MRCS stations October 2010

MRCS Station October 2010

I will be briefly talking about the stations I had in my MRCS part B OSCEs. I will Mention them in the order I faced each station.

My first station was scrubbing. There were two examiners inside the station, and one was acting as the nurse. The description stated that you can ask the "nurse" for anything you want him/her to do. The examiners check the hands under the UV light at the end to see if you had covered all the areas during scrubbing. During the scrubbing, I was quizzed on the advantage and disadvantages of chlorhexidine and iodine, and when I would use one over the other in surgery.

Critical care: essentially the same station described by Amel. I was quizzed on TURP syndrome. As I managed to get through all the questions, the anaesetists quizzed me further on pharmacology of furosemide, and Mannitol, the mechanism of action. They also asked about the indication for intubation in a patient (all covered in Kanani's critical care vivas).

Communication skills. 10 minutes to read some notes about a patient who fell down some stairs after a drunken night out. He sustained a splenic haematoma, and the plan mentions that he needs to stay in the hospital for few days. The task is to convince the patient not to self discharge. The patient is very adamant that he wants to leave. Just had to make sure that he was not under the influence of alcohol, and has capacity to make decision. No one in my circuit managed to convince him to stay.

Pathology: scenario of a patient who presents with fever, new onset cardiac murmur, and has a previous history of rheumatic fever. The discussion was around major and minor criteria of endocarditis, most common organism, and treatment. The discussion then went onto cardiac transplants, and side effects of immunosuppression. Very straight forward station.

Critical care: scenario of a patient who was trapped under collapsed building. Discussion was around ATLS management of trauma, rhabdomyolysis, hyperkalaemia(potassium from muscle getting into the circulation).

Anatomy (specialty). Trunk and thorax. Dissection specimen of abdomen. Asked to point out stomach, duodenum, and pancreas. The different parts of stomach, blood supply. The arteries that bleed in duodenal ulcer. Parts of pancreas, blood supply, function of pancreas (exocrine and endocrine). Blood supply to the colon.

Anatomy 2. Live model present. Asked to point out tibialis anterior tendon on person. Point out Achilles tendon, Extensor Hallucis Longus, and digitorum. Dorsalis pedis and posterior tibial pulse. Show what happens when tibialis andterior and posterior contract together (inversion of the ankle). Point out where peroneus longus attaches. Nerve supply of tibialis anterior, and peroneous longus. Show me where you would test sensation of superficial and deep peroneal, and sural nerve. Demonstrate ankle and knee jerk, and the nerve roots.

Anatomy 3. Dry skeleton. Asked to point out the different parts of the humerus, and sites where nerves can be damaged. Asked what lies around the radial nerve in the radial groove (lateral and medial head of triceps). Origin and insertion of rotator cuff muscle. The examiner pointed to the ASIS and asked me what that point is called, and asked what attaches there (sartorius). Asked which nerve gets compressed around there and what is the pathology called (meralgia paraesthetica). Asked about origin and insertion of quadratus femoris.

Clinical skills: catheterisation on a plastic model (with a live patient sitting on the other side). Quizzed on what I would do if I can't get the catheter in (try bigger size, in experienced hands introducer, or SPC if still can't catheterise. Then quizzed on management of a patient who presents with abdo pain, and tachycardia.they were describing a ruptured AAA case, and how you would manage the patient.



Round 2.

Cardiovascular examination. Patient had a pacemaker. Asked about what precautions I should take; ppm check, careful use of diathermy.

Comm skills2. 10 minutes to read notes about a RTA victim with pulseless leg. Task was to call the trauma consultant to come to hospital. Quizzed about ATLS, management of open fractures, compartment syndrome.

Comm skills 3. Assess cognition of a patient awaiting elective hip replacement. Patient has AMTS of 2/10. Asked what I would do; collateral history from family, GP etc. If new, then investigate cause for confusion. Postpone surgery for now as needs investigation of confusion.

Examination 1. Knee exam of a patient with relatively new arthroscopic ports. Tender medial and lateral compartments, and patient had crutches hidden behind bed. Differential diagnosis: OA, and rheumatoid, tests I would do (weight bearing x-rays, bloods). Finally management of knee pain.

Hernia and scrotal examination: patient with bilateral inguinal hernia, and a hydrocoele. Simple question on differential diagnoses of lump in groin/scrotum, and management of hernias.

Head and neck examination. Examine a patient who has pain in submandibular region pain on eating. I performed normal neck exam, and then bimanual examination of submandibular glands, I wasn't able to feel any abnormalities, and was a but worried that i may be missing something. The examiner then said to me "I appreciate this is a normal patient...but what would you find in a patient with similar symptoms" I breathed a sigh of relief and talked about submandibular calculi. Asked about what nerves can be damaged in submandibular gland surgery, and quizzed about anatomy of parotid gland.

History. Take a history of a patient with increased urinary frequency, hesitancy, and dribbling. Basic questions on management of BPH.

Critical care 3. Scenario of a patient who had a reversal of ileostomy 3 days ago, now has abdo distension, spiking temperatures. Asked about bowel obstruction, and anastomotic leak. Differentiating true obstruction from pseudo obstruction (no bowel sounds in pseudo, and tinkling In true obstruction).

History. Patient with back pain, and numb great toe. Probable disc protrusion and compression of nerve roots. Quizzed about cauda equina, and how I would manage this patient.

Overall, very fair and straightforward exam. The examiners are generally very nice and will help you work out the answer. There are lots of staff that take you from one floor to the other, so no chance of being lost. The exam however is very long and tiring.There is a break between each 9 station where you get coffee and biscuits.

HAPPY 2011

Happy New Year to everyone, and hoping 2011 will bring all your wishes true. I am quite sad to be leaving 2010 behind, as it has been a successful year for me. Ranging from a successful research project which i presented at a national conference (BSET) on the use of iliac conduits on ameurysm repairs, passing the MRCS examination, as well as successfully obtaining an academic run-through fellowship in general/vascular surgery.

2010 has been a busy year, but has been very fruitful. I am looking forward to starting my surgical training in August 2011, and I am still in shock that my next job interview will be for a consultancy post. :o.

In the coming weeks I will be updating the blog/website regularly, so stay tuned.

Romesh

Happy Holidays!

Merry Christmas everyone (not that I can be too cheerful as I am on nights all this week :( ). I have enjoyed blogging about exams and all things surgical this year and hope everyone who has stumbled across our humble blog has found some useful info. Congratulations to Romesh for becoming a member and good luck to everyone else who is planning on sitting the exams soon.

With core surgical applications sent off and interviews obtained, I will try to blog about the experience in the hope that it may help others planning to apply next year.

As for our blog and website, I will be making some changes after interviews. Firstly, I want to re-design the website so that navigation is easier and avoid flash to make it more accessible. In addition, I will be uploding much more content and have designed a quiz generator for practice questions.

So change is coming to IWTBAS - watch this space. As for anyone who has used this blog, I would be very useful if you could let us know how you got on in the exams/what more you would like to see on our blog.

With that Merry Christmas and Happy New Year!

Amel

MRCS OSCE October 2010

After spending every minute of yesterday refreshing the Royal College of Surgeon's website between each theatre case, I found out that I have indeed passed the OSCE from the October sitting.

I will post the stations i had, and tips/tricks in passing the exam in the next few days.

I agree with Amel's advice on the usefulness of the Applied Basic Surgical Sciences for the Intercollegiate MRCS OSCE course.

Rom

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.

Books etc to prepare for MRCS OSCE

When preparing for my OSCES I asked my friend Essie who had already sat and passed her exams for advice on which books to revise with. Although I didn't use al the books she recommended due to time limitations, here are the books I did use:

1. Instant Anatomy: great little book for brushing up on blood vessels, nerves etc... to be used as memory aid rather than for learning from scratch. The free podcasts from the website are also really good.
2. Netter's anatomy atlas. Excellent for learning anatomy from scratch.
3. Get Through MRCS: Anatomy Vivas by Simon Overstall. This book is amazing. 96 pages of anatomy vivas and model answers which really help with structuring answers for exam. It was the one book I couldn't have done on demand.  
4. Master Pass: MRCS Picture Questions Book 2 by Tang and Praveen. This book covered Trauma and Orthopaedics, Transplant, Vascular, Paediatric and Breast surgery. It has amazing pictures and excellent explanations. Can be used as a learning aid.
5. MRCS clinical question book by Catherine Parchment Smith. This book was good for structuring your clinical examinations and useful for anticipating questions around each topic. I dipped into it occasionally but did not use it very much as I was happy with my clinical examinations. Good for targeting weak areas or checking your examinations are in good shape.
6. Rafftery's MRCS book. I used this book for Part A and the pathology section for Part B.

In addition to books I also bought 2 apps on my iphone. Netter's flash cards were useful but I did not learn much from them and it was an expensive app (£20). Rohen's anatomy app is excellent (£15) as it uses dissections and really handy for exam practice as you get dissections in 2 of the anatomy stations.

I also bought the OSCE Cases online course from Pastest as it was on offer for £69. Although they need to do alot of work on the format and increase the content, I thought that Prof Ellis' anatomy lectures were amazing and the OSCE tutorials on the different examinations were excellent. I would not pay more than £69 for the course as it is but if they improve it (Alot of improvements need doing) then it may rival more expensive courses. 

Internet wise, the following free website was absolutely amazing. It allows you to create your own anatomy quiz and uses dissections. The link is http://ect.downstate.edu/courseware/haonline/quiz/practice/u7/quiztop7.htm . Definitely worth trying out. I also discovered Acland's atlas of human anatomy which is a video atlas. You can download/view on University of Warwick's website and youtube. I thought it was very useful as a break from books.

As for critical care, I used the notes I made from the RCS Course that I went on instead of a book. However, if you don't go on the course, these two books cover everything you will need (we got given them free for the course):

1. Surgical Critical Care Vivas by Kanani
2. Applied Surgical Physiology Vivas by Kanani and Elliot

Anyway, I may have gone a little OTT with learning resources but I managed to use all of the above materioals in one way or another to target my weaknesses and it seems to have worked. The trick is to not use everything at once but to start with one or two books and add other learning materials as needed because your weak spots will become evident. Closer to the exam you can start whittling down the books you need.