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  • A
    A admin
    Clinical Examination

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    Anatomy

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    Anatomy

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    Anatomy

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    A admin
    History

    MRCS Part B OSCE - Urology History Taking

    Mr. John Matthews is a 62-year-old man referred by his GP to the urology clinic after developing persistent painless visible blood in his urine. He also reports unintentional weight loss and a poor appetite over the past few months. He is a long-term smoker and currently works in a dye manufacturing factory. Your task is to take a focused history and address his concerns. You do not need to examine the patient.

    Introduction (1)

    Duration and frequency of blood in urine (1 mark)
    Appearance of blood (visible/macroscopic vs microscopic, colour, clots present) (1 mark)
    Timing of haematuria (initial, terminal, throughout stream) (1 mark)

    Lower urinary tract symptoms: frequency, urgency, nocturia, hesitancy, poor stream, incomplete emptying (2 marks)
    Pain assessment: dysuria, loin pain, suprapubic pain (1 mark)

    Weight loss: quantification and timeframe (1 mark)
    Appetite changes, night sweats, fatigue (1 mark)

    Bowel habits, abdominal pain, respiratory symptoms (1 mark)

    Ideas
    Concerns
    Expectations

    Smoking History
    Quantifies smoking history (pack years) and acknowledges as bladder cancer risk factor (1 mark)
    Occupational History
    Explores dye manufacturing exposure and other occupational carcinogens
    Previous urological problems, diabetes, hypertension, medications
    Family history of urological or other cancers (1 mark)

    Identifies bladder cancer as primary concern given age, smoking, painless haematuria: Bladder cancer/urothelial carcinoma
    -other differentials: BPH, UTI, stones, renal causes (1 mark)

    Appropriate next steps:

    urgent flexible cystoscopy, imaging (CT urogram), urine cytology...
    Two urgent investigations (1 mark):
    Flexible cystoscopy (0.5 marks)
    CT urogram/CT IVU (0.5 marks)
    [Acceptable alternatives for investigations:
    Rigid cystoscopy
    Ultrasound KUB (though CT preferred)
    Urine cytology (supportive but not primary investigation)]

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    MRCS_Haematuria_OnePage.pdf
  • A
    A admin
    History

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    Anatomy

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    describe development of pancreas The pancreas develops from two endodermal buds of the foregut: Dorsal pancreatic bud → forms most of the pancreas: body, tail, and part of the head. Ventral pancreatic bud → forms the uncinate process and inferior/posterior part of the head. During development, the ventral bud rotates posteriorly with the bile duct around the duodenum and fuses with the dorsal bud. Duct formation: Main pancreatic duct (duct of Wirsung) = ventral duct + distal part of dorsal duct Accessory pancreatic duct (duct of Santorini) = proximal part of dorsal duct Opening into duodenum: Main duct joins the common bile duct → opens at the major duodenal papilla. Accessory duct may open at the minor duodenal papilla. [image: 1773989803488-d4d51eaf-1914-4bef-b547-4fce2a4566c9-image.jpeg]
  • A
    A admin
    Clinical Examination

    MRCS Shoulder Examination Outline

    1. Introduction

    Greet patient, explain procedure.

    Ensure privacy and adequate exposure of the shoulder.

    Ask about pain, weakness, or functional limitations.

    Obtain consent.

    1. Inspection

    General: posture, muscle wasting, asymmetry.

    Deformities: swelling, bruising, scars.

    Specific signs: scapular winging, acromioclavicular prominence.

    1. Palpation

    Bones: clavicle, acromion, acromioclavicular joint, coracoid process, humeral head.

    Soft tissues: rotator cuff tendons, biceps tendon, deltoid.

    Tenderness: localized or diffuse.

    1. Range of Motion (ROM)

    Active ROM: flexion, extension, abduction, adduction, internal rotation, external rotation.

    Passive ROM: repeat movements to assess joint limitation.

    Look for pain, crepitus, or weakness.

    1. Special Tests

    Impingement:

    Neer’s test – checks for subacromial impingement (YES, included).

    Hawkins-Kennedy – alternative impingement test.

    Labral/SLAP lesions:

    O’Brien’s test (active compression test) – checks for SLAP tears (YES, included if SLAP suspicion).

    Rotator cuff:

    Empty can (supraspinatus), external rotation resistance (infraspinatus), lift-off (subscapularis).

    Instability:

    Apprehension, relocation tests.

    AC joint:

    Cross-body adduction test.

    1. Strength Testing

    Test deltoid, supraspinatus, infraspinatus, subscapularis, biceps.

    Compare bilaterally.

    1. Neurovascular Examination

    Peripheral nerves: axillary, musculocutaneous.

    Vascular: radial pulse, capillary refill.

    1. Conclusion

    Summarize findings to patient.

    Wash hands, allow patient to dress.

    Neer’s test: included for impingement assessment.

    O’Brien’s test: included if evaluating for SLAP or labral pathology; it’s not mandatory in every MRCS exam, but mentioning it shows knowledge of labral assessment.

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  • A
    A admin
    Communication

    You are the SHO in the orthopaedic department. A 35-year-old man, Mr. James Carter, sustained a knee injury following a sports accident three months ago and was diagnosed with a post-traumatic meniscal tear. He was listed for an arthroscopic meniscectomy, but his operation has been cancelled twice before due to emergency cases. Unfortunately, his surgery has been postponed again today for the same reason. Your task is to update Mr Carter and address his concerns.

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  • A
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    Anatomy

    MRCS OSCE: Abdomen Station (L1 Cross-Section)
    Question 1: Demonstrate the transpyloric plane on this subject.
    Model Answer:
    The transpyloric plane (Addison’s plane) is a horizontal plane passing through the L1 vertebral body. It is found:

    Surface Marking: Midway between the jugular notch and the upper border of the symphysis pubis.

    Alternatively: Approximately a hand’s breadth below the xiphisternal joint, or midway between the xiphoid process and the umbilicus.

    Question 2: Is this axial cut section viewed from below (inferiorly) or above (superiorly)?
    Model Answer:
    Radiological and anatomical cross-sections are traditionally viewed from below (looking upward).

    Clinical Correlation: This matches the orientation of a CT scan, where the patient’s right is on the left side of the image.

    Question 3: Identify the space between the anterior abdominal wall and the liver, and the space behind the stomach.
    Model Answer:

    Space between wall and liver: The Subphrenic space (specifically the right or left anterior subphrenic space).

    Space behind the stomach: The Lesser Sac (Omental Bursa).

    Question 4: Describe the blood supply of the stomach.
    Model Answer:
    The stomach is supplied by branches of the Celiac Trunk:

    Lesser Curvature: Left gastric artery (from celiac) and Right gastric artery (from common hepatic).

    Greater Curvature: Left gastro-omental (gastropiploic) artery (from splenic) and Right gastro-omental artery (from gastroduodenal).

    Fundus: Short gastric arteries (from splenic).

    Question 5: Locate the gallbladder on this subject.
    Model Answer:
    The gallbladder is located at the point where the lateral border of the rectus abdominis (linea semilunaris) intersects the 9th costal cartilage.

    Question 6: If you move your finger down along the costal margin to the mid-axillary line, what organ is underneath?
    Model Answer:
    The Spleen.

    Anatomical context: The spleen lies deep to the 9th, 10th, and 11th ribs on the left side, extending as far forward as the mid-axillary line. (Note: If the examiner is referring to the right side, the answer would be the Liver/Right Kidney, but the "costal cartilage" prompt in MRCS usually refers to the splenic clinical examination).

    Summary of L1 Structures (The "Everything in the Picture" Question)
    If the examiner asks you to name everything visible at the L1 level, ensure you mention:

    Pylorus of the stomach.

    Hilus of both kidneys (the left is slightly higher than the right).

    Fundus of the gallbladder.

    Neck of the pancreas.

    Origin of the Superior Mesenteric Artery (SMA) from the Aorta.

    Conus medullaris (termination of the spinal cord).

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    Critical care

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    1. Identify hyperdense mass

    Answer: Meningioma
    Usually extra-axial, well-circumscribed, often hyperdense on CT.

    1. Where does it arise from

    Answer: Arachnoid cap cells
    Correct. These are in the arachnoid villi of the meninges.

    1. What structure might it compress

    Answer: Superior sagittal sinus
    True for parasagittal meningiomas.
    Can also compress adjacent cortex → neurological deficits.

    1. What structures does it lie between

    Answer: Falx and cerebral hemisphere
    Correct. Extra-axial, attached to dura of falx.

    1. What will patient present with

    Answer: Monoparesis contralateral lower limb
    This is classic for parasagittal lesion affecting the leg area of primary motor cortex.

    1. What area of brain affected

    Answer: Motor area 4
    Brodmann area 4 = primary motor cortex.
    Can also mention paracentral lobule specifically for leg involvement.

    1. What area body represented medial side of motor area

    Answer: Lower Limb
    Lateral = face and hand; medial = leg and foot.

    1. Which layer of meninges is the meningioma attached to?

    Answer: Dura mater
    Meningiomas are dural-based tumours, hence the “dural tail” sign on imaging.

    1. What is major vein draining brain parenchyma

    Answer: Internal cerebral veins / deep cerebral veins
    Superficial drainage → superficial cortical veins → dural sinuses.

    1. What drains into dural sinuses

    Answer: Cerebral veins (superficial and deep), diploic veins, emissary veins, CSF via arachnoid granulations

    1. Branches of middle cerebral artery

    Lateral lenticulostriate arteries (deep)
    Cortical branches → frontal, parietal, temporal, insular cortices

    1. Signs of MCA infarction

    Contralateral hemiplegia and hemianesthesia (face and upper limb > leg)
    Contralateral homonymous hemianopia
    Aphasia if left hemisphere dominant
    Neglect if right hemisphere

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    A admin
    Parasagittal meningioma Tumour: Parasagittal meningioma Typical presentation Gradually progressive contralateral lower limb weakness Focal seizures in the leg UMN signs Why Compression of the Paracentral lobule (leg area of the Primary motor cortex). Exam clue Progressive leg weakness + seizures → parasagittal meningioma. Acoustic neuroma (vestibular schwannoma) Tumour: Vestibular schwannoma Typical presentation Unilateral hearing loss Tinnitus Balance problems Later: Facial numbness Facial weakness Why Compression of: Vestibulocochlear nerve (CN VIII) Facial nerve (CN VII) Exam clue Progressive unilateral deafness. Pituitary adenoma Tumour: Pituitary adenoma Typical presentation Bitemporal hemianopia Why Compression of the Optic chiasm. Other clues: Hormonal symptoms (galactorrhoea, acromegaly, Cushing's). Exam clue Loss of temporal visual fields. Cerebellopontine angle tumour Often a Vestibular schwannoma. Symptoms Hearing loss Facial numbness Ataxia Structures involved: Trigeminal nerve Facial nerve Vestibulocochlear nerve Exam clue Multiple cranial nerve deficits in the cerebellopontine angle. Frontal lobe tumour Commonly a Glioma. Typical presentation Personality change Disinhibition Poor judgement Sometimes urinary incontinence Structure affected: Frontal lobe Exam clue Behavioural change before neurological deficit. ✅ Very high-yield MRCS pattern Symptom Likely tumour Leg weakness Parasagittal meningioma Unilateral deafness Vestibular schwannoma Bitemporal hemianopia Pituitary adenoma Behaviour change Frontal lobe tumour Multiple cranial nerve palsies CPA tumour
  • A
    A admin
    Communication

    Communication

    COPD + perforated viscus + ARF + metabolic acidosis.

    Prep station, 73 y old brought by daughter. Hx of COPD on steroids / relievers, seen in ED (Emergency) for being "under the weather", unremarkable until ate some food and suddenly had pain in abdomen. Assessment revealed suspected perforated viscus. Urgent Laparotomy was required.

    Call ICU Registrar for Preoperative advice and request for ITU bed. (Remember to write down his advice because he will make you repeat them at the end). Pick up the phone and start speaking.

    Introduction

    ‱ Introduce yourself
    ‱ Summary of the question you are calling about.
    ‱ SBAR approach

    Escalation

    Hello, I am Dr Z, one of the general surgery SHOs working with Mr X, can I please confirm that I am speaking with the ITU registrar.

    I am calling you from Surgical ward A regarding an acutely unwell patient with query bowel perforation/pancreatitis who needs an ITU.

    Mr X is a 73-year old, presented off legs with sudden onset abdominal pain, peritonitic abdomen, hypotensive and tachycardiac. His most recent results show lactic acidosis, hypokalaemia of 2.1, raised amylase and AKI. His chest XR shows air under the diaphragm, and the U?S shows free intra-abdominal fluid.

    He has a background of COPD and is on salbutamol and steroids.

    Due to his current state, he is likely to need laparotomy for the bowel perforation with I ITU bed pre/post and I was wondering if you are able to come assess and let me know about the availability of beds at the moment.

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  • A
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    Critical care

    STEM:
    You are the general surgical SHO on call in a district general hospital with no gastroenterology service and have been asked to attend A&E to review a patient who had profuse haematemesis and was becoming haemodynamically unstable.

    The patient is known to consume excessive amounts of alcohol and make use of other substances. On arrival in A&E, you find a patient with a BP of 100/70, HR 120, RR 30, Temperature 37.4°C and SpO₂ of 91%.

    What are your differentials?

    Bleeding oesophageal varices due to portal HTN caused by cirrhotic liver
    Mallory–Weiss tear
    Boerhaave's syndrome
    Bleeding peptic ulcer

    What are your concerns regarding this patient?

    Ongoing bleeding resulting in hypovolaemia, as the patient has cirrhosis and clotting abnormalities.
    Likelihood of complications such as:
    Hepatic encephalopathy
    AKI
    Hepatorenal syndrome

    How will you manage this patient?

    I will treat the patient according to CCrISP protocol and admit this patient to HDU.
    Active resuscitation, reduction of portal venous pressure and measures to avoid hepatic encephalopathy:
    High flow oxygen
    Venous access
    Immediate cross-matching, 2–4 units of blood after discussing with haematologists
    Fresh blood transfusion, FFP, platelets after consultation with haematologist
    Close monitoring (pulse, blood pressure, hourly urine output, central venous pressure)
    Assessment of coagulation status
    Prothrombin time
    Platelet count

    Control of bleeding

    Tamponade (Minnesota tube) if bleeding uncontrolled
    Pharmacological measures (e.g. vasopressin / octreotide)
    Urgent endoscopy. Banding or injection sclerotherapy

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    A admin
    History

    CheckTimer.html

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    History

    Pain since this morning. LMP 3 weeks ago

    Introduce yourself and confirm the patient’s name and age.

    Confirm the patient is comfortable and not in severe pain.

    Ask an open question about the presenting complaint (e.g. “What brought you in today?”).

    Ask the patient to point to the site of the abdominal pain.

    Ask about onset (sudden or gradual).

    Ask about the character of the pain (sharp, dull, cramping, burning).

    Ask about radiation of pain (e.g. to back, groin, shoulder).

    Ask about the severity of pain (0–10 scale).

    Ask about the timing and duration (constant or intermittent).

    Ask about exacerbating or relieving factors (movement, food, position, analgesia).

    Ask about associated gastrointestinal symptoms (nausea, vomiting, diarrhoea, constipation, bloating).

    Ask about red flag symptoms (fever, weight loss, rectal bleeding, syncope).

    Ask about urinary symptoms (dysuria, frequency, haematuria).

    Ask about gynaecological history (last menstrual period, cycle regularity).

    Ask about possibility of pregnancy and contraception use.

    Ask about vaginal bleeding or discharge.

    Ask about past medical and surgical history, especially previous abdominal or gynaecological surgery.

    Ask about drug history and allergies, including analgesics and contraceptive medications.

    Ask about family history, particularly gastrointestinal or gynaecological disease.

    Ask about social history and close (smoking, alcohol, occupation; summarise and ask if anything has

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    A admin
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    A admin
    Anatomy

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  • A
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    Critical care
    1. What are the common causes of gastric outlet obstruction in adults?

    The causes can be divided into benign and malignant.
    Benign
    Peptic ulcer disease causing pyloric stenosis
    Chronic pancreatitis
    Caustic ingestion
    Post-surgical strictures
    Crohn’s disease
    Malignant
    Distal gastric cancer (most common modern cause)
    Pancreatic head cancer
    Duodenal carcinoma
    Periampullary tumours
    Historically peptic ulcer disease was the commonest cause, but malignancy is now more common.

    1. Why does gastric outlet obstruction cause vomiting of undigested food?

    The obstruction occurs at the pylorus or proximal duodenum, preventing gastric emptying.
    Food therefore remains in the stomach for prolonged periods and is vomited before reaching the small intestine, so it appears undigested.

    1. What electrolyte and acid–base abnormalities are classically seen?

    The classical abnormality is:
    Hypochloraemic
    Hypokalaemic
    Metabolic alkalosis
    Often associated with hyponatraemia and volume depletion.

    1. Why does vomiting lead to metabolic alkalosis?

    Gastric secretions contain hydrochloric acid (HCl).
    Vomiting causes loss of:
    Hydrogen ions
    Chloride ions
    Loss of hydrogen ions leads to metabolic alkalosis, and loss of chloride contributes to hypochloraemia, which also impairs renal bicarbonate excretion and worsens the alkalosis.

    1. Why does hypokalaemia occur in gastric outlet obstruction?

    Hypokalaemia occurs due to:
    Renal potassium loss from activation of the renin–angiotensin–aldosterone system due to dehydration.
    Hydrogen–potassium exchange in the kidney during metabolic alkalosis, where potassium is excreted to retain hydrogen ions.

    1. What clinical signs might you find on examination?

    Possible signs include:
    Epigastric distension
    Succussion splash (if stomach contains retained fluid)
    Visible gastric peristalsis
    Signs of dehydration (tachycardia, hypotension)
    Possible weight loss if chronic

    1. What investigations would you perform to confirm the diagnosis?

    Investigations include:
    Blood tests: FBC, U&E, LFTs, ABG
    Nasogastric aspiration (large residual volume)
    Upper GI endoscopy (OGD) – confirms obstruction and allows biopsy
    CT abdomen – helps identify malignancy or extrinsic compression
    OGD is the key diagnostic test.

    1. How would you manage this patient initially?

    Initial management is resuscitation and decompression:
    Nil by mouth
    Nasogastric tube for gastric decompression
    IV fluids to correct dehydration
    Correct electrolyte abnormalities
    IV proton pump inhibitor
    Arrange urgent endoscopy
    Definitive treatment depends on the cause (e.g., endoscopic dilation, surgery, or oncological treatment).

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  • A
    A admin
    Critical care

    Link Preview Image
    Thorax Critical Care.pdf

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    Google Docs (drive.google.com)

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    A admin
    Stations Chest Drain Insertion Blood Culture Prepping + Draping Scrubbing Removal of a Skin Lesion (1) Removal of a Skin Lesion (2) Catheterisation Incision + Drainage Ordering a List (1) Ordering a List (2) Surgical Principles Pre-operative Management Wound Debridement Link: https://drive.google.com/file/d/16I0ieZxZrqM_qC-Ec_DWPYWrY_dbefYj/view?usp=sharing
  • A
    A admin
    Anatomy

    Link Preview Image
    some questions with suggested answers.pdf

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  • A
    A admin
    Communication

    PRE-OPERATIVE ASSESSMENT BEFORE THR

    STEM - A 62-year-old man came for his preoperative assessment in Orthopaedic OPD for his scheduled THR in one week, He was diagnosed with OA & months ago, and his operation was cancelled due to his reluctance. Now, his wife has managed him and taken him to Orthopaedic OPD to get a schedule soon as they are going to arrange their daughter's wedding in 2 weeks.
    Now that you are an orthopaedic SHO, considering this a history-taking station, go through his preoperative assessment to inform your consultant.

    (This station is deviated largely from the usual history format. Here patient is already diagnosed and has done all the relevant investigations and came to SOPD to get his schedule for THR with his wife who actually convinced him for operation. There's no need to ask about pain, similarly no need ask questions for differentials. This station largely focuses on pre-operative fitness status, co-morbidities, medications, PMH, PSH that are most concerned issues before operation which need to be optimized).

    1. Introduce yourself
    • Hello, good morning, I’m Dr. Z, one of your surgical doctors.
    1. Confirm patient's ID and verbal consent
    • = Just for documentation purposes, could you please confirm me your name and age please?
    • = Nice to meet you! Good to see you again Mr. X.
    • =I do believe that today you are here to get schedule for your upcoming hip surgery. Before that, I've been told to ask you few questions regarding your health condition and to assess how fit you are for your surgery and anaesthesia so that we can take appropriate measure accordingly. Are you okay with that?
    1. Assess respective concern
    • Mr. X, how’re you feeling today? Is your leg hurting much?
    • I'm so sorry to hear that. I understand you are passing through a difficult situation right now.
    1. Past medical history & medication history
    • May I know, Mr. X, whether you have been diagnosed with some medical conditions or not? Do you have any chronic illness?

    (The patient will bring his prescription and drug list & will tell you to check this. Don't take it; instead, assure him you will check his file once your conversation is finished).
    (Now ask elaborately about those conditions that the patient says one by one)

    • Diabetes

    • How long has it been? Is it under control?

    • Which medication do you take? Dose? How long?

    • Do you have any problems with your feet and hand? Any numbness?

    • Anything wrong with your Vision?

    • Asthma / COPD

    • How long has it been? Is it under control?

    • Which medication do you take? Dose? How long? (ask specially for steroids and inhalers)

    • Cardiac issues, Hypertension

    • How long has it been? Is your HTN under control?

    • Which medication do you take? Dose? How long?

    • Do you have any issues with your heart?

    • Are you attending your cardiology doctor and warfarin clinic regularly?

    5. Past surgical history

    • Have you undergone any surgeries before? (H/O CABG 2 years back, pacemaker insertion 4+ years ago, left nephrectomy 7 years ago)
    • Was there any problem with surgeries or anaesthesia? If yes, what was that?
    1. Personal history
    • Who do you live with?
    • Do you smoke? If yes, how many cigarettes & how long?
    • Do you take alcohol? If yes, how many units & how long?
    1. General fitness & systemic review

    • How far can you walk normally before breathlessness stops you?

    • Is it for pain or are there any other issues?

    • Do you take physiotherapy?

    • Ask for constitutional questions as part of systemic review.

    • Now patient may ask you some questions, for example, “Doctor, when will | be scheduled for my hip surgery? My daughter's wedding is in 2 weeks, Please get me scheduled.as soon as possible”.

    • Your answer would be, “Mr. X. I completely appreciate your concern. Please pardon me, but I can’t tell you my thoughts right now, As you have several medical & surgical conditions and you're on various medications, to ensure a safe surgery and safe anaesthesia for you, we must optimize your health condition and medications first.
      Considering these, I think you're not fit for this major surgery at this moment. Mr. X, I assure you that I will discuss about your surgery with my consultant as soon as possible,

    We need to discuss and seek opinions from endocrinologists, pulmonologists, cardiologists, physiotherapists, and urologists (depending on the history) about optimizing your health condition before surgery. Only after the opinion from MDT, we can schedule the date for your hip surgery.”

    PRESENTATION

    Mr. X, a 62-year-old man, came to SOPD for the awaiting THR. On preoperative assessment, he is noted to have DM/HTN/COPD/CAD. He has a past surgical history of CAG and pacemaker insertion 2 years back, CABG 4 years back and right nephrectomy 4 years back. In addition, he is commenced on warfarin and oral prednisolone,

    Considering his past medical and surgical history, he is not fit for surgery this week as he needs an opinion from MDT, and his warfarin and steroid which need to be optimized along with his comorbidities.

    Is the patient fit for surgery? Why do you think like that?

    I don’t think Mr. X is fit for surgery and anaesthesia. Because of having Significant cardiac history (CABG, Pacemaker)
    HTN
    COPD
    Diabetes
    Patient is on warfarin that must be bridged
    Patient is on steroids which should be optimized to prevent Addisonian crisis

    What are your differentials for hip pain at this age?
    I would consider
    OA
    RA
    AVN
    Paget's disease of bone
    Neoplasm
    Septic arthritis

    How will you optimize his conditions before operation? What are your considerations pre-operatively for this patient?
    I will discuss with MDT

    • Diabetes control (see OR listing station)
      HTN control with opinion from cardiologist
      Pre-op pacemaker setup control (sce OR listing station)
      Reversal of warfarin (see OR listing station)
      Asthma’ COPD optimization (see OR listing station)
      Steroid optimization (see ASSCC steroid station)
      Optimize pre-op fluid and electrolyte imbalance as he has only one kidney
      Pre- and post-operatively under supervision of physiotherapist
      Pre-op thromboembolic prophylaxis (risk factors include orthopaedic operation, patient may have
      polycythemia due to COPD)
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