No fevers. Bilateral knee pain for several months. Takes ibuprofen
only.
• What are you differentials?
• What investigations? Bloods, Radiological, Colonoscopy
• Dx is ulcerative colitis. How would you manage?
15. [CPEJ PE Spine. 70+ yo Man, non-smoker w ith several months history o f left gluteal pain
radiating down th ig h /le g /fo o t Worse on w alking 400m, both up and down hill, and after
standing fo r lOmin.
• What are yo ur differentials?
• What radiological investigations? Xray, MRI
• What management options? Non-surgical vs surgical.

16. [CPEJ PE H ernia. Man presenting w ith left inguinal lump. Referred for likely hernia.
(Large man w ith very distended abdomen. No obvious inguinal lump bilaterally.
?positive cough impulse on Right side even though stem was left side. Examiner satisfied
that I said I couldn't feel it, ?cough impulse right side, and that I'd do an U/S.
• US shows bilateral inguinal hernia.
• W hat is the difference between direct vs indirect inguinal hernia.
• You perform open repair, how w ould you identify if it is indirect or direct
inguinal hernia? Lat/Med to in f epigastric artery
• Discuss surgical options of hernia repair.
• When w ould you offer laparoscopic?

17. [CPEJ PE PVD. Left low er lim b interm ittent claudication. Perform vascular exam.
• What are yo ur findings on the low er lim b pulses?
• Show how you'd perform doppler exam.
• Discuss how you'd perform ABPI. W hat is the normal ABPI
• W hat investigations would you perform to help w ith surgical management?
• How do you diagnose critical limb ischaemia?
• Patient needs to undergo hip replacement op. When w ould re-vascularisation
take presedence over his op and vice versa?

18. [CPEJ PE CVS. Examine CVS exam. Pre-op assessment going fo r TKR.
• Patient has AS m urm ur.
• How w ould you evaluate severity?
• Who w ould you involve in his care?
R esou rces I used w e re :

Pastest Essential Revision Notes 1 and 2 and the Osce book.

Ellis and Acland anatom y videos, Rohen atlas, certain chapters in Last and Ellis
books.

Costanzo fo r physiology

M arino 1CU book fo r critica l care (certain chapters)

Pastest videos really helped, especially w ith clinical exams, anatom y and some o f
the histories. C ritical care videos - some decent, some poor.

1. Anatom y o f head and neck.

Specimens o f head, thorax. Asked to id e n tify facial artery, oesophagus and type o f
epithelium , vagus nerve, parotid, subm andibular, ducts o f salivary gland.
Good exam iner

2. Anatom y o f thigh.

Femoral triangle, borders, contents. Femoral rin g and canal. Muscles o f a n te rio r
com partm ent o f thigh, add ucto r canal and contents, nerve roots o f femoral.
Branches o f profunda femoris.
Cool exam iner

3. Anatom y o f skull foram ina

O ptic canal, su p e rio r o rb ita l fissure, ovale, spinosum and contents.

Course o f hypoglossal nerve in neck.
Mechanism o f papilledem a
Nice examiner.

4. Cvs exam w ith mechanical valve.

Asked about anticoagulation and surgery. Infective endocarditis prophylaxis.

Quoted nice guidelines and he was happy. Exam iner was happy to n o t do bp. Patient
showed me his watch when I tim ed the pulse lol.
5. Abd exam w ith acute appendicitis.

S tra igh tforw ard fu ll abdo exam, and I did p s o a s /ro v s in g /o b tu ra to r and m entioned
dunphy. Guarding and rebound over mcburneys. VERY good female actor. Could
alm ost believe she had appendicitis.

Questions on DDX specific to young female patient, fu rth e r tests to rule in /r u le out.

6. Post cranial fossa exam

Fum bled here. Did m ost o f cerebellar exam b u t le ft o u t a few steps. Classic rom berg,
dysm etria, dysdiadochokinesia, gait, coordination discrepancy. Exam iner kept
asking w h a t else to do. Said I d id n 't kn o w and he moved on. Asked about DDx,
imaging, types o f b rain tum ours, w h a t side I though t the tu m o u r was...

7. E pidural hem atom a in 18 male, gcs 8.

Stone faced exam iner. Saw epidural and to ld him w ith o u t him asking, and he
ignored it. 3 m inutes in to questioning he asked me w hat ct showed : /

Asked w h y to do ct brain, signs and sym ptom s, features on ct, w ho to involve in

decision making, w h a t surgery to do, m o n ito rin g o f 1CP and norm al value.

8. Suturing
Simple in te rru p te d on thigh laceration w ith patient w ho keeps speaking to th ro w
you off. Have m ore than enough tim e to answ er her questions and suture though.
Asked about lidocaine vs Marcaine, doses, w hen to use. Extrem ely nice examiners.

9. Venepuncture and flu id infusion in pelvic fracture.

W orst station. More than h a lf o f the o th e r candidates d id n ’t get a flashback on

cannulation, in clud ing me, b u t 1 knew it was in. Huge veins on m annequin. Asked to
set up d rip w ith saline. Good assistant at station. Make sure to dum p sharps
im m ediately.

D ifficu lt to w rite up infusion o rd e r on u n fa m ilia r form and answ er atls questions on

secondary survey. But whatever. This exam iner was som ew hat fair.

10. Counselling on hernia.

Rough station. Blind, m etallic valve on w a rfa rin , anxiety, lives alone w ith no fam ily
nearby. Came up to w a rd because he has questions th a t the consultant answered
and he forgot. Scheduled fo r re cu rre n t L1H re p a ir in one week.
W o rrie d about stopping w a rfarin, w o rrie d about w hen to a d m it to hospital. Has no
carers fo r post op. Has creps on chest exam (in notes). On Lasix as well. Cant lie flat.
SOB on w a lkin g up stairs. Was counseling on w a rfa rin , w hen to adm it, need fo r
clexane, and then to ld him he may get postponed because he needs w o rku p
regarding chest finding. Bell rang s h o rtly afte r so I d id n ’t get to delve in to that.
Patient very nice.

11. H isto ry on impotence.

A rtist, has w ife and kids, laid o ff 6 /1 2 ago and cant have sex w ith w ife since then.
Can have erection by h im se lf tho, depressed, b it angry. No cardiovascular sym ptom s
o r prostatic disease.
Was asked about diagnosis, reasons, w h a t to test to rule o u t o th e r causes.

12. Breast ca

Very good exam iner, stra ig h tfo rw a rd ques. Most common breast ca, histology re p o rt
to read, w hat to lo o k fo r on it. Who is involved in MDT. Herceptin, trastuzum ab and
how it w o rks at ce llular level.
T old him 1 had no idea and he moved on. Asked about core biopsy and w hat to look
fo r on it, and fu rth e r tests to do on sam ple (IHC)

13. T h yro id Ca w ith bone mets

Lady fell and broke fem ur. M in o r traum a. Asked about pathologic fracture, causes,
w h a t cancers m et to bone. He described the histology and it was sounded like
th yro id . Asked about th y ro id Ca, w hat features to lo o k fo r on radiology, w h ich is
radioresistant (m ed ullary) and w h y (read em bryo).

Also, asked about transfusion reactions (p a tie n t had anemia)

14. Call Vascular consultant.

66 lady w ith ? d iv e rtic u litis and now has one h o u r o f acute lim b ischaemia. ECG
shows a fib.

New dx - m esenteric embolus, ALI. W hat im aging to do. W hat to anticoagulate w ith
and how. How to tran sfer (type o f ambulance)
15. H isto ry o f new seizure, ct abnorm al

Lady w ith firs t ever seizure. Rest o f h isto ry NAD. Signs o f rlCP.

DDX, investigations, management.

16. AAA ru p tu re

Exam iner very a b ru p t in this station. Had to ask him to repeat questions a few times.
AAA w ith prolonged laparotom y. Now hypotherm ic, coagulopathy.
Define hypotherm ia. How it causes problem s. W ho to involve o th e r than ICU and
fam ily? (I said in te rn a l medicine. He wanted a m ore specific answer, meh idk)
Im m ediate com plications o f surgery in this patient.

17. Leg crushed fo r few hours in 28 yo male.

Left unobserved on o rth o ward. Now has bloods consistent w ith acute kidney in jury.
U rine d ip stick has blood.

Asked about specific bloods fo r rhabdo. Asked about fasciotom y. Com partm ent
pressures and norm al values. How to manage rhabdo and AKI due to this.

Good exam iner, good station.

18. Knee Exam

Hugely sw ollen le ft knee. Crepitus. Did fu ll exam, all special tests on rig h t knee
(exam iner stopped me from doing them on le ft knee, b u t observed closely when
doing on rig h t knee). Antalgic gait. 1 forgot the w o rd antalgic in exam. Exam iner
d id n 't b o th e r too much w hen 1 stalled on it.

Asked me about the tests fo r cruciates/ collaterals/m enisci and th e ir names.

Asked features on im aging o f OA. Asked w hat o th e r p a rt o f pa tie n t 1w o u ld w a n t to

examine.

Overall, the stations w ere all very doable. Good luck to all w ho a tte m pt the exam.
 Anatomy

l-(N eck and Mediastinum ) Identify the follow ing structures on cadaver: arch o f the aorta , all branches ,
ECA, ICA, carotid sinus and body site and function , structure just passing in fro n t o f CCA bifurcation
(hypoglossal nerve ) its clinical correlation and how is the presentation o f its injury, Rt vagus, facial
artery and its surface marking ( Q: Can we ligate this w ith o u t sequelae ? ), parotid gland and its opening
in oral c a v ity , submandibular gland and its o penin g, masseter muscle , carina of trachea and its le v e l, Lt
subclavian a rte ry , tell me about subclavian steal syndrome .

2-lower lim b :

Scenario of man stabbed just 10cm below and parallel to the inguinal lig a m e n t. M ention the structures
vulnerable to injury ? , identify inguinal lig a m e n t, borders o f inguinal canal, contents , fem oral ring
boundaries, fem oral canal, femoral artery surface anatom y, femoral nerve and its root value, 4
muscles supplied by it ,

, sartorius m uscle, adductor longus, adductor (sub-sartorial) canal boundaries and co n te n ts, branches
o f fem oral artery and profunda femoris a rte ry , angiogram (aorto-iliac) in iPad idetify a rte rie s ,
dermatomes o f the low er lim b .

3- Skull anatom y :

Borders o f middle cranial fossa , which brain lobe occupies it ? , foramen rotundum and strucures
passing through i t , foram en ovale strucures passing through it, anterior clenoid process, strucure
passing lateral to it ??, optic canal and strucures passing through i t , site o f trigem inal ganglion , site of
cavernous sinus and strucures passing through i t , Q: cavernous sinus throm bosis ( causes and risk
fa c to rs , clinical presentation , why does it present w ith diplopia ? ) , site o f m iddle ear cavity ?
Communication and spread o f infection , fracture base o f skull presentation , pituitary fossa and optic
chiasm .

•Surgical Pathology:

1-Long scenario o f an elderly man w ith presentation o f (GIANT CELL TEMPORAL ARTERITIS ) . D x,
im m ediate m anagem ent, single laboratory investigation to diagnose, com plications, pt started on
steroids presented 1 year later w ith fracture neck o f fe m u r : explain th a t ?(long term use o f steroid)
M ention 2 other possible causes ? W hat pre-op precautions ? Complications ( addisonian crisis ), how to
prevent ?.

2-TESTICULAR TUMORS :

Long scenario i fo rg o t, risk fa c to rs , presentation , types w ith regard to a g e , investigations, tum or

m arkers, spread , read this histopathology report and w hat are 3 pieces o f inform ation w ould you like
to discuss them w ith the patient (ty p e , invasiveness and distant metastasis ) , after orchidectom y
presented w ith para-aortic m ass, biopsy was taken showing differentiated follicular cells (Q: how do you
explain th at ??

> teratom a has potential to differentiate into any cell type ), course o f m anagem ent, follow -up .

•Critical ca re :

1- pt operated for ruptured AAA w ith massive blood transfusion , has intra-op hypothermia .

Definition o f hypotherm ia , m ention 3 ways o f intra-op heat loss, intra-op com plications, risk factors in
this p a tie n t, talk about 3 mechanisms o f hem ostasis, w hat intra-op procedure can be utilized to avoid
the need o f blood transfusion , complications o f massive blood transfusion , read the results (DIC), how
are you going to manage this patient ? (NICE GUIDELINES), w ho would you involve ?
2-Crohn's disease presented w ith small bowel intestinal obstruction , plain abdominal x-ray on iPad ,
read this image , what are the options o f nutrition ? , types o f each , complications , what are the
components o f dietary supplements ? If just restricted to one type w hat will happen ? , central line
complications , signs o f into leran ce, causes o f m alnutrition in Crohn's disease .

3- HYPOTHYROIDISM WITH SURGERY :

Long scenario o f elderly lady w ith features consistent w ith hypothyroidism w ith TFT provided . Whats
the D x, ty p e , difference between lr y and 2 ry , talk about HPT axis , clinical features , pre-op
precautions , complications w ith surgery, blood tests provided showing m acrocytosis, Mx.

•Physical Examination:

1-Simple Nodular Goitre (present yo ur findings , DDX, INVESTIGATIONS, Mx )

2-lipoma in the upper back

( present your findings , DDX, single investigation to reach your diagnosis, if it is near the m idline how
are you going to manage this ? W hat do suspect ? W ho would you involve ? Whats the best
investigation ? O utline your Mx.

3-knee examination ( MCL INJURY WITH MEDIAL MENISCAL TEAR ) present your fin d in g s, DDx,
investigations and Mx.

4-patient post-op day 6 underwent Lt Hemicoloctomy presented w ith pyrexia and generalized
abdominal pain radiating to the tip o f le ft sh o u ld e r. ( EXAMINE H IM )!!! pt has iv line , in severe pain,
midline laparotom y scar, bilateral TED stocking . Pt has exquisitely tender abdomen esp. L t . Lower
quadrant w ith guarding . +ve bowel sounds .
Bedside ECG > AF.

(Present you fin d in g s, DDx (Anastomotic leak ) , M x . [ [ very confusing station ] ] .

•History takin g:

1- middle age male presented w ith im potence ( preceded by loss o f job ) . M ost likely due to stress!!

Present your H x , whats the next step ? W hat are you looking for in physical examination ? > testicular
size, gynecomastia . DDx ?? (Trauma , post-pelvic surgery , lerich syndrom e, iatrogenic ...)

Mx( M ulti-disciplinary team )

2-SOB IN ELDERLY FEMALE ( pre-op anxiety ) w ith vague symptoms (feeling o f lump in th r o a t, tingling
sensation in tips o f fingers ).

DDX, next step ? , Mx .

•Procedural S k ills:

1- Abscess drainage : wash your hands, introduce yo u rse lf, take permission , proper exposure and
repositioning, ask about allergy to L.A ? Ask for the consent (hidden by the exam iner) ? Needle phobia ?.
Equipments prepared in sterile field . Ask for assistant ( the examiner volunteered h im s e lf) , warn the
patient before needle b ric k , infiltrate L.A p ro p e rly, test for numbness before using scalpel!! Talk to the
patient throughout the procedure ! You have to fix the blade properly using hem ostat, take swab
ensure com plete drainage,packing and dressing . Post -procedure instructions and
docum entation .Don't forget SHARPS PIN

Qs: 1-causative organisms ?

2-line o f incision ?

3- complications

( tim e is too s h o r t! ! )

2-knot tying

1- REEF KNOT around rubber bands ( you have to choose suitable suture according to instructions o f the
exa m ine r) e.g non-absorbable,natural and braided » silk

2-DEEP KNOT AROUND A HOOK (be careful not to lift the hook from its place !!), syn th e tic, absorbable
and braided » vicryl

3- hemostatic stitch ( figure o f 8 ) over bleeding point in foam pad ,

Using m o n o fila m e n t, synthetic and non-absorbable » > proline

Dont forget gloves, safely handling sharps and sharps pin !!!!!!

You will be asked anything regarding sutures!!

 Communications:

1-consent OGD fo r esophageal stricture .

2-phone call to vascular surgeon about patient presented w ith acute limb ischemia ( on background o f
acute diverticulitis and atrial fibrillation ) pt was unstable w ith metabolic acidosis , asked about
im m ediate management ? Amenable for transfer ?

Whats the likely cause ?( AF)

Type o f heparin w ill be used ? .

Best o f lu c k ..
1) procedure: Fine Needle Aspiration Cystology in a consented patient
describe procedure, perform WHO check list, scrub, perform FNAC, perform fixation
and label to send to pathology, questions about management of melanoma in
Lower Limb
2) Communication Skills: history taking from an angry patient with back pain, questions
revolved around plan of management.
3) In pre-operative clinic and have a patient scheduled for elective lapchole complaining of
breathlessness with previous history of cardiac history. Take focused history, offer
differential and plan of management.
4) Prep station, patient admitted for left hemicolectomy done 2 days ago found to have
mets to the liver intra-operatively mets to the liver, called to the ward as patient has not
passed urine.
5) Critical care: management of oliguiria, CCrISP protocol.
6) Prep Station: construction worker fell from height hitting his helmeted head with
associated splenic injury and unstable injury
7) Critical care: ATLS protocol
8) Critical Care: Burn patient, to calculate burn area, calculate fluid needed and CXR
showing picture of ARDS followed by management of ARDS
9) Physical examination: case of appendicitis, OSCE questions were easy about
management of women and investigations, last question was about NICE guidelines to
remove non-inflamed appendix (no idea!)
10) Anatomy: layers and anatomy of hernia repair, injury to which nerve causes
parathesia in what area, nerve supply to muscles of the anterior abdominal wall.
11) Anatomy: bones of upper limb scattered, arrange, show major muscle attachments,
discuss nerve injuries of the upper limb and their effect at different levels.
12) Pathology: stomach cancer histopathology, mention gross and microscopic
features, discuss prognostic/risk factors, discuss LFT findings attached
13) Critical care: Diverticulitis with abscess, discuss management, define shock and
methods of assessment of circulation
14) Physical examination: examination of acute painful knee, discuss management and
treatment.
15) Pathology: posterior cranial fossa tumor, discuss symptoms, signs and examination
findings.
16) Pre-operative: optimizing a COPD patient with pigeon chest for hernia repair,
smoke cessation, PFT, mobility, incentive spirometry, analgesia, deep breathing
exercises, weight reduction, etc, etc.
17) Anatomy station: Forgotten
18) Abdominal trauma: liver laceration, discuss liver anatomy, management, and risks
post-op
19) Suturing of a wound, during which discussion of local anaesthesia types, effects
and doses.
Anatomy 1: id radius and ulna, articulate with each other, articulate with the humerus, id trochlea,
capitulum,radial tubrosity. biceptal tendon, median and ulnar nerve, madian nerve injury( motor and
sensory), ulnar nerve injury (motor), ulnar paradox.

Anatomy 2: id atlas.axis ,odontoid process.ligaments attached, parts of atlas and axis, foramen
transversium, structures passing, point to hyoid bone in a man, adentify axis and atlas in lateral xray spine,
open mouth odontoid view, id dens, lateral masses of atlas, what abnormal in xray, structures at the level of
cricoid cartilage

Anatomy 3: id external oblique, internal oblique, attacements, direction of fibers, muscles forming conjoint
tendon, id ovaries, tubes, appendix, terminal ileum, ceacum, douglas pouch, refered pain of appendicitis to
umblicus, pain on flexing hip, psoas muscle, ileoinguinal nerve injury during appendicitis.

Pathology 1: bicuspid aortic valve, why sudden death, why the valve is stenotic, why to replace the valve,
infective endocarditis, why treatment difficult, why to give anticoagulant, mechanism of action, def.
thrombus, microbilogy branching hyphae .what is this

Pathology 2: signet ring carinoma of stomach, gastrctomy with splenectomy, pathology report, tell her
family in 4 sentences, returned with malignant ascites, management

Asscc 1: burn + ards ( repeated)

Asscc 2: ruptured divericulum with pelvic abscess and septcemia, mangement, ABG, investigations to do,
open vs percutaneous drainage adv and disadv.

Asscc 3: polytrauma, pneumothorax, liver tear, mangement

Cpe 1: cerebellar examination of a patient with post. Cranial fossa tumour

Cpe 2: respiratory examination of a patient before hernia repair

Cpe 3: hydrocele examination

Cpe 4: v.vs examination

History 1: pre opetative anxious patient

History 2: backpain

Comm. 1: anxious mother her child is being operated for splenectomy

Comm 2: phone call to on call cosultant updating him about pod1 oliguria

Proced. 1 : FNAC recurrent malignant melanoma

Proced. 2 : suturing a superficial wound

Please make sure your taxi driver knows the route to the college. Our taxi driver got lost somewhere and
had to ask some security guard. Factor in some tim e fo r travel and getting lost
For the AM guys, there are some sandwiches but no one takes them.
Only need stethoscope. No need other equipments
Examination is held in this gigantic hall w ith only makeshift partitions between stations so you can
actually hear w hat the guy next door is saying if hes loud enough.
Certain stations like the calling the consultant station w ill have full 8mins to read notes and stem before
another full 8 mins fo r the station itself. There is also 1 rest station

1. 40 year old man, no PMHx. Came in fo r dysphagia. Had barium swallow done and barium swallow
shows bird beaking. Has been previously explained by the consultant a few weeks ago fo r OGD and
dilatation under GA. Consultant had to go away last m inute, instructed you to obtain consent and
answer any fu rth e r qns th a t the patient m ight have.
a. Double check correct patient. Check w hat the consultant has explained to her before. Explain
indications, risk (risk o f GA + procedure), benefits
b. If biopsy shows Ca, how to mx ?

2. Patient had AAA rupture, had hypovolemic shock, massive blood transfusion protocol instituted.
Patient was brought to the OT fo r urgent laparotomy. However, patient remained unstable, T dropped
to 34deg.
a. W hat is the definition o f hypothermia?
b. W hat are the possible causes o f hypotherm ia in this case?
c. Why is it im portant to prevent hypothermia?
d. How do you reduce risk o f hypotherm ia in this setting?
e. How do you reduce blood loss in the above stem?
f. W hat is autologous blood transfusion?
g. W hat is massive blood transfusion?
h. W hat are the problems faced w ith blood transfusion?

3. Patient was found to have a goitre. Clinically patient has symptoms o f hyperthyroid.
a. Explain the thyroid axis
b. W hat would you expect in a patient w ith secondary hyperthyroidism?
c. W hat are the ddx o f a patient w ith a goitre?
d. Showed blood picture, macrocytic anemia.
e. Why w ould you expect macrocytosis?

4. Patient w ith hx o f Crohn's. Came in w ith symptoms and signs o f abdominal obstruction.
a. Showed AXR o f stack o f coins appearance. W hat is this?
b. W hat are the differen t routes o f n u trition do you know of?
c. W hat is enteral nutrition? When w ill you use enteral nutrition?
d. W hat is parenteral nutrition?
e. When w ill you use parenteral nutrition?
f. W hat are the constituents o f parenteral nutrition?
g. W hat are the type o f electrolytes in TPN?
 h. W hat is dextrose? W hat are sugars?
i. W hat are the complications o f TPN? Examiner is not satisfied w ith just line sepsis,hyperglycemia,
electrolyte disturbances, cholestasis and bowel mucosal atrophy. Wanted more.
j. You m entioned bowel mucosal atrophy, why does it occur?

5. Anatomy: Head and neck and Thorax (Plastic models)

a. Identify trachea, oesophagus, vagus nerve in the neck
b. Points to the branching o f the trachea into 2 bronchus? W hat is this junction called? Examiner
not satisfied w ith carina. W anted something else.
c. W hat level does it branch?
d. Identify parotid, submandibular glands
e. W hat glands does it contain?
f. W here does the duct o f the parotid and submandibular gland open?

6. Anatomy: M iddle cranial fossa

a. W hat are the boundaries o f the middle cranial fossa?
b. Identify all the foram en o f middle cranial fossa and all the cranial nerves passing through it.
c. Points to the groove o f the middle meningeal artery. Which artery passes in this groove?
d. How w ill this artery be injured?
e. Which bones make up the pterion?
f. How can infection spread from the middle ear to the middle cranial fossa? Through petrous part
o f tem poral bone but examiner also wants spread o f infection through mastoid antrum
g. Which lobe o f the brain will be affected in this infection?

7. Anatomy: Femoral triangle and adductor canal (basically just mug Snell pg 575)
a. Points to sartorius. W hat is this muscle?
b. W here is its origin?
c. Which surface does it form in the fem oral triangle?
d. W hat are the other boundaries o f the fem oral triangle?
e. W hat makes up the flo or o f the fem oral triangle?
f. W hat does it contain?
g. Moved on to the subsartorial canal?
h. W hat are the surfaces o f the subsartorial canal?
i. Which nerves runs in it?
j. Which artery runs in it?
k. Showed 2 angiogram, one o f the pelvic artery angiogram and one o f the LL angiogram. Show me
the fem oral artery
I. W hat are the branches o f the fem oral artery? Show me the profunda fem oris on the angiogram?

8. Patient, 50 years old, came in w ith blurring o f vision and throbbing headache?
a. Diagnosis? Giant cell arteritis (Yes, it can come o u t in a surgical exam)
b. Patient complains o f blurring o f vision. W hat do you call it?
c. Give me one blood test th at points to your dx? ESR
d. How do you treat?
e. You treated him w ith the medication th a t you just mentioned, patient came back lOyears later
w ith hip fracture. W hat the potential causes o f the hip fracture? Steroids, post menopausal,
possible im m obility from functional decline. W hat else?
f. How w ill you manage her hip fracture?
 g. You m ention th a t patient w ill need surgery, w hat w ill you be concerned w ith? Addisonian crisis
h. How w ill you prevent Addisonian crisis?
i. Do you have to do anything about the giant cell arteritis before hip fracture surgery? Dont know
w hat the examiner is getting at but shes happy w ith get a consult w ith opthalm o.

9. 28 years old male, came in fo r dragging pain in le ft groin. On examination, you found a mass 3x2cm
over left groin?
a. W hat are your ddx? The usual differentials, plus testicular ca
b. Why testicular ca?
c. How does undescended testis contribute to increased risk o f testicular ca?
d. W hat is choriocarcinoma? Examiner just jum p straight into this w ith o u t asking for different
types o f testicular ca
e. If this is a 60 year old man, w hat is the most common cause o f testicular ca? Lymphoma
f. Histo confirms testicular ca? W hat w ill you do next? Stage disease w ith CTTAP
g. W here is the first place that testicular ca spread? retroperitoneal LN. Examiner w ant more, gave
lungs and brain. He is happy w ith it
h. CTTAP shows presence o f retroperitoneal lymph nodes compressing on IVC. How does this
contribute to throm bosis? Examiner wants to hear Virchow's triad
i. In this case, Virchow's triad is only satisified under 2 out o f the 3 conditions. Which com ponent
o f Virchow's triad does it not satisfy in this instance? Hypercoagulability

10. Perform CVS examination. Patient w ith pacemaker, is here fo r pre-op checkup fo r another
operation. Do CVS examination.
a. Pulse irregular, also has transverse thyroidectom y scar, has pacemaker and prosthetic aortic
valve. Can you put all the signs together and explain why he has all these signs th a t you
detected?
b. Showed ECG. Is this ECG pacemaker dependent?
c. W hat are you going to do w ith the pacemaker befor e the operation?
d. W hat else will you be concerned about? Patient probably w ill be on warfarin
e. How do you titra te warfarin before the op?

11. Perform Thyroid examination. Young male w ith anterior neck mass, moves w ith swallowing but not
protrusion o f tongue. Euthyroid.
a. Dx and differentials?
b. How w ill you evaluate? Examiner wants FNAC
c. How will FNAC help you?
d. Supposedly FNAC shows papillary thyroid ca, you counselled patient fo r hem ithyroidectom y but
patient refuse. How w ill you proceed?

12. Perform Knee examination. M cm urry's test positive

a. Dx and differentials?
b. How will you confirm your diagnosis? Examiner wants arthroscopy
c. How to repair the torn meniscus?

13. Patient has lipoma over the right 5-6th rib region over MCL. Examine.
a. Dx and differentials
b. W hat else will you examine? Axilla LN. Demonstrate examination
c. Describe how to excise lipoma?
 d. Any probability th a t lipoma m ight be malignant? Why no possibility?

14. I&D o f abscess. Real patient w ith a prop over her right knee to simulate the presence o f an abscess.
Assume sterile environm ent. Please explain procedure and confirm correct patient and procedure also
a. Prepare everything yourself. Which needle you choose - to draw lignocaine? to inject?
b. Tooth or non too th forceps?
c. Examiner w ill look at how to handle scalpel to cut the 'abscess'. First cut nth comes out.
Examiner w ill tell you to cut deeper, then all the 'pus' w ill come out.
d. W hat w ill you do next? Irrigate, pack w ith gauze
e. W hat kind o f gauze? Antibiotics soaked gauze
f. Do you suture it immediately? No, why?
g- How often do you have to change dressing?

15. Handtie - Interrupted w ith handtie, tying o f deep cavities, figure o f 8 tie. Follow instructions: you will
have to find the best type o f suture th a t fits the stem's description (ie make a handtie w ith non
absorbable m onofilam ent synthetic suture, then you go and find Prolene)
a. Whats the difference w ith surgeons knot and square knot
b. In deep cavities, w hat is one thing you have to be careful o f when tying? Prevent shearing o f
structure th a t you are tying

16. Communications: Patient came in fo r pre-op check up fo r cholecystectomy. Consultant is away and
ask you to assess patient. Patient complains o f difficulty breathing especially at night these few days,
a /w tingling sensation in limbs. Also has abdo pain at tim es w ith loose stools. Hx sounds like anxiety
attacks.
a. Still must rule out medical causes - Fluid overload, Pneumonia, Pul embolism, Angina,
Hyperthyroidism before coming to a dx o f anxiety attacks
b. Assess fo r potential causes o f anxiety attacks - explore how she fe lt about the surgery, any areas
th a t she is unclear of, is she afraid o f the surgery, TLC a bit. M ight need to o ffe r to explain the
surgery again.
c. W hat kind o f investigations do you w ant to do? Rmb to do TFT
d. H o w to manage this patient?

17. Hx taking: GP referred patient fo r RHC pain. GP did US fo r patient and found gallstones. Please take a
hx from patient.
Patient 30 year old lady, married, works as a factory worker. Has RHC spreading to generalised abdo
pain fo r 1 yr. Alternating constipation and diarrhea. But patient fe lt better w ith passing flatus. Nil LOW
or LOA or PR bleeding. No jaundice/ fever. No Fhx o f Ca. No long term meds. Non sm oker/ drinker
a. Rmber to ask im pt question: ANY OTHER CONCERNS? Then patient w ill tell you th a t husband has
depression and her salary is low, got financial issues
b. Examiner: Present your hx and issues
c. W hat are your ddx: Always rule out colorectal ca coz this patient has alternating diarrhea and
constipation even tho age group not correct. W hat else? said a few others. W hat else? Irritable
bowel syndrome
d. Which part o f the history tells you th a t its irritable bowel syndrome? Better on passing flatus
e. Any blood te s t/ investigations to confirm that? No, clinical diagnosis
f. Any criteria? Rome's criteria. Heng nvr ask fo r components
g. Do you think this is acute cholecystitis? No
 h. US has gallstones. Need cholecystectomy? No need. Only if patient sym ptom atic/ obstructing
biliary tree
i. W hat is the percentage o f gallstones th a t w ill become sym ptom atic and eventually requiring sx?

18. Communications w ith vascular surgeon fo r transfer o f patient. Given a few pages (actually lOpages)
o f patient data. Please note sequential order o f events, your role and the vascular surgeon's name.
Penang uses cordless phone. Do read the instructions on the table how to use the cordless phone. No
one w ill be in the station so you can refer to the patient's notes at any tim e. Patient has acute limb
ischemia
a. Check w ith vascular surgeon it is he w ho is answering the phone
b. Present history and why you are calling
c. W hat is the urgency o f transfer: acute limb ischemia for throm bolysis
d. Vascular surgeon w ill try to dissuade you to transfer but you should just persist. Last qn w ill be:
Are you really sure you w ant to transfer? Say yes. He w ill say ok.
A natom y Station-1

Pt fell o f horse A natom y o f thigh and leg muscles w ith innervations and functions

Examiner very ez and like robin williams

This was plastic anatomical model o f muscles o f right low er limb

Identify structures like gluteus medius,femoral a re ry ,nerve vein,fem oral cana,biceos,common peroneal
nerve,illitibial tract,rectus fem oris

W hat s the function o f rectus fem oris

W hat is the function o f iliotibial tra c t and w hat 2 muscles make this structure up

W hat is the function o f gluteus medius and its innervation

W hat are the contents o f femoral canal and w hat is other name o f the fem oral canal

If c.peroneal nerve get damages .w hat happens

Can damaging gastrocnemius cause loss o f fo o t dorsiflexion

Loss o f dorsiflexion,sensation at webspace can mimic injury at w hat other structure in a patient who fell
from horse

How many parts o f biceps fem oris an supplied by w hat and its function

Functions o f hamstring

A natom y Station 2-

A natom y o f th y ro id and th yro ide ctom y w ith nerve and a rte ria l supply, horners syndrome.

Identify parts o f thyroid ,hyoid,thyrioid and cricoid ctlg and sup thyroid artery and strap muscles,
omohyoid and cricothyroid membrane on a plastic model

Venous supply o f thyroid?

Tum our which has lymphatic spread?

M edullary ca arises from which cells?

Common nerve to get damaged?and w hat happens after the damage?

Attachm ents o f the vocal cords.

Common artery associated w ith cervical sympathetic ganglion

Damage to sympathetic ganglion w ill cause what

Nerve supply o f strap muscles

Function o f strap muscles

Abductors o f vocal cord name?

ANATOMY STATION 3

A natom y o f ro ta to r c u ff w ith nerve supply, pec m ajor nerve supply, attachm ent o f humerus + clavicle
+ scapula. MRI o f the area.

Ide ntify supraspinatus,ters,subscapularis deltoid bones o f glenohumeral jo in t labrum on mri

Identify cadaver bones cavicle scapula humerus and th e ir side and how they articulate together

Identify parts o f humerus and medial lad lateral ends o f the clavicle and all the parts o f the scapula

Common nerve to be damaged in shoulder dislocation and its effects

All the movements o f shoulder demonstrate

Identify pec m ajor its innervation and its 2 muscle components and th e ir separate functions. One special
function o f Pec M ajor other than m ovem ent o f shoulder

Components o f stability o f the shoulder

Nerve supply o f all the ro ta to r cuffs and th e ir innervations

Function o f deltoid muscle sperately

Pathology 1

UC, C rohns, colon Ca, k-ras.

W hat is Ulcerative colitis

Microscopic features o f UC

One main gross feature o f Crohns disease to differentiate between UC

If on biopsy there is severe dysplasia w ith adonocarcinomatic changes w hat would u do

W hat is k ras and w hat does it do detail functioning

W hat is p 53 and w hat does it do detail functioning

Treatm ent o f ulcerative colitis

Please do UC and Crohns disease very w ell research articles level. I mean specially this topic only

This was a tough examiner and the ket=y was to ta lly different from w hat I was answering. I saw the key;)

Pathology 2

Patient was being operated fo r gall stones and had to covert fro m close to open.discharge fro m the
w ound .biopsy showed gall bladder ca

Commonest cause o f gall bladder ca

Yellowish discharge from the wound w hat can be the organism and w hat w ould you do

Now yellowish discharge converted to blackish diagnosis and treatm ent

Organisms fo r Nec Fasc and treatm ent 3 options at least

Patient developed bloody diarrhea now

W hat can be the cause

Shows colonoscopy o f pseudomemb colitis and ask the common features

Organism involved in it and the pathological action o f the organism

Which hospital acquired virus can cause the bloody diarrhea?

S k illsl

Practical Arrange th e a tre list, MRSA pt, strangulated hernia pt, diabetic pt.

For a diabetic patient w hat 2 systems w ould you check before OR renal and fundoscopy

W hat is sliding scale

How does mono and diatherm y works

W hat if patient allergic to penicillin and iodine

Complication relating to chlorhexidine

Pacemaker has w hat structure in them th a t can disturb metals around it (magnets)

Precations fo r pacemaker

Preop assessment o f copd and copd care by anaesthetist and special thing he is going to do fo r copd

W ho else you w ould involve in copd

Skill s2

Practical ATLS, manage A and B (dont forget C-spine)

How to stabilize c spine

How do you choose the size o f the airway and the hard collar

When do you insert e tt nd when do you do cricthyrodotom y

Rest was the same as any o th e r atls

In this station the made you insert the airway and put the hard collar

C om m unication l

Phone call fo r ischaemic lim b, old fem ale, newly AF. Talk to vascular.

Bolus dose o f heparin and maintenance dose o f heparin? Exact dose

W hat would you do im m ediately as urine functions were deteriorating

Com m unication2

about OGD w ith benign stricture on barium sw allow , heavy sm oker and alcoholic, fo r dila ta tio n and
Bx.

W hile explaining the complications he asked w hat if during the procedure my food pipe got perforated
w hat would you do

Com m unication 3

Hx o f backache w ith m ri showing egenerative changes.Patient overw orked nd depressed

d/d,invtgations and management

Com m unication 4

Hx o f bloddy diarrhea in 40 male w ith death o f brother cause o f bowel cancer

Examination 1

Prolapsed vertebral disc spine examination at L5 level 40 male

Examination 2

Medial meniscus Knee examination in young footballer

Examination 3

Appendicitis in 25 female

Examination 4

Submandibular gland examination le ftside

W hat investigation w ill you do 1st

W hat type o f painkillers w ill u give nsaids,paracetamol,aspirin...etc?

W hat is the conservayive managemet

W hat is the surgical management

When do we remove the gland

How do we remove the gland

W hat are the complication o f removal

Critical C arel

to x ic megacolon, acute diarrhea and blood, questions about M x, invsx and surgery. Patient on steroid
fo r m any years

Patient w ith IBD

Na low

K low

Platelets 666.

Hb low

Wbc very high

All the other parameter very high

Anemic patient

W hat is the diagnosis?

Why is Na low

Why is K low
Why are platelets high

Complications o f UC

Critical care 2 about ATLS, traum a w ith liver laceration, types o f shock, pneum othorax, rib fractures.

W here would you tre a t this patient was the first question and everyone including me said ITU and he
was very happy giving you a devilish smile saying I w ould give you JERO for that. Of course in emergency

Airway management

Types o f shock in this patient

Management o f shock say w hatever u know

M onitoring o f shock can be done by w hat techniques

Shows u xrays which have occult rib fractures and when u say pneum othorax gives u another devilish
smile because there is no pneum othorax only an scapular shadow

Ct scan showing laceration o f liver

Critical care 3

70 y r old dem entia Patient w ith recuurent u ti fo r many years devolped urinary re te n tio n catheterized
but no deranged rfts and no urine afterw ard

CRF scenario

Why is Hb low in this patient

How does kidneys help in m aintaining hemoglobin

Maintenance o f K in the body

W hat channels are involved in Na/K transport

how does hyperkalemia and hypokalemia present

how do u managehyperkalemia

w hat is the role o f calcium in management o f hyperkalemia

w hat are ethical issues o f doing a hemodialysis in this patient

1) Anatomy: Thorax and Neck
Plastic model of heart, thorax and neck
• Where is the left vagus nerve (identified in left carotid sheath)
• What is this-points to ascending aorta
• What is this-points to arch of aorta
• What are the branches of the arch of aorta?
• What is this-points to thyroid
• What are the parts of the thyroid- right and left lobes and isthmus
• What is the arterial supply? Where is the superior and inferior thyroid artery from?
• What is the venous drainage? Where do the sup, middle and inf thyroid veins drain into?
• What are the nerves
• What is this?- points to recurrent laryngeal nerve
• What does the RLN supply? Answer: all the intrinsic muscles of larynx except cricothyroid
• What are the nerves at risk of damage during thyroidectomy?

2) Anatomy: Head
Skull bone and lateral skull and cervical XR
• Points and asked to identify on skull bone: Optic canal, superior orbital fissure, foramina rotundum, ovale,
spinosum, and their contents
• What is the motor innervations of the mandibular branch of trigeminal nerve? Answer: muscles of mastication,
mylohyoid, digastric (anterior belly)
• Asked to identify on cervical XR: pituitary gland, sphenoid sinus

3) Anatomy: Foot, Tibia, Fibula

Tibia, Fibula, foot bones
• Articulate tibia and fibula
• Name the bones of the foot
• What constitutes the lateral longitudinal arch?
• In which position is the ankle joint most stable, and why?
• What are the two main inversion muscles of the foot
• What are the tendons in the anterior of the foot
• What is the arterial supply of the foot? How do the dorsal and plantar supplies anastomose?
• What are the actions of the ankle joint? Where does inversion/eversion take place?
• What is the medial ankle ligament? (deltoid) Where does it attach to? ( He was fine with navicular, talus and
calcaneus)
• What is this? - points to sustentaculum tali
• What is the lateral ankle ligament components? 3 main: ATFL, PTFL and CFL

4) Pathology: PUD
FBC, RP results (showing raised serum Ca2+), CLO test positive
• How does CLO test work? (medium contains urea)
• What is the likely cause the PUD in this patient? - H.pylori infection
• What is another possible cause? - suggest that hyperCa2+may be primary hyperPTH, which is associated with
PUD

5) Pathology: Gallbladder CA
Pseudomembrane colitis scope picture
• What is the most common cause of GB ca in UK? (I said chronic cholecysitis)
• Where does GB ca spread to first? (I said to liver then by lymph nodes to other areas, she probed which lymph
nodes and I said porta hepatis. She didn't say anything)
• Assume patient is POD3 and wound site of op is erythematous, but nothing expressed. What would you do? (I
said I would watch first if patient's vitals are stable, give PO abx, wash wound, alternate STO)
• She asked somemore about what If it doesn't improve? (Worry about Nec fasc)
• What are the common organisms for nec fasc? (she wanted 4 , 1could only give group a beta haemolytic strep
pyogenes, Clostridium difficile, staph aureus. I suggested E coli for the last one)
• What to do for Nec fasc? (IV Pen G, IV broad spectrum abx, surgical debridement)
• Patient develops diarrhoea with blood, what are the 4 differentials? (PMC, ischaemic bowel, infective
enterocolitis, stress ulcer)
• What do you see on the scope picture? And hence what is your diagnosis?
 • What are the pseudomembranes made of?
• How does PMC occur?

6) PE: Acute cholecystitis

• Stem: patient has worsening 4 day period of abdo pain
• Examine patient
• What are your differentials? (after cholecystitis, I said biliary colic, hepatitis)
• Do ballot the kidneys, because he told me so, and asked that if there is tenderness, what do you do? So do a
renal punch, and hence can consider if there is any pyelonephritis
• He continued to push me for differentials: finally squeezed out pneumonia and DKA, he looked like he was
searching for pneumonia)
• Asked how do you want to investigate? (LFT, US HBS)
• What will you expect to see on US HBS?
• How do you want to manage the patient?

7) PE: Knee examination

Stem: Patient was playing soccer when he was hit in his knee, now v painful
• Examine patient: seemed to have medial collateral ligament laxity, positive Mcmurray for medial meniscus, had
medial joint line tenderness
• Did tap test, anterior posterior drawer, lachman
• Present findings to examiner
• He asked what other test do you want to do ( I said pivot, but he didn't seem like he wanted that)

8) PE: Pulmonary embolism with left calf DVT

Stem: patient POD8 for midline laparotomy. Now vitals normal BP, Sats 91% on face mask, sinus tachycardia
• Examine patient: I examined respi, cardio
• I asked to open midline wound (patient had gauze with primapore tape to cover), examiner said no need, it is
clean
• Last minute remembered, can check calf if I'm suspecting PE, and lo and behold, patient had left homan's sign
• Present findings to examiner
• Asked what other investigations do you want to do? (I said CXR, ECG, and to diagnose with CT PA. Forgot to say
DVT of left calf)
• What treatment to give? ( anticoagulation IV heparin, and can consider IR thrombolysis and surgical
embolectomy)

9) Procedures: IDC
Materials: Patient's vitals
• To insert IDC for patient, prepare your own materials
• IDC unable to be inserted fully
• What are the possible reasons? (I said BPH, bladder stones (quite unlikely and illogical), and suboptimal
positioning) On hindsight, should have said strictures
• What to do for BPH: use a larger Fr IDC

10) Procedure: Excision biopsy for benign naevus

Materials: suturing set
• Perform excision. Draw elliptical incision and complete suturing
• Patient asked questions: can bathe after procedure, will it be painful, when will I know the results, could it be
malignant, when can I remove the stitches

11) History: Low back pain

Stem: patient mainly had caregiver stress. Husband disabled and she needs to take care of him. Back pain for few years,
not improving, but no symptoms of numbness/weakness/ incontinence
• Present to examiner
• What are your differentials ( I said, MSK, DDD)
• How to investigate?

12) History: IBD

Stem: patient has bloody mucous diarrhoea for last 8 months
• Present to examiner
• What are your differentials (I said IBD, infection, TRO malignancy)
• How do you want to investigate? (I said FBC, RP, then jumped to scope, but they wanted other bloods first)
• What do you expect to see in scope?
 • How to differentiate Crohns and UC?
• How to manage medically first?
13) Communications: RTA with lower limb compartment syndrome vs acute limb ischaemia
• Present to the consultant over the phone
• He was helping to push me towards saying to do a CT Trauma angiogram

14) Communications: Explain to angry wife of patient about malignant ascites

15) EDH
CT slice of EDH
• What is this? EDH
• When would you consider CT Brain for a patient with trauma? (Need to know the Canadian guidelines)
• Why is there lucid interval before patient deteriorates?
• Why did the patient lose consciousness at first?
• What is Monroe Kelly doctrine
• Patient becomes hypertensive, bradycardic, irregular breathing, why and what is that?
• What to do with raised ICP?
• When do you want to intubate?

16) Post operative pain management

Drug chart: patient only had panadol and arcoxia, not given morphine yet
• What do you want to give patient? So I said give morphine
• What is the pain pathway? I said spinothalamic tract, and about crossing at level of spinal cord, but was unable to
give more beyond that
• What are the side effects of opioids? I said ARU, respiratory depression, he wanted more but I couldn't come up
with them
• He seemed to be looking for a referral to pain team if patient still complaining of pain
• What can PCA give to patient?

17) Esophageal variceal bleeding and Sengstaken Blakemore tube

Sengstaken Blakemore tube
• What are differentials in this patient with chronic alcoholism? I said esopheal variceal bleeding, Mallory weiss,
boerhaave syndrome, PUD
• How does chronic alcoholism lead to portal hypertension?
• How to use the sengstaken Blakemore?
• How to manage the patient with acute bleeding at first?
• What could be the cause of the anemia? (I said blood loss, haemodilution from NS resuscitation)
• Patient had macrocytic anaemia, what could be the cause? (I said nutrition deficiency from chronic alcoholism)
1. Anatom y : leg bone .. peroneous muscles insertions .. muscle action o f the ankle , foot &big toe ..
derm oto m e s.. ankle & knee re fle x e s .. S u ra l.. saphenous & common pemoeal nerves ..
2. Anatomy, thorax .. heart ( valves & aorta ).. abdomen ( spleen , pancreas, duedenum , g a llb la d d e r)
Sympathetic chain ..
3. Anatom y : neck ..post triangle. . Nerves .. muscles and N. Supply .. subm andibular.. common
malignancy of lymph node
4. Pathology: melanoma .. herditary disease risk fa c to r.. pathophysiology., responsible Gene .. good
and bad prognostic histological picture., m a n agm en t.. deference between melanoma& S.C.C
5. Pathology : rheumatic h e a r . Infective endocriditis .organisms. Pathophysiology
M a n ag m e n t.. action of anticoagulant
6.Critical care : hemorrhagic shock .. resuscitation .. Investigation .. comment on drug chart about
fluid therapy and vital signs changes
7. Critical care : subdural Hematoma CT comment .e ffe c t. M anagm en t.. post broncoscopy xray chest
com m ent ( pneumothorax ) e ffe c t. management.
8. Critical care : peritonitis .. septic shock .. acute kidney injury .. sirs
9. Examination : respiratory ex. of pt. 9th day post lower abdominal surgery with rt chest pain
10. Examination : rt hip pain .. flexion limitation
11. Examination : bilateral lower limb claudication pain
12. Examination : abdominal mid line incisional hernia
13. History : epigatic pain (pancearitis )
14. Communication skills : angry mother
Her boy at O.R now fo r spleenectom y came to ER with his father and no one call her
15. Hx and Communication skills: depressed patient post gastrecrom y for cancer stomach
16 . Telephone call to book ITU bed for patient with peritonitis and renal impairment prepared for
exploration
17. Surgical skills : naevus excision
18. Organizing a theater list 3 cases .. why and some related questions
A. Diabetic foot with MRSA
B. strangulated hernia in COPD
C. I can't remember i t .. I'll try later
One of them have allergy to penicillen and another one with iodine allergy
ANATOMY

1-head and neck:

-identify structure in this image: Carotid angiogram: internal carotid , anterior and middle cerebral
arteries, w ith visible aneurysm in the middle cerebral.it was difficu lt to be read.

-in skull: identify the internal carotid foramen passage in infra and intracranial view, also asked about
location o f cavernous sinus in the skull.

-give one branch o f internal carotid artery before entrance to skull.

-location o f carotid sinus and body site

-identify common carotid artery and its bifurcation.

-w hat is obvious abnorm ality (aneurysm), w hat possible clinical presentation if ruptured? (contralateral
hemiplegia, and he asked w hat else,

-Also asked to identify foramen transversum in c.ve rtib ra , and how the vertebral arteries pass through
C l vertebra to enter the cranium.

2-neck and thorax:

-Identify thyroid gland, lobes, blood supply and venous drainage, and development

-Parathyroid location, clinical significance o f th e ir embryological origin.(thoracic position)

-Identify vagus nerve and recurrent laryngeal nerve, difference in origin o f right and le ft RLNs.

-w hat fibers carried o u t by vagus nerve

-w hat muscles supplied by RLN

3-foot and ankle:

-identify all the bones o f the foot.

-orien t right tibia and fibula and position them w ith fo o t model.

-type o f distal tibio fibu la r jo in t, and w hat bone is commonly fractured w ith its injury, (lateral malleolus)

-identify lateral arch o f the fo o t

-w hat ligaments form the medial and lateral collateral ligaments o f ankle jo in t

-W hat type o f jo in t is distal Tibiofibular joint? fibrous

-w hat is this part o f bone: sustintaculum tali.

-w hat bones form the midtarsal joints, and show movments o f ankle and and midtarsal joints in your
own foot.

-ankle is m ore stable in which position, (dorsiflextion, bcz talus is in its widest diameter)

-show me the palpable pulses in the foot, and how the form circulation in the foot.

-w hat muscle causes foo t inversion

Pathology:

4-giant cell a rte ritis :

Old female w ith headache, transient loss o f vision, biopsy taken showed giant cell arteritis:

-w hat is giant cell arteritis.

-which part o f the vessel is affected.

-w hat is the most im portant blood investigation to reach the diagnosis. ESR

-w hat is the pathological changes in microscopy

-w hat is the treatm ent

-patient presented w ith blindness , w hat that means, (ophthalm ic artery invovment)

-A fter years patient developed fracture o f neck o f Femur, explain three causes.(age, postmenopausal
female And steroids)

-If you are taking this patient fo r surgery, w hat is your m ajor concerns, adesonian crises.

-W hat precautions to prevent this.

-W hat is the pathological changes th a t occur in osteoporosis: loss o f bone matrix.

-W hat you are concerning about when you treating this lady, (relapse o f the disease)

5-Aortic stenosis:

Causes o f aortic stenosis

How stenosis occurs in bicuspid aortic valve

Cause o f sudden death in aortic stenosis.

W hat are the causes o f infective endocarditis, all o f them

W hat is infective endocarditis

W hy trea tm en t is difficult. Two causes.(avasculrised+vegitations)

Prophylactic antibiotics presurgery (nice guidelines)

If young patient developed tricuspid regurge w ith infective endocarditis w hat do you suspect? IVDA

If metallic valve replacement is done, and patient developed I.E, why vlave shoud be remove.

-In the replaced m etallic valve result showed presence o f branching hyphae, w hat do you think the
organism.

CLINCAL EXAMINATONS:

6-patient presented c/o pain in both low er limbs (claudications) EXAMIN THIS PATIENT

(vascular+ neurological examinations)

Both where normal.

-present your findings:

Investigations and treatm ent

-if the cause is neurological w hat is the possible causes

-w hat trea tm en t medical and surgical fo r spinal stenosis

-if patient had thigh and buttock claudication, where do you think the vessel block, aortoiliac disease

7-abdominal examination o f post abdominal surgery midline incision , incisional hernia+ divarication of
recti, referred by GP as case o f incisional hernia.

-summarize your findings, are you happy w ith GP diagnosis? I think there was a hernia and divercation
o f recti in tha t patient.

-investigation to confirm diagnosis.

-management o f this patient c o n d itio n , conservative &surgical.

8-cardiovascular examination o f a patient in preassessment fo r non cardiac surgery :

Patient had m idline sternotom y incision, w ith audible metallic valve click.

-findings.

-how to prepare this patient fo r surgery

-also ask about warfarin and management pre and post-operative

9-perform FNAC fo r patient w ith le ft thigh s/c lump.

You w ill be asked to give local anesthesia (check the expiry date)

Don't forget to label the slides before procedure

When I w ill come to see the result? she asked.

Pain medications post procedure

10-trauma case (Model), you w ill be asked to manage the patient as ATLS

How to manage airw ay& C.spine and breathing, demonstrate

You w ill be asked to perform , cervical coller, Gudel airway and how to measure size, bag vlave mask

,how many cycles you will give the patient.

-if patient deteriorates w hile you are checking fo r breathing, w hat w ill you do.(return to A again)

-why management o f airway is d ifficu lt in traum a patient

-if intubation is no accessible w hat you w ill do ..cricothyriodotom y.

11-history taking: case o f inflam m atory bowel disease.

Young female w ith 8 months h/o PR bleeding.

W ith frequent diarrhea , oral ulcers, and b /l knee pain.

-w hat is your differentials.

-investigation.

12-middle age pt, w ith right sided knee pain, and 1 month swelling, w ith past h /o knee surgery after h/o
trauma

Defirrential diagnosis, OA knee

Investigation

Management

-if x-ray showed malunion o f old tibia fracture w hat treatm ent option.

-patient was concerning if he can play football after few months.?

13-angry patient ,she was posted for right knee arthroscopy and cancelled twice, this tim e bcz
consultant was bussy w ith life threating emergency in OT.

Easy case and nice actor she w ill give you hints if you forget something.

14- talk through phone to a traum a consultant. ISBAR young male patient involved in RTA 4 hr back

W ith open fracture both bones right le g , nurse discovered lim b become pale and pulseless, suspected
vascular in ju ry , you w ant to take the patient to OT and talk to vascular surgeon which is already in OT

, consultant will keep pressing on you to take back your decision o f sending patient to OT, and order CT
angio first.
Also asked, do you w ant general surgeon to be involved, patient was seen by surgeon and reported as
surgically free, but he ordered ultrasound which later showed fluid collection in the abdomen.

A lo t o f questions asked.

Critical care case:

-about pregnant lady is undergoing laporoscopic surgery fo r necrotic infected gallbladder in reverse
trendelenburg's position.

-questions are d ifficu lt to rem em ber „

-she developed intraoperative hypotension „w h a t are the possible causes fo r that. I said possibly

Sepsis, position o f the patient and may be pnum operitonium .

-w hat is preload and after load.

-w hat factors affecting venous return, and how to improve them.

Station is all about a patient who had been adm itted w ith acute pancreatitis:

-w hat scoring systems do you know.

-is serum amylase is im portant in scoring systems?

-give me tw o situations In acute pancreatitis where you can found serum amylase normal.

-w hat is the clinical presentation o f pancreatic pseudocyst.

Central venous catheter:

CVP inserted blindly and patient developed complications.

W hat is possible complications

He showed me chest x-ray w ith obvious pneumothorax, and then he asked me

How to read this x-ray in a systemic manner, he was searching fo r ABCDE

Also asked is this x-ray adequate? No costopherenic angles visible.

And then asked about the obvious finding. Pneumothorax

Also asked w hat is the recommended way to insert jugular CVP ,he was asking about NICE guidelines

Of using ultrasonic guided procedure and post procedure chest radiograph.

W hat other sites we can insert a CVP and w hat is the most one prone to infection.(fem oral)

That's all w hat remains in memory

Wish you best o f luck

Station 17
Diverticular abscess
Define shock
What shock does this patient has
CT confirmed diverticular abscess how would you manage
What are you other differential
What are the pros and cons of both open and image guided drainage

Station 18
Trauma unstable patient
Define shock
W hat kind of shock does this patient has
Outline the management for this patient
Cxr showed right 6 7 8 rib fracture
CT scan showed large liver hematoma
Did u think patient is stable for CT

Station 1
Anatomy
Layers of the abdominal wall
Origin and nerves innervating the external oblique
W hat forms the conjoint tendon
W hat supplies the appendix and the origin of the vessel
Show me the uterine tubes
Show me the ileum Cecum and the appendix

Station 2
Anatomy
Spine
Show me the atlas and the axis
W hat is the ligament joining the atlas and axis
Name the parts of the atlas and the axis
Show me where the brachial plexus comes out from the posterior triangle
Show me the hyoid bone on a simulated patient. Which vertebral level does it correspond to
Show me the level corresponding structure at c6. W hat Gl structure is there ?
Open mouth view of an x Ray showed
Fracture of the dens

Station 3
Anatomy
Supracondylar fracture showed
Articulate the humerus radius and ulnar
Tell me which side it is
Tell me the relations of the ulnar radial brachial and median nerve
Show it at the model
Tell me the function of median nerve
W hat happens when there's an injury at the proximal median nerve and what happens when
there's an injury distally
Ulnar nerve prox and distal injury

Station 4
Alcoholic with gastric ca
Patient went for operation and the stomach is removed with 12/14 lymph node positive
Likely linitis plastica
Explain to family members abt the hpe finding
Patient was discharged and came back with distended abdomen and liver is enlarged .
What did u think happened and treatment
Patient became delirious, what did u think happened ?
Patient had tenderness of the calf and it was swollen
How can you avoid this ?
What's the mechanism of action of thromboembolic stocking

Station 5
Bicuspid aortic valve
How do u think the valve became stenotic
Tell me the mechanism of action
What's infective endocarditis
W hy do u think this patient has to be on warfarin

Tell me about the coagulation pathway

Where does warfarin not work in this pathway
Patient had a valve replacement and came back again with fever and IE
How would you confirm pathologically ?

Station 6
Physical examination
Posterior cranial fossa lesion
Pt had broad based gait positive dysdiadokinesia on the right and heel shin test positive on the
right
W here would u think the lesion is
How would u investigate and what's your differential

Station 7
Physical examination
Varicose vein
Pt had a incompetent saphenofenoral junction valve
Deep system appears intact
Did tourniquet perthes and the Doppler
Treatment of varicose vein

Station 8
Physical examination
Pt has copd
Going for inguinal hernia surgery
Examine the respiratory system

Station 9
I n d of an abscess on the thigh
W hy do u make the incision as so
Langerhans line
W hat organism are the usual causative factor

Station 10
Suturing
Pick the suitable suture
Do t n s
Dose of the lignocaine
Would u give this patient antibiotics

Station 11
History taking of back pain. Patient has had long term back pain and address her psychosocial
issue cos she has to take care of her husband. Also has ibd
Station 12
History taking
Pt is planned for cholecystectomy and came with breathlessness
Explore her breathlessness husband passed away

Station 13
Call the consultant on call to inform a post hemicolectomy patient day 1. Pt was oliguric dehydrated
tachycardic and BP was coming down in trend and Abg showed slight acidosis

Station 14
Drunk father who brought his child to hosp after a fall and had to go for laparotomy for splenectomy
Anxious mom came later demanding that dad is not to see the child

Station 15

Bums management
Patient has facial burns and soot
ARDS management and definition
Chennai Dec 2016

1. Examination:Cranial nerve exam, patient complains of diminishing vision and waddling

gait occasionally. Examine his cranial nerves. Patient could not count fingers at 3
metres...Examiner Dude got grumpy when I said wanted to check for visual acuity , n Color
blindness, said really? no need, assume vision severely impaired(??... in retrospect I should
ve also done visual fields, but severely limited time).Diagnosis: optic chaism lesion. W hat are
the d/d? - pituitary adenoma, craniopharyngioma, aica aneurysm and meningioma.
Investigation? MRI Brain, why no CT?What approach for resection? Trans sphenoidal.
Tip practice to CN exam fully within 6 min

2.Comms: Splenectomy : Consent from angry mother, fully repeat. Actor was scary and kept
on whining and crying, would not let you speak! Exhausting station. Make sure you only
answer surgery related queries and not touch on the subject of husband being drunk n
neglect child, also mention legal custody of the child not our domain, refer to social worker
etc, actor was not at all convinced( must have just let her cry, it must be really exhausting for
the lady too!), really not sure how I did as I could not convey most things about post
splenectomy that I wanted to!

3.Hydrocele exam : Repeat station, standard questions, very friendly and cheerful examiner,
easy-peasy.

4. Lower limb vascular exam in pt scheduled for hip replacement, honestly , none of lower
limb pulses were palpable, but perfusion ok n so signs of is c h e m ia (© )- pt obese or dunno
actual block!. investigation??what takes precedence? Vascular management or hip
replacement. Not sure what exactly examiner wanted, I said further investigate the cause of
occlusion and treat it as priority as hip replacement not emergency but limb ischemia is.( No
expression from examiner n bell rang, thank God) Time restricted station!

5.Acute mental confusion in a pt scheduled for hip replacement. Standard, repeat. Do AMT
offer to do MMSE. W hat investigations you do? W ho would you like to speak to for further
info? Family members to know whether acute deterioration. But patient stays alone. Then
who? I said Employer (lol) Examiner laughs and says GP to know what treatm ent he had
taken!

6.RS exam in patient scheduled for lap hernia, finding- copd... smoker and all...repeat
question.offer regional anesthesia, not suited for lap surgery, W hat measures you take?
W ho else to involve. W hat intra- op problems-1 went on but very much time limited, I dunno
if examiner was done or bell rang early!

7.Aortic stenosis pathophysiology: pretty neat and standard station. Examiner was a sweet
lady, kept on prompting . Explain PP of AS- talk about LV outflow obstruction. Complications
of AS : pretty standard - IE, Ml, AF, MR, LVF ,... Etc, W hy Ml? W hat are anesthetic
consideration in AS ? W hat investigations? I said ECG, 2D Echo- seemed ok with it. Here's
ECG of p a tie n t, calculate rate n what abnormal? ECG was basically peaked R in left chest
leads s/o LVH, what is definition of tall R wave? ( What!!? I Donno Madam, Smiled I guess
she was happy I could read that ecg!)

8.Gastric outlet obstruction pt was in met alkalosis. W hat type of compensation? Why
hyponatremia, why hypokalemia? W hat type of urine? ( She was expecting paradoxical
aciduria) W hy so - 1said some BS about kidney exchange of Na - H, Examiner was giving no
expressions, W hat fluid? How will you replace K? W hat priority? W ho will you inform? - 1said
ITU may require int, she got cross n like do you really want to intubate or other priorities? I'm
like hyponatremia may go into respiratory depression( © ) then said involve nephrologist as
creat is high ...examiner rolled her eyes(lol) Overall not happy.

9.Pancreas anatomy: Straightforward- blood supply, parts, ducts, embryology, Islet cells
and hormones- name 4. Duodenum peritoneal covering, relations, stomach blood supply.

10.Anatomy of brain: (Crap! I did not revise neuro- anatomy)Read the MRI: I said non
contrast MRI, SOL d/d metastatic/ Primary,blah blah,got annoyed, all he wanted was
meningioma in coronal plane! W hat anatomical structures will be affected? If it grow? Again
blah blah, parietal cortex ventrical, he got annoyed again, not sure what he wanted. Motor
area? I said pre- central sensory n post central motor, again got really cross n said gimme
one answer! Identify the sinuses on skull( OMG- again some blah blah, he said point out
straight sinus, thankfully I did.) Identify jugular foramen. On skull n str passing through.
Overall bad as I guess I pissed the examiner at the start!

11. Anatomy of Gluteal muscles: repeat straight forward. Remember the model is bit wierd
( all gluteal superficial muscle missing) so if u have 2D picture in mind, just turn it around and
look carefully at prosection and take time before u answer...

12.Bile duct injury post chole call consultant: entirely repeat. Easy station

13. Pathology : Adult polycystic kidney D’s... AD transmission,Renal transplant, immune

suppressors, mechanism of rejection, S/E, He asked specifically the triggers for PTLD(?) N
what causes lymphoma in this case...duh!

14.Steroids pre op: repeat, Adrenal physiology. Helpful examiner... All about physiology of
glucocorticoid, so shoot all the effects of steroids, s/ e, how to taper, what to monitor,
standard questions

15.History vascular claudication: pretty standard.

16. Suturing laceration: Easy station- repeat.AII about sutures. W hen will you remove
stitches, do I need antibiotics, will.i have scar? Will it be painful?l told everything to the
patient, and also added any more concerns? Guess she didn't have any more! Done far
ahead of time and went well.

17 . Procedure: I and D of abscess, what else u do? Send swabs, what else? Antibiotic, what
else?( Dunno) W hat type of dressing? W hat organisms, Langer's line, dose of LA? What
specific antibiotics, bell rang.
18.Patient on some xyz thiazide and some alpha blocker ( trade name used so could not
really make o u t ) - not mentioned for what ....scheduled for trans urethral resection of
bladder tumor. W hat pre operative preparation. Very vague station. Examiner kept on asking
what concerns u have abt the thiazide(?) Drug, BS about dehydration, electrolyte
abnormalities... He developed pleurisy and SOB turns out had mass in lung( W hat???) What
bedside investigation? ( Sputum c y to ). He has hypercalcemia. Cause? Malignancy>
paraneoplastic , what else ? ( ??) Dude was unhappy , I could not come up with more
causes...Bell rang! Phew!
Khartoum Nov 2016
day2 and day 3 was repeated

Anatomy

Station 1:
Posterior cranial fossa:
Given skull
1. Bones of posterior cranial fossa
2. Venous sinus tracts in posterior cranial fossa
3. Point to hypoglossal canal
4. Point to jugular foramen
5. Contents of jugular
6. Identify clivus
7. Nerve running on clivus
8. Name last 4 cranial nerves
9. Tract of last 4 CN
10. Benign tumors of posterior cranial fossa
11. W hat name of the juvenile structure that form the clivus (spheno-occipital
synchondrosis., answered by the examiner)
12. W hy patient with acoustic neuroma hear sounds loudly on affected side (affection of
facial nerve>paralysis of stapedius)
13. Contents of foramen magnum
14. W hich bone makes middle ear
15. How infection in middle ear spread to posterior fossa

Station 2
Posterior mediastinum
1. Point to post mediastinum
2. Boundaries of post mediastinum
3. Contents of post mediastinum (she didn't let me untill i answered them all)
4. Level esophagus starts and surface marking
5. W hat level pierces diaphragm right crus
6. Blood supply of esophagus
7. Venous return of esophagus
8. Lymph drainage of esophagus
9. Type of tissue of esophagus she wanted stratified squamous not squamous only
10. Define Barrett esophagus
11. Clinical significance of barret
12. W hat makes an indent on the esophagus in the thorax she wanted by the arch of aorta
and left bronchus
13. Complications of perforated esophagus she want hemorrhage pneumothorax and
hemothorax ( also she didn't allow me to go for the next question until saying it)

Station 3:
Skeleton upper and lower
1. Point to coracoid and acromion
2. Point fossa of scapula
3. W hat are the rotator cuff muscles
4. Origin and insertion of each one point on the skeleton
5. Point to asis
6. Muscle attached to it sartorius
7. Cutaneous nerve related to it lateral cutaneous nerve of the thigh
8. Condition if nerve compressed meralgia paresthetica
9. Gluteus medius and minimus origin and insertion
10. Quadratic femoris origin and insertion
11 .identify the spiral groove which nerve run on it
12.medial epicondyle and ulnar nerve.
13.loss of sensation if ulnar nerve dam age
14. loss of sensation in radial nerve he wanted the first digital web space.
15 which of the thenar muscle effect if ulnar nerve damaged.

Pathology
Station 4
Gallbladder cancer
1. Type of cells of cancer
2. Most common cause in U.K.
3. Spread
4. W ound infected common organism
5. Abscess formed, management
6. Black discharge, what u think of
7. Management of necrotising fasciitis
8. Bleeding rectum causes
9. Picture of pseudomembranous, diagnosis
10. Pathophysiology

Station 5
basal cell carcinoma and giant cell arteritis
1. Treatment of GSA
2. W hy start steroids before biopsy
3. Cause of blindness in GSA
4. Presents with fracture of hip, causes
5. Biopsy shows myeloma, diagnosis
6. W hat test to confirm myeloma
7. W hat is bence jones protein
8. Bone infected, common organism
9. Pt dies post-op, why is it considered unnatural death
10. W hat factors in histology to look for in basal cell carcinoma

Critical care:
Station 6
Trauma:
1. W here would you initially manage this patient
2. How would you manage airway and breathing
3. W hat investigations to do
4. W hat imaging to order initially
5. Chest X ray- pneumothorax
6. Management of pneumothorax
7. CT- liver laceration
8. Management of liver laceration
9. Was CT appropriate for this pt

Station 7
Adrenal physiology
1. Layers of adrenal gland and what each layer secret
2. Regulation of cortisol in the body
3. Function of cortisol
4. Preoperative risk for patient on cortisol
5. W hat advice to give to patient started on cortisol
Station 8
Dementia old man Acute on chronic kidney injury, palpable bladder
1. Pt passed large amount of urine, diagnosis
2. Causes of acute renal failure in this pt
3. Look at CBC and what it shows: normochromic normocytic anemia
4. W hy anemia occurred
5. Shown electrolytes: what is single most important finding: ( hyperkalemia 8.1)
6. Function of aldosterone
7. W hat u worry about in hyperkalemia
8. W hat you worry about in hypokalemia
9. Management of hyperkalemia
10. Function of potassium in body
11. Regulation potassium in body
12. W hat is the ethical considerations when deciding dialysis in this patient

Examination:
1 .Submandibular gland simulator normal examination but the examiner went through all the
D.D
2.Knee examination m. meniscal injury the simulator was good and wearing a sport cloth he
asked the d.d
W hat investigation the treatment i forget to say i would like to complete my examination by
neurovascular for lower limb he pushed me until i say it nice examiner he want all d.d the #
and dislocation the ligament injury but not in detail.
3.Incisional hernia the pt was obese was irreducible examiner asked about best
management i said surgical also he ask about the conservative advice the pt by reduce the
wt preop.
4.Abdomen chest atls and CRISP itu pt with anastomotic leak ask about ct for diagnosis the
contrast to use the bell rang i missed many questions dumn....

Communication
Information gathering:
1 .Back pain history sciatica and neurological deficit of 15 s1
With signs of cauda equina the pt was refuse the admission be his wife died in the hospital
2. Acute pancreatitis a smart simulator she lead the talk to a typical history examiner asked
about lipase and amylase which is sensitive ask about u/s finding ct abdomen when to do i t ,
ask about management the bell rang a g a in .©

1 .Call the hepatobiliary consultant about post cholecystectomy bile leak bile was in the drain
post op no ercp available at ur hospital ur consultant was awayfor colerectal meeting he told
u to refer the pt to had an mrcp at heptobiliary center. Source of bile leakage ask about
ambulance for transfer the investigation and summary of the case was short quick call the
examiner said send the pt. In 4 min lol

2.talk to a wife of pt with ascites malignant cell was found ur consultant ask for ct the ct
machine was broken u can offer a ct at lake hosital 40 mile away as the radiologist worte on
the file or U/S afternoon if the pt have dyspnea offer theraputic paracentesis she asked
about what could be the source of cancer can u chop it out what if fulid reaccumulate what to
do she want to inform his only brother whom lived in australia , littel bit confusing

Skills
1 .Interrupted suture with nonabsorbable material ask how to calculate the local and dosage
when to remove the suture he need antibiotic or not also painkiller.
2.abscess drainage don't forget to pack it ask about how frequent the dressing why i open it
transverse bz of langerhans line how is it in the thigh.
Hi guys, this w ebsite has been extrem ely helpful, so th ough t I'll co n trib u te back. M ost o f m y
questions w ere repeated, so I strongly advise you to keep doing th e TYS if you have lim ited tim e as
these w ill provide the highest yield. I applied fo r the Edinburgh exam b u t g o t sent to M anchester
instead, examiners w ere generally nice and fair, 20 stations w ith 2 prep stations: 3 critical care, 2
procedural skills, 3 anatom y, 2 pathology, 4 physical exams, 2 hx taking and 2 comms (w ith 2 prep
stations). The answers given below are ju st the answers I gave during m y exam, w ould advise you to
double check it or go find yo u r ow n answers.

Critical care

1. Fluid m anagem ent, persistent hypotension and tachycardia in a lady post-op

48 year old lady, im m ediately post THR transferred to w ard at 3PM, persistently
hypotensive and tachycardic w ith w orsening hypotension (70/30 systolic) at 2 AM
Provided w ith flu id chart showing only 2x250mls bolus w ith small im provem ent in itially
W hat are th e 2 m ost likely causes o f hypotension in this lady: D ehydration/Bleeding
(stem said no bleeding, sighs)
Asked to explain th e flu id chart and vitals: Said patient has been persistently
hypotensive and tachycardic on the w ard w ith only 2 fluid challenges and nothing in
between.
IS this adequate? - No
W hat w ould you have done: Given m ore flu id challenges since she appeared to be fluid
responsive
Patient only on 2 ho u rly m o n ito rin g - is this adequate? No - hourly at least, or
continuous in HDU
W ould you have notifie d anyone else?: M y senior. W hen w ould you have notified
h im /h e r: If the patient was still persistently hypotensive despite a few fluid challenges
- How is BP, CO, TPR related : BP = CO x TPR
How can you increase BP then? : fluids fo r TPR and ionotropes fo r CO+TPR
How much flu id bolus w ould you give: said 250mls over 30 mins b u t he w anted a specific
form u la, no idea

2. EDH: Young man, m otorcycle vs car, le ft EDH

Young pa tien t in RTA as above, LOC but GCS 15 on arrival, vom ited tw ice, amnesic o f
events, no CT done in itia lly but found to be GCS 8 later on w ard, CT brain done shows
le ft EDH (biconvex lucency) w ith m idline shift and compression o f le ft ventricle
Asked w hy p atie nt should have had a CT earlier: quoted the criteria fo r th e Canadian CT
rules, p a tien t had a few criteria
Shown th e CT, asked w h a t I w ould be w orried about - m id line shift w ith loss of
ve n tricular space, may result in herniation
Asked w hy w ould the brain herniate - M onroe kellie doctrine etc
W hat is the cause o f dilated pupils in raised ICP (herniation causing compression o f CN3
which carries the parasym pathetic fibres, causing unopposed sympathetics to the pupil
and resultant dilatation )
 W ha t is the norm al ICP : said 15-20 cm H20 (in itia lly said mmH20 but he asked me
w h e th e r it was mm or cm)
Ways to measure ICP: Insertion o f intracranial pressure m onitoring catheter, he w anted
a less invasive way, co u ld n 't th in k o f it so we came back to th e question later; fin a lly got
i t : lum bar puncture. Asked w hat was the danger w ith LP: herniation if ICP is high
How to manage this patient if he was intubated to decrease risk o f brain injury: Sedate
p a tien t to prevent straining, hyperventilate to m aintain norm ocarbia, hypotherm ia,
position patient 30 degrees head up, judicious fluids w ith m onitoring, m annitol

3. Pneum operitoneum : perforated peptic/gastric ulcer

M iddle aged man, has OA taking NSAIDS, comes in w ith peritonism and
p neum operitoneum seen on CXR
Likely diagnosis: Perforated gastric/duodenal ulcer
Risk factors fo r perfo ra tion : NSAIDS/steroids/H pylori/previou s peptic ulcers, he wanted
m ore
M anagem ent options fo r perforated ulcers: om ental patch repair, prim ary repair,
ulcerectom y (asked w ha t an ulcerectom y was, said its excision o f th e ulcer follow ed by
prim ary repair)
D ifference in m anagem ent between PDU and PGU - w ill take biopsies fro m PGU due to
risk o f m alignancy causing the perforation, PDU and rarely due to malignancy
W hat m edication w ill this p atient require post-op : PPIs, asked about th e mechanism o f
action o f PPI: lam ely m entioned some NA-K-ATPase pum p on parietal cells
W hat does HCL do in the stomach: Blanked o u t fo r this, said kills bacteria, aids in
digestion o f food, helps in absorption o f iron. He said it does not help in the absorption
o f iron(oh no), asked how does it help in the digestion - d id n 't know, fro m googling it
a fte r: it activates pepsinogen to pepsin
Asked about phases o f gastric acid secretion: He w anted th e cephalic phase/gastric
phase/intestinal phase which I had to ta lly no clue about
Asked about th e NCEPOD p rio rity OT listing: Said fro m 0-4, 0 is im m ediate, 1 is w ith in 1
hour, 2 is w ith in 4 hours, 3 is w ith in 12 h and 4 is elective (
. Go google it as th e tim in g is a b it d iffe re n t fro m w hat I m entioned.

Procedural skills

1. O rdering o f OT list
Standard question w ith the same 3 cases (Strangulated hernia w ith severe COPD and
pacemaker, Hartmanns fo r diverticulitis w ith allergy to iodine, infected fo o t ulcer fo r
BKA w ith IDDM and MRSA fro m wound
O rdered it in the above order
Asked questions about w hy th a t particular o rder - said strangulated hernia m ost tim e
critical so should go first, then MRSA should go last
Asked about diatherm y/anaesthetic/cleansing solution choice
Asked about diatherm y com plications and pad placem ent fo r all

2. Resuscitation + surgical airw ay options

 Strange station, stem started w ith patient involved in RTA, comes in not breathing but
has pulse and cardiac o u tp u t
Basically to resus the patient - airw ay (chin lift, oro-pharyngeal airway), breathing (bag-
valve mask), C-collar (Asked how to size collar), call anaesthetist early
Patient desaturating again: said to recheck airway and breathing
Basically started asking about options o f surgical airways: cricothyroidoto m y (asked
landmarks), surgical/dilata tion th yroidectom y (asked how to perform , w here to site the
tu be (said 2-3rd tracheal rings), asked about w hat landmarks to use (said halfway
betw een cricoid cartilage and sternal notch - he gave me a strange look)

Anatom y

1. Heart, abdom en anatom y

Exact repeat o f previous questions, exam iner basically pointed to structures or asked me
to name structures
Heart: Identify the pulm onary trunk, id e n tify th e ascending aorta, w hat are the 2
branches o f th e ascending aorta (le ft/rig h t coronary arteries), id entify th e papillary
muscles, w hat is the fu n ctio n o f chordae tendinae (to prevent prolapse o f the m itral
valve during systole)
A bdom en: Identify the azygos vein, name 2 trib u ta rie s to this (hemiazygos and accessory
hemiazygos), w here does it drain into (SVC), id e n tify th e spleen, in a spleenectom y, w hat
stru ctu re m ust you be careful to preserve (tail o f pancreas), describe the course o f the
splenic a rtery (to rtu ro u s course over body o f pancreas, gives o ff short gastric and le ft
gastroepiploic artery prior to supplying spleen), w hat o th e r 2 structures besides the
spleen does it supply (stomach and pancreas). Identify the duodenum , how many parts
are there (4), w h a t are th e 2 ducts th a t e n te r th e duodenum and w here do th e y enter
(Enters at D2 (descending), the pancreatic duct and accessory pancreatic duct). Identify
th e sym pathetic chain, w ha t connects the spinal nerves to the sym pathetic chain (the
ram i com m unicantes)

2. Parotid anatom y
This station had a sim ulated p atient w ho looked u tte rly bored
Asked to id en tify the surface anatom y o f the parotid duct on th e patient (superior
border: in f margin o f zygom atic arch, ant: post border o f masseter, inf: body o f
m andible, post: SCM). Surface anatom y o f parotid duct (m iddle th ird o f line between
a ntitragic notch and phylum , but exam iner was o nly happy a fte r I said 1cm below
zygom atic arch)
Prosections: Identify the parotid duct
W ha t o th e r structures lie w ith in the parotid gland (retrom andibu lar vein and facial
nerve)
Iden tify the branches o f the facial nerve on the prosection (tem poral, zygomatic, buccal,
m arginal m andibular, cervical)
W ha t cranial nerves carry parasym pathetic fibres (3,7,9,10)
W hich cranial nerve supplies th e parotid (CN 9)
 W ha t is the pathophysiology o f Frey's syndrom e (auriculotem poral syndrom e, caused by
damage to the parasym pathetics to th e parotid, causing the fibres th a t usually signal
salivation to connect to the fibres supplying the sweat glands on th e skin o f th e face,
causing gustatory sweating w hen the patient sees/smells food.

3. Lumbar spine anatom y

Given 2 lum bar vertebrae
Iden tify the structures (body, pedicles, laminae, transverse processes, spinous process)
A rticulate th e 2 vertebrae, id entify the intervertebral foram en, w hat comes o u t o f this
foram en (spinal nerves)
W here does th e a n te rio r longitudinal, posterior longitudinal ligam ent and ligam entum
flavum lie (ant to body, post to body, ant to laminae respectively)
W ha t are th e a rticular surfaces betw een the 2 vertebrae (the s u p /in f articular facets). He
w anted m ore (m entioned th e intervertebral discs)
W ha t kind o f jo in t is th e intervertebral disc jo in t (fibrocartilage jo in t), prim ary or
secondary (primary?)
Shown MRI o f coronal section o f spine/spinal cord - asked to name th e vertebrae, asked
to point to an intervertebral disc
C om ponents o f the inte rvertebral disc - annulus fibrosus/nucleus pulposus
W ha t changes to the disc w ith ageing (decreased height)
If the L4/5 disc herniates, w hich spinal nerve w ill be affected (L5)
W here does th e spinal cord end in a neonate (L3-4), in an adult (L2-3)
Surface landm ark fo r lum bar puncture (L4 at iliac crest)
W hat lies betw een L3-S4 in an adult (CSF, spinal nerves, conus m edullaris, cauda equina,
filu m term inale)

Pathology

1. Perforated viscus secondary to diverticulitis w ith endom etriosis

The m ost d iffic u lt station fo r me, exam iner was also quite hostile
Lady came in w ith LIF pain and peritonism , had Hartmanns procedure fo r perforated
colon, histology was perforated diverticulitis w ith endom etriosis
Pathophysiology o f diverticulitis (m entioned 2 causes: congenital and chronic
constipation/ageing causing pressure on th e bowel wall causing outpouchings, then food
particles get stuck in the diverticulum and gets infected)
How did th e endom etriosis get to the colon (Said th a t I know o f 2 m ethods: 1)
transcoelom ic spread fro m fallopian tubes to the peritoneum and seeds o n to the colon -
exam iner got cross and said th a t's called retrograde m enstruation, 2) during
d evelop m e nt th e endom etrial tissue develops on the bowel - he g o t even crosses and
said its called ectopic endom etrial tissue and lectured me on using proper term s and not
inventing m y ow n LOL)
A fe w days la te r the patient developed a collection in the LIF, explain w hy (I said
?anastom otic leak/stom a re traction - he laughed at me and said I m ust be a lousy
surgeon the n. The answer was th a t the patient was already pe rito n itic and perforated
to begin w ith w hich w ould mean some soilage, therefore higher risk o f collections
 Asked about antibiotics (Said augm enting w hat dose and how fre q u e n t (1.2g BD IV fo r 7
days), w ha t if p atie nt if allergic to penicillins (said clindam ycin o r ciprofloxacin), w hat
dose and how long (d id n 't know th e dose b u t said 7 days), he got pissed and asked me
w hy d id n 't I start w ith the sim ple abx (I said d iffe re n t hospitals have d iffe re n t
dem ographics o f bugs and antibiotics w ill differ). He w anted gentam icin
Some questions about DIVC and ARDS and SIRS
During the debrief some o th e r candidates com plained against this exam iner -
apparently he talked to o slow ly and when th e y d id n 't know th e answer to a question
and w anted to move on he d id n 't let them .

2. TB/lym phom a
Exact repeat again - young lady came back from some th ird w o rld country, developed
cervical lym phadenopathy, LOW, night sweats
W ha t are yo ur 2 main differentials (TB and lym phom a)
W ha t lym phom a w ould you suspect (Non-hodgkins as m ost com mon)
W ha t tests fo r TB - culture, stain (Ziel-Neelson), TB PCR, in te rfe ro n gamma assays
(w anted exact name - q uantife ro n gold)
Given FNA result o f necrotic tissue, histiocytes, giant cells
W hat is y o u r diagnosis now - TB
W hat are giant cells - m ultinucleated cells com prising o f macrophages
Name another m ycobacterium th a t's usually involved in im m unocom prom ised patients
- m ycobacterium avium intracellulare
Name 3 o th e r granulom atous infection (not TB/foreign body) - crohns, sarcoidosis, cat-
scratch disease)
How long does a TB culture take - 4-6 weeks
W hat is the proteinaceous substance th a t can be found systemically in TB - n o t a clue

Com m unication

1. Counselling o f patient fo r hernia repair, patient on w arfarin

Patient has a recurrent inguinal hernia (previously repaired 30 years ago), legally blind
fro m cataracts, has had mechanical heart valve replacem ent on w arfarin, anxiety not on
m edication. Already previously talked to consultant in clinic, but now comes to clinic as
unsure about w arfarin and concerned about operation
W en t in to th e room w ith 2 examiners w ho did n o t u tte r a w ord the e ntire 10 mins, and
the p a tie n t w ho had a blind walking stick and w earing sun glasses.
Introduced myself, asked how I could help him
Basically concerned regarding heart valve and w arfarin - was under th e impression th a t
he had to continue it as his cardiologist had previously to ld him he needed to take it fo r
life.
Explained th a t I w ould check w ith th e consultant in charge regarding this as th e usual
practice is to stop w a rfarin fo r operations due to th e risk o f bleeding
Explained th a t if w arfarin was stopped, the risk o f throm bosis is present due to his heart
valve, explained the role o f dexane until the night o f the operation - explained this w ill
involve injections tw ice daily - patient said he lives alone and w ill n o t be able to
 manage, offered to check w ith the nursing manager on w h e th e r nursing services w ill be
able to be provided, otherw ise offered to adm it patient u ntil th e operation
Reassured p atient, asked if any o th e r concerns, w hether patient knew w hat operation
he was having and why
Then sat th e re lam ely fo r 2 m inutes in silence w aiting fo r the tim e to end - made some
small ta lk w ith the pa tien t on how he manages at home
On hindsight I should have had m ore structure to the conversation

2. Phone call to traum a consultant re RTA p atient w ith open le ft LL fracture w ith ischemic
lim b, and possible abdom inal free fluid
Exact repeat, nothing special
Lots o f papers w ith info rm ation
22 year old medical student, cyclist h it and run by car, LOC 15 mins u ntil ambulance
arrived, GCS 15, haem odynam ically stable. Has open fracture o f le ft tib ia /fib u la w ith nil
cold leg, also has u/s abdo w ith ?free fluid, b u t GS reg has examined and abdo is SNT
They had a cordless phone in the room , traum a consultant on the o th e r end, basically
ISBAR,
The traum a con asked a lot o f questions, some questions purposely regarding
in fo rm a tio n th a t was not provided (eg, w hether patient has a c-collar on, w hether
pa tie n t is dehydrated)
Then gave a plan - fo r CT head/abdo/LL, Xray C-spine, if anything worsens to contact
him im m ediately. Initially I th o u g h t it was a test, to ld him th a t I th in k the scan w ill delay
the operation as th e patient has th e ischemic lim b which is more urgent, he got abit
annoyed and asked me if I w ould put the patient under w ith o u t clearing his head a fte r
an RTA w ith LOC.

Physical Exam

1. Ankle
Simulated patient, played soccer and sprained ankle
Tenderness on le ft lateral malleolus, worse on dorsiflexion and internal ro ta tio n , antalgic
gait
Ddx: Sprained lateral ligam ent, TRO fractures o f fibula, metatarsals, cuboid/cuneiform s
Xray shows undisplaced fracture o f fibula w ith swelling o f the ankle - management?:
analgesia, backslab. Asked w hy not fu ll cast - due to swelling which may cause
com pa rtm e nt syndrom e
How to im prove swelling - rest, ice, elevate
Landmarks fo r DP and PTA

2. CVS exam w ith heart m urm ur

Straightforw ard CVS exam w ith pansystolic m u rm u r at m itral area, radiating to axilla
(m itral regurgitation), nil fa ilure symptoms
 Leg oedema, which side heart failure - right, if le ft sided heart failure, w here does fluid
g o - lu n g s
If fingers are blue w ha t does this signify (peripheral cyanosis), lips/tongue blue (central)
W ha t heart conditions causes cyanosis (le ft to right shunts)

3. Hernia exam
Right inguinal hernia, soft and easily reducible, abdo SNT, testes norm al
W ha t o th e r exam w ill you do - PR fo r BPH/resp fo r chronic cough
Presented findings - provisional diagnosis o f right inguinal hernia
W hat investigations w ill you do - I said in this case I'm quite convinced it's a hernia so no
need fo r ix, but if I'm not sure I can do an u/s
W hat options fo r managem ent: Conservative vs surgical - conservative w ith trus belt,
resolving underlying causes o f increased intraabdo pressure eg BPH/cough/heavy lifting,
education on sym ptom s o f incarceration/obstruction, surgical- open vs laparoscopic
Do you advise patients to be managed conservatively - said in clinic I always advise
patients fo r surgery due to the risk o f incarceration and obstruction requiring emergency
surgery, but I also give th em th e alternatives
W hen w ould you advise fo r conservative m anagem ent - when patients are poor surgical
candidates - o ld /p o o r co-m orbids

4. Thyroid exam
Patient comes in w ith an te rio r neck lum p - examine patient
Could not feel the lum p at all - in itia lly I pointed to his adams apple and asked if th a t
was the lum p (zzz), th en I pointed to his right neck and asked if th a t was the lum p (no it
w asn't), asked him to point to the lum p and he pointed vaguely to the le ft neck
Did the w hole th y ro id exam w ith lym ph node exam ination
W hen presenting I to ld th e exam iner to be very honest I could not feel any lum p, but the
was no lum p th a t moved on protrusion o f the tongue/sw allow ing, nil cervical nodes, nil
hyp er/hyp o thyro id sym ptom s
W hat are th e sym ptom s o f hyperthyroidism I was looking fo r - tre m o r, clubbing, racing
pulse, exophthalm os, proptosis, lid lag, pretibial m yxoedema, hyperreflexia
Asked w h a t I w ould do to fu rth e r investigate: said th a t since I cant feel the nodule, ill
organise u/s +/- FNAC o f the lesion, and do TFTs
Patient euth yroid on blood tests, small lum p detected on u/s - w h a t to do n e x t:
proceed w ith FNAC
FNAC comes back as fo llicular cells: said unable to te ll w h e th e r benign o r m alignant, w ill
counsel p a tien t fo r e ith er hem ithyroide ctom y and com pletion th yroidectom y if histology
is m alignant, o r frozen section on table and h e m i/to ta l depending on benign/m alignant

History taking

1. Chest pain and dyspnoea p a tien t on th e w ard a fte r a TKR

 Patient post TKR POD 1, walked to to ile t and developed sudden severe sharp le ft chest
pain w ith associated dyspnoea
DDx - cardiac, DVT/PE, less likely pneum onia/M SK
Investigations : FBC/RP/CMP/trop l/D -d im e r n o t useful as just post-op, CXR, ECG, CT PA
CTPA confirm s PE - m anagem ent: m o n ito r p atient in HDU, anticoagulate w ith
heparin/dexane, if unstable can consider surgical em bolectom y
Asked w h e th e r I w ill give heparin/dexane - said IV heparin based on the protocol based
on body w eight - he w anted m ore details b u t th a t was all I knew.
He said he gives all his patients w ith PE clexane - dose: 1.5m g/kg daily o r lm g /k g BD

2. Knee OA
Repeat question - fo o tb a lle r had right knee in ju ry 30 years ago, some knee operation
th a t he had no idea about, developed worsening right knee pain fo r 4 m onths
DDx - osteoarthritis, rheum atoid arteritis, possible loosening/fracture o f prosthesis from
previous op
Investigations : xray looking fo r decreased jo in t space, osteophytes, subchondral
cysts/sderosis
M anagem ent options: Conservative/m edical/surgical: conservative w ith PT/OT/exercise,
medical w ith analgesia according to WHO pain scale ladder, intra articular steroid
injections/PRP injections, surgical - TKR, partial KR
W ill p atie nt be likely to play soccer in 9 m onths - no
How about in th e long run - said patient unlikely to regain norm al function

Good luck guys, take you r tim e to answer th e questions as 9 m inutes is quite a long tim e . I managed
to finish early fo r m ost stations (d o n 't know if it's a good o r bad thing), but on hindsight I th in k I
should have taken m ore tim e to th in k before answering. Oh wells hope I pass =].
Day 1(all questions repeated from previous years)
Preparation station : Talk to consultant for a patient who is 2nd POD mastectomy with axillary
clearance with previous history of COPD with mild LVF now having confusion and SOB now her
daughter wants to take her home 60 miles away. She was COPD Patient with mild LVF. Now pick up
phone and talk to consultant for his instructions. Pt had drain collection 1st pod 30 ml, 2nd pod- 410
ml, SOB & confusion, S Creatinine slightly raised
Telephone consultation: Consultant asked as usual questions but gave no instructions.
Procedure station: Urethral catheterization of a trumatized patient. Examiner asked to answer the as
usual
Procedure station: Excision o f naevus
A n a to m y : all about Parotid gland
Anatomy: Lumbar vertebra, intervertebral disk, intervertebral joints, spine and spinal cord.
A n a to m y : Mediastinum and Oesophagus
Pathology : Hypercalcaemia and hyperparathyroidism
Pathology: Stages of bone healing. Osteoporosis,MRSA and complications of Prolonged
immobilization.
Examination : Lump over left lum ber region( Neurofibroma) + examiner asked question about
management.
Examination : Patient with right upper abdominal pain ( Acute Cholecystitis) + exam iner asked
questions about investigation and management.
Examination : Patient with pacemakers examine CVS and respiratory system + examiner asked
questions about pre, per & postoperative management.
Examination : Hip examination -pt was previously underwent left hip replacement now came with right
hip pain, exam iner asked about inv and management.
History : Abdominal pain with gallstone asked dx-1 told IBD exam iner told IBS and asked about inv
and management.
History: knee pain with previous history of knee injury + asked about management.
Counselling: Patient with spleen injury wants self discharge despite falling hemoglobin and
tachycardia.
CCrlSP: Hem atem esis with hypotension.
CCrlSP: Diverticular perforation with hypotension + D/D,inv,mx,(percutaneous vs open).
CCrlSP: Sepsis due to perforation, identity CXR with atrial fibrillation & mx of AF.

DAY 2- 100% REPEATED

 By DW

Colombo 22nd July 2016 - PM

1. Diverticular abscess - repeat

a. How to resuscitate - fluids
b. Source control
c. How to select antibiotics
2. Perforated viscus / air under diaphragm + AF - repeat
a. Possible hollow viscera
b. Causes o f AF
c. M anagement o f AF - drugs
3. Patient w ith splenic injury - wanting to go home on D2 - repeat
a. How to convince him
b. W hy not splenectomy on D1
4. Patient w ith post m astectomy seroma - developing on D2 - repeat
a. Causes - she's on Asprin
b. Convince the cover-up consultant to go and talk to her
5. Patient after traum a - principles o f blood transfusion
a. Types o f blood, life span o f RBC - repeat
6. Patient w ith hematemesis
a. Acute management
b. Surgical options
7. Male w ith knee injury 25 years ago, progressive pain and instability while going down stairs -
history + present - repeat
8. Gall stones incidentally detected + symptoms o f IBS - repeat
a. DDx o f LIF pain and increased stool frequency
9. Patient w ith calculus disease + hypercalcemia + peptic ulcers
a. Causes o f PU, treatm ent o f H. pylori, CLO test- repeat
b. Parathyroid adenoma - ? new questions
10. Excision o f pigmented lesion + suturing - repeat
a. Suture kept slipping away, examiner refused to hold the skin together
11. Anatom y - Lumbar vertebrae - repeat
12. Posterior mediastinum
a. Landmarks
b. Blood supply, lymphatic drainage o f oesophagus
c. Diaphragm - openings, levels
13. Catheterization - repeat
a. No urine after catheterization - blocked catheter - flush / AKI
14. Parotid anatom y - repeat
a. Surface markings - actor - 1tried to show w ith pen, he insisted I use the finger - saying
it's not a tropical fish!
b. Anatom y o f duct, Frey's, cranial nerves w ith parasympathetic supply
15. Knee exam ination - straight forw ard
16. Lipoma examination
17. Abdomen examination - actor - RHC pain - repeat
a. Colic / choelecystis
18. Patient w ith pacemaker awaiting Lap. Chole - repeat
a. Basic CVS examination
b. Diathermy precautions
c. AB prophylaxis
Station 1:
Theme: Hypothermia.
An old age man is planned for emergency Laparotomy for some perforation. U were
shown monitoring charts. Patient was in SIRS. Examiner asked Causes of
hypothermia, how to measure core body temperatue , where is it measured, how to
prevent it. How to prevent Hypothermia per opartively. Complications etc.

Station 2:
Theme: Burn.
A gas burn in kitchen Scenario. Patients S p02 was 98 pc on 2 litres Oxygen. What
is your strategy of airway management. How will u start fluids. A diagram was given
to Calculate the pc of burn. Asked to calculate fluids. Then Switched to ARDS.
Asked for definition. And Showed an CXR. Asked for Management etc.

Station 3:
Theme: Cebellar Functions Test
An Actor was Lying on Bed with Gud speech. History was given tht she had a
Posterior Cranial fossa tumour. Examine her. Its difficult to examine a normal lady
with good speech and showing other signs. Examiner was rude so he didnt ask
much questions.

Station 4:
Theme: PVD
An old man was lying on bed. History was that he has been admitted for Hip
replacement, nurse found his both feet cold. This was a real patient. Asked to
Examine and then tell the findings. How will you proceed, time was short Didnt asked
much.

Station 5:
Theme: DVT
A beautiful lady was lying on bed with dyspnea . Had history of Laparotomy for Some
pelvic Malignancy, where ever i touched she had pain. Finally i checked her legs and
thanx God found DVT. Rest were normal questions, ths was difficult station as
patient was not a good actor she was overacting. It would have been a good rest
station.

Station 6:
Theme: History Taking Selling in front of neck with Thyrotoxicosis
Went well

Station 7:
Theme: History Taking Pain Abdomen

Station 8:
Theme: Fluid Managment
History of a Patient who underwent so surgery and is no tachypneic. In eight hours
he ws infused 8 Liters of fluid and is in fluid overload.

Station 9:
Theme: Anastomotic Leak
A patient., actor., was lying with pain in abdomen in left shoulder, he underwent
surgery for sigmoid Ca in emergency. 6th Post Op day. Examine the patient. Answer
Questions. W ht are possible causes of dyspnea and pain

Station 10:
Theme: Communication Skill for Sunday Discharge He has splenic Hematoma and
may need surgery. But want to self discharge.

Station 11:
Theme: Talking to Consultant on Phone..
Bad Examiner and Bad Scenario.

Station 12:
Theme: Upper limb Anatomy
No processions.. Only ATLAS pictures from Netter. Asked for Shoulder joint. Asked
to pick scapula clavicle humerus make joint, show where are rotator cuff muscle on
picture and never supply, Showed an MRI of shoulder asked where is head of
humerus and deltoid and glenoid, long heads of tricep and biceps. Ths picture is
same which is in a book i dont know where i saw it,

Station 13:
Theme: Neck Anatomy and Thyroid Anatomy
Easy station. Simple questions and very cooperative examiner

Station 14:
Theme : Anatomy of Parotid
A man was sitting on chair, asked for surface anatomy of Parotid extent of it. Duct
surface anatomy.. He was interested to listen duct surface anatomy in relation to
zygomatic arch. Asked too many known questions regarding parotid. Nothing
special. He asked Freys Syndrome as well

Station 15:
Theme: Skill. Suture a wound on thigh of a beautiful Lady.
Went well.

Station 16:
Theme: Urinary Catheterization.
Went well. Urine not coming wht will u do .

Station 17:
Theme: Pathology Testicular Tumour Seminoma Classical
Excellent examiner. In a 35 yr old man undescnded testis, now presented with mass
in groin, wht is likely diagnosis. U did surgery HP report came. Showed the re p o rt.
then asked wht are ur concerns now. In report it was Tp4 Nx. invading the lymphatic
and muscular fibers. W ht is lymphoma . in which age group it is common in testes.
Asked about hematoma, and its resolution stages.

Station 18:
Theme: Pathology Clotting profile ABO missmatch. Hypersenitivity. Splenectomy
consequnces etc. It was a poorly designed station so random and abrupt. Even
asked for Bone reparing stages and Formation and activation of Mast cells

Pray for me that I pass.... Thats all from My side. Good Luck to all.
Knowledge:

A natom y:

1. Thorax: A one page long useless scenario given on how a guy got stabbed in the
xiphisternum . Also clearly states th a t this station is not to check o u r clinical m anagement
and only anatom y w ill be tested related to this region (meaning thorax and abdomen).
W aste o f tim e and m ore im po rtantly, energy.

W hen you go in, a really sw eet exam iner standing next to th re e dissected specimens o f
heart, th o ra x and le ft lung (I said sweet exam iner because I accidentaly discarded th e gloves
fro m m y previous station in a hazardous waste bin since it's a natural reflex, this guy ran to
get me gloves him self lol). Anyway, to ld me to pick up th e heart and id entify the cham ber o f
the heart, pulm onary tru nk, aorta. Then pointed to the right auricle and said w hat is this.
Very a ffirm ative expressions as I answered him.

Then moved to th e le ft lung specimen, asked me to pick it up, asked to id e n tify the
pulm onary artery, veins and main bronchus. Asked w hat level does th e pulm onary tru n k
divide a t .. I seemed to w on de r fo r a m om ent before I answered and he said lets come back
to th is (again, very sweet). He then asked me w hat th e pulm onary ligam ent is and where it
attached and I d id n 't w ant to b lu rt o u t som ething I w asn't to o sure o f (bad habit) so I said I'll
skip th a t.

Then moved to th e thorax and abdom en dissected specimen, asked me to pick up the liver
and id e ntify the lobes, falciform ligam ent, boundaries o f caudate lobe (couldn't get them all
so he said lets m ove to the next question, I was happy to), then asked: name the main artery
th a t supplies the liver and stomach, w hat are its branches, w h a t is the venous drainage o f
the liver, w h at ligam ents attach th e liver to th e diaphragm (kept pushing till I named all of
the m and then smiled). Finally asked about th e actual scenario saying w hat organs do you
th in k w ould be damaged in a stab w ound directed 45 degrees tow ards th e le ft shoulder - 1
said le ft lobe o f liver, heart - he stopped me th e re and said no before the heart - so I said
diaphragm and he grinned and said okay we are done b u t do you w ant to go back to the
question about the pulm onary ligam ent? I was about to b lu rt o u t som ething b u t bell rang.

2. A natom y o f the brain : Vague scenario about a child presenting w ith hydrocephalus w ho had
an MRI. Also said we are going to te st your knowledge o f skull foram ina. Scary exam iner
here, had m arked hearing loss too. D idn't even bother to ask me m y candidate num ber, had
to rem ind him to grade me on m y registration num ber lol.

Anyway, he has a printed photo o f a T1 weighted saggital MRI o f th e brain. Asked me to

id e ntify th e occipital bone (gave me a pointer), cervical vertebrae and th e ir parts, corpus
callosum, all the cisterns, cerebellum , cerebellar verm is and tonsils, ventricles, cisterna
magna and interpeduncular cistern. Also asked to describe the drainage o f CSF com plete
w ith all th e foram ina (lushka, magendie, etc).Then asked w hat is Arnold chiari m alform ation
and w h at w ould you see d iffe re n tly on this MRI. I started w ith descent o f tonsils through
foram en m agnum and he seemed okay w ith th a t and quickly m oved on.

Gave me th e skull and said name the last 4 cranial nerves and te ll me where th e y pass fro m
- I started w ith 12th one instead o f the 9th w hich drove him nuts lol. Looked like he was going
to kill me but I w e n t on (I mean w hat difference does it make?). Showed him the hypoglossal
canal, then he asked to id e n tify the occipital bone here again. Then said id e n tify the foram en
magnum here and te ll me w hat passes through it - 1started w ith spinal cord. He literally
backed o ff and stared at me and said are you saying the spinal cord is a nerve? I said no im
ju st nam ing th e contents o f th e foram en m agnum . Then before he could say anything, I
realised he was still stuck on the 'nam e th e last 4 cranial nerves and where th e y pass fro m '
(LOL, hard to read some people som etim es but ALL examiners d id n 't let us go till we
answered w hat th e y w ere looking fo r o r o u trig h tly said we d id n 't know). So anyway - I said I
apologise I co u ld n 't fo llo w you so accessory nerve passes through. He calmed dow n and he
said okay w h at else so I said vertebral arteries, an te rio r spinal, etc.

Very scary exam iner, I d id n 't know w hy he was so angry. Seemed to be th a t way w ith
everyone and sort o f assumed w e w ere all dum b and d id n 't know and lite ra lly talked to us
like we w ere illiterates. M o r a l: apologise but d o n 't freak out.

Upper lim b : Scenario about a young boy w ho had a fall - again it also said we are going to
te s t yo u r knowledge o f upper lim b anatom y. Lol.

Best station fo r everyone because exam iner was literally th e cutest person I have ever seen.
Old guy w ith shiny silver hair, extrem ely adorable. He gave me le ft humerus, radius and ulna
and asked me to articulate them . Asked to id entify th e olecranon, trochlea, capitulum , radial
head. Then asked me w here biceps inserts.

Then gave an xray o f a supracondylar fracture w ith soft tissue swelling a n te rio rly (was very
ju m p y and happy w hen I said soft tissue swelling - apparently no one else had picked it up
before me and I was the 7th person here). Then asked me w hat I w ould be w orried in such an
injury - I said neurovascular status. He said neuro firs t o r vascular, I said vascular and he got
happy at th a t to o (unbelievable I know).

Then to o k me to a dissected upper lim b specimen and said show me the cubital fossa and its
boundaries and its contents. I started w ith the su p e rficia l/ro o f and said here is the median
cubital vein and he's like th a t's not im portant, lets move on - arteries nerves and tendons
quickly (lol). I named all, showed him the courses. He said w hat w ould you expect w ith a
radial nerve injury - i said w ris t drop, he grinned. D idn't w a n t details. Asked me about ulnar
nerve in ju ry and ulnar paradox IN DETAIL - WOULDN'T LET ME GO TILL I DEMONSTRATED IT
ON MY OWN HAND.

Then asked me about the difference in action o f flexor digitorum superficialis and flexor
d ig ito ru m profundus - based on th e ir attachm ents. He to ld me to assume he was a patient
and to check his profundus and superficialis function separately - g ot very happy when I
dem onstrated it. Said good at the end and beamed w ith pride lol.

Surgical Pathology (One o f these is a p ilo t s tation):

1. Scenario : A young lady w ith endom etriosis is at your clinic concerned th a t her father
died o f a cancer a t an early age. She had a colonoscopy ju st now which revealed m u ltip le
polyps, th e larges one being 7 m m and ulcerated.

Then exam iner asked questions about this : asked me the diagnosis, I said FAP and she
seemed to accept it (I have second thoughts about this now), then asked gene involved in
FAP, types o f o th e r cancer causing genes, types o f adenomas, w hich one has the highest
chances o f causing malignancy, then showed a printed picture o f a cancer in filtra tin g
through the submucosa but not breaching it w ith 1 lym ph node positive, asked the DUKES
classification (which I knew) and TNM (which I d id n 't know so I to o k a guess and said T2,
stage 2 and she frow ned and asked me again but I said I d o n 't know TNM so she m oved on).
Then she asked w h a t are th e extra colonic m anifestations o f FAP.. w anted the exact types o f
tu m o rs in all locations which I d id n 't know. Then asked w hat is endom etriosis, describe the
epitheliu m o f the uterus (d id n 't like anything I to ld her about th e uterus - I th in k she w anted
to hear the horm onal changes etc associated w ith epithelial changes, blah - she was nice but
hard to read). Then asked if theres anything I know about recent studies th a t show an
association betw een endom etriosis and malignancy - I to o k a guess and said it is associated
w ith an increased ris k , she said where, I said I d o n 't know. And I saw her m arking a zero
th e re lol. So m y guess was rig ht (as I checked a fte r the exam - endom etriosis is associated
w ith increased risk o f ovarian cancer). I saw m y marks here - got a 10 here. Couldn't name
all th e cancer genes she w anted. Also, she asked w hat advice I w ould give to this lady fo r her
son and I said he w ould have to be screened beginning at age 12 and have colectom y at age
2 0 , she said w hy I said because he w ill get cancer fo r sure by the age o f 40. She accepted
th a t but th e re was d e fin ite ly som ething else here..?

2. Patient w ith hypothyroidism had a hard swelling in her right inguinal region, GP sent her
fo r biopsy, answer th e questions th a t follow :

Am erican exam iner here w ho stood up to greet all candidates, introduced him self and
apologised if w e co u ld n 't get his accent (which all o f us could lol but he was sweet). The
scenario was vague so I thanked God w hen he questions started w ith probable diagnosis. He
said name d iffe re n t types o f lym phom a ,1 said Hodgkin and nonhodgkin and he was happy
(unbelievable). He said w hat w ould favour diagnosis o f th a t (w eight loss, lym phadenopathy,
pancytopenias, etc), he said w h at are o th e r differentials, I named only a fe w causes o f
enlarged lym ph nodes and he was happy. Then he said so okay the results o f our report are
here and it's a m elanom a - w ha t are th e types o f a melom a? W hat is epithelioid melanom a
(d id n 't know this, made up a random d e fin itio n saying its probably a histological fo rm
describing w h at the melanoma looks like - ie, like an epithelium LOL and he accepted it.
Then asked now the m elanom a p a tie n t is here to see you , w here w ould you examine her
and w hy - I said I w a nt to look fo r th e prim ary and I w ant to check fo r fu rth e r mets. He
accepted th a t and asked w here w ill you look fo r prim ary - I said back o f legs and back (since
m ost com m on site in w om en, but I fo rg o t this was an old wom an) and hes like and where
else .. I d id n 't know so he said nail beds and palms and soles (basically w anted all sites, not
ju st th e com m on ones). Then said w hat systems w ill you examine and w hy - chest fo r mets,
brain fo r mets, etc), th e n said how can you tre a t this patient by surgery - to remove the
prim ary and rem ove mets and o ffe r chem o/radio - seemed happy. Then said how can you
know phenotype o f th e tu m o r - I said im m unocytochem istry. Seemed to accept that. Then
said okay so yo ur m elanom a p atient has had her melanom a rem oval fro m the inguinal
region - her w ound is red and swollen but shes otherw ise w ell - culture shows diplococci -
name organism? Next the patient gets toxem ia, swollen groin region w ith rapidly spreading
infection - w ha t are you concerned about (Necrotising fasciitis). W hat is SIRS? W hat
happens to the lungs in SIRS (ARDS) - Define ARDS (W anted pathological d e fin itio n ,n o t the
pulm onary wedge capillary pressure crap). W here w ill you adm it if she has ARDS? How w ill
you tre a t her? W hat are the long te rm sequelae o f ARDS. Phew. He g o t up to say thank you.
Very courteous. I d o n 't know how this station w ent though :S Sometim es he was happy,
som etim es he was blank. :S

3. Scenario o f a young wom an w ith hep c, had splenic injury, bloods show deranged
coagulation profile (all aptt, pt etc increased), severely hypotensive, high fever, etc -
consultant asked differentials, happy w hen I said die, haem orrhage, etc. asked w hat is
die and got happy w hen I said it is w idespread activation o f coagulation and
consum ption o f coag factors thus leading to subsequent bleeding, he said w hat are the
risk factors in this patient, how w ould you manage, w hy does die occur in such
patients,w h at are platelets w here are they produced w hat are th e ir functions (like
seriously?), ju st w anted to hear platelet plugs lol I wasted 2 m inutes ram bling on
anyway. Then he asked w h at is aptt, w hat does it mean w h a t factors and w hat pathway
involved (I fum bled a little on these horrid pathways), he w anted basic teeny tin y details
such as exposure o f ecm , diapedesis, chemotaxis etc. then said okay te ll me the stages
o f fracture h e a lin g , I started w ith the basic three, he smiles and then said no I w ant to
hear at th e cellular level - nobody got this right. A pparently he w anted a breakdown o f
all th e inflam m atory and bone cells and how th e y co n trib u te togethe r to healing. At this
p oint, I gave up tryin g to think about such m inute details. Just said sorry th a t's all I know.
He was tryin g to push me but oh w ell. Anyway, all the exam iners really do try to pass, as
you can see fro m this lengthy discussion.

A p p lie d Sciences/Critical Care:

1. Scenario m orphine toxicity, given ABGs report.

Nice exam iner, w o u ld n 't le t you go till you answer everything but d id n 't let anyone know
w h e th e r th e y w ere rig ht o r w rong. Asked me to in te rp re t the ABGs- respiratory acidosis.
W hat type o f respiratory failure, why. W hy is the bicarb norm al, w hy does m orphine cause
this - how w ould you tre a t th is p atient (couldn't rem em ber naloxone, w anted to kill m yself
here lol). How do kidneys regulate acid base balance, w hat are the types o f resp failure and
w ha t are th e ir causes, describe how C02 retention causes respiratory failure, w rite co2
bicarb equation along w ith its enzyme, where does it happen, describe chloride shift
(co uldn 't get this righ t so stopped m yself fro m blurting o u t crazy stu ff and said sorry ill just
skip this, he d id n 't seem pleased and kept saying lets come back to this again - brain was
to ta lly fried because how he was bom barding questions - sort o f like House,M.D. Every
answer fo llo w e d by w hy. D idn't w a n t to grade th a t easily. I feel like I answered m ost here
b ut even the n I d id n 't do well.

2. Scenario w ith a dude w ho lobectom y and is now on epidural anesthesia. Has right sided
upper lim b paraesthesia, oliguria, low blood pressure, etc.

Nice consultant here, helping us g et to the answer. Asked possible causes, w hat you would
do to (stop epidural im m ediately etc), w hy w ould epidural cause this : increased dose,
incorrect positioning, spinal level to o high, etc. w ho w ould you involve(w anted someone in
addition to th e anesthetist). W hat s/s w ould te ll you patient is getting worse, w hat w ould
te ll you hes getting better. W hy epidural in this case (because post op pain in a patient w ith
lobectom y and h /o copd w ould .... Described lung physio and path here, he seemed to
accept it). Asked if th e re is any recent evidence suggesting epidurals im prove outcom e, I said
yes and he was happy. Asked how I w ould check epidural level and w hy - w hat levels used
fo r w hich surgeries, w hy is higher block dangerous (phrenic nerve, diaphragm paralysis etc),
w hy do w e check tem pe ra ture (I said arrangem ent o f fibres, because m o to r are last to be
affected, seemed to accept it). Nice exam iner but again, n o t easy to read.

3. Scenario o f head injury w ith lucid interval - lovely exam iner, very helpful.

Asked nice guidelines on w hen p atient should be seen, w hy is patient intubated (gcs 8), look
at ct and te ll me w h at you see (extradural hem atom a), w hat is lucid interval and explain its
pathophysiology (concussion>recovery>middle m eningeal a rte ry bleed and collection>raised
icp>herniation>death). Explain M onroe-kelly, explain w hy icp rises in EDH (blood increases
so CSF has to decrease, etc), w h at is MAP, w hat is CSF pressure, w hy hypertension in raised
ICP, name the tria d (only question I co uldn't answer here, fo r some w eird reason th e triad
slipped m y m ind..and th en the exam iner said d o n 't w o rry you've answered everything else
lol. Since im fro m neurosurgery, I to o k this badly th a t I could not regurgitate th e name of
this tria d ..i'll leave it to you).

SKILLS:

C om m unication:

1. Patient w ho presented w ith dysphagia fo r th e past 6 m onths had barium sw allow which
came o u t to be benign, consultant wants to do an OGD w ith biopsy but consultant has
been called in fo r a m eeting so consent the patient (consultant w ill jo in later)and te ll him
th e risks o f dilation particularly. Patient kept asking if this is m alignant, if his drinking and
sm oking caused this,l to ld him we cant know fo r sure till the biopsy, to ld him low risk o f
bleeding, infection and p erforation, etc. he said how soon w ill we know if there is a
p erfo ra tion . D idn't get the chance to even look at the examiner, very talkative patient,
kept talking till the bell rang w ith all the candidates. Guess we all dad badly?!
2. ISBAR - Patient on post op day developed axillary swelling a fte r lum pectom y and
sentinel node biopsy but daughter wants to take her hom e so talk to the consultant on
call and ask him to intervene. The dates on this w ere fro m last year, past paper question
o f course but I got confused w ith the dates. Had to make a m ental map o f dates
spanning over a m onth, fro m last year. Not nice during th e exam, w o n t pass this one I
th in k because I d id n 't notice the patient had longstanding COPD and LVF and consultant
asked me a bo ut th a t in particular :S
History:

1. Lower back pain (consultant looked like he was sick o f life, kept saying youre running out
o f t im e ) : mechanical back pain, patient known case o f IBS, managed w ell at the
m om ent. Obese, etc. consultant asked differentials, how to investigate, red flags, how to
rule o u t the d ifferentials based on history alone, etc.
2. H istory o f enlarged to nsil (very nice consultant, w earing a cool leather jacket lol): same
old case guys. Patient had w eight loss, night sweating,no h /o travel. He w anted to hear
how I w ould rule o u t th e misdiagnosis o f an enlarged tonsil, differentials, investigations
(just started w ith bloods, peripheral smear, said fnac but he said w hat w ould you see on
bloods, I started here but bell rang -h e seemed satisfied though.

Examination and Procedures:

1. D ebridem ent o f a d irty w ound : nice, old consultant. W anted to see us probing the
w ound properly, patient was consented (chicken leg lol). W hat anesthetic w ould you use
and w hats the dose, how w ould you close, w hat w ould you do if radial artery cut, w hat
to do if m edian nerve damaged, w h a t precautions to take (made me recite com plete
tetanus im m unization schedule), w hat a n tibiotic to give, w h a t post-procedural advice.
2. FNAC - Very sweet consultant, was acting as the assistant - usual questions, w hat local
anesthetic, how much (anxious young man w ith fake skin/m uscle layers attached to his
thigh w ith baby tom atoes sandwiched in th e m iddle lol) - consultant asked how to
prepare slides, w hen w ill re port be available..patient kept asking is it m alignant when
w ill I know, very anxious patient constantly saying ow ow ow lol. Even though I had given
LA and checked th a t he co u ld n 't feel anything, was constantly telling him im sorry, just
bear w ith me, we are alm ost done etc. w arned him before needle prick etc b u t he kept
saying being dram atic. Consultant w asn't bothered by this to o (he seemed sick o f the
overacting to o lol). D idn't make me do the fnac form ally, just w anted an overall m ethod
and principles o f slide preparation and which needle to use, how many tim es should
needle be put into th e lesion, which labs to send to, etc. easy station phew.
3. Vascular exam ination o f lo w e r limbs - im going to fail this fo r sure because I fo rg o t to
palpate the fem oral arteries, imagine! Really w ant to die w hen I th in k about it. Was my
second last station, was alm ost dead lol. Simple station though, le ft dorsalis pedis
im palpable, p atie nt had sternotom y and long saphenous vein g ra ft scar b ut exam iner
specifically said d o n 't examine anything else just examine his legs. He was watching like
a hawk w hich is w hy I to ta lly freaked out, he was w atching every single move I made,
even kept handing me s tu ff to aid the exam ination (Doppler, etc, co u ld n 't g et the
D oppler to w o rk because 6 m inute bell rang and I freaked out started hurrying but he
stopped me and said its okay just summarise, I said no pulse on right he said w ell yeah
you fo rg o t fem oral. I was m o rtifie d o f course. He said its okay now te ll me how w ould
you investigate, I said I w ould try to do ABPI first, then grade according to th a t and then
consider Doppler US, angio, etc etc. he accepted th a t but was very disappointed - very
understandable. I'd be super angry if I w ere in his place. Nerves, people nerves. If your
exam iners are w atching you, rem em ber you gotta try to som ehow blind yourself to that.
4. A bdom inal exam ination : severe peritonism in a p atient w ho w o u ld n 't let us touch him,
vitals next to him , had fever tachy, longstanding history o f constipation now has
vo m itin g and diarhea..easy station. Consultant w anted to specifically diverticulitis,
perfo ra tion , obstruction and CHEST XRAY fo r air under diaphragm . He said how w ould
you manage such a p atie nt in ER I said start w ith airway breathing circulation (to
 stabilise patient before starting d e fin ite tre a tm e n t) and he got annoyed, he said this isn't
traum a so I said w ell I w ould like to stabilise him before I do investigations, he seemed
annoyed again and said okay lol. Then he said so how w ould you tre a t, happy
N PO ,fluids,antibiotics,but d id n 't w ant to hear anything apart frm chest xray fo r
investigations (w eird right?), but th e good thing is he was easy to read and was guiding
about w ha t answers hes looking for.
5. Abdom inal exam ination on a patient w ho had surgery fo r sigmoid colectom y -
consultant said d o n 't take o ff bandage - patient very te n d e r in le ft iliac fossa, no o th e r
findings except AFib n ecg - consultant asked about differentials - anastom otic leak and
th en generalised to com m on causes o f post op fever, etc. random usual easy station.
6. Lower back pain, le ft I5 s l parasthesias - disc prolapse. Active sir on le ft at 45 degrees,
consultant w o u ld n 't le t me com plete all the steps, said its okay d o n 't expose to o much,
d o n 't do all sensory exam lol very kind, ju s t checking all th e steps and making me move
on. W anted differentials and how to investigate, w hy s i affected in 15-sl.
Day-1
1.Telephone station perforation itu,
2.Pre Operative confusion,
3.Anatomy leg,
4.Malignant melanoma,
5.Sepsis critical care,
6.Post abdomanial wall anatomy,
7.Naevus excision,
8.Claudication examination,
9.History abdominal pain,
10.Anatom y posterior neck dissection,
11.Rhd Endocarditis pathology,
12.Post op hypotension,
13.CV line and complication,
14.Ot list,
15.Spleen rupture counselling,
16.Post op chest pain
Day-2
Total recall part 2.
Anatomy.
1. Cerebral angio, cerebral blood supply, berry anurym, carotid canal, cavernous sinus, SAH.
2. Lower leg and foot anatom y
3. Neck: thyroid, parathyroid, vagus, recurrent laryngeal, etc
Surgical pathology
1. Temporal arteritis, steroid, hip fracture, fat embolism
2. Infective endocarditis ( thank you).
3. Pregnant lady with perforated gb. Head down position and low bp. Physiology etc
4. Pneumothorax post cvp.
Surgical skills.
1. FNAC
2. Suturing of wound.
3. Examination on hernia
4. Lower limb vascular examination
5. Lower limb neurological examination
6. CVS EXAMINATION (aortic stenosis)
Communication
Talking to consultant.
1. Truma with head and lower limb injury. Catch was free fluid on us.
History

1. Loose motion
2. Knee pain
Counseling.
1. Angry patient cancelled twice fo r arthroscopic repair.
Anatomy
1. Lower limb
STEM: Young man fell off the horse, trapp ed under for hours.
Questions:
> Live patient lying there.
> Surface m ark lateral malleolus, w hat bone is it from
> Surface m ark EHL
> Show the m ovem ent of TA+TP, PL+PB, gastro cn em iu s+ so leu s
> Attachments o f p eron eu s longus, brevis, tertius
> C auses o f foot drop
> M yotomes o f LL + reflexes (sh o w how your elicit knee jerk, ankle jerk)
> Show S I derm atom e
> Name peripheral nerves o f LL
> Name com partm en ts o f the LL and nerve supply
> Muscles o f p osterior com partm en t o f LL
> Patient com plaining of intense pain o f LL given stem, w hat do you su sp ect
(com partm en t syndrom e)

2. T horax and Abdom en

Questions:
> This is a cadaveric station.
> Point to the pulm onary trunk, ascen din g aorta
> Branches o f the ascen din g aorta
> Right ventricle: Name the stru ctures (tricuspid valve, chordae tendinae,
papillary m uscles), their function
> Origin of sym pathetic chain (T1-L2)
> What joins the sym pathetic chain to the spinal nerves (grey rami
com m itantes)
> Identify spleen, blood supply, w hat may be injured during a splenectom y
> Anatomy of the splenic artery an d w hat it su pplies
> Identify gallbladder, su rface marking
> Why would a patient with RUQ pain also have sh o u lder tip pain? Explain
referred pain.

3. Head and Neck

STEM: Man post radical neck dissection for so m e head and neck tum our
Questions:
> This is a cadaveric station.
> Boundaries o f the p osterior triangle
> Identify acce sso ry nerve, w hat d o e s it supply, what h app en s when it is
paralyzed, how to test these m uscles
> Identify the omohyoid
> Identify g re at auricular nerve, what d o e s it supply
> Identify digastric, hypoglossal nerve
> What are the extrinsic m uscles of the tongue, what is the nerve supply,
what muscle respon sible for retraction of the tongue
 > LN mets: what are the p ossible prim aries
> Histo slide of LN: malignant m elanom a mets

Pathology
1. RHD and IE
STEM: 61yo lady, AVR secon dary to AS, PMHx o f joint pains during childhood,
w orsening cardiac function

Questions:
> What do you su sp e c t the patient has?
> What is RHD
> What cau sed the AS?
> 1 hematological test to monitor p ro gressio n of RHD: ESR
> After AVR. why is there a need to anti-coagulate?
> What is the m o st com monly u sed anti-coagulant (warfarin)
> What is the MOA of w arfarin? What test would you do to monitor?
> Lady now presenting with fever. What is the main concern (IE)
> Causative o rg an ism s o f IE, pathophysiology of IE, why is it hard to treat?
> Persistent IE despite treatment, what surgical m an agem en t is definitive?
> W orsening CCF, need transplant, w hat kind o f matching m ost im portant?
(HLA)
> How do im m u n o su p p re ssa n ts w ork? MOA. What sid e effects?
(Malignancy, Infection)

2. M alignant m elanom a (repeat)

Questions:
> How to differentiate m elanom a from SCC
> What are poor prognostic factors?
> What gene is associated with m alignant m elanom a
> What skin condition is asso ciate d with m elanom a?
> What are the other risk factors of m alignant m elanom a?
> Lesion excised Breslow thickness 1.5mm, m argins 0.5cm w hat to do?
> General principles o f surgery. If go for re-excision, w hat to do to ensure
ad eq u ate m argins this time round? (Mohs micrographic surgery, frozen
section)
> Post axillary clearance com plained of arm pain and swelling (axillary vein
throm bosis)
> Risk factors for th rom bosis (Virchow's triad). For this case, malignancy
p re d isp o se s to a pro-throm botic state.

Critical Care
1. Septic shock (repeat)
STEM: Som e guy POD 4 p o st anterior resection, vitals charts, so m e investigations
Febrile, BP low TW > 1 6 RR 28 Tachycardic
RP, ABG, FBC results given.

Questions:
 > What do you think is happening + differentials for POD4 fever. Give the
whole list.
> What is septic shock?
> What is the evidence (show you know SIRS criteria)?
> Initial m an agem en t for septic shock
> Interpret the U /E/C r, ABG, FBC

2. Spinal an esth esia and hypotension

STEM: Post-TKR POD 0 / 1 Spinal anesthesia, has hypotension
Vitals chart provided with I/O charts

Questions:
> What is shock?
> C auses o f shock in this patient and why
> Shown several timelines, ask ed to interpret the vitals - basically
hypotensive
> What bedsid e intervention can you do - insert urinary catheter to
monitor urine output
> How to give fluids, w hat method to decide
> Colloids vs crystalloids
> Frequency of monitoring (w as Q4h) - insufficient
> Asked BP = COxSVR, how to improve BP
> Asked about inotropic support. How d o e s each drug act?

3. CVP insertion and pneum othorax

STEM: CVP insertion by sen io r reg, post-procedure com plained o f SOB, CXR done
Questions:
> How to a s s e s s breathing?
> Investigations to do when SOB
> Principle o f reading an XR? E.g. identify correct patient, projection, etc.
> How do you read a CXR? Is the CXR ad eq u ate (no costophrenic angles
visualized in given CXR), w hat do you se e (L sid ed pneum othorax)
> What kinds of PTX do you know
> CVP line insertion - landm arks for IJV cannulation, alternative method
(subclavian, US guided)
> Complications of CVP insertion other than PTX
> How to prevent line infection, risk factors for line infection

Communications
1. Anxious m other (rep eat)
STEM: 9yo boy fell down in playground com plained of L flank pain, BIB dad who
w a s "un steady on his feet, emotional". BP borderline tachycardic, pale, Scans
suggestive o f splenic injury for em ergency op, consent taken from dad. Prep
station prior, given medical records show ing pt presenting to A&E, review by
surgical registrar/con sultan t, decision for op, con sen t taken from dad, aiming for
splenic repair, KIV partial splenectom y. Aim to conserve spleen. You a re the new
A&E doctor who starte d your shift. Need to go talk to patient's mother. Patient is
now in OT. Anxious m other com es in, a d d r e s s her concerns. (They a re divorced,
she thinks he is drinking, pre- and post-operative m an agem en t if splenectomy.
Other question s include w hat if the whole spleen is rem oved? Talk a little about
antibiotics prophylaxis, imm unizations)

2. R equest for ITU bed and pre-operative m anagem ent (repeat)

STEM: 73yo lady adm itted with vague sy m p to m s o f feeling unwell, PMHx COPD.
Later c / o abd o pain, 0 / E generalized peritonitis, desat, tachycardic. Ix T1RF, AKI,
hypoK, CXR/AXR before on set of pain NAD. (Sell your story, ask ed for pre-op
optimization, rem em b er to write down in case of read back requested, offer to
check with consultant, DON'T LIE!)

Physical examination
1. Hernia
2. Knee exam ination
3. LL (V ascular/N euro)
4. DVT/PE - Do ap p ro p riate exam ination, L calf ten der ++

History taking
1. Low m ood post-gastrectom y
STEM: Som e guy POD 6 p ost-gastrectom y good functional recovery noted to be
low mood. N urses concerned he is d ep ressed , take a Hx. Rmb to screen mental
state!! Asked abo u t management.

2. Acute pan creatitis

STEM: 45yo lady with acute o nset abd o pain after alcoholic binge, radiates to
back, sh arp pain. Also had Hx o f RHC pain couple o f y ears ago, sa w GP given PPI
with good relief. Asked about m ost likely diagnosis (pancreatitis 2' to excess
alcohol intake), other differentials, te sts to confirm, what other te sts to do
(bloods, ultrasound HBS), m an agem en t plan.

Procedures
1. Excision of likely benign naevus
Consent already taken. LA given. Do the procedure.
Provide followup instructions for patient.

2. OT listing (rep eat)

The 3 c a se s w ere (a) MRSA patient with DM coming for L) BKA (b) stran gulated
hernia with COPD (c) diverticular a b sc e ss requiring H artm an's procedure allergy
to iodine prep. Asked abo ut w hat type of skin cleansing prep. Which case would
you list first an d why?
ASP (5 stations)
1) Brachial plexus
• Nerve roots? Point at skeletal model
• Sensory dermatomes
• Which reflexes would you like to test?
• Muscles and sensory supply of musculocutaneous
• How do you test for brachioradialis?
• Which nerve supplies brachioradialis?
• Where to test sensation of radial nerve?
• Which nerve supplies deltoid and what's the sensory area?
• What initiates shoulder abduction?
• Which muscle?
• Where's the attachment of supraspinatus?
• Which muscles rotate the scapula?
• Serratus anterior insertion and nerve supply

2) Abdominal wall prosection

• EOM, nerve supply
• IOM
• TF
• Shiny fibers run anterior to the inguinal canal, what is that?
• Direction of EOM
• Which muscles form the conjoint tendon?
• Pain on extension of the hip, which muscle?
• Psoas muscle-pinpoint
• Rationales behind peri umbilical to RLQ
• W hat’s the dermatome of umbilicus?
• Sometimes we do need to extend the incision during appendicectomy, what's
the potential nerve damage? W hat is the other nerve? What's the nerve root
supply?
• Which embryological remnant would you think about when it comes to
appendix?
• Any rule to that?
• Does that apply to all?
• Identify ovary? Fallopian tube?
• Rectovesical pouch/rectovaginal pouch/Douglas

3) Posterior limb, popliteal fossa

• Two points to locate sciatic
• Muscles of hamstring
• 3 actions of hamstrings
• Identify neurovascular bundle
• One diagnosis for each structure
• Tredelenburg test and the causes
• What does popliteal node drain
4) Prostate cancer
Radical prostatectomy
• 3 blood investigations
• W hat’s main component in white cell count?
• What causes increase WCC post op?
• If UTI, what’s the common organism?
• What multiple biopsy taken?
• W hat’s the grading system?
• If PSA post op 6 months is 3, what do you think? Why?
• Bone mets, which blood component will raise?
• Normally in prostate cancer, one of the treatments is bilateral orchidectomy.
What is your rationale?
• Which primary cell in testes produce testosterone?

5) MEN syndrome
Patient with parathyroid hyperplasia.
• What is hyperplasia?
• Usually hyperplasia involves how many parathyroid?
• Insulinoma- what is the insulin level?
• How do you diagnose?
• Given that this is having parathyroid and pancreatic involvement, what is the
other pathology? What does it called?
• Apart from tumor suppressor gene, what are the other groups of gene
mutation?
• W hat’s a telomere?
• W hat’s apoptosis? Is it energy driven?

ASSCC (3 stations)
6) TURP syndrome
Post op TURP, long hours under SA, hypotensive
• What's your DDx?
• Evaluate blood investigations
• Low P a02, why?
• How does TUR syndrome occur?
• What are the systemic complications of TURP?
• How does hyponatremia lead to his confusion?
• How do you specifically treat TURP?
• Which diuretic would you use?
• Where's the action of loop diuretics?

7) Pain assessment
• How do you assess pain?
• What is your opinion on this likert scale?
• Given this medication chart, what is your order to the nurse?
• If pain still inadequately control despite adequate analgesics, what will you do?
• How does pain affect patient post operatively?
• W hat’s the complications of opioids?
 • What do you know about PCA?
• W hat’s the complications of PCA?

8) Long standing Crohn's; Nutrition

Please interpret this Xray on iPad
• What is the cause of your diagnosis?
• What are the possible methods of feeding?
• W hat’re the main constituents in feeding?
• W hat’s the main constituent in TPN?
• Indications of TPN
• W hat’s the complications of TPN?
• What happens to the gut if parentally fed?
• W hat’s the result of mucosal atrophy?
• What are the complications of glucose only feeding?
• W hat’s the complications of enteral feeding?

CPS (2 stations)
9) O T Iist
• How would you arrange? Why?
• If iodine allergy, what to use?
• If penicillin allergy, what to use?
• Do you give antibiotics?
• Pre/peri op management of pacemaker, anticoagulant, atrial fibrillation, COPD?
• Which diathermy to use?
• How does mono/bipolar work?
• Where to use place the pad? Demonstrate
• What are the complications of diathermy?

10) Sutures
• Hand tie with braided non absorbable
• Deep cavity hand tie with braided absorbable
• Hemostatic suture with figure of 8 using nonabsorbable monofilament

CSH (2 stations)
11)Hx headache
• DDx
• What investigation would you like to do?
• Can you detect a tumor in CT?

12)Hx difficulty in passing urine

• DDx
• What investigations would you like to do?
• How do you differentiate BPH and early prostate cancer?
• How do you investigate if it's a prostate tumor?

CSI (2 stations)
13)ICU referral, pre op optimization
14)Emergency splenectomy

CPE (4 stations)
15)Cranial nerve, mental status examination
• W hat’s the chart called to assess visual acuity?
• And at what distance?
• What do you like to look for in fundoscopy?
• W hat’s the diagnosis?

16)Lipoma at supraclavicular fossa

• DDx
• Features of lipoma
• Radiological investigations
• How does USG differentiate between your DDx?
• If soft tissue what other Ix would you order?
• How to you manage a lipoma?
• W hat’s the name of the procedure?
• In his situation, what form of anesthetic would you perform under?
• How do you tell whether it’s a malignant mass?

17)CVS
• Pre op workout for CVS

18)Varicose vein
• What other Ix would you like to do?
• What are the risk factors of varicose vein?
• What other examination would you like to perform?
• How do you treat varicose vein? Conservative/surgical
• What is the contraindication of varicose vein surgery?
Qn 1: Pathology

Scenario given o f a lady known to have Ulcerative Colitis and on surveillance colonoscopy. Found to
have a lesion less than a cm in sigmoid colon. Currently the disease itself is under control.

1) W hat is ulcerative colitis

2) w hat w ill you o ffe r the lady (total colectomy)
3) why to ta l colectomy (be whole colon susceptible)
4) w hat genes are responsible fo r transform ation to cancer (K-ras, p-53)
5) w hat kind o f genes are these (proto-oncogene and tu m o r suppressor)
6) how do these genes work? (act as gate keepers)
7) w hat do they do? (I am not sure I got this right...he tried to get it out o f me.. I said apoptosis in
the end and he seemed to have accepted it)
8) showed me a picture and asked TNM stage fo r that

Qn2 : Physiology/CC

An elderly patient w ith dementia and underwent urinary retention. His labs showed hyperkalemia and
hyponatremia along w ith AKI. Also he was catheterized and poured out 4L o f urine.

1) W hat do the labs show (hyperkalemia, AKI and hyponatremia)

2) Why has the p t poured out 4L o f urine (recovery phase o f AKI, I am not sure if this was correct)
but he seemed to have accepted it.
3) How does this polyuria phase occur in recovery o f AKI ( inability to concentrate urine)
4) W hat are the causes o f hyponatrem ia in this patient? (SIADH due to distension o f bladder)
5) W hat other surgical discipline uses hyperkalemia (cardiac surgery)
6) W hat is it called (cardioplegia)
7) There were one or tw o m ore qns.. sorry cant recall

Qn3: Critcal Care

Someone w ith RTA and is tachypneic and tachycardic

1) On receiving this patient how w ill you manage his airway and breathing (ATLS)
2) X-ray shown., very poor quality...asked fo r findings (surgical emphysema, rib fractures and
pneumothorax)
 3) Pt in shock.... How w ill you resuscitate (crystalloids, colloids, blood, urinary c a th e te r) he kept
asking fo r m ore ways o f resus... I w asn't sure w t more he wanted to know
4) How w ill you know the response ( from heart rate, BP, m entation, capillary refill and urinary
output)
5) He showed me a CT image., findings., (liver laceration)
6) M anagement ( conservative initially)
7) W hat is conservative management (Hb m onitoring 6hrly and com plete bed rest) if fails then
laparotomy.
8) Is CT a good investigation in this patient (no... the pt was hypotensive and should have
undergone a FAST)

Qn4 : Pathology

Patient w ith a recent history o f diarrhea and PR bleed., no more episodes since 6 hours... now presents
to you.

1) W hat do these labs show ( anemia, leukocytosis and thrombocytosis)

2) Explain each ( anemia sec to bleeding, leuko be o f infection and throm bo be o f acute phase
reaction)
3) Which type o f anemia (norm ochrom ic and normocytic)
4) Why ? as blood is lost as a total
5) Differentials (colitis, GE or tu m o r bleed)
6) How w ill you investigate ( esr, crp, p t/in r, scope later once acute episode settles, SDR)
7) W ould you transfuse this patient ( no, vitally stable and bleeding episodes have stopped)
8) W hat are your concerns regarding transfusion (decreases im m unity, electrolyte imbalance,
infections)
9) W hat else (Jehovas)

Qn 5: Clinical examination

You have a patient w ho has lower back pain which is involving his le ft leg and thigh. Examine

Time was to o short to examine his back and lim b fo r everything... he stopped me at 6 min

1) Present your findings

2) W hat else w ould you like to examine ( saddle anaesthesia)
3) Why w ould you do a DRE
4) Investigations (MRI)
5) Differentials (vascular or neurogenic problem)
 6) How w ill you treat( I did not answer this as bell rung on qn 5 only ) so there could be more parts
to it

Qn6: Examine this patients limb fo r vascular pathology. He is to undergo hip replacement

It was a left sided ischemic limb w ith no pulses beyond fem oral

1) Present your findings

2) Should he undergo hip replacement (No, vascular issues need to be sorted first)
3) How w ill you investigate (ABPI and duplex and angiogram)
4) Bell rang.. I think next qn was management

Qn7: Examine the patients neck and relevant general physical

She had a diffusely enlarged thyroid gland. Also looked fo r peripheral signs

1) Present your findings

2) W hat is the status o f thyroid clinically
3) How w ill you investigate
4) Treatm ent (reassurance and call her back fo r follow up)

Qn 8: Pre-op patient fo r hernia. Examine his CVS

Patient had a sternotom y scar w ith ejection syst m urm ur

1) Present your findings

2) W hat is ur concern (anticoag)
3) How w ill you manage it perioperatively

Qn 9 : Elicit history from a lady w ith PR bleed

She had alternating bowel movements, fam ily history o f cancer and PR bleed

1) Present your history

 2) How w ill you investigate
3) Cant rem em ber the other qns

Qn 10: Elicit history from a young man w ith back pain

He had symptoms o f sciatica w ith red flag signs

1) Present ur history
2) Differentials (sciatica, vascular prob, spinal stenosis)
3) Investigation (MRI)
4) Treatm ent (surg as red flag signs)

Qn 11 : Pathology

Same Gall bladder carcinoma stem w ith wound infection and pseudomembranous colitis

Qn 12: model given., patient w ith RTA... perform

1) Ways o f managing airway (chin lift, jaw thrust, guidel airway, LMA, Intubation) had to perform
chin lift, jaw thrust
2) U have no facility o f intubation., now w hat ( cricothy)
3) Secure patients c-spine... u have to make the model wear a collar
4) Use bag-mask and ventilate pt ( they were looking for how you applied it to models face and
w hether lungs w ere rising on inflation)
5) How w ill you check patients breathing?
6) Investigations
7) N some relevant qns th a t I cant recall but were not difficult

Q n l3 : gather inform ation and call vascular consultant. Same qn p t adm itted w ith diverticulitis and now
had ischemic limb.

Qn 14: counseling.

Same old qn. Patient w ith dysphagia. Counsel regarding endoscopy and dilatation.

Qn 15: Anatomy

Sharjah does not have prosections so they had pictures.

Lower limb.

1) Identify muscles, (gluteus maximus,medius and minimus)

2) Functions and nerve supply
3) Pointed to iliotibial tract
4) W t is its function (stabilizes knee)
5) Femoral triangle
6) Bicep femoris (tw o heads and th e ir nerve supply)
7) Muscles o f leg and func
8) And may b one or more qns cant recall

Qn 16: Anatomy

Head and neck:

1) Pointed to thyroid. W hat is this? How many lobes

2) Arterial and venous supply. W here do they originate and drain ?
3) Cricothyroid membrane
4) Attachm ent o f vocal cords
5) Point to cricoid cartilage
6) Nerves at risk
7) Recurrent if damaged then w t happens
8) And may be one m ore qn cant recall

Qn 17: Anatomy

Upper limb

1) Name the bones ( clavicle, humerus and scapula) and asked fo r parts as pointed
2) Which side to they belong
3) Articular humerus w ith scapula
4) Elicit movements o f shoulder jo in t on bones
5) Articulate clavicle w ith scapula
6) Factors responsible fo r jo in t stability
7) Rotator cuff and nerve supply
8) Pec major origin and insertion and nerve supply
9) Func o f pec major
Q n l8 : organize theatre list. Same old qn o f diverticular abscess, strangulated hernia and diabetic fo o t
w ith MRSA

Good luck all. Remember me in your prayers.

Anatomy

P a ro tid a n d CN 7 A n a t

- Surface mark parotid gland

- Surface mark parotid duct; how long?

- Duct drains to?

- There is a 2x2 lump over 1 side o f a parotid, tender. W hat is it? (Ans examiner

looking for: LN)

- Inflam m atory causes o f parotid swelling. (Ans examiner looking for: sjogrens and

mumps)

- Benign causes o f parotid swelling.

- M alignant causes o f parotid swelling, primary: MAP-

m ucoepidermoid,adenocystic,pleomorphic adenoca , secondary

- CN carrying parasympathetic fibres. 3,7,9,10

- Gustatory sweating. Freys syndrome. Explanation.

- Intracranial course o f facial nerve. (1AM to exit stylomastoid foramen)

- Indicate on prosection 1AM and stylom astoid foramen.

- Branches o f facial nerve a fte r parotid. Indicate on prosection.

Sp in e

- Which vertebra are these? (Lumbar)

- Parts o f vertebra

- Articulating surfaces

- Intervertebral foramen

- W here is the ALL, PLL, lig flavum.

- Shown MRI. Number the vertebras.

- MRI: intervertebral disc, point.

- Anat o f intervertebral disc

- W hat type o f jo in t

- Disorders o f disc

- If disc herniates, which nerve root affected.

- Sensory area fo r L5

- W hat is in the Extra Dural Space

- How does metastasis happen

Oesophagus

- Level o f oesophagus.

- Surface mark beginning o f oesophagus. (C6)

- Border o f post mediastinum.

- Identify: Symp chain, azygous vein, descending aorta, phrenic, L vagus (recurrent

laryngeal).

- Arterial supply, Venous drainage, Lymphatic drainage o f entire oesophagus.

- W hat is achalasia?

- Microscopic features o f achalasia.

- W hat is barrett's oesophagus? W hy do we care if barren's?

- W hat is the histological normal lining o f oesophagus? And in Barrett's?

CRITICAL CARE AND PATHOLOGY

l.P T H , H ypercalcem ia, R e n a l stone, G a stric ulcer, H p y lo ri

- W hat is an ulcer?

- M ost likely cause fo r the ulcer? (H pylori)

- W hat is CLO test? How does it work?

- Treatm ent o f H pylori, (triple therapy)

- O ther causes o f gastric ulcer in this patient.

- Causes fo r hypercalcemia.

- Shown some data o f frozen section. W hat is a frozen section.

- Only 3 parathyroid glands removed. W here w ill you find the last one. (ant

mediastinum)

- W hy lower glands found w ith thymus.

- How to tre a t hypercalcemia?

- W hat is the cause o f UTI in this patient.

2.Po lytra um a, transfusion

- Which blood product would you give? (Pack cells)

- Are there WBC in the packed cells? % WBC in PCT?

- Lifespan o f RBC in the human body in days.

- How w ould you manage the circulation.

- W hat is a GXM. W hat is being crossed matched for?

- W hat would tell a hematologist?

- Stages o f fracture healing.

- Effects on bone after prolonged im m obility.

- Infected im plant. Why must remove?

- W hat is 1 test you w ant to do? (Cultures)

- W hat is PVL Staph aureus? w hat is the action o f cytotoxin

- How w ill Ca level change w ith fractures? It does not!

3.0esophageal Varices,

- How w ould you manage this patient circulatory-wise?

- Surgical tre a tm e nt fo r varices. TIPSS/SHUNT SURGERIES/ANGIOGRAPHIC EMBOLISATION /Liver
transplant

- W here do you expect to find portosystemic anastomosis? Give me the names o f the

veins. Give all.

- If this patient is to go fo r liver transplant, w hat w ould you tell the family. ?? ABSTINENCE FROM
ALCOHOL, HLA MATCHING , IMMUNOSUPPRESSION

- How long must you stop alcohol before you can go fo r liver transplant. ?? 6MONTHS BUT EXAMINER
SAID 1YEAR

Diverticular Abscess

- D ifferential diagnosis.

- Blood gas. M etabolic acidosis. Partial compensation.

- FBC. Intepret. (raised TW)

- W hat is shock.

- W hat kind o f shock is this patient having?

- Management o f septic shock.

AF w ith p e rf viscus

- Before you read this XR. W hat do you want to check.

- Interpret CXR. (air under diaphragm)

- Causes o f AF. Name 4.

- ECG. Calculate rate o f this patient.

-W h y is this AF.

- W hy machine read rate different from w hat you calculated.

- How to tre a t AF. (Rate, Rhythm control, consult CVM, tre a t underlying cause)

- Causes o f perf viscus.

PHYSICAL EXAMINATION

1 ABDOMINAL EXAMINATION~ Cholecystitis

- Abdo PE. RHC pain w ith murphys' positive.

- Differentials.

- How w ould you investigate.

- How to treat: ABC, IV abx, ANALGESIA

2 ?AS w ith Pacemaker

- CVS exam.

- Is this patient in failure?

- ECG. Is the pacemaker functioning. - note spikes.

- W hat is the rate.

-O th e r things on ECG. (LVH)

- M onopolar or bipolar intraop.

- W hat do you need to do pre-op.

3 Lipoma

- Examine.

- W hat other systems you would like to examine.

- How to investigate. US MRI

- When to excise? symptom atic, large

- GA or LA. When to use GA.

4. HIP EXAMINATION

Communications

l.A O R splenic hematoma

-ICE

- Patient understand dx

- Follow up management: memo, call w ife and employer.

2.A0R. Pt daughter and patient wants to AOR.

Post SMAC P0D2 w ith axillary swelling,

drain 400ml. Only preop bloods.

- Speak to on call consultant.

- Inform o f condition and decision to AOR.

- W hat would you give patient on discharge if AOR.

- Plan to end off:

- Check through vitals chart and bloods, do bloods today if not done (only

preop bloods provided)

- Speak to patient first, check competency and let her decide

- Speak to daughter again

PROCEDURAL SKILLS

l.N A EV U S EXCISION BIOPSY AND CLOSURE

2.IDC INSERTION
HISTORY STATIONS

1.PAIN ABDOMEN -

gall stone history ,pain in Irft lum bar and umbilical region ,pain aggravated with food intake and
relieved with flatus d/d - ibs,ibd, investigations fo r ibs ..clinical, other invest - colonoscopy

2. KNEE PA IN . OSTEOARTHRITIS
Anatomy
1. Brachial plexus and Shoulder anatomy
2. Abdominal wall anatomy
3. Lower limb anatomy- muscles, nerves and vascular system

Surgical Pathology
1. MEN syndrome
2. Prostate cancer

Critical Care
1.TPN
2. Hyponatremia/ Post TURP syndrome (probably test station)
3. Analgesia ladder/ opioids/ PCA

Procedures
1. OT listing
2. Suture- Hand-tie, deep cavity tie, hemostatic suture

Physical Examination
1. MMSE + Cranial Nerves Examination
2. Lipoma
3. CVS exam- MR murmur
4. Varicose vein exam

History taking
1. Headache- new onset
2. LUTS- BPH

Oral Comm
1. ITU bed booking
2. Splenectomy consent from mother
1. PE- Examination Of A Hip-OA
(1) Diagnosis w ith differential
(2) Investigation
(3) Management. Conservative/Operative.

2. PE - Examination o f a lump-LIPOMA
(1) Diagnosis w ith differential
(2) Investigation
(3) Management. Conservative/ Operative.

3. PE- Examination CVS w ith pacemaker

(1) Summary o f Examination.
(2) Pacemaker
(3) W hat w ill one plan before surgery as patient has a pacemaker.
(4) ECG- changes in a LVH/Rhythm

4. PE- Examination o f the Abdomen Pain in the right Hypochondria

(1) Summary o f Examination
(2) D ifferential diagnosis
(3) X Ray Gas under Diaphragm- D ifferential diagnosis
(4) Management.

5. Procedural- Catheterization male

(1) Procedure- Retraction o f Prepuce very imp
(2) Chart-Hypotension and tachycardia-causes
(3) No urine-causes
(4) Mass in the low er abdomen-causes
(5) How will you end the procedure- replace the prepuce at the normal position-very imp

6. Procedural- excision o f nevus already draped and anesthetized 14 yr old

(1) Details-consent/ allergies/ drugs
(2) Procedure
(3) Sharps bin
(4) Post op instructions

7. Communication- Post mastectomy seroma patient wants to go home 3rd post op day speak to
the consultant- unhappy w ith the treatm ent.

8. Communication- Self discharge splenic hematoma fall in Hb from 10 to 9.1 otherwise stable.

9. History- Pain abdomen left side o f the abdomen w ith loose stools o ff and on w ith Gall stones on
USG Asymtomatic
(1) Gall stones disease and Irritable bowel Disease
(2) Differentials
(3) M anagement o f gall stones asymptomatic

10. History- Knee Pain-OA B/L

11. Anatom y- Spine Lumbar

(1) Articulation
(2) Identification marks
(3) Parts
(4) Ligaments
(5) Joints
(6) Intervertebral dics-parts
(7) Prolapse intervertebral disc anatomy
(8) Cause o f cauda equine and symptoms
(9) Level o f spinal anesthesia
(10)Surface mark the LP site
(11)Where does spinal cord end in the Adults and children

12. Anatom y- Parotid Gland

(1) Surface mark Parotid gland
(2) Surface mark parotid duct
(3) D ifferential diagnosis o f a parotid lump
(4) Commonest tu m o r in the parotid gland
(5) Lymph node supplying which region if it is present in the parotid region
(6) Show the parotid duct photograph
(7) Show the branches o f the facial nerve o f the photograph
(8) Show where does the facial nerve come out o f the base o f the skull
(9) Complications o f surgery of the parotid Frey's syndrome explain the cause of the symptoms

13. Anatomy-Oesophagus
(1) Posterior m ediastinum boundaries
(2) Contents
(3) Show the contents o f Posterior mediastinum on a photograph
(4) W here is the thoracic duct on the photograph
(5) A t w hat level does the esophagus entre the abdomen and pierce what
(6) Blood supply o f the esophagus
(7) Venous drainage o f the esophagus
(8) Lymphatic draining
(9) W hat is Achalasia Cardia
(10)Where is the pathology in Achalai Cardia
(11) W hat is the epithelium o f the esophagus
(12)W hat is Barrett's esophagus
(13)W hat is the Dysplasia and w hat has happened here and cause.

14. Pathology- Case scenario Hypercalcemia and H pylori and Parathyroid gland
(1) D ifferential diagnosis o f pain abdomen
(2) Peptic ulcer disease
(3) Cause
(4) CLO test and its details
(5) Treatm ent o f PUD
(6) See the investigations and tell about an abnorm ality- Hypercalcemia
(7) Causes
(8) Parathyroid gland
(9) W hat's the use o f frozen section, how is it done and w hat are we seeing in it.
(10) Report o f all the fo u r parathyroid's removed w hat are the cells there in an Adenoma,
(11) W hat do the report tell us-details o f the cellular structure and the weight o f the parathyroid
gland.

15. Pathology- Polytraum a w ith blood products

(1) W hat are the tests done on a blood sample? A,B, O and Rh
(2) W hat is cross match
(3) W hat is Virchow triad
(4) In Packed Cells how much is the Leukocyte percentage?
(5) W hat is the commonest cause o f the Skin infection
(6) W hat is PVL Positive Staph Aureus
(7) Deranged parameters raised PT /APPT w hat is replaced

16. Critical Care-Diverticular abscess

(1) D ifferential diagnosis o f Pain le ft iliac fossa-m ale/fem ale/elderly/child
(2) W hat does it show the reports- Renal failure- sepsis
(3) Management

17. Critical care-Hollow viscus perforation

(1) Diagnosis differential
(2) Investigations
(3) Management

18. Critical Care-Upper Gl bleed

(1) Causes
(2) Management
(3) Deranged liver function test
(4) Biliary cause
Station 1 - Anatomy - Parotid gland anatomy
• Surface mark the parotid gland
• Surface mark parotid duct - how long
• Duct drainage
• Course of facial nerve
• Indicate IAM and stylomastoid foramen
• Indicate branches of facial nerve after parotid - does it come in single nerve branch or in groups
• There is a 2X2 lump over parotid, tender - Answer: LN
• Inflammatory causes of parotid swelling - Sjogrens and Mumps
• Benign cau ses of parotid swelling
• Malignant cau ses of parotid swelling
• Which cranial nerve supply parasympathetic fibre to parotid gland
• Gustatory sweatinq - What's it callsed and pathoqenesis in detail

Station 2 - Anatomy - Spine

• Which vertebra are these? (Lumbar)
• Parts of vertebra, articulating surfaces, lamina, pedicle, vertebral body, spinal canal, etc
• Put 2 vertebra together and show intervertebral foramen
• Where is the A LL. P L L . Lig flavum.
• Shown MRI. Number the vertebras.
• MRI: intervertebral disc, point.
• Anat of intervertebral disc
• What type of joint -secondary cartiliginous
• C au se s of cauda equina
• In posterolateral disc herniation of L4/5. which nerve root affected.
• Sensory area for L5
• What is in the Extra Dural Space and what are contents
• What tumours commonly metastasis to the spine
• Why does metastasis happen - valveless venous drainage
• If no valve, what type of connection do veins have

Station 3 - Anatomy - Oesophagus

• Level of oesophagus.
• Beginning of oesophagus in terms of suface marking - cricoid cartilage
• Superior.lateral.anterior and inferior borders of posterior mediastinum.
• Contents of posterior mediastinum
• Arterial supply. Venous drainage. Lymphatic drainage of entire oesophagus.
• What is achalasia?
• Microscopic features of achalasia
• What kind of disorder is it - waited for motility disorder
• What is Barrett's oesophagus? What is the significance of Barrett's?
• What is the histological normal lining of oesophagus? And in Barrett's?

Station 4 - Pathology - PTH . Hypercalcaemia. Renal Stone. Gastric Ulcer

• What is an ulcer
• Most likely cause for the ulcer? (H pylori)
• What is C L O test? How does it work?
• Treatment of H pylori (Triple therapy)
• Other cau ses of gastric ulcer in this patient.
• Shown some data of histo. of parathyroid glands - oxyphilin and gastrin - whats your interpretation
• What is frozen section?
• Only 3 parathyroid glands removed. Where will you find the last one? (anterior mediastinum)
• Why are they found in anterior mediastinum?
• How does ureteric calculi cause UTI?
Station 5 - Pathology - Polytrauma
• What blood product?
• Are there W B C in the packed cells? % W B C in P C T ?
• Lifespan of R B C produced by marrow
• How would you manage the circulation - Hb w as 7.5 (patient has multiple fractures)
• What is a GXM . What is being crossed matched for? - How to do it. Match recipient R B C to donor's
?blood component
• What would you tell a haematologist?
• Stages of fracture healing.
• Patient treated with prolonged traction, effects on bone after prolonged immobility
• Patient developed DVT. which factors in Virchow s triad acts in this patient
• Pathogenesis of osteoporosis
• Infected implant. Why must remove?
• What is 1 test you want to do? - Cultures (how are you gonna take - Swab)
• Staph aureus is P V L +ve - what does P V L do?
• How will C a level chanqe with fractures? It does not!

Station 6 - Abdominal examination - S P

• stem says patient has R H C pain
• there w as Murphys positive
• diagnosis and differentials
• investigation
• patient has metal implant and doesn't want endoscopy - what investigations for cholecystitis
• treatment for the patient
• antibiotics - base on sepsis guideline
• emergent cholecystectomy indications - within 24-48 hours / empyema

Station 7 - C V S Examination - Real patient

• stem says patient listed for cholecystectomy
• CVM exam, patient had irregular heart beats, previous C A B G (with leg scar, midline sternotomy
scar, left sided pacemaker)
• E C G shown - with pacemaker spikes
• Count the rate
• What else to interpret in E C G
• Monopolar of bipolar pre-op
• What else for pre-op optimization - Refer CVM. 2D E

Station 8 - Right knee examination

• stem states that patient has right knee pain
• present findings: left T K R with scar on posterior knee
• right knee McMurray positive with varus deformity, with small anterior scar (? previous trauma),
crepitus
• diagnosis and differentials - Right knee OA
• investigations for the the patient - examiner waited for MRI
• treatment options - T K R

Station 9 - Abdominal examination - S P

• stem says patient has right iliac fossa pain
• there w as rebound tenderness (?patient responded when I was at right flank)
• diagnosis and differentials
• investigations for right iliac fossa pain
• surgical management - lap vs open appendicectomy

Station 11 - ID C insertion
- intro yourself to S P . verbal consent, comfort patient (points for that)
• asked to prepare all that is needed
• inserted catheter - no urine output
• what to do next - said that I would flush and aspirate
• if nothing, would do bedside ultrasound
• asked my differentials - said the gel may block the catheter, anuric. m ass blocking the urine
Station 12 • Excision of naevus
• LA. cleaned and draped by nurse
• Consultant had to attend emergency
• Introduce myself
• Check consent
• Reassure patient and give post op advice • S T O PO D 14. Analgesia, histo will be informed on f/u
• Excised naevus
• Closed with Ethilon
• Dispose sharps - 1threw the blade (but they were trying to save it - so better check with examiner

Station 13 - History taking for OA knees

• Seem s straightforward
• Mechanical knee pain given analgesia by G P
• What investigations
• 44 years old patient, so what options - stated, arthroscopic debridement. HTO. T K R is last resort if
patient still disabled by knee pain

Station 14 - History taking for Abdo Pain

• Central abdo pain radiating to the left
• Referred from G P for gallstones
• Vague symptoms - which improved with maxolon. alternating diarrhoea and constipation, vague
abdo pain radiating to the left
• Diagnosis and differentials - Examiner said if I had asked some more, would have discovered patient
has anxiety and social issues. So I should include IBS. Said I would still consider colon C a . chronic
pancreatitis. Did not accept chronic cholecystitis
• Investigations
• If scopes were normal, and other investigations unremarkable, what I would do for the gallstones in
this case

Station 15 • Communication A O R
• Post SM A C Day 2 Axillary Haematoma with 400mls in drain
• Patient lives alone
• Daughter insists on discharge for convenience
• Reg has spoken to patient and failed
• Speak to oncall cons regarding the patient
• Plans for the patient - repeat Woods (as last bloods pre - op)
• Patient has S O B and C O P D a s well
• Get patient to sign a form for A O R
• Asked me if I think I was covered if the form w as signed? - Probably wanted to hear that I will
document patient's competency

Station 16 • Communication A O R
• Splenic haematoma
• A O R discharge a s he would like to go for job appointment and wife has cancer
• Hb dropped from 10.1 to 9
• Explained possibility of rupture and catastrophic blood loss
• Plan: Memo to employer, call wife, memo to local hospital

Station 17 - Bleeding oesophageal varices

• In a chronic alcoholic, patient has altered mental state
• Manage this patient • A B C
• Immediate management for varices - endoscopically sclerotherapy/banding
• Other management - Sugiura. T IP S S - asked me whether T IP S S is done via IR or Open
• Coagulapathic picture - explain how to correct - F F P . Vitamin K
• Give all portosystemic anastomosis
• If for transplant, whether can proceed when patient is a alcoholic

Station 18- Diverticular A b scess

• How to manage circulatory wise - only
• Define shock
• What kind of shock is patient having
• Interpret A B G and F B C - Partially compensated metabolic acidosis
 • Explain regarding manage of septic shock based on surviving sepsis guidelines - empirical followed
by specific antibiotics based on cultures
• Management of removing the foci of infection

Station 19 - A F with Perf Viscous

• What would you check before looking at the C X R
• Air under diaphragm in C X R
• Differentials of perf viscous - ischemic colitis. PUD. perf divert
• Interpret E C G - rate rhythm
• Why A F
• C au se s of A F in the elderly
• Why B P machine calculated different to E C G rate
• How to treat A F - treat underlying cause
1. Anatomy of Lower limbs (Simulated patient)
• Demonstrate action of the EHL
• Demonstrate action of the tibialis anterior/tibialis posterior
• Demonstrate action of the peroneus brevis and peroneus longus
• Show how you feel the dorsalis pedis and posterior tibial pulses
• What are the compartments of the leg
• What are the innervations for the individual compartments
• Attachments of peroneus longus/tertius/brevis\
• Sensory distribution for deep and superficial peroneal nerve
• Approach to foot drop
• Level of lesion if unable to dorsiflex toe and loss of sensation of 1st web space

2. Anatomy of Head and Neck (Anatomy specimen)

• Identify the digastric muscle
• What is the innervation of the digastric muscle
• Identify the platysmus
• What is the innervation of the platysmus
• Identify the omohyoid muscle
• What is the innervation of the omohyoid muscle
• Identify the submandibular gland
• Nerves that run close to the submandibular gland
• What are the intrinsic and extrinsic muscles of the tongue
• What are they innervated by
• Identify the hypoglossal nerve
• Identify the great auricular nerve

3. Anatomy of the trunk

• Identify the pulmonary trunk
• What are the branches of the ascending aorta
• Identify the azygous vein
• Identify the sympathetic chain
• What connects the sympathetic chain with the spinal nerves
• Identify the duodenum. How many parts
• What artery lies behind the first part of the duodenum
• Identify the spleen
• What is the surface marking of the spleen
• What structure is most likely to be damaged in a splenectomy
• Identify the fundus of the gallbladder
• What is the surface marking of the fundus of the gallbladder
• W hy does cholecystitis cause shoulder tip pain
• (Pathology slide) This is a lymph node biopsy. Identify the pathology (melanoma)
4. Pathology (just talk to examiner)
• What are the 3 histopathological features of melanoma that are predictors of poorer
outcome
• After resection, margin not adequate. W hat is the next step in management
• What are satellite nodules?
• Patient who ju st had axillary clearance. Now with painful and swollen upper limb.
What is the most likely diagnoses

5. Communications (1 room for reading, 1 room for comms)

• Stem given: Father brought son into hospital. Fell from height 2m in the playground.
Was hypotensive and tachycardic. Bruise over LHC. CT showed hemoperitoneum,
 no definite splenic injury. Consultant brought child in for emergency laparotomy and
splenectomy, consent taken from father
• Mother is upset that child was brought in for surgery without her knowledge and
without the team waiting for her to come
• Asks for reasons that the child had to be brought in without her consent
• Blames father for incident. Divorced and does not think that father is able to consent
• Concerned about a total splenectomy
• Asks about the long term complications of splenectomy on a child
• Asks about management (eg antibiotics and immunizations)

6. Critical care (just talk to examiner)

• Stem given: Patient post anterior resection POD 7 or 8. Now with fever, hypotension
and tachycardia
• What is the most likely diagnosis
• What is the definition of shock
• What are the causes of shock
• What is the most likely cause of shock in this patient
• How would you explain it based on the SEPSIS 3 guideline
• Interpret the renal panel and ABG
• How would you manage this patient
• Who are the individuals that would you need to communicate with while managing
this patient

7. Critical care (just talk to examiner)

• Stem is a chart. Patient post-op spinal analgesia for inguinal hernia. Showing the
vitals chart in the ward, with points marked out A/B/C/D/E
• What are the 2 most likely causes of shock in this patient
• How would you manage this patient
• These are the fluids that were given, how would you intepret the response
• If hypotension persists, how would you manage this patient
• At which point would you escalate to your senior

8. Critical care (talk to examiner)

• Stem is a patient who needed CVP line insertion. Difficult and aborted. Patient
develop SOB. CXR shows large left pneumothorax
• How would you surface mark the internal jugular vein
• How would you perform a CVP line insertion via the IJV
• What position must you be in before inserting a CVP. Why?
• What are the things you would look out for in interpreting a CXR
• What do you see in this CXR
• What would your management be in this patient
• What are some of the complications of CVP insertion apart from pneumothorax
• What are some nursing precautions that need to be taken to prevent line infections

9. Physical examination (real patient)

• Young man, left inguinal scrotal hernia, irreducible
• Diagnosis? Differentials?
• Investigations?
• Management?

10. Physical examination (real patient)

• Old lady, bilateral knee pain. Antalgic gait. Varus deformity. Decreased ROM with
fixed flexion deformities. Crepitus +. Tenderness over right knee medial joint line. No
joint effusions. No ligamentous instability.
 • Diagnosis? Differentials?
• Investigations?
• Management?

11. Procedure (simulated patient)

• Excision biopsy of thigh sebaceous cyst. Consultant gave LA already then left in a
hurry
• Patient already cleaned and draped
• Need to confirm that it is the correct patient
• Prepare your own instruments including attachment of blade
• Create skin incision on foam model
• Excise the lesion and send for histology
• T&S (foam tears very easily)

12. History taking (simulated patient)

• Young lady, admitted to A&E for acute epigastric pain
• After alcoholic binge. Also risk factors for gallstones
• History suggestive of pancreatitis
• What to look out for in examination
• W hat investigations would you do
• W hat investigation clinches the diagnosis
13. History taking (simulated patient)
• Stem is a middle aged lady with lower back pain
• Patient anxious ++, actually has pain all over the back and 4 limbs
• No red flags for back pain
• Had MRI done 2 years ago, degenerative changes
• Has history of IBS
• W hat is the most likely diagnosis
• How would you manage this patient

14. Physical examination (simulated patient)

• Post-op D4 complain of breathlessness and chest pain
• Examine the patient
• Respiratory examination was normal
• Left calf tender
• W hat is the most likely diagnoses?
• W hat investigations would you do?
• What management can you start at the bedside?
• If you are now scrubbed in and the nurses call that patient collapsed, what would you
do?

15. OT prioritization
• Elderly man, pacemaker and COPD. Strangulated hernia
• Lady with AF on warfarin. Diverticular abscess for hartman’s
• Type 1 DM patient with gangrenous foot ulcer, MRSA +, require BKA
• What are your reasons for re-arranging the patients?
• What are the pre-operative considerations for each patient?
• How would you place the diathermy pad for each patient?

16. Communications
• Patient from nursing home. Brought in for abdominal pain. Initial CXR was normal.
A&E fed the patient. Developed acute epigastric pain and vomiting. Vitals stable.
Peritonitic. Consultant impression is perforated viscus, requiring emergency
laparotomy. Need to request pre-operative advice from ICU registrar and request for
 ICU bed post-operatively (even though there is only 1 left, competing with a medical
patient with severe asthmatic exacerbation)

17. Physical examination

• Stem is a elderly gentleman who has pain radiating the right buttock, thigh and calf.
Also has calf pain while walking. Examine the patient
• Lumbar spine/vascular examination
• W hat is your diagnoses and differentials?
• W hat investigations will you do?
• How will you manage this patient?
Day 1
Format of stations:
• 1st half: 2 Comms + 2 prep stations for communication, 4 PE stations, 2 Hx stations
• 2nd half: 3 Anatomy stations, 2 surgical pathology stations, 2 procedural/OT stations,
3 critical care stations

1st Half:

1. History. Acute Adjustment Disorder

a. Post-Gastrectomy POD 7, pt noted to be tearful and feeling down, take a
6min history of his issues and summarize your findings and impression
b. issues tackled:
i. medical treatment, job security, family support
ii. pt did not fit SIGECAPS criteria and too acute, so i labelled as acute
adjustment disorder and examiners accepted
iii. suggest options for issues above, refer social worker, write memo,
offer to arrange meeting w consultant to discuss next step in
management, refer psychologist, refer PSY if suicidal ideation present.

2. History. Acute Pancreatitis.

a. Pt admitted for acute abdominal pain, take a history and summarize your
findings.
b. typical history: epigastric pain radiating to back a/w NBNB vomiting, had a few
rounds of alcohol
i. include drug/fmhx/pmhx/social hx
c. differentials: acute pancreatitis, PUD
d. investigations: amylase and lipase, FBC/UE/LFT/Ca/Glu/ABG for Glasgow
scoring. US HBS / CXR / AXR for imaging
e. patient had this pain before at RHC for several months, treated by GP as
gastritis but never had any scopes or CT done before. I said likely etiology of
pancreatitis could be gallstones still.
f. management was very briefly discussed but the examiners told me not in their
marking scheme.

3. Physical Examination- d v t /p e
a. Pt post-colectomy POD 1, noted to have right chest pain. Examine this patient
and present your findings
b. Pt was an SP, no signs at all. did both CVS/Respi Examination which were all
unremarkable, pt jumped when squeezing calf (this is expected so be
prepared to warn pt, doesn’t look nice if you suddenly squeeze and pt jumps,
when i warned my pt he tensed up and prepared to jum p so you have your
answer there)
c. DVT/PE
i. bloods: FBC UE Coag profile D-dimer GXM
ii. imaging: CXR, CTPA, US DVT

1
 iii. mx: supportive, HD/ICU, anticoagulation, thrombolysis, open
lobectomy if massive PE
iv. what do you think happened if pt suddenly collapses while talking to
you or in toilet? massive PE

4. Physical Examination. Inguinal Hernia

a. Pt referred from GP for right lump in the groin, proceed.
b. Note: looks malay, says doesn’t speak english, try mandarin, typical inguinal
hernia exam, patient said some many students tried on him already that his
lump has disappeared.
c. dx: inguinal hernia, explain why inguinal, direct or indirect?
i. i chose indirect and explained it as per my PE, it should have been
direct but the examiner saw the lump re-appear only after i released
the deep ring so he said he’ll give it to me. '\ ( ‘\ ) / '
ii. some other candidates said direct and they were not stopped.
d. etiologies: fintra-abd pressure, chronic cough, intra-abd mass, BPH,
occupation which carries heavy loads
e. Ix for hernia: pre-op bloods, CXR/AXR for etiology of fintra-abd pressure, no
need for imaging for inguinal hernia, unless suspecting other pathologies
f. Mx:
i. conservative, lifestyle/occupational change, correct etiology
ii. surgical.
lap vs open (lap recommended for bilateral or recurrent hernias)
primary repair +/- mesh (was going to go into contraindications to mesh but
examiner stopped me)
if pt has BPH, would you do lap or open?

5. Physical Examination- Knee o a

a. stem provided mechanical pain hx, examine knees in pain.
b. pt had prev right TKR, stem didn’t say which knee but pt said left knee was in
pain, i examined both knees anyway
c. dx: left knee OA, genu varus, antalgic gait, FFD, decreased ROM, limb-length
discrepancy
d. ix: AP/LAT WB knee XR. skyline knee XR
e. mx:
i. weight loss, lifestyle change, physiotherapy
ii. medical: analgesia, intra-art steroids/hyaluronic acid
iii. surgical: arthroscopic washout, high tibial osteotomy, unicondylar
replacement, TKR
f. look at right post-TKR knee, do you think it's symptomatic? I explained that he
had no effusion, no symptoms, ligaments intact (should have discussed
ROM/no FFD too)

6. Physical Examination- Claudication

a. examiner wasn’t very helpful, patient was an SP, so no clear indication for
neuro or vascular claudication, the stem suggested neurological, and i saw

2
 tendon tapper/satay stick/cotton ball on the table so did spine exam and LL
neuro. but the SP had like zero signs so i did PVD exam after that too and
pulses 2+ all over (6mins is alot of time). So just wing it and when you think
you are done just move ahead with the questions cos that's where your points
are.
b. neurological claudication:
i. ix: AP/Lat spine XR, MRI spine
ii. likely etiology, spinal stenosis, PID, masses(tumour vs abscess)
abutting spinal cord
iii. mx: conservative (analgesia, physiotherapy, lifestyle) vs surgical
(decompression, discectomy, fusion)
c. vascular claudication:
i. etiology: CVS factors, aortoiliac occlusion(leRiche), AAA
ii. ix: abpi, us duplex, LL angiogram, other scans to look for abdominal
etiology
iii. mx: manage risk factors, ulcer management if present, reperfusion via
endovascular angioplasty, surgical bypass

7. Communication. Acute Abdomen call for ICU bed post-op

a. Prep station given, about 6 pages of notes, summarise and consolidate your
points, examiner asked a lot of questions, pt w chronic history of COPD on
steriods/relievers, seen in ED for being “under the weather", unremarkable
until she ate some food and suddenly had acute abdomen, objectives were to
ask ICU reg for pre-op advice and request for ICU bed.
b. remember to write down his advice because he will make you repeat them at
the end.
c. what made you think of perf viscous? PE showed signs of peritonism, Hb
dropped 2 units, US free fluids in abdomen, (CXR was clear but i said i would
re-do to look for free air)
d. what fluid resus would you do? crystalloids, rapid flush, colloids if poor
improvement seen, cross match pt for blood in view of rapid Hb drop
e. asked me to suggest pre-op things to do.
i. ECG: look for arrythmias, T2MI, noted mild hypoK so also looking for
ECG signs(started quoting them but stopped by examiner)
ii. repeat CXR: which i earlier said i'll repeat to look for free air
iii. check if pt took steroid inhalers today, told him if on maintenance
steroids no need for iv hydrocort but will monitor closely
iv. commented on vitals monitoring, told him i’ll keep S a 0 2 threshold
lower in view of chronic COPD. he asked how much oxygen to give
and how
v. contact anesthestist
f. criteria for ICU admission
i. 2 organ systems impaired with acute reversible causes
ii. impaired respiratory system requiring mechanical ventilation
iii. 1:1 nurse patient ratio

3
 iv. 1 organ system chronically impaired with a possible 2nd system being
affected/impaired

8. Communication. Parental Consent

a. Son with splenic rupture, father approved op. Mother appears later crying,
demands to speak to MO
b. Issues discussed
i. explained indication for splenectomy
ii. explained post-splenectomy expected complications and need for
vaccination/abx
iii. explained consent and urgency for op
iv. “is my husband drunk?” focused on explaining why he was able to
give consent (can receive info, can process info, able to make
informed decision and communicate it back to us), did not touch on
him being drunk at all
v. she will keep asking you to make sure son does not speak to
ex-husband, focus on medical, we do not have jurisdiction on who
sees who unless mandated by law (eg. who has actual custody which
is not our daiji)
vi. ask her to leave her handphone number with the nurses so that she
can be contacted when her son is out of OT

2 n d Half:

1. Critical Care. Septic Shock

a. SIRS criteria.
i. temperature
ii. WBC
iii. HR
iv. RR or PaCo2
v. + clear source of infection = sepsis
1. + lactic acidosis = severe sepsis
b. Interpret ABG results: metabolic acidosis with respiratory compensation.
Examiner wanted me to explain every reading, including base excess and
lactate. Reference values provided.
c. How would you manage patient
i. ABC, iv drip, iv abx, investigate for source of infection (blood/urine
cultures, CXR, review wound, abdo examination)
d. HD criteria
i. respiratory impairment not requiring mechanical ventilation
ii. 1 organ system acutely and reversibly impaired
iii. higher nursing:patient ratio
iv. vasoactive drugs
v. invasive monitoring

2. Critical Care. Post spinal anesthesia shock and intake/output. Irritating examiner

4
 a. differentials: spinal shock, hypovolaemic shock, cardiogenic shock
b. interpret vitals chart.
c. examiner here was very slow in talking and speaks in circles, finally
understood that he was asking for IDC insertion to help with shock
management when he kept asking what can you do to monitor blood
pressure.
d. How would you manage shock? reduce epidural dose, inform
senior/anaesthesia, fluid iv bolus, insert catheter etc
e. Apparently drinking water does not help increase intravascular volume
because it is hypotonic. So intake of water orally does not really affect fluid
balance

3. Critical Care. Post CVP Pneumothorax

a. is this adequate CXR? no, cannot see costophrenic angles
b. what is your system of reading any XR? Look at name, 1C, date for
confirmation. Look from outside in or inside out.
c. what is the complication? pneumothorax no tension
d. complications of cvp insertion? during insertion vs long term
e. how to landmark ijv? lateral to carotid artery, between 2 heads of scm insert
direction of ipsilateral nipple etc
f. examiner asked for another way/approach of inserting IJV CVP line. W asn’t
looking for subclavian/femoral vein insertion. Apparently there is a higher
point you can insert into IJV, move on if you do not know.

4. Procedural. OT Listing (repeat entirely)

a. If he has iodine allergy, what do you use? Use chlorhexidine
b. MRSA always last, speak extensively on how you would prep for patients with
DM, chronic COPD

5. Procedural, naevus excision biopsy and closure (repeat entirely)

a. re-check consent, re-check signature by patient
b. no point excising too wide. I had alot of problems closing the "wound’’ as the
sponge was very tough
c. post-procedure counselling

6. Anatom y. Thorax/Abdomen
a. what is this? tricuspid valve, papillary muscle, chordae tendinae. what is
function of chordae tendinae? prevent av prolapse during vent systole
b. what is this? azygous vein (it looks bigger than you think, please don’t
confuse it with right brachiocephalic trunk or right brachiocephalic vein), name
me tributaries? bronchial veins, oesophageal veins, hemi azygous veins,
intercostal veins
c. what is this? gallbladder surface anatomy? L1 transpyloric plane and mid clav
line
d. what is this? spleen surface anatomy? space of traube. between 9th and 11th
rib etc

5
 i. blood supply of speen? splenic artery, describe it's course from it's
branch off celiac axis
ii. what does it supply? duodenum, pancreas, spleen
e. what is this? sympathetic chain. Vertebral levels? T1 to L1. How does it
connect to spinal nerves? preganglionic via ventral rami through commitantes

7. Anatomy. Lower limbs

a. surface markings of DP and PT pulses
b. move the SP’s foot when the following muscles are used.
i. Peroneus longus and brevis together. Eversion
ii. Tibialis anterior and tibialis posterior together. Inversion
iii. Gastrocnemius and soleus together. Plantar flexion
c. Name the 4 (although examiner said 3 to me, ju st label deep/sup post as
post) compartments of LLs and their nerve supply.
d. Demonstrate knee and ankle jerk and nerve roots tested. Tendon tapper
provided. Patient was easy to elicit reflexes from.
e. Dermatomes and Myotomes of LL

8. Anatom y. Head&Neck
a. Boundaries of posterior triangle. “Inferior border is the clavicle" was not
enough. He wanted which third of the clavicle.
b. What is this? Submandibular gland. What acini does it have? Mixed serous
and mucous. W hat 3 nerves might be injured during submandibular gland
op? Hypoglossal nerve, lingual n e rv e ,.....W hat will be the deficit?
c. differentials of swollen LN: infective, infiltrative, neoplastic
(primary/secondary)
i. given a pathology slide with pigmented cells, ?melanoma mets

9. Pathology. Malignant Melanoma

a. what is a melanoma? how is diff from SCC?
b. given biopsy report, what would you like to know, and what else do you need
to know? this is a regurgitation, pis refer to compilation
c. 1cm MM, margins <1mm during procedure, what would you do next?
i. take wider excision
ii. how to do this intraoperative^? frozen section
d. what gene is responsible for hereditary MM?
i. no idea, googling found CDKN2A and CDK4
ii. i tried BRCA, someone tried p53, didn't work haha.

10. Pathology. Rheumatic Heart Disease

a. very repeated, briefly went through RHD criteria (what to look out for)
b. explained process of RHD on valves
i. repeated/recurrent inflammation causing fibrosis, narrowing and
stiffening of valves
c. briefly went through IE criteria
d. what are the common causes of infective endocarditis?

6
 i. throw out the staphs and streps, HACEK
e. mx for IE?
medical: antibiotics
If medical mx fails, for valve replacement
when valve replacement, offer heart transplant, what do you use to
match transplant? HLA antigen
iv. what are you worried about immediately post-transplant?
1. i said graft vs host, but he wanted specific terms, didn’t really
get it.
v. how to prevent the above? immunosuppression
1. what complications? he accepted catastrophic infections, but
not Cushing’s(or anything related to steroids), hepato/renal
toxicity, anaphylaxis/allergies, we think he was waiting for
cancers from biologies.

7
Day 2
After seeing D1 being all repeats, there is an impending sense of doom judging from
previous years.

Anatomy

Parotid and CN7 Anat

- Surface mark parotid gland
- Surface mark parotid duct; how long?
- Duct drains to?
- There is a 2x2 lump over 1 side of a parotid, tender. W hat is it? (Ans examiner
looking for: LN)
- Inflammatory causes of parotid swelling. (Ans examiner looking for: sjogrens and
mumps)
- Benign causes of parotid swelling.
- Malignant causes of parotid swelling, primary: MAP-
mucoepidermoid,adenocystic,pleomorphic adenoca , secondary
- CN carrying parasympathetic fibres. 3,7,9,10
- Gustatory sweating. Freys syndrome. Explanation.
- Intracranial course of facial nerve. (IAM to exit stylomastoid foramen)
- Indicate on prosection IAM and stylomastoid foramen.
- Branches of facial nerve after parotid. Indicate on prosection.

Spine
- Which vertebra are these? (Lumbar)
- Parts of vertebra
- Articulating surfaces
- Intervertebral foramen
- Where is the ALL, PLL, lig flavum.
- Shown MRI. Number the vertebras.
- MRI: intervertebral disc, point.
- Anat of intervertebral disc
- W hat type of joint
- Disorders of disc
- If disc herniates, which nerve root affected.
- Sensory area for L5
- W hat is in the Extra Dural Space
- How does metastasis happen

Oesophagus
- Level of oesophagus.
- Surface mark beginning of oesophagus. (C6)
- Border of post mediastinum.

8
 - Identify: Symp chain, azygous vein, descending aorta, phrenic, L vagus (recurrent
laryngeal).
- Arterial supply, Venous drainage, Lymphatic drainage of entire oesophagus.
- W hat is achalasia?
- Microscopic features of achalasia.
- W hat is barrett’s oesophagus? Why do we care if barrett's?
- W hat is the histological normal lining of oesophagus? And in Barrett’s?

Critical care
PTH, Hypercalcemia, Renal stone, Gastric ulcer, H pylori (Repeat)
- W hat is an ulcer?
- Most likely cause for the ulcer? (H pylori)
- W hat is CLO test? How does it work?
- Treatment of H pylori, (triple therapy)
- Other causes of gastric ulcer in this patient.
- Causes for hypercalcemia.
- Shown some data of frozen section. W hat is a frozen section.
- Only 3 parathyroid glands removed. Where will you find the last one. (ant
mediastinum)
- Why lower glands found with thymus.
- How to treat hypercalcemia?
- W hat is the cause of UTI in this patient.

Polytrauma, transfusion
- Which blood product would you give? (Pack cells)
- Are there WBC in the packed cells? % WBC in PCT?
- Lifespan of RBC in the human body in days.
- How would you manage the circulation.
- W hat is a GXM. What is being crossed matched for?
- W hat would tell a hematologist?
- Stages of fracture healing.
- Effects on bone after prolonged immobility.
- Infected implant. Why must remove?
- W hat is 1 test you want to do? (Cultures)
- W hat is PVL Staph aureus? Dafuq...
- How will Ca level change with fractures? It does not!

Oesophageal Varices, Chronic alcoholic.

- How would you manage this patient circulatory-wise?
- Surgical treatment for varices. TIPSS/Sugiura/Liver transplant
- Where do you expect to find portosystemic anastomosis? Give me the names of the
veins. Give all.
- If this patient is to go for liver transplant, what would you tell the family. ??
- How long must you stop alcohol before you can go for liver transplant. ??

Diverticular Abscess

9
 - Differential diagnosis.
- Blood gas. Metabolic acidosis. Partial compensation.
- FBC. Intepret. (raised TW)
- W hat is shock.
- W hat kind of shock is this patient having?
- Management of septic shock.

AF with perf viscus (Repeat)

- Before you read this XR. W hat do you want to check.
- Interpret CXR. (air under diaphragm)
- Causes of AF. Name 4.
- ECG. Calculate rate of this patient.
- Why is this AF.
- Why machine read rate different from what you calculated.
- How to treat AF. (Rate, Rhythm control, consult CVM, treat underlying cause)
- C a u se s of perf viscus.

Procedures
IDC (Repeat)
- Insert IDC.
- No urine output. W hat would you do? flush, aspiration
- Still no urine. Why???
- US- bladder not distended. Still no urime. Why???
- US shows IDC is in the bladder. Still no urine. Why???
- Hint given: YOUNG gentleman with suprapubic mass.

Excision of benign naevus. Suturing. (Repeat)

- Check consent. (Hidden from sight. Under the table.)
- Pick instruments. Mount blade.
- Proceed.
- Make small elliptical cut. (The bigger u cut, the harder it is to close.)
- Close with prolene. Instrument tie x6.
- Give post procedure advice.

Cholecystitis
- Abdo PE. RHC pain with murphys’ positive.
- Differentials.
- How would you investigate.
- How to treat: ABC, IV abx, ANALGESIA

A S with Pacemaker
- CVM exam. ESM loudest aortic region radiating everywhere. Tissue paper as
pacemaker over sternum. (PM session guys got MR. Another patient with midline
stenotomy scar.)
- Is this patient in failure?

10
 - ECG. Is the pacemaker functioning. - note spikes.
- W hat is the rate.
- Other things on ECG. (LVH)
- Monopolar or bipolar intraop.
- W hat do you need to do pre-op.

Knee
- Knee exam. L OA knee with right TKR.
- W hat are your positive findings, (varus, creps, anthalgic gait)
- How to investigate?
- W hat do you manage to find on XR.
- How to manage? (TKR)
- When to do TKR.

Lipoma (multiple)
- Examine.
- Look at other lipomas. Scars, noted
- 5 was noted
- W hat other systems you would like to examine.
- How to investigate. US MRI
- When to excise? symptomatic, large
- GA or LA. When to use GA.

Communications
AOR splenic hematoma (repeat)
- ICE
- Patient understand dx
- Follow up management: memo, call wife and employer.

AOR. Pt daughter and patient wants to AOR. Post SMAC POD2 with axillary swelling,
drain 400ml. Only preop bloods.
- Speak to on call consultant.
- Inform of condition and decision to AOR.
- W hat would you give patient on discharge if AOR.
- Plan to end off:
- Check through vitals chart and bloods, do bloods today if not done (only
preop bloods provided)
- Speak to patient first, check competency and let her decide
- Speak to daughter again

History Taking
Knee pain
- Case of R knee OA with genu varus/swelling/crepitus/antalgic gait
- W hat is the most likely diagnosis?
- W hat investigations? X-ray

11
 - W hat are you looking for in the XR? loss of joint space, osteophytes, subchondral
cyst and sclerosis
- Where is the crepitus felt? Anterior knee. What does that imply? PFOA
- Management?

Gallbladder
- Examine abdo (Case of acute cholecystitis with RHC pain and Murphy's positive)
- Differentials
- W hat other systems would you like to examine?
- Shown a set of vitals with fever, tachycardia. Interpret.
- Investigations
- Management

12
Physical Examination

1. Acute Diverticulitis
35 year old man with 2 day history of left lower quadrant abdominal pain, nausea, vomiting,
chills, rigors, referred by GP for suspicion of an acute abdomen.
Examine him and tell the examiner your findings.

- Acute abdomen approach, don’t just go for the abdomen

- Confirmed with patient it was Left Iliac Fossa (LIF) that was the most painful
- Rebound, localised guarding at LIF
- What finding would you say determines the extent of his condition?
- Localised guarding. Another term? Localised peritonitis
- Before we continue, have a look at this man’s chart. Have you seen one before? Below
this chart has the MEWS score, can you tell me the significance of it? Such as if it is less
than 2 compared to 3 or more?
- Investigations
- Blood, imaging
- If the CT scan shows only sigmoid wall thickening with 1 locule of gas seen, what would
you do?
- How would that change your management?
- What antibiotics would you give?
- What if no improvement with antibiotics? What will you do?
- Asked what kind of operation would you do? (examiner said no need specifics)

2. DVT with PE [Repeat]

Patient is POD 8 from laparotomy. You have been asked to see patient for dyspnoea and right
sided chest pain. Please examine patient.
- Patient was on hudson mask (15L)
- Right sided pleuritic chest pain (actor simulating)
- Tenderness in calf on palpation, worse with dorsiflexion of foot
- What is your differential diagnosis?
- What investigations would you do? If you can’t do CTPA, what’s the alternative?
- How significant is D-Dimer?
- Medications for treatment?

3. Vascular
History about claudication but doesn’t say which leg. Told to perform the examination. Perform
an ABPI if time permits.
- How do you perform an ABPI
- What does the result represent?
 - What does it mean when the ABPI goes up to 1.4? What do you do next?
- Investigations? What else besides duplex USS and angiogram?
- Management?
- Real PVD patients brought in for this one. Changed patients halfway through exam

4. Cranial nerves and AMT

Patient has been referred by GP for headaches, nausea, vomiting, blurry vision, trouble with
smell. Patient’s daughter also mentioned to GP that the patient has been having memory issues
of late. Examine the patient.
- Equipment: Bottle of peppermint, tongue depressors, torch, Snellen’s chart,
opthalmoscope, tendon hammer
- Unable to smell the peppermint in both nostrils
- What range would you perform the Snellen’s chart?
- Asked patient if she has any reading aids: Reading glasses
- Patient scores Snellen’s at 6/12 in 1 eye after starting from 6/6 and moving upwards, but
examiner then says, “alright, let’s say the patient scores 6/18 in both eyes. Carry on”
- Said I wouldn’t perform the jaw jerk test as it would be uncomfortable for the patient
- Didn’t pick up the opthalmoscope at all
- Finished the cranial nerve portion then remembered about the memory issues
- Did AMT - Asked the version that includes WW2 and current Monarch
- Examiner then requests to summarise findings and what I think about the AMT score
- Asked if he wanted the exact score: “Not necessary, just what your conclusion is.
There’s no significance in the exact score as you can clearly tell there are enough
deficits to point out to you there is a problem"
- Asked how many cranial fossas are there
- Then where I think the lesion was. Said Middle cranial fossa, in the Temporal lobe
initially due to memory issues and I remembered the olfactory cortex being in the
temporal lobe too. However, he asked if I was sure and where would be the more likely
place to have a problem.
- Then diverted the question to what you think the cause is? (Raised ICP)
- Asked again “Now, where do you think the space occupying lesion is, because that is
what you’re most suspecting is the cause of the raised ICP right?"
- Tried to reason out temporal lobe once more being the location (he prompted to try
again), then just gave in and went with Anterior lobe
NB: Anterior cranial fossa: mass can explain loss of smell and loss of vision (near cribriform
plate and optic chiasm/nerve)

Procedural Skills
NB: All excision was done on a dual layer foam (superficial darker layer for skin, deeper
pale layer for subcut fat)

5. I&D thigh abscess. Senior had to go out, you’ve been asked to do the op.
- Checked consent
 - Give anaesthetic
- Incise along Langer’s lines
- The ‘abscess’ is a blue glove filled with mayo between the 2 layers
- Send for c/s
- Break up septations with your finger
- Some people washed the wound, others didn’t (time is short, get to the crucial parts)
- Advised patient about post-op plan (analgesia, abx, review in clinic to follow up c/s and
wound)
- “How did you decide your direction of incision?” Langer’s lines
- “What are Langer’s lines?”
- “What dressing would you use?” (chlorhexidine soaked ribbon gauze), what else would
you use to put into the wound? “Brand names are accepted" consider kaltostat/aquacel
Ag

6. Excision biopsy of naevus. Senior had to run right after giving LA, you are called to do
the op.
- Checked consent, confirmed with patient that LA already given by consultant
- Told to pick your instruments from table that you want to use and place in kidney dish
- Instruments available: toothed small forceps, non-toothed small forceps, toothed big
(DeBakey-size) forceps, non-toothed small forceps, tissue scissors (curved), suture
scissors (straight), ruler, skin hooks, marker, big needle holder, small needle holder
- Naevus is a black marker pen dot on the foam
- Excise lump, suture wound
- Send for histology
- Advised patient about post-op plan (analgesia, abx, review in clinic to follow up histo and
wound)
- Give patient leaflet for wound care, patient ask how long till STO
NB: please do not excise too widely as it was difficult to close

Anatomy

7. Abdomen anatomy
- Showed picture of aortogram, prosection of abdomen with aorta, IVC and branches
- Asked about aorta branches, what lies in front of aorta
- Asked about levels of celiac, SMA, IMA
- Asked what lies in front of IVC
- Tributaries of IVC: (name all of them, not just renal and iliacs)
- Level of aorta entry and bifurcation, surface marking of aorta
- Surface marking of transpyloric plane

8. Cervical spine anatomy. Paper talks about a rugby player sustaining a tackle injury to the
cervical spine
- How many cervical vertebrae are there?
 - How many cervical nerves?
- What are the atypical vertebrae?
- So which are the typical vertebrae?
- What vertebra is this (points to C2). Describe the parts of the vertebra
- What ligaments attach to odontoid?
- What enters through here (points to transverse foramen), at what level does it enter the
cervical vertebrae?
- Showed lateral cervical XR, asked to identify vertebrae
- Let’s talk about the scenario you read. What would you expect to see on the XR other
than a fracture? Soft tissue widening, dislocation
- What do you see on dislocation?
- Come over here to the SP. If I run my fingers down the back of this man’s neck, which is
the most prominent part that I would feel?
- Why is it that I can’t feel any prominences above?
- On this gentleman, what level is the hyoid bone? Show me where it is
- On this gentleman again, what level is the cricoid cartilage? Show me where it is
- The trunks of the brachial plexus pass through 2 muscles. Show me the boundaries of
the posterior triangle. Tell me what the 2 muscles are and show me where the brachial
plexus runs in the posterior triangle on this gentleman?

9. Leg anatomy, guy fell from horse, leg crushed (doesn’t say which part of the leg)
[Repeat]
- On the SP, show me where is the lateral malleolus. Which bone does it belong to?
- What are the compartments of the leg (not the thigh)
- What are the nerves that supply each compartment?
- What are the muscles in the posterior compartment
- Dermatomal area supplied by deep and superficial peroneal nerves, sural and
saphenous nerves
- Show on the SP and name the movements of the muscles I describe to you: Tib
Post+Tib Ant, Peroneus Longus+Brevis, Gastroc+Soleus
- Demonstrate to me the knee and ankle reflexes. What nerve roots are you testing?
- Attachment of peroneus brevis and tertius
- Sensory supply area of L5 and S1 nerve root
- Now let’s talk about the man in the scenario, you have assessed his leg and he is still in
a lot of pain, he complains there is altered sensation in his foot and you cannot feel the
pulse. What condition are you most concerned about? Compartment syndrome

Critical care

10. Patient involved in RTA, GCS 12, RR increased, tachycardia, hypotensive, abdomen
rigid, FAST scan shows some free fluid
- You are in the ED, how would you manage this patient
 - Right you said, airway and breathing. Tell me what you would do to assess and maintain
the airway and breathing?
- What sort of investigations would you do, starting with the simple ones
- Look at this CXR. What does it show? (pneumothorax with trachea deviating towards the
pneumothorax)
- Showed a CT abdomen, what does it show? (liver laceration)
- What are the management options for liver laceration, what fluids would you give?
- Should the patient have gone for CT?

11. Hypothermia. Patient (PMHx of HTN, asthma on ramipril, salbutamol, ipratropium) has
lost a lot of blood from RTA and is under GA. The patient’s chart is next to the scenario.
Main features: temp dropped below 35 once then came back up, BP hovering around
100)
- Have a look at the chart here: tell me what significant findings you can see
- What is hypothermia? How do you measure core body temperature?
- What pre-op and peri-operative risk factors for hypothermia?
- What can be done pre-op and peri-operatively to reduce risk?
- You mentioned Bair hugger? What is the proper name for the Bair hugger?
- What are the complications of hypothermia?

12. Pregnant lady 34 weeks, undergoing cholecystectomy for necrotizing cholecystitis. BP

low, HR low, reverse trendelenburg position (head up), GA and epidural given by
anaesthetist, the surgery is taking longer than expected
- What specialties do you want to involve with this patient?
- Do you want someone to care for the baby if the baby comes out?
- What do you think is happening with the patient? Why BP low?
- What is the definition of shock
- What is the body’s response to shock?
- You mentioned baro-receptors, where are they located?
- What are their nerve supply?
- What is pre-load?
- What maintains our blood pressure during prolonged standing?
- What is the autonomic nervous system made up of?
- Nerves involved in triggering the sympathetic response?????

Communications

13. Young boy with splenic injury, brought in by father (distressed and emotional; no mention
of being drunk like in previous papers), now mother just arrived and wants to talk to you.
[Repeat]
- Prep station before actual station of 9 mins
Prep station info:
0900 history from paramedics of boy brought in by father who is very distressed and emotional.
Father states that boy fell down and is now pale and complaining of left sided abdo pain.
0915 assessment of boy, tender abdomen, fast scan +, consultant surgeon highly suspects
splenic rupture and requests for urgent laparotomy, he will speak to orthopaedics to postpone
their cases.
0930 Surgical reg took further history from father that boy fell off playground and landed on his
helmet over his left side. Conveyed to father about consultant’s suspicion, need for surgery.
Risks and indications explained. Surgical reg will perform surgery. Consultant will be on
standby.
1000 Porter called to pick patient up. 6 units of RBC on standby as requested. Patient will be
transferred to Paeds HDU post-op
- mother not happy that father given consent
- asks who can rightfully give consent
- wants to know who is doing the operation? is he/she experienced? has she/he done op
before?
- anxious and wants reassurance
- any long term problems? will son be able to get back to normal life?
- How come you doctors always insist on a maximum of 2 weeks of antibiotics but you
want to give my son a long course of it? That’s not right isn’t it?

14. Sick patient, likely perforation, team plan for laparotomy. Please call the On-call
Intensivist for pre-op advice and to book an ITU bed post-op
- Prep station to prepare notes 9 mins
Prep station info: 80+ year old lady brought in by daughter. Patient visits a Day Senior Home
daily. Daughter had to leave to send her children to school. Short history provided by daughter
that patient has been off the weather the past 2 days and ate breakfast with her at 0900.
Developed sudden onset abdo pain + confusion at 0930. Assessment by Surgical reg has
suspicion of perforated viscus. Urgent laparotomy required. Will ask CT2 (that’s you) to call
on-call intensivist to book ITU bed and get pre-op advice.
0945 CXR and AXR: NORMAL
1000 Porter called to send patient to operating theatre
- SBAR, make sure you identify yourself and check that you’re speaking to the right
person
- ITU reg asked if ECG done and IDC inserted (info not given in notes)
- how to manage the AF? what fluids is patient on? any antibiotics?
- remember to write down instructions from ITU reg, he will ask at the end what
instructions he gave
- what if I only have 1 ITU bed left, and there’s a brittle asthmatic young lady coming first?
- anything else we can do if bed not available? (can keep in recovery room a bit longer to
observe)
NB: Not an easy station as it was pushed forward by the examiner. Not given a chance to hand
over the case. He went straight in assuming you’ve already done that and asked the questions.
Hot tip: Don’t lie. If it’s not in the notes, just say it’s not done.
History taking

15. Patient with BPH symptoms

- Patient gave all the BPH symptoms in opening answer (frequency, dribbling, urgency,
incomplete micturition)
- Ask for hematuria, dysuria, bladder/bowel dysfunction (TRO bladder CA/neurogenic
causes), LOW, LOA, back pain
- Concerned that it might be cancer
- Also affecting work as he keeps needing to go bathroom, wakes up at night to PU
- What is the likely diagnosis
- What specific investigations? (PSA, USS, Transrectal US and biopsy)
- How to manage
- “The patient mentioned that he takes an intra-nasal spray, did you cover about that?”
- “Well, this spray contains pseudoephedrine (or phenylephrine). Does this affect your
treatment? How so?”

16. Patient at pre-op clinic, for elective cholecystectomy, has breathlessness [Repeat]
- Sounds like hyperventilation picture (peri-oral numbness, tingling in hands, tightness
across the chest)
- What tests would you do?
- Let’s say they all come back normal. Who do you need to inform/refer? (psy, respi,
anaesthetist running list, senior colleagues)

Pathology

17. Showed picture of BCC, asked to describe it

- Why is the surrounding skin red?
- What are possible differentials
- Given histo report - BCC, depth 6.5mm, no invasion to blood vessel or lymph
- Asked what in the report might make lymphatic spread more likely? (wanted 4 points;
went on about microscopic features of malignancy but he wanted more)
- Patient comes back and wound infected. Name 2 likely organisms?
- What is MRSA, how would you manage? (decontaminate, infection control protocols, get
infection control team involved, they apparently eradicate MRSA which is what they want
to hear)
- Now, this is separate from the previous questions. This patient comes back 6 months
later with enlarged neck and abdominal lymph nodes that were palpable and
subsequently seen on CT scan. Histology from one of these lymph nodes shows
malignant changes and the presence of reed Sternberg cells - what is the likely
diagnosis?
18. Patient has murmur and symptoms of heart failure. She also had joint pains with fever as
a child (Repeat)
- What is the likely cause of her aortic stenosis? (rheumatic heart disease)
- What is RHD?
- What is the pathophysiology of the valvular pathology?
- This patient comes back 6 months later with fever, malaise, chills, rigors, weight loss.
You suspect it is infective endocarditis
- Name 2 organisms that can cause infective endocarditis?
- Name 3 signs on the patient’s hands that you might see
- Why is it so hard to eradicate with antibiotics?
- What if right sided valve I.E, what would you suspect?
- What are the treatment options, what surgery can be done?
- After valve replacement what anticoagulation commonly used?
- How to monitor ? (INR for warfarin)
- Any other surgery that you might consider apart from valve replacement?
- Let’s say the patient undergoes a heart transplant. What is the key factor to minimise
rejection?
- How else would you minimise rejection?
- Name 2 drugs used for immunosuppression
1. Thyroid exam ination - euthyroid goitre
2. Massive lipom a exam thoracic region
3. C om m unication - OGD fo r strictures in oesophagus, referred by gp fo r biopsy, explain procedure,
com plications
4. C om m unication - phone call fo r pt in w ard w ith clot in calf, ecg was given, talk w ith icu consultant,
diagnosis, tre a tm e n t and read ecg
5. History - Rectal bleed, 50yr F, fam ily history o f CA rectum
6. History - hypothyroidism
7. Exam - knee injury, lig and meniscal injury
8. Exam - CVS, pacemaker scar
9. Critical care - Small bowel obstruction, xray was given
10. Critical care - can't rem em ber
11. Path - te sticu la r CA
12. Path - Thyroid swelling, posted fo r sx, com plications during sx pre and postop
13. Critical care - Die, was given blood reports, tre a tm e n t, asked about blood products, stages of
homeostasis
14. Procedure - 1AND D
15. Procedure - Suturing - surgical knots, fig o f 8 vessel tie , pedical tie
16. Anatom y - fem oral triangle, adducto r canal
17. Anatom y - m iddle cranial fossa, foram en o f skull
18. Anatom y - neck triangles, partoid gland and nerves around subm andibular gland
A n a to m y
a. Head and Neck, T h o ra x
i. Id e n tify Oesophagus
ii. W h a t e p ith e liu m lines oesophagus - SSNKE
iii. Id e n tify com m on c a ro tid a rte ry , e x te rn a l ca ro tid , in te rn a l c a ro tid
iv. Id e n tify c a ro tid sinus. Function? - B a ro re ce p to r
v. Id e n tify c a ro tid body. Function? - C h em orecep tor fo r pH and Pa02
v i. B ifu rc a tio n o f trachea (Id e n tify , d id n o t accept ca rin a ). Level - T4
v ii. Id e n tify the p a ro tid gland, w h a t k in d o f saliva - Serous
v iii. Id e n tify s u b m a n d ib u la r gland
ix. Can yo u lig a te facial a rte ry - Yes, anastam osis fro m o p p o site side
x. W h e re to p alp ate facial a rte ry - A n te rio r to m asseter, against b o d y o f
m a n d ib le
xi. Id e n tify hypoglossal nerve
x ii. W h a t does in in n e rva te , lik e ly d e fic it, w h a t is th e m echanism - M uscles in
the tongue, d e via te to affected side
x iii. Id e n tify su b clavian a rte ry
xiv . O rig in o f subclavian
xv. W h a t p a rt o f th e b ra ch ia l plexus lines behind the su b clavian a rte ry
b e h in d the fir s t r ib - In fe rio r tru n k
xv i. W h a t is Subclavian steal syndrom e? Stenosis o f subclavian a rte ry >
re tro g ra d e flo w o f b lo o d in v e rte b ra l a rte ry a t expense o f v e te b ro b a s ila r
c irc u la tio n (so called steal) to s u p p ly u p p e r lim b

b. M id d le c ra n ia l fossa, M id d le ear
i. B orders o f m id d le c ra n ia l fossa (Exact p a rts o f bone to be nam ed eg.
lesser w in g o f s p h e n o id )
ii. Bones o f m id d le c ra n ia l fossa
iii. S u p e rio r o rb ita l fissue - W h a t passes th rough?
iv. O ptic Canal - W h a t passes th ro u g h ? - O ptic n erve and o p th a lm ic a rte ry
v. W h a t do yo u k n o w a b o u t th e o p th a lm ic a rte ry and w h a t is the
significane? End a rte ry , no anastam osis. Blockage can cause blindness.
v i. W h y w ill yo u get pa p illo e d e m a w ith raised ICP
v ii. Id e n tify R o tu n du m and w h a t ru n s th ru it
v iii. Id e n tify trig e m in a l ganglion. W h e re does it lie?
ix. Id e n tify fo ra m e n sp in o su m and w h a t ru n s th r u it?
x. W h ic h bone fo rm s the sella turcica?
xi. C ontents o f cavernous sinus
x ii. H o w do the nerves ru n in th e caverous sinus? W h ich nerves ru n s tra ig h t
th ro u g h and w h ic h ones ru n la te ra lly ?
x iii. Signs o f cavernous sinus th ro m b o s is - O p thalm ople gia
xiv . P o in t o u t the r o o f o f m id d le ear in m id d le c ra n ia l fossa
xv. H o w does m id d le ear in fe c tio n cross in to s k u ll - tegm en ty m p a n i
xv i. R elations o f the m id d le ear
x v ii. W h e re else can in spread - m a sto id a ir cells
x v iii. C lin ica l signs o f m e n in g ism - P hotoph obia, neck stiffness, fever
xix. D anger area o f face, w h ic h v e in ( in fe rio r o p th a lm ic v e in )

c. A n te rio r T h ig h - P a tie n t had 10cm la ce ra tio n 10cm in fe r io r and p a ra lle l to

in g u in a l lig a m e n t
 i. B ounda ries o f fe m o ra l tria n g le (In c lu d e Floor, Roof, m edial, la te ra l
b o rd e rs )
ii. W h a t vessels w ill be c u t - s u p e rfic ia l fe m o ra l, c irc u m fle x vessels
iii. W h a t m uscles w ill be c u t (Q uadriceps fe m oris, satorius, a d d u c to r longus)
iv. W h a t nerve is th is - fe m o ra l nerve
v. W h a t m uscles does i t s u p p ly
v i. W h a t cutaneous s u p p ly o f saphenous n erve
v ii. B ounda ries o f a d d u c to r canal
v iii. W h a t ru n s th ro u g h a d d u c to r canal
ix. W h a t e x its a d d u c to r hiatus
x. Fem oral sheath, w h ic h stru c tu re s
xi. B oundaries o f fe m o ra l canal o p enin g
x ii. C ontents o f fe m o ra l canal
x iii. W h a t is the purpose o f the e m p ty space in the fe m o ra l canal? accom odate
expansion o f fe m o ra l vessels

P athology
a. G iant Cell T e m p o ra l A rte ritis , 60s fem ale, te m p o ra l a rte ry pain, visu a l
d is tu rb a n c e
i. W h a t w o u ld yo u do to c o n firm diagnosis - b io p sy
ii. Features o f b io p s y - In tim a l th ic k e n in g w ith lu m in a l stenosis,
m o n o n u c le a r in fla m a to ry cells w ith m edia in va sio n and necrosis, g ia n t
cell fo rm a tio n in m edia
iii. W h y v is u a l d isturbance s - in v o lv e m e n t o f o p th a lm ic a rte ry
iv. B iop sy w as co n siste n t w ith GCT a rte ritis , h o w to tre a t - S teroids
v. 1 y e a r la te r came back w ith NOF fra ctu re , causes? O steoporosis, AVN
v i. Causes o f osteopo rsis in th is case - Female, Post m enopausal, Age 60,
s te ro id s
v ii. R isk factors
v iii. W h a t o th e r p rim a ry bone p ro b le m s cause fra c tu re - Pagets, Secondary
m e ta s ta s is ...
ix. SOB and petechae a fte r THR, diagnosis? Fat em b o lism
x. Cause o f fa t e m b o lism - Long bone fra ctu re , in tra -m e d u lla ry n a ilin g
xi. H o w to manage? M a in ly s u p p o rtiv e

b. 35 y e a r o ld m an, r ig h t in g u in a l mass fo r 1 m o n th , single palpable testes

i. H isto re p o rt s h o w in g te ra to m a , ly m p h a tic invasion, re g io n a l invasion,
p o s itiv e m argins. W h a t are th e s ig n ific a n t fin d in g s o f re p o rt? (As above)
ii. H o w w o u ld yo u manage g ive n h isto re p o rt - m u ltid is c ip lin a ry
m anagem ent, staging scan, resection o f m argins, a d ju v a n t chem o+ RT
iii. W h e re does i t spread to fir s t - para- a o rtic
iv. W h e re does i t spread to n e xt - lo co re g io n a l
v. W h e re does i t spread a fte r - d is ta n t mets
vi. Pt com es back 1 y e a r later, p a ra a o rtic node com pressing renal a rte ry and
v e in, has SOB and P u lm o n a ry em b o lism
v ii. W h a t c o n trib u te s to PE in th is case - H y p e rco a g u la b ility, tu rb u la n c e (
venous stasis)
v iii. W h ic h p a rt o f v irc h o w s tria d does n o t c o n trib u te - e n d o th e lia l damage
ix. W h a t is c h o rio c a rc in o m a - g e rm cell tu m o u r
x. T u m o u r m a rk e r - bHCG
xi. W h a t is the co m m on tu m o u r in th is age g ro u p - sem inom a
x ii. W h a t is the m o st com m on n o n -g e rm cell tu m o u r in 60s p a tie n t - Non
h o d g k in 's lym p h o m a
 x iii. H is to lo g y n o w show s p a p illa ry th y ro id tissue and g a s tro in te s tin a l
adenocarcinom a, e xp la in w h y? - a ll 3 germ cell lines pre se n t - ectoderm
e n d o d e rm in th is case
3. C ritic a l care
a. AAA m assive tra n s fu s io n , T 3 5 degrees
i. W h a t is the d e fin itio n o f p e rio p e ra tiv e h yp o th e rm ia ? - < 35 degrees
ii. Causes o f h y p o th e rm ia in th is p a tie n t
1. P atient: H yp o vo le m ic Shock
2. E x trin s ic: M assive b lo o d tra n sfu sio n , cold e n v iro n m e n t, organs
exposed d u rin g la p ro to m y
iii. C om p lica tio n s o f h y p o th e rm ia - M a in ly C oagulopathy
iv. W h a t is the m echanism s o f w h ic h the p a tie n t loses heat - co n d u ctio n ,
con vectio n , e v a p o ra tio n , ra d ia tio n
v. H o w do n o rm a l people generate heat - S hivering
v i. Can the p a tie n t generate heat in tra o p e ra tiv e ly ? No. p a ra ly tic given.
v ii. C om p lica tio n s o f m assive tra n s fu s io n
v iii. Lab re su lts: L o w Hb, Low Pit, Raised PT / PTT, com m ent, w h a t blood
p ro d u c ts to give
ix. W h a t c lo ttin g factors are s to re d b lo o d p ro d u c ts d e fic ie n t in? - A ll b lo o d
p ro d u c ts . T h a t's w h y fresh b lo o d is better.
x. H o w else can y o u reduce th e use o f blood p ro d u c ts ? - Reuse the p a tie n t's
o w n b lo o d u sin g Cell Saver
xi. M echanism o f haem ostasis - v a s o c o n s tric tio n , p la te le t plug, fib rin
p o ly m e riz e
x ii. W h a t p o ly m e riz e s fib rin - th ro m b in
x iii. H o w does the va scu la r s u rg e ry in fe rfe re w ith m echanism s o f hem ostasis?
xiv . Im m e d ia te post op c o m p lic a tio n s o f AAA
1. General A nethesia re la te d
2. Renal, bow el, lim b ischaem ia, A M I, stro ke

b. N eck lu m p w ith le th a rg y and m alaise

i. W h a t is the diagnosis? H y p o th y ro id is m w ith anem ia
ii. E xplain th e th y ro id h o rm o n e axis. (TRH, TSH, T 3 T 4 w ith negative
feedback m echanism )
iii. 6 fea tures o f h y p o th y ro id is m
iv. 3 causes o f h y p o th y ro id is m - Post th y ro id e c to m y , Io d in e deficiency,
H ashim oto's
v. W h a t are the TFTs i f th e re is a p itu ita r y cause o f h y p o th y ro id is m
v i. P a tie n t w ith h y p o th y ro id is m n o t c o m p lia n t to m e d ica tio n comes in fo r
e m ergency surg ery, w h a t are th e risks? - M a in ly lo o k fo r m yxodem a
coma
v ii. H o w to im p ro v e com pliance o f m e d ic a tio n - S im p lify regim e, in v o lv e
c a re r o r fa m ily m em ber, re g u la r fo llo w ups (E xa m in e r seemed to have
w a n te d m o re )
v iii. B lood tests s h o w m a c ro c y tic anaem ia, cause in th is p a tient? - Associated
a u to im m u n e c o n d itio n n o f p e rn ic io u s anaem ia causing V it b 12
d e fic ie n c y due to lack o f in trin s ic fa c to r

c. P eri-op n u tr itio n : Lady w ith Crohns disease, had ileocecal resection, P 0D 4

a n a s to m o tic leak, so had d e fu n c tio n in g ile o sto m y
i. W h a t does AXR show? sm a ll b o w e l d ila ta tio n
ii. Causes in th is p a tie n t - s tric tu re
iii. M ethods o f feeding - E nteral (O ral, NGT, NJT, PEG, PEJ)vs P arental (TPN
and PPN)
 iv. Routes o f TPN a d m in is tra tio n (PICC, C entral lin e )
v. C ontents o f TPN - C arbohydrate, p ro te in , fat, w a te r, e le c tro ly te , nitro g e n ,
tra ce elem ents
v i. P roblem s w ith co n tin u o u s glucose as the o n ly ene rg y source
1. P oor u tiliz a tio n d u rin g stress
2. Excess co n ve rte d to fats
3. Produces excessive C02
4. h yp e rg lyce m ia
v ii. Besides glucose w h a t is the n e xt highest ene rg y source o f TPN - Fat.
v iii. C o m p lica tio n s o f TPN
1. N u tritio n re la te d - A lso in c lu d e m ucosal a tro p h y causing b a cte ria l
tra n s lo c a tio n
2. Line re la te d
3. m e ta b o lic re la te d - bone, im m u n e system , cholestasis
ix. In d ic a tio n s fo r TPN
1. System ic: B urns, M a ln u tritio n , severe p a n cre a titis, sepsis
2. GIT re la te d : E nterocuta neous fistu la , s h o rt g u t syn d ro m e , C rohn's
4. H is to ry
a. Lady p la n n in g fo r cho lecystecto m y, p resents w ith SOB (P ro tip * : A lw a ys ask fo r
name, age, o ccup a tio n, m a rita l h is to ry and fa m ily tre e !) I fo rg o t to ask the name
and th e y asked me w h a t it w as GG) Had th is occasiona lly f o r 10 years, la s tin g fe w
m in u te s, in cre a sin g in fre q u e n cy th is 6 weeks a fte r b eing scheduled fo r o p e ra tio n
1. no w h e e zin g / coughin g / fe v e r / phlegm
2. no PND / no decreased ET
3. S m oker
4. No Pm hx, o th e r th a n gallstones
5. Tests a t GP fo r SOB to ld to be n o rm a l
6. ICE: w id o w e d w ith 2 kids, fin a n c ia l w o rrie s
ii. D iffe re n tia ls : A n x ie ty / Panic / Respi / CVS / A naem ia / T h y r o id /
H y p e rv e n tila tio n
iii. In v e s tig a tio n s - FBC, TFT, CXR, P u lm o n a ry fu n c tio n te st
iv. M anagem ent: reassurance

b. C hronic P a ncrea titis

i. 40 y e a r o ld d iv o rc e d M ale h a vin g c h ro n ic e p ig a s tric pain, ra d ia tin g to
back fo r past 1 ye a r a / w ste a to rrh e a . Takes 5 glasses o f b e e r/d a y ,
p re v io u s ly a d m itte d fo r acute p a n creatits. Takes 3 0m g o f m o rp h in e a day
ii. S um m arize y o u r h is to ry
iii. W h a t is y o u r diagnosis? w h a t are y o u r d iffe re n tia ls
iv. W h a t do yo u th in k o f his h is to ry o f 30g o f m o rp h in e ? W h a t sh o u ld the
n o rm a l dose be?
v. W h a t blo od in vestigatio ns? fecal fat, u ltra s o u n d
vi. W h a t o th e r in v e stig a tio n s w o u ld help clin c h the diagnosis? MRCP, ?ERCP
v ii. H o w w o u ld yo u manage?

5. C o m m u nica tion s
a. Phone c o n s u lta n t fo r acute lim b ischaem ia
i. Lady a d m itte d fo r re c e n tly fo r m ild d iv e rtic u litis , adm issio n paras
irre g u la r HR, sym p to m s im p ro v in g w ith IV abx and IV flu id s. N o w
c o m p la in in g o f acute rig h t lo w e r lim b pain. O /E L e ft LL p a llo r,
pulselessness, p a in n o t re sp o n d in g to paracetam ol
ii. Bloods: H yp o ka le m ia (GI losses, IV flu id s ), M e ta b o lic A cidosis on ABG
(ischaem ia)
iii. ECG - p re m a tu re v e n tric u la r com plexes, AF ta ch y
 iv. P ick up th e phone and speak to th e co n su lta n t. E xplain in SBAR fo r m a t
1. Is it urgent? Can w e send h e r to m o rro w m o rn in g instead?
2. Do yo u need a c a rd io lo g is t to re v ie w fo r PVC before tra n sfe r?
3. W h a t i f the c a rd io lo g is t ca n 't com e dow n?
4. W h a t do y o u th in k o f h e r presum ed diagnosis o f d iv e rtic u litis
n o w th a t she has th is acute lim b ischaem ia? - P o s s ib ility o f
ischaem ic b o w e l in v ie w o f lim b isachem ia and irre g u la r h e a rt
ra te
5. Do yo u need to scan the abdom en fir s t then? - Said w e w ill scan
th e abdom en a fte r th e tra n sfe r.
6. He asked me i f it co u ld be m esenteric ischem ia s tra ig h t aw ay -- i
said th e abdom en so fa r has been s o ft non te n d e r » c o n tin u e to
do s e ria l abdo exams K IV scan i f lik e ly
7. Ok yo u can send th e p a tie n t over.

b. B enign oesophageal s tric tu re

i. 60 y e a r o ld m an w ith h is to ry o f sm o kin g and alcohol co n su m p tio n
presents w ith dysphagia. Y o u r c o n s u lta n t is gone o ff fo r a m e e tig and you
are tasked to counsel fo r OGD, b io p s y and d ila ta tio n u n d e r GA. Inx
show ed A naem ia, raised b iliru b in and LFT
ii. apologise c o n s u lta n t n o t a ro u n d , reassure th a t he w ill be k e p t in th e loop
a b o u t d iscussion and a n y d oubts, can arrange fo r h im to speak to
con sulta n t.
iii. E xplain in d ic a tio n s, w h a t p ro c e d u re involves, p ro ce d u re risks, w h a t to
lo o k o u t fo r p o st procedure , TCU plans.
iv. P a tie n t asks w h y does he keep sa livating? cos he h u n g ry
v. p a tie n t asks i f his sm o kin g and d rin k in g has caused h im to have cancer

Physical e xa m in a tio n
a. T h y ro id : a n te rio r neck lu m p (D iffu se )
i. W h a t else to exam ine
ii. D iffe re n tia ls - C o llo id g o itre m a in d iffe re n tia l
iii. H o w to in ve stig a te - T F T (lo o k in g for?), U ltrasound, FNAC
iv. w h a t w ill yo u lo o k o u t fo r on ultrasound ?
v. FNAC show s fo llic u la r cells, w h a t do u te ll the p a tient? 25 % chance o f
m a lig n a n cy
v i. W h en do yo u need to operate?

b. Knee e xa m in a tio n : rig h t knee exam (L ik e ly s im u la te d p a tie n t) - This patient

had very variable signs.
i. M ed ial jo in t lin e te n d e r, lim ite d ROM, ? M cm u rra y +ve
ii. Ligam ento us exam n o rm a l
iii. B ilatera l J L T med>lat, tenderness on palpation o f collaterals. Unable to
extend knee to 30deg to adequately do varus/valgus stress tests. Me m urray
•ve, Draw ers -ve, Hip and ankle screen -ve
iv. In v e s tig a tio n
1. X ra y - w h a t do u lo o k for? fra ctu re s, loose bodies
2. MRI - w h a t do u lo o k for? m enisci, OCD, ligam ents, etc
v. DDX
1. Ligam entous
2. M enisceal
3. H a em arthrosis
4. Bone
v i. H o w m ig h t th is in ju ry affect p a tie n t 30 years fro m now ? S econdary OA
 v ii. H o w w o u ld y o u tre a t th is p a tie n t fo r m eniscal in ju ry ? Depends on MRI
and in tra o p fin d in g s. I f am enable to re p a ir - m eniscus im p la n t/re p a ir.
N ot am enable to re p a ir - d e b rid e m e n t, p a r tia l/to ta l m eniscectom y

c. A n a s ta m o tic Leak (s im u la te d p a tie n t)

i. E ld e rly gentlem an p o st le ft h e m ic o le c to m y Day ?6 develops a b d o m in a l
p a in ra d ia tin g to le ft sh o u ld e r tip . ECG show s AF. Has oxygen m ask, lip s
?blue,
ii. P e rfo rm e d b oth abdo and c a rd io exa m in a tio n .
iii. S um m arize y o u r fin d in g s
iv. W h a t in v e s tig a tio n s - CTAP w ith RECTAL c o n tra s t
v. M anagem ent? ABC, b ro a d sp e ctru m a n tib io tic s , e x p lo ra to ry la p ro to m y ,
w a sh o u t, ? d iv e rtin g c o lo sto m y

d. RIF pain in a y o u g la d y (S im ulated p a tie n t)

i. F indings: RIF tenderness w ith re b o u n d and guarding . Rest o f
e x a m in a tio n n o rm a l
ii. P resent fin d in g s
iii. D iffe re n tia ls : A p p e n d ic itis , Gynae causes (ru p tu re d ectopic, o va ria n
to rs io n ), U T I/p y e lo , GE
iv. In v e s tig a tio n s - In clu d e UPT and u ltra so u n d , bloods - FBC
v. In tra o p e ra tiv e ly y o u fin d ble e d in g in th e p e lv ic ca vity, w h a t do y o u do?
R efer O&G, arra n g e fo r b lo o d tra n sfu sio n , call haem atolo gis t

P ro ced ural s k ills

a. K n o t ty in g ru b b e r bands (s ilk ), deep c a v ity tie (v ic ry l), u n d e r-ru n n in g o f suture
(PDS)
i. M a te ria l o f v ic ry l
ii. T e n sile s tre n g th o f v ic ry l. H o w lo n g b e fo re i t is absorbed?
iii. A dvantage o f b ra id e d su tu re
iv. Surgeons k n o t vs re e f k n o t
v. W h a t are the p ro b le m s w ith deep c a v ity tie and h o w to avoid?
v i. H o w w o u ld y o u b ro a d ly cla ssify sutures? m o n o fil/b ra id e d
a b s o rb a b le /n o n a b so rb a b le
v ii. w h a t o th e r m o n o fila m e n t absorbab le s u tu re do u k n o w of? M o n o cryl,
PDS

b. In c is io n and drain ag e o f abscess on u p p e r th ig h

i. Check consent, in d ic a tio n , e xp la in p rocedure . Pt a lre a d y draped. Just
need to give LA. T e ll e xa m in e r w o u ld lik e to w a it 10 -1 5 m in s before
p ro ce e d in g to a llo w LA to ta ke effect. Proceed. T e st LA. Make in cisio n
o v e r abscess alo ng langers line. Give p o st p ro c e d u ra l advice to p a tie n t
w h ile yo u are d o in g this. T e ll p a tie n t w o u n d w o n t be closed and w hy.
D ressing frequency, TCU plans, tra ce re su lts on a rriv a l. POC, w h e n to
com e back to ED (s /s o f w o u n d in fe c tio n ). P a tie n t p reo ccu p ie d w ith pain.
Reassure th a t g iv in g analgesia p o st p rocedure . To expect pain w h e n LA
w ears off. Dispose sharps.
ii. Langers lines
iii. C ollect sam ple w ith sw ab
iv. W h e re w o u ld yo u send th is to? C ytology, M ic ro b io lo g y
v. W o u ld yo u close the w ound? W h y not?
v i. P a tie n t concerned scar, p o st-o p pain
v ii. W h a t ty p e o f d ressing w ill y o u use? (E x a m in e r asked fo r exact brand
nam es)
 v iii. I f v e ry e xu d a tiv e w h a t dressing to use?
ix. H o w to c o ve r on to p - w a te rp ro o f dressing

1. A n a to m y
a. T h o ra x and neck
i. Specim en o f h e a rt
1. W h e re is th e ascending aorta
2. W h e re is th e bra cio ce p h a lic tru n k
3. W h e re is th e re c u rre n t la ryngeal nerve on le ft
4. W h a t are the branches o f th e ascending c a ro tid
ii. Specim en o f neck
1. W h e re is th e th y ro id
2. W h a t are th e lobes o f the th y ro id
3. W h e re is th e e x te rn a l laryngeal nerve
4. W h e re is th e re c u rre n t la ryngeal nerve
5. W h a t is th e b lo o d s u p p ly o f th e th y ro id
6. W h a t is the dra in a g e o f the th y ro id
iii. B ra chia l plexus
1. W h a t is the m o to r loss w h e n p a tie n t has lesion o f th e u p p e r
tru n k ? Erb's palsy
b. P a ro tid
i. Surface m a rk the p a ro tid on p a tie n t
ii. Surface m a rk the stensen's d u ct
iii. I f p a tie n t develops a p a in fu l 2 by 2cm firm nodule in the p a ro tid , w h a t is
i t lik e ly to be? A n sw e r: L ym ph Nodes
iv. A n y o th e r in fla m m a to ry processes o f th e p a ro tid
v. Specim en o f p a ro tid
1. Id e n tify the branches o f th e facial nerve passing th ro u g h p a ro tid
2. W h a t else passes th ro u g h th e p a ro tid
a. R e tro m a n d ib u la r vein
b. Branches fro m the e xte rn a l c a ro tid a rte ry
c. S h o u ld e r a n a to m y
i. W h a t is this? LEFT clavicle
ii. W h a t is this? Scapula
iii. W h a t is this? H um erus
iv. A rtic u la te the clavicle and hum erus. IMPOSSIBLE AS THEY ARE
DIFFERENT SIDES, STUPID EXAMINER
v. Scapula
1. W h e re is in fra s p in a tu s fossa
2. W h e re is su p ra sp in a tu s fossa
3. W h e re does the subscapu laris go
4. W h e re is th e a cro m io n
5. W h e re is th e c o ro co id process
6. W h e re is th e g le n o id fossa
v i. H o w does any jo in t re ta in s ta b ility
v ii. H o w a b o u t sp e cific a b o u t th e s h o u ld e r jo in t?
v iii. W h a t m uscles m ake up the ro ta to r cuff?
ix. W h e re do th e y attach on th e hum erus?
x. W h e re is th e g re a te r and lesser tu b e ro s ity
2. P athology
a. T e s tic u la r cancer
i. Sem inom a
 ii. W h a t a re the im p o rta n t th in g s to note on a p a th o lo g y re p o rt
iii. S erological m arkers
iv. T e ll m e a b o u t hCG
v. Can hCG m easure sem inom a recu rre n ce
v i. W h a t a re the tu m o u rs o f th e testes do y o u k n o w a bout
v ii. W h e re does ly m p h a tics o f the testes spread to
v iii. T e ll m e a b o u t th e stages o f bone healing
b. DIVC
i. T e ll m e a b o u t the p a th o p h ysio lo g y o f DIVC
ii. Stages o f c lo ttin g
iii. Q uizzed a b o u t a p tt and p t
3. C ritic a l Care
a. P a tie n t has h y p o th e rm ia
i. T e ll m e w h y h y p o th e rm ia is d e trim e n ta l
ii. W ays th a t a p a tie n t loses heat in tra o p e ra tiv e ly , p re o p e ra tiv e ly and post
o p e ra tiv e ly
iii. H o w to w a rm a p a tie n t in tra o p e ra tiv e ly and post o p e ra tiv e ly
iv. H o w to m easure core b o d y te m p e ra tu re
b. P a tie n t has o lig u ria p o s t o p e ra tiv e ly
i. W h a t w o u ld yo u do
ii. Reason fo r o lig u ria
iii. H o w does o lig u ria p o s t-o p e ra tio n happen? E xplain th e p a th o p h ysio lo g y
c. P a tie n t has dyspnea and d e s a tu ra tio n on POD 5
i. DVT
ii. Repeat q u estio n
iii. W h a t w o u ld yo u do fo r p a tie n t
iv. W h a t in v e s tig a tio n s to o rd e r
d. P a tie n t w ith a b d o m in a l pain post o p e ra tiv e ly
i. Septic p ic tu re
ii. W o rrie d a b o u t an a sto m o tic leak
e. P a tie n t w ith w h o le b o d y burns
i. P a rkla n d fo rm u la
ii. R esuscitation y o u w a n t to give
iii. W h a t s o lu tio n yo u w o u ld give
iv. H o w w o u ld yo u m anage the p a tie n t
4. Physical E xam ina tion
a. Exam ine a p a tie n t w ith p o s itive SLR and w eakness in L5 m yo to m e
i. Do a back e xa m in a tio n
ii. M o st lik e ly reason? PID
iii. Q uestioned a b o u t sciatica
iv. O th e r reasons fo r sciatica besides pro la p se d in te rv e te b ra l disc
b. Exam ine a p a tie n t's c e re b e lla r system
i. P ositive dysd ia d o ch o kin e sia and past p o in tin g and d y sm e tria
ii. P o sitive R om berg's test
iii. W h e re is the lik e ly lesion?
iv. W h a t can cause the lesion?
v. W h a t im aging?
v i. O th e r th a n MRI, w h y w o u ld y o u c o n sid e r a CT Brain?
v ii. I f p a tie n t has n a u s e a /v o m ittin g / LOC, w h a t w o u ld you be th in k in g of?
5. H is to ry T a k in g
a. A b d o m in a l pain
i. C h ro n ic p a n c re a titis p a tie n t
ii. B a ckgrou n d o f alco h o lism because o f depression
iii. In v e s tig a tio n s
 iv. M anagem ent
b. T h y ro id lu m p
i. G ra d u a lly in cre a sin g in size
ii. H y p e rth y ro id
iii. In ve stig a tio n s
iv. M anagem ent
6. C om m unication s
a. S plenic hem atom a w ith alco h o lic fa th e r and w o rrie d m o th e r. Repeat q uestion
b. U pdate c o n s u lta n t re g a rd in g p a tie n t w ith o lig u ria
i. L ik e ly A K I seconda ry to d e h y d ra tio n
ii. No abdom en signs a t all
iii. T o ld h im w o u ld h y d ra te and s e ria l a b d o m in a l exam s and upd a te again
and case fin is h e d
7. Procedures
a. IDC in s e rtio n
b. S uture a th ig h la ce ra tio n
i. P ick up a non a bsorbable s y n th e tic su tu re
1. E th ilo n
ii. W he n to com e back
iii. W h en to STO
iv. Need a n tib io tic s ?
v. C over w ith w a te rp ro o f dressing fo r 48 h ours

P ro T in s

Examiners - M ix tu re o f d o c to rs fro m Ire la n d and som e local d octors. M a jo rity are v e ry

s e n io r in age. T h e y say th e ir goal is to pass you.

Answering questions: Some e xa m iners w ill m a rk in fr o n t o f y o u so y o u k n o w w h e n you

score th e m ark. O thers m ay n o t w r ite a n y th in g t il l the end so y o u are none the w ise r.
M a jo rity o f que stio n s a re re p e ated fro m p re vio u s years, m ug those 1 - 2 days before.

You can s kip a q u e stio n i f yo u are n o t sure. T h e y w ill be happy to le t y o u a tte m p t it again
a t th e end. T h e y m a y even t r y to h in t o r p ro m p t you.

Physical stations are m o re rush e d a fte r the in itia l 6 m inutes. P e rfo rm a fu ll e xa m in a tio n
(w h a t yo u le a rn t in MBBS). T h e n yo u o n ly have 3 m in u te s to a n s w e r w h ic h is a v e ry
s h o rt tim e . T r y to a n sw e r th e questions succinctly.

Pathology stations: T h e y are lo o k in g fo r key w o rd s o r c o n d itio n s ra th e r th a n b ro a d

te rm s (eg. W h a t is the m a in c o m p lic a tio n a surgeon w ill be w o rrie d a b o u t fo r
h yp o th e rm ia ? C oagulopathy.)
Anatomy. T h e y use p la stic m odels and o f cadavers and c o lo u rfu l m odels fo r th o ra x. No
rea l ones used a t all. A n s w e r s u c c in c tly to get y o u r p o in t and m ove on.
1) Procedure: catheterization ( complete repeat): explain, consent, apply gel, prepare your
instruments ( do not forget to assess the balloon and expiration d a te ), clean, prep, catheter
passed easily, no urine ( causes), what to do ( flush, aspirate) still no urine ( bedside US ( DO
NOT INFLATE BALLOON)

2) Procedure: suturing of superficial wound: patient in emergency, local given by the nurse,
prepare your instruments and suture the superficial wound with non-absorbable simple stitches,
explain the procedure, take a few stitches, (I FORGOT TO ASK FOR THE CONSENT!!!!),
needle in sharps container. Abx and tetanus to be given.

3) History Taking: long standing thyroid swelling, increasing in size over the last couple of
months with symptoms of hyperthyroidism and compressive symptoms, questions from
examiner about triple assessment, workup including TFT ( asked what does that entail said
TSH, T3 & T4 seemed happy), US assessment looking for nodule characters, multiplicity and
regional LN. he asked what else? said can be used for US guided FNAC seemed really happy.

4) History Taking: chronic alcoholic pancreatitis with social issues,abdominal pain ( SOCRATES
assessment) smelly fatty diarrhea, kept coming around to he's depressed and was admitted,
cannot stop having alcohol to numb the pain ( felt I was in Psych rotation) blaming himself for
everything, typical Socrates Assessment and then take a Full ICE and offer help with alcoholism
with social worker, Alcoholics anonymous etc, etc. questions from examiner, what do you think it
can be chronic pancreatitis, what else, pseudocyst, sclerosing cholangitis, PUD with fibrosis,
what tests to confirm blood workup, imaging, mentioned US ( said it was limited due to bowel
gases but can assess biliary tree, touched on management with social worker, multi-disciplianry
team, supplemental oral enzymes.

5 & 6) prep and communication: 3 days post left hemicolectomy with anastomosis with oliguria,
no signs of SIRS on ABG and obs chart. I was halfway through my SBAR when the examiner
stopped me and told me, please give me your candidate number! ( epic fail!), causes of shock in
this patient? do you want me to see? what do you want to do, fluid challenge him? what fluid,
dose? do you want to transfer him? ( was done with the station in less than 6 minutes, not sure
if it's a good or bad thing!)

7 & 8) Prep and communication: Justin White, 9 year old kid brought by father and father saying
I DID NOT MEAN IT. communicate with the angry mother, make sure to calm her down, by
being composed, explain the need for surgery, what is the function of the spleen, why we
couldn't wait, why consent the father ( joint custody) and had capacity ( explained what that
means), is the consultant an expert in this surgery ( how would I know?!!!!!), explained to her
that this is considered the most common abdominal solid injury and he will be in good hands,
explained to her the procedure and possible partial or complete splenectomy depending on
intra-op findings, explained to her OPSI and need to be careful including bracelet.she asked
about antibiotics for the rest of his life?, explained to her the need to bring a social worker on the
case to make sure that the kid is in safe environment and our priority is the kid. how long will he
be staying in the hospital, tell me more about the social worker? do you have to? when can I
see him.

9) Critical care: Burn and ARDS, scenario of extensive burn patient including soot in nose and
mouth, tell me if he has superficial or deep burn, why? what's your initial management, ATLS
protocol, airway with cuffed ET tube, preferably with anesthetist, as we cannot assess for
concomitant C-spine injury, manage breathing, Circulation, what formula? Parkland, any
other?!! what is parkland? where do you want to manage this patient? burn unit, you don’t have
one. Isolation room of ITU. what do you fear? what labs to send? in ITU CXR is taken, tell me
the findings ( shrugged me off when went for the full assessment, told me go for the gold),
bilateral infiltrates on CXR. causes, pulmonary oedema Vs. ARDS, why this patient can have
pulmonary oedema, why ARDS, Berlin Criteria for ARDS, management of ARDS, what Abx?

10) Critical care: Pre-operative hypothermia, define hypothermia, was upset when I said 35 (
wikipedia and many sources say 35, apparently he wanted 36 CORE TEMP, where to measure
core? I said Rectal, vesical and PICCO, LiDCO ( seemed happy), why is this patient
hypothermic, why surgery precipitate hypothermia? procedure heat loss, loss of shivering,
vasodilatation, cold IVF, cold gas of anesthesia machine, ways of heat loss? how to avoid heat
loss?

11) Critical Care: post-op patient with tachycardia, hypertensive emergency. CXR showing
bilateral pulmonary infiltrates, with fluid chart, given crystalloids and colloids, kept asking what
do you make of the fluid given to this patient? didn't know what he was getting at. moved along,
what is management, furosemide in liaison with medics, where to manage, HDU. why is he at
high risk of Ml, tachycardia decreasing the diastole time and increased resistance increasing
work load on heart, which receives blood in diastole only, what can be done to prevent this from
happening again? quality control, inform people, better education, closer monitoring in the
immediate post-op period, root cause analysis.

12) Anatomy: plastic model of heart and great vessels, plastic model of the neck, branches of
aortic arch, point to vagus, point to recurrent laryngeal, describe thyroid, isthmus lobes, blood
supply and drainage, nerves at risk, what does recurrent laryngeal supply? origin of thyroid?
from foramen caecum descends into neck, what is thyroglossal cyst? patient with motorcycle
injury has arm abducted internally rotated and extended elbow ( basically waiter tip) what is his
injury? erbs palsy, what nerve roots ( C5,6)? if lower roots are affected, what is it called?
Klumpke) what would be the motor and sensory deficits?
13) Anatomy: Parotid Gland, draw on SP the surface anatomy of the parotid and parotid duct,
swelling of the parotid, what could it be? lipoma, sebaceous cyst, abscess, stone, mumps,
sjogren, ( as in KL 1/16 he was after LN), what area does it drain, just winged it and told him as
part of the superficial group), tumors affecting parotid, what is malignant) moved to plastic
models, show me facial nerve, exit from skull on skull and branches of facial nerve what are
other structures within the partoid gland? external carotid and terminal branches, what else?
Retromandibular vein, Branches of the great auricular nerve, what supplies autonomic fibers to
parotid? auriculotemporal nerve, describes gustatory sweating, what is called? Fray, why it
happens? what cranial nerves carry autonomic fibers?

14) Anatomy ( all candidates had an issue with that station): Shoulder anatomy, scapula and
clavicule, side, articulate, shoulder girdle, what gives stability? muscles, ligaments, capsule, forgot
labrum and negative pressure within the joint, what are the muscles? rotator cuff? name them? point
them on plastic dissection, action of each and nerve supply, action of teres major and point to
muscle? bell rang! ( others were asked more questions on muscles detailed actions, nerve supply to
different heads and MRI image.)

15) Pathology: inguinal swelling, she adds when in bay that examination reveals a single testiclein
scrotum, what you think swelling is? undescended testicle, what investigation you want to do? US
scrotum, why?reveals mixed swelling, solid and cystic, do we need to remove it? yes, why?
malignant transformation, blood tests? routine + AFP + HCG, which HCG? B-HCG. what other
condition it is elevated, i said recurrence, she meant pregnancy!! what are the tumors you know from
testis, seminomas, non-seminomas, in 70 yo gentleman what's the most expected pathology? what
is teratoma? what is choriocarcinoma? read path report and tell me 3 sig info, incompletely excised,
seminoma, invasion, what does Nx mean? what LN do testicular cancer spread to? aortic, why?
embryological origin, what workup will you do? MDT, CT TAP. post op he develops hematoma ( still
stable), mention stages of hematoma resolution

16) Pathology: hep C patient suffered trauma injuring her spleen with significant blood loss., losing
blood, blood picture and coag given showing low platelet and DIC. explain picture? why does DIC
happen? what does APTT test? what does PT test? how is extrinsic pathway activated? how is
intrinsic pathway activated? what are platelets? how do they work? give reasons this patient is
having DIC? hep C + shock, what are complications of hep C on liver? fibrosis, cirrhosis and
malignancy, functions of the spleen.

17) physical examination: post op for laparotomy with tachypnea, on oxygen. S/P patient, talking in
full sentences, tachypneic using accessory muscles,wound closed, did full CVS and resp exam, had
pleuritic pain on the right lung on deep inspiration, needed to be prompted for leg exam!! had DVT
and PE. what investigations? bell rang.
18) physical examination: neurological assessment of the1 lower limbs ( I JUST MESSED UP THIS
STATION) seemed straightforward, but I panicked and performed poorly, questions asked include
L5 dermatomes, causes of sciatica? why he has this gait?

19) Physical Examination: day 7 post left hemicolectomy with primary anastomosis complaining of
lower abdominal pain and left shoulder pain, full abdominal assessment with obs chart, he had full
SIRS and was in sepsis, causes of sepsis suspected? anastomosis and deep abscess, why
shoulder pain? look at ECG. tell me what it has? tachycardia and I said AFib ( he was genuinely
surprised! show me) what you want to do to the patient, sepsis 6 ( bell rang)

20) physical Examination: posterior cranial fossa examination

a) an S/P with right cerebellar lesion, typical DANISH assessment with wide gait,
questions included what to do for assessment of posterior cerebellar lesion,
imaging needed, what is the contrast medium for MRI ( bell rang)

in general physical exam stations are really stretched for time, critical care and communication are
fine as well as procedure, hope your exam goes well.

regards,
Anatomy
1) Landmarks on skeleton
• Rotator cuff origin and attachments
• Medial epicondyle of humerus
• Ulnar nerve injury, ulnar paradox
• ASIS, muscle attachment
• Meralgia paresthetica
• Glut. Medius et minimus origin and attachment
• Quadratus femoris
2) Thorax
• Oesophagus, blood supply, lymphatics
• Epithelium, common cancer, Barrett's oesophagus
• Post mediastinum contents
• Diaphragmatic openings
3) Posterior cranial fossa
• Boundaries
• Dural sinuses
CN IX, X, XI
• Foramen magnum
• Common benign tumours
• Clivus

Pathology
1) GB cancer, Nec. Fasc, C. Dif
• Common risk factor for GB Ca in the UK
• Spread
• Wound infection post open chole, common organism
• Common organisms for nec. Fasc.
• C. dif DD, mechanism of pseudomembranes
2) GCA, myeloma, pathological fractures
• GCA treatment, complications
• Complications of long term steroid use
• Myeloma diagnosis
• Causes of pathological fractures

Applied science/Critical care

1) Trauma. Liver laceration, hypovolaemic shock
2) Chronic renal failure, acute on chronic kidney injury, hyperkalaemia
3) Adrenals, steroids use, Cushing's, perioperative steroids management

History taking
1) Chronic back pain, with new sciatica type and saddle anaesthesia
2) Acute pancreatitis

Communication
1) Transfer call. Bile leak post lap. Chole, discuss with HPB prof
2) Upset wife, patient with cancer, CT scanner is broken

Examinations
1) Abdomen (incisional hernia)
2) Unwell patient on ITU, ABCDE as per CCrlSP
3) Peripheral vascular
4) Submandibular gland
Skills
1) Suturing skin lac.
2) Abscess l&D
Communication-
1- Telephone conversation with consultant.
POD1 patient post sigmoid colectomy for bowel adeno CA. Seen by
the FY1 . now has poor urinary output.. Full set of notes including
bloods.
(ABG results put at the back !)
Poorly hydrated pre and post op
2- Patient with splenic haematoma now wants to self discharge-
Prep station with notes. HB drop from 10 to 9.1.Try to convince.
(Explain to patient the gravity of his decision and still persists allow to
discharge but explain that will need to sign against medical advice and
needs to report to hospital near home ASAP for repeat HB.

3-History taking for Thyroid Lump

4- History taking Abdominal Pain (Chronic Pancreatitis)

ANATOMY-
A-(Picture provided no prosections)Upper thorax
1-Aortic arch and branches
2- vagus nerve and type of supply
3- thyroid gland and blood supply.
4 supply of recurrent laryngeal nerve
5- describe Erb’s palsy and Klumpke’s palsy.

B-Shoulder
1- Osteology of humerus, clavicle &scapula- asked to identify parts of the
bone whether clavicle was right or le ft. superior and inferior surface. And to
articulate clavicle and scapula.
2- What nerve is damaged surgical humeral neck fractures.
Movements of humerus
3- Identify deltoid and its movements and its parts.
4- Identify Pectoralis major on picture + functions and nerve supply

C- Parotid Gland
1- surface anatomy and surface anatomy of the parotid duct.
2-Structures passing through parotid gland.
3- branches of facial nerve through gland.
4- Describe Frey’s syndrome
5- Parasympathetic supply to Parotid
6- Cranial nerves with parasympathetic supply
commonest tumor and cancer

PATH O LO GY
1- Scenario given - trauma with lady bleeding and had splenectomy. Bloods
given with deranged clotting,
1- What is this? (DIC)
2 -possible causes.
3- How does it occur.
4- what Part of the pathway does APTT test.?
5-What activates the extrinsic pathway
6- Function of platelets
7

2- Seminoma( scenario of 35 yr old right scrotal lump for last 2 months)

further history given by examiner ( Professor...) history of undescended
right testis.Histology report given
1-Name 3 things in history that will be of concern, (invasion, tumor margins
and diagnosis of course!(totally forgot that examiner hinted it to me)
2- route of spread
3- Common cancer in this age group.
4- tumor marker B-hcg and AFP
5- Possible scrotal cancer cause in70 year old- Choriocarcinoma
6- Where does it arise from?

Clinical skills

1-Insertion of Urethral Catheter-

- sterile conditions, after catheter inserted no urine.
- Don’t inflate balloon.
- Why no Urine?
2-Suturing station
-Questions on Local anaesthetic

Critical care

1— Burns -Patient with 60% burns

- How would you manage airway and breathing
- Calculate burns and formula you would use
- How would you manage patients circulation
 - Fluid resuscitation (what type) any other fluid to be considered? (NO)
in the first 24hours
- Parkland formula and to calculate fluid in patient
- What type of burns does patient have?- (burn described in scenario)
2 - Hypothermia
3- A RD S
4- Heart Failure secondary fluid overload

Examination

1- Lower Limb Arterial exam- Present your findings

2 -Cerebellar examination- Patient with posterior cranial fossa mass
(I believe this was the pilot station)-
Present your findings
Asked which side I thought lesion was on. Patient had right sided
symptoms so said left side. Examiner wasn’t too impressed
- what imaging to do? I said MRI asked what benefit that would be?
Instead of a CT.
- Types of tumor that could be causing this

3 - 4days Post op with chest pain . pis examine this patient (PE)
This is a Ccrisp station.(For My IMG that don’t know- Care of the
critically ill surgical patient)
- Charts by side of bed.
- Essentially assess using ABCDE (Remember to give oxygen)
Whent you examine the limbs patient squeals in pain on squeezing left
calf. Pis remember to warn patient before squeezing.

Questions follow in line of PE investigation and treatment

4 -8 days post op hemicolectomy Abdo pain radiating to left shoulder
tip
(another ccrisp station)
Fumbled on this one.
Charts given with ECG.
Questions - how would you investigate.
Specific investigations
What would you do next?
Anatomy and pathology
1. Man fell from horse scenario-Muscles of leg action insertion and innervations.
2.cervical spine anatomy. Muscles of neck and brachial plexus in posterior triangle.
3.AAA - ANATOMY
4.ulcer- DD bcc.SCC. MRSA
5.RHD and IE
Applied surgical science and Critical care
6.hypothermia questions . Emergency laparotomy case scenario
7.trauma case scenario. Questions on pneumothorax , abdominal trauma
8. Pregnant lady undergoing emergency cholecystectomy. Questions mainly only preload
Clinical procedural skills
9.abcess drainage
10.excision of naevus
Physical examination
11. Scrotal swelling
12.back and lower limb neuro
13. Cranial nerve and mental status
14. Respiratory in a pod 8 patient
Communication taking and giving
15. Mother - boy splenic injury father drunkard scenario
16. Call itu registrar- book bed post-op
17.history - urinary symptoms bph
18. History -breathlessness preop cholecystectomy
Anat-
1 )Skull base with all foramen and structures passing through them.
2)anatomy of duodenum
Blood supply
Relations of duodenum
Was given a intraop photo to identify duodenum.
Pathology
Perforated duodenal ulcer Patient
Asked about do test(repeat station )

Critical care-
Fracture tibia fibula Patient with compartment syndrome and rhabdoMyolisis

History-
Female with groin lump-iv drug abuse
Back pain

Clinical examination-
Thyroid
Cvs with pacemaker in situ
Abdomen examination-acute cholecystitis
Knee OA

All station repeat with same questions

Communication-
Phone call for diverticulitis Patient with acute lower limb.
Consent for OGDscopy

Proced ure-
Excision of naevus
Incision and drainage
1 skull with tentorium attached very mortified old specimen difficult to identify stuff oculomotor nerve .
2 upperlimb shoulder girdle all bones involved .
3 esophagus posterior mediastinum .relations.
4 diverticulitis.
5 polycystic kidney disease reason of cyst formation . patient needs renal transplant types of rejection, patient
post transplant developed Gallstones and cbd stone ercp done came with spiking temperature wbc
elevated what has happened, what three risks for this patients developing complications.
6 locked knee post sports injury examination .patient in severe pain difficult to exam (good actor of course
ocked knee is painfull) forgot to check the extensor mechanism .asked what is prognosis .
7 submandibular swelling exam (no swelling was found ) asked which nerve will you examine too.
8 abdominal examination laprotomy scar hernia present incisional obese lady .asked risk factors for
developing this.
9 post laprotomy day 4 patient with left side chest pain very easy case messed up full time forgot everything
very distracting examiner not happy .did not do well.
10 canulla insertion, asked about which fluid for resuscitation to give easy one. nice lady examinar.
11 insertion on chest drain easy too flat face examiner no response.
12 patient with chronic low back pain history taking went ok asked management.
13 patient with urinary hesitence frequency nucturia hx of vasectomy . went ok examinary asked what is
diagnosis which investigations.
14 anxious mother (child brought in by father (separated) after injury fell from monkey bars or
something rupture spleen father signed concent now mother worried and not happy that father gave concent
he does not have legal custody, waa good actor too many question mannnn .
14 crushed injury scenario.
15 pregnant lady reverse trendelenberg position cholecystectomy for gallbladder gangrene, interoperative
hypotension reasons .please don t forget fat embolism venacaval compression especially.
16 call consultant orthopeadic surgeon for open tibia fracture in polytrauma patient .now pulseless limb .
17 compartment syndrome kidney failure reperfusion injury,
forgot one station .
need prayers now all the best to you.
Anatomy

1.
2. H istory (Hx) - You are going to assist your consultant fo r AAA. So boss decide to discuss
aorta anatom y w ith you. Picture o f the abdom en given.
a. Ide ntify the abdom inal aorta (AA)
b. Starting and end levels
c. Name its branches and vertebral levels
d. Surface m arking o f the AA
e. W hat structures lie an te rio r to AA a t L I
f. Dem onstrate IVC and its branches.
g- W hat is an aneurysm
h. Angiogram m e given. Ide ntify Coeliac tru n k and its
branches, SMA, IM A

3. Hx - Rugby player sustained neck in ju ry during a tackle. (Actor + single exam iner) picture of
the axis vertebra given on ipad.
a. Id en tify the vertebra. Name th e parts.
b. How m any cervical vertebras
c. How m any cervical nerves
d. Point to m ost p rom inent spinuous process on the patient. W t vertebra is th a t. Why
is it prom inent?
e. Atlas vertebra picture shown on Ipad. Identify odontoid process. W hat are the
ligam ents attached to it.
f. Point to hyoid bone on patient
g. Point to a structure lies in a n te rio r neck at C6 level - cricoid
h. W t Gl structure is related there.
i. Show the boundaries o f the posterior triangle on the patient.
j. W here the roots o f brachial plexus lie. Between which 2 muscles,
k. Surface m ark brachial plexus on the patient

4. A cto r sits beside.

a. Dem onstrate on p atie nt -
i. Eversion and inversion
ii. A ction o f EHL
iii. A ction o f com bined TA & TP
iv. A ction o f PL & PB
b. W here to palpate pulses o f fo o t
c. Origin and insertion o f P.brevis and P.tertius
d. W hat are the com partm ents o f the leg?
e. W hat muscles in each com partm ent?
f. A rterial and nervous supply o f each com partm ent
g. Root value fo r superficial and deep peroneal nerves
h. If p atie nt has 1 web space numbness and fo o t drop, w hat is th e diagnosis -
com p artm en t syndrom e
i. Root value o f knee and ankle jerk
 j. Surface m ark the area o f d istrib u tio n o f deep and superficial peroneal nerves
k. Surface m ark S I derm atom e

Pathology/ Critical care

5. Hx - 58yr old lady w ith HTN, Asthma aw aiting laparotom y. Still in w ard, but going to fetch in
1 hr. Tem perature chart - last reading 34 C.
a. W hat is th e condition - Hypotherm ia
b. Define hypotherm ia
c. Risk factors in th is patient?
d. Com plications o f hypotherm ia
e. W hat w d u do in the ward.
f. W hom do you inform
g. Do you th in k need to postpone th e surgery?
h. How to prevent hypotherm ia (expected all the possible causes)

6. Picture o f Basal cell carcinom a given.

a. Describe the picture. (Nodule w ith central ulcer and bleeding.
b. 3 DDs?
c. Name 2 causes fo r surrounding erythem a
d. Define metastasis
e. Describe the pathological meachanism o f lym phatic spread in
th is patient

7. Hx - 60yr old lady w ith childhood Rheumatic heart disease. Now com ing fo r
Cholecystectomy.
a. Im m une mechanism o f Rheumatic fever
b. Pathogenesis o f A ortic sclerosis and stenosis
c. Define IE
d. W hat organisms
e. W hat to look fo r in 2DE
f. Name 3 lesion found in the hand
g- Name a single investigation to m o n ito r response to Abx
h. If p a tie n t n o t im proving then w h a t - A ortic valve replacem ent
i. W hat o th e r specialities you refer
j- If p atie nt go fo r cardiac transplant, w hat to check fo r organ rejection - HLA
k. W hat are the mechanism o f action o f know n im m une-suppressants
1. W hat are the com plications o f im m unosuppressants
m. W hat is th e mechanism o f lym phom a w ith Immunos?

8. Discussion only. Given history o f RTA. Polytraum a. BP 100/60, HR 134, Right chest air entry
dim inished. Rigid abdomen.
a. Discuss managem ent. (ATLS principles)
b. Define shock. W hat shock this patient is in.
c. W hat IV fluids
d. W hat Xrays
e. W hen to do Xray
 9. Hx - Pregnant lady POA 34 weeks undergoing open cholecystectom y. Intraop tachy cardia
and BP dropping.
a. Define preload
b. Factors governing the preload
c. W hy BP drop in th is patient?
d. Do you th in k this surgery is necessary? Give factors fo r and against. (WTF pt halfway
through the op.) I gave the indications w ould have been empyema blah blah)
e. W hat w ould do you to im prove pt condition?
f. How th e venous re tu rn differs in standing vs Supine
g. How to prevent DVT
h. W hat is th e mechanism o f action o f DVT stockings

History taking

10. 65yr old gentlem an d iffic u lty to pass urine. BPH picture. Irrita tive and obstructive
sym ptom s+. No m alignant features. Pt has taken nasal drops fo r last 2weeks.
a. Present ur history
b. How do you manage? 1started staying "1 II do thorough exam ination..." exam iner got
pissed said "give you r m anagem ent o n ly !"
c. W t blood investigations?
d. W hat are norm al values fo r PSA? W hen suggestive o f BPH/Cancer
e. Conservative/surgery
f. W hat medical trea tm en t?
g- Surgical options?
h. W hat is th e relation o f nasal drops in causing d ifficu lty passing urine? WTF

11. Instructions- 30yr old lady aw aiting cholecystectom y. And you are seeing her in th e pre­
assessment clinic. Patient com plains o f chest pain. Take her history.

Hx - lO yr history o f dyspnea. Aggravated fo r last 6 weeks. Specially a t night. Non smoker. No

exertional dyspnea. No O rthopnea. (Seems like asthma/COPD) Has visited GP CXR and ECG
taken and found norm al. Takes pain killers o f abdom inal pain

a. Present the history

b. DDs
c. W hat investigations?
d. A fte r CXR you come to th e diagnosis o f asthma, W hat o th e r investigation you do? -
Spyrom etry
e. W hat is th e relevant fam ily hx you should ask? I said allergies/hay fever. (Examiner
n o t happy)

Examination

12. Patient w ith large BL hydrocele. Examine this patients scrotum . Patient was fidgety. C/o o f
pain fo r slightest touch. So excuse and progress. (Pt doesnt speak English. Examiner was not
observing me during the exam ination)
a. Present y o u r findings. It was a large tense hydrocele. No penis visible.
b. W hat are yo u r DDs
c. W hat imaging. - USS
 d. W t u expect to find in USS
e. W hat else? I said CT TAP. N ot sure
f. How do you manage? Conservative/surgical. Expected to know the steps o f lords
and Jabulouy

13. Hx - lO yr duration o f Anosmia. Im paired vision fo r 6 m onths. Do th e relevant exam ination.

a. I did the cranial nerve exam ination. (Expected to do fundoscopy/ Snellen's chart-
provided). Very poor vision cannot properly count the num ber o f fingers. Rest o f the
exam norm al
b. Present the findings
c. DDs?
d. W hat Imaging
e. W hat surgical approaches

14. Hx- POD4 laporotom y. Complaining o f right sided chest pain. Do the relevant exam ination.
On general exam ination-Left calf tenderness. CVS/RS norm al. Observation chart given.
W hich shows Sao2 dropping. RR increasing.
a. Present the findings
b. W hats yo ur diagnosis
c. How do you investigate
d. M anagem ent- acute/longterm

Advice - Do General exam ination including ankle oedem a/ calf tenderness check fo r all CVS/RS
exam inations.

15. LL peripheral vascular system exam ination. Patient w ith right dorsum o f fo o t ulcer, 4th toe
am putated. 3-5,h to e gangrene. BL DP/PT absent.
a. Present the findings
b. Discuss management.
c. CT o r MRI angiogram me is best?

Com m unication

16. 8yr old son fell fro m height. A d m itted w ith splenic laceration. Rpt.
a. M o th e r kept on asking how the surgery is being done.
b. Had to explain th e laparotom y fro m th e incision
c. Com plications a fte r splenectomy.
d. How to prevent

17. Telephone referral. Instructions said go through the notes (10 pages) and discuss the
findings w ith senior colleague.
Hx- 83yr old lady fro m a nursing home ADL I. A dm itted w ith sudden abdom inal pain a fte r
breakfast. Diagnosed as abdom inal viscus perforation by th e consultant and planned fo r a
laparotom y. But a fte r his next case as patient is stable at th e m om ent. Investigations Hb low,
Urea and S creat high, ABG m etabolic acidosis w it partial com pensation. (I th in k it was for
ICU referral. But it w asn't m entioned in th e instructions. M ay be w ritte n som ewhere in the
case notes. I haphazardly discussed th e findings. Next station was a rest station. And I heard
next candidate discussing about th e ICU referral.) Did n o t do well in this station.
So advice read through notes carefully.
Surgical skills

18. Excision o f a naevus. LA given already. Consent. Excise. Suture. Pt advice. (Rpt)
19. I and D thigh abscess.(Rpt)
a. Consent. Give LA
b. W hat needle size?
c. Check LA strength, Expiry date.
d. Incision direction?
e. W hy? - Langers line
f. Dem onstrate langers line direction in thigh.
g. W hat dressing to pack inside. W hat dressing outside. (I saw on past papers
som ebody had m entioned a bout giving tra d e names. But m y indian exam iner was
n o t happy w hen I gave trade names eg: aquacell.

Good luck.
1. Anatom y- Cyclist in crash w ith brachial plexus injury. Specimen- Articulated cervical vertebrae.
Simulated patient.
List nerve ro o t values o f brachial plexus. How to test fo r nerve injuries. Show on vertebrae
where cervical nerves exit (above) Palpate the coracoid process on the simulated patient. W hat
3 muscles are attached to the coracoid process? (Pectoralis m inor, Coracobrachialis and short
head o f biceps brachii)
2. Clinical Examination- Elderly man on oxygen, COPD, coming in fo r elective hernia repair. Do a full
respiratory examination. W hat is the pre, intra and post-operative considerations in this
patient?
3. Clinical exam ination- Varicose veins. M iddle aged woman. Un-cooperative and irritable ©
Doppler probes and to u rn iqu e t supplied. Assess w hat level the incompetence is.
4. Anatom y- Abdom inal aorta. Specimens- Abdom inal aortogram, picture from Netter's atlas of
anatomy. Name various branches o f AA. Identify infrarenal aneurysm. Define w hat an aneurysm
is
5. Clinical exam- simulated patient w ith right upper quadrant pain and m urphy's sign positive.
Cholecystitis fo r laparoscopic cholecystectomy
6. Anatom y- posterior thigh, sciatic nerve, boundaries and contents o f the popliteal fossa
7. ATLS- Patient in crash. Airway management. Examiner is your assistant
8. Communication- consent taking fo r esophagoscopy and dilation o f malignant stricture
9. Clinical exam- Examination fo r cranial nerves. Instructions- do not test fo r smell, visual acuity, or
gag reflex. Patient had bitem poral hemianopia. Further tests? MRI vs CT in imaging o f pituitary?
W hat is gadolinium
10. Procedure- male catheterization. Take consent then proceed. Remember to apply the sterile no
touch technique. A fter catheterization no urine, w hat to do next?
11. Physiology- Thyroid. Illustrate the hypothalam o-pituitary-thyroid axis. Interpret thyroid function
tests- primary hypothyroidism. Possible complications a fte r surgery on a hypothyroid patient
(hypotherm ia, prolonged recovery from anesthesia, bradycardia w ith hypotension, myxedema
coma)
12. Pathology- Patient w ith hepatitis C, cirrhosis, portal hypertension w ith splenomegaly who has a
splenic laceration. Develops DIC. Discuss the coagulation cascade
13. Communication- Phone call to ICU registrar fo r elderly lady w ith perforated viscus. No ICU beds.
Discuss resuscitation
14. History taking- elderly lady w ith anxiety disorder presenting fo r elective cholecystectomy
15. Pathology- cryptorchidism w ith malignant transform ation. Histological types o f testicular cancer.
Evaluate pathological report.
16. History taking- patient w ith unilateral tonsillar swelling, fevers, weight loss, night sweats.
Differentials
17. ATLS- patient post trauma w ith liver laceration and hematoma. Management
18. Pathology- inflam m atory bowel disease. Investigations, laboratory tests, management
 A n atom y:
1M o d e l o f B o w e l n r o s e c t i o n
Identify stomach- C a r d i a , fu n d u s , P y l o r u s . g r a n d le s s c u r v a t u r e , a n tr u m
Id e n tify d u o d e n u m an d p a n crea s
W h i c h p a r t o f d u o d in t r a p e r it o n e a l
Identify Pancreas : w h i c h p a r t in t r a p e r it o n e a l, w h a t r u n s in it - T a i l o f th e p a n c r e a s , s p e n i c v e s s e l s ,
b l o o d s u p p l y t o p a n c r e a s : s u p p a n c r e a t ic d u o d e n a l f r o m g a s tr o d u o d e n a l a r t e r y ,In f p a n c r e a tic o
d u o d e n a l f r o m S M A , P a n c r e a t i c b r a n c h e s o f s p l e n i c a r te r y ,
b lo o d s u p p ly to s to m a c h
s t r u c t u r e p o s t t o d u o d e n u m 3 rd p a r t
w h e r e d o e s p a n c r e a t ic d u c t o p e n s , h o w m a n y d u c t s : 2 d u c t s , M a j o r p a n c r e a t ic d u c t ( Duct of
Wirsung) & m i n o r p a n c r e a t ic d u c t ( Duct o f Santorini) O p e n s s e p a r a t e ly .
Embryological origin o f p a n c r e a s : P a n c r e a s o r i g i n a t e s f r o m D o r s a l a n d V e n t r a l buds.
W h i c h p a r t f r o m w h i c h : D o r a l p a n c r e a s f o r m s th e h e a d , b o d y a n d ta il.
The Ventral f o r m s th e Uncinate process a n d p a r t o f th e h e a d .

2M o d e l o f sk u ll b a s e :
I d e n t i f y s u p o r b i t a l f is s u r e , f o r a m e n s p in o s u m , f o r a m e n o v a l e , f o r m e n r o t u n d u m . o p t i c c a n a l
a n d n a m e th e s t r u c t u r e s p a s s in g t h r o u g h e a c h f o r a m e n .
w h i c h a r t e r y in o p t i c c a n a l, w h a t is t h e s p e c i a l i t y - i t is a n e n d a r te r y .
w h e r e is t r i g e m i n a l g a n g l i o n s it u a t e d - s h o w o n th e m o d e l

w h a t s t r u c t u r e is h e r e - c a v e r n o u s s in u s . W h a t a l l s t r u c t u r e s p a s s in g t h r o u g h it - I C A , A b d u c e n t
n erve.
S t r u c t u r e s o n la t e r a l w a l l - 3 rd, 4 th, 5 - 1 ,5 - 2 c r a n ia l n e r v e s
H o w i n f e c t i o n s p r e a d f r o m f a c e - s u p a n d i n f o p h t h a l m i c v e in s
B o u n d a r i e s o f m i d d l e c r a n ia l f o s s a , i d e n t i f y p i t u i t a r y fo s s a .

3 .Chest n r o s e c t i o n a n d s k e le t o n h u m e r u s , c l a v i c l e a n d s c a p u l a
C l a v i c l e : i d e n t i f y t h e u p p e r s id e , s t e r n a l a n d s h o u l d e r e n d s
s h o w h o w it a r t ic u la t e s w i t h s c a p u la
I d e n t i f y s p i n e o f s c a p u la , a c r o m i o n a n d c o r a c o i d
I d e n t i f y o r i g i n o f s u p r a s p in a t u s , in fr a s p in a t u s , t e r e s m i n o r a n d s u b s c a p u la r is
w h a t a r e th e s t a b i l i z e r s o f s y n o v i a l j o i n t s in g e n e r a l ?
w h a t is th e m a in s t a b i l i z e r s o f s h o u l d e r j o i n t - r o t a t o r c u f T m u s c le
I d e n t i f y G r t u b e r o s i t y , l e s s e r t u b e r o s it y , a n a t o m ic a l a n d s u r g ic a l n e c k o n th e H u m e r u s m o d e l .
A r t i c u l a t e h u m e r u s w i t h s c a p u la a n d s h o w a l l th e m o v e m e n t s .

P r o s e c t i o n o f c h e s t : i d e n t i f y p e c t o r a l i s m a j o r - w h a t is th e f u n c t io n o f c l a v i c u l a r a n d s t e r n a l p a r ts
C l a v i c u l a r p a r t - f l e x i o n ,s t e r n a l p a r t - A d d u c t i o n
W h a t is th e a d d it io n a l f u n c t i o n - A c c e s s o r y m u s c le f o r in s p ir a t io n
I d e n t i f y d e l t o i d m u s c le , w h a t is t h e f u n c t io n : A n t f i b r e s - f l e x i o n , M i d d l e f i b e r s - A b d u c t i o n
b e y o n d 3 0 * . P o s t fib e r s -E x tn .
w h i c h m u s c le s f l e x t h e e l b o w : B i c e p s , b r a c h i a l i s , b r a c h i o r a d i a l i s
M r i s c a n S h o u l d e r in I p a d :
Id e n tify th e p a r ts : h u m e r u s h e a d , g l e n o i d , a c r o m i o n , s u p r a s p in a t u s a n d d e l t o i d m u s c le .
C r itic a l care

4 .R h a b d o m y o ly s is + c o m p a rtm e n t syn d rom e

Y o u n g g e n tle m a n le g g o t c a u g h t u n d e r a b u ild in g c o lla p s e f o r s o m e tim e

W h a t a re c o m p lic a tio n s : R h a d o m y o ly s is ,c o m p a r tm e n t s y n d ro m e
H o w d o you m anage: A B C
W h a t b l o o d te s ts : h ig h L D H , C P K
W h a t a r e th e c l i n i c a l f e a t u r e s o f c o m p a r t m e n t s y n d r o m e ? P a s s i v e S t r e t c h p a in , t e n s e
c o m p a r t m e n t , d e c r e a s e d p u ls e v o lu m e / a b s e n t p u ls e , n u m b n e s s a n d p a r a l y s i s ( v e r y l a t e )
W h a t d o u d o -F a s c io to m y
w h a t w i l l u s a y t o th e p a t e n t w h e n u c o n s e n t f o r f a s c i o t o m y ? : C h a n c e f o r a m p u t a t io n
w h y r e n a l f a i l u r e - m y o g l o b i n f r o m m u s c le le a d s t o A c u t e k i d n e y in ju r y .

5 L a d y in th e E R w i t h a b d o m i n a l p a in :
. S h o w n a C h e s t X - r a y , w h a t is it: F r e e g a s u n d e r d ia p h r a g m
S o w h a t d o s u s p e c t : R u p t u r e d h o l l o w v is c o u s .
H o w d o you m anage?: A B C
W h a t is m o s t i m p f ir s t t o c h e c k a t a c h e s t x - r a y - p a t ie n t d e m o g r a p h i c s
S h o w n E C G ; w h a t i s th e r a te , w h a t is t h e d i a g n o s i s : A t r i a l f i b r i l l a t i o n .

W h a t a r e th e 5 c a u s e s o f A F
h o w t o m a n a g e a t r ia l F ib r illa t io n .

6 . P a t i e n t w i t h h e m a t e m e s i s in c r i t i c a l c o n d i t i o n
R e a d t h e b l o o d te s t r e s u lt s , s h o w n C B C r e p o r t .
h o w c a n u s a y h e is a l c o h o l i c l o o k i n g at C B C - h ig h M C V
w h y h e h a s p o r t a l h y p e r t e n s i o n - f r o m L i v e r c ir r h o s is .
W h a t h a p p e n s - t h e r e is f i b r o s i s in th e l i v e r p a r e n c h y m a .
W h y t h r o m b o c y to p e n ia : H y p e r s p le n is m
p l a t e l e t r e p o r t s h o w s c o u n t o f 7 5 0 0 0 0 - W i l l u t r a n s f u s e ? Y e s a s th e p a t ie n t is a c t i v e l y b l e e d i n g ,
p ic tu r e o f S in g s o t o n B la c k m o r e t u b e - i d e n t i f y , w h a t is th e u s e ?
T a m p o n a d e g a s tr o e s o p h a g e a l v a r ic e s .
S h o w w h i c h is g a s t r ic p a r t a n d w h i c h is e s o p h a g e a l p a rt.
w h a t c o m p l i c a t i o n c a n h a p p e n ? i s c h e m i c n e c r o s is d u e t o d i r e c t p r e s s u r e .
P a th o lo g y p h ysio lo gy
7 .L a d y w it h k id n e y s to n e s a n d d o d e n a l u lc e r c a m e t o E r
W h a t is a n u l c e r
H c l is s e c r e t e d b y w h i c h c e l l : P a r i e t a l c e l l s
h o w t o d i a g n o s e H p y l o r i : U r e a s e te s t
e x p la in : H p y lo r i c o n v e r ts u re a t o a m m o n ia w it h e n z y m e u rea se,
w h a t is th e c o n d i t i o n s h e h a s ? P r i m a r y h y p e r p a r a t h y r o i d i s m
h o w t o tr e a t H p y l o r i ? : t r i p l e t h e r a p y
P a tie n t h a d P a r a t h y r o id e c t o m y d o n e , s h o w n th e r e p o r t ( s h o w s 4 g la n d s e x c i s e d ) - w h a t is w r o n g
in t h e r e p o r t
A n s : n o m e n t i o n o f p a r a t h y r o id a d e n o m a .
S o w h e r e is it - e x c i s e t h y m u s ( s a m e e m b r y o n i c o r i g i n , 3 rd p h a r y n g e a l p o u c h )

8 . . P o s t o p p r o s t h e t ic r e p l a c e m e n t o f p r o x i m a l f e m u r p a t ie n t w i t h i n f e c t i o n
w h y th e i n f e c t i o n is d i f f i c u l t o t r e a t ? : A n t i b i o t i c s w o n ' t p e n e t r a t e , b i o f i l m
w h a t n e x t - r e m o v a l o f p r o s t h e s is
w h a t is o s t e o m y e l i t i s
w h i c h o r g a n is m
w h a t is s e q u e s t r u m ?
f e w m o r e q u e s t io n s —

E x a m in a tio n s :

1 .3 5 y r o l d m a l e w i t h e x o p h t h a l m o s e s ^ D i f f u s e t h y r o i d s w e l l i n g a n d s i n g l e n o d u le
E x a m in e :

G e n e r a l e x a m i n a t i o n s h o w s : t a c h y c a r d ia , f i n e t r e m o r s , L i d la g , p r o p t o s i s , n o o p h t h a l m o p l e g i a .
S w e l l i n g D i f f u s e B / L w i t h o n e n o d u le .

D ia g :T o x ic M N G / T o x ic d iffu s e g o itr e
w h y d o y o u s a y it is t o x i c : t a c h y c a r d i a , A s w e a t i n g , t r e m o r , e y e s ig n s
w h a t in v e s t ig a t io n f o r r e tro s te r n a l e x t e n s io n - ? C t scan/ R a d io io d in e (1 1 3 1 ) sca n

2.R i g h t h y p o c h o n d r i a l p a in y o u n g m a l e a c t o r
E x a m i n e th e a b d o m e n :

T e n d e r r ig h t h y p o c h o n d r iu m ,
M u r p h y ’ s s ig n +

D ia g : A / c C h o le c y s t it is
D / D : H e p a t i t is , p e p t i c u l c e r p e r f o r a t i o n , A / c L o w e r l o b e p n e u m o n ia ,
w h a t in v e s tig a tio n s to c o n fir m th e d ia g n o s is :U S G , H 1 D A sca n
m a n a g e m e n t o f a c u te c h o le c y s t it is :c o n s e r v a t iv e : I V flu id s , N P O , I V A n tib io tic s + / -
S u r g i c a l : L a p c h o l e c y s t e c t o m y / I n t e r v e l la p c h o l e y s t e c t o m y
3 . 3 8 y r m a le p o s t o p la p a r o t o m y 10 d a y s b a c k c a m e n o w w it h S O B
E x a m i n e th e c h e s t :

G o as p e r A B C ( C c r is p p r o to c o l)
V e r y c o - o p e r a t i v e a c t o r . T e n d e r n e s s o v e r th e r ig h t u p p e r c h e s t w i t h S O B .
L a p a r o t o m y d r e s s i n g o v e r th e a b d o m e n .
R ig h t c a l f te n d e r n e s s p r e s e n t(b o th H o m a n a n d m o s e s s ig n + )
D i a g : P u l m o n a r y e m b o l i s m f r o m D V T r ig h t c a l f

W h a t i n v e s t i g a t i o n t o d o ? :C 'h e s t X - r a y , A B G , C T P A
h o w t o m a n a g e ? P r o p u p , 0 2 , I V f lu id s , L M W H , I f m a s s i v e p u l m o n a r y e m b o l i s m - n e e d
e m b o le c to m y .
H o w t o p r e v e n t ; T E D s t o c k in g s , e a r l y m o b i l i z a t i o n , L M W H
Y o u a r e s c r u b b e d in th e O T c a l l f r o m w a r d p a t ie n t c o l l a p s e d w h a t w i l l y o u d o ? C a l l th e s w it c h
a n d R a i s e a la r m .

4 . Y o u n g l a d y w i t h p a i n a n d n u m b n e s s o f r i g h t h a n d s i n c e la s t f e w m o n t h s .
E x a m in e :

C a r p a l tu n n e l s y n d r o m e
D / D : c e r v i c a l r a d ic u lo p a t h y , t h o r a c i c o u t l e t s y n d r o m e .

W h a t a r e m u s c le s s u p p l i e d b y m e d i a n n e r v e in t h e h a n d : L O A F m u s c le s
W h y t h e p a t ie n t h a s w e a k n e s s o f l o n g f i n g e r f l e x o r s ? M a y b e l e s i o n h ig h ,w h e r e ? T h o r a c i c
o u t l e t s y n d r o m e , c e r v ic a l d is c p r o la p s e .
w h a t a ll c a u s e c a r p a l t u n n e l s y n d r o m e ? C o l i e s fr a c t u r e . L u n a t e d i s l o c a t i o n
a c r o m e g a ly , m y x o e d e m a .
H o w w i l l y o u m a n a g e c o n s e r v a t i v e l y : W r i s t s p lin t , s t e r o i d in j e c t i o n s

H isto ry:

5.H /o L o w b a c k p a in , y o u n g l a d y h a s d o n e s o m a n y te s ts i n c l u d i n g m r i s c a n o f lu m b a r
s p i n e ( s h o w s o n l y m i l d d is c d e g e n e r a t i o n s ) h a s s e e n o r t h o . n e u r o b u t n o r e l i e f o f s y m p t o m s .
S t a r t e d a f t e r th e h u s b a n d lo s t j o b a n d g o t ill.

D i a g ; F u n c t io n a l b a c k p a in
D o n ' t f o r g e t t o a s k r e l e v a n t n e g a t i v e h i s t o r y ( b o w e l , b l a d d e r c o n t r o l , s a d d le a n a e s t h e s ia , s e n s o r y
m o to r s y m p to m s )
h o w w i l l y o u m a n a g e th e p a t ie n t

6. H /0 y o u n g m a l e w h o n o t i c e d a s w e l l i n g o v e r th e l e ft g r o i n s i n c e la s t f e w m o n t h s .
T a k e a h i s t o r y f r o m th e p a t ie n t :
O n h i s t o r y h e v o l u n t e e r e d t a k in g d r u g i n j e c t i o n s a n d th e s w e l l i n g is p u ls a t ile .

C o m p l e t e th e h i s t o r y
Q n s : W h a t a r e th e D / D ? : F e m o r a l a r t e r y a n e u r y s m . A b s c e s s , s e b a c e o u s c y s t , l i p o m a , h e r n ia
H o w w ill u m a n a g e? - I n v e s t i g a t e t o c o n f i r m th e d i a g n o s i s - D o p p l e r s c a n
T t:E n d o v a s c u la r p ro c e d u r e s , b y p a s s

com m u n ica tion

7 . S t e m : E x p l a i n t o th e p a t ie n t r e g a r d i n g O G D + e n d o s c o p i c d ia la t a t io n f o r b e n i g n o e s o p h a g e a l
s t r ic t u r e
P a t i e n t h a d B a r iu m s w a l l o w in a n o t h e r h o s p it a l a n d s h o w e d a s t r ic t u r e m o s t l i k e l y b e n ig n .
E x p l a i n th e p a t ie n t r e g a r d i n g th e O G D , d o n o t t a k e c o n s e n t .

A c t o r is v e r y c o - o p e r a t i v e , e x p l a i n t h e p r o c e d u r e ( c a m e r a te s t, t o i d e n t i f y a n d l o c a t e th e
p r o b l e m , t a k e b i o p s y a n d d o t h e d i a l a t a t i o n ) . r is k s i n v o l v e d
E x p l a i n o n th e c h a n c e o f e s o p h a g e a l p e r f o r a t i o n s o h e s h o u ld s e l f - m o n i t o r a f t e r th e p r o c e d u r e i f
h e w i s h e s t o g o h o m e th e s a m e d a y .
N o q u e s t i o n s f r o m e x a m in e r .

P r e p s t a t io n : W h o l e s e t o f n o t e s :

8 . S t e m : 8 0 y r. o l d l a d y w i t h l i m b i s c h e m i a + a b d o m i n a l p a in d i a g n o s e d a s d i v e r t i c u l i t i s o n i v
f l u i d s a n d a n t ib io t ic s .
S p e a k t o th e v a s c u la r c o n s u lt a n t o n c a l l t o t r a n s f e r t h e p a t ie n t t o th e x y z h o s p it a l.

C o l l e c t a ll th e r e l e v a n t i n f o r m a t i o n f r o m th e p i l e o f p a p e r s p r o v i d e d .
C h e c k a n d r e m e m b e r th e h o s p it a l n a m e a n d y o u r c o n s u lt a n t n a m e
N o t e d o w n P a tie n t’ s c o n d it io n a n d c o - m o r b id it ie s .

Do SBAR

Q ns:
W h a t in v e s t ig a t io n to d ia g n o s e ? : A r t e r ia l d u p le x sca n
w h a t th e e c g s h o w s ? - A t r i a l f i b r i l l a t i o n ( k e p t a n E C G o n th e t a b le in th e s e c o n d r o o m )
w h a t d o u s u s p e c t th e c a u s e o f a b d p a in ? : In v i e w o f A L I a n d A F it c o u l d b e M e s e n t e r i c
i s c h e m ia .
W h a t is th e c a u s e - p o s s i b l e e m b o lu s .
w h a t t r e a t m e n t f o r l i m b is c h e m ia : E m b o l e c t o m y , B y p a s s , L M W h e p a r in .
H o w to m o n ito r L M W h e p a r in ? A P T T n o t v e r y u s e f u l, A n t i F a c t o r X A is t h e g o l d s ta n d a r d .
procedures:
9 . E x c i s io n o f n e v u s + r e p a i r o f w o u n d
C o n s u l t a n t h a s b e e n c a l l e d a w a y . Y o u a r e t h e R e g i s t r a r in th e d e p t , s o p e r f o r m th e p r o c e d u r e .

C h e c k th a t c o n s e n t is s i g n e d b y t h e p a t ie n t , c h e c k f o r th e L A is a c t i v e b e f o r e s t a r t in g
Y o u h a v e t o s e l e c t a l l t h e in s t r u m e n t s y o u n e e d t o p e r f o r m th e p r o c e d u r e fir s t .
N o a s s is ta n t s a v a i l a b l e .
M a k e an e llip t ic a l in c is io n a ro u n d th e n e v u s a n d d o th e e x c is io n .
S u t u r e w i t h 3 0 n y l o n in t e r r u p t e d s u tu r e s . T h e e x a m i n e r k e e n l y o b s e r v e d th e w h o l e p r o c u r e .
S e n t th e s p e c i m e n f o r h i s t o p a t h o l o g y (ju s t s a y t h a t )
G i v e a d v i c e t o th e p a t ie n t w h i l e y o u p e r f o r m th e s u t u r in g l i k e - c h a n g e o f d r e s s in g a n d r e v i e w in
c l i n i c o n c e t h e r e p o r t is r e a d y w h i c h u s u a lly t a k e s 2 w e e k s
T a k e th e p r e s c r ib e d m e d ia t io n s .
r e p o r t t o E R i f t h e r e is a n y f e v e r , r e d n e s s , d is c h a r g e , s w e l l i n g e tc .
Q ns:
w h i c h i n c i s i o n is b e t t e r a n d w h y ? L o n g i t u d i n a l a l o n g th e l a n g e r s lin e s a s it g i v e s b e t t e r s c a r.

10 . L o c a l i n f i l t r a t i o n + In c is io n a n d d r a i n a g e o f a b s c e s s t h ig h
S t e m : T h e s k in is a l r e a d y p r e p a r e d , a n d c o n s e n t ta k e n .
Y o u h a v e t o i n f i l t r a t e w i t h l o c a l a n e s t h e t ic a n d d o I & D o f th e a b s c e s s .

O n e A s s is ta n t a v a ila b le .

Y o u h a v e a r r a n g e y o u r in s t r u m e n t s fir s t
S t a r t w i t h L A c h e c k th e e x p i r y , a s k f o r 2 4 g n e e d l e
I n f i l t r a t e th e L A . T e l l th e p a t ie n t w i l l w a i t f o r s o m e t i m e f o r th e m e d i c i n e t o a c t.
C h e c k th e L A is a c t i v e . P e r f o m I n c i s i o n lo n g i t u d i n a l , as s o o n a s th e p u s c o m e s o u t a s k f o r P u s
s w a b a n d s e n t f o r C & S . in s e r t f i n g e r b r e a k a ll th e l o c u l i a n d r e m o v e a ll th e c o l l e c t i o n .
U s e a g a u z e p i e c e w i c k a n d in s e r t in th e w o u n d a n d a s k th e a s s is ta n t t o p u t th e d r e s s in g .
G iv e a d v i c e t o t h e p a t ie n t w h i l e d o i n g th e p r o c e d u r e r e g a r d i n g c h a n g e o f d r e s s i n g a n d n e x t
c lin ic v is it.
D i s p o s e o f f th e s h a r p s .
I f y o u h a v e t i m e i r r i g a t e th e w o u n d w i t h s a l i n e i f a v a i l a b l e ( d i d n ’ t d o )

Q ns:
i n c i s i o n w h y l o n g i t u d i n a l : la n g e r s li n e s a r e a l o n g t h e l o n g i t u d i n a l a x i s in l im b s , s o g i v e s b e t t e r
s c a r.
w h at absorbent dressing you can use instead o f the g a u ze - A quacel.

T i p s : G e t h i g h s c o r e s f o r a n a t o m y s t a t io n s as y o u c a n p a s s th e k n o w l e d g e s e c t i o n e v e n i f y o u r
c r it ic a l c a r e / p a t h o lo g y g o e s d iffic u lt .
D o n ' t o v e r l o o k h i s t o r y a n d c o m m u n i c a t i o n a s it is e a s y t o s c o r e h ig h m a r k s i f y o u p r e p a r e a n d
p r a c t i c e s o th a t y o u c a n m a n a g e e v e n i f t h e c l i n i c a l e x a m i n a t i o n s t a t io n g o e s t o u g h .
E x a m i n a t i o n s k ills : M a n a g e th e t i m e w i s e l y , c o m p l e t e th e e x a m i n a t i o n s b e f o r e t i m e s o th a t y o u
g e t t i m e f o r q u e s t io n a n s w e r .

M o s t o f th e e x a m i n e r s a r e g o o d a n d s o a r e th e a c t o r s , t h e y d o h e l p y o u w i t h th e c u e s .
no procedure station
20 stations quite a few repeats so i’ll copy the same qns from the compilation
sorry cant remember all

ANATOMY

Station 1 thorax
pictures of cadavers used, examiner points and you just name it

1. what is this? tricuspid valve, papillary muscle, chordae tendinae. what is function of chordae
tendinae? prevent av prolapse during vent systole
2. Branches of the ascending aorta - R and L coronary artery
3. what is this? azygous vein
4. Name me tributaries? bronchial veins, oesophageal veins, hemi azygous vein, accessory
azygos vein, intercostal veins

Station 2 lumbar spine

actual bone models used and a photo of an MRI

- Identify the structures (body, pedicles, laminae, transverse processes, spinous process)
- Articulate the 2 vertebrae, identify the intervertebral foramen, what comes out of this
foramen (spinal nerves)
- W here does the anterior longitudinal, posterior longitudinal ligament and ligamentum flavum lie
(ant to body, post to body, ant to laminae respectively)
- W hat are the articular surfaces between the 2 vertebrae (the sup/inf articular facets, intervertebral
disc)
* W hat kind of joint is the intervertebral disc joint (fibrocartilage joint)
* Shown MRI of coronal section of spine/spinal cord - asked to number the vertebrae, asked to
point to an intervertebral disc
- Components of the intervertebral disc - annulus fibrosus/nucleus pulposus
* W hat changes to the disc with ageing (decreased height)
* If the L4/5 disc herniates, which spinal nerve will be affected (L5)
* sensory area for L5
* Where does the spinal cord end in a neonate (L3-4), in an adult (L2-3)
- Surface landmark for lumbar puncture (L4 at iliac crest)
* W hat lies between L3-S4 in an adult (CSF, spinal nerves, conus medullaris, cauda equina, filum
terminale)
* Contents of spinal canal below L2
* Location of paravertebral venous plexus
* Clinical significance (Tumors metastasizing to vertebral column)
- how do tumours spread to the entire spine (venous plexus has no valves)

Station 3
parotid and cranial nerves
there is an SP for you to demonstrate surface anatomy
cadaver picture of a parotid
bone model of base of skull

surface anatomy of the parotid duct on the patient (superior border: inf margin of zygomatic arch,
ant: post border of masseter, inf: body of mandible, post: SCM).
- Surface anatomy of parotid duct (middle third of line between antitragic notch and philtrum, 1cm
below zygomatic arch)
- where does the duct drain to? (opposite 2nd upper molar)
* which nerve supplies parotid gland
* identify branches of CN7 on the picture (mistook the posterior auricular nerve for the cervical
branch but examiner says everyone mistook it, cervical branches are smaller and travel more
obliquely from the parotid)
* There is a 2x2 lump over 1 side of a parotid, tender. W hat is it? (Ans examiner looking for: LN)
- Inflammatory causes of parotid swelling. (Ans examiner looking for: sjogrens, mumps,
sarcoidosis)
- Benign causes of parotid swelling.
* Malignant causes of parotid swelling, primary: MAP-
* mucoepidermoid.adenocystic,pleomorphic adenoca , secondary
* CN carrying parasympathetic fibres. 3,7,9,10
- Gustatory sweating. Freys syndrome. - damage to the parasympathetics to the parotid, causing
the fibres that usually signal salivation to connect to the fibres supplying the sweat glands on the
skin of the face, causing gustatory sweating when the patient sees/smells food.
- where does the facial nerve exit on base of skull? stylomastoid foramen, identify on skull model

PATHOLOGY

1. TB
Stem: young indian girl travels overseas, comes back with night sweats, LOW and 2cm lump over
anterior triangle of neck

What are your 2 main differentials (TB and lymphoma)

* W hat lymphoma would you suspect (not sure, i said hodgkin's lymphoma in view of her age
group and she didn’t look upset)
* what would you do to make a diagnosis?
* what would you do with the sputum/aspirate sample? says all clinical info is on the bag already,
answer is to label appropriately and put in biohazard bag. didn't want to hear about putting
relevant info or informing authorities
* Given histology report: necrotic debris, giant cells,
- whats the diagnosis? TB
* what is a giant cell? multinucleated cells comprising of macrophages
* W hat tests for TB - culture, stain (Ziel-Neelson), TB PCR, interferon gamma assays (tb
quantiferon gold)
* How long does a TB culture take - 4-6 weeks
* W hat will you need to do with the patient after dx TB (i said contact tracing and isolation if
necessary)
- W hat other mycobacterium do you know that affects immunocompromised individuals ( looking
for MAC. mycobacterium avium complex)
* 3 causes of granulomatous inflammation. Foreign body and TB are not counted, only managed
to say crohns and sarcoidosis.
* W hat is the proteinaceous substance that can be found systemically in TB - AA amyloid
abnormal deposition of fibers of insoluble protein in the extracellular space of various tissues
and organs (just said amyloid and she accepted)

2. PUD
Stem: man who is taking NSAIDS gets abdo pain. XR shows free air under diaphragm
- what is the diagnosis: perf viscus likely secondary to PUD
- what is the risk factor in this patient: NSAID use
* how do NSAIDs cause PUD: didn't really know but examiner was nice and helped me derive that
suppression of PG synthesis cause increase acid secretion, less mucus and bicarb secretion for
protection, reduction in blood flow
* what other risk factors for ulcers: h.pylori, diet, stress ulcers, also looking for zollinger ellison
syndrome
* what is ZE syndrome? pancreatic gastrinoma resulting in multiple peptic ulcers
* what does gastric acid do? looking for pepsin
- W hat are the different phases controlling gastric acid secretion? cephalic, gastric, intestinal,
explain each phase
* W hat medications would this pt require in the long-term?
* How do PPIs work?
* how would you treat an ulcer surgically? primary repair vs omental patch

3. diverticulitis, endometriosis, MODS, ARDS

Stem: Lady came in with LIF pain and peritonism, had Hartmanns procedure for perforated
colon, histology was perforated diverticulitis with endometriosis

1. what is diverticulitis
2. what is endometriosis
3. patient becomes tachycardic, tachypneic, febrile, labs show raised TW, raised Cr. saturations
drop
4. explain what has happened? pt has sepsis with MODS and ARDS
5. what is fever
6. what is a pyrogen
7. what would you find histologically in ARDS
8. is the edema in ARDS a transudate or exudate?
9. some questions about DIVC somewhere in between

CRIT CARE
also repeated

trauma, c-collar and oral airway insertion

24/M hit by car
you are the ED dr. patient is not breathing
mannequin with various oral airways and c-collars (Aspen and some soft c-collars)
one examiner will act as your ED nurse

ATLS principles
airway: clear airway ensure no FB in mouth
demonstrate how to clear FB from mouth
pt is not breathing still
to insert oral airway (guedel).
demonstrate how to size the oral airway
what could be causes of airway problems in this patient?
- said FB such as dentures, teeth, laryngeal #, bleeding with aspiration, vomitus etc
pt is now breathing. So you don’t bag pt and put on facemark instead
continue with your ATLS
C-spine: show how you would put the c-collar on. ask the examiner to do in line stabilisation for
you with clear instructions
choose correct c-collar.
what else? continue with rest of ATLS survey
circulation, disability, GCS
pt s GCS is 3
offer to intubate patient in view of low GCS
pt has stopped breathing
demonstrate BVM. can ask the examiner to bag for you while you use double handed seal,
demonstrate how to feel carotid pulse

Spinal anaesthesia complicated by neurogenic shock

stem: patient underwent elective surgery with spinal anaesthesia now has hypotension
given charts to interpret: vitals, intake/output (will hide this until you ask for it or he decides to give
it to you)

1. differentials for hypotension: hypovolemia, neurogenic, cariogenic

2. interpret vitals
3. what is shock?
4. what other bedside monitoring would you like? didn’t really understand the question but was
looking for IDC insertion to chart output
5. what is usual urine output
6. what is your first management for this patient: fluid resuscitation, inform senior
7. comment on the frequency of monitoring (was Q4H) - insufficient
8. what is BP? BP = COxSVR
9. what kind of a fluid is normal saline? crystalloid
10. given four points on the chart ABCD, at which point would you have called your senior? i think
i said B, after seeing no response from fluid challenge
11. given IO chart, it says patient got 250x2 fluid challenges, comment? insufficient
12. pointed out that patient drank 1500ml fluid, need to comment that oral intake is not a good way
of increasing intravascular volume as water is hypotonic

PHYSICAL EXAM
each stem will tell you NOT to present as you go and to talk to patients as little as possible but if it
is better, they won't stop you from presenting at the same time

Thyroid
patient with a goitre
examiner was really mean to everyone so everyone got different questions, i can't really
remember, he wasted a lot of time nitpicking at what you said instead of going through the
questions
overhead him scolding someone about forgetting to check for thyroglossal cyst

CVM valve replacement

stem is that this patient is coming in for pre-op assessment for some other elective procedure

TBH i think it was a MVR but some of us had differing opinions, audible clicking heard
large lady with pendulous breasts, midline sternotomy scar
they will let you present everything fully at the end
some questions about Preoperative concerns : INR etc

ankle
simulated patient although he was quite good i thought it was real
said too painful to stand so i let him sit down explaining that ideally i would get him to stand up so i
can see the posterior aspects and alignment
said tender over lateral ligaments and painful on DF, inversion
ant drawer negative,
compared to opposite side
differentials: injury to lateral ligament complex, TRO bony pathology
investigations: XRay, KIV MRI if not improving after a period
XR shows undisplaced distal fib # (no picture) - management? backslab, KIV convert to full
cast/airboot when swelling subsides

inguinal hernia
missed the previous hernia repair scar on the le ft :(
not very obvious but patient was nice, allowed me to get him to stand up to see the lump, lie down
to reduce it and stand up again,
how to tell it is indirect vs direct
if patient has been telling you he has urinary frequency, nocturia, how does that change your
management?

COMMUNICATION
repeats

counselling of patient on warfarin for valve replacement, planned to have mesh inguinal hernia
repair next week

stem: you’re the dr on call, patient who is blind has walked into the ward and demanded to speak
to a dr as he is anxious about his surgery next week.
you are given 9 minutes to read through the correspondences between his other drs and the
hospital, also has a pre-op assessment saying his INR is 2.1 or something (adequate range)

mm apparently patient shouted at some people

good actor who is very anxious, will keep talking about what will happen if his warfarin is stopped
for surgery, have we checked with his cardiologist, will he die, will his valve thrombose,
said usually we bridge with clexane which is a SC injection (but i think even if you didn’t bring this
up, its not wrong), said he’s blind cannot do SCinjections. said will look into home nursing support
for him
main thing is to offer to check with his main surgeon, check with CVM etc
didn’t ask me about what surgery he was going for but supposed to remember that he’s going for a
mesh hernia repair

acute LL ischemia

examiner sat behind a screen

given 9 minutes to read through the stem and documentation, documentation is not good enough
with some key details omitted.
stem: 22 year old medical student, cyclist hit and run by car, LOC 15 mins until ambulance
arrived, GCS 15, haemodynamically stable. Has open fracture of left tibia/fibula with nil
cold leg, also has u/s abdo with ?free fluid, but GS reg has examined and abdo is SNT

reports by radiologist: XR showing tin-fib #, US and showing ?free fluid

on call dr (your colleague) got called to see patient as limb became cold, brief documentation that
leg is pulseless but he was called away for a code blue

you have to call the trauma con on call and explain the situation

speak in SBAR format and to the point.

will ask about things like is patient on C-collar. do you think his spine can be cleared, mentioned
NEXUS c-spine criteria so no, he should have a c-collar on (but you don't know because no one
has documented)
how will you manage, what investigations are you going to ask for now
looking for: CT brain (in view of LOC), CTAP, CT LL + angio

HISTORY TAKING
repeat

Knee OA
stem: youngish patient with R knee pain

plays football recreationally but really keen to continue playing

- had right knee injury 30 years ago, some knee operation
that he had no idea about, developed worsening right knee pain for 4 months
- DDx - osteoarthritis, rheumatoid arteritis, possible loosening/fracture of prosthesis from
previous op
- Investigations : xray looking for decreased joint space, osteophytes, subchondral
cysts/sclerosis
- no picture but told that you see a malunited # of a previous tib#
- Management options: Conservative/medical/surgical: conservative with PT/OT/exercise,
medical with analgesia according to W HO pain scale ladder, intra articular steroid
injections/PRP injections, surgical - TKR, partial KR
- Will patient be likely to play soccer in 9 months - no
* How about in the long run

pulm embolism
POD5 THR now chest pain and SOB

patient with acute R sided chest pain, SOB, hemoptysis

claims has been ambulating
ddx: PE, pneumonia, ACS
investigations
management
1.Communication

-counsel the w ife o f a man who was adm itted for abdominal distension and ascites fo r which peritoneal
tap revealed m alignant cells.He was planned fo r CT abdomen however current CT scan machine in the
hospital broke down and the nearest facility is 40 minutes away.The consultant supposed to speak to
the fam ily but was called to scrub fo r a case in OT so you are called to speak to the w ife who was
distraught.

2.A young girl who was post traum a and presented w ith reduced le ft hearing.Perform examination of
hearing (including otoscopy) and relevant examination

-how to perform otoscopy?direction to pull the ear

-w hat is your interpretation o f finding?impression?differential diagnosis

-Investigation?

-Diagram o f otoscopy given.W hat does it show?hemotympanum

-D ifferential diagnosis

-W hat investigation would you do and how manage?

3.Patient had a sports injury and complained o f right ankle.Perform ankle examination.

-W hat is your finding?

-W hat is your im pression?differential diagnosis?

-W hat investigation w ould you do?

-Supposed it is lateral malleolus fracture,w hat is the expected findings and management?

-How long to put a patient on POP cast?

4 .Patient presented w ith groin swelling (hernia).Examine

-W hat is your finding?

-W hat is your diagnosis?

-W hat investigations w ould you do?

-W hat are the risk factors in the patient?

-How w ould you manage?

-W hat are the options o f surgery?

-How w ould mx d iffe r if patient has bph?

5.Patient planned fo r surgery but noted to have pacemaker.Perform cardiovascular examination.

-W hat is your finding?

-W hat is your impression?

-Interpret ECG.Pacemaker functioning?

-Preoperative preparation if patient has pacemaker?

-W hat diatherm y would you use?

6.Referring case to a consultant.A patient who is post op day 2 laparoscopic cholecystectomy

complaining o f severe abdomen.USG abdomen noted free fluid,impression post cholecystectomy bile
duct injury.

Questions asked

-W hat is your management so far fo r the patient?

-W hat antibiotic w ould you give and why?

-The beds are currently full now,is it necessary to send now?

7.Anatomy o f Thorax and neck

-identify esophagus, carina, subclavian artery, external and internal carotid artery, recurrent laryngeal
nerve

-level o f carina

-epithelium o f esophagus

-explain subclavian steal syndrome

8.Anatomy

-carpal bones

-identify muscles in posterior forearm , innervations, blood supply

-anatomical snuff box

-significance o f blood supply to scaphoid and the condition(AVN)

-identify dorsal digital expansion and explain its function

9.Cranial cavity/Head/Neck

-identify middle cranial fossa and its borders,foramen rotundum,cavernous sinus,optic canal,superior
orbital fissure

-Structures passing through foram en ovale,rotundum,cavernous sinus,optic canal,superior orbital fissure

-how does middle ear infection spread to cranial cavity?

-how does cavernous sinus throm bosis present?its route o f infection?

-identify parotid and submandibular gland,where does the duct open

10.Pathology

-Young girl w ith abdominal pain and on o ff bloody stool. Right hemicolectom y done. HPE right
hemicolectomy:presence o f noncaseating granuloma

-impression?Chron's disease

-Macroscopy picture o f Chron's disease (Right hemicolectomy specimen).Identify features o f chron's

disease

-W hat are the extraarticular manifestations o f Chron's disease?

-Interpret blood results,anemia

-Role o f v it B12 and folate in hemopoiesis.Effect o f deficiency

11.Pathology.Post total thyroidectom y,patient developed hypocalcemia.

-Physiological roles o f calcium..wanted at least 5

-Features o f hypocalcemia?signs

-management o f post thyroidectom y hypocalcemia

-cause o f hypocalcemia

-medications to be given

-how is calcium carried in circulation

-w hat protein is it bound to

12.Tie surgeon's knot,deep cavity tie and figure o f 8

-types o f knot th a t you know

-m aterial fo r vicryl,its absorption and retention tim e

-num ber o f throw s if absorbable and nonabsorbable

13.Pathology.Triple A patient,underw ent emergency repair became hypotensive.Intraop blood ix

revealed anemia and coagulopathy

-impression?
-Definition o f hypothermia?

-How does hypotherm ia affect surgery?

-How to prevent hypotherm ia intraoperatively?

-How to tre a t coagulopathy?

-Definition o f massive transfusion?

-W hat are the effects o f massive transfusion?

-How does the presentation o f ARDS and TRALI differ? pathophysiology and tim e line and treatm ent

14.Pathology,post pancreatitis came back w ith pancreatic pseudocyst and ARDS.

-Shown CT abdomen o f patient. Dx? pancreatic pseudocyst

-Blood investigations

-systemic complications o f pancreatitis?

-how does it cause hypocalemia?

-Shown CXR.Dx?ARDS

-Definition o f ARDS

-M anagem ent o f ARDS

-investigations

15.History taking o f patient 60 year old c/o impotence fo r 6 months, underlying hypertension and on
beta blocker.

-Impression? Causes o f impotence? w hat is the cause in this patient?

-Investigations? management?

-W hat type o f UTI/STD cause impotence? pathophysiology?

16.history taking o f middle aged gentleman who had sports injury when young(meniscal injury) and
complaining o f 6 months of knee pain.

-Dx?post traum atic OA

-findings if examine

-Investigations

-management o f OA

17.Prioritizing cases
Anatomy

Station 1

H is to ry given - Rugby p layer sustained neck in ju ry d u rin g a tackle.

Questions w ill be asked a ro u n d the re le va n t anatom ical structures.

Ipad having p ic tu re o f axis and atlas.

- Id e n tify the ve rte b ra and name the parts?

- H ow m any cervical vertebras?

- W hich are the ty p ic a l and a typica l vertebrae?

- H ow m any cervical nerves?

- Id e n tify the D ens/O dontoid.
W hat are th e ligam ents attached to it -
o A la r Ligam ents
o A pical Ligam ent o f dens

- P o in tin g to Foram en T ra n sve rsa riu m - W hat are the s tru ctu re s passing
th ro u g h this? W h a t is the course o f V e rte b ra l A rte ry?

Show ing Xray Open m o u th v ie w and la te ra l Cervical x-ray

- W hat is this x ra y view.
- W hat are the s tru ctu re s (on each vie w ) you can id e n tify -
On open m o u th v ie w - dens, Spinous processes. Transverse
process, S u p e rio r and in fe rio r facets
- P o in tin g to w a rd s C7 on the p a tie n t (m ost p ro m in e n t spinous process). W hich
ve rte b ra is that. W hy is it p ro m in e n t and w h y cant you feel the verte bra e above
it? As the Ligam entum Nuchae is th ic k and the spinous processes o f vertebrae
above are b ifid

- P oint to h yo id bone on patient? W hat level. - C3

- P o int to a s tru c tu re lies in a n te rio r neck a t C6 level - crico id cartilage

- W t GI s tru c tu re is re la te d there. Pharyngo-esophageal ju n c tio n

- Show the boundaries o f the p o s te rio r tria n g le on the patient.

- P o int o u t lo ca tio n o f roots o f Brachial plexus on the p a tie n t. Between

w h ich 2 muscles.

Station Z

Scenario given - P atient w ith a Car accident and crush in ju ry o f lo w e r lim b

Inside S im ulated p a tie n t

a. D em onstrate on the p a tie n t -

- Eversion, Inversion, D o rsifle xio n & P la n ta rfle xio n o f foot

-A c tio n o f EHL

- A ctio n o f com bined TA & TP

- A ctio n o f Peroneus longus and brevis

- W here to palpate pulses o f fo o t

- O rigin and in s e rtio n o f Peroneus b revis and Peroneus te rtiu s

- W h a t are the com partm en ts o f the leg?

- W h a t muscles in each com partm ent?

- A rte ria l and nervous su p p ly o f each co m p a rtm e n t

- Root value fo r su p e rficia l and deep peroneal nerves

- P a tient has tense s w e llin g and pain w h a t is diagnosis - C om pa rtm e nt

syndrom e

- I f p a tie n t has pain in D o rsifle xio n o f fo o t w h ic h co m p a rtm e n t is involved? -

posterio r.

- Root value o f knee and ankle je rk

- Surface m a rk the area o f d is trib u tio n o f deep and s u p e rficia l peroneal nerves

- Surface m a rkin g o f S I derm atom e.

Station 3

A n a to m y o f A o rta and IVC

P icture o f abdom en dissection given.

- Id e n tify the a b d o m in a l aorta

- S tart and end ing levels o f A b d o m in a l aorta

- Name its branches and v e rte b ra l levels

- Surface m a rkin g o f the AA

- W h a t stru ctu re s lie a n te rio r to AA at L I - He w a nte d 4 stru ctu re s and the name
tra n s -p y lo ric plane.

- Show IVC and its branches.

- W hat is an aneurysm

- W hat is dissecting aneurysm

- Betw een w h ich layers does the dissection in dissecting aneurysm occur -
betw een m edia and in tim a ( som e places given w ith in layers o f m edia)
 A ngiogram given. Id e n tify Coeliac tru n k and its branches, SMA, IM A

Pathology

Station 4

P icture o f Basal cell carcinom a given.

i. Describe w h a t you see (N o d u lo -u lce ra tive g ro w th w ith ce n tra l ulcer

w ith everted edges a bo ut 1 cm in size and bleeding).

ii. 3 DDs? Sq cell Ca, Basal Cell Ca, A m e la n o tic M a lignan t melanoma,

iii. Name 2 causes fo r s u rro u n d in g eryth em a - Reactive ca p illa ry

form ation /N eoan gio genesis.

iv. Define m etastasis

v. Describe the pathological m echanism o f ly m p h a tic spread in

th is patient.

vi. A p a tie n t comes w ith h /o fever and sw ellings a ro u n d the body. A

biopsy is p e rfo rm e d and the re p o rt shows Reed Sternberg cells. W hat
is the diagnosis - H odgkin's lym phom a.

Station 5

Scenario - Lady w ith ch ild h o o d R heum atic h ea rt disease. N ow com ing fo r

Cholecystectom y.

i. Im m une m echanism o f R heum atic fever - Ag-Ab reaction d / t au to im m u n e

mech and m o le cu la r m im icry.

ii. W hy does a o rtic stenosis occur in R hem atic h ea rt ds -C o m m isu ra l fusion

and w e a r and te a r causing th ic k e n in g o f leaflets

iii. Define IE

iv. W hat organism s - Staph S trepto and HACEK

 v. W hat to lo o k fo r in 2D Echo

vi. Name 3 lesion fo und in the hand

vii. H ow w ill you trea t? - A n tib io tic s

v iii. Name a single in ve stig a tio n to m o n ito r response to Abx

ix. N ow i f the p a tie n t does n o t im p ro v e on a n tib io tic s then w h a t - A o rtic

valve replacem ent

x. W hy is it d iffic u lt to tre a t IE w ith a n tib io tic s alone - Valves are avascular

structures, Vegetations have high b a c illa ry conc. D iffic u lt to penetrate
a n tib io tic as fib rin mesh,

xi. W hat else a p a rt fro m Valve replacem ent - Cardiac tra n sp la n t

xii. W hat o th e r specialities you re fe r

x iii. If p a tie n t go fo r cardiac tra n sp la n t, w h a t to check fo r organ re je ctio n -

HLA

xiv. W hat are the m echanism o f action o f kn o w n im m uno-suppressants

xv. W hat are the com plication s o f im m une-suppressants? - w a n te d skin

cancers and lym phom a.

xvi. W hat is the m echanism o f lym pho m a w ith im m unosu ppressive drugs?

- w anted m e n tio n o f EBV and mech by w h ich EBV causes lym phom a.

Critical Care

Station 6

H yp o th e rm ia -

Scenario - 5 8 y r old lady w ith HTN, Asthm a a w a itin g laparotom y.

1 hr. T e m p e ra tu re ch a rt - last reading 34 C.

 i. W hat is the c o n d itio n - H yp oth erm ia

ii. Define h y p o th e rm ia - Tem p <36 deg C.

a. (A n sw e r is n o t b e lo w 35 deg cel.. W ik i is w ro n g this tim e )

iii. H ow w o u ld you m easure core body te m p e ra tu re - Esophagus, Tym panic

m em brane, U rin a ry bladder, Rectal and LiDCO & PICCO catheters.

iv. Risk factors in th is patient? Old age, laparotom y, th e a tre tem p, no preop
w arm ing.

v. C om plications o f h y p o th e rm ia - I said MI, healing problem , coagulation

problem s b u t exam in er w a n te d an sw e r prolonged recovery time.

vi. W hat w o u ld you do in the w ard.

vii. W hom do you in fo rm

v iii. Do yo u th in k there is need to postpone the surgery?

ix. H ow to p re ve n t h y p o th e rm ia - pre-op, in tra -o p and p o st-op.

Station 7

Scenario o f a RTA w ith p t having P olytraum a. BP 1 0 0 /6 0 , HR 134, R ight chest a ir

e n try dim inish ed. Rigid abdom en.

i. Discuss m anagem ent. (ATLS p rin cip le s)

ii. Say ABC in d iv id u a lly w ith w h a t all thing s done in each. I had fo rg o tte n
in itia lly to say th a t I'd s ta rt the p a tie n t on O 2 and w e n t on a bo ut the types
o f a irw ays in c lu d in g O ropharyngeal a irw ay, ET etc. was then re m in d e d by
the exam iner.

iii. Define shock. W hat shock this p a tie n t is in.

iv. W hat IV flu id s

v. W hat Xrays

vi. W hen to do Xray

vii. Was then show n a p ictu re o f a chest Xray sh o w in g pneum othorax.

 Id e n tify co nd ition .

v iii. W hat is tre a tm e n t o f pneum othorax.

ix. W hat o th e r in ve stig a tio n - FAST fo r blood in abdomen.

x. Was then show n a CT scan sho w in g L iv e r Laceration and asked to

diagnose the co n d itio n . ( In T raum a se ttin g i f CT abdom en is show n lo o k
fo r L iv e r la cera tion and th a t w ill m o stly be the answ er in y o u r OSCE)

xi. T re a tm e n t o f L iv e r la cera tion - Em ergency Lap aroto m y and packing w ith

a re lo o k su rg e ry a fte r 24 hrs o r w h en the p a tie n t is stable and p e rfo rm
m ore d e fin itiv e surgery.

xii. Should th is p a tie n t have been taken fo r a CT scan - No, as p t was not
hem od ynam ically stable.

Station 8

Scenario - 34 weeks pre g n a n t lady undergoin g open cholecystectom y fo r

n e c ro tic /in fe c te d ch o lecystitis in Reverse T re n d e le n b u rg p o sitio n . In tra -o p
tachycardia and hypotension, (scenario changed fro m p re v year papers w h e re pt
was undergoin g laparoscopic cholecystectom y)

a. W ho all w ill you in vo lve in the tre a tm e n t o f th is p a tie n t - gynaecologist,

neo natolo gist and ane sth e tist/IC U physician ( exam in er said "and you as a
surgeon w ill n o t be in v o lv e d !" and sm iled)

b. W h a t is Preload

c. Factors go ve rn in g the preload

d. W hy BP d ro p in th is patient? Surgical Blood loss. Venous po o lin g d / t position,

Reduced VR d / t Pressure on the IVC by the G ravid uterus.

e. Do you th in k th is su rg e ry is necessary? Give factors fo r and against.

f. W h a t w o u ld do yo u to im p ro ve p t cond ition ?

g. H ow the venous re tu rn d iffe rs in standing vs Supine

h. H ow to p re ve n t DVT

i. W hat is the m echanism o f action o f DVT stockings - im proves VR, decreases

the cross section o f lim b and th e re fo re dec a m o u n t o f blood stasis.

History Taking

Station 9

BPH

65 ye a r old m ale g iv in g typ ica l h is to ry o f BPH w ith a ll sym ptom s.

Also had a h is to ry o f nasal drop use in the past 2 weeks, (you have to ask fo r this
specific h is to ry )

- Sum m arize fin d in g s (p ra ctice su m m a rizin g fo r a ll h is to ry cases- v e ry

im p o rta n t)
- Investigations
- M edical tre a tm e n t (had fo rg o tte n this in itia lly . Said it a fte r surgical
m anagem ent w hen the exa m in e r asked me i f I w o u ld d ire c tly operate upon the
p a tie n t)
- Surgical tre a tm e n t
- Significance o f the nasal drops?

Station IQ

Scenario - 3 0 y r old la d y a w a itin g cholecystectom y. A nd yo u are seeing her in the

pre-assessm ent clinic. P atient com plains o f chest pain. Take h e r history.

H is to ry given by p a tie n t - lO y r h is to ry o f dyspnea. Aggravated fo r last 6 weeks..

Non sm oker. No e xe rtio n a l dyspnea. No O rthopnea. Has visite d GP CXR and ECG
are norm al.. Takes pain k ille rs o f abd om inal pain. H is to ry o f death o f husband 10
years back. P atient has been ra isin g h e r 2 c h ild re n by herself. But on asking if
there has been any fin a n cia l d iffic u lty she denied it.

i. Sum m arize the h is to ry

ii. DDs - m ost lik e ly A n x ie ty d iso rd e r

iii. W hat investigations?

 iv. H ow w ill yo u tre a t - re fe r to social nurse. Psychologist counseling and
psych i f needed.

v. Should the p a tie n t be operated in such a cond ition ?

- No, o n ly a fte r coun selling and Psych assessment i f she is deemed f it then
she should be operated upon.

Communication Skills (B oth Repeat questions)

Station 11

ICU re fe rra l

Repeat question about ICU re fe rra l fo r Old lady w ith acute abdom en.
Speak to ICU re g is tra r reque sting fo r postop ICU bed and adv about im m ediate
management.

- T e ll about c o n d itio n and h is to ry o f patient.

- Present in v findings
- Was asked a bo ut ECG fin d in g s b u t I could n o t see any ECG o r ECG re p o rt.
So I said th a t the p a tie n t could have changes becoz o f the hypokalem ic
picture. E xam iner asked me i f an ECG has been done - said w e w ill get it
done and I w ill in fo rm ASAP.
- H ow w ill yo u s h ift p a tie n t
- Could you s h ift the p a tie n t to a n o th e r ho sp ita l and w o u ld you do this p re ­
op o r post-op.
- E xam iner said th a t a p a tie n t w ith acute asthm a is going to come and there
is o n ly one bed - give a plan th a t the asthm atic can be sta b ilize d firs t and
t ill then w e w ill observe o u r p a tie n t in the postop recovery room .

Station 12

Child w ith splenic in ju ry . T a lk to M o th e r and counsel her.

Repeat question.
A ll usual questions by M o th e r as in p re v papers.
A d d itio n a lly she asked w h e th e r the su rg e ry was being done by a co n su ltant o r
ju n io r. I d id n 't rem e m be r this being m ention ed anyw here.
Pis check th is d u rin g the prep sta tio n i f th is scenario gets repeated in y o u r exam.

Clinical examination

Station 13

Hydrocoele

Old P a tient w ith large B ila te ra l hydrocele.

Exam ine this patie nts scrotum .
P atient did n o t understand English.
TIP - Finish o ff w ith y o u r e xam in ation q u ic k ly and m ove o n to the questions.

a. Present y o u r findings. It was a large tense hydrocele. No penis visible.

b. W h a t are y o u r DDs - Hydrocoele, Hematocoele, E p ididym al Cyst, Varicocoele,

Tum or

c. W h a t im aging. - USG

d. W h a t do u expect to fin d in USG

e. W h a t else?

f. H ow do you manage? C onservative/surgical.

Expected to k n o w the steps o f Lord's and Jaboulay's procedure.

Station 14

Cranial N erves exam ination with Mental testing

lO y r d u ra tio n o f Anosm ia. Im p a ire d visio n fo r 6 m onths. Do the releva nt

exam ination.
 a. I did the cranial nerve exam ination. (Snellen's ch a rt - p ro vid e d b u t
exa m in e r stopped me and to ld th a t the visio n was 6 /1 8 ). CN 1 and 2 affected
rest o f the cra n ia l nerve e xam in ation norm al.
Then p e rfo rm e d ten p o in t A M T (A b b reviated M ental Test) - P atient
scored p re tty poorly.

b. Present the findings

c. DDs? F rontal lobe o r a n te rio r cra n ia l fossa lesion eg M eningiom a, A strocyto m a

etc

d. W h a t Im aging

e. W h a t surgical approaches

f. New que stion asked here was W h a t te st can you ask the p a tie n t to p e rfo rm on
a piece o f paper
Ans - D ra w shapes on the paper, 3 step com m and to fo ld the paper.

Station 15

Peripheral v ascu lar d isease

Old guy w ith gangrenous changes in rig h t fo o t in v o lv in g distal parts o f fo o t

in clu d in g 3rd and 5 th toes and fo u rth toe p re v io u s ly am putated.
Fem oral b ru it presen t on rig h t side and A n t T ib ia l, D orsalis and P o ste rio r T ib ia l
pulses n o t palpable. Again a non-E nglish speaking patient.

i. Sum m arize findings

ii. Investigations
iii. M anagem ent optio ns

P a rtic u la r questions asked w e re a bo ut Buerger's te st and Risk factors fo r

PVD.

Station 16

Case - Day 1 Postop colectom y patient h as b reath lessn ess. Evaluate.

P erform ed R e sp ira to ry system E xam ination (P atien t was an SP) and also
checked fo r c a lf tenderness.
Patient had tenderness in le ft c a lf and chest pain d u rin g deep breathing.
No o th e r findings

Sum m arized the fin d in g s and offered a diagnosis o f DVT w ith P ulm onary
em bolism .
A ch a rt was also show n w h ic h show ed d e clin in g oxygen sa tu ra tio n and fever.

i. Was asked a bo ut DD's o th e r tan PE. Pneum onia, Pleural effusion.

ii. E xam iner also w a nte d S ubphrenic abscess fo llo w in g ana stom otic leak as
a DD as he asked me w h a t could have happened in the abdom en.
iii. W ho w ill you in fo rm ? Senior
iv. Investigatio ns- CTPA, VQ scanning, Blood and CXR
v. H ow w ill you Manage. ABCDE+ Specific t / t fo r Pulm Em bolism .

Clinical Skills ( both Repeat)

Station 17

In cision and Drainage o f Absces

Patient w ith Foam attached to thigh

Check Consent
Give Lignocaine
Test fo r Effect o f LA
Incise
W ash and dressing

S im ila r questions as before

W hy do you incise in th a t d irectio n?

W hat are Langer's lines? They are topological lin es d ra w n on a m ap o f the
hum an body. They corre spond to the n a tu ra l o rie n ta tio n o f collagen fibers in the
derm is, and are generally p a ra lle l to the o rie n ta tio n o f th e u n d e rly in g muscle
fibers.
M ost Com m on O rganism in abscess - Staph
W hat w ill you use fo r dressing - K a ltosta t o r Aquacel AG (b u t the exam iner
d id n 't respond m uch to th is answ er)
Station 18

Excision o f Naevus and su tu rin g

Pt w ith foam attached having a black m a rk e r pen d o t fo r naevus

Senior has alrea dy given Local Anesthesia b u t had to go fo r som e urg e n t w o rk.
You have to do the excision and su tu rin g . The exa m in e r acts as y o u r nurse.
Check consent
Explain procedure
Select in s tru m e n ts you w ill need to p e rfo rm proced ure and take them o n to y o u r
s te rile tray.
Test fo r effect o f LA
Incise
Then s u tu re w ith c o rre ct technique
The exam in er keeps a close w a tch on h o w you do the excision and s u tu rin g
A n sw e r the p a tie n ts concerns -
W ill th ere be a scar?
- H ow long w ill the pathology re p o rt take
- W hen do I need to fo llo w - up fo r Suture rem oval
- W ill it pain
- Is it cancer

Just keep ta lk in g to the p a tie n t w h ile doing the proced ure so th a t you
fin ish o ff w ith the questions a t the same tim e.
(I managed to fin ish s u tu rin g ju s t a few seconds before the bell).
DAY ONE OF THE EXAM

1. EXTRADURAL HAEMATOMA
2. CLINICAL SKILLS AIRWAY RESUSCITATION IN A MANNENQUIN
3. ANATOMY PAROTID GLAND
4. TELEPHONE CONVERSATION WITH TRAUMA SURGEON
5. ANATOMY : MEDIASTINUM, HEART, ABDOMEN
6. HISTROY : POST OP PATIENT WITH CHEST PAIN
7. A N A T O M Y : VERTEBRA AND SPINAL CORD
8. CRITICAL CARE : SHOCK
9. PATHOLOGY: TUBERCULOSIS
10. PATHOLOGY : PEPTIC ULCER
11. HISTORY : KNEE PAIN SECONDARY OA
12. CLINICAL EXAM : CVS VALVALULAR HEART DISEASE
13. CRITICAL CARE : DIVERTICULAR ABSCESS WITH ENDOMETROSIS
14. CLINICAL EXAM : ANKLE INJURY
15. COMMUNICATION : PRE OP PATIENT HAS CONCERNS
16. CLINICAL EXAM THYROID SWELLING
17. CLINICAL EXAM : INGUINAL HERNIA
18.OT LIST ORDER

I EXTRADURAL HAEMATOMA

Stem : A cyclist has been h it by a vehicle and a fte r a b rie f spell o f

unconsciousness he is b ro u g h t to hospital. Shown CT scan o f th e brain
asked to te ll th e find ings. Convex shaped hyper dense shadow in le ft
pa rieta l region. M in im a l s h ift o f th e m id lin e seen. Asked ab o u t
m anagem ent o f this p a tie n t. W h a t is norm al ICP, h o w do you m easure ICP.
W h a t is peculiar a b o u t th e increased in tra ce re b ra l pressure. W hy is the
pupil dila te d . W hen w o u ld you decide to do endo tracheal in tu b a tio n fo r
th e p a tie n t. If this p a tie n t is in tu b a te d h o w can you reduce th e ICP. W here
w o u ld you site th e b u rr hole.

II AIRWAY RESUSCITATION IN A MANNENQUIN

Stem: P atient has m e t w ith tra u m a , and is n o t b reath ing, h e a rt is beating,

h o w w o u ld you proceed.

Asked fo r Gloves, n o t available, given hand wash instead. A pproached the

p a tie n t checked fo r breathing, e x a m in e r: No breath e ffo rt, go ahead. I o u t
fin g e r in th e m o u th to check fo r blood, loose te e th , # M a ndib le . Exam iner
says no o b s tru c tio n , go ahead. Asked fo r suction to lo o k fo r secretions in
laryngo pharynx. E x a m in e r: No secretions. Looked fo r bruising and sw elling
in th e neck. Exam iner says th e re is suspicion o f neck tra u m a . Asked fo r
Collar, m easured th e size fro m m andib le to clavicle, asked fo r assisatant to
s u p p o rt th e neck, co lla r applied. Chin Lift d e m o n stra te d . Exam iner says
p a tie n t is breath ing now . I asked fo r IV line. Suddenly P atient has stopped
breathing, w h a t w ill you do. I p u t face mask w ith oxygen. Pt is still no t
breathing. Checked heart, still beating. Asked fo r A m bu bag. Examiner
w a n te d to see how I use th e am bu bag. (Please see th e vide o on You tu b e
U S M LE ).

III PAROTID ANATOMY A cto r

Asked to show he surface a n ato m y o f P arotid on th e a cto r

W here th e d u ct lies, w h e re it opens

W h a t are th e sts passing th ro u g h th e p a ro tid fro m lateral to m edial

P rosection o f dissection in th e face. Show th e branches o f th e facial nerve

W h a t gives pa rasym path etic supply to pa ro tid .

N am e th e cranial nerves w h y carry pa rasym path etic fibres 3, 7, 9 ,1 0

W h a t is Freys syndrom e, w h a t is th e cause.

IV Telephone C onversation w ith Traum a C onsultant

Given 9 m ins to read sheaf o f papers w ith notes and investigations

A m edical stu d e n t was h it and run by a vehicle. A w itness fo u n d him in an

unconscious state and called th e am bulance. He was awake w hen
am bulance arrived. GCS 15, no m e n tio n o f neck in ju ry o r cervical spine
xrays. The re p o rts given show ed Right hand # MP jo in ts , Left hand
sw elling, # Tibia and fib u la le ft leg. U /s abdom en flu id around th e le ft para
colic g u tte r. Bloods Hb 11 gms, Am ylase increased. A fte r a fe w hours nurse
in fo rm s th a t th e le ft leg feels cold, and p a tie n t com plains o f severe pain in
th e leg. Clinical notes le ft lo w e r lim b pulses absent: DP PT and p o p lite a l.
O th e r lim b norm al pulses.

Exam iner asked various details ra n d o m ly fro m firs t to last page o f th e case
sheet. So w rite d o w n all th e findings. SBAR re p o rtin g . Asked m y
assessment. W h a t investigations are n o w re quire d. W hats th e cervical spine
Xray fin d in g .W h y n o t done. W h a t is th e GS planning now . I said close
ob serva tion and re vie w o f ab dom inal findings. He asked do you w a n t a CT
abdom en, to w hich I said w e need to look fo r a b dom inal injuries, esp
pancreas..G ood sta tio n w e n t o ff very w ell.

V ANATOMY M EDIATINUM , HEART, ABDOMEN PROSECTIONS

Id e n tify various sts in m e diastin um , a n a to m y o f azygos veins, sym p athe tic

tru n k in d e tail - preganglionic fibres, post ganglionic, cardiac
fib re s,e tc.a n a to m y o f esophagus.

Cut section o f h e a rt show ing th e rig h t ve n tric le . Id e n tify th e valve, cho rda te
ten d in e a , w h a t is this pa pillary m uscle,etc.

A bdom en id e n tify and nam e parts o f duode num . Relations o f the

du ode num various parts. Describe th e course o f th e spleenic artey. W h a t
are its branches. D uring sple ene ctom y one st w hich needs to be pro te cte d .
Surface a n a to m y o f spleen, Gall bladder. Good exa m ine r guides you to the
answ er.
VI HISTORY STATION PULMONARY EMBLOISM

Post surgery Hip replacem ent, day 5 p a tie n t de veloped le ft sided chest pain
and breathlessness, cough w ith blood ting ed sputum .

Pt was coughing on & o ff asked w h e th e r she was c o m fo rta b le and w illin g to

discuss a b o u t her co n d itio n . Pain Socrates, cough & breathlessness try to
kno w h o w bad is th e in d isp o sitio n . Past h isto ry o f varicose vein surgery. No
H /o takin g any m e dicatio n such as con trace ptive s, Pt was n o t previously
ta kin g anticoagulants. Taken personal and fa m ily histo ry. Presented th e
case. Discussed th e m anagem ent, investigations, and plan.

VII ANATOMY SPINE

Given th o ra cic ve rte b ra , asked to nam e th e parts. Nam e and show th e

a tta ch m e n ts o f all th e ligam ents o f th e spine. W hich nerve passes betw een
th e in te rv e rte b ra l fo ra m e n o f L4 /L5. W h a t is presen t in th e sub arachnoid
space b e tw een L2 to S2. New born spinal chord level, a d u lt w h a t level does
spinal chord end. W here do you do LP, w h a t is th e id e n tify in g surface
a n a to m y — in te rcrista l line. D erm ato m e o f L5 supplies w hich p a rt show me
on y o u r body- dorsum o f th e fo o t.

VIII SHOCK

D e fin itio n

Post Op charts w e re given. Took me som e tim e to understand th e fo rm a t.

P atient has reduced u rin e o u tp u t, w h a t are th e steps you w o u ld take. W h a t
is th e fo rm u la fo r flu id challenge ( Paul M a rik : 250-500 ml given in 15-20
m ins should produce a rise in CVP Of 2-4 cms o f w a te r).

Scenario: p a tie n t o p era ted under spinal anesthesia, clam p had slipped
d u rin g surgery.P a tien t is n o w in shock. H ow w o u ld you establish th e cause.
Was asked to read th e charts and show n a p a rtic u la r tim e pe riod w he n the
BP was lo w , U rine o u tp u t was low . W h a t should have been do ne in those 3
hours.
STATION IX Pathology TB

Young P atient had been to Bangladesh 5 m o nths ago, comes to th e clinic

w ith cervical Lymph node. H ow w o u ld you investigate . W h a t's the
d iffe re n tia l diagnosis. W h a t are th e c o n firm a to ry tests. W h a t w o u ld you do
fo r th e contacts. W h a t w o u ld you do fo r th e c o m m u n ity . W h a t are gia nt
cells, W h a t is caseation. W h a t is IGRA. W h a t staining is used fo r TB (Ziehl -
Neelsen). Do you kno w any o th e r m yco bacte rium . Name 4 co n d itio n s assoc
w ith granulom a fo rm a tio n .

STATION X PEPTIC ULCER

D e fin itio n o f ulcer, W h a t causes Peptic u lce ra tio n to o c c u r :

patho physiolo gy. Im balance b e tw een defensive and causative factors..
N am e th e defensive factors. Phases o f G astric secretion. In h ib ito rs o f
G astric secretion. M echanism o f actio n o f PPIs.

Scenario o f m idd le aged lady on NSAIDs C/o Pain abdom en and signs o f
p e rito n ism . H ow w o u ld you proceed. W h a t is th e likely diagnosis, DD. How
w ill you co n firm th e diagnosis.. If it is p e rfo ra te d p e p tic ulcer h o w w ill you
m anage. W h a t class o f urgency & tim in g o f surgery as pe r NCEPOD. W h a t
w o u ld happen if surgery is delayed. W h a t surgery w o u ld you do. Is th e re a
d iffe re n ce in m anagem ent o f G astric Vs Duodenal Ulcer. W h a t is the
fu n c tio n o f HCI.

STATION XI H istory OA Knee

F orm er Prof fo o tb a ll player, n o w a coach C /o Right knee pain since 4 weeks.

Pain Increases w ith a ctivity, does n o t le t him sleep, relieved w ith pain
killers. If you go in to th e past histo ry, he w o u ld re lu c ta n tly te ll a b o u t a knee
in ju ry several years ago, w hich needed som e kind o f surgery. No fa m ily
h isto ry o f a rth ritis . Non sm oker, occ A lcohol, no re crea tiona l drugs. This
p ro b le m has an im p a ct on his w o rk . D uring th e discussion he started
w in cin g w ith pain and ru bbin g his knee - you should catch these signals and
e m path ise w ith him ( ge t 2 marks).

STATION XII Clinical exam CVS

Pre op exam o f CVS fo r non Cardiac surgery. Go th ro u g h all th e steps. The

exa m ine r kept d istra ctin g me th a t finish fast, th e re are m any questions. But
I w e n t th ro u g h a system atic CVS exam. There was a m u rm u r in th e a o rtic
area w ith co n ductio n to th e carotids. A usculta te w ith th e p a tie n t s ittin g up
and bending fo rw a rd and co n ce n tra te d u rin g e x p ira tio n . Keep a fin g e r on
th e carotids. Had tim e fo r a fe w questions. Investigations, discussion on
echo re p o rt, g ra d ie n t across th e valve, eje ction fra c tio n if it is 50 w h a t does
it signify. Bell rang.

STATION XIII C ritical Care D ivericular Abscess w ith E ndom etriosis — P atient
u n d e rw e n t H artm an's Procedure.

D ef o f D iverticulosis, D ive rticu litis.

H ow to manage D ive ticu litis w ith abscess. H ow do you grade th e severity.

H ow did th e e n d o m e triu m com e th e re . ( C oelom ic m etaplasia th e o ry )

P atient de veloped breathlessness, fever, tachycardia - w h a t are th e likely

causes. W h a t is SIRS, Septicem ia, ARDS. H ow do you m anage acidosis.

STATION XIV CLINICAL Exam A nkle Injury

SP a c to r very w e ll tra in e d . S urprisingly as a Gen surgeon I did ve ry w ell.

Did p ro p e r A nkle exam . Standing, gait, exam ine th e sole, check fo o tw e a r.

Go th ro u g h th e fu ll exam step w ise. D ont fo rg e t to do S im m onds te s t fo r

A chilles te n d o n ru p tu re . Diagnosis Lateral lig a m e n t in ju ry o f Ankle.

Grades o f Potts Fracture, etc.. W e n t o f ve ry w ell.

S tation XV C om m unica tion : Pre - op p a tie n t has concern a b o u t stopping
w a rfa rin b e fo re Inguinal hernia surgery. Given 9 mins to stud y th e case
papers o f th e p a tie n t, th e n cam e to face him .

Case details : R ecurrent Inguinal hernia, ve ry sym p to m a tic. Past H /o MVR

done 3 years ago, has been asked n o t to stop W a rfa rin .

Discussed th e standard procedure done in o u r surgery u n it. Stop w a rfa rin 5

days before, b u t he shall be p ro te c te d by da ily e va luatio n o f PT/ PTT. W e
shall s ta rt Clexane in j daily. He said he lives alone and can not manage.
O ffe red to ta lk to nearby health fa c ility , o r ge t a d m itte d . Had w o rry w h a t if
m y PT is n o t c o n tro lle d , w h a t happens to me. I said w e can s ta rt a Heparin
d rip , w hich is sh o rt acting and w e can c o n tro l th e dose to be given and he
w o u ld be safe. This is regular procedure and o u r tea m is geared up to m eet
any e ve n tu a lity.T h e re is no need to fe a r as w e have all checks and balances
in p la ce .A fte r th a t th e in te rv ie w w e n t o ff very sm o o th ly and he seem ed to
be satisfied. Good sta tio n .

STATION X V I - CLINICAL EXAM THYROID SWELLING

STEM : Examine this lady w h o has a sw elling in fro n t o f th e neck

W ash hands, in tro d u ce m yself, Id e n tify p a tie n t nam e date o f b irth , explain
th e procedure, g e t verbal consent.

Did fu ll th y ro id exam. Hands, Eye signs,pulse,etc

Inspection o f th e sw elling fro m fro n t and side. There was a scar be lo w the
th y ro id suggestive o f previous surgery on th e th y ro id . Look fo r m o ve m e n t
on d e g lu titio n , p ro tru d in g th e ton gu e.

P alpation o f th e sw elling fro m behind. All fea tures o f a sw elling. Feel fo r

m o ve m e n t o f th e sw elling on d e g lu titio n .

Look fo r signs o f hyer / Hypo th y ro id is m . Look a t th e legs fo r p re -tib ia l

sw elling.
Peresented th e case. Diagnosis: R ecurrent M u lti n o d u la r T hyroid G oitre,
p ro b a b ly e u th yro id status. Q uestions asked: W h a t inve stigatio ns w o u ld you
do. W h a t is th e significance if th e re is change o f voice. W h a t surgery w o u ld
you do. C om plications o f surgery. Bell rang.

STATION XVII CLINICAL EXAM : INGUINAL HERNIA

W ash hands, to o k a pair o f gloves. In tro d u ce self, id e n tify p a tie n t name

da te o f b irth . Explain th e procedure in d e ta il. O btain c o n firm a tio n o f
understanding. G et consent.

C om plete Hernia exam w ith p a tie n t lying d o w n and in th e standing position.

M ake sure p a tie n t is n o t in pain. There was a sw elling in Inguino scrotal
region extending up to th e u p p e r pole o f th e testis. On close inspection o f
th e o th e r side inguinal region th e re was a scar o f previous surgery on the
o th e r side. Back to th e hernia, w ith gentle m a n ip u la tio n I could reduce th e
sw elling co m p le te ly. Did 3 fin g e r te st. The fin g e r o ve r th e deep ring
preven ted th e sw elling fro m reappearing on coughing Hence In d ire ct
hernia. Presented th e case Discussion: W h a t investigations. W h a t o th e r
systems to exam ine - R espiratory, A bdom en, U rinary. EXAMINER says
p a tie n t has BPH. W h a t w o u ld you do. I said firs t tr y m edical m a nagem ent o f
BPH , if th e re is response do surgery fo r hernia. W h a t surgery - 1said open
Lichenstiens repair. A void Laproscopic re p a ir in v ie w o f th e BPH as th e
dissection in th e cave o f retzius could lead to a lte red a n ato m y and
dysuria.H e seemed to be happy.

STATION XVIII OT LIST

1. S trangulated Inguinal Hernia in P atient w ith pace m aker

2. Below knee a m p u ta tio n in m idd le aged lady w ith Diabetes
3. M a jo r surgery in e ld e rly man w ith previous H /o MVR and is MSRA
positive.

Thanks to this site, I did w e ll and glad to share th a t I have passed th e exam.

You are doing a yeom an's service. H at's o ff to you and y o u r team .
A nonym ous
+FBT = finished before tim e (i.e. all questions attem pted)
J Bell = There m ay have been questions th a t w ere not asked

Clinical Knowledge

1. A natom y: neck
• Arch o f aorta - identify, branches
• Left vagus, Left recurrent, muscle it supplies
• Type o f fibres in vagus in the thorax - parasym pathetic
• Thyroid - parts, Blood supply, venous drainage, nerves at risk, developm ent
• Thyroglossal cyst etiology
• Physiological problem w ith to ta l thyroidectom y - th y ro id horm one replacem ent and
calcium replacem ent
• Parathyroid - num ber, location, horm one produced, function
• Reason fo r hoarseness in bronchial mass
• Brachial plexus - id e n tify upper trunk, ro o t values, Erb's palsy, Klumpke's palsy
• Ulnar nerve sensory te rrito ry
(FBT+)

2. A natom y: posterior thigh

• Sciatic nerve - identify, bony landmarks, Anatom ical variation o f its emergence, root
values
• Gluteus m edius - identify, nerve supply, function
• Trendelenburg te st - describe, causes o f positive test
• Hamstrings -id e n tify (exam iner kept confusing ST fo r short head o f biceps
fe m o ris? ?!!), origin, fun ction at hip and knee, individual fu n ctio n o f SM/ST and BF
• Popliteal fossa - contents, structures at risk in # fem ur
• Popliteal nodes drainage
• Name 1 swelling arising fro m each structure in th e popliteal fossa
(FBT)

3. A natom y: Base of skull (cadaveric section, axial view)

• Ide ntify te n to riu m Cerebelli, attachm ent
• Ide ntify optic nerve, ophthalm ic artery, pitu ita ry stalk
• How does optic nerve exit
• O culom otor nerve - Identify, where does it arise fro m - m idbrain, exits fro m , ocular
muscle supply, findings in th ird nerve palsy, w hat is 'false localizing sign', w hy pupil
dilates, w hy ptosis
• A rte ry th a t form s im pression on inner table o f skull - M iddle meningeal artery
• Name o f a high-grade gliom a
• Layers inside skull, w here is CSF found
• Lesion posterior to central sulcus, which bone to d rill - parietal
(FBT)

Pathology: Obstructive jaundice

• Patient chart shown - w ha t type o f jaundice (obstructive)
• Forms o f b ilirubin in blood - unconjugated and conjugated
• W hy urine shows no urobilinogen - bilirubin cannot reach gut to fo rm urobilinogen
• Bilirubin processing in gut - details
• How is urobilinogen absorbed and excreted - details
• Bile salts - fun ction , enterohepatic circulation im portance, fro m where bile salts are
absorbed - term inal ileum , w hat happens if there is deficiency - fa t m alabsorption
(steatorrhea), ADEK deficiency
• W hat are th e fat-soluble vitam ins
• W hy coagulation is deranged here - Vit. K def
• How does Vit. K d e f cause coagulopathy, how to assess - PT. Measures w hat -
extrinsic pathway
• how to t r e a t - vit. K and FFP
• If p atie nt has fever and pain - reason - cholangitis
• W hat ABX
• USG findings o f biliary obstruction
• USG shows dilated biliary radicles. Then - confirm w ith MRCP f/b ERCP
• W hy ERCP- pa pilloto m y and Dorm ia basket stone extraction
• Before th a t - stenting to relieve obstruction
(FBT)

Pathology: Parotid tumor

• Name com m onest parotid tu m o r
• w hy is it called pleom orphic - variable com ponents fro m epithelial, strom a, fibrous
tissue o f gland
• Investigations in OPD - USG + FNAC
• W hat are FNAC f/ o m alignancy - increase nucleus: cytoplasm ratio,
hyperchrom atism , increased mitosis, aneuploidy
• Difference betw een FNAC and core biopsy
• FNAC shows epitheloid cells w ith brow n cytoplasm - M alignant melanoma
 • FNAC shows lym phoid cells w ith pleom orphism - Lymphoma
• W hich stain to use to d iffe re n tia te b /w pleom orphic carcinoma and lym phom a -
Im m unohistochem istry
• f/ o m alignant change in Pleom orphic adenoma
• d /d b /w sensitivity and specificity
• during FNAC assistant has needle prick injury - w hat to do
(FBT)

6. C ritical care: TURP syndrome

• study chart and describe abnorm alities - hyponatrem ia, Low Creatinine
• Causes o f hyponatrem ia - h ig h /n o rm a l/lo w volum e
• W hat is TURP syndrom e
• W hy agitated, confusion
• W hy hypoxia
• W hat diuretics w ill you use -osm otic diuretics, w hy not loop diuretics - can
aggravate
• W here w ill you manage this patient - m inim um in HDU. W hy - intensive m onitoring,
organ support
(FBT)

7. C ritical care: Iatrogenic pneumothorax following CVP line insertion

• CVP line - landm arks fo r insertion
• Recommended technique - US guided
• How to insert
• How to m aintain s te rility before insertion - paint, drape, scrub up, sterile technique
• W hich position to remove CVP line and w hy - head dow n to avoid air embolism
• Im m ediate com plications - pneum othorax, hem atom a, arrhythm ias, valvular injury
• Causes o f late CVP line infection - predisposing factors - DM, septic foci, local
w ounds, (w anted more)
• Showed CXR - in itially w h at to look fo r - name, age, date taken
• How to approach and read CXR
• Findings - pneum othorax. W hat type and w hy - simple, no tracheal deviation
• Types o f pneum othorax
• How to assess breathing
(FBT)

8. C ritical care: Polytrauma with multiple tts

• Stages o f # healing - details
• How is calcium affected - n o t affected
 • Osteoporosis - define, w ha t happens to bone architecture - no change, in DEXA
scan, w ho do we com pare findings to - com pare to sex and age m atched healthy
individual
• W hat happens to bone on im m obilization
• V irchow 's triad define. W hich factors are operating here
• Bone fixed w ith ORIF. Now discharge fro m w ound - w hy, which organism
responsible - s. aureus and s. epidermidis
• W hy to rem ove plate - rem ove septic focus
• W hat is PVC staph - toxin produced by some stains o f staph
• W hat blood product w ill you transfuse, any WBC in PRBC - no
• Cross m atching - w hat is crossmatching, procedure- details
• W hat blood groups are tested
(FBT)

Clinical Skills

9. C om m unication (Phone to co nsultant): acute limb ischaemia fo r transfer to vascular

surgeon
• Lady presented w ith f/o diverticulitis, diarrhoea. Received tre a tm e n t. Since 1 hr,
developed f/o ALI w ith pale, pulseless lim b and acute pain. Hypertensive. Deranged
renal function, m etabolic acidosis, hypokalemia, ECG shows AF
• SBAR fo rm a t - Introduce yourself, patient and reason fo r calling - yes
• Can she move her limbs, opposite leg pulses - d o n 't know, w ill check and inform
• Pulses absent - w hich ones - below fem oral all
• Reason fo r h ypo kale m ia -d ia rrh o e a
• W hat else does she have - M etabolic acidosis w ith partial respiratory com pensation
• W hy m etabolic acidosis - maybe, ischemic colitis and n o t diverticulitis
• Reason fo r ALI - acute em bolism
• ECG findings - AF. W hy - irregular rhythm w ith absence o f P wave
• W hy em bolism in AF - m ural throm bus fo rm a tio n and em bolism
• W hat else can be the cause - Throm bo-em bolism fro m atherosclerotic plaque
• If it was d /t atherosclerosis, w hat w ould have been the clinical picture - h /o
claudication
• Can you tra nsfe r her to m o rro w - no, via b ility at risk
• W hy deranged renal fun ction -
• How w ould you tre a t her - anticoagulants. W hich ones - LMWH o r UFH heparin
(B e ll})
10. C om m unication (p a tie n t): OT cancelled angry patient
• Post trau m atic meniscal in ju ry fo r arthroscopic surgery. OT postponed 1 m onth ago.
Now cancelled as consultant has to go fo r ER surgery. Job as postman affected.
• Introduce, confirm name - yes
• 'IC E '-ye s
• O ffered pain-relief. Says has Gl issues (gas) d /t NSAIDS. O ffer PPI
• O ffered to speak to fa m ily
• O ffered to speak to jo b supervisor regarding delay
• O ffered to place him on p rio rity list
• O ffered to try and fin d replacem ent surgeon/ have consultant slot him in another
hospital
• (Patient rem ained angry till th e end. N ot able to calm him down)
(FBT)

11. Exam ination: Hand - Carpal tunnel syndrome

• Wash hands, Introduce, take permission, thank pt - yes
• E xam ine-yes
• Summarize - pain in median nerve te rrito ry , weakness o f opposition, failure to make
a fist, w eak 'OK sign', positive 'pen te st', no sensation at index fin gertip, fine m o to r
weak, Phalen's/Tinel's/D urkan's - all positive
• Causes o f CTS in this patient - pregnancy, hypothyroidism , RA, tu m o r
• Tests to do - X-ray, USG, CT/MRI, EMG and NCV
• T reatm ent - NSAIDS, splint
(Bell)

12. Exam ination: CVS - pacemaker

• Wash hands, Introduce, take permission, thank pt - yes
• CVS e xa m in e - y e s
• Summarize - clubbing, p ittin g edema, R infraclavicular region pacemaker
• W here is pacemaker usually located - infraclavicular region
• P itting edema reason - RHF
• Preop investigations fo r patient - ECG, CXR, 2D Echo
• W hy 2D echo - to assess ve n tricular function
• ECG examine and com m ent - pacemaker spikes
• D iatherm y precautions fo r pacemaker
• Preop m edications - ABX
• W hat e ls e -a n tic o a g u la tio n
• disadv o f pacemaker in elective surgery - arrhythm ias
• Adv - ?
 • Problems in ER surgery
(Bell)

13. Exam ination: Abdomen - acute cholecystitis

• Wash hands, Introduce, take permission, thank pt - yes
• Examine abdom inal system and abdom en - yes
• Summarize positive findings - clubbing, RUQ pain, tenderness w ith +ve M urphy's
• W hat else w ill you examine fo r - groin, ext genitalia, DRE, limbs fo r edema
• D /d - acute chole, hepatitis, PUD, Renal pathology, Pancreatitis
• How to d iffe re n tia te b /w acute chole and pancreatitis - serum amylase and lipase
• W hat investigations
(FBT)

14. Exam ination: Submandibular gland - sialolithiasis

• Wash hands, Introduce, take permission, thank pt - yes
• Simulated p a tie n t w ith no findings - examined
• Summarize - d id n 't know w hat to say. Examiner said a good sum m ary w ill be to say
- it was a norm al exam ination, and smiled
• Summarize w h a t all you looked fo r - yes
• Nerves associated and how to look fo r them
• A natom y o f subm andibular gland
• W here is opening o f W harton's duct
• Based on scenario give diagnosis
• Investigations - blood, US w ith FNAC
• Anything to look fo r in face - Sjogren's. How - xerophthalm ia (Schirmer's test).
Xerostomia
• Specific inv - sialography and X-ray.
• W hat percentage o f stones are radiopaque -?
• How to tre a t
• If stone in distal duct, a fte r rem oval w hat w ill you do - M arsupialization
• W hat is m arsupialization
• How to avoid injury to marginal m andibular nerve - incision 2 cm below m andibular
border
(FBT)

15. Procedure: sutures

• Wash hands, w ear g lo v e s -yes
• Hand tie on string w ith non-absorbable, braided
• Hand tie hook w ith absorbable braided
• Instrum ent 'fig u re o f 8' suture fo r bleeding point w ith nonabsorbable m onofilam ent
 • D iff b /w surgeon's and re e f knot
• W hat o th e r knots can you place -?
• Advantage o f braided suture
• How long Vicryl m aintains tensile strength
• Problem associated w ith tying a t depth - avulsion o f structure
• How to avoid
• Vicryl chemical com position
• Prolene chemical com position
• W hy 'figure o f 8' fo r bleeding point
• Do you underrun o r overrun the bleeding p o in t - underrun
(FBT)

16. Procedure: OT listing

• arrange in o rd e r - (Repeat)
• W hy strangulated hernia first
• W hat type o f anesthesia - Regional
• D iatherm y p atie nt plate electrode and cable photo - id entify
• Precautions fo r pacemaker
• w here to place pad and w hy
• le ft colectom y - w here to site th e stom a, show on patient and give reasons
• w hy through rectus muscle
• Preop m anagem ent o f insulin dependent DM
• W hy MRSA posted last
(FBT)

17. H istory: Diarrhoea fo r last 6-8 months

• Introduce, take permission, thank p t - Yes
• Take h is to r y - Yes
• Summarize - 3-6 tim es/day, blood tinged, no mucous, w t loss present, afebrile, no
fecal urgency, no stress factors
• In history, you asked fo r radiation exposure. M eaning —►CT scan
• d /d - IBD, CRC, infestation (amoebiasis)
• Inv - bloods, colonoscopy
• Anything before colonoscopy - sigmoidoscopy
• How w ill you dx on colonoscopy - colonoscopy w ith biopsy
• Others - stool fo r OCP, CT w ith oral contrast
• HPE f/o Crohn's - transm ural inflam m ation, patchy involvem ent, non-caseating
granulom as
• How w ill you tre a t Crohn's - steroids, sulfa-salazine
(Bell)
18. H istory: Cognitive assessment
• Introduce, take permission, thank p t - yes
• AMTS - 5-6/10
• Can she give inform ed consent - no
• W hat w ill you do - p erform MMSE
• W hat else - if MMSE is deranged postpone Sx
• Thank you, you have finished. Now w a it till the bell. W hat??!!!
• W en t back to rectify m y answer - if MMSE deranged, w ould assess fo r any organic
cause including bloods, CT brain, rule o u t infection, check medications, rule o f
delirium
(FBT)

**B est o f Luck**

A n a to m y

B a y -1 -- p ro s e c te d c a d e v e r ic s p e c im e n s

( 1 ) A b d o m e n : S p le e n , its rela tio n s , b lo o d s u p p ly

S p le n ic a rtery

D u o d e n u m an d its rela tio n s

( 2 ) C h e s t: P u lm o n a ry trunk

A z y g o s / S y m p a th e tic tru nk an d c o n n e c tio n s

H e a r t (o p e n c h a m b e rs ) ch ord ae/ p a p illa r y m u s cle s

C o u r s e , b ra n ch es o f a s c e n d in g aorta

E x a m in o r p o in ts to e a c h structure an d a sk to nam e

B a y -2 — B on es/ p ictu res

( 1 ) T h y r o id g la n d a n a to m y

( 2 ) L a r y n g e a l an atom y/ c a r tila g e s & v o c a l c o rd s

( 3 ) V e rte b ra e ... Id e n t ify parts an d d iffe r e n c e s o f e a c h ty p e

B a y -3 - A r tic u la te d hand and p ro s s e c te d s p e c im e n o f U L

( 1 ) c a rp a l b o n e s , f le x o r retin a c u lu m , c a rp a l tu n nel.. Its s u rfa c e m ark s an d co n te n ts

( 2 ) m e d ia n .N , its c o u r s e an d b ra n ch es

( 3 ) F D P & F D S te n d o n s an d its a c tio n s to d e m o n s tra te o n o w n hand

S u rg ic a l p a th o lo g y

B a y -4 --P ic tu r e o f a B a sa l c e ll C a ll. Id e n tify , D /D an d m a n a g e m e n t

P ic tu r e o f c e lls ( b ilo b e d , la rg e n u c le i) fro m n e c k n o d e ..id e n tify

R ie e d -S te r n b e r g c e lls

W h a t's th e c o n d itio n , o th e r c e ll ty p e s , in v e s tig a tio n s & m a n a g e m e n t

B a y -5 — C lin ic a l s c e n a rio o f S ic k e l c e ll d is e a s e , its s ig n ific a n c e in a s u rg ic a l p atien t

G e n a tic s o f s ic k e l c e ll d is ea se

M e c h a n is m o f s ic k e l c e ll c ris is

* * * * A l l th ose w e r e rep e a te d q u e s tio n s in rec e n t p a s t...!!!!

P h y s io lo g y & c rit ic a l c a re

B a y - 6 — P e r fo r a te d g a stric/ d u o d en a l u lc e r c a s e s c e n a rio

P h y s io lo g y o f g a s tr ic a c id s e c r e tio n an d its r e g u la tio n

H . P y lo r i ..... its d ia g n o s is & e ra d ic a tio n m eth o d s

N S A I D s c a u s in g P U D m ec h a n is m

B a y -7 -- H y p o th y r o id is m : C a u s e s, risk a s s o c ia te d w ith s u rg ic a l p atien t (p r e op/intra op ./p ost o p ).

M a n a g e m e n t, H o w to im p r o v e c o m p lia n c e

B a y -8 -- X r a y a n d E C G o f a p atient

A i r u n der d ia p h ra g m & A t r ia l fib r illa tio n

C a u s e s f o r e a c h c o n d itio n an d th e r e la tio n s h ip b e tw e e n th e t w o

R a te c a lc u la tio n an d m a n a g e m e n t o f A F

H is t o r y ta k in g

B a y -9. P a tie n t w ith fre s h P R b le e d in g

B a y -1 0 . P a tie n t w ith rec e n t e n la r g e d g o ite r w ith to x ic featu res

C o m m u n ic a tio n s k ills

11. P re p . S tation

B a y -12. Y o u n g b o y w ith m a jo r s p le n ic la c e ra tio n f o llo w in g trau m a o n d a y 2, w a n ts to g o

h o m e a g a in s t m e d ic a l a d v ic e

13. P re p . S tation

B a y -14. In fo r m o n c a ll c o n su lta n t a b ou t lo w U O P o n a p a tie n t a fte r d a y 2 la p a r o to m y

a fte r g o in g th ro u gh c lin ic a l n o te s ...(o v e r th e p h o n e )

P ro c e d u r a l s k ills

B a y -15. E x c is io n o f a n e rv o u s in fo r e arm an d su tu rin g

B a y -16. U r in a r y c a th e te r iz a tio n a fte r A R U in a m a le

C lin ic a l e x a m in a tio n

B a y -17. U p p e r c ra n ia l .N e x a m in a tio n ... D ia g n o s is o f b ite m p o ra l h e m ia n o p ia

B a y -18. G r o in e x a m in a tio n .... In g u in a l h e rn ia

B a y - 19. K J e x a m in a tio n ... O A o f K J / m a n a g e m e n t

B ay- 20. CVS e x a m in a tio n of a young boy w ith M a r fa n o id featu res, m e c h a n ic a l v a lv e

rep la c e m e n t, o n w a r fa r in , e v id e n c e o f s/c b le e d in g

C o n c e r n s o f th is p a tie n t d u rin g a e le c t iv e n o n -c a rd ia c s u rge ry

2 1 , 2 2 - R e s t stations
1-Brain MRI meningioma , sinuses.
2-liver lung heart and diaphragm target questions
3-hands FLexor Renticulum FDP/FSP function movement of thumb
Critical and patholo
1-fluid management and chart
2-AS ,IE and anticoagulant
3-Bum+ARDS and management
4-MEN +historical report show medullary ca and grading
5-EDH
Examination :
1-ankle examination
2-cvs mitral regurgitation
3-submandibular gland
4-lipoma on trunk
H istory:
1-SAH headache
2-thyroid status
Communication:
1-phone call cvs consultant
2-warfarin stop for hernia repair
Procedures:
1-suture skin
2-male catheterization
1) Anatomy - Upper limb brachial plexus exam
• Patient involved in RTA and had injury pulling between head and shoulder
• What kind of palsy is this -erb’s palsy
• What are the nerve roots involved - c5/6
• Point to me on the model which nerve roots are c5/6
• Show me cutaeneous distribution of c5/6 on the SP
• Test power of shoulder abduction for me - what muscle are you testing?
• Test power of elbow flexion for me - what muscle are you testing?
• Test biceps jerk and brachioradialis - what are the nerve roots involved?
• What muscle does the musculocutaneous nerve supply
• What cutaeneous supply does the musculocutaneous nerve supply
• Show me movement of brachioradialis
• What nerve supplies the brachioradialis
• What is the sensory distribution of radial nerve
• What nerve supplies the deltoid
• What is the cutaneous supply of the axillary nerve
• What muscles rotate the scapula?
• Attachments and insertions and innervation of trapezius and serratus anterior
• Show me the coracoid process on the SP
• What muscles are attached to the coracoid proess?

2) Anatomy - Abdomen
• Surface mark the gallbladder on the SP
• Surface mark the L1 transpyloric plane
• Mid-axillary line - costal margin - what rib is here?
• Shown cross section of abdomen (t12 level) - is the orientation top down or bottom up?
• Name the 5 organs you see - spleen, stomach, liver, pancreas, kidney
• What is the blood supply of the spleen
• What vessels go from spleen to supply stomach? - left gastroepiploic and short gastric
arteries
• Show me on cross section where the lesser sac is
• What is this? - falciform ligament
• What are the two spaces on the left and right of this?
• What is this - tranversalis fascia
• What ligament is this - gastrosplenic ligament
• How does the splenic artery get to the spleen? - superior to pancreas and thru lienorenal
ligament

3) Anatomy - Lower limb

• Patient fell from horse and had crush injury to the leg
• Show on sp
• Function of gastroc Soleus
• Function of peroneus brevis and Longus
• Function of ta and tp
• Function of ehl
• Landmark for dp/pt
• Nerve roots for knee and ankle reflexes? Demonstrate reflexes on patient
 • Compartments of the leg and inner action
• If foot drop with good plantar flexion and inversion which nerve root is affected
• Sensory supply of sural nerve deep and superficial perineal nerve and saohenous nerve

4) Pathology - temporal arteritis

• What is the diagnosis - Giant cell arteritis
• What can she not see ? - opthalmic artery involvement
• What are the histological findings on biopsy
• How is this treated? - steroids
• Come back for Nof fracture - why? - steroid induced osteoporosis
• What is osteoporosis
• What are possible causes of easy fractures in an elderly lady besides osteoporosis -
bone mets, renal osteodystrophy, osteomalacia
• What are the perioperative concerns - addisons and need for hydrocortisone

5) Pathology - bicuspid aortic valve with infective endocarditis

• why bicuspid aortic valve would result in stenosis in the Long run
• Needs replacement. Why must anticoagulants after replacement
• What is a common outpatient anticoagulant for such patients?
• Moa of warfarin
• Factors blocked by warfarin
• What pathway is not blocked by warfarin
• Tell me what is in the common pathway of coagulation cascade
• Lady returns post op 1 year with fever and hand weakness / numbness
• What is the dx?
• Why is the left hand numb and weak?
• How does ie occur?
• What is the pathological role of esr and crp? Acute phase response
• How to confirm bacteria involved in ie?
• What requirements for the blood culture? 2 sites 2 different times
• What are common ie bugs? Name 2
• Why if cannot treat with antibx we should replace the valve - source control
• If valve removed grew hyphae what are 2 common fungal organisms

6) PE - Spine
• This patient has claudication. ABPI has been done which is normal. Please examine him
• Spine examination - essentially normal
• Asked what are your investigations
• X-ray, MRI
• What is your management
• Phsyio, injections (asked where and what to inject), surgery (asked what is the
surgery to be done - just wanted decompression)
• Asked what I would do if I thought it was arterial cause - US duplex
• Asked when I would do a Angiogram - said no, it is invasive and I will only do it if I am
performing an intervention
• Asked whether I would cath from same side or opposite side (apparently opposite side is
the right answer)

7) PE Inguinal hernia indirect

• wheeze + indirect hernia
• What are the landmarks for deep inguinal Ring
 • how would you manage this patient
• what kind of anaesthesia
• What kind of hernia repair would you do - 1said !?Lichtenstein/ shouldice? I said I would
use a mesh
• Slight discussion regarding lap vs open
• Examiner told me mesh repair is for direct hernias
• Discussion regarding complications - Aru and need for idc post op

8) PE - Peripheral venous exam

• examine left venous system
• great saphenous torturous veins
• Asked to do sfj torniquet test
• Asked to do Doppler
• Asked about management of the chronic venous disease
• How would you investigate and what are you looking for
• In a younger lady what surgical options are there

9) PE - CVS
• Mitrial regurg with AF and Heart failure
• What else will you examine? Ankles, sacrum, lungs, liver and spleen for signs of HF
• Asked to take blood pressure
• What investigations will you order?
• What are the likely causes of MR?

10) Procedure OT Listing

• Complete repeat - see other accounts

11) Procedure - C collar sizing and opa insertion

• Patient rta. Brought in bp stable but not breathing cyanosis. What. Do you do
• Airway
• Jaw thrust with c spine protection
• Ask nurse to in line
• Place in opa and size
• Asked what are the causes of airway obstruction in a trauma patient
• Patient is now breathing, what do you do? Place NRM
• Asked how many litres of o2 for face mask
• Sats now dropping again. W hat do you do? Assess breathing. Go back to bagging
patient. Get definitive airway
• Asked what to do if patient cannot be tubed - said Lma, but examiner said intubation is
already difficult how will an Lma be better?
• Asked if there are any other options a surgeon can do

12) History Taking OA Knee

• Complete repeat - see other accounts

13) History Taking - IBD

• Complete repeat - see other accounts

14) Comms - rta patient with Cold and pulse less leg. Call trauma con
• Complete repeat - see other accounts
 • Only thing is that consultant was unhappy that i wanted to do CT Brain / CT AP. He said
maybe in Singapore you would because we are rich. In malaysia, there is no good
reason to scan. W e can just CLC and serial abdo exam

15) comms - ot cancellation of ?meniscal op

• Young man with a meniscal tear seen on MRI. Planned for op but has been postponed
once before. Pain has been getting worse and affecting job as a postman. Also putting
on weight.
• Has come for op today but needs to be postponed because consultant is attending to
emergency case
• Speak to patient in consultant’s absence
• Angry that op has to be cancelled. Has had to take time off work, travel in from another
town. Boss unhappy - offered to write memo.
• Questions patient asked:
• Reason why his op is postponed
• Putting on weight because he cant play soccer like he used to, how else can he keep his
weight down?
• Taking brufen for pain but getting gastritis, anything you can do to optimise meds?
• Will there be long term damage to the knee if the op is postponed?
• What if I want to complain?

16) crit care - O&g patient with hypotension

• What is preload
• What in this scenario shows this is a preload problem?
• What are the factors affecting preload? Rate and volume of venous return.
• Who should be involved in the care of this patient? Obstetrician
• Where should this patient be postop? Obstretric HD
• How do you increase preload in a conscious and standing person? Squat.
• What is the mechanism? Reduce pooling of blood in LL
• How would you manage this situation intra op?
• What are the risk benefit of operating on this patient?
• What thromboembolic prophylactic measures have an effect on preload? TEDS / calf
pumps.
• What are their mechanisms of action?

17) crit care - pancreatitis acute

- Given stem with suggestive history and blood results
- comment on the bloods
- what is the dx?
- what scoring systems do you know?
- What is the utility of these scoring systems?
- What are the components?
- Is amylase predictive of severity?
- Under what circumstances might amylase be normal in pancreatitis?
- What other investigations will you do and what are you looking for?
- Where should this patient be admitted to?

18) EDH - critical care

• patient rta admitted to ortho
Gcs drop in the ward. Who would you call for help
Ct scan done - what is it? EDH with subtle midline shift
Why do some head trauma patients have blown pupils
How can you monitor icp? Clinically, ICP monitor, LP
In the ventilated patient, what can you do to lower icp
What is normal icp?
What are the benefits and risks of monitoring ICP? Risks of inserting monitor, risk of
coning with LP
Total 20 statio n

2 rest sta tio n , be fore co m m u n ic a tio n stations

S tation 1 (A natom y)

Prosection o f th o ra x and abdom en

• Id e n tify th e ascending a o rta and arch o f aorta,

• Tell m e th e branches o f th e ascending a o rta - th e rig h t and le ft coronary
arteries
• Id e n tify th e rig h t ve n tricle
• W h a t is this s tru c tu re - tricu sp id valve, pa pillary muscles
• W h a t is this s tru c tu re - cordae ten do nae
• Function o f this str - th e cordae te n d o n a e attach th e valve and p a pillary
muscles th e re b y p re ve n tin g th e prolapse o f th e tricu sp id valve du ring
th e c o n tra ctio n
• Id e n tify th e azygous vein
• W h a t are th e trib u ta rie s o f th e azygous system - th e p o s te rio r
in te rco sta l veins and lu m b a r veins on th e rig h t and on th e le ft,
hem iazygous vein and assessory hem iazygous vein
• Id e n tify th e sym p a th e tic tru n k
• W h a t levels o f spinal cord c o n trib u te to it —T1 to L2
• W h a t com m unicates th e spinal ro ots and post ganglionic fib re s - gray
ram i com m unicantes
• Id e n tify spleen
• Blood supply o f th e spleen
• Tell me th e course o f th e splenic a rte ry
• W h a t stru ctu re s are supplied by th e splenic a rte ry a p a rt fro m th e spleen
• W h a t is th is s tr - d u o d e n u m
• H ow m any parts
• W h a t ducts e n te r in to i t - f r o m w h e re
• Id this s t r - g a ll bla dde r
• Surface a n a to m y o f th e gall bladder
S tation 2 (anatom y)

Prosection o f th e a n te rio r neck

• Show m e w h e re is th e th y ro id gland
• H ow m any lobes
• Blood supply
• W h a t nerves are a t risk d u rin g th e o p e ra tio n
• Show m e re c u rre n t laryngeal nerve
• W h a t is this muscle - su p e rio r belly o f om ohyo id
• N erve supply o f this muscle
• W h y th y ro id moves upw ard w ith sw allow ing
• Infrah yoid strap muscles
• Types o f th y ro id cancers
• If th e re is lym p h a tic spread, w h e re w o u ld it go
• If damage to re c u rre n t laryngeal nerve, w h a t w o u ld happen

S tation 3 (anatom y)

U p p e rlim b (p rose ction o f fo re a rm , hand x ray and bony m odel)

• Id e n tify th e carpal bones in hand X ray

• Significance o f tenderness in th e anato m ical snap box
• W h a t w o u ld u concern w ith th e scaphoid # and w h y
• P rosection - id e n tify th e fle x o r d ig ito ru m superficialis
• Id m edian nerve - sensory d e fic it if damage
• Id u ln ar nerve - sensory d e fic it if dam age
• Show me th e atta ch m e n ts o f th e fle x o r re tin a cu lu m
• W h a t stru cture s passing th r it
• H ow w o u ld u te s t fo r th e actio n o f FDS
• Show me th e actions o f th e th u m b

S tation 4 (surgical pathology)

Surgical pa th o lo g y - BCC

• Show me a ph o to g ra p h and describe th e lesion (I d id n 't do w e ll)

• W h a t w o u ld u th in k -B C C
• Show me th e histo logy re p o rt, m argin in v o lv e m e n t (+)
 • The natural h isto ry o f BCC
• If th e re is a lym p h a tic spread, w h a t steps need to... (I answ ered the
extensive local d e stru ctio n and lym phovascular in v o lv e m e n t and th e n it
may spread to lym phatics,,, he said no, a t th e end o f questions, I trie d to
answ er infection??? He said w h a t else.... T o ta lly no idea)
• U nclear m argins - w h a t w o u ld u do

S tation 5 (procedural skill)

C athete rization

• S urrogate w ith a d u m m y o f penis in b e tw een his legs

• Pt c o m p la in t o f unable to voide fo r a n ig h t w ith ab dom inal pain
• U are n o t allow e d to exam ine his abdom en
• Discussion - if no urine, w h a t are th e possibilities
• H ow w o u ld u do it
• If no urin e a fte r flush ing o f c a th e te r - USG- w h a t gonna fin d
• If no - he w ants m e renal fa ilu re - pre-re na l, renal and post-renal

S tation 6 (surgical pathology)

Scenario - m idd le aged g e n tle man, w ith abdom inal pain and fre e gas under
diaphragm in ab dom inal film , had h isto ry o f ta kin g NSAID

• W h a t do u th in k
• P athophysiology o f p e p tic ulcer disease
• Effect o f NSAID on gastric mucosa
• Phases o f gastric acid secretion
• H ow w o u ld u m anage DU Vs GU
• W h a t m e dicatio n m ig h t p t need fo r long te rm ? - PPI
• M echanism o f actio n o f PPI
• Do u kno w NCEPOD, te ll me
• W h a t o p e ra tio n fo r this p t according to NCEPOD

S tation 7 (surgical pathology)

Scenario - 33 y r old fem ale c o m p la in t o f w e ig h t gain and lathergic, TFT - high

TSH and lo w T3 and T4, CBC given - m a crocytic anaem ia
 • W h a t is y o u r diagnosis
• Tell m e how is th e secretion o f th y ro id h o rm o n e c o n tro lle d .
• If secondary w h a t w o u ld be th e TFT
• S ym ptom s o f h yp o th yro id is m a p a rt fro m these sym ptom s
• Causes o f h yp o th yro id ism in this p t
• H ow do u th in k o f this anaem ia
• W h a t are th e pre, in tra and post o p e ra tive concerns o f h y p o th y ro id is m

S tation 8 (surgical pathology)

P atient w ith chrons disease, pre se n t w ith ab dom inal pain and vo m itin g ,
d e fu n ctio n in g ile o sto m y was done and ile o sto m y reversal was done. This is
post op day 5, no surgery previously, plain X ray abdom en given

• W h a t do u see in this x ray.... D istended loops o f bow els

• D iagnosis- 1 0
• Causes o f this co n d itio n in this pt
• H ow w o u ld u d iffe re n tia te 10 vs ileus
• W h a t m ethods o f n u tritio n - e n tera l and p a ren tera l
• Indications fo r p a ren tera l and enteral
• C om plications o f p a ren tera l and enteral

S tation 9 (surgical patho lo gy)

P atient w ith sickle cell disease, head in ju ry, accidentally fin d SOL in brain

• W h a t is sickle cell disease

• H ow is it in h e rite d
• W h a t is th e surgical concerns o f sickle cell disease
• W hy bone pain
• W hy im m u n o co m p ro m ise d
• W h a t do u th in k o f th is SOL brain
• N atural h isto ry o f brain tu m o u rs
• Biopsy done - squam ous cells (+)
• W h a t do u th in k - secondary m etastasis
• W here m ig h t be th e p rim a ry o f SCC
• The w o u n d becom e in fe cte d and th e analysis o f th e discharge flu id
revealed th e glucose o f ...g/dl (I d o n 't re m e m b e r th e value b u t
s o m e w h a t high) - co n nectio n w ith CSF
S tation 10 (p roce dural skill)

Excision biopsy o f a navus

• Your co n su lta n t is a b o u t to p e rfo rm an excision o f th e abnorm al m ole in

rig h t th ig h o f this p t b u t he le ft due to an em ergency p a tie n t
• U have to explain th e procedure and explain u w ill p e rfo rm instead o f ur
c o n su lta n t
• Check fo r th e consent
• Choose th e in stru m e n ts u need
• U have to explain a b o u t dressing, th e drugs and th e biopsy re p o rt

S tation 11 (rest station)

U have to deal w ith a cha rt fo r th e next sta tio n

S tation 12 (co m m u n ica tio n sta tio n - in fo rm a tio n giving)

• Phone re p o rt to th e oncall co n s u lta n t a b o u t post op p t

• W h o gets oliguria (urine o u tp u t - nil fo r 2 hrs)
• Fluid ch a rt - flu id d e fic it
• Ask w h e rth e r u need to a d m it to HDU o r n o t - I said no and I w ill do a
flu id challenge firs t and in fo rm u w h e th e r th e re is response o r n o t, o n ly
a fte r th a t I w ill consider adm ission to HDU

S tation 13 (in fo rm a tio n gathering)

• M id d le aged lady w ith lum p in neck - long standing a b o u t 10 yrs,

increase in size w ith in 6 m ths
• There is also sym ptom s o f h yp e rth yro id ism

S tation 14 (rest sta tio n )

U have to deal w ith a p t cha rt

S tation 15 (in fo rm a tio n giving)

• Deal w ith an angry p a tie n t w h o request self-discharge a d m itte d last 2

days fo r fall fro m height
• He has a jo b in te rv ie w w hich is ve ry im p o rta n t to him
• And also his w ife was diagnosed w ith CA breast, and have an
a p p o in tm e n t to her d o c to r, he w a n ts to be w ith her d u rin g th e
co n su lta tio n
 • I explained a b o u t th e c u rre n t co n d itio n and consequences o f discharge
fro m th e ho spital and o ffe r o p tio n s to sit in te rv ie w fro m th e ho spital and
he denied
• And th e n I o ffe re d tra n s p o rt to in te rv ie w by o u r tra n s p o rt and m edical
cover - seems to accept it

S tation 16 (in fo rm a tio n gathering)

• M id d le aged p t w ith bleeding d u rin g d e fe ca tio n fo r 6 m ths

• Positive fa m ily fo r CRC
• Diagnosis, d iffe re n tia l, h o w u investigate, pre-o p investigations

S tation 17 (physical exa m ina tion)

• Examine cranial nerves fu n c tio n s fo r this lady w h o presen t w ith

headache and b lu rre d vision
• U d o n 't need to te s t o lfa cto ry , visual acuity, colo r vision, gag re fle x and u
r n o t provided w ith tu n in g forks
• Pt has b ite m p o ra l hem ianopsia
• W h a t is ur findings
• W h a t co n d itio n s can give rise to this clinical pictures
• Some discussion ab o u t th e p itu ita ry tu m o u rs

S tation 18 (physical exa m in a tio n )

• M id d le aged man w ith in d ire c t inguinal hernia

• Diagnosis, do u w a n t to do any inve stigatio n to co n firm ur diagnosis - I
said no, cos th e diagnosis o f hernia is m a in ly clinical
• Pre op inve stigatio ns and issues a b o u t u n d e rlyin g cause - COPD and BPH

S tation 19 (physical exa m in a tio n )

• M id d le aged man w ith hernia - do preop assessment

• Pt w ith s te rn o to m y scar and I th in k 5th to 6th day post op - according to
w o u n d co n d itio n
• No signs o f h e a rt fa ilu re
• O bvious m etal valve sound, no m u rm u r
• The sound is loudest a t apex, and th e re fo re I said m itra l valve
re p lace m en t
• Pt has bruises a t b o th w rists
• Some discussion ab o u t pre op and post op w a rfa rin and heparin
S tation 20 (Physical exa m in a tio n )

• M id d le aged man w ith rig h t knee

• Full e xa m in a tio n o f knee
• Discuss a b o u t OA knee

Good luck to you all...

Examination
Knee- Examine the knees please. Bilateral knee pain.

Pain on both, m ore on R

Inspec- crutches, arthroscopic scar on R side, some hyperthrophic scars on L side

Palpate- tender throughout. M ore lim ited ROM on R side

Special test only up to collateral ligament. Very difficu lt to examine!

Question: D/D, oa,sa, gout, psuedogout,

Xray MRI. Management- TKR, arthroscopic, realignm ent osteotom y, conservative

m anagement too

Pt has latex allergy- how w ould u manage intraop. W hat protocol

Examination
CVS- pacemaker, preop asses fo r lap chole

Inspect- periph edema, large RUQ scar- subcostal and some epigas, elevated JVP, pacemaker
present.

Palpate nad. Auscultate difficu lt to hear heart sounds!!! But no m urm ur

Inves- ECG showed pacing spikes, LAD, asked fo r rate. It was regular. 75bpm.

Asked fo r pacemaker how w ould u manage perioperatively.

Asked if there is what heart failure is assoc w ith periph edema, asked why patient needs
pacemaker

Examination
Neck lump- GP ref w ith neck lump

Patient w ith L side fresh scar on neck, drain from L infrascapular into a pouch in his front,
hemoserous drain

Did the periph signs lid lag blabla and allowed to continue

Occipital node on L side was present, lipoma im m ediately below it, another on R
supraclavicular fossa, and another visible on R arm.

Examine as is a lump. Asked regard d/d, forgot lym phoma! I m entioned USS, CT. forgot FNAC!
D idn't do too well
Examination
Please examine patient w ith ?posterior cranial fossa lesion

Walked in and asked to examine the cerebellar. Great!

DANISH. Broad based, dysdiadocho on R side, hypotonia R side, intention/pas pointing R side.
VF nad

Asked re etiology o f broad based gait- vermis.

Asked re investigations. Asked re types o f tum o ur in this patient.

Asked re imaging. I said CT w contrast and MRI. Heard people asked MRI w ith w hat contrast???
Asked which side of lesion. R side o f course. Asked re: lesions th a t mets to the brain.

Pathology
Showed skin lesion, and com m ent on the appearance.

20mm w ith central necrosis. Looks like SCC, but he told me it's BCC.

Asked me how it spread to lymph (essentially looking for def o f mets), asked why is it redder
on surroundings, I said angiogenesis= hypervascularity

W anted to know trea tm ent methods surgically to ensure excision- frozen section and moh's
surgery= asked me w hat it is.

Asked me now patient post op returned w ith pus discharge.

W hat bacteria most common. S aureus. W hat is MRSA- m ulti drug resistant SA. How to treat-
m upirocin, chloerhexidine wash. Decolonization, groin nasal swab. Happy w ith o u t even
having to m ention IV/systemic abx therapy.

Pathology
Lady w ith UC fo r 30 years. Now w ith tubular adenoma on surveillance scope

Tell me abt UC, w hat is it. W hat histology w hat spread pattern. W hat is IBD. W hat is Crohn's
histological features- looking fo r non caseating granuloma, asked w hat is it, w hat is
granulomatous inflam m ation, asked w hat is the name=looking for Langhan's cell.

Asked w hat treatm ent- panproctocolectom y. Asked Kras, P53, w hat they are. Asked steroid
long term effect on adrenal c o rte x ..

Dukes and TNM staging

Practical
Suture types

Non absorbable, braided on this 2 strings please

Absorbable braided on this deep hook

Non absorbable non braided z suture to stop bleeding, instrum ent tie please

Advantage o f braided, w hat knot types are there

How to stop deep knot slipping.

When does vicryl lose tensile strength

W hat is vicryl

Practical
Catheter- 25 year old man w ith urine retention. Catheter. One assistant available.

Consent and explain. Check expiry date! Check everything! Double glove or change glove

Pull back prepuce. Inserted catheter- no urine. Do not inflate! Do bladder scan. Flush and
aspirate. So bladder scan confirm ed balloon in cath, tell me w hat causes o f renal failure in
this man w ith acute abdominal pain. Pre-renal, abdo traum a. Push back prepuce please

Anatom y
Lumbar vertebra

show me pedicle and lamina.

How are they connected to one another.

Tell me abt the intervertebral disc.

Keeps asking patho phys o f disc prolapse. If L4-L5 vertebra prolapse, which nerve
compressed. Show me interverbra foram en. W hat passes thru it.

W hat is cauda equina. How does it happen.

Show me on the MRI where is the vertebra.W hat is the space where we go for LP. ?landmarks.
W hat level does the spinal cord end in newborn and adult. W hat is between L2 and S2 in the
subarachnoid space.

W hat is the space between dura and the ligam entum flavum - epidural space.

W hat is inside- veins, blablabla lymph, fat w hat I was saying. WHAT VEIN. Intervertebral
venous plexus- w hat is the significance. W here are the ligaments supporting the spine- ALL,
PLL and flavum.
Anatom y
Intraabdo

W here is th e pancreas. W here is the stomach. Describe blood supply and point to them . Tell
me the parts o f stomach. Relation o f duodenum and pancreas to peritoneum .

Tell me em bryology o f the pancreas, tell me the ducts and where they drain into. W hat is
in fro n t D3, w hat vessel. W hat is behind it. W hat is behind body o f pancreas, w hat is behind
neck. W hat is the space behind stomach called. W hat ligam ent connects tail pancreas to the
spleen.

Anatom y
Post cranial fossa

Tell me bones which form ed post cranial fossa.

W hat is clivus. W hat nerve passes near clivus.

W here is 1AM and w hat passes. W hat vessel pass thru lA M -labyrinthe art

Comment on The venous sinuses please. Nerves th ru jugular foramen. The foram en magnum
structures.

The end plate o f developm ent in the skull- told me it was sphenooccipital synchondroses.
WTF is that.

Asked me w hat the cavernous sinus. Asked me how m id ear infection spread into the venous
sinus- he said mastoid air cells.

How is hearing affected when 7th nerve is damaged. Hyperacusis. Other effects o f 7th nerve
injury

W hat nerve from clivus- abducens

W hat benign brain tu m o u r m ore common in adults-m eningiom a, acoustic neuroma- what
nerves are affected by this. W hat do u mean by benign. W hat are the symptoms.

Crit care
88 year old man w ith painless jaundice weight loss.

Asked me types o f jaundice, pre, intra and post hepatic, asked for examples.

Then wanted post hepatic- asked fo r intralum inal, luminal and extralum inal.

W anted cholangio, pancreatic head Ca, and bilary stricture ie PSC.

Asked w hat imaging. Uss, MRCP, CT. Asked how can our radiology colleague help us, I said
pTC- unhappy, then said ERCP, she appeared happier.

Showed blood results, basically anemia, obstructive LFTs compared to only m ild ALT.

Asked bile acid func- wanted to hear the w ord em ulsification, micelles

Asked how much bile is produced a day. How many percent o f bile acid goes into
enterohepatic circulation. W hat is in bile.

Crit care
Burns- 44 year old.

showed the Wallace rule o f nines. W ith body picture shaded in certain areas. Blister wet
w ound, w hat type o f burn?

Asked how to assess A&B. then how to assess fluid resus- Parklands. W hat fluid. W hat other
aspects, I said fluid balance, nutritional support.

Then showed Xray o f ARDS, asked how to diagnose, W here to trea t patient. How to support
the resp function.

Crit Care
Crohn's com plicated bv SBO. had ileocecal resec and then develop post op leak

Showed SBO XRAY.

Asked re:types o f TPN and EN. Asked benefit. Asked risks. Asked regarding glucose use in sick
patients. Asked types o f contents o f the nutrition.

Asked regarding refeeding syndrome

Asked effect o f TPN on bowels= bacterial translocation, sepsis. Asked indications o f TPN.

History
Lady w ith 10 years hx o f thyroid lump, over 1 month, weight loss, agitated, dysphagia,
am enorrhea, warm+++, diarrhea.

Asked re investigations, blood test, treatm ent. D/D.

History
Post THR. Chest pain SOB 2 hrs hemoptysis, no leg pain, 5 days post op. no PMH, FH.
Inves please. W anted to hear D dim er

D/D. Treatm ent please. Considerations when giving trea tm ent anticoag.

Communication
Speak to upset wife

W ife whose husband had abdo swelling, tap showed malignant cells, to ld by reg there's no
hope. Needs abdo therapeutic drain. In prep note, the CT machine is broken, next CT machine
is 40 miles away, which can be arranged.

W ife was tearful not angry. Please note husband given her permission to speak to us. Wife
w ill latch on to you if you say things like it may not be cancer. Just d o n 't give her false hopes
but also d o n 't say it's term inal disease.

Communication
Phone consultant cardiothoracic for d/d. inves. management and transfer

Post RTA, chest and sternum tender. Complains of R thigh pain, chest pain, tachy, low BP, low
Hb. CXR- Broad m ediastinum ,. R pleural effusion, hem othorax in drain 200ml. AXR- no psoas
shadow. R thigh X ray- #fem ur shaft Again CT scan was bloody broken. Already given 4L IVF.
Borderline T2RF w ith mild acidosis.

Asked w hat kind o f shock is this guy in, where do u think is bleeding from . How would you
clear C spine. W hat do you want me to do fo r this man. W ho w ould you arrange to accompany
this men for transfer. Why? W hat for?

X rays have no names. They d o n 't seem bothered when I say I wan the patients' details and
assess quality o f X rays
Thyroid Anat
• STA & ELN, ITA &RLN
• Horner's syndrome
• Parathyroid location

Bile physiology
• Pt w ith obstructive jaundice. Shown a set o f ix including dipstick
• Asked to explained RE pathophysiology o f bile production and recycling
• Asked to explain RE Urobilinogen

OT List
• Placement o f m onopolar/unipolar leads
• Rank MRSA pt, strangulated hernia, pacemaker
• Precautions fo r pace maker

Sick p a tie n t- A n asto m otic leak

• GCS
• H o w to re su s
• How to manage a septic pt

Abdo exam- Cholecystitis

• Early vs late treatm ent

Subm andibular gland exam

Odd station
Given water
Did thyroid exam
WEAR GLOVES
Talk about mx of submandibular gland stone
Patho of sialolithiasis
Suturing
Select suture
Silk. Prolene Vicryl
Handtie with silk
Figure of 8 with prolene
Deep cavity tie with vicryl
M ental Com petency
• AM TSvsMMSE
• Determine if pt is fit to consent

C om m unication- Pt tran sfer

• Acute limb
• Speak to vase on call via telephone
• Present pt, present sx
• Rutherford criteria
• How you would mx pt in the meantime

Angry p a tie n t
Op cancelled again x2
Offer PALS
Sciatic Nerve
• Roots
• Anatom y- where it emerges
• Popliteal fossa
• Identify hamstrings

Carpal Tunnel UL Exam

Tricky one. Pt had odd sx not completely in line with CTS
TURP Syndrome
• Caused by
• Systemic signs and symptoms

Traum a PT
• MTP
• PCT consists o f what WBC?
• PVL- LL

Parotid gland histo

immunohistochemistry
Crohn's history
Station 1 communication
Phone call vascular surgeon for case of tibia fibular fracture with cold lower limb
20 years old medical student, alledged mva motorcyclist against car. Post mva with loss of consciousness
but gcs 15 on arrival to ED. Had done ultrasound noted ? free fluid in abdomen. Blood investigation in
ward noted hb 13 drop to 11, serum Idh, ast, alt raised. Serum amylase 300. Urea 8. Serum ca 1.8.
Day 1 in ward, noted cold lower limb informed by sn, gcs 15, hemodynamically stable, ask to call vascular
consultant
Question:
-ask about cervical clearance ( tell that no information about the cervical examination and investigation,
so will definitely do x ray cervical as patient had episodes of loss of consciousness )
-ask about the abdomen ( tell that noted free fluid, drop of hb, investigation suggest pancreatitis, would
proceed with ct abdomen to assess intraabdominal injury)
-ask about drop of hb ( will take gxm and for transfusion if hb worsen)

Station 2 communication
To inform angry patient that his knee operation will be cancelled again for 2nd time due to staff shortage.
He himself also has weight gain due to lack of activity. He work as a postman and this knee pain affect
his work and his employer is not happy with that. He is taking pain killers now but he has gastric pain. He
is planned for knee arthroscopy for ? meniscal injury
Patient will ask you why cancel, his job affected how. his knee pain worsen how, his painkiller still can
continue? W hat is his operation. Will he be permanently disabled if keep delay surgery

Station 3 critical care

Acute pancreatitis
Question
-name 2 score system
-mention all the components in the system
-why hypocalcemia (must have keyword saponification and foaming process)
-what scan and what findings
-what findings in ct scan

Station 4 critical care

Pregnant lady 34 weeker with perforated gallbladder. Planed for surgery with reverse tredelenburg
position. Developed hypotension and tachycardia
Question
-what is preload
-what is the cause of reduced preload in this patient
-what is the cause of hypotension is this patient
-how do you manage this patient

Station 5 critical care

EDH. Show ct brain of edh
Question
-describe ct brain
-diagnosis
-how you manage this patient
-how ventilation help for this patient

Station 6 anatomy
Brachial plexus
Question
-show on skeleton c5 and c6 nerve root (patient have upper trunk injury)
-show on simulated patient the dermatome
-what is the nerve root of musculocutaneous nerve
-what is the muscle of its innervation
-what attach to coracoid process
-what is the attachment of trapezius and serratus anterior
-what is the action of coracobrachialis, how to assess

Station 7 anatomy
Transpyloric plane
Show picture of transpyloric plane in axial section
-what view is it (liver on right side, so it is looking upward)
-point out 5 organs on the picture
-what is the name of space separated by falciform ligament
-what is the ligament between gaster and spleen
-what is the course of splenic artery
-what is the ligament contain the splenic artery, what else in the ligament
-what is the blood vessel branch from splenic artery that supply the gaster
-name 3 organ can be damaged by splenectomy

Station 8 anatomy
Lower limb
-name hamstring muscle and nerve supply
-name muscle of anterior compartment
-name muscle in posterior compartment
-surface mark the posterior tibial artery and dorsalis pedis artery
-dermatome of superficial peroneal and deep peroneal nerve
-muscle for eversion and inversion
-what complication if patient complain of numbness of anterior compartment and big toe extension pain

Station 9 patho
Giant cell temporal arteritis and osteoporosis
-what is the histology finding
-what is the treatment
-what is the complication of corticosteroid
-what is the risk factor of osteoporosis
-what is the histology finding of osteoporosis
Station 10 patho
Infective endocarditis and aortic stenosis
-what is the definition of infective endocarditis
-why is aortic stenosis happening
-why metallic valve need anticoagulation
-why bicuspid patient can have sudden death
-name 2 fungal cause IE with hyphae
-what pathology test for valve surgery

Station 11 clinical exam

Patient complain of chronic leg pain. ABSI normal . examine the lower limb

Station 12 clinical exam

Inguinal hernia (? Direct or indirect, I got direct, some of my friends got indirect)
Name the surgery can be done for the patient
W hy need mesh repair for this patient
Pros and cons of laparoscopic repair

Station 13 clinical exam

Varicose vein
What is the finding of duplex scan, what do you want to assess

Station 14 clinical exam

Cvs exam for preassessment (MR with CCF)
What is you management
Do you think can proceed surgery
Who else you should refer

Station 15 procedure
Airway management
Patient alledge mva. Not breathing, cyanosis, got pulse
Assess airway and put cervical collar, check any foreign body and do suction, the put oropharyngeal
airway
Put patient on hfm
Patient not response, start ambubag
Patient response, regain consciousness.
Put on hfm, remove oropharyngeal airway
W hat is the emergency airway- tracheostomy and cricothyroidotomy

Station 16 procedure
Ot list
-patient strangulated hernia with iodine allergy
-patient af on warfarin plan for amputation
-patient copd. on pacemaker and insulin with mrsa

Question
-arrange list
-preop mx for each case and anesthesia
-what to use to replace for iodine allergy
-where to put the electrode pad and why

Station 17 history taking

Knee pain

Station 18 history taking

Chronic diarrhea 8 months with joint pain
Station 1 - critical care. PUD. repeated questions
• Diagnosis, pathophysiology of PU D
• R isk factors, different phases controlling gastric acid secretion
• C au ses?
• Meds?
• How P P I works?

Station 2- critical care— fluid chart (totally new. definitely screwed up and examiner not helpful also)
• Total hip replacement PODO-1
• Show 3 pages of fluid chart and asked what's the problem and what medical team should have done
between some certain time points of A .B .C etc
• Define shock
• What kind of shock is patient having

Station 3 - critical care- ED H . fully repeated, plz refer to the past questions

Station 4 - Anatomy - heart, thoracic cavity and abdo (examiner say the heart is made from real heart!!!)
• What is this? - chordae tendineae
• What it attach to—the papillary muscle and cusps
• What function it is— prevent the valve from collapsing
• Point out the pulmonary trunk and aorta
• What are the branches of ascending aorta— left and right coronary artery
• What is it— azygos vein
• Name two other trifurcation of azygos vein— hem iazygos and accessory hemiazygos
• What is it— sympathetic trunk
• Which spine level it is from— T 1 to ?L2
• What does it call connecting the spinal nerve and organ?— ganglion(didn't get the answer though)
• What is it —duodenum
• What parts it has— 151 to 481
• Ampulla of vater open to which part— 2nd part
• What duct is drained though the ampulla of vater— pancreatic duct and common bile duct
• When you do the splenectomy, need to preserve what structures? What runs in them?

Station 5 - Anatomy - Spine (fully repeated, perfectly done within 6 min haha)
• Which vertebra are these— Lumbar spine
• Tell me all the parts of the lumbar spine— transverse and spinal process.superior and inferior
articular facet, lamina, pedicle, pars, vertebral body, spinal canal
• Put 2 vertebra together and show intervertebral foramen
• What joints the spine have between the two vertebrae—disc and facet articular joint
• What kind of joint the disc joint is— secondary cartilaginous
• What motion the lumbar spine have— flexion and extension
• Show where the A L L. P LL . Ug flavum should be
• Shown MRI. Number the lumbar spine and point out the disc
• Anatomy of intervertebral disc— Inside is anulus fibrosus. outside is nucleus pulposus
• What type of joint the disc joint is-secondary cartilaginous
• Explained what will happen to the disc while aging—dry up and loss of height
• How the P ID happen? -an u lu s fibrosis rupture and nucleus bulging out
• In posterior disc herniation of L4/5. which nerve root will be affected— L5
• Sensory area for L5 — to show on my own body
• There is a space called extra Dural Space, what are contents?— spinal nerve, lymphatic vessel and
internal vertebral vein
• What's the significance of internal vertebral vein?-- valveless vein, it is the basis of theory why easy
for metastasis to spine
• Spinal cord ends at which level, adult and child—L1 and L3
• Which level to do the lumbar puncture and how to define it— L3/L4, iliac crest
• What's the content from L4 -S 2 — spinal nerve. C S F . cauda equina, conus medullaris. filum terminale
Station 6 - Anatomy - Parotid gland - a patient model and a plastic model
• Surface mark the parotid gland - to show on the patient
• Surface mark parotid duct - to show on the patient(not happy enough with middle third between
phylum and antitragic. need 1-2cm below the zygomatic arch)
• Duct opening(upper 2nd molar teeth)
• Point to stylomastoid foramen
• Point out all branches of facial nerve after parotid (shit. 2 branches I m essed up two with the external
carotid artery, too nervous)
• Other than facial nerve, what may also be damaged during op— retromandibular vein and external
carotid artery which run thru parotid
• There is a 5mm lump over parotid, tender, what it will b e - LN
• Inflammatory causes of parotid swelling - Sjogrens and Mumps
• Most common Benign causes of parotid swelling— pleomorphic adenoma
• Most common Malignant causes of parotid swelling— either mucoepithelial carcinoma or adenoid
cystic carcinoma
• Which cranial nerve supply parasympathetic fibre to parotid gland— glossopharyngeal nerve
• Explain frey syndrome

Station 7 - Pathology - TB/lymphoma. repeated but examiner difficult

Young lady back from third world country, developed cervical lymphadenopathy. LOW . night sweats.
• What are your 2 main differentials?-- TB/Lymphoma
• What lymphoma you suspect?- non-hodgkins
• What test for TB? - culture. T B P C R . Interferon gamma assay(need exact name. T B quantiferon
gold)
• What are giant cell of langhans?-macrophage
• Name one other mycobacterium commonly seen in immune compromised patient? -M A C . full name
• Name three other granulomatous changes, not TB/foreign body— told her crohn. sarcoidosis,
atypical mycobacterium, leprosy, rheumatic fever, she still need one more, prob cat-scratch disease
• How long does T B culture take
• What is the proteinaceous substance can be found in T B ? A A amyloid
• What should you do after T B diagnosed? Report to C D C and she need more and more, not sure

Station 8 - Pathology - diverticulitis, seem s repeated but didn't prepare well

• Pathophysiology of diverticulitis?
• Why endometriosis caused pain?
• How did endometriosis get to the colon?— retrograde menstruation and ectopic endometrial tissue
• Perforated and got abscess, what's the content inside ab scess?
• How the neutrophils go to the infection site?

Station 9 - Ankle exam ination-SP

• Exam ed injured ankle and the examiner reminded me to exam the other side
• Tenderness over the right lateral mall and 5,r MT base. Ligaments all ok
• It w as fracture over right lateral mall, comfirmed by x-ray finding(examiner will tell you)
• Management? R IC E . slab, limb elevation. If the fracture high like weber C will need above knee slab,
if low. need below knee slab, examiner say let resume low
• What else want to tell patient? Casting 4-6weeks. follow up time. MC

Station 10 - Aortic stenosis pre-op exam— real patient

• Full examination for C V S
• Only findings is the systolic murmur, asked what kind of systolic murmur?

Station 11 - Hernia— real patient

• Patient had bilateral hernia but it is a malay patient cannot speak English and he pointed out only left
side. DO exam both sides
• Question: directed or indirect hernia? do you need image to diagnose? how to manage. C x vs S x
Station 12 • thyroid - real patient
The patient thyroid located to extreme right. I thought it w as lipoma rather than thyroid
• Question: differentials? Lipoma, the other thyroid differentials
• Examiner say let's assum e it is a thyroid patient, what investigation? T F T . U S. FNA
• FN A found follicular cell, how to manaoe?

Station 13 - history
• Chest pain with SO B
• Differetials a s P E . AMI
• Investigations and treatment

Station 14 - history
• Knee pain and very typical O A knee, the S P w as reading his own note all through the whole session
haha
• Differentials and investigation

Station 15 - Procedure O T listing, repeated guestions but not well prepared. Please refer to the past account,
already well stated. The scenario details combination may change.

Station 16 - Procedure R e su s on model, new

• Got a model and ask for resus. A B C etc. examiner nice and led me through the session, just need
A C L S knowledge

Station 17, 18 - Communication

• Prepared for one session and a lot of info, reported to trauma consultant or vascular consultant, he
asked guite detailed info, but nicely lead you to the answers
• Open fracture or tib/fib with vascular injury
• Summarize the management in the end after this discussion with consultant

Station 19. 20 - Communication

• To answer a pre-op patient three concerns, this patient due for recurrent hernia repair next week and
heart function not good
• Warfarin bridging, anesthesia, very worried
• Ju st need to explained and show your P L C . enjoyed it a s last station
Stations T opics (Repeat all fro m Kuching AUG 2016 except LBP)
1 B rachial plexuses and e xam in ation o f Nerves lesion
A ttachm ents and in s e rtio n o f UL muscles
Test fo r each nerve in ju ry (Repeat)

2 A bdom en and organs, blood supp ly

3 L o w e r lim b Dissection.
Muscle, Sciatic nerve, H am string Muscle and th e ir actions (Repeat)

4 MEN 1, Patients w ith hypoglycem ic attacks, H y p e rp a ra th y ro id is m

Genes and 2 hits hypothesis???. T elom ere and its action

5 BPH (Patho) (Repeat)

Ca p ro state and b ila te ra l o rch id e cto m y-> rationales
Frozen section
Rectal tu m o u r cell included in H isto e xam -> H ow to d iffe re n tia te
(H isto chem ical stain???)

6 LBP e xam in ation and discussion (Repeat)

7 CVS Exam ination, AF and antico agulation

8 Varicose ve in e xam in ation (Repeat)

9 Sutures
K not tie
Deep ca vity tie
Haem ostaic su tu re (Repeat)

10 C ranial nerve exam inations

MMSE (Repeat)

11 Post op pain (Repeat)

12 H is to ry ta k in g on Headache (Repeat)

13 H is to ry ta k in g on u rin a ry sym ptom s and DDX

M x on BPH

14 In fo rm ICU fo r pre-op advice and request Post op ICU bed.

Case o f p e rfo ra tio n a fte r meal in an e ld e rly p a tie n t w ith COPD trea ted by s te ro id fo r 8
years. (Repeat).

15 Splenic ru p tu re in 8-year-o ld boy w ith his fa th e r

P atient is in OT fo r em ergency Laparotom y. (CT proven)
M o th e r Qs a bo ut su rg e ry w ith o u t h e r consent
Upset b u t calm and ask a ll the Q uestions fo r Post splenectom y
(In fo rm a tio n given) (Repeat case b u t d iffe re n t approach)
16 P atient w ith Sym ptom s o f TURP,
Give diagnosis and D /D x.
In te rp re t the result.
Discuss TURP and its com plications. (Repeat)

17 Crohn and N u tritio n (Repeat)

18 OT List (Repeat)
H is to ry ta k in g -
-Enlarge right tonsil - staright forward hist, make 2-3 differentials, investigation, etc

-Knee pain hist - Truamatic knee 25 years ago, early arthritis

E xa m in a tio n s-
-Cranial nerves examination - Memory problem, CN I and II findings, my advice do AMTS first and
then cranial nerves

-CVS exam - Pre-op examination, Valve replacement, ankle edema, on warfarin, do mention CPEX

-Lipoma exam - multiple lipoma on the back, easy station

-Varicose vein exam - eldery frail patient, varicosities on both greater and lesser saphenous vein
territory, you want to rush but patient was too frail so my advice take your time and discuss in 3
minutes with examiner

C o m m u n ic a tio n -
-Patient with splenic injury, self discharge - explore concern , after 6 minutes do mention he needs to
sign for self discharge and make sure help available and tell him signs and symptoms of what to look
for in case if something goes wrong

-Speak to ICU reg about patient with ulcer perforation ( Pre-op planning, basic management, Fluids,
abx, ECG, CXR, will need ICU bed but could stay in recovery or to look for patients who could be step
down to the ward from HDU)

S k ills -
-Abscess drainage

-Primary survey on manikin ( ATLS protocol. Airway - head tilt / chin lift, oxygen, geudel airway, bag
mask vetilation, neck immobilisation ( use your assistant), intubation ( call anaesthetist), surgical or
needle trachy ( duration we can keep both in) etc

A n a to m y -
-Neuro anatomy ( MR brain with parietal meningioma), look for the body parts get affected by parietal
meningima

-Forearm anatomy; all muscle, nerves- very easy

-Neck anatomy, brachial plexus, injuries etc - Erbs and Klumpke palsy, root involved

C ritic a l Care-
-Post hip replacement, shock, management ( Definition, types of shock, step by step management,
when to involve seniors)

-CVC ( landmarks technique , NICE guideline), pneumothorax, how to read CXR

P a tho lo g y-
-Bowel ca, different types, lab techniques to identify, transfusion reaction, SOB, wheeze, Ml, from
where troponin released

-Gastric ulcer, phases of gastric acid secretions and hormones involved, CEPOD classification etc

B est o f lu c k
 Day 1, PM session

A n a to m y (Thorax and abdom en) - w ith cadaver

Iden tify pulm onary tru nk, papillary muscle, chordae tendinae.
W ha t is the fu nctio n o f chordae tendinae?
Iden tify ascending aorta.
W ha t are th e branches o f ascending aorta?
W ha t is this structure? (Azygous vein)
W ha t are th e trib u ta rie s o f azygous vein?
W ha t is this structure? (Sym pathetic chain)
W hich spinal segments co n trib u te sym pathetic chain?
W ha t connects sym pathetic chain to spinal nerves?
Iden tify spleen.
On w hich ribs does the spleen lie?
W hat structure is susceptible to injury during isolation and ligation o f splenic artery?
Describe the course o f splenic artery.
W hich o th e r organs does it supply?
Iden tify duodenum .
How many parts?
W hich a rtery lies behind the firs t part?
W hich structures open in to th e ampulla o f Vater?
W here does AOV drain into?
W hat is this? (Fundus o f gall bladder)
Surface m arking o f it.
W hy does cholecystitis cause shoulder tip pain?

A n a to m y (Thyroid and its surrounding) - cadaver

Iden tify thyro id gland and its parts.
How w ould you confirm th y ro id gland on exam ination?
W hat is the attachm ent o f pretracheal fascia?
Blood supply o f th yro id
Iden tify superior th y ro id artery.
Iden tify infrahyoid muscles.
W hat is th e ir nerve supply and root value o f th a t nerve?
Vocal cord attachm ent
W hich muscle contraction causes tense vocal cord?
W hat is the nerve supply o f th a t muscle?
W hat structure is closely related to in fe rio r thyroid a rte ry and w hat w ill happen if th a t
stru ctu re is injured?
W hat structure is closely related to superior th yro id artery and w hat w ill happen if th a t
stru ctu re is injured?
W hich vessels o f th y ro id gland are related to sym pathetic trunk?
How w ill you establish upper airway access in case o f emergency?
Iden tify cricothyroid m em brane
A n a to m y (Hand and fo re a rm ) - hand X-ray, skeleton and cadaver
Iden tify carpal bones - on X-ray as w ell as th e skeleton.
W ha t is the significance o f scaphoid fracture?
Iden tify the fle xo r retinaculum . W hat are its attachm ents?
Iden tify median nerve and ulnar nerve.
W hich intrinsic hand muscles does median nerve supply?
W ha t is the sensory innervation o f the m edian nerve?
W ha t structures pass through the carpal tunnel?
Iden tify flexo r dig ito ru m superficialis and profundus.
Iden tify distal attachm ents o f FDS and FDP.
How w ill you te st th e fu nction o f FDS and FDP separately?
Iden tify com m on flexo r origin.
W hat is the ro o t value fo r intrinsic muscles o f th e hand?
W hat is this structure? (Ulnar artery and superficial palm ar arch)
How w ill you te st sufficient ulnar a rte ry supply to the hand?
Describe Allen's test.
M ovem ents o f th e thu m b and innervation fo r each muscle

Pathology
Scenario: 58 year old lady w ith sickle cell disease fell down and injury to th e parietal
area. CT scan was done. Brain tu m o r found.
W hat is sickle cell disease?
Surgical relevance o f sickle cell disease.
W hy patients w ith sickle cell disease are prone to get infections?
W hat is the m ost com m on prim ary tu m o r o f parenchymal origin?
W hat is the natural history o f th a t tu m o r if le ft untreated?
Biopsy o f the brain shows SCC w ith keratinization. W hat is the diagnosis and w hat are
the possible primaries?
Post-op craniotom y w ound is infected. W hat is the com m on causal agent?
Fluid fro m th e w ound shows glucose 3.3m m ol/l. W hat does it mean?

Pathology
Given the picture o f ulcerative lesion near the hairline showing raised and rolled edge,
telangiectasia and surrounding redness,
W hat are yo ur physical findings?
W hat are yo ur d iffe re n tia l diagnoses?
Biopsy shows BCC w h at findings you w ill look fo r in the report.
There is no margin clearance in the report. So, w h a t w ill you plan fo r marginal
assessment in next operation?
W hat is frozen section?
W hat are th e steps in th e metastasis o f tum ors via lym phatic spread?
Skin g ra ft was done and the patient had g ra ft failure subsequently.
W hat was th e cause fo r the g ra ft failure?
Common organism fo r w ound infection?
- W hat is MRSA?
W ho w ill you involve in the m anagement?
 Patient developed axillary LN enlargem ent. LN biopsy showed large cells w ith bilobed
nucleus w ith p ro m in en t eosinophilic inclusion like nucleoi resembling an o w l's eye
appearance.
W ha t is y o u r diagnosis now?

6. C ritical care and applied physiology

A p atie nt w ith acute abdom inal pain, signs o f peritonism , free gas under thediaphragm ,
had taken NSAIDs fo r musculoskeletal pain
W ha t is the diagnosis?
W ha t are th e aetiologies o f peptic ulcer disease?
W ha t are th e causes o f increased gastric acid secretion?
W ha t are th e controlling physiological mechanisms o f gastric acid secretion?
W ha t are th e phases o f gastric acid secretion?
W ha t m edication w ill you involve in the long te rm m anagem ent o f this patient?
W ha t is the mechanism o f action o f p roton pum p inhibitors?
W ha t is the NCEPOD classification fo r urgency o f operations?
W ha t is the urgency o f this case fo r operation?
W ha t are th e surgical m anagem ent o f PDU and PGU?

7. C ritical care and applied physiology

A p a tie n t w ith h ypo th yro idism , n o t c o m p la in t to m ed icatio n s p re s e n te d to P reo perative
clinic fo r e le c tiv e surgery
Blood results - reduced Hb, increased MCV, high TSH, low T 3 and T 4
In te rp re t the TFT and w h at is your impression?
D raw and explain the th y ro id horm one axis.
6 clinical features o f hypothyroidism .
W hat are th e 3 causes o f hypothyroidism ?
How can you im prove this patient's com pliance to m edication?
W hat concerns you m ost if a hypothyroid p atient is to undergo an operation?
W hat are th e clinical features o f myxedema coma?
How w ill you prevent this?

8. C ritical care and applied Physiology

A p atie nt w ith Crohn's disease post-op 3rd day ileostom y, plain abdom inal X-ray (pre-op)
shows small intestinal obstruction
W ha t is y o u r diagnosis?
W ha t are th e routes fo r n u tritio n in surgical patients?
W ha t are th e indications fo r parenteral n u tritio n ?
W ha t are th e constituents o f parenteral n u tritio n ?
How does mucosal atro ph y occur in TPN and w hat are possible com plications?
A part fro m carbohydrate, w hich com ponent gives m ost o f the energy?
W hat are th e com plications?
W hat are th e indications fo r enteral n u tritio n ?
W hat are th e com plications o f enteral nutrition?
9. Procedural Skills
U rinary catheterization
Questions
W hat w ill you do if no urine com ing o u t aftercatherization?
M anagem ent o f oliguria, anuria
Fluid challenge

10. Procedural Skills

Removal o f nevus and suturing o f the wound
Questions
A fte r care
Follow-up

11. Physical Exam ination

Examination o f cranial nerves - Bitem poral Hemianopia
M anagem ent o f p itu ita ry tu m o r

12. Physical Exam ination

Examination o f le ft inguinal hernia
M anagem ent o f ind ire ct inguinal hernia
W hat if the patient has BPH?

13. Physical Exam ination

Examination o f cardiovascular system - M itra l valve replacem ent (W ith sternotom y and
le ft subm am m ary scars, m etallic click)
Patient is on w arfarin. W hat is your preoperative management?

14. Physical Exam ination

Examination o f knee jo in t - O steoarthritis o f right knee jo in t (W ith effusion and
lim ita tio n o f knee flexion)
D ifferential diagnoses
M anagem ent

15. C om m unication - Phone call to consultant

Post op 2nd day oliguria
Patient's consultant is away. Call to consultant on-call.

16. C om m unication - Request fo r discharge

Splenic haem atom a due to in ju ry during playing rugby
Patient w ants to be discharge.
Hb drops 2 mg% fro m base line 48hr a fte r admission
Concerns - Job interview , W ife
17. C om m unication - In fo rm a tio n gathering
Old age gentlem an, bleeding per rectum , mucous stool mixed w ith blood, LOW, LOA,
chronic constipation
Diagnosis - CRC
D ifferential - D iverticulitis, Inflam m atory bowel disease
M anagem ent o f CRC

18. C om m unication - In fo rm a tio n gathering

M iddle age lady, long standing goiter, recent toxic change
Diagnosis - Toxic m ultin od ula r g oiter
M anagem ent o f to xic MNG
2019 compilation

Last updated 11 Jan 2020

First run:

Station 1 history pr bleed

58 year old lady 6 m onths o f pr bleeding, stool mixing, dull abdominal pain no other
type b symptoms weight lost, appetite change e t c , strong fam ily history (brother has
colorectal ca)
Further question
Differentials colorectal malignancy, inflam m atory bowel disease, haemorrhoids,
diverticula disease
Investigation blood test colonoscopy w ith biopsy

Station 2 day 5 post op le ft colectom y peritonitic abdomen. Acute assessment 6

m inutes(com bine Abcde w ith abdominal exam and assessment o f wound) later given
ecg(tachy af), vital sign(septic trending) and blood results(raised inflam m atory
markers), w hat im m ediate management: fluid resuscitation+m onitor input output,
commence antibiotic as per protocol, possible blood transfusion as required request to
preform ct? W hat's differentials: anastom otic leak, internal bleeding, hospital acquired
infection( pneumonia or uti) and to rule out pe as well ( would do abg but forgot to
m ention) w hat definite management: depend on ct results if localised infective
collection then can perform ir drainage or not then reoperate

Station 3 pathology patient w ith bicusp aortic valve, what's pathogenesis the risk of
aortic stenosis in patient (higher pressure o u tflo w causing turbulence and
progressively leading to chronic inflam m ation/fibrosis o f valve thus stiffen the valve?)
w hat's o ther possible risk due to bicusp valve-higher risk o f infective endocarditis, how
does the disease spread-from blood stream. W hat com m on organism causing
endocarditis- group a staph aureus a n d .......patient progressive require TAVI y? As the
infection cause vegetation at difficult to eradicate. W hy patient need to be on warfarin
and nothing else, as need to archive higher level of anticoagulation what's is the
pharmacodynamic o f warfarin , prevent activation of extrinsic and common pathway
clotting factor via vitam in k

Anatom y three pictures o f anterior thigh, posterior hip and popliteal fossa, ask me to
identify muscle under ileotibial band( I said vastus lateralis but not the Answer he
wanted) what's the action o f ileotibial band- to secure help to stabilise knee jo int,
move to second picture ask me to identify gluteus medius, it's nerve supply (superior
gluteal nerve) and it primary action while walking (to prevent tiltin g of other side of
the hip). Move to third picture, ask me to identify biceps Femoris it's nerve supply,
how many heads(2) and it's action while walking(extend hip and flex knee. Ask me
what's the nerve run across fibulae head-common peroneal nerve, ask me what
sensory supply( it supply dorsum o f the foot via superficial branch, first web space of
toe via deep supply and lateral cutaneous branch via form ing sural nerve, w hat muscle
it supply lateral com partm ent Peroneus and anterior com part the extensors muscles,
tibialis and pronator Tertius, w hat presentation when the nerve is damage- foot drop
and lost o f eversion w ith dorsum sensory lost
Procedure station- suture. Ask to select instrum ent including needles(choose ethelon)
to o th forceps needle holder and suture scissors, need to check expiry date. Pinch
patient w ith forceps to assess effect o f analgesia. Perform 4 interrupted sutures w ith
instrum ent tie, and need to handle sharps safely. Ptn w ill ask question: is it painful-
explain the local w ill work for a few hours afte r can take some paracetamol and
ibuprofen if necessary. Explain as this is non absorbable suture thus need to remove
suture 10 days either g p / district nurse, however if notice redness, bleeding, infective
looking require to reopen suture earlier. Examiner ask abt w hat local to be use-
lignocaine, why for both adrenaline and w ith o u t adrenaline, use lignocaine because
quick onset o f effect, use adrenaline because vasoconstriction reduce bleeding and
localised effect. Calculate the dosage can be given. Bell ring(unsure if there is anymore
question)
Anatom y station 2: ask to identify optic nerve, exit point o f the nerve(optic canal), ask
to identify the dural layer overlying m iddle and posterior cranial fossa, ask to identify
internal carotid artery( this is tricky as it only a luminal structure appear next to optic
chiasm, but examiner kindly help u rule out other answer eg m iddle cerebral artery,
carvenosus sinus etc.) as to identify oculom otor
Nerve, where is it origin( I said piercing out from pons but i think he wants where the
nucleus o f the nerve is) where is it exiting craniofossa via superior orbital nerve, what
muscle does it supply, superior inferio r medial rectus and levetor palpabrae superialis
and pupillary muscle via parasympathetic supply. W hat prom inent sign when it is
compress by sol blow out pupil, w hat is the type o f aggressive form o f glioblastoma-
m ultiform e w hat is the other presentation o f oculom otor nerve palsy-ptosis and
laterally deviated(abducent nerve) and dow nw ard looking(by trochlear nerve)
definition o f false localising sign......

Ent- ask to identify external carotid artery and ascending pharyngeal artery, ask to
identify facial artery if transected is it detrim ental to its supply-no as it has cross
tributaries from opposite facial artery and lingual artery as well. At w hat level common
carotid bifurcate-c4,c5 w hat is carotid sinus presence of baroreceptor detect change in
blood pressure, w hat is carotid body presence o f chem oreceptor detect ph pa02 level
fo r changes. Ask me to identify subm andibular gland as where is the duct opening into
at next to frenulum flo o r o f m outh via duct o f W harton, ask to identify parotid gland
w hat type o f secretion it produced serous, where is it's duct opening at opposite of
second upper molar(exam iner w ant specifically the space between the teeth and
buccal mucosa

Anatom y station upper thorax-identify oesophagus, surface made up of w hat cell

stratified non keratinised squamous epithelial layer where is the dual blood supply in
oesophagus, low er end receive blood supply from azygos and le ft gastric vein can
cause varicose vein increase risk o f bleeding. Second picture identify carina bifurcate at
t4 level. W hat is the nerve travelling at the side o f trachea I said vagus nerve. And we
move on to the third picture indicating ascending aortic branch identify common
carotid artery rpt level o f bifurcation. Identify le ft subclavian artery which part of
brachial plexus travel posterior to it- inferior trunk, w hat is subclavian steal syndrome
retrograde blood flo w away from vertebral artery due to subclavian artery stenosis
thus leading to ischaemia o f brain supply when increase required blood flow to arm eg
during exercise

Discussion station: anxious patient to be consented for ogd patient had recent barium
swallow showed likely benign structure but bloods results and symptoms indicating
otherw ise ? Malignancy. Try to explain the procedure after confirm ation o f id, patient
keep interrupting by telling his anxiety w hile had to explain the risk o f procedure which
is quite a challenge?

Physiology station: n u tritio n post upper gi op patient n u tritio n requirem ent. W hat is
classification o f n u tritio n intake: is enteral and parenteral. Ask example fo r each
subclass eg oral, ng, peg and jejenostom y, parenteral partial peripheral and total
w hat's the indication o f each and th e ir com plication, eg during insertion, during
delivery o f nutrien t and long term . W hat com ponent o f nutrien t for ptn eg
carbohydrate and lipid and protein(nitrate) and m ineral and vitam in, ask about
possibility o f com plete carbohydrate feed is it feasible? I say no due to risk of Dm and
some tissue rely on d ifferent energy source from lipid

Second run:

First station: p a tie n t adm itted w ith p e rito n itic abdomen, ask to review problem on vital chart
noted patient hypotherm ia o f 35 celcius. D efinition o f core tem perature hypotherm ia, w hat is
th e w ay o f m easurem ent o f hypotherm ia. Possible risk fa cto r o f hypotherm ia: patient-sm all
body habitus(S lkg), surgical risk (exposure tim e, patient require laparotom y, general
anaesthesia-losing shivering mechanism due to muscle relaxant). W hats is the effect o f
hypotherm ia: increase risk o f bleeding affected clo ttin g cascade, increase risk o f infection,
causing cardiac arrhythm ia, poor recovery fro m anaesthetic. How to prevent hypotherm ia in
wards- switch on heater, close w ind ow , using cotton w ool/a lu m in iu m blanket. How to prevent
hypotherm ia during surgery, usage o f biere hugger, using hum idified w arm air fo r ventilation ,
using pre-w arm ed iv flu id /b lo o d products, lesser exposure tim e and surface area and usage of
plastic cover fo r laparotom y.

Second station: discussion w ith consultant regarding w orrying a bout patient: post m astectom y
tw o days insisted to go home w ith 410 mis o f drain and feeling sob she was persuaded by her
daughter as her daughter is staying at 60m iles away fro m the hospital and she was bounded by
her jo b and need to take care o f her fam ily m em ber. Explain sbar to the consultant. As about
w h at possible cause o f increase drainage-slipped vein ligation. Also asked w h a t o th e r possible
o th e r w orries, need to make sure patient does n o t have o th e r cause o f SOB eg actelectasis,
chest infection, pe, anaemia, ect. Also ask w h ether is th a t w hat patient w ant, explained
u n fo rtu n a te ly you are not sure as you have n o t seen p atient yourself and not seen p atient full
vitals chart and have not access patient w h e th e r has capacity fo r 4at score(exam iner ask me to
clarify how to access patient capacity( iam not sure w h e th e r th e exam iner w anted the
com ponent to define capacity or each com ponent o f 4at or specific te st such as MMSE) if
p atie nt has capacity w h at o th e r advise w ould you give, advise signs o f red flag, and clarify is
th e re nearby hospital to seek fo r help and also need to com m unicate w ith daughter fo r
alternative. If p a tie n t has no capacity w h a t to do, need to w eight risk and benefit m ight need
to detain p atie nt to stay if need be.

Third station: exam ination: p atie nt com plain o f bilateral claudication pain/associating w ith
back pain, worse going uphill, claudication(pain relieve upon resting), but abpi norm al.
Examiner has neurotip and tendon hammer. A ttem pted to do back exam ination and low er
lim b neuro and vascular exam ination (not finished). Patient also has bilateral varicosity at
popliteal fossa as w ell, confusing station and I flung it.

Fourth station: patient com plained o f sob and cough fo r 6 m onths as patient pre-op fo r
surgery. Ask to examine respiratory system. Normal exam ination finding-no lym ph node
palpation (probably required), ask w h at diffe re n tia l diagnosis is I said possible COPD but can't
rule out malignancy. Ask w h at o th e r investigation check oxygen saturation, and perform
respiration fu n ctio n test, and spirom etry and also perform chest x-ray to rule o u t malignancy
effusion. Asked if p atie nt presented w ith pleural effusion, w hat clinical signs o f pleural
effusion, reduced air entry, dull upon percussion and reduced chest expansion. W hat fu rth e r
imaging required to rule o u t malignancy, CT scan.

Five station: hand exam ination: p a tie nt com plained o f weakness on his le ft hand, examine look
feel move w ith specific sign patient has tr y to dem onstrate poor ulnar flexor weakness and
tingling upon tapping o f medial epicondle cubital tunnel syndrom e. Ask fo r cause o f ulner
nerve palsy, guyon canal compression, m edial condyle compression, due to golfers elbow.

Station 6: history fo r th yro id disease: patient presented w ith chronic hyperthyroidism , noticed
recently new lum p developed a t unilateral neck, w ith sym ptom s o f sensitive to hot. No
m alignant type b sym ptom s and ju st re p o rt back to exam iner and brief discussion o f fu rth e r
investigation and m anagem ent: eg Fine needle aspiration, and th yro id function te s t depend on
results consider pet scan fo r malignancy, d /d : graves disease toxic nodular goiter. And
discussed about m edical(carbim azole/radioactive iodine) and surgical m enagem ent

Station 7: pathophysiology: asked to discuss a 19 year old gentlem en w ho has circum cision
recently. It sort o f like a mixed station. W hats is the main blood supply to penile gland and
shaft I said dorsal plexus? And patient u n fo rtu n a te ly developed haem atom a, I have been asked
about w hat m anagem ent w ould you do: resus and eg review and decision fo r evacuation,
penile ultrasound to assess severity, reapplication o f pressure dressing, recheck patient full
blood count and c lo ttin g and fo r cross m atch/group and save. Later exam iner shown me the
c lotting blood results showed raised aptt. W hich pathway has been used to measure by it,
intrinsic and com m on pathway. W hich clotting fa cto r involve in com m on pathway: activation
o f pro throm b in to th ro m b in and w hich cleave fibrinogen to fib rin fo rm meshlike netw ork w ith
activation by calcium and fa c to r XIII. Patient was referred to haem atology fu rth e r te st revealed
p atie nt is lo w in fa c to r 9. W hat is th e condition call: Christmas disease, o r type 2 haem ophilia
w hich is a sex link genetic disease.

Station 8: repeated station o f p rio ritization o f cepod list:

 a) Patient w ith critical lim b ischaemia w ith m u ltip le co-m orbidities fo r low er limb
am putation, patient is MRSA positive
b) Patient w ith strangulation hernia, patient is allergy to alcohol
c) Patient w ith diverticular abscess, not responding to conservative tre a tm e n t, is
penicillin allergy

Station 9: Ask to see a 25 week pregnant lady w ith com plained o f breathlessness, likely
developed PE, ask to identify d iffe re n tial diagnosis, investigate and m anagem ent. Further
m ore questions about anticoagulation, actions on coagulation cascade. Patient has fu rth e r
investigation fo r chest x-ray, noted presence o f grow th in one o f the lung lobes, turned o u t to
be malignancy, small cell lung tu m o u r, patient progressively developed hypertension,
tachycardic and pyrexic-paraneoplastic syndrom e secondary to serotonin like protein.
Anatomy

Identify: biceps femoris, saphenous nerve,

structures in femoral canal 4 structures in femoral sheath
Common perineal nerve muscle supply
Other cause of Same symptom: L5 spinal nerve injury
Tensor fascia lata and three muscle attached to it
Distribution of L5

(B) cut section of brain with falx cerebri intact

Identify falx cerebri
Identify oculomotor root and optic nerve and which foremen do they go
Occulomotor palsy sign and pupil position
Eyelid position in oculomotor palsy and why
Trochlear and abducens palsy sign
Layers from dura to meninges
CSF flows in which space
Lateral supply of cerebrum
False localising sign- Example of it

(C)Mediastinum and neck structures

Identify Ansa cervicalis Subclavian veinFacial arteryWhere will you palpate
Subclavian steal syndrome
Level of carotid bifurcation
Carotid body and sinus difference
Aortic body function
Nerve at carotid bifurcation
Identify Parotid, duct opening and secretion
Identify submandibular gland, opening and secretion
Carina level
Identify Oesophagus and nerve below trachea
Oesophagus epithelium and Barrera Oesophagus

History:

1: thyroid swelling with hyperthyroidism

2 PR bleed: colon cancer

Examination:
1: gentleman with Claudication pain and normal ABPI: couldn’t find any + finding: did neuro,
vascular and spine examination ( at the center I asked many candidates, no one found any
problem)

2: sick patient with anastomotic leak

3: respiratory examination : construction workerHad silicosis with wheeze and effusionViva on
pleural effusion
4: ulnar nerve compression neuropathyCompression proximal
Procedure:*!: suturing: wanted me to ask for X-ray and need to examine neurovascular as well
which I did
2: procedure: Listing procedure as per priority as in your station
Communication:
1: anxious patient for OGD under GA for possibly benign oesophageal structure explain about
dilation risk in detail
2: lady wants to take her mother homeMother is not well, tak to consultant

Pathology:
1: phimosis: 3 common causes
Difference between phimosis and paraphosis
Treatment
Postop Bleeding in which layer of penis
Safety net to patient
When will you observe or explore for hematomaHematoma resolution steps
Patient had Christmas disease
Wanted to hear genetic testing postop ( he hinted and I grabbed it)Common pathway of
coagulation

2: infective endocarditis
Why aortic stenosis occur in bicuspid valve
Cause of death in AS
How to identify IE: blood culture and mod dukes: Major and minor criteria
Why thrombosis in prosthetic valve
Why weak arm in IE
Diff between osier and janeway lesion
Warfarin Mechanism of action
Common pathway of coagulation
What is factor 1 and 2 of coagulation
Which is the most common pathway in coagulation system
What is APTT and what does it measure

3: lung cancer:
Two other most common lung cancer apart from small cell cancer
5 cancer to metastasize in bone
Investigation for lung cancer before biopsy
What are different paraneoplastic syndrome in lung ca
What is FISH in lung ca and how does it affect management of lung ca
What is DIC
What is platelet

4: hypothermia: What is hypothermia

Risk factor
Places to check core temperature
Causes of heat loss in postop
How to prevent
Problem associated with hypothermia
ARDS features
Bilateral lung infiltrate: ARDS
Two more causes

5: burns with nutrition

Bum depth calculation
Calculate fluid
EMSB steps
Fluids given in burn
When will you give blood
Same as in your station on nutrition
What is CRP and where does it come from
1. Anatomy: Oesophagus + posterior mediastinum - including lymph drainage and
what vertebral levels
2. Communication: Repeat: Discuss malignant cytology with wife and CT scanner
not working
3. Anatomy: Dural sinus, formamina, which veins do sinuses drain
4. Critical care: Hypovolaemic shock, pelvic and tibial fracture
5. Pathology: Repeat: Diverticulitis and endometriosis, what is the mechanism of
a fever?
6. Critical care/Examination: Repeat: Anastamotic leak, management, what
operations could you do?
7. Anatomy: Shoulder anatomy, MRI, what movements need to happen to fully
abduct shoulder
8. Skills: Suture laceration
9. Skills: l+D abscess
10. Pathology: Hypercalcaemia, causes. Patient had breast cancer, think about
metastases. How do aromatase inhibitors work? What are her risk factors for
DVT, what is the mechanism of how they form and how does the body break
down clots?
11. Pathology: Bowel cancer, staging vs grading. What are the 2 key things you
want to look at on pathology report? What is the name for omental tumours?
What is the mechanism of clot formation and degredation? How do tyrosine
kinase inhibitors work?
12. Critical care: Repeat: Pancreatitis, Psuedocyst on CT, ARDS, Would you give
gelofusin to resuscitate
13.Communication: Repeat: Call vascular consultant AF critical ischaemia
14. History: Repeat: Impotence, what investigations would you do?
15. Examination: Shoulder exam, actor, universal reduced ROM in shoulder, what
management options
16. Examination: Cranical nerves, actor, bitemporal hemianopia, medical treatment
of pituitary microadenoma
Station 1: Crit care
Gentleman post sigmoid collectomy- tachycardic and unwell. Stem labelled it a physical exam
station but felt more like a critical care as the scenario progressed. Likely an anastamotic leak

Station 2: inguinal hernia physical exam

Station 3: submandibular gland exam

Likely diagnosis- sialolithiasis. Need to know how to investigate and manage

Station 4: lower limb peripheral nervous system exam

Gentleman post varicose vein surgery (RFA + MSA)
Now presents with lower limb weakness
Stem leads on to reveal foot drop. Common peroneal nerve injury
Management asked- physio, OT (examiner wanted to hear the word splint)

Station 5: communication skills

70+ year old lady with COPD
Issue is a perf viscus. Needs surgery
Also has AKI now
Is septic
Very few bits of info available- ECG not done etc. examiner will ask- need to be honest and say
you don’t have it on hand
Telephone conversation with ITU registrar to book a bed and for preop advice

Station 6: anatomy
Abdomen
Given anterior abdominal wall and cross section about the level of appendix
Ext oblique muscle origin, nerve supply
Conjoint tendon- what makes it up
Muscle in front of the deep ring
Nerve injured during an appendictomy that now results in patient having a hernia- ilioinguinal, as
well the nerve root
Identify structures
Embryological remnant one should think about in differentials for RIF pain
(Meckel’s)
Explain about Referred pain

Station 7: anatomy
Thyroid
Asked about the infrahyoid muscles (name 3 below the hyoid)
Functions of the infrahyoid muscles
Nerve supply to these muscles and nerve roots if the nerve
Thyroid vein drainage
Some questions on the nerves (recurrent, external laryngeals)

Station 8: anatomy
Shoulder
Given scapula, clavicle, humerus
Identify some structures on these
Rotator cuff structure identification
Nerve supply
Given an MRI of the shoulder joint- asked to identify muscles

Station 9: procedural skills

knot tying
They’ll give you directions
Eg
Approximate the two bands using a non absorbable multifilament suture
Tie a knot at depth with a braided absorbable etc
Figure of 8 stitch around a bleeding vessel (red mark on a sponge)

Station 10: history

Knee pain

Station 11: pathology

Lady with Hep C
Involved in an MVA
Sustained a splenic laceration, proceeded with splenectomy
Post op bloods
Hb 7
Platelets 70
Aptt prolonged
PT prolonged
Asked what could be the cause of the coagulopathy- DIVC
Why anemia- blood loss from spleen
Where do platelets originate from- megakaryocytes, function? Happy with involved with
coagulation
Appt tests- intrinsic and final common pathway
Why does the patient need antibiotics? Post splenectomy
On giving penicillin- patient got a rash- type of hypersensitivity? 1
And why?- IgE associated mast cell degranulation
Patient had a blood transfusion- developed fever after;why?
Was happy with 1-2 reasons

Station 12: OT listing

1. 70/lady-diverticular abscess for a hartmans
She has an iodine and penicillin allergy
2. 60/male
Critical limb ischemia planned for Below knee amputation
He has MRSA, diabetes
3. 60/male
Strangulated hernia. Has a pacemaker

Arrange the above. Discuss diathermy choices, how the pad will be applied etc
Station 13: pathology
Testicular cancer
3 Possibilities of a testicular mass
Given a pathology report post orchidectomy- CD4 and CD20 (can’t remember) positive. Other
features on the report pointed towards lymphoma.
Other sites lymphoma can develop
Risk factors for lymphoma
Patient had an ulcerated lesion over face. Excised- reported as an SCC. What features in the
report do you want to look out for?
Sometime later he develops an axillary lymph node. What bedside test can you do at your clinic
that can give you a result within an hour? FNAC
Given the FNAC report
Generally says that the lymph node structure has some mild pleomorphism which is to be
expected, some epitheloid cells with keratinization. Need to say that this is metastasis from the
SCC (not the lymphoma)

Station 14: critical care

Patient post trauma, had LOC, vomiting
GCS was full in ED. Also had an ankle fracture. Just as she was about to be taken for surgery-
GCS drops. Who would you call? How would you approach?
Ct done- shown image of an EDH (asked to identify)
Asked if you would have done the ct earlier (need to say that patient had signs that would have
warranted an early ct (quoted the Canadian head ct rule)
Some questions on ICP
Monroe kellie docrtrine
Normal ICP 5-15
How to measure ICP
Strategies to reduce/maintain ICP (cerebral protection- broad principles are fine, don’t need to
get into details
For eg- nurse propped, maintain normocarbia, prevent hypoxia, consider barbiturates etc

Station 15: crit care

Pregnant lady for open cholecystectomy
Trendelenburg position
BP drops
Who would you involve in care?
Why did the Bp drop
What do you want to do?
What are the benefits of surgery for this patient at this point of time
What physiologically happens when bp drops?
Baroreceptor stimulation, where? How do afferent fibres get from Carotid body to the spinal cord
etc (basically wanted to hear glossopharygeal nerve
Define preload
What effects EDV
Mechanisms of venous return
Station 16: com skills
Splenic hematoma at own risk discharge
Patient wants to
Go home on day two of admission as he has a job interview, wife has breast ca. Couldn’t get
him to stay, but he’s happy to sign the forms and can understand and communicate decision

Station 17: critical care

Patient post colectomy
Day 2 has developed tachycardia and breathlessness and fever
Possible differentials
ABG given- type 1 respiratory failure with respiratory alkalosis
CXR given- costophtenic angle blunting both sides
ECG- sinus tachycardia
Suspect PE- what would you do? CTPA
What do you look for in the CTPA?

Station 18: history

Lady day 5 post hip replacement
Had chest pain and hemoptysis
Differentials must include PE
examiner asks what you’d like to do
PE Management
phy exam:
1) cvs w pacemaker
2)lipoma rt back
3)thyroid
4)post op varicoae v wif I4-I5 weakness

historyl) thyroid, 2)diarrhoea

practical
1)suture laceration wound,
2)i n d abscess

anat
1)hamstring sciatic n
2)thyroid n brachial plexus
3)skull

communications
1)postpone rt knee op
2)refer vascular surgeon critical limb

critical care
1)burn
2)post op head n neck nutrition ng tubes
3)post op ant resection oliguria

pathology
1)carcinoid tumor
2)nephrectomy+ frozen section
1. A n a to m y - neck & th o ra x
W hat structures are this? (points to diagram)
Iden tify aortic arch and its 3 branches
Iden tify le ft recurrent laryngeal nerve (winding around aortic arch)
Anatom y o f th y ro id gland (on diagram shown)
Right lobe, isthm us, le ft lobe, pyram idal lobe
Nerves damaged during th y ro id surgery and w hat o th e r vessels they are close to
External branch o f superior laryngeal nerve (near superior th yro id artery)
Recurrent laryngeal nerve (near in fe rio r th yro id artery)
Anatom y o f parathyroids

2. A n a to m y -S k u ll
W here is th e pterion? (p oin t to skull)
W hat are the bones th a t make up th e pterion?
W hat is th e significance o f the pterion?
M iddle meningeal a rtery lies below it
Can result in extradural hem atom a if th e re is traum a
Identify foram en lacerum, foram en spinosum and jugular foram en (on skull)
W hat are the structures th a t run through them ?
Identify superficial tem poral artery and ECA on diagram
W here does the deep tem poral a rtery com e from ?

3. A n a to m y - ham strings, g lu te a l region, p o p lite a l fossa

Point to hamstrings on diagram
Origins o f the hamstrings muscles
Identify sciatic nerve on diagram
W hat are the 2 bony landmarks associated w ith the sciatic nerve?
Course o f sciatic nerve
Gluteal muscles and th e ir nerve supply
Identify structures in popliteal fossa on diagram (from deep to superficial)

4. C ritical care - burns

How w ould you manage airw ay and breathing?
Calculate body surface area o f burns (picture shown) based on rule o f 9s
How is th e fluid requirem ent calculated? - Parklands form ula
W here w ould you manage th e patient?
W hat types o f ve n tila tio n do you know?

5. C ritical care - n u tritio n

W hat are the pros and cons o f parenteral vs enteral nu tritio n ?
W hen w ould you choose to use each one?
W hat are the contents o f enteral n u tritio n ?
6. Physio - renal, flu id s
Understanding o f renal physiology
D ifferent types o f diuretics and w hich part o f the kidney do th e y w ork on
Know the counter curre nt mechanism

7. PE - fo o t drop
Stem: Patient w ho recently underw en t varicose veins surgery, now com plaining o f lo w e r lim b
weakness
Examination o f lo w e r lim b s - g a it, pow er, reflexes, sensation
Dx: Foot drop 2' com m on peroneal nerve palsy
Questions:
W hat is y o u r diagnosis?
W hat investigations w ill you do? - NCS, EMG
W hat is y o u r management?

8. P E - th y r o id
Stem: Lady presents w ith an te rio r neck swelling
Examination o f neck - Large g oitre w ith bruit
Questions:
D ifferentials fo r goitre
W hat investigations w ill you do?
W ill you do a core biopsy? W hat can the core biopsy te ll you th a t the FNAC cant?
W hat is y o u r management?
If the FNAC comes back as fo llicular cells, w hat w ill you o ffe r th e patient?
Is th e re a chance th a t a fte r a hem ithyroidectom y, she may require fu rth e r surgery?

9. P E -lip o m a
Large lipom a o f the back
Rmb to check fo r any surrounding lym phadenopathy
Rmb to use all the equipm en t given (including auscultation, transillum ination , measuring tape)
Questions:
D ifferentials
W hy is there is need to check fo r any enlarged LNs?
W hat invg w ill you do?
W hat is y o u r management?

10. PE - CVS
Stem: Lady w ith pacemaker undergoing pre-op assessment
Exam: Left infraclavicular scar w ith pacemaker insitu
Questions:
In te rp re t the ECG (pacemaker spikes w ith LBBB)
Indications fo r pacemaker insertion
W ho else w ill you involve in the care o f this patient?
Pre-op preparation
Intra-op things to note
o Use bipolar diath erm y is possible
o If unipolar diatherm y needed, ensure electrode pads placed as fa r away fro m p t as
possible
11. H x -d ia rrh o e a
Dx: IBD
W hat are the differentials fo r her diarrhea?
W hat investigations w ill you do? - Colonoscopy and biopsy

12. H x - th y r o id
S traightforw ard history
W hat are yo ur differentials?
W hat investigations w ill you do?

13. Comms - cancelled op

Stem: Speak to angry pa tien t regarding having to cancel his meniscus surgery as your consultant is
urgently called away to deal w ith a traum a emergency
Rmb to address p t's o th e r concerns
Being u n fit fo r his jo b as a postm an (offer to w rite a m em o to his boss)
W ife having to take leave fro m her jo b (o ffe r to w rite a m em o to her boss)
Gaining w eight and having increased knee pain (o ffe r physio, increase analgesia, lifestyle mx
advice)
Having gastric sym ptom s fro m taking NSAI Ds fo r m onths (o ffe r to change analgesia, add
omeprazole)
O ffer p a tien t liaison services as feedback avenue fo r pt
Rmb to summarise yo ur plan o f action

14. Comms - call vascular fo r acute lim b ischemia

Scenario: Pt w ith know n AF adm itted fo r diverticulitis on IV Abx, developed sudden lo w e r lim b pain
Rmb to include com p artm en t syndrom e as a d ifferential
Questions:
W hat is y o u r impression?
W hat o th e r differentials?
Is the cardiologist involved?
Do you th in k this p a tie n t needs a fasciotom y?
W ho w ill accom pany th is patient fo r hospital transfer?

15. P a th o -c a rc in o id
W hat are the main cells seen in acute inflam m ation?
Characteristics o f carcinoid syndrome
Investigations fo r carcinoid syndrom e

16. Patho - hyperPTH

How does chronic renal failure cause hyperPTH? - due to hypocalcemia in CRF
How does PTH work?
Explain the process o f frozen section fro m th e tim e the specimen is taken o u t till the tim e the results
are received
W hat are you looking o u t fo r on the pathology report? - Grading, Size, Margins, LNs involvem ent
17. Skills - l& D o f abscess
S traightforw ard station
Know LA dosing
Know the lines o f langers
Rmb to th ro w away all th e sharps

18. Skills - excision o f naevus and suturing

S traightforw ard station
1) A n a to m y -U p p e r lim b
Skeleton provided
W hat nerve supplies deltoid?
Sensory deficit if nerve palsy?
W hat nerve supplies biceps?
Area of sensation supplied by this nerve
Other muscles supplied by musculocutaneous nerve
Radial nerve - sensory distribution
Function o f pec major?
Demonstrate biceps and brachioradialis reflex on SP
W hat myotomes?
Muscles involved in full abduction o f arm?
W hat muscles involved in rotation o f scapula
Trapezius/serratus anterior supplied by w hat nerve?
Surface m arking o f coracoid process on SP
W hat muscles attach to coracoid process?

2) Anatom y - Cervical spine and neck

Identify parts o f cervical vertebrae
Typical vertebrae?
Identify atlas, axis, C7
W hat ligaments connect to dens
W hy cannot feel C1-C6 spinous process
Identify hyoid
W hat level
Lateral CXR - how do u look for soft tissue swelling/airw ay compromise
Swimmers view - w hat view is this? Identify dens/lateral mass

3) Anatom y - Abdomen (transpyloric plane)

On SP: dem onstrate surface anatom y fo r GB, m idaxillary line
W hat costal cartilage at costal margin
On photo o f cadaver - transverse section o f transpyloric plane
Identify 4 organs
Looking from feet or from head
Organs th a t touch the spleen
Blood supply o f spleen - specifically lienorenal ligament
Splenic artery supplies w hat arteries to the stomach
Other ligam ent o f spleen connecting to le ft kidney
W hat muscle is this? Diaphragm

4) Pathology - PVD and mesothelioma

Define gangrene
W hat types o f gangrene?
Pathophysiology o f gangrene
3 risk factors of atherom a form ation apart from HLD, DM, smoking?
 Affects which blood vessels? Large
CXR shows lung mass, likely cancer
Also having pleural plaques. Significance?
At risk o f w hat type o f cancer?

5) Pathology - Necrosis, abscess, osteom yelitis

Stem: Old man w ith worsening knee pain, fever, previous knee plate for fracture 3
years ago on same knee
Difference between necrosis and apoptosis
W hat is an abscess?
W hat are the outcomes o f an abscess?
Constituents o f pus
Is pus alive or dead? Both
W hat is infection o f bone called
W hat is sequestrum and involucrum
Protein deposition related to OM?
W hy must remove im plant?
W hat are common bacteria th a t cause OM?

6) Examination - Knee meniscus injury > OA

23-year-old involved in football tackle pretending to have medial jo in t line
tenderness and fixed flexion deform ity of R knee. Asked to summarize the findings,
m anagement plan and management o f a meniscal injury.
Ddx
Investigations? XR, MRI
Conservative and surgical options - RICE, arthroscopic and open repair
Patient develops worsening knee pain at 55 years old - Diagnosis?
W hat kind o f OA
M anagement o f OA

7) Examination - Abdom inal pain (anastom otic leak)

Same as previous years

8) Examination - Submandibular gland

SP - left subm andibular gland swelling
Summarize findings
Differentials
How do you assess fo r Cx LN
Show me where the subm andibular duct opens
W here w ill you feel fo r stone
Investigations? M ention XR fo r radio-opaque stones
Management?
Conservative - w hat foods increase saliva production

9) Examination - Abdom inal pain (cholecystitis)

SP - RHC pain w ith positive m urphy's sign
 Summarize findings
Investigations?
How to confirm dx? US HBS
Management?
W hat if patient gets better w ith o u t surgery, but LFT still deranged? Check Hep panel

10) Skills - Ordering OT list

a. Cases:
i. Strangulated hernia, COPD, pacemaker
ii. Debridem ent o f fo o t gangrene, DM, MRSA
iii. Hartman's procedure, iodine/penicillin allergy
b. Discussion on diatherm y for patients w ith pacemaker
c. COPD patient: w hat considerations, why?

11) Skills - Suturing thigh laceration w ith instrum ent tie

Consent done, LA given, draped, nurse to assist
Choose non-absorbable suture - Ethilon vs vicryl (choose ethilon)
Patient w ill ask:
How many stitches w ill I have?
Is it going to be painful later?
When can remove?
Anything to take note?

Questions:
W hat LA?
W hy lignocaine vs other LA?
Lignocaine safe dose - lignocaine only, w ith adrenaline
Bupivacaine safe dose

12) History - Pre-op SOB

Same as previous years

13) H is to ry -A b d o m in a l pain (pancreatitis)

History: Epigastric pain radiating to back, started yesterday afte r 20 cans o f beer,
vom ited x 5
W hat investigation w ill you do to confirm your diagnosis?
W hat are the other most im portant investigation you w ill do? (badly phrased qn)
(Did not reach management)

14) Comm unication - Update ITU registrar, secure ICU bed (peritonitis)
Stem: Read notes, COPD patient adm itted fo r abdo pain, became peritonitic in ward,
arrange ITU bed and ask reg for advice
Notes: M etabolic acidosis, septic
Did you do ECG/What is the UOP? No - not done, do not lie

15) Comm unication - AOR (splenic rupture)

 Exactly same as previous years - see accounts

16) Critical care - Burns and ARDS

Stem: patient brought in afte r suffering burns - noted signs o f inhalational burns
Painful - w hat type of burn is this?
TBSA shaded - calculate burnt area, w hat rule is this? Include perineal burn
Airw ay burns - how to manage? W ill you do ETT? W hat o ther features do you look
for?
How to manage circulation? How to calculate fluid replacement?
W hat type of fluid?
CXR-ARDS
Features o f ARDS? Name 6
M anagement? Type o f ventillation

17) Critical care - Hypothyroidism

Name 6 symptoms o f hypothyroidism
Name 4 causes o f hypothyroidism : autoim m une, iatrogenic, pituitary, iodine
deficiency
Explain the control o f thyroid horm one synthesis
Indications for surgery
Complication o f surgery
Explain the symptoms o f d ifferent types o f recurrent laryngeal nerve injury
How will u manage a such patient w ith bilateral incom plete injury
TFT shown: TSH high, T4 low - is this a pituitary cause? Why?
FBC shown: MCHC anemia - cause?

18) Critical care - Perforated viscus w ith AF

W hat is the first thing you look for on CXR and ECG? Looking fo r 2 identifiers
CXR - free air under diaphragm. Why?
Causes o f air under diaphragm?
ECG - AF
W hat rhythm is this? Why?
Calculate the rate
BP machine says different HR than w hat you calculated. Why? Pulse pressure
Constituents o f cardiac output
A n a to m y

Heart and lungs.

1. Identify the structures - right ventricle, pulm onary valve, le ft ventricle, right atrial
appendage.

2. Identify pulm onary valve, where do you auscultate fo r it?

3. W hat does the pulm onary trun k divide into?

4. W hat is the most anterior structure on the lung hilar?
5. Identify the pulm onary veins? Identify the ligament attached to the lung and name it

6. The man was stabbed beneath the xiphisternum , w hat structure m ight be injured?
7. W here does the liver extend to on the left?
8. Identify the quadrate lobe and w hat are its boundaries?
 9. W hat is the venous drainage o f the liver?
10. How does the phrenic nerve innervate the diaphragm?
11. W here is the pain fe lt in a le ft subdiaphragmatic abscess and why?

Spine
1. Name th e parts of the vertebrae

2. How do spinal nerves exit the vertebrae?

3. Show me how 2 vertebraes articulate w ith each other
4. W hat are the joints between the vertebraes
5. W hat jo in t is the intervertebral-disc jo in t
6. Describe the intervertebral disc
7. Point out intervertebral disc on MRI
8. Explain pathophysiology o f PID
9. W hat happens to the intervertebral disc when we age
10. W hat happens in a posterior-lateral herniation at L4/5, which nerve is affected?
11. Show me the L5 derm atom e
12. W here does the spinal cord end in an a d u lt/ child
13. W here do you perform a lum bar puncture?
14. W hat is in the epidural space afte r L4
 15. How does a patient w ith cauda equina present?
16. W hat is in the extra dural (or epidural) space?
17. How do spinal metastasis occur?
18. W hich cancers spread to th e spine?

Cranium
1. W here is the superior sagittal sinus/parietooccipital fissure/corpus calleosum /lateral
ve n tricle /fo u rth ventricle on this MRI scan?

2. W hat is the likely diagnosis?

3. W hich 2 structures are compressed?
4. How does the superior sagittal sinus drain into the IJV?
5. W hich gyrus does the prim ary m otor cortex occupy?
6. W hat neurological deficits w ill the patient have if his prim ary m otor cortex is
affected in this location?
7. W here is the straight sinus located?
8. W hat contributes the most to the straight sinus
9. W hat contributes the most to the dura venous sinuses
10. Show me the path on the skull where the IJV exits
11. W hat exits w ith the IJV in the jugular foram en

Pathology

23 year old lady returns from Bangladesh w ith an anterior neck swelling
1. Differentials?
2. Giant cell etc in the pathology report, w hat is the likely differential
3. W hat is a giant cell?
4. How do you w ant to label the specimen?
5. W hat category o f biohazard is this?
6. W ho do you w ant to inform?
 7. How do you perform contact tracing?
8. W hat are 2 serology tests th a t you can do to confirm the diagnosis
9. W hat stain do you use to diagnose TB?
10. How long does the culture take
11. W hat are 3 other causes o f giant cells in a lymph node
12. W hat is the proteinaceous substance th a t can be found systemically in tuberculosis?
13. W hat other mycobacterium is involved in im m unocom prom ised patients?

Adult polycystic kidney disease w ith polycystic liver

1. W hat is the cause o f renal failure in polycystic kidney disease
2. W hat is the inheritance pattern
3. How do you match the transplanted kidney to the recipient
4. W hat do you do if the kidney is not a com plete match
5. W hat are the types of rejection
6. Patient now develops cholangitis features, w hat are his predisposing factors (name
3)
7. W hat is the pathophysiology o f cholangitis
8. W hat w ill you see on the histology report

Surgical Science and Critical Care

Biker involved in a bike v bike accident (40km /h), currently BP 100/70, SP02 95% on 15L
1. How will you assess the patient? W hat are the components o f the prim ary survey?
2. W hat w ill you assess breathing?
3. RR 16 per m inute, shallow breathe sounds. W hat investigation do you want?
4. Inte rpret ABG. p02 low pC02 high.
5. W hat investigation do you w ant to do?
6. C-spine x-ray shown. W hat do you see? Fractured C3 w ith loss o f spinal alignment.
7. How does this co-relate w ith your clinical findings? Phrenic nerve innervates
diaphragm etc.
8. W hat investigation do you w ant to do?
9. W hat can you do in the ED?
10. So you've called neurosurgery, w ho else do you w ant to call?
11. W hat do you w ant to tell the relatives?
12. W hat do you w ant to do under neurosurgery arrives?
13. W hat is the prognosis like?

Diabetes. Blood sugar level o f 16m m ol/l

1. W hat are the types of diabetes th a t you know and how are they different?
2. W hat Preoperative and postoperative concerns m ight you have?
3. The patient's surgery has been delayed by 4 hours, w hat do you w ant to do?
4. W hat pre operative investigations do you w ant to do in a patient w ith diabetes
5. W hat Preoperative orders would you w rite?
6. In w hat patients do you start variable insulin?
7. W hat hormones control glucose
8. How does insulin work?
9. How does glucagon work?
 10. W h o else w o u ld yo u lik e to in v o lv e in th e care o f th is p a tie n t?

Hypothyroidism w ith large unsightly goitre

1. Describe how thyro id horm one is regulated
2. W hat are the causes o f hypothyroidism
3. Shown macrocytic anemia, w hat is the likely cause o f her hypothyroidism
4. W hat are the signs and symptoms o f hypothyroidism
5. W hat investigations w ould you do
6. W hat are the risks o f thyroid surgery
7. W hat are the signs o f hypocalcemia
8. W hat are the signs o f RLN injury
9. W hat can you do fo r the patient w ith post thyroidectom y RLN injury

Procedural skills
1. Excision o f nevus
Questions from patient. Is this cancer? When do I have to remove the stitches? Can I
shower? W ill this hurt/leave a scar?

2. OT listing, the usual 3

Questions (new ones)
a) W hat antibiotics can you use fo r MRSA? (Offered vane, tige, dapto, Bactrim but
did not get it right)
b) W here w ill you place the diatherm y patch
c) Offered GA fo r patient on w arfarin fo r BKA as he is not a candidate for spina
anaesthesia in view o f risk o f hematoma fo rm a tio n —any other option for
anaesthesia?
d) W ill you bowel prep a diverticular abscess?

Communication skills

Referring to vascular surgery fo r acute lim b ischemia b/g adm itted fo r diverticulitis
SBAR. Remember to tell the surgeon the relevant exam ination findings (cold pulseless lim b
w ith sensory loss, doppler no waveform ) and lab results (m etabolic acidosis from lactic
acidosis, acute kidney injury, raised CRP, anemia, TW w ith neutrophil predominance) and
ECG (new AF)
Questions:
a) W hat are your differentials (DVT and ALI according to FY2 w ho saw the patient)
b) Is there evidence o f chronic lim b ischemia (no patient only has HTN as PMH)
c) Do you w ant to make a cardiology referral?
d) W hat are the ways to revascularize
e) Is there benefit in doing ultrasound doppler o f the abdomen
f) Is there a role fo r low er limb angiogram
g) Tell me m ore about intravenous thrombolysis
h) Is there a role for th a t in this patient?
i) Why is the calf swollen?
j) W hat are you concerned about afte r revascularization
k) How do you trea t com partm ent syndrome?
Gentleman whose meniscal op was cancelled again. Also the clinical notes m entioned that
patient has been gaining weight and it has cause worsening knee pain
His concerns
1. W ill my op be cancelled again? Cancelled previously because o f staff shortage
2. NSAIDS causing gastritis
3. Afraid th a t he m ight lose his jo b
4. W eight gain - w ill refer dietician and suggested low im pact sports
5. Patient is hungry as he has been fasting
6. W ill you promise me that it w ill not happen again?

Physical examination

Ankle exam ination - lateral mallelous fracture

1. Differentials
2. W hat investigations w ill you do
3. How will you manage
4. W hat advice w ill you give him?
5. W hen w ill you see him again and w hat investigations w ill you do then?
6. If you w ant to give him 1 crutch, do you place it on the left or right?

COPD
1. W ill you perform laproscopic repair in this patient?
2. W hat must you tell him about when you counsel him fo r surgery - risk o f recurrence
3. W hat investigations w ill you do pre operatively
4. How will you optim ize him preoperative aside from asking the respiratory physicians
to see him.

Lipoma (a little birdie said th a t the LN should be examined, but I am not sure how to on the
trunk)
1. Differentials, why and why not
2. Investigation
3. Surgical indications
4. Patient managed conservatively, but now comes back w ith red hot angry lump, what
do you w ant to ask him?
5. W hat has happened? W hat are your differentials?
6. How will you managed?

Thyroid - solitary thyroid nodule, clinically euthyroid

1. Differentials
2. Investigation
3. W hat surgery can you offe r her at this point in tim e (no TFT results or FNAC results)
4. Managed conservatively, subsequently has complaints of airway compromise, what
do you w ant to ask her?
5. Risks o f thyroidectom y
6. How do you replace thyroid hormones?
History taking

BPH
LUTS x 2 years, worse in last 2 m onths
1. Differentials
2. Investigations
3. How can you obtain histology
4. W hat medications can you use?
5. How does pseudoephedrine worsen the LUTS

Seizure
Headache fo r 2 m onths w ith red flags (worse in the morning, developed weakness in the
last 2 weeks). First seizure.
Pre ictal: headache as above
Ictal: GTC witnessed by colleagues
Post ictal: Felt fine, no drowsiness or worsening neurological deficits
Adm itted to hospital 24 hours ago, was told th a t it looked sinister on CT brain, started on
Keppra and steroids
1. Differentials
2. Investigations
3. Management

That's all folks!

I .V a ric o s e ve in s : It w a s m y firs t s ta tio n ,the D o p p le r d id n ’t w o rk ,a n d ran o u t o f tim e
2 .In c is io n a l h e rn ia A b d o m e n ;E a s y c a s e ,n o th in g new .
3 .O b s tru c tiv e J a u n d ic e : E a s y q u e s tio n s
4 .T e n s io n p n e u m o th o ra x a nd fla il c h e st: x ra ys and m a n a g e m e n t and o th e r q u e s tio n s
5 .O p e n fra c tu re b o th b o n e s leg and v a s c u la r in ju ry :C a ll tra u m a c o n s u lta n t:re p e a t
6 .H is to ry ta k in g :K n e e Pain ;n o th in g new .
7 .H is to ry ta k in g im p o te n c e
8 .A n a to m y P ic tu re s :T h o ra x :H e a rt,a z y g o u s v e in s ,
9 .A n a to m y P ictu re s: L o w e r lim b s :m u s c le s ,n e rv e s .a rte rie s
1 0 .H ead a nd n e c k a n a to m y :re la te d to to n g u e s ,IC A ,C C A ,E C A ,C ra n ia l n e rve s.
I I .N a s o p h a ry n g e a l c a rc in o m a
1 2 .M a lig n a n t m e la n o m a : 2 w e ird q u e s tio n s a b o u t im m u n o h is to c h e m is try
1 3 .C le a n w o u n d :s u tu rin g ;d o n ’t s p e a k u p ,ju st d e m o s tra te .b e c a re fu l a b o u t d is p o s a l o f w a ste
a fte r fin is h in g p ro c e d u re s
1 4 .O T list: q u e s tio n s a b o u t d ia th e rm y in p a c e m a k e r,d ia b e tie s p e rip h e ra tive
m a n a g e m e n t,a rra n g in g lists: ru d e e x a m in e r lol
1 5 .R u p tu re d s p le e n in c h ild ,m o th e r a n x io u s w a itin g o u ts id e o t I
16.A n a s to m o tic le a k w ith A tria l fib rilla tio n E C G -C C risp
1 7 .B ila te ra l s u b a m in d ib u la r g la n d s w e llin g e xa m in a tio n
1 8 .C a n t’ re m e m b e r th e last one.

T h a n k yo u e v e ry o n e ,this site re a lly h e lp e d .D e d ic a te d to all th e h e ro e s w h o fe ll and rose

a g a in !!!!
A fte r all, life is a n e v e r e n d in g b a ttle :)
L u c k ily ,i p a sse d

A L L T H E B E S T !!!
Stations

1. Preparation for next station - read through notes of gent who has malignant
cells in his peritoneal fluid. Wife is apparently angry as she has not been
spoken to. Also CT scanner is broken so would need to be transferred away
(nearest hospital with working CT is 2 hour away) for staging scan
2. REPEAT Communication station using notes from before. Basically tell her
it’s malignant but she was aware it is cancer. Not angry, mainly upset.
Surprisingly easy station. Just stay calm and say we don’t know where the
cancer has come from. Relative was very easy to talk to once you were
honest and apologetic
3. REPEAT Anatomy station - neck - triangles, contents, identify important
nerves and vessels
4. REPEAT - pathology station. Given blood gases and blood results. Take 2
mins to read them as they are dated as well. Then a complete repeat
station on gastric outlet obstruction and causes for electrolyte disturbances
and paradoxical aciduria.
5. NEW - history station, patient with headache and meningism but no fever.
Mention SAH In DDx and don’t exclude meningitis. Discussion on
management and investigations
6. REPEAT - pathology station. Given report on patient with lesion on face,
found to be squamous cell cancer. Discussion on investigations and
management, including staging and grading. Then given report on same
patient with neck swelling stating no evidence of carcinoma but had cells
with owl eye appearance. Said HL is a possibility and examiner happy
7. REPEAT - anatomy station, base of skull and foramina above and below
8. REPEAT - skills station - l&D. Assistant v unhelpful but got through it. Didn’t
finish but discussed what I would do to finish. And discussion on LA doses
9. REPEAT - anatomy station, femoral triangle and contents, borders. What
runs through the adductor canal and boundaries (also asked for nerve to
vastus as one of the content- almost forgot but said as bell rang). Also
angiogram of lower limb vessels and told to identify
10. NEW - pathology station - weird station on pancreatitis. Asked some weird
qs on pancreatitis, patient had gallbladder removed a few months(?) ago
and developed pain. Causes, investigation and management. W as quite a
strange examiner and all of us on that circuit complained about this
examiner afterwards
11. NEW(?) - management of trauma case. Given CXR (small pneumothorax)
and ATLS principles tested in full
12. REPEAT - communication station. Discuss with consultant about patient
who wants to self discharge post mastectomy and loads of blood on drain
and things I would do to mitigate risk if he does - mention contact other
hospital A&E and other surgical team
13. REPEAT - examination of abdomen - non critical so simple abdo exam in
female patient young. Mention UPT for investigations amongst the usual
things. Offer appendicitis, ectopic etc. Barn door
14. NEW - examination station - strange station with spiel saying patient has
clarification pain but ABPI done by GP was normal. I did lower limb and
spine exam focussed as inside there was equipment for a neuro exam. I
also felt the pulses and noted patient had lost hair. Make sure to say I can’t
 rule out vascular disease. Spinal claudication also offered as diagnosis and
examiners seemed ok
15. REPEAT - examination station - this was a repeat of the post varicose vein
stripping foot drop station that is prevalent in the past stations. Do a lower
limb exam and gait and find the drop
16. REPEAT - examination station - ALS/CCRISP exam. Look at patient notes
before starting because the examiner tells you to. He was quite arsey but
once you picked up and do your A-E he calms down a bit. Patient was very
unhelpful Imao. He was septic post left hemi I think. Offer anastomotic leak
for your differential for the examiner to chill out a bit
17. REPEAT - suturing and discussion of dosage of LA
18. REPEAT - history station. Impotence from last year. Threw a few people off
last year but having revised this, was a simple history. Ask vascular,
neurological, urological and psychological qs and drug history too. Turns
out patient has been stressed at work and wife does not have time for him
either.

Reflection:

It’s a fair exam. Only one of my examiners was weird, everyone else was quite good
at just moving on or going back to questions I didn’t get.
1. Anatom y o f the M iddle ear
Borders and boundaries
Nerve passing through it
Spread to the brain
Mastoid cavity known as
Location on the skull on a superior view
Foramen R otundum / spinosum / SOF
Cavernous sinus boundaries and contents
Cavernous sinus throm bosis
Papillodema and cause and significance in raised ICP
2. X ray o f the cervical spine
Ligaments attached at the dens
Key features
Typical and atypical Cervical vertebra
Hyoid bone
Features on a lateral view o f a cervical X ray
C3 / C6 levels and structures
3. Anatom y o f the neck and thorax
Nerve lateral to trachea - RLN/ Phrenic ?
Features?
Nerve at the carotid bifurcation
W hat if u tie the facial artery ?
Some basic questions on trachea and oesophagus
4. Communication - Call a cons on call about a patient post mastectomy and blood in drain whose
daughter wants to take home and discuss plan o f action. Go through the notes and discuss the
plan fo r the same.
5. Anxious patient w ith old M itral valve repair on warfarin and due fo r a hernia repair wants to
know if he should stop warfarin and if so how. Also doesn't w ant to take injections and have to
counsel him. Post op management scenario to be explained to him
6. Knee pain history taking. Had a history o f old injury to the knee and some surgery several years
ago. O steoarthritis knee.
7. Abdomen examination fo r RIF pain
8. Thyroid exam ination - lump in the neck and questions regarding the diagnosis and management
9. Knee jo in t examination - acute trauma, very tender knee, barely moving it o r allowing to.
Couldn't stand or move his knees. Very tender on medial side. Could barely do any examination
and some questions on possible causes and management.
10. CVS examination w ith ESM (MR) and questions on that
Asked if he has Heart failure. I said I d id n 't find any basal crepts
Questions on physiology o f it
Is due fo r surgery in a week and has to go on a cruise in a month. Advise on the same
11. Shock station w ith tibia and fem ur fracture and basic questions
 Some questions were dodgy
Abdominal com partm ent syndrome and features
Narrow MAP and cause fo r it ?
12. GOO station and discussion on causes o f it and the various biochemical abnormalities
13. A ortic Stenosis w ith ECG given. Questions on the pathophysiology o f the same.
14. Gall stone pancreatitis after an old cholecystectomy and management questions.
Splenic artery aneurysm
Pseudocyst
Lab tests and causes
15. Knot tying - standard knot, deep knot and Z knot
16. Abscess drainage and questions on LA dosing
17. Knee pain since 2 days. Old history o f im plant fo r upper tibia fracture. Septic arthritis and
osteom yelitis o f the bone questions
18. Diarrohea history taking and questions related to that.

W here I struggled -

1. Completing my examinations. Learn to tim e yourself better than I did

2. Read up on the head and neck anatomy well
3. Practice knot tying
4. Answer to the point
5. How you do at a station also depends on the examiner's a ttitude on th a t station, especially the
ones involving VIVA questions. Some are cordial and genuinely try and help and guide you if you
deviate. A couple were iffy, o f which one was dow nright unpleasant even. Don't bother much
about them as they are like th at to almost everyone in the exam generally.
Station 1 - HPE axis - Usual questions. Asked about all the adrenal hormones
effects.
Station 2 - Pain management station. Asked to read a drug chart. Outside info said
about a situation where patient was immediate post op had pain and tachycardia but
all systems are normal.
Station 3 - Nutrition and feeding. Shown X-Rays with NG tubes. Usual questions.
Station 4 - Carcinoid tumor and pin worm haha. Questions about NET’S and
psudomembranous colitis.
Station 5 - Communication - Repeated station - Diverticulitis patient with
thromboembolism of leg. Discuss with vascular surgeon.
Station 6 - History - Diarrhoea - IBD
Station 7 - Skills - Abscess drainage.
Station 8 - Hyperparathyroidism and kidney stones
Station 9 - History - Hyperthyroidism with neck mass
Station 10 - Anatomy - Popliteal fossa
Station 11 - Base of skull - Tricky station i felt.
Station 12 - Nevus excision with suturing.
Station 13 - Exam - Common peroneal nerve injury
Station 14 - Exam - CVS exam c pacemaker
Station 15 - Exam - Thyroid swelling
Station 16 - Exam - Multiple swellings over thunk
Station 17 - Communication - Angry patient; cancelled procedure. He wasn't really
that angry lol.
Station 18 - Anatomy - Thyroid.
Day 2

P a r ti

1. Pathology - patient 23yo, comes back fo r Bangladesh now w ith anterior neck swelling. History
o f night sweats part 3 weeks
a. Differentials?
b. Investigations to confirm
c. If lymphoma, likely w hat type?
2. Parotid gland
a. Boundaries o f parotid gland
b. Stensen's duct surface anatomy
c. On plastinated model: point to stensens duct, and branches o f the facial nerve
d. D ifferential diagnosis o f parotid swelling
e. M ost common parotid cancer
f. Lymphatic drainage o f parotid
g. Line which denotes drainage o f
3. Lower limb anatomy
a. W here is lateral malleolus
b. W here to palpate posterior tibial artery and dorsalis pedis
c. Attachm ents o f peroneus longus and brevis
d. Effect o f tibialis posterior and anterior contracting together, show the movement
e. Effect o f peroneus longus and brevis contracting together, show the movem ent
f. Muscles in posterior com partm ent
g. Nerves suppling each com partm ent
h. Dermatomes o f SI
i. D istribution o f sural/saphenous nerve
4. Thoracic and abdominal anatomy
a. Show pulm onary trunk
b. W hat is this structure? And branches (possibly aorta)
c. Behind the heart and points to hemiazygos vein - tributaries?
d. splenic artery and branches
e.
5. Pathology - patient w ith HTN, DM, smoker, w ith baretts esophagus and noted cancer
a. W hat type o f cancer this patient likely has?
b. Given TNM staging and diagram o f tum our invasion - stage this tum our
c. Now patient underw ent resection but came back w ith supraclavicular lymph node -
w hat test w ill you do
d. W hat cytological features will this patient likely have
e. Now patient developed pleural effusion - w hat tests to show diagnosis
f. W hat test to differentiate epithelial and gastrointestinal tum our
6. Hypotherm ia - patient w ith perforated viscus. Background COPD and hypertension. Given obs
chart w ith hypotherm ia and tachycardia, normotensive. W eight 51kg
a. Definition o f hypothermia
 b. How to measure tem perature
c. W hat patient risk factors to have hypothermia
d. How to treat hypothermia
e. Complications o f hypotherm ia
7. Post-op oliguria - patient post hem iarthroplasty fo r NOF - uneventful, minimal blood loss -
inform ed by nurse, patient SOB, tacypneic. Examination creps lungs
a. Given fluid b a la n c e -c o m m e n t
b. Obs chart - com m ent on obs at 2000. Shows hypertension, some tachycardia
c. C X R -flu id overload
d. W hat investigations w ill you do
e. Management
8. Cortisol - patient has RA on pred. planned fo r surgery
a. Tell me about HPA axis
b. Functions o f cortisol
c. How significant dose is cortisol to be considered for replacement?
9. Suturing - patient w ith laceration wound, cleaned - pick non-absorbable suture and perform
w ith instrum ent tie
a. Need antibiotics?
b. W hat local anaesthetic needed? How much dose?
10. Incision and drainage o f abscess
a. W hat to do after draining abscess?
b. W hat dressing?
c. If excessive exudate in dressing?
d. How do you plan yo ur incision?

part 2

1. Examination hand - you are called to dialysis centre to attend to a patient w ith hand pain and
coldness
a. Doppler provided
b. Differential?
2. Examination - CVS - patient planned fo r hernia repair - w hat considerations
a. Had median sternotom y scar - supposedly w ith metallic click - w hat considerations?
b. Patient on warfarin and then given INR levels - management?
3. Examination - inguinal hernia
a. Difference fem oral and inguinal hernia
b. Is this indirect or direct?
c. Any scars noticed on examination? Had laparoscopic scar - previous repair - what
w ould you recommend then?
4. Examination - ear - patient fell from horse, now hearing difficulty
a. CN8 + 7 - le ft whisper negative, le ft rinne positive. Otoscope provided - shows
haemotympanum
b. Differential?
 c. Investigations?
d. Management?
5. R eadin g -so n had splenic rupture
6. Attend to m other anxious about son
a. Father shouldn't have custody - how to deal?
b. Post-splenectomy prevention
7. History - inform ed by nurses patient confused - not sure if can take consent - assess
a. Any scores to assess mental state? W hat is the cutoff?
b. How to investigate?
c. Management?
8. Reading - patient h it and run w ith unconscious period; no ED notes; had le ft tib /fib fracture;
right metacarpal fracture; ultrasound abdomen showed fluid in le ft paracolic gutter
9. Call consultant regarding plan
10. H is to ry -c h ro n ic diarrhea, streak blood, some paleness; polyarticular; m outh ulcers
a. Investigations fo r IBD?
b. Management?
1.History s ta tio n l - Back Pain, CES essential

2.Hx Station 2 - U rinary frequency - BPH, but also DD w ith CA

3.Clinical Skills Station - Excission o f naevus

4 .Clinical Skills Station - O perative list order

-A guy w ith strangulated hernia w ith significant com orbidities

-sb fo r Hartmans due to abscess and pacemaker

-BKA - Insulindepndent d ia b e tic , A f and cardiaccom orbidities

5.Pathology - General m alignancy cytology histology and grading system C l-5

6 .Pathology -Jaundice

7.Pathology Sq Cell Ca - W ith unclear m argins fu rth e r m anagem ent, frozen section

8.CNS cranial nerve exam ination - bitem poral haeminanopia

9 .Hand exam ination - CTS

10.Critical Care - A ppendicitis, exam A to E + abdom inal exam w asn't very clear, n o t really helpful
exam iner. Not d e fin ite CCriSp station but yeah finally AP. Approach managem ent and w h a t if it starts
bleeding.

11.Critical Care - PE - look fo r calves as w ell :D, despite the obvious diagnosis D8 post surgery,
Investigations, bloods, m anagem ent

12.ATLS scenario - Head injury and basically just ta lk through w hat are you doing. Epidural
haem atom a etc.

13.Critical care - Septic patient perforation, AF on ecg m anagem ent o f AF, read and XR. Cardiac
physiology.

14.Anatom y - Skeleton(weird one) random questions fro m upper and low er lim b, asked fo r ro ta to r
cuff, nerves, insertion points, Pelvis, Lateral cutaneous nerve o f th e thigh and how th e entra p m e n t f
th a t nerve is called. Pelvic muscles.

15.Anatom y - A orta and abdom inal branches and correspondence to o th e r organs

16.Anatom y - Neck, triangles o f th e neck and innervation.

17.Consent fo r OGD

18.Discuss w ith ITU regarding a bed fo r a patient o f yours w ho is going fo r urgent laparotom y fo r
perfo ra tion .
Knowledge

1. A natom y - T rian gles o f the neck

2. A natom y - Ankle d issection + Tibia Fibula Ankle Foot bones
3. A natom y - P o sterior m ediastin um esp. o eso p h agu s

4. Pathology - N asoph aryn geal carcinom a

5. Pathology - D iverticulitis an d en d om etriosis
6. Pathology - O bstructive jaun dice
7. Critical Care - Burn and ARDS
8. Critical Care - Nutrition in patien t with im m ediate post-op with trach eostom y

Skills

Physical exam ination

9. V aricose vein
10. Scrotal lump (H ydrocoele)
11. CVS a sse ssm e n t (P acem aker)
12. H earing lo ss (+O toscope)

13. H istory taking o f Knee Pain (H /0 knee su rg e ry for sp o rts injury)

14. H istory taking o f Patient req u estin g for I&D o f groin a b sc e ss

15. Inform ation giving - Inform ing CS for self-d isch arge requ est
16. Inform ation giving - Anxious patient concerning an ticoagulation for MVR

17. P rocedural skill - Suturing lacerated w ound

18. P rocedural skill - I&D o f thigh a b sc e ss
Knowledge

1. A natom y - T rian gles o f the neck

- B ou n daries o f p o sterio r triangle
- Identify - Spinal acce sso ry nerve, how to test its action
- Omohyoid bellies and nerve su p ply
- M uscles attach ed to hyoid bon es and nerve su pply
- Extrinsic tongue m u scles and are their nerve su p p lies
- Identify - su b m an d ib u lar gland, secretion type, n erves a t risk o f d am age during
surgery, how to te st h y poglossal nerve action
- histological im age o f a lymph node with brow n sp o ts in cytoplasm o f so m e cells.
Frankly I d o n ’t know w hat it is. W hat do you think ab o u t the histology?

2. A natom y - Ankle d issection + Tibia Fibula Ankle Foot bones

- Identify all foot bones.
- A rticulate tibia, fibula and ankle joint
- Ligam en ts o f ankle
- D em on strated ankle join t m ovem ent on m yself
- Inversion and eversion - m u scles involved
- B on es a re involved in arch es o f foot?
- Joint betw een distal tibia and fibula - type. W hat injury occurs if it d isru p ts?
- M ajor p u lses in foot and how to p u lsate them
- A rterial arch es o f foot
- Identify ten don s in an terio r o f ankle joint

3. A natom y - P o sterior m ediastin um esp. o eso p h agu s

- B oun daries
- O esoph agus - su rface m arkings, epithelium , arterial supply, ven ous drainage,
lymph node drain age, ach alasia, B arre tt's o eso p h agu s, through which p art o f the
diaph ragm d o e s it exit the thorax.

4. Pathology - N asoph aryn geal carcinom a

- M iddle aged Chinese m ale with ulcer in nasopharynx, recently Chemo + RT
taken. DM +
- Risk factors for n asoph aryn geal carcinom a
- Define Carcinom a
- DDx.
- Other non-epithelial tu m ou rs
- If palpab le lymph node, how to a sse ss. Cytology Vs. H istology
- Scale o f Radiation dose
- If sw ab gro w s hyphae, w hat is it? M ost com m on fungal sp ecies. Risk factors.
5. Pathology - D iverticulitis an d en d om etriosis
- Lining 2 lay ers o f colon? C olum nar cell layer and ???
- Diverticular d isease, diverticulitis, en d o m etriosis
- O perated and tissu e sam p le sh o w s n eutroph ils - w hat d oes that m ean ? How
n eutrophils arrive h ere? Neutrophil life span
- W hat is a b sc e ss?
- How to m an age intra-abdom inal collection?
- How d o e s en d o m etrio sis occur?

6. Pathology - O bstructive jaun dice

- Classify jaundice. C auses
- Show n the invx. including LFT. Dx. How to classify OJ & cau ses
- Bile production p er day, com position, how bile em ulsify fats?, actions
- Why no urobilinogen in urine?
- E nterohepatic circulation, why bile sa lts recycled?
- How clotting is im p aired in OJ - K -dependent CFs., Liver function im paired

7. Critical Care - Burn and ARDS

- TBSA sh aded. Calculate burnt area. Likely 6 3 % by rule o f nines. Not to take
account o f perin eal burn.
- T ype o f burn. Depth.
- Only n asal burn (I think) m entioned in scen ario. Airw ay m anagem ent. Will you
do ETT? Why? W hat o th er featu res to look for?
- Fluid m an agem en t - in terrupted after d escribin g Parkland form ula and division
o ver First 8 hr and next 16 hr. No need to calculate. Type o f fluid.
- CXR - ARDS, F eatu res o f ARDS, How to rule out card iac cau se?
- Mx. Type o f ventilation. PEEP mode.

8. Critical Care - Nutrition in patien t with im m ediate post-op with trach eostom y
- p ro blem s with trach eostom y?
- ty p es o f nutrition, en teral Vs. paren teral, w hat type for this patient
- Indication for paten teral
- How to confirm NG tube is in stom ach ? CXR show n and tube in Rt low er lungs -
how to do?. Again an oth er CXR with tube under left dom e o f diaph ragm - correct
position. NG Vs. Nj.
- Com ponents o f nutrition.
- If NG feeding, p ro blem s o f m alabsorption. How to a s s e s s the problem ?
Skills

Physical exam ination

9. V aricose vein
- M iddle aged lady. Problem is th at the long p an ts is not to be taken off and
difficulty in ex p o sin g groin. T ournique w as broken in so m e late candidates.
Hand-held d o p p ler provided.
- Dx., Points for Dx., T reatm en t options.

10. Scrotal lump (H ydrocoele)

- Pipes and torch provided.
- DDx., T yp es o f hydrocoele. W hat type for him?
- T ypes o f surgery.
- If the patient is 20 y r old, will you do Jabouley?

11. CVS a sse ssm e n t (P acem aker)

- Pre-op a sse ssm e n t. Recently im planted pacem aker.
- ECG show n
- Indication for pacem aker
- P roblem s with diatherm y
- W hat com plication s in this patien t? How to a s s e s s th is?

12. H earing lo ss (Tuning fork + 0 to sc o p e )

- H/O drinking, head injury an d hearing loss.
- Show how to handle otoscope, pull ear, Picture o f oto scop y given.
- Dx., C auses, Type o f hearing loss. Treatm ent.
- Does h aem otym pan um h as good p ro g n o sis?

13. H istory taking o f Knee Pain (H /0 knee su rgery for sp o rts injury)
- Points for Dx., T reatm en t

14. H istory taking o f Patient req u estin g for I&D o f groin a b sc e ss

- ODD station, p atien t said to be referred by GP to I&D at hospital, b y p assed
Em ergency an d arrived at surgical dept., req u estin g for I&D im m ediately.
- Took h istory o f a b sc e ss and he said he is registered dru g user. He m entioned it
looks like pulsating. A sked w hat can it be?
- Explained it can be a p seu d oan eurysm .
- Inform ation giving ab o u t the condition and calm ed dow n patient. Risks.
- W hat is p seu d o an eu ry sm ? Can you do I&D. Com plications. Risks. Rx.

15. Inform ation giving - Inform ing CS for self-d isch arge requ est
- P ost o f m astectom y pt. p ersu ad e d by d au gh ter to go hom e in stead o f dyspnoea,
puffy axilla and in creased drain. R egistrar cou n selled and pt. still refused to stay.
- Issu e s - pt. capacity to decide, dyspnoea, in creased drain, com m ents on current
condition, invx., Rx., plan after going home, GP contact.
- W hat problem s with goin g hom e?
16. Inform ation giving - Anxious patient concerning an ticoagulation for MVR
- Blind, MVR, recurren t hernia for rep air
- Why w arfarin taking, when to stop, why to stop, how to m anage, how it is safe
to change to heparin, SE s o f heparin, a sk concerns.

17. P rocedural skill - Suturing lacerated w ound

- Suturing on foam . N on -absorbable sim ple interrupted. A lready cleaned &
draped. LA given. Ju st to talk, ch o o se suture, glove and sutu re. N urse will d ress.
- T e st LA, num ber o f stitches, sc a r form ation, m edication after procedure.

18. P rocedural skill - I&D o f thigh a b sc e ss

- Rush station. R eq uest X-ray. Distal n eu ro v ascu lar statu s. Consent form check.
- P repare tray, culture cotton buds, calculate LA dose. Clean, d rap e and LA inject.
- Need to put blade on handle by forceps.
- Difficult to e x p re ss out all the fluid. It cam e out again and again. Break septa.
- D ispose sh arp s. O thers a s usual.

Personal E xperiences

• New q u estio n s every y ear

• O verlapping statio n s like h istory+exam in ation o r h istory+com m un ication skills
• Exam ination - patien ts so m etim es not a p p e a r a s in practice before, not to panic,
check all the p ro p s given
• Procedural sk ills - scen ario s and settin g s m ay vary. May need to only do the
operation o r do all the pre- and post- procedu res.
• Inform ation taking - alw ay s ask Concerns and solve.
• Com m unication sk ills - sh ow em path y and act accordingly.
• Practice, Practice & Practice
• For skill statio n s - never m iss the ste p s an d outline. P repare for 3 min questions.
S ta tion (1) E xam ination
• C V S exa m fo r p re-op ch o le cyste cto m y
• P a tien t has m edian s te rn o to m y and pa ce m a ke r insertion sca r on th e left
• M e ta llic heart so un d aud ible
• E C G - pacing spikes w ith le ft bundle branch block.
• W h y w as p a c e m a k e r in se rte d ? M o st probably, he d e velop ed heart block a fte r ca rd ia c
surgery.
• R e asons fo r and a g a in st ch o le c yste cto m y in this patient.
• P recaution s fo r p a c e m a k e r in tra o p e ra tiv e ^ - use bipolar electrodes, p a ce m a ke r check
by e le ctro p h ysio lo g ist p reo pe ra tively, e quipm en ts a va ila b le fo r intra-op in case
pa ce m a ke r dysfunction.

S ta tion (2) E xam ination

• Lipom a
• 35 y e a r old lady has lum p on the back - a b o u t 6-7 cm in d ia m e te r
• W h a t is y o u r d ia g n o sis? Lipom a
• D ifferen tials, and h ow w o u ld you distin g u ish ? F u rth e r in vestigatio ns?
• M an a ge m e n t?

S ta tion (3) E xam ination

• H earing test a fte r fall
• P a tien t has con d u ctive hearing loss on the left
• O to s c o p y - show ed h ae m o tym pa num picture
• S igns o f basal skull fracture
• M a na ge m e n t

S ta tion (4) E xam ination

• H and exam - arterial
• P a tien t in dialysis unit com p la in s o f cold painful arm
• A rm not p ainful a t the m om ent, but having night pains
• F istula visible on the arm affected
• Is the fistula used a ctively?
• W h e n w ill fistu la be no lo ng e r u sed? P eritoneal d ialysis and renal tra n sp la n t
• D o p p le r a va ila ble inside station

S ta tion (5) A n ato m y

• T h o ra x a nd a b do m e n
• H eart a n a to m y - pa pillary m u scles and ch o rd a e ten d in e a e and functions
• Ide ntify azygos vein. W h a t a re its tributaries?
• Ide ntify pu lm o n a ry trunk, lung h ila r anatom y
• S u rfa ce la n d m a rk fo r g a llb la d d e r - m u st in clude lateral m argin o f rectus a bdom inis
• Ide ntify spleen. W h a t ribs c o ve r spleen? 9 -1 1th ribs
• S p le n ic a rte ry a n a to m y and su pplies - pancreas, stom ach
S ta tion (6) A n ato m y
• A n te rio r thigh
• B u tch e r injured h im self w h ile cutting, in ju ry - 1 0 cm long cu t parallel to inguinal ligam ent,
10 cm b e low inguinal lig a m en t
• W h a t are bo u n d a rie s o f fe m o ra l tria n g le ? C ontents?
• W h a t stru ctu re s w ould be injured by the cut? A rte rie s, veins, nerves, m uscles
• F em oral sheath, fem oral canal
• M uscles su p p lie d by fe m o ra l nerve
• W h a t p asse s th ro u gh a d d u c to r canal?
• S a ph e n o u s nerve anato m y, and se n so ry area

S ta tion (7) A n ato m y

• C ranium a natom y
• S h o w ed frontal p rojection o f a n giog ra m - m iddle cerebral artery aneurysm
• W h a t w ill h a ppen if it ru p tu re s? SAH
• S igns and sym p to m s if th e a n e u rysm ru ptures?
• Ide ntify o th e r b ran ch e s in the a ngiogram (show ed picture)
• S h o w carotid ca n a l on skull bone - both inside and outside view
• W h a t su p plie s brain o th e r than carotid artery? V ertebral arteries
• W h a t is the c o u rs e o f ve rte bral arteries?
• E xa m in e r g a ve a tla s (C 1 ) bone and asked to dem o n stra te passage o f ve rte b ra l artery

S ta tion (8) P ath olo g y

• T hyroid , co ag u la tion cascade
• P a tien t p resents w ith neck lum p and la te r found to have h a em atom a o f neck
• F N A C vs core b iop sy - pros and cons
• M e ch an ism o f c a n c e r ce lls spread to lym ph node
• T u m o u r erodin g internal ca ro tid artery
• W h a t is IN R ? W h a t is it used for?
• W h a t o th e r te sts fo r b leeding?

S ta tion (9) P ath olo g y

• B asal cell ca rcinom a
• S h o w ed a picture - d e scrib e the lesion
• D iffe re ntia ls fo r the lesion show n
• M e ch an ism o f c a n c e r ce lls spread to lym ph node (yes, sam e question w ith prev station)
• M a n a g e m e n t for basal cell carcinom a
• A fte r excision, p a tie n t com es back w ith yellow ish d isch a rg e from the w ound
• W h a t is h a pp e nin g ? W ound infection
• W o u n d sw a b sho w e d E coli. W h a t is th a t? N o idea!
• A ls o asked a bo u t P V L staph, M R S A and its eradication th e ra p y
S ta tion (10) C ritica l care
• A T LS m ana ge m e n t
• P olytrau m a p a tien t a fte r R T A
• Low S a ts on 100% oxyge n , high HR, low BP, decre a se d a ir entry on th e right
• H ow w o uld you m ana ge a irw ay and breathing?
• S h o w ed C X R w ith rig ht sided p neu m o th o ra x - w h a t is m anagem e nt?
• D efine shock, types o f shock, h ow w o u ld you m anage shock

S ta tion (11) C ritica l care

• C h olecystitis
• A m idd le aged w o m an presented w ith sig n s o f cholecystitis
• W h a t is the d ia g n o sis and d iffe rentials?
• W h a t is the m e ch a nism o f bile stone fo rm ation?
• L a te r d e ve lop ed ch o la ng itis, w h a t is the m ana g e m e n t?
• M R C P and E R C P indications
• W h e n w ould you do ch o le c y s te cto m y and w hy?
• In tra o p e ra tive co m p lica tio n s o f ch o le cyste cto m y - w anted m ore than 5
• V e ry co n fu sing sta tion - a co u p le m ore vague questions, c o u ld n ’t re m e m b e r them

S ta tion (12) C ritica l care

• P ost-op pain m a na ge m e n t
• P ost-op day 1 lap aroto m y w ith o u t a n y com plications, hight HR, high BP
• H ow w o uld you m ana ge pain? W H O pain la d d e r
• S h o w ed drug chart, no pain m e d ica tio n s given post-op, o nly pre-m eds given. Identify
issues here.
• O th e r than GA, w h a t o th e r options o f a n a esth esia exist?
• P a tien t con tinu e d to have pain. E scalated on PC A. W h a t is PC A?
• W h a t a re safety fe a tu re s o f P C A ?
• W h a t a re co m p lica tio n s o f P C A ?

S ta tion (13) P rocedure

• S utu rin g
• S im p le interru pte d s u tu re w ith non -a b so rb a b le suture
• V icryl and N ylon given
• P a tien t a sked a few que stio n s a b o u t pain, how and w h e n sutures w ill be rem oved
• E xa m in e r w ante d m ore tha n 3 sutures (tim e w a s up w h ile a b o u t to tie 4th knot)
• P a tien t tw itche d h er leg w h ile suturing, said sorry, but she said it’s ok, it’s not pain
• E xa m in e r a lso asked a bo u t L A d o se calculation
• E xa m in e r a nd p atie nt try th e ir best to d istra ct the candida te, LO L
S ta tion (14) P rocedure
• O rd ering a list
• S tra n gu la ted hernia w ith p ace m aker
• H a rtm a n n ’s pro ce d u re fo r left d ive rticu la r a b scess
• Left leg a m p u ta tio n w ith M R S A positivity
• A sked to re-arrange, and m ention reasons
• P a c e m a k e r p re-op, in tra -o p precaution s
• W h a t type o f d ia th e rm y w o uld you use fo r th e o p e ra tio n s and w hy?

S ta tion (15) H istory

• H yp erthyro id ism - to x ic adeno m a
• M iddle aged lady w ith 1 0-yea r h isto ry o f neck lum p, noticed the lum p started to g ro w in
the past few w e e k s w ith difficu lty sw allow ing
• T h o u g h t it w a s m a lig n a n c y case, but turned o u t to be toxic adenom a
• M a n a g e m e n t o f n eck lum ps in general, and sp e cific m a n a g e m e n t fo r this case

S ta tion (16) H istory

• A cu te a b do m e n
• M iddle aged lady w ith s h arp e p ig a stric pain radiating to the back
• W h a t is y o u r diffe re n tia l diag no sis?
• W h a t a re yo ur in ve stig a tio n s and m anagem e nt?

S ta tion (17) C o m m u n icatio n

• R T A - re fe r to C T surgeon
• R T A ca se w ith w idened m ed ia stinum and le ft m id sh a ft fem oral fracture
• R esuscitated w ith 4L o f crysta lloids
• C h e s t drain in se rte d - 2 00 m l o f blood stained fluid
• W h a t’s left to do in the m a na g e m e n t? Thom as sp lin t and C X R post-op drain insertion
h a sn ’t been done yet.
• H b 80. A ske d w h e th e r m a ssive tra n sfu sio n protocol has been activated o r not?
• W h o w ould a cco m p a n y the p a tie n t on transfer?
• A sked a b o u t H b on blood gas. T here is no Hb on blood gas. A sked to interpret th e rest
o f results - m ild m e ta b o lic acid osis

S ta tion (18) C o m m u n icatio n

• M a lig n a n cy in peritonea l tap
• T a lk to p a tie n t’s w ife a b o u t m a lignant ce lls found in the tap, re g istra r told the p atient
• U rge nt C T scan sche du le d , but broken dow n, e a rlie st w ould be next w eek
• R a d io lo g ist said th e re is U S a bdom en, and could talk to nearest hospital fo r C T scan -
4 0 m iles a w ay
• S he cried a lot, a nd ke p t crying and crying until bell rang
• I kept sa yin g so rry a nd so rry and sorry
• B oth e xa m in ers w e re looking dow n fo r the m o st o f the tim e w h ile crying
Brief stem and topics tested

1. Brachial plexus injury

Stem: RTA w ith shoulder weakness and upper limb deform ity
Anatom y o f RC and testing o f UL power
Discussion o f site o f lesion and deficits (to dem onstrate dermatomes)

2. RC anatom y and LL hip anatom y

RC anatomy including origin/insertion and innervation
LL anatom y o f hip point, gluteal region and thigh
Thigh innervation and ligaments (inc iliotibial band syndrome)

3. A bdo transpyloric plane

Demonstrate anatomical landmarks on SP: M uprhy's point, transpyloric plane, subcostal margin
Clinical photo: prosected specimen (transpyloric plane), name organs, diaphragm, vessels
Discuss liver segments, portal triad, spleen vasculature and ligaments

4. Neck lum p TB lym phadenopathy (repeat qn)

Discuss differentials and invx o f neck swelling in young patient

5. IBD steroids hip #

Stem: IBD patient coming in fo r surgery, is on long term steroids. Considering TNF-aplha
antagonist therapy
Inflam m ation pathophysiology, role o f TNF-alpha
Ddx fo r hip pain follow ing surgery fo r IBD patient (cause is hip fragility #)
Post hip # fixation, reasons fo r poor wound healing

6. Varicose fo o t drop
Stem: Patient w ith lim p 1/52 follow ing varicose veins procedure
Physical exam: full neuro, screen pulses and rule o u t com partm ent syndrome
Clinical findings consistent w ith common peroneal nerve palsy
Discuss fu rth e r invx (NCS, EMG, XR MRI) and management

7. Postop DVT + PE (repeat qn)

Postop SOB, review charts, do physical exam and discuss Ddx + management

8. Thyroid nodule (repeat qn)

Thyroid exam (full), discuss invx and management

9. Inguinal hernia (repeat qn)

Physical exam: groin swelling
Discuss ddx, predisposing factors, management inc risk counseling in males
10. Op planning (repeat qn)
Discuss schedule inc periop arrangments (pacemaker, postop ITU, T1DM fasting, steroids)

11. Suturing thigh abscess I&D (repeat qn)

Tip: marks given fo r confirm ing correct site/indicatio n/patient identifiers, testing LA
Address pt's queries w hile suturing to save tim e

12. Comms- preop SOB (repeat qn)

Approach to SOB (full hx) including workup and pt counseling

13. Hx taking- approach to PR bleed

Diagnosis and management o f likely CLR CA (based on hx)

14. Update consultant- hypotension and postop low urine o u tp u t (repeat qn)
Ddx including hypovolemia, postop hemorrhage and sepsis (less likely)
Escalation to HD m onitoring, discuss use o f adjuncts inc bedside u/s, IA, CVP, inotropes

15. Comms- preop w a rfa rin bridging

Patient on long term warfarin fo r metallic valves. Going for elective hernia repair
Discuss options fo r bridging inc Clexane, IV heparin (pros and cons o f each)

16. Crit care- approach to hematemesis (partial repeat)

Emergency management o f hematemesis
Pathophysiology o f portal hypertension, sites o f porto-systemic anastomoses
Use o f balloon devices fo r variceal bleeding: discuss Sengstaken Blakemore and insertion

17. Thyroid axis

Interpretation o f thyroid hormone profile
Illustration o f HP and thyroid axis (Include exogenous thyroxine). Ddx fo r hypothyroidism
Risks o f to ta l thyroidectom y, postop m onitoring

18. Crit care- extradural hem orrhage (partial repeat)

Interpret CT and explain Monroe-Kellie doctrine
Discuss Canadian CT rules fo r scan
Discuss indications fo r intubation
Management o f EDH inc ICP m onitoring, fluid management, ventilation, nursing, adjunct meds
1. Station 1

Communication -

Angry Patient - Patient w ith meniscus injury - 2nd proposed surgery delayed

Concerns - th ird tim e delay, postman - job affected, w eight gain, w ife has to pick him and drop him,
gastritis due to ibuprofen, can I complain at the hospital - PALS, wants definite tim e and date o f surgery.
Asked about the proposed surgery - arthroscopy.

2. Station 2

Anatom y - Neck and shoulder

a) Thyroid gland - Lobes, Arterial supply, venous drainage, embryology, position o f parathyroid.
b) Anatom y and supply o f RLN - where does it loop, w hat fiber it carries. Nerve at risk during Sup
thyroid A ligation.
c) Why bronchial carcinoma causes hoarseness o f voice.

3. Station 3

Skill - Excision o f neavus

Instruction given - Consultant got a call, so he asked you to perform the surgery, local given and draped
- Sterile tray provided, Patient w ill be given leaflet by the nurse.

Mistake com m itted - checked fo r consent a little late, wide excision o f neavus, could not
approxim ate edges adequately, and patient kept interrupting.

Bell - Poor station, d id n 't go well

4. Station 4

Examination - Scenario - Post Saphenous vein RFA and m ultiple perforator ligation - Patient complains
o f difficulty in m oving his foot. Bandages o f lateral aspect o f leg. Do relevant examination. Provided
cotton and neurotip

Poor actor
Did inspection, palpation- asses Touch sensation, movements o f leg affected.
Finding - loss o f sensation in common peroneal n region w ith difficulty in dorsiflexion and
eversion. Gait assessment.! I fo rg o t about this)
Questions - You're finding.
■ W here does sup and deep peroneal nerve supply
■ W hy is gait affected?
■ How w ill you proceed - NCS, Duplex to rule o u t DVT
■ Treatm ent o p tio n -

Bell - perform ed poorly - Didn't assess gait, and could not assess sensation properly as patient d idn't
act o u t relevant finding.

5. Station 5

Examination - CVS - patient fo r OT

a) Finding
Left Infraclavicular scar
Left Lateral Thoracotom y scar
Could not hear any clear m urm ur
6 min Up - could not assess Lung fields and sacral edema
b) Questions
Finding summary
W hat does Infraclavicular scar indicate - Pacemaker
W hat do you look fo r in heart failure - pedal edema, sacral edema, JVP and pulmonary crepts.
Showed the ECG - w hat do you see - Pacemaker Spikes, W hat else - irregular HR...??
W hat precautions do you take w hile preparing this patient fo r OT?
W hether needs surgery now - No.
Which cautery to use and why not monopolar, If monapolar used - w hat precautions.
W hom w ill you involve in the care o f this patient?

6. Station 6

Post thigh Anatom y

a) Scaitic Nerve - identification, root values, anatomy, variations.

b) Landmark o f sciatic N
c) Trendelenburg test - which muscles tested, the nerve supply.
d) Causes o f positive trendelenburg test
e) Identify hamstring - actions, nerve supply.
 f) Content o f popliteal fossa
g) Pathology from each one o f them

7. Station 7

Examination - MNG in euthyroid state

a) Do relevant examination - Don't forget eye signs

b) Thyroid physiology - TRh to T3
c) How thyroid horm one affect cells, fuction o f thyroid horm one
d) Investigations- Fnac finding, USG finding in MNG vs Ca
e) Thyroid scan
f) W hat surgery you propose and why?
g) If she comes w ith difficulty in respiration after 3 months? - Tracheomalacia

Bell w ent o ff

8. Station 8

Cranial Anatom y station

a) Point o u t pterion, bones forming, Importance?

b) Rotundum and structure through it.
c) Lacerum and structure through it.
d) Clivis form ed by which bone
e) Calcification btw tw o plates o f skull??? Diplopic veins?
f) X ray - point o f pituitary fossa, sphenoid sinus.
g) X ray point out lambdoid suture

9. Station 9

Pathology - secondary parathyroidism in patient w ith ADPKD

a) W hat is function o f parathyroid

b) How does it regulate Ca?
c) Ca level in sec hyperPTH?
d) Renal stones complication in pelvis?
e) Types o f carcinoma in renal tra ct - cause
f) W hat cells PTH acts on in the bone and where does it act in renal tubule?
g) ??? could not recollect
10. Station 10

Procedure - I&D

They just watch w hat you do - check consent, speak to patient about procedure, allergy to medication.
LA to be used, check date, m aintain sterility, w hat instrum ents you pick, how you put on gloves, incision
direction, com plete removal o f abscess pouch, ask fo r pus culture to be collected and form to be ready,

Questions - langer lines, def o f abscess, types o f dressing.

11. Station 11

History - Middle age lady w ith diarrhea - blood in stool, jo in t pain - Crohns - Actor(ask about previous
trea tm e nt history)

Questions - DD

a) How to you evaluate.

b) Specific investigations
c) W hat are extra intestinal m anifestation of IBD
d) Colonoscopy finding
e) Biopsy finding
f) Treatment?
g) Indication fo r surgery?

12. Station 12

Physio/Critical care - Post op pain management

Screwed up big tim e. Please read the drug chart properly - see if the medicine is applicable fo r the day.

a) Types o f pain assessment scales - VAS, NRS,

b) Check trea tm en t chart - Check chart clearly - medication may be w ritte n but it may not be
applicable fo r the day he is asking
c) Action o f cyclizine
d) W hether NSAIDS given if patient on LMWH?
e) M orphine - Dosage, side effects, complications?

Bell w ent o ff - examiner was demeaning and sarcastic - can put you o ff track.

13. Station 13

Long term steroid

a) Layers o f adrenal and the hormones

b) CRH-ACTH-Cortisol Axis
c) Action o f aldosterone
d) Pathway
e) Effects o f steroid - metabolic, glycemic, wound healing, immunosuppression, bone, etc
f) Should steroids be always replaced w ith IV steroids???? Didn't get w hat he was asking
g) Symptoms o f patient on long term steroids - eyelashes, face, humps, central obs, etc
h) Steroid horm one effect on Carbs, proteins and fats

14. Station 14

Examination - M ultiple Lipoma.

a) Ask the patient to undress his torso - Exposure

b) Exam o f lipoma
c) DD
d) Pathology, causes
e) Treatm ent
f) Liposarcoma chances

15. Station 15

Critical care - Post Hemim anidulectomy feeding

a) Types o f feeding -N G /N J... etc

b) Complications o f each - early and late
c) W hat is constituents o f enteral feeding
d) How to asses NG in stomach
e) If you aspirate NG - Ph is 7 - w hat is cause?????
f) Actions o f gastric acid

16. Station 16

Pathology - Post appendectomy Carcinoid

1. When is appendectomy sufficient?

2. If not - w hat other surgery required
3. W hat is carcinoid syndrome - cell o f origin, features
4. Diagnostic test
5. Post 5 days a ntibiotic - diarrhea - cause - DD
6. Name organism - Cl. Difficale
7. Diagnosis o f Cl. D iff - cytotoxin and colonoscopy
8. W hat are tw o things you do to patient o th e r than treatment???? D idn't get the question
 17. Station 17

Communication - Call vascular surgeon regarding patient whose lim b has gone pale.

Scenario - patient adm itted fo r diarrhea and abd pain, suspected (not diagnosed) diverticulitis - IV
fluids and Antibiotics started - pain has decreased, diarrhea persists.

Ih r - pain and pale - le ft low er limb. Pulses mentioned, discuss patient w ith vascular surgeon

ISBAR

a) Phone c a ll-g iv e all info -

b) Which leg affected, w hat tim e you checked patient - you need to mention I d id n 't see the
patient the nurse inform ed me
c) Could diarr be associated w ith pale leg? - ischemic colitis?
d) E C G -find in g o f AF
e) W hom w ill you involve - cardiologist
f) W ill you w ait if cardiologist is late?
g) W hat empirical management w ill you start - ABCDE, IV Fluids, throm bolysis is advised or no?
h) W hat investigations w ill you do.
i) How w ill you transfer the patient to vascular unit??? - 1will shift the patient and accompany(
d o n 't know w hat I needed to tell)

18. Station 18

History station - 1d o n 't recollect the satan(station).

 2020 compilation
Last updated 8 Dec 2020

Email to: [email protected]

All contributors are anonymised and

accounts redacted for safety
Crit care
24 m ale falls off ladder,
- body p a rts in jured?
- con stitu en ts o f GCS?
- sin gle blood te st to confirm d iagn osis
- CT h ead - extradural
- m an agem en t o f raised ICP
- GCS d ro p s - m an agem en t?
- Cause o f seco n d ary GCS drop?

Hx
Hx o f pleuritic chest pain, PE 5 days p o st THR
- Dad had clot
- Non com pliant with ted s
- H aem optysis
- In vestigations
- T reatm en t?
- Em bolectom y vs th rom bolysis

Path station
BCC
- d escrib e lesion
- c au ses for eryth em a - telan giectasia
- DDX?
- How tum our sp re a d s? Lym phatic sp re a d - em bolus
- In traoperative in vestigation s
- Path report (ow l eye sign ) Reed Stern berg cell (h odgkins lym phom a)

Anatom y
- Right h eart (pap illary m uscles, chordae tendinae, azy go s vein tribu taries
and d rain age - SVC)
- P urpose o f ch ordae tendinae
- B ran ch es o f ascen d in g ao rta (coron ary a rterie s)
- A natom y o f spleen (ribs overlying - 9 - 1 1 ) , duodenum ,
- O rgans su p p lied by splen ic artery
- W hat not to d am age during splen ectom y (tail o f p an creas)
- D escribe cou rse o f sp len ic artery (coeliac trunk, lienorenal ligam ent,
p o sterio r to stom ach )
- Surface m arkin gs o f gallblad d er
- Why referred pain to sh oulder tip

Skill - rem ove naevus

LA given, clean ed and d rap ed , ?WHO, allergies, an ticoagu lan ts
-sam e a s previous

C-spine anatom y -
-Structure a t C3, C6,
- p a r t o f gut at C6
- explain p arts o f C2
- talk through open m outh view o f xray
- talk through lateral view
- ligam en ts o f odontoid peg
- ligam ent p a ssin g posteriorly (tran sv erse)
- why C7 verteb ra prom inent?
Point to brachial plexus
Point to hyoid and cricoid on actor
C ourse o f vertebral artery
Atypical v erteb rae (C l, 2, 7)

Comms
- Read through n otes - MVR aw aitin g hernia op, w arfarin bridging, blind
guy, a s previously d escrib ed

Know ledge
Hand anatom y
Point to m edian and ulnar nerve
Sen sory su pply
M otor su pply
FDS an d FDP attach m en ts
Contents o f carp al tunnel
A ttachm ents o f flexor retinaculum
What attach es to flexor retinaculum
Xray o f hand - nam e carp al bones
How to te st action o f FDS
M ovem ents o f thum b (extension, abduction, flexion, o pp osition )
N erves innervating each action

Exam - confusing station

5 d ay s p o st left hemi, unwell, irreg. HR, febrile (exam sa y s p lease exam ine
ap p ro p riately - w e think do CCRISP)
A-E - CCRISP +ve findings, fast AF, stern otom y scar, LIF guardin g
In sert an oth er cannula
M anagem ent o f patien t? H artm ans procedu re
S ep sis 6
DDx - an asto m o tic leak, su bp h ren ic a b se ss, isch aem ic bowel
Patient had stern o to m y an d lap aro sco p ic p orts (?oesoh agectom y)

Ear exam
- in spect
- te st hearing
- otoscop y
- rinne + w eb ers
- facial nerve
- chorda tym pani
- balance
- w hat in vestigation s (p u re tone au diom etry and tym panom etry), CT
- d escrib e picture (h aem otym panum )
Knee - 25y.o. 3 h ours p o st football tackle
Fixed flexion deform ity
M edial join t line te n d n erss
Unable to WB
Pain on m edial collateral s tr e s s test
Cruciates norm al
No effusion
Differentials - m eniscal tear, fracture, MCL
MMX - an algesia, splint, arth roscopy, rep air

Catheter - as previously d escrib ed

- qu estion re: c au ses o f no urine output

Traum a
- m an stab b e d in epigastrium
- given blood resu lts - raised lipase, free air in abd om en - which organ s
d am ag ed ? Bowel, p an creas, blood v essel
- drain in serted - high output ?te st (am y lase)
- cau se o f low calcium (sapon ification )
- cau se o f h ypoglycaem ia (in ad equ ate endocrine function)
- H istology o f ARDS?

Hx - groin a b sc e ss
R eferred in by GP
IVDU
No other m edical issu e s
Pulsatile sw elling
Anxious ab o u t gettin g next hit
Investigation s - duplex, CTA
M anagem nt - US guided com pression , throm bin injection, ligation o f artery
What is % chance o f leg lo ss? 10%

Bone cancer - 48 y.o lad y with pathological fracture

Thyroid prim ary
Folliciular cells
What tu m ou rs com m only m e tasa tsise to bone
What te sts w ould you do?
What further te sts? Im m unohistochem istry
Radiological te st? R adioiodine
What tum our d oesn 't sh ow up on radioiodin e scan ? - m edullary becau se
parafollicu lar c cels don't participate in iodine uptake

Aortic sten o sis

-seq u aelae o f aortic sten o sis
- define LVH on ECG

T raum a tran sfer

Aortic rupture
Fem oral fracture
Reduced GCS
Potentially abdom in al injury
C auses o f m ediastin al w idening? A ortic tran section an d p ericardial effusion
Plan?
-Thom as splin t
C sp in e xray
Send with retrieval team to receiving h ospital and blood in am bulan ce

PE
Crit care, left sid ed chest pain ?DDX
Unwell on w ard, tachy, low sa ts
ABG, CXR, bloods
ABG sh o w s T1RF
M anagem ent?
Critical care
Epidural bleed
24 year old fell from 3 meters

CT scan: Epidural bleed, mid line shift, loss of Grey white matter differentiation, effacement of
ventricle
CT head indications
GCS of 6 needing tubing
Investigations
Causes o f low GCS in this patient from blood tests especially
W hat else would you be worried a b o u t: cervical spine
Management

Critical care
Aortic stenosis
Patient for TURP, on bendro and doxazosin, ejection systolic murmur in aortic area.

Likely pathology ie aortic stenosis

Pathophysiology o f aortic stenosis and effect on myocardium
Presentation
Risk and benefits of surgery
ECG with LVH
Calculate HR
Other investigations like ECHO and invasive intra op monitoring
Side Effect of bendro and risk in surgery
Effect of postponing TURP surgery
NICE guidelines regarding antibiotics

Critical care
Acute Pancreatitis
Alcoholic, high BMI and diabetic, blood tests

Likely diagnosis
Differentials
Management
Investigations
W hy hypocalemia
MRCP and ERCP
VTE Prevention
W hat is a pseudocyst
When would you suspect and the clinical features
W hy might be amylase be low in Pancreatitis
Is amylase useful in prognosis
State the scoring that you know and describe one.
W here would you manage this patient.
Pain control

Pathology
BCC
Describe the lesion : rolled edge, ulceration, telengectasia, erythema, size
W hy is there erythema
Differentials
How to ensure complete resection intra op
Describe Moh's
MCS shows E. coli
Likely contaminated so repeat swab
MSRA Treatment and barrier nursing
Infection control notification

Pathology
SSI and Nec fas
Post lap chole, diabetic and obese

Histopathology of gallstone in the gallbladder eg fibrosis, inflammation

Erythema so likely SSI,
Give possible organisms
Management
Not getting better why? possibly drug resistance, or progression to Nec fas
Risk factor of obesity and DM
Now necrotic and black
Likely organisms
Which blood test would point to possible NEC fas FBC EUCr

Pathology
GIST
Histopathology report showing GIST, sarcoma, ulceration, CD 117, nodal involvement, no spread
otherwise. H. Pylori

Difference between GIST and gastric adenocarcinoma

How is the tum or likely to behave ( it had gone through lymph nodes but no distant metastasis)
W hy is the patient jaundiced
W hat is jaundice
Patient develops ascites how do you investigate ( cytology and liver biopsy for recurrence)
W hat is CD 117 ( happy with immunohistology marker)
W hat is H. pylori
W hat does it causes

Clinical skills
I and D
Give local
Look at consent form
Langer lines
Would it scar?
W hat about pain?
Test local
Pack the wound
How would you dress
W hy MCS
W hat would you expect to grow

Clinical skills
Suturing
Hand tie with silk on the rig (non absorbable braided)
Hand tie at depth with vicryl
Instrument tie Figure o f 8 with prolene
Problems with tying at depth
Benefits o f braided sutures

Examination
ABCDE exam
Ten days post op with right sided chest pain so assess.
Obs chart present

Pain on inspiration
Calf tenderness
Likely diagnosis
Investigations
Treatment
Patient collapses what would you do.

Examination
Carpal tunnel
Right hand pain and tingling worse at night
Positive phalens and tinels
Parasthesia
No muscle weakness
Diagnosis
Risk factors
Treatment

Examination
Cholecystitis
Upper abdominal pain and perform any other necessary exam eg face and hand
RUQ with Murphys positive
When to perform lap chole: early or late
Getting better but jaundice so likely CBD stone
How to manage
MRCP and ERCP

Examination
MMSE and CN examination
Long standing anosmia now coming with headache and vomiting.
Pen touch and peppermint provided.
Do the relevant CN exam and a MMSE (I don't think you're actually supposed to complete this in 6
minutes so I did AMTS)

Likely diagnosis
Investigations

Communication
M otorcycle RTA
Bilateral haemothorax, chest tube in drained 200mls
M ediastemal widening
Left femoral fracture
Discuss with consultant
Ensure to clear cervical spine
Places he could be bleeding from
Treatment of aortic disruption
How would you transfer

Communication
Canceled op
Same classic meniscus injury canceled arthroscopy scenario

Communication (history taking)

Back pain
Take history o f lower back pain, has IBS, previous MRI, uses walking aid
Likely diagnosis
Red flag symptoms
Investigations
Treatment

Communication (history taking)

Pseudoaneurysm
IVDU
Management of pseudoaneuryms
Investigations ( HIV HBV)
Anatomy
Lower limb anatomy
Femoral triangle
Name four muscles you can see
Femoral canal ( boundaries and function)
Adductor canal
Dermatome
Supply of saphenous nerve
Roots of femoral nerve
Landmark of femoral artery
CT Angio and branches of femoral artery

Anatomy
Thorax and abdomen
Azygos vein and tributaries
Pulmonary trunk
Ascending aorta and branches
Papillary muscles and function
sympathetic trunk and the limits
duodenum and parts
landmark o f gallbladder
Splenic artery and supply
Location and ribs of spleen
Artery behind D1
Referred pain to shoulder tip

Anatomy
Skull
Foramen spinosum
ovale
rotundum
cavernous sinus and nerves
Symptoms of cavernous sinus thrombosis
Middle ear infection and spread
Nerve around middle ear
Cause of papilloedema
Many thanks questions. I passed.

1. Procedure station : Naevus excision., straight forward. Patient and examiner very
cooperative. When to remove sutures? Will there be pain? Recurrence?

2. Anatomy station : C5.C6 nerve root anatomy. Scenario : Chap who has fell from
height and had abduction injury.
Que - where do C5, C6 root arise. Show on skeleton.
Dermatomes. SSP origin n insertion. W hat initiates abduction? Musculocutaneous
nerve supplies?
Show biceps n supinatir reflex on model. How to test trapezius. Nerve supply to it.
Test elbow flezion.

3. Anatomy station. Abdominal aorta branches. IVC tributaries. Abd aorta surface
marking. Bifurcation level and marking. Show me different arteries supplying GIT.
What crosses in front of aorta transversely - 3 structures.

4. Anatomy station : Child fallen from tree. Swelling at elbow. Anatomy station : SC
humerus. Articulate bones. Median nerve supply. Relation of median brachial art n
radial nerve. Ulnar paradox muscle? Median nerve injury abovr elbow results in?
Radial nerve course and relation to humerus., show artery, nerve etc. Brachilradialis
action.

5. Surgical pathology. Female who had pathological fracture of femur. What is

pathological fracture? Causes? Classify bone tumors? What metastasises to bone -
5 tumors? Thyroid follicular carcinoma mode of metastasis? What will u look in
histology single most imp finding? Thyroglobin. How to test? Radioiodine. Which
thyroid tumor not detected by radioiodine? Why? Medullary as from para follicular.
Where else does ectopic thyroid can b found apart from chest n neck? Examiner
hinted to gonads..

5. Surgical pathology : metal plate in tibia 3 year ago now with knee swelling :
What is cause? What are sequelae of tibial abscess? What is sequestrum?
Involucrum? 4 organisms causing septic arthritis? Why metal work needs to b
removed? Sinus vs fistula? Why antibiotics wont work?

6. Arrange OT list and give reasons. Just same as pastyear questions. Hartmans
procedure, mrsa foot amputation and pacemaker guy with hernia.. Precautions for
using cautery. Justifications for arranging..

7. Critical care : lady postop day 2 after colon resection: sats droppin.. tachy.. pao2
dropped., left sided chest pain..3 reasons for this? What will u ask in history? Abga
shows type 2 failure. Reason? Pulm embolism investigation of choice? What will u
see on investigation? How to prevent DVT? What to do intraop to prevent? Saddle
embolis found on CT what to do? : Embolectomy.

8. Critical care. 40 yr old bicycle hit at high speed. On spine board., sats droppin
tachy, patient can speak and oriented.
Que : diagnosis. Immediate management:- as per atls. What investigation?Cervical
xr shows c3-4 dislocation. What to do? Intubate. Whom will u involve? Neurosurgeon
n anesthetist., physiological reason for sats droppin? What is line of thot for
management onwards from ER?

Second round :

1. Hand examination. Label said gentleman who has problem with function in his
dominant hand. Father and grandfather had amputation. He is diabetic., do relevant
examination n other system if needed..
Vague station as everyone thought of arterial n nerves exam., however many of us
did only hand exam. Showed dupuytren’s contracture.
Que- etiology? Treatment?

2. Communication : Talk to ITU reg. lady admitted today. COPD. Generalised

peritonism. Amylase raised. Only 1 bed available..
Que - why bed required? COPD what will u do? Will u give antibjotics? What to do
before giving antibiotics? Whats her fluid balance? Ecg taken? What if it shows atrial
fibrillation? Repeat the main points.

3. Communication : man with ascites. Tap shows malignant cells. CT not working.
Man in pain and discomfort. Wife is here., knows that cancer is present. Talk to her
and address questions... straight forward., dont forget to read in notes that he was
workin in dye industey so can be bladder carcinoma., also that surgical reg has told if
ptnt uncomfortable than do therapeutic tap to help..

4. History., vascular claudication. Pain in calf.: stops after rest. Smokes a lot. Not
radiating., que : what favors vascular over neuro? How will u manage? What lifestyle
modifications to advise?

5. History : vague station. U r neuro trainee. Ptnt referred from other hospital. No
other information. Go n talk to her. Turns out to be a subarachnoid hemorrhage.,
what r riskfactors? How will u treat? Mentions that her relative had this., berry
aneurysm.. I C E.

6. Examination. Abdominal exam with cholecystitis., murphy positive.

Straightforward..

7. Examination : submandibular swelling. Same as before.

8. Examination : CVS. A fragile lady with real clubbing n palmar erythema., mitral
regurgitation murmur., thats what I said., dnt knw for sure., what r ur preop n intraop
concerns? What will ECHO tell u?

Many thanks to previous examinees who took time to post questions. It really helped.
I was very nervous after exam as I thought I waffled at many stations. In the end I
managed to pass on first a tte m p t!:)
Advice : just what all is universally told. Take enough rest. If one station goes wrong
do not panic. Be yourself and be honest. You can change your mind if you think you
answered wrongly and let examiner know. All the best!
 1. Hand exam - carpal tunnel syndrome, causes and management
2. I+D o f abscess - orientation o f incision, which packing, which dressing
3. 40yo with weight loss and change in bowel habit, FHx o f bowel C a - ???d o a lymph
node exam ?differentials - in retrospect, to complete the “ lymphoreticular
examination” I would have also palpated for hepatosplenomegaly for Xtra gold
s t a r s * **
4. Pancreatitis - clinical hx and bloods presented. Why would amylase be normal? (very
early, or late pancreatitis) What scoring system s? How do you decide to escalate care?
Cause o f hypocalcaemia? What is a pseudo cyst? How does it present? (Gastric outlet
obstruction)
5. Pathology - red hot knee. Differentials, what test, what to send for in lab, commonest
crystal arthropathy. Given path report G + cocci, what is this? Commonest organisms,
why does metal work have to be removed, what is an abscess, what process is this?
(Osteomyelitis), sequestrum and involutrum
6. RTA ped vs vehicle. LO C then G C S 15, then unresponsive - what is this interval
called? How would you assess if pt needs urgent C T head. Image o f extradural. What
is the monroe kellie doctrine and how' does it explain lucid interval. What causes the
bradycardia and hypertension. What is CPP
7. PREP station
8. Phone trauma consultant - ED RTA cyclist vs car. LO C at scene now' G C S 15.
Obvious open tib/fib but clinically stable. Had IV, bloods, Abx, tetanus and fluids in
ED. C X R nad, bids NAD. U S S abdo ?fluid L subphrenic area. What are the priorities
for mgmt (c spine, splint #, assess pt, call other specialties, C Ts)
9. You are neurosurgery SH O - in clinic, hx young man, sudden severe headache back o f
head, photophobia, vomiting. FH - Aunt died o f SAH . What DDx, what is your
management, would you admit the patient
10. Submandibular gland examination - DDx, management
11. Abdo exam - 63M LIF pain, diarrhoea. Obs show' tachy, febrile and raised WCC. OE
- midline sternotomy and x3 port scars. LIF tenderness with guarding. DDx, mgmt o f
sepsis, scan? Definitive mgmt, how long will he stay in hospital, can you reverse
stoma later (yes if histology not ca), how to counsel pt for stoma reversal
B R EA K
1. Stem - otitis media. Anatomy o f base o f skull. What attaches here? Cavernous sinus -
what is contained inside, how does thrombosis happen, how does it present. How does
infection spread from middle ear. Wrhere does C N V ganglion sit, mechanism o f
papilloedema, significance o f ophthalmic artery
2. Chest drain insertion, show-n C X R pneumothorax first, w'hat equipment you need,
select drain size, how do you mark where to insert, drain stitch, name 3 complications
o f chest drain? E.g. infection, pain, damage to local structures, bleeding, (funnily
enough the C X R showed a left pneumothorax but the model could only have insertion
on the right!)
3. Articulate humerus, radius and ulna. Biceps tendon insertion. Median nerve
transection at elbow and wrist, radial nerve transection at wrist, ulnar nerve functions
and paradox. Shown anatomy diagram - point out the artery and nerves, how do they
pass at the elbow
4. Rest
5. Prep
6. Speak to wife - husband referred with asymptomatic ascites, found to be malignant,
awaiting staining, awaiting tumour markers. C T scanner broken. Consultant in theatre
7. 34 week pregnant lady undergoing surgery lor abscess related to perfd necrotic GB.
M odified trendelenburg, becomes hypotensive. Adv and risks o f doing this surgery,
why is she hypotensive, what can you do about it, what is preload, how can body
increase preload, how does body sense changes in BP, how does normal body
increase venous return when stranding
8. History - woman with multiple life stressors presents with back pain which varies in
location and has no red Hag Sx. ?Functional back pain
9. Anatomy - pictures o f illustrations and prosections o f pancreas and duodenum, blood
supply pancreas and duodenum. Relations o f both to peritoneum. What is in front o f
and behind the pancreas and D3. Embryology o f pancreas. Pancreatic ducts and where
they drain
10. Path - stem - “ you will be tested on path and shown a picture” . Picture o f colon with
multiple polyps. Dx? Pt presents age 22 what tx would be, name 3 extra intestinal
manifestations o f FAP, what is APC, what is an ulcer
11. Pt POD4 post laparotomy. R sided CP. obs tachycardia, tachypnoeic, borderline
pyrexia and dropping sats. A-E assessment - signs/paraphernalia. 0 2 mask next to pt,
dry wound dressing and tender L calf. How would you manage. What investigation?
Any other imaging besides CTPA ? Tx options
12. Rest
Anatomy:

• E lbow /forearm anatom y

• Coeliac tru nk, pancreas (te rrib le q u ality photographs)
• Base o f skull/cranial nerve

Critical care/physiology:

• Necrotic gallbladder in a pregnant p atient - positioning, cardiac o u tp u t and preload

• Extradural haem atom a

Pathology:

• FAP - polyp types, m anagem ent options, extraintestinal m anifestations

• Infected m e ta lw o rk in an orthopaedic patient - associated pathogens, tre a tm e n t options,
biofilm fo rm a tio n etc
• Pancreatitis - scoring systems, hypocalcaemia

Com m unication:

• Angry w ife - husband has been to ld about m alignant cells in an ascitic tap, to ld th a t there
are no tre a tm e n t options, CT scanner is broken. Consultant unavailable - calm the w ife
dow n, apologise, explain w h at has been found, concerns and tre a tm e n t options (unknow n
prim ary, so surgery, chem otherapy, radiotherapy, sym ptom based etc).
• C onsultant conversation - traum a p atient w ith ?com partm ent syndrom e a fte r tib /fib #.
Vascular consultant is in th e a tre w ith reg and you haven't seen the patient yet.

Examinations:

• Abdom inal exam: acute abdom en/LIF pain in SAU

• Hand exam: carpal tun ne l syndrom e
• Abdom inal exam: painless jaundice
• Subm andibular gland exam ination
• ABCDE: 10 days post 'm ajo r abdom inal surgery' patient has right sided chest pain, le ft calf
te n d e r on exam ination; PE. Overall, a badly run station.

History:

• Headache: young man w ith sudden onset headache, photophobia. Clinically w ell. Family
h istory o f ?SAH
 • Back pain: 10 year history o f back pain, no red flag sym ptom s

Practical procedure

• Insertion o f a chest drain

• Drainage o f an abscess, local anaesthetic injection
1) Anatomy
-S h o w on skeleton
‘ id en tify acro m ion and co ra coid process
•T e ll m e the ro ta tor c u ff m uscles and sh o w on skeleton origin and insertion
•s h o w m e the spiral g roove and w h a t runs in it
*sh o w m e m edial e p icon d yle and w h a t runs u n d e r it
•T e ll m e o ne m ajo r s e n so ry loss w h e n the radial nerve is injured
‘ id en tify A S IS and w h a t m uscle on it
•T e ll m e o ne nerve injured w hich ru ns u n d e r o f A S IS and w h a t is th e syndrom e called (lateral
c u ta n e o u s nerve o f th igh )
•S h o w m e G luteus m edius origin and insertion
‘ F unction o f G luteus m e dius on w alking
•C o uld you sh ow m e the Q u a d ra tu s fe m oris m uscle origin and insertion

2) Communication Phone call

ITU re gistra r
* W h a t is y o u r plan o f action ?
•H a v e you checked the urine ou tp u t? (sa y not done)
•H a v e you given a n y a n tib io tics (say not given). W h a t a n tibiotics do you p re fe r ? (B road
spe ctru m w ith blood c u ltures)
*H a ve you done blood cultu re (n o t do ne)
•W h a t pe rce n t o f oxyge n satu ra tion w ould you like to keep fo r C O P D ? (8 8 -9 2 % ) and w hy
(becau se co2 re tention)
•H o w m uch litres o f oxyg en w o u ld you prefer (2-4L)
•W h y is the p atie nt a cid o tic ? (b eca u se la ctic a cid o sis due to h ypope rfu sion and ana e ro b ic
g lycolysis)
•A n y o th e r blood te st you sp e cifica lly like to repeat? (potassium )
*E C G fin d in g s you e xp e ct ? a nd H ow to deal w ith it? (contact ca rdiologist)
•B ed not available , w h a t to do ?
•D o you thin k the p atie nt w ill im prove w ith su rg e ry ? W h o do you w a n t to c o n ta ct ?(fam ily
m em b ers)

3)_H.istory
B ack pain w ith IBS history
•W h a t d x and w h a t d iffe re ntia ls ?
•In ve stig a tio n s
* T re a tm e n t (please sa y social w o rk e r)

4)Communication
OGD
Q ue stio n s p a tien t asked - W ife and fa m ily m em bers sad , C o m p lica tio n s , Blood reports finding ,
e xplain the pro ce d u re , how can i u n de rstan d w hen the co m p lica tio n s a rise a fte r i reach hom e .

5) Critical care (Head Injury)

‘ C o m po ne n ts o f A irw a y and B reathing
‘ C o m po ne n ts o f circulatio n
* 2 n eurolog ical sig ns (O cu lo m o to r and a bduce ns nerve palsy , False lo ca lizin g sign)
•P a tie n t fe lt fro m 3 m e te rs he igh t so w h e re w ould he injured h im self?( b asically tell all the sites)
•In v e s tig a tio n you w ou ld like to do fo r head injury?
•T re a tm e n t
*C T scan criteria ?
•C o m m e n t on the c t scan o f head ( ED H )
* 1 d e fin itive tre a tm e n t fo r th is ct scan fin d in g s (C ra n io to m y w ith burrhole o r o p e n )
•P a tie n t gcs w a s 15 and now d eclined w h a t do you th in k is the ca u se and w h a t are the causes
behind it? (sa y tra um a , tu m o r , he m o rrh a g e )
•C o m p o n e n ts o f C P P ?

6)Critical care (Obstructive jaundice)

•B lo o d pictu re w ith R aised - ggt and A L P and bilirubin
w h a t is y o u r idea? (O b stru ctive ja u n d ic e )
•C la s s ify Ja u n d ice
•G iv e e xa m p le s o f ja u n d ic e
•C la s s ify O b s tru c tiv e Ja u n d ic e ( In tra lu m in a l, lum inal and e xtra lu m in a l)
•W h y clotting d e ra n g e d in O b s Jau n dice ?
•E x p la in the w ho le e n te ro h e p a tic circu lation ?
•Im a g in g s you w o u ld love to do ?
* W hich one has d ia g n o stic and th e ra p e u tic va lu e and w h a t can it do ? (S te n t and dorm ia
basket ston e re trie val)
•F u n c tio n o f B ile sa lts in dig estio n o f fat?
•C o m p o sitio n o f bile ?

7)Critical care (Abdominal pain)

•F irs t th in g you se e w h ile you scan through reports o f yo u r hospital? (d e m o g ra p h ics like nam e
ag e , dob)
*D /D o f pe rforate d viscu s on an O LD person?
•F e a tu re s in X R A Y - G as u n d e r D ia p hragm
•F e a tu re s in E C G - a bse nt P w ave s
•F e a tu re s on an EC G ( P, qrs , T w a ve s , H eart rate, vo lta g e )
•W h a t can AF ca u se ? ( S urgical failu res , stroke , M l)
•W h y M l (D ecrea se d ia sto lic tim e )
•S u rg ica l cause o f A F ( H ypoka lem ia , sepsis , M l , T h yro to xico sis , V a lvu la r h e a rt lesions , sick
sin us syn d ro m e , hypoxia and m a ny m ore)
•T re a tm e n t o f A F
•S in c e the p a tie n t has d e m e n tia , h ow w ould you like to proceed ? ( C o n ta ct fa m ily m em bers and
co n se n t p a p e r 4)
*W h a t d oes the EC G show , w h y is the H R on th e EC G and the H R on the BP cu ff different?

8) History
B P H (C la ssic fin d in g s- S lo w stream , in crease fre q u e n cy , term inal dribbling , h esitancy ,
u rg e n c y , N octuria)
P a tien t ta ke s S u d a fe d nasal drops
•D iffe re n tia ls
•In v e s tig a tio n s - S ay I w o uld firs t like to e xam ine the abdom en and perform D R E to check for
h ard n e ss , irre gu larities , firm n e ss )
•T re a tm e n t

9)Examination ( Stem - Headache and vision problems)

C la ssic cranial nerve e xa m ina tion w h ich fits 6 m ins)
•D /D
•In ve stig a tio n s
•tre a tm e n t

10)Examination ( Stem - Postoperative 4 days of surgery, now complaining chest pain)

C R IS P e x a m ina tion P u lm o n a ry e m b o lism == M A K E S U R E YO U A U S C U L T A T E TH E B A C K OF
C H E S T and S Q U E E Z E TH E C A LF )
•D /D
•In ve stig a tio n s
•Y ou scru b b e d in OT. n o w p a tien t c o m p la in s o f ch e st pain ? (crash c a ll)
•T re a tm e n t

11 Examination ( Stem - acute abdomen)

C la ssic A b d o m in a l exa m in a tio n R ig ht ilia c fo ssa pain - A c u te A p p e n d icitis
•D /D fo r both m ale and fem ale
•In v e s tig a tio n s fo r both m ale and fe m a le (b hcg in urine)
•T re a tm e n t (w hy lap chol fo r fe m a le p a tie n t)
•N o w you see blood in the abdom en, w h a t w ill you do ? usual talks a b o u t calling o b stetrician
•W ill you m ake the incision b igg er ?

12) Examination ( Stem - examine the superficial venous system)

C la ssic V a rico se exa m in a tio n , D o p p le r provided , 2 to u rn iq u e ts a lso provided)
-P e rfo rm to u rn iq u e t on both sfj and a bove knee
-T ry to p erform a d o p p le r o r ju s t say you w a n t to end exa m in a tio n w ith d o p p le r
•D /D
•In ve stig a tio n s
•T re a tm e n t
•a w om en taking O C P, w h a t w o uld you a d vice ?
13) Procedure (OT LISTING)
* w h y w o u ld you like to place S trang ula ted hernia a t firs t (M ore ch a n ce o f Ischem ia and
O b stru ctio n )
* A n a e sth e sia fo r S tra ng u la ted hernia
* P a ce m a ke r c o m plicatio ns
* D ia th erm y a d ju stm en ts
*W h y A lle rg ic to p enicillin at second
*w h a t a n tib io tics ? ( i said e ryth ro m ycin , vancom ycin because he d id n ’t a cce p t
ce fa zo lin /ce fu ro xim e )
*W h a t to give fo r a llergic to Iodine?
*2 w ords for d ia b e tic patients, P reoperative m a n a g e m e n t ? - G KI S LID IN G S C A LE
*w h y M R S A a t la st ?( H e d id n ’t a cce p t C ro ss co ntam inatio n o r to ensu re ad e q u a te cleaning o f
th ea tre s, N O idea w h a t he w a n te d Im ao)
*W h a t a n a e sth e sia fo r B K A ? (sa y G A because he has A F w ith w a rfarin so re g ional/sp inal will
ca u se h e m a to m a/b le ed ing )
*W h a t a n tib io tics fo r M R S A ? If resista nce to V a n co m ycin , w h a t a n tibiotics? ( G ive T ige cyclin e )
*H o w to m a n a g e A trial fib rilla tio n ?

14)Procedure (Nevus excision)

* W ill it pain a fte rw a rd s?
* Is it cancer?
* M y m om is scared ? ( nothing to w o rry about, hopefu lly it w o n ’t be nothing serious, w e w ill call
you a fte r the re su lts a re o u t )
* A n y s ca r m a rks ?
* W hen i need to rem ove the stitches?
D isp o se sharpies

15)Anatomv
P ictures from M cm inn
*S h ow th e b o u n d a rie s o f P o ste rio r T riangle
*S h ow a c c e sso ry nerve
*W h a t m uscles it su pp ly ?
‘ F unction o f the se m u scles ?
*S h ow p o s te rio r a uricle nerve ( h in t ab ove ste rn o cle id o ) .W hat does it sup p ly?
*S h ow s u b m a n d ib u la r glan d . W ha t se cretions ?
'Im a g in e a m uscle a b o ve it and b e tw e en skin, w h a t is it? (p la tysm a ) nerve supp ly? (ce rvica l
branch o f the fa c ia l nerve )
*S h ow O m o h yo id ?nerve su pp ly o f it w ith roots?
•S h o w p o s te rio r be lly o f d ig a stric ? ne rve su pply ?
'Id e n tify Internal ca ro tid artery a nd E xternal carotid a rte ry .H ow can you id entify ( First branch
given by s u p e rio r th y ro id a rte ry in eca)
•G iven m icro sco p ic picture o f M ela no m a in lym ph nodes
•W h a t s p re ad s in lym ph n o d e s(lym p h o m a ,le u ke m ia ,m e ta sta sis). C om m on sites fo r m e ta sta sis
16) Anatomy
P icture o f a b d o m e n vessels
•Id e n tify A o rta and IVC
•A o rta starts and e nds level
•w h a t is tra n s p y lo ric plane?
•A n te rio r relations o f A o rta ?
•S h o w m e bran ch e s o f aorta both in ca d a ve r d issection picture and M R A?
•P o s te rio r branch es o f A o rta ?
*IV C sta rts a nd ends level
•T rib u ta rie s o f IVC
•P ic tu re o f a sp ecim en sho w ing S a c c u la r aneurysm b e lo w renal veins o f A orta
•W h a t is a n e u rysm ?
* w h a t is dissecting a n e u rysm ?
* w h a t p ercentage o f a rterial w all should increase till you s a y it’s an ane u rysm ? ( I said 30-60% )

17) Pathology
Non hea ling skin ulcers
*S o if th is is a SCC
•w h a t is a ca rcin om a ?
•w h a t are the h istolo gy re p o rts you need to be a w a re fo r S C C ?
•w h a t are the tre a tm e n t o p tio n s? (take w id e r excision and radiothera py)
•T e ll m e 2 P ath olo g ica l investig a tio ns fo r this S C C ( Frozen section and excision biopsy)
•W h a t is fro ze n section ?
•D is c h a rg e Y e llo w pus a fte r p la ce m e n t o f graft, w h a t do you think is happe ning ?
•A n y in ve stig a tio n s ? any m ic ro bio lo gical in ve stig a tio n s? ( gram stain and c/s)
•W o u nd C /S sh ow s M R S A ? T re a tm e n t and E radication th e ra p y in b rie f ?
•T e ll m e 5 steps on how m eta stasis o ccu rs from skin to lym ph nodes ( the usual)

18) Pathology
B reast can cer
•W h a t is C ulture a nd H isto lo g y ?
•W h en do you say the cu lture is ina de q uate ? (w as able to a n sw e r o nly ina d e q u a te tissu e )
•W h a t is se n sitivity a nd s pe cificity?
* H isto log y rep ort sh o w P le o m o rp h ism w ith e p ithelia l ce lls w ith C 4 grading
•W h a t a re the g rad in gs ? (c1-c5)
•W h a t is the action o f O e stro g e n rece ptors ?
•w h a t is the action o f herce p tin ?
•W h ile perfo rm ing the g ra ft placem ent, the surgeon noticed redness, edem a around the site of
lesions, w h a t do you thin k is happening ? (p a g e t’s dise a se o r eczem a)
•w h a t are the ca uses o f paget's d ise a se in bre a st ?
•s u d d e n ly the pa tien t d e velo p e d a de cre a se in bp soon a fte r the su rg e ry w ith one dose of
antib io tic, w h a t do you th in k is happe ning ? ( a n a p h yla xis ). E xplain M e chanism and w h a t type
o f hyp e rse n sitivity reaction ?
A n a to m y

1 - Upper Limb c5/6 lesion following RTA

2 - Lower Limb, Femoral Triangle and Adductor canal
3 - Hand bone, Intrinsic muscle hand
4 - Posterior Mediastinum, Heart, Spleen
5 - Cervical Vertebra
6 - Cranial vault, Middle Cranial fossa, Papilledema
7 - Upper Limb elbow
8 - Upper GI, Pancreas relations, lesser sac
9 - Skull, foramina, middle cranial fossa
10 - Axis, Atlas [Surface anatom y]

C ritic a l ca re

1 - Anastomotic Leak
2 - ATLS C Spine
3 - BCC
4 - Pancreatitis
5 -P E
6 - Pancreatitis
7 - Preload in pregnancy, VTE prophylaxis
8 - Extradural Haemorrhage, ICP
9 - Renal Failure [Pre,Renal,Post]
10 - Aortic Stenosis ECG

P a th o lo g y

1 - Colorectal cancer
2 -G IS T
3 - Infective Endocarditis
4 - Aortic Stenosis
5 - BCC, Lymphoma
6 - Pathological Fracture
7 - Thyroid Ca
8 - FAP and Colorectal Ca
9 - Abscess, Osteomyelitis, Healing, Ulcer
10 - Thyroid Ca
11 - Metastasis proliferation, lymphatic

H is to ry

1 - Claudication
2 - Pancreatitis
3 - Chest Pain post total Hip
4 - Groin Swelling in IVDU, Psudoaneurism
5 - back Pain
6 - head Ache in young guy SAH
E x a m in a tio n

1 - PE, Resp examination

2 - Abdo RUQ pain, Obstructive Jaundice
3 - Ankle Fracture
4 - Abdo examination, LLQ, Diverticular Perf
5 - Knee examination
6 - Ear & Cranial Nerves examination
7 - ABCDE Anastomotic Leak
8 - Hands carpal tunnel
9 - Hands ulnar deficit
10 - CcriSP, PE
11 - Abdomen LIF Pain
12 - Submandibular Gland
13 - Arterial/Venous Fistula
14 - Gynecomastia

C o m m u n ic a tio n s

1 - W arfarin counselling blind patient

2 - Referring Trauma patient to cardiothoracic Centre
3 - Young RTA w ith abdo pain discuss w ith consultant
4 - Chat w ith w ife o f guy w ith m alignant cytology and CT broken
5

P ro c e d u re s

1 - Chest drain
2 - Abscess
3 - Catheter
1.A natom y - id e n tify Thyroid on prosection image(Blood supply and venous drainage, nerves at risk
during thyroidectom y), muscles supplied by recurrent laryngeal.

Identify aortic arch and branches on prosection. Identify this nerve (I th in k it was th e Vagus, image
was n o t great), id e n tify th e recurrent laryngeal.

Identify this (it was part o f th e brachial plexus, I guessed at posterior cord), w hat are it's nerve
roots? M otorcyclist suffers forced depression o f shoulder, w hat nerve palsy m ay occur (Erb's), w hat
de fo rm ity? (w aiters tip ) was asked to describe th e jo in t positions in the w aiter's tip deform ity.

2.A n ato m y - Identify th is muscle on prosection image (Gluteus Maximus), w hat is it's nerve supply.
W hat is th e Function o f Gluteus MEDIUS. W hat are th e bony landmarks associated w ith th e sciatic
nerve. The sciatic nerve passes under piriform is, w hat are the o th e r 2 anatom ical variants in relation
to piriform is. Iden tify the th re e ham string muscles on a prosection. Identify th e structures in the
popliteal fossa in a prosecution image (popliteal artery, vein, tibial and com m on fib u la r nerve).

W hat structure is at risk in a supracondylar fracture. Rapid fire differentials fo r a popliteal swelling
due to skin, artery, vein, jo in t)

3 .P athology - Histology re p o rt a fte r appendectom y, reporting incom plete excision o f a carcinoid

tu m o u r. Defining characteristics o f a carcinoid tum our, w hat type o f tu m o u r is it? W hat concerns
you about the histology report? (tu m o u r partially excised). W hat is E nterobius v e rm ic u la ris , (I h a d
n o idea, tu r n s o u t Its th re a d w o rm ). Later p atient develops; abdo pain, sweating, etc, w hat is this
called (w anted me to say carcinoid syndrom e a fte r I initially said serotonin syndrom e).

C.difficile questions, diagnosis, histology seen on biopsy. W hat do you need to do fo r C.Diff o ther
than th a t fo r colitis?! (I talked about barrier nursing).

4.C ritical care - Patient becomes breathless a fte r failed IJV central line insertion. Describe
anatom ical landm ark fo r IJV line insertion. Explain your assessment o f the patient's breathing. W hat
w ould you do fo r them ? Given a CXR w hen I said I w ould get one (massive L Pneum othorax). Was
asked to describe my system o f assessing a CXR w ith o u t talking about th e pathology. Asked if this
was a technically adequate film fo r th is case (the costophrenic angles w ere not included, but I said I
w o u ld n 't be looking to do another CXR fo r this significant pathology). Asked w hat kind o f pneumo
(no tracheal or m ediastinal deviation). Asked how to classify pneum othoracies. Asked about
im m ediate com plications o f central line insertion. Asked a bout th e com m onest organism fo r central
line infection and risk factors fo r Central line infections.

Asked w hat the recom m ended technique is fo r identifying the insertion site fo r a IJV insertion,
(ultrasound)

5.C ritical care - Large bowel obstruction, AXR in te rp re ta tio n . M anagem ent and investigation o f LBO.
Can't rem em ber much else about this one

6.C ritical care - Painless jaundice. In te rp re ta tio n o f LFTs. Describe th e origin o f bilirubin, describe
entero-hepatic recirculation, w h at is it's function. How much bile is produced per day? How does
bile em ulsify fats? How do you classify jaundice? W hat are your d ifferentials fo r painless jaundice?
W hat can a radiologist do to help w ith this?

7 .H istory - 6 weeks o f neck swelling, lots o f th yro id symptoms. Asked fo r differentials, investigation
and m anagem ent. Ran o u t o f tim e during questioning.
8 .ln fo - Talk through OGD fo r an apparently benign stricture. Asked to talk specifically about risks o f
dilata tio n . Patient was anxious. Bloods showed anaemia, had w eight loss. Heavy sm oker and drinker.
Ran o u t o f tim e to discuss lifestyle m odification.

9 .Info - Talk to on-call consultant on the phone about a case. Patient had a m astectom y and has an
increasing blood o u tp u t in th e drain. No bloods taken fo r 4 days, obs showed a borderline pyrexia.

P a tien ts m o th e r w ants to take her o u t th e hospital today. No idea w hat the patient w ants as I
haven't spoken to her in th is scenario. Talked about assessing capacity and w hat m y plan was next.

10.Exam - Patient under observation fo r 2 days a fte r a drunken head injury. Now reporting loss o f
hearing. Please do an ear exam.

Shown picture o f hem otym panum . Asked about how to do W ebbers and Rene's te st several times...

W hat m anagem ent do you w an t to do fo r this patient.

11.Exam - Resp exam. Pleural effusion. Asked about differentials, got to m y 3rd diffe re n tia l o f
M esotheliom a and exam iner lite ra lly said 'th a t's n o t likely in a m iddle aged construction w o rke r in
the UK'.

12.Exam - Low back pain, sciatic sym ptom s. No red flags. Only sign was weakness o f ankle
dorsiflexion. Asked fo r differentials, I said disc prolapse, malignancy, vertebral crush type fracture,
and then kept g etting pressed fo r m ore. Asked w hat disc was likely to be prolapsed, asked on
m anagem ent o f disc prolapse.

13.Procedure - 1. Suture w ith a hand tie using non-absorbable braided. 2. Suture w ith hand tie at
depth using absorbable braided. 3. Control a bleeding ulcer using a z-type (figure 8) suture, using
non-absorbable m onofilam ent.

W hat a disaster... I look down at the fo u r packets o f suture and th e re is only m onofilam ent (PDS and
Prolene), I keep saying th a t these are not braided, and get nothing fro m the examiner. I'm losing
tim e here. He tells me to proceed, I have to cut the double needles o ff and try and suture w ith hand
tied m o no fila m en t th a t I can barely hold onto. I'm in a b it o f a panic now. Trying to tie at depth w ith
prolene was impossible. I get to ld to m ove on to the ulcer. I then see th a t there are 2 LOOSE bits o f
suture lying on th e fucking table... I then run o u t o f tim e a fte r taking m y firs t bite o f the suture pad.

2 x reading stations and a rest s ta tio n .

 1. Examination o f Ear - as usual
2. Examination o f diverticulitis- as usual
3. Examination o f foot- diabetic man, ulceration, what is charcots foot, what can cause it-
NEW
4. Burns + A R D S - as usual
5. Prep
6. Angry wife + C T scan - as usual
7. Prep
8. Call trauma consultant for aortic rupture - as usual
9. Ordering list- as usual- extra questions RE what skin prep to use in each circumstance,
where to place diathermy
10. Posterior thigh from behind- as usual- muscles, innervation + popliteal fossa (NEW ) from
side, labelled, name all neurovascular structures according to label
11. Testicular tumours- as usual- as usual-
12. Inner part o f skull lined by dura, sm all nerves: identify pituitary stalk, CN 3, CN4, ICA,
tentorium cerebelli and attachments, where does optic nerve open into- Few new questions
13. History taking: thyroid tumour- patient has classic findings o f palpitations, tremors,
14. NP tumour and tracheostomy and feeding, C X R x2 with different NOT placements- as
usual
15. Respiratory acidosis secondary to morphine overdose- as usual
2021
compilation

Last updated 29 Aug 2021

Email to: peanutbutterm onster@ gm ail.com

All contributors are anonym ised and
accounts redacted for safety
1. History: Unilateral tonsillar swelling
o 45M R sided tonsil swelling, no pain, no difficulty swallowing, no resp/abdo, no other
lumps. Weight loss, tiredness,
o Differentials - SCC, lymphoma, TB, asymmetrical tonsils,
o Investigations - biopsy and EUA
o Further management - MDT, CT for staging, MRI
2. Comms: Discussion with ITU reg - pre-op plan and booking bed on ITU
o 76M, PMHx COPD on salbutamol/steroids, admitted off legs’, sudden onset abdominal
pain on ward with peritonism on examination. Hypokalaemic (2.1), lactic acidosis on
blood gas, new AKI, raised amylase. BP drop and HR increased since admission,
o ?ECG findings in hypokalaemia (Prolonged PR. U waves, ST depression, flat P wave)
o ?Other ECG findings in sepsis (AF)
o ?Cause of findings - perforation likely DU, DDx pancreatitis
o ?lnitial management - needs central line for faster K* replacement, cardiac monitoring,
IVT
o Only one bed on ITU which needs to go to medical patient, alternatives? - ward round -»
discharge/step down to open up new bed, stay in recovery.
3. Comms: Wife discussion (unhappy)
o Husband admitted with ascites, no other symptoms, previously worked as painter. Ascitic
tap shows malignant cells. CT broken, earliest scan next week or if urgent, could be
performed at hospital 40 miles away. Tumour markers sent and USS booked for
tomorrow in meantime. Wife informed by registrar that it is advanced malignancy and no
treatment available (this was not the case in the notes),
o Discussion about is it definitely cancer/advanced malignancy - essentially yes to cancer
but do not know if advanced
o ?Cause - unknown at present, further investigations required.
o Will delay in CT cause problems? Can he be transferred? - no, can wait until next week,
other investigations will likely take time,
o W hat treatment? Following investigations, will depend on what found, MDT discussion
and options would then be discussed,
o W hat if he experiences pain? Can have therapeutic tap on ward.
4. Pathology: femoral pseudoaneurysm + HIV
o Young man, Hep B + C + HIV positive, IVDU. Groin swelling, tender, erythematous,
raised inflammatory markers,
o W hat is a retrovirus?
o Causes of aneurysm - * atherosclerosis, trauma, connective tissue, infective (bacterial
and fungal)
■ Did not want causes of atherosclerosis - took HTN, diabetes, smoking etc as one
answer
o Difference between pseudoaneurysm and aneurysm - involvement of whole vs part of
vessel wall
■ Asked which part involved in pseudoaneurysm
o Venepuncture PPE precautions in HIV - normal Covid PPE
o Management of bleeding pseudoaneyrusm - A-E, fluids ± blood, pressure, FemStop,
surgery.
o Problems of pseudoaneurysm - bleeding, rupture, compression on surrounding
neurovascular structures.
5. Critical Care: Steroids
o Middle aged man undergoing pre-op assessment for oesophagectomy, background of
RA and on steroids,
o Describe layers of adrenal gland + what is produced - cortex: zona
glomerulosa/fasciculata/reticularis, medulla. Mineralocorticoids, glucocorticoids,
androgens, adrenaline and noradrenaline,
o W hat does aldosterone do? - Fluid retention - resorption of sodium and excretion of
potassium
 o Impact of steroids on surgery - risk of Addisonian crisis, hyperglycaemia, poor wound
healing, infection, kept asking for more,
o Other side effects of steroids
o How would Addisonian crisis present - abdominal pain, confusion, nausea/vomiting,
shock. Hyponatraemia/hyperkalaemia.
o How to prevent - IV on induction, double dose.
6. Critical Care: Crush Injury with # tib and fib, AKI( compartment syndrome + bicarbonate use? +
differentials + causes of AKI + management - fasciotomy etc)
o Middle aged man 24hrs post injury (wall fell onto L leg resulting in #tib and fib), new AKI
on bloods.
o Initial management: A-E (kept brief, interrupted and asked to focus on C), acidotic on
ABG with raised lactate. Worsening pain in leg.
o Further bloods tests - CK, lactate, coag + G&S teeing up for surgery
o Explain likely pathophysiology of current problem - myoglobin + release from injured
muscle ± developing compartment syndrome/rhabdomyolysis resulting in AKI and
acidosis.
o How would patient present with compartment syndrome - 6 Ps
o Management - Fasciotomy
■ Asked where incision would be made and which incisions for which
compartments
7. Anatomy: Neck - all images of prosections, structures labelled with letters
o Which letters make up posterior triangle and what are they
o Location of accessory nerve
o W hat is the thin muscle just under skin - platysma
o Pointed to several structures - posterior belly of digastric, external and internal carotid,
submandibular gland, great auricular nerve
o W hat are the extrinsic muscles of the tongue
o W hat is their nerve supply
o Showed image of histology sample - no idea.
8. Anatomy: Ankle - all images of prosections/diagram of bones, structures labelled with letters
o Name bones of foot and point to letter they correspond to
o Which bones make up lateral arch
o Identify + name: structures behind medial malleolus, muscles involved in inversion of foot
o Where is dorsalis pedis and posterior tibial palpated, describe + show on images
o W hat is the blood supply to the foot
o Actions at the tibio-talar joint - dorsiflexion, plantarflexion
o Actions at the sub-talar joint - inversion, eversion
o Demonstrate inversion and eversion (examiner stood up to see me demonstrate)
o Which muscles are responsible for eversion - peroneus longus, brevis
o Ligaments of the medial ankle
o Ligaments damaged in medial malleolus fracture
9. Procedure: Hand tying + suturing
o Hand tie under tension (between two bits of rubber band) using braided absorbable
suture
o Hand tie at depth, without pulling hook attached to magnet off base (using braided
absorbable suture)
o Z-suture to under-run bleeding vessel (dot drawn on rubber) using non-absorbable
monofilament
o Notes:
■ Asked to cut hand tie down to appropriate length
■ Sutures are in packets which say what type of suture they are (mono/braided,
absorbable/non)
■ Prolene came as double ended suture, was told Ethilon had run out - ended up
cutting off one of the needles and examiner was happy
■ Told by other candidates examiner was keen for people to keep a tidy space and
get rid of rubbish.
 10. Examination: Hand examination, findings given whilst doing examination
o Elderly man, hand pain, dropped a cup recently. Findings: muscle wasting at thenar
eminence, reduced thumb abduction + flexion, Tinel's and Phalen's positive,
o Differentials - Carpal tunnel, De Quervains, cervical radiculopathy, neuropathy, OA?
o Investigations - XRs, nerve conduction (?), USS (?)
o Management - conservative vs surgical
11. Examination: Back pain and claudication symptoms - choose appropriate examination
o Elderly man with lower back pain radiating down to calves on walking uphill and downhill,
relieves with rest.
o Did lower limb neuro/vascular examination + lower back examination, findings:
Weakness of GT dorsiflexion, numbness around toe.
o Asked what would look for on PR - reduced sphincter tone and reduced perianal
sensation to pin prick
o ?Differentials - spinal stenosis, CES/SCC,
o ?Causes for compression - prolapsed disc, malignancy (primary or secondary), abscess
o Management of CES - urgent neurosurgical input ± laminectomy/discectomy
12. Examination: Groin lump exam.
o Notes: quite a lot of people complained about the examiner for this station, didn’t allow
much progression and was guite standoffish,
o Young man with scrotal swelling. Findings: 10x7cm swelling on testicle, not discernible
from testicle, transilluminates. No hernia symptoms,
o Describe how you try to get above lump
o Asked other examinations to perform: abdominal exam and inguinal lymph nodes.
■ Asked why would you palpate inguinal lymph nodes if suspect testicular cancer -
where does testicular cancer spread (para-aortic), asked why palpate inguinal
nodes then (said mass could be scrotal in nature)
o Differentials - hydrocoele, testicular cancer, varicocoele, lipoma, scrotal abscess/cyst,
orchitis.
o Blood tests - normal blood tests + AFP + 3-HcG
o Other investigations - USS, staging CT if concerning
o Management - MDT ± inguinal orchidectomy
13. Critical Care: Perforation (pneumoperitoneum on CXR and AF - causes and management,
cardiac output and diastole)
o Elderly man, confused, abdominal pain. CXR shows pneumoperitoneum, raised
inflammatory markers, lactic acidosis,
o How would you start assessing XR/ECG
o Given XR - asked to identify abnormal findings (bilateral pneumoperitoneum)
o Given ECG - asked to calculate rate and identify rhythm (AF)
o Differential based on above info - perforated viscus
o Other causes of pneumoperitoneum - post-laparoscopic surgery (asked for more but
couldn’t think of any, started listing places of perforation)
o W hy would rate on ECG be different to that from blood pressure cuff? - varying pulse
pressure in AF
o W hat concerns do you have with AF - reduced diastole resulting in reduced blood flow to
coronary arteries, risk of ischaemia/MI/progression to other arrhythmias
o Management of AF - treatment of underlying cause, rate vs rhythm control (discuss with
medics) - asked to give examples (beta blockers, digoxin) cardioversion if
haemodynamically unstable, anticoagulation.

Reflection:
Overall:
Fair exam. Examiners varied - some were nice and guided me to answers, some just asked direct
guestions/difficult to read, generally they were all pleasant and no one was horrible. Set up was fine, in a
big hall with booths' set up using big tall panel dividers, got a bit loud at times but difficult to hear other
candidates.
Stations:
First station was almost word for word "PTM" history station. Image quality in anatomy stations was good,
didn’t have an excuse for being so bad at the neck station. Critical care stations always interrupted me
when I started talking through my rehearsed thorough A-E assessment - just wanted to get to the parts
that were actually relevant to station. Two of the examination stations stated please do this exam', the
other one just asked to examine the patient - 1had to decide which exam to do - seems to be a pattern of
this in previous exams as well.
1. Physical exam (verbalising) lower bachache radiating to lower limbs, with paresthesia. With
foot drop and sensory loss on L5. Causes? Treatment? What should be done to complete my
examination?

2. Physical exam scrotal lump (hydrocele). Asked questions about management of suspected
testicular cancer and hydrocele at 25 yr age. What type of cancer at this age? Management of
hydrocele. ? DDs of scrotal lump. How to classify testicular tumors.

3. Physical examination of submandibular gland. ( h/o intermittent swelling of submandibular

gland) causes? How to investigate? How to complete my examination? Treatment of salivary
duct stones.

4. History of a patient referred by GP with a seizure, plus had headache and arm weakness.
Differentials.? Treatment? Investigations? Special surgical instruments in neurosurgery? What
are primary and secondary tumors? What are primary brain tumours?

5. Counselling of a patient whose arthroscopy was cancelled. Same scenario, same questions
regarding weight gain, pain affecting work, angry due to delay. Wife’s work also being
affected. What are the implications of delay?

6. Communication: referring a patient to cardiothoracic surgeon. Pt 27/ male, came after RTA,
hypotensive, tachycardia and tachypneac, chest X-ray showed widened
mediastinum, abdominal Xray shows absent psoas shadow. Refer to him. He asked
about primary survey (was not clearly documented to have completed properly), also
asked about what needs to be done next? How to transfer? Causes of shock in this patient?

7. Critical care: young patient in RTA, with respiratory acidosis. Pulse, bp normal. Causes
of respiratory depression? Mechanism of respiratory depression? image of MRI sagittal
view shows fracture of C3 with cord compression, effects of this spinal injury? Central
cord syndrome,? How to assess breathing in ATLS? How to manage spine fracture?

8. Critical care: hypothermia. Read obs chart showing hypothermia. Define hypothermia,
causes in a patient going for laparotomy, how does patient will lose heat in theatre? how to
avoid ? Complications due to hypothermia? How to measure core body temperature?

9. Critical care: "new station”. 6 yr child with tonsillectomy 5 days ago coming with bleed from
tonsillar fossa, and is a Jehovah witness. How to manage? What does it mean that he is
a Jehovah witness? What are the options for resuscitation? How much fluid to be given for
resuscitation in children in shock? What fluids should be given in children? How to calculate
maintenance fluid dose? Definitive treatment for tonsillar bleed? WHAT TO do after
bleeding stops? Hb dropped afterwards, how to treat?

10. Anatomy: neck and shoulder region: identify thyroid gland, blood supply of thyroid gland and
parathyroid gland, venous drainage, identify vagus nerve and recurrent laryngeal nerve. Effects
of injury to recurrent laryngeal nerve, nerves at risk during thyroid surgery, klumpke’s palsy
details of sensory and motor loss, Erb’s palsy details, position of upper limb in Erb’s
palsy? Identify arch of aorta and its branches.

11. Ankle anatomy: identify bones of foot and orientate tibia and fibula. Movements at ankle
and subtalar joints, lateral longitudinal arch, muscles causing eversion? Muscles
causing inversion? Identify ligaments of ankle joint with their individual parts. What ateries cross
ankle joint? How to palpate them? Identify extensor hallucis. Muscles of anterior
compartment? Identify posterior tibial artery, how does it supply plantar aspect of
foot. What joint is the lower tibiofibular joint?

12. Surgical pathology. Patient with diverticular abscess. What is an abscess? HOW DOES
WBC reach the area? Constituents of pus? What causes fever? Life span of WBC? What
are neutrophils? Where are they formed? ARDS pathophysiology? How to diagnose
DIC? Treatment of diverticular abscess?

13. Procedural skills: stitch a thigh laceration under local anesthesia. Doses of local anaesthetic,
how much to give (in ml) when to remove skin sutures? How to test before starting the stitches?
1. Crit care- RTA- Identify injury on xray- C3 # dislocation. ABG sh ow ed -
type 2 re sp failure- R eason? Had shallow breathing. Phrenic nerve
involvement. Physiological effects o f shallow respiration? How to
m an age? Who will you inform?
2. Suturing a laceration on thigh wound- Nurse to help, Check mark, local,
consent. Was being ask ed question while suturing- will it give a sc ar? Will
it be painful? How m any su tu re s? When to rem ove? Asked question s
about LA in the end.
3. Anatomy: Pictures of M ediastinum an d Neck. They w ere a bit zo o m ed in.
T ook time to orientate. Identify Vagus, Phrenic, RLN, Brachial plexus.
Thyroid and its blood supply, Erb's an d Klumpke's paralysis- features.
4. Anatomy- Ankle and foot- p hotograp h s again plus bone model o f fo o t One
very impractical question on how we will articulate tibia an d fibula via
photographs- difficult to understan d the question. Bones o f foot identify,
arches, blood supply o f foot. Ankle an d sub-talar movements, tendons
causing inversion- identify.
5. Pathology- Diverticulitis and endom etriosis patient. Very basic pathology
question about neutrophils origin, lifespan, MOA. Cells and horm ones
involves in inflammation? What is en dom etriosis?
6. Crit Care- reactionary tonsillar bleed in a 6 y ear old. How to m an age in
ED? Fluid resuscitation an d maintenance dosage, parents- Jehovah's
w itn ess will you give blood transfusion? How to sto p bleeding in theatre?
WHO checklist.
7. Crit Care- Hypothermia station. Core tem p eratu re? What to do in w ard ?
Why in creased risk in theatre? W ays of heat loss in theatre? Things to
prevent or d ec re ase chances of hypotherm ia? Complications?
8. Communication- Angry patient- 2 nd tim e cancelled arthroscopy for
m eniscectom y due to consultant called off to em ergency theatre. Went
through all the usual points. Also in the end, ask ed m e to explain the
procedure, its risks and benefits a s time remaining!
9. Examination- Subm an dibular gland swelling. Questions abo ut Sialadenois
diagn osis and management.
10. Examination- Scrotal lump- Questions about Hydrocoele and testicular
tumors.
11. Examination- Low er limb neurology examination- CPN palsy. Had to give
clarifications a s I w as going through the examination bit. How ill you
investigate and manage.?
12. Communication- Phone call- Discuss with CTVS consultant- advice and
potential tran sfer of patient. RTA, Mediastinal widening, Fem ur fracture,
free fluid in abdom en; CT scan n er broken; Lots o f lab values and
observations- found it had multiple things going on with many
dimensions. Found the phone call to be very haphazard a s did not know
which w ay it w as going. At the end - w as ask ed how will you tran sfer and
the bell goes!
13. History- 51 yr old tran sferred from another hospital after som ething
abnorm al detected in brain scan- Had h /o GTCS, headache and right arm
 w eakness. Frontal lobe SOL- DD; What will you do currently in ward-
m anagem ent?

Have given it a shot!! Can be a bit subjective to know how you have really done.
At tim es Finished early in certain stations and we w ere ju st sitting for the
remaining time- Now don't know if they liked my a n sw e rs or ju st m oved on with
the questions. :D Now lets se e w hat the results sh ow up... Fingers crossed!
A natom y (3)

1. Base o f Skull and foram en

-Layer o f scalp

2. A natom y o f shoulder w ith ro ta to r muscle groups and scapula/clavicle/ hum erus detailings

3. Liver, Heart and Kidney anatom y

Physiology(l)

1. Calcium Homeostasis
(explanation o f free calcium fo rm , role o f calcium,

Pathology(l)

1. Abscess and Pus

P rocedure(l)

1. Suturing Procedure

C o m m u n ica tio n ^)

1. Phone call
-consultant call to discuss a b ou t a patient request AOR discharge

2. Explanation o f OGDS procedure to patient

Critical care(3)

1.Patient w ith Heamatemesis, m anagem ent

2.XRay re v ie w , pneum othorax ty p e s , m anagement

E xam in atio n ^)

Cranial nerve exam ination

Chest /CVS exam ination fo r p a tie n t w ith pacemaker going fo r operation

Hx T a k in g ( l)

1.Patient w ith abdom inal pain(Pancreatitis)

Please be relaxed and fo llo w old past year papers, you w ill do fine. Do pray fo r me to pass.

©
Anatomy

1. Head and neck

Brain
- neck region
- name the triangles and borders
- name anterior triangle and the 3 sub triangles
- w hat is this muscle- om ohyoid- w hat is innervation
- w hat are the external muscles o f tongue-w hat are their innervations
- submandibular gland- w hat 3 nerves pass
- w hat kind o f secretion does submandibular gland produce
- Idetify Carina, w hat level bifurcate
- identify facial artery
- If you ligate facial artery, w ill you end up w ith necrosis o f the muscles it supplies? Answer is no,
why? Anastomosis from Lingual Artery

- Identify glossopharyngeal nerve. W hat does it supply

- show eca, w hat nerve passes just anterior to eca
Neuroanatom y - shown cerebral angio. Identify vessels.
W here does carotid enter.
W hat branch given o ff before anterior/m iddle cerebral. Point it o ut on neck dissection.
How tre a t aneurysm.
W hat type o f haemorrhage when ruptures.
W hat signs o f MCA infarct. W hat o ther vessel supplies.
W here does it enter skull. How cross over atlas.

Name all the venous sinuses and how they run

b. Point to me w hat sinus is this (straight sinus)
c. Identify the ventricles and flo w o f CSF
d. MRI picture (Astocytoma): w hat are your differentials

Skull bone and lateral skull and cervical XR

0 Points and asked to identify on skull bone: Optic canal, superior orbital fissure, foram ina rotundum , ovale,
spinosum, and th e ir contents
0 W hat is the m otor innervations o f the mandibular branch o f trigem inal nerve? Answer: muscles o f mastication,
mylohyoid, digastric (anterior belly)
0 Asked to identify on cervical XR: pituitary gland, sphenoid sinus

a. Identify trachea, oesophagus, vagus nerve in the neck

b. Points to the branching o f the trachea into 2 bronchus? W hat is this junction called? Examiner
not satisfied w ith carina. W anted something else.
c. W hat level does it branch?
d. Identify parotid, submandibular glands
e. W hat glands does it contain?
f. W here does the duct o f the parotid and submandibular gland open?.

- which parasympathetic ganglion supplies the parotid gland?

- which region o f the body does the pre auricular lymph node drain?
- on the base o f skull, show me where the facial nerve exits

Specimens o f head, thorax.

Asked to identify facial artery,
vagus nerve, parotid, submandibular, ducts o f salivary gland.

structure just passing in fro n t o f CCA bifurcation (hypoglossal nerve ) its clinical correlation and how is the presentation
o f its injury,
Rt vagus, facial artery and its surface marking ( Q: Can we ligate this w ith o u t sequelae ? )

Skull
W hat is diploic veins
e. Foramens on base o f skull - name them
i. Foramen spinosum - m iddle meningeal artery
ii. Foramen ovale &amp; nerve
iii. Stylomastoid foramen &amp; nerve
f. Pterion - significance and bones th a t make it up
g. Muscles attached to styloid process
h. Show cervical vertebrae on Cspine xray
i. W hat is odontoid process
ii. W hat is the jo in t between odontoid and atlas - pivot
jo in t
-Mandible, muscles o f mastication
-Cspine lateral XR shown: identify C l structure
-Skull, foram en ovale and structures. Stylomastoid foramen and structure (w hat happens if cut)
-How old when mastoid developes?
- Identify condylar process o f mandible
- Describe how and where it articulates w ith skull
- Demonstrate articulation between mandible and skull
Temporal mandibular jo in t
i. W hat jo in t is it: P articular fibrocartilaginous jo in t
ii. In a living person w hat do you find???
iii. Movements o f the TMJ
iv. Muscles acting on jo in t
- Which muscles depress mandible, which muscles move mandible from side to side
- On skull inferior view, identify stylomastoid foram en, which nerve passes through
- On inferior view, identify foram en ovale, foramen spinosum and structures passing through
- Styloid process - w hat muscles attach here
- Show w here pterion is, what is significance o f area
- Lateral skull XR - identify ethm oid sinus, pituitary fossa, different suture lines

Optic canal, superior orbital fissure, ovale, spinosum and contents.

Course o f hypoglossal nerve in neck.
Mechanism o f papilledema

Borders o f middle cranial fossa , which brain lobe occupies it ? , foramen rotundum and strucures
passing through i t , foram en ovale strucures passing through it, anterior clenoid process, strucure
passing lateral to it ??, optic canal and strucures passing through i t , site o f trigem inal ganglion ,
site o f cavernous sinus and strucures passing through i t , Q: cavernous sinus throm bosis ( causes and risk
fa c to rs , clinical p rese nta tio n, why does it present w ith diplopia ? ), site o f middle ear cavity ?
Communication and spread o f infection , fracture base o f skull presentation , pituitary fossa and optic
chiasm .

Identify the pterion.

w hat are the 4 bones th a t converge here and show them on the skull,
w hat is its clinical significance
Identify this bone -- atlas
W hat part is this? A nterior tubercle o f atlas
Show me the foramen lacerum
w hat is posterior cranial fossa form ed by?
Identify this part: petrous tem poral bone
Given lateral XRay o f skull - show me the sella turcica.
W hat is this: ethm oid sinus
On prosection: W hat is this muscle -- tem poralis
W hat is its blood supply? Deep tem poral artery. W here is it from ? LOL.really dunno man.
W hat supplies the scalp over the tem poralis muscle? Superficial tem poral artery. W here is it from ?
On prosection: This is the optic chiasma. W hat nerve is this? Occulom otor nerve.
W hat are the autonomic innervation to the pupil? W hat does sympathetic do and w hat does
parasympathetic do?
W hat do you get in raised ICP?
Why?
W hat exact structure is CNIII pressed against? Show me on the prosection.

Subm andibular gland

a. Boundaries o f posterior triangle, "m iddle 3rd clavicle"
b. W hat is this? Submandibular gland. W hat acini does it have? Mixed serous and mucous. W hat 3 nerves m ight be
injured during submandibular gland op? Hypoglossal nerve, lingual nerve, marginal mandibular branch o f the facial
nerve
W hat w ill be the deficit?
• Weakness o f the low er lip - a low er branch o f the facial nerve (the marginal mandibular branch), affects the
m ovem ent o f your lower lip, leading to a slightly crooked smile.
• Numbness o f the tongue - the lingual nerve is rarely bruised. Since it is the nerve th a t supplies feeling to the
side o f the tongue bruising results in a tingly or numb feeling in the tongueLoss o f taste could also result from
this injury.
• ^Restricted tongue m ovem ent - the hypoglossal nerve is only very rarely bruised. It is a nerve that makes the
tongue move and damage can therefore result in decrease o f tongue movement.

c. differentials o f swollen LN: infective, infiltrative, neoplastic (primary/secondary)

i. given a pathology slide w ith pigmented cells, ?melanoma mets

Parotid and CN7 Anat

surface anatom y o f the parotid duct on the patient (superior border: in f margin o f zygomatic arch, ant: post
border o f masseter, inf: body o f mandible, post: SCM).
Surface anatom y o f parotid duct (m iddle third o f line between antitragic notch and phylum, but examiner was
only happy a fte r I said 1cm below zygomatic arch) how long?
- Duct drains to?
CN9 supplies the parotid
- There is a 2x2 lump over 1 side o f a parotid, tender. W hat is it? (Ans examiner looking for: LN)
- Inflam m atory causes o f parotid swelling. (Ans examiner looking for: sjogrens and mumps)
lipoma, sebaceous cyst, abscess, stone, mumps, sjogren,
- Benign causes o f parotid swelling.
- Malignant causes o f parotid swelling, prim ary: MAP-
mucoepidermoid,adenocystic,pleomorphic adenoca, secondary

- CN carrying parasympathetic fibres. 3,7,9,10

- Gustatory sweating. Freys syndrome. - damage to the parasympathetics to the parotid, causing the fibres th a t usually
signal salivation to connect to the fibres supplying the sweat glands on the skin o f the face, causing gustatory sweating
when the patient sees/smells food.
- Intracranial course o f facial nerve. (1AM to exit stylomastoid foramen)
- Indicate on prosection 1AM and stylomastoid foramen.
- Branches o f facial nerve after parotid. Indicate on prosection.
2- vagus nerve and type o f supply
4 supply o f recurrent laryngeal nerve

Specimen o f neck - th yro id

1. W here is the thyroid
2. W hat are the lobes o f the thyroid
3. W here is the external laryngeal nerve
4. W here is the recurrent laryngeal nerve
5. W hat is the blood & nerve supply o f the thyroid
6. W hat is the venous and lymphatic drainage o f the thyroid
W hat is this?- points to recurrent laryngeal nerve
0 W hat does the RLN supply? Answer: all the intrinsic muscles o f larynx except cricothyroid
0 W hat are the nerves at risk o f damage during thyroidectom y?
physiological response to thyroidectom y

-Embrylogy o f thyroid, form ation o f thyroglossal cyst

- identify aortic arch, vagus nerve and recurrent laryngeal nerve
Arterial and venous supply. W here do they originate and drain ?
3) Cricothyroid membrane
4) Attachm ent o f vocal cords
5) Point to cricoid cartilage
6) Nerves at risk
7) Recurrent if damaged then w t happens

o Nerve Innervation - autonom ic nervous system. Parasympathetic fibers come

from the vagus nerves, and sympathetic fibers are distributed from the
superior, m iddle, and inferior ganglia o f the sympathetic trunk. Controls
perfusion o f the gland

o Nerve close to inferior thyroid artery - RLN

o Commonly injured nerves during thyroidectom y - RLN, SLN, vagus
o Strap Muscles: Sternohyoid (medial hyoid), Sternothyroid, Thyrohyoid
(greater cornu hyoid), Omohyoid
o Nerve Supply - all are ansa cervicalis except thyrohyoid - C l nerve via
hypogloassal n

o Action -depress the hyoid during swallowing or speech

o Attachm ent o f Vocal cords : anterior to thyroid cartilage, posterior to
arytenoids, laterally to laryngeal muscles &amp; medially free edge
o W hat tenses the vocal cords -p o s t cricoarytenoid abducts.

o W here w ill you do cricothyroidectom y

o W hat thyroid Ca spreads lymphatically: only wanted papillary
o Cell Origin o f M edullary Carcinoma -parafollicular C cells!
Thyroid and its lobes. Why does the thyroid move up w ith swallowing?

Strap muscles: which is sternothyroid, which is sternohyoid. Innvervation o f infrahyoid strap muscles?
Nerve roots o f ansa cervicalis?

Omohyoid
Superior thyroid artery. W hat structure is closely related? W hat happens when this structure is injured?
W hat structure is closely related to bifurcation o f ECA and ICA? W hat is the clinical significance of
injuring this structure?
W hat is the landmark used in an emergency airway? Cricothyroid membrane. Identify it.
Identify cricothyroid muscle. W hat innervates this?

branches o f aortic arch, point to vagus, point to recurrent laryngeal, describe thyroid, isthmus lobes,
nerves at risk, w hat does recurrent laryngeal supply? origin o f thyroid?
from foram en caecum descends into neck, w hat is thyroglossal cyst?

Show me the vagus nerve.

0 Show me the recurrent larngeal nerve. W hat does it supply? W hat w ill patient present w ith if damanged? W hat
supplies cricothyroid muscle?

a. Identify different parts o f thyroid gland, omohyoid muscle

b. Strap muscles in fro n t o f thyroid gland
c. Nerve supply o f strap muscles
d. Sympathetic Ganglia in relation to which thyroid artery
e. Muscle causing stretching o f vocal cords
f. Nerve supply o f th a t muscle
g. Name cartilages o f larynx
0 Thyroid - How do you anatomically divide the thyroid? (2 lobes and isthumus,
occasional pyramidal) W hat is the blood supply (arterial and venous) o f thyroid
gland?

v. Specimen o f parotid

1. Identify the branches o f the facial nerve passing through parotid

2. W hat else passes through the parotid
a. Retromandibular vein
b. Branches from the external carotid artery
Branches o f the great auricular nerve, w hat supplies autonom ic fibers to
parotid? auriculotem poral nerve.

a. Head and Neck, Thorax

i. Identify Oesophagus, blood supply, lymphatics
ii. W hat epithelium lines oesophagus - SSNKE
iii. Identify common carotid artery, external carotid, internal carotid
iv. Identify carotid sinus. Function? - Baroreceptor
v. Identify carotid body. Function? - Chemoreceptor fo r pH and Pa02
vi. Bifurcation o f trachea (Identify, did not accept carina). Level - T4
vii. Identify the parotid gland, w hat kind o f saliva - Serous
viii. Identify submandibular gland
ix. Can you ligate facial artery - Yes, anastamosis from opposite side
x. W here to palpate facial artery - A nterior to masseter, against body o f mandible
xi. Identify hypoglossal nerve
xii. W hat does in innervate, likely deficit, w hat is the mechanism - Muscles in the tongue, deviate to affected side
xiii. Identify subclavian artery
xiv. Origin o f subclavian
xv. W hat part o f the brachial plexus lines behind the subclavian artery behind the first rib - Inferior trunk
xvi. W hat is Subclavian steal syndrome? Stenosis o f subclavian artery &gt; retrograde flo w o f blood in vertebral artery at
expense o f vetebrobasilar circulation (so called steal) to supply upper limb
• Epithelium, common cancer, Barrett's oesophagus
• Post mediastinum contents
• Diaphragmatic openings & attachm ent
• Meralgia paresthetica

id external oblique, internal oblique, attacements, direction o f fibers,

muscles form ing conjoint tendon,
id ovaries, tubes, appendix, term inal ileum, ceacum, douglas pouch,
refered pain o f appendicitis to umblicus, pain on flexing hip, psoas muscle, ileoinguinal nerve injury during appendicitis.

1-head and neck:

Carotid angiogram: internal carotid , anterior and middle cerebral arteries, w ith visible aneurysm in the middle
cerebral.it was difficult to be read.
-in skull: identify the internal carotid foram en passage in infra and intracranial view, also asked about location of
cavernous sinus in the skull.
-give one branch o f internal carotid artery before entrance to skull.
-location o f carotid sinus and body site
-identify common carotid artery and its bifurcation.
-w hat is obvious abnorm ality (aneurysm), w hat possible clinical presentation if ruptured? (contralateral
hemiplegia, and he asked w hat else,
-Also asked to identify foramen transversum in c.vertibra , and how the vertebral arteries pass through
C l vertebra to enter the cranium.

-Parathyroid location, clinical significance o f th eir embryological origin.(thoracic position)

-Identify vagus nerve and recurrent laryngeal nerve, difference in origin o f right and le ft RLNs.
-w hat fibers carried o u t by vagus nerve
-w hat muscles supplied by RLN
Parathyroid glands
i. Number
ii. Location
iii. Why do inf thryoids go down into thymus

- W hat physiological problems after to ta l thyroidectom y (hypothyroidism and

hypoparathyroidism)
- W here are the parathyroid glands located
- W hat is th e ir function, w hat does PTH do

M iddle cranial fossa. M idd le ear

i. Borders o f middle cranial fossa (Exact parts o f bone to be named eg. Lesser wing o f sphenoid
ii. Bones o f middle cranial fossa
b. Identify all the foramen o f middle cranial fossa and all the cranial nerves passing through
- cavernous sinus and contents o f medial and lateral wall

- optic canal: surrounding sheath o f optic nerve and clinical significance. W hat o th e r structure:

ophthalm ic artery and it&#39;s significance.

c. Points to the groove o f the middle meningeal artery. Which artery passes in this groove?
d. How w ill this artery be injured?
e. Which bones make up the pterion?
iii. Superior orbital fissue - W hat passes through?
iv. Optic Canal - W hat passes through? - Optic nerve and ophthalm ic artery
v. W hat do you know about the opthalm ic artery and w hat is the significane? End artery, no anastamosis. Blockage can
cause blindness.
vi. Why w ill you get papilloedema w ith raised ICP
vii. Identify Rotundum and w hat runs th ru it
viii. Identify trigem inal ganglion. W here does it lie?
ix. Identify foram en spinosum and w hat runs th ru it?
x. Which bone form s the sella turcica?
xi. Contents o f cavernous sinus
xii. How do the nerves run in the caverous sinus? Which nerves run straight through and which ones run laterally?
xiii. Signs o f cavernous sinus throm bosis - Opthalmoplegia
xiv. Point o u t the ro o f o f middle ear in middle cranial fossa
xv. How does middle ear infection cross into skull - tegmen tympani
xvi. Relations o f the middle ear
xvii. Where else can in spread - mastoid air cells
xviii. Clinical signs o f meningism - Photophobia, neck stiffness, fever
xix. Danger area o f face, which vein (inferior opthalm ic vein)
f. How can infection spread from the middle ear to the middle cranial fossa? Through petrous part
o f tem poral bone but examiner also wants spread o f infection through mastoid antrum
g. Which lobe o f the brain w ill be affected in this infection?

3) Posterior cranial fossa

• Boundaries
• Dural sinuses
• CN IX, X, XI
• Foramen magnum
• Common benign tum ours
• Clivus

Posterior triangle o f neck

0 Identify accessory nerve, w hat does it supply, w hat happens when it is paralyzed, how to test these muscles
0 Identify the omohyoid
0 Identify great auricular nerve, w hat does it supply
0 Identify digastric, hypoglossal nerve
0 W hat are the extrinsic muscles o f the tongue, w hat is the nerve supply,
w hat muscle responsible for retraction o f the tongue

11 w eighted saggital MRI o f the brain.

Asked me to identify the occipital bone (gave me a pointer)
cervical vertebrae and th e ir parts,
corpus callosum,
all the cisterns,
cerebellum,
cerebellar vermis and tonsils,
ventricles, cisterna magna and interpeduncular cistern.
Also asked to describe the drainage o f CSF complete w ith all the foram ina (lushka, magendie, etc).
Then asked w hat is Arnold chiari m alform ation and w hat would you see differently on this MRI.
1started w ith descent o f tonsils through foram en magnum and he seemed okay w ith that and quickly moved on.

skull
and said name the last 4 cranial nerves and tell me where they pass from

2. Thorax/Abdomen
Heart
a. w hat is this? tricuspid valve, papillary muscle, chordae tendinae. w hat is function o f chordae tendinae? prevent av
prolapse during vent systole
0 Branches o f the ascending aorta
b. w hat is this? azygous vein (it looks bigger than you think, please do n 't confuse it w ith right brachiocephalic trunk or
right brachiocephalic vein).
Name me tributaries? bronchial veins, oesophageal veins, hemi azygous veins, intercostal veins

c. Gallbladder surface anatomy? L I transpyloric plane and mid clav line

0 Why w ould a patient w ith RUQ pain also have shoulder tip pain? Explain referred pain.
d. Spleen surface anatomy? space o f traube. between 9th and 11th rib etc
w hat may be injured during a splenectomy
i. blood supply o f spleen? splenic artery, describe it's course from it's branch o ff celiac axis
course: - (she wanted to hear lienorenal ligament in particular),
ii. w hat does it supply? stomach, pancreas, spleen
W hat drains into the thoracic duct?
e. w hat is this? sympathetic chain. Vertebral levels? T1 to L I (or L2). How does it connect to spinal nerves? preganglionic
via ventral rami through com m itantes (grey rami commitantes)

W hat structure must be preserved in splenectomy? W hat 2 other structures

does it supply? Identify this structure. (Duodenum.) How many parts does it have? Which part does
ampulla o f vater open into? W hich structures open into the duodenal papilllae? W hat do they drain?
W hat blood vessel runs posterior to D l?

i. Specimen o f heart
1. W here is the ascending aorta
2. W here is the braciocephalic trunk
3. W here is the recurrent laryngeal nerve on left
4. W hat are the branches o f the ascending carotid
W here is the le ft vagus nerve (identified in le ft carotid sheath)
W hat is this- points to ascending aorta
0 W hat is this- points to arch o f aorta
0 W hat are the branches o f the arch o f aorta?

- w hat are the branches o f the pulmonary trunk?

Lung
le ft lung specimen
identify the pulm onary artery, veins and main bronchus.
Asked w hat level does the pulm onary tru nk divide at
w hat the pulm onary ligament is and w here it attached
- Identify hilum o f lung
- W hat is in the hilum, identify all the components
- How many pulm onary veins are there in each lung
- Which is most anterior in hilum
- W hat level is the hilum at
- W hat passes through central tendon o f diaphragm
- W hat are the bony attachments o f the diaphragm
- W hat are the ligaments o f the diaphragm (I just said median arcuate ligament and he moved
on. Didn't get to say the rest)
hila o f lung, Which lung, identify bronchus. W hat is pulmonary ligament.

Description o f outline o f pleura. Describe the locations o f transverse and horizontal fissure o f right lung.
Specimen o f lung and heart- Pick them up and name the parts. I spoke fo r a while until the chap got bored and moved
on.
Section o f calf dem onstrating DVT- w hat is it? describe the course o f the clot from leg to lung.

Liver
identify the lobes
falciform ligament
boundaries o f caudate lobe
name the main artery th a t supplies the liver and stomach, w hat are its branches,
w hat is the venous drainage o f the liver,
w hat ligaments attach the liver to the diaphragm

- Organs damaged by knife just under the xiphiod. (Answer he wanted was left lobe o f liver
and diaphragm. I said heart first but he kept pushing fo r liver and diaphragm)
- How far does the le ft lobe o f the liver extend to norm ally (he said YES! When I said le ft mid
clavicular line. Anyhow guess =S)
- W hat divides le ft and right lobe o f liver.
- W hat attaches liver to diaphragm (have to point on specimen.)
- Identify quadrate lobe and name its boundaries.

- w hat are the first 2 organs injured in a stab wound to the epigastrium?

Given specimen o f right lung, w hy right lung, shown the hilum , identify the structures
Number o f bronchopulm onary segments in each lung
W hat happens if clot - PE
Show on skeleton the surface markings o f the lungs on both sides
Usual questions on right bronchus - where foreign body w ill lodge and why
W hat are the surface markings to determ ine vertebra level - m entioned the inferior angle o f scapula
and spine o f scapula
Also wanted me to mention C7 as the m ost prom inent vertebra to count downwards

Next given specimen o f heart, identify atria, ventricles, SVC, IVC

- w hat demarcates the le ft and right lobes o f the liver?
- w hat is the venous drainage o f the liver?
- w hat branch o f the celiac tru nk supplies both the stomach and the liver?
- In w hat structure does it run to reach the porta hepatis?
- point out the quadrate lobe
- w hat are the boundaries o f the quadrate lobe?

W hat are lobes o f liver. Identify H and portal triad. Shown

Lung anatom y an outline

Orientate the lung (right lung)

W hat nerve lies in fro n t and w hat behind - ant: phrenic nerve, post: sympathetic chain
Name the fissures
How many bronchi pulm onary segments are there?
Talk about DVT
W hat is the best test? PE: CT angiogramand V/Q scan
Talk through the path o f a clot starting in the calf - deep veins o f the calf -- &gt; popilteal vein, femoral
vein, ext iliac, common iliac, ivc, atrium , AV valve, pulm onary valve to the pulmonary artery
Lower long saphaneous vein anatom y w ith some lung anatomy surface anatomy- arises from the
dorsal veins o f the foot, passes anterior to the med malleolus, rises in the med aspect o f the calf, lies
4 finger breath post to the med condyle o f the fem ur, rises up the med aspect o f the thigh before
ending in the SFJ medial to the fem oral artery.
W hat nerve is in close relation to this vein (saphaenous nerve)
X-ray o f a pneumothorax
Where would you insert a chest drain; triangle o f safety, 5 th intercoastal space, bounded anteriorly
by the post border o f pectoris major, posteriorly by the mid axillary line
If tension where do you decompress - mid calvicular line, 2 nd intercoastal sapce

Abdom en

whats the border o f posterior mediastinum?

contents?
which level eso enters diaphram? w hat part o f diaphgram?
where eso begins? level
w hat LN does esophageus drain to?
Arterial supply plus drainage?
W hat is the cells lining the esophagus?
w hat is barrets esophagus?
w hat risk?

HPB (Transpyloric plane anatom y prosection)

a. Name the m ajor structures in the area
b. Explain form ation o f the pancreas
c. Explain renal vessels

Identify the duodenum, how many parts are there (4),

w hat are the 2 ducts th a t enter the duodenum and where do they enter
(Enters at D2 (descending), the pancreatic duct and accessory pancreatic duct).
Identify the sympathetic chain, w hat connects the spinal nerves to the sympathetic chain (the rami communicantes)
Identify sympathetic chain, name 2 structures which sympathetic fibres leave w ith (spinal nerves, blood vessels).
- Identify right atrium , pulm onary trunk, aortic valve, right auricle
- How many cusps does pulm onary valve have
- W hat does pulmonary trun k divide into

1- ID: appendix, caecum, ascending colon, how to know the caecum from the ascending colon( the
blind low er end),. Ovary Fallopian tubes,recto uterine pouch, it&#39;s alternative name( Douglas pouch),
interpretation o f initial and localised pain i.e. Its afferent pathway( read this in Raftery book page 450
OSCE 2.1) ID : external &amp; internal oblique muscle, origin&am p; nerve su p p ly, direction o f the muscles
.which fleshy muscle infront the deep inguinal ring. In appendicectomy we open the ex obliq muscle in
which direction???

- stomach/pancreas
- cardia/fundus/pyloric antrum
- name blood supply o f stomach
- name blood supply o f pancreas
- space behind stomach
- point where is pancreas
- w hat is peritoneal relation o f head/body/tail o f pancreas
- w hat is peritoneal relation o f l/2 /3 /4 th part o f duodenum
- ducts o f pancreas
- w hat substances are produced by tum ours o f islet cells? name 3
- w hat vessel goes anterior to 3rd part o f duodenum and w hat vessels are posterior
- if you do whipples, w hat vessels do you encounter
 Id e n tify

o External and Internal Oblique and Attachments: external O-ribs 5-12, l-iliac
crest, pubic tubercle, linea alba; internal O: inguinal ligament, iliac crest,
lumbodorsal fascia, I: linea alba, conjoint tendon, ribs 10-12

o Innervation o f External Oblique (N: thoracoabdominal nerve T7-11 &amp;

Subcostal nerve T12) and Internal Oblique (N: thoracoabdominal N T6-11,
subcostal T12, iliohypogastric &amp; ilioinguinal (LI)

o Nerve root o f inguinofem oral: genitofem oral nerve (fr lumbar plexus L1-L4).
Genital branch Ll&am p;L2 ( w ith spermatic cord through deep inguinal ring into
scrotum) &amp; fem oral branch Ll&am p;L2 (w ith external iliac artery under inguinal
ligament -skin onver anterior surface o f upper part o f thigh)

Abdom inal Aorta

- point out the aorta
- point out the IVC
- branches o f aorta (specifically which are the posterior branches, which branches supply the Gl tract
and at w hat level does it exit)
- which level does the aorta enter the abdominal cavity
- which level does it bifurcate
- w hat structures overlie the aorta: duodenum 1 and 4, head o f pancreas, liver
- point out the tributaries o f the IVC
- identify the le ft and right gonadal vein (the le ft couldnt be seen actually, was hidden between all
the o th e r structures)
- shown mesenteric angiogram, asked the identify the branches
- shown CT angiogram o f AAA. asked to identify it (saccular, infrarenal AAA)
- w hat is a dissecting aneurysm
- w hat is the pathogenesis
- w hat are the causes? which is the most common cause w orldw ide (hypertensive sec to
atherosclerosis sec to smoking)
- w hat runs across the aorta -left renal vein, pancreas, duodenum
- w hat drains into IVC - form s at L5 by confluence o f common iliac veins, pierces central tendon
diaphragm at T8
- where does aorta start T4 (angle o f Louis) and end at L4 (just below umbilicus) the surface marking
- w hat is aneurysm - abnormal dilation o f an artery
- causes fo r Aneurysm -true due to weakening o f tunica media, false - post traum atic

Pelvis
Genitourinary Tract
1. Identify bladder
2. Blood supply o f the b la d d e r: vesical arteries via the internal iliac artery
W hat are the peritoneal relations: Superior surface, upper part o f the posterior surface.
3. Identify the internal iliac artery
4. W hat is the muscle o f the bladder wall? : Detrusor muscle
1. Innervation o f the Detrusor? : prim arily parasympathetic via pelvic sphlanchnic nerves
W hat is the muscle in the wall: detrusor. W hat is the histo o f this muscle? Smooth muscle.
Epithelial lining: Transitional cell
Nerve supply o f the muscle: Vesical and prostatic plexuses

W hat are the symptoms o f bladder CA?

Painless haematuria
Urinary tra ct infection
Systemic symptoms (he looked disdainful)
Irritative symptoms, (freq, urgency, nocturia)

Sympathetic fibres from T10 -L2

Parasymp from pelvic splanchnic N (s2-s4)

5. M ost com m on cancer o f the bladder (give 2 ): TCC and SCC
6. W hat is transitional epithelium
1. W here is transitional epithelium found

7. Orientate model o f bladder/penis

1. Identify structures on the posteroinferior aspect o f the bladder
8. Identify the ureters
1. How does the ureter enter the bladder?

2. Identify the opening o f the ureters on the inner surface o f the bladder
9. Relations o f the peritoneum to the bladder: covers dome o f bladder only
10. Layers encountered when doing suprapubic catheterization

3. Spine
C l and C2 - w hat is this - odontoid, lamina, pedicle, transverse foramen, etcetc
w hat ligaments are at the atlanto-axial jo in t th a t contribute to its stability
which level is the hyoid (c3)
How many cervical vertebrae are there?
How many cervical nerve roots are there?
Which vertebrae are atypical?
W hat are the atypical features?
Gives you bone - w hat is this vertebra? (C l atlas.)
Show me the features. W hat runs through foram en transversarium? W hat level do they first enter?

On patient, landmark the hyoid bone. W hat level is it? W hat structure is found at C6? W hat part o f Gl
tract is found at C6?
W here does esophagus end?
I feel downwards on the C-spine;
whats the first process I feel?
Why can;t I feel the upper spinous processes? (Bifid and attached to nuchal ligament.)
Landmark the brachial plexus on this patient.
W hat muscles does the brachial plexus run between?

Lat C spine X-ray and open m outh odontoid - Identify cervical vertebrae on lat x-ray. (Wants you to count C l down to
C7.)
W hat this? (Body o f C2.) W hat this? (Hyoid.)
Apart from fracture, w hat o th e r signs o f c-spine injury can be seen on lateral x-ray?
(Abnormal alignment, prevertebral soft tissue swelling.)
How this view taken? (Open m outh odontoid.) W hat features can you see? (Odontoid process, lateral masses o f C l, C2
spinous process.)
W hat ligaments are attached to odontoid process?

Cx spine vertebrae ID c2 its feature, w hat pass in the foram en transversarum, from which vertebral
foram en it start to ascend,
c7 W hat is its name,
w hy cant feel the other Cx vertebra, ligaments attach to dense,
surface anatom y o f brachial plexus, where is it on a living Show me, cricoid at which
verteb level, show me hyoid bone on a living person,,, from which part o f GIT c6 develop?????
Plain x-Ray w hat is this?=open m outh v ie w ,
ID CX spine on lateral plain x Ray, all vertebrae??
ID structures in the open m outh view(dense. Lateral mass o f atlas spine o f axis and the teeth ???
Signs o f or features o f trauma??? Is this x Ray normal or not???

- Shown cervical vertebrae, skull, Right lateral Cerebral angiogram and

cadaveric specimen o f neck.

0 Asked to identify arteries on angiogram.

0 Show me the path o f the ICA on this skull, including which foram ina it goes thru
0 Asked to identify ECA on cadaver
0 How to tell between upper and low er m otor neuron lesion on the face?
0 W hat neuro deficits w ill patient have if MCA is occluded?
0 W hat abnorm alitie s do you see on the angio? (aneurysms)
0 W hat sort o f intra cranial haemorrhage w ill be associated w ith a ruptured berry
0 O ther supply comes from vertebro-basillar system. Name the parts o f the brain
aneurysm?
supplied by this.

Lumbar spine anatomy

b. Arrange in anatomical position
c. M ovem ent on these vertebrae
- Identify the structures (body, pedicles, laminae, transverse processes, spinous process)
- Articulate the 2 vertebrae, identify the intervertebral foramen, w hat comes out o f this
foramen (spinal nerves)
- W here does the anterior longitudinal, posterior longitudinal ligament and ligamentum flavum lie (ant to body, post to
body, ant to laminae respectively)
- W hat are the articular surfaces between the 2 vertebrae (the sup/inf articular facets). He wanted more (mentioned the
intervertebral discs)
- W hat kind o f jo in t is the intervertebral disc jo in t (fibrocartilage joint), primary or secondary (primary?)
- Shown MRI o f coronal section o f spine/spinal cord - asked to name the vertebrae, asked
to point to an intervertebral disc

- Components o f the intervertebral disc - annulus fibrosus/nudeus pulposus

- W hat changes to the disc w ith ageing (decreased height)

- If the L4/5 disc herniates, which spinal nerve w ill be affected (L5)
- W here does the spinal cord end in a neonate (L3-4), in an adult (L2-3)
- Surface landmark fo r lum bar puncture (L4 at iliac crest)
- W hat lies between L3-S4 in an adult (CSF, spinal nerves, conus medullaris, cauda equina, filum term inale)
Level o f spinal cord in new born and aduts

g. Contents o f spinal canal below L2

h. Location o f paravertebral venous plexus
i. Clinical significance
j. Tumors metastasizing to vertebral column

- Sensory area fo r L5
- W hat is in the Extra Dural Space
- How does metastasis happen
atlas,axis,odontoid process,ligaments attached, parts o f atlas and axis, foramen
transversium, structures passing, point to hyoid bone in a man, adentify axis and atlas in lateral xray spine,
open m outh odontoid view, id dens, lateral masses o f atlas, w hat abnormal in xray, structures at the level o f

cricoid cartilage
Oesophagus

- Level o f oesophagus.
- Surface mark beginning o f oesophagus. (C6)
- Border o f post mediastinum.
- Identify: Symp chain, azygous vein, descending aorta, phrenic, L vagus (recurrent laryngeal).
- Arterial supply, Venous drainage, Lymphatic drainage o f entire oesophagus.
- W hat is achalasia?
- Microscopic features o f achalasia.
- W hat is barrett's oesophagus? W hy do we care if barren's?
- W hat is the histological normal lining o f oesophagus? And in Barrett's?

4 . U p p e r lim b

-1 st Rib, point out sup/inf/late ra /m edial surfaces

- How does it articulate w ith sternum and acromion
- Give you scapula, dem onstrate how it articulates
- Point out im portant parts o f scapula: Supraspinatus fossa, ISP fossa
- Give you humerus, show how it articulates, point out greater/lesser troch, surgical neck, bicipital
groove
- Show me all how the jo in t moves (dem onstrating w ith the bones) during abduction
- Rotator cuff muscles and innervation
- Pectoralis major and innervation
- W hat is the o th e r im portant function o f Pec Major? Respiratory muscle
- Point out axillary nerve
Scapula anatomy
Attachm ents of
o Serratus A nterior - 9 or 10 slips from 1 st to 8 th ribs attached to medial border o f scapula

§ Nerve involved: Bell's Nerve

o Trapezius -external occipital protuberance , superior nuchal line, spinous
process o f C7, then spinous process o f all thoracic vertebrae) inserts on
lateral 3rd o f clavicle, medial acromion, as an aponeurosis over spine o f
scapula
§ Innervation CN XI

- bones: clavicle, humerus, scapula

- prosection: chest wall, shoulder girdle
- MRI shoulder
- identify this bone (clavicle). W hich side is it from ? Name the parts o f the clavicle
- identify this bone (scapula). Which side is it from ? Name the parts o f the scapula
- identify this bone (humerus). Which side is it from ? Name the parts o f the superior aspect o f the bone.
W here is the surgical neck? W here is the anatomical neck?
- please articulate the scapula and humerus
- please articulate the clavicle and scapula
- w hat movements take place at the shoulder joint? Show me using the scapula and humerus
- w hat contributes to the stability o f the shoulder joint?
- o f these, which is the most im portant? (Rotator cuff)
- w hat are the components o f the rotato r cuff?
- identify these muscles please (points to supraspinatus, infraspinatus, teres minor, subscapularis). W hat
innervates them?
- identify this muscle (pec major). W hat innervates it?
- w hat is this structure? (Cephalic vein in arm piercing clavipectoral fascia)
- w hat is this structure? (Long head o f biceps). From where does it originate? W hat attaches to the humerus
medially and laterally to it?
- w hat are these structures? (Long and lateral head o f triceps). W hat innervates them?
- w hat passes through this space? (Quadrangular space)
- w hat does the axillary nerve supply?
- identify the structures you see on the MRI o f the shoulder

iii. Brachial plexus

1. W hat is the m otor loss when patient has lesion o f the upper trunk? Erb's palsy
if low er roots are affected, w hat is it called? Klumpke) w hat would be the m otor and sensory deficits?
Points and asked to identify superior tru nk o f brachial plexus. W hat roots do these originate from ?

c. Shoulder anatomy
- piece the calvide scapula and humerus
- whats the surgical and anatomical neck
- parts o f the scapula
- greater and lesser tuberosity
- range o f m otion o f shoulder jo in t
- factors affecting stability o f a shoulder jo in t
- w hat does shouder jo in t need to do to complete abduction? (internally rotate)
- muscle th a t stabilises shoulder jo in t
- identify supraspinatus infraspinatus teres m inor and subscapularis. whats the nerve supply
- identify functional parts o f the pec major
- nerve root supply o f pec majo
-actions o f deltoid
- axillary nerve dmg, whats the consequence
- where does the brachial plexus run? (posterior triangle o f neck)

- MRI shoulder photos

i. W hat is this? LEFT clavicle
ii. W hat is this? Scapula
iii. W hat is this? Humerus
v. Scapula
1. W here is infraspinatus fossa
2. W here is supraspinatus fossa
3. W here does the subscapularis go

4. W here is the acromion

5. W here is the corocoid process
6. W here is the glenoid fossa
vi. How does any jo in t retain stability
vii. How about specific about the shoulder joint?
viii. W hat muscles make up the rotato r cuff?
ix. W here do they attach on the humerus?
x. W here is the greater and lesser tuberosity

Asked to identify the olecranon, trochlea, capitulum , radial head.

Then asked me where biceps inserts.

Then gave an xray o f a supracondylar fracture w ith soft tissue swelling anteriorly
w hat I w ould be w orried in such an injury - I said neurovascular status. He said neuro first or vascular, I said vascular

dissected upper lim b specimen and said show me the cubital fossa and its boundaries and its contents,
radial nerve injury - i said w rist drop
ulnar nerve injury and ulnar paradox

difference in action o f flexor digitorum superficialis and flexor digitorum profundus - based on their attachments,
check his profundus and superficialis function separately

• Rotator cuff origin and attachments

• Medial epicondyle o f humerus

MRI o f shoulder asked where is head o f humerus and deltoid and glenoid, long heads o f tricep and biceps.

2- W hat nerve is damaged surgical humeral neck fractures.

Movements o f humerus
4- Identify Pectoralis m ajor on picture, origin + functions and nerve supply

id radius and ulna, articulate w ith each other, articulate w ith the humerus, id trochlea,
capitulum ,radial tubrosity, biceptal tendon, median and ulnar nerve, madian nerve injury( m o to r and
sensory),

- Which part o f the humerus is involved in the elbow jo in t

- Which part o f ulnar and radius participates in the elbow jo int. Asked to identify EXACTLY
where is olecranon.
- Showed Xray o f supracondylar fracture. W hat is this fracture
- W hat are you w orried about?
- How do you assess fo r this? (I said check brachial pulse. Asked if got any distal pulses. Also
said check fo r neurological deficit but he was not impressed. Kept asking fo r more but I
really dunno w hat he was getting at)
- Ask fo r cutaneous distribution o f median nerve.
- W hat happens if median nerve cut at elbow. State the functional loss. - loss o f flexion o f fingers, abduction o f thum b
and flexion o f w rist)
- If you asked the patient to flex the wrist, w hat would happen. (Basically ulnar deviation)
- Asked about ulnar paradox

Point o u t the acromion and coracoid process

- W hat are ro ta tor cuff muscles and origins and attachments
- Point out spiral groove. W hat nerve runs in it
- Point out medial epicondyle. W hat nerve. W hat are the cutaneous deficits o f radial and
ulnar nerve.
- Why is grip strength weaker if radial nerve is affected. (You cant grip things if you cant
extend the wrist)

- W hat is the origin and attachm ent o f gluteus medius and its function. (He d id n 't let me go
w ith a vague pointing around the iliac crest fo r the origin lol.)

- W hat is the origin and insertion o f the quadratus fem oris ( =( I forgot)
- W hat is the main flexor o f the hip
- Pointed to ASIS. W hat is this and w hat muscle attaches here
- W hat nerve is this. Lateral cutaneous nerve
- W hat is the condition if this nerve is compressed.

Hand
- Shown X-ray o f hand
Identify all the carpal bones
- Shown bony model o f hand
Point out the attachments o f the flexor retinaculum
W hat are the structures running through the carpal tunnel?
- Shown cadaveric hand. Asked to identify:
Median nerve
Ulnar nerve
W hat is this structure? Ulnar artery
How to test fo r sufficient ulnar artery supply to hand? Describe Allen's test.
W here do the tendons o f FDS and FDP insert? Demonstrate how to test fo r FDS
W hat are the movements o f the thum b? Demonstrate on yourself
W hat is the innervation o f all the muscles m oving the thum b?
Name all the m ovements o f the thum b and dem onstrate it to me. Show me which muscles control
these m ovements and w hat is th e ir innervation?
Show me the median nerve distribution o f the hand. They ask fo r the extent o f the dorsum also.
W hat muscles make up the thenar eminence.
W hat is the nerve supply o f thenar eminence?
W hat are the boundaries o f the anatomical snuffbox? Demonstrate to me where is the anatomical
snuffbox. W hat is in the anatomical snuffbox?
W hat is the significance o f snuffbox tenderness?
Why do you get AVN in scaphoid #?
How do you test fo r collateral circulation o f the hand?
Describe the test fo r me.
Identify the superficial palmar arch (on prosection). W hat is the supply?
W hat are the roots o f the ulnar nerve? W hat does it supply in the hand?

5. Lower Limb

a. surface markings o f DP and PT pulses

b. surface mark EHL
c. Shown skeleton, which bones make up hip jo int, stabilising factors, why iliofem roal ligam ent strongest? Muscles
o f walking and climbing stairs on cadaver.
Deltoid ligament anatomy.
Asked to identify the tendons w ith a metal pointer,
b. move the SP's fo o t when the follow ing muscles are used.
i. Peroneus longus and brevis together. Eversion
Attachm ent o f Perroneus Longus and Peroneus Brevis
Muscles o f dorsi flexion
W hat to expect when gluteus medius injured. W hat does gluteus medius do in walking,
f. Muscles o f Plantar Flexion

ii. Tibialis anterior and tibialis posterior together. Inversion

iii. Gastrocnemius and soleus together. Plantar flexion

Nerve ro ot o f knee extension, flexion, Foot dorsiflexion and plantar flexion
j. Nerve ro o t value o f plantar relex
k. Cutaneous supply o f dorsal surface o f fo o t and verntral surface o f foot.
Lower lim b - asked to identify bits like biceps femoris, tensor fascia lata. Gastrocnemius?
Asked about nerve supply fo r biceps heads and w hat inserts into TFL. W hat is the function o f
this muscle.

c. Name the 4 (although examiner said 3 to me, just label deep/sup post as post) com partm ents o f LLs and their nerve
supply.
0 Muscles o f posterior com partm ent o f LL
d. Demonstrate knee and ankle jerk and nerve roots tested. Tendon tapper provided. Patient was easy to elicit reflexes
from.

e. Dermatomes and M yotom es o f LL

0 Attachm ents o f peroneus longus, brevis, tertius

0 Causes o f fo o t drop
0 Show S I derm atom e
i. Boundaries o f fem oral triangle (Include Floor, Roof, medial, lateral borders) & contents
ii. W hat vessels w ill be cut - superficial femoral, circumflex vessels
iii. W hat muscles w ill be cut (Quadriceps femoris, satorius, adductor longus)
iv. W hat nerve is this - fem oral nerve, (root value) w hat 4 muscle supplied by it
v. W hat muscles does it supply
vi. W hat cutaneous supply o f saphenous nerve
vii. Boundaries of adductor canal
viii. W hat runs through adductor canal
ix. W hat exits adductor hiatus
x. Femoral sheath, which structures
xi. Boundaries o f fem oral canal opening
xii. Contents o f fem oral canal
xiii. W hat is the purpose o f the em pty space in the fem oral canal?
accomodate expansion o f femoral vessels

Moved on to the subsartorial canal?

h. W hat are the surfaces o f the subsartorial canal?
i. Which nerves runs in it?
j. Which artery runs in it?
k. Showed 2 angiogram, one o f the pelvic artery angiogram and one o f the LL angiogram. Show me
the fem oral artery
I. W hat are the branches o f the femoral artery? Show me the profunda fem oris on the angiogram?

Arterial supply o f foot

Asked about the deltoid ligament, ATFL, CFL and PTFL and its attachments.
Also asked about w hat happens to the DP and PT after it leaves the fo o t (I only said th a t the DP enters in to the foot
though the 1 st web space, becomes the plantar arches and gives o ff the digital arteries

Glut. Medius et minim us origin and attachm ent

Quadratus fem oris

1) Identify muscles, (gluteus maximus,medius and minimus)

2) Functions and nerve supply
3) Pointed to iliotibial tract
4) W t is its function (stabilizes knee)
5) Femoral triangle
6) Bicep fem oris (two heads and th e ir nerve supply)
7) Muscles o f leg and func
Identify ITB, muscles attached (gluteus maximus, tensor fascia lata), function (lock knee in extension)
Identify gluteus medius, nerve supply (superior gluteal nerve), function w hile walking (pelvic tilt)
Identify biceps fem oris (short/long head), nerve supply (sciatic nerve, he wanted
specific nerves gg - found out later short head innervated by common peroneal
branch, long head by tibial branch)
Identify semitendinosus semimembranosus, function (flex knee)
Identify common peroneal nerve, landmark (neck o f fibula), muscle groups supplied
(anterior and lateral com partm ent), sensory distribution (posterior and lateral aspect of
leg, dorsum o f foot)
Identify gastrocnemius, nerve supply (tibial nerve)
FHL weakness plus dorsum numbness - suspect L5 nerve root

a. Name all the nerves

b. Name all the muscles o f the hip (the usual)
c. If have injury here (gluteal region) w hat can be injured
d. Name LL vessels
e. Something about fo o t drop and where the areas o f injury could be

Femoral triangle, borders, contents. Femoral ring and canal.

Muscles o f anterior com partm ent o f thigh,
adductor canal and contents,
nerve roots o f femoral.
Branches o f profunda femoris.

Identify Sciatic Nerve

- sciatic nerve path. Hamstring muscles - origin /insertion.
Contents o f popliteal fossa. W hat can give rise to a lump in popliteal fossa - name one lump per tissue

- skin, artery, vein, nerve, muscle, joint..

1. Nerve roots
2. The bony landmarks from which it emerges : ischial tuberosity and greater trochanter
3. Variations o f its norm al course in the buttock
1. Normal: from under pyriform is
2. Can be over pyriform is or under gamellus superioris

2. Identify gluteus medius

1. Nerve supply
2. Action and consequence o f weakness
3. Causes o f weakness o f gluteus medius
4. Describe tredelenburg test

3. Contents o f the Popliteal Fossa

1. Identify Popliteal artery
2. Identify common peroneal and tibial nerve

4. Structures th a t may be damaged in a supracondylar fracture

5. Possible causes o f a swelling in the posterior knee (popliteal fossa)

1. Skin; Subcutaneous; Vascular; Bony
1. W here does the lymph nodes in the popliteal fossa drain from ? : from the lateral leg
and foot, follow ing the course o f the short saphenous vein

There is a skeletal model and you are given a pointer.

- W hat is the principle flexor o f the hip
- W here is the insertion. Show me.
- W hat muscle has its origin at the ASIS?
- W hat is its nerve supply?
- W hat nerve runs under the inguinal ligament?
- W hat syndrome happens if this nerve is caught?
- show me the origin and insertion o f the gluteus medius and minimus
- show me the origin and insertion o f the quadratus femoris

-Look at the provided LL angiogram, which one is SFA? W hat are the 3 branches?

A nterior thigh - Identify fem oral vein. W hat structure is medial? (Femoral canal.) W hat structures are
found in fem oral sheath? Is fem oral nerve inside fem oral sheath? W hat structure is this? (Rectus
femoris.) W hat function? Point o u t ITB. W hat inserts into ITB? W hat does the ITB do when l&#39;m
standing at attention?
Posterior gluteal region, reflected gluteus maximus - W hat is this structure? (Gluteus medius.) Nerve
supply? W hat is its function when l&#39;m marching?
Posterior thigh - Identify biceps femoris. How many heads? Nerve supply? Identify common peroneal
nerve. W hat muscles does it supply? W hat sensory supply? W hat happens in common peroneal
nerve transection? W hat is this? (Gastrocnemius.) Is it affected if I cut the common peroneal nerve? If
no traum a but got loss o f dorsiflexion and numbness o f dorsum o f foot, where do I look for the lesion?

Tibia, Fibula, fo o t bones

Please put the tibia and fibula in its correct orientation. Now place it on the foot
in the right orientation - Have to put the tib and fib together and put it on the
talus o f the fo o t correctly.

0 Name the bones o f the fo o t (and point on the skeleton)

0 There are 4 ligaments that make up the medial collateral ligament o f the foot.
W hat are they and show me th e ir attachments.
0 W hat are the lateral ligaments o f the fo o t th a t attach to fibula?
0 W hat type o f jo in t is the inferior tibio fibu la r joint?
0 ‘ Points at doral fo o t tendons - Name these tendons: Tibialis anterior, Ext
hallucis longus, Ext digitorium , Peroneus tertius

0 Articulate tibia and fibula

0 Name the bones o f the foot
0 W hat constitutes the lateral longitudinal arch?
0 In which position is the ankle jo in t most stable, and why?
0 W hat are the tendons in the anterior o f the fo o t
0 W hat is the arterial supply o f the foot? How do the dorsal and plantar supplies anastomose?
0 W hat are the actions o f the ankle joint? W here does inversion/eversion take place?
0 W hat is the medial ankle ligament? (deltoid) W here does it attach to? ( He was fine w ith navicular, talus and
calcaneus)
0 W hat is this? - points to sustentaculum tali
0 W hat is the lateral ankle ligament components? 3 main: ATFL, PTFL and CFL

- bones th a t make up medial and lateral arch. Remember that lateral arch distally includes 4th
metatarsal to o apart from ju st the 5th. Got this wrong.
- medial and lateral collateral ligaments. NOT the deltoid ligaments.
- identify extensor tendons in dorsum o f foot from medial to lateral
- which muscles invert evert foot, most stable position o f ankle..
- Articulate tibia and fibula (handed me fibula upside down)
- Show how ankle mortise fits together
- W hat kind o f jo in t is distal tib -fib jo in t (syndesmotic?)
- Show (using own ankle) m ovem ent o f ankle jo in t purely (dorsi and plantar flexion)
- Show (using own ankle) movements o f subtalar jo in t (inversion/eversion)
- Which position is ankle more stable in and w hy (dorsiflexion due to w ider talus anteriorly)
- Describe main com ponent o f deltoid ligament (think he wanted tibionavicular?)
- Show w here lateral collateral ankle ligaments attach on skeleton
- Identify sustentaculum tali
- Identify bones o f fo o t and medial + lateral longitudinal arches
- Tendons on anterior o f fo ot
- Blood supply o f foot (wanted details o f how PT splits into medial and lateral plantar arteries to form plantar arch,
where DP pierces through dorsum o f fo o t to plantar side, and which plantar artery it joins w ith)

6. foot and ankle:

-identify all the bones o f the foot.

-orient right tibia and fibula and position them w ith fo o t model.
-type o f distal tibiofibula r jo in t, and w hat bone is com m only fractured w ith its injury, (lateral malleolus)
-identify lateral arch o f the foot
-w hat ligaments form the medial and lateral collateral ligaments o f ankle jo in t
-W hat type o f jo in t is distal Tibiofibular joint? fibrous
-w hat is this part o f bone: sustintaculum tali.
-w hat bones form the midtarsal joints, and show movments o f ankle and and midtarsal joints in your
own foot.
-ankle is m ore stable in which position, (dorsiflextion, bcz talus is in its widest diameter)
-show me the palpable pulses in the foo t, and how the form circulation in the foot.
-w hat muscle causes fo o t inversion
Communication

Acute Abdom en call fo r ICU bed post-op

a. Prep station given, about 6 pages o f notes, summarise and consolidate your points, examiner asked a lot o f questions,
pt w chronic history o f COPD on steriods/relievers, seen in ED fo r being "under the w eather", unremarkable until she ate
some food and suddenly had acute abdomen, objectives were to ask ICU reg fo r pre-op advice and request fo r ICU bed.

b. rem em ber to w rite down his advice because he w ill make you repeat them at the end.

c. w hat made you think o f perf viscous?

PE showed signs o f peritonism, Hb dropped 2 units, US free fluids in abdomen, (CXR was clear but i said i would re-do to
look fo r free air)

d. w hat fluid resus w ould you do? crystalloids, rapid flush, colloids if poor im provem ent seen, cross match pt fo r blood in
view o f rapid Hb drop

e. asked me to suggest pre-op things to do.

i. ECG: look fo r arrythmias, T2MI, noted m ild hypoK so also looking fo r ECG signs(started quoting them but stopped by
examiner)
ii. repeat CXR: which i earlier said i'll repeat to look fo r free air
iii. check if p t took steroid inhalers today, told him if on maintenance steroids no need fo r iv hydrocort but will m onitor
closely
iv. comm ented on vitals m onitoring, told him i'll keep Sa02 threshold
lower in view o f chronic COPD. he asked how much oxygen to give
and how

E C F K + and ECG
• H y p o k a le m ia
• ♦/- 5.5 mE<VL
- S T d s p r o ii.o 'i
P iw in e o t U w ave
• 2.5 mE<VL
- P R n vfc.31 c*obna**3
- ST « p re « K > n
- I wavs inverts
- P w J n e n t U w ave
• H y p e r k a le m ia
• ♦/-7.0mE<»'L
- T a l sk»r*at i p e a te d T w aves
cresent
• *t- 8.5mEi»'L
- ►*> ev id en ce o( a tn al a c u ity
- Q R S - tr o a a ar.3 slurred
- Q R S in le r v * - wKJe
- T w m v rem ain t s l s k m je f
• F urther iiw e a & e in K « - v e o tte u la r
tach yca rd ia fe rita U o n

v. contact anesthestist

f. criteria fo r ICU admission

i. 2 organ systems impaired w ith acute reversible causes

ii. im paired respiratory system requiring mechanical ventilation
iii. 1:1 nurse patient ratio
iv. 1 organ system chronically impaired w ith a possible 2nd system being affected/im paired

Com m unication. Parental Consent

a. Son w ith splenic rupture, fa th e r approved op. M o th e r appears later crying, demands to speak to MO
b. Issu e s d isc u sse d

i. explained indication fo r splenectomy

ii. explained post-splenectomy expected complications and need for
vaccination/abx

iii. explained consent and urgency fo r op

iv. "is my husband drunk?" focused on explaining why he was able to give consent (can receive info, can process info,
able to make inform ed decision and communicate it back to us), did not touch on him being drunk at all

v. she w ill keep asking you to make sure son does not speak to ex-husband, focus on medical, we do not have
jurisdiction on w ho sees who unless mandated by law (eg. who has actual custody which is not our daiji)

vi. ask her to leave her handphone num ber w ith the nurses so that she can be contacted when her son is o u t o f OT

make sure to calm her down, by being composed,

explain the need fo r surgery,
w hat is the function o f the spleen,
why we couldn't wait.
why consent the father ( jo in t custody) and had capacity ( explained w hat th a t means),
is the consultant an expert in this surgery ( how w ould I know ?!!!!!).
explained to her that this is considered the most common abdominal solid injury and he will be in good hands,
explained to her the procedure and possible partial or complete splenectomy depending on intra-op findings, explained
to her OPSI and need to be careful including bracelet,
she asked about antibiotics fo r the rest o f his life?.
explained to her the need to bring a social w orker on the case to make sure th a t the kid is in safe environm ent and our
priority is the kid.
how long w ill he be staying in the hospital.
tell me more about the social worker? do you have to? when can I see him.

AOR splenic hem atom a (repeat)

-ICE
- Patient understand dx
- Follow up management: memo, call w ife and employer.

Young pt who was in an RTA and suffered a large splenic hematoma. Observed fo r 48h, remained well,
but planned by consultant fo r fu rth e r observation KIV splenectomy if hematoma ruptures. Pt wants to
AOR discharge because he has an im portant interview the next day. Also facing financial difficulties
because o f w ife's new diagnosis o f cancer.

- Explored ICE w ith pt

- Offered alternatives of home leave, but cannot: interview in next tow n
- Offered w riting a m em o or calling employer, but cannot: weekend currently, em ployer unforgiving in
previous cases
- Offered speaking to wife, but pt declined
- In the end agreed to let pt discharge, but w ith a memo to seek medical treatm ent as soon as he reaches
back home
- Also got pt to agree to have someone accompany him on the journey back
- Given abdo advice to watch for signs and symptoms o f hematoma rupture
- Asked pt to sign indem nity form
AOR. Pt daughter and patient wants to AOR. Post SMAC POD2 with axillary swelling, drain 400ml. Only preop bloods.

- Speak to on call consultant.

- Inform o f condition and decision to AOR.
- W hat would you give patient on discharge if AOR.

- Plan to end off:

- Check through vitals chart and bloods, do bloods today if not done (only preop bloods provided)
- Speak to patient first, check competency and let her decide
- Speak to daughter again
1. no wheezing / coughing / fever / phlegm
2. no PND / no decreased ET
3. Smoker
4. No Pmhx, o th e r than gallstones
5. Tests at GP fo r SOB told to be normal
6. ICE: widow ed w ith 2 kids, financial worries

ii. Differentials: Anxiety / Panic / Respi / CVS / Anaemia / Thyroid/

Hyperventilation

iii. Investigations - FBC, TFT, CXR, Pulmonary function test

iv. Management: reassurance

Phone consultant fo r acute lim b ischaemia

i. Lady adm itted fo r recently fo r m ild diverticulitis, admission paras

irregular HR, symptoms improving w ith IV abx and IV fluids. Now
complaining o f acute right lower lim b pain. O/E Left LL pallor,
pulselessness, pain not responding to paracetamol

ii. Bloods: Hypokalemia (Gl losses, IV fluids), M etabolic Acidosis on ABG (ischaemia)
iii. ECG - prem ature ventricular complexes, AF tachy
iv. Pick up the phone and speak to the consultant. Explain in SBAR form at.

1. Is it urgent? Can we send her to m o rro w m orning instead?

2. Do you need a cardiologist to review fo r PVC before transfer?
3. W hat if the cardiologist can't come down?
4. W hat do you think o f her presumed diagnosis o f diverticulitis
now th a t she has this acute lim b ischaemia? - Possibility o f
ischaemic bowel in view o f limb isachemia and irregular heart
rate

5. Do you need to scan the abdomen first then? - Said we w ill scan
the abdomen a fte r the transfer.
6. He asked me if it could be mesenteric ischemia straight away - I said the abdomen so far has been soft non tender >
continue to do serial abdo exams KIV scan if likely
7. Ok you can send the patient over.

LL ischaemia
- 22 year old medical student, cyclist hit and run by car, LOC 15 mins until ambulance
arrived, GCS 15, haemodynamically stable. Has open fracture o f left tibia/fibula w ith nil
cold leg, also has u/s abdo w ith ?free fluid, but GS reg has examined and abdo is SNT
- They had a cordless phone in the room , traum a consultant on the o th e r end, basically ISBAR,

- The traum a con asked a lot o f questions, some questions purposely regarding
inform ation th a t was not provided (eg, w hether patient has a c-collar on, whether
patient is dehydrated)

- Then gave a plan - fo r CT head/abdo/LL, Xray C-spine, if anything worsens to contact

him immediately. Initially I thought it was a test, told him th a t I think the scan will delay
the operation as the patient has the ischemic lim b which is m ore urgent, he got abit
annoyed and asked me if I would put the patient under w ith o u t clearing his head after
an RTA w ith LOC.
 SBAR TEMPLATE - to submit issues of concern to NNLC
The S B A R (Situation-Background-Assessment-Recommendalion) technique provides a framework for communication
between members of the health care team. Although this technique w as original developed to target a patient-centered
condition, the N N LC will implement this technique to communicate and address critical issues to support immediate
attention and action by the committee. This S B A R tool w as developed by Kaiser Permanente.

s Situation:
What is the situation you are writing about?
• Identity self, health care site. area, title, date. etc.
• Briefly state Ihe problem/issue, what is it. when it happened or started, and how severe.

EXAM PLE:
Author: Sharon Feldstein, Chair-Albuquerque Area Council of Nurse Executives
Date: Ju ly 10. 2008
Situation: Public Health Nursing Funded Positions
Backqround

B
Pertinent background information related to the situation could include the following:
• The history of problem/issue, the date of the problem'issue.
• List of current situations.
• Most recent occurrences.
• National standards, policy, regulations, standards, requirements.

EXAM PLE:
Background:
At the Jo hn P. Morgan Health Center, during F Y 2008, the Public Health Nursing (PHN) department
consisted of 5 PHN s. During this time. 3 P H N s were detailed to outpatient on average 40% of their time and
supervised by the Clinical Director, which decreased the PH N Provider Productivity significantly.
The IH S Public Health Nursing scope of Practice is designed to build healthy communities by promoting
healthy behaviors and lifestyles through provision of care based on a primary prevention public health model.
The American Nurses Association Scope of Practice Model describes the practice of the PHN as placing
emphasis on primary prevention in all health promotion & health protection strategies with the focus on
population level outcome.
The G P R A objective related to the Health Promotion & Disease Prevention correlates directly with the PH N
program funding & is most effective with the PH N planning, developing. & supporting system s in the
community setting.
PHN visits are done primarily in the home. PHN specialty clinics. PH N office setlmgs. school & community
sites with primary prevention a s the focus for meeting the IH S mission.
PHN core services are divided into direct & indirect care activities listed in the RRM document with do not
cover services defined in the clinic settings supervised by another discipline.
The standard PH N position description, which is held at a minimum educational level of B S N , describes PHN
supervision directly under the DPH N & with the scope of community focused primary prevention.
Assessm ent
What is your assessm ent of the situation?

A EXAM PLE:
Assessm ent: A lack of adherence to the defined standards identified in the PH N PD. Poor use of PHN
services in addressing public health issues. Disregard for IH S line-item funded PH N position.
Recom m endation

R
What is your recommendation or what do you want (say what you want done)?

EXAM PLE:
R ecom m endation: NNLC w ill support th e follow ing recom m endations-
1) T he PHN funded positions m ust follo w PHN job description duties w ith education q ualifications
adhered to & functions w ith p rim ary prevention focus under the direction o f the DPHN; therefore, the
utilization o f th e PHN staff in their highest potential capability.
2) PHN funded positions w ill no longer be detailed fo r non PHN-duties.
N N LC reviewed o n :___________________________________ (date)
Recommendations were made o n :_____________________ (date)
W as this forwarded to the Chief N u rse? ____ Y e s :_____No. If so. on what date:
Management o f free fluid in abdomen
Benign oesophageal stricture

i. 60 year old man w ith history o f smoking and alcohol consum ption presents w ith dysphagia. Your consultant is gone o ff
fo r a m eetig and you are tasked to counsel fo r OGD, biopsy and dilatation under GA. Inx showed Anaemia, raised
bilirubin and LFT

ii. apologise consultant not around, reassure th a t he w ill be kept in the loop
about discussion and any doubts, can arrange fo r him to speak to
consultant.
Check w hat the consultant has explained to her before. Explain
indications, risk (risk o f GA + procedure), benefits
b. If biopsy shows Ca, how to mx ?

iii. Explain indications, w hat procedure involves, procedure risks, w hat to look o u t fo r post procedure, TCU plans.
iv. Patient asks w hy does he keep salivating? cos he hungry
v. patient asks if his smoking and drinking has caused him to have cancer

Patient kept asking if this is malignant, if his drinking and smoking caused this,I told him we cant know fo r sure till the
biopsy, told him low risk o f bleeding, infection and perforation, etc.
he said how soon w ill we know if there is a perforation.
Didn't get the chance to even look at the examiner, very talkative patient,
kept talking till the bell rang w ith all the candidates. Guess we all dad badly?!

b. Update consultant regarding p a tie n t w ith oliguria, use SBAR

1. Likely AKI secondary to dehydration
ii. No abdomen signs at all
iii. Told him would hydrate and serial abdominal exams and update again and case finished
3 days post le ft hemicolectom y w ith anastomosis w ith oliguria,
no signs o f SIRS on ABG and obs chart.
causes o f shock in this patient?
do you w ant me to see?
w hat do you w ant to do, fluid challenge him?
w hat fluid, dose? do you w ant to transfer him?

2. ISBAR - Patient on post op day developed axillary swelling a fter lum pectom y and
sentinel node biopsy but daughter wants to take her home so talk to the consultant on
call and ask him to intervene. The dates on this w ere from last year, past paper question
o f course but I got confused w ith the dates. Had to make a m ental map o f dates
spanning over a month, from last year. Not nice during the exam, w ont pass this one I
think because I d id n 't notice the patient had longstanding COPD and LVF and consultant
asked me about th a t in particular :S

1. Counselling o f p a tie n t fo r hernia repair, p atie nt on w arfarin

- Patient has a recurrent inguinal hernia (previously repaired 30 years ago), legally blind
from cataracts, has had mechanical heart valve replacement on w arfarin, anxiety not on
medication. Already previously talked to consultant in clinic, but now comes to clinic as
unsure about warfarin and concerned about operation
the patient who had a blind walking stick and wearing sun glasses.

- W ent in to the room w ith 2 examiners who did not u tte r a word the entire 10 mins, and
- Introduced myself, asked how I could help him
- Basically concerned regarding heart valve and warfarin - was under the impression that
he had to continue it as his cardiologist had previously told him he needed to take it fo r life.

- Explained th a t I w ould check w ith the consultant in charge regarding this as the usual
practice is to stop warfarin fo r operations due to the risk o f bleeding

- Explained th a t if warfarin was stopped, the risk o f throm bosis is present due to his heart
valve, explained the role o f clexane until the night o f the operation - explained this will
involve injections tw ice daily - patient said he lives alone and w ill not be able to
manage, offered to check w ith the nursing manager on w hether nursing services w ill be able to be provided, otherwise
offered to adm it patient until the operation

Reassured patient, asked if any other concerns, w hether patient knew w hat operation he was having and why

14. Speaking to ICU registrer fo r potential need o f v e n tila to r to a patient w ho had come in ER w ith
Duodenal perforation and emeregency operation was planned

a. Says no bed is available then what

b. Asks certain investigations to get done and then asks to repeat w hat he said

15. Councelling o f p atie nt w ho w ants to get LAMA, Had traum atic splenic laceration, being manged conservatively

16. Stem: Guy is m otorbike rider. In RTA by h it and run. Was unconscious in itia lly but GCS 15 on arrival.
Adm itted. Ultrasound showed ?free fluid in paracolic gutter. Xrays showed left tibial + fibula fracture
open fracture. Noted by nurse to suddenly have a cold lim b + pulseless. Please inform trauma
consultant on call. Blood investigations on admission all normal. Raised CRP and TW only
- Basically SBAR and spammed him w ith all the inform ation.
- Asked me fo r my plan o f management. ( I said CT brain, AP, send to op, start ABx
- W hat can I do before sending to OT (he was looking fo r analgesia + traction)
- W hat blood investigations w ill u send for
- How w ill you fix his fracture (I said external fixation. He asked why)
- W hat w ill you do fo r the wound (I d id n 't really understand initially, but he wanted me to say
debridem ent o f necrotic tissue)

1. Call consultant in o th e r hospital fo r transfer

a. Your boss made a mistake did a lap chole now got CBD injury need to transfer to
another hospital w ith a HPB surgeon fo r b etter management
b. W hole list o f blood investigations there must tell bout the cr (aki) as well as biliary obstruction, raised TW and CRP
c. They use a cordless phone w ith intercom so no one else there w ith u do take your tim e to look through the
investigations and op notes

Consent taking fo r paeds patient fo r lap appendectom y

a. Consent from w ife but kid already in OT induction room

b. W ife insist on seeing kid first but cannot go in but need to take consent
c. Made worse because surgeon on call killed the husband last year in some crazy op
so once w ife finds o u t the surgeon is M r xyz she w ill th ro w a fit and ask fo r another
surgeon (but there is no one else)

14) Communications: Explain to angry w ife o f pa tient about m alignant ascites

12. Update traum a con re: open tib /fib fracture in ED
h ttp s ://w w w .y o u tu b e .c o m /w a tc h ? v = fs a z E A rB y 2 g

- One prep station prior to this one - given case notes, no vitals chart
- Case notes had many entries (typed out) from GS, radiologist etc.
- Basically young guy, RTA, LOC, GCS 15 OA at ED, vitals stable
- Fluid resus given, GXM done
- Blood results more or less normal
- Right tib /fib open #, gross soilage, antibiotics + ATT given
- S/B GS, abrasions on le ft flank, abdo soft, does not think needs CT AP but ordered U/S
- U/S - d ifficu lt exam, ?LHC free fluids, suggested CT AP
- Pulses initially not mentioned, but nurses later noted fo o t getting colder and paler,
difficu lt to feel pulses

- XRs showed tib /fib #s, right hand MC #s

- Next station was to call consultant regarding case.
- Asked - why are you calling me now (w ill need overnight surgery), why did GS ask for
U/S when they fe lt abdo was norm al (wanted to hear about the abrasions, possible
splenic injury)

- Plan - NBM; C collar; reduce and splint tib /fib -> reassess pulses and neurology, KIV
w ith bedside doppler -> call vascular if necessary; update GS; CT brain, C spine, A/P;
CT LL angiogram if pulses still not well fe lt (I d id n 't offer this at first, he had to prise it
o u t o f me)

- People I may need to call e ithe r pre- or intra-op - OT, anesthesia, GS, Vascular,
Plastics (again, he had to drag this out o f me)

Prep reading 9 min. Discuss case w ith Trauma consultant over phone - 21 yo med
student, car hit him w hile riding bicycle at 2330 hrs. LOC fo r unknown am t o f tim e, but
was consciouss by the tim e ambulance arrived (~15min). On arrival to A&amp;E,
haemodynamically well. O/E Right hand swollen, abrasions le ft upper abdo, open
fracture left leg. Abdo soft, non tender. GCS 15. Xrays - Right hand MC fracture, Left
tib /fib fracture. CXR normal. GS registrar saw - No need fo r emergency laparotom y for
now. Suggest US abdo. US abdo subsequently shows ?free fluid in le ft para-colic gutter.
At about 120am, left leg became pale, DP/PT pulses not palpable. Worsening pain.
Bloods given - Hb 11. UECr, LFTs, PT/PTT normal. Tetanus and Abx given in A&amp;E. 2L
N.Saline given. GXM pending.

0 Call traum a consultant to handover case

0 W ho do you w ant to get involved In this case? Plastics, ortho, GS.
0 Any other investigations you w ant to perform?
0 W hy you think he needs GS involvem ent? W hy Plastics?

CT scanner dow n, ta lk to patient's w ife

- One prep station prior to this one - case notes given

- Patient referred from GP fo r ascites
- Peritoneal tap - malignant cells on cytology
- Tum our markers sent, pending
- Planned fo r CT AP today, but CT broke down. Engineer sent for, coming tom orrow ,
CT w ill only be up next week. Radiologist offered to do U/S abdo today
- Consultant was supposed to S/T wife, but had to go to EOT.
- Registrar w rote in notes th a t if patient very SOB, can consider therapeutic tap

- Task was to update patient's wife

- Angry woman ++. M ust be very tiring fo r the actress
- Aside from normal questions, w ife also asked about w hat we can do if patient still
very SOB -> therapeutic tap asked how often we can do it, w hat the risks may be
- Was also angry th a t reg told her all hope is lost
- Had this fixed, unshakeable idea th a t all cancers are curable; I tried to gently disabuse her o f that notion
- Just stay calm folks, she ran o u t o f steam eventually

Patient came in fo r pre-op check up fo r cholecystectomy. Consultant is away and

ask you to assess p atient. Patient com plains o f d iffic u lty breathing especially at night these few days,
a /w tin g ling sensation in lim bs. Also has abdo pain at tim es w ith loose stools. Hx sounds like anxiety
attacks.

a. Still must rule out medical causes - Fluid overload, Pneumonia, Pul embolism, Angina,
Hyperthyroidism before coming to a dx o f anxiety attacks

b. Assess fo r potential causes o f anxiety attacks - explore how she fe lt about the surgery, any areas
th a t she is unclear of, is she afraid o f the surgery, TLC a bit. M ight need to o ffe r to explain the
surgery again.

c. W hat kind o f investigations do you w ant to do? Rmb to do TFT

d. How to manage this patient?

POD 1 post-left hem icolectom y fo r sigmoid adenocarcinoma w ith liver biopsy fo r suspicious liver nodule.
Intra-operative ly had slipped clamp w ith blood loss. N ow anuric, IDC already flushed. Hb slight drop, renal
panel shows AKI w ith raised Ur and Cr. Have to speak to on-call consultant regarding lo w urine ou tp u t.

- Introduce yourself, p fs prim ary consultant and pt

-SBAR
- W hat are your differential diagnoses fo r the pt?
- Is there an anastom otic leak?
- How are you going to manage the pt? Does he require HDU transfer? Does he require op now?
- If HDU is full, who are you going to speak to?
- Does the consultant need to come and see him now?

14. Call Vascular consultant.

66 lady w ith ?diverticulitis and now has one hour o f acute lim b ischaemia. ECG shows a fib.
New dx - mesenteric embolus, ALL W hat imaging to do. W hat to anticoagulate w ith
and how. How to transfer (type o f ambulance)

1-consent OGD fo r esophageal stricture .

2-phone call to vascular surgeon about p atie nt presented w ith acute lim b ischemia ( on background of
acute diverticulitis and atrial fib rillatio n ) pt was unstable w ith metabolic acidosis, asked about
im m ediate management ? Amenable fo r transfer ?
Whats the likely cause ?( AF)
Type o f heparin w ill be used ? .

AOR
Anyway is POD 2 s/p R SMAC, patients daughter wants to AOR because she doesn't w ant to travel to
and fro between the hospital and her own house. Environment is not ideal because her husband
and herself w ork as school teachers, and she stays w ith 2 teenage daughters. I think also got a dog.
She has convinced the m other to go home, although prior to this the m other was more keen to
recover in hospital before going back home.
4 pages o f labs are all normal - but note these are all preop
Call your consultant to tell her about the situation.

Salient points - 58 y r old Caucasia lady who is POD 2 R sentinel lymph node biopsy, then continued
to perform SMAC. No intraop complications, blood loss minimal. Postop D1 well, POD 2 developed
SOB, mild tachycardia HR 95 and BP holding 135/90. Drain o u tput 410mls (bloody) & lt;- 30mls
(serous). Axilla is also puffy.
Use the standard SBAR form at, and update consultant as per how u would on a normal ward round.

No biggie.
Form to sign fo r AOR, o ffe r to update the team&#39;s prim ary consultant.
&quot;ls there any policy in the hospital th a t we can force her to stay in fo r treatm ent?& quot;
Hmm. I said if she is mentally com petent can sign AOR and we can&#39;t keep her unfortunately ( i dunno
w hether this is right). Then she asked, so is the p t m entally competent?
I said th a t i hadn&#39;t assessed form ally, but noted from the notes that it seemed that she was.

Transfer o f care
Young m otorcyclist involved in RTA, w earing fu ll leathers and helm et at tim e o f in ju ry
Quite a few pages o f info from patients notes
- documented by reg th a t ST1 should call fo r transfer to CTVS before going to see the patient
- noted in patients bag an appointm ent card fo r a diabetic clinic this coming Tuesday
- patient GCS 14, PR 120, HR 100/80, T 37, complaining o f right sides chest pain, 4L crystalloids given so far,
requested 6 units o f blood fo r standby
- noted le ft thigh swollen, no open wounds, ?fracture - no Thomas&#39; traction yet
- CXR: widened m ediastinum, bilat pleural effusions
- AXR: psoas shadow not seen, dilated small bowel loops
- Left fem ur XR: shaft fracture
- CT not available fo r next 3 hours as it is being serviced
- registrar also documented insertion o f chest tube on the right. Swinging fluid w ith 200mls o f blood stained
fluid
- Hb 8, otherwise FBC normal, UECr/LFT normal, CRP raised very minimally
- pH 7.32, Pa02 lOkPa, PaC02 6.0kPa, HC03 19

W anted to give SBAR but examiner kept interrupting to ask questions

-w h a t is the issue?
- w ill you do CT scan?
- w hat w ill you do fo r his C-spine?
- w hat are you going to do fo r his leg?
- is there any abdominal issue?
- w hat are you going to do about the blood pressure?
- why should you not increase the BP? - prevent fu rth e r bleeding
- w hat are his blood abnormalities?
- why do you say metab acidosis?
- who w ill accompany the patient?

18. Angry patient whose operation got cancelled again (Communications)

Previously arthroscopy cancelled. Symptomatic. Now here fo r arthroscopy again. Op cancelled due to
emergency case. Patient frustrated.
W ent in preparation bay to find a stack o f about 10+ pages o f notes ranging from patient details to patient&#39;s
GP le tte r to blood results.

- take note o f all the dates, as they may not run in order
- you have 9 minutes to w rite down on the papers provided all the inform ation th a t you w ill need, before going
to the next station to talk to the patient
The story: this guy has le ft knee pain, and his GP has assessed him to have possible meniscal tear. W rote
referral to O rtho. Ortho assessed him, recommended him fo r arthroscopy for diagnosis KIV repair.

Op was scheduled last m onth, but got cancelled due to some reason. Also noted CRP at th a t tim e to be high,
possibly related to sinusitis. Rescheduled fo r operation. GP w rote another le tte r urging O rtho to expedite
operation, as his w ork as postman is affected, and he has been putting on weight. Also, he is in pain.
Knee xray shows jo in t space narrowing. However, this operation w ill have to be postponed again as
consultant has to attend to E-trauma.

- it helps to w rite a num bered list o f the issues you need to address w ith the patient.
1) his knee pain - he w ould te ll you his ibuprofen has been causing him gastric pain, give him alternatives
2) w eight loss - sw im m ing, physio, etc w ith analgesia cover
3) w ork as postm an - o ffe r to w rite to em ployer to explain situation and cover w ith MC
4) sinusitis - m ust get GP to sort it out to prevent operation being cancelled a 3rd tim e
5) o ffe r avenue to com plain - PALS Patient Advice and Liaison Service
6) o ffe r to ta lk to w ife
7) assure him his operation w ill be placed on p rio rity list, etc etc
- it helps to ju s t keep quiet and le t him talk, so th a t you can understand his issues th a t need addressing. Of
course w ith the usual cues o f listening in conversations like nodding etc

talking%to%a%patient,%whos%operation%was%postponed%
twice.%This%time%surgeon%has%gone%for%e*OP.%Remember%the%MC,%analgesia,%
try%to%get%an%early%appointment%to%see%con.

Comms: Interval cholecystectomy POD2. Op uneventful, 2 clips to CBD 2 clips to cystic artery, but
since yesterday worsening abdo pain w ith tachycardia, US shows free fluid in abdomen no CBD
dilatation. Labs show TW 18 and CRP 50, bilirubin raised (something like that). Your consultant thinks
there is bile leak from CBD injury, wants you to transfer to HPB consultant Prof Archibald Rose at
regional centre. His reg picks up. Reg not to o happy th a t your labs are from yesterday and nothing
was done now you are calling at 4pm on a Friday. W hat do you think he has? W here is the source of
the bile leak? Do you have any evidence where it&#39;s coming from ? Could you arrange ERCP to confirm
the source o f the bile leak? Is it urgent? W ill you need to speak to anyone? (Bed manager)

8) comms: call a consultant to discuss abt a case

expected to read through &#39;case notes&#39; and piece the story together w ith in ten mins prep station,
scenario was an elective left hem icolectom y fo r caecal tum or, w ith liver biopsy fo r suspected mets.
currently postop D l, having persistent tachycardia 120 and hypotension SBP 90-100 post op, tem p
37.5. postop bloods unremarkable except drop in Hb from 12 to 10, Cr 116, Urea 16. ECG normal -
no MI/PE. CXR clear, pt documented as having benign abdomen, appears dehydrated. I/O in
negative 150mls balance, GW nurses said theres no urine o u tput in IDC. asked to call consultant on
call, as consultant incharge is on leave.
- asked who the consultant o f the case was (need to pick up this info in prep station, some
candidates didnt realise leading to some confusion)
- asked to summarize the case
- asked &#39;so w hat do you thin k it is?&#39; (offered dehydration, need to check w hether catheter is blocked&#39;
- asked fo r plans o f action, w hether pt need to be brought down to H
- asked w hether candidate feels the consultant oncall needs to come back (i said no, but w ill call him
again if p t does not respond to fluid resuscitation or the repeat set o f bloods shows any worsening,
offered to proceed w ith CTPA if has desaturation, but w ill keep on clexane and TED stockings for
now)

- asked w hether it is possibly an anastamotic leak? ( i offered that as p t is non toxic, its very unlikely,

but i&#39;ll do serial abdo exam, and let consultant know again if pt becomes peritonitic)

2. CSI prep Reading station

Repeated question, patient POD 3 lap chole now w ith ? bile leak. Abdo pain w ith
jaundice, bloods given TW CRP bil high. Fluid collection noted. The consultant was
very good, all he w rote in the entry was to transfer to HPB centre. Your jo b is to call
some superbigshot Prof about the transfer and the current management plan.
For the reading stations, you are given a small stack o f case notes, lab results, scan
results, and you have 9 minutes to process them (which is honestly a luxury).

So use this tim e to SBAR properly, and try to anticipate w hat possible qns they will
ask. - differentials, management, why need to transfer and cannot manage at the
current hospital etc.

3. CSI

The phone to call the Prof was in the middle o f the room. I took about 1 min before
figuring o u t how the phone worked.
Just go w ith the norm al SBAR and it was no problem.
Possible dx - bile leak from damage to CBD, clip slippage, retained stone.
Hardly asked me any questions at all and had lots o f tim e le ft over, to well, stone.
Management usual - IV drip, NBM, roc/flagyl, arrange fo r MRCP (ERCP centre
closed), PFO bloods

15. Was told to call consultant re a post op pt w ith low urine output. Pt had a elective low
anterior resection w / ?primary anastomosis. In the end pt was underloaded. Pt only had
800ml over 2 days and pt was NBM.

Comm skills
Scenario: 60 yo man post le ft hemicolectom y fo r sigmoid Ca, POD1, oliguric. M ildly
raised Cr 115, I/O chart, vitals chart given. Call consultant to report the situation and
form ulate a plan.
- Basically do as you w ould in real life, rem em ber SBAR. I volunteered to transfer pt
to HD fo r m onitoring, KIV insert CVC. Ensure you have all the facts on hand so you
d o n 't have to keep flipping notes to get the numbers when you call. There's a prep
station before this so you have lO m in to w rite down all the im pt facts on one sheet.

3 rd station - Communication skills, giving and receiving inform ation.

Essentially, this station is l8 minutes long. You have 9 minutes to prepare in a
room and another 9 minutes in a neighboring room to perform the task.
Stem: This post-op day 1 patient noted to have low urine o u tput by ward nurses.
You are the MO on call seeing this patient. Please see the notes and summarize
the events and come out w ith a management plan to update the surgeon in
charge o f her.
Came to this room w ith tem perature, BP, HR chart (took some tim e to
understand as it looks diffe re nt from local charts. Essentially, patient has
tachycardia, low-grade tem perature, mild hypotension and a narrow pulse
pressure. Urine o u tp u t is 10-20 m ls/hr fo r last 8 hrs. Received only HOOmls o f
NS fo r POD1.) Notes documented th a t catheter is not blocked. Operation notes
stated some blood loss but transfused 2 pints. Last Hb 12. Last TWC 14. Renal
panel showed raised urea and borderline high creatinine. Results given can be
quite misleading if you d o n 't check the dates to find out the sequence o f events.
E.g. they attached a pre-op renal panel (at the back o f the case notes), which
appeared normal, but somewhere in the case notes it was documented w ith the
latest renal penal results (which showed the above changes mentioned).
I did m ost o f the talking by summarizing the case and giving him th a t my
assessment is th a t he is dehydrated. I w ill w ant to start him w ith blood transfusion,
which I later retracted, and say IV fluids instead. Said th a t I w ill give 1L NS over 1
hour and continue m onitoring closely in wards. I w ill repeat bloods tom orrow
morning and if HB downward trend then to transfuse. If no response to fluid
challenge overnight I w ill insert CVP and m on itor in HD and m onitor further.
Consultant asked w hether he needs to come down and see this patient. I told him
that I will fluid challenge the patient first and then update the consultant again
subsequently.

Actor was quite friendly but persistent in wanting to go home. I first got him to
tell me w hat he knows about his condition. Then asked him about his reason on
wanting to leave hospital so soon. His reason is th a t he has im portant job
interview in 2 days tim e and th a t it w ill give him a significant pay rise. His wife
has CA breast and he wants to earn money to bring her on holiday. He does not
w ant to leave his w ife alone at home (another tow n). He talked fo r quite long
before he shagged out and then I asked him is there other reasons besides the
ones he just told me? He was quite bemused and said: Is th a t not enough? I
laughed also and said th a t is quite good enough. I explained th a t his condition is
more serious then he thinks and although he is stable now, the splenic
hematoma m ight rupture anytime. If he is outside walking about, he w ill not
make it back to hospital in tim e. Told him repeatedly I understand his situation
but in this situation it is more im portant to watch his own health first. If
something happens to him, his w ife w ill be even worse o ff because no one to look
after her. Offered referral to inpatient liaison officer to arrange fo r w ife to come
over and stay w ith him in the ward or nearby hospital. Towards the end the
actor interrupted and said he still wanted to go home. I told him th a t we cannot
stop him and that there are risks involved th a t he must understand. I started to
re-elaborate the reasons as I did not w ant to give in to his AOR request because
the stem asked me to persuade him to stay. Saved by the bell in the end!
 cs tcpmmsgfc S infggyin g/rec^ ngj - tgik to tpllggjft
Call HPB surgeon about bile leak. No Info abt ur own guy. Only know th at previous cholecystitis,
jaundice x 6 /1 2 ago, no LFT, no kncxvn previous ERCP/retained stones. Routine ap cho-e. Notes very
brief, no vital signs (d o th ey w an t me to lie about it?)
P O D 1-ja u n d ice d , labs show high bil. Slightly tachcardic U/S showed fluid in peritoneal cavity. ERCP
service decided to close shop cos of staff shortage. Consultant went for nonsense non-urgent
meeting.
P O D 2 - docum entation for th e morning rounds are the best, consultant just w rote a one-liner for the
on-call dr to call fo r transfer. No vitals, nothing....

Ca ed guy. w anted your candidate num ber over the phone which kind o f broke m y m omentum as I
was read to deliver the SBAR. Sti went ahead w ith SBAR. Guy asked for causes of bile leak -
mentioned a the usua cystic stump clip s ppage, CBD transection, retained stones. W hat to d o ’
Transfer, E R C P -d e lin ea te anatom y KIV stent vs HJ. M eanw hile drain insertion, start abx. monitoring,
inform fam.

This is a com m only recycled past year que. the dates in the question w ere all like 2 years ago so you
pretend you tim e trave ed till 2 years ago. Thankfully I mugged all th e different types and location of
CBD damage and could deliver m y speech.

Examiner says ok, bed ready in h « hospital and to transfer patient. Thanked examiner. Bell rang

| Effective drain m srfu [ | No drain / ineffective drain

1 A
Leave U S S i dram insertion

\
Poritonitis/Sepsis
Yes

*
d ^Monrtor dran~^>

> 200 ml'day Stops

ERCP ♦ stent insertion
Laparoscopy, lavage, drain ----------- 1—
insertion t repair leak ERCP + stent
insertion

i i
Repeat ERCP 6 weeks after leak scaled ± rem ove stent

common bile duct stones were identified and an endoscopic sphincterotomy performed in order to retrieve these
and allow any further stone fragments to pass. An internal biliary stent was routinely left in situ in order to
promote preferential drainage o f bile into the duodenum attenuating the leak and allowing it to stop. These were
removed in all patients 6 weeks after discharge.

ERC has both a diagnostic and therapeutic role.6 It allows identification o f both the site o f the leak as well as
any residual stones w ith in the bile duct that may be contributing to it. Such stones can be removed and various
strategies used to reduce the pressure gradient between the bile duct and the duodenum created by contraction
o f the sphincter o f Oddi.6,7,11 This encourages the preferential flow o f bile into the duodenum thus attenuating
the bile leak and allowing the site to heal

nsert either nasobiliary or internal biliary duodenal stents.

- Communication 2: Discharge le tte r to GP regarding Seroma. if I rem em ber well there was also a
reduced Hb which needed checking by GP and Seroma to be reviewd in Clinic and aspirated as needed,
the plan is pretty much w ritte n in notes but just need to be efficient in summary and tim e is a real factor in
this station.
8. Inform ation giving: Jehovah's witness. Describe w hat we can do to minimise bloos loss. Discuss options for
replacement (w hat w o n 't be done, reassuring that we w o n 't transfuse.)

Telephone - refer a patient w ith a possible common bile duct injury post lap chole
to the local liver unit. Questions regarding w hat do you think may have happened -
clipped the CBD instead o f the cystic artery, ? retained stone. W hat is biliary
perotinitis? Does this patient need transfer now?

telephone conversation regarding transfer o f traum e patient w ith widened mediatinum(CXR) w ith CT consultant
@ regional cardiothoracic centre.
Critical care

acute pancreatitis:
why is there hyperglycemia &amp; hypocalcemia in pancreatitis.
45 year old male, diagnosed and managed fo r acute pancreatitis tw o weeks back. Now presents
w ith tachycardia, tachypnea and shortness o f breath.

Glasgow criteria. Causes o f hypocalcemia - talked about fa t saponification but wanted more, asked
w hat else happens, he wanted ARF causing hypocalcemia

-w hat scoring systems do you know.

-is serum amylase is im portant in scoring systems?
m ortality rate given a particular score (go memorise rough m ortality rates),
CT/ultrasound findings (oedema, fa t stranding, collection, necrosis,
abscess, pseudocyst), causes o f hypocalcaemia in pancreatitis (saponification o f fat,
hypoalbuminemia),
-give me tw o situations In acute pancreatitis where you can found serum amylase normal.
-w hat is the clinical presentation o f pancreatic pseudocyst.

a. W hat are the possibilities

b. Show a picture o f CT scan, asks to identify diffe rent structures on CT film . (Liver, spleen, pancreas, aorta, vertebrae)
c. Shows a blood report having hypocalcemia. Asks about cause o f hypocalcemia in acute pancreatitis. (Wanted to listen
at least two)

- Shown CT scan w ith massive pseudocyst. Identify main organs. (Stomach was squished till it
became a line w ith a small black lining inside. Keep probing me till I said stomach lol)

- Main abnorm ality (pseudocyst. I said dilated ducts as well and he asked me to point it out.)

-T o ld me patient is now hypocalcemic and hyperglycemic. Explain w hy (I said

saponification o f calcium soap. He asked fo r one m ore reason. I shrugged.)
- Patient is now tachypneic. WHY? (He wanted to hear abdo pain, splinting o f diaphragm
due to large cyst, ARDS, sympathetic overdrive as patient is not stable)(He wanted all
the reasons before allowing me to move on...)

Acute pancreatitis. Lady, recurrent alcoholism w ith epigastric pain. Shown bloods - LFTs, FBC, UECr, Ca/M g/P04.
Amylase 2100.

0 W hat's the diagnosis?

0 W hat radiological investigations w ill you do? US HBS first, CT Abdo. W hat are
0 How w ould you manage this patient?
0 How w ould you manage her pain? WHO Pain ladder
0 Name 2 scoring systems used to risk stratify patients?
0 Pick one and te ll me th eir components. How does the score relate to m ortality?
you looking for?
(Asked to give a score and corresponding m ortality risk i.e score 0-2: 2%, 3-4:
15% m ortality, etc). I made the numbers up but she was happy I got the correct
gist o f it.
How does paracetamol overdose cause liver injury (toxic m etabolite NAPQI depletes glutathione andblood trans
accumulates in liver - free radical injury)?

0 W hat are the components o f pseudocyst? How long a fte r w ill you suspect this?
How w ill they present?
0 W hat are the diffe re nt ways to assess pain? (Pain score, descriptive, smiley
faces, Visual Analogue Scale)

0 How much pain is this patient in? [you&#39;re shown a visual analogue scale]
0 How w ould you manage his pain initially? (IV paracetamol and IV m orphine
titra te d to effect)
0 Explain the WHO ladder
0 Why is codeine bad? (10% population lack enzyme to metabolise,
constipation, SEs etc)
0 W hat are the o th e r effects o f pain? (Emotive, physiological)
0 W hat are the physiological effects o f pain?
0 W hat o th e r modalities o f analgesia are there? (PCA, epidural etc)
0 W hat are the safety factors o f PCAs? (Lockout, measured dose, locked unit,
non-return valve on line)

Guy w ent out partying, drank alcohol, has epigastric pain radiating to back. Showed some bloods outside the
station fo r you to read in 1 m inute before entering. Basically amylase 2100, and out o f Glasgow score,
glucose, albumin, calcium, urea, to ta l whites w ere deranged
- w hat is the diagnosis, differentials
- w hat in the investigations led you to your diagnosis (amylase)
- name me one scoring system fo r severity, no need the values, just components
- fo r your scoring system, w hat is the tim e interval to do the tests?
- causes o f normal amylase in pancreatitis? (too early, to o late)
- how do you manage the pain? opioids
- why cannot give NSAIDS? (afraid o f renal injury)
- w hat other option if opioids not enough? (epidural)
- w hat is pseudocyst?
- why is calcium low?
- complications o f pseudocyst?
- w hat in blood results leads you to suspect pseudocyst? (amylase)
- is amylase a m arker o f severity? (no)
- where would you manage the patient? (ITU)
- w hat is the WHO analgesia ladder?

- is morphines effect on the sphincter spasm real or theoretical

Septic Shock
0 W hat do you think is happening + differentials fo r POD4 fever. Give the whole list.

a. SIRS criteria.
i. tem perature
ii. WBC
iii. HR
iv. RR or PaCo2
v. + clear source o f infection = sepsis
1. + lactic acidosis = severe sepsis

b. Interpret ABG results: m etabolic acidosis w ith respiratory compensation.

Examiner wanted me to explain every reading, including base excess and
lactate. Reference values provided.
c. How would you manage patient
i. ABC, iv drip, iv abx, investigate for source o f infection (blood/urine cultures, CXR, review wound, abdo examination)

d. HD criteria
i. respiratory im pairm ent not requiring mechanical ventilation
ii. 1 organ system acutely and reversibly impaired
iii. higher nursing:patient ratio
iv. vasoactive drugs
v. invasive m onitoring

Post spinal anesthesia shock and in ta k e /o u tp u t.

a. differentials: spinal shock, hypovolaemic shock, cardiogenic shock

b. interp re t vitals chart.

c. he was asking fo r IDC insertion to help w ith shock management when he kept asking w hat can you do to m onitor
blood pressure.

d. How w ould you manage shock? reduce epidural dose, inform senior/anaesthesia, fluid iv bolus, insert catheter etc

e. Apparently drinking w ate r does not help increase intravascular volum e because it is hypotonic. So intake o f water
orally does not really affect fluid balance

0 W hat is shock?
0 W hat bedside intervention can you do - insert urinary catheter to m o n ito r urine output
0 How to give fluids, w hat m ethod to decide
0 Colloids vs crystalloids
0 Frequency o f m onitoring (was Q4h) - insufficient
0 Asked BP = COxSVR, how to improve BP
0 Asked about inotropic support. How does each drug act?

Scenario w ith a dude w ho lobectomy and is now on epidural anesthesia. Has right sided upper limb paraesthesia,
oliguria, low blood pressure, etc.
Asked possible causes, w hat you would do to (stop epidural im m ediately etc),
why w ould epidural cause this : increased dose, incorrect positioning, spinal level too high, etc. who w ould you
involve(wanted someone in addition to the anesthetist).
W hat s/s would tell you patient is getting worse
w hat would tell you hes getting better.
Why epidural in this case (because post op pain in a patient w ith lobectomy and h/o copd w ould .... Described
lung physio and path here, he seemed to
Asked if there is any recent evidence suggesting epidurals im prove outcom e, I said yes and he was happy.
Asked how I would check epidural level and why -
w hat levels used fo r which surgeries, why is higher block dangerous (phrenic nerve, diaphragm paralysis etc),
why do we check tem perature (I said arrangement o f fibres, because m otor are last to be affected, seemed to
accept it).

Differentials - should have spammed cause o f SOB, AKI

Advantages- sleep v no sleep , CVS, respi effect?
W hy test pain tem perature and not dorsal column in checking levels (BS abt thick th in fibres, I
obviously did not know w hat I was talking about lol)
W hy m ight epidural be dangerous at T4? (BS something about transaxial line)
W hat would you do if suspect overanaes/toxicity, how to check
Level of block depends o n ___(dose, duration, position)

3. Post CVP Pneum othorax

0 How to assess breathing?
0 Investigations to do when SOB
a. is this adequate CXR? no, cannot see costophrenic angles
b. w hat is your system o f reading any XR? Look at name, 1C, date fo r confirm ation. Look from outside in or inside out.
c. w hat is the complication? pneum othorax no tension
d. complications o f cvp insertion? during insertion vs long term
e. how to landmark ijv? lateral to carotid artery, between 2 heads o f scm insert direction o f ipsilateral nipple etc
f. higher p oint you can insert into IJV, move on if you do not know.
0 How do you manage this (pneumothorax)?
0 Tell me how you would insert a chest drain
She suddenly becomes more short o f breath and hypoxic. W hat is
happening? W hat do you do? W here to insert needle? Tension pneumothorax.
Needle thoracocentesis mid clav 2 nd intercostal space.
Central venous catheter:
CVP inserted blindly and patient developed complications.
W hat is possible complications
How to read this x-ray in a systemic manner, he was searching fo r ABCDE
Also asked w hat is the recommended way to insert jugular CVP ,he was asking about NICE guidelines
Of using ultrasonic guided procedure and post procedure chest radiograph.
W hat other sites we can insert a CVP and w hat is the most one prone to infection.(fem oral)

Initial Management: ABC, inspect/percuss/palpate, 02

b. Before looking at CXR w hat to do - check pt identifiers, date etc.
c. How to look at CXR - check view, exposure, rotation, well inspired?, etc.
d. Types o f pneumothorax
e. Management - insertion o f chest tube

PTH, Hypercalcemia, Renal stone. Gastric ulcer, H pylori (Repeat)

- W hat is an ulcer?
- Most likely cause fo r the ulcer? (H pylori)
- W hat is CLO test? How does it work?
- Treatm ent o f H pylori, (triple therapy)
- O ther causes o f gastric ulcer in this patient.
- Causes fo r hypercalcemia.

- Shown some data o f frozen section. W hat is a frozen section.

- Only 3 parathyroid glands removed. W here w ill you find the last one. (ant mediastinum)
- Why low er glands found w ith thymus.

- How to tre a t hypercalcemia?

- W hat is the cause o f UTI in this patient.

Polytraum a, transfusion

- Which blood product would you give? (Pack cells)

- Are there WBC in the packed cells? % WBC in PCT?
- Lifespan o f RBC in the human body in days.
- How w ould you manage the circulation.
- W hat is a GXM. W hat is being crossed matched for?
- What would tell a hematologist?

- Stages o f fracture healing.

- Effects on bone a fte r prolonged im m obility.
- Infected im plant. Why must remove?
- W hat is 1 test you w ant to do? (Cultures)
- W hat is PVL Staph aureus? Dafuq...
- How w ill Ca level change w ith fractures? It does not!

CT brain o f 80 yo wom an who fell down (SDH). In A&E eyes open to pain, makes
incomprehensible sounds, and w ithdraw s to painful stimulus.
0 W hat does it show? Lense shape hyperdense lesion. Right SDH.
0 W hat does loss o f grey-white m a tter suggest?
0 W hat is "GCS", and w hat is her GCS?
0 W ho w ill you involve in her care?
M idline shift. Loss o f grey-white m atter

Management: Acute SDH

Urgent surgical evacuation o f hematoma for

1. acute SDH , +/- coma, w ith neurologic deterioration (signs o f increased intracranial pressure)
since tim e o f injury &amp; potential fo r recovery

2. fo r clot thickness &gt;10m m or midline shift &gt;5m m on initial brain CT

Nonsurgical managed patients should be nursed in ICU w ith ICP m onitoring &amp; serial head CT
scans. Next scan at 6-8 hrs. If w ith signs o f neurologic deterioration or persistently increased
ICP &gt;20mmHg, urgent surgical evacuation w ith in 2-4hrs od deterioration

Why would you choose to intubate patient

-1 . if patient cannot maintain or protect own airway (GCS 8 o r less/ cannot swallow own
secretions)
- 2. if there is failure to oxygenate (agitated, restless, sp02) or failure to ventilate (retaining
Co2)
- 3. is there an anticipated need fo r intubation - elderly w ith pneumonia in sepsis or burns
w ith inhalational injury

Trachy tube - easier oral to ile t. Less likely to aspirate. Less dead space. Better tolerated long

term ( not gagging /d o n 't need sedation). Easier to wean &amp; decannulate.

Noninvasive positive pressure ventilation only for patients who can protect th e ir own airway

/can swallow
7-poly traum a ( pt came in RTA having pneum othorax & rigid abdomen).
How to manage?=ATLS,...
How to confirm rupture organ? Said FAST Scan and CT.. W hat to see on FAST Scan? = fluid= bleeding..
Read the scenario again?? You w ill do CT, I said t t t pneumothorax w ith needle in the 2nd I.C.space +chest tube + if
haemodynamic stability we can do CT,„ If not. Go directly to urgent laparotomy.(examiner now very ha p p y)..
Showed me CT Abdomen.. W hat do you see ( the abnormal) = liver laceration( search fo r ct abdomen w ith liver
lacerations on Google you w ill find it and d e a rly )))..
How to t t t it??? Said conservative if haemodynamic stable but if not surgical w ith packing and control bleeding via
Pringle's manover.
Oesophageal Varices, Chronic alcoholic.

- How w ould you manage this patient circulatory-wise?

- Surgical tre a tm e nt fo r varices. TIPSS/Sugiura/Liver transplant
- W here do you expect to find portosystemic anastomosis? Give me the names o f the veins. Give all.
- If this patient is to go for liver transplant, w hat w ould you tell the family. ??
- How long must you stop alcohol before you can go for liver transplant. ??

Diverticular Abscess
- Differential diagnosis.
- Blood gas. Metabolic acidosis. Partial compensation.
- FBC. Intepret. (raised TW)
- W hat is shock.
- W hat kind o f shock is this patient having?
- Management o f septic shock.

AF w ith p e rf viscus (Repeat)

- Before you read this XR. W hat do you w ant to check.

- Interpret CXR. (air under diaphragm
- Causes o f AF. Name 4.
- ECG. Calculate rate o f this patient.
-W h y is this AF.
- Why machine read rate diffe re nt from w hat you calculated.
- How to tre a t AF. (Rate, Rhythm control, consult CVM, tre a t underlying cause)
- Causes o f perf viscus.

AAA massive transfusion, T35 degrees

i. W hat is the definition o f perioperative hypothermia? <36 core degrees

ii. Causes o f hypotherm ia in this patient hypothermia? Massive blood loss and transfusion, resuscitation w ith unwarmed
fluids, open surgery which was prolonged,
1. Patient: Hypovolemic Shock

2. Extrinsic: Massive blood transfusion, cold environm ent, organs exposed during laprotom y

iii. Complications o f hypotherm ia - M ainly Coagulopathy

iv. W hat is the mechanisms o f which the patient loses heat -
conduction, convection, evaporation, radiation

c. W hy is it im portant to prevent hypothermia?

d. How do you reduce risk o f hypotherm ia in this setting?
e. How do you reduce blood loss in the above stem?
f. W hat is autologous blood transfusion?
g. W hat is massive blood transfusion?
h. W hat are the problems faced w ith blood transfusion?
Name 3 diffe re nt blood components (PRBC, platelets, FFP, cryo, Blood -packed/irradiated/leukodepleted). Give 3
indications o f platelet transfusion (massive transfusion &gt;4 units, platelets &lt;50 and sym ptom atic fo r surgery,
DIC). W hat is the shelf life o f platelets (5 days)?
How are platelets transfused (shelf life 5 days, transfused 30-60min)? W hat is massive transfusion (replacement o f total
blood volum e &gt;10units in
24hrs or 4units in 1 hour)?

Definition o f h yp oth e rm ia ,
mention 3 ways o f intra-op heat loss
intra-op complications
risk factors in this patient
talk about 3 mechanisms o f hemostasis
w hat intra-op procedure can be utilized to avoid the need o f blood transfusion
complications o f massive blood transfusion , read the results (DIC),
how are you going to manage this patient ? (NICE GUIDELINES), who would you involve ?

v. How do norm al people generate heat - Shivering

vi. Can the patient generate heat intraoperatively? No. paralytic given
vii. Complications o f massive transfusion
viii. Lab results: Low Hb, Low Pit, Raised PT/ PTT, com m ent, w hat blood products to give blood products. That's why
fresh blood is better.

ix. W hat clotting factors are stored blood products deficient in? - All
x. How else can you reduce the use o f blood products ? - Reuse the patient's own blood using Cell Saver

xi. Mechanism o f haemostasis - vasoconstriction, platelet plug, fibrin polymerize

xii. W hat polymerizes fibrin - throm bin
xiii. How does the vascular surgery interfere w ith mechanisms o f hemostasis
xiv. Immediate post op complications o f AAA
1. General Anethesia related
2. Renal, bowel, lim b ischaemia, AMI, stroke

How does a vessel stop bleeding after you transect it? Initially was 'huh?' d o n 't understand the
question, but got led on to say the 3 factors he wanted, vasoconstriction, platelets and clotting
factors.
W hy AAA cannot stop - again talk about above 3 factors, all cannot
Management o f ruptured AAA.

(b) discussion on diffe re nt types o f blood products

W hole blood - rarely used nowadays as separated into its components
Packed red cells - whole blood from which plasma has been removed to
haem atocrit about 70 percent. RBCs suspended in SAG-M (sodium chloride,
adenine, glucose and m annitol) volume about 180-350ml, largely increases Hb
by 1 g/dl, stored at 4 degrees Celsius. Has no coagulation factors, WBC die
a fte r ????

Platelets - should be given w ith in 60 minutes used fo r low numbers or non­

functioning platelets
Fresh frozen plasma - 200ml from 1 donor unit, stored at -30 degrees Celsius,
contains all coagulation factors but takes 30min to thaw out.
Cryoprecipitate - 20ml o f FFP supernatant containing factor VII:C, VII:vWF
and fibrinogen
Clotting factor concentrates - VIII, IX
Albumin
Immunoglobulin

Neck lum p w ith lethargy and malaise

i. W hat is the diagnosis? Hypothyroidism w ith anemia
ii. Explain the thyroid hormone axis. (TRH, TSH, T3 T4 w ith negative feedback mechanism)
iii. 6 features o f hypothyroidism
iv. 3 causes o f hypothyroidism - Post thyroidectom y, Iodine deficiency, Hashimoto's
v. W hat are the TFTs if there is a pituitary cause o f hypothyroidism
vi. Patient w ith hypothyroidism not com pliant to medication comes
in fo r emergency surgery, w hat are the risks? - M ainly look for
myxodema coma
vii. How to im prove compliance o f m edication - Simplify regime,
involve carer or fam ily member, regular follow ups (Examiner seemed to
have wanted more)

viii. Blood tests show macrocytic anaemia, cause in this patient? -

Associated autoim m une conditionn o f pernicious anaemia causing Vit b
12 deficiency due to lack o f intrinsic factor

Lady w ith low T4 and High TSH.

Asked to draw diagram to explain thyroxine secretion, ie. Hypothalamus, pituitary, thyroid axis
Difference between T3 and T4
How does T4 come about
W here does conversion o f T3 to T4 take place
Shown FBC, leucocytopenia and anemic. Macrocytic anemia
Likely cause? Pernicious anemia
Likely cause o f hypothyroidism - autoim m une
Markers to do
Signs o f hypothyroidism
W hat to do fo r surgical patient w ith hypothyroidism? Which other specialties to involve?

Peri-op n u tritio n : Lady w ith Crohns disease, had ileocecal resection, POD4 anastom otic leak, so had defunctioning
ileostom y - TPN

i. W hat does AXR show? small bowel dilatation

ii. Causes in this patient - stricture
iii. Methods o f feeding - Enteral (Oral, NGT, NJT, PEG, PEJ)vs Parental (TPN and PPN)
iv. Routes o f TPN adm inistration (PICC, Central line)
v. Contents o f TPN - Carbohydrate, protein, fat, water, electrolyte, nitrogen, trace elements
Problems w ith continuous glucose as the only energy source
1. Poor utilization during stress
2. Excess converted to fats
3. Produces excessive C02
4. hyperglycemia
vii. Besides glucose w hat is the next highest energy source o f TPN - fat
viii. Complications o f TPN
1. N utrition related - Also include mucosal atrophy causing bacterial
translocation
2. Line related
3. metabolic related - bone, immune system, cholestasis

ix. Indications for TPN

1. Systemic: Burns, M alnutrition, severe pancreatitis, sepsis
2. GIT related: Enterocutaneous fistula, short gut syndrome, Crohn's

TPN indications, complications, w hat are required in making it up,

w hat ratio o f carbs, fats etc. w hat is refeeding syndrome and cause behind it,

- w hat does xray show? (small bowel I/O)

- w hat is the likely cause? ( SB stricture sec to Crohns)
- w hat are the feeding options? (parenteral vs non parenteral)
- w hat are types o f non parenteral feeding options?
- w hat are the complications o f non parenteral feeding?
- w hat are constituents o f TPN? (i didnt m ention w ater & #39;)
- w hat is the main source o f carbohydrate in TPN?
- w hat is the consequence o f using glucose only as a the main form o f carbohydrate source?
- w hat are the complications o f parenteral feeding?
- how do you give parenteral feeding?
- w hat are the indications fo r parenteral feeding?
- w hat are the consequence o f bowel mucosa atrophy?

Showed AXR o f stack o f coins appearance. W hat is this?

b. W hat are the d iffe re n t routes o f n u trition do you know of?

c. W hat is enteral nutrition? When w ill you use enteral nutrition?
d. W hat is parenteral nutrition?
e. When w ill you use parenteral nutrition?
f. W hat are the constituents o f parenteral nutrition?
g. W hat are the type o f electrolytes in TPN?
h. W hat is dextrose? W hat are sugars?
i. W hat are the complications o f TPN? Examiner is not satisfied w ith just line sepsis,hyperglycemia,
electrolyte disturbances, cholestasis and bowel mucosal atrophy. Wanted more.
j. You m entioned bowel mucosal atrophy, why does it occur?

N utritional status
How to calculate? N utritional calculators, age, activity level,
Burns: basal requirem ent +replacement = 25-30 kcal/kg + 70kcal/kg/% burn
W hat methods do you know o f parenteral and enteral
Nj, ng, peg
W hat increases requirem ent -- &gt; sepsis, post surgery,
W hat is in tpn
W hat are the complications o f an ng/nj - dislodgement, infection, aspiration, diarrhea, colonisation
o f bacteria, overfeeding, refeeding syndrome- hypophosphatimia
How is tpn administered and why: thru a central line. Thickness o f the fluid and also causes
pheblelitis due to the high osm olarity
W ht happens to the gut after prolonged tpn. Mucosal atrophy
W hat is the im plication o f this? Translocation o f bacteria to the blood stream causing sepsis
Why is glucose not a good substitute? Higher respiratory quotient, lesser energy value, critically ill
are glucose intolerant, lack o f essential fa tty acids

DIVC
b. DIVC
i. Tell me about the pathophysiology o f DIVC - widespread activation o f coagulation and
consum ption o f coag factors thus leading to subsequent bleeding
ii. Stages o f clotting
iii. Quizzed about aptt and pt
c. Patient has dyspnea and desaturation on POD 5
i. DVT
ii. Repeat question
iii. W hat would you do fo r patient
iv. W hat investigations to order
explain picture? why does DIC happen?
w hat does APTT test? w hat does PT test? how is extrinsic pathway activated?
how is intrinsic pathway activated? w hat are platelets? how do they work? give reasons this patient is having DIC? hep C
+ shock, w hat are complications o f hep C on liver? fibrosis, cirrhosis and malignancy, functions o f the spleen.

Scenario o f a young woman w ith hep c, had splenic injury, bloods show deranged coagulation profile (all aptt, p t etc
increased), severely hypotensive, high fever, etc -
asked differentials, happy when I said die, haemorrhage, etc. asked w hat is
w hat are the risk factors in this patient
how w ould you manage
why does die occur in such patients,
w hat are platelets where are they produced w hat are th e ir functions (like seriously?), just wanted to hear
platelet plugs
Then he asked w hat is aptt, w hat does it mean w hat factors and w hat pathway involved
tell me the stages o f fracture healing

Hypotherm ia he w anted 36 CORE TEMP.

a. Patient has hypotherm ia
i. Tell me why hypotherm ia is detrim ental
ii. Ways th a t a patient loses heat intra operatively, preoperatively and post
operatively
iii. How to warm a patient intraoperatively and post operatively
iv. How to measure core body tem perature
I said Rectal, vesical and PICCO, LiDCO ( seemed happy),
w hy is this patient hypothermic,
w hy surgery precipitate hypotherm ia? procedure heat loss, loss o f shivering, vasodilatation, cold IVF, cold gas of
anesthesia machine, ways o f heat loss? how to avoid heat loss?

b. Patient has oliguria post operatively

ii. Reason fo r oliguria
iii. How does oliguria post-operation happen? Explain the pathophysiology

Post op oliguria and post IDC polyuria. HyperK+. Clinical relevance and
management. Causes o f Renal failure.

d. Patient w ith abdom inal pain post operatively

i. Septic picture
ii. W orried about anastom otic leak

Burn and ARDS.

w hat labs to send? in ITU CXR is taken, tell me the findings ( shrugged me o ff when w ent fo r the full assessment, told me
go fo r the gold), bilateral infiltrates on CXR. causes, pulmonary oedema Vs. ARDS,
w hy this patient can have pulm onary oedema, why ARDS,
Berlin Criteria fo r ARDS, management o f ARDS, w hat Abx?
Define ARDS (W anted pathological defin ition ,not the pulm onary wedge capillary pressure crap).
W here will you adm it if she has ARDS?
How w ill you tre a t her?
W hat are the long term sequelae o f ARDS.
d. Shows X Ray Chest o f the patient, Asks fo r positive findings (Pulmonary infiltrats in all zones bilaterally)
e. Asks mechanis o f ARDS
f. Diagnostic criteria o f ARDS
g. Etiologic factors of pancreatitis, wanted to listen 5-6
h. Bell rings, could not com plete this station (I think so)

- W hat is this. ARDS and rattle o ff criteria

- How to management
- Pathophysiology o f ARDS
- W hat happens to lung compliance? Complication o f ARDS

e. Patient w ith whole body burns

te ll me if he has superficial or deep burn, why?
w hat's your initial management, ATLS protocol.
Parkland, any other?!! w hat is parkland?
where do you w ant to manage this patient? burn unit, you d o n 't have one. Isolation room o f ITU. w hat do you fear?
i. Parkland form ula
ii. Resuscitation fluid you w ant to give - hartmann
iii. W hat solution you would give
If used saline w ould you use the same formula?? Said yes( seems accepted)...
iv. How w ould you manage the patient

Fluid overload
post-op patient w ith tachycardia, hypertensive emergency. CXR showing
bilateral pulm onary infiltrates, w ith fluid chart, given crystalloids and colloids.
w hat is management, furosem ide in liaison w ith medics, where to manage, HDU. why is he at
high risk o f M l, tachycardia decreasing the diastole tim e and increased resistance increasing
w ork load on heart, which receives blood in diastole only, w hat can be done to prevent this from
happening again? quality control, inform people, better education, closer m onitoring in the
im m ediate post-op period, ro o t cause analysis.

Patient s/p op, now BP high, desaturating and low urine output, (asked to interpret the vitals chart
and I/O chart which is not given prior in the stem).
Explained fluid overloaded cos net 5L + input.

W hat are your expected physical exam findings?

W hat investigations w ould you w ant to do? W hat are your expected findings?
Interpret this CXR: pulm onary edema ++, loss o f cardiophrenic angle, cardiomegaly.
How w ill you manage this pt?
Can you explain the patient&#39;s low urine output? W hat is the m inim um urinary output?
W hat are some physiological causes fo r his low urine o u tput postop?
Explain w hat are the fluids th a t have been given. Which are crystalloids, colloids.
W hat is the Na requirem ents in a patient?
W hat are the K requirem ents in a patient?
Can you give a few suggestions on how this situation can be prevented or detected earlier?
In retrospect -- maybe the answer he was looking for was CVP line insertion postop.

- Acute pulm onary Edema post op. showed CXR w ith ECG. D idn't do too
well on this. Many questions on management o f cardiac failure. Drugs u can use.

Scenario m orphine toxicity, given ABGs report.

 Asked me to interpret the ABGs- respiratory acidosis.
W hat type o f respiratory failure, why. W hy is the bicarb normal
why does m orphine cause this - how w ould you tre a t this patient - naloxone
How do kidneys regulate acid base balance
w hat are the types o f resp failure and w hat are th e ir causes,
describe how C02 retention causes respiratory failure,
w rite co2 bicarb equation along w ith its enzyme,
where does it happen
describe chloride shift
W hat is the side effect o f naloxon.
W ithdrawal. Pain, nausea vom iting, seizures.
- How does your body sense hypercarbia
- Response mechanisms to hypercarbia

how carbon dioxide is transported in the body. (1

carbaminohaemoglobin, dissolved in plasma, HCO- ion). Draw the h20 and co2
equation. Where is carbonic anhydrase found? Interpret the ABG (acute respiratory
acidosis). He asked why Pa02 normal range and why no metabolic compensation.
Pa02 in 'norm al range' because FI02 is 60% so PA02 reference range needs to be
adjusted accordingly (FI02 & lt;in %&gt; - 10?). No metabolic compensation because
acute. Kidney takes tim e to react.

1) W hat is causing the respiratory acidosis?

2) How does m orphine work? Receptors?
3) How does body detect these changes? W here are the respiratory centers
4) How w ill I manage this patient? W hat is the side effect o f naloxone?
and where are the receptors? How do the center and receptors detect
the changes in the blood?
W hat is the dose to give? W hat do I need to look o u t for? W here w ill I
m onito r this patient?

head in ju ry w ith lucid interval

w hy is patient intubated (gcs 8),

look at ct and tell me w hat you see (extradural hematoma),
w hat is lucid interval and explain its pathophysiology (concussion -> recovery ->middle meningeal artery bleed
and collection -> raised icp -> herniation -> death).
Explain Monroe-kelly, explain why icp rises in EDH (blood increases so CSF has to decrease, etc).
w hat is MAP, w hat is CSF pressure,
w hy hypertension in raised ICP, name the triad

An elderly patient w ith dem entia and underw ent urinary retention. His labs showed hyperkalem ia and
hyponatrem ia along w ith AKI. Also he was catheterized and poured out 4L o f urine.
1) W hat do the labs show (hyperkalemia, AKI and hyponatremia)
2) Why has the pt poured o u t 4L o f urine (recovery phase o f AKI, I am not sure if this was correct)
but he seemed to have accepted it.
3) How does this polyuria phase occur in recovery o f AKI ( inability to concentrate urine)
4) W hat are the causes o f hyponatrem ia in this patient? (SIADH due to distension o f bladder)
5) W hat other surgical discipline uses hyperkalemia (cardiac surgery)
6) W hat is it called (cardioplegia)

1. Fluid management, persistent hypotension and tachycardia in a lady post-op

- 48 year old lady, im m ediately post THR transferred to ward at 3PM, persistently
hypotensive and tachycardic w ith worsening hypotension (70/30 systolic) at 2 AM
- Provided w ith fluid chart showing only 2x250mls bolus w ith small im provem ent initially
- W hat are the 2 most likely causes o f hypotension in this lady: Dehydration/Bleeding
(stem said no bleeding, sighs)

- Asked to explain the fluid chart and vitals: Said patient has been persistently
hypotensive and tachycardic on the ward w ith only 2 fluid challenges and nothing in
between.

- IS this adequate? - No
- W hat w ould you have done: Given m ore fluid challenges since she appeared to be fluid
responsive
- Patient only on 2 hourly m onitoring - is this adequate? No - hourly at least, or
continuous in HDU
- W ould you have notified anyone else?: My senior. When would you have notified
him /her: If the patient was still persistently hypotensive despite a few fluid challenges
- How is BP, CO, TPR related : BP = CO x TPR
- How can you increase BP then? : fluids for TPR and ionotropes fo r CO+TPR
- How much fluid bolus w ould you give: said 250mls over 30 mins but he wanted a specific
form ula, no idea

EDH
EDH: Young man, motorcycle vs car, le ft EDH

- Young patient in RTA as above, LOC but GCS 15 on arrival, vom ited twice, amnesic of
events, no CT done initially but found to be GCS 8 later on ward, CT brain done shows
le ft EDH (biconvex lucency) w ith m idline shift and compression o f le ft ventricle

- Asked why patient should have had a CT earlier: quoted the criteria fo r the Canadian CT
rules, patient had a few criteria
 Canadian CT Head Rule
CT H ead is only req u ire d fo r m in o r head injury patie n ts w ith any o n e o f the
fo llo w in g findings. M in o r head injury patients present w ith a GCS score o f
13-15 a fte r w itnessed loss o f consciousness, am nesia, o r confusion.

High-Risk (fo r N eurosurgical In terv e n tio n )

1. GCS score < 15 a t 2 hours a fte r injury

2. Suspected o p en o r depressed skull frac tu re
3. A ny sign o f basal skull fra c tu re *
4. V o m itin g 2 2 episodes
S. A ge 2 65 years

M edium -R isk (fo r B rain In ju ry o n CT)

6. A m nesia before im pact > 30 m inutes

7. D angerous m echanism * •

• Signs o f Basal Skull Fracture;

- hemotympanum. 'racoon' eyes. CSf ouxrtiea I rhinotrhea. Battle's sign

*♦ Dangerous Mechanism:
pedestrian struck by m o to r vehicle
• occupant ejected fro m m o to r vehicle
- fall from elevation 2 3 feet or 5 stairs

Rule n o t applicable i t
- N on-traum a case
• GCS < 1 3
- Age < 16 years
• W a rfa rin or bleeding disorder
- Obv.ous open skull fracture

- Shown the CT, asked w hat I w ould be w orried about - mid line shift w ith loss o f ventricular space, may result in
herniation
- Asked why w ould the brain herniate - Monroe kellie doctrine etc
- W hat is the cause o f dilated pupils in raised ICP (herniation causing compression o f CN3 which carries the
parasympathetic fibres, causing unopposed sympathetics to the pupil and resultant dilatation)
- W hat is the normal ICP : said 15-20 cmH20 (initially said mmH20 but he asked me
w hether it was mm or cm)

- Ways to measure ICP: Insertion o f intracranial pressure m onitoring catheter, he wanted

a less invasive way, couldn't think o f it so we came back to the question later; finally got
i t : lum bar puncture. Asked w hat was the danger w ith LP: herniation if ICP is high
- How to manage this patient if he was intubated to decrease risk o f brain injury: Sedate
patient to prevent straining, hyperventilate to maintain normocarbia, hypothermia,
position patient 30 degrees head up, judicious fluids w ith m onitoring, mannitol

W hy did the patient lose consciousness at first?

0 W hat is M onroe Kelly doctrine
0 Patient becomes hypertensive, bradycardic, irregular breathing, why and w hat is that?
0 W hat to do w ith raised ICP?
0 W hen do you w ant to intubate?

- Layers passed through when doing a burrhole over the pterion

- When I w ould consider intubating this patient (in addition to low GCS, airway, pC02
control, also wanted to hear " if I need to transport the patient to another hospital")
- Benefits o f intubation - a fte r I said decrease pC02, he prom pted me "and the other
gas...?" W anted to hear oxygenation to prevent HIE

P neum operitoneum : perforated peptic/ga stric ulcer

- Middle aged man, has OA taking NSAIDS, comes in with peritonism and pneumoperitoneum seen on CXR

- Likely diagnosis: Perforated gastric/duodenal ulcer

- Risk factors fo r perforation: NSAIDS/steroids/H pylori/previous peptic ulcers, he wanted more
- Management options fo r perforated ulcers: om ental patch repair, prim ary repair,
ulcerectomy (asked w hat an ulcerectomy was, said its excision o f the ulcer follow ed by prim ary repair)

- Difference in management between PDU and PGU - w ill take biopsies from PGU due to risk o f malignancy causing the
perforation, PDU are rarely due to malignancy
- W hat m edication w ill this patient require post-op : PPIs, asked about the mechanism of
action o f PPI: lamely mentioned some NA-K- ATPase pump on parietal cells

- W hat does HCL do in the stomach: Blanked out fo r this, said kills bacteria, aids in
digestion o f food, asked how does it help in the digestion: activates pepsinogen to pepsin

- Asked about phases o f gastric acid secretion: He wanted the cephalic phase/gastric phase/intestinal phase which I had
to ta lly no clue about

- Asked about the NCEPOD prio rity OT listing: Said from 0-4, 0 is immediate, 1 is w ithin 1
hour, 2 is w ithin 4 hours, 3 is w ithin 12 h and 4 is elective (based on experience from
TTSH). Go google it as the tim ing is a b it diffe re n t from w hat I mentioned.

PE
1. Chest pain and dyspnoea patient on the ward after a TKR
- Patient post TKR POD 1, walked to to ile t and developed sudden severe sharp le ft chest
pain w ith associated dyspnoea
- DDx - cardiac, DVT/PE, less likely pneumonia/MSK
- Investigations : FBC/RP/CMP/trop l/D -dim er not useful as just post-op, CXR, ECG, CT PA
- CTPA confirm s PE - management: m o n ito r patient in HDU, anticoagulate w ith
heparin/clexane, if unstable can consider surgical embolectomy
- Asked w hether I w ill give heparin/clexane - said IV heparin based on the protocol based
on body weight - he wanted more details but th a t was all I knew.
- He said he gives all his patients w ith PE dexane - dose: 1.5mg/kg daily or lm g /k g BD

Ruptured divericulum w ith pelvic abscess and septcemia,

mangement, ABG, investigations to do, open vs percutaneous drainage adv and disadv.

polytraum a, pneum othorax, liver tear, management

M iddle aged male, had lo w a n te rior resection 5 days back. Now having persistent fever,
tachycardia and d iffic u lty breathing.

a. W hat are possibilities

b. Shows ABGs having picture o f metabolic acidosis. Asks about interpretation
c. Shows serum report having raised creatinine and potassium, asks about cause of
d. Show com plete blood count. Asks w hat is SIRS. Which o f SIRS factors are positive in this patient. (All four were
positive)
e. How to manage hyperkalemia in this patient

Hypocalcemia
13) Critical care - Calcium homeostasis
Stem: Post thyroidectom y hypocalcemia. Given investigation: Calcium 1.8. P04 0.7. Everything else
ok
- W hat is the cause fo r hypocalcemia
- How is calcium transported in body
- W hat is calcium used for
- 3 hormones involved in homeostasis
- How is V it D formed
-W h a t is V it D actions
- W hat are the actions o f parathyroid
- W hat are clinical symptoms o f hypocalcemia
- Which muscle are you w orried about in hypocalcemia tetany (I really d id n 't get the correct answer fo r this one. I said
diaphragm, intercostals. He just shook his head. So I told him I d id n 't know)
- How to tre a t hypocalcema (Told him IV calcium gluconate. He asked fo r specific dose. I said
IV infusion over 10 mins 10 mis o f 10% calcium gluconate. He said he w ill accept that)

Post to ta l thyroidectom y pt w ith low Ca. All other bloods normal

Explain how Ca is carried in the body and which part is active (bound the albumin, ionized fraction is active)
Which hormones are involved in Ca regulation (name 3). W hat are th e ir actions? (examiner asked
the exact mechanism o f how parathyroid horm one causes phosphate excretion in the kidneys, w tf.

How is active v it D3 formed?

W hat are the physiological roles o f Ca in the body? Name 4.
Cardiac, nervous, haemostasis and bone.

Can you tell me why this lady has hypothyroidism ? Inadvertant removal o f parathyroids.
W hat is a more common cause? Ischemia to parathyroid glands.
So w hat w ould you be worried about in this lady? Tetany
And so? Respiratory embarassment
How does hypoCa cause SOB? Laryngospasm causing upper airway obstruction
W hat o ther signs o f HypoCa do you know of? Chovsteks and Trousseaus sign.
Can you describe them fo r me?
So w hat w ould you w ant to do for her? Give Ca replacement - IV Ca gluconate. W hat is the exact
dose th a t you would give? and the concentration? W hat would you ink up in the IMR? lOmls 10% Ca glue
W hat o ther management? Said A, B, C.. examiner not interested. M onitoring -- ECG, Sa02 m onitoring.
W hat else? Regular Ca m onitoring? Digoxin? HD? bell ring. Sigh.

Hormones involved in calcium homeostasis

o PTH -increases plasma Ca by 1. increased bone resorption, 2. increased
alpha 1 hydroxylation o f calcidiol to calcitriol - increases gut Ca &amp; P04
absorption , 3. increased renal retention o f Ca w hile increasing P04 secretion

o Calcitonin

Vitam in D Metabolism - skin, dietary - fa tty fish &amp; eggs -need 600 IU /day
o Start from skin to activation in Kidneys:
1. skin - 7-dehydrocholesterol - sunlight - cholecalciferol.- bound to v it D
binding proteins -&gt; liver

2. diet (cholecalciferol D3 or ergocalciferol D2) - SB - chylomicrons -& g t; liver

3. liver - 25hydroxylase - 25 hydroxy v it D or calcidiol

4. kidney (m itochondria PCT) - calcidiol - alpha 1 hydroxylase - 1,25 dihydroxy
v it D or calcitriol (physiologically active)

5. calcitriol - increased gut absorption o f Ca, decreased renal excretion o f Ca &amp;

P04, bone resorption (thru PTH). Can also inhibit PTh in case o f hypoP04
(increase Ca &am p; P04 intestinal absorption w ith dec P04 renal excretion
Trousseau sign - carpopedal spasm after inflating BP cuff above systolic BP x 3mins

Chvostek sign - contraction o f facial muscles w hile tapping on facial nerve anterior to ear
o Structural Names at each stage o f Vitamin D Metabolism

o How it is Metabolised

Enterocutaneous fistula
19) Critcal Care - Enterocutaneous fistula

- W hat is a fistula
- W hat factors predispose to form ation o f ECF
- W hat factors prevent spontaneous closure o f ECF
- W hat conservative management can you do for ECF
- W hat complications o f ECF
- W hat w ill make you bring the patient into the OT w ithin the first 24 hrs (He nodded and gave
approval when I said distal obstruction, intraabdom inal sepsis. I said a lot o f other things but
he d id n 't let me go till I said those 2)
- W hat are signs o f intraabdom inal sepsis
- Given blood results: Low Na, K,HC03
- W hy low bicarb
- W hat is the principle o f fluid management in this patient
- W hat are the principles o f management for ECF

W hat are the risk factors for the form ation o f enterocutaneous fistula? Divided into patient, surgeon and other
factors

W hat are the factors th a t predispose non closure o f a fistula? FRIENDS

If the patient is fo r conservative Tx, w hat would your management be? SNAP but no P
W hat other complications w ill the fistula have besides metabolic disturbances? Dehydration, wound infection
Why would the patient be acidotic? W here is Bicarb mainly produced from?

HPA Axis (RA p a tie n t on steroids/im m unom o dullators)

a. Explain the axis and how it works
b. Symptoms if patient is supressed
c. Relavence in surgery, how to prep patient for op things to watch out for
i. Neck fo r RA
ii. Steroids and to give stress dose how to calculate and convert pred/hydrocot
d. Complications o f long term steroid use
(must know)

3. Patient was found to have a goitre. Clinically patient has symptoms o f hyperthyroid.
a. Explain the th y ro id axis
b. W hat w ould you expect in a patient w ith secondary hyperthyroidism?
c. W hat are the ddx o f a patient w ith a goitre?
d. Showed blood picture, macrocytic anemia.
e. Why would you expect macrocytosis?
Pt w ith hypothyroidism , non-com pliant to medications planned fo r elective surgery
- Blood results shown:
&gt; FBC showed macrocytic anemia
&gt; fT4 low, TSH high-
 Questions asked:
Interpret TFT
&gt; Explain HPT axis
&gt; Clinical presentation o f hypothyroidism
&gt; W hy m ight pt be hypothyroid / w hy m ight p t be non-com pliant
&gt; W hat are the perioperative concerns w ith hypothyroidism
&gt; How w ould you enforce compliance (s /t pt, fam ily, w ork w ith GP, etc.)

Gastric o u tle t obstruction w ith m etabolic alkalosis (usual question)

a. Standard pathophysiology
b. Symptoms to watch o u t fo r
c. Symptoms o f NA changes
d. How to tre a t w hat to investigate
Causes o f hyponatremia - classify by volume status,
why is the chloride low - vom iting
why is the Crt & U high - dehydration, AKI
why is the K low
Patient has paradoxical aciduria why.
likely diagnosis (pyloric stenosis)
Management
W ho w ould you like to seek help from , (renal? God?)

Given labs to intepret: Hyponatremic, Hypochloremic, hypokalemic, metabolic alkalosis.

Questions:
Classification and causea of hyponatrem ia: Dilutional vs excess loss (depending on volume status:
hyper/hypo/euvolem ic)

Likely cause in this pt: Gastric o u tle t obstruction. Pathophysiology o f hypochloremic hypokalemic metabolic
alkalosis w ith paradoxical aciduria
-- &gt; Kidney main function is to conserve sodium as opposed to tonicity: PRoximal tubule: NA-CL cotransport:
short o f Cl, cannot function. Ascending lim b o f Henle: Na-K- 2CI co transport: cannot function cause short of
Cl-
Distule tubule: Aldosterone mediated Na/K exchanger: potentiates hypokalemia. Once K runs low, uses Na/H
exchanger. Therefore paradoxical aciduria
Management: HD, judicious replacement to prevent ceberal pontine oesteomyelosis. Manage cause likely CA

16) Post operative pain m anagement

Drug chart: patient only had panadol and arcoxia, not given m orphine yet
0 W hat do you w ant to give patient? So I said give m orphine
0 W hat is the pain pathway? I said spinothalamic tract, and about crossing at level o f spinal cord, but was unable to
give more beyond that
0 W hat are the side effects o f opioids? I said ARU, respiratory depression, he wanted m ore but I couldn't come up
w ith them
0 He seemed to be looking fo r a referral to pain team if patient still complaining of pain
0 W hat can PCA give to patient?
- How to assess severity o f patient's pain
- W hat does this VAS mean (showed 0-10 VAS line w ith X somewhere to the right o f centre)
- If you saw this drug chart, w hat would you tell the nurse? Drug chart was strangely
form atted, but seemed to show th a t both PRN drugs and regular drugs hadn't been
given fo r a while.

- How to manage this patient's pain (wanted to hear refer pain team on top o f the rest o f the answers)
- Adverse effects o f post-op opioids
- Problems caused by post-op pain
- How does PCA work, and w hat are its features
- Complications o f PCA - wanted to hear 4, which I d idn't manage to give
Post op analgesia. PCA benefits and drawbacks. Normal dosage.
Side effects o f morpine.

17) Esophageal variceal bleeding and Sengstaken Blakemore tube

Sengstaken Blakemore tube

0 W hat are differentials in this patient w ith chronic alcoholism? I said esopheal variceal bleeding, M allory weiss,
boerhaave syndrome, PUD
0 How does chronic alcoholism lead to portal hypertension?
0 How to use the sengstaken Blakemore?
0 How to manage the patient w ith acute bleeding at first?
0 W hat could be the cause o f the anemia? (I said blood loss, haem odilution from NS resuscitation)
0 Patient had macrocytic anaemia, w hat could be the cause? (I said nutrition deficiency from chronic alcoholism)

14. Hematemesis, esophageal varices

- Stem was patient who is a chronic alcoholic, p /w hematemesis x3, BP dropping, HR

rising
- Differentials fo r this patient
- Acute management o f variceal bleed
- Which varices are usually bleeding (GEJ)
- Causes o f throm bocytopenia in this case - wanted quite a few answers. CLD
(hypersplenism...? Wanted at least 2 more I think); possible DIVC (he eventually said
this answer him self when I d id n 't come up w ith it)

- Shown a tube - 1th ink it was a Minnesota tube (4 lumens), but he was happy enough
w ith Sengstaken Blakemore, ju st shrugged and nodded when I corrected my answer
to Minnesota. Asked to explain how it works. He looked at me in the eyes, grabbed my
w rist and said "IN BROAD PRINCIPLES" (I gave him a 2 m inute spiel anyway)

- Risks and complications of using Sengstaken Blakemore tube

c. Sengstaken Blakemore tube
i. Describe usage
ii. 3 ports - w hat are they for and where do the balloon
iii. W hat is the m odification - p o rt anterior to sits oesophagus? If there is no m odification, w hat do you do?
(insert NGT)
iv. problems associated
2 common causes fo r hypercalcaemia - parathyroid adenoma,
renal failure
g. shown pathology report w ith chief cells 0 parathyroid adenoma
h. where are parathyroid glands located
i. management o f parathyroid -s e s ta m ib i scan, parathyroidectom y
10
Pt POD 5 post-ileostom y reversal w ith signs o f sepsis: febrile, tachycardic. Also noted to have a right UL
patch on CXR. Dilated small bowel loops on AXR

- Questions asked:
&gt; AXR shown: w hat is the diagnosis?
&gt; W hat are the ddx fo r dilated SB loops on AXR? 10 vs ileus
&gt; How to differentiate them? Bowel sounds
&gt; W hat are the possible causes fo r pt's clinical presentation?
&gt; How to treat? W hat antibiotics to give? W hy should not give cephalosporins? (apparently answer was
because it causes C. diff...)
&gt; W hen w ould you o p t fo r surgical management?

C om partm ent syndrom e

17. Leg crushed fo r few hours in 28 yo male.
Left unobserved on ortho ward. Now has bloods consistent w ith acute kidney injury.
Urine dipstick has blood.
Asked about specific bloods fo r rhabdo. Asked about fasciotomy. Com partm ent
pressures and normal values. How to manage rhabdo and AKI due to this.

34 weeks pregnant lady undergoing laparoscopic cholecystectom y for

gangrenous cholecystitis. She is in reverse trendelenburg position. BP drops from
107/60 to 85/56, HR 110.
0 W hat are the benefits and risks fo r this patient undergoing this op?
0 W ho should be involved in her care? Anaesth, 0&am p;G , ?neonatologist (He wasn't
satisfied w ith 1 st 2, wanted more) W here w ould she be m onitored post-
operatively? (W asn't happy w ith HD, Surgical ICU. I said 0&am p;G HD/ICU. Not sure
if it exists here)
0 W hat is preload?
W hat mechanisms are involved in venous return? How w ould mechanical DVT
prophylaxis affect this?
0 In this lady, how would you manage this drop in BP?
- W hat is preload?
- W hat affects preload?
- How does preload affect you systemic circulation?
- In this patient most likely cause? They w ere going for compression o f IVC by the uterus
- How w ould you tre a t this patient? I w ent for fluid resuscitation
- W hat measures can you do to prevent fu rth e r hypotension? Lift the uterus up during surgery and
tilt the patient head down 30 degrees

5. [CPS] Primary survey - 24 M was h it by a car. N ow in A8iamp;E. Patient is not responsive. Not
breathing. Appears cyanotic. Assume circulatory status is adequate. M anequin there. On
table they displayed d iffe re n t sizes o f C-spine collar, guedels, a bag 8iamp; mask.
0 Examiner stops you at Airway and breathing - Patient not breathing, w hat do
0 Why did you pick th a t size o f guedel? - Show me how you measure. Show me
0 Ok patient breathing now. W hat you do next? Secure C-spine, ensure adequate
you do? Insert oropharyngeal airway, bag and mask (asked to do it). Suggested
intubation but need anaesth to do it. We are not qualified,
how you insert. Show me your bag-&amp;- mask technique (got to show th a t both
mannequin lungs w ere inflated adequately)
ventilation. Show me how you'd insert C-spine collar. Examiner is the "nurse".

Trauma activation
You have a m otorcyclist who is now GCS 3, cyanosed and not breathing. Has cardiac output.
Examiner and mannequin.
Gel and glove up.
Has no C collar on.
Testing ATLS.
- 1said would ask the nurse to hold the head or put sandbags
-Secure airway --ja w thrust: sweep foreign bodies. W hat foreign bodies could these be? Patients
vom itus, dentures, loose teeth etc.
-Patient is still cyanotic. W hat w ill your next step be? Guedel airway.
-Sats still not picking up. Offered intubation - &quot;you mean you can intubate?&quot; I said i w ill ask an A&amp;E
colleague haha. & quot; Well, th a t is not wrong.&quot;

-But w hat else can you do?

Bag valve mask the patient. Show me.
- Now the sats have started to pick up., w hat else do you w ant to do?
Put on the C collar. &;OK, show me.

- W hat if sats still not picking up. W hat w ill you do?
If upper airway obstruction., offered needle cricothyroidotom y -&gt; form al cricothyroidotom y. Asked
on how to do it.
And how long can a cricothyroidotom y last?
Is it permanent?
How to perform a tracheostomy?
And why is it perform ed at the level o f the 2nd and 3rd rings o f the trachea? I said low er risk of
tracheal stenosis but this is wrong :(.

Opioid Overdose

0 How is C02 transported in blood

0 W rite form ula fo r C02 transport in blood and carbonic anhydrase which
part o f form ula does it act on
0 Interpret ABG - w hat type o f Respiratory failure
0 W here does Opioid act on
0 Respiratory drive - chemoreceptors

70+ presents w ith peritonism , confusion

-Given: CXR pneum operitoneum , ECG AF (need to say check name, 1C, tim e and date o f XR and ECG)
-Causes o f the above
-Consent in confused patient, speak to fam ily regarding pre-m orbid wishes regarding surgery, any
designated NOK
-Consultant sign consent

Respiratory acidosis in type 1 failure

- illustrate co2 and h20 equation in blood

- how is co2 transported in blood- 3 ways
- which part o f blood does reaction occur
- explain m etabolic compensation mechanism- kidneys and bicarb
- explain chloride shift

O bstructive Jaundice
read and interpret lab results: obstructive jaundice
- W hat is bilirubin conjugated to?
- W hat is urobilinogen?
- Explain the enterohepatic circulation o f bile salts
- W hat is the function o f bile salts in digestion o f fat?
- W hat investigations w ould you do fo r this patient? Bloods, US HBS
- If us hbs shows stones, w hat would be your next step? Ercp
- If this patient has fever and pain, w hat w ould you be w orried about? Ascending cholangitis
- Also o th e r questions but forgot
which ALP/ GGT more im portant?
bilirubin metabolism:
w hat are the salts?
w hat are urobilinogen?

enterohepatic circulation
Gastric o u tle t obstruction: Lady vom itin g , epigastric fullness. Labs show Na 125, K 1.9, Cl 59, pH 7.2 etc. W hat does
she have? W hy got hypochloremic alkalosis? Why got hyponatremia? How to classify hyponatremia
and w hat examples? W hat are the complications o f hyponatremia? W hy got hypokalemia (the simple
answer)? (Loss in vom itus.) W hy got aciduria? W hat is the key elem ent in these exchanges?
(Sodium.) How w ould you treat? W ho else should be involved in management? W hen would this lady
be fit fo r surgery?

Crit care: S/p lobectom y and epidural T3 T4 level, now has hypotension bradycardia Sp02 92%.
W hat causes o f this clinical picture? What&#39;s so good about epidural in this patient? W hy do we use
tem perature sensation to check? How would you do it in real life? How to manage?
Post low er lobectomy, pt now is hypotensive, bradycardic and desaturation, p t had

spinal anaesthesia atT 4/T 5, and had epidural catheter

- w hat are your differentials? (hemopneum othorax, paralysis o f diaphragm, paralysis o f intercostal
- w hat is the management plan? (fo r all the diffe re nt scenarios, rem em ber to call consultant o f op as
well as anaesthetist to review)

- w hat factors affect the epidural efficacy?

- why do you test fo r tem perature sensation rather than pain?
- how do they test for tem perature sensation in the OT?
- how does epidural cause the hypotension and bradycardia?

3. Spinal anaesthesia com plicated by to ta l spinal.

Pt post TKR w ith spinal anaesthesia. Few hrs after, BP crashed and HR low
Question:
lmpression:Total spinal causing spinal shock
Types o f spine anaesthesia
Marcain vs Lignocaine
Management: HD m onitoring. Supportive w ith fluid support o f BP till spinal wears out. Possible need for
adrenaline as p t requires both beta and alpha receptors support.
Types o f inotrope.: Alpha, beta, mixed, dopaminergic. Explain using preload, load and afterload module.

Crit care: Elderly gentleman has abdo pain, looks confused. CXR showing free air under diaphragm,
ECG showing AF. W hat must you confirm on CXR and ECG? W hat is the problem w ith taking consent
from this dude? W hat do you call all this stu ff about how patient must understand inform ation be able
to repeat? W ho should make decision? W hat&#39;s the significant finding on this CXR? W hat is differential
diagnosis o f perforated viscus? W hat pathologies in the large bowel could cause it? Tell me about this
ECG. (Irregularly irregular.) W hat is the rate? How come different from my autom atic reading? W hat
are the causes o f AF in a SURGICAL population? W hat broad principles to manage AF? If stable how
to manage? W hat 1st line drug? W hat dose?
- W hat are causes o f his peritonitis? Perf viscus. Causes o f perf viscus?
- Causes o f AF? In this patient?
- How w ould you tre a t his AF?
- How to tell AF on ECG
- How do you read an ECG? Rate rhythm name, etc etc
- 1was asked mode o f action o f beta blockers, but others got different questions on AF
4) W hat do I look out fo r in the ECG. How to calculate heart rate from ECG?
Why is this d iffe re n t from the one calculated during physical
examination? (130 on ECG vs 100 noted in the stem given).

Elderly patient w ith perf DU and peritonitis

CXR w ith air under diaphragm
ECG - AF
Questions in this station were quite strange, first question he asked me was w hat do
you do FIRST when you see a CXR or ECG (check name, number, date? very
ambiguous)
W hat does the CXR show - air under diaphragm, Riglers
where are the possible perforations - DU, PU, appe, caecum, sigmoid etc
w hat does the ECG show, why is the HR on the ECG and the HR on the BP cuff
differen t - said something about the AF causing a smaller volume pulse, BP puff
cannot read.
Causes o f AF
- classify by cardiac, pulmonary, septic, others
M ost likely cause o f AF in this patient

Management o f AF
- tre a t underlying cause
- w ent by ACLS principles
- rate/rh yth m control, how?
side effects o f beta blockers and CCBS

Jaundice
Jaundice. Causes o f jaundice. P re-hepatic/hepatic/post-hepatic, enterohepatic circulation o f
bile. How does bile help w ith fa t digestion /absorption

surgery in pregnant patient

- preload - how to increase preload in this instance. Generally
how is blood pressure controlled when you stand up. W here to adm it patient after surgery - obstetric
HD

4) W hat can help to improve the pre-load o f this patient? W hat else can be
done to improve the cardiac output? (fluids, inotropes)

5) How does the inotropes work. W hat receptors do they act on?

6) Talk about the sympathetic and parasympathetic control o f the heart.

How does the body detect low BP? W here are these central and
peripheral receptors located?

7) Can you name some medical devices used in throm boem bolic events that
can help im prove the circulatory parameters o f this patient?

Station 8: Post-Anterior Resection POD4, M etabolic Acidosis, Fever, Raised Tw, Renal Failure, Raised Respi Rate

Describe UECR: Raised Urea, Creatinine, Hyperkalemia

Causes o f Acute Renal Failure in THIS POD4 patient: Abdom inal Com partm ent Syndrome
Describe ABG: Compensated M etabolic Acidosis w ith Compensatory Respiratory
 SIRS Criteria -fe v e r &gt;38 or hypotherm ia & lt;36, tachycardia &gt;90, tachypnea &gt;20 or pC02
& lt;4.1 kPa, TW & lt;4 o r &gt;12
ICU Admission Criteria - needs mechanical support o f at least 1 organ function. Has 1:1 nursing care

pH and buffer system o f blood.

Adrenal gland . Cushing's syndrom e and the com plications during operation.
Full anatom y o f adrenal Gland. Asked about feedback system . HPO Axis.
W hat are the layers.
Hormones secrete
W hat is the control. Hypothalamic pituitary axis.
Effect o f glucocorticoid on the body:
Cortisol.
W hat happens on long term steroids going fo r surgery.
Stop. Bridge w ith IV hydrocort.
Hypotension
Nausea
Vom iting
CRH-ACTH-CORTISOL

4. Crit care. 77 yo man, Hx o f dem entia, renal im pairm ent. Baseline creat 250+. Develops
UTI and then ARU. Creat shot up to 700+. Showed the FBC, UEC etc. W ants to know
the diagnosis (AoCRF but I said obstructive uropathy) Then p t had catheter inserted and
subsequently had increased urine o u tp u t (4L/day) examiner wants to know why. Wants to
know indications fo r dialysis. Asked to discuss the ethics o f dialysing a 77 yo w /
dementia

Crit care. W ants to know w here cortisol is produced. W ants to know w h a t controls
cortisol production.
W hat are glucocorticoids?
0 W hat are th e ir action?
0 W here are they produced?
0 W hat are the diffe re nt parts o f the adrenals? (cortex/m edulla)
0 W hat are the layers o f the adrenal cortex, and w hat is made in each?
0 W hat is made in the adrenal medulla?
0 How is cortisol release controlled? (i.e. describe the adrenal axis)
0 W hat are the effects o f cortisol excess?
0 W hat are the surgical problems associated w ith elevated cortisol?
0 W hat problems w ith wounds?
0 W hat are the anaesthetic considerations o f an elevated cortisol?

01W hat is this investigation? (CT Head w /o contrast)

0 W hat does it show? (Large subdural haematoma w ith effacement o f ventricles
and midline shift w ith oedema)
0 How do you know this is blood? (Bright w hite)
0 How do you know this is not an extradural haematoma?
0 W hat is GCS?
0 W hat is this patient&#39;s GCS? (9 - E2V3M4 -&gt; Given the various details in the
rubric)

0 W ho w ould you need to discuss this patient w ith? (Neurosurgeons and ITU)
0 Why do you need ITU? (Airway protection given dropping GCS, ventilation,
m onitoring etc)

2. TURP syndrome (pt post TURP confused, hypoxic, BP low, sats low) - w hat is glycine, how to mx this patient, why they
use glycine, how to mx, where w ill u mx, will u give hypertonic NaCI (NO !!!!), medical mx - diuretics, tell me how they work
and where they act (mug ur renal physio)

TURP syndrome (pt post TURP confused, hypoxic, BP low, sats low) -
(a) W hat is glycine?
Glycine is an am ino acid
(b) How w ould you manage this patient,
This patient has severe dilutional hyponatremia and is presenting w ith:
neurologic symptoms like confusion, pulm onary symptoms like hypoxia likely
due to pulmonary oedema, cardiovascular problems like cardiac failure and
possibly haematological ones e.g. dilutional coagulopathy/throm bocytopenia.
I w ould resuscitate this patient, going by airway, breathing, circulation.
Transfer him to ITU, m on itor using invasive methods e.g. CVP line to guide
fluid therapy in view o f hypoxia/low saturations, intra-arterial line to m onitor
blood pressure, consider intubation and ventilation in view o f level of
consciousness and shortness o f breath, frusem ide fo r pulmonary oedema, do
bloods FBC, electrolytes, clotting panel, arterial blood gas, glucose and
ammonia levels, fluid restriction to tre a t hypervolemic hyponatremia, correct
electrolyte imbalances and coagulopathy

(c) Why do they use glycine?

This is because they are using an electrocautery loop to perform TURP.
Normal saline cannot be used as irrigation solution because the dissemination
o f the electric current w ould be dangerous to both, surgeon and patient.

(d) W here w ill you manage this patient?

See above.

(e) W ill u give hypertonic NaCI?

No. I w ill only give 250-500ml o f 3% NaCI through the CVP line if the patient
has seizures.

Medical mx - diuretics, tell me how they w ork and where they act?
Diuretics can be divided into:
Osmotic e.g. mannitol, work by osmosis
Thiazide duretics w ork on PCT to block Na resorption
Loop diuretics w ork on descending loop o f Henle to inhibit Na Cl absorption,
then distal convoluted tubule tries to preserve Na and loses K
Spironolactone works by being an aldosterone antagonist blocking
aldosterone binding at DCT
Am iloride binds to Na channel at DCT
History taking

Acute A djustm ent Disorder

a. Post-Gastrectomy POD 7, pt noted to be tearful and feeling down, take a

Anhedonia (reduced pleasure) or Depressed mood) at least 2W + (5/9)

Medseape® www.medscape.com
S Sleep (insom nia or hypersom nia)

I Interests (dim inished interest o r p leasu re from activities)

(i (iuilt (excessive o r in app ro p riate guilt; feelings o f w orthlessness)
E Energy (loss o f en ergy o r fatigue)
C C oncentration (dim inished concentration o r indecisiveness)
A A ppetite (decrease o r increase in ap p etite; weight loss o r gain)
P Psychom otor retardation/agitation
S Su icide (recurrent thoughts o f d eath, suicidal ideation, o r suicide attem pt)
Source: CH F G 2003 Le Jacq Communicatu

b. issues tackled:

6min history o f his issues and summarize your findings and impression

1. medical treatm ent, job security, fam ily support

ii. p t did not fit SIGECAPS criteria and to o acute, so i labelled as acute

adjustm ent disorder and examiners accepted

iii. suggest options fo r issues above, refer social worker, w rite memo,

o ffe r to arrange meeting w consultant to discuss next step in

management, refer psychologist, refer PSY if suicidal ideation present.

2. History. Acute Pancreatitis.

a. Pt adm itted fo r acute abdominal pain, take a history and summarize your findings

b. typical history: epigastric pain radiating to back a /w NBNB vom iting, had a few rounds o f alcohol

i. include drug/fm hx/pm hx/social hx

c. differentials: acute pancreatitis, PUD

d. investigations: amylase and lipase, FBC/UE/LFT/Ca/GIu/ABG fo r Glasgow

scoring. US HBS / CXR / AXR fo r imaging

e. patient had this pain before at RHC fo r several months, treated by GP as

gastritis but never had any scopes or CT done before. I said likely etiology of
pancreatitis could be gallstones still.

f. management was very briefly discussed but the examiners told me not in their marking scheme.

Chronic Pancreatitis

1. 40 year old divorced Male having chronic epigastric pain, radiating to back for past 1 year a /w steatorrhea. Takes 5
glasses o f beer/day, previously adm itted fo r acute pancreatits. Takes 30mg o f m orphine a day

11. Summarize your history

iii. W hat is your diagnosis? w hat are your differentials
iv. W hat do you think o f his history o f 30mg o f m orphine? W hat should the normal dose be?
v. W hat blood investigations? fecal fat, ultrasound
vi. W hat other investigations would help clinch the diagnosis? MRCP, ?ERCP
vii. How would you manage?
chronic alcoholic pancreatitis w ith social issues,abdominal pain ( SOCRATES
assessment) smelly fa tty diarrhea, kept coming around to he's depressed and was adm itted,
cannot stop having alcohol to numb the pain ( fe lt I was in Psych rotation) blaming him self for
everything, typical Socrates Assessment and then take a Full ICE and offer help w ith alcoholism
w ith social worker, Alcoholics anonymous etc, etc. questions from examiner, w hat do you think it
can be chronic pancreatitis, w hat else, pseudocyst, sclerosing cholangitis, PUD w ith fibrosis,
w hat tests to confirm blood workup, imaging, m entioned US ( said it was lim ited due to bowel
gases but can assess biliary tree, touched on management w ith social worker, m ulti-disciplianry
team, supplemental oral enzymes.

12. 25 female comes in ER w ith abdominal pain

a. Patient had epigastric pain, radiating to back. Vom iting

Knee pain
- Case o f R knee OA w ith genu varus/sw elling/crepitus/antalgic gait
- W hat is the most likely diagnosis?
- W hat are you looking fo r in the XR? loss o f jo in t space, osteophytes, subchondral cyst and sclerosis
- W here is the crepitus felt? A nterior knee. W hat does th a t imply? PFOA
- Management?

2. Knee OA
- Repeat question - footballe r had right knee injury 30 years ago, some knee operation
that he had no idea about, developed worsening right knee pain fo r 4 months

- DDx - osteoarthritis, rheum atoid arteritis, possible loosening/fracture o f prosthesis from

previous op

- Investigations : xray looking fo r decreased jo in t space, osteophytes, subchondral

cysts/sclerosis

- Management options: Conservative/medical/surgical: conservative w ith PT/OT/exercise,

medical w ith analgesia according to WHO pain scale ladder, intra articular steroid
injections/PRP injections, surgical - TKR, partial KR
- W ill patient be likely to play soccer in 9 months - no
- How about in the long run - said patient unlikely to regain normal function

SOB
a. Lady planning fo r cholecystectomy, presents w ith SOB (Pro tip *: Always ask for
name, age, occupation, m arital history and fam ily tree!) I forgot to ask the name
and they asked me w hat it was GG) Had this occasionally for 10 years, lasting few
minutes, increasing in frequency this 6 weeks after being scheduled fo r operation

Details
0 M iddle aged wom en being seen in Preop assessment fo r elective Lap Chole
follow ing simple gallstones.
0 Incidentally reports in te rm itta n t episodes o f SoB
0 Increasing in frequency over past 2yrs, now 2-3 episodes daily.
0 Associated w ith chest tightness.
0 No relationship to any triggers, position o r exertion.
0 No palpitations or syncopal sx.
0 No hx o f atopy.
0 No PND/orthopnoea.
0 Not lim iting walking distance or ADLs.
0 Denies chest pain.
0 Ex-smoker.
0 Never form ally investigated by GP - had peak flo w but nil else.

Viva questions

0 Differential diagnosis
0 Baseline investgiations: Peak flow , spirom etry, CXR etc.
0 Definition o f FEV1, FVC, FEV1/FVC ratio.
0 Obstructive and restrictive spirom etry graph shapes.

Thyroid mass and h yperthyroid & compressive sym ptom

questions from examiner about trip le assessment, workup including TFT ( asked w hat does th a t entail said
TSH, T3 & T4 seemed happy), US assessment looking fo r nodule characters, m ultiplicity and
regional LN. he asked w hat else? said can be used for US guided FNAC seemed really happy.

Has symptoms o f hyperthyroidism - LOW, heat intolerance, anxiety, palpitations, tachycardia, diarrhea,
irregular menses
Also has symptoms o f compression- dysphagia solids worse than liquids
Nil other fam ily hx, nil hoarseness o f voice, nil SOB

W hat investigation w ould you do on this patient ? U/S and FNAC

W hat other investigations w ould you do? Radioisotope scan
W hat are the possible causes o f the sudden enlargement? - Benign (Toxic adenoma, part o f MNG) Malignant
(Papillary follicular medullary, less likely anaplastic)
W hat are the possible treatm ents? Trick question. W ith compressive symptoms no choice but to op. Spoke
about hemi vs total thyroidectom y
W hat possible complications o f the surgery w ould you advice this patient? Risk o f RLN injury, hypocalcemia,
lifelong thyroxine replacement

Lower back pain

mechanical back pain, patient known case o f IBS, managed w ell at the mom ent. Obese, etc. consultant asked
differentials,
how to investigate, red flags, how to rule out the differentials based on history alone, etc.
Differentials (sciatica, vascular prob, spinal stenosis)
- IX MRI
 Treatm ent (surg as red flag signs

Back pain history

5 year history o f back pain
Worse in the last 3 years
MRI 4 years ago showed m ild degenerative change w ith no pid
Spouse is an invalid
No neurological symptoms
No trauma
No weight loss or other sinister red flags
This was a plain low er back pain station
Asked about investigations ie repeat MRI
Refer to chronic pain specialist and then to psychologist

Asked all the questions re; back pain, systemic disease, cancer etc. In the end, found out that patient was
very stressed up and depressed on social history a fte r i have exhausted all my medical questions, MRI spine
all norm al and she w ent to see many doctors. Husband was bedbound and she was caregiver, on top o f
financial and w ork comm itm ents.
When history appears confusing and your going in circles, think o f somatisation / depression.
Question: Clinical exmaination. Blood test and imaging. How woud you manage her: refer social nurse and
social worker. Manage her stressors.

Long hx 5 yrs o f back pain. Basically I presented it as functional back pain but to rule
out organic pathology, because the lady had rest/night pain 5 years along entire length
o f spine, tingling in fingers/toes, and also had chronic headaches, IBS, chronic pelvic
pain syndrome, all on f/u w ith specialists but no m eds/interventions. She also had
social history +++++ w ith disabled husband etc etc. Invx and mx. (inflam m atory
markers, Xrays, KIV MRI, refer social support, analgesia PRN)

(History o f enlarged tonsils

Patient had weight loss, night sweating,no h /o travel. He wanted to hear how I would rule out the misdiagnosis
o f an enlarged tonsil, differentials,
investigations just started w ith bloods, peripheral smear, said fnac but he said w hat would you see on bloods,
Hx: Unilateral right sided tonsil enlargement fo r 5-6 months. A /w night sweats, LOW. No o th e r hx o f note. No
travel / contact hx. No smoking hx. No fam ily hx.
- Present your hx
- Differentials
- Investigations

She had alternating bowel movements, fam ily history o f cancer and PR bleed
2) How w ill you investigate

In te rm itte n t claudication
13. 30 male in clinic w ith leg pain
a. Inte rm itte n t claudication, was smoker
b. W hat specific clinical tests to do (Berger, ABPI)
a. Explain severity
b. Risk factors
c. Indications fo r intervention and when to intervene
d. At present need surgery? (no need as fontaine not high enough yet, can do

exercisetherapy w ith medical treatm ent)

Vascular claudication 6/12. Distinguish from neurogenic. Look fo r risk factors
including fam ily history. Questions on distinguishing between vascular/neurogenic,
clinical assessment (pulses, ABPI, Doppler), if ABPI 0.8 w hat next (conservative mx
- control risk factors, stop smoking, exercise regime, aspirin). Do not say
conservative vs surgical mx if it is mild. Got glared at fo r even letting the words
arterial duplex escape my mouth.

pseudoaneurysm
2) History taking - Left sided groin swelling
Hx: Left sided groin mass x 1 week. Acute onset. No previous hx o f abscesses. PULSATILE. IVDA
(heroin) frequently injects into the femoral. No other complications o f pseudoaneurysm. No signs o f
widespread sepsis or infective endocarditis. No w ithdraw al symptoms - last dose was a few hours
ago or something

- Present your hx
- Differentials
- Investigations
- Management o f pseudoaneurysm

investigations. I said U/S o f the lump and arteriogram. Asked w hat type o f arteriogram, I said fem oral artery. Dude
nodded. Asked about management. Only managed to squeeze out stenting before bell rang. History taking station very
lim ited by time.

M M SE/AM T
Examiners asked
1) W hat is my management o f this patient since I m entioned he is not fit for
consent ( cancel op, w ork out differentials).

2) W hat are my differentials fo r his confusion? (Endocrine, metabolic, sepsis,

substance-related)

3) W ho w ill I speak to w ith regards to his condition? (I said his fam ily
members to find out baseline m ental state, my consultant and anesthetist to
cancel the operation).

4) W ho should be involved in the care o f this patient? (Family, psychiatrist

(after ruling out o th e r causes).

5) Under w hat conditions can a patient w ho is confused be operated on?

(Emergency situation I w ill speak to family, 2 consultant sign, speak to legal
services. However, this is an elective op so I w ill not carry on before working
up his condition).

Do you know w hat you are here for.

Aware o f operation?
Assess AMT
W hat is your assessment.
W hat you going to do.
Inform consultant
Inform fam ily
Delirium workup: Hypoglycemia, chest infection (fbc, uecr, blood culture), electrolyte
inbalances, UTI (UFEME), Alcohol.

Speak to fam ily to find out if this is acute.

Speak to anaesthetist
a. Patient 80 years old previously signed consent for hip replacement now unable to
b. Assess using history fitness fo r consent
c. Should patient go ahead w ith surgery?
d. He has no other fam ily now in the area, can the doctor just sign? Patient just outside OT
e. M ust take FULL AMT and atte m pt MMSE as much as possible
Assess Causative Factors fo r Confusion State

Present findings: Organic and Inorganic Causes

I Just did AMT scored 1 / 1 0 - patient had to purposely think before answering so he could answer wrongly
Don't forget to ask fam ily fo r collaborative history - apparently AMS is longstanding
W hat test did you ju st do and w hy did you do it?
W hat are the causes o f AMS in a patient like this?
W ill he be able to give consent? Why? No! Coz based on cannot retain inform ation, cannot make an informed
decision etc. (based on principles on Dr Exam)

Should the surgery proceed? Only if patient has lasting powers o f attorney
Family does not have lasting pow er o f attorney but wants surgery to proceed. Can they? No . Say w ill refer for
w ork up o f AMS
If this was an emergency can the surgery proceed? Yes, w ith 2 consultants signatures, in the best interest of
the patient.

- did AMT scoring, offered MMSE.

- discussed w ith examiner: said th a t pt definitely not fit fo r op.
- offered to speak to pts daughter to see if confusion was acute or chronic
- to speak to doctor w ho took the consent
- if acute, offered various ix fo r workup: hypocount, bloods, vitals, neuro exam
- if chronic, offered geriatric review kiv scan head
- to reschedule another appt to assess fitness fo r consent as OA hip replacement was nonurgent
examiners

Some patient post-gastectomy, POD 5 ready fo r home but nurses tells you he looks depressed, please clerk this patient
and manage according. (Like WTF !!!) so turns o u t patient had reactive depression due to poor sleep in hospital (change
o f environm ent), refer pysch, refer social worker, refer to social care nurse (that the answer th a t they were looking for,
apparently every surgical team in UK has a social care nurse which helps the team deal w ith social issues like this)

Low back pain

Stem: patient mainly had caregiver stress. Husband disabled and she needs to take care o f him. Back pain fo r few years,
not improving, but no symptoms o f numbness/weakness/ incontinence
0 Present to examiner
0 W hat are your differentials ( I said, MSK, DDD)
0 How to investigate?

Station 2: History taking

Lady comes in w ith 6/12 o f PR bleed and change in bowel habits
Examiner did not le t me get past the differential diagnosis - gave differentials o f malignancy, polyps,
diverticular disease, haemorrhoids. I think they were looking fo r IBD. Sigh.
Stem: patient has bloody mucous diarrhoea fo r last 8 months
0 Present to examiner
0 W hat are your differentials (I said IBD, infection, TRO malignancy)
0 How do you w ant to investigate? (I said FBC, RP, then jum ped to scope, but they wanted o th e r bloods first)
0 W hat do you expect to see in scope?
0 How to differentiate Crohns and UC?
0 How to manage medically first?

- Young patient (I think 25/F) referred from GP due to diarrhea

- 6-8 months o f loose watery stools, gradually increasing in frequency
- Spots o f blood in stools, no frank bleed
- a /w RIF pain during stools
- a /w LOA + LOW (5+ kg)
- No abdo bloating, no fever, no nausea/vomiting
- Menses normal, no thyroid symptoms
- PHx o f bilateral knee pain fo r 1 year +, S/B GP told arthritis, on codeine and
ibuprofen
- No FHx o f autoim m une / colon problems
- Hairdresser, diarrhea affecting w ork because she needs to keep running to to ile t
- When asked about concerns, kept asking if she's taking too much codeine, w hat's the
safe dose o f codeine to take everyday, should she stop taking the codeine. A b it weird.
1kept reassuring her and telling her I would go through her meds later and review.

- Differentials - 1offered IBD, IBS, malignancy. Examiner's eyes bugged o u t when I said
malignancy.

- Investigations - examiner kept asking me "looking for?" after every investigation, so this took a lo t o f tim e
- Prompted me w hat o ther basic test to do besides bloods/imaging - stool tests.
- Colonoscopy - w hat gross findings if this is Crohn's. Was looking fo r cobblestone
appearance (which I d id n 't get, and was stuck on for the rest o f the station.)

- Person after me said cobblestone appearance, and w ent on to talk about medical
management o f the patient (I was eavesdropping during my rest station)

GP referred patient fo r RHC pain. IBS GP did US fo r patient and found gallstones. Please take a
hx from patient.
Patient 30 year old lady, married, works as a factory worker. Has RHC spreading to generalised abdo
pain fo r 1 yr. Alternating constipation and diarrhea. But patient fe lt better w ith passing flatus. Nil LOW
or LOA or PR bleeding. No jaundice/ fever. No Fhx o f Ca. No long term meds. Non sm oker/ drinker

a. Rmber to ask im pt question: ANY OTHER CONCERNS? Then patient w ill tell you th a t husband has
depression and her salary is low, got financial issues

b. Examiner: Present your hx and issues

c. W hat are your ddx: Always rule o u t colorectal ca coz this patient has alternating diarrhea and
constipation even th o age group not correct. W hat else? said a few others. W hat else? Irritable
bowel syndrome

- Go in, first thing lady says is central abdo pain radiating to left side, a /w change in bowel habits,
alternating constipation and diarrhea
- Make sure you rule out renal colic, Colorectal Ca, and UC/Crohns
- Discussion after on investigations, management
- To end o ff they tell you Sigmoidoscopy normal, w hat would you consider as a diagnosis in her? IBS

d. Which part o f the history tells you th a t its irritable bowel syndrome? Better on passing flatus

e. Any blood te s t/ investigations to confirm that? No, clinical diagnosis

f. Any criteria? Rome criteria. He nvr ask fo r components

g. Do you think this is acute cholecystitis? No

h. US has gallstones. Need cholecystectomy? No need. Only if patient sym ptom atic/ obstructing

biliary tree

i. W hat is the percentage o f gallstones th a t w ill become symptom atic and eventually requiring sx?

18. History taking

25 yr old girl p /w diarrhea, blood stains

a. D iffe re n tia ls -in fla m m a to ry bowel disease, IBS, cancer
b. Investigations - FBC, UECr, Stool c/s, colonoscopy
c. Features seen on colonoscopy

Pt w ith 6 /1 2 hx o f PR bleed w ith significant fam hx o f colorectal cancer

- W hat are the ddx fo r the pt?

- How w ould you investigate?

- If confirm ed to be CRC, how else would you investigate?

Differentials:
Colon CA, IBD, Haemorrhoids.

Investigations:
FBC, UECr, LFT, Colonoscopy.
Next: Stage disease: Tumour markers, CT thorax, abdo pelvis, bone scan.

16-SOB a fte r started preparing fo r surgery( anxious patient)...

18- Phone call. Oliguria POD1.

Questions w hat do you th in k the cause is?
how to know th a t he is dehydrated?
Decreased level o f consciousness a fte r how much o f fluid loss???i do not know s ir© 1© © ©
W hat w ill you do? Do you w ant me to come?

11. History on im potence.

Artist, has w ife and kids, laid o ff 6/12 ago and cant have sex w ith w ife since then.
Can have erection by him self tho, depressed, bit angry. No cardiovascular symptoms
o r prostatic disease.
Was asked about diagnosis, reasons, w hat to test to rule out other causes.

PE
- POD5 THR now SOB take history
- Took full SOB history; Acute onset SOB w ith haemoptysis and pleuritic chest pain
- Differentials? PE, Pneumonia, TRO ACS
- Investigations; ECG, CXR, Bloods, CT PA, V /Q Scan
- Management?: anticoagulants if stable, consider throm bolysis/em bolectom y if not

PR bleed

- PR bleeding (?malenic stools) x months

- W hat are your differentials
- How w ould you investigate
- Colono shows a sigmoid tum or, How w ould you proceed?
middle age lady, alternating bowel habits, fam ily hx o f cancer, pr bleed for 6/12
- conversation was tota lly not guided by examiners, had to tim e my own history taking, move on to
differentials and investigations, didnt manage to move on to management, on hindsight, shouldnt
have spent so much tim e on taking an extensive history

Guy comes w ith right groin lum p ~ likely hernia, sym ptom atic, affecting w ork
Drinking some tonic thingy. Had previous GU problem (think it&#39;s gonorrhea). Asked if he had slow
stream but didn&#39;t have (was w orried about urethral stricture)
Specific questions asked -- how w ould you manage hernia? w hat are your d/dx: said inguinal,
fem oral hernia, saphena varix (what else, w hat else), LN, fem oral aneurysm. Examiner satisfied.
How to repair hernia - lap vs open.
Which w ould you recommend fo r him -- open: unilateral
Are you w orried bout the tonic -- Yes, I would like to know if these are steroid containing
Good, so he goes hypotensive after the op - explain Addisonian crisis.
W hat is your management -- ABC, Fluids, hydrocortisone

Pt presents w ith R knee pain over many yrs duration. Recently getting worse.
A /w pain tha t wakes him up from sleep. Otherwise very mechanical. I asked if he had any previous
medical issues -- He denied. But, if you elicit enough history, then he w ill tell u he had injured his
ligament before and had a washout done when he was younger. Affecting work.

Summarize your findings

W hat is your diagnosis?
W hat signs in the PE will u be looking for?
W hat other differentials? RA knee, gout flare, ligamentous instability. Why do you say that
secondary OA is your top differential?
How to investigate? Xrays (skyline, weight bearing AP/Lat), FBC, ESR, CRP.
W hat else? MRI knee, uric acid.
Management?

Differentials:
OA, RA, Gout

Treatm ent options:

Medical:
Analgesia
Physio
Injections
Ops

1) W hat would I do to confirm my diagnosis? I said I would do a full physical

examination and do a x-ray o f the knee looking out for loss o f jo in t space,
marginal osteophytes, sub-chondral sclerosis/cyst.
2) How about investigations to rule out your differentials? I answered th a t I
will do a FBC, Inflam m atory markers like CRP/ESR/Rheumatoid markers.
3) W hat is your management fo r this patient? I will start o ff with
conservative trea tm e nt first. Analgesia, physiotherapy fo r muscle
strengthening, lifestyle modifications. Failing which I may recommend
him to try I/A Synvisc injections, which may help delay the need for
surgery as he is still young fo r a TKR but not totally contra-indicated I
added. The definitive treatm ent fo r him w ill be a TKR if my diagnosis of
OA knee is correct. They asked me w hat physiotherapy would benefit this
patient so I answered quadriceps and hamstrings strengthening.

History: Progressive dysphagia 6m th w ith odynophagia, LOW 2 stones (= 201b), drinker. Likely
diagnosis and differentials? (Oesophageal cancer.) How to manage?
Pt pub owner, drinks, tells you got vo m it blood x l/7 . But actually dysphagia x6/12 , solid&gt;liquid, LoW
+, DRINK 5u/d, Smoke since teenager, no fhx, takes nsaids fo r hip replacement pain
Differentials - esophageal adenocarcinoma (from barretts esophagus), benign stricture, PUD (lol,
during hx taking, I told pt it is likely PUD?!? then the examiner come round and ask whats my top
differentials, I had to backpaddle like shid.) this examiner is cfm laughing executioner type !! still say
well done at the end. Confirm GG

Patient w ith l x episode o f haematememis, dyaphagia fo r 6/12 progressively

worsening, LOW
Straightforward Ca esophagus history,
investigations and management per usual.
fo r the management, they did not even ask th a t kind o f operation to be done. All I said
was something along the lines o f an en-bloc resection o f entire tum our w ith adequate
margins, w ith the removal o f the corresponding lymph nodes and lymphovascular
supply, and they nodded happily and cut me o ff there. This was one o f my fall back
statem ents to use in GS MBBS when I d id n't know w hat was going on.

Depressed pt
Patient post op after gastrectomy fo r cancer, physically well and due fo r discharge
today but nurses think he is depressed. Interview patient and assess. Patient makes no eye contact
and gives monosyllabic answers, looks down and shakes his head says & quot;l don&#39;t know &quot; to everything.
Asked why he is upset? Cancer may come back; There&#39;s nothing I can do. Asked if we can help in
anyway - no. Present your findings. W hat is the cause o f his depression? M anagement plan? Who
should see patient? W ould you discharge this patient today?

Headache

1. History taking: BPH

Standard history: LUTS symptoms, how it affects patient

Questions: Pathophysiology. Differentials. Medical and surgical management.
2. difficulty PU X few mths, LUTS - discuss BPH inx and management, side effects o f alpha blockers and 5a-reductase
inhibitors

alpha-blockers e.g. alfuzosin:

postural hypotension, fatigue, headache, nausea, impotence

5alpha-reductase e.g. finasteride:

rash, breast tenderness/enlargement, decreased libido, decreased volume o f
ejaculate, impotence

12 th Station - Com m unication skills and history taking

Stem: This lady was referred by GP to see you fo r gallstones detected on US.
Please take a history from her.
Patient was fair, fa t and female in her thirties though. History taking started o ff
w ith abdominal pain fo r 18/12. Constant dull ache 3/10 w ith occasional sharp
exacerbations to 7/12. Pain is central, radiating to the left side. No aggravating or
relieving factors. No signs o f obstructive jaundice. No treatm ent was given to her
before. No previous fever. I was ready to present as cholecystitis until I casually
asked her about her bowel habits and she gave a history or altered bowel habits!

She has been having constipation w ith episodic diarrhea. Stools are normal, no
bloody stools o r malena. No constitutional symptoms. No previous medical
history. No fam ily history; she was adopted. I forgot to ask about smoking
history and alcohol intake. I presented my case as a cholecystitis anyway.

Examiner questioned me on the following:

1) Does cholecystitis give central pain to the left? I said not typically. So w hat
else can it be? I trie d pancreatitis. So again they asked w hether
pancreatitis presents like that. I said not typical as w ell because
pancreatitis tend to radiate to the back. So w hat else can it be? I said in
view o f her change in bowel habit I will need to think about malignant
condition o f the bowel. They finally agreed and moved on.

2) They said sigmoidoscopy done was normal. W hat o ther investigations

would I w ant to do? I said sigmoidoscopy is not enough and she needs a
full colonoscopy especially since in her case, the pathology m ight likely be
more proximal. They agreed on this but asked me fo r more tests I can do. I
answered the routine blood investigations: FBC U /e /cr CEA LFT. They
asked me about w hether I w ould do inflam m atory markers so I said yes I
would do ESR and CRP as w ell to rule out IBD.

3) W hat is the management fo r her gallstones? How many percent o f them

w ill become symptomatic?

Specialty choice 2 (head and neck): Case o f BPPV. Pt presented w ith vertigo
Take history, quizzed on investigation, dix hallpike (how you do it) and a p le /s maneuver
Nothing too difficu lt about history taking. Examiner prom pted me about stu ff I forgot to ask.
Pathology

M alignant Melanom a

a. w hat is a melanoma? how is d iff from SCC?

Melanoma, the most serious type o f skin cancer, develops in the cells (melanocytes) th a t produce melanin

b. given biopsy report, w hat w ould you like to know, and w hat else do you need to know?
Tum or depth (breslow thickness)
Anatomical level o f invasion (dark's level)

Ulceration, present o f mitoses, lymphovasc invasion

Host response (any tu m o r infiltrating lymphocytes), regression
Imm unohistochem istry staning fo r lineage (s-100), or proliferation markers (Ki67 antigen)

c. 1mm M M , margins < lm m during procedure, w hat would you do next?

Lesion excised Breslow thickness 1.5mm, margins 0.5cm w hat to do?

Melanoma insitu: 0.5cm

Melanoma <2mm: 1cm margin
Melanoma > 2mm : 2cm margin

I. take w ider excision

ii. how to do this intraoperatively? frozen section

d. w hat gene is responsible fo r fam ilial MM?

i. googling found CDKN2A and CDK4 m utation
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0 W hat are poor prognostic factors?

Male, old age...ulceration, site: LL, UL, trunk, head n neck

0 W hat gene is associated w ith malignant melanoma

CDKN2A,CDK4,
RBI - retinoblastom a, MC1R (m elanocortin-1 receptor) gene
Mdm 2 gene m utation, BRCA 2

0 W hat skin condition is associated w ith melanoma?

Xeroderma pigmentosum
autosomal recessive genetic disorder o f DNA repair in which the ability to repair damage caused by ultraviolet (UV) light
is deficient

Albinism
congenital disorder characterized by the complete or partial absence o f pigm ent in the skin, hair and eyes due to
absence o r defect o f tyrosinase

W hat are the other risk factors o f malignant melanoma?

0 General principles o f surgery. If go for re-excision, w hat to do to ensure adequate margins this tim e round? (Mohs
micrographic surgery, frozen section)
 HOW MICROGRAPHIC SURGERY WORKS

0 Post axillary clearance complained o f arm pain and swelling (axillary vein thrombosis)
0 Risk factors fo r throm bosis (Virchow's triad). For this case, malignancy predisposes to a pro-throm botic state.

b. Breslow classification and management

c. A fter treatm ent, presented w ith mass in axilla, w hat are possibilities
d. How to differentially diagnose (FNAC)
e. Had extensive surgery fo r axillary lump, presented w ith red swollen upper extrem ity,
w hat are possibilities
f. How to tre a t deep vein throm bosis
Acute trea tm e n t w ith parenteral anticoagulation (low molecular weight heparin, fondaparinux,
M aintaining patients on anticoagulation fo r at least 6 months is the standard o f practice
W arfarin, to keep INR 2-3, standard doses range between 1-10 mg per day fo r 6 months

Catheter-directed throm bolysis (CDTL) are a clot less than 14 days in duration or acute phlegmasia cerulea dolens in
patients w ith no contraindications to throm bolytic therapy.26 A clot present fo r more than 14 days leads to throm bus
organization th a t lim its the effectiveness o f thrombolysis.
Use tPA
The tPA is generally administered as a continuous infusion o f 0.5-1 mg per hour fo r at least 8 hours (an initial bolus can
also be infused at the physicians discretion) (Fig. 1). The patient should have laboratories drawn every 6 -8 hours to
m onitor fibrinogen levels, which should be kept above 100 m g /d L to avoid depletion. Fibrinogen levels below 100 mg/dL
can increase the patient's likelihood o f a m ajor hemorrhagic complication
Upon term ination o f the procedure, the patients are systemically anticoagulated w ith warfarin fo r 6 month

Indications fo r SVC filte r placement are failure or contraindication to therapeutic anticoagulation or for presurgical
prophylaxis in the setting o f substantial throm boem bolic risk factors

g. Complications
h. How to manage pulmonary throm boem bolis

0 Risk factors
0 W hat macroscopic/microscopic features o f m alignant lesion
0 Histology vs. Cytology

BCC
Given clinical hx o f pt w ith lump over arm. Ex bx done, shown histo report o f BCC w ith depth o f invasion,
deep margin involvem ent
- Questions asked:
W hat is BCC? skin's basal cells, which line the deepest layer o f the epidermis (the outerm ost layer o f the skin).
Natural hx o f BCC
 indolent w ith slow progression,
locally destructive but lim ited potential to metastasise
W hat are your concerns regarding the histo report?
How w ould you manage a pt w ith deep margin involvement?
Treatm ent options fo r basal cell carcinoma

Surgical:
Curettage and cautery - (scraping away the tum o ur and stopping bleeding w ith cautery
Excision w ith prim ary closure, flaps, grafts, and secondary intention healing - excision margin o f 4 mm around the
tum our is recommended where possible.

Cryotherapy (w ith liquid nitrogen), but cant obtain tissue biopsy

M ohs' m icrographic surgery - Serial sections are taken and examined histologically until all margins are clear.
Radiotherapy

Topical photodynam ic therapy - 6-aminolaevulinic acid made up in a 20% emulsion and applied topically, Tum our tissue
absorbing this porphyrin m etabolite becomes photosensitive w ith its conversion to protoporphyrin IX and subject to
photodestruction when exposed to light, usually in the wavelength range 620-670 nm
Topical fluorouracil 5%
Topical im iquim od 5%

How to prevent recurrence o f deep margin involvem ent during re-operation?

If recurrent, go fo r moh's micrographic surgery

Skin graft placed fo r pt and subsequently had graft failure

Cause fo r graft failure? Wound infection
Common organism? S. aureus

W ound c/s grew MRSA

W hat is MRSA?
How would you manage this pt w ith MRSA wound infection?
Outpatient Inpatient
Clindamycin; infected tissue should be debrided and cultured, and an
Linezolid em piric antibiotic initiated pending the results o f the
Am oxicillin plus either TMP/SMX or a tetracycline culture

Drug Dose D uration

ALL ORAL
Vancomycin Dose to target trough level 7-14
days

Linezolid 600 mg twice daily, PO or IV 7-14

days

Daptomycin 4 mg/kg once daily 7-14

days

Telavancin 10 mg/kg once daily 7-14

days

Clindamycin 600 mg IV or 300 mg PO 3 7-14

times daily days

Subsequently pt developed axillary lymph nodes

Concerns? Unlikely BCC (no LN mets)

FNAC o f axillary LN done, showed Reed-Sternberg cells. Diagnosis? HL

RHD
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- w hat is the pathophysiology o f aortic stenosis?
Aortic stenosis is the obstruction o f blood flo w across the aortic valve
Congenital (unicuspid or bicuspid valve), calcific (due to degenerative changes), and rheumatic

Aortic valve becomes stenotic,

resistance to systolic ejection occurs
systolic pressure gradient develops between the le ft ventricle and the aorta d t o u tflo w obs
increase in le ft ventricular (LV) systolic pressure.
Concentric hypertrophy o f LV occurs d t compensatory mechanism to normalize LV wall stress
Leads to reduced diastolic compliance
At this stage, the chamber is not dilated and ventricular function is preserved

Development o f heart failure

Eventually, LV end-diastolic pressure (LVEDP) rises, which causes a corresponding increase in pulm onary capillary arterial
pressures and a decrease in cardiac o u tp u t due to diastolic dysfunction.
The contractility o f the myocardium may also diminish, which leads to a decrease in cardiac ou tp u t due to systolic
dysfunction. Ultim ately, heart failure develops.

Although cardiac o u tp ut is normal at rest, it often fails to increase appropriately during exercise, which may result in
exercise-induced symptoms.

Diastolic dysfunction may occur as a consequence o f impaired LV relaxation and/or decreased LV compliance, as a result
o f increased afterload, LV hypertrophy, or myocardial ischemia.

In patients w ith severe aortic stenosis, atrial contraction plays a particularly im portant role in diastolic filling o f the left
ventricle. Thus, developm ent o f atrial fibrillation in aortic stenosis o ften leads to heart failure due to an inability to
maintain cardiac output.

Angina results from a concom itant increased oxygen requirem ent by the hypertrophic myocardium and diminished
oxygen delivery secondary to diminished coronary flo w reserve, decreased diastolic perfusion pressure, and relative
subendocardial myocardial ischemia.

- w hat are the symptoms o f aortic stenosis

Exertional Chest pain: Angina pectoris in patients w ith aortic stenosis is typically precipitated by exertion and relieved by
rest
Exertional dyspnea
Exertional Syncope: Often occurs upon exertion when systemic vasodilatation in the presence o f a fixed forw ard stroke
volume causes the arterial systolic blood pressure to decline
Heart failure: Symptoms include paroxysmal nocturnal dyspnea, orthopnea, dyspnea on exertion, and shortness o f
breath

- w hat are the signs o f aortic stenosis, where do you hear the m urm ur
carotid arterial pulse typically has a delayed and plateaued peak, decreased am plitude, and gradual downslope (pulsus
parvus et tardus)
Hyperdynamic left ventricle: Unusual; suggests concom itant aortic regurgitation or m itral regurgitation
normal SI
Diminished or absent A2: The presence o f a normal or accentuated A2 speaks against the existence o f severe aortic
stenosis
Paradoxical splitting o f the S2: Resulting from late closure o f A2
Accentuated P2: In the presence o f secondary pulmonary hypertension
Ejection click: Common in children and young adults w ith congenital aortic stenosis
Prominent S4: Resulting from forceful atrial contraction into a hypertrophied left ventricle
Systolic m urm ur: The classic crescendo-decrescendo systolic m urm ur o f aortic stenosis begins shortly after the first
heart sound; the intensity increases tow ard midsystole and then decreases, w ith the m urm ur ending just before the
second heart sound

- w hat are the complications o f aortic stenosis

Heart failure d t LVOTO
MR

- read this ECG, w hat does it show? (LVH)

- how do you calculate the heart rate from the ECG? (just nice about 60 bpm)
- w ould you still let him go fo r op? w hat would you do? (contact consultant, contact anaesthesia, refer CVM,
explain to patient, call OT to cancel listing, MDT, etc)

- if cancel the op, w hat are you w orried about? (that is is a cancer and it should be done the sooner the better)
- w hat investigation w ould you do fo r him? (2DE)
- need antibiotics fo r him? (yes, NICE guidelines)

- w hat is your diagnosis from the case vignette?: previous rheum atic fever w ith rheum atic heart disease

- Pathophysiology o f rheum atic heart disease

Type 2 HPS rxn
Pharyngitis due to GABHS (streptococcal pyogenes)
Cross reacting antibody which interacts w ith myocardium
Incites inflam m atory reaxtion

In the acute stage, this condition consists o f pancarditis, involving inflam m ation o f the m yocardium, endocardium, and
epicardium. Chronic disease is manifested by valvular fibrosis, resulting in stenosis and/or insufficiency.

In rheum atic aortic stenosis, the underlying process includes

progressive fibrosis o f the valve leaflets w ith
commissural fusion, often w ith retraction o f the leaflet edges and, in certain cases,
valve thickening & calcification.

- W hat do you expect to see macroscopically?

- Post valve replacement; anticoagulant used

- W hat are the common anticoagulants you know o f
- Their mechanism o f action

- W hat factors are vitam in k dependent?

- Reversal o f warfarin? Vitamin k
- If you need it reversed urgently? FFP
- How do you m onitor warfarin? INR

- Now patient fever etc you suspect IE

- w hat signs do you look fo r in the hands?

- Pathophysiology o f osiers nodes and janeway lesions

- W hy are patients w ith Rheumatic heart disease and or heart valve replacement more susceptible to IE?

- W hat features are you looking fo r on 2D echo

- If you see right sided vegetations, w hat aspect o f the history do you need to ask the patient? IVDA

-Treatm en t o f IE?

- If still does not resolve w ith long term IV antibiotics in this patient? Consider surgical revision

5-Aortic stenosis - causes

how stenosis occurs in bicuspid aortic valve???

Bicuspid valves do not cause significant narrowing o f the aortic orifice during childhood.
Altered architecture o f the bicuspid aortic valve induces turbulent flow w ith
continuous traum a to the leaflets,
ultim ately resulting in fibrosis,
increased rigidity
calcification o f the leaflets,
stenosis o f the aortic orifice in adulthood.

Why bicuspid valve may cause sudden death?? Myocardial infarction, aortic dissection

AVR done & patient develop weak arms and some facial paralysis, why?= throm bosis & embolism to the brain,
w hy thrombosis in the metallic valve?
Define thrombosis?
Solid mass o f coagulated blood form ed w ith in the circulation

if infection happened in metallic valve why should be removed?? = to eradicate the infection because valve is s
foreign body.
on examination o f throm bus after removing the valve, a branching hyphae seen??? W hat does this means?=
fungal infection ( e.g. Candida)?
Which drug is used fo r long term anticoagulantion??=Warfarin? Mechanism o f action?????

W hat is RHD
RHD criteria (what to look out for)
 Table. Jones criteria for the diagnosis of acute rheumatic fever.

D iagnosis requ ire s tw o m a jo r m a n ife sta tio n s o r one m a jo r and tw o m ino r m a nife statio n s
along w ith e vid e n ce o f p rece d ing Streptococcus pyogenes in fe ctio n . The p rese n ce of
chorea o r c a rd itis m ay n o t re qu ire the add itio n o f e vidence o f p rece d ing S pyogenes in fe c ­
tio n . P atie nts fo r w h o m a re c u rre n t episode is being assessed m ay re qu ire o n ly one m ajor
o r se vera l m ino r m a nife statio n s along w ith e vid e n ce o f p rece d ing S. pyogenes infection.
E vidence o f p re ce d in g S. pyogenes in fe c tio n m ay inclu d e a positive th ro a t s w a b o r a raised
o r risin g a n tistre ptolysin 0 titer.

M a jo r m a nife statio n s M in o r m a nife statio n s

• Carditis • A rth ra lg ia
• P o lya rth ritis • Fever
• Chorea • Elevated ESR o r CRP
• Erythem a m arginatum • EKG e vid e n ce o f a prolonged PR in te rv a l
• S u b cutan e o us nodules

b. explained process o f RHD on valves - repeated/recurrent inflam m ation causing fibrosis, narrowing and
stiffening o f valves
0 1 hematological test to m onito r progression o f RHD: ESR

0 A fter AVR. why is there a need to anti-coagulate?

0 W hat is the most commonly used anti-coagulant (warfarin)
0 W hat is the MOA o f warfarin? W hat test w ould you do to m onitor?

W hat are the causes o f aortic stenosis ?

0 W ho w ould you involve in pre-op assessment? W hat investigations required?
0 Patient eventually underw ent metallic valve replacement. W hat are the peri-op
implications o f this? Discuss anti-coagulation

0 W hat common anti-coagulant is norm ally used? W arfarin. How does warfarin
work? W hat are the vitam in K dependent vitamins?
0 W hat is infective endocarditis? Name 2 common microorganisms associated
w ith IE.

0 If it were a young man having right sided heart valve IE. W hat particular risk
factor w ill you be concerned about? IV drug use.

0 W hat investigation would you do to identify vegetations.

0 Antibiotics may not be effective against clearing vegetations. Why?
Eradicating bacteria from the fibrin-platele t throm bus is extrem ely difficult because
(1) high concentration o f organisms present w ithin the vegetation (ie, 10-100 billion bacteria per gram o f tissue),
(2) positon deep w ithin the vegetation
(3) in both a reduced metabolic and reproductive state, therefore less susceptible to bactericidal abx
(4) produce exopolysaccharide which act as barrier to m ovem ent o f penicillin into cell wall
(5) fibrin meshwork o f throm bus interferes w ith m igration and phagocytic fx o f PMN leucocytes and abx penetration
Avascularised area
because bacteria forms biofilm - glycocalyx covering - th a t shields them from antimicrobials (confers resistance) &
allows some to enter a latent state during inhospitable conditions

For all o f these reasons, bactericidal antibiotics are considered necessary fo r cure o f valvular infection.

0 Patient may eventually require removal o f artificial valve. W hat is the principle behind this?
Examiner basically looking for "rem oval o f septic focus".
 Why are prosthetic heart valves more prone to infective endocarditis - because organisms
like staph aureus attaches on its surface &amp; forms biofilm.

Why are patients placed on warfarin - to prevent embolization o f vegetation fragments

causing stroke, myocardial infarcts, blindness, ischemic limbs, PE, renal or splenic infarcts

Mechanism o f action o f warfarin - blocks vitam ins K epoxide reductase preventing it frm
being recycled a fte r it is oxidized. U ltim ately decreases synthesis o f V it K dependent clotting
factors 1972.

If tricuspid valve infective endocarditis, w hat is likely cause? IVDA -nonsterile injection into
venous system - manifest as pneumonia or septic PE

How would you management infective endocarditis

Valve replacement w hat would you instruct patient

1. why is it necessary?
2. how is this done?
3. w hat is the risk?
4. alternatives to the procedure
5. after the procedure

c. IE criteria

Modified Duke criteria

Major criteria
Two sep arate positive blood cultures with m icroorganism (s) typical for infective endocarditis: Viridans
streptococci. Streptococcus bovis. IIACKK group. Staphylococcus aureus, community acquired enterococd.

Echocardiographk evidence o f endocardial involvement:

Typical valvular lesions: vegetation, ab scess, o r new partial dehiscence o f a prosthetic valve

New valvular regurgitation

Minor criteria
Predisposition: predisposin g heart condition or Intravenous drug use

Tem perature g reater than 38.0*C

Vascular phenomena: m a)or arterial em boli, septic pulmonary* Infarcts, mycotic aneurysm , intracranial
hem orrhage, conjunctival hem orrhage, laneway lesions
Immunological phenom ena: glom erulonephritis. Osier nodes. Roth spots, rheum atoid factor

M icrobiological evidence: positive blood culture but not m eeting m ajor criterion, o r serologic evidence
o f active Infection with organism consistent with infective endocarditis
define IE
d. w hat are the common causes o f infective endocarditis?
Why treatm en t is difficult. Two causes.(avasculrised+vegitations)
i. th ro w o u t the staphs and streps, HACEK
how to treat
why is it hard to tre a t
0 Persistent IE despite treatm ent, w hat surgical management is definitive?
0 Worsening CCF, need transplant, w hat kind o f matching most important?(HLA)
0 How do immunosuppressants work? MOA. W hat side effects?
Prophylactic antibiotics presurgery (nice guidelines)

(Malignancy, Infection)
e. mx fo r IE?
i. medical: antibiotics
ii. if medical mx fails, fo r valve replacement
iii. when valve replacement, o ffe r heart transplant, w hat do you use to match transplant? HLA antigen

iv. w hat are you w orried about im m ediately post-transplant?

Hyperacute rejection is humorally m ediated and occurs because the recipient has preexisting antibodies against the
graft

Acute rejection
Acute cellular rejection
recipient lymphocytes th a t have been activated against donor antigens
donor dendritic cells (also called passenger leukocytes) enter the circulation and function as antigen-presenting cells
(APCs).

Humoral rejection
antibodies are either preform ed antibodies or represent antidonor antibodies th a t develop a fter transplantation

v. how to prevent the above? Immunosuppression

2 phases: the initial induction phase, which requires much higher doses o f these drugs, and the later maintenance
phase.____________________________________________________________________

Im m unosuppressant Drugs
□ass Examples Mechanism |
Cidosporin Calcineurin activates transcription of IL-2. Cidosporin
Calcineurin
binds with cytosolic cydophilin to form a complex
Inhibitors Tacrolimus which inhibits calcineurin.

Sirolimus
mTOR Sirolimus binds to cytosolic FK-blnding protein 12
Inhibitors Temsirolimus (FKBP12). Thiscomplex inhibits mTOR, thereby
blocking activation of B and T cells.
Everolimus
Azathioprine Is an antimetabolite which interferes in
Azathioprine purine biosynthesis which, in turn, disrupts DNA
Antiproliferative synthesis in the S-phase of the cell cycle.
Agents Mycophenolic
Acid Mycophenolic acid inhibits the enzyme inosine
monophosphate dehydrogenase, the enzyme needed
for de novo synthesis of purines for B and T cells.
Basilixim abbindstothe a-subunit of the IL-2 receptor
lnterleukin-2 Basiliximab on activated T-cells, preventing their proliferation.
Receptor
Antibodies Dadizumab Daclizum abbindstoCD25,thealphasubunit of the IL-
2 receptor on T-cells.
y ^P harm aF actZ mTOR = Target of Rapamydn {former name o f Sirolimus)

1. w hat complications? he accepted catastrophic infections, but not Cushing's(or anything related to steroids),
hepato/renal toxicity, anaphylaxis/allergies,
cancers from biologies.

-W hat surgery may be perform ed?

- if the p t suddenly develops renal im pairm ent, whats the cause?

- if the p t does not respond to antibiotics, w hat options are there? (i gave aortic valve replacement,
but i think examiner was looking fo r heart transplant)
- w hat kind o f matching do you need before transplant? (HLA antigen)
- w hat kind o f immunologic reaction w ill occur if not matched? w hat is the consequence?
- how do you prevent transplant rejection?
- whats the consequence o f long term steroids? (looking fo r lym phom a/lukemia as malignancy)

Giant Cell Temporal A rte ritis, 60s fem ale, tem poral artery pain, visual disturbance

i. W hat w ould you do to confirm diagnosis - biopsy, which artery?

ii. Features o f biopsy-
Intimal thickening w ith lum inal stenosis,
mononuclear inflam atory cells w ith
tunica media invasion and necrosis,
giant cell form ation in media
iii. Why visual disturbances - involvem ent o f opthalm ic artery
iv. Biopsy was consistent w ith GCT arteritis, how to tre a t - Steroids
v. 1 year later came back w ith NOF fracture, causes? Osteoporosis, AVN
vi. Causes o f osteoporsis in this case - Female, Post menopausal, Age 60, steroids
vii. Risk factors
viii. W hat other primary bone problems cause fracture - Pagets, Secondary metastasis ...
ix. SOB and petechae after THR, diagnosis? Fat embolism
x. Cause o f fa t embolism - Long bone fracture, intra-m edullary nailing
xi. How to manage? Mainly supportive

-w hat is giant cell arteritis.

-which part o f the vessel is affected.
-w hat is the most im portant blood investigation to reach the diagnosis. ESR

Lady subsequently needs a surgery. W hat are concerns fo r this lady undergoing op? Taking steroids, need peri-op stress
steroids if taking large doses fo r long time.

0 W hat side effects o f steroids w ill you need to counsel patient about?
0 Lady then has a fall and fractures her hip. W hat are the likely causes in this
situation?
0 W hat is the pathophysiology o f osteoporosis? W hat are the causes o f osteoporosis?
Osteoporosis is a metabolic bone disease characterized by low bone mass and m icroarchitectural deterioration o f bone
tissue, w ith a consequent increase in bone fragility

-If you are taking this patient fo r surgery, w hat is your m ajor concerns, adesonian crises.
-W hat precautions to prevent this.
-W hat is the pathological changes th a t occur in osteoporosis: loss o f bone matrix.
-W hat you are concerning about when you treating this lady, (relapse o f the disease)
You treated him w ith the m edication th a t you ju st mentioned, patient came back lOyears later
w ith hip fracture. W hat the potential causes o f the hip fracture? Steroids, post menopausal,
possible im m obility from functional decline. W hat else?
f. How w ill you manage her hip fracture?
g. You m ention that patient w ill need surgery, w hat w ill you be concerned w ith? Addisonian crisis

h. How w ill you prevent Addisonian crisis?

i. Do you have to do anything about the giant cell arteritis before hip fracture surgery? Dont know
w hat the examiner is getting at but shes happy w ith get a consult w ith opthalmo.
35 year old man, right inguinal mass for 1 month, single palpable testes - teratoma testis

i. Histo report showing teratom a, lymphatic invasion, regional invasion, positive margins. W hat are the significant
findings o f report? (As above)
ii. How w ould you manage given histo report - m ultidisciplinary management, staging scan, resection o f margins,
adjuvant chemo+ RT
iii. W here does it spread to first - para- aortic
iv. W here does it spread to next - locoregional
v. W here does it spread a fte r - distant mets
vi. Pt comes back 1 year later, paraaortic node compressing renal artery and vein, has SOB and Pulmonary embolism
vii. W hat contributes to PE in this case - Hypercoagulability, turbulance ( venous stasis)
viii. Which part o f virchows triad does not contribute - endothelial damage
ix. W hat is choriocarcinoma - germ cell tum our
x. Tum our m arker - bHCG

xi. W hat is the common tu m o ur in this age group - seminoma

xii. W hat is the most common non-germ cell tum o ur in 60s patient -N o n hodgkin's lymphoma
xiii. Histology now shows papillary thyroid tissue and gastrointestinal
adenocarcinoma, explain why? - all 3 germ cell lines present - ectoderm endoderm in this case

iii. Serological markers

iv. Tell me about hCG
v. Can hCG measure seminoma recurrence
vi. W hat are the tum ours o f the testes do you know about
vii. W here does lymphatics o f the testes spread to

undescended testicle, w hat investigation you w ant to do? US scrotum, why?

reveals mixed swelling, solid and cystic, do we need to remove it? yes, why?
malignant transform ation.

blood tests? routine + AFP + HCG, which HCG? B-HCG.

w hat o th e r condition it is elevated, i said recurrence, she meant pregnancy!!

w hat are the tum ors you know from testis, seminomas, non-seminomas.
in 70 yo gentleman what's the m ost expected pathology? W hat is teratom a? w hat is choriocarcinoma?
read path report and tell me 3 sig info, incom pletely excised, seminoma, invasion, w hat does Nx mean? w hat LN do
testicular cancer spread to? aortic, why? embryological origin.
w hat w orkup w ill you do? MDT, CT TAP.
post op he develops hematoma ( still stable), m ention stages o f hematoma resolution

Scenario o f 32 year old male w ith undescended testis, presented w ith abdominal lump

a. Risks associated w ith undescended testis

b. Gave pathology report, showing teratom a. W hat is teratom a
c. How to explain bone tissue in teratom a
d. Tum or markers o f testicular malignancies
e. Which factors o f Virchow's triad for DVT are positive in this patient
f. Why hypercoagulability in tum or
tu m o r cells to produce and secrete procoagulant/fibrinolytic substance which activate coagulation cascade
stim ulation o f tissue factor production by host cell
g. Name the factor th a t converts fib rin to fib rin polymers
throm bin
9. 28 years old male, came in fo r dragging pain in le ft groin. On examination, you found a mass 3x2cm
over left groin?

a. W hat are your ddx? The usual differentials, plus testicular ca

b. W hy testicular ca?
c. How does undescended testis contribute to increased risk o f testicular ca?
d. W hat is choriocarcinoma? Examiner ju st jum p straight into this w ith o u t asking for different types o f testicular ca

e. If this is a 60 year old man, w hat is the most common cause o f testicular ca? Lymphoma
f. Histo confirm s testicular ca? W hat w ill you do next? Stage disease w ith CTTAP
g. W here is the first place th a t testicular ca spread? retroperitoneal LN. Examiner w ant more, gave
lungs and brain. He is happy w ith it
h. CTTAP shows presence o f retroperitoneal lymph nodes compressing on IVC. How does this
contribute to thrombosis? Examiner wants to hear Virchow&#39;s triad
i. In this case, Virchow&#39;s triad is only satisified under 2 o u t o f the 3 conditions. Which com ponent
o f Virchow&#39;s triad does it not satisfy in this instance? Hypercoagulability

FAP
Scenario : A young lady w ith endometriosis is at your clinic concerned that her father

died o f a cancer at an early age. She had a colonoscopy just now which revealed m ultiple

polyps, the larges one being 7 mm and ulcerated.

asked me the diagnosis, I said FAP

gene involved in FAP
types o f other cancer causing genes
types o f adenomas
which one has the highest chances o f causing malignancy,
then showed a printed picture o f a cancer infiltrating through the submucosa but not breaching it w ith 1 lymph
node positive, asked the DUKES classification (which I knew) and TNM
extra colonic manifestations o f FAP - wanted the exact types o f tum ors in all locations which I d id n 't know.
Then asked w hat is endometriosis, describe the epithelium o f the uterus (didn't like anything I told her about
the uterus - I think she wanted to hear the horm onal changes etc associated w ith epithelial changes
Then asked if theres anything I know about recent studies th a t show an association between endom etriosis and
malignancy (endometriosis is associated w ith increased risk o f ovarian cancer).
Also, she asked what advice I w ould give to this lady for her son and I said he would have to be screened
beginning at age 12 and have colectomy at age 20, she said why I said because he w ill get cancer fo r sure by the
age o f 40.
- Diagnosis

- W hat gene defect

- W hat does APC gene do normally:

it is a TSG, on chr 5
negative regulator that controls beta-catenin concentrations and interacts w ith E-cadherin, which are involved in cell
adhesion

- Extraintestinal manifestations
Patient has a 2 year old son. W hat would you tell the mom
- Genetic inheritance
- W hat surgery w ill you do for FAP
- W hat type o f polyps has highest malignancy potential
- Shown a diagram w ith tum ou r invading past muscularis propria
- W hat is T staging and duke staging o f this. (Omg I d idn't know the T staging lol.)
- W hat is dysplasia
Abnorm al grow th & dydx of tissue in epithelia

W hat are some extraintestinal manifestations o f FAP? (Desmoid

tumours, gastric fundal polyps, osteoma o f jaw.) Histo shows dysplastic polyp;
W hat lifestyle changes in general population to reduce risk o f colon Ca?
His ulcers heal by secondary intention; w hat is secondary intention? W hat is an ulcer? Ulcer gets infected
w ith staphylococcus aureus; w hat are the features o f staph aureus? (Gram positive cocci in clusters.)

UC
Scenario given o f a lady known to have Ulcerative Colitis and on surveillance colonoscopy. Found to
have a lesion less than a cm in sigmoid colon. Currently the disease itself is under control.

1) W hat is ulcerative colitis

2) w hat w ill you o ffe r the lady (total colectomy)
3) why total colectom y (be w hole colon susceptible)
4) w hat genes are responsible fo r transform ation to cancer (K-ras, p-53)
5) w hat kind o f genes are these (proto-oncogene and tu m o r suppressor)
6) how do these genes work? (act as gate keepers)
7) w hat do they do? (I am not sure I got this right...he tried to get it out o f me.. I said apoptosis in the end and he
seemed to have accepted it)
8) showed me a picture and asked TNM stage for that

W hat is UC? Inflam m atory bowel dz

Pathophysiology. Just need to say unknow n/idiopathic and u get the mark. Added th a t studies show
immunogenetics link (HLADR 2) but not needed (wasted my time).
On histo, how to tell if it is Crohn's? I said CD usually transm ural, skipped lesions, fistula, stenosis but all were
not the Keyword th a t examiner wanted to score the marks

Why need to scope? Said bleeding... then keyword. Risk o f CA.

Recent colono histo result: Tibular dysplasia in one part, adenocarcinoma in one part
Picture o f cancer eroding through muscularis layer
Name one tu m o r staging classification and stage tum or. Duke's. So tum or is Duke A.
Describe APC pathway. APC tu m o r suppressor gene damage leading to hyperproliferation. M utation to
Oncogene KRAS leading to dysplasia. Loss o f p53 causing adenocarcinoma
Surgical Mx: Colectomy. Asked examiner which part CA is in colon. Examiner asked if I wanted to do partial
colectomy in a very shock manner. Got the hint and said to ta l colectomy since patient has UC.

12) Pathology: UC lady, on long term immunosuppression

- w hat is pathogenesis o f ulcerative colitis
- if it is crohns, w hat w ill the microscopic features be
- w hat is a pro oncogene
- why w ill the patient require colonoscopic surveillance
- colono done shows TA w ith LGD and evidence o f invasive adenoCa. w hat surgery w ill you offer the
patient? (total colectomy)
- identify the duke or TNM staging (schematic diagram given, showing invasion into propria and 1/4
LN affected)
- if there was liver mets, how w ill it affect the TNM staging?
- how w ill you manage the patient preoperatively in view o f long term steroids
- questions on HPAA axis, how w ill the cortisol affect the adrenal gland? w ill it cause both the cortex
and medulla to atrophy?
- postoperatively, pt was found to be unconscious and hypotensive. ABG and bloods were normal,
w hat is the cause? (addisonian crisis)
- whats the pathogenesis o f addisonian crisis
- how w ill it affect the glycemic control o f the patient?
hypoglycemic episodes due to an increase in insulin sensitivity

Melanoma
Patient w ith hypothyroidism had a hard swelling in her right inguinal region, GP sent her
fo r biopsy, answer the questions th a t follow :

name diffe re nt types o f lymphoma ,1 said Hodgkin and nonhodgkin

w hat would favour diagnosis o f th a t (weight loss, lymphadenopathy, pancytopenias, etc).
he said w hat are other differentials, I named only a few causes o f enlarged lymph nodes.
the results o f our report are here and it's a melanoma -
w hat are the types o f a meloma? W hat is epithelioid melanoma
Then asked now the melanoma patient is here to see y o u , where would you examine her and why
- 1said I w ant to look fo r the prim ary and I w ant to check fo r further mets.
where w ill you look fo r prim ary - I said back o f legs and back (since most common site in wom en, but I forgot
this was an old woman), I d id n 't know so he said nail beds and palms and soles (basically wanted all sites, not
just the common ones).
w hat systems will you examine and why - chest fo r mets, brain fo r mets, etc).
then said how can you tre a t this patient by surgery - to remove the prim ary and remove mets and offer
chem o/radio - seemed happy.
how can you know phenotype o f the tu m o r - 1said immunocytochemistry. Seemed to accept that,
her wound is red and swollen but shes otherwise well - culture shows diplococci -
gram-negative diplococci are Neisseria sp., Haemophilus, Moraxella catarrhalis, Acinetobacter, and Brucella
name organism? Next the patient gets toxemia, swollen groin region w ith rapidly spreading
infection - w hat are you concerned about (Necrotising fasciitis).
W hat is SIRS? W hat happens to the lungs in SIRS (ARDS) -

• Myeloma diagnosis
• Causes o f pathological fractures

1) GB cancer, Nec. Fasc, C. Dif

• Common risk factor fo r GB Ca in the UK
• Spread
• Wound infection post open chole, common organism
• Common organisms fo r nec. Fasc.
• C. d if DD, mechanism o f pseudomembranes

1. Perforated viscus secondary to d ive rticu litis w ith endom etriosis

- Lady came in w ith LIF pain and peritonism, had Hartmanns procedure fo r perforated
colon, histology was perforated diverticulitis w ith endometriosis

- Pathophysiology o f diverticulitis (m entioned 2 causes: congenital and chronic

constipation/ageing causing pressure on the bowel w all causing outpouchings, then food
particles get stuck in the diverticulum and gets infected)

- How did the endometriosis get to the colon (Said th a t I know o f 2 methods: 1)
transcoelomic spread from fallopian tubes to the peritoneum and seeds onto the colon -
examiner got cross and said that's called retrograde m enstruation,
2) during development the endom etrial tissue develops on the bowel - he g ot even crosses and

said its called ectopic endom etrial tissue

- A few days later the patient developed a collection in the LIF, explain why
The answer was th a t the patient was already peritonitic and perforated
to begin w ith which would mean some soilage, therefore higher risk o f collections

- Asked about antibiotics (Said augmentin), w hat dose and how frequent (1.2g BD IV fo r 7
days), w hat if patient if allergic to penicillins (said clindamycin or ciprofloxacin), what
dose and how long (didn 't know the dose but said 7 days), he got pissed and asked me
why d id n 't I start w ith the simple abx (I said different hospitals have different
demographics o f bugs and antibiotics w ill differ). He wanted gentamicin
- Some questions about DIVC and ARDS and SIRS

TB/lym phom a
How do you label the specimen? (Category 3 hazard.)
W hat is the histological appearance o f TB?
- Exact repeat again - young lady came back from some th ird w orld country, developed
cervical lymphadenopathy, LOW, night sweats
- W hat are your 2 main differentials (TB and lymphoma)
- W hat lymphoma w ould you suspect (Non-hodgkins as most common)
- W hat tests fo r TB - culture, stain (Ziel-Neelson), TB PCR, interferon gamma assays (wanted exact name - tb
quantiferon gold)
Granuloma - give 3 examples
0 Giant cell o f Langhans - w hat are they?
0 Name one other Mycobacterium
0 Culture medium fo r M ycobacterium : Lowenstein-Jensen medium
0 Rapid detection o f Mycobacterium
- Given FNA result o f necrotic tissue, histiocytes, giant cells
- W hat is your diagnosis now - TB
- W hat are giant cells - m ultinucleated cells comprising o f macrophages
- Name another m ycobacterium that's usually involved in im munocompromised patients
- mycobacterium avium intracellulare
- Name 3 other granulomatous infection (not TB/foreign body) - crohns, sarcoidosis, cat- scratch disease)
- How long does a TB culture take - 4-6 weeks
- W hat is the proteinaceous substance th a t can be found systemically in TB - AA amyloid abnormal deposition o f fibers
o f insoluble protein in the extracellular space o f various tissues and organs

Stem: Indian girl travel overseas again, come back w ith neck lump

- Investigations
- Which labs w ill you send the sputum to (he d id n 't want to hear all th a t rubbish about ZN stain, auromine rhoamine gel.
He wanted to hear, m icrobiology lab, cytology lab.)

- W hat o th e r investigations (TB PCR, mantoux, interferon gamma.)

- W hat w ill you do once you collected the sputum sample (Put in biohazard bag, inform CDC. I w asn't sure about the UK
equivalent, so I said I w ill inform the UK e qu iva le n t o f CDC and m inistry o f health. He laughed really loudly and asked
how do we do it in Singapore. I said online or call)

- W hat is the public health concern fo r TB diagnosis

- W hat is contact tracing and w hat w ill you advice to the contacts.
- W hat o th e r mycobacterium do you know. (I said mycobacterium avium. He said th a t is
not the full name. W hat is the full name. I couldn't recall. Someone else said MAC and
he was happy w ith that.)

- Given histology report: TB histo

- W hat is a giant cell. Describe its morphology
- W hat is a granuloma: an aggregate o f epitheliod macrophage often including giant cells
- 3 causes o f granulomatous inflam m ation. Foreign body and TB are not counted.

signet ring carinom a o f stomach,

gastrctomy w ith splenectomy, pathology report,

w hat are the tw o m ajor risk factors fo r gastric cancer?

Tobacco smoke
Nitrosamines
Male
Blood group A
Hpylori.

Explain the pathology report to the fam ily in 4 sentences,

Look at Patho report, and pick out main points to tell family:
Signet cell, nodes positive, margins not clear.
Prognosis poor
Require chemo
May require another surgery
W hat are 2 pathological investigations you can use to confirm this: ???????? totally no idea. I
gave him CTAP, US HBS, AFP all o f which was not w hat he wanted.
Do an peritoneal tap w ith cytology.

7 or 10 days post operative have Axillarry vein thrombosis, w hat is in this patient predispose to this???(hypercoagulation
in malignancy, Age, m ajor surgery),
6 m onths later came w ith ascitis &amp; liver functions deranged? W hat the tw o pathological tests to do? Ascitis tap, to
see what?? Cells & liver biopsy to see what?? Cells and liver architecture + accepted but I think there was something
else Here.
W hat is the t t t fo r this patient now??? Two things???? I do not know??? Tried chemotherapy &amp; radiotherapy? But
was wrong

Necrosis (picture o f toe gangrene)

a. Define necrosis
b. Explain the cause and pathophysiology
c. Complications
d. Treatm ent options: Chop or d o n 't chop?

APKD (picture o f PKD)

a. W hat is the pathology (cysts)
b. W hat o th e r differentials
c. Complications o f the pathology
d. Underwent nephrectomy - why?
e. Had kidney transplant - explain the different rejection reactions
f. Immunosuppresion fo r a while, noted to now have malignancy - w hat kind
Chronic rejection appears as fibrosis and scarring in all transplanted organs

g. How to tre a t this com plication thereafte r (chemo)

PUD
W hat is an ulcer
FBC, RP results (showing raised serum Ca2+), CLO test positive
0 How does CLO test work? (medium contains urea)
c. Exact mechanism o f clo test
i. The basis o f the test is the ability o f H. pylori to secrete the
urease enzyme, which catalyzes the conversion o f urea to
ammonia and carbon dioxide. A biopsy o f mucosa is taken
from the antrum o f the stomach, and is placed into a
medium containing urea and an indicator such as phenol
red. The urease produced by H. pylori hydrolyzes urea to
ammonia, which raises the pH o f the medium , and changes
the color o f the specimen from yellow (NEGATIVE) to red
(POSITIVE).
0 W hat is the likely cause the PUD in this patient? - H.pylori infection
0 W hat is another possible cause? - suggest th a t hyperCa2+may be prim ary hyperPTH, which is associated w ith PUD

Questions:
W hat is a an ulcer?
Does it involve all layers of the epithelium ?
What are the causes of ulcer in this patient?
How does the CLO test work?
How would you treat the H .pylori infection
Any other causes in th is age group?
What are the causes of the urinary tract infection?
W hat investigations w ould you d o 5
What is on histology of a parathyroid adenom a? How is this different from the norm al parathyro id
glands?
What investigation w ould you order to investigate for the causes of hypocalcaem ia3
How would you localize the parathyroid adenoma
W hat is a frozen section?
Histo of glands:
1 gland 0.2g chief cells
3 glands rang ng from 0.08 to 0.09 g oxyphilic ce lls and fat cells
What is the diagnosis? W hat is happening to the other g ands?
Where w ould you find them if \ou do not seem them in the usual position3
What is the em bryological reason behind the variability of the positions of the parathyroid glands?

- Treatm ent o f H pylori

- O ther possible causes o f ulceration in her? (labs also showed hypercalcemia increased gastrin production)
- Likely causes o f hyperCa in this patient - parathyroid adenoma, malignancy
- W hat is a parathyroid adenoma
- 2 tests to investigate - think she only wanted Sestamibi and PTH assay
- How to manage, w hat sort o f surgery - was not happy w ith parathyroidectom y. Kept
saying "and...?" Shot me a w ithering stare when I offered subcutaneous parathyroid im plantation at same setting. Don't
know w hat she wanted.
- Histo report showed one gland th a t was heavier than the rest w ith predom inantly
chief cells, and the others w ith predom inantly oxyphil cells. Asked to interpret

You see a prom inent spot on sestamibi, w hat w ould you do? O ffer parathyroidectom y
- W here do you expect to find the parathyroid glands?
- Why can the inferior parathyroid glands be found near / w ith the thymus?
- Frozen section report interpret: hypertrophy o f one parathyroid gland w ith prim arily chief cells, others show involution
- W hat is a frozen section? How is the specimen fixed in an FS?

Clincial scenario o f a pt coming in w ith abdo pain, guarding and free air under diaphragm. Has PMHx o f some chronic
pain issues on NSAIDs.

W hat is the likely diagnosis?

W hat is the pathophysiology o f PUD?
W hat are the causes o f increased gastric acid secretion?
W hat are the differen t phases controlling gastric acid secretion?
W hat medications would this pt require in the long-term?
How do PPIs work?
How urgently does this pt need to go to OT?
How w ould you tre a t this pt surgically if it was a PDU vs a PGU?

5) Pathology: G allbladder CA
a. comm onest histo o f gallbladder CA - adenoCA
b. commonest cause o f gallbladder CA in UK - stones causing chronicinflam m ation
c. site where gallbladder CA com m only spreads to - liver segment V
Pseudomembrane colitis scope picture
M ost common histology o f gallbladder ca, risk factor
0 W hat is the most common cause o f GB ca in UK? (I said chronic cholecysitis)
0 W here does GB ca spread to first? (I said to liver then by lymph nodes to other areas, she probed which lymph
nodes and I said porta hepatis. She d id n 't say anything)

0 Assume patient is POD3 and wound site o f op is erythematous, but nothing expressed. W hat w ould you do? (I
said I would watch first if patient's vitals are stable, give PO abx, wash wound, alternate STO)
0 She asked somemore about w hat If it doesn't improve? (W orry about Nec fasc)
0 W hat are the com m on organisms fo r nec fasc? (she wanted 4 , 1could only give group a beta haemolytic strep
pyogenes, Clostridium difficile, staph aureus. I suggested E coli fo r the last one)

0 W hat to do fo r Nec fasc? (IV Pen G, IV broad spectrum abx fortum , surgical debridem ent) - LRINEC CRP>150, WBC >25,
H b d l , Na<135, Crea >141, Glucose>10
o W ho w ould you involve in Care: Plastic Surgeons, intensivist, ID Specialists
0 Patient develops diarrhoea w ith blood, w hat are the 4 differentials? (PMC, ischaemic bowel, infective
enterocolitis, stress ulcer)

Look at the colonoscopy picture -- w hat do you see?

Pseudomembranes

Can you tell me w hat the exact mechanism o f how C d iff causes pseudomembranes? Exudative
fibrin deposition as the bacteria secretes proteases to damage the bowel mucosa.

0 W hat do you see on the scope picture? And hence w hat is your diagnosis?
0 W hat are the pseudomembranes made of?
0 How does PMC occur?

W hat causes gallbladder CA? Chronic inflam m ation (gallstone, polyps..etc)

W hat kind o f CA? Adenocarcinoma most common
First area th a t it spreads to? Said CBD, Liver. Examiner asked again. LN?
Post op had localised collection. W hat to do? I said Abx w ith drainage (open vs percutaneous). Examiner
asked if w e give Abx fo r abscess? Told him drainage most im pt as Abx do not penetrate abscess well.

Now there is pain, swelling over surgical site, septic. Why? Told him wound dehiscence. Need TRO
necrotising faciitis (since all o f us knew from TYS th a t it w ill lead this way.)

W hat organisms? Staph Aureus, Strep pyogenes, Clostiridium perfigens (gas gangrene)
Patient started having bloody diarrhoea. Name 4 d iffe re n tia ls . GE, IBD, Opsite bleeding, PMC.
Showed colonoscopy pic o f PMC (as expected). W hat is this? PMC
Cause? Due to use o f broad spectrum Abx (eg. Augmentin, clinda), normal flora destroyed. Overgrowth of
Clostridum difficule. Produce Enterotoxin A,B leading to PMC form ation.

18. Post-op surgical site infection, pseudomem branous colitis

- Stem is patient s/p open cholecystectomy
- Wound very w et and oozy w ith green liquid coming out? W hat do you suspect, what
organism do you think, and w hat antibiotics w ould you give?

- W hat if wound was dry but had erythema and tenderness around wound edges?
W hat do you suspect, w hat organism do you think, w hat antibiotics would you give?
- W hat if wound had black edges, looked necrotic; what are possibilities
- W anted to hear nec fasc. W hat organisms cause this, w hat is management
- Post-op had bloody diarrhea - DDx? Offered ischemic colitis, C. d iff +
pseudomembranous colitis. W anted 2 m ore Ddx..l offered antibiotic related diarrhea,
which d id n 't get me any marks.

- Shown image o f colono w ith pseudomembranous colitis. W hat is this, how can you
tell. Pathophysiology o f pseudomembranous colitis.

Pt w ith sickle cell disease coming in w ith brain tu m o r

- Questions asked:
W hat is sickle cell disease?
Surgical relevance? Gallstones, immunocom prom ise, bone crises
W hy are pts im munocompromised? Autosplenectomy
W hat is the most common prim ary brain tu m o r in elderly pt?
Natural history o f prim ary brain tum or?
Brain biopsy showed squamous cells w ith keratinisation. Relevance? Likely metastatic SCC
Possible prim ary sources o f SCC?
Post-biopsy had wound infection
Common organism?
W ound fluid showed glucose 3.3. Relevance? CSF communication

M ost common breast ca, histology report to read, w hat to look fo r on it.
W ho is involved in MDT.
Herceptin, trastuzumab and how it works at cellular level.
Told him I had no idea and he moved on.
Asked about core biopsy and w hat to look fo r on it, and fu rth e r tests to do on sample (IHC)

- hard station, started w ith giving you a stem "45yo lady noted to have 5cm lump on mammogram in
le ft breast, w ith palpable lymph nodes, you seeing her in clinic"
- W hat investigations would you do next? Core biopsy (hands you histo results)
- W hat does this show you? Ductal carcinoma
- W hat o th e r investigations you w ant to know ? ER/PR, Her2Neu receptors etc etc
- Gone fo r surgery, now you have the gross specimen, w hat w ill you look out for? Margins of
clearance, LN involvem ent, extension/local invasion, vascular n lymphatic invasion
- W hat is Herceptin? How does it work?
- Patient has gone fo r a im plant and flap, w hat SINGLE MICROBIOLOGICAL SCREENING TEST would
you do for this patient? Stun fo r damn long, apparently answer is MRSA screen
- Now has breast erythem a and discharge from nipple, w hat single microbiological test w ould you do
now? Discharge for cultures
- How w ould you tre a t her? Broad spectrum abx, most said Augmentin

Previously w ell 53 y r old a d m itted fo r 1/52 duration o f bloody diarrhea. Suddenly stopped having
any m ore episodes o f diarrhea and now having abdo distension.

W hat are your d/dx: Enterocolitis, IBD, colon CA. W hat else? C d iff
Interpret the lab results: Na 128 K 3.1 Cr 109 U 9. Hb 8.7 (hypochromic, microcytic), TW 12 (raised).
PLT 666.
Explain all the abnormalities.
Do you think he has chronic or acute anaemia? CHronic. Why? MCHC anaemia. W ould be NCNC in
acute hemorrhage.
Why are the platelets high? Dehydration, acute bleed. These are right, but w hat else? Acute phase
response.
W hat do you see on the AXR? Thum bprinting
Besides all these investigations, how else w ould you investigate this patient? (FBC, UECr, AXR done)
CRP, ESR, stool c/s + OCP, Stool C diff, CEA, specific antibodies fo r Crohns and UC (Yes, but only at a
later date right?) How else w ill u investigate the patient? Colonoscopy at later date (doesn&#39;t seem
like the answer)
How w ill you m onito r this patient&#39;s progress? Clinically - fever settles, diarrhea settles.
Investigations —TW, CRP decreases.
W hat would you do fo r this patient?
W hat are the indications fo r operative management?
W hat surgery will you perform fo r him?

- M edullary th y ro id CA: stains calcitonin +.

- asked you to fill up the pathology report.
- W hat is it associated w ith? MEN2
- W hat are the other features o f MEN 2?
- W hat is the oncogene m utation fo r MEN 2?
- W hat is the mode o f inheritence o f MEN 2?
- W hat w ould you like to exclude before operation? Phaeo.
Why? Labile BP, dangerous.
- How do you do so? Urine VMA, Metanephrines. W hat else? I w ant a blood test.
- Explain in layman terms w hat im m unohisto chemical staining is.

40yo lady got pathological fracture o f fem ur shaft w h ile cycling. Examiner is a
W hat is a pathological fracture?
W hat could be the causes?
W hat 5 cancers classically metastasise to bone?
Fixation done, how to check w hat malignancy?
Histo shows follicular cells, where is it from?
Cannot find anything wrong w ith thyroid, where could the cancer be?
Pathologist wants to confirm its from the thyroid, how?
W hat epithelial malignancy o f thyroid cannot be found on radionuclide scan and why?

Path. 2: gangrene def, diff. Bw dry and w e t, asthersclerosis, risk factors, types o f cell death, diff. Bw
m esothelioma and bronchogenic caricinoma, signficance o f pleural plaques, risk factors o f mesothelioma, bell
rang

breast CA -pathology report.

W hat to look o u t for. Size, mitosis, estrogen receptor.
M ost com m on type o f breast CA, then you'll be presented w ith the report &amp; ask how to manage n e x t- tu m o r
board. Referrals to make.

Lung cancer

- one simple bedside non-invasive Test fo r dx- sputum and cytology

- one classification o f lung cancer: small cell vs non small cell
- w hat is adenocarcinoma - from glandular epithelium (common in nonsmoker), peripheral
- most common is squamous cell CA. Bronchial. Central
- Now pt presents w ith Mets: poorly differentiated - how to tell its epithelial in origin? Immunohisto staining
- if tu m o u r is epidermal grow th factor receptor positive w hat chemo drugs? Apparently it&#39;s tyrosine
kinase inhibitor? Glevac.
- pathology o f pleural plaque - isolated thickening &amp; calcification o f pleura after exposure to asbestos
and malignancy risk - mesothelioma
Physical Examination.

Thyroid
i. W hat else to examine
ii. Differentials - Colloid goitre main differential
iii. How to investigate - TFT(looking for?), Ultrasound, FNAC
iv. w hat w ill you look o u t fo r on ultrasound?
v. FNAC shows follicular cells, w hat do u tell the patient? 25% chance o f malignancy
vi. When do you need to operate?

b. How w ill you evaluate? Examiner wants FNAC

c. How w ill FNAC help you?
d. Supposedly FNAC shows papillary thyroid ca, you counselled patient fo r hem ithyroidectom y but
patient refuse. How w ill you proceed?

- Did the whole thyroid exam w ith lymph node examination

- When presenting I told the examiner to be very honest I could not feel any lump, but the
was no lump th a t moved on protrusion o f the tongue/swallowing, nil cervical nodes, nil
hyper/hypothyroid symptoms

- W hat are the symptoms o f hyperthyroidism I was looking fo r - trem or, clubbing, racing
pulse, exophthalmos, proptosis, lid lag, pretibial myxoedema, hyperreflexia

- Asked w hat I w ould do to fu rth e r investigate: said that since I cant feel the nodule, ill
organise u/s + /- FNAC o f the lesion, and do TFTs

- Patient euthyroid on blood tests, small lump detected on u/s - w hat to do n e x t:

proceed w ith FNAC

- FNAC comes back as follicular cells: said unable to tell w hether benign or malignant, will
counsel patient fo r either hem ithyroidectom y and com pletion thyroidectom y if histology
is malignant, or frozen section on table and hem i/total depending on benign/malignant

Differentials. Pathophysiology. W hat are red flag signs in US. Investigations. Managment o f hyperthryoid:
Carbimazole and propanolol. Surgical only if obstructive symptoms, signs o f cancer or failed medical management.

Hernia
c. dx: inguinal hernia, explain w hy inguinal, direct or indirect?
d. etiologies: "Nntra-abd pressure, chronic cough, intra-abd mass, BPH, occupation which carries heavy loads
e. Ix fo r hernia: pre-op bloods, CXR/AXR fo r etiology o f ^in tra -a b d pressure. No need fo r imaging fo r inguinal hernia,
unless suspecting other pathologies

He asked me about management o f this hernia. Discussion w ent on

regarding w hether it should be elective or emergency. Difference
between direct vs indirect hernia in term o f management. Types of
hernia repair tha t is done (he was okay when I only mentioned Mesh
repair and did not elaborate further). He specifically asked about
aparoscopic vs open hernia repair. Pros and Cons o f each.
Lap Open
GA LA
Laparoscopic - mesh posterior Open - mesh anterior to defect
to defect. Mesh incites a fib ro tic reaction th a t contributes to the
 more rapid recovery, less postop pain, less scar strength o f repair in groin hernias
earlier return to work
fewer recurrences (5 percent vs. 10 percent) and less
chronic pain than open repairs, but took longer to
perform
suitable fo r bilateral hernias th a t occur on both the right
and le ft sides and recurrent hernias

uncommon but severe complications - b o w e l,

bladder, nerve, vascular injury

0 Lap injures lat fem oral cutaneous nerve o f thigh. O pen-

0 Lap contraindicated if had prior surgery in ilioinguinal or genitofemoral
preperitoneal space like prostatectomy, incarcerated
hernias, large scrotal hernia, cirrhosis

0 Open repair is as good or if not better than Lap

In open surgery, the patch is placed over the hole. In laparoscopy, it is put in from behind the abdominal wall.

I m entioned about nerve injuries and he asked me about w hat nerves are injured during open hernia repair.
The ilioinguinal nerve is a sensory nerve th a t innervates the skin over the groin region, the medial aspect o f the thigh,
the upper part o f the scrotum and the penile root. It is norm ally encountered during open repair o f inguinal hernia.

f. Mx:
i. conservative, lifestyle/occupational change, correct etiology
Conservative vs surgical - conservative w ith trus belt,
resolving underlying causes o f increased intraabdo pressure eg BPH/cough/heavy lifting,
education on symptoms o f incarceration/obstruction

ii. surgical.
lap vs open (lap recommended fo r bilateral or recurrent hernias)
prim ary repair +/- mesh (was going to go into contraindications to mesh but examiner stopped me)
if pt has BPH, w ould you do lap or open? Risk factors fo r urinary retention after laparoscopic inguinal hernia repairs.

- Right inguinal hernia, soft and easily reducible, abdo SNT, testes normal
- W hat o th e r exam w ill you do - PR fo r BPH/resp fo r chronic cough
- W hat investigations will you do - 1said in this case I'm quite convinced it's a hernia so no need for ix, but if I'm not sure
I can do an u/s o f groin, esp in obese pt

- W hat options fo r management:

Is there any relationship between open appendicectomy and hernia? How else can you test the ilioinguinal nerve?
(Sensation on lateral side o f scrotum.)
W hat types o f repair are there? W hen w ould laparoscopic repair be favoured? (Bilateral hernia.)
W hat types o f anaesthesia? When would you use RA/local anaesthesia?

- Do you advise patients to be managed conservatively - said in clinic I always advise

patients fo r surgery due to the risk o f incarceration and obstruction requiring emergency
surgery, but I also give them the alternatives

- When would you advise for conservative management - when patients are poor surgical
candidates - o ld /p o o r co-morbids
You perform open repair, how would you identify if it is indirect o r direct
inguinal hernia? Lat/M ed to in f epigastric artery
considerations in respi patient, patient advice post op

-Abdominal pain (short Hx: T3N2 low rectal CA s/p APR years ago)
-Real pt w ith parastomal hernia over le ft side (pt: plz do not open the stoma bag, examiner: plz do
not open his stoma bag... w hile i poke poke the shit on the stoma to see the mucosa)
-How to tre a t parastomal hernia, w hat are principles of repair, why mesh not encouraged here
Conservative Surgical
skin protective sealants, a flexible appliance high recurrence rate
Abdominal support belts
No heavy lifting, heavy work Relocation o f the stoma, w ith or w ith o u t using
a synthetic mesh
used a split mesh technique

Stoma relocation - first parastomal hernia.

If a stoma is relocated, it should be created on the
opposite side o f the midline due to higher rates o f PSH
fo r same-side relocation
For recurrence, repair using prosthetic material appears
to have the best outcomes (Rubin, 2004).

Risk o f mesh usage

fistula fo rm a tio n from mesh erosion into proximal bowel (therefore use PTFE, not polypropylene)
dense intra-abdom inal adhesions to the mesh making future surgery difficu lt (therefore use PTFE, not polypropylene)
infectious complications because o f bacterial contam ination o f the mesh by the stoma itself

-Need TRO recurrence, tum or m arker trend, colonoscope, CT scan

-W hether w ill recommend surgical resection (depends on staging if really recurrence)
- where is the deep ring? where is the inguinal ligament landmarks?
- w hat are your differential? examiner looking fo r lipom a o f cord
- w hat ix w ill you do? i offered US o f contralateral side because i thought there m ight also be a
contralateral hernia
- p t doesnt w ant operation because his jo b requires heavy lifting, has no money, cannot take MC. i
offered to discharge pt w ith advice, but apparently examiner was looking for a second tea w ith pt to
let p t reconsider
- how long must pt avoid heavy lifting fo r a fter hernia repair? 30 days

11. CPE - patient w ith stoma ? parastomal hernia?

Male w ith transverse RIF/suprapubic scar (never seen any scar like this before),
colostom y bag in LIF. Had APR previously according to the stem. Was draining
brown stool, examiner told me to assume that bag is em pty w ith no o u tp u t fo r past
few hours.
fe lt a ? parastomal hernia.

Rambled on about the possible complications o f stoma.

Did not reach invx or management.

CVS
AS w ith Pacemaker
 Pacemaker spikes
If Pacemaker is pacing the heart you will see a A t r ia l P .ic o m .ik e r ( t i n g le c h a m b e r )
s p ik e To determine what is being paced. Look at
location of spike

IWfore P pacing J

®AJ■Jv f k ilh puring both

Before OftS Pacing VENTRICLE

V e n tric u la r P a cem a ker ( tin g le c h a m b e r)

O n * ip rto producing a iT M ltn o U r capture I

- CVM exam. ESM loudest aortic region radiating everywhere. Tissue paper as
pacemaker over sternum. (PM session guys got MR. Another patient w ith m idline stenotom y scar.) - M y case was an
uncomplicated right pacemaker, w ith o u t any m urmurs irregular rhythm..

- Is this patient in failure?

- ECG. Is the pacemaker functioning. - note spikes.
- W hat is the rate.
For regular rhythm s: Rate = 300 / num ber o f large squares in between each consecutive R wave.
For slow or irregular rhythm s: Rate = num ber o f complexes on the rhythm strip x 6 (this gives the average rate over a
ten-second period).

-O th e r things on ECG. (LVH)

- M onopolar or bipolar intraop.
- W hat do you need to do pre-op.
Asked about warfarin and how to manage pre op / intra and post op.
Pacemaker dude w ith aortic valve replacement
- CVS Exam, location o f pacemaker
- Indications fo r placing a pacemaker: sym ptom atic bradycardia
 T e m p o r a r y Pacing P e r m a n e n t Pacing
A V Block 3 r d - d e g r e e A V block w i t h o u t P e rs is te n t 3 r d - d e g r e e A V block
a d e q u a te e sc a p e r h y th m : in p o s te r io r w a ll in fa rc tio n ( m o r e
- s y m p to m a tic p a tie n t th a n 1 0 da y s a f t e r in fa rc tio n )
- v e n tric u la r ir r ita b ilit y P e rs is te n t 3 r d - d e g r e e A V block
- h e m o d y n a m ic w o rs e n in g in a n t e r io r w a ll in fa rc tio n

Sinus N o d e D y s fu n c tio n P a tie n t w i t h n o P a tie n t w it h

re s p o n s e to o th e r tre a tm e n t SA blo c ka d e s
(a tr o p in e )
B u n d le B ranch Block - A n t e r io r w a ll in fa r c t w i t h n e w • A lt e r n a t in g le f t a n d / o r rig h t
le ft b u n d le b ra n c h blo c k and b u n d le b ra n c h block
h e m o d y n a m ic in s ta b ility - S y m p to m a tic p a t ie n t w i t h r ig h t
- A lte r n a tin g le ft a n d / o r rig h t b u n d le b ra n c h b lock a n d le f t
b u n d le b ra n c h block a n t e r io r h e m ib lo c k a n d / o r le f t
- R ight b u n d le b ra n c h block p o s te r io r h e m ib lo c k
a n d le f t a n t e r io r h e m ib lo c k
a n d / o r le f t p o s te r io r h e m ib lo c k
- L e ft b u n d le b ra n c h block
a n d 1 s t d e g r e e A V block

- W hat are your surgical concerns: ACID, bipolar diatherm y

AAI
DDD - dual pacing, dual sensing, dual inhibition
DVI - dual pacing, only senses the ventricle, is only inhibited by the ventricle. DVI ignores the atrial contraction

D D D
Pacing Sensing Inhibition
A- Atrial A 1- inhibited by ventricle
V- Ventricular V D - means: dual inhibited
D- dual D - means: dual sensing 0 - no inhibition
0 - no sensing

Therefore asynchronous pacing mode: DOO: Heart pace both atria and ventricle, doesn't sense current frm diatherm y
and doesn't inhibit pacing
VOO: heart pace ventricle, rest as above

Only fo r use in OR:

A fter op: change back to DDD or W l, or pt got risk fo r VT/VF if heart pace on T wave (R on T)

pacemaker pre op: ask technician to review the pacemaker and set the pacemaker
set to VOO/DOO: pacing as usual, but no sensing (so no pacing inhibition at cautery, tachytherapy deavticated so no
shocks given during cautery

The pacemaker is inhibited by electrocautery

Intraop: use bipolar if possib le, if m onopolar then place pad away from defib eg at LL, if defib
needed place pads away from pacemaker

Patient was an elderly man w ith a pacemaker at the le ft infraclavicular fossa and a
stoma bag in RIF. No o ther surgical scars noted. No peripheral signs. No signs of
cardiac failure. Heart sounds dual, no murmurs.

Why do you th ink patient has a pacemaker? I m entioned sick sinus syndrome and
IHD. He then asked how IHD leads to patient requiring a pacemaker so I said if the
SA node or conducting pathway is affected then patient my get SSS. He prompted
me and said w hat else can happen? I m entioned com plete heart block and he was
happy to move on.
Who w ould you call to manage this patient pre-operatively? W hat intra-operative
precautions would you w ant to take fo r this patient? (I said use bi-polar, get
technician to adjust pacemaker settings before surgery).
W hat one fu rth er investigation would you do pre-operatively? I said 2DE and he
was happy to let me go 2-3 minutes before time.

b. Showed ECG. Is this ECG pacemaker dependent?

d. W hat else w ill you be concerned about? Patient probably will be on warfarin
e. How do you titra te warfarin before the op?
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a. Explain complications o f aortic stenosis

b. Causes
c. How it affects surgery (talk about fixed o u tflow obstruction)
d. When to o ffe r surgery
e. So if patient now has gastric cancer - do op straight or do heart op first to optimise
Since severe AS is a risk factor fo r perioperative m orbidity and m ortality, it has been recommended th a t elective
noncardiac surgery be postponed until after aortic valve surgery for those patients who have indications for aortic
valve replacement
f. How to optim ise prior to surgery and things to consider

The m ajor considerations in such patients are:

Preoperative echo assessment o f AS severity: severe AS: an aortic valve area <0.7 cm2 or mean gradient >50 mmHg
 Careful evaluation fo r coexisting coronary artery
Sudden reductions in systemic vascular resistance, as may be induced by epidural or
spinal anesthesia, may result in a substantial decrease in coronary perfusion. Thus,
anesthesia techniques should be tailored to maintain an adequate TPR
Optim ization o f volum e status in the perioperative period
Both vascular volum e and preload must be maintained. Because o f the decrease in left
ventricular compliance, marked reductions in preload, as may be induced by anesthetics or
other drugs, may be poorly tolerated.

Maintenance o f norm al sinus rhythm is im portant. Because the atrial "kick" may provide up to 40 percent o f ventricular
filling, especially in a le ft ventricle w ith decreased compliance, rhythm s other than sinus rhythm can have deleterious
hemodynamic effects.
In addition to losing the atrial "kick," the associated tachycardia w ill decrease coronary
perfusion, which is dependent upon an acceptable diastolic tim e interval

Hypotension after induction o f anesthesia should be treated w ith phenylephrine, an alpha

agonist th a t has no chronotropic properties.
h ttp ://w w w .uptoda te.com /online/conten t/topic.do?topicKey=valve_hd/13397&view=print 11/22/2010

i. W arfarin if patient w ent fo r m etallic valve

ii. Concern fo r spread if delay cancer surgery
iii. Concern fo r on table cardiac event if d o n 't do valve surgery
(equivalent to heart failure patient)

Signs th a t I got: Super loud ESM at aortic region. Signs o f cardiac failure (bibasal creps, peripheral
oedema, LVH, radiates to carotids) No medications at side.

- Diagnosis
Pre op cardiac investigations
- Management
- If patient is on w arfarin, when w ould you stop pre op
 Is surgery elective or emergency/urgent?

Is warfarin interruption needed <24 hours >24 hours

in patients who are undergoing
elective surgery?

Administer IV vitamin Administer IV

K |, 2-4 mg, and fresh vitamin K|,
No Yes frozen plasma or 2-4 mg
prothrombin complex
concentrate i f needed

Bleeding risk associated with Bleeding risk associated with

surgery/procedure is low surgery/procedure is not low

No need to stop warfarin Is bridging anticoagulation needed during warfarin interruption?

before surgery or
procedure

No Yes

Patient is at low risk for Patient is at high ± moderate risk for

thromboembolism thromboembolism

Day -5: stop warfarin (last dose Day -6) Dav -5: stop warfarin (last dose on Day -6)
Day -1: INR testing ( i f INR >1.5, Dav -3: start therapeutic-dose heparin bridging
administer vitamin K|, 1.0 to 2.0 nig Dav -1: INR testing ( if INR >1.5, give vitamin K i, 1.0-2.0 nig orally);
orally) stop LMW H on morning before surgery (omit evening dose with twice-
Day 0 : resume warfarin on evening after daily dosing; reduce total daily dose by 50% with once-daily dosing)
surgery i f patient drinking fluids Dav 0 : assess postoperative surgical site hemostasis; resume warfarin on
Dav -1 to +3: resume warfarin when evening after surgery i f patient taking fluids
patient drinking fluids Dav +1 to +3: resume heparin bridging when hemostasis secured and not
within 24 hours after surgery ; resume warfarin when patient taking fluids
Dav +5 to - 6 : stop LMW H when INR therapeutic

- W hat would you do fo r a patient on warfarin going fo r op

Also asked w hat is a MIBI scan, myocardial perfusion (MIBI) scan is carried o u t to investigate the blood supply to the
heart. These tests w ill be carried out before you have your scan. There are tw o parts to the investigation, a rest test and
a stress test, which are carried o u t on separate days.

Patient had a sternotom y scar w ith ejection syst m urm ur

2) W hat is ur concern (anticoag)
3) How w ill you manage it perioperatively
-how to prepare this patient fo r surgery
-also ask about warfarin and management pre and post-operative
c. Risks in surgery
d. Give warfarin chart. How to manage preoperatively and intraoperatively

MR w ith rhf
- Straightforward CVS exam w ith pansystolic m urm ur at m itral area, radiating to axilla
(m itral regurgitation), nil failure symptoms
- Leg oedema, which side heart failure - right, if le ft sided heart failure, where does fluid
go - lungs
- If fingers are blue w hat does this signify (peripheral cyanosis), lips/tongue blue (central)
- W hat heart conditions causes cyanosis (left to right shunts)

Has a MVR (not told at start). Asked to perform full CVM exam.
Pt had m idline sternotom y scar, no scars over LL. Loud metallic SI. Not in heart failure.
&gt; W hat are your perioperative concerns fo r this pt?
&gt; Shown pt's INR trend, which was supratherapeutic. How would you manage this?

Pre-op CVS assessment. Mechanical heart valve. Examination wise only the loud first
heart sound, no m urm urs or pacemaker. Questions on diagnosis, things to do pre-op
(refer CVM, 2D echo, ECG, CXR, titra te w arfarin/heparin), w hat other meds needed
(antibiotic prophylaxis fo r all ops).
For dental, oral, respiratory, and oesophageal procedures, prophylaxis is required mainly against streptococci.
Am oxycillin is the preferred antibiotic in a single dose o f 2 or 3G 1 h p rio r to the procedure. Patients allergic to penicillin
should receive clindamycin, azithromycin, or clarithrom ycin.
For gastrointestinal and genitourinary procedures, prophylaxis should be directed mainly against Enterococcus faecalis,
using am picillin 2G intravenously plus gentam icin 30 min before starting the procedure w ith a second dose 6 h after the
procedure. Patients allergic to penicillin should receive vancomycin plus gentamycin.

Respi
1. Respi (COPD)
a. Full respi examination as per MBBS
b. Features o f severity - signs o f respiratory failure (confusion, wheezing, tachypneic), hypercapnia (warm periphery,
bounding pulse, confusion) and cor pulmonale (pulm edema, pitting edema)
 T a b le 2
Stages and Recommended Treatment of COPD
S ts * Features Recommended Treatment

A ll stag** A.oid ink factors sucha

smotarij. irritants aHergans
Ftecer.-e hflu e n za vaccine
amuaty
Pneumococcal polysaccha­
ridevaccine
T reat c o m p lk a a o re a cco rd ­
in g
S la»e i : M i d COPD FEV,/FVC<J0% Use short-actin g broncho-
FEV, .=60% pre d c te d dilator as needed

W ith or w ith o u t symptoms

Stage 2 : M o d e ra te COPD rev,/Fvc <70% M ain te n a n ce therapy w M i t

50*. iFEV, <»% o r m ore bronchoA lators. pul-
padctad m onaiy re h a fa h u e cn

W it i or w itt o u t symptoms

S U fe J: Severe COPD FEV/TVC<70N M aintena nce therapy w ith

30*.t FEV, <»% o n * a m ere brcnchod>lntc»t
p re d c te d Ir fa te d corticostero ids for
W ith or w iih o u t symptoms patients w rth re c u rrn g e xa c­
Table 1 erbations or with persist#rt
sym ptoms despite therapy
w rth tro n c h o d ria tcrs. pulm o­
GOLD Staging System nary rehabilitatio n

Stage FEV,/FVC P o s tb ro n c h o d ila to r FEV, S ta y * 4: Vary w i w * rev/fvc <m Regular treaertem w ith 1 or
COPO FtV. <3O K predicted or m ote b ro rr.h o d ilsto is
Stage I: Mild <0.70 >80% predicted <50% p re d c te d p lus pres­ Use in haled corticostero ids
Stage II: Moderate <0.70 50% to 79% predicted enceof c h ro n ic re s p ta it sym ptoms p e ra s t d e tp te
toryM u* (PaQ, < ® mm bioncnoddator tharapy. p d -
Stage III: Severe <0.70 30% to 49% predicted Hg w h ite b re a th rq room m onary reha b h ta o cn
Stage IV: Very severe <0.70 <30% predicted or a r a t saa level ) Long-term oxygen tte r a p y if
<50% predicted + respiratory failure chronic respiratory failure
Consrter s u g ic a l treatm ents
GOLD: Global Imituiiv* f i r (J>rvntc O h trw tirt t.ung Obtmt; FBT,• fo rt« l n p r a tx y vokjna n 1 iBccmJ: PtC- fa road veal cap a rty PaO,- ar u ra l partial f t mu■ tf
/■'IVr f i r t n i t x p i u u r y tirfum t in a n t ttotnd. F V Q f o r t n l \ t u l o i f * n i l ) cm#,n
A r L t p itJ fr itu r r f n t n t t 6.

c. Explain how COPD w ould impact surgery

Poor lung function (fatique respi muscle) w ith hyperexpanded chest and right heart failure 2nd cor pulmonale
Barotraum a frm PPV
Upper airway instrum entation (eg, tracheal intubation) and inhalation o f irritants (eg, desflurane, external
disinfectants) triggers vagally-mediated reflex bronchoconstriction thereby prom oting the expiratory collapse o f
the peripheral airways w ith incom plete lung alveolar em ptyin
Bacterial colonization o f airway,

GA effect
The combined effects o f the supine position, GA and thoracic/abdom inal incision
produce a decline in lung volumes with
atelectasis form ation in the most dependent parts o f the lung
Residual neuromuscular blockade persisting a fter anesthesia leads to
deficient coughing
silent aspiration o f gastric contents
depressed hypoxic ventilatory drive

d. How to prep patient prior to surgery

Preop
Smoking cessation at least 4-8 weeks preoperatively and
Optimize lung function can decrease postoperative complications.
Optimize n u tritio n to maintain good energy balance

Intra op
RA over GA

Postop:
Early mobilisation, deep breathing, in te rm itte n t positive-pressure breathing, incentive spirom etry and effective
analgesia may decrease postoperative complications.

lnvestigation?=PEFR, CXR, RFT, bloods & ABG.

Should anaesthesia see this pt.? Said yes, Why?
Better to avoid general anaesthesia?
How to prepare fo r surgery??where to tre st postoperative? HDU OR ITU Why? = high risk o f respiratory failure.

- Ddx: COPD
- W hat are your operative considerations now? Need to refer Anes, Respiratory, manage COPD
first, advise smoking cessation, consider furthe r investigations, cannot do laparoscopic hernia
repair

- really got signs- nicotine stains, and expiratory wheeze bilaterally

- w ill not recommend fo r hernia repair
- but patient adamant fo r surgery-&gt; how to manage
- use open surgery, not laparoscopic because o f co2 pneum operitoneum and copd
- use regional, spinal not GA
- preop care- &gt;chest physio, stop smoking, incentive spiro, anaesthetist consult
- postop care-&gt; early mob, chest physio, incentive spiro, manage in HD

Abdomen
Cholecystitis
- Abdo PE. RHC pain w ith murphys' positive.
- Differentials.
- Complication
- How w ould you investigate.
- How to treat: ABC, IV abx, ANALGESIA
- W hat o ther systems would you like to examine?
- Shown a set o f vitals w ith fever, tachycardia. Interpret.
- Investigations
- Management

Specialty choice 1 (trunk and thorax ): RHC tenderness

Standard abdo exam like you do in MBBS. DDx, investigations. Lets say US HBS got dilated ducts,
w hat w ill u do next? ERCP vs MRCP, but MRCP not invasive, so do MRCP first to look at the cause
o f obstruction first.

e. When to op: so if day 1 op? so if day 5 op?

http://bestpractice.bm j.eom /best-practice/evidence/intervention/0411/0/sr-0411-il.htm l
Early cholecystectomy w ithin 7 days o f onset o f symptoms is the treatm ent o f choice fo r acute cholecystitis.
Early surgery reduces LOS compared w ith delayed surgery, but does not reduce morbidy, m ortality or postop
complications and conversion rate.
Complications included pneumonia, wound infection, wound dehiscence, incisional hernia, intra-abdominal abscess,
mesenteric thrombosis, pancreatitis, M l, and transient psychosis

Surgery fo r acute cholecystitis could be tim e critical. According to Zhu et. al., gallbladder inflam m ation during the first 72
h o f onset o f symptoms may not involve structures w ithin the triangle o f Calot [23]. Surgical dissection w ithin this critical
period therefore appears easiest due to lack o f organized adhesions. Cholecystectomy w ithin this tim e frame reduces
the risk o f injury to the structures w ithin the triangle o f Calot. This is reflected in the low rates o f complication and
conversation.

0 Stem: patient has worsening 4 day period o f abdo pain

0 Examine patient
0 W hat are your differentials? (after cholecystitis, I said biliary colic, hepatitis)
0 Do ballot the kidneys, because he told me so, and asked th a t if there is tenderness, what do you do? So do a
renal punch, and hence can consider if there is any pyelonephritis

0 He continued to push me fo r differentials: finally squeezed out pneumonia and DKA, he looked like he was
searching fo r pneumonia)

a. Differentials fo r RHC pain: cholecystitis, PUD, cholangitis, low er

lobe pneumonia, pancreatitis, renal pathology

b. Bedside tests you can do to help in your diagnosis - blood tests,

UFEME, US abdomen
c. US shows gallstones 0 cholecystitis
d. M gt o f cholecystitis - abx (3 rd gen cephalosporin + metronidazole)
e. Surgical options

0 Asked how do you w ant to investigate? (LFT, US HBS)

0 W hat w ill you expect to see on US HBS?
0 How do you w ant to manage the patient?

- Investigations - a fte r bloods, said U/S HBS. W hat else? I said CT AP. W hat other
options fo r imaging biliary system. I said MRCP?
- Management - w hat antibiotics?
- Likely approach fo r surgery
- Options fo r tim ing o f surgery - early vs interval. I initially said interval in view of
already D4, then he said w hat if it was only D1 - 1said in my experience mostly early.
- W hat if patient clinically im proving post-op, but LFTs were worsening. Differentials?

RIF pain in a youg lady (Simulated patient)

i. Findings: RIF tenderness w ith rebound and guarding.
ii. Present findings
iii. Differentials: Appendicitis, Gynae causes (ruptured ectopic, ovarian torsion), UTI/pyelo, GE
iv. Investigations - Include UPT and ultrasound, bloods - FBC
v. Intraoperatively you find bleeding in the pelvic cavity, w hat do you do?
Refer O&G, arrange fo r blood transfusion, call haematologist

acute appendicitis.
Straightforward full abdo exam, and I did psoas/rovsing/obturator and mentioned
dunphy. Guarding and rebound over mcburneys. VERY good female actor. Could
almost believe she had appendicitis.

W hat are the differentials:

Cholescysitis
Appendicitis
Pancreatitis

W hat invx would you do?

FBC, UECr, LFT, Amylase

Imaging: US HBS, CTAP (for appendix), MRCP(if dilated CBD found on US, or suspect pancreatitis)
If there is gallstones found? Do ERCP.
Vitals chart shown. Fever, mild tachycardia.
UFEME: Normal
Treatm ent:
NBM IV drip,
Analgesia abx (Roc, flagyl)

- How w ould you perform an appendicectomy?

Open vs laparoscopic
- w hat are the advantages o f lap? less scarring, can perform diagnostic lap
- w hat w ill u be looking at in the lap?
- How do you do the diagnostic lap and where do you insert the ports?
Infraum bilical and suprapubic, and RLQ / LLQ

Questions on DDX specific to young female patient, further tests to rule in/rule out.

severe peritonism in a patient w ho w o u ld n 't let us touch him, vitals next to him, had fever tachy, longstanding history of
constipation now has vom iting and diarhea
wanted to specifically diverticulitis, perforation, obstruction and CHEST XRAY fo r air under diaphragm,
how w ould you manage such a patient in ER -
how w ould you treat, happy NPO,fluids,antibiotics,but d id n 't w ant to hear anything apart frm chest xray for
investigations

5. Abdom inal examination on a patient w ho had surgery for sigmoid colectom y-

patient very tender in le ft iliac fossa, no other findings except AFib n ecg -
consultant asked about differentials - anastom otic leak and then generalised to comm on causes o f post op fever, etc.
random usual easy station.

Elderly pt w ith previous abdominal surgery, now c/o painful lump over incisional site.
Very frail old lady w ith a T shaped scare over lower abdomen. Had a lump in RIF region th a t was only
apparent after standing up (pt started in a supine position). Not incarcerated or strangulated. Bowel
sounds +

- Questions:
&gt; W hat is the diagnosis?
&gt; How would you manage this p t conservatively and surgically?
&gt; W ould you o ffe r this pt surgery?

-POD6 elective le ft hemicolectom y for CA, now abd pain, BNO ld a y (actor actually looked septic!)
-Given charts: rising tem perature, rising PR, BP sliding down slowly, 02 requirements rising to
m aintain Sp02
-Given bids: TW raised, Hb normal, CRP raised, Urea Creatinine on the rise
-Given ECG: AF
-Examination abdo left sided tenderness, localized guarding and rebound, otherwise soft, no
generalized peritonism , not distended, BS present, radial pulse not in AF (haha.. examiner ask to
ignore radial pulse), pt in TEDS stockings
-Anastomtic leak and Mx (NBM, abx, drip, IDC, KIV NG tube if starts vom iting), CXR, CT AP w ith
contrast, CT PA (TRO PE as cause fo r AF and increasing 0 2 requirements)

LIF tenderness post colectomy

this young lady POD 5 le ft colectomy, now w ith LIF tenderness, fever, TW CRP
so just do an abdo exam
signs were LIF, lum bar pain, had laparatom y scar w ith dressing intact, was not
allowed to remove the dressing.
diagnosis - ? anastomotic leak, perf viscus
management - usual. NBM, IV drip, hourly urine output, IV roc/flagyl, tell consultant

Viva questions

0 Differential diagnosis: anastomotic leak

0 How w ould you manage? (See obs chart please)
0 [Shows tachycardia, pyrexia, hypotension, tachyopnea and increasing 02
requirements]
0 [Go through basic resus measures]
0 W hat other things would you like to do? [ABG, ECG, bloods]
0 You&#39;re shown ABG results and ECG and asked to interpret
0 W ho w ould you like to involve? (Seniors i.e. consultant, and ITU)

Hip
Obese p t w ith previous THR, now c/o contralateral hip pain. Perform full hip examination.
Pt had BILATERAL THR scars and bilateral TKR scars. Tried to do hip examination but pt was tender over
entire hip. ROM restricted in all directions.
- Questions:
&gt; W hat is the diagnosis? OA??? Prosthesis loosening??? Pt doesn't fit the description...
&gt; How w ould you manage this pt?

Limbs and spine: OA Hip

Pt was not prim ed properly. Kept complaining o f right hip pain when the stem was a le ft hip pathology.
Signs: Right lateral THR scar. Trendelenburg on right leg. Gluteal wasting on right. Decrease ROM globally on
right &gt; left.

Question:
Differentials. Explain the tredenlenburg test. Explain and demonstrate thomas test.
Imaging: Standing pelvis AP and lateral hip xray.
Management: Non medical, medical and surgical

Knee OA
c. dx: left knee OA, genu varus, crepts, antalgic gait, FFD, decreased ROM, limb-length discrepancy
f. look at right post-TKR knee, do you think it's symptomatic? I explained th a t he had no effusion, no symptoms,
ligaments intact (should have discussed ROM/no FFD too)
d. ix: AP/LAT WB knee XR. skyline knee XR and w hat finding
e. mx:
i. w eight loss, lifestyle change, physiotherapy
ii. medical: analgesia, intra-art steroids/hyaluronic acid
iii. surgical: arthroscopic washout, high tibial osteotom y, unicondylar replacement, TKR
When to do TKR
iv. Investigation
1. Xray - w hat do u look for? fractures, loose bodies
2. MRI - w hat do u look for? menisci, OCD, ligaments, etc
v. DDX
1. Ligamentous
2. Menisceal
3. Haemarthrosis
4. Bone
vi. How m ight this injury affect patient 30 years from now?
Secondary OA
vii. How would you tre a t this patient for meniscal injury? Depends on
MRI and intraop findings.
If amenable to repair - meniscus im plant/repair.
Not amenable to repair - debridem ent, p a rtia l/to ta l meniscectomy

Knee - LCL / meniscus injury

- Stem was patient presenting w ith right knee pain after tw isting knee during soccer
- Simulated patient lying on bed, unable to stand and walk due to pain
- +ve findings o f right knee decreased ROM, lateral jo in t line tenderness, tenderness
over LCL and pain on stressing LCL. Also had positive M cM urray's w ith pain and a
CLICK when doing it

- Differentials
- Investigations and management
- W hat I'm looking fo r on XR, and on MRI
b. How w ill you confirm your diagnosis? Examiner wants arthroscopy
c. How to repair the to rn meniscus?
The surgeon repairs the meniscus using sutures (stitches) or anchors.
Debride back to sm ooth and stable margins
Remove hypertrophic synovium

Ankle
- Simulated patient, played soccer and sprained ankle
- Tenderness on le ft lateral malleolus, worse on dorsiflexion and internal rotation, antalgic gait
- Ddx: Sprained lateral ligament, TRO fractures o f fibula, metatarsals, cuboid/cuneiform s
- Xray shows undisplaced fracture o f fibula w ith swelling o f the ankle - management?:
analgesia, backslab. Asked why not full cast - due to swelling which may cause
com partm ent syndrome
- How to improve swelling - rest, ice, elevate
- Landmarks for DP and PTA
PTA approxim ately halfway along an imaginary line from tip o f medial malleolus and the point o f the heel

LL Neuro & vascular - Claudication

Left low er lim b in te rm itte n t claudication. Perform vascular exam.

How long m ust you w ait n Buerger test?

Buerger's test is used to assess the adequacy o f the arterial supply to the leg. It is perform ed in tw o stages.

W ith the patient supine, elevate both legs to an angle o f 45 degrees and hold fo r one to tw o minutes. Observe the color
o f the feet. Pallor indicates ischaemia. It occurs when the peripheral arterial pressure is inadequate to overcome the
effects o f gravity. The poorer the arterial supply, the less the angle to which the legs have to be raised fo r them to
become pale.

Then sit the patient up and ask them to hang th e ir legs down over the side o f the bed at an angle o f 90 degrees. Gravity
aids blood flo w and colour returns in the ischaemic leg. The skin at first becomes blue, as blood is deoxygenated in its
passage through the ischaemic tissue, and then red, due to reactive hyperaemia from post-hypoxic vasodilatation.

Both legs are examined simultaneously as the changes are most obvious when one leg has a normal circulation.

W hat other examination w ould you do? (CVS.)

W hat's the cause o f his peripheral arterial disease based on his history? (Smoking.)
W hat tests can you do in clinic since you can't palpate pulses? (Doppler.)
W hat would you expect his ABPI to be?
How to manage?

0.00-0.40: Severe peripheral arterial disease (PAD) sufficient to cause resting pain or gangrene
0.41-0.90: PAD sufficient to cause claudication
0.91-1.30: Normal vessels
> 1.30: Noncompressible, severely calcified vessel

0 W hat are your findings on the low er lim b pulses?

0 Show how you'd perform doppler exam.
0 Discuss how you'd perform ABPI. W hat is the normal ABPI
0 W hat investigations would you perform to help w ith surgical management?
0 How do you diagnose critical lim b ischaemia?
0 Patient needs to undergo hip replacem ent op. When w ould re-vascularisation take presedence over his op and vice
versa?

- W hat else w ould you like to do? ABPI, Doppler o f LL pulses, examine abdomen and CVS
- W hat are you looking fo r when examining the abdomen and CVS systems
- W hat is your diagnosis? Critical limb ischemia (patient c/o pain at rest when I asked before
examining + tissue loss)
- Basis o f buerger&#39;s test?

1) W hat do you think this man had surgery fo r previously? I answered

previous bypass graft due to possible traum a or aneurysm.. He asked
w hat else I w ould like to examine so I said abdomen fo r aneurysm and he
moved on.

2) He asked me w hat graft I think could have been done fo r him. I said
abdom inal-fem oral or iliac-fem oral graft. He w anted to challenge my
answer fu rth e r but the bell rang.

A o rto -B ife m o ra l F e m o ra l-P o p lite a l F e m o ro -F e rm o ra l

B ypass B ypass C ro s s o v e r

neurological claudication:
i. ix: AP/Lat spine XR, MRI spine
ii. likely etiology, spinal stenosis, PID, masses(tumour vs abscess) abutting spinal cord
iii. mx: conservative (analgesia, physiotherapy, lifestyle) vs surgical (decompression, discectomy, fusion)

- back pain radiating down LL bilaterally complains o f numbness examine LL neurologically

- Tenderness over L4/5 L5/S1 region w ith para vertebral spasm
- No o th e r clear cut Neuro signs, sensation normal
- Differential diagnosis? Spinal stenosis vs. vascular claudication
- Pathophysiology o f pain in spinal stenosis? Stenosis causing ischemia o f the cord
- Investigation? MRI spine
- Management?

c. vascular claudication:
a. Full vascular exam (Doppler included and provided)
b. Show me signs o f PVD
c. Explain how to grade severity
d. How to treat

e. Surgical options elaboration

i. etiology: CVS factors, aortoiliac ocdusion(leRiche), AAA
ii. ix: abpi, us duplex, LL angiogram, other scans to look fo r abdominal etiology
iii. mx: manage risk factors, ulcer management if present, reperfusion via endovascular angioplasty, surgical bypass

Lower back pain, le ft I5 s l parasthesias - disc prolapse. Active sir on le ft at 45 degrees,

W anted differentials and how to investigate, why s i affected in 15-sl.

2) W hat else w ould you like to examine ( saddle anaesthesia)

3) Why would you do a DRE
4) Investigations (MRI)
5) Differentials (vascular or neurogenic problem)
How w ill you tre a t
Signs th a t I got: Bilateral PVD skin changes. Hair loss, dry shiny skin. No ulcers / gangrene. Buerger's
positive. Offered to com plete by doing ABPI, BP, fundoscopy, urine analysis. Guy just nodded.
- Investigations
- Management

Varicose vein
Present your finding„D D = prim ary W , secondary ( abdominal mass postthrom botic. DVT.investigation ?duplex
scan,
w hat you w ant to see from duplex scan?= deep venous system patent or not+ incom petent perforators+
W hat to do for the pt( ttt)

Lower limb
Examine a patient w ith positive SLR and weakness in L5 myotome
i. Do a back examination
ii. M ost likely reason? PID
iii. Questioned about sciatica
iv. O ther reasons fo r sciatica besides prolapsed intervetebral disc

DVT/PE
1. a. Pt post-colectomy POD 1, noted to have right chest pain. Examine this patient
CVS/Respi Examination which were all normal
warn pt before squeezing calf, p t tensed up and you have your answer

FBC, UE, Coag profile, D-dimer, GXM

Imaging: CXR, US DVT, CTPA,

Mx:
1. supportive, HD/ICU, anticoagulation, thrombolysis, open lobectom y if massive PE
 2. W hat do you think happened if pt suddenly collapses while talking to you or in toilet? massive PE

Stem: patient POD8 fo r midline laparotomy. Now vitals normal BP, Sats 91% on face mask, sinus tachycardia
0 Examine patient: I examined respi, cardio
0 I asked to open midline wound (patient had gauze w ith prim apore tape to cover), examiner said no need, it is
clean
0 Last m inute remembered, can check calf if I'm suspecting PE, and lo and behold, patient had le ft homan's sign
0 Present findings to examiner
0 Asked w hat o th e r investigations do you w ant to do? (I said CXR, ECG, and to diagnose w ith CT PA. Forgot to say

DVT o f le ft calf)

0 W hat treatm ent to give? ( anticoagulation IV heparin, and can consider IR throm bolysis and surgical

embolectomy)
Qns

1) Present your findings - Pleuritic chest pain on deep inspiration w ith no wheeze/dullness to percussion
and patient speaking full sentences. Tender le ft calf.
2) Differential diagnosis - Pulmonary embolism from deep vein thrombosis
3) Investigation - FBC, coagulation profile, d-dimer, fibrinogen. Definitive: CT pulm onary angio
4) Mx - ABC, anticoagulate w ith IV heparin. If haemodynamically unstable, fo r embolectomy

Spine
70+ yo Man, non-smoker w ith several months history o f le ft gluteal pain
radiating down th ig h /le g /fo o t. Worse on walking 400m, both up and down hill, and after
standing for lOmin.

0 W hat are your differentials?

0 W hat radiological investigations? Xray, MRI
0 W hat management options? Non-surgical vs surgical.

Lump: Lipoma (multiple)

- Examine.
- Look at other lipomas. Scars, noted
- W hat o ther systems you w ould like to examine.
- How to investigate. US MRI
When to get MRI

- When to excise? symptom atic, large

- GA or LA. When to use GA.
- 5 was noted
a. Dx and differentials
b. W hat else w ill you examine? Axilla LN. Demonstrate examination
c. Describe how to excise lipoma?
d. Any probability th a t lipoma m ight be malignant? Why no possibility?

Anastamotic Leak (simulated patient)

i. Elderly gentleman post left hem icolectom y Day ?6 develops abdominal
pain radiating to le ft shoulder tip. ECG shows AF. Has oxygen mask, lips ?blue,
ii. Performed both abdo and cardio examination.
iii. Summarize your findings
iv. W hat investigations - CTAP w ith RECTAL contrast
blood tests FBC and CRP (raised WCC and CRP), U&Es, LFTs (low albumin), and a clotting screen. A venous blood gas
(raised lactate) w ill assess degree o f tissue perfusion. A repeat Group and Save w ill be needed fo r possible surgery or
radiological drainage.
The definitive diagnosis o f anastom otic leak is made by a CT Scan (Abdomen Pelvis) w ith Contrast.

v. Management? ABC, broad spectrum antibiotics, exploratory laprotom y,

washout, ?diverting colostomy

Cranial nerve
Neuro (Bitemporal hemianopia)
a. SP patient: not very good cause donno w hat she doing
b. Examine this patient's neurology ?loss o f vision
c. W hat and where is the likely pathology
d. W hat o th e r signs are you looking for
e. Treatm ent
; W hat are the causes o f bitem poral hemianopia?
; How would you investigate this pt?
; W hat is the pathophysiology behind bitem poral hemianopia?
- Simulated patient, p /w headache and abnormal vision
- Cranial nerves all norm al except very clear bitem poral hemianopia
- Pen torch, tuning fork, cotton w ool provided
- Asked fo r likely area where pathology occurs
- Possible causes o f lesion at optic chiasm
- W hat else I would like to examine - was looking fo r thyroid status, evidence of
Cushing's, evidence o f acromegaly, nipple discharge etc.
- Investigations - did not w ant all the individual hormones to be tested, was happy
w ith "horm one assays". MRI pituita ry - why not CT scan. Advantages vs disadvantages
o f CT scan? (he was looking for another disadvantage o f CT besides poorer soft tissue
visualisation, need fo r constrast, radiation...not sure what)
- Management - Endocrine, surgery - trans-sphenoidal vs. transfrontal

Cerebellar system
b. Examine a patient's cerebellar system
i. Positive dysdiadochokinesia and past pointing and dysmetria
ii. Positive Romberg's test
iii. W here is the likely lesion?
iv. W hat can cause the lesion?
v. W hat imaging?
vi. O ther than MRI, why would you consider a CT Brain?
vii. If patient has nausea/vom itting/ LOC, w hat would you be thinking of?
In DD asked which brain tum our,, I said glioma( Astrocytom a)what else said meningioma,, asked from which site. I said
from tectorium cerebellum.
My feeling tha t there was something else more but he was little b it satisfied...
Investigations ?? CT and MRI.. W hat advantage and disadvantage fo r each?? MRI b e tte r soft tissue visualisation...CT
=radiation exposure

Ear
o f this patient and related nerves (Patient had RTA a day back)
a. Positive findings (Decreased air conduction o f left, W eber lateralized to left)
b. Further investigations (CT, Acoustometry)
c. Show picture o f otoscopy (Hemotympanum)

- perform webers and rinnes

- did a full CN examination anyway because there was tim e, qns
- whats the finding?
- all the causes fo r conductive hearing loss - ear wax, infection, hemotympanium sec to trauma
- which CN is the most im portant to examine together? CN7. exits together at IAM
- how will u fix the otoscope, how to perform otoscopy, how w ill u position the pts ear to make
otoscopy easier
showed picture o f hemotympanium
- w hat is this?
- w hat ix to do? cT brain, audiogram, ent review.
- Physical Exam: Gross hearing decreased on le ft s id e , Bone conduction better than air conduction,
o th e r cranial nerves normal
- Asked to put signs together: Conductive hearing loss le ft ear (didn't get this)
- Examiner gives you diagnosis and move on
- w hat else w ould you do? Otoscopy
- Shows you an otoscopy picture, w hat is this? Haemotypnum
- Causes: base o f skull fracture
- Cause? Trauma
- Gives you history he was involved in a car accident 3 weeks ago now, w hat investigations would
you do next to investigate? CT Brain
- Which part o f the CT Brain are you looking out for? M iddle cranial fossa

S u b m a n d ib u la r s w e llin g
Stem: Guy presents w ith swelling and pain during eating. Swelling comes and goes.
Signs th a t I got: C ouldn't see / feel the swelling.
Asked patient to point it out. He pointed to the right.
Did bimanual palpation.
Checked parotid as well.
Checked opening o f ducts.
Asked patient to stick o u t tongue and say ah as well.
Also checked cervical lymphadenopathy. Normal patient basically
- Differentials

- Investigations

- Management

Straight forw ard sialolithiasis.

Submandibular gland swelling -- erm. the swelling was not easy to feel, it&#39;s only like 2cm, and quite
deep.

Questions asked: w hat are your differentials fo r the swelling?

W hat are the causes o f each differential? Enlarged cervical LN and submandibular gland
enlargement
Asked how to d/dx btw Submandibular gland and enlarged cervical LN
Push the tongue against roof o f m outh, the submandibular gland appears less mobile
And also by bimanual palpation
So which is your top differential and why?
W hat is the management of this swelling?

-Examiner looked puzzled but proceed w ith DDX, Ix and Mx (tricked me, keep asking w hat o th e r XR
will I ask fo r o th e r than sialography, but the answer she wanted was CT SCAN)
-If painful, need TRO malignancy
-Need full ENT examination if suspected lym phadenopathy

Hx: Patient noticed swelling below tongue fo r few days, Swelling worsen and pain on ingesting o f food. No
discharge,
No fever, No LOW, no LOA.
PE: no distinct lump felt. No LN palpable. Slight swelling over right floor o f m outh on bimanual palpation. No
discharge from opening o f w harton's duct.
No tongue deviation, able to depress mandible
Differential? Sialolithiasis, Infection, tu m o r (benign vs malignant)
Investigation: Sialogram. Examiner asked fo r something non-invasive. XR KIV U/S
Management? Conservative. Some stones can pass out or can be milked out. If not, surgery.

Parotid
Go by the Andre Tan PE and it was fine - look feel move, cervical LN, facial nerve,
examine m outh and duct, o ffe r bimanual palpation
lc m lump fe lt at the angle o f the mandible
differentials and invx

Scrotal swelling
Signs th a t I got: Left sided swelling o f scrotum.
Examination signs are basically hydrocele. But it does not transilluminate.
I also noted unilateral pitting oedema on the left leg w ith some inguinal lymphadenopathy.
So I did a quick abdo exam as well.
- Differentials (I said testicular malignancy in view o f everything but also very quickly offered
- Blood tests fo r testicular tum our
- Management fo r hydrocele
Didn't feel too good fo r this station cause he asked me again if I fe lt inguinal lymph nodes. Most
people said hydrocele. =(

Breast
Pt w ith long-standing hx o f smoking and drinking presents w ith increasing breast size. He is getting
increasingly self-conscious. Perform the relevant physical examinations.
Obese pt. Did a full breast examination, no lumps fe lt in breasts or in axilla. Did an abdo examination
targeted tow ards looking fo r signs o f chronic liver disease. Forgot to check the genitalia. Wanted to check
fo r visual fields but examiner said to assume normal.
- Questions asked:

&gt; How w ould you like to com plete your examination? Check fo r testicular atrophy
&gt; W hat is the likely diagnosis?
&gt; W hat are the causes o f gynaecomastia?
&gt; How w ould you investigate the pt?
&gt; How w ould you manage this pt
Hydrocele
w ith Testicular Mass

- le ft hydrocele w ith enlarged testis

- W hat else w ould you like to examine? Abdomen
- O ther differentials? Hernia, varicocele
- W hat investigation you&#39;d do? US Scrotum
- US shows hydrocele and enlarged testis, differentials? Testicular tum or
- US only shows hydrocele, management? Jaboulay

Pre-operative assessment

Stem: Elderly gentleman going for Lap. Cholecystectomy. Determine if he is fit fo r op.
Findings: Right pace maker. No signs o f overanticoagulation or valve replacement. Abdo has a stoma and
midline laparotom y scar. Clinically no abd pain and no complains o f RIF pain
Questions:
- Preoperative cardiac assessment, w hat you looking for in examination, history taking. W hat investigations.
Preop,op and postop management o f pacemaker.
- Should he proceed w ith op: No, as pt asymptomatic. D ifficult abdomen fo r lap chole in view o f previous
surgery, stoma. Laparoscopic requires insufflation and thus raised intraabdomen and subsequently raise
intrathoracic pressure, not suitable in this patient. Thus conservatively managed as p t asymptomatic.

A lady has been complaining o f inability to smell over the last 6 months. She also
has been having poor vision and headaches. Lately, she has been more forgetful
than usual. Please examine her neurologically and assess her higher mental
functions.
M orbidly obese female patient who looks hypothyroid. Not sure if she is a real
patient or an actress. I started by testing her orientation to time, place and person,
which she is able to answer me correctly (GCS 15).

I confirm ed w ith her th a t she has been having loss o f smell over the last 6/12. It
was bilateral. Tested fo r CN2 by asking her to count fingers. She gave me a wrong
answer fo r her right eye. (Later at the end o f my physical examination, I repeated
this test and she gave me a w rong answer on the left eye). Visual field testing
seemed normal. Otherwise her eye m ovements were fine. No nystagmus. Pupillary
reflex was present and consensual light reflex (I struggled because she was slightly
ptosised both) was present. (I forgot to test fo r accommodation). Sensation o f face
was normal bilaterally. I did not taste for muscles o f m astication. Muscles o f facial
expression were normal. Examiner stopped me when I was testing for cn8 by telling
me th a t hearing was normal. Palate was not deviated. Tongue was not deviated.
Trapezius and SCM was normal bilaterally as well.
I presented my findings as abnorm ality o f CN1 and 2 likely due to frontal brain
pathology. Examiner asked w hat else I w ould like to do/exam ine and I said I will
use a snellen's chart to test fo r eyesight. He told me Snellen chart test shows 6/18
vision both sides. So I said th a t it is abnormal and confirms my diagnosis that
something is going on w ith her frontal lobe. He asked me how come I never test for
higher m ental function (I did not read the question properly which to be fair, did
specifically say test fo r higher m ental function). M y reply was that I tested for her
general mental state (Orientated to TPP and GCS 15) instead and I agreed th a t I
should have done at least a MMSE or other assessment (actually I cant remember
how to test fo r higher mental state so even if I read the question correctly, I may
not have attem pted to do it!) Anyway, the examiner let me go on this one.
For prim ary and differential diagnosis, I said likely mass occupying lesion in the
frontal lobe because o f insidious onset. Possibilities are prim ary brain tum or
(benign and malignant) or secondary metastatic tum or(s).

Mini-Mental State Examination (MMSE)

Patient's N am e:____________________________________________ Date:

In stru ctio n s: Ask the questions in the ord e r listed. Score one p o in t fo r each correct
response w ithin each question o r activity.

Maximum Patient's
Questions
Score Score

5 ‘What is the year? Season? Dato? Day of the week? Month?'

5 'Where are we now: State? County? Town/city? Hospital? Floor?*
The examiner names three unrelated objects clearly and slowly, then
asks the patient to name a l throe ol them. The patient's response is
3
used for scoring. The examiner repeats them unti patient learns all of
them, if possible. Number of trials:
*1 would kke you to count backward from 100 by sevens.’ (93.86, 79,
5 72,65. ...) Stop after five answers.
Alternative: 'Spell W O RLD backwards.’ (D-L-R-O-W )
'Earlier 1told you the names of three thugs. Can you tell me what those
3 were?*
Show the patient two simple objects, such as a wristwatch and a penci.
2
and ask the patient to name them.
1 •Ropeat the phrase: No ifs. ands, or buts.”
'Take the paper in your right hand, fold it in half, and put it on the floor.’
3
(The examiner gives the patient a piece of blank paper.)
’ Please read this and do what it says.* (Written instruction is ‘Close
1
your eyes.')
'Make up and write a sentence about anything.* (This sentence must
1
contain a noun and a verb.)
'Please copy this picture.' (The examiner gives the patient a blank
piece ol paper and asks him/her to draw the symbol below. All 10
angles must be present and two must intersect.)

OU
1

30 TO TA L
(Adapted to m Rovner & Folslein. 1987)

1
Soiree wwwm octorv« i*ow a aduAg*c/tod«/oagntr>«'M M SE p t f FV0 V<<J9 <J t y NM C Qf .0K M -4 10
Picture 1 - M in i m en ta l state e x a m in a tio n (M M S E )

W h a t is th e a p p r o x im a te tim e ?
W h a t d a y o f th e w e e k is it?
T e m p o r a l o r ie n ta tio n
W h a t is th e d a te to d a y ?
(5 p o in ts )
W h a t is th e m o n th ?
W h a t is th e year?

W h e r e a rc \\v n o w ?
W h a t is th is p lace?
S p a tia l o r ie n ta tio n
In w h a t d is tric t a re w e o r w h a t is th e ad d re s s h ere?
( 5 p o in ts )
In w h ic h t o w n are w e ?

In w h ic h state a re w e ?
R egistraii<>n ( 3 p<»in is) R e p e a t th e f o llo w in g w o r d s : C A R , Y A S H , B R I C K
A t t e n t io n a n d c a lc u la tio n
S u b tra ct: 1 0 0 -7 = 9 3 -7 = 8 6 -7 = 7 9 -7 = 7 2 -7 = 6 5
( 5 p o in ts )
R e m o te m em o ry
( i m y o u r e m e m b e r th e 3 w o r d s y o u h a ve just said?
(3 p o in ts )
N a m i n g 2 o b je c ts
W a tc h an d p e n
( 2 p o in ts )
R liP K A T
"N O II-S. A N 1 )S O R B U I S "
(1 p > in t)
S ta g e c o m m a n d
" T a k e this p ie c e o f p a p e r w ith y o u r rig h t h a n d , f o ld it in h a lf, an d put it o n the f l o o r ”
( 3 p » in t s )
W r it in g a c o m p le t e s e n te n c e
W r it e a s en ten ce th a t m ak es sense
(1 p > in t)
R e a d in g and o b e y
C lo s e y o u r e y e s
(1 p o in t)
C o p y t w o p e n ta g o n s w it h an in te r s e c tio n

C o p y the d ia g ra m
(1 p o in t)

Fontc: Brucki S M I), N itn n i R , Caram clli P, B crtolucci P H F , O k a m o to IH . Sugestocs pnra o uso d o m ini-exam c d o cstado mental no
Brasil. A r q N curopsiquiatr. 2003; 61(3B):777-81.
P r o c e d u r a l.

OT Listing (repeat entirely)

A. COPD w ith strangulated hernia
B. divert abscess w ith penicillin and iodine allergy.
C. Mrsa dm fo ot fo r BKA.

For the COPD, Pacemaker patient, he

asked me w hat surgical factors I should consider? I talked about the use of
bipolar diathermy. Asked me who should be involved in the pre-operative
planning fo r this patient. I said cardiologist, pacemaker technician to set the
correct mode. He did not seem to be happy. He prom pted me towards saying
consider spinal anesthesia. For type 1 DM guy, asked about how to m onitor and
manage his hypo-count in the wards pre-operatively. He wanted to hear Insulin
sliding scale before he was satisfied.

Both o f us did it in th a t order. Hernia first because emergency and best done w ith o u t prior
contam ination. Offered dm fo o t last case by doing spinal or RA.
Then examiner asked w hat pre op orders u w ant fo r each case. le. w hat anaesthesia, what
cleaning solution (choose between iodine and chlorhex) and w here to place diatherm y pads fo r each case.

a. If he has iodine allergy, w hat do you use? Use chlorhexidine

b. MRSA always last, speak extensively on how you would prep fo r patients w ith DM, chronic COPD

- Standard question w ith the same 3 cases (Strangulated hernia w ith severe COPD and
pacemaker, Hartmanns fo r diverticulitis w ith allergy to iodine, infected fo o t ulcer for
BKA w ith IDDM and MRSA from wound

- Ordered it in the above order

- Asked questions about why th a t particular order - said strangulated hernia most tim e
critical so should go first, then MRSA should go last
- Asked about diatherm y/anaesthetic/cleansing solution choice
- Asked about diatherm y complications and pad placement fo r all

3) Im portant things to take note fo r each pt

- strangulated hernia: in view o f severe COPD, should attem pt RA rather than GA. in view o f pacemaker,
should use bipolar
- w hat prophylactic antibiotics? cefazolin
- pencillin and iodine allergy: in view o f iodine allergy, can use alcohol/chlorhexidine based antiseptic, in
view o f pencillin allergy, can use clindamycin or vancomycin

- if you are not sure? consult the hospital bacteriogram and the infectious disease physicians

- BKA: IDDM, need sliding scale, warfarin, need to make sure INR&lt;1.5 and LMWH stopped in the
m orning. MRSA, vancomycin fo r prophylactic abx
- another abx: bactrim, clindamycin?
- if you are not sure, w hat can you do? refer to ID physician fo r antibiotics guidance.
- have you heard o f "tigerm ycin"? (some T drug which i didnt recognise)

- why the order above?

- how long w ill you expect each operation to last? how extensive w ill you clean and drape the pt?
- w hat to w orry about fo r copd? (may not be suitable for ga)
- qns on m onopolar and bipolar diatherm y
- how to manage the pacemaker
- w hat to give if has iodine allergy
- how to manage dm and af preop (scsi, stop clexane 12hrs before)
- when to give spinal or epidural anaesthesia led on to mannequin on the bed
- where w ill you place the diatherm y pad fo r m onopolar and bipolar (trick qn fo r the bipolar bit),
why that spot?
- if you have to use monopolar fo r the pacemaker pt, where w ill you place the pad?

Naevus excision biopsy and closure (repeat entirely)

- Instructed to perform ex bx and close wound w ith synthetic, non-absorbable sutures in interrupted
fashion.
- Introduced myself and asked w hether pt was ok w ith me perform ing procedure instead o f consultant
- Consent re-taken and checked against w ritten consent (have to check against pt's w rist tag)
- You have to choose the instrum ents you w ant by placing them into sterile field (have to choose between
prolene and vicryl sutures)
- Perform an elliptical incision and excise as per usual
LA dose, w ith or w ith o u t adrenaline and side effects after.

- Take big bites w hile closing to prevent tearing through foam

a. re-check consent, re-check signature by patient
b. no point excising too wide. I had alot o f problems closing the "w ound" as the sponge was very tough
c. post-procedure counselling
a. Why mattress suture
b. Apply m onofilam ent, non absorbable suture
c. W ill scar be there
d. W ill it cause pain
Asked about lidocaine vs Marcaine, doses, when to use.

1. Wound closure
a. Show LA injection and how much to give
b. Explain choice o f suture and type o f closure
c. Make sure stitch well they w ill use forceps to try to pry open your knots
d. Number o f knots im portant as well
e. Talk about tetanus and antibiotics requirements
Questions about type o f anaesthesia to give& w hat max dose?

0 Patient asked questions:

No need a n tib iotic
w ill it be painful,
w hen w ill I know the results, could it be m alignant,

w hen can I rem ove the stitches,

dressing
w hen to come back to ED

can bathe after procedure,

- Explained situation to patient, patient agreeable fo r me to excise

- Choose instrum ents you need, suture you w ant
-Tested anesthesia
- Elliptical excision o f naevus (big dot o f ink on a foam pad), sent fo r histo
- Closed w ith Prolene
- Explain dressing changes, STO, histo results w ill take a while
- When I asked her if she had any questions, patient had specific questions about
histo - w orried about skin Ca as m other had it. Also asked w hat else she should look
out for - to ld her to watch o u t fo r evidence o f infection

IDC (Repeat) - CBD

a. 14Fr catheter
b. commonest causes o f anuria - blocked catheter
c. commonest causes o f blocked catheter - gel
d. if obstruction - flush catheter and aspirate
e. flushed and aspirated, still no urine shown tem perature and vitals chart - consider hypovol shock
- Insert IDC.
do not forget to assess the balloon and expiration date)
- No urine output. W hat w ould you do? flush, aspiration
- Still no urine. Why???
- US- bladder not distended. Still no urime. Why???
- US shows IDC is in the bladder. Still no urine. Why??? still no urine ( bedside US ( DO NOT INFLATE BALLOON)
- Hint given: YOUNG gentleman w ith suprapubic mass.

- IDC insertion.

- w hat w ill you do if there is no urine -- aspirate the urine. If still no urine? flush and aspirate.
W hat is your logic fo r flushing and aspirating?
- If still no urine and no good flow -- w hat w ill you do? take out the IDC
Why? W hat are your differentials? False passage, catheter tip in urethra instead o f bladder
- W hat else?
Not a true palpable bladder -- ie, a suprapubic mass
- W hat are the suprapubic mass d/dx? Pt was male. Malignancy from bladder, prostate, CLR CA,
pelvic collections, abscesses, mesenteric cysts.
Materials: Patient's vitals

0 To insert IDC fo r patient, prepare your own materials

0 IDC unable to be inserted fully
0 W hat are the possible reasons? (I said BPH, uretral strictures, bladder stones (quite unlikely and illogical), and
suboptim al Positioning)
0 W hat to do fo r BPH: use a larger Fr IDC

- IDC set, 14F IDC, cotton balls, gauze, chlorhex, water, lignocaine, syringe, drapes,
gloves. No urine bag to connect.
- He initially gave Aquagel in a tube, I asked him fo r some in a syringe instead and he
obliged by squirting Aquagel into my em pty syringe.
- 1also asked fo r a sponge holder to hold my cotton balls, he rolled his eyes and gave
me plastic forceps. Oh well.

- A fter testing IDC, cleaning, draping and jelly-ing, IDC could only be inserted up to
halfway. I w asn't sure if it was mannequin issues or if it was really supposed to be
blocked, so I was pulling the penis up and down and gently adjusting the IDC
- He eventually smirked at me and asked if I was having problems
- Likely cause o f obstruction at this level - BPH
- If BPH, how would I try to hold penis so IDC may be able to go in? Initially said hold
penis downwards (pointing to feet), but he said nope, hold it pointing up (to ceiling)
- If unable to insert, w hat w ould I do? A tte m p t larger IDC. Why? Stiffer, easier to push
through obstruction.
- O ther possible causes o f obstruction
- risk and complication o f cbd insertion

Knot tyin g rubber bands (silk), deep cavity tie (vicryl), under-running o f suture (PDS)
https://w w w .youtube.com /w atch?v=X bkkD C rH 8X Y
Skills: Given silk, vicryl, prolene. Hand-tie 2 rubber bands together w ith braided non-absorbable. Hand
tie deep hook in cylinder w ith braided absorbable. Overrun bleeder w ith figure of 8 using
m onofilam ent non-absorbable and instrum ent tie. Wear gloves and th ro w away your sharps. W hat
knot did you use fo r your rubber bands? Why did you use a square knot?
W hat other knots could you use? - d iff o f square knot (AKA reef knot), surgeon knot,
h ttp s ://w w w .youtube. com/watch?v=cuNwp_Pi33s
W hat are advantages o f braided sutures? W hat is vicryl made of? How long does vicryl last?

W hat&#39;s the difficulty w ith deep tying and how to overcome it?
i. M aterial o f vicryl - polyglactin 910
ii. Tensile strength o f vicryl. How long before it is absorbed? 56-70 days
iii. Advantage o f braided suture
iv. Surgeons knot vs reef knot
v. W hat are the problems w ith deep cavity tie and how to avoid?
vi. How w ould you broadly classify sutures? m onofil/braided, absorbable/nonabsorbable
vii. w hat other m onofilam ent absorbable suture do u know of?
Monocryl, PDS

Follow instructions: you w ill have to find the best type o f suture th a t fits the stem&#39;s description (ie make a handtie
w ith non absorbable m onofilam ent synthetic suture, then you go and find Prolene)

a. Whats the difference w ith surgeons knot and square knot

b. In deep cavities, w hat is one thing you have to be careful o f when tying? Prevent shearing of
structure th a t you are tying

1- REEF KNOT around rubber bands ( you have to choose suitable suture according to instructions o f the
e xa m in e r) e.g non-absorbable,natural and braided » silk

2-DEEP KNOT AROUND A HOOK (be careful not to lift the hook from its place !!) , syn th e tic, absorbable
and braided » vicryl

3- hemostatic stitch ( figure o f 8 ) over bleeding point in foam pad ,

Using m o n o fila m e n t, synthetic and non-absorbable » > proline
Dont forget gloves, safely handling sharps and sharps pin !!!!!!
You will be asked anything regarding sutures!!

Advantage o f braided suture vs m onofilam ent.

Vicryl - w hat is it, how long does it last.

- hand tie o f vessels

- surgeons knot o f deep visceral structures
- underm ining o f bleeding vessel w ith figure o f &#39;8&#39; suture

Questions: type o f suture: they gave a 6 d iffe re n t sutures w ith o u t the packaging and asked the candidate to
choose which suture to use fo r each o f the above knots
they also asked re the characteristics o f each suture and how you identify them , duration o f tensile strength

- hand tie: silk (black, braided, non absorbable)

- surgeons knot o f deep visceral: prolene (blue, m onofilam ent, non adsorbable, lots o f memory)
- underm ining vessels: vicryl (braided, adsorbable, last 4-6 weeks)

Incision and drainage o f abscess on upper thigh

i. Check consent, indication, explain procedure. Pt already draped. Just

need to give LA. Tell examiner w ould like to w ait 10-15mins before
proceeding to allow LA to take effect. Proceed. Test LA. Make incision
over abscess along langers line. Give post procedural advice to patient
w hile you are doing this. Tell patient wound w o n t be closed and why.
Dressing frequency, TCU plans, trace results on arrival. POC, when to
come back to ED (s/s o f wound infection). Patient preoccupied w ith pain.
Reassure tha t giving analgesia post procedure. To expect pain when LA
wears off. Dispose sharps.

iii. Collect sample w ith swab

iv. W here w ould you send this to? Cytology, M icrobiology
v. W ould you close the wound? W hy not?
vi. Patient concerned scar, post-op pain
vii. W hat type o f dressing w ill you use? (Examiner asked fo r exact brand names)
viii. If very exudative w hat dressing to use?
ix. How to cover on to p - w aterproof dressing

a. Principles o f lines o f langers (where to incise)

Langer lines o f skin tension are topological lines drawn on a map o f the human body,
correspond to the natural orientation o f collagen fibers in the dermis, and
are generally parallel to orientation o f underlying muscle fibers.

b. Do we give LA? Is LA useful in such a situation- local tissue acidosis neutralizes local anesthetics.
c. Make sure to irrigate and currete
d. Pack and explain to patient give ABX etc

a. W hat sort o f dressing w ill you do

b. W ill you give antibiotics
c. W ill scar be there

wash your hands, introduce yo u rse lf, take permission , proper exposure and repositioning
ask about allergy to L.A ?
Ask fo r the consent (hidden by the e xa m in e r)?
Equipments prepared in sterile field .
Ask fo r assistant ( the examiner volunteered h im s e lf) ,
warn the patient before needle b ric k ,
infiltrate L.A p ro p e rly ,
test fo r numbness before using scalpel !!
Talk to the patient throughout the procedure !
You have to fix the blade properly using he m o sta t,
take swab
ensure com plete drainage,packing and dressing .
Post -procedure instructions and docum entation .Don't forget SHARPS PIN

Qs: 1-causative organisms ?

2-line o f incision ?
3- complications
Debridem ent o f a d irty w ound :
W hat anesthetic w ould you use and whats the dose
how w ould you close
w hat would you do if radial artery cut,
w hat to do if median nerve damaged
w hat precautions to take (made me recite com plete tetanus im m unization schedule),
w hat antibiotic to give,
w hat post-procedural advice.

FNAC
w hat local anesthetic, how much
You w ill be asked to give local anesthesia (check the expiry date)
Don't forget to label the slides before procedure
how to prepare slides,
when w ill report be available
D idn't make me do the fnac form ally, just wanted an overall method and principles o f slide preparation and
which needle to use,
how many times should needle be put into the lesion (pass it back and forth through the lesion 5-6 times), which
labs to send to, etc. easy station phew.

Perform FNAC on a old lady w ith previously excised melanoma on right leg, now presenting w ith new lum p on right
thigh.
Perform FNAC, put on slides, smear and spray. Left overs for cytospin bottle,
labelling the histology pot.

Qn 12: model given., patient w ith RTA... perform

1) Ways o f managing airway (chin lift, jaw thrust, guidel airway, LMA, Intubation) had to perform
chin lift, jaw thrust
2) U have no facility o f intubation., now w hat ( cricothy)
3) Secure patients c-spine... u have to make the model wear a collar
4) Use bag-mask and ventilate p t ( they were looking fo r how you applied it to models face and
w hether lungs were rising on inflation)
5) How w ill you check patients breathing?
6) Investigations

2. Resuscitation + surgical airway options

- Basically to resus the patient - airway (chin lift, oro-pharyngeal airway), breathing (bag-
valve mask), C-collar (Asked how to size collar), call anaesthetist early
- Basically started asking about options o f surgical airways: cricothyroidotom y (asked
landmarks), surgical/dilatation thyroidectom y (asked how to perform , where to site the
tube (said 3rd & 4th tracheal rings), asked about w hat landmarks to use (said halfway
between cricoid cartilage and sternal notch - he gave me a strange look)
h ttp s ://w w w .youtube. com/watch?v=dvWy9NXiZZI

IV cannulation

Stem: RTA victim . Presents at AnE. BP hypotensive, GCS 15, tachycardic. Please start IV infusion fo r him.

- Prepared equipment.
- Checked patient identity etc.
- IV super easy to set, put on the prepared infusion. Infusion flowed well.
- W rite flu id orders on paper IMR
- How w ould I manage this patient ( I said everything but analgesia. He kept asking me w hat
more w ould I do but I forgot analgesia omg... bell rang)

Viva questions
0 W hat w ould you send the blood for? (FBC, U&amp;Es, Xmatch, Coag, Venous Gas)
0 W hat w ould your next fluid be? (I&#39;d like to see the obs chart please)
0 [Obs chart shows p t to be a fluid non-responder)
0 W hat w ould your next fluid prescription be? (2L warmed Hartmanns stat)
0 Please prescribe this... (given prescription chart - be sure to fill in all the
details, including allergies, height and weight)
0 W hat adjuncts to the prim ary survey do you know of?
ABG, RR
End tidal C02 m onitoring
ECG
NG, CBD
Cervical, chest, pelvic xr
FAST or DPL

0 W ould you take this patient to CT? (No! Fluid non-responder w ith abdo pain,
therefore mandates theatre fo r laparotomy)

Chest tub e insertion

httPs://w w w .voutube.com /w atch?v=EclD kJH R q8c
https://w w w .youtube.com /w atch?v=qR 3VcueqBgc
Given xray o f pneumothorax. Please point out the pneumothorax. (The xray was damn blur... hardly
could make o u t the pneumothorax)
- Triangle o f safety fo r insertion.
- W hat size chest tube w ill you insert

Sp ecific C onsiderations
How lo choose a chest tube size?

□ Pneumothorax — A 16 to 24 Fr chest tube.

□ T raum atic pneumothorax — 28 to 40 Fr chest tube

■ drainage o f blo o d in addition to a ir m ay be ncccssary.
□ M align an t effusion — A 20 t o 24 Fr chest tube

□ Empyema — 28 to 36 Fr chest tube

■ M ay need m ore than one tube for loculated areas
□ Hemothorax — 32 to 40 Fr chcst
■ L-arger caliber helps prevent occlusion

- Inserted chest tube w ith running comm entary. Attached to underwater seal
- 1said I would check its oscillating, under the patient and do a purse string. He said go ahead.
- Complications o f chest tube insertion
Insert chest drain. W hat size o f tube?
Complications - short and long term ? If w ater not bubbling ?causes
(CXR)? Nerve supply to parietal and visceral pleura,
how to insert tracheostomy, layers, on cadaver.
Parietal Pleura

The parietal pleura is sensitive to pressure, pain, and tem perature. It produces a well localised pain, and is innervated
by the phrenic and intercostal nerves.

The blood supply is derived from the intercostal arteries.

Visceral Pleura

The visceral pleura is not sensitive to pain, tem perature or touch. Its sensory fibres only detect stretch. It also receives
autonomic innervation from the pulmonary plexus (a netw ork o f nerves derived from the sympathetic trunk and vagus
nerve).

Arterial supply is via the bronchial circulation (internal thoracic arteries), which also supplies the parenchyma o f the
lungs.

blood culture taking.

Remember ask fo r consent and wash hands before. Fill up the blood forms & bottle first!

1. handwashing, gowning, degowning (w ill check under UV light!!)

Scrubbing and gowning- gel initially on hand, and examiner acts as scrub nurse. First scrub o f day.
Cap and mask not needed, really assessing scrubbing and no touch technique when gowning, practice this!
Also asked to show how one de-gowns, and alcohol b4 leaving.
OSCE stations from the Chennai (india) exam (december session)

1) Counselling and consenting a patient for an oesophagoscopy. Needs smooth talk

and the patient will interrupt with questions like, will you give me an anaesthesia?
how painful is it? etc. Do mention the complications to him while you talk him through
it.

2) Thyroid examination

3) Knee examination

4) CVS exam: murmur in a kid (this was a real patient who did have a murmur)

5) Reading station with case notes, a pen etc informing and discussing with
consultant an young adult patient who has had a RTA with fracture of the tibia and
fibula. Don't forget C-spine stabilization first (I forgot that!!)

6) History taking in Impotence

7) History taking in a case of headache. Turned out the patient had a SDH.
Questions towards the end were," what are the signs and symptoms in a patient with
an SDH?"

8) Inguinal hernia examination. He also asked me about skin preparation before

surgery.

9) Skill station: suturing a lacerated wound.

10) Microbiology: Gas gangrene, necrotising fascitis, causes of post operative

diarrhoea in a hospital.

11) The physiology of adrenal gland and signs/symptoms of Cushing's syndrome

12) A station on Tuberculosis. Tuberculoid granuloma picture was shown. Culture/

how to grow the organism was asked.
(this station came one day previously. I appeared on the second day).

13) Make an operative list and prioritize the patient. (One was a diabetic so I put him
first on the list.) Cautery with a patient plate electrode was shown and questions
were asked about monopolar and bipolar cautery.

14)a 3D model of heart; blood supply to the brain; cervical vertebra; identify the
azygous vein, brachiocephalic trunk and the sympathetic chain on a picture of a
cadaver.

15) Klumpkes paralysis and a volley of questions on upper limb anatomy. Examiner
had a whole skeleton in front of him; muscle attachments, nerve supply of muscles
and root value of nerves (i remember suprascapular)

16) pH and buffer system of blood.

M RCS K L 2 0 1 4

A n a t o m y S ta tio n s
1) T h orax & N eck
• B ra n ch es o f a o r ta a rch
• A r t e r ia l s u p p ly / V e n o u s d r a in a g e / ly m p h d r a in a g e o f t h y r o id
• N e r v e s u p p ly t o t h y r o id
• V a g u s / P h r e n ic n e r v e
2 ) B a se o f Skull
• O p tic ca n al
• F o ra m e n R o tu n d u m / O v a le / S p in o s u m
• B o u n d a r y o f M id d le cra n ia l fo s s a
• S p re a d o f in fe c tio n t h r o u g h m id d le e a r c a v it y
• C a v e rn o u s sinus
• S p re a d o f in fe c tio n fr o m fa c e
3 ) F o o t/ A n k le
• N a m e b o n e s o f fo o t
• D e lto id lig a m e n t
• W h ic h p o s it io n is t h e a n k le m o s t sta b le
• P u t tib ia a n d fib u la t o g e t h e r
• T en d o n s o f fo o t
• A r t e r ia l s u p p ly o f fo o t
• I n v e r s i o n - w h a t m u s c le s / n e rv e
• A c tio n s o f a n k le jo in t

P a t h o lo g y
1 ) Skin le s io n - M e la n o m a
• R isk fa c to rs
• W h a t m a c r o s c o p ic / m ic r o s c o p ic fe a tu re s o f m a lig n a n t le s io n
• H is t o lo g y vs. C y t o lo g y
• A x illa r y v e in t h r o m b o s is - m a n a g e m e n t
2) A n t e r io r N e c k L u m p - T B ly m p h o m a
• T y p e o f ly m p h o m a
• W h a t in fo r m a t io n n e e d e d o n r e q u e s t fo r m
• G ra n u lo m a - g iv e 3 e x a m p le s
• G ia n t c e ll o f L a n g h a n s - w h a t a re th e y ?
• N a m e o n e o th e r M y c o b a c te r iu m
• C u ltu re m e d iu m fo r M y c o b a c te r iu m
• R a p id d e t e c tio n o f M y c o b a c te r iu m

C ritic a l C are
1 ) B u rn s M a n a g e m e n t
• In itia l m a n a g e m e n t - A B C D E
• C a lcu la tio n o f T B S A
• P a rk la n d fo r m u la a n d t y p e o f flu id g iv e n
• In t e r p r e t C XR o f A R D S
• W h a t is A R D S
• M an agem en t o f ARDS
 • C o m p lic a tio n s o f A R D S
2) O p io id O verd ose
• H o w is C 0 2 t r a n s p o r t e d in b lo o d
• W r it e fo r m u la fo r C 0 2 t r a n s p o r t in b lo o d a n d c a rb o n ic a n h y d ra s e w h ic h
p a r t o f fo r m u la d o e s it a c t o n
• In t e r p r e t A B G - w h a t t y p e o f R e s p ir a t o r y fa ilu re
• W h e r e d o e s O p io id a c t o n
• R e s p ir a t o r y d r iv e - c h e m o r e c e p to r s
3 ) R T A - l i v e r la c e r a tio n / P n e u m o th o r a x
• In itia l m a n a g e m e n t a t A & E - A B C D E
• T y p e o f a ir w a y m a n a g e m e n t
• H o w y o u w o u ld m a n a g e m e n t "C ir c u la tio n "
• T r a u m a s e r ie s X R s
• In t e r p r e t C XR - su b cu ta n eo u s e m p h y s e m a
• In t e r p r e t C T A P - l i v e r la c e r a tio n
• H o w w o u ld y o u m a n a g e liv e r la c e r a tio n

S k ills / P rin c ip le s
1 ) C lo s in g w o u n d
• P r e p a r e y o u r o w n t r a y - s u tu re / in s tru m e n t
• A n s w e r q n s fr o m p a tie n t - p a in fu l? A n tib io tic s ? STO ? Scar?
• T y p e o f L A - m a x im a l s a fe d o s e
2 ) R e -a r ra n g e O T lis t
• W a r fa r in m a n a g e m e n t
• DM m anagem ent
• CO PD m a n a g e m e n t ( p r e - o p )
• P e n ic illin a lle r g y - w h a t p r o p h y la c tic a n tib io tic s fo r la p a r o t o m y
• S h o w o n m a n n e q u in t h e e x te n t o f c le a n in g f o r e a ch o p - la p a ro to m y ,
h ern ia , B K A
• T y p e o f d ia t h e r m y fo r e a ch p a tie n t - p a c e m a k e r
• S h o w o n m a n n e q u in t h e lo c a tio n o f e le c tr o d e p la te p la c e m e n t

E x a m in a tio n
1 ) C a r d io v a s c u la r E x a m in a tio n
2 ) K n e e E x a m in a tio n
3 ) C ra n ia l N e r v e E x a m in a tio n
4 ) H e r n ia E x a m in a tio n

H is to r y
1 ) A b d o m in a l P a in
2 ) A s s e s s m e n ta l c a p a c ity fo r c o n s e n t-ta k in g

C o m m u n ic a tio n s
1 ) P h o n e c o n s u lt - r e q u e s t fo r p o s t- o p ICU b e d
2] T a lk to fa m ily r e g a r d in g a scites

K E E P C A L M & C A R R Y O N ! A ll th e B est!
 JANUARY'16 KUALA LUMPUR
2ND GROUP

A n a to m y
1. Low er limb
STEM: Young man fell off the horse, trapped under for hours.
Questions:
> L iv e p a tie n t ly in g th e re .
> Surface mark lateral malleolus, what bone is it from
> Surface m a rk E h L
> Show the movement of TA+TP, PL+PB, gastrocnem ius+soleus
> Attachments of peroneus longus, brevis, tertius
> Causes of foot drop
> Myotomes o f LL + reflexes (show how your elicit knee jerk, ankle jerk)
> S how S i d e rm a to m e
> Name peripheral nerves of LL
> Name compartments of the LL and nerve supply
> Muscles of posterior compartment of LL
> Patient complaining of intense pain of LL given stem, what do you suspect
[compartment syndrome)

2. T h orax and A bdom en

Questions:
> This is a cadaveric station.
> Point to the pulmonary trunk, ascending aorta
> Branches of the ascending aorta
> Right ventricle: Name the structures (tricuspid valve, chordae tendinae,
papillary muscles], their function
> Origin of sympathetic chain (T1-L2)
> What joins the sympathetic chain to the spinal nerves (grey rami
commitantes)
> Identify spleen, blood supply, what may be injured during a splenectomy
> Anatomy of the splenic artery and what it supplies
> Identify gallbladder, surface marking
> Why would a patient with RUQ pain also have shoulder tip pain? Explain
referred pain.

3. H ead an d N eck
STEM: Man post radical neck dissection for som e head and neck tumour
Questions:
> This is a cadaveric station.
> Boundaries of the posterior triangle
> Identify accessory nerve, what does it supply, what happens when it is
paralyzed, how to test these muscles
> Id e n tify th e o m o h y o id
> Identify great auricular nerve, what does it supply
> Identify digastric, hypoglossal nerve
> What are the extrinsic muscles of the tongue, what is the nerve supply,
what muscle responsible for retraction of the tongue

Page | 1
 > LN mets: what are the possible primaries
> Histo slide of LN: malignant melanoma mets

Pathology
1. RHP and IE
STEM: 61yo lady, AVR secondary to AS, PMHx of joint pains during childhood,
worsening cardiac function

Questions:
> What do you suspect the patient has?
> What is RHD
> What caused the AS?
1 hematological test to monitor progression of RHD: RSR
> After AVR. why is there a need to anti-coagulate?
> What is the most commonly used anti-coagulant (warfarin)
> What is the MOA of warfarin? What test would you do to monitor?
> Lady now presenting with fever. What is the main concern (IE)
> Causative organism s of IE, pathophysiology of IE, why is it hard to treat?
> Persistent IE despite treatment, what surgical management is definitive?
> Worsening CCF, need transplant, what kind of matching m ost important?
(HLA)
> How do im m unosuppressants work? MOA. What side effects?
(Malignancy, Infection)

2. M a lig n a n t m elanom a (re p e a t)

Questions:
5^ How to differentiate melanoma from SCC
> What are poor prognostic factors?
> W h a t genii is associated w ith m a lig n a n t m elanom a
> What skin condition is associated with melanoma?
> What are the other risk factors of malignant melanoma?
> Lesion excised Breslow thickness 1.5mm, margins 0.5cm what to do?
> General principles of surgery. If go for re-excision, what to do to ensure
adequate margins this time round? (Mohs micrographic surgery, frozen
section)
> Post axillary clearance complained of arm pain and swelling (axillary vein
throm bosis)
> Risk factors for throm bosis (Virchow’s triad). For this case, malignancy
predisposes to a pro-thrombotic state.

Critical Care
1. Septic sh ock (re p e a l)
STEM: Some guy POD 4 post anterior resection, vitals charts, some investigations
Febrile, BP low TW >16 RR 28 Tachycardic
RP, ABG, FBC results given,

Questions:

Page | 2
 > What do you think is happening + differentials for POD4 fever. Give the
whole list.
> What is septic shock?
> What is the evidence (show you know SI RS criteria)?
> Initial m anagem ent for septic shock
> Interpret the U/ E/Cr, ABG, FBC
2. Spinal anesthesia and hypotension
STEM: Post-TKR POD 0 /1 Spinal anesthesia, has hypotension
Vitals chart provided with I/O charts

Questions:
> What is shock?
>■ Causes of shock in this patient and why
> Shown several timelines, asked to interpret the vitals - basically
hypotensive
> What bedside intervention can you do - insert urinary catheter to
monitor urine output
> How to give fluids, what method to decide
> Colloids vs crystalloids
> Frequency of monitoring (w as Q4h) - insufficient
> Asked BP = COxSVR, how to improve BP
> Asked about inotropic su p p o rt How does each drug act?

3, C V P in s e r t io n a n d p n e u m o th o r a x
STEM: CVP insertion by senior reg, post-procedure complained of SOB, CXR done
Questions:
> H o w to assess b re a th in g ?
> Investigations to do when SOB
> Principle of reading an XR? E.g. identify correct patient, projection, etc.
> How do you read a CXR? Is the CXR adequate (no costophrenic angles
visualized in given CXR), what do you see (L sided pneumothorax)
> What kinds of PTX do you know
> CVP line insertion - landmarks for IJV cannulation, alternative method
(subclavian, US guided)
> Complications of CVP insertion other than PTX
> How to prevent line infection, risk factors for line infection
Communications
1. Anxious m oth er (rep e a t)
STEM: 9yo boy fell down in playground complained of L flank pain, BIB dad who
w as "unsteady on his feet, em otional”. BP borderline tachycardic, pale, Scans
suggestive of splenic injury for emergency op, consent taken from dad. Prep
station prior, given medical records showing pt presenting to A&E, review by
surgical registrar/consultant, decision for op, consent taken from dad, aiming for
splenic repair, KIV partial splenectomy. Aim to conserve spleen. You are the new
A&E doctor who started your shift. Need to go talk to patient's mother. Patient is
now in OT. Anxious mother com es in, address her concerns. (They are divorced,
she thinks he is drinking, pre- and post-operative management if splenectomy.
Other questions include what if the whole spleen is removed? Talk a little about
antibiotics prophylaxis, immunizations)

Page | 3
 2. Request fo r ITU bed and p re-o p erative m anagem ent (re p e a t)
STEM: 73yo lady admitted with vague sym ptoms of feeling unwell, PMHx COPD.
Later c/o abdo pain, 0 /E generalized peritonitis, desat, tachycardic. IxT lR F , AKI,
hypoK, CXR/AXR before onset of pain NAD. (Sell your story, asked for pre-op
optimization, remember to write down in case of read back requested, offer to
check with consultant, DON'T LIE!)
Physical examination
1. Hernia
2. Knee exam ination
3 . LL (Vascular/Neuro)
4. DVT/PE - Do ap p rop riate exam ination, L ca lf ten d er ++

History taking
1. Low m ood post-gastrectom y
STEM: Some guy POD 6 post-gastrectomy good functional recovery noted to be
low mood. Nurses concerned he is depressed, take a Hx. Rmb to screen mental
state!! Asked about management.

2. Acute pancreatitis
STEM: 45yo lady with acute onset abdo pain after alcoholic binge, radiates to
back, sharp pain. Also had Hx of RHC pain couple of years ago, saw GP given PPI
with good relief. Asked about m ost likely diagnosis (pancreatitis 2' to excess
alcohol intake), other differentials, tests to confirm, what other tests to do
(bloods, ultrasound HBS), management plan.

I’rocedures
1. Excision o f likely benign n aev u s
Consent already taken. LA given. Do the procedure.
Provide lollowup instructions for patient.

2. OT listing (repeat)
The 3 cases were (a) MRSA patient with DM coming for L) BKA (b) strangulated
hernia with COPD (c) diverticular abscess requiring Hartman's procedure allergy
to iodine prep. Asked about what type of skin cleansing prep. Which case would
you list first and why?

Page | 4
 C o m m u n ic a tio n -
1- Telephone conversation with consultant.
POD1 patient post sigmoid colectomy for bowel adeno CA. Seen by
the FY1 . now has poor urinary output.. Full set of notes including
bloods.
(ABG results put at the back !)
Poorly hydrated pre and post op
2- Patient with splenic haematoma now wants to self discharge-
Prep station with notes. HB drop from 10 to 9.1 .Try to convince.
{Explain to patient the gravity of his decision and still persists allow to
discharge but explain that will need to sign against medical advice and
needs to report to hospital near home A S A P for repeat HB.

3-History taking for Thyroid Lump

4- History taking Abdominal Pain (Chronic Pancreatitis)

ANATOMY-
A-(Picture provided no prosections)Upper thorax
1-Aortic arch and branches
2- vagus nerve and type of supply
3- thyroid gland and blood supply.
4 supply of recurrent laryngeal nerve
5- describe Erb's palsy and Klumpke's palsy.

B-Shoulder
1- Osteology of humerus, clavicle &scapula- asked to identify parts of the
bone whether clavicle was right or le ft. superior and inferior surface. And to
articulate clavicle and scapula.
2- What nerve is damaged surgical humeral neck fractures.
Movements of humerus
3- Identify deltoid and its movements and its parts.
4- Identify Pectoralis major on picture + functions and nerve supply

C - Parotid Gland
1- surface anatomy and surface anatomy of the parotid duct.
2-Structures passing through parotid gland.
3- branches of facial nerve through gland.
4- Describe Frey’s syndrome
5- Parasympathetic supply to Parotid
6- Cranial nerves with parasympathetic supply
commonest tumor and cancer

PATHOLOGY
1- Scenario given —trauma with lady bleeding and had splenectomy. Bloods
given with deranged clotting,
1- What is th is? (DIC)
2 -possible causes.
3- How does it occur.
4- what Part of the pathway does A P T T test.?
5-What activates the extrinsic pathway
6- Function of platelets
 scenario of 35 yr old right scrotal lump for last 2 months)
2 - S e m in o m a (
further history given by examiner ( Pro fessor...) history of undescended

1-Name 3 things in history that will be of concern, (invasion, tumor margins

and diagnosis of course!(totally forgot that examiner hinted it to me)

5- Possible scrotal cancer cause in70 year old- Choriocarcinoma

- sterile conditions, after catheter inserted no urine

- How would you m anage airway and breathing

- Calculate burns and formula you would use
- How would you m anage patients circulation
- Fluid resuscitation {what type) any other fluid to be considered? (NO)

- Parkland formula and to calculate fluid in patient

- What type of burns does patient have?- (burn described in scenario)

4- H e art F ailu re s e c o n d a ry flu id o v e rlo a d

1- L o w er L im b A rte ria l e x a m - Present your findings

2 -C e re b e lla r e x a m in a tio n - P a tie n t w ith p o s te rio r c ra n ia l fo s s a m ass

Asked which side I thought lesion was on. Patient had right sided
symptoms so said left side. Examiner wasn’t too impressed
- what imaging to do? I said MRI asked what benefit that would be?

- T yp e s of tumor that could be cau sin g this

3 - 4 d a y s P o s t o p w ith c h e s t pain . p is e x a m in e th is p a tie n t (PE)

T h is is a C c ris p s ta tio n . (For My IMG that don’t know- Care of the

- Essentially a sse ss using A B C D E (Remember to give oxygen)

Whent you examine the limbs patient squeals in pain on squeezing left
calf. P is remember to warn patient before squeezing.

Questions follow in line of P E investigation and treatment

4 -8 d a y s p o s t o p h e m ic o le c to m y A b d o p ain ra d ia tin g to le ft s h o u ld e r
2nd Group

An old age man is planned for emergency Laparotomy for some perforation. U were
shown monitoring charts. Patient was in S IR S . Examiner asked Causes of
hypothermia, how to measure core body temperaUe , where is it measured, how to
prevent it. How to prevent Hypothermia per opartively. Complications etc.

A gas burn in kitchen Scenario. Patients S p 0 2 was 98 pc on 2 litres Oxygen. What

is your strategy of airway management. How will u start fluids. A diagram was given
to Calculate the pc of burn, Asked to calculate fluids. Then Switched to A R D S,
Asked for definition. And Showed an C X R . Asked for Management etc.

An Actor was Lying on Bed with Gud speech. History was given tht she had a
Posterior Cranial fossa tumour. Examine her. Its difficult to examine a normal lady
with good speech and showing other signs. Examiner was rude so he didnt ask

An old man was lying on bed. History was that he has been admitted for Hip
replacement, nurse found his both feet cold. This was a real patient. Asked to
Examine and then tell the findings. How will you proceed, time was short Didnt asked

A beautiful lady was lying on bed with dyspnea . Had history of Laparotomy for Some
pelvic Malignancy, where ever i touched she had pain. Finally i checked her legs and
thanx God found DVT. Rest were normal questions, ths was difficult station as
patient was not a good actor she was overacting. It would have been a good rest

Theme: History Taking Selling in front of neck with Thyrotoxicosis

History of a Patient who underwent so surgery and is no tachypneic. In eight hours

he ws infused 8 Liters of fluid and is in fluid overload.
 A patient., actor., was lying with pain in abdomen in left shoulder, he underwent
surgery for sigmoid Ca in emergency. 6th Post Op day. Examine the patient. Answer
Questions. Wht are possible causes of dyspnea and pain

Theme: Communication Skill for Sunday Discharge He has splenic Hematoma and
may need surgery. But want to self discharge.

No processions.. Only ATLAS pictures from Netter. Asked for Shoulder joint. Asked
to pick scapula clavicle humerus make joint, show where are rotator cuff muscle on
picture and never supply, Showed an MRI of shoulder asked where is head of
humerus and deltoid and glenoid, long heads of tricep and biceps. Ths picture is
same which is in a book i dont know where i saw it.

Easy station. Simple questions and very cooperative examiner

A man was sitting on chair asked for surface anatomy of Parotid extent of it. Duct
surface anatomy.. He was interested to listen duct surface anatomy in relation to
zygomatic arch. Asked too many known questions regarding parotid. Nothing

Theme: Skill. Suture a wound on thigh of a beautiful Lady.

Theme: Pathology Testicular Tumour Seminoma Classical

Excellent examiner. In a 35 yr old man undescnded testis, now presented with mass
in groin, wht is likely diagnosis. U did surgery HP report came. Showed the report.
then asked wht are ur concerns now. In report it was Tp4 Nx. invading the lymphatic
and muscular fibers. Wht is lymphoma . in which age group it is common in testes.
Asked about hematoma, and its resolution stages.

Station 18:
Theme: Pathology Clotting profile A B O m issm atch. Hypersenitivity. Splenectom y
consequnces etc. It w as a poorly designed station so random and abrupt. Even
asked for Bone reparing stages and Formation and activation of Mast cells
Qn 1: Pathology

Scenario given of a lady known to have Ulcerative Colitis and on surveillance colonoscopy. Found to
have a lesion less than a cm in sigmoid colon. Currently the disease itself is under control.

1) What is ulcerative colitis

2) what will you offer the lady {total colectomy)
3) why total colectomy (be whole colon susceptible)
4) what genes are responsible for transformation to cancer (K-ras, p-53)
5) what kind of genes are these (proto-oncogene and tumor suppressor)
6) how do these genes work? (act as gate keepers)
7) what do they do? (I am not sure I got this right„.he tried to get it out of me.. I said apoptosis in
the end and he seemed to have accepted it)
8) showed me a picture and asked TNM stage for that

Qn2 : Physiology/CC

An elderly patient with dementia and underwent urinary retention. His labs showed hyperkalemia and
hyponatremia along with AKI. Also he was catheterized and poured out 4L of urine.

1) What do the labs show (hyperkalemia, AKI and hyponatremia)

2) Why has the pt poured out 4L of urine (recovery phase of AKI, I am not sure if this was correct)
but he seemed to have accepted it.
3) How does this polyuria phase occur in recovery of AKI ( inability to concentrate urine)
4) What are the causes of hyponatremia in this patient? (SIADH due to distension of bladder)
5) What other surgical discipline uses hyperkalemia (cardiac surgery)
6) What is It called (cardioplegia)
7) There were one or two more qns.. sorry cant recall

Q n3: C ritcal Care

Someone w ith RTA and is tachypneic and tachycardic

1) On receiving this patient how will you manage his airway and breathing (ATLS)
2) X-ray shown., very poor quality...asked fo r findings (surgical emphysema, rib fractures and
pneumothorax)
3) Pt in shock.... How will you resuscitate (crystalloids, colloids, blood, urinary catheter) he kept
asking for more ways of resus... I wasn't sure w t more he wanted to know
4) How will you know the response ( from heart rate, BP, mentation, capillary refill and urinary
output)
5) He showed me a CT image., findings., (liver laceration)
6) Management ( conservative initially)
7) What is conservative management (Hb monitoring 6hrty and complete bed rest) if fails then
laparotomy.
8) Is CT a good investigation in this patient (no.,, the pt was hypotensive and should have
undergone a FAST)
Patient with a recent history of diarrhea and PR bleed., no more episodes since 6 hours... now presents

1) What do these labs show ( anemia, leukocytosis and thrombocytosis)

2) Explain each ( anemia sec to bleeding, leuko be of infection and thrombo be of acute phase

3) Which type of anemia (normochromic and normocytic)

6) How will you investigate ( esr, crp, pt/inr, scope later once acute episode settles, SDR)
7) Would you transfuse this patient ( no, vitally stable and bleeding episodes have stopped)
8) What are your concerns regarding transfusion (decreases immunity, electrolyte imbalance.

You have a patient who has lower back pain which is involving his left leg and thigh. Examine

Time was too short to examine his back and limb for everything... he stopped me at 6 min

2) What else would you like to examine ( saddle anaesthesia)

6) How will you treat( I did not answer this as bell rung on qn 5 only ) so there could be more parts

Qn6: Examine this patients limb for vascular pathology. He is to undergo hip replacement

It was a left sided ischemic limb with no pulses beyond femoral

2) Should he undergo hip replacement (No, vascular issues need to be sorted first)
3) How will you investigate (ABPI and duplex and angiogram)

Qn7: Examine the patients neck and relevant general physical

She had a diffusely enlarged thyroid gland. Also looked for peripheral signs

2) w hat is the status of thyroid clinically

4) Treatment (reassurance and call her back for follow up)

Qn 8: Pre-op patient for hernia. Examine his CVS

Patient had a sternotomy scar with ejection syst murmur

3) How will you manage it perioperatively

She had alternating bowel movements, family history of cancer and PR bleed

1) Present your history

2) How will you investigate
3) Cant remember the other qns

Qn 10: Elicit history from a young man w ith back pain

He had symptoms of sciatica with red flag signs

1) Present ur history
2) Differentials (sciatica, vascular prob, spinal stenosis)
3) Investigation (MRI)
4) Treatment (surg as red flag signs)

Qn 11: Pathology

Same Gall bladder carcinoma stem w ith wound infection and pseudomembranous colitis

Qn 12: model given., patient w ith RTA... perform

1) Ways of managing airway (chin lift, jaw thrust, guidel airway, LMA, Intubation) had to perform
chin lift, jaw thrust
2) U have no facility of intubation., now what ( cricothy)
3) Secure patients c-spine... u have to make the model wear a collar
4) Use bag-mask and ventilate pt ( they were looking fo r how you applied it to models face and
whether lungs were rising on inflation)
5) How will you check patients breathing?
6) Investigations
7) N some relevant qns that I cant recall but were not difficult

Qnl3 : gather information and call vascular consultant. Same qn pt admitted with diverticulitis and now
had ischemic limb.

Qn 14: counseling.

Same old qn. Patient with dysphagia. Counsel regarding endoscopy and dilatation

Qn 15: Anatomy

Sharjah does not have prosections so they had pictures.

 1) Identify muscles, (gluteus maximus,medius and minimus)

4) Wt is its function (stabilizes knee)

6) Bicep femoris (two heads and their nerve supply)

8) And may b one or more qns cant recall

Qn 16: Anatomy

Head and neck:

1) Pointed to thyroid. What is this? How many lobes

2) Arterial and venous supply. Where do they originate and drain ?
3) Cricothyroid membrane
4) Attachment of vocal cords
5) Point to cricoid cartilage
6) Nerves at risk
7) Recurrent if damaged then wt happens
8) And may be one more qn cant recall

1) Name the bones ( clavicle, humerus and scapula) and asked for parts as pointed

4) Elicit movements of shoulder joint on bones

8) Pec m a jo r o rig in a n d in s e rtio n a n d n e r v e s u p p ly

Qnl8 : organize theatre list. Same old qn of diverticular abscess, strangulated hernia and diabetic foot
with MRSA
Qn 1: Pathology

Scenario given of a lady known to have Ulcerative Colitis and on surveillance colonoscopy. Found to
have a lesion less than a cm in sigmoid colon. Currently the disease itself is under control.

1) What is ulcerative colitis

2) what will you offer the lady {total colectomy)
3) why total colectomy (be whole colon susceptible)
4) what genes are responsible for transformation to cancer (K-ras, p-53)
5) what kind of genes are these (proto-oncogene and tumor suppressor)
6) how do these genes work? (act as gate keepers)
7) what do they do? {I am not sure I got this right„.he tried to get it out of me.. I said apoptosis in
the end and he seemed to have accepted it)
8) showed me a picture and asked TNM stage for that

Qn2 : Physiology/CC

An elderly patient with dementia and underwent urinary retention. His labs showed hyperkalemia and
hyponatremia along with AKI, Also he was catheterized and poured out 4L of urine.

1) What do the labs show (hyperkalemia, AKI and hyponatremia)

2) Why has the pt poured out 4L of urine (recovery phase of AKI, I am not sure if this was correct)
but he seemed to have accepted it.
3) How does this polyuria phase occur in recovery of AKI ( inability to concentrate urine)
4) What are the causes of hyponatremia in this patient? (SIADH due to distension of bladder)
5) What other surgical discipline uses hyperkalemia (cardiac surgery)
6) What is It called (cardioplegia)
7) There were one or two more qns.. sorry cant recall

Q n3: C ritcal Care

Someone w ith RTA and is tachypneic and tachycardic

1) On receiving this patient how will you manage his airway and breathing (ATLS)
2) X-ray shown., very poor quality...asked fo r findings (surgical emphysema, rib fractures and
pneumothorax)
3) Pt in shock.... How will you resuscitate (crystalloids, colloids, blood, urinary catheter) he kept
asking for more ways of resus... I wasn't sure w t more he wanted to know
4) How will you know the response ( from heart rate, BP, mentation, capillary refill and urinary
output)
5) He showed me a CT image., findings., (liver laceration)
6) Management ( conservative initially)
7) What is conservative management (Hb monitoring 6hrty and complete bed rest) if fails then
laparotomy.
8) Is CT a good investigation in this patient (no.,, the pt was hypotensive and should have
undergone a FAST)
Patient with a recent history of diarrhea and PR bleed., no more episodes since 6 hours... now presents

1) What do these labs show ( anemia, leukocytosis and thrombocytosis)

2) Explain each ( anemia sec to bleeding, leuko be of infection and thrombo be of acute phase

3) Which type of anemia (normochromic and normocytic)

6) How will you investigate ( esr, crp, pt/inr, scope later once acute episode settles, SDR)
7) Would you transfuse this patient ( no, vitally stable and bleeding episodes have stopped)
8) What are your concerns regarding transfusion (decreases immunity, electrolyte imbalance.

You have a patient who has lower back pain which is involving his left leg and thigh. Examine

Time was too short to examine his back and limb for everything... he stopped me at 6 min

2) What else would you like to examine ( saddle anaesthesia)

6) How will you treat( I did not answer this as bell rung on qn 5 only ) so there could be more parts

Qn6: Examine this patients limb for vascular pathology. He is to undergo hip replacement

It was a left sided ischemic limb with no pulses beyond femoral

2) Should he undergo hip replacement (No, vascular issues need to be sorted first)
3) How will you investigate (ABPI and duplex and angiogram)

Qn7: Examine the patients neck and relevant general physical

She had a diffusely enlarged thyroid gland. Also looked for peripheral signs

2) w hat is the status of thyroid clinically

4) Treatment (reassurance and call her back for follow up)

Qn 8: Pre-op patient for hernia. Examine his CVS

Patient had a sternotomy scar with ejection syst murmur

3) How will you manage it perioperatively

She had alternating bowel movements, family history of cancer and PR bleed

1) Present your history

2) How will you investigate
3) Cant remember the other qns

Qn 10: Elicit history from a young man w ith back pain

He had symptoms of sciatica with red flag signs

1) Present ur history
2) Differentials (sciatica, vascular prob, spinal stenosis)
3) Investigation (MRI)
4) Treatment (surg as red flag signs)

Qn 11: Pathology

Same Gall bladder carcinoma stem w ith wound infection and pseudomembranous colitis

Qn 12: model given., patient w ith RTA... perform

1) Ways of managing airway (chin lift, jaw thrust, guidel airway, LMA, Intubation) had to perform
chin lift, jaw thrust
2) U have no facility of intubation., now what ( cricothy)
3) Secure patients c-spine... u have to make the model wear a collar
4) Use bag-mask and ventilate pt ( they were looking fo r how you applied it to models face and
whether lungs were rising on inflation)
5) How will you check patients breathing?
6) Investigations
7) N some relevant qns that I cant recall but were not difficult

Qnl3 : gather information and call vascular consultant. Same qn pt admitted with diverticulitis and now
had ischemic limb.

Qn 14: counseling.

Same old qn. Patient with dysphagia. Counsel regarding endoscopy and dilatation

Qn 15: Anatomy

Sharjah does not have prosections so they had pictures.

 1) Identify muscles, (gluteus maximus,medius and minimus)

4) Wt is its function (stabilizes knee)

6) Bicep femoris (two heads and their nerve supply)

8) And may b one or more qns cant recall

Qn 16: Anatomy

Head and neck:

1) Pointed to thyroid. What is this? How many lobes

2) Arterial and venous supply. Where do they originate and drain ?
3) Cricothyroid membrane
4) Attachment of vocal cords
5) Point to cricoid cartilage
6) Nerves at risk
7) Recurrent if damaged then wt happens
8) And may be one more qn cant recall

1) Name the bones ( clavicle, humerus and scapula) and asked for parts as pointed

4) Elicit movements of shoulder joint on bones

8) Pec m a jo r o rig in a n d in s e rtio n a n d n e r v e s u p p ly

Qnl8 : organize theatre list. Same old qn of diverticular abscess, strangulated hernia and diabetic foot
with MRSA
2018

Felicia Chua MRCS KL January 2018

Joshua Franklvn MRCS Hyderabad Jan 2018

Jeffrey Lee Penang Jan 2018

Athirah Azman Kuala Lumpur Jan 2018

Anneona Ghosh London Feb 2018

Anonymous Glasgow Clvdeband Feb 2018

Anonymous MRCS London Feb 2018

Sarah Huan London Feb 2018

Anonymous MRCS(Edin) Coventry Feb 2018

Drabrar Ahmad Dublin Feb 2018

Md Abdul Baten Joarder MRCS Edin Delhi 26 Mar 2018

Anonymous MRCS-I Dubai April 2018

Anonymous Sheffield May 2018

Anonymous 2 Sheffield May 2018

Sammv ConrovSheffield May 2018

Anonymous Dublin May 2018

Anonymous London May 2018

Anonymous London May 2018

Muhammad Mamun London May 2018

Jason Rattan Edinburgh May 2018

Anonymous Delhi July 2018

Md Abdul Baten Joarder MRCS Eng Delhi July 2018

Shardool Vikram Gupta New Delhi July 2018

Raiib Naskar Delhi July 2018 -1

Raiib Naskar Delhi July 2018 - 2

Anonymous MRCS Penang Aue 2018

Anonymous Colombo 20 Aug 2018

Athirah Azman Kuching Aug 2018

Sarah Liew RCS England KLSep 2018

David Sim KL Sep 2018

Toddlers MRCS KL Sep 2018

Anonymous MRCS KL 29 Sep 2018

Spin Doctor KL 30 Sep 2018

Anonymous MRCS Part B Glasgow Oct 2018

Anonymous Sheffield Oct 2018

Anonymous Dublin Oct 2018 1

Anonymous Dublin Oct 2018 2

Anovmous London Oct 2018 account 1

Anonymous London Oct 2019 account 2

 K lI A L A L U M P U R 16 JA N U A R Y 201 8 D A Y 2 P M S T A T IO N S

MRCS PART B OSCE STATIONS

20 stations in total: 2 preparation, 18 actual stations
1 minute reading time for all stations (including preparation)
9 minutes for each station: this is generally broken down into 6 m inutes for exam ination, remaining 3
minutes for going through findings/ reporting back and asking questions
Anatomy and surgical pathology
1 Cranial P age 2
2 Posterior mediastinum Page 3
3 Bon es (U L and L L ) P age 4
4 G all bladder Cancer with N ecrotising Fasciitis P age 5
5 Perforated ulcer P age 6
Applied surgical science and critical care
6 Extradural hematoma P age 7
7 G astric outlet obstruction P age 8
8 O esophageal varices P age 9
C linical and procedural skills - patient safety
9 Rank operation Page 11
10 Suture P age 11
Com munication skills - givin g and receiving information
11 Operation cancelled Page 11
12 Phone consultant P age 11
Com munication skills and history taking
13 Seizure history (intracranial m alignancy) P age 12
14 BPH Page 12
C linical and procedural skills - physical examination
15 Hernia P age 13
16 Subm andibular gland P age 13
17 Right pleuritic chest pain (D V T / PE) P age 13
18 C arpal tunnel syndrome P age 13

Page 1 / 13
C r a n ia l
G iven: 1) skull 2 ) an gio gram 3 ) neck prosection 4 ) cervical m id b one and 5 ) C l .
Sh ow ed the angiogram . Identify this artery. V ery o b vio u s ICA .
H ow d o es IC A enter the sk u ll? Sh ow m e on the skull. Point out the foram en lacerum and carotid canal.
He w anted both from b ase o f skull and from below the skull.
Sh ow ed p a ssa g e o f IC A (petrous part to cavernou s portion). W hat lies in this C av ern ou s sinus.
region?
W hat branches o f f before the IC A bifurcation? O phthalm ic artery.
G iven prosection o f neck. A sk ed to identify C C A and IC A /E C A . Sh ow w hich one is IC A .
Sh ow ed an gio gram again . Identify the branches o f ICA . M C A and A C A .
W hat is th is? H uge aneurysm at M C A .
W hat type o f hem orrhage d o e s this c au se? Subarach noid hem orrhage.
W hat are the sig n s o f M C A infarction? Contralateral h em iplegia o f U L and face; contralateral
h om onym ous h em ianopia; num bness; neglect; aph asia.
W hy is there foreh ead sp aring? U pper foreh ead receiv es dual innervation (both m otor
cortex).
W hat else contributes to intracranial circulation? Posterior circulation: vertebral artery.
Explain ed vertebral artery jo in s to b asilar artery and thereafter the posterior C erebellum . B rain stem (m idbrain, pon s, m edulla).
circulation (P C A etc); ask ed w hat d o es this su p p ly ? W anted 3 things. O ccipital lobes.
Sh ow ed m id cervical vertebral b ody. A sk ed to identify w here vertebral artery Foram en transversarium .
lies.
Sh ow ed C 1 vertebral body. A sk ed to explain how vertebral artery co u rses C 1 . T h e vertebral artery ex its the foram in a transversarium
and cu rves posteriorly and m edially in a g ro o v e on the
upper su rface b efo re it enters the foram en m agnum .
A TLA S- C l
Groove for
vertebral Posterior tubercle Superior
artery (virtually no spinous view
& Cl nerve Proces,s>
\ 1 Posterior arch

Suboccipital Greater occipital

nerve (posterior \ \ nerve (posterior
ramus o f Cl) —■, ramus C2)

T r a n s v e r s e - '^ V - - \ ^ Foramen transversum

process /• \
/ » Superior facet
Cl anterior ramus 1 (kidney shaped)
(between facet & /
artery) Anterior arch & tubercle
(attachment o f longitudinal
ligament)

H ow d o es vertebral artery enter the sk u ll? Through the foram en m agnum .

P o ste rio r m e d ia stin u m
G iven: Thorax cadaver (but d idn ’t need to refer to it at all)
W hat are the boundaries o f the posterior m ediastinu m ? Superior: transverse plane betw een sternal angle to the
intervertebral disc betw een vertebrae T IV and T V
Inferior, diaphragm
Anterior, posterior pericardium
Posterior, posterior ch est w all (T 5 to T 1 2 )
N am e m e 6 things that lie in the posterior m ediastinum . 1. E so p h ag u s
2. T h oracic aorta
3. A z y g o s system o f veins
4. T h oracic duct and a sso ciated lym ph nodes
5. Sym pathetic trunks
6. T h oracic splanchnic nerves
C o m p licatio n s o f perforated o eso p h agu s? M ediastinitis. E m physem a.
W hat epithelium lines eso p h agu s? Stratified sq u am o u s (non-keratinizing) ce lls
W hat level d o es eso p h agu s b egin at? C 6 vertebra (starts at the cricoid cartilage from the
oropharynx)
W hat level d o es it end at? T 1 0 as it enters diaphragm .
W hat p art o f the diaphragm is that? Enters m u scu lar part o f diaphragm through eso ph ageal
hiatus).
W hat is the blo o d su pply o f the eso p h a gu s? Upper 1/3: inferior thyroid artery (thyrocervical trunk
from su b clav ian artery)
Middle 1/3: o so p h ageal b ranches o f descen din g aorta
Lower 1/3: left gastric and inferior phrenic arteries
W hat is the ven ou s drain age o f eso p h a gu s? Upper 1/3: inferior thyroid vein
Middle 1/3: a z y g o s vein
Lower 1/3: left gastric vein
W hat is the lym phatic drain age o f eso p h agu s? Upper 1/3: deep cervical nodes
Middle 1/3: m ediastinal nodes
Lower 1/3: nodes alo n g left gastric b lo o d v e sse ls and
celiac nodes
W hat tw o structures leave an indentation in eso p h a gu s? A ortic arch and left m ain bronchus.
W hat is the m o st com m on eso ph ageal tum our? Sq u am o u s cell carcinom a.
W hat happens in barrett’ s eso p h agu s? M etaplasia o f S C C to colum nar ce lls - prem alignant
condition.
W hat is a ch alasia? A bnorm al p e ristalsis with resultant failure o f L E S to
relax.
W hat is the path ophysiology behind a ch alasia? A b sen ce or destruction o f auerb ach ’s (m yenteric)
plex u s (aetio lo gy unknown)
G iven skeleton o f entire body pointed out to different parts to ask origin and insertion etc.
U p p e r L im b
W hat bone is th is? W here d o es the fracture u su ally occur? C lav icle . M iddle third.
T ell m e about the rotator c u ff m u scles. O rigin and insertion. Muscle Origin Insertion
Show m e on th skeleton. Supraspinatu s Sup rasp in o u s fo ssa G reater tubercle o f
—
o f scapula hum erus

km L
Intraspinatus Infraspinous fo ss a o f
sc ap ula
R o tator c u ff m uscles
T eres m inor M iddle 2/3 o f lateral
Anterior Posterior b order o f sc ap ula

S u b scap u laris M edial 2/3 o f L e sse r tubercle o f

su b scapu lar fo ssa hum erus

S E g f i B ^ ^ T e r c s minor
. . . ,
Subscapulans
/ <^M / muscle
f lw M
muscle ln^rasP'natous
. Jm usc le
fliA D A M
S h ow m e the sp iral groove. W hat nerve runs through it? Point out sp iral groove. R adial nerve.
W hat nerve runs behind the m edial epicondyle? U ln ar nerve.
Sh ow m e the sen sory deficit. M edial 1.5 fin gers - he ask ed sp ecifically i f both do rsal and palm ar
su rface: yes.
W hat is the only thenar m u scle a ffected in ulnar nerve p alsy / A ddu ctor po llicis
injury?
L o w e r L im b
W hat is th is? (points to A S I S ) A nterior su perior iliac spine.
W hat attaches here? Sarto riu s (he ju st w anted one answ er).
W hat runs here? (pointed to region ju st b eside A S I S under Lateral fem oral cutaneous nerve
im aginary “ inguinal ligam ent” )
W hat condition d o es this cau se? M eralgia paresthetica
W hat is the m ajo r fle x o r o f the hip? Ilipsoas.
W hat d o es it attach to? L e sse r trochanter.
A sk ed about gluteu s m u scles; origin and insertion (point out on G lu teus m axim u s G lu teal (posterior) Iliotibial tract
the skeleton). su rface o f the G lu teal tuberosity
ilium , sacrum and o f fem ur
co ccy x.
G lu teus m edius G lu teal su rface o f L ateral su rface o f
ilium g r e a te r
tro c h a n te r
G lu teus m inim us Ilium C o n v erges to form
a tendon, inserts to
anterior sid e o f
g r e a te r
tro c h a n te r

A sk ed about function o f gluteu s m ediu s/ m inim us. W ant to hear T rendelenburg sign. A nd go o d sid e sa g s. D ue to lo ss o f
hip abductors.
W here d o es quadratus fem o ris insert? Sh ow on skeleton. Intertrochanteric crest.
W here d o es quadratu s fem oris o riginate? Ischial tuberosity.
G a ll b la d d e r c a n c e r w ith n e cro tiz in g fa sc iitis
W hat is the m o st com m on type o f g a ll b ladder cancer? A d enocarcinom a.
W hat is the m ost com m on ca u se in U K ? G all ston es cau sin g chronic in flam m ation?
W here d o es gall b ladder cancer sp read to ? H e ju st w anted 2 answ ers. Segm en ts 4/5 liver, lym ph node.
H ow can cancer sp read ? H em atogen ous, lym phatic, direct invasion.
Patient is po st o p d ay 3 ? N o w w ound is red with yellow -ish d isch arge. W hat W ound infection.
w ould you su sp ect? N ecrotisin g fasciitis.
W hat are 4 com m on o rgan ism s that cau se necrotizing fa scc itis? S taph y loco ccu s aureua, Esch erichia co li, Clostridium
perfringens, proteus.
M anagem ent? A ntibiotics - b road based.
Su rgical m anagem ent? D ebridem ent.
When do you sto p? Repeated debridem ents until plane is clear; and clinical
follow -u p to m onitor com plete resolution.
P ost o p patient h as b lood y diarrhea. G iv e 4 differen tials. P seudom em branous colitis. B o w el isch em ia. Infective
enterocolitis. M alignancy.
G iven c o lo n o sco py picture, ask ed w hat it is ? Pseudom em branous colitis.
W hat is the m ech an ism o f pseudom em bran e form ation ? E xudativ e fibrin deposition in respon se to bacterial
(clostridium d ifficile overgrow th with production o f
enterotoxin a and b) pseudom em bran e form ation.
P e rfo ra te d u lc e r
W hat are risk facto rs fo r peptic u lcer d isea se? H elico pylori. N S A ID s. S m o kin g. Steroids.
H ow d o es h elico pylori c a u se u lcers? H. pylori induces predom inantly antral gastritis,
characterized by in creased acid production and reduced
duodenal bicarbonate. It h as unique m icro bio lo gic
ch aracteristics such a s urease production, allo w in g it to
alkalinze its m icroenvironm ent and su rv iv e fo r y ears in
the hostile acidic environm ent o f the stom ach, w here it
ca u ses m u cosal inflam m ation. Chronic inflam m ation
p red isp o ses to cancer.
C X R done later sh o w s air under diaphragm . W hat h appened? Perforation.
H ow d o es N S A ID s ca u se ulcer? N S A ID s inhibits function o f prostaglan dins
(P rostaglandins o f E type - P G E ) (inhibit gastric acid
production, in crease m u co u s and bicarbonate
production, in crease v a sc u la r p erfusion, m u cosal b lood
flow rem o v es acid and provid es bicarbonate to the
su rface epithelial cells).
D o es h. pylori predispo se to can cer? W hat type? Y e s. A denocarcinom a.
W hat other stom ach tum ours do you kn ow ? M A L T . G IS T .
W hat is a frozen section? L aboratory procedure w here specim en is rapidly
frozen, em bedded in a ge l, then cut frozen, p laced on
g la ss slide and stained.
W hat are the p ro s and cons o f a frozen section? Frozen section: F ast, sm all specim en.
IH C : slo w process.
H isto lo gy reports sh ow s - features o f m alignancy (he said a few things).
A sk ed about stom ach cancer (ca n ’t really rem em ber what).
W hat is found in P R B C - is there platelets? N o.
E x tr a d u r a l h em ato m a
R T A G C S 15, 2 ep iso d es o f vom iting, am nesic events then suddenly G C S 8.
W hat do you see on C T brain? ED H .
N orm al v alu e o f IC P ? 7-15m m H g.
W ays to m easure IC P ? Invasive: IV C m onitor v ia E V D , intraparenchym al m onitor v ia ICP monitor.
N on -in vasive: L P (openin g p ressure); transcranial D oppler can m easure M C A velo city and
derive pu lsatility index correlating with ICP.
P ath oph ysiology o f in creased IC P ? M onroe-kellie doctrine. Sku ll is a fix ed b o x with 3 com ponents: brain 8 0% , b lood (arterial and
v en ou s) 10% and C S F 10% . An in crease in any o f th ese com pon ents m ust be o ffse t by an equal
d ecrease in another. T h e body tries to com p ensate and reduces C S F first then blood, how ever,
once it h as p asse d its critical volum e o f com pensation (~ IC P 2 5 m m H g) sm all in creases in brain
v olum e can lead to m arked elevation s in ICP, leading to failed intracranial co m p lian ce and brain
herniation.
M anagem ent A B C D E m odel. G C S 8 o r le ss is indication fo r intubation to protect airw ay and assu re optim al
oxygen ation and ventilation; which can a lso help facilitate ICP m anagem ent. IV flu id s, head up
3 0 d egrees (im prove ven ous drain age), hypotherm ia, m annitol/ hypertonic salin e (in crease
serum osm olality and in turn reduce w ater in brain), keppra 2 w eeks (anticonvulsants),
barbiturate com a. Surgery: evacu ate clot (> 5 m m m idline sh ift with > 3 0 m L ), d ecom pressiv e
craniectom y.
C a u se s o f dilated pu pils in raised IC P ? Transtentorial herniation; tem poral lobe over tentorial cerebelli w here C N 3 c ro sses, resulting in
inhibition o f parasym path etic innervation to iris sphincter; resulting in unopposed sym pathetic
innervation to pupil and resultant dilatation.
B en efits o f ventilation 1. Ensure adequate oxygen ation to prevent H IE (h y po xic isch em ic encephalopathy)
2. Control o f p a C 0 2 to hyperventilate patient (a s below )
H ow to m an age this patient i f he w as H yperventilate patient.
intubated to d ecrease brain injury? C 0 2 is a potent vasod ilator, in hyperventilation, this reduces the arterial C 0 2 resulting in
vasoconstriction o f cerebral blood v esse ls. T h is in turn reduces the overall b lood volum e and
thus intracranial pressure.

H ead up 30 d egrees to allow adequate v en ou s return from brain. S ed ate/ p araly se patient to
reduce cerebreal m etabolic requirement. H ypotherm ia. Ju d ic io u s flu ids with strict I/O
m onitoring (ID C ), m annitol/ hypertonic salin e to reduce cerebral edem a.
G a s tr ic O u tle t O b stru c tio n
L ad y vom iting, epigastric fulln ess. L a b s show N a 125, K 1.9, C l 59, pH 7.2.
W hat d o es sh e have? G astric outlet obstruction.
C a u se s? P yloric sten osis secondary to chronic peptic ulceration, m alignancy. P U D , stricture.
W hy is sodium low ? G astric contents vom ited out, leading to hyponatrem ia.
M etabolic alk a lo sis, kidneys excrete N a H C 0 3 to reduce b lood alkalinity -> hyponatrem ia.
T y p es o f hyponatrem ia I g a v e the w hole sp ew about h ypo-osm olar, iso-osm olar, h yper-osm olar; then a ss e s s clinically
fo r hydration status (under, over or a dequately filled).
H e just w anted the differen tials, 1 said 3 he seem ed okay: S IA D H , C S W , heart failure.
C o m p licatio n s o f h yponatrem ia? C erebral ed em a, seizures, confusion , lethargy, m u scle w eakn ess, brain herniaion, com a, death.
W hy is p o tassium low ? G astric contents vom ited out, leadin g to hypokalem ia.
Increased aldosterone in respon se to h ypovolem ia.
W hy bicarbonate in creased? Increased uptake o f bicarbonates in renal tubules in respon se to lo ss o f chloride in order to
m aintain electroch cm ical neutrality.
W hy creatinine and u rea high? D ehydration, h ypovolem ia, (he w asn ’ t happy with this, he w anted more)
H ow w ould you treat? IV hydration,
h so p n a g e a i v a ric e s
45y o , chronic alco h o lic, 3 tim es hem atem esis, low B P , high H R , eso ph ageal varices. A ltered m ental state.
D ifferen tials? 1. E so p h ag eal varices due to poral hypertension
2. M allory-w eiss tear
3. U pper G I bleed - peptic/ duodenal ulcer______
S ite s o f portosystem ic a n asto m osis?
P O R T O S Y S T E M IC A N A S T O M O S E S

Oesophageal
“I I branches o f
3A5 le ft gastric,
Portal

1 Low er o e sop h agu s 4 Bare area of liver

Portal: Oesophageal branches Portal: Hepatic/portal veins
o f left gastric veins Systemic: Inferior phrenic veins
Systemic: Azygos veins
5 Patent ductus ve no su s (rare)
2 U p pe r anal canal Postal: Left branch o f portal
Portal: Superior rectal vein vein
Systemic: Middle/inferior Systemic: Inferior vena cava
rectal veins
6 Retroperitoneal
3 Umbilical Portal: Colonic veins
Portal: Veins of ligamentum Systemic: Body wall veins
teres
Systemic: Superior/inferior
epigastic veins
H ow w ill you m anage this patient?
A cu te bleedinj A B C . L o o k fo r early sig n s o f sh ock (tach ycardia, postural hypotension).
A s se ss hydration status. A s se ss m ental state. K IV intubation. V ascu lar
a cce ss, flu ids/ blood resuscitation and b lood in vestigations. A im : keep Hb
around 9, o v er en thusiastic transfusion can in crease portal pressure and
cau se m ore bleeding.
(1 ) I V so m a to sta tin / o c tre o tid e : S planchnic v asocon strictor w hich
d e crease s portal b lood flow and hence portal pressures.
(2 ) A cid su p p r e s sio n : IV PPI om eprazole
(3 ) A n tib io tic s: broad spectrum , reduces infection risk.
(4 ) E n d o sc o p y : confirm d ia g n o sis and institute m anagem ent; can do
ban ding or sclerotherapy.
(5 ) I f not re so lv e d w ith en d o sco p ic in terv e n tio n th en : B allo o n
ta m p o n a d e : Linton (only h as a gastric balloon portion), S e n g sta k e n -
B la k e m o re tu b e (eso ph ageal and gastric balloon; and gastric aspiration)
and M in n e so ta (eso ph ageal and gastric balloon; eso ph ageal and gastric
aspiration). Inflate gastric balloon and pull up again st cardioesoph ageal
junction (balloon p resses onto perforator v eins entering oeso ph agus
from stom ach, and d ecreases o eso ph ageal variceal bleeding). R epeat
en do sco py 10-12 hours later (m u cosal necrosis).
(6 ) S e c o n d a ry p r o p h y la x is: P ropanolol

Others:
> R ad io lo g ically gu ided insertion o f transju gu lar intrahepatic porto­
system ic shunt (T I P S S ) g
> Shunt surgery
Paraesophspagaanc > Snainra nrnreHnre. Hast resortV a snrpiral terhninnp. that involves the
 KUALA LUMPUR 16 JANUARY 2018 DAY 2 PM STATIONS

gastric devascularisation, selective v ago to m y , pyloroplasty, o eso ph ageal

d evascularisation , o eso ph ageal transection and rean astom sed to ju st
above the cardia.

TIPSS
S en gstake n -B la ke m o re

Sh ow ed b lood result with low H b and raised D IC .

fibrinogen degradation products. A sk ed w hat?
H ow to m an age? F B C , platelets, FFP.
W hat is m a ssiv e transfusion proto col? R atio. 1: 1: 1.
A scite s in this patient. W hat is the c a u se? W anted 2 1. R educed album in production (liv er cirrhosis).
causes. 2. V asodilatation theory: portal hypertension leads to vasodilation
w hich c a u ses decreased effective arterial b lo o d volum e. A s natural
history o f the d isea se p ro g resse s, neurohum oral excitation
in creases, m ore renal sodium is retained, and plasm a volu m e
exp an d s. T h is leads to overtlow o f tluid into peritoneal cavity.
R a n k o p e ra tio n p r io rity
Priority o f operations and ju stify why.
A sk ed about PPM . W ho is needed? PPM technician.
W hy u se b ip olar for PPM .
H ow d o es m onop olar w ork?
Patient h as iodine allergy, w hat do you C hlorhexidine/ alcohol.
u se?
D M related questions. N B M drip with dextrose; regular m onitoring; insulin infusion.
C O P D related questions. U se regional anesth esia instead.

S u tu r e
W ound, sp o n ge pad given.
Prepare instrum ents. Pick out the non-absorbable suture.
T est L A . Suture.
A n sw er patient questions - pain, w hen to S T O , show , dressin g change.

C a ll c o lo re c ta l su rg e o n . P a tie n t h a s a c u te lim b isch em ia.

R T A , open tib/fib fracture with p u lseless foot; abd om inal collection.
U S show ed free fluid in paracolic gutter.
X R sh ow ed left tibia open fracture. C lin ically had cold, p ale and pu lseless limb.

E ssen tially S B A R , expan d on m anagem ent A B C D s, flu ids abx stabilize patient etc.
A sk ed w hether spin e w as a sse sse d ? W as not m entioned in notes; said I’ ll check clin ic ally and organ ize C T scan fo r patient. In mean
tim e w ill get hard co llar fo r patient.
A sk ed what to do with paracolic gutter W ill get C T abdom en fo r patient.
free flu id?
A sk ed w ho e lse to get in volved in A nesthetist, v ascu lar surgeon, orthopedic su rgeon and plastic surgeon (fo r cover).
patient’ s care?

A n g ry p a tie n t, o p can ce lle d .

P ostm an, m edial m en iscus injury, arthroscopy operation cancelled once before already. N o w consultant-in-charge h as em ergency surgery
to do, patient is frustrated.
G iven preparation station. P revious surgery go t cancelled already (c a n ’t rem em ber fo r w hat).
Been gain ing w eight, w orsenin g pain, unable to w ork (postm an).
E xplain to patient op cancelled.
Concerns: 1. Jo b - w ill write letter to com pan y to explain
2. W ife - liv es far aw ay , h as to ge t w ife to send him to h ospital; very inconvenient every
tim e it ge ts cancelled. A p olo gized , exp lain ed w ill get so c ial w orkers on b o ard for
travel fund to get a cab etc.
A sk ed w hen I can confirm another op U nable to giv e exact date, but w ill w rite in to prioritise and expedite surgery.
date.
O ffer su ggestio n s. L ife sty le ch ange: physiotherapist.
A n algesia: he brought up that he had been getting reflux b ecau se o f the an a lg esia given by GP.
E x plain to add a P PI/ anatacid to reduce risk o f stom ach ulcers.
IC E .

S e iz u re .
First ep iso de seizure, currently in h ospital. T ak e a history 6 m inutes, present fin dings, then d isc u ss further m anagem ent.
S eizu re history taking. W itnesses. D uration o f seizure, w hat type o f seizure. A ny pre-aura sy m ptom s, any L O C , p o st­
ictal sym ptom s. H eadach e, nausea, vom iting, w eakn ess. Then standard PM H x, F M H x,
m edication s, allerg ies, so c ial history.
Patient reveals been h aving 2 m onths headache a sso ciated with early m orning nausea although no vom iting, with 2 w eeks w orsenin g right
U L clu m sin ess, seizure w a s tonic-clonic unsure o f duration with com plete L O C , no aura/ p ost-ictal sym ptom s. On m edication history
taking: h e’ s been started on phenytoin and steroids - states he fee ls better now.
Present findings.
Then told C T brain d one sh ow ed left M R I brain with contrast.
parietal region hyperintense lesion with
surrounding edem a. Investigations?
W hat are y our likely d ifferen tials? M alignancy. M ilitary T B brain infection (he sp ecifica lly w anted to hear m ilitary T B to b ra in ).
A b sce ss. Lym ph om a. D em yelinatin g condition.
W hat su rgical interventions? Stealth gu ided biopsy.
C raniotom y and ex cisio n o f lesion.
W hat intra-operative help? S T E A L T H (neuro-navigation).
Frozen section.
Stain ing intra-op to look fo r tum our c e lls w hile resecting.

U rin e reten tio n (B P H ).

D ifficulty with initiating urination, slow stream , hesitancy, urgen cy and in creasing frequency. N o m alignancy features.
Urinary history taking. Standard urinary irritation sy m pto m s/ obstructive sym ptom s. A sk ed about m align an cy related
q uestions - w eight lo ss/ L O A / bone pain. F ev e r (in fective sym ptom s).
Patient a lso takes nasal sp ray s containing phenylephrine - said it’ s been w orse after taking it.
Patient a lso had concerns about prostate cancer - had to ad d ress them.
Present findings.
H ow d o es phenylephrine affect
sym pto m s?
D dx: B P H , prostatic cancer, obstruction, overactive bladder.
M anagem ent. Full clinical exam ination including PR , b lo o d s (P S A , U F E M E and urine culture), im aging:
transrectal ultrasound; and i f n ecessary b io p sy fo r g lea so n scoring.
Treatment. M edical: A lpha-adrenergic blocker: tam sulosin . 5 alpha reductase inhibitor: finasteride.
Su rgical: T U R P

12
H ern ia .
D o hernia exam ination 6 m inutes then present findings.
D ifferen tials? H ernia (in guinal/ fem oral). H ydrocele, testicular m aldescent, saphena varix, fem oral artery
aneurysm .
A sk ed how to differentiate inguinal v s fem oral hernia. D irect v s indirect inguinal hernia.
C a u ses C O P D , B P H , chronic cough, raised intra-abdom inal p ressures, occupation which carries heavy
loads.
Investigations? Pre-op b lo o ds, C X R / A X R fo r etio lo gy o f intra-abdom inal pressure.
M anagem ent? C o nservative - lifesty le/ occupational ch ange, correct etiology.
Su rgical: lap v s open, prim ary repair +/- m esh.

S u b m a n d ib u la r g la n d .
D o subm andibular exam ination 6 m inutes then present fin dings. N o sig n s clinically.
D ifferentials? S ialo lith iasis. Infection. Tum our.
Investigations? Sialo gram . X R .
A re ston es u su ally radiolucent/ Opaque.
opaq ue?
M anagem ent? C o nservative - p a s s the stone out.
S u rgical - ask e d about app roach es (intra-oral) v s directly through subm andibular gland i f stone
is m ore proxim al to gland.
N erv e s in volved/ a ffecte d ? H v n o elo ssal. L ineual. M arginal m andibular.
D V T/ PE.
P ost-op day 1, right ch est pain. Exam in e patient.
C ardio v ascu lar, respiratory exam ination. W anted to d o L L exam ination but exam iner stopped me.
W hat in vestigations? B lo o d s: F B C , R P , IN R /P T /A P T T , D -dim er, G X M .
Im aging: C X R , U S low er lim b, C T P A or V /Q scan i f contraindicatcd.
M anagem ent? Supportive. H D U / IC U .
A n ticoagulation: therapeutic clexan e (1 m g /k g B D )
Intervention: throm bolysis
S u reical: throm bectom v
C a r p a l tu n n e l sy n d ro m e .
Patient fakin g m edian nerve im pingem ent sign s: w eakn ess o f L O A F m u scles, tinnel and phalen + v e sign.
What e lse to do ? Full neurovascu lar exam ination - tw o point discrim ination, fine touch, reflexes.
A llen test fo r v ascu lar in su fficien cy ?
Investigations? E M G , U S , X R , M RI.
M anagem ent? C o nservative (lifesty le), an algesia. Su rgical: C arpal tunnel release surgery.
H y d e ra b a d MRCS p a rt B Ja n u a ry 201 8

A ll th e q u e s tio n s w e re re p e a te d fro m p re v io u s ye a rs s ta tio n s . T ha nks a bun ch.

S ta tio n s

A n a to m y

■ Back o f th ig h - sc ia tic n e rv e a n a to m y a n d r o o t v a lu e , h a m s trin g m uscles and p o p lite a l

fo s s a — s tra ig h t fo rw a r d s ta tio n
■ A n a to m y o f s to m a c h - b lo o d s u p p ly and p a rts , a n a to m y and re la tio n s o f th e pancreas
in c lu d in g b lo o d s u p p ly . P e rito n e a l re la tio n s o f th e pancreas
■ Base o f skull and b ra in . C a vern ous sinus, M RI b ra in - co rp u s c a llo s u m , v e n tric u la r d ra in a g e
o f CSF. Sulcus and G yri. V e n o u s sinuses. F o ra m e n th ro u g h th e base o f skull.

P a th o lo g y and c ritic a l care

1. T h ro m b u s , G an g re n e , A p o p ts is and A th e ro s c le ro s is
2. A d u lt p o ly c y s tic k id n e y a n d re n a l tra n s p la n t s ta tio n
3. G a s tric o u tle t o b s tru c tio n - m e ta b o lic d is o rd e rs and IV flu id m a n a g e m e n t.
4. F u n c tio n a l p h y s io lo g y o f a d re n a l g la n d - HPA A xis and stress re s p o n s e t o s te ro id s .
5. A o rtic s te n o s is and p o s t o p m a n a g e m e n t o f a n ti-c o a g u la n ts .

P ro c e d u re

1. S u tu rin g skin
2. D rainage o f abscess

H is to ry and e x a m in a tio n

1. C o n fu s io n a l s ta te in a p a tie n t - AM TS and M M SE
2. P e rip h e ra l v a s c u la r disease - c la u d ic a tio n pain
3. B ite m p o ra l h e m ia n o p ia - p itu ita r y tu m o u r - CNS e x a m in a tio n
4. L4,L5 disc p ro la p s e w ith classical fin d in g s on SLRT, s e n s a tio n loss and high s te p p in g g a it.
5. H y d ro c o e le e x a m in a tio n - s tra ig h t fo rw a r d basic q u e s tio n s
6. A c u te a p p e n d ic itis - s tra ig h t fo rw a r d a b d o m in a l e x a m in a tio n

C o m m u n ic a tio n -

l.T e le p h o n e call w ith c o n s u lta n t - p o s t o p s ig m o id c o le c to m y w ith p re -re n a l d e h y d ra tio n -

2 .S p lenic tra u m a p a tie n t w a n te d t o g e t d is c h a rg e d a t re q u e s t - c o u ld n o t c o n v in c e h im t o s ta y back.

M rcs p a rt b Penang 20 ja n 2018

1. A n a t : skull base, p o s te rio r c rania l fossa b o rders, nerves nea r clivus, s p h e n o o c c ip ita l
syncho ndrosis, sinuses o f th e brain , ju g u la r fo ra m e n & s tru c tu re s passing th ru it.
2. A n a t : s h o u ld e r g ird le a n a to m y , r o ta to r c u ff m uscles, in n e rv a tio n , a c tio n . D e lto id m uscle
fu n c tio n , ne rve in n e rv a tio n . M ri c o ro n a l plane o f s h o u ld e r and id e n tify parts ( re p e a t), pec
m a jo r and parts
3. A n a t : pancreas and s u rro u n d in g a n a to m y . S tru c tu re s passing in fr o n t o f uncus, beh in d d3, b lo o d
sup p ly o f pancreas, e m b ry o lo g y o f pancreas, b lo o d sup p ly o f stom a ch
4. Patho : h p y lo ri pud and h y pe rcalcem ia le adin g to p a ra th y ro id ade nom a p rim a ry
h y p e rp a ra th y ro id is m ( re p e a t)
5. Patho : post knee im p a n t e ffu s io n . W h a t to lo o k fo r, w h a t risk, o s te o m y e litis m ic ro b io lo g y ,
seq u e s tru m and in v o lu c ru m , m o s t co m m o n c rystal a rth ritis th a t a ffe c t knee, sequelae o f ch ro n ic
in fla m m a tio n
6. C rit care : pgu, in te rp re t c x r(a ir u n d e r dia p h ra g m ), ecg ( af, h o w to c o u n t h r in af) causes o f a f in
e ld e rly , w h y a u to m a tic bp m achin e c a n t pick up real h r in af? ( real h r 140-150, m achin e said
100 - 110 )
7. C rit care : rha b d o m y o ly s is , re p e rfu s io n sy n d ro m e , w h a t serum te s ts to take, c o m p lic a tio n ,
fa s c io to m y , h y p e rk a le m ia and m a n a g e m e n t
8. C rit care : hae m atem esis w ith u n d e rly in g c h ro n ic alco h o lis m , varicea l bleed, m an a g e m e n t, w h a t
vessels in vo lve d , sengstaken b la c k m o re and m inesso ta tu b e
9. Phy exam : knee oa( r e p e a t )
10. Phy exam : th y ro id mass (re p e a t)
11. Phy exam : p u lm o n a ry e m b o lis m ( repeat)
12. Phy exam : acute c h o le c y s titis and h o w to diagnose, m anage
13. H is to ry : p seu doaneu rysm ( in itia lly gp diagnosed as in g u in a l abscess)
14. H is to ry : c h ro n ic back pain
15. C om m : re fe rrin g to vascular fo r acute lim b ischem ia
16. C om m : e x plain risk o f ogds and d ila ta tio n
17. P roced ure : i& d o f abscess
18. P roced ure : excision o f naevus
MRCS (Edinburgh) KL January 2018

Critical Care
1. liver cirroshis
- Variceal bleed
- How to manage
- How m any clips
- Escalate
- W ho to contact/discuss with
- Liver transplant

2. Chronic Vomiting
- electrolytes im balance
- Low potassium /low sodium
- Acid base im balance
- Paradoxical acid urea
- Possible diagnosis

3. Head Injury
- m anagem ent
- ICP and Surgical options

Procedural Skills
1. Procedure
- OT list and applying diatherm y

2. Suturing

Anatom y & Surgical Pathology

1. Surgical Site Infection
- how to treat
- Pseudom em braneous colitis
S ta tio n s F e b 2 0 1 8 R C S (L o n d o n ) - A n n g o n a

1. A n atom y - brachial plexus. W hat are the nerve roots o f the brachial plexus? W hich nerve roots would
accou nt fo r an upper trunk injury? (C5.C6), illustrate on this person (live patient sat on couch) w h at sensory
deficit this patient w ould have on account o f an upper trun k injury? illustrate on this patient the sensory
deficit you w ould expect if the m usculocutaneous nerve w as injured? W hich m uscles are innervated by the
m usculocutaneous nerve? Point to the live person's coracoid process (surface anatom y)? W hich three
m uscles attach to the coracoid process? T est the function o f the deltoid on this patient? (basically test
shou lder abduction on the live person). E xam iner then took me to a skeleton and asked the follow ing: show
m e w h ere the spinal nerves com e ou t from ? W hat about C8 spinal nerve? W hich m uscles are responsible
fo r shou lder abduction beyond 90 degrees? (answ er here is serratus anterior and trapezius) and point on
the skeleton th e ir origins and attachm ents?

2. A n atom y - spine. W hat are the atypical cervical vertebrae? (answ er C 1 , C2 and C7). W hat are their
atypical features? W hich vertebrae is this? (exam iner pointed to C2 - axis). Took me to a live person and
pointed to the m ost prom inent vertebrae in his neck? Asked me w h at this w as - answ er - C 7 (vertebrae
prom inens). W hy m ost prom inent? (non-bifid spinous process and attachm ent o f nuchal ligam ent). Then
asked to talk through a lateral cervical spine X ray (also asked me to point to hyoid bone) and open peg
v ie w - nam e featu res i.e. lateral m asses o f C1 etc.

3. A n atom y - abdom inal. Started o ff with surface ana tom y on a live person. 1. S urface anatom y o f gall
bladder, surface ana tom y o f the transpyloric plane? structures a t this le vel? vertebral level? Then w ent
through a tran sverse prosection o f the abdom en - som e really strange questions w hich I could not answ er!!
Like w h at is behind the lesser sac?? (don't know w h at he w as after) and am I looking at this from an inferior
or supe rior view ? T he rem a inde r o f the questions w ere fine: asked - identify 4 abdom inal structures in this
im age? (so liver, spleen, pancreas, left kidney etc). Then pointed to a vessel (this w a s the splenic artery)
and asked about its course - here he w as looking for the lienorenal ligam ent. W hat other structures pass
through this ligam ent? w h at are the branches o f the splenic artery which supply the stom ach and w hat
structure do they pass through?

4. Com m unication skills - prep station first, going through notes for a sick patient w ho is going to need a
la parotom y fo r a perforated peptic ulcer w ho is curre ntly under the m edics. You have not yet seen the
patient. Liase w ith the ITU registrar and get a bed for her post-operatively and obtain som e advice from ITU
about her m anagem ent. Pretty sim ple station - use S B AR and then ITU reg will ask you "has an ECG been
done?" etc - the trick is not to lie - ju s t say it does not app ear to have been done but I w ill m ake sure it
is.....blah blah blah. Then he says that he has a 16 ye a r old m ale w ith an acute asthm a attack in ED who
w ill need an ITU bed and there's only one bed left...(argue y our case!). Then asks you to repeat his
in structions fo r her ongoing care - he basically advised you to give her a bolus o f fluids, give her IV Abx, do
an ECG etc - ju s t testing that you've listened to w h at he said. He eventually agreed to give the bed to the
patient.

5. Knee exam ination - right m eniscal injury. 23 year old in volved in football tackle pretending to have
m edial jo in t line tenderness and fixed flexion deform ity o f R knee. Asked to sum m arise the PO SITIVE
findings, m anagem ent plan and m anagem ent o f a m eniscal injury. I m entioned plain film s and he asked
w h at I w ould be looking fo r (i.e. fracture, loose bodies); do not forg et to say MRI and then talk through
conservative and surgical options - RICE, arthroscopic and open repair.

6. A bdom inal exam - case o f acute cholecystitis. Asked to do a com plete G l exam ination so hands, face
etc. M urphy's positive. E xam iner qs: please sum m arise y our findings? W hat are your dffierentials? (here he
w as looking fo r m edical causes too so don't forg et to say pneum onia!), w h at is yo u r m anagem ent plan?
(ABC DE, bloods including am ylase, NBM, erect CXR, IV fluids, IV Abx). Last question w as "he has been
diagnosed w ith acute cholecystitis. A fe w days later he has deranged LFTs w ith a bilirubin o f 45. W hat
single investigation w ould you do now ?" - answ er is MRCP.

7. S u bm andibular exam - lady w ho gets interm ittent sw elling o f L SM and pain on eating- a case o f SM
calculus. T he re w a s no palpable lum p. W hat are y our differentials? W hat investigations would you like to
do? M anagem ent? W hat is the SM duct called? - this is all very w ell covered in passthem rcs w e bsite -
sam e questions!

8. A B C D E exam o f a m an in HDU 6 days post L hem icolectom y, pyrexic w ith fast AF. I think this w as a
case o f anastom otic leak. Again, differentials and m anagem ent. The y did not ask you to do A B C D E here -
you have to m ake a decision o f w h at exam ination to do - because he w as sick, I did AB C D E and not ju s t an
abdom inal exam . Judging by w hat other candidates did that day, I think that w a s the right thing to
do! Differentials w ould include anastom otic leak, intra-abdom inal collection, wound infection etc (basically
causes o f pyrexia in a postop patient w ith abdom inal pain).

9. O rde r an operating list. Cases w ere 1) strangulated in guinal hernia patient w ith allergy to iodine and with
severe C O PD - repair und er GA, 2) lady w ith pacem aker with diverticu lar abscess allergic to penicillin, 3)L
below knee am putation fo r a patient with M RSA.
Q uestions were: w h at order and w hy? (so I put hernia first, then abscess and infected case last),and then
talk through each patient's issues so issues around pacem aker - w h at w ould you do? anything you would
change fo r hernia patient? - answ er here w as avoid G A due to severe C O PD - liase with anaesthesist
about doing this under regional instead and use chlorhexidine gluconate as prep, not iodine in light o f
allergy. Then there w as a model and asked to place the return electrode in a suitable place fo r hernia chap
(I chose left thigh). Then told to pick up bottle o f chlorhexidine and asked m e w h at I w ould be w orried about
in light o f diartherm y use (has alcohol in it so burns). W hat A B x w ould you give pacem aker lady? (allergic
to penicillin).

10. Critical care - burns and A R D S . Bog standard A TLS questions - how I would m anage? W anted to hear
about signs o f inhalational injury so say w orried about airw ay, how would you assess breathing? C alculate
his percentage burns? (given a diagram show ing his injuries) - answ er w a s 64% . H ow did you w o rk this
out? - rule o f 9s. Form ulae fo r fluids? - Parkland. W hat fluids? I said H artm anns and then he asked can you
give norm al saline (answ er is yes). W hat is the Parkland form ula? W hat colloids do you know ? G iven CXR
show ing bilateral pulm infiltrates? W hat is this? (AR D S)? W hat is the diagnostic criteria (rattle off Berlin's
criteria)?, How would you m anage A R D S ?

11. Critical care - m anagem ent o f fast A F and pneum operitoneum . Asked "w hat are the first tw o things you
would look at w hen analysing a CXR and EC G?" - the answ er here w a s patient dem ographics and
date/tim e. How would you consent this patient if he w as confused? H ow do you assess capacity?
Given an ECG and asked w h at it show ed (answer: fast AF; w hy? : abse nt P w aves, irregular rhythm ) and
calculate rate. His rate is 140 but the pulse oxim eter says 102, w hy? (answ er is pulse deficit).
Then gives m e a CXR. W hat is the abnorm ality on this CX R ? (answ er w a s penum operitoneum ). Asked
w h at are the causes o f pneum peritoneum ? You m entioned perforated viscus - give exam ples? W hat are
the causes o f fast AF in a surgical patient? How w ould you m anage this patient?

12. Physiology - hypothyroidism . Tell me about the thyroid axis? A nalyse these TFT s? W hat is the
diagnosis? Nam e tw o causes o f hypothyroidism ? N am e 6 clinical featu res o f hypothyroidism . W hat picture
would you see in the TFT s if the cause w as central hypothyroidism ? W hat are the surgical concerns o f a
hypothyroid patient? (m ention m yxoedem a com a, bradycardia, hypotherm ia etc), W hy has he got
m acrocytic anaem ia? (answ er is pernicious anaem ia - autoim m une), how can you im prove a patient's
com pliance to thyroid m eds? (m ention supp ort group, getting fam ily involved, dangers o f untreated
hypothyroidism , get GP involved, sim plify dosing regim en, aide m em oirs etc).

13. C linical skills - com pletely failed this station. M annequin. A irw ay com prom ise post RTA. Had to put on
collar, do ja w thrust, put in a guedel. Asked about surgical airw ay and cricothyroidotom y - how w ould you
do it? C annot recall all the questions as it w a s so bad! - blocked it out.

14. Com m unication skills - patient with splenic haem atom a w a nts to self-discharge. Ultim ately, the patient
ends up self-discharging anyw ay.

15. H istory taking - case o f acute pancreatitis secondary to ETOH excess. 1 day history o f epigastric pain
radiating to back w ith vom iting. Clue w as the fact she tells you she is a publican. Differentials and
m anagem ent. M ake sure to m ention severity scoring w ith G lasgow severity score.

16. H istory taking - pre-op clinic - patient fo r lap cholecystectom y. H istory o f chest pain - basically turns out
to be a case o f panic attacks. D ifferentials? H ow w ould you m anage? W ould you delay her lap chole?

17. P athology - toe gangrene. W hat is necrosis? Differences between necrosis and apoptosis? Dry and wet
gangrene? G ive me 4 RFs fo r atherosclerosis except diabetes, hyperlipidaem ia and sm oking. W hat are
pleural plaques? G ive m e tw o causes o f hypercalcaem ia in a lung ca patient? W hat single bedside test can
give you the diagnosis? - answ er here is sputum cytology.

18. Pathology - osteom yelitis and abscess.

Examination:
PVD: Pt with claudication 50-100 meters. PMH: angina, smoker. Do ABPI if possible.
Present the case and findings. What investigations?. What is ABPI? What possible treatment?

Cranial nerves: Pt with headache and visual problems. Don't test 1st cranial nerve or visual acuity
or corneal reflex or gag reflex. Pt has bitemporal hemianopia. There is no tuning fork to test for
rennie weber. What is your findings? What causes bitemporal hemianopia? What is the most
common pituitary tumor? Secretions of pituitary gland? What investigations? M R I, what else?

Hernia: Pt referred by GP for swelling in groin for 6 months. O/E: pt has left inguinal hernia, can be
reduced. ?direct hernia. No testicular swelling. Tell me your findings, location of deep inguinal and
superficial inguinal rings, location of inguinal and femoral hernia, management options, Indication
of laparoscopic repair.

Chest pain. Young lady 8 days post major abdominal surgery. Rt sided chest pain. Sats 92,
tachycardia, tachypneic. Tender Lt calf on examination. What is your diagnosis? What
investigations? wants to hear USS calf beside the normal investigations (CXR, bloods, CTPA).
How to treat? Now if pt collapsed in toilet what do you think might have happened? occlusion of
pulmonary artery. How to treat? thrombolysis +/- embolectomy and medical review

Procedures:
IV cannula: Real pt with prosthetic arm involved in RTC. A + B are clear. Has pelvic fractures and
abdominal pain. Insert a cannula and connect to fluids and write it on the chart. Pt tells you to call
his wife to pick up children from school. When started with ABC examiner asked to insert cannula
only. Available cannulas (grey, green, pink). I picked grey examiner said that's the right one but use
the green for now. Cannula inserted and there is a flash back. N.Saline present next to pt. I said I
would use hartmans examiner agrees but asked to connect Saline. Asked how fast would you run.
I said STAT. Asked to write on a chart. Asked who to get invole? ortho (apply pelvic binder) and
general surgeons. Asked who else do you want to call?? wants to hear I want to call the wife.

Sutures:
On table present 3 packs of prolene, 3 packs of vicryl, 3 packs of Silk. Examiners ask to pick
braided non absorbable and hand tie on rubber band to bring them together. What is the name of
the knot you did? what other knots do you know? Difference between Reef knot and surgical knot/?
Then pick braided absorbable and do hand tie on a hook without moving the hook. Asks what is
vicryl made of? When does it dissolve? Now there is a red dot (bleeding point) do figure of 8 using
monofilament non absorbable (instrument tie).

History:

Knee pain: 55 pt with knee pain affecting daily activities. Had sport injury to knee 30 yrs ago. Pt not
sure what was the diagnosis but says it was treated with above knee cast, pt says he is worried
about surgery as 2 of his friends had complications after surgeries. Took full history and clarified
about his friends and the complications (MRSA and PE). I explained that before we decide about
whether surgery is needed or not we need to run some investigations first and reassured him that
people react differently to surgeries, explained to him that even though surgeries have
complications but it doesn’t mean that he will get the same complications. Present findings to
examiner. What investigations to do? I said to start with simple AP/lateral view Xray. Asked in
which position? Said weight bearing views (agreed). Asked what is your top diagnosis? Said post
traumatic osteoarthritis. Asked what injury do you think he had in the past? Said intra articular
fracture (agreed). What is the management? Said can be operative or non operative however pt is
young and it is affecting his daily activities so likely will need surgery. Asked what surgery? said
osteotomy or total knee replacement. Examiner very satisfied.
AMTS:
Pt scheduled for total hip replacement. Nurse asked you to see him as appeared confused.
Straightforward AMTS questions. Pt scored about 5/10. Has wrist band and keeps looking at it and
acting confused saying he is here to see his friend. Explained to examiner that pt doesn’t have
capacity. Should surgery go on? Said no as we need to find out why he is confused? What do you
think it might be? infection (Chest, UTI), recent change in medication, etc. Will you send him
home? No he needs to be investigated and want to do confusion screen. Who will you inform?
surgeon, anaesthetist and medical reg for admission. Which non medical ppl will you call? bed
manager, family for collateral history.

Communication skills: 2 preparation stations before them to read notes.

Explain risks of OGD under GA to pt as consultant had to go to ward to speak to medical director
about bed situation but she will come back later to consent pt.
Need to be quick as big sets of notes. Pt seen in clinic few days ago. Had barium swallow which
showed likely benign stricture of oesophagus. Consultant booked for OGD under GA and dilatation
of stricture. In the notes pt is a heavy smoker, lost 10kg of weight in last month, deranged LFTs,
dysphagia to solids and liquids. Very confusing station as I am not sure what to talk about exactly
and not sure whether it is safe to dilate a stricture when his history is pointing towards cancer.
Explained the risks to pt in general. Explained that I would like to speak to the consultant and to
clarify whether she is aware of his wt loss and deranged LFTs. Pt is holding tissue in his hand and
keeps on saying that he is producing a lot of saliva for last 4 weeks and would like to know why -
no idea.

phone conversation. Pt day 1 post op. laparotomy for sigmoid tumor, intra operatively slipped
clamp and lost 2 L of blood, transfused by anaesthetist. Seen by reg for low urine output and she
asked you to speak to on call consultant for advice. Again very confusing station as a lot of notes
and didn’t have time to have a clear picture of what is going on. Struggled to find obs chart and
fluid chart. Pt hypotensive and tachycardic. Oliguric, AKI. Be aware of bloods in notes as some of
them are pre op! Phoned on call consultant and explained the situation. Asks what do you think?
pre renal failure? how to manage? fluid challenge, could it be anastomotic leak? less likely as
documented in notes that abdomen is soft and non tender but still a possibility. Would you like me
to see pt before clinic or after clinic or tomorrow/? (tomorrow is weekend). Said before clinic
(maybe should have said will check response to fluid challenge. Asked where do you think pt
should be treated? I said will discuss with HDU as has signs of organ failure.

Anatomy:
Hand anatomy: forearm/hand specimen with visible tendons and nerves, hand skeleton. Xray hand
of iPad, names of carpal bones, show me ulnar nerve and median nerve, show me flexor
retinaculum, bony attachments of flexor retinaculum. What passes in the tunnel? Does FCR (flexor
carpi radials) run inside the carpal tunnel? No. Show me thumb movements and tell me which
muscles and nerve innervation of each. Median nerve sensory distribution in hand. Show me FDS
and FDP. Where do they attach to? identify palmar arch. What is the main contributor? ulnar artery.
How do you test for adequacy of blood supply? Allen's test, show me.

Head+spine anatomy: Lateral view of cerebral angio on iPad. What is this? internal carotid artery.
Is there any abnormality? there were 2 obvious aneurysms (one of them in MCA) What is this
structure? anterior carotid artery. Identify internal carotid artery on prosection. Give 3 structures
supplied by the basilar artery (brainstem (he didn’t accept parts of brainstem i.e. medulla
oblongata, pons, midbrain), occipital lobe, didn’t know 3rd one, it’s cerebellum). Examiner showed
C1 vertebra, tell me the parts (anterior and posterior arch, anterior and posterior tubercle). What is
this? transverse foramen. What passes through? vertebral artery. What is its relation to C1 ? once
passes through the transverse foramen they travel across the posterior arch of C1 then through the
sub occipital triangle to enter foramen magnum. Symptoms of MCA infarction? wanted to hear
contralateral homonymous hemianopia. other symptoms include numbness and weakness of
contralateral face and upper limb, aphasia. How to differentiate clinically between upper and lower
motor neurone disease. Raise eyebrows. Asked for explanation.

Heart, thorax, abdomen: 3 prosections.

Heart: show me Rt atrium and left ventricle. Pointed to 1 structure what is this? I said atrium
appendage. Show me pulmonary trunk. What are the parts of pulmonary trunk? right and left
pulmonary arteries.
Thorax: This is the hilum of the lung what are the structures? 2 veins, 1 artery, 1 bronchus. Identify
them. What attaches the lung to the diaphragm ? pulmonary ligament
abdomen: If stabbed in the epigastric region from inferior to superior what structures at risk?
diaphragm and left lobe of liver. Where does left lobe of liver extends to on surface anatomy? left
midclavicular line. What are the lobes of the liver? right and left, show me the quadrate lobe. What
are the boundaries of quadrate and caudate lobes? caudate: laterally: IVC. medially ligamentum
venousum. superior: hepatic veins. lnferior:porta hepatis. Quadrate: medial: ligamentum trees.
Lateral: gallbladder, superiorporta hepatis. What structure separates right and left lobes of liver?
falciform ligament- identify it. What does it connect to? anterior abdominal wall. What are the
attachments of the liver to the diaphragm? Rt and left coronary ligaments (continuation of falciform
ligaments). Right and left triangular ligaments. What are the bony attachments of the diaphragm?
xiphoid process of sternum, lumbar vertebrae, ribs attachments 7-12 ribs.

Critical care stations:

pancreatitis: Pt with hx of alcohol excess has epigastric pain radiating to back and vomitting.
Shown blood results (high amylase 2000, high WCC 17 and slightly deranged LFTs) what is your
diagnosis? Acute Pancreatitis, why? raised amylase. Examiner said raised amylase can happen in
ruptured AAA or perforated duodenal ulcer. I said but not this high. What are your other
differentials? cholecystitis, cholangitis, etc. When can amylase be normal in acute pancreatitis? in
early or late episodes pancreatitis (usually peak with 48 hrs) or chronic pancreatitis. Tell me 2
names of criteria we use to assess for pancreatitis. I said Glasgow and APACHI. He didn’t accept
APACHI. I said Ramsons criteria. What do they assess? severity of pancreatitis and associated
mortality, components of glascow criteria. Why is there hypocalcemia in acute pancreatitis? acute
pancreatitis cause release of pancreatic enzymes resulting in saponiphication of omental fat. The
free fatty acid which are release chelate calcium leading to hypocalcemia What else causes
hypocalcemia ?said renal failure but didn’t accept it. Other candidates said low albumin - not sure if
correct. What symptoms pt has if there is pseudocyst? epigastric pain and epigastric fullness. What
is pseudocyst and how is it different from a normal cyst? it lacks endothelial and epithelial cells and
contains pancreatic enzymes.

Head injury; Young pt with head injury, loss of consciousness, regains full consciousness, later in A
+E drops GCS and has hypertension and bradycardia. CT brain on iPad. What can you see? it was
a clear left sided epidural haematoma with mid line shift to the right. When pt regain consciousness
what is that called and how to explain it? called lucid interval, happens due to expanding
haematoma secondary to middle meningeal artery laceration and this increases the ICP to an
extent where brain can’t compensate and that causes sudden drop in GCS. What is Monroe-Kelly
Doctrine? The doctrine states that the skull contains a constant amount of brain, blood and CSF,
any change in the occupying space in any of these will displace the others. How do you explain pt
hypertension and bradycardia? This is called Cushing triad, it happens as the body response to a
fall in CPP is to raise systemic blood pressure and dilate cerebral blood vessels. This results in
increased cerebral blood volume, which increases ICP, lowering CPP further and causing vicious
cycle. What is the formula of CPP? MAP-ICP. When do you do CT head in head injuries?
According to NICE guidelines CT head is indicated when there is head injury with 2 or more
episodes of vomitting. Drop in GCS. neurological symptoms. Elderly patients on anticogulants.
signs of basal skull fracture (panda eyes, battle signs, otorrhea, rhinorrhea, etc). When do you
intubate? If pt unable to maintain airways, GCS below 8 and below the need for controlled
ventilation.
Oesophageal varices: Pt with alcoholic liver disease comes with haematemesis. What do you think
is happening? oesophageal bleed. Why? portal hypertension. What is the endoscopic
management? wanted to hear band ligation and sclerotherapy. What else can be done? TIPS.
What does it stand for? Transjugular intrahepatic portosystemic shunt. Where will the shunt be?
between portal vein and hepatic veins. What is the definitive management in patients with end
stage alcohol liver disease and haematemesis? liver transplant. What is the criteria for liver
transplant in this type of patients? should be alcohol free for at least 6 months and compliance with
follow up. What are the areas of portosystemic anastomosis and give me some names of the
veins? Google it. lower oesophagus, umbilical, retroperitoneal, bare are of the liver, patent ductus
venosus, upper anal canal.

Pathology:
Difficult station. Can't remember the question exactly but was about Pt with ulcerative colitis with
hip pain and tumour necrosing factor (TNF). What is TNF? What is Virchow’s triad? hyper
coagulability, endothelial injury, stasis of blood flow. What is a platelet? What single test you do to
assess platelets? ?bleeding time. How do you differentiate platelets from other blood components?
?shape. What are the natural anticoagulation in the body? protein C, protein S, antithrombin. Why
do you think this pt has hip pain? avascular necrosis of the femoral head.

Breast Ca. Pt comes with a lump. How do you assess? triple assessment (hx and examination,
USS/mammography, biopsy). What biopsy? core biopsy, shown mammogram report shows
lymphovascular invasion- can't remember what questions followed the report. What operations do
you know for breast Ca? wide local excision or mastectomy . When you send the pathology
specimen what is the pathologist looking for? severity and grade of tumor, number of lymph nodes
involvement, oestrogen receptors, HER2 receptors, lymphovascular invasion,
1. Thyroid lump, hypo thyroid. Causes. ?pre op considerations fo r hypothyroid patients.
2. Suture a wound closed. (Non absorbable m onofilam ent) doses o f local anaesthetic
3. 24F recent travel to Bangladesh. Night sweats and neck lump. DDx - TB and Non Hodgkin
Lymphoma. ? Causes o f granulom atous inflammation. ?other m ycobacterium causing this
4. Cranial nerve exam ination. Bitemporal hemianopia. ? Cause. DDx. How would you Ix. ?blood tests
5. Neck and Thorax anatomy. Identify oesophagus. Identify Corina. Parotid and subm andibular glands.
O penings o f ducts. Nerves. Facial artery and vein
6. O steology o f scapula and humerus. Rotator cuff muscles and origin. Lunar and radial nerve injury.
O steology o f lower limb, origin and insertion of muscles
7. Surface anatom y o f transpyloric plane. Identify surface landm arks o f gallbladder, mid actually line.
Section through cadaver at L1. Identify 5 organs. Path o f splenic artery, blood supply to the stomach
8. Patient post left hemi has low u/o. D/w consultant
9. Hx station. Patient has longstanding episodes o f DIB. Now worse. Awaiting cholecystectom y. DDx
(anxiety/asthm a) how would you investigate. W ho would you inform?
10. C rohn’s disease on im m unosuppressant therapy has hip pain. W hat is TNF? W hat is the cause of
hip pain. (Osteoporosis and Avn o f the hip)
11. RIF pain exam - ?appendix. O ther tests and DDx
12. Resp exam - patient had a P.E.
13. LL Neuro exam - recent vascular surgery (vein stripping)
14. Hx pr bleed
15. Comms
16. Upper G l bleed- m anagem ent of. Songs taken blakem ore tube
17. RTA, extradural haematoma, Cushings triad
18. O T list - order o f priority. W here does the diatherm y pad go?
19 s ta tio n s (1 te s t)

A n a to m y
1. UL
- nam e r o ta to r c u ff m uscles
- w h a t nerve in n e rv a te s d e lto id
- d e m o n s tra te a b d u c tio n
- e x plain s u p ra s p in a tu s /d e lto id a c tio n in a b d u c tio n
- w h a t nerve in n v e rv a te s brach io ra d ia lis
- w h a t is th e a c tio n o f b ra c h io ra d ia lis
- w h a t nerve in n e rv a te s biceps and brachialis
> w h e re does th is n erve su p p ly fo r sensation
- p o in t o u t th e coracoid process on th e SP

2. UL/LL
- p o in t o u t r o ta to r c u ff m uscles o rig in s and a tta c h m e n ts
- w h e re does th e q u a d ra tu s fe m o ris o rig in a te and atta ch
- w h e re do th e g lu te a l m uscles o rig in a te and a tta c h
- w h a t is th e nam e o f th e c o n d itio n w h e re th e n erve ru n n in g u n d e r in gu in a l lig a m e n t is com pressed
- p o in t o u t g ro o v e w h e re radia l n erve runs on th e s keleto n
- d e m o n s tra te w h a t w o u ld hap pen to th e n a r m o v e m e n ts if u ln a r n erve is a ffe c te d
- w h y do p a tie n ts c o m p la in o f w e a k g rip if th e ir radia l nerve is a ffe c te d

3. A b d o m e n (SP present)
- la ndm arks fo r th e tra n s p y lo ric plane
- p o in t o u t th e m id a x illa ry line
- p o in t o u t th e costal m arg in
> w h a t ribs m ake up th e costal m arg in?
(cross s ection o f ab d o m e n )
- p o in t o u t 4 organs
- b lo o d sup p ly o f th e spleen?
> w h e re does th is run?
- b lo o d sup p ly o f th e s tom a ch th a t com es fro m th e splenic a rte ry
> w h e re does th is run?
- (p o in te d to p e rih e p a tic space, fa lc ifo rm lig a m e n t): w h a t are th e nam es o f th e s e s p a c e s /s tru c tu re s

C o m m u n ic a tio n s
1. U p d a te c o n s u lta n t
(re p e a t qn)
- p a tie n t POD 1
> p rio r to op, IV plug fa ile d and was k e p t NBM w ith o u t flu id
> post o p n o t ta k in g t h a t w e ll y e t
- vita ls : BP b o rd e rlin e , HR tac h y c a rd ic , o th e rw is e NAD
- called by SN due to lo w u rin e o u tp u t (~15 o v e r th e past h o u r)
- e x plain s itu a tio n to c o n s u lta n t, give a plan

2. A n xious p a tie n t
- b a ckg rou nd: p revio us MVR, on w a rfa rin c u rre n tly ; a d m itte d f o r som e op w h ic h w ill re q u ire s to p p in g
w a rfa rin
> e x plain to p a tie n t re g a rd in g need to brid g e w a rfa rin w ith cle xane
> p a tie n t c once rne d a b o u t clexane b rid g in g and e ffective ness
> o ffe r to a d m it p a tie n t 5-6 days b e fo re o p t o brid g e cle xane

C ritical care
1. DVT/PE
- p a tie n t p re s e n tin g w ith chest pain, POD 5-6 (c a n 't re a lly re m e m b e r w h a t op sorry)
- possible causes fo r th e c hest pain
- ECG, CXR results
- possible causes fo r th e DVT
- s u b s e q u e n t tre a tm e n t

2. GCS d ro p in RTA
(re p e a t qn)
- p a tie n t had GCS d ro p fro m 15>8
- q u o te Canadian CT rules
- M o n ro e Kellie d o c trin e
> h o w does th is explain his c o n d itio n
- id e n tify th e EDH
> b e tw e e n w h a t layers o f th e skull does th e h e m a to m a exist

3. H e m atem esis fro m esophageal varices

P a tie n t has kn o w n b a ckg rou nd o f liv e r cirrhosis, alco h o lism
- possible causes fo r th e hem atem esis
- w h y w o u ld th e p a tie n t have a c u te c o n fu s io n /fla p
- possible reasons f o r c o a g u lo p a th y
- id e n tify th e SB tu b e

4. H y p o th y ro id is m
- p rim a ry vs secon dary h y p o th y ro id is m
- m a c ro c y tic anem ia
> cause + p a th o p h y s io o f th e anem ia

H is to ry ta k in g
1. SOB
- lady w ith SOB o v e r th e past 1 -2 /1 2

2. PR b leeding
- g e n tle m a n w ith PR bleed +- tenesm us, fa m ily h is to ry +ve (b ro th e r has som e b o w e l issue th a t resulted
in having op + stom a )
- discuss possible c o n d itio n s and s u b s e q u e n t in v e s tig a tio n s /m a n a g e m e n t

P a thology
1. UC on s te ro id s
- n o w p re s e n tin g w ith NOF #
> path o p h y s io lo g y ?
- o rig in s o f pla te le ts
> te s t fo r p la te le t fu n c tio n

2. T B /ly m p h o m a
- 3 causes o f g ra n u lo m a to u s in fla m m a tio n
- p ro te in secreted in TB
- TB n o tific a tio n system in UK
- w h a t la b o ra to ry te s ts w o u ld yo u send fo r
- TB b lo o d te s ts (gold s tandard)

PE
1. AS
- CVM exam
- w h a t are th e lik e ly m e d ic a tio n s she is on
> w ill th is change m a n a g e m e n t in fu tu re
- c o n d itio n s u n d e r w h ic h in te rv e n tio n m ig h t be needed

2. Hernia
- huge hernia e x te n d in g all th e w a y in to th e scro tu m
- p revio us scar fro m old lap he rn ia re p a ir
- discuss in d ire c t vs d ire c t hernia
- surgical m a n a g e m e n t o f hernia
> lap vs open
> m esh?

3. T hyroid
- d iffu s e ly large g o ite r
- discuss in v e s tig a tio n s
> do TFT: if e u th y ro id , w h a t m a n a g e m e n t w o u ld you re c o m m e n d ?
> if h y p e rth y ro id , w h a t m a n a g e m e n t - RAI vs th y ro id e c to m y

4. Peroneal ne rve in ju ry
- p a tie n t cam e in fo r s trip p in g /h ig h tie o f varicose veins
- n o w p re s e n tin g w ith LL w e akness, un a b le t o d o rs ifle x + e v e rt rig h t fo o t
> a /w senso ry d e fic it o v e r L3-5 d e rm a to m e s

Procedures
1. S u tu rin g (clean w o u n d )
- LA a lre a d y given
- choose th e su tu re m a te ria l (p ro le n e vs vicryl)
- check conse nt, e xplain t o p a tie n t
- STO d a te , TCU dates
- any re q u ire m e n t fo r a n tib io tic s
- ty p e o f LA you w o u ld give and h o w m uch

2. OT lis tin g
(re p e a t qn)
- basically lis t o u t th e o rd e r o f surgery
> stra n g u la te d hernia
> d iv e rtic u la r abscess w ith pace m ake r to u n d e rg o H a rtm a n n 's
> MRSA f o o t nee ding BKA
- w h a t's th e ra tio n a le fo r th e above o rd e r
- w h e re does th e s tom a fo r H a rtm a n n 's p ro c e d u re usually go
- w h a t w o u ld yo u be c once rne d a b o u t w ith p a tie n ts w ith C O P D /pacem aker w h e n u n d e rg o in g surgery
> b ip o la r d ia th e rm y ?
MRCS (Ed) 07/02/18 Coventry

1. Surgical pathology - 98M with DM with gangrenous toe

?difference between w et/dry gangrene

1. Knee pain - no recent trauma - plate screw in knee. DDx

?organism causing knee pain ?lx, ?name 2 crystal arthropathies com m only affecting knee

1. Unwell patient - septic. CXR, free air under diaphragm

DDx ?
How would you read an ECG
Treatm ent o f AF

1. Anatom y - shoulder

Erb’s Palsy - ?nerve root C5/C6

?which derm atom e affected in Erb’s Palsy
Supraspinatus origin and insertion
Muscles that rotate the scapula
Skin affected by axillary nerve dam age
Attachm ents to caracoid process
Nerve supply to biceps
O ther muscles supplied by m usculocutaneous nerve

1. Com m s Skill - ITU reg discussion

74 F, off legs, no Hx, prev sm oker and on salbutamol

Urgent review, abdominal pain, peritonitis, cons- laparotomy
Bed post op (SBAR)
Asthm atic patient inbound- ?what to do

1. Hx - 45F with epigastric pain, smoker, drinker, lanzoprazole (not taking) ?pancreatitis, perforated
ulcer, cholecystitis. How would you manage this patient? Pancreatitis -? Scoring systems.
?m anagem ent o f this patient. ?why would you do C T scan.

1. C-spine anatom y - identify axis and parts. Dens/odontoid apical ligam ent and alar ligament.
O dontoid PEG view XR. W here is Hyoid bone. ?what level. Cricoid. Cervical prom inence, ?nam e of
supraspinous lig. W hat 2 things would be visible on C-spine x-ray

1. Hx - Preassessm ent for planned cholecystectom y. Breathless. W heezing. 10 year hx o f SOB.

CO PD/ Pneum onia/ anxiety. M anagement. ?bedside test.
Anxiety m anagement.

1. ATLS on a manikin - unconcious traum a patient. Airw ay management.

1. Anatom y - picture o f cadaver L1 level. Name 5 organs you can see. Surface anatom y o f gallbladder.
Costal cartilage in mid axillary line. ?origin o f splenic artery. O rgans that touch the spleen. Falciform
ligament, w hat peritoneal ligam ent (coronary and triangular)

1. Abdo exam - m urphy’s positive. Ddx

1. 6/7 post left hem icolectom y - Chest exam ination. ?P.E

1. Subm andibular gland exam ination -

1. Knee ex - ddx m anagem ent medial m eniscus

1. O perating list order

1. Com m s skill- self d/c patient splenic haematoma

1. Burns m anagem ent - parklands and ards, W allace rule o f nine. Rule o f palm, Lund + Brow der chart

1. Thyroid - how thyroid horm ones controlled - draw it out

Causes o f hypothyroidism , pre-op optim isation em ergency surgery.

DUBLIN RCSI 0 8 -02-2018

First o f all I am re a lly s o rry I c a n 't recall all q u e s tio n s o f each sta tio n s .

AN A TO M Y

1. Head n N e c k ...Id e n tify carina & its v e rte b ra l level, co m m o n c a ro tid , ECA ICA & b ifu rc a tio n level,
Vagus nerve, fa c ia l ne rve w h e re p a lp a te and if ligate w h a t w ill hap pen,? c a ro tid sinus and bulb
id e n tify and its fu n c tio n , id e n tify s u b m a n d ib u la r gland and p a ro tid gland and w h e re th e re d ucts
ope n, id e n tify subclavian a rte ry and its re la tio n to brachial plexus.
2. UL & LL; on SKELETON POINT fo r m e o rig in and in s e rtio n o f r o ta to r c u ff m uscles and th e re
nerves, radia l g ro o v e id e n tify , s tru c tu re s in it, s ensa tion loss, w h a t w ill dam age in m edia l
e p ic o n d y le fx, te ll senso ry and m o to r loss, ask a b o u t a d d u c to r p olicies........ W h a t is th is ? ASIS
m uscle a tta c h on iT. N erve com press h e re ...c o n d itio n n a m e ..M y ra lg ia P a resthetica....next m ove
on to g lu te s M e d iu s & q u a d ra tu s fe m o ris o rig in and in s e rtio n , T re n d e le n b u rg te s t, p o in t to
Pubic tu b e rc le and its re la tio n s w ith in guin al and fe m o ra l hernia.
3. ABDO M EN; assisting c o n s u lta n t in WHIPPLE p ro c e d u re he w ill ask som e q ue stions. Stom ach
b lo o d supply, pancreas blo o d supp ly, d e v e lo p m e n t, in tra p e rito n e a l p a rt, nam es tu m o r o rig in
fro m pancreas, id e n tify th is , IM V w h e re it d ra in ...in to sp le n ic ...w h e re p o rta l v e in fo rm ?
D u odenum in tra p e rito n e a l p a rt, 3 rd p a rt a n t and post re la tio n s , ask a b o u t lesser sac.

CRITICAL CARE

4 EDH ..all sam e que s tio n s b u t keep on asking a b o u t u n it o f in tra c ra n ia l pressure....w ho w ill yo u call in
th is case...how t o m easure in tra c ra n ia l p ressure...how t o decrease ICP and tre a tm e n t

5.VARICEAL BLEEDING...same q u e s tio n s asking a b o u t ENCEPHALOPATHY...how in s e rt tu b e . W h y p la te le ts

decrease. Id e n tify th is ? B lackm ore tu b e p ic tu re . Tell him a b o u t M in n e s o ta tu b e as w e ll.

6. OBSTRUCTIVE JAUNDICE...Bile fu n c tio n ? W h y e n te ro h e p a tic c irc u la tio n . W h e re it occur? H o w b iliru b in

fo rm and tra n s p o rte d ? Keep on asking on U rine r e p o rt th a t th e re is B iliru b in +++ b u t u ro b ilin o g e n
UNDETECTABLE...why???

PATHOLOGY

7. M ALIG N AN T M ELA N O M A . C o nge n ita l c o n d itio n s associated w ith it? Genes responsible? P rognostic
fa c to rs ? H yp erc o a g u la tiv e s tate? H o w t o c o n firm c o m p le te excision in OR? Frozen s ection

8. T.B p t cam e fro m Bangladesh n o w n ig h t sw e ats and lo w grade fe v e r...D /D . Likely diagnosis,
in v e s tig a tio n s ? W h a t is ra p id te s t fo r it? T re a tm e n t and c o n ta c t tre a tm e n t. W h a t is g ia n t cell?
C o n d itio n s w ith g ra n u lo m a ? W h e re w e place its sam ple? BIOHAZARD BAG

HISTORY

9 .CHEST PAIN a fte r THR...PE D /D . T re a tm e n t...in v e s tig a tio n s (ECG ABG..DONT fo rg e t th e s e )...p t w ill go
ho m e on h e p a rin o r n o t? H o w lo ng w ill yo u give w a rfa rin ?

10. BLEEDING P /R ...for 6 m o n th s 5 5yr old . W ith a b d o m in a l pain D /D ..investigation s.

COUNSELLING

11. M r G reen, BLIND, w a n d e rin g in w a rd lo o k in g anxious and c onfused and fo rg o t w h a t c o n s u lta n t to ld

a b o u t WARFARIN. N urse call y o u , ta lk him a b o u t s to p p in g o f w a rfa rin fo r his INGUINAL HERNIA
o p e ra tio n AN D give answ ers to his q ue stions. ACTOR w as w e a rin g black glasses. W h e n I g re e t him he
w as a c tin g lik e BLIND

12. TELEPHONE to c o n s u lta n t SURGEON on call ...tell him a b o u t p o s t m a s te c to m y p t and h e r d a u g h te r

w a n t to ta k e h e r ho m e to d a y 60 m iles aw ay...keep on asking w h y b lo o d in her dra in ? R e actionary
he m o rrh a g e ...h e w as lo o k in g f o r VESSEL LIGATURE SLIPPAGE...at th e end he ask...WRITE LETTER TO HIS
GP? W h a t w ill yo u m e n tio n in it?

EXAMINATIONS;

13. ABDO MINAL... pain RHC....D/D investigations...M RC P...ER CP...W hich a n tib io tic s ?

14. re s p ira to ry system...COPD w ith in gu in a l h e rn ia ...h o w w ill yo u p re p a re him pre -o p ? in vestigations?

15. CRANIAL NERVES + AM TS....i d id o n ly fir s t 6 nerves th e n e x a m in e r ask m e h o w to check, e x plain next
6 nerves...te ll m e 5 q u e s tio n s o f A M T S ..D /D ....in v e s tig a tio n ...A c to r had change in sense o f sm ell, B/T
h e m ia n o p ia and senso ry loss o v e r o p h th a lm ic d iv is io n area V /A can read up t o 2nd lin e fro m to p on
Snellen chart.

16. V e ry c onfusing. POST OP a fte r RFA and stab p h le b e c to m ie s had senso ry loss...exam ine PERIPHERAL
NERVOUS SYSTEM(not m e n tio n o u ts id e )...I s ta rte d by d o in g a rte ria l system th e n m ove on to nervous
system b u t c ould n o t c o m p le te e x a m in a tio n ...a c to r had f o o t d ro p on w a lkin g...sensory lo st o v e r big
to e ...D /D c o m m o n pero n e a l n erve in ju ry . ln vestigations...N C T & E M G .... tre a tm e n t...c o n s e rv a tiv e .
P h ysiotherapy

PROCEDURES

17. pass FOLEYS...why anu ria? Cause? Investigation s?

18. s titc h w o u n d w ith n o n -a b s o rb a b le s u tu re . A c to r was keep on in te rru p tin g m e ...h o w m a n y s titc h w ill
y o u do? Scar? Pain killers?

T h a t's all.

REMEMBER ME IN YOUR PRAYERS.

 M R C S E D IN BU R G H D E LH I 26,h M A RC H /2018
Anatom y:

1) Neck & Thorax region

Pic o f Arch o f Aorta region: Identify Arch- name its 3 branches

show left vagus Nerve & tell what it wings, identify left phrenic nerve (how it passes through
diaphragm)
Root value o f brachial plexus at post. Triangle, Erb’s & Klumpke’s paralysis
Identify thyroid
Name arteries supplied & venous drainage o f thyroid gland along with its site o f origin/drainage
Common electrolyte def. after thyroid surgery?
Commonly injured nerves during thyroid surgery?
Parathyroid: exact location & origin (from which pharengeal pouch), different locations o f inf.
thyroid gland, Thymus: origin
Nerve Supply o f Laryngeal muscles

2) Pic of cranial fossae with intact dura:

Identify tentorium cerebelli & tell its attachment.
Show Optic Nerve-through which canal it passes
Identify Internal carotid artery, identify pituitary fossa.
Show Occulomotor nerve-origin from Midbrain, muscles supplied by it, Paralysis o f Nerve leads
to (examiner wants to hear Is' -Dilated Pupil, then others), passes through sup. orbital fissure
Name muscles supplied by IV & VI cranial Nerve
Blood vessel present inner table o f pterion
Tumor just behind the central sulcus, most common approach to reach it- I answered Trans­
sphenoidal, trans-frontal approach (Examiner wants only 1)
False localizing Sign in Neurology (New ques)
Aggressive form o f Glioma

3) Pic of right gluteal region and popliteal fossa

Sciatic nerve: identify & anatomical Landmark, route value, variations with regard to the sciatic
nerve exit the pelvis
show hamstring muscles with its origin & action
Identify Gluteus medius, nerve supply, action, Trendelenburg test
Identify Popliteal fossa-boundaries, contents superficial to deep, LN draining the area, D/D o f
lump from popliteal fossa (examiner wants to hear examples from each 1 structure like from
vein-popliteal vein varicosities; from artery, nerve, fat, bone)
Most common structure in popliteal fossa can injured during surgery
C ritical care

4) O bstructive Jau n d ice

(epigastric pain, nausea, vomiting diarrhea, increased A LT, A ST , ALP, GGT, Urobilinogen
undectable in urine)
Causes o f Obs. Jaundice? How do you manage?
Why clotting deranged? Which Inv you want to do to monitor.
Functions o f bile salt? How bile salt help in fat emulsification?
What is bilirubin conjugated to?
What is urobilinogen? how it formed? Why Urobilinogen undectable in urine in above senario?
Enterohepatic circulation?
How to correct clotting abnormality?
Other Investigations you want to do?- U SG o f Abdomen Special attention to HBP region
If the patient had fever, pain chills-Ascending Cholangitis
In details Management o f Ascending Cholangitis (Antibiotic + Others )
few more questions—

5) Pneum othorax+ C V line insertion

Shown a Chest Radiograph o f Simple Pneumothorax (inadequate because costophrenic angles
not shown), System for reading C XR. What is the most imp. first to check at a chest x-ray-
patient demographics. Items to be commented on Chest radiograph.
Types o f Pneumothorax. How do you manage?
Anatomical Landmark o f C V line insertion in IJV, Technique o f insertion & removal,
Complications other than pneumothorax & air embolism, Organism causing infection, how to
prevent line infection, predisposing/risk factors o f having CV line infection.

6) T IIR P Syndrom e
Post TURP Confused, hypoxic, hypotensive— D/D (told TURP syndrome, Hyponatraemia,
Effects o f analgesia/sedation, Cerebrovascular disease). Examiner wants more-told me TURP
syndrome is due to dilutional Hyponatraemia, so tell more— I guess she wants Blood Loss as d/d
Define, C/P, Management o f this patient?
Having N a+ 120mmol/L, how will you correct his hyponatraemia?
Other system affected by TURP
What diruetics you want to use here in a pt o f having N a+ 120mmol/L & potassium 3.5mmol/L?
How does Furosemide works? Where spironolactone acts?
Pathology

7) Parotid tum ors

What is most common parotid benign swelling?
What is the meaning o f pleomorphic? - Remarkable histologic diversity (examiner wants more)
Describe pleomorphic adenoma appearance?
Clinical signs o f malignancy? Features o f malignant cells?
Virchow’s Triad
Test to differentiate Carcinoma & Lymphoma? -Immunohistochemistry
To rule out malignancy peroperative frozen section done, If you find
Lymphoid cell with pleomorphism > Lymphoma; Lymphocytes with Langerhans Giant cell >
Granuloma, Epitheloid cell with brown cytoplasm > Malignant Melanoma
What is high sensitivity & high specific test? Said (Sensivity-True positive rate, Specificity-True
negative rate), Examiner wants explanation.

8) Blood T ransfusion+ O steoporosis (examiner gave me 19 out o f 20 © )

Patient having Hb 7.8g/dl-Which blood product u will give? -Packed RBC
In Packed RBC pecentage o f W BC?- Zero
What test to do before transfusion? Life span o f R B C ’ s?
What is Group & Matching?
Stages o f bone healing?
Effect o f prolonged immobility? (Examiner specially wants to hear Osteoporosis)
Infected implant why should you remove? What is the 1st test to do? -Wound swab for C/S
what is osteoporosis? How osteoporosis losses bone density (M/A)
what is PVL Staph Aureus? Effect o f its cytotoxin

E xam inations:

9) 35 yr old male assume that he has Rt. Su b m an d ibu lar swelling (simulated pt.)
Examine: I examined the patient thoroughly-done every steps+LN +3 Nerve test & at the end said
to complete my examination I want to examine other salivary glands as well- Examiner laughed
& said who stopped you to doing that, plz proceed___ Then I did full parotid examination as well
along with VII cranial nerve examination
D/D: Stone disease / Neoplasm
Why stone disease most common in Submandibular gland?
what investigations you want to do?
Surgical Management- examiner happy when I started with depends upon proximal/distal to
Lingual nerve (also said not to say Marsupialization here)

10) C ard iac Pacem aker aged male (pacemaker Rt.infraclavicular zone)
Examine the C V S: Present your case
Indications o f Cardiac pacemeaker? ECG given— shows pacemaker spikes, no P-wave
Whom do you inform/involve? What should be the preoperative health check-up? Precations you
need to take in OT in dealing with such o f patients ?
Ask few ques about Diathermy as well
Co-operative actor. Tenderness over the right hypochondrium.
Murphy’s sign+
Diag: Acute Cholecystitis (Examiner wanted emphasis on case presentation)
D/D?
What investigations you want to do according to d/d?
Wants details about abdominal x-ray & U SG findings?
(Examiner was happy when I told calcium containing stones are Radio-opaque)

12) Young lady with pain and num bness of right hand since last few months.
Examine: Carpal tunnel syndrome (Simulated patient)
D/D: cervical radiculopathy/disc disease, Diabetic neuropathy.
What are muscles supplied by median nerve in the hand & forearm
what are the causes o f carpal tunnel syndrome?-Colles fracture, Lunate dislocation
acromegaly, myxoedema.
How will you manage conservatively: Wrist splint, steroid injections, pain killer
Operative options? -release o f carpal tunnel

History:

13) H/o per rectal hlcdding , young lady gave h/o IBD.
D/D Examiner was eager to heard amoebic/bacillary dysentery
Ask details about Crohn’s & UC
how will you manage the patient (Want to hear details Investigation)

14) Prc-opcrative Confusion

Test memory o f the patient: A M TS/M M SE
On history also asked about the red coloured wrist band patient had.
On entering ques o f Language & Praxis o f M M SE bell rang so can’t complete the history
D/D? Should the operation go ahead? Management (Whom do you involve)?

Com munication

15) Stem :Explain to the patient regarding Arthoscopy cancelled

Patient had Meniscal tear in left knee. Cancelled before
Explain the patient that Mr.Mann has been called away for an emergency case.
Actor was too good (angry but co-operative), explain the situation
Took it as my own responsibility to let him know the next possible date over phone.
End the conversation by offering him a cup o f coffee with some biscuits.
Prep station : Whole set o f notes:

16) Stem: Old lady with limb ischemia + abdominal pain diagnosed as diverticulitis on iv fluids
and antibiotics.
Speak to the vascular consultant on call to transfer the patient to the Tertiary hospital.
Collect all the relevant information from the papers provided.
Check and remember the hospital name and your consultant name
Note down Patient’s condition and co-morbidities.
Do SB A R
Qns:
D/D- a) Acute limb ischemia b) DVT
What investigation to diagnose?: Arterial duplex scan
What is the cause - possible embolus.
what treatment for limb ischemia: Embolectomy, Bypass, LMW heparin.
What about Cardiac Consultation?
Any signs o f peritonism??
How will you transfer? Whom do you need to talk

Procedure Stations

17) Catheterization
After Checking Id obtain verbal consent, ask about allergy, medications, whether he experienced
this before, proper positioning
(Gloves & Gown provided) Have to select all the instruments you need to perform the procedure
first. Check date o f Jasocaine jelly & Catheter.
Assistants available.
After inserting the tube in aseptic technique (want to change gloves after giving proper wash,
examiner told that assume u r in 2nd gloves) 1 asked the examiner is the urine coming, i f yes then
I want to inflate— Examiner stopped me & told that no urine is coming— Ask why Anuria?
Again why? Why?
Answered & examiner was satisfied when I ended with seeking help from Urologist
Dispose o ff everything before leaving the room.

18) Knot tying-

A) R eef knot with non-absorbable braided suture (Silk)
What other knots do u know? In Surgeon’s knot how many through u need to give by index
finger?
B) Deep cavity knot by absorbable braided suture (Vicryl) ? Done as per basic surgical video but
Examiner asked how many through u need to give in case o f vicryl’s to secure-1 told 3, so he
asked u should give there as well.
Ques: What is vicryl made up from? When is absorped? Tensile strength? Advantage o f braided
Suture ? How to protect tissues while tying depth?
C) Figure o f 8 S u ture in closing b leeding Vessels- Choose S u ture (P rolene).. H o w m a n y th ro u g h u need to
give-6

* Start this station by asking to wash my hand with sterilizer, Examiner was happy & told it’s a
good approach to start but assume that u r gloves & gown

Tips: Appearing o f this type o f exam is playing with your own nerves. Try to enjoy each & every
station as much as possible by communicating with examiners & patient’s. 1 used to ask
Antiseptic hand wash in every station at the beginning & end as well. Manage the time wisely;
complete the examinations before time so that you get time for question answer.________________

Dr. M d. Abdul Baten Jo a r d e r (Rossy)

M B B S, M RCS(Eng), M RCSEd, M R CS(G lasg), MPH(Epi)
Resident M S Urology, National Institute o f Kidney Diseases & Urology
Dhaka, Bangladesh.
Email: [email protected]
MRCS OSCE Ireland 13 April 19, 2018 Dubai Center

S ta tio n 1 A n ato m y o f Thorax and neck

A n a to m y

id e n tify esophagus, carina , subclavia n a rte ry , e x te rn a l and in te rn a l c a ro tid

a rte ry , re c u rre n t la ryng eal nerve, p a rt o f brachial plexus ju s t p o s te rio r to
subclavian, w h ic h tru n k is ju s t p o s te rio r
level o f carina
Level o f c a ro tid b ifu rc a tio n
C a ro tid b od y and Sinus
id e n tify p a ro tid and s u b m a n d ib u la r gland, w h e re does th e d u c t open
e p ith e liu m o f esophagus
e x plain subclavian steal syn d ro m e
S ta tio n 2 A n ato m y o f extensor co m pa rtm ent o f Arm
A n a to m y

N am e th e m uscles, M u scle a tta c h m e n ts , N erve sup p ly o f m uscles, b lo o d

supp ly
A n a to m ic a l s n u ff box b ou ndaries
Radial tu b e ro s ity
N am e carpal bones
sig nifican ce o f b lo o d supp ly t o scaphoid and th e c o n d itio n (AVN), w h y it
happens
id e n tify dorsal d ig ita l expa nsion and explain its fu n c tio n
S ta tio n 3 M id d le Cranial Fossa A n ato m y
A n a to m y

id e n tify m id d le crania l fossa and its b o rd e rs

Id e n tify fo ra m e n s and s tru c tu re s passing th ro u g h th e m
cavernou s sinus, o p tic canal, s u p e rio r o rb ita l fissure
W h ic h a rte ry in o p tic canal, w h a t is th e s p e c ia lty and conse quence o f its
th ro m b o s is
H ow does m id d le ear in fe c tio n spread t o c rania l cavity?
H o w does cavernou s sinus th ro m b o s is pre se n t? Its ro u te o f in fe c tio n ?
W h a t s tru c tu re is here - cavernou s sinus? W h a t are s tru c tu re s passing
th ro u g h it -ICA, A b d u c e n t nerve
S tru c tu re s on la te ra l w a ll - 3 rd ,4 th ,5-1 ,5-2 c rania l nerves
Loca tion o f T rig e m in a l ganglion
S ta tio n 4 Young girl w ith abdom inal pain and on o ff bloody stool. Exam showed
P a th o lo g y ulcer in rectum and anal canal Right hem icolectom y done. HP shows
chronic granulom atous inflam m ation
Im pression
M acro scopic p ic tu re o f C hron 's disease (R ight h e m ic o le c to m y specim en).
Id e n tify fe a tu re s o f c h ro n 's disease
W h a t are th e extra a rtic u la r m a n ife s ta tio n s o f C h ron 's disease?
ZN S taining organism
In te rp re t b lo o d results, anem ia
Role o f v it B12 and fo la te in hem opo iesis. E ffe ct o f de ficie n cy, w h y
m a c ro c y tic
S ta tio n 5 50 fem ale w ith 5 cm lum p in breast and strong fam ily history
P a th o lo g y
MRCS OSCE Ireland 13 April 19, 2018 Dubai Center

H o w w ill yo u app roa ch

M a m m o g ra m show s s pecu lated app earance
W h a t ty p e o f biopsy
Biopsy show s a ty p ic a l cells, w h a t is y o u r in te rp re ta tio n
W h a t are c o m m o n e s t ty p e o f bre a s t ca
W h a t a d d itio n a l te s ts w ill yo u do on tru c u t
w h a t is ER/PR/HER2
U n d e rw e n t m a s te c to m y fro z e n p o s itiv e so c o m p le te clearance, w h a t w ill be
n e x t step
W o u n d gets discharge, w h a t w ill you send
W h a t are fe a tu re s th a t yo u w ill see in h is to p a th o lo g y re p o rt
W h a t is Trastuzum ab, m echanism o f action
S ta tio n 6 A gen tlem an w h o w as post tra u m a and presented w ith reduced left
E xam hearing
P e rfo rm e x a m in a tio n o f hea ring (in c lu d in g o to s c o p y ) and re le v a n t
e x a m in a tio n , Facial nerve e x a m in a tio n , v e s tib u la r e xa m in a tio n
D iffe re n c e b e tw e e n w e b e r and re n e 's te s t
H ow to p e rfo rm o to scopy? d ire c tio n to p u ll th e ear
W h a t is y o u r in te rp re ta tio n o f fin d in g ? Im pression? d iffe re n tia l diagnosis
In vestigation ?
Diagram o f o to s c o p y given. W h a t does it show ? h e m o ty m p a n u m
D iffe re n tia l diagnosis
W h a t in v e s tig a tio n w o u ld you d o and h o w m anage?
S ta tio n 7 Patient had a sports injury and com plained o f right ankle. Perform ankle
E xam exam inatio n.
W h a t is y o u r fin d in g ?
W h a t is y o u r im pressio n?
D iffe re n tia l diagnosis?
W h a t in v e s tig a tio n w o u ld you do? MRI
Supposed it is la te ra l m a lle o lu s fra c tu re , w h a t is th e e xpe cted fin d in g s and
m a n age m ent?
H o w lo ng t o p u t a p a tie n t on POP cast?
W h e n w ill p a tie n t re tu rn t o a c tiv ity
W h e n w ill he be able to play
W h a t if fra c tu re does n o t heal, w h a t are o p tio n s
S ta tio n 8 Young m ale M a jo r abdom inal surgery 4 days back cam e now w ith SOB
E xam and chest pain
Exam ine th e chest:
Go as p e r ABC ( Ccrisp p ro to c o l)
Tenderness o v e r th e rig h t u p p e r chest w ith SOB.
Laparoscopy dressing o v e r th e a bd om e n.
V ita ls s h o w HR 120 and fe v e r 38
D iffe re n tia ls
P u lm o n a r y e m b o lis m

W h a t in v e s tig a tio n to d o ? .C h e s t X -ra y , A B G , C TP A

H o w to m a n a g e ? P ro p u p , 0 2 ,IV flu id s , L M W H , I f m a s s iv e

p u lm o n a r y e m b o lis m - n e e d e m b o le c to m y .

H o w to p r e v e n t; TE D s to c k in g s , e a r ly m o b iliz a tio n , L M W H
MRCS OSCE Ireland 13 April 19, 2018 Dubai Center

You are scrubbed in th e OT call fro m w a rd p a tie n t collapsed w h a t w ill you

do? Call th e sw itc h and Raise a larm .
S ta tio n 9 Young m ale w ith right iliac fossa tenderness
C lin ic a l S k ills

E xam ination
D iffe re n tia ls
If fe m a le and w h ile o p e ra tin g has b lo o d , w h a t w ill yo u do, w ill yo u do
a p p e n d e c to m y
W h a t are o th e r d iffe re n tia ls in m ale p a tie n t
S ta tio n 1 0 Sequencing cases w ith scrub nurse
C lin ic a l s k ills 1. 70 years M a le w ith diabetic gangrene, w ith pacem aker in place
planned fo r BKA, p atien t is on heparin infusion fo r atrial
fib rillatio n and has MRSA
2. 68 fem ale w ith penicillin allergy and com plicated diverticular
abscess undergoing hartm an's
3. 70 m ale w ith exacerbation o f COPD and asthm a has obstructed
hernia
P rio ritiz e
W hy
Preop p re p a ra tio n s
W h ic h d ia th e rm y to be used
W h ic h a n tis e p tic p re p a ra tio n
W h ic h a n tib io tic s
S ta tio n 11 Suture Knot
C lin ic a l S k ills

Hand K not tie

Deep K not tie
Figure o f 8 k n o t
Type o f su tu re , m a te ria l, p re fe re n c e o f size and ty p e
S tre n g th o f vicryl
Problem s o f dee p k n o t m a te ria l fo r vic ry l, its a b s o rp tio n and re te n tio n tim e
n u m b e r o f th ro w s if abso rb a b le and non -a b s o rb a b le
S ta tio n 1 2 History taking of p atien t 60 year old c /o im potence fo r 6 m onths
H is to r y Sm oker, Lost Job 6 m onths back, HTN takes atenolol for 2 years
Im pression?
Causes o f im p o te n c e ? W h a t is th e cause in th is p a tie n t?
Investigation s?
M a n age m ent?
W h a t ty p e o f UTI/STD cause im p o te n c e ?
P athop hysiology?
S ta tio n 1 3 H is to ry ta k in g o f m id d le aged g e n tle m a n w h o had s p o rts in ju ry 30 years
H is to r y back and u n d e rw e n t surgery n o w c o m p la in in g o f 6 m o n th s o f knee pain
Dx? post tra u m a tic OA
fin d in g s if exam in e
Inves tig a tio n s
m a n a g e m e n t o f OA
Station 14 Telephone On-call surgeon
MRCS OSCE Ireland 13 April 19, 2018 Dubai Center

C o m m u n ic a tio n

70 y e a r fe m a le u n d e rw e n t m a s te c to m y and a x illa ry cle ara nce fo r breast

cancer, p o s to p e ra tiv e ly d ra in o u tp u t serous 30 m l, 2 POD d ra in o u tp u t 450
m l b lo o d , and w o u n d is soggy and red, p a tie n t has ta c h y c a rd ia and is
h y p o te n s iv e , She w a n ts to g e t tre a te d and th e n go h e r o w n hom e, her
d a u g h te r w a n ts t o ta k e h e r to h e r h om e 60 m iles aw a y and persuaded
p a tie n t t o go ho m e and e v e ry th in g is fin e , she is lo ne w o rk e r usually
re m a in s outs id e
T e le p h o n e o n-call surgeon and u p d a te
S ta tio n 1 5 C o m m u n ic a tio n w ith w ife
C o m m u n ic a tio n

W ife w h o s e husband had a b d o m in a l s w e lling, ta p sh o w e d m a lig n a n t cells,

p a tie n t is to ld by re g is tra r by m is ta k e th a t p a tie n t has cancer. Needs
a b d o m in a l th e ra p e u tic dra in ? In prep n o te , th e CT m achin e is b roken, next
CT m achin e is 40 m iles aw ay, w h ic h can be arra nged.
The c o n s u lta n t supposed to speak to th e fa m ily b u t w as called to scrub fo r a
case in OT so yo u are called t o speak and c o n s u lta n t has said to "h o ld th e
f o r t " . B ro th e r in A u stra lia
S ta tio n 1 6 M id d le aged g e n tle m a n u n d e rw e n t e m e rg e n c y A A A su rg e ry , re q u ire d
C r itic a l c a r e tra n s fu s io n , d e v e lo p e d h y p o th e rm ia
D efine h y p o th e rm ia
C o m plicatio ns
H ow does h y p o th e rm ia a ffe c t surgery?
H o w to p re v e n t h y p o th e rm ia in tra o p e ra tiv e ly ?
H ow to tre a t c o a g ulopa thy?
W h a t is p hysiolo gy o f co a g u la tio n
D e fin itio n o f m assive tra n s fu s io n ?
W h a t are th e e ffe c ts o f m assive tra n s fu s io n ?
H o w does th e p re s e n ta tio n o f ARDS and TRALI d iffe r? p a th o p h y s io lo g y and
tim e line and tre a tm e n t
S ta tio n 1 7 P ost th y ro id e c to m y d u e t o th y ro id to x ic itie s d e v e lo p s tin g lin g o f m o u th
C r itic a l C a r e

D iffe re n tia ls
P hysiological roles o f calcium ., w a n te d a t least 5
F eatures o f hypo calcaem ia? signs
m a n a g e m e n t o f post th y ro id e c to m y hypo calcaem ia
cause o f hypocalcaem ia
m e d ic a tio n s to be given
h o w is calcium c a rrie d in c irc u la tio n
w h a t p ro te in is it bo u n d to
W h a t is hom eostasis o f calcium
Role o f v ita m in D
H om eostasis o f V ita m in D
S ta tio n 1 8 Y o ung m a le p re s e n te d w ith a c u te a b d o m e n , dis c h a rg e d n o w cam e back in
C r itic a l c a r e ER w ith severe a b d o m in a l p a in , s h o rtn e s s o f b re a th and h y p o te n s io n his
w o rk u p re v e a le d p a n c re a titis
Look a t CT im age and give m e d iffe re n tia ls (P ancreatic necrosis and fre e
MRCS OSCE Ireland 13 April 19, 2018 Dubai Center

flu id )
Blood Inve stig a tio n s
C o m plicatio ns
W h y s h ortness o f b re a th lo ok a t c hest Xray, d iffe re n tia ls
Look a t blo o d te s ts (hypocalcaem ia), h o w does it cause hypo calcaem ia
M a n a g e m e n t o f ARDS
Inves tig a tio n s
S ta tio n 1 9 M id d le age m ale had pain in right iliac fossa pain, surgery done showed
P a th o lo g y / D u m m y / d ilated appendix looked like mass, histopathology showed some findings
P ilo t E x a m

P a thology sh o w e d a p p e n d ic u la r abscess -D e fin e abscess

W h a t is abscess w a ll m ade o ff?
H ow does n e u tro p h ils m ig ra te
W h a t are b lo o d te s ts th a t w ill id e n tify in fla m m a tio n
H ow does c a rc in o id tu m o r spread
W h y a person w ith heavy m eta stasis in liv e r have s y m p to m s ra th e r th a n
fe w m etastasis
H o w does tu m o r m etastasize
H ow does m e ta s ta tic d e p o s it survive
W h a t in v e s tig a tio n s w ill you d o t o id e n tify m etastasis
W h a t te s ts in u rin e w ill you d o f o r carcin o id
M R C S P art B S ta tio n s

Sheffield - 16 M a y 2 0 1 8 - P M session

A p o lo g ie s f o r lack o f e x p a n d e d d e ta ils , I'm o n ly lis tin g th e s ta tio n s w ith b r ie f d e ta ils ra th e r th a n give

a fu ll a c c o u n t o f th e s ta tio n s as I le ft it t ill I g o t m y re s u lts t o re ca ll th e s ta tio n s and ty p e th is so

fo rg o t a lo t o f th e specifics n o w ! A n y w a y , I passed f ir s t tim e w ith a v e ry go o d score m a n y th a n k s to

th is s ite , so th o u g h t it's o n ly f a ir to c o n tr ib u te ! M a jo r ity o f s ta tio n s are re p e a te d a n d m o re in fo can

be fo u n d in lo ts o f th e past y e a r acco u n ts , and if y o u d o y o u r o w n s tu d y in g a ro u n d th e s e high y ie ld

to p ic s y o u s h o u ld be a b le t o a n s w e r m o s t q u e s tio n s easily.

G ood lu ck!

A n a to m y

• Skull - sh o w n d ry b o n e skull and la te ra l s k u ll x ra y - asked to id e n tify bon es, fo ra m in a + w h a t

nerv e s pass th ro u g h th e m , s u tu re s , p te r io n and s ig n ific a n c e , d ip lo ic veins

• Low er lim b - a n a to m y p ro s e c tio n (p o s te rio r v ie w o f leg) - s c ia tic n e rv e a n a to m y and

la n d m a rk s , g lu te a l m uscles and n e rv e s u p p le , id e n tify v a rio u s h a m s trin g m uscles, s tru c tu re s

in p o p lite a l fossa, causes o f lu m p in p o p lite a l fossa, v e n o u s d ra in a g e o f lo w e r leg

• Thyro id - a n a to m y p ro s e c tio n - id e n tify p a rts o f th y ro id , e m b ry o lo g y , p a ra th y ro id re la tio n s ,

th y ro g lo s s a l d u c t cyst, a rte rie s , veins, ne rv e s in c lu d in g w h ic h nerv e s a re re la te d t o w h ic h

vessels, m uscles s u p p lie d b y la ry n g e a l nerves and c o n s e q u e n c e s o f in ju ry

Pathology

• Carcinoid - p a tie n t w h o had a p p e n d ix m ass re m o v e d and h is to s h o w e d c a rc in o id th e n asked

q u e s tio n s a b o u t c a rc in o id tu m o u rs , d e fin itio n , c o m m o n lo c a tio n s , m a lig n a n t p o te n tia l,

c a rc in o id s y n d ro m e , asked a b o u t m e th o d s o f tis s u e s a m p lin g and t o e x p la in

im m u n o h is to c h e m is try

• P ancreatitis - p a tie n t w ith p re v io u s c h o le c y s te c to m y , p re s e n ts w ith a b d o pain and

o b s tru c tiv e LFTs and raised a m ylase . A ske d w h a t is a m ylase and fu n c tio n , lik e ly diagnosis,

lis t o th e r s p e c ific b lo o d te s ts y o u w a n t and reason f o r each, f u r t h e r in v e s tig a tio n s and

m a n a g e m e n t, p s e u d o c y s t fo rm a tio n , m a n a g e m e n t
C ritical C are

• A d re nal - c a n 't re m e m b e r th e sce n a rio , w a s asked q u e s tio n s a b o u t zones o f a d re n a l glands,

h o rm o n e s p ro d u c e d , e x p la in h y p o th a la m ic p itu ita ry a d re n a l axis, c o n s e q u e n c e s o f lo n g te rm

s te ro id s , a d re n a l in s u ffic ie n c y , signs o f a d re n a l crisis, w h e n IV s te ro id s nee d e d

p e rio p e ra tiv e ly

• R habdom yolysis - p o s to p p a tie n t w ith b ila te ra l o p e n t ib / f i b fra tu re s , b lo o d s s h o w e d AKI

and raised m y o g lo b in . Asked q u e s tio n s re g a rd in g causes and p a th o p h y s io lo g y o f AKI, w h y

u rin e d ip s tic k p o s itiv e f o r b lo o d vs no b lo o d on u rin e m ic ro s c o p y , o th e r b lo o d

te s ts /in v e s tig a tio n and m a n a g e m e n t o f rh a b d o m y o ly s is , c o m p a r tm e n t s y n d ro m e

• Feeding - in itia lly s h o w n c h e s t xrays and asked t o c o m m e n t o n NG tu b e p o s itio n , o th e r

m e th o d s t o c o n firm p o s itio n , m a n a g e m e n t i f u n h a p p y w ith p o s itio n o n x ra y o r c a n 't g e t

a s p ira te . C o n s titu e n ts o f fe e d s , p a re n te ra l vs e n te ra l, in d ic a tio n s , risks etc.

• P a ra thy ro id - s tra ig h t fo rw a r d p h y s io lo g y q u e s tio n s a b o u t p a ra th y ro id h o rm o n e s , ca lc iu m

h o m e o s ta s is etc, re n a l o s te o d y s tro p h y , d a ta ite m s in m in im u m d ata s e t f o r p a ra th y ro id

ca n ce r

C o m m un ication Skills

• T elep h o n e referra l ( D iv e rtic u litis w ith AF + a c u te ly is c h e m ic lim b ) - read th ro u g h a fe w

pages o f n o te s and re fe r t o v a s c u la r c o n s u lta n t - p le n ty o f tim e so no nee d t o rush

• Angry p a tie n t (C ancelled a rth ro s c o p y ) - p o s tm a n a tte n d s f o r a rth ro s c o p y (p re v io u s ly

ca n c e lle d tw ic e ) - have t o e x p la in p ro c e d u re c a n c e lle d again as c o n s u lta n t a w a y a t

e m e rg e n c y

History

• Crohns - h is to ry fro m y o u n g fe m a le w ith 10 m o n th s h is to ry o f a b d o pain, d ia rrh o e a , w e ig h t

loss. Asked a b o u t d iffe r e n tia l diagnosis, in v e s tig a tio n s and m a n a g e m e n t. Asked a b o u t

c o e lia c disease as a d iffe r e n tia l and h o w t o dia g n o s e th is

• Thyro id - h is to ry fro m m id d le aged la d y w ith neck lu m p and s y m p to m s o f h y p e rth y ro id ,

w o rr ie d a b o u t cance r. Asked a b o u t d iffe r e n tia l dia g n o sis, in v e s tig a tio n s and m a n a g e m e n t

Exam ination

• Foot d ro p - p a tie n t p re s e n t w ith f o o t d ro p p o s to p v a ric o s e v e in s u rg e ry - e x a m in e . Asked

a b o u t d iffe r e n tia l diagnosis, w h a t o th e r e x a m in a tio n s y o u w a n t t o d o , in v e s tig a tio n s and

m anagem ent

• Thyro id - la dy p re s e n ts w ith n e c k lu m p - e x a m in e . M y p a tie n t had a th y ro id e c to m y scar and

a sm all rig h t th y ro id lu m p . Asked w h a t m y lik e ly d iagnosis w a s (I p re s u m e d she had a

p re v io u s le ft h e m ith y r o id e c to m y f o r fo llic u la r a d e n o m a ). Asked a b o u t fu r t h e r in v e s tig a tio n s

and m a n a g e m e n t, o p tio n s if FNAC s h o w s fo llic u la r c e lls /in d e te rm in a te , m e d ica l

m a n a g e m e n t o f th y ro id s ta tu s , w h a t if p a tie n t th e n refu ses th y ro id e c to m y , w h a t fo llo w u p ?

• Lipom a - m an p re s e n t w ith back lu m p - e x a m in e . Had m u ltip le lip o m a s . Asked a b o u t

d iffe r e n tia l diagnosis, w h a t o th e r e x a m in a tio n s y o u w a n t t o d o , in v e s tig a tio n s and

m anagem ent

• Cardiovascular - p a tie n t a tte n d s p re -o p c lin ic - e x a m in e . P a tie n t had p a c e m a k e r and m ild

signs o f h e a rt fa ilu re . S h ow n ECG and asked t o d e s c rib e . P e rio p e ra tiv e c o n s id e ra tio n s in th is

p a tie n t.

Procedural

• Incision + drainage o f abscess - c o n s u lta n t has c o n s e n te d a lre a d y and p a tie n t p re p p e d and

d ra p e d , b u t he had t o leave. Check c o n s e n t, a d m in is te r lo cal, p e rfo rm p ro c e d u re . P a tie n t

asked s o m e q u e s tio n s a b o u t ana lgesia, sc a rrin g , can she s h o w e r, fo llo w u p . Asked q u e s tio n s

a b o u t Langers lin e s and d ire c tio n in th ig h , w h y pack w o u n d and le ave o p e n , w h a t packing

and d re s s in g w ill y o u use and w h y

• Excision o f skin lesion - c o n s u lta n t had c o n s e n te d , p re p p e d and d ra p e d and a d m in is te re d

lo cal, b u t had t o leave. Check c o n s e n t e tc and p e rfo rm p ro c e d u re . P a tie n t asked a b o u t

ana lgesia, sc a rrin g , fo llo w u p , w h e n she w ill fin d o u t re s u lts etc. M a n y c o m p la in th a t th e

s pon ge m a te ria l is d iffic u lt t o close, b u t I b e lie v e if y o u d o n 't ta k e excessive m a rg in s , have

ta k e n a w e ll- p r o p o r tio n e d e llip s e , and have g o o d s u tu rin g te c h n iq u e s y o u w o n 't ha ve a

p ro b le m .
S h e ffie ld M ay 201 8

E x a m in a tio n : Lum p
A s k e d to e x a m in e 3 lu m p s to b ack. S oft, w e ll c irc u m s c rib e d , no t te th e re d , no tra n s illu m in a tio n / b ru its /
p u ls a tility . N o ly m p h a d e n o p a th y . N o tic e d s p id e r na e vi, c h e rry h a e m a n g io m a , d ia ly s is fis tu la .
D iffe re n tia l? In v e s tig a tio n s ? (k e p t p u s h in g fo r d iffe re n t im a g in g m o d a litie s - s o m e o f th e o th e rs said
P E T -C T )

S kills: l+ D
D ra in a g e o f a b s c e s s b e c a u s e c o n s u lta n t ca lle d a w a y ; yo u g e t an a s s is ta n t. P a tie n t w ith pad on
a n te rio r thig h , c o n s e n t d o n e , b u t c o n firm e d n a m e / d o b / p ro c e d u re / q u e s tio n s / a lle rg y . T o d o LA
b lo c k and e xcise . P us d id n ’t rupture , s o to o k it o u t lik e s e b a c e o u s c y s t and then co n tin u e d w ith
a b s c e s s m a n a g e m e n t.
P a tie n t asked : w ill it hu rt/ a n y s c a rrin g / w o u n d m a n a g m e n e t
E x a m in e r a s k e d : h o w to c lo s e / w h e re la n g e rs lin e s on th ig h / w h a t w o u ld yo u u s u a lly p a c k w ith

S kills: N a e v u s e x c is io n
E x c is e n a e v u s b e c a u s e c o n s u lta n t ca lle d a w a y ; yo u g e t an a s s is ta n t. P a tie n t w ith pad on a n te rio r
th ig h , c o n s e n t a n d LA d o n e , b u t c o n firm e d n a m e / d o b / p ro c e d u re / q u e s tio n s / alle rg y. M e a s u re d
e x c is io n m arg in (had to u s e th e s id e o f th e pen b e c a u s e th e re w a s no p ro p e r ruler). E x c is e d a n d to
c lo s e w ith in te rru p te d non a b s o rb a b le s u tu re s , in s tru m e n t tie. P a d w a s p o o r and w o u n d d id n ’t c o m e
to g e th e r w e ll - e x p la in e d I w o u ld g o b a c k to su tu re it p ro p e rly a fte r b rin in g th e w o u n d to g e th e r. S o m e
o f th e o th e rs did m a ttre s s s u tu re s
P a tie n t a s k e d : s c a rrin g / w h e n fin d o u t a b o u t re s u lts / pain a fte rw a rd s

S c ia tic n erve a n a to m y
C a d a v e ric s p e c im e n
S c ia tic n erve ru n s m id p o in t b e tw e e n w h ic h 2 la n d m a rk s
A lte rn a tiv e c o u rs e s o f th e s c ia tic nerve
N e rv e roots
P o in t o u t h a m s trin g s
W h a t a c tio n s and hip and knee
P o in t o u t p o p lite a l fo s s a c o n te n ts
W h a t m u s c le is th is (g lu t m e d iu s )
W h a t d o e s it do
W h a t is T re n d e le n b e rg ’s sign

N e c k a n a to m y
C a d e v e ric s p e c im e n o f th o ra x a n d neck
W h a t is th is (arch o f a o rta )
W h a t a re th e s e (b ra c h io c e p h a lic / c a ro tid / su b c la v ia n )
P o in t o u t v a g u s
W h a t w h y is th e re h o a rs e v o ic e w ith b ro n c h ia l c a rc in o m a
P o in t o u t re c u rre n t la ry n g e a l n erve
W h a t is th is (th y ro id )
W h a t is th e a rte ria l s u p p ly
W h a t is th e v e n o u s d ra in a g e
W h e re a re th e p a ra th y ro id g la n d s
H o w m a n y a re th e re
P o in t o u t th e u p p e r tru n k o f th e b ra c h ia l plexus
W h a t d a m a g e le a d s to a rm fle x io n , lo ss o f a b d u c tio n and w ris t e x te n s io n
W h a t p a ls y is cau s e d by d a m a g e to p ro o ts c 8 /T 1

R est
S ku ll a n a to m y
B o n y s k u ll a n d p la s tic is e d m o d e l;X R on p a p e r and iP ad
P o int o u t th e pterion
W h a t b o n e s jo in
W h y is it im p o rta n t
W h a t ty p e o f h a e m o rrh a g e
W h a t v e s s e ls d a m a g e d if e x tra dural
W h e re d o e s th e blood c o lle c t
W h a t is th is - la m b d o id su tu re
W h a t is th is - p o s te rio r a rch axis
W h a t a re th e s e - sm all v e in s in th e s k u ll bon e
W h a t is th is - s p h e n o id sin u s
P o in t o u t w h e re th e m id d le m e n in g e a l a rte ry e n te rs th e skull + n a m e (u n d e rs id e o f s k u ll)
W h a t e n te rs here (IC A )
W h a t is th is (ju g u la r fo ra m e n )
W h a t e n te rs here

C a rc in o id
Y o u n g w o m a n has a p p e n d ic itis , re m o v e d and fo u n d c a rc in o id no t e x te n d in g b e y o n d m u s c u la ris
P a tie n t has d ia rrh o e a and flu s h in g a fte rw a rd s - w h a t s y n d ro m e (w a n te d c a rc in o id n o t s e ro to n in )
D o yo u nee d to g o b a c k s u rg ic a lly to re m o v e
W h a t do yo u m e a s u re
W h a t do yo u lo ok a t to d e te rm in e if m e t is c a rc in o id
R isk o f m a lig n a n c y
H o w lo ng do R B C live
W h y d o yo u g ive th is la dy iron a fte r p a rtial liv e r re s e c tio n
O n a n tib io tic s and d e v e lo p s d ia rrh o e a . W h a t is m o s t lik e ly ca u s e
W h a t do yo u s e e on b io p s y w ith C d iff
W h y d o yo u se e p s e u d o m e m b ra n e s
W h a t te s t
H o w to c o n firm c le are d

P a n c re a titis
M an, p re v io u s g a lls to n e s , no s ig n ific a n t a lc o h o l
In v e s tig a tio n s y o u ’d w a n t and b rie fly w h y
W h a t is th e m o s t lik e ly c a u s e o f g a lls to n e s in th is p a tie n t
W h a t is C R P and w h e re is it m ade
G e ts g a s tric o u tle t o b s tru c tio n
W h a t is th e lik e ly ca u s e
W h a t in v e s tig a tio n
D e v e lo p s s p le n ic a rte ry a n e u ry s m - h o w c a n yo u tre a t it
H o w d o e s e n d o v a s c u la r c o ilin g w o rk
T a k e m e th ro u g h th e e x trin s ic c lo ttin g pa th w a y
He d e v e lo p s s e p s is - tre a te d on a n tib io tic s bu t d o e s n ’t g e t b e tte r
W h y m ig h t he ha ve n o t re s p o n d e d to a n tib io tic s

C V e x a m PP M
P re -c h o le c y s te c to m y w ith P P M o n ly ju s t re a lis e d in place
N o rm a l C V e x a m - s o m e m ild pitting o e d e m a to le gs, I d id n ’t th in k J V P w a s raised , no b ibasal
c ra c k le s - e x a m in e r u n im p re s s e d w h e n I s aid he w a s n ’t in h e a rt fa ilu re
P re s e n t fin d in g s
R e v ie w E C G - p a c in g spikes
O p e ra tiv e c o n s id e ra tio n s - p a c e m a k e r te c h n ic ia n , ? e x te rn a l pacing, o th e r c o n s id e ra tio n s w ith
d ia th e rm y

LL n e u ro p o s t v a ric o s e v ein ligation

P a tie n t p re s e n ts w ith lo s s o f s e n s a tio n and fo o t d ro p R a fte r radio fre q u e n c y a blation
F o o t d ro p on w a lk in g a n d lo ss o f s e n s a tio n to th e la teral a s p e c t - u n a b le to fin is h exam
W h a t do yo u w a n t to do to c o m p le te th e e xa m in a tio n
W h a t has c a u s e d th e n e u ro lo g ic a l lo ss o f fu n c tio n

N eck exam
P re s e n ts w ith n e c k s w e llin g
S m a ll a n te rio r n e c k s c a r on in s p e c tio n , no o th e r s y m p to m s
W h a t in v e s tig a tio n s
W h a t is th e m o s t lik e ly ca u s e
W h a t im a g in g + w h y
S y m p to m s o f h y p e r/ h y p o th y ro id is m

B reak

R est

P a th - rh e u m a to lo g y / stero id
D e s c rib e th e s tru c tu re o f th e a d re n a l gla n d and w h a t th e y p ro d u c e
H o w is c o rtis o l c o n tro lle d
W h y is c o rtis o l se c re te d
H o w d o e s c o rtis o l e x e rt its e ffe c ts
W h a t risks a re th e re o f lo ng te rm s te ro id s
P re /in tra a n d p o s t o p e ra tiv e c o n s id e ra tio n s if on s te ro id s
W h a t is th e d iffe re n c e a b o u t be in g on a c u te and lo ng te rm s te ro id s ?
W h a t d o e s a ld o s te ro n e do
W h y is it re le a s e d
W h a t e le c tro ly te d e ra n g e m e n t h a p p e n s in A d d is o n ’s
W h o d o y o u g e t in v o lv e d p re -o p e ra tiv e ly

P ath - rh a b d o m y o ly s is
B u ild e r tra p p e d u n d e r fa lle n rubble, re m o v e d and n o w h a s A K I, B P 90, K+ 7.1, a c id o s is
W h a t is th e d ia g n o s is
H o w to d ia g n o s e rh a b d o m y o ly s is
W h a t b io c h e m ic a l te s ts x 2 (ca and C K )
W h y is K + ra ised
H o w can you tre a t (u rin a ry a lk a lis a tio n - h o w d o e s it w o rk )
W h y d o yo u g e t c o m p a rtm e n t s y n d ro m e
W h a t h a p p e n s if tre a tm e n t fa ils
H o w to d ia g n o s e c o m p a rtm e n t s y n d ro m e

P ath - fe e d in g
P a tie n t p o s t m a n d ib le ex c is io n
W h a t m e th o d s are th e re o f fe e d in g
B e n e fits and risks
W h ic h is b e tte r
NG c a n yo u fe e d - no, in R b ro n c h u s
NG c a n yo u fe e d - yes, g o th ro u g h th e s teps
H o w to te ll if w o rk in g
H o w m u c h a s p ira te
W h y w o u ld yo u g iv e tp n - risks
W h a t is in tpn
In w h ic h p a tie n ts w o u ld yo u g iv e p a re n te ra l fe e d in g
Rig fe e d in g ris k s / c o m p lic a tio n s

P a th - C K D and v it D
W h y is th e re h y p e rp a ra th y ro id is m w ith C K D
W h a t is th e m e c h a n is m o f PT H on c a lc iu m
W h a t e lse c h a n g e s e le c tro ly te s
H o w can you te ll if it is m a lig n a n t
D e s c rib e fro z e n s e c tio n
W h a t is a s s o c ia te d w ith p e lv ic s to n e
U ro th e lia l ce ll c a rc in o m a - w h y d o e s it hap pen
T y p e s o f c a rc in o m a in renal pelvis
W h a t in fo rm a tio n is pro v id e d in a path re p o rt (s ta n d a rd d a ta s e t) - m a c ro s c o p ic

R est
C o m m prep
P a tie n t a d m itte d fo r d iv e rtic u litis , tre a te d c o n s e rv a tiv e ly (o n ly c le rk e d b y FY 1). 1 h r lo s s o f p u ls e s /
s e n s a tio n / d e c re a s e d p o w e r/ cold; re fe r to v a s c u la r s u rg e o n ; E C G A F - no t know n; s m o k e r
C o m m - a c u te lim b is c h a e m ia
SBAR
F o r re v ie w
S a fe fo r tra n s fe r? A c id o tic - lik e ly fro m leg s o nee d to tre a t ca u s e
C an it w a it till m orn ing
? L IF pain s e c o n d a ry to th ro m b u s ?

H is to ry - d ia rrh o e a y o u n g w o m a n
4 w h is to ry o f d ia rrh o e a , p a le w a te ry s to o l w ith m u c o u s and blood, g e ttin g w o rs e
No tra v e l, in fe c tio n , d e c re a s e d a p p e tite
No P M H x / D H x
N o etoh
Sm oker
D iffe re n tia l
IBD - ? C ro h n s / p a n c re a titis
W h a t te s t d o yo u w a n t to do - c o lo n o s c o p y
W h a t h a p p e n s if th a t is n e g a tiv e ?
W h a t e ls e co u ld yo u do a t UG I e n d o s c o p y

C o m m prep
P o s tm a n had kn e e a rth ro s c o p y ca n c e lle d 2 nd tim e a s c o n s u lta n t had to g o to dea l w ith tra u m a
C o m m - p a tie n t a rth ro s c o p y c a n c e lle d
W hy
C an s o m e o n e e ls e do it
It’s a h o s p ita l w h y d o e s he ha ve to go, is n ’t th e re s o m e o n e else
E xp lained
ICE
O th e r m e a n s o f c o n tro llin g pain - on ib u p ro fe n ; he n o w ha s he a rtb u rn

H is to ry - e n la rg in g th y ro id lu m p
P re s e n ts w ith e x p a n d in g lu m p to th ro a t, in c re a s in g in s iz e fo r th e la s t 2 w e e k s . P re v io u s ly d ia g n o s e d
10 y e a rs ago , in v e s tig a te d 8 y e a rs , to ld B e nign . D o e s n ’t re m e m b e r w h a t d ia g n o s is w a s
H y p e rth ry o id s y m p to m s . W o rrie d ca n c e r
P re s e n t p o s itiv e fin d in g s
In v e s tig a tio n s
W h y did y o u a s k g a la c to rrh o e a
W h a t a re th e lik e ly c a u s e s
D id sh e h a v e c o m p re s s iv e s y m p to m s - fo rg o t to a s k s w a llo w in g d iffic u ltie s / bu t c h e c k e d a irw a y
Sheffield MRCS Part B - May 2018

Station 1 - Pathology station: Nasopharyngeal Carcinoma

56yo Chinese M ale with ulcerating lesion at back o f nasopharynx. Diagnosed with
nasopharyngeal carcinom a. Recently underw ent chem otherapy and has T2DM .
• W hat are RFs for nasopharyngeal carcinom a in this patient?
• How would you define a carcinom a?
• W hat would be your differentials in this patient?
• W hat other non-epithelial tum our would you consider in this patient? (lym phom a)
• He w as found to have palpable lym phadenopathy, how could you assess a lym ph node?
• W hat are the positives and negatives o f cytology v histology?
• W hat is the scale by which we assess a radiation dose?
• You take a sw ab o f the wound and it grew hyphi. W hat would your diagnosis be? (fungal)
• W hat would be the m ost likely fungal infection in this patient?
• W hat are the RFs for fungal infection in this patient - DM, recent chemo.

Station 2 - (pilot station) Also pathology, sim ilar to above but focussing on breast
cancer. C an't really rem em ber m any o f the questions because the exam iner w a sn ’t there
when I started and so I had to com plete the station in 5 mins.

Station 3 - Cardiovascular examination:

Midline sternotomy, LVH, pacemaker, murmur.
Asked to interpret ECG afterw ards and w hat things would need to be considered pre-op in
a patient undergoing elective surgery with a pacemaker.

Station 4 - Varicos Vein examination:

S tandard exam ination. M assive varicose veins in both the great and lesser saphenous
territory.
Asked to do a doppler.
Also finished with peripheral pulses etc.
But m ainly an exam ination o f inspection.
Q uestions: W hich distribution? W hat treatm ent options? (refer to NICE guidance)

Station 5 - Acute abdomen (very good actor and interpretation of observation

chart... clearly deteriorating).
Full abode exam. Patient acted out a guarding in the LIF very well.
In light o f 65yo m ale (actor was young, so read the ag e ... I got caught out) with LIF pain.
Acute m anagem ent
Differentials
How to grade diverticulitis (H inchey C lassification).
How to treat if it w as a sigm oid perforation.

Station 6 - Cranial nerves/otoscopy/Rinne & Webers (very odd)

Given the BG o f a 40yo alcoholic has fallen and hit his head on the ward, he is
com plaining o f hearing loss on the left. Do a relevant exam ination...
A ssessm ent o f cranial nerves 7 and 8.
Rinne and W e b e r’s.
Otoscopy.
Looked fo r signs o f basal skull fracture.
Q uestions: Explain Rinne and W ebers - you need to know which is Rinne pos/neg
Explain conductive and sensorineural hearing loss.
Shown a picture of haem otym panum - w hat is the likely diagnosis?
W hat is battle sign?

Station 7 - Procedure: Local anaesthetic infiltration & ab sce ss drainage.

You did not need to take consent. Just confirm it w as there, confirm the patient (obviously)
and then do a field block with the LA and drain the abscess on the actors thigh (plastic
model).
Q uestions: Asked why you make an incision in Langer’s lines?
Asked w hat type o f packing you would use - know a few different brand nam es because
he asked me for two.

Station 8 - Procedure: Suturing & Local Anaesthetics

Suture the wound with a non-absorbable suture (had to choose between vicryl
(absorbable) and another suture). You did not need to counsel the patient about anything
because it stated in the instructions that she would receive a leaflet after you’d finished.
However, you do need to know because she chatted to me the w hole w ay through.
Q uestions: Had to calculate LA dose, know how much to give with and w ithout adrenaline,
and needed to know different options for im m ediate acting and longer acting anaesthetics.

Station 9 - Anatomy 1: Foot 8c Ankle

• Nam e all the bones
• Nam e all the ligam ents on the m edial (4) and lateral aspect (3) - and point them out.
• W hat bones m ake up the lateral arch?
• Dem onstrate on yourself the m ovem ents o f the ankle joint.
• W hat are the tendons o f anterior com partm ent and identify them on the specim en.
• W hich tendons invert the foot
• W here would you identify the pulse on the dorsum o f the foot

Station 10 - Anatomy 2: Mediastinum & Oesophagus

• W hat are the boundaries o f posterior m ediastinum ?
• W hat structures run in it (nam e 6) - show me on the model if possible
• W hat is the standard length and surface m arkings o f the oesophagus?
• W here does it exit the thoracic cavity?
• W hat is the blood supply o f the oesophagus?
• W hat is the lym phatic drainage o f the oesophagus?
• W hat is im portant about the venous drainage o f the oesophagus? (portosystem ic
anastom osis at low er oesophagus between left gastric and azygous)
• W hat is barretts oesophagus?
• W hat is achalasia?

Station 11 - Anatomy 3: Head & Neck

• W hat are the boundaries o f posterior triangle?
• W hat is this structure? (Spinal accessory nerve)
• How do you test it?
• W hat m uscle is this - inferior belly om ohyoid and w hat is it’s nerve supply
• W hat is this muscle - stylohyoid and w hat is it’s nerve supply
• W hat are the extrinsic tongue m uscles and w hat are th e ir nerve supplies?
• W hat gland is this - subm andibular gland
• W hat type o f secretions does it produce?
• W hat nerves m ight be dam aged and how would you explain the deficits to a patient?
• Shown a histological im age with brown spots in it... W hat do you think about the
histology o f this LN - had melanin deposits - m elanom a
Station 12 - Pathology: Diverticular disease & endometriosis
• W hat is diverticula disease and w hat is diverticulitis?
• You find neutrophils in the tissue sam ple, how do you explain this? (Looking for an
explanation o f m igration/chem otaxis)
• W hat cell line do neutrophils originate from ?
• W hat is the average life span o f a neutrophil?
• Define an abscess.
• How do you m anage an intraabdom inal collection?
• W hat is endom etriosis?
• How does the ectopic tissue get there?

Station 13 - Communication: 9 mins reading time and time to make notes...

Basically, old wom an with breast ca had m astectom y and axillary clearance 2/7 ago,
daughter now w ants to take her home - 60m i aw ay and both her and her husband w ork full
tim e ie. w o u ld n ’t be able to look after her properly.
Current issues - SOB and has blood POURING out o f her drain. Not had bloods since pre­
op. Discuss the situation with cons on call.

Station 14 - Communication: Calling the cons on call

• Confirm it is the consultant
• Tell him who you are, w here you are.
• SBAR
For this situation
• Basically need to assess patient capacity and see if the patient actually wants to go
hom e with her daughter.
• Address patient and fam ily concerns
• Explain the need to stay for further tests - ie she is SOB and could require a blood Tx
due to losses from drain
• If refusing to stay - she has autonomy.
• O ffer care at a hospital closer to her fa m ily...
• If still refusing, contact local GP for regular hom e visit review to check she is ok
• If no capacity, w ould have to stay out o f best interests etc.

Station 15 - History taking (6min), Presentation & Questions (3min):

Knee pain, likely post traum atic secondary oa knee after m eniscectom y when younger

Station 16 - Communication: Explanation

Blind man with M VR on w arfarin w ho is very anxious about stopping it. Very good actor.
Patient very anxious as his cardio cons told him NEVER to stop warfarin.
• Need to explain bridging fo r high risk patient
• Explain that you will inform the necessary people - his cardio cons, his GP, district nurses
• G et him inform ation in brail if possible
• If still not happy, offer for him to com e in a couple o f days pre-op to ensure that he
receives the correct doses
• Give him a contact num ber to call if he has any further questions

Station 17 - History taking (6min), Presentation & Questions (3min):

IVDU with groin lump.
Lump in groin, ‘feels like its pulsating'
Ddx o f groin lum p and stressed concern about fem oral aneurysm /pseudoaneurysm .
W hat do you do for fem oral pseudo aneurysm ?
W hat are the com plications o f venous grafting v stenting?

Station 18 - Critical Care: Burns & A R D S

Patient involved in a house fire. 11% eTB S A burns with singed eyebrow s and black
nostrils. Burns look pink and wet, have blistered already, none are circum ferential.
• How would you m anage a and b in this patient? (Need anaesthetist as ?airw ay
com prom ise +/- CO)
• How to assess burns surface area - different classification systems.
• W hat type o f burns are they?
• C alculate fluid requirem ent over first 24h and how w ould they be given? Ie. split into 50%
over 8h and 50% over 16h.
• W hat fluid would you use to resuscitate?
• W hat does this CXR show? ARD S
• W hat are the clinical findings in AR D S? (He wanted 4 things)
• How do you m anage? ITU and ventilate
• Asked about pressures because we had finished and he w as trying to push me - 1d id n ’t
know.

Station 19 - Applied Science: Painless jaundice

• How do you classify the different types o f jaundice? Unconj v conj, or by cause: pre
hepatic, hepatic, post hepatic
• W hat is the com position o f bile?
• How much bile is produced per day?
• W hat is the action o f bile on lipids?
• Explain the enterohepatic recycling o f bile.
• W hy does it get recycled?
• W hy does it affect clotting if there is obstructive jaundice?

Station 20 - Applied Science: Nutrition

• W hat are the different types o f feeding? po v enteral v parenteral
• How do you know and NG tube is in stom ach? aspirate and test, CXR if not
• W hat are the benefits and risks o f NJ v NG?
• W hat are the indications fo r parenteral nutrition?
• Look at this CXR and tell me w hat is w rong - NG tube in lung
• W hat would you do in this situation?
• W hat are the com ponents o f nutrition?

Key revision tips:

• Learn your anatom y from a decent anatom y atlas, then focus it down in the final couple
o f w eeks based on past questions - they were alm ost all repeats o f previous years.
• Practise your exam ination technique - m ost o f the m arks are in the doing bit, not the
questions at the end. Know how to do opthalm oscopy/otoscopy/AB PI/doppler, as this will
throw you if you don't feel com fortable.
• Learn your basic physiology based on past questions (all o f m ine were repeats from
previous years).
• For history stations - the diagnosis will be relatively obvious. Take a focussed history and
keep your presentation to a m inim um (they have ju s t heard you take the history), this will
give them m ore tim e to ask you questions.

Good luck!
DUBLIN MAY 2018

1) P t p r e s e n t s w ith rig h t g ro in m a ss . US sh o w s so lid a r e a s

If it is ly m p h o m a , w h a t a r e 2 b r o a d c a te g o r ie s H o dgkin v s n o n h o d gk in
o f ly m p h o m a y o u k n o w
P t u n d e r g o e s FNAC. T u rn s o u t to b e ep ith e lo id A risin g fro m ep ith e lia l c e lls
m e la n o m a . W h at d o e s it m e a n b y th e te rm
ep ith e lio id ?
N am e 4 ty p e s o f m e la n o m a S u p e rfic ia l sp r e a d in g , n o d u la r, a m ela n o c y tic ,
le n tigo m a lig n a
W h ere w o u ld y o u ex a m in e th e p t? N a ils o f h a n d s a n d feet, sc a lp , n eck, tru n k , b ac k
F o u n d to h a v e n o d u la r m e la n o m a o f th e to e .
L a te r u n d e rw e n t e x c isio n b io p s y a n d g ro in
d isse c tio n . W hy?
A fte r w h ich h ad e r y th e m a fe v e r a n d p u s fro m S tre p to c o c c u s
th e g ro in w o u n d . C u ltu re g r e w g r a m p o sitiv e
co cci in c h a in s. W h at o r g a n ism ?
D e v e lo p e d A RD S. W h at is th e lo n g te rm P u lm o n a ry fib r o s is
se q u a e la e o f ARDS
W h ere to m a n a g e p t H D/ICU

2) P ro c e d u ra l sta tio n . In se rtio n o f IV C an n u la

a. Pt p o s t RTA h a s p e lv ic fra c tu re . H R 1 2 0 , H y p o te n siv e n e e d in g flu id re su sita tio n
Q u estio n s:
In s e rt IV c a n n u la a n d ru n th e N S flu id . W rite d o w n y o u r flu id o r d e r s
W h at e lse w o u ld y o u d o ?
W h at o th e r in v e stig a tio n s w o u ld y o u d o ?
W h ere to d o a IV c u td o w n

3) P ro c e d u ra l sta tio n . D e b rid e m e n t o f w o u n d . P t h a d a a r m la c e ra tio n a n d d ir ty w o u ld .

D e b rid e a n d c le a n th e w o u n d
_________ a. A n a e sth e sia a n d c o n s e n t a ir ta k e n . Ju s t n e e d to d e b rid e a n d a n sw e r q u e stio n s
W h at w ill y o u d o if r a d ia l a r te r y cu t?
W h at to d o if m e d ia n n e rv e in ju red
W ill y o u c lo s e th e w o u n d ?
W h at a n tib io tic s to g iv e
A ny o th e r th in g s y o u w o u ld lik e to d o ? T e ta n u s to x o id b o o ste r, Ig
A ny o th e r in v e stig a tio n s X ra y to lo o k fo r f ra c tu re s , fo re ig n b o d ie s

4) P t p r e s e n t s w ith b lo o d y d ia r r h o e a x 1 0 d a y s. S h o w e d FBC H b8 MCHC, th ro m b o c y to s is

p it 6 6 6 , TW 17. H y p o n a tre m ia 1 2 5 , K 3 .1 C r n o rm al
D iffe re n tia ls fo r th e d ia rrh o e a E n te ro c o litis, isc h e m ic b o w e l, In flam m a to ry
b o w e l d is e a s e (C ro h n s, UC), m a lign a n cy ,
d iv e rtic u la r b le e d
E x p lain th e FBC a b n o rm a litie s
W hy p its high D eh y d ra tio n , a c u te b le e d , re a c tiv e r e sp o n se
E x p lain th e e le c tro ly te a b n o rm a litie s
W h at a r e th e a r g u m e n ts fo r a n d a g a in s t
tr a n s fu s in g th is h ea lth y p t w ith Hb 8 ?
W h at d o y o u s e e on AXR T h u m b p rin tin g s ig n
A n a to m y

F o o t/a n k le (b o n e s ) - S ta n d a rd f o o t a n k le session, n a m e th e b o n e s o f th e fo o t, c la ssify th e d is ta l

t ib u lo fib u la r jo in t , all th e c o m p o n e n ts o f th e m e d ia l a n d la te ra l a n k le lig a m e n ts , a tta c h m e n t o f th e
arches (d e m o n s tra te ). D e m o n s tra te a n k le m o v e m e n ts w h e n asked.

Head and neck (p ic tu re s ) - e x te rn a l to n g u e m uscles n am e and n e rv e s u p p ly , w h ic h b rin g s th e to n g u e

p o s te rio r and s u p e rio r (s tyloglo ssus?), s tra p m uscles n a m e and in n e rv a tio n , id e n tify o m o h y o id ,
id e n tify d ig a s tric - w h a t is it's ne ve s u p p ly , id e n tify accesso ry ne rv e , w h a t d oe s it in n e rv a te , if it is
dam a g e d in th e p o s te rio r tria n g le o f th e neck w h ic h m u s c le is a ffe c te d , id e n tify g re a te r a u ric u la r
n e rv e /a u ric o te m o ra l, hypo g lo s s a l n e rv e id e n tific a tio n a t th e b ifu rc a tio n o f th e c a ro tid , id e n tify o n a
p ic tu re w h ic h is th e in te rn a l vs e x te rn a l c a ro tid a rte rie s , s h o w n p a th o lo g y s lid e ly m p h n o d e b io p s y -
w h a t is th is excess b ro w n s ta in in g ?

O esophag us (p ic tu re ) - th re e p a rts o f th e oeso p h a g u s, a rte ria l s u p p ly , v e n o u s s u p p ly , ly m p h

d ra in a g e , b o u n d a rie s and c o n te n ts o f th e p o s te io r m e d ia s tin u m , p o te n tia l c o m p lic a tio n s o f O G D 4 x ,
p a th o p h y s io lo g y o f a c h a la s ia /o e s o p h a g e a l s tric tu re s , e x it o f te oes o p h a g u s w h ic h p a r t o f th e

d ia p h r a g m , s u rfa c e m a rk in g o f th e b e g in n in g o f th e oes o p h a g u s t o p vs b o tto m o f c ric o id ? , id e n tify

azygos v ein

C ritic a l care

B u rns - H o w are b o n e c la s s ifie d , d e m o n s tra te th e ru le o f 9s (g iven s c h e m a tic o f a ffe c te d p e rson

asked t o c a lc u la te area, e x p la in w o rk in g ), w h ic h flu id s w o u ld y o u use, w h y w o u ld y o u n o t use NaCI
(h y p e rc h lo ra e m ic acidosis), y o u r a p p ro a c h t o th e b u rn s p a tie n t (DRABCDE), w o rrie s in th is p a tie n t
(in h a la tio n a l in ju ry ), w h a t is an escha r, p a th o p h y s io lo g y and h o w are th e y m anaged?,
p a th o p h y s io lo g y o f v e n tila tio n in b u rn s b e n e fits o f NIV, n u rs in g and m e d ic a l tre a tm e n t, d e fin itio n o f

D iv e rtic u litis /e n d o m e trio s is s ta tio n - w h a t is a d iv e rtic u lu m , w h a t is th e p a th o p h y s io lo g y o f

d iv e rtic u la r disease and d iv e rtic u litis , w h a t are th e in d ic a tio n s f o r c t „ h o w is it u s u a lly tre a te d , h o w
m ig h t ra d io lo g ic a l co lle a g u e s assist ou in it's m a n a g e m e n t, h o w is it m an a g e d s u rg ic a lly , w h ic h
o p e ra tio n w o u ld y o u do,

N u tr itio n - N a s o p h a ry n g e a l c a rc in o m a th e n tra c h e o s to m y - w h a t a re th e ty p e s o f fe e d in g , w h a t are

th e adv a n ta g e s , w h a t a re th e d is a d v a n ta g e s o f each ty p e , w h e n w o u ld y o u use th e m , w h a t d ru g
m ig h t y o u g ive t o im p ro v e g a s tric m o tility , lo o k a t th is CXR t ip c le a rly in RLL, lo o k a t th is re p e a t
e q u iv o c a l c o u ld have b e e n in s to m a c h o r LLL w a s n o t 100% , h o w c o u ld y o u c h eck p o s itio n a t th e
b ed side, w h e n m ig h t a NG a s p ira te n o t be h e lp fu l ( h e lp fu l if <4, b u t if m id d lin g c o u ld be m id p la c e d
o r p a tie n t o n PPIs etc)

Path

N a s o p h a ry n g e a l c a rc in o m a - w h a t is a c a rc in o m a , w h a t is dysplasia , m e ta p la s ia , d iffe r e n tia tio n ,

w h a t cance rs arise fro m th e n a s o p h a ry n x , w h ic h p rim a ry m a lig n a n c ie s m a y arise in th e ly m p h nod es
o f th is re g io n , w h ic h s e c o n d a ry m a lig n a n c ie s , w h ic h SI u n it m ea s u re s ra d ia tio n ,

Jau n d ice - h o w is ja u n d ic e cla s s ifie d , g iv e su rg ica l causes o f ja u n d ic e , m o s t lik e ly in th is p a tie n t

(head and neck ca), w h ic h ra d io lo g ic a l p ro c e d u re s assiste in th e m a n a g e m e n t o f o b s tru c tiv e ja u n d ic e
- w h a t d o t h e y a c tu a lly d o , w h a t are th e in d ic a tio n s f o r MRCP, ARDS e x p la in p a th o lo g y (h y a lin e
m e m b ra n e s ) e x p la in e x tra h e p a tic c irc u la tio n , w h a t is th e c o m p o s itio n o f b ile , h o w d oe s b ile h e lp in
th e d ig e s tio n o f fa ts , w h a t are th e b ro k e n d o w n b its o f fa t c a lle d , w h a t a cts on th e m ? Look a t th e s e
b lo o d te s ts o b s tru c tiv e p a tte rn vs h e p a to c e llu la r p a tte n
E x a m in a tio n s

Ear - head in ju r y please e x a m in e p a tie n ts e a r and re le v a n t c ra n ia l ne rv e s (h e a rin g and o th e r c ra n ia l

nerves), s h o w n p ic tu re o f h a e m o ty m p a n u m , w h a t d o y o u su s p e c t, w h a t in v e s tig a tio n s m ig h t he
need, w h a t a re y o u lo o k in g fo r, w h a t are y o u r d iffe re n tia ls , w h a t are th e causes o f a c o n d u c tiv e
h e a rin g d e fic it, h o m ig h t th e y p re s e n t d iffe r e n tly ,

A b d o m e n - d iv e rlic u la r pain m id d le aged m an - a c to r w a s a p a tie n t m id lin e s te rn o to m y , le ft in fu in a l

h e rn ia re p a ir scars, a c to r fe ig n in g te n d e rn e s s in LIF, w h a t a re y o u r d iffe rn tia ls , w h a t is yo u
m a n a g e m e n t plan, lo o k a t th is o b s e rv a tio n c h a rt w h a t d o y o u see, w h a t w il y o u do , h o w w o u ld yo u
m anage him

H is to ry

B lind m an w ith m a c u la r d e g e n e ra tio n , m e ta llic h e a rt v a lv e needs t o sw ich fro m w a rfa rin , w a n ts an

e x p la n a tio n f o r th e changes, h is to ry o f a n x ie ty , g ive s o m e sens ib le h a rm r e d u c tio n o p tio n s and
check his u n d e rs ta n d in g , re c o g n is e his a n x ie ty and o ffe r s o lu tio n s and g e n e ra l adv ic e a b o u t
fo llo w in g th is u p back w ith his gp. Id e n tify p o te n tia l o p tio n s f o r h o m e a d m in is tra tio n b e fo re o ffe rin g
t o a d m it?

S peak t o c o n s u lta n t a b o u t la d y w h o w is h e s t o s e lf d is c h a rg e b u t n o te s w r itt e n suggest b e in g co e rce d

by d a u g h te r, tu rn e d in to a viva - id e n tify th e red flags, w h a t is c a p a c ity , w h a t w o u ld y o u d o on th e
w a rd , h o w w o u ld yo u m a nage th is p a tie n t a c u te ly (p o s t lu m p e c to m y , w ith 5 0 0 m ls b lo o d in d ra in ,
la st seen in am and th is is 4 p m ), asked d ire c tly have y o u seen th e p a tie n t d o n o t lie e tc etc, w h a t
w o u ld y o u lo o k fo r h o w w o u ld y o u assess th e p a tie n t

OA h is to ry - m id d le aged m a n , p re v io u s tra u m a tic h is to ry , re g u la r ana lgesic in ta k e , no c han ge -

w h a t can be d o n e d o c to r, w a k in g up a t n ig h t (all g iv e n w ith o u t m u c h p ro m p tin g ) w h a t a re th e key
p a rts o f th e h is to ry , h o w w o u ld y o u m anage th is p a tie n t, w h a t a re th e n o n surg ic a l o p tio n s , w h a t are
th e u rgica l o p tio n s , w h a t a re th e o th e r poss ib le causes o f m o n o a rth ro p a th ie s in th is m an

Abscess d ra in a g e (p re p p e d d ra p e d ) - w h a t are la ngers lines, w h a t w ill y o u send o f f fo r, d o I need

abx, d o I nee d pain k ille rs , w ill I ha v e a scar, h o w m ig h t th is be m anage d, w h a t dressin gs are used,

S u tu re leg la c e ra tio n (cle a n e d ) - classic s ta tio n , fin d th e n o n a b s o rb a b le m o n o fila m e n t s u tu re ,

s im ila r q u e s tio n s t o a b o v e , e x a m in e r v m ad as I w a s d o u b le ch e c k in g th in g s w ith th e p a tie n t - 1
guess he w a s b o re d and an g ry, th o u g h c le a rly no m a rk s f o r it! Did s p e c ify in s tr u m e n t tie th o u g h .
ANATOM Y

• F o o t + a n k le
• P o s te r io r m e d ia s tin u m - a lo t o f fo c u s o n t h e o e s o p h a g u s ( b lo o d /ly m p h /n e r v e )
• T ria n g le s o f th e n e c k - a lo t o f in d iv id u a l m u s c le in n e r v a tio n s + a s lid e o f w h a t I t h in k
w a s m e la n o m a

PA THO LO G Y

• D iv e r tic u litis - h o w d o e s a n a b sce ss f o r m + life s p a n o f a n e u tr o p h il + h o w m ig h t

e n d o m e tr io s is o c c u r
. N a s o p h a ry n g e a l c a n c e r - n e w s t a tio n t h a t h a d n o t c o m e u p b e fo r e . D e fin e c a rc in o m a
• J a u n d ic e - v e r y s t r a ig h t fo r w a r d s t a tio n

CRITICAL CARE

. B u rn s + ARDS
.T P N

COMMS

• C a llin g a c o n s u lta n t b e c a u s e a p a t ie n t's r e la tiv e w a n ts t o s e lf-d is c h a rg e th e m ; o d d

s t a tio n in v o lv in g ta lk in g t o s o m e o n e o v e r t h e p h o n e w h ils t t h e y 'r e in t h e s a m e r o o m
as y o u . T h e y a s k e d a b o u t is s u e s lik e c a p a c ity , s a fe d is c h a rg e e tc
• W a r fa r in + m a c u la r d e g e n e r a tio n - m id d le - a g e d m a n w it h m a c u la r d e g e n e r a tio n t u r n s
u p t o w a r d o n a F rid a y a f te r n o o n . H e is d u e t o h a v e an e le c tiv e in g u in a l h e rn ia
re p a ire d n e x t w e e k b u t is c o n fu s e d a b o u t s to p p in g his a n tic o a g u la tio n (h e is
w a r fa r in is e d d u e t o m e ta llic h e a r t v a lv e ). T h e p la n w a s f o r h im t o s t a r t ta k in g L M W H
b u t h e is c o n fu s e d b y t h is a n d m a y n o t b e a b le t o a d m in is t e r in je c tio n s d u e t o s ig h t
is su es. H e is a ls o c / o o f a b d o m in a l p a in a n d n a u s e a . I t h o u g h t s a fe s t t o a d m it f o r
o b s e rv a tio n a n d b r id g in g t h e r a p y .
. O A h is to r y - e x - fo o tb a ll p la y e r, p r e v io u s k n e e in ju r y . Has c o m e u p s e v e ra l t im e s b e fo r e

C LIN IC AL SKILLS

. S u tu r in g - g iv e lo c a l a n a e s th e tic ( th e r e is a m a x t o t a l d o s e o f lid o c a in e - ? 3 0 0 m g e v e n if
t h e p e rs o n w e ig h s t h e s a m e as an e le p h a n t) a n d th e n t h r e e s im p le in te r r u p t e d
s u tu r e s
. In c is io n d ra in a g e absce ss

E X A M IN A T IO N S

• V a ric o s e v e in e x a m - a s k e d t o d o d o p p le r
. 5 d a y p o s t- o p c h e s t p a in ?PE
. A c u te a b d o m e n e x a m
London 23rd May, 18
Anatom y
Lower limb
Thoracic and abdomen
Posterior neck
Critical care
Jaundice
Rta
IBD
Pathology
N asopharyngeal CA
M alignant m elanoma
Procedure
O T list
Suturing would
Examination
Varicose vein
Anastom otic leak
Diverticulitis
Subm andibular gland
History
Impotence
Knee pain
Comm unication
Spleen rupture
Traum a consultant (Rta)

N asopharyngeal CA station:
Define: Neoplasm, Differentiation
Risk factors of Nasopharyngeal ca
Causes
Frozen section procedure
Unit o f radiation
Pathway to metastasis to LN
Fungal infection in throat
Examinations
Subm andibular gland swelling.
How to manage salivary gland calculus

Abdominal exam
Dx - diverticulitis
How to manage. Hinchey

CVS
Aortic stenosis.

Knee
OA.
Treatm ent options

History
Child fell from tree and carried to OT for exp lap. He was brought in by father who
appears intoxicated. Mother then arrives and wants to know why child is in surgery
without her permission

Man with erectile dysfunction

Lady with headaches

Speak to consultant in another hospital about transferring a patient with acute limb
ischemia, afib and resolving diverticulitis.

Practical stations
Suturing of a leg laceration and advise patient on follow up

Organise an OT list
Diathermy principles and where you would place diatherm y pad on the patients for OT
eg. pacemaker, amputation

Pathology
Blood products
How to store them
How to group and cross match
Discussion about RBC and platelets

Photo o f skin lesion

Differentials
Treatment
Steps from local invasion to metastasis

Anatomy
Anatomy of lower limb. Muscles o f thigh and gluteal region. Nerve and blood supply

Surface anatom y of parotid gland and duct.

Base of skull anatomy

Specimen of aorta
Name branches and identify
IVC and branches
Aneurysms

Critical care
Diagnosis and managem ent of oliguria and SBO.
Managem ent o f acute pancreatitis
Managem ent o f crush injury to leg including atls,
Rhabdomyolysis, AKI
Delhi examination centre
RCSEN G
4th July, 2018

Station 1- Anatomy

Extensor compartment o f Upper Limb - Forearm and hand

There was no prosection; only few photos were shown. There was a plastic model o f
skeleton o f hand and 2 forearm bones.

1. Identify different muscles and tendons as pointed out by the examiner

2. Identify dorsal interosseus followed by its function, nerve supply and show on
your own hand its action
3. Identify the extensor communis tendon and its function
4. Identify the styloid process o f radius
5. Identify different bones o f the wrist, specifically each and every carpal bones

Station 2 - Anatomy

Anatomy o f skull - specially the sinus system

There was half cut skull with few MRI images

1. Identify the pathology in the MRI image - A hyperintense well defined tumor
located in the falx cerebri region indenting one o f the cerebral hemispheres.
Answer was MENINGIOMA
2. Which 3 structures will this tumor affect once it grow s? Answers were Superior
Sagittal sinus, Cerebral hemisphere
3. What will be the clinical picture o f the patient who has this M RI? Answer was
Lower Limb Weakness
4. Show different structures in MRI coronal and sagittal images
a. Lateral ventricle
b. 4th ventricle
c. Corpus Callosum
d. Cerebellum
e. Pons

5. In the skull, show the course taken by sinus system and name all the sinuses while
you describe
6. What is the major vein draining the brain parenchyma? Answer : Great Cerebral
vein
7. How does straight sinus reach Internal Jugular vein? Point out in the skull interior
surface. Answer: Showing the groove o f Sigmoid sinus

1
 8. Show the position o f cavernous sinus. Answer: Right and Left Cavernous sinus
positions ju st below the anterior Clinoid process
9. What are the structures that pass through this foramen (Jugular foramen was
pointed out)? Answer: CN IX, X and XI
10. Identify Falx cerebelli and Tentorium cerebelli in a picture

S t a tio n 3 - Communication Skill

A splenic trauma patient who wants to go home from hospital in another town, because
he has a job interview back in his hometown and cannot m iss it in any case

The patient was very understanding, communicated well and discussed about the
consequences and gave hint that he can safely travel to his howetown in an ambulance
and join the interview and go back to local hospital for further care.

Don’t forget to ask the patient to fill out the ‘discharge against medical advice’ form and
the advice him about red flag signs o f abdominal hemorrhage.

S t a tio n 4 - Procedural Skill

A patient with anterior thigh abscess asked to perform an I and D procedure.

Description was given in which patient was already given local anesthetic and scrub
nurse had already done all the draping.

You need to do following in 6 minutes -

• tray preparation by choosing correct instruments
• give incision in the direction o f langer lines
• do the incision and drainage,
• wash it
• application o f dressing

Now 3 minutes for V iva Q & A

1. Dose o f Local anesthetic
2. Why did you give that incision?
3. What are the advices you give to the patient?

Station 5 - Anatomy

Anterior Neck anatomy focused primarily on Thyroid

There was a picture o f anterior neck, muscle and other structures.

1. Identify Thyroid

2
 2. What are the parts o f thyroid?
3. Show the artery supplying the thyroid
4. Show the veins draining the thyroid
5. Show bilateral recurrent laryngeal nerves
6. Where are the parathyroid glands located?

S t a tio n 6 - Pathology and Microbiology

Examiner gives you description o f a patient who has pain, tenderness, redness and all
features o f abscess in a thigh.

1. What is an abscess?
2. How it differs from cellulitis?
3. What are the constituents o f a pus?
4. How do you know which organism is the cause without any test?
5. What are the causes o f an abscess?
6. What are the cause o f non-bacterial abscess?
7. How do you treat an abscess?
8. When is an antibiotic required for abscess?
9. Which stain is used for tubercular bacilli?

S t a tio n 7 - Critical Care

Internal Jugular Vein line insertion and related Iatrogenic Pneumothorax

1. During the procedure, patient suddenly became dyspneic and his blood pressure
started to fall. What is your line o f management?
2. What is your diagnosis?
3. What is your methodology o f reading a C X R ?
4. Describe an C X R showing left sided pneumothorax
5. Complications o f Central Venous line insertion
6. How do you prevent infective complications

S t a tio n 8 - History taking

Post-traumatic Osteoarthritis - History taking within 6 minutes and discussion in 3

minutes

1. Present the summary o f case

2. What is your line o f management?

S t a t io n 9 - Communication skills

3
Preceded by a preparatory Station where a file was given - 85 yr female in shock with 4
hours o f history o f pain abdomen suggestive o f bowel perforation; planning to do
laparotomy, need to call ITU registrar for arranging a bed in ITU. Issues were -
metabolic acidosis with lactic acidosis, COPD, steroid taking pt. ITU registrar asked
details o f the patient and said there is one young female with asthmatic attack in
Emergency and your patient does not seem to survive the operation.

S t a tio n 10 - Clinical Examination

(Real patient)
Mitral valve replacement pt. with sternotomy scar was being prepared for hernia; asked
for doing complete C V S examination. (Please do not forget to examine the legs for vein
graft as examiner reminded me to check). 6 mins o f focused examination and summary. 3
mins for discussion.

1. Auscu ltatory find ings

2. How will you prepare this patient?
3. Who will you inform?
4. What is the usual dose o f warfarin?
5. What is PT/INR?
6. What is used for reversal o f warfarin?

S t a tio n 11 - Neurological Examination

(Actor)
Cranial nerve examination + Abbreviated Mental Test Score (AM TS)
Finding was Olfactory Nerve dysfunction with low AMTS.

I could not finish both in 6 mins

1. What is your diagnosis?

2. Causes o f raised ICP

S t a tio n 1 2 - Critical Care

A case being prepared for laparotomy was stopped because it was noted that he had a
temperature o f 34.2 C

1. What is the definition o f Hypothermia?

2. What are the ill effects o f Hypothermia?
3. What are the measures to correct Hypothermia?
4. If this pt. is taken to surgery, what are the risk factors for Hypothermia in this pt.?

S t a tio n 13 - Clinical Examination

4
An actor with severe RUQ pain with Murphy sign +ve; complete abdominal examination
was asked to do

1. What is your diagnosis?

2. What is your l sl line o f investigation?
3. NO stone was seen in U SG. What investigation would you like to do to confirm
cholecystitis?
4. What Sx would you do for G SD ?

S t a tio n 1 4 -Pathology
A histopathology report was produced which was a clear cut case o f Adenocarcinona o f
Rectum. Gross and microscopic features were described.

1. What is Duke staging and TNM staging in this case?

2. Other Qs forgot

S t a tio n 15 —Clinical Examination

Real patient - Varicose vein examination with skill assessment on use o f Hand held
Doppler

1. Summarize the case

2. What are the investigations you would like to do in this pt.?
3. What is your plan o f management?
4. What is Minimally Invasive option for this patient?

S t a tio n 1 6 - Pathophysiology

Acid peptic disease and gastric ulcer

1. Phases o f gastric acid secretion

2. How is an ulcer formed?
3. What is secreted by Chief cells etc.?
4. What are the drugs necessary for Rx?
5. How does PPI act?
6. What antibiotic will you use for Rx?

S t a tio n 17-H istory taking

25 years female actor with Unilateral tonsillar enlargement for 3 months.

History o f night sweats; no contact with TB, dyspnea +nt, seemed anemic.

1. Summarize your case

2. What is your working diagnosis?
3. List 2 differentials

5
 4. What investigations would you like to send?
5. Describe the reason for each o f the elements o f investigation that you are sending.

S t a tio n 18 - Procedural skill

Lacerated wound on the anterior thigh; Local anesthesia already given, draped and
prepped. You need to do the following -

i. Choose appropriate suture

ii. Choose appropriate instruments
iii. Perform interrupted simple suture
Q and A part
1. What is the dose o f xylocaine?
2. What is the dose o f Bupivacaine?
3. Why did not you use Bupivacaine in this case?
4. Can the dose o f Bupivacaine be increased if used with Adrenaline?
5. What are the side effects o f Bupivacaine?

Remembered by a Nepali student.

Best o f luck to all!
 MRCS(Eng.), part B 4th July, 2018: New Delhi Day 2

Compiled by Dr. Shardool Vikram Gupta

M.S., M.Ch.(std.) (M inim al Access Surgery, AIIMS, New Delhi)
M edical Android Developer and A uthor
(We are like dwarfs sitting on the shoulders of giants- Isaac
Newton. Dedicted to the Giants who stood before me)

-18 stations w ith 6 rest stations: Each 10 minutes.

D istribution: 1+6+3 mins, 1 m inute fo r reading instruction, 6 minutes
o f History/exam ination, 3 minutes fo r discussion.
-16 repeats, 2 new stations
Knowledge
Anatomy
1. Parasaggital m eningioma, Dural Venous Sinus
-Name all the venous sinuses and how they run? (Gave me skull to
show)
-Point to me w hat sinus is this (straight sinus)?
-Venous origin o f Straight Sinus? Said Great Vein of Galen
-Show me on this (Print out from Netter's)
ANATOM Y

1. U p p e r lim b
C5, C6 r o o ts c o m e f r o m w h e r e - s h o w in s k e le to n
I n it ia t o r o f s h o u ld e r a b d u c tio n
D e m o n s tr a te c h e c k in g p o w e r o f s h o u ld e r a b d u c to r s a n d e lb o w fle x o r s
N e rv e s u p p y o f d e lto id
S e n s o ry s u p p ly o f a x illa ry n e rv e , r a d ia l n e rv e
M u s c le s s u p p lie d b y a n d s e n s o ry d is tr ib u tio n o f m u s c u lo c u ta n e o u s n e rv e
A c tio n o f b r a c h io ra d ia lis
D e m o s tr a te r e fle x s u p p lie d b y C5, C6
M u s c le s r e q u ir e d f o r o v e r h e a d a b d u c tio n - s e r ra tu s a n t e r io r , tra p e z iu s
O rig in o f s e r ra tu s a n t e r io r , its n e rv e s u p p ly
S h o w c o r a c o id o n p a t ie n t
M u s c le a tta c h m e n ts t o c o ra c o id
N a m e e lb o w fle x o r s
W h ic h n e rv e s w il b e d a m a g e d w it h e x c e s s iv e s tr e tc h in g o f n e c k t o o n e s id e - U p p e r t r u n k - C5,
C6

2. L o w e r lim b
M a s s a t b a c k o f p o p lite a l fo s s a , w h a t c o u ld it b e if it a ris e s fr o m
> S k in , s u b c u t
> M u s c le
> Bone
> J o in t
S c ia tic n e rv e
> R o o t v a lu e
> A n a to m ic a l v a r ia tio n s in r e la t io n t o p y r if o r m is - a b o v e it, t h r o u g h it
> Passes b e tw e e n w h ic h t w o b o n e p r o m in e n c e s in g lu te a l r e g io n
C o n te n ts o f p o p lite a l fo s s a , t h e ir r e la tio n s t o e a c h o t h e r
A c tio n s o f h a m s trin g s - fu n c tio n s o f in d iv id u a l m u s c le s
I d e n t if y m u s c le s in p ic tu r e - g lu te u s m e d iu s
N e rv e s u p p ly t o g .m e d
F u n c tio n o f a b d u c to r s
W h a t is m e a n t b y p o s itiv e t r e n d e le n b e r g t e s t

3. V a s c u la r s y s te m in a n d o
I d e n t if y a o r ta , IVC
W h e r e d o t h e y pass t h r o u g h d ia p h r a g m ?
W h e r e d o e s b ifu r c a t io n o c c u r?
N a m e p o s t e r io r b ra n c h e s o f a o r ta - h o w m a n y p a irs o f lu m b a r a r te r ie s
W h ic h 2 s t r u c tu r e s c ro s s t h e a o r ta a n t e r io r ly - le f t re n a l v e in , 3 rd p a r t o f d u o d e n u m
I d e n t if y 3 m a in b ra n c h e s o f a o r ta s u p p ly in g G l t r a c t , a n d t h e ir b ra n c h e s - o n t h e a o r to g r a m
I d e n t if y th e p a th o lo g y in th e p ic tu r e - A A A
In w h ic h plane does a o rtic disse ctio n occur

PA THO LO G Y

1. S e m in o m a - c lin ic a l s c e n a rio g iv e n - 3 5 y rs m a le , lu m p in R ig h t g r o in . R ig h t h e m is c r o tu m
e m p ty
W h a t c o u ld it b e ? - u n d e s c e n d e d te s tis w ith t u m o r

H is to p a th o lo g y r e p o r t g iv e n - S e m in o m a
W h a t 3 th in g s w ill u c o u n s e l p a t ie n t b a s e d o n t h is r e p o r t?
W h a t d o e s Nx m e a n ? (T 4, N x)
W h a t is t h e s e c o n d m o s t c o m m o n n o n s e m in o m a t u m o r o f t e tis ? C lu e - it is c o m m o n e r in o ld
m en - Lym phom a
W h e r e d o e s te s tis ly m p h d ra in ?
T u m o r m a rk e rs p r o d u c e d in s e m in o m a , t e r a to m a
W h e r e is HCG n o r m a lly fo u n d ? - p r e g n a n t fe m a le s
W h a t c e lls a re s e e n in c h o r io c a rc in o m a ? - T r o p h o b la s t

2. C o a g u la tio n
S c e n a rio : y o u n g fe m a le , iv d r u g a b u s e r, HC V p o s itiv e , H /O RTA, u n d e rg o e s s p le n e c to m y , o n ly
c r y s ta llo id s g iv e n . B lo o d p ic tu r e s h o w s t h r o m b o c y tio p e n ia , r e d u c e d c lo tt in g fa c to r s , a n e m ia ,
ra is e d PT, aPTT
W h a t e x p la in s t h is p ic tu r e ? - D ilu tio n a l c o a g u lo p a th y
W h y e ls e c o u ld h e r c lo tt in g fa c to r s b e lo w ? - h e p a titis , b lo o d loss
aPTT m e a s u re s w h ic h p a r t o f c o a g u la tio n ? - in tr in s ic a n d c o m m o n p a th w a y s
S te p s o f h e m o s ta s is - p la tle t p lu g , f ib r in p lu g
S ta g e s o f b o n e h e a lin g
H o w d o p la tle ts h e lp in c lo tt in g ? - p la tle t p lu g , d e g ra n u la tio n
H o w is e x tr in s ic p a th w a y a c tiv a te d ? - tis s u e th r o m b o p la s t in
W h e r e a re p la tle ts p r o d u c e d ?
W h a t c o u ld b e t h e s e q u a la e o f HCV in fe c tio n ? - C h ro n ic h e p a titis , HCC
P a tie n t is g iv e n a n t ib io t ic s a n d v a c c in e s p o s t o p , w h y ? - s p le n e c to m is e d p a t ie n t

3. U lc e r a tiv e c o litis
S c e n a rio : 1 0 d a y s H /O b lo o d y d ia rr h e a , n o w re d u c e d . B lo o d p ic tu r e - a n e m ia , t h r o m b o c y to s is ,
CRP ra is e d .
D D -U C
E x p la in t h e b lo o d f in d in g s
W h a t ty p e o f a n e m ia is it? M ic r o , h y p o ( re d c e ll in d ic e s g iv e n )
A b d o x ra y g iv e n , fin d in g s ? - D ila te d b o w e l lo o p s
W h e n w ill y o u o p e r a te in UC? T o x ic m e g a c o lo n , n o r e s p o n s e t o m a x m e d ic a l t h e r a p y
W h a t s u r g e r y w o u ld y o u d o ?
Pt s ta r te d o n s te ro id s , h o w w ill y o u m o n it o r t h e re s p o n s e
PHYSIOLOGY
1. T h y r o id
S c e n a rio : w o m a n , c / f o f h y p o th y r o id , la rg e g o itr e
E n u m e ra te f e a tu r e s o f h y p o th y r o id is m
C a uses o f h y p o th y r o id is m
W h e n w o u ld y o u n e e d t o o p e r a te f o r a g o ite r ?
W h a t a re t h e s p e c ific c o m p lic a tio n s o f t h y r o id e c t o m y ?

B lo o d p ic tu r e - a n e m ia w it h in c re a s e d c e ll v o lu m e
W h a t ty p e o f a n e m ia is it? - M e g a lo b la s tic i.e . PERNICIO US
C a uses o f m e g a lo b la s tic a n e m ia
So w h a t d o e s t h is la d y h a v e ? - A u to im m u n e d is o rd e r. H e n c e , h a s h im o to 's t h y r o id itis
D iffe r e n c e b e tw e e n T3 a n d T4
E x p la in h y p o th a la m u s - p it u it a r y - t h y r o id axis

HISTORY TA K IN G

1. U n ila te r a l to n s illa r s w e llin g : A c t o r c o m p la in e d o f s w e llin g n o tic e d w h e n b ru s h in g , p a in le s s ,

Ass. w it h w e ig h t lo ss a n d n ig h t s w e a ts .
C a uses - i f t u m o r , w h ic h ?
H o w w ill y o u in v e s tig a te ?

2. SOB: P a tie n t t o b e p o s te d f o r c h o le c y s te c to m y , ta k e h is to r y f o r PAC. c / o SOB s in c e 10 y e a rs ,

w o rs e a f te r h u s b a n d p a s s e d a w a y , s y m p to m s s u g g e s tiv e o f a n x ie ty , o t h e r w is e h e a lth y .
W h a t a re t h e DD?
H o w w ill y o u in v e s tig a te ?

E X A M IN A T IO N

1. C ra n ia l n e rv e s : H /O h e a d a c h e a n d v is u a l d is tu r b a n c e . I d e n t if y t h e c ra n ia l n e rv e s .
A c t o r h a d b ite m p o r a l h e m ia n o p ia
W h a t a re t h e DD s? W h a t tu m o r s c o u ld it be?
H o w w o u ld u m a n a g e ? - s u r g e r y b y w h ic h ro u te ?
H o w w ill y o u e x a m in e t h e r e m a in in g c r a n ia l n e rv e s ?

2. R e s p ir a to ry s y s te m : P a tie n t t o be p o s te d f o r h e r n ia re p a ir. H /O s m o k in g a n d CO PD. E x a m in e

th e r e s p ir a to r y s y s te m . O n e x a m in a tio n , i t w a s a ll n o r m a l.
H o w w ill y o u o p t im iz e p r e - o p a p a t ie n t w it h CO PD?
W h a t k in d o f a n a e s th e s ia w o u ld y o u use?
W h a t k in d o f p o s t- o p p r o b le m s c o u ld o c c u r?
S h o u ld y o u g o a h e a d w i t h s u r g e r y w it h s o m a n y c o - m o r b id itie s ?
3. A b d o m e n e x a m in a tio n : R ig h t u p p e r q u a d r a n t te n d e r n e s s , M u r p h y 's sig n p o s itiv e .
In v e s tig a tio n s g iv e n : h y p e r b ilir u b in e m ia +. T o ld t o e x a m in e th e p a t ie n t a n d o b s e rv a tio n c h a rts .
W h a t a re t h e DDs
H o w w ill y o u in v e s tig a te ?

4 . L o w e r lim b v a s c u la r s y s te m : P a tie n t is b e in g p o s te d f o r t h r . N u rs e c a lls y o u b e c a u s e lim b

a p p e a rs c o ld . O n e x a m in a tio n , a r te r ia l u lc e r p re s e n t.
A s k e d a b o u t B u e rg e r t e s t
W h a t in v e s tig a tio n s w o u ld y o u d o ?
W h a t s u rg e ry can be d o n e ?
If p a t ie n t in s is ts o n t h r b e fo r e v a s c u la r in te r v e n t io n , h o w w o u ld y o u c o u n s e l h im ?

PROCEDURES

1. S u tu r in g

W h ile s u tu r in g , p a t ie n t a s k e d :
W ill I h a v e p a in ?
W ill y o u g iv e m e a n tib io tic s ?
H o w m a n y s titc h e s w ill I h a v e ?

E x a m in e r a s k e d :
W h a t a n a e s th e tic w o u ld y o u use?
W h a t is t h e d o s e o f lig n o c a in e ?
W h a t is t h e a lte r n a t iv e t o lig n o c a in e ?
W ill y o u g iv e a n t ib io t ic ?
O n e e x a m in e r tu g g e d o n a ll th e s u tu r e s a t t h e e n d t o s e e if t h e y w o u ld c o m e u n d o n e .

2. C a th e te r is a tio n
M o d e l h a d p r e p u c e a lso
W h a t w ill y o u d o if u r in e d o e s n o t c o m e o n in s e r tin g c a th e te r?
G a v e in v e s tig a tio n c h a r t, p a t ie n t w a s n o r m o te n s iv e . E x a m in e r a s k e d w h a t i f h y p o te n s iv e , w h a t
w ill y o u d o th e n ?
W h a t in v e s tig a tio n o f a b d o m e n w o u ld y o u d o t o d e t e r m in e t h e s ite o f b le e d ?

C O M M U N IC A T IO N

l. H / O d y s p h a g ia s in c e 6 m o n th s . S m o k e r a n d ta k e s a lc o h o l s in e m a n y y e a rs . GP d id b a r iu m
s w a llo w , s h o w e d b e n ig n a p p e a r in g n a r r o w in g . C o u n s e l a c t o r f o r O G D s c o p y w it h d ila t a t io n a n d
b io p s y u n d e r G A . In v e s tig a tio n s g iv e n : U re a , AST ra is e d , H b lo w
A c t o r a s k e d m a n y q u e s tio n s :
W h a t is t h is p ro c e d u re ?
W h a t d o m y in v e s tig a tio n s s h o w ?
C o u ld I h a v e c a n c e r?
W h a t w ill b e d o n e i f I h a v e c a n c e r?
W ill t h is t e s t d e f in it iv e ly c o n f ir m w h a t's w r o n g w it h m e ?
H o w lo n g f o r th e b io p s y r e p o r t?
W h a t c o m p lic a tio n s c o u ld o c c u r f r o m t h e p r o c e d u re ?
W h e n c a n I g o h o m e a f t e r it?
W h y d o I k e e p d r ib b lin g s a liv a ?
If I s to p s m o k in g a n d a lc o h o l, ca n I d o w i t h o u t th e s c o p y ?

2. P h o n e ITU r e g is tr a r
E ld e rly fe m a le in n u r s in g h o m e , p r e v io u s ly w e ll o t h e r th a n CO PD f o r w h ic h sh e is o n s a lb u ta m o l
a n d s te r o id in h a le r, t h r e e m o n th s o ld ABG g iv e n ( re s p ir a to r y a lk a lo s is ). C a m e w it h a c u te a b d o
p a in s in c e h a lf h o u r, ju s t a f te r b r e a k fa s t. P e rfo r a tio n s u s p e c te d , c o n s u lta n t in fo r m e d , s aid its
fre s h p e r f so n e e d t o e x p lo r e im m e d ia te ly .
In v e s tig a tio n s : a n e m ia , w b c h ig h , u re a n o r m a l, c r e a t s lig h tly ra is e d , h y p e rk a le m ia , ABG
m e ta b o lic a c id o s is .
O b s e r v a tio n c h a r t: p u ls e ris in g , BP fa llin g , s a ts fa llin g , RR h ig h .
P h o n e ITU r e g is tr a r a n d a rra n g e ITU b e d a n d ask f o r a d v ic e r e g a r d in g p re o p o p t im iz a tio n .

E x a m in e r a s k e d f o r ECG, I/O c h a r t - a d m it t e d th e y w e r e n o t d o n e . T o ld m e t o d o th e m .
W h a t w ill y o u d o if sh e ha s A F ib ?
S a id t h e r e is n o ITU b e d . W h a t w ill y o u d o ?
A s k e d w h y d o e s y o u r p a t ie n t n e e d ITU b e d
W h a t w ill y o u d o p o s t o p if p a t ie n t re q u ire s ITU b e d b u t n o n e is a v a ila b le ? W h e r e w ill y o u
m a n a g e h e r? - He f in a lly t o ld m e I s h o u ld m a n a g e h e r in p o s t o p r e c o v e ry .
T o ld t o s t a r t h e r o n a n t ib io t ic s a n d flu id s .
A s k e d in t h e e n d t o r e p e a t w h a t a ll he h a d a d v is e d m e .

CRITICAL CARE

1. S c e n a rio g iv e n : P o ly tra u m a - GCS p o o r b u t n o e / o h e a d in ju r y . R ig h t s id e b r e a th s o u n d s

d e c re a s e d , a b d o m e n d is te n d e d . H y p o te n s iv e , ta c h y c a rd ic .
H o w w ill y o u m a n a g e s te p w is e ?
M o s t q u e s tio n s r e la te d t o ATLS p r o to c o l
W h a t a re t h e a d v a n ta g e s a n d d is a d v a n ta g e s o f f u ll b o d y CT?
W h a t t e s t w ill y o u d o t o c h e c k a b d o m e n ? - w a n te d t o h e a r FAST
A f t e r g iv in g c r y s ta llo id s a n d b lo o d , w h a t w o u ld y o u c o n s id e r g iv in g n e x t? - w a n te d t o h e a r FFP
 MRCS( Ed i n ) COLOMBO
August 20, 2018 (Afternoon session)

KNOWLEDGE
• S u rg ic a l A n a to m y

1. T h y r o id a n d n e c k

2. R ig h t f e m o r a l t r ia n g le

3. A o r t a & IVC

• S u rg ic a l P a th o lo g y

4. T e m p o r a l a r t e r it is

5. S h o c k & c o a g u la t io n r e la t e d

• A p p lie d S u rg ic a l S c ie n c e a n d C r itic a l C a re

6. A c u te a b d p a in a n d d is t e n t io n

7. F e c a l p e r it o n it is s e c t o d i v e r t ic u lit is

8. EDH

SKILLS
• C o m m u n ic a tio n - H is to r y ta k in g

9. L e ft le g c la u d ic a tio n

10 . S e iz u re s

• C o m m u n ic a tio n - I n f o r m a t io n g iv in g t o p a t ie n t

1 1 . E s o p h a g e a l d ila t a t io n o f s t r ic t u r e

• C o m m u n ic a tio n - I n f o r m a t io n g iv in g t o c o lle a g u e

1 2 . R e fe r r in g e ld e r ly la d y w i t h a c u te lim b is c h e m ia t o t e r t ia r y c e n t r e

• P h y s ic a l E x a m in a tio n

1 3 . C a rp a l t u n n e l s y n d r o m e

14 . I n g u in a l h e r n ia

1 5 . P o s t- tr a u m a t ic h e a r in g lo ss

16 . P a in a b d & d is te n s io n ( p o s t la p a r o to m y , d a y 5)

• P r o c e d u ra l s k ills

1 7 . E x c is io n o f n e v u s

18 . O r d e r in g O T lis t

PS: E v e ry s t a tio n a n d a ll q u e s tio n s in e a c h s t a tio n w e r e c o m p le te r e p e a ts . So p le a s e g o

t h r o u g h t h e p a s t a c c o u n ts o f a t le a s t la s t 3 y e a rs .

A ll t h e b e s t!
MRCS (Edinburgh) Kuching 2018

Anatom y & Surgical Pathology

1. TB
- lymph node involvem ent
- Investigation of choice
- TB staining
- Lym phoma staining
- Additional TB investigation
- W hat is giant cell?
- Causes of granulom a in lymph nodes
- W ho to inform if confirm TB

2. O esophageal Cancer
- prognosis
- TNM
- Histology Staining

3. Use of corticosteroids
- different layers of edrino and function
- Functions of glutocorticoids
- Functions of m ineralocorticoids
- How to bridge cortisol
- Effects of long term of cortisol
- Cushing Syndrome
- Advice to patient

4. Lower leg Anatom y

- Com partm ent m uscles and nerves
- Action
- Sensation
- Reflexes
- Derm atomes

5. Thoracic and Abdom inal Anatom y

----- rtzygous vein
- Papillary m uscles
- Spleen, Pancreas, Duodenum, Gall Bladder
- Pancreatic and Bile Duct

6. Parotid Glands

Critical Care
1. Lip Fracture
- com partm ent syndrom e
- Fasciotomy
- Crush injury
- Rhabdom yolysis
- AKI
- Bank bloods
- Urine dipstick blood
- Alkaline line

2. Post-Op
- SOB
- APO /Pneum onia
- Pshysiology of AKI in surgery
- Critical m anagem ent

Procedural Skills
1. Abscess Incision
- ING

2. Suturing

Com m unication Skills

1. To inform consultant on AOR discharge
2. Breaking bad news
- splenectom y
- M other with ulterior motive
Examination
1. ENT and Cranial Nerve
2. Cardiovascular Examination
- m etallic heart
- W arfarin usage and bridging
3. A.V fistula
- how to use Doppler
- Stills Disease
4. Inguinal Hernia & treatm ent

Inform ation/History Taking

1. Consent and MMSE
2. Abdom inal Pain
- C hron’s Disease
MRCS PART B KL SEPT 2018 - DAY 1, AM SESSION (RCS ENGLAND)

Most questions are repeat of what has been shared here with one or two small changes. I will list down as much as I can remember followed by
what tips I recommend for preparation for the exams.

22 stations (including 2 rest stations & 2 prep stations, so in total 18 questions)

Do take note that for the ANATOMY & PATHOLOGY questions/instructions outside the bay, there were CLEAR INSTRUCTIONS that only the
particular stations were only testing for knowledge and not clinical skills.

Patho: 4,Aanatomy: 3, Crit care: 1. Exams: 4, history taking: 2, Comm: 2, Procedure: 2.

STATIONS INSTRUCTIONS QUESTIONS BREAKDOWN Answers (do cross-reference whatever answer

1have said here with a proper textbook just so
you don't make a silly mistake)
STATION 1 - REST STATION
STATION 2 - PATHOLOGY - What is the diagnosis? - Malignant melanoma
Given description of a patient who - How does melanoma differ from SqCC - Origin of cells (SqCC from Sq cell, etc)
has just had an excision of a - What features are suggestive that a melanoma is - Size, depth, invasion locally & mets
suspicious nevus. Histopathology of poor prognosis? (WANTED TO HEAR BRESLOW'S)
report showed pigmented cells - During excision, HPE results noted close margin - Needs re-excision/wider excision
invading into structures deep to of 1mm. what to do next?
dermis & arises from - What other Rx may be given? - KIV RT, chemo, close surveillance
dermoepidermis junction. - What factors may suggest good prognosis? - Did not understand this question well (1
think they were looking for depth, mets, local
invasion)
- What intraoperative measure can be taken to - Frozen section
ensure good margin?
- What 2 genetic condition are related to - Albinism, xeroderma pigmentosum
Malignant melanoma?
- Why does UV light cause melanoma? - Due to DNA damage in melanocytes.
STATION 3 - HISTORY TAKING Pt was a middle aged single lady who smokes heavily - What is your provisional DDX?- colorectal
Middle aged lady with rectal with family hx of colorectal Ca who has PR bleed a/w Ca. DDX: IBD
bleeding. To take history. constipation 6/12 a/w alternating bowel habits. - What to look for in examination: cachexia,
Denies 10 symptoms other than constipation. No clubbing, IBD stigmata, DRE, Masses per
LOW or LOA. Occasional alcohol consumption. No abdomen. Examine for fitness for op.
STATION 7 -SKILLS - 1mentioned that 1would check for the consent & - Asked on dose of LA & how much to give.
Scenario of a young man who had a pt's allergies & wrist band, but the examiner Basically wanted to hear lignocaine (why
fight with someone and sustained a rushed me along said "ALL IS DONE, QUICKLY choose lignocaine) 3mg/kg max. if using
superficial laceration wound over START). 1%, pt weight of 70kg then can infiltrate
his thigh. LA given by nurse already. - Chose suture Dafilon 3-0. Begin by testing for total of 20cc or so.
Wound draped already. Specifically effect of LA. Then only sutured. Managed to - SHARPS SAFETY
stated in the instructions to not be suture the whole length with no issues. Had one
distracted if patient talks too much. suture with was a little bit too tight but the
"nurse" helped me hold the knot.
- During the whole station, pt asked few
questions, when to remove stitch & dressing etc.
Whether will be given any pain meds.
STATION 8 -SKILLS - Need to tell examiner what 1want prepared: - If no urine, what to do?
Scenario of a man whom your Foley's syringe. Set, what to use to clean, etc. - Flush the CBD, use USG to check tip of
registrar suspects to be having AUR. - Then perform the procedure. catheter. TO REMOVE & NOT TO INFLATE
Needs a CBD. TO inserted CBD. THE BALLOON.
Specific instruction: explain to pt • Risk and complication of CBD insertion
during procedure but NOT TO
EXAMINE.
STATION 9 -PATHOLOGY - What diagnosis? - TB, DDX lymphoma
Young lady who just returned from - How to investigate? - Other than bloods: FNAC, USG
5/12 stay in Bangladesh with - Causes of granuloma formation other than - Wagener, sarcoid, Crohn's
anterior neck swelling a/w night foreign body?
sweats. - What other infection causes granuloma? - Mycobacterium avium.
- What are giant cells? - Many macrophages fusing together as one
large cell. Has multiple nuclei.
- What else other than clinical info would you - BIOHAZARD
write on the lab form if sending for infective
tests? *sorry don't remember a great deal of this
station. The examiner was rather
flabbergasted & annoyed throughout for
reasons unknown.
STATION 10 - EXAMINATION - Middle aged man comfortable during - Diagnosis? How to investigate?
examination. Right sided thyroid enlargement

anemic symptoms. 1forgot to ask about other - How will you investigate? colonosocpy
bleeding tendencies. with biopsy. May need CT. needs basic
blood works & Ix for op.
- If confirmed Ca, how will you advise on
surgery? Depends on site, either complete
resection like left hemicolectomy, with or
without a colostomy.
STATION 4 - HISTORY TAKING Elderly lady post THR c/o 2hours sudden onset - Diagnosis? PE, Ml, Pneumonia
Scenario of pt post THR complaining history of left sided sharp chest pain a/w dyspnea - How to investigate? Basic blood work,
of chest pain and hemoptysis. Premorbidly has COAD. Post op CTPA, ECG, Dupplex LL.
ambulating and claims given SC injection for DVT. - If confirmed PE how to manage, needs
LMWH, KIV thrombolysis KIV
embolectomy. Needs intensive care.
STATION 5 - PREP STATION Read through notes of patient who is 75yo man who - Proceed with next station.
lives alone & legally registered as blind with MVR
done 4 years ago, planned for lifelong warfarin by
cardio surgeon. Aim INR 2.S-3.5. Planned for op
hernia repair with mesh next week. Inguinal hernia is
occasionally not reducible & pt on & off develops
nausea when tries to reduce the hernia. Already
given plan & counselled for by Consultant prior to
this. Pt has walked into ward, rather anxious about
stopping warfarin and anxious about op. Noted that
pt has previous session with PSY team.
STATION 6 - COMMUNICATION Basically the aim of this station was to talk to patient Did spend some time explaining on what will
Refer to Station 5. To counsel pt for & address his anxiety. 1am not sure how it went happen. Get himself admitted earlier for
op & address his anxiety. with the other candidates but this guy was a good bridging. Etc etc. 1think this station requires
actor (REALLY ANXIOUS) and what made it worse to allow patient to express their concerns but
was that he was wearing a sunglasses so you lose also knowing when to stop pt. DON'T FORGET
out on eye contact. 1allowed the patient to explain TO REASSURE PT THAT YOU WILL MAKE
& elaborate on his worries (he was worried about his ARRANGEMENT WITH THE NURSES ON THE
heart problems if stopping warfarin, worried he WARD TO ASSIST HIM WITH AMBULATION.
needs to be admitted for bridging, and no one to
care for him post op as he is blind).
Man with anterior neck swelling for with no retrosternal extension & no cervical - If FNAC follicular neoplasm, what to do?
past few years. Examine lymphadenopathy. Thyroid status normal. Offer op to pt.
accordingly. - If op confirms Ca, what intraoperative
steps would you take to prevent second
op? Frozen section
STATION 11 - PATHOLOGY - What are your concerns? - Bleeding esophageal varices with
Middle aged man who is a chronic hypovolemic shock?
alcoholic with stigmata of chronic - Cause of esophageal varices? - Portal hypertension
liver disease who presents with - other sites of portosystemic anastomosis? - umbilical, upper anal canal, bare area of
hematemesis. Currently BP dropped liver, retroperitoneal
and becomes more tachycardic. - How to manage pt? - ABC. Resusc. Plan for OGDS.
- What can be done on OGDS? - banding, sclerotherapy
- Why low pit in this pt? - DIVC, pit sequestration.
- Indications to correct pit with pit tx in this pt. - low pit with bleeding & hypovolemic shock
- Other than meds, how to treat portal - TIPS.
hypertension?
STATION 12- REST
STATION 13- PREP STATION - Given notes on pt who has breast Ca, is post op - Proceed with next station
D2 left MAC, clinically looks like hematoma with
drain 400cc & swelling over left axilla. Pt lives
alone. But daughter wants to take her out for
AOR dc as daughter stays 60miles away & works
full time & has two daughters to care for. Pt has
aspirin & statin with furosemide & has COAD.
Anaesth preop review was high risk for op,
needs ICU backup. Registrar has already spent a
lot of time counselling against AOR dc, but still
insist to dc.
STATION 14- COMMUNICATION - Called up consultant who is not the pt's own - Consultant asked me few questions
Call up your consultant on-call & surgeon. Informed her regarding her current regarding pt & how to persuade daughter
discuss the case. status of patient, has developed complication to keep pt here. Also to address how to
from op. And that daughter insists on AOR. advise them if they insist on discharging
despite advise given. Furthermore asked
me whether pt is stable, told her honestly

1don't know and will find out once done

with the phone call & update her back. BE
HONEST.
STATION 15- ANATOMY Given few pictures on the upper abdominal contents
You are to assist a surgeon on (prosection images & some from Netter's Atlas)
pancreatectomy. You are to revise - Asked to point out pancreas, parts of the
anatomy with the surgeon. pancreas.
- Asked to point out stomach & it's - Greater & lesser curvature
borders/curvatures.
- Blood supply of these structures - Stomach: Celiac axis, to breakdown the
branches. Pancreas: celiac & SMA
- Which part of pancreas are intraperitoneal & - D1 first 2cm & tail are intraperitoneal.
retroperitoneal. Others retroperitoneal.
- What are immediate posterior relations of the - IVC & aorta.
uncinate process?
- Describe the development of pancreas? - Dorsal & ventral buds.
- Describe the ducts of the pancreas. - Main & accessory duct of pancreas.
STATION 16 - EXAMINATION - Pt lying down. Got him to stand with adequate - How to investigate? USG, tumor markers
Pt with a right scrotal swelling. TO exposure & chaperone. Clinically was a large - What else to examine? Abdomen.
examine accordingly right hydrocele. Left testes normal - Differentials: hydrocele, testicular tumor,
abscess, hernia. Lipoma of cord.
- How to treat this pt? Jaboulay's.
STATION 17 - EXAMINATION - This was a little tricky as it wasn't clear what - Diagnosis: right common peroneal nerve
Male pt with varicose vein post op examination to perform (vascular, neuro, injury
right LSV RFA and multiple joints?). The hint was the history given. So read - Why reach that diagnosis? Foot drop,
phlebectomies. Pt has a steristrip instructions carefully to guide you through the weak dorsiflexion, sensory loss at 1st
over right lateral leg just below desired examination. dorsal webspace.
head of right fibula. Currently c/o - As 1was not too sure exactly what was the flow - How to investigate? (did not do well on
numbness over foot with stumbling they expected, 1started with inspection of the this particular question). 1said EMG but
on walking. To perform leg with the patient standing. Noted the examiner did not look happy. So 1presume
examination to come to a diagnosis. steristrip. Did gait: foot drop. Then 1decided to MRI/CT??
go with neuro examination - PNS. - How to treat foot drop? Physiotherapy,
occupational therapy.
 - Clinically was a right common peroneal nerve
injury (Although this didn't tally well as he also
had some weakness on plantarflexion).
STATION 18 - ANATOMY - Given bony skeleton. Needed to identify many - NOTE: SOME OF THE SKELETON USED WAS
You are an orthopedic registrar who things from UL to LL: humerus spiral groove, NOT VERY OBVIOUS. ESP THE SPIRAL
will be taking some medical greater & lesser tuberosity, coracoid process & GROOVE (even the examiner agreed on
students for anatomy lesson. You the muscles attached there, what structure this difficulty).
are revising your bony anatomy. through the spiral groove, what happens if this
structure is injured. Identify rotator cuffs origin
& insertion points. Identify gluteus medius
insertion & origin sites. Identify quadratus
femoris. Identify medial epicondyle of humerus.
STATION 19 - ANATOMY - Given images of cadaveric prosection & also
You will be assisting in a parotid images from Netter of neck & thorax. Identify:
surgery. You are revising on the ECA, ICA, CCA bifurcation, identify hypoglossal
head & neck & thorax anatomy. nerve. Carotid body & sinus location & function.
Explain opening of Stensen & Wharton's duct.
Type of saliva from parotid. Identify
submandibular gland. What is subclavian steal
syndrome. Identify subclavian artery.
STATION 20- EXAMINATION - 1started with general examination followed by - Differential: anastomotic leak, collection,
Middle aged man post op left abdomen. Pt was a good actor, looked lethargic, SSI. PE.
hemicolectomy D5 today (for already on FM02 and one large bore cannula but - Ix needed: CT scan
malignant obstructed lesion, no Foley's. - How to manage: ABC. Call intensivist. Call
difficult intraop resection) with - Abdomen was guarded & tender LIF & left consultant, call Radiologist, Family.
complaints of left sided abdominal lumbar. Pt was good as simulating this sign. - Need abx, need fluids, needs another
pain. Given a bunch of charts which cannula & Foley's. Need to be managed in
showed T 39C, tachycardic, BP HDU/ICU.
lowish with AF on ECG and rising (somehow this station felt like examination &
WBC & CRP levels. RP normal. critical care mashed together)
STATION 21- PATHOLOGY - What type of jaundice is this? - Obstructive jaundice
Young lady with obstructive - How is bilirubin carried in the blood? - DID NOT ANSWER THIS WELL AS 1DID NOT
jaundice, TB 100, ALP 300, ALT 45, UNDERSTAND THE QUESTION AT ALL.
- Explain enterohepatic circulation

RP normal with abdominal pain. No - Explain how excreted into feces,

amylase level available. reabsorbed after metabolized, etc etc.
- Why in this patient UFEME showed no urobilin - Bilirubin obstructed passage to small
intestines hence cannot enter
enterohepatic circulation.
- Function of bile - Fat emulsification & vitamin ADEK
absorption.
- Why clotting abnormalities? & what type? How - Vit K deficient as no bile. Coagulation
it occurs. cascade affected, namely extrinsic
pathway which lead to prolonged PT &
INR.
- How to correct? - Vit K & FFP.

(sorry cant remember a few other questions

related to this jaundice thing)
STATION 22 - CRITICAL CARE - Do you think CT should have been done? - Yes. Why? Pt had vomiting, amnesia, LOC.
Young man alleged RTA. On arrival - How to manage pt now? - ABCDE: needs intubation & ventilation.
GCS full but had vomiting x2 in ED Large bore lines. Need to arrange for Ct
with retrograde amnesia & LOC at scan, call up intensivist, superior, family.
site of incident. Admitted to ortho - Given CT image. What is this? - Left temporoparietal EDH with midline
ward for right tib/fib closed shift.
fracture. 2 hours into admission GCS - Why unequal pupils in raised ICP? - 3,d nerve palsy.
dropped to 8, pupils unequal. With - Forgot the question but something about Munro
high BP, bradycardia. No prior CT Kellie doctrine.
done in ED. - How does ventilating patient help? Basically
about cerebral protection.
- What else can be done to ensure no further rise - Raise bed to 30deg, normothermia,
in ICP? normoglycemia, normal PC02/P02, fluids
with saline, mannitol
- How to measure ICP? - EVD. Opening pressure on LP. Wanted a
few more but this was all 1am familiar
with.
- How to reduce ICP surgically? - Decomp craniectomy, craniotomy, burr
hole.
 |- Can LP be done in this pt? |- No. Why? Risk of herniation."

Tips on preparing for the Part B exams:

1. This is inherently & completely different that the Part A. Don't be burying yourself in books only. Go out, see more patients, examine
them properly as you would in exams. This matters a whole lot. Pay attention to your superiors who will teach you a lot in their
mannerism & word choices on communications.
2. Time is important. I think 3 months of intensive preparation should suffice to revise for the knowledge portion & to practice your skills.
3. Some of my previous seniors had partners to coach them along, a luxury I didn't have. I practiced my examination on my patients, went
back to check again if I made any mistakes, practiced in front of the mirror. For examinations which I weren't very familiar/comfortable
with (for e.g. ortho stuff, since I am in General Surgery), I repeated the examinations over & over again with husband till I could do it like
a spinal reflex. The other option I would suggest is to sit in the Ortho clinic of your center and examine patients as many as you can. I
stress on practice3 as it really shows if you don't know your stuff.
4. Books:
a. For anatomy: I used LAST. Physiology: Ganong. For surgical topics: Bailey and Love with Kirk Textbook. For ortho: Apley.
b. For basic examination I used Browse. But I feel in general the MRCS examinations had a little bit more finesse than what Browse
has to offer. Nevertheless I used Browse as it helped with explaining different signs (esp for certain tests such as tourniquet,
Buerger's test etc). For ortho examination, I used Apley which was very helpful visually.
c. For the exams: Closer to date, like 3 months prior to the exams, I moved on to more "anastomotic books" i.e. books tailored for
the exams with all topic "anastomosed" together into a book. The few books I used were: Bailey& Love OSCE Prep (Has quite
extensive topic on examination & procedural skills which is sufficient if your basics are already strong, nevertheless I still had to
refer back to some main textbooks for certain examination details), Parchment (DID NOT FIND THIS BOOK HELPFUL AT ALL
DESPITE THE REVIEWS), DREXAM BOOK 1 & 2 (Very concise and was helpful with all the mnemonics & all the charts) good for
quick revising anywhere. For anatomy questions I used Anatomy vivas for the imrcs & Jeremy Lynch. Others: cracking the MRCS
VIVA (although I didn't have enough time to finish this book, I like this book as well as it had a broad range of topics neatly
subdivided).
d. OVERALL: IT DOESN'T MATTER HOW YOU USE THESE BOOKS. AS LONG AS YOU GO BACK TO BASICS, THE QUESTIONS WILL
REVOLVE AROUND THE SAME STUFF.
5. During the exams: BE PUNCTUAL. DO NOT FORGET YOUR ADMISSION LETTER (one candidate forgot to bring hers, was a mess). I brought
my own stets. Although everything is provided, I was not happy with the paper they provided for the transillumination test which was

pretty useless, they didn't provide me paper for fine tremors (had to use a tissue, one on each hand). I did bring my own pin for the
visual field test although I did not get around to using it. In short, if you are worried about using their equipments, you can bring your
own. But remember you will only be allowed to bring yourself in. So travel light. During the exams, there was a pattern on how it is run.
Basically, you will be broken down to a group of 11 candidates which means you go around one circuit, following which, you swap with
the other group to go around the other circuit. By about halfway, I noticed that my first circuit was primarily on Pathology & Comm skills
whilst my second circuit was Anatomy & Exam/Procedural Skills. It wasn't very nice that my first station was a rest station but beggars
can't be choosers.
6. Prep Course: I highly recommend it. Many of the questions during the course are EXTREMELY SIMILAR/REPEATED FROM THE EXAMS. I
took my part A two years prior to this, so you can imagine how rusty I was with everything and I was panicking for the exams as I did not
know to prepare & approach it. I went for the prep course in May 2018,4 months prior to the exams. It really tailored how I studied 8i
prepared for the following months to come as it gave me a clearer & more succinct idea on the focus of the exams. As I studied and
prepared alone (no study group), this prep course helped me to tailor my preparation style to the demands of the exams. I came to
realize from the course that it is not about knowing everything, but rather knowing clinically important topics (for eg, it is highly unlikely
someone will ask you about club foot, but it would be likely that you will be asked on sciatic nerve injury esp with regards to the hip
surgeries). The exams/questions during the course do have the same feel as the exams do as there will be stations, plus you will have
other potential candidates looking you on as you make blunders and vice versa. You will only appreciate the mistake once you've made
it or seen another friend make it. The course coordinators will definitely guide you on scoring tips and time management (lOmins per
station is not much to shine!). DO GO FOR THE PREP COURSE IF THE OPPORTUNITY OPENS ITSELF TO YOU.
7. Finally, if you are not able to go for the prep course, I recommend MRCS Resource as this was my last 2-3 weeks of revision and it
tailored me further on the types of questions to expect.
8. In general, the exams are fair. There will be external observers in your favor. You may get one or two difficult examiners or patients but
don't fret as it probably will only affect you in one or two minute points if your style & form is right anyways. Don't carry the failure of
one station to the next. Last but not least, failing one station does not equate to failing the exams. AIM TO PASS EVERY STATION.

Hope my contribution would be in your favor (as those who have succeeded before me have helped me in ways I cannot repay, esp via
this website.)

God bless.
Live long and prosper.

Sincerely,
SIL.
all repeated questions except for LL neurology (footdrop)

history
-POD6 postpo PE
-rectal bleeding 6 months

procedure
-IDC
many people were stumped and there is still no consensus to what the examiner is
looking for to the following question - what if the IDC is inserted into the bladder
(confirmed by US) and there is still no urine (confirmed by US), seems like pre-
renal/renal cause is not the answer
-suture laceration

exams
-real thyroid lump (likely thyroid Ca, no lymphadenopathy)
-real hydrocele
-simulated acute abdomen pod6 anastomotic leak with AF
-LL neuro footdrop common peroneal nerve palsy
this seems to be a new station. POD2 after ligation/stripping of great saphenous vein
with phlebectomy presenting with weakness and abnormal sensation of the lower limb,
asked for causes and management

comms
-blind person on warfarin going for inguinal surgery
-discuss AOR with consultant (see previous notes on the website - elderly lady POD2
mastectomy/axillary clearance coerced by daugher to go home 60 miles away even
though low-grade fever, high drain output and tachycardic)
for this station, the examiner/consultant-on-the-phone did not even ask any specific
questions or give any input/suggestions on what to do for the patient, i just summarized
the different issues and give my management plan, do note to say that there are no
recent post-op blood results, that you have not examined nor spoke to the patient
physically.

path
-TB/lymphoma
-malignant melanoma

anat
-pancreas/duodenum/stomach
-carotid/oesophagus
-scapula/hip/proximal femur (note: intertrochanteric crest insufficient- need to say pubic
tubercle for insertion of quadratus femoris)

crit care
 KUALA LUMPUR 29™ SEPTEMEBER 2018

Examinations:

1. Fo o t s e c o n d a r y to N e u ro p ra x ia o f C o m m o n P e ro n e a l: (sim u la te d
p atien t)

Patient present with foot drop after 7 days of ra d io fre q u e n c y a b la tio n of

varicose vein- examine.
Fin d in g s:

1. Multiple steris-trip on the anteromedial and anterolateral aspect of the leg

2. High stepping gait
3. Weak dorsiflexors and everters
4. Sensory loss at the dorsum of the foot and 1st web space
5. Tinel's test positive at neck of fibula for common peroneal nerve.
Asked about differential diagnosis, what other examinations you want to do,
investigations and management
2. T h y ro id (R e al p a tien t)

Middle age male with a right sided swelling examine the lump.
Fin d in g s:

1. The swelling moves with deglutition.

2. Not fixed with underlying structures or skin.
3. Firm in consistency.
4. Single.
5. Measuring 5x6 cm.
6. Cervical lymph nodes were not enlarged.
7. Not thyroid status symptoms present and pulse was regular and normal.
Asked about differential diagnosis, what other examinations you want to do,
investigations and management
3. H y d ro c e le (R e al p a tie n t)

Old age patient had right sided scrotal swelling.

Fin d in g s:

1. Can reach the upper lim it of scrotum,

2. Transilluminable swelling.
3. Testis not palpable separately.

Asked to perform direct inguinal ring test and surface anatomy of superficial and
deep inguinal rings, differential diagnosis, what other examinations you want to do,
investigations, tum or markers for testicular pathology and management of the
disease.
-jaundice (include questions about binding of bilirubin in circulation as well as how
obstructive jaundice affects coagulation)
- RTA (extra-dural haemorrhage and raised ICP)
- variceal bleed
 KUALA LUMPUR 29™ SEPTEMEBER 2018

Examinations:

1. Fo o t s e c o n d a r y to N e u ro p ra x ia o f C o m m o n P e ro n e a l: (sim u la te d
p atien t)

Patient present with foot drop after 7 days of ra d io fre q u e n c y a b la tio n of

varicose vein- examine.
Fin d in g s:

1. Multiple steris-trip on the anteromedial and anterolateral aspect of the leg

2. High stepping gait
3. Weak dorsiflexors and everters
4. Sensory loss at the dorsum of the foot and 1st web space
5. Tinel's test positive at neck of fibula for common peroneal nerve.
Asked about differential diagnosis, what other examinations you want to do,
investigations and management
2. T h y ro id (R e al p a tien t)

Middle age male with a right sided swelling examine the lump.
Fin d in g s:

1. The swelling moves with deglutition.

2. Not fixed with underlying structures or skin.
3. Firm in consistency.
4. Single.
5. Measuring 5x6 cm.
6. Cervical lymph nodes were not enlarged.
7. Not thyroid status symptoms present and pulse was regular and normal.
Asked about differential diagnosis, what other examinations you want to do,
investigations and management
3. H y d ro c e le (R e al p a tie n t)

Old age patient had right sided scrotal swelling.

Fin d in g s:

1. Can reach the upper lim it of scrotum,

2. Transilluminable swelling.
3. Testis not palpable separately.

Asked to perform direct inguinal ring test and surface anatomy of superficial and
deep inguinal rings, differential diagnosis, what other examinations you want to do,
investigations, tum or markers for testicular pathology and management of the
disease.
4. A n a s to m o tic le a k a g e w ith le ft s h o u ld e r tip pain.

7th post-operative day after resection of a caecal tum or via right hemicolectomy.
Patient complains of distress and SOB with tachycardia and left sided shoulder pain.
Examine. Follow CCrISP protocol.
F in d in g s:

1. Airway patent.
2. Decreased chest expanision, trachea central, tachypnea.
3. Dehydrated and tachycardic and capillary refill less than 2 seconds.
4. Alert and conscious.
5. Pyrexic with no TEDs on the right leg and generalized tenderness on
palpation ( I omitted abdominal palpation as I asked at the start about
pain and told the examiner as the patient looks septic further palpating
will be uncomfortable and I have all the findings of peritonitis)
6. New Early Warning Score 6.
Asked about differential diagnosis M U S T say L E F T S U B P H R E N IC A B S C E S S , what
other examinations you want to do, investigations and management.

H isto rie s:

1. P er R e ctal B le e d in g w ith w e ig h t loss

Gentleman with PR bleed with 5 kg weight loss and± tenesmus, fam ily history +ve
(brother had bowel cancer at the age of 40 years)
Asked about differential diagnosis M U S T tell F am ilia l A d e n o m a to u s P o ly p o sis
and subsequent investigations/management
2. C H E S T PAIN s e c o n d a r y to P u lm o n a ry E m b o lis m p o st o p d a y 2 o f T H R

Acute onset of pain for the last 6 hours with few blood clots on cough, dyspnea and
SOB, previous history of varicose veins surgery 3 years back, on ward there was no
heparin given, not wearing TEDs.
Asked about differential diagnosis M UST tell A c u te a n g in a an d a c u te M I, a c u te
G a s tritis , A c u te P a n c re a titis an d P n e u m o n ia and subsequent
investigations/management.
C o m m u n ic a tio n S k ills

1. W a rfa rin c o u n s e llin g

Preparation Bay 9 mins reading time and tim e to make notes

M r G re e n , B L IN D , w ith M V R o n w a r f a r in w h o is v e r y a n x io u s a b o u t s to p p in g i t a s h is
c a r d io lo g is t to ld h im N E VE R t o s to p w a r f a r in .

N u rs e c a lls y o u in t h e p r e - o p d l in i c , t a lk t o h im a b o u t s to p p in g o f w a r f a r in f o r h is IN G U IN A L
H E R N IA o p e r a tio n A N D g iv e a n s w e r s t o h is q u e s tio n s . A C T O R w a s w e a r in g b la c k g la s s e s .
V e ry g o o d a c to r .

1. N e e d t o e x p la in b r id g in g f o r h ig h r is k p a t ie n t
2. E x p la in t h a t y o u w ill in fo r m t h e n e c e s s a ry p e o p le - h is c a r d io c o n s , h is GP,
d is t r ic t n u rs e s
3. G e t h im in fo r m a tio n in b r a il i f p o s s ib le
4. I f s t ill n o t h a p p y , o f f e r f o r h im t o c o m e in a c o u p le o f d a y s p r e - o p t o e n s u re t h a t
h e re c e iv e s t h e c o r r e c t d o s e s
5. G iv e h im a c o n t a c t n u m b e r t o c a ll i f h e h a s a n y f u r t h e r q u e s tio n s

2. O N C all C o n s u lta n t Call to u p d a te s e lf-d is c h a rg e

Preparation Bay 9 mins reading time and tim e to make notes

7 8 y e a r s o ld M rs . G re e n w ith b r e a s t c a n c e r h a d m a s te c to m y a n d a x illa r y c le a ra n c e 2 d a y s
a g o , d a u g h te r n o w w a n ts t o t a k e h e r h o m e - 6 0 m ile s a w a y a n d b o th h e r a n d h e r h u s b a n d
w o r k f u ll t im e i.e . w o u ld n 't be a b le t o lo o k a f t e r h e r p r o p e r ly .

C u r r e n t is s u e s - S O B a n d h a s b lo o d P O U R IN G o u t o f h e r d r a in . N o t h a d b lo o d s s in c e p r e ­
o p . D is c u s s t h e s it u a t io n w it h c o n s u lt a n t o n c a ll.

S p e a k t o on call consultant whose not the consultant of the patient a b o u t la d y w h o

w is h e s t o s e lf- d is c h a r g e b u t n o te s w r it t e n s u g g e s t b e in g c o e rc e d b y d a u g h te r , tu r n e d in t o a
v iv a - id e n t if y th e r e d f la g s , w h a t is c a p a c ity , w h a t w o u ld y o u d o o n t h e w a r d , h o w w o u ld
y o u m a n a g e t h is p a t ie n t a c u t e ly ( p o s t lu m p e c to m y , w ith 5 0 0 m ls b lo o d in d r a in , la s t s e e n in
a m a n d t h is is 4 p m ) , a s k e d d ir e c t ly h a v e y o u s e e n t h e p a t ie n t d o n o t lie , w h a t w o u ld y o u
lo o k f o r h o w w o u ld y o u a s s e s s t h e p a t ie n t

THINGS TO DO
1. C o n firm i t is t h e c o n s u lt a n t
2. T e ll h im w h o y o u a r e , w h e r e y o u a re .
3. F o llo w I-S B A R f o r m a t .
4. A s s e s s p a t ie n t c a p a c ity a n d s e e i f t h e p a t ie n t a c t u a lly w a n ts t o g o h o m e w ith h e r
d a u g h te r .
5. A d d re s s p a t ie n t a n d f a m ily c o n c e rn s
6. E x p la in t h e n e e d t o s ta y f o r f u r t h e r t e s ts - i. e . s h e is S O B a n d c o u ld r e q u ir e a
b lo o d T x d u e t o lo s s e s fr o m d r a in
7. I f r e fu s in g t o s t a y - s h e h a s a u t o n o m y .
8. O ffe r c a re a t a h o s p ita l c lo s e r t o h e r fa m ily ...
9. I f s t ill r e fu s in g , c o n t a c t lo c a l GP f o r r e g u la r h o m e v is i t r e v ie w t o c h e c k s h e is o k
1 0 . I f n o c a p a c ity , w o u ld h a v e t o s t a y o u t o f b e s t in te r e s t s e tc .
P ro c e d u ra l S k ills

1. S u tu rin g o f an in cise d c lea n w o u n d on th e a n te r io r a s p e c t o f th ig h

Suture the wound infiltrated with a local anesthetic with a non-absorbable suture
(had to choose between vicryl (absorbable) and prolene). You need to counsel the
patient about scar and post procedure complications. C h e c k th e e ffe c t o f local
a n d th e e x p iry d a te o f th e su tu re .

Questions: Had to calculate LA dose, know how much to give with and without
adrenaline, and needed to know different options for immediate acting and longer
acting anesthetics.

2. C a th e te r iz e th e p a tie n t to re lie v e fro m a c u te u rin a ry re te n tio n

Patient has no previous episodes of retention or instrumentation of the urinary

passage.
Counsel the patient regarding the procedure especially failure to pass catheter, also
check for bleeding tendency and blood thinners, inform about topical anesthesia
that it will be cold and may sting initially.
Check the expiry date of foley's and local anesthetic gel.
Causes of anuria and steps to resolve if no urine coming after foley's.
P ath ology
Excisional biopsy done for lesion at the forearm show ing m elanocyte proliferation
M A L IG N A N T M E L A N O M A
Definition o f melanoma m alignant neoplasm o f melanocytes
2 Skin conditions associated with melanoma: 1. X eroderm a pigm entosa
2. Fitz patric skin type 1

Comm ent on the pathology report: 1. Size

2. B reslow thickness: m easured in mm. From the top o f stratum
granulosum to the deepest point o f tumour involvement
3. Depth o f invasion ( d a rk 's levels)
4. Ulceration, m itoses, lym phovascular invasion
5. Immunohistochemistry staining
Poor prognostic factors: 1. increased tumour thickness( B reslow thickness)
2. Increased depth o f invasion
3. Type o f melanom a: N o d u la r, am elanotic melanoma
4. Prescence o f ulceration
5. Prescence o f lymphatic or perineural invasion
6. Prescence o f regional or distant m etastsis
H ow to diff. MM from S C C ? M elanom a: arise from the low er layer o f the epiderm is from any part
o f the body
S C C : arise from upper and mid layer o f epiderm is with keratin pearl
formation usually on sun exposed areas

L esion excised , B reslow thickness 1.5 mm, m argins 0.5 mm, Re- excision + safety margin 3 cm m a rg in * post-op radiotherapy
what to do ?
G enes responsible for fam ilial M M ? C D K N 2 A and C D K 4 (exam iner not agreeing)
What to do to ensure adequate m argins? Frozen section, M oh's m icrosurgery
What effect does sun light have on skin cells? Alters the nuclear D N A o f the cells leading to malignant
transformation.

P ath ology
A young lady cam e back from a foreign travel from Bangladesh with cervical lym phadenopathy, LOW , N ight sw eating
T u b e rc u lo sis
D ifferentials 1. H odgkin’ s lymphoma
2. Tuberculosis.
Which labs you will send her sputum to? 1. M icrobiology
2. Cytology
What 2 tests for T B you will do ? 1. Quantiferon ( interferon gam m a assay s)
2. F N A C o f lymph node
Where will you put the specim en? Biohazard bag
Organism o f T .B ? M ycobacterium T .B
M ycobacteria found in im m unocom prom ised patients mycobacteria avium / intracellulare(M AC)

H ow long does it take to culture? 1-8 weeks

G iven the F N A C result: necrotic tissue, histocytes, giant cells TB
What type o f protein deposition is seen in T b? Am yloid AA
What are giant cells? M ultinucleated cells com prising o f m acrophages often forming
granulom a
Surgically relevant exam ples o f granulom a Sarcoidosis, Crohn's , Rhematoid arthritis
P h ysiology
Fem ale having epigastric pain, nausea, vom iting ,diarrhea, increases A L T , A S T , A L P , G G T , urobilinogen undetectable in urine
O b stru ctiv e Ja u n d ic e
Why clotting is deranged: 1. liver synthesize m ost o f the clotting factors
2. Vit. K required to activate factors 2,7 ,9 ,1 0 in severe liver
dam age and biliary obstruction there will be decreased
absorption o f vit. k
3. This will lead to increased prothrombin time.
Function o f bile: Em ulsification o f fat into m icelles thus provides a greatly increased
surface area for the action o f the enzym e pancreatic lipase
H ow d oes bile salts help in em ulsification o f fat? B ile salt anions are hydrophilic on one side and hydrophobic on the
other side; consequently, they tend to aggregate around droplets o f
lipids (triglycerides and phospholipids) to form m icelles, with the
hydrophobic sid es tow ards the fat and hydrophilic sides facing
outwards. The hydrophilic sid es are negatively charged, and this
charge prevents fat droplets coated with bile from re-aggregating into
larger fat particles.
What is bilirubin conjugated to Conjugates with glucouronic acid by the enzyme
glucuronyltransferase, in the liver.
Bilirubin m etabolism : 1. Conjugated bilirubin go e s into the bile and thus out into the
sm all intestine. Though most bile acid is resorbed in the
terminal ileum to participate in enterohepatic circulation,
conjugated bilirubin is not absorbed and instead p asses into
the colon
2. There, colonic bacteria deconjugate and m etabolize the
bilirubin into colorless urobilinogen, which can be oxidized
to form stercobilin: these give stool its characteristic brown
color.
3. 10% o f the urobilinogen is reabsorbed into the enterohepatic
circulation to be re-excreted in the bile: som e o f this is
instead processed by the kidneys, coloring the urine yellow.

What is urobilinogen and how it is form ed? It is a byproduct o f bilirubin m etabolism form ed in the intestine by
gut flora
Define enterohepatic circulation? R eabsorption o f bile salts from the terminal ileum and return them
back to the liver ( 95% )
H ow to correct clotting abnorm ality? - i.v vit. K
- fresh frozen plasm a
- Prothrombin com plex concentrates
- Consult hem atologist
What other investigation you want to do? Abdom inal ultrasound
I f you find a C B D stone? ER C P
I f the patient had fever, pain, chills? A scending cholangitis
Bones
Given skeleton o f entire body - pointed out to different parts to ask origin and insertion etc.
U p p e r L im b
What bone is this? Where does the fracture usually occur? Clavicle. M iddle third.
Tell me about the rotator c u ff m uscles. O rigin and insertion. Muscle Origin Insertion
Show me on th skeleton. Supraspinatus Supraspinous fossa Greater tubercle o f
o f scapula humerus

Jm
Intraspinatus Infraspinous fo ssa o f
scapula
R o tato r c u ff m u sc les
T eres minor M iddle 2/3 o f lateral
Anterior „ Posterior border o f scapula
Supraspinatous muscle
Subscapularis M edial 2/3 o f L esser tubercle o f
subscapular fossa humerus

tSKj A P ^ ^ T e r e s minor
r . . . muscle
Subscapularis
muscle w M r . Infraspinatous
vU E r n. musc*e
'J'AnA.M.
Show me the spiral groove. What nerve runs through it? Point out spiral groove. R adial nerve.
What nerve runs behind the m edial epicondyle? U lnar nerve.
Show me the sensory deficit. Medial 1.5 fingers - he asked sp ecifically i f both dorsal and palm ar
surface: yes.
What is the only thenar m uscle affected in ulnar nerve palsy/ Adductor pollicis
injury?
L o w e r L im b
What is this? (points to A S IS ) Anterior superior iliac spine.
What attaches here? Sartorius (he ju st wanted one answer).
What runs here? (pointed to region ju st beside A S I S under Lateral fem oral cutaneous nerve
im aginary “ inguinal ligament” )
What condition d oes this cause? M eralgia paresthetica
What is the m ajor flexor o f the hip? Ilipsoas.
What d oes it attach to? L esser trochanter.
Asked about gluteus m uscles; origin and insertion (point out on G luteus m axim us G luteal (posterior) Iliotibial tract
the skeleton). surface o f the
Gluteal tuberosity
ilium, sacrum and
coccyx. o f femur

G luteus m edius Gluteal surface o f Lateral surface o f

ilium g re a te r tro ch a n te r

G luteus minim us Ilium C onverges to form

a tendon, inserts to
anterior side o f
g re a te r tro ch a n te r

A sked about function o f gluteus m edius/ minimus. Want to hear Trendelenburg sign. And good side sags. Due to loss o f
hip abductors.
Where d oes quadratus fem oris insert? Show on skeleton. Intertrochanteric crest.
Where d oes quadratus fem oris originate? Ischial tuberosity.
E x tra d u ra l h em atom a
R TA G C S 15, 2 episodes o f vom iting, am nesic events then suddenly G C S 8.
What do you see on C T brain? EDH.
N orm al value o f IC P ? 7-15mmHg.
W ays to m easure ICP? Invasive: IV C monitor via E V D , intraparenchymal monitor via ICP monitor.
N on-invasive: L P (opening pressure); transcranial D oppler can m easure M C A velocity and
derive pulsatility index correlating with ICP.
Pathophysiology o f increased ICP? M onroe-kellie doctrine. Skull is a fixed box with 3 com ponents: brain 80% , blood (arterial and
venous) 10% and C S F 10%. An increase in any o f these components must be offset by an equal
decrease in another. The body tries to com pensate and reduces C S F first then blood, however,
once it has passed its critical volum e o f com pensation (~ IC P 25m m H g) sm all increases in brain
volum e can lead to marked elevations in ICP, leading to failed intracranial com pliance and brain
herniation.
M anagement A B C D E model. G C S 8 o r less is indication for intubation to protect airw av and assure optimal
oxygenation and ventilation; which can also help facilitate ICP management. IV fluids, head up
30 degrees (im prove venous drainage), hypothermia, mannitol/ hypertonic saline (increase
serum osm olality and in turn reduce water in brain), keppra 2 w eeks (anticonvulsants),
barbiturate coma. Surgery: evacuate clot (> 5 m m midline shift with > 3 0 m L ), decom pressive
craniectomy.
C au ses o f dilated pupils in raised IC P ? Transtentorial herniation; tem poral lobe over tentorial cerebelli where CN 3 crosses, resulting in
inhibition o f parasym pathetic innervation to iris sphincter; resulting in unopposed sym pathetic
innervation to pupil and resultant dilatation.
B enefits o f ventilation 1. Ensure adequate oxygenation to prevent H IE (hypoxic ischem ic encephalopathy)
2. Control o f p a C 0 2 to hyperventilate patient (a s below)
H ow to m anage this patient i f he was Hyperventilate patient.
intubated to decrease brain injury? C 0 2 is a potent vasodilator, in hyperventilation, this reduces the arterial C 0 2 resulting in
vasoconstriction o f cerebral blood vessels. This in turn reduces the overall blood volum e and
thus intracranial pressure.

Head up 30 degrees to allow adequate venous return from brain. Sedate/ paralyse patient to
reduce cerebreal m etabolic requirement. Hypothermia. Judicious fluids with strict I/O
monitoring (ID C ), mannitol/ hypertonic saline to reduce cerebral edema.
E so p h ag e a l v arice s
45yo, chronic alcoholic, 3 tim es hem atem esis, low B P , high HR, esoph ageal varices. Altered mental state.
D ifferentials? 1. Esophageal varices due to poral hypertension
2. M allory-w eiss tear
3. U pper G I bleed - peptic/ duodenal ulcer
Sites o f portosystem ic anastom osis?
P O R TO SY ST EM IC A N A S T O M O S E S

O eso ph ageal
“1 i branch es o f
3 4 5 / l e f t g a stric

^ J^ ^ p le n ic JV . Sp|een

f- Right 1 1 Left ,
“ lic ( P n colic
Superior A. p Inferior
m esenteric L m esenteric

1 Superior
* rectal
1 Lower oesophagus 4 Bare area of liver
Portal: Oesophageal branches Portal: Hepatic/portal veins
of left gastric veins Systemic: Inferior phrenic veins
Systemic: Azygos veins
5 Patent ductus venosus (rare)
2 Upper anal canal Postal: Left branch of portal
Portal: Superior rectal vein vein
Systemic: Middle/inferior Systemic: Inferior vena cava
rectal veins
6 Retroperitoneal
3 Umbilical Portal: Colonic veins
Portal: Veins of ligamentum Systemic: Body wall veins
teres
Systemic: Superior/inferior
epigastic veins
How will you m anage this patient?
Acute A B C . Look for early sign s o f shock (tachycardia, postural hypotension).
A sse ss hydration status. A sse ss mental state. K IV intubation. V ascular
access, fluids/ blood resuscitation and blood investigations. Aim : keep Hb
around 9, over enthusiastic transfusion can increase portal pressure and
^ fc tn to n f cause more bleeding.
W^ Mi nnesot a (1 ) IV so m ato sta tin / o c treo tid e: Splanchnic vasoconstrictor which
Blakemore ^ decreases portal blood flow and hence portal pressures.
(2) Acid su p p re ssio n : IV PPI om eprazole
(3) A n tib io tics: broad spectrum, reduces infection risk.
(4) E n d o sco p y : confirm diagnosis and institute m anagement; can do
banding or sclerotherapy.
(5) I f not reso lv ed with en do sco pic in tervention th en: Balloon
tam p o n a d e: Linton (only has a gastric balloon portion), Sen gstaken -
B lak em o re tu be (esoph ageal and gastric balloon; and gastric aspiration)
and M in n eso ta (esophageal and gastric balloon; esoph ageal and gastric
aspiration). Inflate gastric balloon and pull up against cardioesophageal
junction (balloon presses onto perforator veins entering oesophagus
 from stom ach, and decreases oesophageal variceal bleeding). Repeat
endoscopy 10-12 hours later (m ucosal necrosis).
(6) S e co n d ary p r o p h y la x is: Propanolol

Others:
> R adiologically guided insertion o f transjugular intrahepatic porto­
system ic shunt (T IP S S )
> Shunt surgery
> Sugiura procedure (last resort): a surgical technique that involves the
rem oval and transection o f blood vessels that supply the upper portion o f
the stom ach and oesophagus, with splenectom y. Splenectom y, proxim al
gastric devascularisation, selective vagotom y, pyloroplasty, oesophageal
devascularisation, oesoph ageal transection and reanastom sed to ju st
above the cardia.

TIPSS
Sengstaken-Blakem ore
Tube

Showed blood result with low Hb and raised DIC.

fibrinogen degradation products. A sked what?
How to m anage? F B C , platelets, FFP.
What is m assive transfusion protocol? Ratio. 1:1:1.

A scites in this patient. What is the cau se? Wanted 2 1. Reduced album in production (liver cirrhosis).
causes. 2. Vasodilatation theory: portal hypertension leads to vasodilation
which causes decreased effective arterial blood volume. A s natural
history o f the disease progresses, neurohumoral excitation
increases, m ore renal sodium is retained, and plasm a volume
expands. This leads to overflow o f fluid into peritoneal cavity.
Patient with m acrocytic anem ia, what could be the Nutrition deficiency ( vitam in b 12 defeciency) with chronic alcoholism
cause?
C ause o f thrombocytopenia in this case ? 1. H ypersplenism
2. D IC
Pictures taken from N e tte r’ s - pointed out to d ifferen t structures and so m e clin ica l anatm oy etc.
R oot o f N eck
Identify brachial plexus A nsa Cervical is and V agu s N erve
Tell me about the follow ing strcutures.

Trachea bifurcates at which level? T4/T5 Point out spiral groove. R adial nerve.
Where is carotid sinus located and what is its functions?

What is subclavian steal syndrom e?

A bdom en
Pictures taken from M cM inn 's - pointed out to different structures and som e clinical anatmoy etc.
R oot o f N eck
Identify parts o f the stomach Em bryology o f Pancreas.

What is B arrett's esoph agus?

Tell the blood supply o f stom ach with reference to the arteries o f What are the parts o f pancreas?
origin
A r t e r i a l S u p p ly : Supplied b y branches o f celiac trunk (foregut)
Esophageal a.
Celiac trunk ^ s"10rt
gastric aa.

Hepatic _
artery proper
Gastroduodenal a.
Supraduodenal

Left gastro-
omental a.
Right gastro-omental a.
Superior pancreaticoduodenal a
Where d oes m ajor and minor pancreatic ducts open? What are structures are related to the body o f pancreas?
What are the peritoneal relations o f the pancreas and the What structures are related to the 2 nd and 3 rd parts o f duodenum
stom ach? during surgery?_______________________________________________
 2nd Part:
• It is 3 inches long descending vertically from L1 to L3.

• The bile duct opens in its postero-medial aspect.

• The bile duct usually unites with the m ain pancreatic duct to form the am pulla of
Vater & opens at the m ajor duodenal papilla.

- The a c c e ssory pan c re a tic d u c t opens separately at the m in o r duodenal

pa p illa 1 inch above the m ajor duodenal papilla i f l f t

- Relations:
* Anterior: the liver & the transverse colon

• Posterior: the Rt. kidney & Rt. psoas major

3 rd P a rt: 0
- It is 4 inches in length at the level of L3 vertebra.
- It is covered by peritoneum anteriorly & inferiorly.
Relations:
•Anterior: superior mesenteric vessels at root of mesentry
N.B: S uperior mesenteric vein lies on the rig h t side o f superior
m esenteric artery
•Posterior: the aorta, IVC, origin of the inferior mesenteric artery, Rt. ureter and
psoas major
•Superior: head of pancreas
•Inferior: small intestine
It w as tw o circ u its , each w ith 11 s ta tio n s (1 p re p and 1 break), th e n a fte r 11 s ta tio n s g e t to rest, th e n
s w itc h to o th e r c irc u it.

G ro u p e d in to :

• 1 p ro c e d u re , 1 com m s, h is to ry , path, c rit care

• 1 p ro c e d u re , 1 com m s, ana t, e x a m in a tio n s

1. P athology: TB
a. 23 y ear old goes t o Bangladesh fo r 5 m o n th s com es back w ith 2cm lu m p in neck
i. D iffe re n tia ls ? TB and ly m p h o m a
ii. H o w to d iffe re n tia te ? FNAC
iii. W h a t you send fo r? C ytology and M ic ro b io lo g y
iv. Shows yo u th e re p o rt g o t som e n e c ro tic tissue and g ia n t cells: TB
v. W h a t o th e r serolo gical te s ts can yo u send fo r TB? TB PCR, q u a n tife ro n gold
(o n ly seem ed to w a n t these)
vi. H o w lo ng do TB c u ltu re s ta k e to c o m e back? Said 4 -8 w e eks and g o t th e
m ark
v ii. W h a t w o u ld y o u place on th e bag if yo u suspe cting in fe c tio n : biohazard
s tic k e r (th is is th e an sw e r th e y lo o k in g fo r, he said YES!)
v iii. W h a t else do you need to do if TB? C o nta ct tra c in g and in fo rm in g
a u th o ritie s
ix. W h a t a u th o ritie s ? CDC, h o s p ita l in fe c tio n c o n tro l etc
x. W h a t o th e r g ra n u lo m a to u s diseases o th e r th a n TB and fo re ig n body? Cat
scratch, sarcoid, cro h n 's
xi. W h a t p ro te in d e p o s itio n ? AA a m y lo id

2. P athology: M e la n o m a
a. Gives you h is to r e p o rt o f m a lig n a n t m ela n o m a
i. W h a t is d iffe re n c e b e tw e e n m e lan om a and SCC?
ii. W h a t fe a tu re s are suggestive o f p o o r prognosis in h is to r e p o rt do yo u lo o k o u t
fo r?
iii. W h a t fe a tu re s are suggestive o f goo d prognosis d o yo u lo ok o u t fo r?
iv. N am e 2 g e n e tic skin c o n d itio n s th a t predispose to m e lan om a -
accep ted x e ro d e rm a p ig m e n to s u m b u t n o t a lb in is m o r F itz p a tric k skin types
v. You c u t o u t a 1.1m m m e la n o m a w ith 1m m c le ar m arg in , w h a t do yo u w a n t to
do?
vi. W h a t m arg ins do you w a n t?
v ii. W h a t specific genes do yo u send fo r te s tin g th a t w ill a ffe c t
m anage m ent?
v iii. W h a t is a s a te llite lesion?
3. C o m m u n ic a tio n : W a rfa rin
a. O ne p re p s ta tio n : guy w ith PM H m ac d e g e n e ra tio n (b lin d ), a n x ie ty (n o t on meds),
p revio us L in gu in a l he rn ia re p a ir, c o m in g in fo r a n o th e r L in gu in a l hernia re p a ir in 6 days
tim e , 4 years ago had MVR on w a rfa rin ta rg e t 2.5-3.5, has a lo t o f que s tio n s a b o u t
w a rfa rin b rid g in g basically
b. C om m s ta tio n : an sw e r his 1000 q u e s tio n s on w h e n t o s to p w a rfa rin , he's b lin d h o w to
give clexane if nee ded, w h e n t o a d m it, a fte r o p care etc

4. C o m m u n ic a tio n : D a u g h te r w a n ts m o th e r to AOR
a. O ne p re p s ta tio n : Pt is 7 5 y /o re tire d , lives in b u n g a lo w alone, is POD 2 le ft bre a s t SMAC,
vac d ra in in s itu : 35 m l day 1 th e n 4 1 0 m l day 2, o n ly has pre o p b loods availab le
(u n re m a rk a b le hb 13.9, u r 91 cr 115, all o th e r b loods u n re m a rk a b le ), no b loods
re p e a te d since. POD 2 g o t axilla pain and p u ffy , lo w grade T spike 37.8. D a u g h te r w a n ts
to AOR p a tie n t (reg has trie d and fa ile d to c onvince n o t to AOR). D a ughter specifically
w a n ts to b rin g p a tie n t to h e r o w n house w h ic h is 60 m iles fro m h o s p ita l w h e re she lives
w ith husband tw o c h ild re n and a p e t dog, b o th w o rk as s c h oo lteachers so no tim e . She
fe e ls th a t it is easier fo r h e r to lo ok a fte r h e r m o th e r th e re .
b. C om m s ta tio n : call and speak t o c o n s u lta n t fo r advice
i. W h a t do you w a n t t o do fo r p a tie n t? R epeat bloods, assess capa city, exam ine
arm etc
ii. W h a t do you th in k c ould be cause o f p u ffy axilla?
iii. W h a t in v e s tig a tio n s do yo u w a n t to do?
iv. W h a t d o yo u th in k c ould be cause o f 4 1 0 m l d ra in in g
v. W h a t do you w a n t t o te ll d a u g h te r t o convince n o t to AOR?
vi. If th e y insist, w h a t else w ill yo u do, and w h a t w ill yo u d o c u m e n t?
Capacity, expla in e d risks, sa fe ty n e t, give e a rly TCU, arra nge d is tric t nurses,
u p d a te GP, w r ite m e m o etc

5. E xa m ination: S crotal exam

a. G in o rm o u s b ila te ra l s c ro ta l sw e llin g , bigger on rig h t
i. It d id n o t tra n s illu m in a te b u t e x a m in e r said le t's say it did
ii.T ypes o f hydro c e le : p rim a ry and secon dary
iii. Causes o f secon dary hydro c e le : In fe c tio n , tu m o u r, tra u m a
iv. W h a t ty p e o f in fe c tio n s , w h a t bugs?
v .T ypes o f te s tic u la r tu m o u rs ?
vi. W h a t cance r m arke rs fo r w h a t types?
v ii. H o w d o y o u w a n t to in v e s tig a te th is p a tie n t?

6. E xa m ination: A n te rio r neck lu m p

a. A n te rio r rig h t sided neck lu m p th a t rises w ith s w a llo w in g n o t to n g u e p ro tru s io n , no
ly m p h a d e n o p a th y
 . P roceeded to exam in e fo r p e rip h e ra l th y ro id status
i. D iffe re n tia ls ? D o m in a n t n o d u le o f M NG , ca etc
ii. Investigation s?
v. M a n a g e m e n t?

E xa m ination: A b do
a. POD 6 le ft h e m ic o le c to m y , dev e lo p e d abd o pain + s h o u ld e r t ip pain, ECG show s fa s t AF
and paras u n s ta b le spo2 94 on 6L
b. A p p ro a ch e d ABC instead o f abd o, e ssen tially p e rito n itic
i. H o w w o u ld yo u like to m anage p a tie n t? W e n t th ro u g h in d e ta il all th e w a y

E xa m ination: LL n e u ro exam
a. S /p varicose v ein s trip p in g 2 /5 2 ago, n o w has loss o f sensa tion o f fo o t and has been
trip p in g o v e r fo o t
i. W h a t do you th in k th is is? C o m m on pero n e a l nerve in ju ry
ii. M a n a g e m e n t?

9. H isto ry: PR bleeding

a. 55 y ear old lady PR b le e d in g 6 m o n th s da rk red b lo o d m ixed w ith s to o l, no pain on
d e fe c a tio n b u t has lo w e r abd o pain, a lte rn a tin g c o n s tip a tio n and dia rrh e a , no system ic
s y m p to m s , has FH b ro th e r CRC age 55
i. D iffe re n tia ls ? Investigation s? M a n a g e m e n t?

10. H isto ry: PE

a. POD 6 THR n o w 2h sudden o n s e t chest pain and p le u ritic chest pain
i. D iffe re n tia ls ? Investigation s? M a n a g e m e n t?
ii. W h a t exa c tly d o y o u expe ct to see on CTPA?
iii. Do y o u th in k D d im e r w ill be useful in th is p a tie n t?

11. A n a to m y : S keleton m odel

a. Id e n tify a c ro m io n , c o racoid process
b. W h a t are th e r o ta to r c u ff m uscles?
c. W h a t are th e ir o rig in s and in s e rtio n s ? D e m o n s tra te it
d. Id e n tify m e dia l ep ic o n d y le
e. W h a t n erve tra v e ls nea r it
f. Sensory d is trib u tio n o f u ln a r nerve
g. S how m e spiral g roove
h. W h a t n erve runs th e re and senso ry d is trib u tio n o f ra d ia l nerve
i. W h y do yo u g e t w e a k g rip w h e n radia l n erve gets in ju re d ?
 j. Id e n tify ASIS
k. N am e one m uscle th a t atta ch e s th e re - S a rtorius
I. N erve th a t tra v e ls ju s t n e x t t o ASIS (la te ra l cuta n e o u s nerve o f th ig h ) and w h a t is
c o n d itio n w h e n it gets in ju re d ? M e ra lg ia p a resthetica
m. O rigin and in s e rtio n o f g lu te u s m edius
n. F un ction o f g lu te u s m edius
o. O rigin and in s e rtio n o f qu a d ra tu s

12. A n a to m y : S tom ach and pancreas

a. 1 p ic tu re fro m N e tte r's and 2 p ic tu re s o f p rosection s
b. W h a t is th is (p o in ts a t p ic tu re o f p ro s e c tio n ) - stom a ch
c. Id e n tify all th e parts o f th e stom a ch (fun dus, cardia, bod y, a n tru m , pyloru s)
d. Blood su p p ly to th e stom a ch? W a n te d m o re th a n le ft and rig h t g astric and
g a s tro e p ip lo ic and w h e re th e y fro m
e. W h a t is th is ? - p a n c re a s
f. Blood s u pp le o f pancreas
g. P e rito n e a l re la tio n o f b o d y o f pancreas and ta il o f pancreas
h. D escribe b rie fly th e d ucts o f pancreas
i. W h a t vein lies be h in d neck o f pancreas
j. W h a t v ein lies be h in d b o d y o f pancreas
k. E m bryolo gical d e v e lo p m e n t o f pancreas?
I. P e rito n e a l re la tio n o f du o d e n u m
m. W h a t lies beh in d and in fr o n t o f d u o d e n u m a t D3
n. N am e 3 th in g s th a t is le t cells secrete

13. A n a to m y : Neck and th o ra x

a. 1 p ic tu re o f th o ra x fro m te x tb o o k and 2 p ic tu re s o f pro s e c tio n s o f neck
b. Id e n tify oesophagus
c. W h a t cell type?
d. W h a t is n erve ru n n in g on rig h t side o f oesophagus
e. W h a t ty p e o f ana stom osis can be here? P o rto-system ic
f. N am e th e veins in vo lv e d
g. W h a t is th is ? Carina
h. W h a t level? U p p e r o r lo w e r b o rd e r o f T4?
i. Id e n tify s u b m a n d ib u la r gland, w h e re does d u c t ope n?
j. Id e n tify p a ro tid gland, w h e re does d u c t ope n, w h a t ty p e o f sec re tio n ?
k. Id e n tify CCA, w h a t level b ifu rc a te , id e n tify ECA, ICA
I. W h a t is n erve crossing ECA
m. Id e n tify fa c ia l a rte ry
n. Can it be ligated? W hy?
o. Id e n tify subclavian
p. W h ic h p a rt o f b rachial plexus runs p o s te rio r t o subclavian
 q. Explain subclavian steal

14. P rocedure: IDC in s e rtio n

a. C leaned and d ra p e d , yo u ju s t need to fin d y o u r o w n IDC and lign o c a in e je lly , can o nly
use o n e set o f s te rile gloves
i. No urine , w h a t do you w a n t t o do e tc sam e que s tio n s

15. P rocedure: S u ture la c e ra tio n

a. C leaned and d ra p e d , LA a lre a d y given, pick y o u r s u tu re and p a tie n t asks his o w n
que s tio n s
i. W ill it leave a scar?
ii.D o I need a n tib io tic s ?
iii. Dressing care etc
iv. STO
b. E xam iner q ue stions:
i. W h a t LA? W hy?
ii.H o w m uch LA?
iii. If th is is a 70kg m an and you are given 1% lignoca ine, h o w m any m l is
m ax dose?

16. C ritical care: O esophageal varicea l bleed

a. K n ow n a lc o h o lic com es in w ith hae m a te m e sis and h a e m o d y n a m ic a lly unstable
i. W h a t do you th in k th is is?
ii. A side fro m oesophageal varices, w h e re else can yo u g e t th e m and w h a t are th e
veins in volved ?
iii. H o w w ill you m anage th is p a tie n t? ABC etc, w a n te d to k n o w w h a t
b loods yo u w ill send fo r, w h a t s tu ff yo u w ill give IV, th e n OGD and w h a t yo u can
d o on OGD
iv. W h y th ro m b o c y to p e n ia in th is p a tie n t?
v. W h y do c h ro n ic alcoholics g e t p o rta l hyp e rte n s io n ?
vi. S how n a p ic tu re o f Sengstaken B lakem ore tu b e - w h a t are th e parts,
e x plain h o w it w o rk s , h o w m uch pressure you in fla te to , w h e n w ill yo u rem o ve
it
v ii. W h a t else in th e b loods suggest c h ro n ic a lc o h o lic (m a c ro c y tic anaem ia)
and w h y?

17. C ritical care: EDH

a. Young c yclist a ccident, LOC th e n lu cid in te rv a l th e n 2 eps o f v o m itin g th e n n o w GCS 8.
Also has som e a nkle in ju ry and scratch o v e r his te m p le ,
i. W h a t do you w a n t t o do in fir s t instance? A irw a y
 ii. W ho do you w ant to get involved
iii. W h a t te lls y o u th a t p a tie n t s h ou ld have had a CT scan e a rlie r th a n he
did? LOC + 2 eps v o m itin g
iv. H ere is his CT b ra in , w h a t do yo u see - EDH + m id lin e s h ift
v. H o w do you m easure ICP?
vi. W h a t is n o rm a l ICP?
v ii. Explain M o n ro e -k e llie d o c trin e
v iii. W h y d o y o u g e t d ila te d pu p il? T e n to ria l h e rn a tio n th e n o c c u lu m o to r
ne rve uno p p o s e d s y m p a th e tic s tim u la tio n etc
ix. In an in tu b a te d p a tie n t, w h a t can yo u do to decrease ICP?
x. W h a t surgical th in g s can y o u do to decrease ICP

18. C ritical care: O b s tru c tiv e ja u n d ic e

a. G iven LFTs w ith o b s tru c tiv e ja u n d ic e p ic tu re and u rina lysis w ith zero u ro b ilin o g e n
d e te c te d
i. W h a t ty p e o f ja u n d ic e is this?
ii. Explain e n te ro h e p a tic c irc u la tio n o f bile
iii. W h y is th e re no u ro b ilin o g e n ?
iv. 2 m echanism s b ile helps w ith d ig e s tio n o f fa t
v. Effect o f no bile salts - p ro b le m s abs o rb in g fa ts and p ro b le m s w ith fa t soluble
v ita m in s
vi. W h y does it a ffe c t c lo ttin g ? V it K
v ii. H o w can yo u reverse this?
v iii. P a tie n t gets fe v e r and rigors and pain, w h a t are yo u w o rrie d a b o u t
ix. W h a t d o yo u w a n t to d o th e n ?
x. W h a t are c o m m o n organism s th a t y o u are co ve rin g fo r?
xi. Investig a tio n s y o u w a n t, w h a t w ill yo u see on USHBS
xii. If yo u see stones, w h a t do you w a n t t o do next? ERCP
Day 2 30,h august 2018

Exam inations
Ccrisp
Pain in le ft iliac region
W h a t d o u like to do?
Inves tig a tio n s
M anagem ent
Bell rang

A c u te a b d o m in a l pain in rig h t h y p o c h o n d ria c

P ositive m u rp h y s sign
In v e s tig a tio n
W h a t u see in usg
M anagem ent
W o u ld u lik e t o do su rg e ry fo r th is p a tie n t
Bell rang

Cranial nerve
N o need o lfa c t io n , ja w je rk , visu al acu ity , o p th a lm o s c o p e ,
B loody p a tie n t d id n 't act p ro p e rly w as n o t able t o see b o th nasal and te m p o ra l vis io n in b o th eyes o n ly
said yes w h e n I b ro u g h t fin g e r in c e n tre o f eye fro m all fo u r q u a d ra n ts
H o w w ill u in vestigate
C o m m on fu n c tio n a l tu m o u r o f p itu ita ry
Ct o r m ri w o u ld u do? W hy?
T re a tm e n t o th e r th a n b ro m o c rip tin e and s u rgery ?

V aricose v ein
M u ltip le to u rn iq u e ts p r e s e n t, D o p p le r pre se n t
Causes o f varicose vein
W h ic h in v e s tig a tio n u w a n t to do
H o w w ill u tre a t th is p a tie n t?

History
A n x ie ty
Came fo r breathlessness due to g a llb la d d e r surgery
Gave h is to ry o f 10 years b u t m o re in last 1 y ear
Increased w h e n th in k in g o f surgery
F o rg o t to ask h o w lo ng she had th is g a llb la d d e r pain
W h a t d o u th in k a b o u t 10 years h is to ry o f sob
Bell rang

Tonsil
Right sid ed to n s il s w e llin g
W t loss pre s e n t, a p p e tite n o r m a l, tire d n e s s p resent
N o o th e r p o s itiv e h is to ry
Dd?
H o w to diagnose ly m p h o m a o th e r th a n biopsy) m ay b w a n te d to hea r c t scan)
Bell rang

Procedure
K n o ttin g
W h y did u use re e f k n o t
W h a t o th e r k nots u k n o w
A d vanta ge o f braided?
W h a t is v ic ry l m a d e o f
Tensile s tre n g th o f vicryl?
W h a t can hap pen w h e n ty in g aat d e p th
H o w to p re v e n t dam age to u n d e rly in g s tru c tu re s
D o n 't fo rg e t to th r o w sharps even if d o u b le nee dle package is given and u use o n e , discard th e o th e r
unu sed nee dle as w e ll

C a th e te r
No u rin e com ing
W h a t u w a n t to do?
W h o m to call?

Com m unication

Ogd co u n c e llin g
C o n s u ta n t called aw ay fo r 20 m ins
Explained p ro c e d u re
A ny c o m p lic a tio n o f th is p ro c e d u re
Is s m o k in g and a lcohol th e cause o f th is p ro b le m feels g u ilty n o w
W ill it reverse if he q u it s m oking n o w
A re u a b s o lu te ly sure th is is cancer
W h y am I d ro o lin g like th is
W h e n w ill I g e t m y te s t results

Call itu re g is tra r fo r icu bed

Pt a d m itte d w ith fe e lin g o ff her legs fo r 2 d a y s , on s te ro id s fo r copd , n o w a d m itte d w ith severe pain
c o n s u lta n t seen and d ecided p e rfo ra tio n and nee ded la p a ro tm y , p t has h ypo kalaem ia, no ecg present,
no flu id c h a rt present,
d id u d o ecg ( no), te ll m e w h ic h flu id u gave. ( n o t given), w h ic h flu id s u w a n t t o give ? H o w w ill u
m a n a g e , h o w m uch oxygen w ill u g iv e - 4 1 th ro u g h nasal ca n n u la ,re p e a t back his advices

anatom y

a n d o m in a l a orta
id a b d o m in a l a o rta fro m p ic tu re o f post a b d o m in a l w a ll specim e n
v e rte b ra l level o f a b d o m in a l a o rta , level in diap h ra g m o p e n in g
surfa ce m a rk in g o f a b d o m in a l a o rta (2 .5 cm abo ve th e tra n s p y lo ric plane)
trib u ta rie s o f ivc
vessels im m e d ia te ly in fr o n t o f a b d o m in a l a o rta
p ic tu re o f ang io g ra m given
id th e branches s u p p ly in g th e g u t
s how s p ic tu re o f in fra renal aneurysm
d e fin e ane urysm ) d id n 't accep t m o re th a n 1.5 tim e s )
a b d o m in a l dissection d e fin itio n
occurs th ro u g h w h ic h layers) w h ic h m uscle layer)

u p p e r lim b
tra c tio n in ju ry b e tw e e n head and s h o u ld e r in rta accident
w h ic h in ju ry u r suspecting
ro o t v alue o f u p p e r tru n k o f b rachial plexus
s h o w on sk e le to n w h e re th e nerves e x it fro m
m uscles o f a b d u c tio n
s h o w o rig in and in s e rtio n o f th e s e m uscles w ith ne rve sup p ly
s h o w on a c to r h o w to te s t p o w e r o f s h o u ld e r a b d u c tio n , e lb o w fle x io n
s h o w th e je rk s o f th e s e ro o t values
m uscles su p p lie d by m u s c u lo c u ta n e o u s ne rve
s h o w senso ry d is trib u tio n o f m u s c u lo c u ta n e o u s nerve and radia l nerve
s h o w senso ry d is trib u tio n o f axilla ry nerve
fu n c tio n o f b ra c h io ra d ia ls and ne rve supp ly

lo w e r lim b p o p litia l fossa

id th e g lu te u s m ediu s fro m p ic tu re
ne rve supp ly
fu c tio n
e x plain tre n d e le n b e rg sign
causes o f tre n d e le n b e rg sign
id scia tic nerve
v a ria tio n s o f sciatic nerve
s h o w th e b on y pro m in e n c e s b e tw e e n w h ic h scia tic n erve passes
id th e m s d e s o f h a m s trin g m uscles and th e ir o rig in and th e ir fu n c tio n
id s tru c tu re s In p o p litia l fossa
dd o f s w e llin g th a n can hap pen in p o p lite a l fossa
te ll th e d rain age o f p o p lite a l ly m p h nodes in supe rfic ia l and dee p drain age

pathology

und escended te s te s
sce n a rio o f a p a tie n t having one sided lu m p in in gu in a l and o th e r side s ro tu m e m p ty
w h a t is th e reason
p a th o lo g y r e p o rt g iv e n - w h ic h are th e th re e fin d in g u w a n t to m e n tio n
te ll th e ly m p drain a g e o f te s te s
w h ic h h o rm o n e u w a n t to check fo r sem in o m a ? O th e r h o rm o n e
tu m o r c o m m o n in o ld age
w h e re bhcg n o rm a lly p roduce d
w h a t is ch o rio c a rc in o m a
a fte r su rg e ry p a tie n t had h a e m a to m a
te ll th e stage o f h a e m a to m a re s o lu tio n

p o ly tra u m a and tra n s fu s io n

h ep c w ith liv e r cirrh o s is spleen in ju ry
w h ic h changes u see in b lo o d p ic tu re - die
w h a t is die
h o w p la te le ts are fo rm e d and th e ir fu n c tio n
la te m a n ife s ta tio n o f hcv
h o w e x trin s ic p a th w a y and in trin s ic p a th w a y a c tiv a te d
w h ic h p a th w a y a p tt m easure
w h y need va c c in a tio n and a n tib io tic s a fte r spleen rem o val
a fte r p e n ic illin p a tie n t d e v e lo p e d rea c tio n
w h y explain
e x plain stages and cells in v o lv e d in b o n e hea lin g
w h ic h c o m p o n e n t u w a n t to check fo r g ro u p in g
w h a t is g ro u p cross m atc h in g

Critical care

H y p o th y ro id is m
Explain th e c o n tro l o f th y ro id h o rm o n e synthesis
S ym p to m s o f h y p o th y ro id is m
Cause o f h y p o th y ro id is m
C o m p lic a tio n o f surgery
Explain th e s y m p to m s o f d iffe re n t ty p e s o f re c u rre n t la ryng eal ne rve in ju ry
H o w w ill u m anage a such p a tie n t w ith b ila te ra l in c o m p le te in ju ry
D o n 't re m e m b e r th e re s t que s tio n s

P o lytra u m a p a tie n t
H o w to m anage
Shows chest x ra y o f p n e u m o th o ra x
H o w to m anage p n e u m o th o ra x
W h a t w ill u d o f o r c irc u la tio n
W h ic h flu id w ill u give
C o m p lic a tio n in g iving flu id ( w a n te d to h e a r d ilu tio n c o ag ulopa thy)
In v e s tig a tio n s u w a n t to d o f o r a b d o m e n ) w a n te d to h e a r fa s t scan)
Ct scan w ith liv e r te a r w h a t can u see
Bell rang
B loody dia rrh e a
W h ic h ty p e o f ana em ia can u see
Cause o f h y p o n a tra m ia in th is p a tie n t
Casue o f p e re c ta l bleeding
W h y p la te le ts elevated
W h e n u need s u rg e ry in th is scena rio
W h ic h su rg e ry u w a n t t o do
W h y n o t to tra n s fu s e b lo o d
W h a t else do u w a n t to in v e s tig a te in th is p a tie n t
H o w to m o n ito r response in th is p a tie n t

Exam is easy b u t th e stress a ffe c ts u b a d ly so keep calm .

Please p ray f o r m e if th is helps u.
thanks
Anatomy
L u m b a r Spine A n a to m y

1) W h a t ty p e o f v e rte b ra e is th is ? - L u m b a r
2) N a m e p a rts - Body, S p inou s process, T ransverse process, P edicle, Lam ina
3) W h e re a re a rtic u la tio n s o f 2 s p in o u s processes - P edicles and In te rv e rte b ra l discs
4) W h a t m o v e m e n t d oe s th e lu m b a r in te r v e r te b ra l disc a llo w - fle x io n and e x te n s io n
5) W h a t o th e r m o v e m e n ts o f lu m b a r sp in e a re th e re ? - la te ra l fle x io n
6) Id e n tify in te r v e r te b ra l fo ra m e n
7) W h a t runs th ro u g h h e re ? - Spinal n e rv e ro o ts
8) W h a t m akes up th e in te r v e r te b ra l disc - N ucleus p u lp o s is and a n n u lu s fib ro s is
9) W h ic h is in th e c e n tre ? - nu cle u s p u lp o s is
10) W h ic h is h a rd e r? - A n n u lu s fib ro s is
11) W h a t n e rv e r o o t is a ffe c te d if th e re is a p ro la p s e o f disc a t L4/L5? - L5
12) W h a t ha p p e n s t o in te r v e r te b ra l disc h e ig h t? - Loss o f h e ig h t
13) Look a t M RI (la te ra lly ) and id e n tify each v e rte b ra e y o u can see - L2, L3, L4, L5, S I
14) W h a t a b n o rm a lity can y o u see? - C ord c o m p re s s io n
15) W h a t s y m p to m s d o y o u g e t w ith c o rd c o m p re s s io n - N u m bn ess, Pain, w e akness o f
a rm s /le g s , f o o t d ro p , im p o te n c e
16) Causes o f c o rd c o m p re s s io n ? T u m o u r, T ra u m a , Scoliosis, In fe c tio n
17) W h a t le vel d oe s th e s pinal c o rd te rm in a te in a d u lts ? L I
18) W h a t le vel d oe s th e s pinal c o rd te rm in a te in n e o n a te s ? L3
19) W h e re is th e v e rte b ra l v e n o u s plexus and w h y is it im p o r ta n t? E x tra d u ra l tis s u e . Im p o rta n t
because it p ro v id e s c o lla te ra l ro u te s o f v e n o u s re tu rn w h e n th e r e is c o m p re s s io n o f ju g u la r
v e in s o r d u rin g in fe r io r ve n a cava o b s tru c tio n .
20) W h a t ha p p e n s t o th e n u c le o u s p u lp o s is as y o u g e t o ld e r? - d rie s u p (loss o f w a te r)
21) W h a t o th e r th in g s m e ta s ta s is e t o th e bo n e ? - B ronch us, Breast, T h y ro id , Renal, P ro s ta te

C ranial A n a to m y

On an iPAD, y o u s c ro ll th ro u g h 3 p ic tu re s o f th e sam e M RI hea d (b u t fro m 3 d iffe r e n t

p la n e s /s e c tio n s ). T h e re is an o b v io u s b rig h t w h ite m ass in th e le ft c e re b ru m . On th e ta b le , th e
c ra n ia l fossa m o d e l is p re s e n t, and a dis s e c te d s a g itta l s e c tio n o f th e brain .

1) W h a t is th is ? P o ints t o C o rpu s c o llo s u m

2) W h a t is th is ? L ateral v e n tric le
3) W h a t runs in th is space? - S u p e rio r s a g itta l sinus
4) W h a t runs in th is space? C e re b e lla r T e n to riu m
5) P o in t t o th e 4 ,h v e n tric le (in th e sp e c im e n ).
6) W h a t are th e d iffe re n tia ls o f th is le sion? M e n in g io m a . D iffe re n tia ls : L y m p h o m a , s e c o n d a ry
m e ta s ta s e s (h a e m a n g io p e ric y to m a ).
7) W h a t p a rt o f th e m e n in g e s is it d e riv e d fro m ? D ura
8) W h a t runs th ro u g h th e s u b a ra c h n o id space? - CSF
9) D e scribe th e v e n o u s sin us d ra in a g e o f th e s k u ll (s p e c ific a lly s u p e rio r and in fe r io r s a g itta l
sinuses, c o n flu e n c e o f sinuses, tra n s v e rs e sinus, s tra ig h t sin us and s ig m o id sinus)
10) W h e re d oe s th e s ig m o id sinus d ra in in to ? - In te rn a l Ju g u la r Vein
11) W h a t fo ra m in a d oe s th e In te rn a l J u g u la r v e in go th ro u g h - J u g u la r Foram en
12) W h a t o th e r s tru c tu re s go th ro u g h th is ? - CN 9 , 1 0 , 1 1
13) Asked t o p o in t t o a n o th e r s tru c tu r e e ith e r sid e o f th e sella tu rs c ia
 11) W h a t p ro te in (d e p o s its ) a re a s sociated w ith in fla m m a to r y disease? - A m y lo id
12) W h a t o th e r m y c o b a c te ria l in fe c tio n s d o y o u g e t w ith im m u n o c o m p ro m is e d p a tie n ts ?
M y c o b a c te riu m a v iu m in tra c e llu la ris (you HAVE t o say in tra c e llu la ris ).

P o ly c y s tic K idney Disease and G e n e ra l p a th o lo g y a b o u t in fla m m a tio n

1) W h y d o y o u g e t cysts in th e kid n e y?
2) W h y d oe s p o ly c y s tic k id n e y disease cause re n a l fa ilu re ?
3) W h a t are th e b ro a d ty p e s o f re je c tio n ? Cell m e d ia te d o r h u m e ra l
4) W h a t is th e process th ro u g h w h ic h h y p e r-a c u te re je c tio n h a p pens?
5) W h a t w o u ld y o u see - duskiness. Yes W h y ?

A p a tie n t w ith a tra n s p la n t c om es in w ith CBD s to n e s and is h y p o te n s iv e , u n w e ll

6) W h a t c o n d itio n d oe s th is p a tie n t have? - Sepsis s e c o n d a ry t o a s c e n d in g c h o la n g itis

7) W h a t risk fa c to rs are th e r e f o r th is p a tie n t t o have sepsis? Im m u n o s u p re s s io n , o b s tru c tiv e
ja u n d ic e /b a c te ria l stasis, g a lls to n e s
8) If y o u to o k th e CBD u n d e r a m ic ro s c o p e , w h a t w o u ld y o u see?
9) T alk m e th ro u g h th e d iffe r e n t stages o f in fla m m a tio n
10) H o w d oe s pha go c y s to s is h a p p e n ? O p s o n is a tio n e tc

C ritic a l Care

D iabetes

M a n has a n d is d ia g n o s e d w ith flu c tu a n t p e ri-a n a l le sion (p e ri-a n a l abscess). He is g o in g f o r Incision

and D rainage o f th is abscess.

1) H o w m a n y ty p e s o f D ia b e te s a re th e r e and te ll m e a b o u t t h e ir p a th o p h y s io lo g y -
A u to im m u n e T y p e 1 (u s u a lly in y o u n g e r p a tie n ts ) w h ic h is d u e t o d e s tru c tio n s o f th e Beta
Islets cells o f Langerhans. T ype 2 (u s u a lly in o ld e r p a tie n ts b u t n o t alw ays) w h ic h is t o do
w ith Ins u lin re s is ta n c e (o r lack o f s e n s itiv ity t o in s u lin is a n o th e r w a y o f saying it)
2) H o w d oe s In s u lin w o rk - GLUT 4 tra n s p o rte d th a t a llo w s cells t o u p ta k e glucose
3) T ell m e th e d iffe r e n t a c tio n s o f In s u lin - U p ta k e o f glucose, g ly c o g e n s ynthesis, S yn thesis o f
fa tt y acids in liv e r, In h ib itio n o f b re a k d o w n o f f a t etc.
4) W h a t are th e risks o f th is p a tie n t w ith re g a rd s t o his b lo o d glu co se - H y p e rg ly c a e m ia ,
H yp o g ly c a e m ia
5) Risks o f H y p e rg ly c a e m ia ? - P o o r w o u n d he a lin g , sepsis etc. H y p e rg ly c a e m ic H y p e ro s m o la r
(HO NK) N o n -K e to tic Com a.
6) W h a t w o u ld y o u s ta rt p a tie n t on t o c o n tro l h y p e rg ly c a e m ia ? V a ria b le Rate In s u lin In fu s io n
7) W h a t is in th e V a ria b le Rate In s u lin In fu s io n - IV In s u lin , D e x tro s e 5% (o r 0.9% Saline) and
P o tassium
8) W h a t w o u ld y o u m o n ito r w h ils t p a tie n t w a s o n th is ? B lo o d G lucose (h o u rly , o r w h a te v e r th e
h o s p ita l p ro to c o l suggests)
9) H o w else w o u ld y o u lik e t o o p tim is e th is g e n tle m a n 's tre a tm e n t? W ith h o ld m e tfo r m in
10) W h ic h o th e r p e o p le c o u ld y o u g e t t o see th is p a tie n t re g a rd in g his d ia b e te s ? D ia b e tic
s p e c ia lis t n u rs e & E n d o c rin o lo g is t
11) P o s t-o p e ra tiv e ly , w h e n w o u ld y o u s to p th e V a ria b le Rate Ins u lin In fu s io n ? W h e n th e p a tie n t
is a b le t o e a t and d rin k
Thorax Anatom y

In s tru c tio n s s ta te t h a t a m an w a s s ta b b e d in 2 places - by th e lu n g h ilu m and ju s t in fe r io r to

x ip h is te rn u m . 2 spe c im e n s p re s e n t - a) H e a rt b) T h o ra x /A b d o m in a l c a v ity w h ic h has th e rig h t sid e o f
th e liv e r p re s e n t (b u t le ft sid e d is s e c te d a w a y ), th e d ia p h ra g m , th e a o rtic arch.

1) If s ta b b e d in x ip h is te rn u m , w h a t s tru c tu re s w o u ld be d a m a g e d ? - L e ft lo b e liv e r, D ia p h ra g m
2) P o in t t o th e rig h t a triu m and le ft v e n tric le
3) P o in t t o th e th e p u lm o n a ry tru n k
4) W h a t d oe s th e p u lm o n a ry t r u n k d iv id e in to ? - L e ft and rig h t p u lm o n a ry a rte rie s
5) W h a t le vel d oe s th e p u lm o n a ry tru n k d iv id e ? - T5
6) H o w m a n y cusps d oe s th e p u lm o n a ry valv e ? - 3
7) N a m e th e cusps? - A n te rio r, le ft and rig h t
8) N a m e th is s tru c tu re ? C o ro n a ry Sinus
9) W h a t is th e p u lm o n a ry lig a m e n t? - P a rie ta l and v is c e ra l p le u ra t h a t e x te n d s fro m h ilu m to
th e d o m e o f th e h e m id ia p h ra g m
10) W h a t lies in th e lu n g h ilu m and h o w m a n y o f each s tru c tu re - O ne b ro n c h u s , 2 a rte rie s , 2
v e in s
11) W h a t s tru c tu re is th e m o s t a n te r io r a t th e h ilu m ? P u lm o n a ry v ein
12) A tta c h m e n ts o f d ia p h ra g m - L u m b a r v e rte b ra e , c o s ta l (7-1 2), X ip h is te rn u m
13) W h a t 2 s tru c tu re s ru n th ro u g h th e c e n tra l te n d o n o f th e d ia p h ra g m ? IVC and R ight P h ren ic
14) H o w fa r d oe s th e le ft lo b e o f th e liv e r e x te n d ? L e ft m id c la v ic u la r lin e
15) W h a t lig a m e n ts a tta c h th e liv e r t o th e d ia p h ra g m ? C o ro n a ry lig a m e n ts + T ria n g u la r lig a m e n ts
16) T h ro u g h w h a t lig a m e n t does th e p o rta h e p a tis ru n ? ??
17) P o in t t o th e q u a d ra te lobe.
18) W h a t are th e b o u n d a rie s o f th e q u a d ra te lo b e ? P o s te rio r = p o rta h e p a tis ; on th e rig h t =
fossa g a ll-b la d d e r; and o n th e le ft = fossa fo r th e u m b ilic a l v e in .
19) W h a t is th e v e n o u s d ra in a g e o f th e liv e r? - H e p a tic v e in s
20) W h a t d oe s th a t d ra in in to ? IVC
21) W h a t vessel p ro v id e s b lo o d s u p p ly t o th e s to m a c h and liv e r? - C o m m o n h e p a tic a rte ry

P a th o lo g y

23 y o A sian la dy c om es back fro m 2 m o n th t r ip fro m Bangladesh. N o w has s w e llin g in neck, n ig h t

sw e a ts and w e ig h t loss

1) G ive 2 d iffe re n tia ls ? - TB and Lym p h o m a

2) W h ic h ty p e o f ly m p h o m a ? - H o dgkin s
3) If yo u FNA, w h a t w o u ld y o u send it fo r? C y to lo g y and M ic ro s o c o p y
4) W h a t s ta in w o u ld y o u use? Z iehl N e ilso n
5) W h a t o th e r te s ts can y o u d o f o r TB? PCR and Q u a n te fe ro n
6) H o w lo n g w o u ld th e g ro w th ta k e ? - 6 w e eks
7) If yo u dia g n o s e TB, w h a t 2 th in g s m u s t y o u d o ? - In fo rm P u blic H e a lth (E n g la n d /S c o tla n d ),
and C o n ta c t T ra cin g
8) You g e t a r e p o r t w h ic h says th e re w e re g ia n t cells? - E p ith e lio id M a c ro p h a g e t o fo rm a
g ra n u lo m a
9) W h a t o th e r th in g s cause g ra n u lo m a to u s disease - Fungal in fe c tio n s , C ro h n 's , S arcoidosis
10) W h a t ty p e o f re a c tio n is th is ? - T ype IV H y p e rs e n s itiv ity R eaction
 11) W h a t p ro te in (d e p o s its ) a re a s sociated w ith in fla m m a to r y disease? - A m y lo id
12) W h a t o th e r m y c o b a c te ria l in fe c tio n s d o y o u g e t w ith im m u n o c o m p ro m is e d p a tie n ts ?
M y c o b a c te riu m a v iu m in tra c e llu la ris (you HAVE t o say in tra c e llu la ris ).

P o ly c y s tic K idney Disease and G e n e ra l p a th o lo g y a b o u t in fla m m a tio n

1) W h y d o y o u g e t cysts in th e kid n e y?
2) W h y d oe s p o ly c y s tic k id n e y disease cause re n a l fa ilu re ?
3) W h a t are th e b ro a d ty p e s o f re je c tio n ? Cell m e d ia te d o r h u m e ra l
4) W h a t is th e process th ro u g h w h ic h h y p e r-a c u te re je c tio n h a p pens?
5) W h a t w o u ld y o u see - duskiness. Yes W h y ?

A p a tie n t w ith a tra n s p la n t c om es in w ith CBD s to n e s and is h y p o te n s iv e , u n w e ll

6) W h a t c o n d itio n d oe s th is p a tie n t have? - Sepsis s e c o n d a ry t o a s c e n d in g c h o la n g itis

7) W h a t risk fa c to rs are th e r e f o r th is p a tie n t t o have sepsis? Im m u n o s u p re s s io n , o b s tru c tiv e
ja u n d ic e /b a c te ria l stasis, g a lls to n e s
8) If y o u to o k th e CBD u n d e r a m ic ro s c o p e , w h a t w o u ld y o u see?
9) T alk m e th ro u g h th e d iffe r e n t stages o f in fla m m a tio n
10) H o w d oe s pha go c y s to s is h a p p e n ? O p s o n is a tio n e tc

C ritic a l Care

D iabetes

M a n has a n d is d ia g n o s e d w ith flu c tu a n t p e ri-a n a l le sion (p e ri-a n a l abscess). He is g o in g f o r Incision

and D rainage o f th is abscess.

1) H o w m a n y ty p e s o f D ia b e te s a re th e r e and te ll m e a b o u t t h e ir p a th o p h y s io lo g y -
A u to im m u n e T y p e 1 (u s u a lly in y o u n g e r p a tie n ts ) w h ic h is d u e t o d e s tru c tio n s o f th e Beta
Islets cells o f Langerhans. T ype 2 (u s u a lly in o ld e r p a tie n ts b u t n o t alw ays) w h ic h is t o do
w ith Ins u lin re s is ta n c e (o r lack o f s e n s itiv ity t o in s u lin is a n o th e r w a y o f saying it)
2) H o w d oe s In s u lin w o rk - GLUT 4 tra n s p o rte d th a t a llo w s cells t o u p ta k e glucose
3) T ell m e th e d iffe r e n t a c tio n s o f In s u lin - U p ta k e o f glucose, g ly c o g e n s ynthesis, S yn thesis o f
fa tt y acids in liv e r, In h ib itio n o f b re a k d o w n o f f a t etc.
4) W h a t are th e risks o f th is p a tie n t w ith re g a rd s t o his b lo o d glu co se - H y p e rg ly c a e m ia ,
H yp o g ly c a e m ia
5) Risks o f H y p e rg ly c a e m ia ? - P o o r w o u n d he a lin g , sepsis etc. H y p e rg ly c a e m ic H y p e ro s m o la r
(HO NK) N o n -K e to tic Com a.
6) W h a t w o u ld y o u s ta rt p a tie n t on t o c o n tro l h y p e rg ly c a e m ia ? V a ria b le Rate In s u lin In fu s io n
7) W h a t is in th e V a ria b le Rate In s u lin In fu s io n - IV In s u lin , D e x tro s e 5% (o r 0.9% Saline) and
P o tassium
8) W h a t w o u ld y o u m o n ito r w h ils t p a tie n t w a s o n th is ? B lo o d G lucose (h o u rly , o r w h a te v e r th e
h o s p ita l p ro to c o l suggests)
9) H o w else w o u ld y o u lik e t o o p tim is e th is g e n tle m a n 's tre a tm e n t? W ith h o ld m e tfo r m in
10) W h ic h o th e r p e o p le c o u ld y o u g e t t o see th is p a tie n t re g a rd in g his d ia b e te s ? D ia b e tic
s p e c ia lis t n u rs e & E n d o c rin o lo g is t
11) P o s t-o p e ra tiv e ly , w h e n w o u ld y o u s to p th e V a ria b le Rate Ins u lin In fu s io n ? W h e n th e p a tie n t
is a b le t o e a t and d rin k
 C-Spine

B lu rb s ta te s t h a t a 45 y o fe m a le had a b ic y c le a c c id e n t w ith a n o th e r b icycle a t a speed o f 40

m p h . She has b e e n b r o u g h t in v ia a m b u la n c e and is o n a sp in a l b o a rd and im m o b ilis e d

1) W h a t b ro a d p rin c ip le s w o u ld y o u m a n a g e th is p a tie n t w ith ? (C)ABCDE (ATLS)

2) T he a irw a y is c le a r. H o w w o u ld y o u assess th e b re a th in g ? O b se rve fo r re s p ira to ry distress,
p a lp a te tra c h e a l d e v ia tio n , c h e s t e x p a n s io n , perc u s s io n , a u s c u la ta tio n , m e a s u rin g
R e s p ira to ry ra te and oxyge n s a tu ra tio n s .
3) W h a t in v e s tig a tio n s w o u ld y o u do? ABG and CXR
4) S how s y o u ABG - R e s p ira to ry a cidosis w ith v e ry m ild m e ta b o lic c o m p e n s a tio n and h y p o x ia -
th e r e fo r e T ype 2 R e s p ira to ry F ailure
5) H o w w o u ld m anage th e T y p e 2 R e s p ira to ry fa ilu re - N o n -in v a s iv e v e n tila tio n eg. BIPAP. He
push ed m e fu r t h e r and I said call th e a n a e s th e tis t t o in tu b a te and v e n tila te (he said yes)
6) S how s y o u la te ra l C -spine X ray and says w h a t d o y o u see? - D is lo c a tio n o f C3
7) W h a t in v e s tig a tio n w o u ld y o u d o n o w ? M RI s pine
8) W h a t d oe s th e M RI sh o w ? C o m p re s s io n o f th e c o rd a t C3 (caused b y v e rte b ra l d is lo c a tio n )
9) B ila te ra l a rm w e a k n e s s and m ild b ila te ra l leg w e akness. W h a t is th is p a tte rn ?
10) H o w w o u ld y o u m a nage th is p a tie n t? 1) D e c o m p re s s iv e la m in e c to m y . 2) S pinal fix a tio n
11) H o w w o u ld y o u c o o rd in a te g e ttin g th is p a tie n t t o th e a tre ? - Liaise w ith A n a e s th e tis t,
N e u ro s u rg e o n s , T h e a tre s ta ff (s tre s s in g u rg e n c y o f th is o p e ra tio n ), a n d c o n ta c t a n y fa m ily
and discuss w ith th e m ( if th e p a tie n t c o n s e n ts t o th is ).
12) P a tie n t has s h a llo w b re a th in g . In th is p a tie n t, e x p la in th is p a tte rn o f b re a th in g - a)
C o n tu s io n s o f th e c h e s t w h ic h causes re s tric tiv e b re a th in g and m o s t im p o r ta n tly , b) C3 is
p a rt o f s pinal n e rv e r o o t o f th e p h re n ic n e rv e (C3, C4, C5). T h e re fo re if th e r e is C3
c o m p re s s io n , y o u g e t a p h re n ic n e rv e palsy, w h ic h causes ris e in th e d ia p h ra g m w h ic h also
causes re s tric tio n o f b re a th in g .

T h y ro id

B lu rb s ta te s m id d le aged la dy had m a la ise and le th a rg y and a g o itre . Discuss re s u lts

1) W h a t are th e s y m p to m s o f h y p o th y ro id is m - H a ir loss, w e ig h t gain, b ra d y c a rd ia ,

c o n s tip a tio n , le th a rg y /fa tig u e , c o ld in to le ra n c e , " to a d - lik e " face, loss o f la te ra l e y e b ro w s -
asked w h a t th is sign w a s c a lle d (Sign o f H e rto g h e o r Q u e e n A n n e 's sign)
2) W h a t are th e causes o f H y p o th y ro id is m - H a s h im o to 's , De Q u e riv a n 's T h y ro id itis , Io d in e
d e fic ie n c y , P o s t-T h y ro id e c to m y
3) W h a t are th e in d ic a tio n s o f s u rg e ry fo r h y p o th y ro id is m - g o itre w ith a irw a y c o m p ro m is e
4) W h a t c o m p lic a tio n s are th e re o f th y ro id s u rg e ry ? R e c u rre n t la ry n g e a l n e rv e , s u p e rio r
la ry n g e a l n e rv e in ju ry , w o u n d sepsis, w o u n d dishiscen ce, scars, DVT/PE, In fe c tio n ,
H a e m a to m a /b le e d in g
5) C hoose o n e o f th e s e c o m p lic a tio n s and e x p la in h o w y o u w o u ld m a nage it? - I chose
h a e m o a to m a and I said im m e d ia te ly u n d o th e c lip s and discuss w ith s e n io r a b o u t ta k in g
back t o th e a tre ( if y o u ch o o se h y p o c a lc a e m ia yo u g e t in to a lo t o f d iffic u lt q u e s tio n s . Choose
w is e ly !)
6) T h e y g ive y o u b lo o d te s ts w h ic h s h o w lo w Hb (91) and M CV (107). W h a t does th is sh o w ? -
M a c ro c y tic A n a e m ia
7) Explain w h y she has m a c ro c y tic a n a e m ia - T his p a tie n t is lik e ly to have an a u to im m u n e
cause o f H y p o th y ro id is m (H a s h im o to s ) and w ill also have a c o n c u rre n t a u to -im m u n e
 c o n d itio n c a lle d p e rn ic io u s a n a e m ia w h ic h is w h e re th e re are a u to a n tib o d ie s t o p a rie ta l cells
in th e s to m a c h and because p a rie ta l cells relea se in trin s ic fa c to r (w h ic h in t u rn is re q u ire d
f o r a b s o rp tio n o f B12), yo u g e t a B12 d e fic ie n c y w h ic h causes M a c ro c y tic a n a e m ia .
8) You are g iv e n b lo o d re s u lts o f High TSH and lo w T4. Asked "Is th is c o n s is te n t w ith a p itu ita ry
cause o f h y p o th y ro id is m " - No. Because t h a t w o u ld cause a lo w TSH and lo w T4
9) D ra w o u t th e TSH re g u la tio n m e c h a n is m - H y p o th a la m ic -P itu ita ry -T h y ro id (all th e h o rm o n e s
and th e n e g a tiv e fe e d b a c k as w e ll)
10) W h ic h th y ro id h o rm o n e is th e a c tiv e o n e ? T3

KNOW LEDGE EXAM

P ro c e d u re s

1) In c is io n and D rainage o f R ight T high Abscess u n d e r local a n a e s th e tic . R e g is tra r has c o n s e n te d ,

d ra p e d p a tie n t b u t has bee n ca lle d a w a y t o th e a tre .

Im p o rta n t p o in ts : Check id e n tity o f p a tie n t fro m th e w r is t b a n d ( w ith 3 in fo r m a tio n b its = N am e,

H o s p ita l n u m b e r, D a te o f B irth ) a g a in s t th e c o n s e n t fo rm on th e desk. G o th ro u g h c o n s e n t again
w ith h e r b rie fly (because p a tie n t s ta rts asking q u e s tio n s a b o u t th e sid e e ffe c ts o f su rg e ry ).

You o n ly g e t 2% L idocaine. It's e x p ire d 3 years ago so y o u ha ve t o pick t h a t up b u t to ld t o use it

a n y w a y . You d ra w up a n a e s th e tic w ith b lu n t n e e d le . E x a m in e r said use th e sam e n e e d le fo r
in filtr a tio n (re m e m b e r t o c heck w e ig h t and k n o w th e m a x im u m dose ). P a tie n t s ta te s she is o n ly 45
kg ( th e re fo re safe dose = 3 x 45 = 135 m g th e r e fo r e m a x im u m safe a m o u n t = 6.75 m is. If yo u g ive all
10 m is h ere, y o u w ill cause to x ic ity . Check w ith to o th e d fo rc e p s a b o u t w h e th e r area is n u m b .

Incise a c c o rd in g t o Langer Lines. Take o u t pus, w a s h w ith saline. T h e re w a s n o th in g th e re t o pack so

said I w o u ld use s o m e th in g lik e so rb a sa n . E v e n tu a lly packe d it w ith gauze th a t w a s th e re and
dressed it w ith gauze. T h e re w a s n o ta p e o r m e flix b u t said w o u ld use th a t. O ffe r t o d o c u m e n t and
g ive a le a fle t t o p a tie n t.

2) Excision b io p s y o f nae vus and s u tu rin g . A g ain, p a tie n t is c o n s e n te d and d ra p e d . R e g istra r w as

c alled aw ay.

Im p o rta n t p o in ts : In th is case th e e x a m in e r, said d o n 't w o r r y a b o u t c o n s e n t o r local a n a e s th e tic .

YOU HAVE TO ASK f o r a r u le r a n d m a rk e r o th e rw is e y o u w ill n o t be g iv e n th e m . Naevus w a s 1 cm
across. M e a s u re 1 cm on th e le ft and 1 cm t o th e rig h t. T he n d ra w ju s t a b o v e and b e lo w . C reate
e lipse. T he n c heck t h a t she has n o fe e lin g . Excise th e le s io n . T hen d o 3 in te r u p te d s u tu re s , 1 a p a rt.
You can d o it as in s tr u m e n t tie s .

C o m m u n ic a tio n S ta tio n s

C a n c e lla tio n o f P ro c e d u re

You g e t 9 m in u te s t o p re p a re w ith so m e n o te s and th e n go in to th e s ta tio n . E sse ntially, 51 y o m ale

w h o is a p o s tm a n c o m e s f o r a le ft knee o p e ra tio n (m e n is c u s te a r). His o p e ra tio n has bee n c a nce lle d
on ce b e fo re . N o w th e c o n s u lta n t w h o w a s g o in g t o d o an o p e ra tio n has b e e n c alled a w a y t o a
tra u m a case so c a n n o t d o th e o p e ra tio n . So th e g u y 's o p e ra tio n is n o w g o in g t o be ca n c e lle d again.
E xa m in a tio n s

A n k le E x a m in a tio n

Y o ung m a n , p la y in g fo o tb a ll, rig h t a n k le in ju ry . E xam ine a n k le (m a in fin d in g is t h a t he has la te ra l

m a lle o lu s te n d e rn e s s )

F o llo w up q u e s tio n s :

1) D iffe re n tia ls - F ra c tu re , S p ra in e d a nkle

2) In v e s tig a tio n - X R (2 v ie w s )
3) M a n a g e m e n t - A n alge sia, S p lin t f o r im m o b ilis a tio n . Rest, Ice, E le v a tio n , C ru tch e s

R e s p ira to ry E x a m in a tio n

E ld e rly g e n tle m a n d u e fo r in g u in a l h e rn ia re p a ir. N o w has S h o rtn e s s o f b re a th . Please e x a m in e

re s p ira to ry s y s te m . F indin gs: T a c h y p n o e ic and e x p ira to ry w h e e z e

F o llo w up q u e s tio n s :

1) D ia g n o s is -C O P D
2) H o w w o u ld y o u th e o p e ra tio n - F irst d o fu ll h is to ry a n d e x a m in a tio n . T he n c h eck th a t th e
p a tie n t a c tu a lly w a n ts th e o p e ra tio n . Does he nee d it? Liaise w ith a n a e s th e tis ts . If he does
and w a n ts it, th e n c o n s id e r w h e th e r d o in g it u n d e r Local A n a e s th e tic is poss ib le (as GA
m ig h t be m o re d iffic u lt) . R e m e m b e r L a p aro scopic s u rg e ry c re a te s p n e u m o p e rito n e u m so
w o u ld also m a k e b re a th in g w o rs e . So d o o p e n LA re p a ir.

Lipom a E x a m in a tio n

E xam ine p a tie n ts tru n k

R e m e m b e r: Look, p a lp a te , percuss, a u s c u lta te (yes eve n f o r a lip o m a ) and TRANSILLUM NATE. Check
ly m p h a d e n o p a th y . F o llo w up q u e s tio n s :

1) If y o u had h e a rd a b r u it, w h a t w o u ld t h a t in d ic a te ?
2) D iffe re n tia ls - Lip o m a , sebaceous cyst, M a lig n a n c y
3) W h a t kin d o f m a lig n a n c y ? - M y o lip o s a rc o m a
4) W h a t in v e s tig a tio n s ? - U ltra s o u n d , CT T h o ra x /A b d o /P e lv is ( fo r sta g in g ), MRI ( b e tte r f o r s o ft
tis s u e )
5) W o u ld y o u w a n t t o re m o v e le sion? - n o t if th e p a tie n t d o e s n 't w a n t it re m o v e d .
6) If y o u w a n te d t o re m o v e it, h o w w o u ld y o u re m o v e it, LA o r GA? - Id e a lly GA, b u t ta k e in to
a c c o u n t th e c o -m o rb id itie s . Liaise w ith th e a n a e s th e tis ts and s urgeon .

N eck E x a m in a tio n

Basically d o th y ro id exam . Lady has big g o itre

F o llo w up q u e s tio n s

1) D iffe re n tia ls
2) W h a t is h e r th y ro id s ta tu s ? H y p o th y ro id
3) W h a t t r e a tm e n t is th e re f o r th is la d y - T h y ro x in e
4) W h a t in v e s tig a tio n s w o u ld y o u do?
From th e n o te s : He g o t a kn e e in ju r y because o f fo o tb a ll. You also have b lo o d te s ts , all o f w h ic h are
n o rm a l e x c e p t a CRP o f 76. You e n te r and he is s u p e r c h e e ry t o g e t his o p e ra tio n .

C o n firm he is th e rig h t p e rs o n , c h eck w h a t he k n o w s and w h a t he is e x p e c tin g . T he n t e ll h im th a t

y o u a re a fra id y o u have s o m e bad ne w s (give a w a rn in g pause). Explain t h a t th e c o n s u lta n t w as
called aw a y f o r a tra u m a case and so c a n n o t d o th e p ro c e d u re . He says No no no , e n o u g h o f th is ,
g e ts a n n o y e d . A c k n o w le d g e his f ru s tr a tio n and t e ll h im he is rig h t t o be a n n o y e d . Tell h im if th e re
w a s a n y th in g t h a t yo u co u ld d o t o c han ge th is y o u w o u ld b u t th e r e is n 't u n fo r tu n a te ly because th e
e m e rg e n c y case is v e ry s e rio u s ly u n w e ll and th e r e is o n ly o n e th e a tre space a v a ila b le . He calm s
dow n.

His c o n c e rn s :

1) He m ig h t lose his jo b because he c a n 't w a lk -> o ffe r sick n o te and d e ta ile d le tte r t o w o rk
2) Pain c o n tro l -> He has bee n on ib u p ro fe n , it is d o in g n o th in g fo r his kn e e -> b e tte r pain
c o n tro l
3) He has bee n h a v in g e p ig a s tric pain, a fte r b e in g o n ib u p ro fe n f o r 2 m o n th s -> P ro b a b ly
g a s tritis + /- -> s to p ib u p ro fe n and sugg est o m e p ra z o le and o u tp a tie n t OGD
4) N eeds h e lp m o b ilis in g -> P h y s io th e ra p y
5) T ell h im y o u w ill re a rra n g e his s u rg e ry as a m a tte r o f u rg e n c y and he w ill be in fo rm e d o f his
d a te
6) Check if he w a n ts y o u t o spea k t o a n y o n e -> You can te ll m y w ife .

It is re a lly im p o r ta n t t o give a s h o rt 30 secon d s u m m a ry t o th e p a tie n t o f w h a t y o u have discussed

a nd th e a c tio n s yo u have agreed .

SBAR t o C o n s u lta n t o v e r p h o n e s ta tio n

You g e t 9 m in u te s b e fo re han d t o lo o k th ro u g h so m e n o te s . E sse ntially a la d y in h e r 70s w a s

a d m itte d t o h o s p ita l 24 h o u rs ago. She had LIF a b d o m in a l pain and te n d e rn e s s and s lig h tly raised
in fla m m a to r y m a rk e rs . She w a s dia g n o s e d (c lin ic a lly ) has h a v in g D iv e rtic u litis a n d s ta rte d on IV Abx.
A b o u t 2 h o u rs ago she c o m p la in e d o f s u d d e n o n s e t severe pain in th e leg.

A n FY2 assessed h e r and d o c u m e n te d t h a t she had a c o ld leg, w ith d im in is h e d fo o t pulses. Her

o b s e rv a tio n s a re o k a p a rt fro m h e r be in g s lig h tly ta c h y c a rd ic . She has n o t b e e n fe b rile . She has a
h is to ry o f H y p e rte n s io n and AF (n o t a n tic o a g u la te d ).

In th e n e x t ro o m , y o u e n te r and d ia l a n u m b e r to pick up a p h o n e . O n th e end o f th e p h o n e is a

V a s c u la r C o n s u lta n t a t a n o th e r h o s p ita l.

G ive a h a n d o v e r u sing an SBAR a p p ro a c h (S itu a tio n , B a ckg ro u n d , A sse ssm en t, R e c o m m e n d a tio n s ).

Explain th e s a lie n t p o in ts , g ive y o u r d iagnosis (lik e ly a c u te is c h a e m ic leg s e c o n d a ry e m b o lu s ). You
re c o m m e n d t h a t th e p a tie n t needs th e basic ABCDE r e s u s c ita tio n /s ta b ilis a tio n b u t th e n u rg e n t
V a s c u la r re v ie w + /- e m b o le c to m y . E x a m in e r te lls y o u t h a t th e re are no beds a v a ila b le so th e r e w ill
be de la y. You nee d t o push fo r tra n s fe r and sugg est t h a t y o u tra n s fe r th e p a tie n t t o t h e ir A&E.

He th e n says ok, b u t w h a t w o u ld y o u lik e t o s ta rt in th e m e a n tim e as th e r e w ill be an u n a v o id a b le

d e a ly -> IV H e p a rin in fu s io n (m e a s u re APTT a c c o rd in g t o h o s p ita l g u id e lin e s ). He also asks y o u w h a t
im age s w o u ld be u s e fu l. CT A n g io g ra m + /- CT A b d o Pelvis.
H isto ry t a k in g

S e izure H is to ry

Lady cam e th ro u g h A & E and had a " f it "

H is to ry : G e n e ra lis e d to n ic -c lo n ic se iz u re 3 days ago, w itn e s s e d b y w o rk colle a g u e s. F irst e v e r seizure.

She had to n g u e b itin g , p o s t-ic ta l phase. N o w e ig h t loss. N o PM H , No DHx, N o FH, N o s ig n ific a n t
social h is to ry .

F o llo w up q u e s tio n s :

1) D iffe re n tia ls - Space o c c u p y in g le sion

2) W h a t ty p e s o f Space o c c u p y in g le sion? G lio b la s to m a M u ltifo r m e , M e n in g io m a
3) W h a t o th e r d iffe re n tia ls ? M e ta s ta s e s
4) In v e s tig a tio n s ? She has a lre a d y had a CT Head. So g e t an M RI Head and sta g in g CT
5) M a n a g e m e n t - N e u ro o n c o lo g y M DT, plan f o r s u rg e ry if fo r c u ra tiv e

BPH H is to ry

U rin a ry s y m p to m s - te rm in a l d rib b lin g , fre q u e n c y , d iffic u lty in itia tin g u rin a tio n b u t n o pain o r
d y s u ria . N o w e ig h t loss, no b o n e pain. S y m p to m s o n g o in g m o n th s .

DHx - ta k in g Sudafed

1) D iffe re n tia ls - BPH, M a lig n a n c y , Renal C a lculi, UTIs

2) In v e s tig a tio n s - Rectal e x a m in a tio n , U rin e Dip, US KUB, B loods (to c heck U+Es + PSAs)
3) M e d ic a l m a n a g e m e n t- T a m s u lo s in and F in a s te rid e (te ll m e a b o u t m e ch a n ism s)
4) S u dafe d - also causes u rin a ry r e te n tio n
S t a t io n (1 ): E x a m in a tio n - S u ra l n e r v e a n d d e e p p e r o n e a l n e r v e p a ls y

• P a tie n t h a d s m a ll s a p h e n o u s v e in s t r ip p e d s t e r i s t r ip s t ill in p la c e .
• P a tie n t s it t in g o n c h a ir , n o c o u c h .
• D if f ic u lt t o ass e s s r e fle x e s
• Loss o f s e n s a tio n f o r s u r a l n e r v e a n d d e e p p e r o n e a l n e r v e
• Loss o f d o r s if le x io n o f a f fe c t e d f o o t

S t a tio n (2 ): E x a m in a tio n - M a le b r e a s t e x a m in a tio n a n d d o r e le v a n t e x a m .

• P a tie n t c o m p la in s o f b ila t e r a l e n la r g e m e n t o f b r e a s ts , a s h a m e d o f t a k in g c h ild r e n t o

s w im m in g p o o l.
• B re a s t e x a m in a tio n
• A ls o d id c r a n ia l n e r v e II e x a m , b u t n o a b n o r m a l f in d in g s .
• V e r y c o n f u s in g s t a tio n .

S t a tio n (3 ): E x a m in a tio n - S u b m a n d ib u la r g la n d e x a m in a tio n , d o o t h e r r e le v a n t e x a m s .

• N o a b n o r m a l e x a m in a tio n fin d in g s .
• F o r g o t t o d o n e r v e e x a m s f o r h y p o g lo s s a l, lin g u a l a n d m a r g in a l m a n d ib u la r n e r v e
• E x a m k e p t a s k in g w h a t o t h e r r e le v a n t e x a m w o u ld y o u d o . M e n t io n e d t h e a b o v e
e x a m s b u t c o u ld n o t d o it b e c a u s e o f t im e .

S t a tio n (4 ): E x a m in a tio n - M u lt ip l e lip o m a

• U s u a l lip o m a e x a m in a tio n .
• M u lt ip l e lip o m a s o n t h e b a c k .
• D ia g n o s is - F a m ilia l lip o m a t o ts is .
• In v x - E x a m in e r w a n te d t h e in v e s tig a t io n t o d e t e r m in in e h o w d e e p t h e lip o m a is.
• M a n a g e m e n t.

S t a tio n (5 ): A n a to m y - T r a n s p y lo r ic p la n e

• D e fin e t r a n s p y lo r ic p la n e
• G a v e 3 d e f in it io n s , e x a m in e r lik e d n o n e o f th e m .
• A s k e d t o s h o w fu n d u s o f g a llb la d d e r o n t h e p a t ie n t.
• A s k e d t o s h o w c o s ta l c a r tila g e o f m id - a x illa r y lin e .
• Ip a d im a g e s h o w e d t r a n s p y lo r ic p la n e tra n s v e r s e s e c tio n , a s k e d f iv e o r g a n s t o p o in t .
S h o w e d d ia p h r a g m a n d a s k e d w h a t s t r u c t u r e . D ia p h r a g m is v e r y t h in a n d h a r d t o
see.
• E n d o f s p in a l c o r d le v e l in a d u lt.
• L ie n o - r e n a l a n d lie n o - g a s t r ic lig a m e n ts a n d c o n t e n t s .

S t a tio n (6 ): A n a to m y - P o s te r io r c r a n ia l fo s s a
 • A s k e d t o s h o w t h e b o u n d a r ie s o f p o s t e r io r c r a n ia l fo s s a o n s k u ll, a s k in g n a m e s o f
bones.
• N e rv e s p a s s in g b e h in d c liv u s ( a b d u c e n t) .
• A s k e d t o s h o w in t e r n a l a c o u s tic m e a tu s a n d c o n t e n t s .
• W h ic h a r te r ie s s u p p ly it? L a b y r in th in e a r t e r y
• A c o u s tic n e u r o m a
• F a c ia l n e r v e p a ls y ( u p p e r vs lo w e r m o t o r n e u r o n le s io n s )
• A s k e d t o s h o w t h e v e n o u s d r a in a g e o f t h e s k u ll, p o in t in g a t in t e r n a l o c c ip ita l
p r o t u b e r a n c e , f r o m c o n f lu e n c e o f s in u s e s t o in te r n a l ju g u la r v e in f o r m a t io n .
• S ig m o id s in u s in fe c t io n s p r e a d f r o m w h e r e ? M a s to id a ir c e lls .
• C o n te n ts o f f o r a m e n m a g n u m

S t a tio n (7 ): A n a to m y - E x te n s o r c o m p a r t m e n t o f t h e h a n d

• M u s c le s o f e x t e n s o r c o m p a r t m e n t
• S h o w e d c a d a v e r d is s e c tio n o n ip a d , a s k e d t o id e n t if y te n d o n s .
• A s k e d t o s h o w a n a to m y s n u f f b o x o n t h e h a n d , a s k e d b o u n d a r ie s .
• A s k e d a b o u t s c a p h o id f r a c t u r e .
• E x te n s o r h o o d
• O rig in s a n d in s e r t io n s o f a ll e x te n s o r s o n b o n e a s s e m b le d h a n d .

S t a tio n (8 ): P r o c e d u re - C h e s t d r a in in s e r t io n

• Ip a d im a g e s h o w e d la rg e p n e u m o th o r a x w i t h o u t m e d ia s tin a l s h ift . A s k e d
m a n a g e m e n t.
• L a rg e b o r e c h e s t d r a in in s e r t io n , c o n n e c tio n t o u n d e r - w a t e r s e a l, a n c h o r in g t h e
d r a in w i t h s ilk s u tu r e .

S t a tio n (9 ): P r o c e d u re - M a le c a t h e t e r iz a t io n

• M a le p a t ie n t w i t h m a n n e q u in b e t w e e n le g s . A s k e d t o e x p la in a b o u t t h e p r o c e d u r e
t o t h e p a t ie n t.
• C a th e te r iz a tio n p r o c e d u r e . P a tie n t t a lk in g d u r in g p r o c e d u r e a n d e x p r e s s e d p a in .
• N o u r in e c o m e s o u t a f t e r c a t h e t e r iz a t io n . A s k e d a b o u t t h e n e x t s te p .
• O b s c h a r t s h o w e d lo w b lo o d p r e s s u r e .

S t a tio n (1 0 ) : P a th o lo g y - A c u te a n d c h r o n ic in f la m m a t io n

• A c u te a n d c h r o n ic in f la m m a t io n a t c e llu la r le v e l
• A s k e d a b o u t h o w h y p o th a la m u s r e g u la te s b o d y t e m p e r a t u r e .
• A b s c e s s a n d c e llu lit is . D e f in it io n a n d d iffe r e n c e s .
• T w o c a u s e s o f n o n - b a c te r ia l a b s c e s s

S t a t io n (1 1 ) : P a th o lo g y - CA b r e a s t c y t o lo g y
 • C y to lo g y a n d h is to lo g y . P ro s a n d c o n s .
• A s k e d t o in t e r p r e t c y t o lo g y r e p o r t o f b r e a s t c a n c e r.
• C y to lo g y r e p o r t s h o w s v a r ia b le s h a p e o f c e lls w i t h p le o m o r p h is m .
• W h a t is C 4 o n c y t o lo g y r e p o r t m e a n s , a n d w h a t a r e o t h e r t e r m s t h a t y o u a r e a w a re ?

S t a t io n (1 2 ) : C r itic a l c a r e - N u t r it io n

• S c h e m e - C r o h n 's p a t ie n t w i t h ile o c e c a l d is e a s e , h a d r e s e c tio n w i t h ile o s t o m y

• W h a t a r e n u t r it io n o p t io n s ?
• E n te r a l a n d p a r e n t e r a l n u t r it io n . P ro s a n d C o n s
• TP N e f fe c t s o n e le c t r o ly t e a b n o r m a lit ie s .
• E x a m in e r a b it s lo w , c o u ld n o t fin is h t h e s t a tio n .

S t a t io n (1 3 ) : C r itic a l c a r e - EDH

• Y o u n g m a le f e ll f r o m la d d e r a b o u t 3 m .
• GCS d r o p p e d t o 6 a f t e r a d m is s io n a f t e r lu c id in te r v a l. In tu b a te .
• S h o w e d CT im a g e o f s k u ll. E x tr a d u r a l h a e m a to m a .
• M a n a g e m e n t - m a n n ito l, s te r o id s , h y p e r v e n t ila t io n , h y p o th e r m ia , c r a n io to m y ,
in fo r m n e u r o s u r g e o n
• D e fin it io n o f in tr a c r a n ia l p e r f u s io n p re s s u re .
• In d ic a tio n s o f CT s c a n - m e n t io n e d 6 in d ic a t io n s , b u t e x a m in e r w a n ts m o r e

S t a t io n (1 4 ) : C r itic a l c a r e - H y p o th y r o id

• C lin ic a l f e a tu r e s o f h y p o th y r o id
• 6 5 - y e a r - o ld la d y w i t h c h r o n ic f a tig u e a n d m a la is e a n d n e c k s w e llin g s - d if f e r e n t ia ls
• C a u s e s o f h y p o th y r o id is m
• S h o w e d b lo o d t e s ts - FBC, TFT, a s k e d t o in t e r p r e t r e s u lts
• FBC - m a c r o c y tic a n a e m ia . A s k e d w h y - p e r n ic io u s a n a e m ia , T FT - TSH v e r y h ig h
• M a n a g e m e n t o f h y p o th y r o id is m
• S u rg ic a l c o n c e rn s o f h y p o th y r o id is m - b r a d y c a r d ia , h y p o te n s io n , a lte r e d m e n ta l
s ta te , m y x o e d e m a c o m a

S t a t io n (1 5 ) : H is to r y - C h e s t p a in a f t e r TH P

• M a le p a t ie n t h a d t o t a l h ip r e p la c e m e n t f e w d a y s a g o .
• S h a rp le ft - s id e d c h e s t p a in , n o r a d ia tio n , c o u g h in g a n d tr a c e s o f b lo o d in s p u tu m .
• D iff e r e n t ia ls
• In v e s tig a t io n s a n d m a n a g e m e n t.

S t a t io n (1 6 ) : H is to r y - C h ro n ic is c h a e m ic lim b

• P a tie n t w i t h 6 m o n t h s h is to r y o f le f t c a lf p a in .
 • P a in o n e x e r t io n e s p e c ia lly g o in g u p - h ill.
• H e a v y s m o k e r , h y p e r t e n s io n a n d h y p e r lip id e m ia . N o d ia b e te s .
• I n v e s tig a tio n s
• M a n a g e m e n t.

S t a t io n (1 7 ) : C o m m u n ic a tio n - I n fo r m t r a u m a c o n s u lt a n t a b o u t o p e n f r a c t u r e

• 1 0 m in s p r e p s t a tio n . P a p e r p r o v id e d t o t a k e n o te s .
• Y o u n g m a le , k n o c k e d o f f b ik e b y h i t- a n d - r u n c a r
• L e ft- s id e d r ib f r a c t u r e s , r ig h t - h a n d f r a c t u r e , le f t t ib ia a n d f ib u la f r a c t u r e s .
• G e n e r a l s u r g e o n s a id n o n e e d f o r la p a r o to m y . A d v is e d p la s tic s u r g e o n t e a m r e v ie w .
• P a ra c o lic g u t t e r f lu i d c o lle c t io n p r e s e n t o n u ltr a s o u n d . CT s c a n n o t d o n e y e t.
• P a tie n t s t a r t e d t o h a v e c o m p a r t m e n t s y n d r o m e s y m p to m s .
• R e g is tra r g o t a n e m e r g e n c y b le e p a n d w e n t t o t h e a t r e w i t h a n e m e r g e n c y s u r g e o n .
• A s k e d t o c a ll t h e t r a u m a c o n s u lt a n t
• In v e s tig a tio n s .
• M a n a g e m e n t.

S t a t io n (1 8 ) : C o m m u n ic a tio n - S p le n ic h a e m a t o m a p a t ie n t w a n ts t o s e lf- d is c h a rg e .

• 1 0 m in s p r e p s t a tio n . P a p e r p r o v id e d t o t a k e n o te s .
• Y o u n g m a le t r ip p e d a n d f e ll f r o m s ta ir s u n d e r t h e in flu e n c e o f a lc o h o l.
• P a tie n t v is itin g f r o m a n o t h e r t o w n , h a v e in t e r v ie w f o r p r o m o t io n , s o h e w a n ts t o g o
h o m e . W if e w i t h c a n c e r.
• L e ft b a s a l p u lm o n a r y c o n t u s io n . L e ft s id e d r ib s f r a c t u r e s a n d s p le n ic h e m a t o m a . H b
d ro p p e d fro m 110 t o 90.
• P e rs u a d e t h e p a t ie n t t o s ta y .
• P a tie n t a g r e e d t o s ta y a t la s t.
Anatom y

1. Thyroid / infrahyoid muscles

2. Spine / cauda equina
3. Pancreas / surrounding anatom y / stomach (also a q on the developm ent of
pancreas!)

P a th o lo g y

1. Return from Bangladesh with lump in neck - TB / Lymphoma questions

2. Testicular tumours but focus on lymphoma / non germ cell and also part about SCC

C r it C a r e

1. Epidural haematoma and subsequent managem ent / quesitons on ICP / CPP

2. Diabetic medication managem ent peri-op / factors involved in glucose homeostasis
3. Cholestatic LFT's on bloods - all about bile, enterohepatic circulation etc

Exam s

1. Cranial nerves - Bitemporal hemianopia

2. Bilateral inguinal hernia
3. Hand exam - Dupuytrens / scar above right elbow also
4. ?? can't remember!

H is to r y ta k in g

1. Assess capacity for confused patient in for elective total hip replacement
2. Obstructive LUT's

Communication

1. Mother wants to know about son who has been taken to OT for urgent splenectom y
post fall while in fathers care. Mix breaking bad news / NAI
2. Contact ICU registrar for peri-op advice on managem ent and book post op ICU bed
for ? Perforated ulcer going for emergency laparotomy

Procedures

1. Types of sutures / knot tying / tying at depth / underrun ulcer with figure of 8
2. Site IVC then mixed with crit care - went on to discuss fluid management, venous cut
down etc
 KV 13I L F U D l i n 1 U ' U C l ZU 10

1. A M T S, needed to assess capacity to consent for THR, Old man, daughter present, the usual station, he
didn’t, explain why, dementia, what investigations, what more focused test to further do, Full MOCHA,
M M SE etc.

2. BPH: lower urinary tract symptoms, very difficult actor, w as very conscious he delayed presenting to GP
for 2 years, note you needed to pick up he’ s taking Sudafed regularly for ages, it exacerbates BPH , reassure
som e sim ple tests need to be done, but cannot rule out C a etc,

3. Prep Station for ICU transfer

4. ICU, really sick lapartomy needs ICU in another bigger hospital, loads o f reasons why he can’t take them,
come up with good solutions like hold patient in recovery for longer, hold in theatre for longer, aim to
review surgical patients in ICU currently with potential step down to H DU care, very quick station,
examiner was a slow taker and hard o f hearing.

5. TB travelling patient, differential o f hodgkins vs TB, shown a histo slide, what is it, define Giant Cell,
process in T B , prognosis, The examiner didn’t let you speak, it was simple one word answers, you either
know or you don’t.

6. Cranial Nerve exam, can’t exactly recall, she definitely had a bitemporal hemianopia, why, differentials
etcs, some anosmia, no facial nerve problems or otherwise, there was a few you didn't have to test so be
careful on time, few question at the end on types o f pituitary tumours and surgery and access for surgery etc

7. DV T/PE, post op day 5 or something, good actor, simple enough Cardio/Resp exam mixed with a CCrISP
type scenario, ju st don’t forget to check his calves, and its very obvious, then questions on what you main
differential is, Tx and what to be careful of, Im aging choice etc

8. Hand Duypetrans, straight forward hand exam, loads o f signs, loads o f questions on fam hx, differentials,
causes, stages and types o f treatment

9. Abdo incisional hernia: Huge abdominal hernia, he had like 4, one in each quadrant basically, BM1 must
have been >45-50, poor guy, had very bad COPD too, sim ple enough abdo exam, examiner ju st wanted risk
factors, Jenkins rule etc, mesh repairs, why hernia, COPD, then little about component separation, in this
case this man had very poor social circumstances and we were going ahead with surgery but his wife is
wheelchair bound and cant care for him post op, ie arrange convalesce or similar, fam ily involvement etc.

10. A N A TO M Y : Thyroid Neck specimen, vessels, nerves, muscles etc, all fairly straight forward

11. A N A T O M Y : Lumber Spine, som e vertebrae, align them, point out the parts, he points you say, what
level are the from, few more, then and MRI slice, whats going on, prolapse, and causing cauda, what to do
now, questions on layers o f spinal cord, where it ends, then about veins and supply and why prostate cs
spreads rapidly if spinal, because o f valveless veins

12. A N A TO M Y : Abdo anatomy mainly focused on Pancreas, Stomach and Duodenum, very straightforward
again, blood supply mostly, Pringles manoeuvre, nerves, etc

13. Testicular Ca, shown a slide, tumour marker, talk types, prognosis etc, surgical approach and why and
then sam e patients m isses follow up later gets SC C face, key w as to say its not a recurrence it’s a separate
primary incidentally

14. Pseidoaneurysm in an IVDU, w as profusely bleeding at the scene, questions about true causes o f
a n p iirv Q m s n p rsn n a l n r n fp r t iv p w p a r i f H T V p fr
15. Prep station for next one

16. Mother with kid splenic injury, father brought kid to ED , grade 4 injury, in theatre with Cons and SpR ,
going very well, Husband drinker, separated from Wife, she becom es difficult and wants you to blame him,
sim ple playground injury, he fell from a jungle gym witnessed whilst playing, brought directly in, don’t
blame, she says he’ s drinking, cant consent, who consented and why, Cons can, emergency, then delve into
long term issues with a splenectomy and what precautions, vaccines and prophylactic abx etc, she then goes
full circle when you have done everything and wants to ban the husband from the hospital, he has custody
rights and so you can involve Soc Work but cant ban him

17. Suture at depth, types o f material, when, why, why advantages, simple

18. IV Cannulae & IVF, prescribe fluid regeime for shock man, you put IVC in fake arm but actor is a bit o f
a pain, ju st be really sympathetic to him and its fine, then goes into larger lines talk, if cant get access try
Central or Cut Down, describe cut down where and why.

19. D M pre op, can't exactly recall, alot o f medical detail about DM , pre op patient, needs surgery, G K I
protocol, etc, pathophysiology o f DM , more info on gycogenolysis etc

20. Biliary Sepsis: sim ple station, Acute Chole, then developed a C B D stone, did U S, what next, MRCP,
what next ER C P, what would you expect done, then patient is septic and unwell, manage it etc, types o f
bilious disease, then went into entero hepatic circulation etc

21. EDH: Head injury, shown CT, maybe an M RI too? Just go through the motions for head injury as
previously on this site, Monroe kellie doctrine, etc, C SF , management etc
 K C S1 Dublin 1U " U c t 2UI8

1. A M T S, needed to assess capacity to consent for THR, Old man, daughter present, the usual station, he
didn’t, explain why, dementia, what investigations, what more focused test to further do. Full MOCHA,
M M SE etc.

2. BPH: lower urinary tract symptoms, very difficult actor, w as very conscious he delayed presenting to GP
for 2 years, note you needed to pick up he’ s taking Sudafed regularly for ages, it exacerbates BPH, reassure
som e sim ple tests need to be done, but cannot rule out C a etc,

3. Prep Station for ICU transfer

4. ICU, really sick lapartomy needs ICU in another bigger hospital, loads o f reasons why he can’t take them,
come up with good solutions like hold patient in recovery for longer, hold in theatre for longer, aim to
review surgical patients in ICU currently with potential step down to H DU care, very quick station,
examiner was a slow taker and hard o f hearing.

5. TB travelling patient, differential o f hodgkins vs TB, shown a histo slide, what is it, define Giant Cell,
process in T B , prognosis, The examiner didn’t let you speak, it was simple one word answers, you either
know or you don’t.

6. Cranial Nerve exam, can’t exactly recall, she definitely had a bitemporal hemianopia, why, differentials
etcs, some anosmia, no facial nerve problems or otherwise, there was a few you didn’t have to test so be
careful on time, few question at the end on types o f pituitary tumours and surgery and access for surgery etc

7. DV T/PE, post op day 5 or something, good actor, simple enough Cardio/Resp exam mixed with a CCrISP
type scenario, ju st don’t forget to check his calves, and its very obvious, then questions on what you main
differential is, Tx and what to be careful of, Im aging choice etc

8. Hand Duypetrans, straight forward hand exam, loads o f signs, loads o f questions on fam hx, differentials,
causes, stages and types o f treatment

9. Abdo incisional hernia: Huge abdominal hernia, he had like 4, one in each quadrant basically, BM I must
have been >45-50, poor guy, had very bad COPD too, sim ple enough abdo exam, examiner ju st wanted risk
factors, Jenkins rule etc, mesh repairs, why hernia, COPD, then little about component separation, in this
case this man had very poor social circumstances and we were going ahead with surgery but his wife is
wheelchair bound and cant care for him post op, ie arrange convalesce or similar, family involvement etc.

10. A N A T O M Y : Thyroid N eck specimen, vessels, nerves, muscles etc, all fairly straight forward

11. A N A T O M Y : Lumber Spine, som e vertebrae, align them, point out the parts, he points you say, what
level are the from, few more, then and MRI slice, whats going on, prolapse, and causing cauda, what to do
now, questions on layers o f spinal cord, where it ends, then about veins and supply and why prostate cs
spreads rapidly if spinal, because o f valveless veins

12. A N A TO M Y : Abdo anatomy mainly focused on Pancreas, Stomach and Duodenum, very straightforward
again, blood supply mostly, Pringles manoeuvre, nerves, etc

13. Testicular Ca, shown a slide, tumour marker, talk types, prognosis etc, surgical approach and why and
then sam e patients m isses follow up later gets SC C face, key w as to say its not a recurrence it’s a separate
primary incidentally

14. Pseidoaneurysm in an IVDU, w as profusely bleeding at the scene, questions about true causes o f
T ha nk y o u so m uch fo r this! T h e efforts o f p eo ple like you are app reciated m ore than yo u realise. T he re
are so m a n y unscru p u lo u s in dividuals o u t there exploitin g p o s tgraduate m edica l exam anx ie ty as an
op p o rtu n ity to m ake pro fit -often using o th e r p e o p le ’s in tellectual property th a t is provided fre e o f charge.
For e x am ple, P a stT est has th e a u d a c ity to in clude a link to th e fre e and brilliant resource
T ea c h m e A n a to m y in its o nline subscrip tion th a t it ch a rg e s fo r as part o f th e selling points! O dious. I sat
the M R C S part b in O c to b e r 2 01 8 in Lon don. I’d like to lis t th e s tations a s I w a n t to m ake a positive
contributio n fo r others:

24 stations in total (1 9 + 3 + 2): 3 x rest; 2 x prep (for th e 2 com m u n ic a tio n stations);

C linical skills
1. S u ture hand tie and s u rgica l knot. Z -su tu re to stop a bleeding vessel
3. O rde ring a theatre list (1. pt nee ds a s ig m oid colecto m y has a llergy to penicillin a nd iodine. 2. IDDM pt
w ith M R S A in fected ulcer nee ds BK A. 3. A m an w ith s tran gula ted I final hernia)

P athology
1. T e s tic u la r tum o r, types, origin o f m edullary carcinom a, lym p h o m a s - w h e re do th e y m eta stasise?
2. blood tra n sfu sio n , tran sfusion reaction (w hat is the basis o f tran sfusion reaction). H e aling bon e fracture

A natom y
1. B o nes o f u pp er lim b (hum eru s, scapula, cla vicle ). R o tator c u ff m uscles and th e ir n erve supp ly
2. T hyroid ana to m y including blood sup p ly and adjacent structures
3. T h o ra x and a bd om e n (abdom in al w a ll m uscles, nerve roots); nerve s t risk o f in ju ry during
app endice ctom y.

C o m m unication
1. T alk in g to a m an w ith s p le n ic rupture w h o w a nts to s e lf discharge. D iscussin g risks and attem pting to
reach a decision to s ta y (later learned s p lenic rupture is graded and doe s not nece s s a rily require
e m ergency s p le n e c to m y if cla ssed as lo w e r g ra d e - 1, II, III but can be m anaged c o n s e rv a tiv e ly w ith
observation).
2. R e ferring a pt fo r e m e rg e n c y la p a ro to m y w h o has perforated to in ten sivist fo r post-op ITU

H istory
1. K n ee pain
2. P o st-op (T H R ) p leuritic c h e s t pain

C ritical Care
1. H ead in jury pt youn g gu y in R T A w ith loss o f c o n sciousness a t s cene, c onscious b u t vom itin g in ED -
m onroe-K elly doctrine. C u s h in g ’s triad. E xtradural H a em atom a, in terpret head C T (extradural
h ae m atom a, describ e: la teral h y p o dense c o n v e x ity in e xtra dural s pace w ith effa c e m e n t o f la teral ventricle
and m idline shift)
2. B iliary c o lic a s s e s s m e n t o f g allstones, pathology o f g allstones, in vestigations.
3. Pt PE post-op. Interpretation o f A B G . Investigation & m anagem ent.
4. A pregna nt pt. w ith s p le n ic rupture requiring em e rg e n c y splenectom y, hyp o te n sive w ith no ev id e n c e of
blood loss d urin g a s p le n e c to m y do n e w ith patie nt in reverse tre lende nburg position. Q uestioned re
cause s o f hypo tension (eg S P IN A L S H O C K ) B u t could have c o n sidered also ana p h y la x is from age nt
given by ane asthe tist). M ay have a ls o have a placental abruptio n o r sepsis. S tated o c c u lt so u rc e s o f bid
loss but also reduced ven o u s return from uterus).

C linical exam in ation

1. S u b m a n d ib u la r sw elling
 2. A b dom inal e xam in ation 30 yo F w ith 24 hr o f ab d o pain. R ight sid ed (R IF) a b d o pain w rebound
tenderness. Q uestions abo ut w h a t w o uld I do next. (U P T /blds/U S abd o/pe lvis).
3. E xa m ination o f a pt le ft hem i o r w h o has beco m e s eptic (feb rile and ta c hycardia and c/o LIF pain
radia ting to sh o u ld e r tip)
4. E xa m ination o f the leg o f a pt w h o presents w ith num bne ss and clu m siness follow ing phlebectom ies
(varicose vein surgery) - w h ich nerve is injured (superficial perone al) and testing o f m o to r and senso ry
aspe cts

15. Prep station for next one

16. Mother with kid splenic injury, father brought kid to ED, grade 4 injury, in theatre with Cons and SpR ,
going very well, Husband drinker, separated from Wife, she becom es difficult and wants you to blame him,
sim ple playground injury, he fell from a jungle gym witnessed whilst playing, brought directly in, don’t
blame, she says he’ s drinking, cant consent, who consented and why, Cons can, emergency, then delve into
long term issues with a splenectomy and what precautions, vaccines and prophylactic abx etc, she then goes
full circle when you have done everything and wants to ban the husband from the hospital, he has custody
rights and so you can involve Soc Work but cant ban him

17. Suture at depth, types o f material, when, why, why advantages, simple

18. IV Cannulae & IVF, prescribe fluid regeime for shock man, you put IVC in fake arm but actor is a bit o f
a pain, ju st be really sympathetic to him and its fine, then goes into larger lines talk, i f cant get access try
Central or Cut Down, describe cut down where and why.

19. DM pre op, can’t exactly recall, alot o f m edical detail about DM , pre op patient, needs surgery, OKI
protocol, etc, pathophysiology o f DM , more info on gycogenolysis etc

20. Biliary Sepsis: sim ple station. Acute Chole, then developed a C B D stone, did U S , what next, MRCP,
what next ERCP, what would you expect done, then patient is septic and unwell, manage it etc, types o f
bilious disease, then went into entero hepatic circulation etc

2 1. EDH: Head injury, shown CT, maybe an M RI too? Just go through the motions for head injury as
previously on this site, Monroe kellie doctrine, etc, C SF , management etc
MRCS London October 2018

A ll o f m y s t a tio n s w e r e p r e t t y m u c h e x a c t r e p e a ts o f p r e v io u s s t a tio n s a lr e a d y in c lu d e d o n
t h is w e b s it e . (FYI, t h is w a s a c t u a lly m y p r im a r y r e s o u r c e f o r r e v is io n a n d I p a s s e d
c o m fo r t a b ly .)

1. P a th o lo g y - A P K D , c h o la n g itis , w h a t c h a n g e s w o u ld y o u s e e o n m ic r o s c o p y , w h a t
h a p p e n s in t h e b o d y d u r in g a n in fe c t io n

2. R e st

3. C a ll t h e o n c a ll t r a u m a c o n s u lt a n t r e g a r d in g a n o p e n t i b / f i b f r a c t u r e

4. C a th e te r is a tio n ( m a le ) , q u e s tio n s r e g a r d in g r e n a l f a ilu r e

5. C h e s t d r a in in s e r t io n , q u e s tio n s r e g a r d in g c o m p lic a t io n s

6. H a n d a n a to m y ( v e ry d e t a ile d q u e s tio n s a s k in g t o id e n t if y e x a c t t e n d o n s in t h e
h a n d s , t h e i r in s e r t io n s e t c - I k n e w v e r y l i t t le o f th is )

7. A b d o m e n a n a to m y

8. S k u ll a n a to m y

9. P a th o lo g y - a b s c e s s , a b s c e s s v c e llu lit is , w h y w o u ld y o u d r a in a n a b s c e s s

1 0 . L o w e r lim b n e u r o e x a m in a tio n - p o s t o p s a p h e n o u s v e in h a r v e s tin g , f o o t d r o p (I

d i d n 't e v e n f in is h t h e e x a m in a tio n )

11 . H i s t o r y - c la u d ic a t io n

12 . H is to r y - p o s t o p PE

13 . P a r e n te r a l v s e n t e r a l fe e d in g

14 . R e st

1 5 . S p e a k t o s p le n ic h a e m a t o m a p a t ie n t w h o 'd lik e t o s e lf d is c h a r g e

16 . E x a m in a tio n - LIF p a in p o s t o p , a n a s to m o t ic le a k

1 7 . E x a m in a tio n - LIF p a in , d iv e r t ic u lit is

18 . E x a m in a tio n - s u b m a n d ib u la r s w e llin g

19. E x tr a d u r a l h a e m o r r h a g e ,
2 0 . E x a m in a tio n - la d y w i t h h y p o th y r o id is m , a s k e d re c a u s e s , in d ic a t io n s f o r r e m o v a l,
p o s t o p c o m p lic a t io n s .
2019

Daniel Ne Kuala Lum pur Jan 2019

Anonym ous Hyderabad Jan 2 019

Raieev Pullaeura Hyderabad Jan 2 019

Anonym ous Yangon Jan 2019

Ekansh Debuka Glasgo w Feb 2019

Anonym ous London Feb 2019

Day 2

P art 1

1. P a thology - p a tie n t 23yo, com es back fo r Bangladesh n o w w ith a n te rio r neck sw e llin g . H is to ry
o f n ig h t s w e ats p a rt 3 w eeks
a. D iffe re n tia ls ?
b. In v e s tig a tio n s to c o n firm
c. If ly m p h o m a , lik e ly w h a t ty p e ?
2. P a rotid gland
a. B oundaries o f p a ro tid gland
b. Stensen's d u c t surface a n a to m y
c. On p la s tin a te d m o d e l: p o in t to stensens d u c t, and branches o f th e facial nerve
d. D iffe re n tia l diagnosis o f p a ro tid sw e llin g
e. M o s t c o m m o n p a ro tid cancer
f. L y m phatic drain a g e o f p a ro tid
g. Line w h ic h d e n o te s drain a g e o f
3. Low er lim b a n a to m y
a. W h e re is la te ra l m a lleolu s
b. W h e re t o p a lp a te p o s te rio r tib ia l a rte ry and dorsalis pedis
c. A tta c h m e n ts o f pero n e u s lo ngus and brevis
d. E ffe ct o f tib ia lis p o s te rio r and a n te rio r c o n tra c tin g to g e th e r, s h o w th e m o v e m e n t
e. E ffe ct o f perone us longus and brevis c o n tra c tin g to g e th e r, s h o w th e m o v e m e n t
f. M uscles in p o s te rio r c o m p a rtm e n t
g. Nerves sup p lin g each c o m p a rtm e n t
h. D e rm a to m e s o f S I
i. D is trib u tio n o f s u ra l/s a p h e n o u s nerve
4. T ho racic and a b d o m in a l a n a to m y
a. S how p u lm o n a ry tru n k
b. W h a t is th is s tru c tu re ? A n d branches (possib ly a o rta )
c. B ehind th e h e a rt and p o in ts t o hem iazygos vein - trib u ta rie s ?
d. splenic a rte ry and branches
e.
5. P a thology - p a tie n t w ith HTN, D M , sm o ke r, w ith b a re tts esophagus and n o te d cancer
a. W h a t ty p e o f cance r th is p a tie n t lik e ly has?
b. G iven T N M staging and diagram o f tu m o u r invasion - stage th is tu m o u r
c. N o w p a tie n t u n d e rw e n t resection b u t cam e back w ith su p ra c la v ic u la r ly m p h n o d e -
w h a t te s t w ill yo u do
d. W h a t c y to lo g ic a l fe a tu re s w ill th is p a tie n t lik e ly have
e. N o w p a tie n t dev e lo p e d p le u ra l e ffu s io n - w h a t te s ts to s h o w diagnosis
f. W h a t te s t to d iffe re n tia te e p ith e lia l and g a s tro in te s tin a l tu m o u r
6. H y p o th e rm ia - p a tie n t w ith p e rfo ra te d viscus. Background COPD and h y p e rte n s io n . G iven obs
c h a rt w ith h y p o th e rm ia and ta c h y c a rd ia , n o rm o te n s iv e . W e ig h t 51kg
a. D e fin itio n o f h y p o th e rm ia

rhart with hunnthormia anrl tarhwrarHia nr\rmntpnci\/p U/pioht •illfo

 b. H o w t o m easure te m p e ra tu re
c. W h a t p a tie n t risk fa c to rs t o have h y p o th e rm ia
d. H o w to tre a t h y p o th e rm ia
e. C o m p lic a tio n s o f h y p o th e rm ia
7. P ost-op o lig u ria - p a tie n t p o st h e m ia rth ro p la s ty fo r NOF - u n e v e n tfu l, m in im a l b lo o d loss -
in fo rm e d by nurse, p a tie n t SOB, ta cyp n e ic. E xa m ination creps lungs
a. G iven flu id balance - co m m e n t
b. Obs c h a rt - c o m m e n t on obs a t 2000. Shows h y p e rte n s io n , som e tachycardia
c. CXR - flu id ov e rlo a d
d. W h a t in v e s tig a tio n s w ill you do
e. M anagem ent
8. C o rtisol - p a tie n t has RA on p red. pla n n e d fo r surgery
a. T ell m e a b o u t HPA axis
b. Fun ctions o f co rtis o l
c. H o w s ig n ific a n t dose is c o rtis o l to be c o n sidered fo r re p la c e m e n t?
9. S u tu rin g - p a tie n t w ith la c e ra tio n w o u n d , cleaned - pick n o n -a b s o rb a b le s u tu re and p e rfo rm
w ith in s tru m e n t tie
a. Need a n tib io tic s ?
b. W h a t local a n a e s th e tic nee ded? H o w m uch dose?
10. Incision and drain age o f abscess
a. W h a t t o do a fte r d ra in in g abscess?
b. W h a t dressing?
c. If excessive e x u d a te in dressing?
d. H o w do yo u plan y o u r incision?

p a rt 2

1. E xa m ination hand - yo u are called to dialysis c e n tre t o a tte n d t o a p a tie n t w ith hand pain and
coldness
a. D o p p le r p ro v id e d
b. D iffe re n tia l?
2. E xa m ination - CVS - p a tie n t planned fo r hern ia re p a ir - w h a t c o n s id e ra tio n s
a. Had m edia n s te rn o to m y scar - su p p o se d ly w ith m e ta llic click - w h a t consid e ra tio n s ?
b. P a tie n t on w a rfa rin and th e n given INR levels - m anage m ent?
3. E xa m ination - in g u in a l hernia
a. D iffe re n c e fe m o ra l and in gu in a l hernia
b. Is th is in d ire c t o r dire c t?
c. A ny scars n o tic e d on e x a m in a tio n ? Had la paroscopic scar - pre vio u s re p a ir - w h a t
w o u ld yo u re c o m m e n d th e n ?
4. E xa m ination - ea r - p a tie n t fe ll fro m horse, n o w hea rin g d iffic u lty
a. CN8 + 7 - le ft w h is p e r neg ative, le ft rin n e p o s itiv e . O toscop e p ro v id e d - show s
h a e m o ty m p a n u m
b. D iffe re n tia l?

6. Hypothermia - patient with perforated viscus. Background COPD and hypertension. Given obs
Station 1 - HPE axis - Usual questions. Asked about all the adrenal horm ones
effects.
Station 2 - Pain m anagem ent station. Asked to read a drug chart. O utside info said
about a situation w here patient w as im m ediate post op had pain and tachycardia but
all system s are normal.
Station 3 - Nutrition and feeding. S how n X-Rays with NG tubes. Usual questions.
Station 4 - Carcinoid tu m o r and pin w orm haha. Questions about NET'S and
psudom em branous colitis.
Station 5 - C om m unication - Repeated station - D iverticulitis patient with
throm boem bolism o f leg. Discuss with vascular surgeon.
Station 6 - History - Diarrhoea - IBD
Station 7 - Skills - Abscess drainage.
Station 8 - Hyperparathyroidism and kidney stones
Station 9 - History - H yperthyroidism with neck mass
Station 10 - A natom y - Popliteal fossa
Station 11 - Base o f skull - T ricky station i felt.
Station 12 - Nevus excision with suturing.
Station 13 - Exam - Com m on peroneal nerve injury
Station 14 - Exam - CVS exam c pacem aker
Station 15 - Exam - Thyroid swelling
Station 16 - Exam - M ultiple sw ellings over thunk
Station 17 - C om m unication - A ngry patient; cancelled procedure. He w asn't really
that angry lol.
Station 18 - A natom y - Thyroid.
 c. Investigation s?
d. M a n a g e m e n t?
5. R e a d in g -s o n had splenic ru p tu re
6. A tte n d to m o th e r anxious a b o u t son
a. Father s h o u ld n 't have c u s to d y - h o w t o deal?
b. P o s t-s p le n e c to m y p re v e n tio n
7. H is to ry - in fo rm e d by nurses p a tie n t c onfused - n o t sure if can ta k e co n s e n t - assess
a. A ny scores to assess m e n ta l s tate? W h a t is th e c u to ff?
b. H o w to in vestigate?
c. M a n a g e m e n t?
8. Reading - p a tie n t h it and run w ith unco nscious p e rio d ; no ED n otes; had le ft t ib / f ib fra c tu re ;
rig h t m eta c a rp a l fra c tu re ; u ltra s o u n d ab d o m e n sh o w e d flu id in le ft paracolic g u tte r
9. Call c o n s u lta n t re gardin g plan
10. H is to r y - c h r o n ic d ia rrh e a , strea k b lo o d , som e paleness; p o ly a rtic u la r; m o u th ulcers
a. In v e s tig a tio n s fo r IBD?
b. M a n a g e m e n t?
Station 1 - HPE axis - Usual questions. Asked about all the adrenal horm ones
effects.
Station 2 - Pain m anagem ent station. Asked to read a drug chart. O utside info said
about a situation w here patient was im m ediate post op had pain and tachycardia but
all system s are normal.
Station 3 - Nutrition and feeding. Shown X-R ays with NG tubes. Usual questions.
Station 4 - Carcinoid tum or and pin worm haha. Q uestions about NET'S and
psudom em branous colitis.
Station 5 - C om m unication - R epeated station - D iverticulitis patient with
throm boem bolism o f leg. Discuss with vascular surgeon.
Station 6 - H istory - Diarrhoea - IBD
Station 7 - Skills - Abscess drainage.
Station 8 - H yperparathyroidism and kidney stones
Station 9 - H istory - Hyperthyroidism with neck mass
Station 10 - A natom y - Popliteal fossa
Station 11 - Base o f skull - T ricky station i felt.
Station 12 - Nevus excision with suturing.
Station 13 - Exam - Com m on peroneal nerve injury
Station 14 - Exam - CVS exam c pacem aker
Station 15 - Exam - Thyroid swelling
Station 16 - Exam - M ultiple sw ellings over thunk
Station 17 - Com m unication - Angry patient; cancelled procedure. He w asn't really
that angry lol.
Station 18 - A natom y - Thyroid.
MRCS- England, January 20, 2019 - Hyderabad (2nd Day) - Held at
Westin Hotel, Hyderabad - Dr Rajeev Pullaqura

A b o u t 32 m e m b e rs a tte n d e d th e 2nd day exam in H yderabad. Since it w a s in th e b a llro o m o f w e s tin hote l

- No gross a n a to m y specim e n, no c ritic a l care e q u ip m e n t.

1. S ta tio n 1

C o m m u n ic a tio n -

A n g ry P a tie n t - P a tie n t w ith m eniscus in ju ry - 2 nd pro p o s e d su rg e ry delayed

C oncerns - th ir d tim e delay, po s tm a n - jo b a ffe c te d , w e ig h t gain, w ife has to pick him and d ro p him ,
g a s tritis due t o ib u p ro fe n , can I c o m p la in a t th e hosp ita l - PALS, w a n ts d e fin ite tim e and d a te o f surgery.
Asked a b o u t th e pro p o s e d su rg e ry - a rth ro s c o p y .

2. S ta tio n 2

A n a to m y - Neck and sh o u ld e r

a) T h y ro id gland - Lobes, A rte ria l s upp ly, ve n o u s drain age, e m b ry o lo g y , p o s itio n o f p a ra th y ro id .

b) A n a to m y and su p p ly o f RLN - w h e re does it lo op, w h a t fib e r it carries. N erve a t risk d u rin g Sup
th y ro id A lig a tio n .
c) W h y bro n c h ia l carc in o m a causes hoarseness o f voice.

3. S ta tio n 3

Skill - Excision o f neavus

In s tru c tio n given - C o n s u lta n t g o t a call, so he asked yo u to p e rfo rm th e surgery, local given and draped
- S terile tra y p ro v id e d , P a tie n t w ill be given le a fle t by th e nurse.

- M is ta k e c o m m itte d - checked fo r c o n s e n t a little la te, w id e excision o f neavus, co u ld n o t

a p p ro x im a te edges a d e q u a te ly , and p a tie n t k e p t in te rru p tin g .

Bell - P o or s ta tio n , d id n 't go w e ll

4. Station 4

E xa m ination - Scenario - Post Saphenous v e in RFA and m u ltip le p e rfo ra to r lig a tio n - P a tie n t c om pla ins
o f d iffic u lty in m o v in g his fo o t. Bandages o f la te ra l aspect o f leg. Do re le v a n t e x a m in a tio n . Provided
c o tto n and n e u ro tip

- Poor a c to r
- Did in s p e c tio n , p a lp a tio n - asses Touch sensa tion, m o v e m e n ts o f leg a ffe c te d .
- Finding - loss o f sensa tion in co m m o n pero n e a l n regio n w ith d iffic u lty in d o rs ifle x io n and
eversio n. G ait assessm ent.! I fo rg o t a b o u t th is )
- Q u e s tio n s - Y o u 're fin d in g .
■ W h e re does sup and d e e p pero n e a l nerve sup p ly
■ W h y is g a it a ffe c te d ?
■ H o w w ill yo u proceed - NCS, D uplex to ru le o u t DVT
■ T re a tm e n t o p t io n -

Bell - p e rfo rm e d p o o rly - D id n 't assess g a it, and c ould n o t assess s ensa tion p ro p e rly as p a tie n t d id n 't
a c t o u t re le v a n t fin d in g .

5. S ta tio n 5

E xa m in a tio n - CVS - p a tie n t fo r OT

a) Finding
- Left In fra c la v ic u la r scar
- Left Lateral T h o ra c o to m y scar
- C ould n o t h e a r any c le ar m u rm u r
6 m in Up - c ould n o t assess Lung fie ld s and sacral edem a
b) Q uestions
- Finding su m m a ry
- W h a t does In fra c la v ic u la r scar in d ic a te - Pacem aker
- W h a t d o yo u lo ok fo r in h e a rt fa ilu re - pedal ede m a, sacral ede m a, JVP and p u lm o n a ry crepts.
- Show ed th e ECG - w h a t do yo u see - Pacem aker Spikes, W h a t else - irre g u la r HR...??
- W h a t p re c a u tio n s do y o u ta k e w h ile p re p a rin g th is p a tie n t fo r OT?
- W h e th e r needs su rg e ry n o w - No.
- W h ic h c a u te ry t o use and w h y n o t m o n o p o la r, If m o n a p o la r used - w h a t p recautio ns.
- W h o m w ill yo u in v o lv e in th e care o f th is p a tie n t?

6. S ta tio n 6

Post th ig h A n a to m y

a) Scaitic N erve - id e n tific a tio n , ro o t values, a n a to m y , va ria tio n s .

b) Lan dm a rk o f scia tic N
c) T re n d e le n b u rg te s t - w h ic h m uscles te s te d , th e n erve supply.
d) Causes o f p o s itiv e tre n d e le n b u rg te s t
e) Id e n tify h a m s trin g - action s, ne rve supply.
 f) C o n te n t o f p o p lite a l fossa
g) P a thology fro m each o n e o f th e m

7. S ta tio n 7

E xa m ination - M N G in e u th y ro id s ta te

a) Do re le v a n t e x a m in a tio n - D o n 't fo rg e t eye signs

b) T h y ro id p h y s io lo g y -T R h t o T3
c) H o w th y ro id h o rm o n e a ffe c t cells, fu c tio n o f th y ro id h o rm o n e
d) In v e s tig a tio n s - Fnac fin d in g , USG fin d in g in M NG vs Ca
e) T h y ro id scan
f) W h a t su rg e ry yo u p ro p o s e and w h y ?
g) If she com es w ith d iffic u lty in re s p ira tio n a fte r 3 m o n th s ? - Tracheo m alacia

Bell w e n t o ff

8. S ta tio n 8

C ranial A n a to m y s ta tio n

a) P o in t o u t p te rio n , bones fo rm in g , Im p o rta n c e ?

b) R o tu n d u m and s tru c tu re th ro u g h it.
c) Lacerum and s tru c tu re th ro u g h it.
d) Clivis fo rm e d by w h ic h bone
e) C a lcifica tio n b tw tw o plate s o f skull??? D ip lo p ic veins?
f) X ray - p o in t o f p itu ita ry fossa, sp h e n o id sinus.
g) X ray p o in t o u t la m b d o id su tu re

9. S ta tio n 9

P a thology - secon dary p a ra th y ro id is m in p a tie n t w ith ADPKD

a) W h a t is fu n c tio n o f p a ra th y ro id
b) H o w does it re g u la te Ca?
c) Ca level in sec hyperPTH?
d) Renal stones c o m p lic a tio n in pelvis?
e) Types o f carc in o m a in renal tra c t - cause
f) W h a t cells PTH acts on in th e bon e and w h e re does it act in renal tu b u le ?
g) ??? co u ld n o t re c o lle c t
10. S ta tio n 10

P roced ure - l& D

The y ju s t w a tc h w h a t y o u do - check conse nt, speak to p a tie n t a b o u t p ro c e d u re , a lle rg y to m e d ic a tio n .

LA to be used, check date, m a in ta in s te rility , w h a t in s tru m e n ts yo u pick, h o w y o u p u t on gloves, incision
d ire c tio n , c o m p le te re m o va l o f abscess pou ch, ask fo r pus c u ltu re t o be c o lle c te d and fo rm to be ready,

Q ue s tio n s - la nger lines, d e f o f abscess, ty p e s o f dressing.

11. S ta tio n 11

H is to ry - M id d le age lady w ith d ia rrh e a - b lo o d in s to o l, jo in t p a in - C r o h n s - A ctor(a sk a b o u t previo us

tre a tm e n t h is to ry )

Q ue s tio n s - DD

a) H o w t o yo u evaluate.
b) Specific in v e s tig a tio n s
c) W h a t are e x tra in te s tin a l m a n ife s ta tio n o f IBD
d) C olono scopy fin d in g
e) B iopsy fin d in g
f) T re a tm e n t?
g) In d ic a tio n fo r surgery?

12. S ta tio n 12

P h y s io /C ritic a l care - Post o p pain m a n a g e m e n t

Screw ed up big tim e . Please read th e d ru g c h a rt p ro p e rly - see if th e m e d ic in e is app lic a b le fo r th e day.

a) Types o f pain assessm ent scales - VAS, NRS,

b) Check tre a tm e n t c h a rt - Check c h a rt cle a rly - m e d ic a tio n m ay be w r itte n b u t it m ay n o t be
app lic a b le fo r th e day he is asking
c) A c tio n o f c y d iz in e
d) W h e th e r NSAIDS given if p a tie n t on LM W H ?
e) M o rp h in e - Dosage, side e ffe c ts , com p lic a tio n s ?

Bell w e n t o f f - e x a m in e r w as d e m e a n in g and s a r c a s tic - c a n p u t yo u o fftra c k .

13. S ta tio n 13

Long te rm s te ro id

a) Layers o f adre n a l and th e h o rm o n e s

b) CRH-ACTH-Cortisol Axis
c) A c tio n o f a ld o s te ro n e
d) P athw ay
e) Effects o f s te ro id - m e ta b o lic , glycem ic, w o u n d hea lin g, im m u n o s u p p re s s io n , bone, etc
f) Should s te ro id s be alw ays repla ced w ith IV steroids???? D id n 't g e t w h a t he w as asking
g) S ym ptom s o f p a tie n t on lo n g te rm s te ro id s - eyelashes, face, hum ps, c e n tra l obs, etc
h) S teroid h o rm o n e e ffe c t on Carbs, p ro te in s and fa ts

14. S ta tio n 14

E xa m ination - M u ltip le Lipom a.

a) Ask th e p a tie n t to undress his to rs o - Exposure

b) Exam o f lipom a
c) DD
d) P athology, causes
e) T re a tm e n t
f) Liposarcom a chances

15. S ta tio n 15

C ritical care - Post H e m im a n id u le c to m y fe e d in g

a) Types o f fe e d in g -N G /N J ... etc

b) C o m p lic a tio n s o f each - ea rly and late
c) W h a t is c o n s titu e n ts o f e n te ra l fe e d in g
d) H o w to asses NG in stom a ch
e) If yo u a s p ira te NG - Ph is 7 - w h a t is cause?????
f) A c tio n s o f gastric acid

16. S ta tio n 16

P a thology - Post a p p e n d e c to m y C arcinoid

1. W h e n is a p p e n d e c to m y s u ffic ie n t?
2. If n o t - w h a t o th e r surgery re q u ire d
3. W h a t is c a rc in o id s y n d ro m e - cell o f o rig in , fe a tu re s
4. D iagno stic te s t
5. Post 5 days a n tib io tic - d ia rrh e a - cause - DD
6. N am e organism - Cl. D ifficale
7. Diagnosis o f Cl. D iff - c y to to x in and c o lonoscopy
8. W h a t are tw o th in g s y o u do to p a tie n t o th e r th a n tre a tm e n t? ? ? ? D id n 't g e t th e q u e s tio n
 MRCS OSCE Y angon 2 0 1 9 Jan 9, Day 1, A fternoon

K now ledge

1. A natom y - T rian gles o f the neck

2. A natom y - Ankle d issectio n + Tibia Fibula Ankle F oot bo n es
3. A natom y - P o sterio r m ed iastin um esp. oeso p h agu s

4. Pathology - N asoph aryn geal carcinom a

5. P athology - Diverticulitis an d en d om etriosis
6. P athology - O bstructive jau ndice
7. Critical Care - Burn an d ARDS
8. Critical Care - N utrition in p atien t with im m ediate p ost-op w ith trach eostom y

Skills

Physical exam ination

9. V aricose vein
10. Scrotal lum p (H ydrocoele)
11. CVS a sse ssm e n t (P acem aker]
12. H earing lo ss (+ 0 to sc o p e )

13. H istory takin g o f Knee Pain (H /O knee su rgery for sp o rts injury]
14. H istory takin g o f Patient req u estin g for I&D o f groin a b sc e ss

15. Inform ation giving - Inform ing CS for self-discharge re q u e st

16. Inform ation giving - A nxious p atien t concerning an ticoagulation for MVR

17. Procedural skill - Suturing lacerated w ound

18. Procedural skill - I&D of thigh a b sc e ss
c) A c tio n o f a ld o s te ro n e
d) P athw ay
e) Effects o f s te ro id - m e ta b o lic , glycem ic, w o u n d hea lin g, im m u n o s u p p re s s io n , bone, etc
f) Should s te ro id s be alw ays repla ced w ith IV steroids???? D id n 't g e t w h a t he w as asking
g) S ym ptom s o f p a tie n t on lo n g te rm s te ro id s - eyelashes, face, hum ps, c e n tra l obs, etc
h) S teroid h o rm o n e e ffe c t on Carbs, p ro te in s and fa ts

14. S ta tio n 14

E xa m ination - M u ltip le Lipom a.

a) Ask th e p a tie n t to undress his to rs o - Exposure

b) Exam o f lipom a
c) DD
d) P athology, causes
e) T re a tm e n t
f) Liposarcom a chances

15. S ta tio n 15

C ritical care - Post H e m im a n id u le c to m y fe e d in g

a) Types o f fe e d in g -N G /N J ... etc

b) C o m p lic a tio n s o f each - ea rly and late
c) W h a t is c o n s titu e n ts o f e n te ra l fe e d in g
d) H o w to asses NG in stom a ch
e) If yo u a s p ira te NG - Ph is 7 - w h a t is cause?????
f) A c tio n s o f gastric acid

16. S ta tio n 16

P a thology - Post a p p e n d e c to m y C arcinoid

1. W h e n is a p p e n d e c to m y s u ffic ie n t?
2. If n o t - w h a t o th e r surgery re q u ire d
3. W h a t is c a rc in o id s y n d ro m e - cell o f o rig in , fe a tu re s
4. D iagno stic te s t
5. Post 5 days a n tib io tic - d ia rrh e a - cause - DD
6. N am e organism - Cl. D ifficale
7. Diagnosis o f Cl. D iff - c y to to x in and c o lonoscopy
8. W h a t are tw o th in g s y o u do to p a tie n t o th e r th a n tre a tm e n t? ? ? ? D id n 't g e t th e q u e s tio n
5. Pathology - Diverticulitis an d en d om etriosis
- Lining 2 lay ers o f colon? C olum nar cell lay er and ???
- D iverticular d isease, diverticulitis, en d om etriosis
- O perated and tissu e sam p le sh ow s n eu troph ils - w h at d o es th at m ean ? How
n eu troph ils arriv e h ere? N eutrophil life sp an
- W hat is a b sc e ss?
- How to m an age in tra-abdom in al collection?
- How d o es en d o m etrio sis occur?

6. Pathology - O bstructive jau ndice

- C lassify jaundice. C auses
- Show n the invx. including LFT. Dx. How to classify OJ & cau se s
- Bile production p e r day, com position, how bile em ulsify fats?, actions
- Why no u robilinogen in urine?
- E nteroh epatic circulation, w hy bile sa lts recycled?
- How clotting is im paired in OJ - K -dependent CFs., Liver function im paired

7. Critical Care - Burn an d ARDS

- TBSA shaded. C alculate bu rnt area. Likely 63 % by rule o f nines. Not to take
accou nt o f perin eal burn.
- Type o f burn. Depth.
- Only n asal burn (I think) m entioned in scen ario. Airw ay m anagem ent. Will you
do ETT? Why? W hat oth er featu re s to look for?
- Fluid m an agem en t - in terru pted after d escrib in g Parklan d form u la and division
over first 8 hr and next 16 hr. No n eed to calculate. Type o f fluid.
- CXR - ARDS, F eatu res o f ARDS, How to rule ou t card iac cau se ?
- Mx. Type o f ventilation. PEEP m ode.

8. Critical Care - N utrition in p atien t with im m ediate p ost-op w ith trach eostom y
- p ro b le m s w ith trach eostom y?
- ty p es o f nutrition, enteral Vs. paren teral, w h at type for this patien t
- Indication for paten teral
- How to confirm NG tu b e is in sto m ach ? CXR show n and tu b e in Rt low er lungs -
how to do?, Again an oth er CXR w ith tu be u n d er left dom e o f d iaph ragm - correct
position. NG Vs. NJ.
- C om ponents o f nutrition.
- If NG feeding, p ro b le m s o f m alabsorption . H ow to a s s e s s the problem ?
K n o w le d g e

1. A natom y - T rian gles o f the neck

- B ou n daries o f p o ste rio r triangle
- Identify - Spinal a cc esso ry nerve, how to te st its action
- O m ohyoid b ellies and nerve su pply
- M uscles attach ed to hyoid bo n es and nerve su pply
- E xtrinsic ton gu e m u scles and are th eir nerve su p p lies
- Identify - su b m an d ib u lar gland, secretion type, n erv es at risk o f d am age during
su rgery , how to te st h yp oglossal nerve action
- histological im age o f a lym ph node with brow n sp o ts in cytoplasm o f so m e cells.
Frankly I don't know w h at it is. W hat do you think ab o u t the histology?

2. A natom y - Ankle d issectio n + Tibia Fibula Ankle F oot bo n es

- Identify all foot bones.
- A rticulate tibia, fibula an d ankle joint
- Ligam ents o f ankle
- D em on strated ankle join t m ovem ent on m y self
- Inversion and eversion - m u scles involved
- B on es are involved in arch es o f foot?
- join t betw een d istal tibia and fibula - type. W hat injury occu rs if it d isru p ts?
- M ajor p u lses in foot and how to p u lsate them
- A rterial arch es o f foot
- Identify ten d on s in an te rio r of ankle joint

3. A natom y - P o sterio r m ediastin um esp. oeso p h agu s

- B ou n daries
- O esoph agu s - su rface m arkings, epithelium , arterial supply, ven ous drainage,
lym ph node drain age, ach alasia, B arre tt's o esop h agu s, through which p art o f the
diaph ragm d o es it exit the thorax.

4. Pathology - N asoph aryn geal carcinom a

- M iddle ag ed C hinese m ale w ith ulcer in n asoph arynx, recently Chem o + RT
taken. DM +
- Risk factors for n aso ph ary n geal carcin om a
- Define Carcinom a
- DDx.
- Other non-epithelial tu m ou rs
- If p alp ab le lym ph node, how to a sse ss, Cytology Vs. H istology
- Scale of Radiation d o se
- If sw ab g ro w s hyphae, w h at is it? M ost com m on fungal sp ecies. R isk factors.
Skills

Physical exam ination

9. V aricose vein
- M iddle ag ed lady. Problem is th at the long pan ts is not to be taken off and
difficulty in ex p osin g groin. T ournique w as broken in som e late can d idates.
Hand-held d o p p ler provided.
- Dx., P oints for Dx., T reatm en t options.

10. Scrotal lum p (H ydrocoele)

- P ipes and torch provided.
- DDx., T y pes o f hydrocoele. W hat type for him ?
- T y pes o f surgery.
- If the patien t is 20 y r old, will you do Jabouley?

11. CVS a sse ssm e n t (P acem aker)

- Pre-op a sse ssm e n t. Recently im planted pacem aker.
- ECG show n
- Indication for pacem ak er
- P roblem s with diath erm y
- W hat co m plications in this patien t? How to a s s e s s this?

12. H earing lo ss (Tuning fork +O toscope)

- H/O drinking, head injury and h earin g loss.
- Show how to handle otoscope, pull ear, Picture o f oto sco p y given.
- Dx., C auses, Type o f hearing loss. Treatm ent.
- Does haem otym panu m h as good p ro gn o sis?

13. H istory takin g o f Knee Pain (H /O knee su rgery for sp o rts injury)
- P oints for Dx., T reatm en t

14. H istory takin g o f Patient requ estin g for I&D o f groin a b sc e ss

- ODD station, patien t said to be referred by GP to I&D at hospital, b y p assed
Em ergency an d arrived at su rgical dept., requ estin g for I&D im m ediately.
- Took h istory o f a b sc e ss an d he said he is reg istered drug user. He m entioned it
looks like pulsating. A sked w hat can it be?
- E xplained it can be a pseud oan eu ry sm .
- Inform ation giving ab o u t the condition and calm ed dow n patien t. Risks.
- W hat is p se u d o an eu ry sm ? Can you do I&D. C om plications. Risks. Rx.

15. Inform ation giving - Inform ing CS for self-disch arge re q u e st

- P ost o f m astectom y pt. p e rsu a d e d by d au gh ter to go hom e in stead of d yspnoea,
puffy axilla and in c reased drain. R e gistrar coun selled and pt. still refu sed to stay.
- Issu e s - pt. capacity to decide, d yspnoea, in creased drain, com m ents on current
condition, invx., Rx., plan after goin g hom e, GP contact.
- W hat p ro b le m s w ith goin g hom e?
5. Pathology - Diverticulitis an d en d om etriosis
- Lining 2 lay ers o f colon? C olum nar cell lay er and ???
- D iverticular d isease, diverticulitis, en d om etriosis
- O perated and tissu e sam p le sh ow s n eu troph ils - w h at d o es th at m ean ? How
n eu troph ils arriv e h ere? N eutrophil life sp an
- W hat is a b sc e ss?
- How to m an age in tra-abdom in al collection?
- How d o es en d o m etrio sis occur?

6. Pathology - O bstructive jau ndice

- C lassify jaundice. C auses
- Show n the invx. including LFT. Dx. How to classify OJ & cau se s
- Bile production p e r day, com position, how bile em ulsify fats?, actions
- Why no u robilinogen in urine?
- E nteroh epatic circulation, w hy bile sa lts recycled?
- How clotting is im paired in OJ - K -dependent CFs., Liver function im paired

7. Critical Care - Burn an d ARDS

- TBSA shaded. C alculate bu rnt area. Likely 63 % by rule o f nines. Not to take
accou nt o f perin eal burn.
- Type o f burn. Depth.
- Only n asal burn (I think) m entioned in scen ario. Airw ay m anagem ent. Will you
do ETT? Why? W hat oth er featu re s to look for?
- Fluid m an agem en t - in terru pted after d escrib in g Parklan d form u la and division
over first 8 hr and next 16 hr. No n eed to calculate. Type o f fluid.
- CXR - ARDS, F eatu res o f ARDS, How to rule ou t card iac cau se ?
- Mx. Type o f ventilation. PEEP m ode.

8. Critical Care - N utrition in p atien t with im m ediate p ost-op w ith trach eostom y
- p ro b le m s w ith trach eostom y?
- ty p es o f nutrition, enteral Vs. paren teral, w h at type for this patien t
- Indication for paten teral
- How to confirm NG tu b e is in sto m ach ? CXR show n and tu b e in Rt low er lungs -
how to do?, Again an oth er CXR w ith tu be u n d er left dom e o f d iaph ragm - correct
position. NG Vs. NJ.
- C om ponents o f nutrition.
- If NG feeding, p ro b le m s o f m alabsorption . H ow to a s s e s s the problem ?
16. Inform ation giving - A nxious p atien t concerning an ticoagulation for MVR
- Blind, MVR, recu rren t h ernia for rep air
- Why w arfarin taking, w hen to stop, w hy to stop, how to m anage, how it is safe
to chan ge to heparin, SE s o f heparin, a sk concerns.

17. Procedural skill - Suturing lacerated w ound

- Suturing on foam . N on -ab sorb able sim ple interrupted. A lready clean ed &
drap ed . LA given. Ju st to talk, ch oo se su tu re, glove an d su tu re. N urse will d ress.
- T e st LA, n u m ber o f stitch es, sc a r form ation, m edication after procedu re.

18. P rocedu ral skill - l&D o f thigh a b sc e ss

- Rush station. R equ est X-ray. Distal n eu ro v ascu lar statu s. C onsent form check.
- P rep are tray, culture cotton bu ds, calculate LA dose. Clean, d rap e and LA inject.
- N eed to p u t blade on handle by forceps.
- Difficult to e x p re ss ou t all the fluid. It cam e ou t again an d again. B reak septa.
- D ispose sh arp s. O thers a s usual.

P ersonal E xperiences

• N ew q u estio n s every y ear

• O verlapping statio n s like history +exam in ation o r h istory+com m u n ication skills
• E xam ination - patien ts so m e tim es n ot ap p e a r a s in practice before, not to panic,
check all the p ro p s given
• P rocedural skills - sc en ario s and se ttin g s m ay vary. M ay need to only do the
op eration or do all the pre- and post- proced u res.
• Inform ation takin g - alw ay s a sk C oncerns an d solve.
• C om m unication sk ills - sh ow em path y and act accordingly.
• Practice, P ractice & Practice
• F or skill statio n s - never m iss the ste p s and outline. P rep are for 3 m in qu estio n s.
MRCS Part B Exam Glasgow - Valentine's day ^

1. A n a to m y o f th e M id d le ear
- Borders and bou n d a rie s
- N erve passing th ro u g h it
- Spread t o th e brain
- M a s to id c a v ity kn o w n as
- Location on th e skull on a s u p e rio r v ie w
- Foram en R o tu n d u m /s p in o s u m /S O F
- C avernous sinus b o u n d a rie s and c o n te n ts
- C avernous sinus th ro m b o s is
- P apillode m a and cause and sig nifican ce in raised ICP
2. X ray o f th e cervical spine
- Ligam ents a tta c h e d a t th e dens
- Key fe a tu re s
- Typical and a typica l C ervical v e rte b ra
- H yoid bone
- Features on a la te ra l v ie w o f a cervical X ray
- C3 / C6 levels and s tru c tu re s
3. A n a to m y o f th e neck and th o ra x
- N erve la te ra l to tra c h e a - RLN/ Phrenic ?
- Features?
- N erve a t th e c a ro tid b ifu rc a tio n
- W h a t if u tie th e facial a rte ry ?
- Some basic q u e s tio n s on tra c h e a and oesophagus
4. C o m m u n ic a tio n - Call a cons on call a b o u t a p a tie n t p o s t m a s te c to m y and b lo o d in d ra in w hose
d a u g h te r w a n ts to ta k e ho m e and discuss plan o f a c tio n . Go th ro u g h th e n o te s and discuss th e
plan fo r th e same.
5. A n xious p a tie n t w ith o ld M itra l valve re p a ir on w a rfa rin and due f o r a hernia re p a ir w a n ts to
k n o w if he s h ou ld s to p w a rfa rin and if so h o w . A lso d o e s n 't w a n t t o ta k e in je c tio n s and have to
counsel him . Post op m a n a g e m e n t scenario to be explain ed to him
6. Knee pain h is to ry ta k in g . Had a h is to ry o f old in ju ry to th e knee and som e su rg e ry several years
ago. O s te o a rth ritis knee.
7. A b d o m e n e x a m in a tio n fo r RIF pain
8. T h y ro id e x a m in a tio n - lu m p in th e neck and q u e s tio n s re gardin g th e diagnosis and m a n a g e m e n t
9. Knee jo in t e x a m in a tio n - acute tra u m a , v e ry te n d e r knee, b a re ly m o v in g it o r a llo w in g to .
C o u ld n 't stand o r m ove his knees. V e ry te n d e r on m e dia l side. C ould b a re ly d o any e x a m in a tio n
and som e q u e s tio n s on possible causes and m anage m ent.
10. CVS e x a m in a tio n w ith ESM (M R ) and que s tio n s on th a t
- Asked if he has H e art fa ilu re . I said I d id n 't fin d any basal c repts
- Q uestions on ph ysio lo g y o f it
- Is due fo r su rg e ry in a w e e k and has to go on a cruise in a m o n th . Advise on th e same
11. Shock s ta tio n w ith tib ia and fe m u r fra c tu re and basic q ue stions
 - Some que s tio n s w e re dodgy
- A b d o m in a l c o m p a rtm e n t s y n d ro m e and fe a tu re s
- N a rro w M AP and cause fo r it ?
12. GOO s ta tio n and discussion on causes o f it and th e va rio u s bioch e m ic a l a b n o rm a litie s
13. A o rtic Stenosis w ith ECG given. Q ues tio n s on th e p a th o p h y s io lo g y o f th e sam e.
14. Gall sto n e p a n c re a titis a fte r an o ld c h o le c y s te c to m y and m a n a g e m e n t que stions.
- Splenic a rte ry aneurysm
- Pseudocyst
- Lab te s ts and causes
15. K not ty in g - s ta n d a rd k n o t, d e e p k n o t and Z k n o t
16. Abscess drain age and q u e s tio n s on LA dosing
17. Knee pain since 2 days. O ld h is to ry o f im p la n t fo r u p p e r tib ia fra c tu re . Septic a rth ritis and
o s te o m y e litis o f th e bon e que s tio n s
18. D iarroh ea h is to ry ta k in g and que s tio n s re la te d to th a t.

W h e re I s trug gled -

1. C o m p le tin g m y exa m in a tio n s . Learn to tim e y o u rs e lf b e tte r th a n I did

2. Read up on th e head and neck a n a to m y w e ll
3. Practice k n o t ty in g
4. A n s w e r to th e p o in t
5. H o w yo u do a t a s ta tio n also d ep ends on th e e x a m in e r's a ttitu d e on th a t s ta tio n , e spe cially th e
ones in v o lv in g VIVA qu e s tio n s . Some are c o rd ia l and g e n u in e ly t r y and help and g u id e you if you
dev ia te . A c o u p le w e re iffy , o f w h ic h o n e w as d o w n rig h t unp le a s a n t even. D o n 't b o th e r m uch
a b o u t th e m as th e y are like th a t to a lm o s t e v e ry o n e in th e exam gen era lly.
Stations

1. Preparation for next station - read through notes o f gent w ho has m alignant
cells in his peritoneal fluid. W ife is apparently angry as she has not been
spoken to. A lso CT scanner is broken so would need to be transferred away
(nearest hospital with working CT is 2 hour away) fo r staging scan
2. REPEAT C om m unication station using notes from before. Basically tell her
it’s m alignant but she was aware it is cancer. Not angry, m ainly upset.
Surprisingly easy station. Just stay calm and say we d on’t know w here the
cancer has com e from . Relative was very easy to talk to once you were
honest and apologetic
3. REPEAT A natom y station - neck - triangles, contents, identify im portant
nerves and vessels
4. REPEAT - pathology station. Given blood gases and blood results. Take 2
m ins to read them as they are dated as well. Then a com plete repeat
station on gastric outlet obstruction and causes for electrolyte disturbances
and paradoxical aciduria.
5. NEW - history station, patient with headache and m eningism but no fever.
M ention SAH In DDx and don't exclude m eningitis. D iscussion on
m anagem ent and investigations
6. REPEAT - pathology station. Given report on patient w ith lesion on face,
found to be squam ous cell cancer. D iscussion on investigations and
m anagem ent, including staging and grading. Then given report on same
patient with neck swelling stating no evidence o f carcinom a but had cells
with owl eye appearance. Said HL is a possibility and exam iner happy
7. REPEAT - anatom y station, base o f skull and foram ina above and below
8. REPEAT - skills station - I&D. A ssistant v unhelpful but got through it. Didn't
finish but discussed w hat I would do to finish. And discussion on LA doses
9. REPEAT - anatom y station, fem oral triangle and contents, borders. W hat
runs through the adductor canal and boundaries (also asked for nerve to
vastus as one o f the content- alm ost forgot but said as bell rang). Also
angiogram o f low er lim b vessels and told to identify
10. NEW - pathology station - weird station on pancreatitis. Asked som e weird
qs on pancreatitis, patient had gallbladder rem oved a few m onths(?) ago
and developed pain. Causes, investigation and m anagem ent. W as quite a
strange exam iner and all o f us on that circuit com plained about this
exam iner afterw ards
11. N EW (?) - m anagem ent o f traum a case. Given CXR (small pneum othorax)
and ATLS principles tested in full
12. REPEAT - com m unication station. Discuss with consultant about patient
w ho wants to self discharge post m astectom y and loads o f blood on drain
and things I w ould do to m itigate risk if he does - m ention contact other
hospital A&E and other surgical team
13. REPEAT - exam ination o f abdom en - non critical so sim ple abdo exam in
fem ale patient young. M ention UPT for investigations am ongst the usual
things. O ffer appendicitis, ectopic etc. Barn door
14. NEW - exam ination station - strange station with spiel saying patient has
clarification pain but ABPI done by GP w as norm al. I did lower limb and
spine exam focussed as inside there was equipm ent fo r a neuro exam. I
also felt the pulses and noted patient had lost hair. Make sure to say I can’t
 rule out vascular disease. Spinal claudication also offered as diagnosis and
exam iners seem ed ok
15. REPEAT - exam ination station - this w as a repeat o f the post varicose vein
stripping foot drop station that is prevalent in the past stations. Do a lower
lim b exam and gait and find the drop
16. REPEAT - exam ination station - ALS /C C R ISP exam . Look at patient notes
before starting because the exam iner tells you to. He was quite arsey but
once you picked up and do your A-E he calm s down a bit. Patient was very
unhelpful Imao. He w as septic post left hemi I think. O ffer anastom otic leak
for yo u r differential fo r the exam iner to chill out a bit
17. REPEAT - suturing and discussion o f dosage o f LA
18. REPEAT - history station. Im potence from last year. T hrew a few people off
last year but having revised this, was a sim ple history. Ask vascular,
neurological, urological and psychological qs and drug history too. Turns
out patient has been stressed at w ork and w ife does not have tim e for him
either.

Reflection:

It’s a fa ir exam. O nly one o f m y exam iners w as weird, everyone else was quite good
at ju s t m oving on or going back to questions I d id n ’t get.

I spent 7 w eeks solidly revising for this exam, about 3-4 hours each evening and
w eekends were lost revising too so even with this little tim e it is possible. I am an F2
so I w as expecting to score higher in knowledge and low er in skills which is exactly
w hat happened.

In histories, always ICE!! T hey love it

The past resource is your best friend in the last 1-2 w eeks o f revision. As you can
see, there are soooooo m any repeats or derivations o f past stations. G et a friend to
revise with you!!! It’s m uch better to know stuff in more detail because it’s useful for
the future; the exam in my opinion d id n ’t ask fo r much depth o f knowledge but more
breadth.

Thanks fo r m aintaining this resource. It is a gold mine and sorry that this is so late!

I sat the exam in London in February.

 MRCS England, Part B Exam inations
Kolkata, India - July, 2017

fFBT = finished before tim e (i.e. all questions attem pted)

J Bell = There m ay have been questions th a t w ere not asked

Clinical Knowledge

1. A natom y: neck
• Arch o f aorta - identify, branches
• Left vagus, Left recurrent, muscle it supplies
• Type o f fibres in vagus in the thorax - parasym pathetic
• Thyroid - parts, Blood supply, venous drainage, nerves a t risk, developm ent
• Thyroglossal cyst etiology
• Physiological problem w ith to ta l th yro id e cto m y - th y ro id horm one replacem ent and
calcium replacem ent
• Parathyroid - num ber, location, horm one produced, function
• Reason fo r hoarseness in bronchial mass
• Brachial plexus - id e n tify upper trunk, ro o t values, Erb's palsy, Klumpke's palsy
• U lnar nerve sensory te rrito ry
(FBT t )

2. A natom y: posterior thigh

• Sciatic nerve - identify, bony landmarks, Anatom ical variation o f its emergence, ro o t
values
• Gluteus medius - identify, nerve supply, function
• Trendelenburg test - describe, causes o f positive test
• Hamstrings -identify (exam iner kept confusing ST fo r short head o f biceps
fem oris??!!), origin, function at hip and knee, individual fu n ctio n o f SM/ST and BF
• Popliteal fossa - contents, structures at risk in # fem ur
• Popliteal nodes drainage
• Name 1 swelling arising fro m each structure in th e popliteal fossa
(FBT)

3. A natom y: Base o f skull (cadaveric section, axial view)

• Id e n tify te n to riu m Cerebelli, attachm ent
• Id e n tify o ptic nerve, ophthalm ic artery, p itu ita ry stalk
• How does optic nerve exit

• Oculomotor nerve - Identify, where does it arise from • midbrain, exits from, ocular
muscle supply, findings in third nerve palsy, what is 'false localizing sign', why pupil
dilates, why ptosis
• Artery that forms impression on inner table of skull - Middle meningeal artery
• Name of a high-grade glioma
• Layers inside skull, where is CSF found
• Lesion posterior to central sulcus, which bone to drill parietal
(FBT)

4. Pathology: Obstructive jaundice

• Patient chart shown - what type of jaundice (obstructive)
• Forms of bilirubin in blood - unconjugated and conjugated
• Why urine shows no urobilinogen - bilirubin cannot reach gut to form urobilinogen
• Bilirubin processing in gut - details
• How is urobilinogen absorbed and excreted - details
• Bile salts - function, enterohepatic circulation importance, from where bile salts are
absorbed - terminal ileum, what happens if there is deficiency - fat malabsorption
(steatorrhea), ADEK deficiency
• What are the fat-soluble vitamins
• Why coagulation is deranged here - Vit. K def
• How does Vit. K def cause coagulopathy, how to assess - PT. Measures what -
extrinsic pathway
• how to tr e a t- vit. K and FFP
• If patient has fever and pain - reason - cholangitis
• What ABX
• USG findings of biliary obstruction
• USG shows dilated biliary radicles. Then-co n firm with MRCP f/b ERCP
• Why ERCP- papillotomy and Dormia basket stone extraction
• 8efore that - stenting to relieve obstruction
(FBT)

5. Pathology: Parotid tumor

• Name commonest parotid tumor
• why is it called pleomorphic - variable components from epithelial, stroma, fibrous
tissue of gland
• Investigations in OPD - USG + FNAC
• What are FNAC f/o malignancy - increase nucleus: cytoplasm ratio,
hyperchromatism, increased mitosis, aneuploidy
• Difference between FNAC and core biopsy
• FNAC shows epitheloid cells with brown cytoplasm - Malignant melanoma

• FNAC shows lym phoid cells w ith pleom orphism - Lymphoma

• W hich stain to use to d iffe re n tia te b /w pleom orphic carcinoma and lym phom a -
Im m unohistochem istry
• f/o m alignant change in Pleom orphic adenoma
• d /d b /w sensitivity and specificity
• during FNAC assistant has needle prick in ju ry - w h a t to do
(FBT)

6. Critical care: TURP syndrome

• study chart and describe abnorm alities - hyponatrem ia, Low Creatinine
• Causes o f hyponatrem ia - h ig h /n o rm a l/lo w volum e
• W hat is TURP syndrom e
• W hy agitated, confusion
• W hy hypoxia
• W hat diuretics w ill you use -osm otic diuretics, w h y n ot loop diuretics - can
aggravate
• W here w ill you manage this p a tie n t - m inim um in HDU. W hy - intensive m onitoring,
organ support
(FBT)

7. Critical care: Iatrogenic pneumothorax following CVP line insertion

• CVP lin e -la n d m a rk s fo r insertion
• Recommended te c h n iq u e -U S guided
• H o w to insert
• How to m aintain s te rility before insertion - paint, drape, scrub up, sterile technique
• W hich position to rem ove CVP line and w h y - head dow n to avoid air em bolism
• Im m ediate com plications - pneum othorax, hem atom a, arrhythm ias, valvular injury
• Causes o f late CVP line infection - predisposing factors - DM, septic foci, local
wounds, (w anted more)
• Showed CXR - in itially w hat to look fo r - name, age, date taken
• How to approach and read CXR
• Findings - pneum othorax. W hat type and w hy - simple, no tracheal deviation
• Types o f pneum othorax
• How to assess breathing
(FBT)

8. Critical care: Polytrauma with multiple Us

• Stages o f # h e a lin g -d e ta ils
• How is calcium affected - not affected

• Osteoporosis - define, w hat happens to bone architecture - no change, in DEXA

scan, w ho do w e com pare findings to - com pare to sex and age m atched healthy
individual
• W hat happens to bone on im m obilization
• V irchow 's triad define. W hich factors are operating here
• Bone fixed w ith ORIF. Now discharge fro m wound - why, w hich organism
responsible - s. aureus and s. epidermidis
• W hy to rem ove plate - rem ove septic focus
• W hat is PVC staph - toxin produced by some stains o f staph
• W hat blood product w ill you transfuse, any WBC in PRBC - no
• Cross m atching - w hat is crossmatching, procedure- details
• W hat blood groups are tested
(FBT)

Clinical Skills

9. C om m unication (Phone to consultant): acute limb ischaemia fo r transfer to vascular

surgeon
• Lady presented w ith f/o diverticulitis, diarrhoea. Received tre a tm e n t. Since 1 hr,
developed f/o ALI w ith pale, pulseless lim b and acute pain. Hypertensive. Deranged
renal function, m etabolic acidosis, hypokalemia, ECG shows AF
SBAR fo rm a t - Introduce yourself, patient and reason fo r calling - yes
Can she move her limbs, opposite leg pulses - d o n 't know, w ill check and inform
Pulses absent - w hich ones - below fem oral all
Reason fo r hypokalemia - diarrhoea
W hat else does she have - M etabolic acidosis w ith partial respiratory com pensation
W hy m etabolic acidosis - maybe, ischemic colitis and not diverticulitis
Reason fo r ALI - acute em bolism
ECG findings - AF. W hy - irregular rhythm w ith absence o f P wave
W hy em bolism in AF - mural throm bus fo rm a tio n and em bolism
W hat else can be th e cause - Throm bo-em bolism fro m atherosclerotic plaque
If it was d /t atherosclerosis, w h a t w ould have been th e clinical picture - h /o
claudication
Can you transfer her to m o rro w - no, via b ility at risk
W hy deranged renal fu n ctio n -
How w ould you tre a t her - anticoagulants. W hich ones - LMWH o r UFH heparin
(BellJ)

10. C om m unication (p a tie n t): O T cancelled angry patient

• Post tra u m a tic meniscal injury fo r arthroscopic surgery. OT postponed 1 m onth ago.
N ow cancelled as consultant has to go fo r ER surgery. Job as postm an affected.
Introduce, confirm name - yes
'ICE' - yes
Offered pain-relief. Says has Gl issues (gas) d /t NSAIDS. O ffer PPI
Offered to speak to fam ily
O ffered to speak to jo b supervisor regarding delay
Offered to place him on p rio rity list
O ffered to try and fin d replacem ent surgeon/ have consultant slot him in another
hospital
• (Patient rem ained angry till th e end. Not able to calm him down)
(FBT)

11. Exam ination: Hand - Carpal tunnel syndrome

• Wash hands, Introduce, take permission, thank pt • yes
• Examine - yes
• Summarize - pain in median nerve te rrito ry , weakness o f opposition, failure to make
a fist, w eak 'OK sign', positive 'pen te st', no sensation a t index fingertip, fine m o to r
weak, Phalen's/Tinel's/D urkan's - all positive
• Causes o f CTS in this patient - pregnancy, hypothyroidism , RA, tu m o r
• Tests to do - X-ray, USG, CT/M Rl, EMG and NCV
• T re a tm e n t-NSAIDS, splint
(Bell)

12. Exam ination: C V S-p a ce m a ke r

Wash hands. Introduce, take permission, thank p t - yes
CVS e x a m in e -y e s
Summarize - clubbing, p ittin g edem a, R infraclavicular region pacemaker
W here is pacemaker usually located - infraclavicular region
P itting edema reason - RHF
Preop investigations fo r p atient - ECG, CXR, 2D Echo
W hy 2D echo - to assess v e ntricular function
ECG examine and com m ent - pacemaker spikes
D iatherm y precautions fo r pacemaker
Preop m edications - ABX
W hat else - anticoagulation
disadv o f pacemaker in elective surgery - arrhythm ias
Adv - ?

• Problems in ER surgery
(Bell)

13. Exam ination: Abdomen ■acute cholecystitis

• Wash hands, Introduce, take permission, thank p t - yes
• Examine abdom inal system and abdom en - yes
• Summarize positive findings - clubbing, RUQ pain, tenderness w ith +ve M urphy's
• W hat else w ill you examine fo r - groin, ext genitalia, DRE, lim bs fo r edema
• D /d - acute chole, hepatitis, PUD, Renal pathology. Pancreatitis
• How to d iffe re n tia te b /w acute chole and pancreatitis - serum amylase and lipase
• W hat investigations
(FBT)

14. Exam ination: Submandibular gland - sialolithiasis

Wash hands, Introduce, take permission, thank p t - yes
Sim ulated patient w ith no findings - examined
Summarize - d id n 't know w h a t to say. Examiner said a good sum m ary w ill be to say
- it was a norm al exam ination, and smiled
Summarize w h a t all you looked fo r - yes
Nerves associated and how to look fo r them
A natom y o f subm andibular gland
W here is opening o f W harton's duct
Based on scenario give diagnosis
Investigations - blood, US w ith FNAC
Anything to look fo r in face - Sjogren's. How - xerophthalm ia (Schirmer's test),
Xerostomia
Specific inv - sialography and X-ray.
W hat percentage o f stones are radiopaque -?
How to tre a t
If stone in distal duct, a fte r rem oval w hat w ill you do - M arsupialization
W hat is m arsupialization
How to avoid in ju ry to marginal m andibular nerve - incision 2 cm below m andibular
border
(FBT)

15. Procedure: sutures

• Wash hands, w ear g lo v e s -yes
• Hand tie on string w ith non-absorbable, braided
• Hand tie hook w ith absorbable braided
• Instrum ent 'fig u re o f 8' suture fo r bleeding p o in t w ith nonabsorbable m onofilam ent

• D iff b /w surgeon's and reef knot

• W hat o th e r knots can you place -?
• Advantage o f braided suture
• How long Vicryl m aintains tensile strength
• Problem associated w ith tying a t depth - avulsion o f structure
• How to avoid
• Vicryl chemical com position
• Prolene chemical com position
• W hy 'figu re o f 8' fo r bleeding p o in t
• Do you underrun o r overrun th e bleeding point - underrun
(FBT)

16. Procedure: OT listing

• arrange in order - (Repeat)
• W hy strangulated hernia first
• W hat type o f anesthesia - Regional
• D iatherm y patient plate electrode and cable photo - identify
• Precautions fo r pacemaker
• w here to place pad and why
• le ft colectom y - w here to site th e stom a, show on p atient and give reasons
• w h y through rectus muscle
• Preop m anagem ent o f insulin dependent DM
• W hy MRSA posted last
(FBT)

17. H istory: Diarrhoea fo r last 6-8 months

• Introduce, take perm ission, th a n k pt - Yes
• Take h is to ry -Yes
• Summarize - 3-6 tim es/day, blood tinged, no mucous, w t loss present, afebrile, no
fecal urgency, no stress factors
• In history, you asked fo r radiation exposure. M eaning -> CT scan
• d /d - IBD, CRC, infestation (amoebiasis)
• In v -b lo o d s , colonoscopy
• Anything before colonoscopy - sigmoidoscopy
• How w ill you dx on colonoscopy - colonoscopy w ith biopsy
• Others - stool fo r OCP, CT w ith oral contrast
• HPE f/o Crohn's - transm ural inflam m ation, patchy involvem ent, non-caseating
granulomas
• How w ill you tre a t Crohn's - steroids, sulfa-salazine
(Bell)

18. H istory: Cognitive assessment

• Introduce, take permission, thank pt - yes
. A M T S - 5-6/10
• Can she give inform ed co n se n t- n o
• W hat w ill you d o - p e r fo r m MMSE
• W hat else - if MMSE is deranged postpone Sx
• Thank you, you have finished. N ow w a it till the bell. W hat??!!!
• W e n t back to re ctify m y answer - if MMSE deranged, w ould assess fo r any organic
cause including bloods, CT brain, rule o u t infection, check m edications, rule o f
delirium
(FBT)

* * Best o f Luck**

Page 8 / 8
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Cairo, Egypt Day1, RCS ENGLAND, MARCH 2018

Cairo day one

clinical

1-L.L ischemia

2-submandiblar gland (actor)

3-inguinoscrotal

4-leaking anastomosis

communication

1-angry patient (Husbend need CT and its broke)

2-call ITU register fo r ITU consult and bed

history

1-back pain

2-acute epigastric pain

skills

1-abcess and give local anesthesia

2-suture

anatomy

1-skeleton (plastic assembled) questions on UL and LL land marks and muscle

2-skull foramina

3-thorax with qurstion mainly on esophgus

pathology

1-gall bladder ca+nicririzing fascitis

2-temporal artritis+M M + and osteoprosis

critical care

1-trauma case with x-ray of rib# liver lac

2-FRF with hyperkalemia

3-patient on steroids

Dr Yadnik Jadhav, with help from a willing friend who wished to be anonymous
 Cairo Day 2

Anatomy

1 .Posterior Cranial fossa

2.;5tomach and pancreas

3. Lumbar vertebrae

Pathology

1.BCC

2.Ulcerative colitis

Critical care

1. Nutrition

2.Burns

3. Jaundice

History

1. Thyroid status

2. Post op chest pain- PE

Examination

1. CVS

2. Cerebellum

3.Hip Examination

4. Lipoma on back

Procedures

1. Male catheterization
2.Knot tying.

Communications

1. OGD consent

2. Call CVTS consultant

Dr Yadnik Ja dh av, as provided by a helping friend who wished to remain anonymous.

Cairo Day 3 March 2018.

cc:

acute pancreatitis

usual questions. Diagnosis, what can you see in the CT (edema with pancreatic necrosis
obvious), management, which labs? (don't forget those of scoring system and ABG and lactate),

Dextrose 5% why not for resussetatcion?

then shifted to ARDS, what can you see in the xray, management.

hypothermia

what com plications of AAA repair (don't forget hemorrhage first then others)

what to give to decrease the need for blood transfusion (erythrobiotin, iron and rest)

hypocalcemia

serious com plication (laryngeal spasm)

pathology:

breast cancer

skin culture for MRSA before flap from where? Nose

Crohn's (bad picture of terminal ilium excised) what can you see in the picture? edema in the
wall., he wanted more things, I think inflam m ation and necrosis o f the appendix and obstruction.

anatomy

thorax

which part of brachial plexus between clavicle and subclavian artery, (picture showing nerves
below clavicle and above subclavian)
hand extensors!!

extensor mechanism, why in radial nerve injury there is weak grip (he wanted specifically the
synergistic work between extensors and flexors to strengthen the grip)

skull

where does parotid duct open (apparently opposite to 2nd mollar and vestibule wasn't the
answer!)

examination:

hernia

what other systems to examine? it's a tricky station in examination.

ear

Hemotympanum. asked h o w to hold otoscope, investigations to do.

critical limb ischemia

dd of popliteal fossa swellings

cvs

right vs left sided heart failure signs, what can you see in the ecg.

communication:

angry ct patient

will you do ct after the U/S? why to do it again? why not now.

will you do tapping now? insisting to do it before discussion with Mr mann! (apparently wanted
to hear that I'm gonna deal with it imidiately with an o2 mask or whatever)

why not to take him now to the other hospital which is 40 miles away to do the CT? you are
ignoring my husband?!

call oliguria

usual but be cautious of investigations and why to ask? he will insist on asking do you need me
to come now?

History:

impotence

past history BB, why BB cause ED (mechanism?)

knee pain

actor was vague about medications and I was asked specifically about doses despite I asked
the patient about them and he was like I take the recommended dose!!)

skills:

operative list

usual

knot tie

Questions subm itted by M 111.

 Hyderabad JAN 2018 Day 2

Note:B-bell rang, I thinksome questions may have been le ft

*:question or answers not present in our past year accounts so fa r

18 stations w ith almost 12 rest stations in between. A ll stations w ere repeat

Procedures

1)I and D

Straightforrw ard repeat station w ith an abcess on thigh,registrar gone fo r an emergency

surgery,asked you to do it.

Introduced , confirm ed identity, do not fo rg e t to confirm name on consent, ask fo r allergies.

Asked w eight o f patient, expiry date and conc. Of lignocaine,Gave local, asked fo r pain,
examiner asked maximum dose permissible.

Take h o rizo n ta l incision on th ig h (thosewho to o k lo n gitud inal got sm irked upon by

exam iner) , drain abcess, break loculations w ith finger, ask to take swab fo r C/S: examiner
acting as nurse said move on

Questions:

1. What are Langers lines

2. Why is to take incision along Langers lines

3. Common causative organism fo r abcess

4. Complications o f I & D: Looking fo r haemorrhage

5. How w ill you manage haemorrhage.

Bell rang

2)Suturing o f w ound

Repeat station

Patient w ith laceration on thigh, local given, explain procedure and suture wound.

Had to co lle ct own instruments.

Simple in terrupted sutures are okay

Questions:
1) What is the dose o f lignocaine th a t you w ill use , w ith and w ith o u t adrenaline (7mg/kg
w ith adrenaline, 3mg/kg w ith out)

2) Advantages and disadvantages ofusing lignocaine w ith and w ith o iu t adrenaline.*

3) Since I had explained possibility o f a scar earlier, asked me i f allyhe patients w ill
develop scar?

Toldhim about hypertrophic scar since i t ws a lacerated wound, there was a possibility,
which m ight increase i f there was infection

4) Asked sites fo r hypertrophic scarring: could only manage extensor surfaces

5) Asked predisposing factors and races fo r keloid form ation

Bell rang

Com m unications

3) Splenic hem atom a p a tie n t wants discharge

Station said convince him to stay in hospital, but aswe all know, he doesn’ t agree.

Tip is not to waste too much tim etrying to convince him, but get to other aspects like
explaining him symptoms o f rupture, to have company w h ile travelling fo r interview,
seeking medical help a t the nearest hospital and asking tosign a Medico legal
document.

Examiner doesn’ t u tte r a word during entire 9 minutes

4) Phone call to co n su ltant fo r Post op D1 hem i co lecto m y p a tie n t w ith no co­

m o rb id itie s w ith ost op o lig u ria . Inform on call consu ltant and ask fo r advice

Informed in SBAR form at.

A ll questions repeated from past year accounts

1. Why is he acidotic?

2. How w ill you manage? Fluid challenge.

3. Do you suspect leak? Do you suspect bleeding? The notes said abdomen was soft
and NT, but pulse and BP was deteriorating. Told him th a t w ill keep both in mind,
reasses and w ill inform him.
 4. Do you need me to come right now? When do you need me to come?

5. Where w ill you manage ? HDU. Why? Renal shutdown.

Lovely examiner, didn’ t trouble anyone a t all.

HISTORY

5.)54 year old m ale w ith h is to ry o f claudication. Smoker, hypertensive, diabetic,

claudication distance 50 yards a t present. M other and fa th e r died o f AMI

Q uestions:

1)What was claudication distance now and before (hadnt asked fo r before)

2) Is he diabetic

3)Is fa m ily history significant here? (yes)

4) A t w h at age did his m other and fa th e r die ? (60yrs and 70yrs . Patient had mentioned this in
history)*

5)How w ill you manage?

6) What w ill you examine?

Bell rang

6)AMTS: P atient scheduled fo r hip replacem ent found confused by w ard nurse. Assess his
m ental state and take consent.

Questions:

1. How w ill you manage? Refer to passmrcs confused p a tie nt or shaiilendra singh solved
com pilation.

2. What investigations w ill you do?

3. W ill you allow him to go fo r surgery? No, since score was 4

4. What would you do i f i t was an emergency surgery? Proceed w uth signature o f two
consultants

5. What is capacity?

Questions th a t others w ere asked

What is MMSE? Components o f MMSE?

 What tests would you ask him to do w ith a piece o f paper? Ask him to fold the
paper ,keep i t on floor. Asktodraw 2 intersecting pentagons.

Exam ination

7)Cranial nerve exam ination. W ell ta ilo re d station to f i t inside 6 m inutes. Not expected to
do sm ell,acuity, co lo u r vision, gag re fle x , corneal re fle x , ja w je rk . And 8th nerve

Patient had bitem poral hemianopia(simulated patient)

Questions:

1)Differentials: p itu ita ry adenoma, craniopharyngioma, meningioma, ACA aneurysm

2) Where is the lesion? Optic chiasma

3) What else w ill you look for? Signs o f hyperthyroidism , acromegaly, cushings and
Galactorrhea due to hyperprolactinem ia

4)What investigation? MRI and hormone assays

5) How w illyou manage? Surgery (transfrontal or transsphenoidal), manage endocrine

problems i f any, examiner looking fo r managekent o f raised ICP.

Bell rang

8) Spine exam ination w ith L4,L5 weakness

Simulated p atie nt w ith high stepping gait, tenderness over lower lumbar spine, painful
forw ard and lateral bending, positive SLRT, weakness in L4,5 Dermatome and Myotome

Questions:

1) D ifferentials: PID other: LCS, Infection,tum our inclding mets, vascular

2) What level PID do you suspect? L4-L5

3) What special investigations w ill you do? MRI, Bone scan

4) What blood investigations?

5) How w ill you manage him? Started w ith conservative non medical, medical and bell
rang

6) Questions th a t others got above this What surgery? Decompression w ith discectomy

7) What w illyou do i f he doesn’ t improve a fte r surgery?

9) A cute abdomen :sim ulated p a tie n t w ith tenderness, guarding , rig id ity in RIF, positive
Psoas and o b tu ra to r sign.

Questions:

1)What is your diagnosis? Said appendicitis and gave other causes o f acute abdomen as
differentials

2)What special investigations? USG, CT abdomen

3) Asked to in te rp re t vitals chart.Those working in India , go through OSCE by Bailey and love
book. There is a sim ilar chart, ju s t to get aquainted.

4)How w ill you manage? ABCDE, fb urgent surgery

5) What w ill you look fo r during surgery? Said inflam m ed appendix,mass. Bell rang

Questions th a t others got

What to look fo r during surgery? Above plus free fluid?

What w iil you do i f you find blood in pelvis during appendicectomy in a fem ale patient?

Call OB and Gyn,BT, Hematologist

10)Groin exam ination in an e ld e rly male w ith large hydrocoele.

Straightforward exam ination. Examined inguinal region and abdomen as w e ll( exam iner la te r
asked i f I fe lt any mass in abdomen)

Questions:

1) D ifferentials: Hydrocoele, epididym al cyst, testicular malignancy

2) Why not inguinal hernia? Said, possible to get above swelling, non reducible, no cough
impulse

3) How w ill you manage? Since i t was large, said Excision and eversion o f sac Jaboulays if
f i t fo r surgery.Others said he was looking fo r asoiration as w e ll i f u n fit fo r surgery

4) What w ill you do i f this was a 25 year old male? What w ill be your diagnosis?testicular
malignancy

5) Tell me more about testicular malignancy( could he be any more vague?)

Bell rang

Pathology
11)Polycystic kid ney disease

Stem saying a 25 year old malemunderwent bilateral nrphrectomy

Shown a photo inside w ith large kidney w ith m ultiple cysts and areas o f haemorrhage

1,W hat is the diagnosis?

2.Mode o f inheritance o f polycystic kidney disease. AD

3.W hat com plication ofpathology is not seen in this picture. Infection(maybe)

4.W hat com plications o f pathology can leadto pain? Haemorrhage, infection

5.W hat are pathological types o f transplant reactions?

6.Type o f matching required before transplant?HLA and ABO

7.Can a non perfectly matched kidney be transplanted? Yes

8.How to prevent transplant rejection? Immunosuppresion

9.Patient comes 6years a fte r transplant on immunosuppresion w ith decline in renal function.
Biopsy shows lym phocytic in filtra tio n w ith blast cells. W hat is the diagnosis? Lymphoma

10.Why is i t not rejection? Presence o f blast cells

11.How to tre a t Post transplant lym phoproiferative disorder?

Answer:Reduce immunosuppresion, chem otherapy and anti CD-20 antibody Rituximab

12.Causative fa cto r fo r PTLD Post transplant lym phoproiferative disorder? Oppurtunistic

infection w ith EBV and CMV

13.7 days A fte r transplant , p atie nt developed swelling a t the op site w ith declining
renalfunction. What do you think is happening? Acute rejection

12. Necrosis and gangrene.

78 y r old man w ith black discoloration o f g reat toe.

1 .What is the pathology? Gangrene

2.W hat are the types o f cell death? Necrosis and apoptosis

3. 4 differences between Necrosis and apoptosis.

4. Typesof gangrene.

5. 4 differences between w e t and dry gangrene

6. Post gangrene, surrounding area shoes redness. What is the pathological process?
inflam m ation leading to hypoxia and vaso dilatation (examiner wanted post hypoxia vaso
dilation. Gave i t to me a fte r a long spiel)

7. What are the pathologicalcells present in an atheroma? Foam cells (macrophages) and
lymphocytes

8. A part from Htn, Diabetes and male sex, w h at are the other 3 m ajor risk factors fo r
atherosclerosis?

Smoking, fam ily history, Age, Hyperlipidemia

9.Which size and type o f vessels are affected by atherosclerosis?

Large and medium size ARTERIES

10. Patient shows Xray w ith pleural plaques. W hat are pleural plaques?deposits o f collagen
and fibrosis , may or may not be calcified

11. Significance? Chronic asbestos exposure, incresed risk o f developing bronchogenic CA and
mesothelioma.

12. Simple bedside investigation to do to d etect broncgogenic CA? Sputum fo r cytology

Examiner was the Legendary Prof David Lowe (author o f surgical pathology book) , Said I was
the only one who got a perfect score th a t day.(I was 3rd last here)

C ritica l care

1 3.A o rtic Stenosis

Stem said p a tie n t posted fo r TURBT found tohave e je c tio n systolic m urm ur in pre op
assessment

1 .w hat is the diagnosis?AS

2.pathophysiology

3.Symptoms

4.Complications

5.Intraop com plications which can lead to death?

6.Anaesthetic considerations?

7.Pre op investigation to do? Lookig fo r 2D echo

8.Adv and disadv o f doing AS surgery firs t vis s vis doing cancer surgery firs t

9.A ntibiotic prophylaxisNICE guidelines i f p a tie nt w e n t AS valve replacem ent firs t fb Bladder
surgery.
Bell rang

14.Gastric outlet obstruction

Stem w ith p a tie n t having hypoK , hypo Cl Alkalosis a fte r prolonged non bilious vo m ittin g

1. Diagnosis? GOO

2. Causes? Benign vs m alignant

3. Explain abnornality. Why K is low? Loss in vomitus and action o f aldosterone(wanted

both)

4. Why is Chloride low? Loss o f acid. Why alkalosis? Loss o f H+, retention o f bicarb to
compensate fo r lost Cl-

5. Why hyponatremia? I said Na is lost as NaHCO3. He asked me i f i t is excreted as a

whole ion? Said no. He seemed to accept

6. Causes o f HypoNa. Said hypervolemic , euvolemic and hypovolemic

7. Asked how to corre ct this? I said Nacl w ith K supplementation

8. Who w ill you involve? Said Physician, intensivist and anesthesist. Accepted

9. When w ill this p a tie nt be f i t fo r surgery? A fte r correction o f hypo Na, Cl, K and
alkalosis

10. What is Chloride shift?

15. HPA axis suppresion.

P atient w ith RA on steroids posted fo r Hip replacem ent surgery

1 .w hat are the functional divisions o f adrenal gland? Cortex and medulla

2.Sub division o f cortex and th e ir hormones? Glomerulosa- M ineralocorticoid, fasciculata-

glucocorticoid, reticularis - sex steroids

3. Hormones o f m edulla. Adr and norad

4, Actions o f steroids? Long spiel system wise

5.Surgical com plications o f a p atie nt on steroids? Wanted pancreatitis and PUD along w ith SSI
and delayed wound healing along w ith others

6. Anaesthetic considerations o f the p t on steroidds? HypoK, Htn, Hyperglycemia/DM

7. Pt collapsed a fte r surgery, reason? Addisonian crisis.

8. How to prevent? Bridge therapy w ith IV Hydrocort. Asked to quote how dose o f hydrocort
according to m inor and m ajor surgery.

9. What is the maximum dose o f hydrocort you can give? I said 50mg qid. He said 200mg

10.Symptoms and signs o f addisonian crisis.

11. w h at w ill you te ll a p a tie nt taking steroids? Don’ t stop abruptly, steroid book/ m edicalert
bracelet

12. Who w ill you involve in her care? Wanted rheum atologist in addition to anaesthesist,
intensivist, endocrinologist and consultant.

ANATOMY.

16. MRI brain showing parasagittal m eningiom a . Google search parasagittal m eningioma.
Image was same

1 .What is the diagnosis? Above

2.W hat structures does i t lie between? Wanted Falx and cerebral hemisphere

3.Id corpus callosum and lateral ventricle.

4. Which layer o f meninges is meningioma attached to? Dura (ref Robbins pathology)

5. Shown Supsagittal sinus? What is this structure? Describe blood flo w from SSS to IJV

6.Describe location o f straight sinus. Tentorium cerebelli and fa lx ju nction( wanted th a t

specific answer)

7.W hat drains in to straight sinus? Great vein o f Galen

8.Show transverse sinus and sigmoid sinus on skull bone model

9.W hat blood is received in to dural venous sinuses? Said cerebral veins and diploic veins

10.Show parieto occipital sulcus( shitty image, even exam iner said so)

11. What area is located in pre central gyrus? Peimary m otor cortex

12. What area o f body is represented on medial side o f m otor area? Lower limbs

17.Pro Section showing stomach, pancreas , duodenum .

1 .Id this. Shown stomach.

2. Id parts o f stomach

3. Shown veseels o f coeliac axis. Describe blood supply o f stomach and shiow branches on the
image

4.Id pancreas

5.Describe development o f pancreas. Epithelial proliferation from duodenus,ventral and dorsal

pancreatic bud , asked me to stop

6. peritoneal relation o f pancreas. Except ta il,re s t is retro peritoneal

7.Blood supply o f pancreas. Supand in f pancreatico duodenal. Don’ t fo rg e t splenic artery

8. Describe the ductaldrainage system o f pancreas. Said m ajor duct drains p art o f head and
a llo f body and ta il opens a t m ajor duedenal papilla.M inor duct drains uncus and part o f head

9.Vessel present behind body o f pancreas? Splenic A

10. Space present behind pancreas. Lesser sac

11.vessel present behind neck? [portal vein

12. Peritoneal relations o f duodenum? Said except 1st cm o f 1st part, rest is retroperitoneal

13. Vessels present in fro n t and behind 3rd p art o f duodenum. In fro n t Sup mesentreric
vessels, behind in f mesenteric vein.

18. Back o f th ig h and g lute al region w ith re fle c te d G maximus

1.Id sciatic nerve

2. Root value- L4,5S123

3.2 points to surface m arkit in gluteal region: midway betn Gt and ischial tuberosity

4.Id G medius. Origin and insertion. N supply- sup gluteal nerve

5.Action o f g med during walking - prevents drooping o f pelvis on opposite side

6.Clinical te st i f G med is weak- Trendelenbergs test

7. other causes o f a positive Trendelenbergs test- divide in to fulcrum , lever and power

8. Name hamstring muscles

9.Actions o f hamstring muscles-flexion a t knee jt , weakextensors a t hip, med and la t rotation

in a semi flexed knee
10.Id Biceps, semi m , semi t

11. Structures in popliteal fossa

12. Which structure is a t risk in supracondylar fem ur fracture? Pop artery

13.Causes o f a swelling in popliteal fossa accoding to structure o f origin. Saif popliteal vein
thrombosis fo r vein, examiner w aits, I corrected to varicosity. Examiner says you should be
kicking yourself fo r that.

Hyderabad Day 1

1 .Leg muscles

2.pro section o f thorax , heart and abdomen

3.Parotid gland anatomy

4.Hpa axis suppresion

5. CA oesophagus. C om pletely new sta tio n , risk facto rs, TNM stage

6. Crush in ju ry w ith Rhabdomyolysis

7.Young fem ale gone to 3rd w orld country, TB and Lymphoma

9. Splenectomy child, anxious m other

10. Phone call to consultant. Post axillary clearance D2 p t wants discharge

11. History taking: AMTS

12.History : Female p t w ith diarrhea and

Mouth ulcers, IBD

13. Examination o f Hernia

14. POD 6 colectom y p t w ith generalised abdominal pain. CcrISp protocol

15. Exam ination o f AV fis tu la . Stem said p a tie n t had blue discoloration o f upper lim b ove r
night.

C om pletely new station

16.Ear exam ination. Post traum atic conductive deafness and hemotympanum

17. I & d
18. Suturing Lacerated wound

Dr Yadnik Jadhav

I would like to thank this site fo r helping me w ith the preparation. This is my little
contribution fo r the e ffo rt. Thank you.
 MRCS OSCE QUESTION

1. Communication-
• Barium swallow X ray shows benign stricture, counsel for OGD and dilatation.
(Alcohol/smoking history + bloods all screwed up Hb low, LDH high, bilirubin high.
counselling for ogd + biopsy + dilatation, counsel for likely blood transfusion, and advise
management of smoking/alcohol.

2. Pathology- lump in neck of woman who went Saudi arabia.

• 2 diagnoses
• What's granuloma? 3 causes of granuloma?
• What patho test for TB?
• What other organisms can cause?

3. Skills- IV drip station

• Fluid management
• Management of trauma patient

4. History taking- First seizure, turned out to be brain tumor management

5. Skills- Trauma patient motorcyclist hit by car. ATLS principle

(Got oropharyngeal airway, got c-collar apply).

6. Communication- Patient likely perforation of viscus, need pre-op advise from ICU reg and need
to book bed).
• Call on phone and speak to reg.
• damn sneaky he'll ask you to do invx/procedure for patient at the end, and just before you
put down, he'll ask you to repeat all the stuff he ask you to do, so better copy down
everything.

7. History taking- Patient here for pre op assessm ent for cholecystectomy. Has shortness of breath.
( just go through cardiac/respiratory, then ask stress or turned out to be anxiety
• Dx?
• Management

8. Pathology- show picture of colon with numerous polyps.

• What condition? FAP
• What behaviour/lifestyle modification will you advise his siblings?
• What kind of gene?
• What kind of expression?
• List 3 extra-intestinal manifestations of FAP?
• What is dysplasia? What is ulcer

9. Anatomy- stomach/pancreas
• Cardia/fundus/pyloric antrum
• Name blood supply of stomach and pancreas
• What are space behind stomach?
• Point where is pancreas, Show ducts of pancreas
• What is peritoneal relation of head/body/tail of pancreas?

1
 • What is peritoneal relation of l/2 /3 /4 t h part of duodenum?
• What substances are produced by tumours of islet cells? (Name 3 substances)
• What vessel goes anterior to 3rd part of duodenum and what vessels are posterior
• If you do whipples, what vessels do you encounter?

10. Anatomy- Neck region

• Name the triangles and borders
• Name anterior triangle and the 3 sub triangles
• What is this muscle- omohyoid- what is innervations?
• What are the external muscles of tongue- what are their innervations?
• Submandibular gland- what 3 nerves pass?
• What kind of secretion does submandibular gland produce
• Show ECA, what nerve passes just anterior to ECA?
• Show spinal accesory nerve, what msucles do they innervate?
• Some lymph nodes -&gt; what drains -&gt; exclue head and neck maligancy-&gt; list all the
possible malignancy. Shown photo of patho slide -&gt; apparently malignant melanoma!

11. Anatomy- Foot anatomy

• Shown bones of foot, name the arches and constituents.
• Fix tibia/fibula together with talas
• Which position is most stable?
• Deltoid ligaments of ankle
• Lateral collateral ligaments of ankle
• List all the tendons present on anterior foot
• Which muscles cause inversion?
• Where are the PTA and dorsalis pedis artery?

12. Critical care- Trapped in burning room

• Calculate total surface and fluids regiman
• Shown CXR -& gt; ARDS
• What is ARDS? Managment of ARDS

13. Clinical exam- Post op day 8. Now complain of right inferior chest pain -& gt; but pointed like
right hhc. so in the end, did respi, abdo, cvs but i knew most likely DVT AND PE. so last minute go
check limbs, painful left limb when squeezed
• DVT
• Management of PE

14. Clinical exam- Lump on arm (lipoma)

• Dx, D/D, Managment of lipoma

15. Clinical exam- supposed to come for some surgery but preop assesm ent felt leg cold. Do
arterial exam.
- Really Buerger'spositve 30 degrees, cannot feel any pulse except femoral, but Doppler Positive in
DP and popleteal artery bilaterally, negative in pt. I have to rush -&gt; not enough time, i just
managed to do brachial BP but not ankle BP.
• Managmenet of PVD

2
16. Clinical exam- Patient here for preop assesm ent for hernia repair but complaining of SOB.
Respiratory system exam?
• Really got signs- nicotine stains, and expiratory wheeze bilaterally.
• Will not recommend for hernia repair but patient adamant for surgery; how to manage? Use
open surgery, not laparoscopic because of CO2 pneumoperitoneum and COPD
• Use regional, spinal anesthesia but not GA.
• Preop care- chest physio, stop smoking, incentive spiro, anaesthetist consult, respiratory
medicine specialist.
• Postop care- early mobilization, chest physio, incentive spiro, manage in HDU.

17. Critical care: 2 scenarios

Post operative patient has SOB, CXR shows pneumothorax
• What kind of pneumothorax?
• Diagnosis- clinical, CXR
• Management- chest tube
• Examiner wants step by step how to do chest tube insertion, triangle of safety etc, why?
• Not trocar, blunt dissection with forceps and finger etc
• Suddenly worsening SOB, hypotension- tension pneumothorax
• What will you do now? Needle decompression

Can't remember 2nd scenario..................

18. Patho/critical care- Diverticular abscess, septic shock, metabolic acidosis.

• Management

3
 MRCS OSCE QUESTION

1. 2 Radiological Cases:
• A CXR of Lady who underwent bronchoscopy - Shows large left pneumothorax, Makes
mediastinal/tracheal deviation. No
1. What does the X-ray show? What system do you use to look at X-rays?
2. How do you manage this (pneumothorax)?
3. Tell me how you would insert a chest drain
4. She suddenly becomes more short of breath and hypoxic. What is happening? What do you
do? Where to insert needle? (Tension pneumothorax. Needle thoracocentesis mid clavicular
line, in 2nd intercostal space.)

• CT brain of 80 yrs woman who fell down (SDH). In A&E, eyes open to pain,
incomprehensible sounds, and withdraws to painful stimulus. Midline shift. Loss of grey-
white matter.
1. What does it show? Lense shape hyperdense lesion. Right SDH.
2. What does loss of grey-white matter suggest?
3. What is “GCS”, and what is her GCS?
4. Who will you involve in her care?

2. Anatomy: Cadaveric specim en of thorax and neck.

• Points to specimen and asked to identify- Brachiocephalic artery, aortic arch.
• Show me the vagus nerve.
• Show me the recurrent larngeal nerve. What does it supply? What will patient.
• Thyroid - How do you anatomically divide the thyroid? (2 lobes and isthumus.
• Points and asked to identify superior trunk of brachial plexus. What roots do?
• What motor and sensory deficits will result from inferior trunk damage? (Klumpke's palsy).
• What position would the arm be if this is damaged (asked to show the upper limb
position/deformity of erbs palsy)?
• (He wasn't right common carotid, left common carotid, left subclavian, Thyroid gland,
superior trunk of brachial plexus. present with if damaged?
• What supplies cricothyroid muscle? occasional pyramidal)
• What is the blood supply (arterial and venous) of thyroid gland? These originate from?

3. Anatomy: Given a tibia, fibula foot skeleton, and cadaveric specimen of leg/foot. in the right
orientation - Have to put the tibia and fibula together and put it on the talus of the foot correctly.
• Please put the tibia and fibula in its correct orientation. Now place it on the foot.
• Name the bones of the foot (and point on the skeleton).
• What bones make up the lateral longitudinal arch of foot?
• There are 4 ligaments that make up the medial collateral ligament of the footW hat are they
and show me their attachments?
• What are the lateral ligaments of the foot that attach to fibula?
• What type of joint is the inferior tibiofibular joint?
• Points at dorsal foot tendons - Name these tendons: Tibialis anterior, Exthallucis longus, Ext
digitorium, Peroneus tertius.
• Show me on yourself, what movements occur at the ankle joint? What
• What are the movements occurring at the subtalar joint?

1
4. A 34 weeks pregnant lady undergoing laparoscopic cholecystectomy forgangrenous cholecystitis.
She is in reverse trendelenburg position. BP drops from 107/60 to 85/56, HR 110.
• What are the benefits and risks for this patient undergoing this op?
• Who should be involved in her care? (general surgeon, anaesth, Obs&Gynae, neonatologist)
• Where would she be monitored post-operatively? (Wasn't happy with HD, Surgical ICU. I
said O&amp;G HD/ICU.
• What is preload?
• What mechanisms are involved in venous return? How would mechanical DVT?
• In this lady, how would you manage this drop in BP?

5. Prim ary survey - A 24 yrs male was hit by a car. Now in A&E. Patient is not responsive. Not
breathing. Appears cyanotic. Assume circulatory status is adequate. Manequin there. On table they
displayed different sizes of C-spine collar, guedels, a bag &amp; mask.
• Examiner stops you at Airway and breathing - Patient not breathing, what to do?
• Why did you pick that size of guedel? - Show me how you measure?
• Ok patient is breathing now. What you do next? Secure C-spine, ensure adequate
• What you do? Insert oropharyngeal airway, bag and mask (asked to do it). Suggested
intubation but need anaesthetist to do it. We are not qualified.
• How you insert. Show me your bag-&amp;- mask technique (got to show that both
Mannequin lungs were inflated adequately)
• Ventilation. Show me how you'd insert C-spine collar. Examiner is the “nurse”.

6. Acute pancreatitis. Young lady, recurrent alcoholism with epigastric pain, radiating to back.
Shown bloods - LFTs, FBC, UECr, Ca/Mg/PO4. Amylase 2100.
• What's the diagnosis?
• What radiological investigations will you do? US HBS first, CT Abdoman. What are you
looking for?
• Prophylaxis affect this?
• How would you manage this patient?
• How would you manage her pain? WHO Pain ladder
• Name 2 scoring systems used to risk stratify patients?
• Pick one and tell me their components. How does the score relate to mortality?
• What are the components of pseudocyst? How long after will you suspect this?
• (Asked to give a score and corresponding mortality risk i.e score 0-2: 2%, 3-4:15%
mortality, etc). I made the numbers up but she was happy I got the correctgist of it.
• How will they present?

7. Anatomy - Shown cervical vertebrae, skull, Right lateral Cerebral angiogram and cadaveric
specimen of neck.

• Asked to identify arteries on angiogram.

• Show me the path of the ICA on this skull, including which foramina it goes
• Asked to identify ECA on cadaver
• How to tell between upper and lower motor neuron lesion on the face?
• What neurological deficits will patient have if MCA is occluded?
• What abnormalities do you see on the angiogram? (aneurysms)

2
 • What sort of intra cranial haemorrhage will be associated with a ruptured berry aneurysm?
• What are the causes of aneurysm?
• Other supply comes from vertebro-basillar system. Name the parts of the brain

8. Pathology: Lady with temporal arteritis who underwent temporal artery biopsy.
• What histopath features would you see on biopsy specimen?
• Which artery is biopsied?
• What is usual treatment? Steroids
• Lady subsequently needs a surgery. What are concerns for this lady undergoing op? Taking
steroids, need peri-op stress steroids if taking large doses for longtime.
• What side effects of steroids will you need to counsel patient about?
• Lady then has a fall and fractures her hip. What are the likely causes in this situation?
osteoporosis
• What is the pathophysiology of osteoporosis?

9. Exam ination: Man has bicuspid valve, and you hear a murmur suggestive of aortic stenosis.
• What are the causes of aortic stenosis?
• Who would you involve in pre-op assessment? What investigations required?
• Patient eventually underwent metallic valve replacement. What are the peri-op..?
• What common anti-coagulant is normally used? Warfarin. How does warfarin act?
• What is infective endocarditis? Name 2 common microorganisms associated with it?
• If it were a young man having right sided heart valve IE. What particular risk factor? IV drug
use.
• What investigation would you do to identify vegetations?
• Antibiotics may not be effective against clearing vegetations. Why?
• Patient may eventually require removal of artificial valve. What is the principle behind this?
Examiner basically looking for “removal of septic focus”.
• Discuss how anti-coagulation work? What are the vitamin K dependent vitamins?

10. Procedure: Perform FNAC on a old lady with previously excised melanoma on right leg, now
presenting with new lump on right thigh.
• Perform FNAC, put on slides, smear and spray. Left overs for cytospin.
• No questions asked by examiner. Just perform procedure and interact with implications of
this?

11. Consultation: Prep reading 9 min. Discuss case with Trauma consultant over phone - 21 yrs
medical student, car hit him while riding bicycle at 23:30 hrs. LOC for unknown amt of time, but
was consciouss by the time ambulance arrived (~15min). On arrival to A&E,
Hemodynamically well. O/E Right hand swollen, abrasions left upper abdoman, open fracture left
leg. Abdo soft, non tender. GCS 15. Xrays - Right hand MC fracture, Left tib/fib fracture. CXR normal.
GS registrar saw - No need for emergency laparotomy. Suggest US abdo. US abdo subsequently
shows free fluid in left para-colic gutter. At about 12:00am, left leg became pale, DP/PT pulses not
palpable. Now worsening pain. Bloods given - Hb 11. UECr, LFTs, PT/PTT normal. Tetanus and Abx
given in A&amp;E. 2L N.Saline given. GXM pending.
• Call trauma consultant to handover case
• Who do you want to get involved In this case? Plastics, ortho, GS.
• Any other investigations you want to perform?

3
 • Why you think he needs GS involvement? Why Plastics?

12. Angry patient. Has severe knee OA planned for surgery? Postponed last time because lack of
manpower. Now consultant has emergency op, so have to postponed again. Patient not happy. Talk
to him.

13. History OA knee. A 60 yrs male with worsening left knee pain past 6 months. Was on and off
last few years but worse last 6 months, a/w swelling. Worse after walking. No stiffness. No fevers.
Was a professional footballer and had high impact injury during a game 30 yrs ago.
• What are you differentials?
• What investigations?
• How you manage his OA?
• How would you help off-load his knee? Knee brace

14. History IBD. A 30 yrs Female, with 6 months history of loose stools with mucus, a/w RIF pain
not relieved with defecation. LOA/LOW 6 kg over 6 months. No PR bleeding or malaena. No fevers.
Bilateral knee pain for several months. Takes ibuprofen only.
• What are you differentials?
• What investigations? Bloods, Radiological, Colonoscopy
• Dx is ulcerative colitis. How would you manage?
15. PE Spine. A 70 yrs Man, non-smoker with several months history of left gluteal pain radiating
down thigh/leg/foot. Worse on walking 400m, both up and down hill, and after standing for 10min.
• What are your differentials?
• What radiological investigations? Xray, MRI
• What management options? Non-surgical vs surgical.

16. PE Hernia. Man presenting with left inguinal lump. Referred for likely hernia. (Large man with
very distended abdomen. No obvious inguinal lump bilaterally. Positive cough impulse on Right
side even though stem was left side. Examiner satisfied. Then I said I couldn't feel it, but cough
impulse on right side, and that I'd do an U/S. US shows bilateral inguinal hernia.
• What is the difference between direct vs indirect inguinal hernia.
• You perform open repair, how would you identify if it is indirect or direct inguinal hernia?
(Lat/Med to inf epigastric artery).
• Discuss surgical options of hernia repair.
• When would you offer laparoscopic?

17. PE PVD. Left lower limb intermittent claudication. Perform vascular exam.
• What are your findings on the lower limb pulses?
• Show how you'd perform doppler exam.
• Discuss how you'd perform ABPI. What is the normal ABPI?
• What investigations would you perform to help with surgical management?
• How do you diagnose critical limb ischaemia?
• Patient needs to undergo hip replacement op. When would re-vascularisation take
presedence over his op and vice versa?

18. PE CVS. Examine CVS exam. Pre-op assessm ent going for Total Knee Replacement.
• Patient has AS murmur.
• How would you evaluate severity?
• Who would you involve in his care?

4
 M R C S E D IN B U R G H D E L H I 26th M A R C H /2018
A natom y:

1) N eck & T h orax region

Pic o f Arch o f Aorta region: Identify Arch- name its 3 branches

show left vagus Nerve & tell what it wings, identify left phrenic nerve (how it passes through
diaphragm)
Root value o f brachial plexus at post. Triangle, E rb’ s & Klum pke’ s paralysis
Identify thyroid
Nam e arteries supplied & venous drainage o f thyroid gland along with its site o f origin/drainage
Common electrolyte def. after thyroid surgery?
Commonly injured nerves during thyroid surgery?
Parathyroid: exact location & origin (from which pharengeal pouch), different locations o f inf.
thyroid gland, Thymus: origin
Nerve Supply o f Laryngeal muscles

2) Pic o f cranial fossae with intact dura:

Identify tentorium cerebelli & tell its attachment.

Show Optic Nerve-through which canal it passes
Identify Internal carotid artery, identify pituitary fossa.
Show Occulomotor nerve-muscles supplied by it, Paralysis o f Nerve leads to (examiner wants to
hear 1st -Dilated Pupil, then others), passes through sup. orbital fissure
Nam e muscles supplied by IV & V I cranial Nerve
Blood vessel present inner table o f pterion
False localizing Sign in Neurology (New ques)
Aggressive form o f Glioma

3) Pic o f right gluteal region and popliteal fossa

Sciatic nerve: identify & anatomical Landmark, route value, variations with regard to the sciatic
nerve exit the pelvis
show hamstring muscles with its origin & action
Identify Gluteus medius, nerve supply, action, Trendelenburg test
Identify Popliteal fossa-boundaries, contents superficial to deep, L N draining the area, D/D o f
lump from popliteal fossa (examiner wants to hear examples from each 1 structure like from
vein-popliteal vein varicosities; from artery, nerve, fat, bone)
M ost common structure in popliteal fossa can injured during surgery
C ritical care

4) O bstructive Jau n d ice

(epigastric pain, nausea, vomiting diarrhea, increased A LT, A ST , ALP, GGT, Urobilinogen
undectable in urine)
Causes o f Obs. Jaundice? How do you manage?
Why clotting deranged? Which Inv you want to do to monitor.
Functions o f bile salt? How bile salt help in fat emulsification?
What is bilirubin conjugated to?
What is urobilinogen? how it formed? Why Urobilinogen undectable in urine in above senario?
Enterohepatic circulation?
How to correct clotting abnormality?
Other Investigations you want to do?- U S G o f Abdomen Special attention to HBP region
If the patient had fever, pain chills-Ascending Cholangitis
In details Management o f Ascending Cholangitis (Antibiotic + Others )
few more questions---

5) Pneum othorax+ C V line insertion

Shown a Chest Radiograph o f Simple Pneumothorax (inadequate because costophrenic angles
not shown), System for reading C XR. What is the most imp. first to check at a chest x-ray-
patient demographics. Items to be commented on Chest radiograph.
Types o f Pneumothorax. How do you manage?
Anatomical Landmark o f CV line insertion in IJV, Technique o f insertion & removal,
Complications other than pneumothorax & air embolism, Organism causing infection, how to
prevent line infection, predisposing/risk factors o f having C V line infection.

6) T U R P Syndrom e
Post TURP Confused, hypoxic, hypotensive— D/D (told TURP syndrome, Hyponatraemia,
Effects o f analgesia/sedation, Cerebrovascular disease). Examiner wants more-told me TURP
syndrome is due to dilutional Hyponatraemia, so tell more— I guess she wants Blood L o ss as d/d
Define, C/P, Management o f this patient?
Having N a+ 120mmol/L, how will you correct his hyponatraemia?
Other system affected by TURP
What diruetics you want to use here in a pt o f having N a+ 120mmol/L & potassium 3.5mmol/L?
How does Furosemide works? Where spironolactone acts?
Pathology

7) P arotid tum ors

What is most common parotid benign swelling?
What is the meaning o f pleomorphic? - remarkable histologic diversity (examiner wants more)
Describe pleomorphic adenoma appearance?
Clinical signs o f malignancy? Features o f malignant cells?
Test to differentiate Carcinoma & Lymphoma? -Immunohistochemistry
To rule out malignancy peroperative frozen section done, If you find
Lymphoid cell with pleomorphism > Lymphoma; Lymphocytes with Langerhans Giant cell >
Granuloma, Epitheloid cell with brown cytoplasm > Malignant Melanoma
What is high sensitivity & high specific test? Said (Sensivity-True positive rate, Specificity-True
negative rate), Examiner wants explanation.

8) Blood T ran sfu sion + O steoporosis (examiner gave me 19 out o f 20 © )

Patient having Hb 7.8g/dl-Which blood product u will give? -Packed R B C
In Packed R B C pecentage o f W BC?- Zero
What test to do before transfusion? Life span o f R B C ’ s?
What is Group & Matching?
Stages o f bone healing?
Effect o f prolonged immobility? (Examiner specially wants to hear Osteoporosis)
Infected implant why should you remove? What is the 1st test to do? -Wound swab for C/S
what is osteoporosis? How osteoporosis losses bone density (M/A)
what is PV L Staph Aureus? Effect o f its cytotoxin

E xam in atio n s:

9) 35 yr old male assume that he has Rt. Su b m an d ib u lar swelling (simulated pt.)
Exam ine: I examined the patient thoroughly-done every steps+LN +3 Nerve test & at the end said
to complete my examination I want to examine other salivary glands as well- Examiner laughed
& said who stopped you to doing that, plz proceed___ Then I did full parotid examination as well
along with VII cranial nerve examination
D/D: Stone disease / Neoplasm
Why stone disease most common in Submandibular gland?
what investigations you want to do?
Surgical Management- examiner happy when I started with depends upon proximal/distal to
Lingual nerve (also said not to say M arsupialization here)

10) C ard iac P acem ak er aged male (pacemaker Rt.infraclavicular zone)

Examine the C V S: Present your case
Indications o f Cardiac pacemeaker? E C G given— shows pacemaker spikes, no P-wave
Whom do you inform/involve? What should be the preoperative health check-up? Precations you
need to take in OT in dealing with such o f patients ?
A sk few ques about Diathermy as well
11) R igh t hypochondrial pain young male actor h/o 4 days pain
Examine the abdomen: (Simulated patient)

Co-operative actor. Tenderness over the right hypochondrium.

Murphy’ s sign+
Diag: Acute Cholecystitis (Examiner wanted emphasis on case presentation)
D /D ?
What investigations you want to do according to d/d?
Wants details about abdominal x-ray & U S G findings?
(Examiner was happy when I told calcium containing stones are Radio-opaque)

12) Y oun g lady with pain and num bness o f right hand since last few months.
Examine: Carpal tunnel syndrome (Simulated patient)
D/D: cervical radiculopathy/disc disease, Diabetic neuropathy.
What are muscles supplied by median nerve in the hand & forearm
what are the causes o f carpal tunnel syndrome?-Colles fracture, Lunate dislocation
acromegaly, myxoedema.
How will you manage conservatively: Wrist splint, steroid injections, pain killer
Operative options? -release o f carpal tunnel

H istory:

13) H/o per rectal bledding , young lady gave h/o IBD.
D/D Examiner was eager to heard amoebic/bacillary dysentery
A sk details about Crohn’ s & UC
how will you manage the patient (Want to hear details Investigation)

14) Pre-operative Confusion

Test memory o f the patient : A M TS/M M SE
On history also asked about the red coloured wrist band patient had.
On entering ques o f Language & Praxis o f M M SE bell rang so can’t complete the history
D/D? Should the operation go ahead? Management (Whom do you involve)?

Com m unication

15) Stem :E xplain to the patient regarding Arthoscopy cancelled

Patient had M eniscal tear in left knee. Cancelled before
Explain the patient that Mr.Mann has been called away for an emergency case.
Actor was too good (angry but co-operative). explain the situation
Took it as my own responsibility to let him know the next possible date over phone.
End the conversation by offering him a cup o f coffee with some biscuits.
Prep station : Whole set o f notes:

16) Stem: Old lady with limb ischemia + abdominal pain diagnosed as diverticulitis on iv fluids
and antibiotics.
Speak to the vascular consultant on call to transfer the patient to the Tertiary hospital.
Collect all the relevant information from the papers provided.
Check and remember the hospital name and your consultant name
Note down Patient’ s condition and co-morbidities.
Do SB A R
Qns:
D/D- a) Acute limb ischemia b) D V T
What investigation to diagnose?: Arterial duplex scan
What is the cause - possible embolus.
what treatment for limb ischemia: Embolectomy, Bypass, LMW heparin.
What about Cardiac Consultation?
Any signs o f peritonism??
How will you transfer? Whom do you need to talk

Procedure Stations

17) C atheterization
After Checking Id obtain verbal consent, ask about allergy, medications, whether he experienced
this before, proper positioning
(Gloves & Gown provided) Have to select all the instruments you need to perform the procedure
first. Check date o f Jasocaine jelly & Catheter.
Assistants available.
After inserting the tube in aseptic technique (want to change gloves after giving proper wash,
examiner told that assume u r in 2nd gloves) I asked the examiner is the urine coming, if yes then
I want to inflate— Examiner stopped me & told that no urine is coming— A sk why Anuria?
Again why? Why?
Answered & examiner was satisfied when I ended with seeking help from Urologist
Dispose o ff everything before leaving the room.

18) K n ot tying-
A) R eef knot with non-absorbable braided suture (Silk)
What other knots do u know? In Surgeon’ s knot how many through u need to give by index
finger?
B) Deep cavity knot by absorbable braided suture (Vicryl) ? Done as per basic surgical video but
Examiner asked how many through u need to give in case o f vicryl’ s to secure-I told 3, so he
asked u should give there as well.
Ques: What is vicryl made up from? When is absorped? Tensile strength? Advantage o f braided
suture?How to protect tissues while tying depth?
C) Figure o f 8 Suture in closing bleeding V essels- Choose Suture (Prolene).. How many through
u need to give-6
* Start this station by asking to wash my hand with sterilizer, Examiner was happy & told it’ s a
good approach to start but assume that u r gloves & gown
 M R C S E D IN B U R G H D E L H I 27th M A R C H /2018

Anatom y- Posterior mediastinum and Oesophagus

B ase o f skull and cerebral angiogram and aneurysm
Shoulder, nerves o f upper limb
Gluteal region

Pathology- Cholecystectomy and necrotizing fasciitis

Peptic ulcer disease

C ritical C a re - Gastric outlet obstruction,

EDH,
Oesophageal varices with portal HTN

H istory Taking- Seizure

BPH

C om m unication-
Angry patient cancelled surgery
Call vascular consultant RTA

P rocedure skills - Lacerated wound suturing

OT listing

E xam ination- Pulmonary embolism

Hernia
Submandibular gland
Hand

Tips: Appearing o f this type o f exam is playing with your own nerves. Try to enjoy each & every
station as much as possible by communicating with examiners & patient’ s. I used to ask
Antiseptic hand wash in every stations at the beginning & end as well. M anage the time wisely;
complete the examinations before time so that you get time for question answer.

Dr. M d. A bdul B aten Jo a r d e r (Rossy)

Resident M S Urology
Dhaka, Bangladesh.
Email: abjrossy@ gm ail.com
 Mncs part b osce cairo march-2015

Anatomy 1: id radius and ulna, articulate with each other, articulale with the humerus, ri trochlea,
capitulum,radial lubrosity, biceptal tendon, median and ulnar nerve, madian nerve mjury[ motor and
sensory), ulnar nerve injury (motor), ulnar paradox,

Anatomy 2: id atlas,axis .odontoid processjigaments attached, parts of alias and axis, foramen
transversiuim, structures passing, point to hyoid bone in a nan, adentify axis and atlas In lateral xray spine,
open mouth odontoid view, id dens, lateral massos of atlas, whs: abnormal in xray, structures at the level of
cricoid cartilage

Anatomy 3: id external oblique, internal ob iqua. attachments. direction of fibers, muscles forming conjoint
tendon, id ovaries, tubes, appendix, tenninal ileum, Ceacum, douglas pouch, refered pain of appendicitis to
umblicus, pain on flexing hip, psoas muscle, ileoinguinal nerve injury during appendicitis.

Pa'Jiology 1: bicusp d aortic valve, why sudden death, why the valve is slerotic, why to replace the valve,
infective endocarditis, why treatment difficult, why to give anticoagulant, mechanism of action, def.
thrombus, microbilogy branch ng tiyphas .what s this

Paihology 2: signet ring carinoma of stomach, gasrtnctomy with splenectomy, paihology report, fell her
family in 4 sentences, returned with malignant ascites, management

Asscc 1: burn + ards { repealed)

Asscc 2: ruptured diveritulum with pelvic abscess and septcenia, rnangement. ABG, invest gations to do.
open vs percutaneous drainage adv and disadv.

Asscc 3: polytrauma, pneumothorax, liver tear, mangerneni

Cpe 1: cerebellar examination of a patient w th post. Cranial fossa tumour

Cpe 2: respiratory examination of a patien: before hernia repair

Cpe 3: hydrocele examination

Cpe 4: v.vs examination

History 1: pre opelalive anxious patienl

History 2: bacKpa n

Comm. 1: anxious mother her child is being operated for splenectomy

Comm 2: phone call to on call cosuliant updating him about pod1 oliguria

Proced. i : FNAC recurrent malignant melanoma

Proced. 2 : suturiig a superficial wound

[
MARCS Part B OSCE - Delhi - March 27th, 2018 (Day 2)

1. History taking - BPH

65 yrs old gentleman
• History was quite straight forward and elaborate from the patient himself.
• All history directed towards Uncomplicated chronic bladder outlet obstruction.
• Summarize and give differential diagnosis
• How will you investigate?
• What is the Sensitivity and Specificity of PSA?
• What will you do if a suspicious lesion is seen? TRUS guided Bx
• Drugs for BPH? I told Tamsulosine and Dutasteride - They wanted more names of drugs,
but no details.
• Patient was taking ephedrine for nasal congestion. What are the implications?

2. Examination - Painful wrist

• 25 yrs old girl, has a painful right Wrist. No other history given.
• Examination suggestive of median nerve dysfunction.
• Tinel's Sign positive, Phalen's test positive
• I examined MCPs, ICPs and Elbow for completion of Examination.
• But additionally was expected to complete examination by also including C-Spine and
thyroid examination (was asked to me in Viva, that followed)
• Investigations
• Probably management question missed due to completion of 9 minutes.

3. Examination - Right side chest pain

• Patient on post op day 8, following "Major abdominal Surgery".
• Sister has called you as the patient has right sided chest pain
• Go through the charts and examine patient - 6 min.
• Patient had Fever, increased RR and tachycardia. BP and urine output were normal.
• Questions were regarding pneumonia, pulmonary embolism.
• Investigations, findings specific to these differentials, etc.

4. Examination - Incisional Hernia

• Young patient, referred by GP for abdominal swelling, which he/she thinks is an
incisional hernia.
• Examine the patient - 6 min.
• Had a midline laparotomy scar, Right iliac fossa scar for previous ileostomy, which was
closed later. Hernia was at stoma site.
• Had good tone of abdominal wall muscles.
• Questions were about, diagnosis, investigations, management.
• One question I didn't understand was -
 S Patient's father is bed bound and patient is the only caretaker.
S He has to lift his father 2-3 times a day.
S He cannot come for surgery, none else to come for help
S How will you mange, what will you offer.
I did hit around the bush for a while, saying it is uncomplicated hernia and may
postpone surgery; giving binder. But that was not, what examiner was looking
for. Someone outside told me later that they probably expected an intervention
by social services. I was not aware of any such services for UK. So couldn't
answer it.

5. Examination Submandibular gland

• Young patient
• History of swelling in submandibular region while eating, No other complaints
• Examine in 6 min
• Was wearing a neck support. But couldn't elicit a reason as asking question was not
allowed. He removed it for examination.
• Examination - No findings
• Questions were straight forward regarding presentation of sialolith, examination
findings, investigations, management, structures at risk in gland excision, features of
injury to these three nerves - Marginal mandibular, lingual and Hypoglossal.

6. GOO
• 72 yrs old lady
• Multiple episodes of vomiting with undigested food material
• Collapsed at GPs office, but remained conscious
• Na - 122, K- 2, Cl was also low. Raised creat and Urea
• Questions were regarding, reasons of why each of these electrolytes were low,
classification of hyponatremia, features of hyponatremia, basis of biochemical profile of
GOO with respect to alkalosis, paradoxical renal aciduria, etc.
• Cause of raised Creat.
• In this scenario, at what point of time, you can take up patient for surgery. (Indication of
surgery being irrelevant. So question was when will the patient be fit for surgery)

7. EDH
• Trauma patient - history had loss of consciousness for 15 min, at presentation GCS -
15/15, h/o vomiting present. Laceration on left temple and fracture on leg.
• After initial stabilization and suturing of laceration, patient admitted under Ortho.
• Timelines of presentation and bleep of pager were given. It was 7 hrs past presentation
and patient was unconscious. Now the CT is done, s/o EDH.
• Questions - What will you do in ward and which specialties will you involve, Diagnosis
looking at CT, cause, clinical features, what are the indications in history suggesting CT
 should have happened at presentation, Treatment, methods of ICP measurement, what
is normal ICP, mechanism of pupilary dilatation (anatomical structures involved).

8. ISBAR - Inform Trauma patient

• Trauma Sp SR giving you over about one patient. Sp SR going to vascular surgery case,
will be free after an hour and hence I should call trauma consultant and inform about
patient.
• Patient - Timelines give, Ix done so far are given, had right finger fracture, Left leg
fracture with contaminated open wound, popliteal not palpable but femoral is, h/o loss
of consciousness for 15 min at trauma site, CXR - clear, USG a/p - contour of solid
organs maintained but examination inadequate due to gases, left paracolic gutter has
free fluid.
• I introduced myself, told why I am calling and not Sp SR (Background) also gave full
history and examination, gave my plan according to priorities. But I had missed loss of
consciousness, for getting CT head done, examiner drove me to it. Otherwise no other
questions. He seemed to agree with my plan, but probably I should have confirmed it on
phone as Surgical On call.

9. History taking - Siezure - 42 yrs old lady.

• Siezure today, referred by GP, started on Steroids and phenytoin.
• History was pretty exhaustive from patient herself. Started as headache, specific area,
and then seizure.
• Questions - Differential Diagnosis - SOL classified as neoplastic and non neoplastic,
Investigations, immediate management, instruments used in excision, CUSA.

10. OT list Planning

• Scenario
- Patient with Obstructed hernia, Age - 76, has a pacemaker and on warfarin, now
given LMWH.
- Patient, Age - 72, Smoker with Acute limb ischaemia and gangrene for below knee
amputation; has infected wound, culture has grown MRSA, Diabetic.
- Patient for cholecystectomy. Age 68, HCV +ve, Diabetic.
• Four common questions for each of scenario - Type of anaesthesia, where exactly to
attach cautery, which antibiotic.
• Specific question - which cautery with pacemaker, how will you monitor coagulopathy
for patient on Warfarin and/or LMWH.

11. Simple suturing for laceration

• Painted and draped tight thigh of patient with a longitudinal laceration, for simple
suturing. Local anaesthesia has been infiltrated.
• Choose type of suture and open it yourself
 • No need to wear cap, mask, gown.
• Patient may ask you questions regarding pain, antibiotics, follow up, suture removal,
while you are performing the procedure
• While I performed the procedure, after first suture my needle rolled down the drape
and became unsterile. I asked examiner if I can change the suture, he said continue with
current one.
• Questions asked later - which LA and why, dose in mg and in ml.

12. Anatomy - Skeleton

• Shoulder joint - Show bony landmarks, Rotator cuff, which muscles, origin & insertion.
• Hip joint - Show ASIS, Origin and insertion of Iliopsoas, Origin insertion of Guteii.

13. Anatomy - Intracranial vessels

• Only right half of the cerebral angiography with sudden cutoff in one of the vessels was
shown. Left side angiography was removed.
• Asked to name various vessels and where the pathology is.
• Branches of ICA
• Show foramen lacerum on skull
• Vessels supplying brain other than carotids
• Vertebral artery branches
• Course of vertebral artery based on 1st and second cervical vertebra kept in front.

14. Anatomy - Oesophagus

• Boundaries of posterior mediastinum
• Contents
• Blood supply and LN drainage of oesophagus
• Natural constrictors in oesophagus
• Complications of perforation of posterior surface of MID oesophagus while performing
endoscopy.
• What is Barrett's oesphagus and Achalasia.

15. Pathology - Gastric ulcer

• Scenario - Patient has symptoms of Acid peptic disease, has OA with chronic history of
NSAID intake, Endoscopy s/o ulcer and H. pylori diagnosis confirmed. Smoker and
alcoholic.
• Questions were:
• Definite causes of gastric ulceration - According to examiner (at least for this patient)
they do not include Smoking and alcohol use as they only exacerbate gastritis/ulcer.
• Mechanism of how H.pylori causes ulceration - complete and step by step answer
expected.
• Mechanism of NSAID induced ulcer
 • Further change in scenario - patient develops Ca Stomach
• Most common type of Ca, cancer affecting stomach other than AdenoCa?
• Has Liver Mets - How does metastasis occur? Microscopic mechanism from malignant
cells dislodging from tumor till getting lodged in liver and grow were expected.
• Next scenario - After blood transfusion - patient has developed fever. Causes, source of
antigen, source of antibody.
• What is anaphylaxis, mechanisms at molecular level? - Again expected step by step.

16. Critical care - Oesophageal varices

• Scenario - Patient has had two episodes of hematemesis. Has raised PT, aPTT and INR
(values given in chart)
• Questions - Immediate management, immediate intervention, methods of stopping
bleeding during endoscopy, definite intervention, source of bleeding, sites of
portosystemic anastomosis, specific counseling of relatives before putting the patient
on transplant list.

17. Communication with patient - Cancelled DOSx

• Postman - has to walk a lot for work related reasons.
• Has had knee pain for three months, referred by GP two months back when few
investigations were ordered. MRI revealed meniscal tear.
• Got date for arthroscopy one month after his first consult - cancelled due to lack of
adequate staff
• Next date is after one month, that is today. Today the Orthopedic consultant has rushed
for an emergency surgery in a poalytrauma patient. So the procedure being cancelled
today. Talk to the relative.
• Actor was extremely good.
• Pressing issues brought up were - in pain and cannot function, has gastritis with the
usage of analgesics and upon leading question informed that no PPIs were prescribed,
cannot walk so has to take multiple leaves, employer is losing faith in patient.
• After apologizing, confirmed that patient has enough analgesics, fresh prescription for
PPIs will be given, will confirm that contact details are correct, will personally talk to
consultant to reschedule as soon as possible and will inform personally to the patient.

I am sorry I have amnesia of the Station 18.

Few observations
1. Workshop gave a nice PREVIEW of what goes on in exam
2. Examination was very well conducted
3. It is better to practice examination multiple times, especially for those who are not recently pass
out from general surgery and for orthopedic stations.
 4. There are a few things, which are specific to UK, which need to be known beforehand. Disease
specific or the services available for people in UK through doctors or hospitals. E.g. management
of TB in which contact tracing and reporting of TB is important; social services which can help
patient's social rehab.
5. Practice needed for quickly picking up points from a page length instruction and start structuring
the answer. One min is small duration.
6. Anatomy questions were quite relevant to clinical significance and not any miniscule or tedious
topic.
7. Examiners were quite helpful. I missed one point in history where examiner suggested reading
the instructions again. Every examiner came back to the blank / wrong answer given previously
after their set of questions was over.

Overall my enemy in exam preparation was not having a partner and less practice of examination, which
actually has significant marks.
 16/05/2018 Sheffield RCSEng

Histories

1)Thyroid

2)IBD

Communication

1)D iverticulitis ischemic limb

2)Arthroscopy

Examjnation

1)Thyroid

2)Lipoma: M u ltiple swellings on back so I gave dd o f lipoma (darcum disease) sarcoma Bt examiner kept
asking give positive points fo r lipoma n negative

Positive fo r sarcoma negative fo r

I to ld him it can't b sebaceous cyst as no punctum he said ok Bt I couldn't make him satisfy either these
w ere lipoma or sarcoma so it w e n t so so

3)Peripherally neurological disease

4)CVS: patient had pacemaker activated fistula m idline sternotom y scar drain scar marks dentures
central cyanosis anemia ...everything. Was there .my husband to ld me if u see above fistula then palpate
it m ust n feel the th rill so I did it .he had regular Bt low volum e pulse.on ecg I showe spikes .

He asked indictatons if pacemaker n w arfarin

Pathology

1) Carcinoid (appendicular carcinoma detected incidentally..,6m m size involving mucosa n muscularis

propria...

W hat is carcinoid

It's significance

M ost com m only found

How it is detected
M ethods to diagnose carcinoid

W hat does it release

W hich hormones are released

W hich cells are involved

W hen it becomes sym ptom atic

Signs n symptom s o f carcinoid spread

M ost com m on m etastatic site

W hat is im m unohistochenistry

Procedure o f im m unohistochenistry

Significance o f procedure

W hich speciality does it

Sighnificance o f ihc in carcinoid

Two significances o f ihc

Pseudomembrane

Clostridium

How it is detected

Sign

Symptoms

Only one te st to detect pseudomem brane form ed by clostridium

T reatm ent

2) Parathyroid (there w ere many new questions)

How many glands

Em bryology....(rem em ber 3rd pharyngeal pouch not arch okkkk) it's decent w ith thym us

W hole procedure o f frozen section

Difference in form alin fixation n paraffin advantages n disadvantages

W hat is rational o f parathyroid surgery (I d id n 't know)

Role o f pth

Role o f v it d in hemostasis

Calcitonin

w hat bony diesease is associated w ith pth

W hat is calcium n phosphorous level in ckd

Osteoporosis causes

Lytic bony lesions in which ca mets

How ca level is increased In hyperparathyroidism

W hy hypocalcemia after parathyroid surgery

Normal range o f Serum Ca

Osteoporosis pathophysiology

W hole calcium hemostasis mechanism

Signs n symptom s hypercalcemia

Sign sym ptom s o f hypocalemia

Causes o f hypocalcemia

Treatm ent o f hypercalcemia

Critical Care

1) Pancreatitis:

W hich enzymes to be checked apart from amylase n lipase(LDH)

Post cholecystectomy pancreatitis causes

Patient comes w ith jaundice and ascending cholangitis 6 m onths after surgery., reason?

Pseudocyst contents

Difference between ca & pseudocyst

Side effects

Necrosis investigation (ct)

W hat CT findings

W hat biochemical findings

W hy calcium level is low

W hy hyperglycaemia

Role o f cortisol in pancreatitis

W hat is Crp (all dr rafe stuff)

Is amylase valuable?-no, w hy no...released in other cases too

Is lipase valuable ?-yes

How to confirm acute pancreatitis

Complications ..local complications...general

Splenic vein throm bosis(Treatm ent w ill be LMWH. Remember..Thrombosis any w here..treatm en t is
Heparin)

t/m coiling....com plications o f coiling.....

Examiner kept asking abt splenic vein throm bosis.He said how u w ill treat.etc.he asked rest of questions
on it as I d id n 't know so d o n 't rem em ber even w hat he was taking about

2)N utrition: (there w ere new questions)

Indication o f TPN

Indication o f enteral feed

Enteral feed contents

Tpn contents

Side effects

Refedding syndrome

Indication and com plication o f enteral fe e d /tp n

why enteral is preferred over tpn

W hy oral is preferred in enteral

W hat should be m onitored regularly during feed

How to assess th a t patient can't tolerate

Types of enteral feeds w hy N-J is b e tte r than nasogastric, (nasojejunal cause it reduces risk o f aspiration
pneum onia if patient has bad chest)

TPN ratio of CHO, protein & fa t

Glucose side effects

Fats side effects

He kept asking abt enteral feed all the tim e so plz do it perfectly as I couldn't reply w ell.he showed 2 X-
rays(both w ere chest xrays) and asked te ll me which feed is preferable in this situation. One was
pulm onary edema o th er i d id n 't get. Fluid overload scene. He asked watch this n show w ill u give enteral
feed or not

3)Rhabdomyolsis:

D/d

W hy AKI

T reatm ent

W hy alkalinize urine

In rhabdomyolysis examiner w anted to ask significance if alkalisation of urine .i to ld him to neutralize

acid bar balance as potassium is high in AKI. But he w anted som ething d iffe re n t which I d id n 't know

4)Steroid long te rm . Steroid questions w ere same like in Singh's Note.

W ho should be involved in surgery o f patient taking steroids

W hole hypo...pit....adrenal axis w ith hormones

P ituitary hypoplasia

Adrenal Insufficiency
How to optimize patient taking steroids

How to educate o t I steroids

Complications o f steroids...he d id n 't stop me I had to te ll him all then he said ok .he w anted to listen all
systems which r effected

W hat pre op measures intra op measure post op measure

Considerations

Anesthesia considerations

Explain in one line w hat to ask patient w hile discharging ...I said ....tapper o ff according to medical
advice D on't stop it at once ...he said ok

Addisonian crisis

A n ato m y

Station 1: Lower lim b

Sciatic nerve

It's ro o t value

Hamstrings

Nerve supply

Attachm ents

Actions

Show on body

Sciatic nerve course

Landmarks on body

Variations in course

Hamstrings actions

Gluteus medius...she asked to find w here it is

Actions
Nerve supply

Trendenlenburg test when positive when negative

Gluteus medius actions

If nerve damages

A ttachm ents on bones

W hich muscle assists?

Nerve supply of tensor Fascia lata

S tation 2: Neck n upper limb

Find vagus

W hich fibres it carry

W here does it arise

It's course

Up till w here it supplies

W here on neck.along which structures

Find n show

It's role in GIT functions,heart

Phrenic nerve .supply.root value.

Recurrent laryngeal nerve.its sensory n m o to r supply.

Find n show

W here right arches

W here left arches

W hat if damages unilateral, bilateral- com plete,partial

Tell course o f recurrent laryngeal Nerve after exiting thyroid

Blood supply, nerve supply o f thyroid

Long term com plications

Thyroidectomy

W hat o th er structures in ferior thyro id artery supplies

Superior th yro id is branch of?

Inferior branch of?

Thyroid interna can arise from????

Klumpke ,roots,sensory loss,m otor loss

Erb ,roots,sensory,m otor.

S tation 3: Skull

M iddlecranial fossa boyndry

Foramina

Structures

EDH which vessels r endangered

SDH which vessels

O culom otor

ICP relation occulom otor

W here compressed

ICP raise consequences stepwise

Both nerves damaged toge the r or one after other

False localising sign in Neurology- is like when there is a SOL in Brain, it shifts mass which in returns
compresses o the r things .In raised ICP brain compresses down abducent nerve so defected lateral gaze
occurs

Carotid canal

Course o f internal carotid artery