MRCS Part B OSCE

Singapore, August 2012

1. Comm skills
Scenario: 50 y.o. man with 6/52 history of ascites. Previously well. Peritoneal tap
showed scanty malignant cells. CT planned but hospital CT scanner down –
radiologist has offered U/S vs transfer to nearby hospital (40miles) to do CT. Patient’s
wife is upset and wants to speak to consultant. Consultant called away to emergency
OT. Explain to patient’s wife the situation.
- No one managed to finish the entire conversation. The last bell will ring while
you are still talking to the wife

2. Anatomy (Thorax/Abdo)
Identify azygos vein, name 2 tributaries (intercostal veins, superior lumbar veins),
empties into SVC.
Identify sympathetic chain, name 2 structures which sympathetic fibres leave with
(spinal nerves, blood vessels).
Identify pulmonary trunk, ascending aorta, branches (coronary arteries)
Identify papillary muscles, what do they attach to (chordae tendinae), function
(prevent eversion of AV valve)
Identify spleen, location (behind 9 to 11 ribs), blood supply (splenic artery), course of
splenic artery (she wanted to hear lienorenal ligament in particular), distribution of
splenic artery (spleen, pancreas, stomach)
Identify gallbladder, surface marking (fundus at tip of 9th costal cartilage) explain
shoulder pain in cholecystitis (diaphragm, phrenic nerve)

3. Anatomy (Lower Limb)

Identify femoral triangle, femoral vein, what is medial to it (femoral canal, containing
Cloquet’s node and lymphatics)
Identify rectus femoris, function (flex hip, extend knee)
Identify ITB, muscles attached (gluteus maximus, tensor fascia lata), function (lock
knee in extension)
Identify gluteus medius, nerve supply (superior gluteal nerve), function while walking
(pelvic tilt)
Identify biceps femoris (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 of fibula), muscle groups supplied
(anterior and lateral compartment), sensory distribution (posterior and lateral aspect of
leg, dorsum of foot)
Identify gastrocnemius, nerve supply (tibial nerve)
FHL weakness plus dorsum numbness – suspect L5 nerve root

4. Anatomy (Abdomen)
Identify abdominal aorta, level enter abdomen (T12), level of bifurcation (L4), surface
marking of the 2 levels.
Branches of abdominal aorta. Tributaries of IVC (remember: only right
adrenal/gonadal vein and not left).
Structures passing in front of aorta (duodenum, pancreas, left renal vein)
See arteriogram: identify branches of aorta supplying GI tract (celiac, SMA, IMA,
internal iliac via inferior rectal)
Look at patho pot of AAA – causes of AAA, complications. Define dissecting
aneurysm, complications if in the arch/ascending aorta (AMI/stroke)

5. Applied surgical pathology

Scenario: 45 yo lady with 5cm breast lump + clinical axillary involvement.
Questions on triple assessment, particularly features looked for in biopsy report
Commonest type of breast Ca. (IDC)
Trucut biopsy report now given: ER++ ductal Ca. Patient goes for SMAC.
Who should be involved in her care? (Multidisciplinary team etc etc)
Features to look for in final patho report? (confirm diagnosis, margins, number of LN
etc)
What is trastuzumab (Herceptin) and how does it work? Her2Neu receptor
monoclonal antibody, targeted therapy only targets cells with overexpression.

6. Clinical/procedural skills
Excision of benign naevus. Skin is infiltrated and cleaned already. Consultant ran off
to emergency OT once again. You select instruments (they give 2 of each type –
scalpel, scissors, forceps, sutures – so select the right ones) and do the procedure.
Explain to the patient the situation first to ensure consent taken etc. The foam thing
can’t be closed properly so just make a show of it but don’t try so hard the foam keeps
cutting through or you just waste time. Timing can be quite tight here.

7. Clinical/procedural skills
Setting IV cannula, taking bloods, connecting up the IV infusion set for a hypotensive
patient. This actor was damn irritating kept asking if he needed surgery or if he was
going to die, while I was trying to cannulate the mannequin limb. I probably lost some
professionalism marks for ignoring/being brusque to him. Otherwise straightforward.
Some questions on basic invx (routine bloods, FAST, trauma series Xrays, KIV CT if
stable)

8. Surgical Science/Critical care

Scenario: Classic history/examination findings of pancreatitis. Some blood results
with amylase 2100, hypocalcaemia, hyperglycaemia, LDH/AST raised.
Questions: Diagnosis (acute pancreatitis), severity (NOT amylase level, talk about
Ranson/Glasgow), mortality rate given a particular score (go memorise rough
mortality rates), CT/ultrasound findings (oedema, fat stranding, collection, necrosis,
abscess, pseudocyst), causes of hypocalcaemia in pancreatitis (saponification of fat,
hypoalbuminemia), general mx, some questions on pseudocyst definition, natural
history, mx.

9. Surgical Science/Critical care

Scenario: Enterocutaneous fistula after bowel resection, past hx of cervical cancer
with irradiation, some blood results given with hyponatraemia, hypokalaemia, raised
urea/Cr, low bicarb.
Questions: Define fistula, predisposing factors for enterocutaneous fistula (i.e. poor
wound healing/anastomosis factors), explain biochem results, fluid management
(maintenance plus losses as assessed with I/O chart and insensible losses, and correct
electrolytes), management of enterocutaneous fistula (SNAP), factors unfavourable
for spontaneous closure (FRIENDS), complications and how to prevent them.

10. Surgical Science/Critical care

Scenario: CVP line insertion gone wrong after anaesthetic registrar tried to do it blind
using landmark technique only. Patient tachypneoic, desaturated. CXR given showing
large left pneumothorax (some dispute as to whether tension or not - ?slight
mediastinal shift)
Questions: How to read CXR (checks on name/DOB, rotation, exposure, inspiration,
and then on systematic reading technique), diagnosis (pneumothorax), types of
pneumothorax, why do you think it is tension, CVP insertion technique (gold standard
ultrasound guided), show the landmarks if no U/S available, removal technique (head
down to prevent air embolism), other complications of CVP insertion (haematoma,
arterial puncture etc)

11. Comm skills

Scenario: 60 yo man post left hemicolectomy for sigmoid Ca, POD1, oliguric. Mildly
raised Cr 115, I/O chart, vitals chart given. Call consultant to report the situation and
formulate a plan.
- Basically do as you would in real life, remember SBAR. I volunteered to transfer pt
to HD for monitoring, KIV insert CVC. Ensure you have all the facts on hand so you
don’t have to keep flipping notes to get the numbers when you call. There’s a prep
station before this so you have 10min to write down all the impt facts on one sheet.

12. Physical examination

OA knee. Straightforward. Remember to walk patient, look for walking aids, check
neurovascular status at the end. Questions on diagnosis, severity, importance of NV
status.

13. Physical examination

Incisional hernia. Already given diagnosis in the stem (GP referred with suspected
incisional hernia). Make a show of palpating the whole abdomen though, including
looking for other herniae. I auscultated the lungs and found bilateral wheeze so said
that’s probably the reason. Questions on risk factors for incisional hernia,
management (conservative vs surgical), and some scenario if he has a disabled wife
he has to carry around.

14. Physical examination

Pre-op CVS assessment. Mechanical heart valve. Examination wise only the loud first
heart sound, no murmurs or pacemaker. Questions on diagnosis, things to do pre-op
(refer CVM, 2D echo, ECG, CXR, titrate warfarin/heparin), what other meds needed
(antibiotic prophylaxis for all ops).

15. Physical examination

Thyroid lump. Solitary lump with no peripheral signs or other neck lumps. Discussion
on diagnosis, differentials (adenoma, cyst, dominant nodule, Ca), invx (TFT, U/S,
FNA), pros/cons of FNA, if follicular cells then what next (hemithyroidectomy KIV
completion, vs surveillance if not keen for op).

16. History taking

Long hx 5 yrs of 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
of spine, tingling in fingers/toes, and also had chronic headaches, IBS, chronic pelvic
pain syndrome, all on f/u with specialists but no meds/interventions. She also had
social history +++++ with disabled husband etc etc. Invx and mx. (inflammatory
markers, Xrays, KIV MRI, refer social support, analgesia PRN)

17. History taking

Vascular claudication 6/12. Distinguish from neurogenic. Look for risk factors
including family history. Questions on distinguishing between vascular/neurogenic,
clinical assessment (pulses, ABPI, Doppler), if ABPI 0.8 what 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 for even letting the words
arterial duplex escape my mouth.

18. History taking

PR bleed 6/12. Change in bowel habits. Suspicious for malignancy. Questions on
differentials (IBD, diverticular disease, angiodysplasia), invx (essentially
colonoscopy), staging if tumour found (CT, endoscopic US, CXR).

OK that’s more or less it, good luck with the exams!

Kae Sian