Two circuits: 12 stations in each (including 2 rest stations in each circuit, and one prep station in each circuit before the comm skills stations) i.e. 18 actual assessment stations in total.
Start on one circuit, complete the circuit, and then break of around 10-15mins before moving to the second circuit.
Each station is 9 minutes: 6 minutes history/exam, 3 minutes viva (warning bell at this time). One minute to get between stations and read rubric outside each station.
For the viva/comms/skills (but not hx taking stations) the 3 minute warning bell is meaningless - just continue with the station.
The comms skills stations have a prep station (i.e. 9 mins) before going into the actual station.
The skills stations also tend to appear to have marks available for comm skills too - so be aware of this.
- Typical!
- Choice of still or sparkling mineral water!
- Seeing a patient in Ortho outpatients. GP referred for right knee pain.
- Chronic pain for past 3yrs, increasing over past 6 months.
- Night pain, knee feels like giving way going down stairs.
- Previous hx of knee injury whilst playing football 30yrs ago.
- Had a (likely) meniscectomy as a consequence.
- Patient wants a TKR.
- Differential diagnosis
- Initial investigations
- Management? Would you offer him an arthroplasty?
- Surgical alternatives to arthroplasty? (Osteotomy etc)
- Seeing a patient in surgical outpatients. GP referred for PR bleed.
- 6 month hx of increasing dark red blood PR mixed in with stool.
- Change in bowel habit (alternately constipated/loose).
- No weight loss or annorexia.
- No fever, night sweats or other systemic sx.
- FHx: brother had Ca Bowel and some form of resection with stoma
- Pt concerned he might end up with stoma that cannot be reveresed (like brother)
- Differential diagnosis: Ca, diverticular bleed etc.
- Initial investigations: colonoscopy +/- CT staging
4. Exam: General exam (mainly abdo) of patient Day 6 post left hemicolectomy with primary anastomosis
- You are SHO on-call for nights and ATSP re abdo pain and unwell
- Clearly tachyopneac and in pain
- Locally peritonitic in left abdomen with guarding and percussion pain
- [Examined using an ABCDE approach and then an abdo exam thrown in at the end]
- Differential diagnosis: anastomotic leak
- How would you manage? (See obs chart please)
- [Shows tachycardia, pyrexia, hypotension, tachyopnea and increasing O2 requirements]
- [Go through basic resus measures]
- What other things would you like to do? [ABG, ECG, bloods]
- You're shown ABG results and ECG and asked to interpret
- Who would you like to involve? (Seniors i.e. consultant, and ITU)
- Middle aged women being seen in Preop assessment for elective Lap Chole following simple gallstones.
- Incidentally reports intermittant episodes of SoB
- Increasing in frequency over past 2yrs, now 2-3 episodes daily.
- Associated with chest tightness.
- No relationship to any triggers, position or exertion.
- No palpitations or syncopal sx.
- No hx of atopy.
- No PND/orthopnoea.
- Not limiting walking distance or ADLs.
- Denies chest pain.
- Ex-smoker.
- Never formally investigated by GP - had peak flow but nil else.
- Differential diagnosis
- Baseline investgiations: Peak flow, spirometry, CXR etc.
- Definition of FEV1, FVC, FEV1/FVC ratio.
- Obstructive and restrictive spirometry graph shapes.
- Rubric gives 2 scenarios:
- Young male with spontaneous SoB and resp distress.
- Elderly lady who hit head after mechanical fall, now has reduced GCS.
- First 6 minutes spent discussing first case and CXR.
- Last 3 minutes spent discussing second case and CT Head (single image).
- What is your system for examining a CXR? Talk me through it...
- Look at this CXR - what is the diagnosis? (Large simple pneumothorax)
- Is this a tension PTX? (No) What are the signs of a tension PTX?
- How would you treat a tension PTX?
- How would you treat this [simple] PTX? (Chest drain)
- What are the landmarks for placing a chest drain?
- Talk me through how you would place a chest drain.
- Would you aspirate this PTX? (No, too large.)
- What are the limits for aspirating a PTX?
- Do you know any recent published guidance on PTXs and chest drains? (Didn't have a clue on this one)
- What is this investigation? (CT Head w/o contrast)
- What does it show? (Large subdural haematoma with effacement of ventricles and midline shift with oedema)
- How do you know this is blood? (Bright white)
- How do you know this is not an extradural haematoma?
- What is GCS?
- What is this patient's GCS? (9 - E2V3M4 -> Given the various details in the rubric)
- Who would you need to discuss this patient with? (Neurosurgeons and ITU)
- Why do you need ITU? (Airway protection given dropping GCS, ventilation, monitoring etc)
- 60yo man
- "Examine this gentleman's hips..."
- Old scar on left hip from lateral approach
- Equal leg length
- Globally reduced ROM in all movements on left
- Fixed flexion deformity of 10° on Thomas test
- Normal Trendelenburg test
- Differential diagnosis: OA
- Initial investigations
- What are the radiographic signs of OA?
- What are the management options for OA hip?
- Young women in 20s presents with RIF pain
- Examine her abdomen
- Clearly tender and locally peritonitic in RIF
- Rosvigs +ve
- Obs chart: mild pyrexia and tachycardia
- Differential diagnosis (acute appendicitis, ruptured ovarian cyst)
- Initial investigations (obs, urine dip, beta HCG, bloods)
- Any imaging? (USS abdo - normal does not exclude appendicitis)
- How would you manage? (Laparoscopy +/- procede)
- Any conservative options? (Observe with IV abx)
- Which abx? (Amox and Metro)
- 60yo women
- Seen and discharged from A&E after mild head injury following fall
- Now presents to clinic with left sided deafness
- "Examine this patient's hearing and any other cranial nerves you feel relevent..."
- Conductive deafness on left side
- Abnormal Rinne's and Weber's tests
- Otoscopy demonstrates haemotympanium
- All cranial nerves intact
- What is the cause of deafness?
- Are Rinne's and Weber's tests positive or negative?
- What is the significance of the haemotympanium? (Base of skull #)
- What investigations would you like to perform? (CT Head)
- 74yo women admitted with 48hrs of off legs. Confused. Unable to give hx.
- Now suddenly peritonitic - seen by your consultant, needs urgent laparotomy for likely perf.
- Consultant thinks needs ITU postop, asks you to d/w ITU SpR.
- Given patient notes with brief clerking, ABG, obs chart, and bloods.
- Problems:
- Partially compensated metabolic acidosis
- AKI
- Hypokalaemia
- T1RF
- Hypotensive and inadequately resuscitated
- ITU SpR discusses case and gives appropriate mx plan. Asks you to repeat plan back to him.
- ITU SpR explains no room in ITU, asks about other alternatives as to where to recover pt if can't extubate (suggest theatre recovery or remain in theatre)
- 30yo male presents to clinic with right groin lump, dysuria, and yellow urethral discharge
- Groin lump transpires to be ectopic testes with odd USS appearence. Therefore excised. You're given the histology report -> shows teratoma.
- What is the cause of the yellow discharge and dysuria? (Gonorrhoea)
- Who should manage his care? (GUM clinic with infectious disease consultants, contact tracing etc.)
- What are the concerning features on the histology report? (incomplete margins, lymphatic invasion)
- What markers are useful for Teratoma? (AFP, HCG)
- Explain the broad concepts of the TNM staging system
- Young man Day 0 postop laparotomy. Currently in severe pain.
- Septic, so no epidural used/in-situ.
- You're given the drug chart and asked to comment (no analgesia given postop)
- What are the different ways to assess pain? (Pain score, descriptive, smiley faces, Visual Analogue Scale)
- How much pain is this patient in? [you're shown a visual analogue scale]
- How would you manage his pain initially? (IV paracetamol and IV morphine titrated to effect)
- Explain the WHO ladder
- Why is codeine bad? (10% population lack enzyme to metabolise, constipation, SEs etc)
- What are the other effects of pain? (Emotive, physiological)
- What are the physiological effects of pain?
- What other modalities of analgesia are there? (PCA, epidural etc)
- What are the safety factors of PCAs? (Lockout, measured dose, locked unit, non-return valve on line)
- Shown a prosection of the abdominal aorta, IVC and associated vessels (e.g. coeliac trunk, renals, SMA, IMA, iliacs.) Bowel has been removed.
- Shown an arteriogram as the abdominal aorta and branches
- Shown a specimen of an AAA
- Identify the abdominal aorta
- Identify three branches of the aorta
- What other vessels come off the aorta after the IMA? (4x lumbars and iliacs)
- What vertebral level does the aorta cross the diaphragm and bifurcate?
- Identify IVC
- Identify the tributaries to the IVC? (common iliacs)
- What are the complications of AAA?
- What are the risk factors for AAA?
- Shown a prosection of the thyroid and infrahyoid muscles and neck
- Shown a prosection of the larynx and trachea
- What is the arterial supply of the thyroid?
- What is the venous drainage of the thyroid?
- What is the innervation of the larynx?
- Identify the superior and inferior thyroid arteries
- Identify the superior, middle and inferior thyroid veins
- Identify the infrahyoid muscles
- Identify omohyoid
- What is the function of the infrahyoid muscles?
- Shown a full skeleton
- Asked about shoulder and hip/pelvis
- Identify the acromion and corocoid processes
- What muscles comprise the rotator cuff?
- Identify where each of the rotator cuff muscles arise and insert
- Identify the common flexor origin of the humerus
- What nerve runs in close proximity to the CFO? (Ulnar)
- Identify the spiral groove of the humerus
- What nerve runs close to the groove? (Radial)
- Why does a radial nerve palsy affect grip? (?inability to extend wrist?)
- What is the major hip flexor? (iliopsoas)
- What is the function of gluteus medius during walking?
- Where does gluteus medius originate and insert?
- Where does quadratus femoris originate and insert?
- Where is the lateral musculocutaneous nerve of the thigh lie?
- What can compression of this nerve cause?
- 20yo man in A&E after RTC. Complaining of abdo pain.
- Told that primary survey has been completed.
- Your task is to cannulate, take blood, administer a fluid challenge, and prescribe appropriate further fluids.
- What would you send the blood for? (FBC, U&Es, Xmatch, Coag, Venous Gas)
- What would your next fluid be? (I'd like to see the obs chart please)
- [Obs chart shows pt to be a fluid non-responder]
- What would your next fluid prescription be? (2L warmed Hartmanns stat)
- Please prescribe this... (given prescription chart - be sure to fill in all the details, including allergies, height and weight)
- What adjuncts to the primary survey do you know of? (FAST, trauma series xrays, DPL etc.)
- Would you take this patient to CT? (No! Fluid non-responder with abdo pain, therefore mandates theatre for laparotomy)
- Young women in 20s in day case for excision of skin naevus under LA.
- Your consultant has prepped skin and given LA, only to be called to a different theatre for an emergency. You're been asked to sub in and excise the lesion.
- You have not met this patient before, therefore remember to re-do the WHO check and check the side and consent form! The patient is wearing a wristband, hidden under their sleeve. Check this for their hospital number.
- What instruments would you like? [Pick from a selection]
- What suture would you like? [Offered a selection - instructions specified to close with interrupted non-absorbable, therefore chose Ethilon]
- Remember to check that skin is anaethetised adequately with forceps before beginning
- Remember to mark incision first with marker pen in an elipse.
- Measure length as 3-4 x required width - remember to get adequate margins.
- Put excised specimen in tub and ask to be sent to histology
- Explain to pt about postop care and when sutures can come out
- What are glucocorticoids?
- What are their action?
- Where are they produced?
- What are the different parts of the adrenals? (cortex/medulla)
- What are the layers of the adrenal cortex, and what is made in each?
- What is made in the adrenal medulla?
- How is cortisol release controlled? (i.e. describe the adrenal axis)
- What are the effects of cortisol excess?
- What are the surgical problems associated with elevated cortisol?
- What problems with wounds?
- What are the anaesthetic considerations of an elevated cortisol?
- 54yo man admitted yesterday on general surgical take with 6/52 hx of abdo distension with ascites.
- Ascitic tap demonstrated "malignant cells"
- Your registrar told patient last night he had incurable cancer
- No imaging yet done - awaited, but CT is broken (i.e. definitive diagnosis not yet reached)
- Wife has now arrived and thought she was due to see the consultant to discuss husband's condition and prognosis, but consultant has been called to theatre and you've been asked to temporarily step in
- Wife is angry and upset about the way husband was told and also wants to know what the diagnosis and prognosis is
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