More MRCS Exam stuff!

Sorry but it has been brought to my attention that I forgot to post the two clinical skills stations which
I received. They were both single examiner and 9 minutes in length.

1) The scenario was someone was involved in an RTA and you needed to put in a cannula and write up fluids. Things to remember are confirm patient ID, correctly insert cannula and write up drug chart. After this it becomes an ATLS viva where thy quiz you on management of trauma. Its not a difficult station if you stay calm.
2) The second station was to excise a benign appearing lesion as your consultant was going to do it but he had to run to theatre. You have to pick the blade and suture you need to use and mount the scalpel (I found this the trickiest bit as my hands were shaking). Remember to check consent form, infiltrate with local and give advise as to when to remove stitches, how long to leave dressing and when histology will be back. Also give follow up details.

Hope this helps!

MRCS Stations - Efficiency Of Time Critical

With the next sitting of MRCS rapidly approaching, I thought that I would post what stations I got in the exam in May to help give you an idea of what the exam was like. Obviously, you need to prepare for the probability that anything can come up but this may help give you a flavour of what to expect.


So the exam is done at the Royal College of Surgeons HQ in London if you're sitting at the English College. The exam is split over two floors with chaperones escorting you between stations. There was also a 20 minute break half way through the exam with tea and biscuits which I must admit was very welcome!


On the day, you register and put your things in a locker (do not forget to put away your mobile otherwise its an instant fail!). You are then split into two groups and do a circuit of 9 stations then a break followed by the second circuit. Here were my stations:

Rest station

Head and neck: asked to examine a neck. On exam patient had enlarged left lobe of thyroid. I examined her neck and then I said I would like to examine the rest of her thyroid system. So I looked for proximal myopathy, exophthalmos, lid lag, AF, myxoedema etc… when I was done I said that she was euthyroid but with an enlarged left lobe. I was asked for differential diagnoses, investigations and management plans. Then I was asked to talk about different cancers of thyroid (so I did the whole epidemiology, pathology, investigations and management of each…). Good station, I finished early and had a nice chat with examiner and patient.

Investigations station: I got a CXR which showed NG in bronchus as well as the patients notes and asked to comment (basically SHO did NG tube then left at 17:30 without handing over for anyone to check. Patient then NG fed erroneously and ends up in ITU with respiratory distress). The examiner was an anaesthetist who was very quick with questions so you had to answer quickly. Asked what management of patient was (obviously remove and replace tube immediately). Second was a CT abdo slice of px and blood results. Diagnosis was acute cholecystitis and gallstones in gall bladder. Asked about management. Simple station but it was rushed and you have to think fast.

Examination of Resp system: patient needed elective inguinal hernia repair. I immediately looked around room and spotted inhalers. He had hypo-expanded chest and expiratory wheeze. I diagnosed COPD and was asked how this affects his management. So I mentioned getting pulmonary function tests, optimisation of his COPD treatment, informing HDU as although it is normally a day case procedure he may have difficulties, let surgeon and anaesthetist know. I also mentioned consider use of regional anaesthesia.

HISTORY 1: Back pain in a gardener. Toe is numb. Pain radiates to right leg and increased urinary frequency. She was constipated but was using dihydrocodeine for back pain. My differential was L5/S1 herniation of disc or sciatica. I said I needed to thoroughly examine and exclude cauda equine (MRI if necessary). I said if suspect cauda equine admit immediately, otherwise MRI as outpatient, analgesia, physio and discuss scans with spinal surgeon in case needs decompression if disc prolapse.

HISTORY 2: basically woman with panic attacks. Asked to give a string of differentials so I said asthma, heart failure, vasovagal syncope, angina… For management I said investigate by doing bloods, CXR, echo, PFT and inform anaesthetist, surgeon as well as relatives as she may need support prior to surgery.

Abdo Exam: Asked to examine abdo of patient with abdo pain but patient kept refusing to let me see her abdo so I examined her by piece meal. I also forgot to look at obs chart first so examiner got upset at that (even though he had it hidden in his hand). Handed a piece of paper with urine analysis. There was bilirubin in her urine though she was not jaundiced. Pain was epigastric. I said cholecystitis, pancreatitis, gastritis as differentials and ran ourt of time. Everyone else said they had a tough time with the patient and examiner as neither were helpful. Examiner didn’t ask clear questions.

HISTORY 3: primary school teacher with change in bowel habit, LIF pain and mucous PR. She is adopted and does not know her biological family. So I gave IBD, hereditary bowel ca and said if she was old I may hink diverticulitis but she was only 30!. I would investigate with flex then colonoscopy if needed, barium enema/CT depending on scope results.

  

EXAM Ortho: hip exam of someone with pain in left hip, has scar on right hip, reduced flexion of left hip, fixed flexion deformity on right and small leg length discrepancy (I asked to measure his leg length so examiner got a tape measure out of his pocket). Tested trendelneberg which was normal. I gave differential of OA and then he asked what else so I said RA reluctantly. I said I wanted to do an xray of his hips. Asked about management so I said analgesia, physio, hip replacement if indicated but he wanted to know what else (think he wanted me to say bisphosphonates and calcichew which slipped my mind despite orthogeris).

TELEPHONE: 10 minutes to read patient notes investigations etc in one room then asked call the trauma consultant). Scenario is RTA of 23 year old male. ?free fluid in left paracolic gutter and absent pulses. ?compartment syndrome/critical leg ischaemia and possible head injury. Asked what I would do and said CT head and abdo if stable. Asked how to investigate leg. I said I would also consent patient for laparotomy, fasciotomy and possible leg amputation.  Then ran out of time.

REST

Anatomy 1: examiner pointed at bladder, vas deferens, seminal vesicles etc… asked about blood supply and posterior relations of bladder. Also types of bladder cancer (yay shistosomiasis!)

  

Anatomy 2: surface anatomy of ankle. Asked to point out peroneus longus, brevis and tertius. Where do they originate and insert? What happens to foot if tibialis anterior and posterior contract together? Where is EHL and EDL (Surface marking). What are the roots fof the knee and ankle reflexes. Demonstrate knee and ankle jerk. Demonstrate foot pulses. If patient had crush injury what is he at risk of? Sensory distribution of deep peroneal, saphenous, sural and S1?

Anatomy 3: Abdomen. Asked to find ascending colon on cadaver. Where is appendix, caecum and ileum. Demonstrate internal and external oblique. Nerve supply to external oblique. What makes the conjoint tendon and the nerve supply? Which nerve gets damaged in inguinal hernia repair and how does it present? Asked to name all the positions that the appendix can lie in. why does pain refer to RIF? 

CRITICAL CARE 1: 2 examiners, both anesthetists. Given vignette of patient who had TURP and is now confused, hypotensive and hyponatraemic. I said Trans uretheral resection of prostate syndrome likely diagnosis but differentials maybe sepsis, hypovolaemic shock and explained why it was not these things. Asked why TURPS occurs, so I said due to the osmotic actions of glycine the asked what glycine is. I said an amino acid. Then asked why confusion?  So I said that glycine breaks down into ammonia and causes confusion.  Asked what other conditions this occurs in and I said hepatic encephalopathy. Asked management so i said in ITU/HDU and went through how to carefully manage his acute issues.

PATHOLOGY: vignette of someone with gastric ca. asked about epidemiology, pathophysiology, investigations and management. Shown another vignette of patient at 6 months post op now with swollen abdomen so I said ascites likely die to peritoneal mets. Asked how to investigate and overall management in light of all this.

COMM SKILLS: given ten minutes to read patients notes and investigations. Then to explain to patient with obstruction and perforation why he needs surgery. Also explained stoma formation, complications, how long he needs it for…

CRITICAL CARE 2: 2 examiners and 20 minute station. Vignette on someone who had accident, swollen leg, renal impairment etc… discussed that problems due to crush syndrome and resulting rhabdomyolysis. Talked about acute management of his rhabdomyolysis.      

1)  All in all a fair exam in that examiners do give you a chance to prove yourself but you effectively only have 6 minutes to examine/take history and present findings in order to be able to answer as many questions as possible to score points. Most people have the knowledge but you need to compose yourself and be professional at all times! I hope this helps a little in preparing for the exams and I wish you all the best of luck.