MRCS Penang Day 2 AM

MRCS Penang has 2 days. Day 1 all qns repeated. Day 2 almost all qns not repeated. So be mentally
prepared.
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 time for 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 with only makeshift partitions between stations so you can
actually hear what the guy next door is saying if hes loud enough.
Certain stations like the calling the consultant station will have full 8mins to read notes and stem before
another full 8 mins for the station itself. There is also 1 rest station

1. 40 year old man, no PMHx. Came in for dysphagia. Had barium swallow done and barium swallow
shows bird beaking. Has been previously explained by the consultant a few weeks ago for OGD and
dilatation under GA. Consultant had to go away last minute, instructed you to obtain consent and
answer any further qns that the patient might have.
a. Double check correct patient. Check what the consultant has explained to her before. Explain
indications, risk (risk of 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 for urgent laparotomy. However, patient remained unstable, T dropped
to 34deg.
a. What is the definition of hypothermia?
b. What are the possible causes of hypothermia in this case?
c. Why is it important to prevent hypothermia?
d. How do you reduce risk of hypothermia in this setting?
e. How do you reduce blood loss in the above stem?
f. What is autologous blood transfusion?
g. What is massive blood transfusion?
h. What are the problems faced with blood transfusion?

3. Patient was found to have a goitre. Clinically patient has symptoms of hyperthyroid.
a. Explain the thyroid axis
b. What would you expect in a patient with secondary hyperthyroidism?
c. What are the ddx of a patient with a goitre?
d. Showed blood picture, macrocytic anemia.
e. Why would you expect macrocytosis?

4. Patient with hx of Crohn's. Came in with symptoms and signs of abdominal obstruction.
a. Showed AXR of stack of coins appearance. What is this?
b. What are the different routes of nutrition do you know of?
c. What is enteral nutrition? When will you use enteral nutrition?
d. What is parenteral nutrition?
e. When will you use parenteral nutrition?
f. What are the constituents of parenteral nutrition?
g. What are the type of electrolytes in TPN?
 h. What is dextrose? What are sugars?
i. What are the complications of TPN? Examiner is not satisfied with just line sepsis,hyperglycemia,
electrolyte disturbances, cholestasis and bowel mucosal atrophy. Wanted more.
j. You mentioned 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 of the trachea into 2 bronchus? What is this junction called? Examiner
not satisfied with carina. Wanted something else.
c. What level does it branch?
d. Identify parotid, submandibular glands
e. What glands does it contain?
f. Where does the duct of the parotid and submandibular gland open?

6. Anatomy: Middle cranial fossa

a. What are the boundaries of the middle cranial fossa?
b. Identify all the foramen of middle cranial fossa and all the cranial nerves passing through it.
c. Points to the groove of the middle meningeal artery. Which artery passes in this groove?
d. How will 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
of temporal bone but examiner also wants spread of infection through mastoid antrum
g. Which lobe of 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. What is this muscle?
b. Where is its origin?
c. Which surface does it form in the femoral triangle?
d. What are the other boundaries of the femoral triangle?
e. What makes up the floor of the femoral triangle?
f. What does it contain?
g. Moved on to the subsartorial canal?
h. What are the surfaces of the subsartorial canal?
i. Which nerves runs in it?
j. Which artery runs in it?
k. Showed 2 angiogram, one of the pelvic artery angiogram and one of the LL angiogram. Show me
the femoral artery
l. What are the branches of the femoral artery? Show me the profunda femoris on the angiogram?

8. Patient, 50 years old, came in with blurring of vision and throbbing headache?
a. Diagnosis? Giant cell arteritis (Yes, it can come out in a surgical exam)
b. Patient complains of blurring of vision. What do you call it?
c. Give me one blood test that points to your dx? ESR
d. How do you treat?
e. You treated him with the medication that you just mentioned, patient came back 10years later
with hip fracture. What the potential causes of the hip fracture? Steroids, post menopausal,
possible immobility from functional decline. What else?
f. How will you manage her hip fracture?
 g. You mention that patient will need surgery, what will you be concerned with? Addisonian crisis
h. How will you prevent Addisonian crisis?
i. Do you have to do anything about the giant cell arteritis before hip fracture surgery? Dont know
what the examiner is getting at but shes happy with get a consult with opthalmo.

9. 28 years old male, came in for dragging pain in left groin. On examination, you found a mass 3x2cm
over left groin?
a. What are your ddx? The usual differentials, plus testicular ca
b. Why testicular ca?
c. How does undescended testis contribute to increased risk of testicular ca?
d. What is choriocarcinoma? Examiner just jump straight into this without asking for different
types of testicular ca
e. If this is a 60 year old man, what is the most common cause of testicular ca? Lymphoma
f. Histo confirms testicular ca? What will you do next? Stage disease with CTTAP
g. Where is the first place that testicular ca spread? retroperitoneal LN. Examiner want more, gave
lungs and brain. He is happy with it
h. CTTAP shows presence of retroperitoneal lymph nodes compressing on IVC. How does this
contribute to thrombosis? Examiner wants to hear Virchow's triad
i. In this case, Virchow's triad is only satisified under 2 out of the 3 conditions. Which component
of Virchow's triad does it not satisfy in this instance? Hypercoagulability

10. Perform CVS examination. Patient with pacemaker, is here for pre-op checkup for another
operation. Do CVS examination.
a. Pulse irregular, also has transverse thyroidectomy scar, has pacemaker and prosthetic aortic
valve. Can you put all the signs together and explain why he has all these signs that you
detected?
b. Showed ECG. Is this ECG pacemaker dependent?
c. What are you going to do with the pacemaker befor e the operation?
d. What else will you be concerned about? Patient probably will be on warfarin
e. How do you titrate warfarin before the op?

11. Perform Thyroid examination. Young male with anterior neck mass, moves with swallowing but not
protrusion of tongue. Euthyroid.
a. Dx and differentials?
b. How will you evaluate? Examiner wants FNAC
c. How will FNAC help you?
d. Supposedly FNAC shows papillary thyroid ca, you counselled patient for hemithyroidectomy but
patient refuse. How will you proceed?

12. Perform Knee examination. Mcmurry'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. What else will you examine? Axilla LN. Demonstrate examination
c. Describe how to excise lipoma?
 d. Any probability that lipoma might be malignant? Why no possibility?

14. I&D of abscess. Real patient with a prop over her right knee to simulate the presence of an abscess.
Assume sterile environment. 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 tooth forceps?
c. Examiner will look at how to handle scalpel to cut the 'abscess'. First cut nth comes out.
Examiner will tell you to cut deeper, then all the 'pus' will come out.
d. What will you do next? Irrigate, pack with gauze
e. What kind of gauze? Antibiotics soaked gauze
f. Do you suture it immediately? No, why?
g. How often do you have to change dressing?

15. Handtie - Interrupted with handtie, tying of deep cavities, figure of 8 tie. Follow instructions: you will
have to find the best type of suture that fits the stem's description (ie make a handtie with non
absorbable monofilament synthetic suture, then you go and find Prolene)
a. Whats the difference with surgeons knot and square knot
b. In deep cavities, what is one thing you have to be careful of when tying? Prevent shearing of
structure that you are tying

16. Communications: Patient came in for pre-op check up for cholecystectomy. Consultant is away and
ask you to assess patient. Patient complains of difficulty breathing especially at night these few days,
a/w tingling sensation in limbs. Also has abdo pain at times with 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 of anxiety attacks
b. Assess for potential causes of anxiety attacks - explore how she felt about the surgery, any areas
that she is unclear of, is she afraid of the surgery, TLC a bit. Might need to offer to explain the
surgery again.
c. What kind of investigations do you want to do? Rmb to do TFT
d. How to manage this patient?

17. Hx taking: GP referred patient for RHC pain. GP did US for 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 for 1 yr. Alternating constipation and diarrhea. But patient felt better with passing flatus. Nil LOW
or LOA or PR bleeding. No jaundice/ fever. No Fhx of Ca. No long term meds. Non smoker/ drinker
a. Rmber to ask impt question: ANY OTHER CONCERNS? Then patient will tell you that husband has
depression and her salary is low, got financial issues
b. Examiner: Present your hx and issues
c. What are your ddx: Always rule out colorectal ca coz this patient has alternating diarrhea and
constipation even tho age group not correct. What else? said a few others. What else? Irritable
bowel syndrome
d. Which part of the history tells you that its irritable bowel syndrome? Better on passing flatus
e. Any blood test/ investigations to confirm that? No, clinical diagnosis
f. Any criteria? Rome's criteria. Heng nvr ask for components
g. Do you think this is acute cholecystitis? No
 h. US has gallstones. Need cholecystectomy? No need. Only if patient symptomatic/ obstructing
biliary tree
i. What is the percentage of gallstones that will become symptomatic and eventually requiring sx?

18. Communications with vascular surgeon for transfer of patient. Given a few pages (actually 10pages)
of patient data. Please note sequential order of 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 will be in the station so you can refer to the patient's notes at any time. Patient has acute limb
ischemia
a. Check with vascular surgeon it is he who is answering the phone
b. Present history and why you are calling
c. What is the urgency of transfer: acute limb ischemia for thrombolysis
d. Vascular surgeon will try to dissuade you to transfer but you should just persist. Last qn will be:
Are you really sure you want to transfer? Say yes. He will say ok.