First run:
- Station 1: History PR bleed
~58 year lady 6 months of PR bleeding, stool mixing, dull abdominal pain; no other type b symptoms- weight lost, appetite change etc,; strong family history (brother has colorectal ca)
~Further question
—Differentials (colorectal malignancy, inflammatory bowel disease, haemorrhoids, diverticular disease)
—Investigation (blood test colonoscopy with biopsy) - Station 2: Clinical Examination-Acute abdomen:
~day 5 post op left colectomy peritonitic abdomen.
~Acute assessment 6 minutes(combine Abcde with abdominal exam & assessment of wound) later given ecg(tachy af), vital sign(septic trending) & blood results(raised inflammatory markers),
—what immediate management: (fluid resuscitation+monitor input output, commence antibiotic as per protocol, possible blood transfusion as required request to preform ct?)
—What’s differentials: {anastomotic leak, internal bleeding, hospital acquired infection( pneumonia or uti) & to rule out PE as well ( would do abg but forgot to mention)}
—what definite management: (depends on ct results if localised infective collection then can perform ir drainage or not then reoperate) - Station 3: pathology:
~Patient with bicuspid aortic valve,
—What’s pathogenesis the risk of aortic stenosis in patient (higher pressure outflow causing turbulence & progressively leading to chronic inflammation/fibrosis of valve thus stiffen the valve?)
—What’s other possible risk due to bicusp valve-(higher risk of infective endocarditis),
—How does the disease spread-from blood stream?
—What common organism causing endocarditis- (group a staph aureus & patient progressive require TAVI)
—Why? (As the infection cause vegetation at difficult to eradicate.)
—Why patient need to be on warfarin & nothing else,( as need to archive higher level of anticoagulation)
—What’s is the pharmacodynamic of warfarin , (prevent activation of extrinsic & common pathway clotting factor via vitamin k) - Station 4: Anatomy:
~3 pictures of anterior thigh, posterior hip & popliteal fossa,
—Identify muscle under ileotibial band (vastus lateralis but not the Answer he wanted)
—What’s the action of ileotibial band- (to secure help to stabilise knee joint)
—(2nd picture)- identify gluteus medius, its nerve supply (superior gluteal nerve) & its primary action while walking (to prevent tilting of other side of the hip).
—(3rd picture)- identify biceps Femoris, it’s nerve supply, how many heads(2) & it’s action while walking(extend hip & flex knee)
—What’s the nerve run across fibular head-(common peroneal nerve)
—What sensory supply (it supply dorsum of the foot via superficial branch, first web space of toe via deep supply & lateral cutaneous branch via forming sural nerve),
—What muscle it supply (lateral compartment Peroneus & anterior compart the extensors muscles, tibialis & pronator Tertius)
—What presentation when the nerve is damage- (foot drop & lost of eversion with dorsum sensory lost) - Station 5: Procedure station– suture.
—Select instrument including needles(choose ethelon) tooth forceps needle holder & suture scissors, need to check expiry date.
—Pinch patient with forceps to assess effect of analgesia.
—Perform 4 interrupted sutures with instrument tie, & need to handle sharps safely.
~Ptn will ask question: is it painful- (explain the local will work for a few hours after can take some paracetamol & ibuprofen if necessary). –Explain as this is non absorbable suture thus need to remove suture 10 days either by gp/ district nurse, however if notice redness, bleeding, infective looking require to reopen suture earlier.
~Examiner asked abt:
—What local to be used- (lignocaine),
—Why & What dose for both adrenaline & without adrenaline, (use lignocaine because quick onset of effect, use adrenaline because vasoconstriction reduce bleeding & localised effect.)
—Calculate the dosage that can be given.
Bell ring(unsure if there is anymore question) - Station 6: Anatomy–
—Identify optic nerve, exit point of the nerve(optic canal),
—Identify the dural layer overlying middle & posterior cranial fossa,
—Identify internal carotid artery( this is tricky as it only a luminal structure appear next to optic chiasm, but examiner kindly help u rule out other answer eg middle cerebral artery, carvenosus sinus etc.)
—Identify oculomotor nerve, where is it origin( I said piercing out from pons but i think he wants where the nucleus of the nerve is)
—Where is it exiting craniofossa (via superior orbital nerve),
—What muscle does it supply, (superior inferior medial rectus & levetor palpabrae superialis & pupillary muscle via parasympathetic supply.)
—What prominent sign when it is compressed by sol (blow out pupil)
—What is the type of aggressive form of glioblastoma- multiforme
—What is the other presentation of oculomotor nerve palsy-{ptosis & laterally deviated(abducent nerve) & downward looking(by trochlear nerve)}
—Definition of false localising sign…
—Identify external carotid artery & ascending pharyngeal artery
—Identify facial artery; if transected is it detrimental to its supply-(no as it has cross tributaries from opposite facial artery & lingual artery as well)
—At what level common carotid bifurcate-(c4,c5)
—What is carotid sinus (presence of baroreceptor detect change in blood pressure)
—What is carotid body (presence of chemoreceptor detect ph paO2 level for changes)
—Identify submandibular gland & where is the duct opening iwnto (at next to frenulum floor of mouth via duct of Wharton),
—Identify parotid gland; what type of secretion it produced( serous),
—Where is it’s duct opening {at opposite of second upper molar(examiner want specifically the space between the teeth & buccal mucosa) - Station 7: Anatomy : upper thorax
—Identify oesophagus,
—surface made up of what cell (stratified non keratinised squamous epithelial layer)
—Where is the dual blood supply in oesophagus, (lower end receive blood supply from azygos & left gastric vein- can cause varicose vein increase risk of bleeding)
~2nd picture:
—Identify carina- bifurcate at? (t4 level).
—What is the nerve travelling at the side of trachea (I said vagus nerve we move on to the)
~3rd picture: indicating ascending aortic branch
—Identify common carotid artery (rpt); level of bifurcation.
—Identify left subclavian artery
—Which part of brachial plexus travel posterior to it- (inferior trunk).
—What is subclavian steal syndrome (retrograde blood flow away from vertebral artery due to subclavian artery stenosis thus leading to ischaemia of brain supply when increase required blood flow to arm eg during exercise) - Station 8: Communication sills/Discussion station:
~anxious patient to be consented for ogd patient had recent barium swallow showed likely benign structure but bloods results & symptoms indicating otherwise ? Malignancy.
— Try to explain the procedure after confirmation of id, patient keep interrupting by telling his anxiety while had to explain the risk of procedure which is quite a challenge? - Station 9: Physiology station:
~Nutrition post upper gi op patient nutrition requirement.
—What is classification of nutrition intake: (enteral & parenteral.)
—Asked example for each subclass eg oral, ng, peg & jejenostomy, parenteral partial peripheral & total
—What’s the indication of each & their complication, eg during insertion, during delivery of nutrient & long term.
—What component of nutrient for ptn (eg carbohydrate, lipid & protein(nitrate) & mineral & vitamin,)
—Asked about possibility of complete carbohydrate feed is it feasible? (I said no due to risk of Dm & some tissue rely on different energy source from lipid)
Second run:
- Station 1: Critical Care:
~Patient admitted with peritonitic abdomen, asked to review problem on vital chart noted patient hypothermia of 350C.
—Definition of core temperature hypothermia,
—What is the way of measurement of hypothermia.
—Possible risk factor of hypothermia: {patient-small body habitus(51kg), surgical risk (exposure time, patient require laparotomy, general anaesthesia-losing shivering mechanism due to muscle relaxant)}.
—Whats is the effect of hypothermia: (increase risk of bleeding affected clotting cascade, increase risk of infection, causing cardiac arrhythmia, poor recovery from anaesthetic.)
—How to prevent hypothermia in wards- (switch on heater, close window, using cotton wool/aluminium blanket).
—How to prevent hypothermia during surgery, (usage of biere hugger, using humidified warm air for ventilation, using pre-warmed iv fluid/blood products, lesser exposure time & surface area & usage of plastic cover for laparotomy.) - Station 2: Communication skills:
~Discussion with consultant regarding worrying about patient: post mastectomy two days insisted to go home with 410 ml of drain & feeling SOB. She was persuaded by her daughter as her daughter is staying at 60 mile away from the hospital & she was bounded by her job & need to take care of her family member.
—Explain SBAR to the consultant. As about what possible cause of increase drainage-(slipped vein ligation).
— Also asked what other possible worries,( need to make sure patient does not have other cause of SOB eg actelectasis, chest infection, PE, anaemia, ect).
—Also asked whether is that what patient want, (explained unfortunately you are not sure as you have not seen patient yourself & not seen patient full vitals chart & have not access patient whether has capacity for 4at score)
—Examiner asked me to clarify how to access patient capacity( iam not sure whether the examiner wanted the component to define capacity or each component of 4at or specific test such as MMSE)
—If patient has capacity what other advise would you give, (advise signs of red flag, & clarify is there nearby hospital to seek for help & also need to communicate with daughter for alternative).
—If patient has no capacity what to do, (need to weight risk & benefit might need to detain patient to stay if need be). - Station 3 : Examination:
~Patient complains of bilateral claudication pain/associating with back pain, worse going uphill, claudication(pain relieve upon resting), but abpi normal. Examiner has neurotip & tendon hammer.
~Attempted to do back examination & lower limb neuro & vascular examination (not finished).
~Patient also has bilateral varicosity at popliteal fossa as well, confusing station and I flung it. - Station 4: Examination
~Patient complained of SOB & cough for 6 months as patient pre-op for surgery.
—Asked to examine respiratory system–Normal examination finding-no lymph node palpation (probably required),
—Asked what is differential diagnosis? (I said possible COPD but can’t rule out malignancy).
—Asked what other investigation (check oxygen saturation, perform respiration function test, & spirometry & also perform chest x-ray to rule out malignancy effusion).
—Asked if patient presented with pleural effusion, what clinical signs of pleural effusion (reduced air entry, dull on percussion & reduced chest expansion).
—What further imaging required to rule out malignancy, (CT scan). - Station 5: Hand examination:
~Patient complained of weakness on his left hand, (examine look feel move with specific sign)
~Patient tried to demonstrate poor ulnar flexor weakness & tingling upon tapping of medial epicondle (Cubital tunnel syndrome).
—Asked for cause of ulner nerve palsy, (guyon canal compression, medial condyle compression, due to golfers elbow). - Station 6: History for thyroid disease:
~Patient presented with chronic hyperthyroidism, noticed recently new lump developed at unilateral neck, with symptoms of sensitive to hot.
~No malignant type b symptoms & just report back to examiner & brief discussion of further investigation & management: eg Fine needle aspiration, & thyroid function test depending on results consider pet scan for malignancy. D/D: Graves disease, toxic nodular goiter.
~And discussed about medical(carbimazole/radioactive iodine) & surgical menagement - Station 7: Pathophysiology:
—Asked to discuss a 19 year old gentlemen who has circumcision recently. It sort of like a mixed station.
—Whats is the main blood supply to penile gland & shaft (I said dorsal plexus?)
—And patient unfortunately developed haematoma, I have been asked about what management would you do: (resus & eg review and decision for evacuation, penile ultrasound to assess severity, reapplication of pressure dressing, recheck patient full blood count & clotting & for cross match/group & save).
—Later examiner shown me the clotting blood results showed raised aptt.
—Which pathway has been used to measure by it, (intrinsic and common pathway).
—Which clotting factor involve in common pathway: (activation of prothrombin to thrombin which cleave fibrinogen to fibrin form meshlike network with activation by calcium and factor XIII).
—Patient was referred to haematology further test revealed patient is low in factor 9. What is the condition call: (Christmas disease, or type 2 haemophilia which is a sex link genetic disease). - Station 8: repeated station of prioritization of OT list:
—Patient with critical limb ischaemia with multiple co-morbidities for lower limb amputation, patient is MRSA positive
—Patient with strangulation hernia, patient is allergy to alcohol
—Patient with diverticular abscess, not responding to conservative treatment, is penicillin allergy - Station 9:
~Asked to see a 25 week pregnant lady with complained of breathlessness, likely developed PE,
—Asked to identify differential diagnosis, investigate and management.
—Further more questions about anticoagulation, actions on coagulation cascade.
—Patient has further investigation for chest x-ray, noted presence of growth in one of the lung lobes, turned out to be malignancy, small cell lung tumour, patient progressively developed hypertension, tachycardic & pyrexic-paraneoplastic syndrome secondary to serotonin like protein.