| Contents | Introduction Themes 27. 28. 29. 30. . Vascular trauma- management . Tatrogenic vascular injuries .. . Classical arteriographic findings . , Vascular grafts ..., . Basic vascular operations . History of vascular surgery . Management of abdominal aortic aneurysm . . AAA-Imaging ...... . Aortic surgical exposures .... . Complications of aortic surgery . Chronic lower limb ischaemia—Pathology . Five year graft patency rates . . Vascular graft occlusion |. Upper limb ischaemia ... » Upper limb ischaemia Treatment . Vascular diagnosis . Acute limp ischaemia: Diagnosis Diagnostic investigations ... Doppler characteristics Duplex scans ........... Vascutar pharmacology-Action of anticoagulants .. Vascular pharmacology-Circulation enhancing drugs Vascular pharmacology-Monitoring ,... Extremity vascular trauma-Management AAA-Aetiopathology .. Chronic lower limb ischaemia~Treatment Investigations for cerebrovascular disease Management of carotid artery lesions Swellings in vascular surgery Renal and mesenteric vascular disease31. 32. 33. 34. 35. 36. 37. 38. 39 40. 4. 42. 43. 44. 45. 46. 47. 48. 4s. 70. 71, 72. . Abdominal diseases of childhood . Paediatric neck lumps _ Scrotal swellings .... . Scrotal swellings/pain .. . Investigations for scrotal conditions .. , Treatment for testicular tumours |. Treatment for testicular swellings . . Diagnosis of penile conditions ... . Diagnosis of penile conditions . . Diagnosis of penile conditions . . Diagnosis of mate infertility . . Perioperative management .. . Prophylaxis of wound infection .. _ Trauma in young children ......- . Children’s orthopaedics |. Swellings in the neck .. _ Tumour syndromes/associations _ Tumour syndromes/associations . Biochemistry .. Acute limb swelling .. Risk factors for dvt Thromboprophylaxis . Thromboembolism diagnosis .. Thromboembolism~Treatment Chronic unilateral leg swelling Varicose veins-Aetiology --.. varicose veins-Investigations Treatment of venous disease . Leg ulcers ...... Acute neonatal conditions Acute neonatal conditions Neonatal conditions ...... Paediatric gastrointestinal disorders . Paediatric conditions .. . Investigations for paediatric conditions Choice of surgery ... Paediatric investigations . Paediatric tumours .... Chemotherapy .. Hyponatraemia « ECG changes Medications in GI disorders 15773. Side effects of antibiotics . 74, Analgesics in surgery 75. Cytotoxic drugs .... 76, Hormone secreting tumours . 77. Palliative care «4+. 78, Embryology «.... 79. Skin grafting in burns 80. Antipiatelet therapy - 81. Treatment of burns 82. Pathologies of the groin . 83, Lump in the groin .. 84, Hernia ., 181 85. Hernia . 183 86. Hernia 87. Hernia . 88. Hernia .. 189 89, Indirect hernia 191 90. Repair of hernia . 193 91, Skin lesions ......... 195 92. Soft tissue swellings . .197 93. Skin lesions .... 199 94, Management of skin cancers . 201 95. Upper gastrointestinal haemorrhage - .203 96, Gastrointestinal haemorrhage .205 97, Gastrointestinal haemorrhage 98. Rectal bleeding . 99. Dysphagia .. 100. Acute abdomen 101. Acute abdomen .. 102, Abdominal pain 103. Abdominal conditions . 104. Abdominal disease 105, Abdominal disease 106. Abdominal disease .. 107. Abdominal disease 108, Investigations for abdominal pain 109, Investigations for abdominal pai 110. Investigations of the gastrointestinal tract . 111. Abdominal lumps .... 112. Abdominal fumps . 113. Postoperative pyrexia198. Head and neck IUMPS - 199. Goitre ve 200. Management of goitre 201. Thyroid disease «- 202. Management of thyroid turmps 203. Complications of thyroid surgery 204. Thyroid disease +» 205. Lumps in the neck « 206. Neck jumps 207. Neck lumps ----- 208, Cervical lymphadenopathy - 209. Thyroid neoplasms « 210. Laryngeal cancer - 211. Soft tissue tUMOUTS --+- 312, Management of skin and soft tissue lesions - 313. Malignant melanoma oe 214. Salivary gland disease 215. Suture material -- 3168. Surgical complications 317. Salivary gland tUMOUTS « 318, Benign lesions of skin 219, Premalignant lesions of skin 220. Peri-anal pain «~~ 221. Complications of gallstones 222. Consent for surgery -- 224. Local anaesthetic agents 225. Mode of tumour spread 226. Jaundice .-. 227, origin of mediastinal masses - 228. Terminology in transplantation .. 229. Types of allograft rejection « 330. Surgical microbiology 231, Renal imaging «- 232, Chest trauma 333. Trauma in urology 234, Major injury - 335, Brain and spinal tumours »-- 236. Chest and thoracie wall injuries 237. Head injury 238, Lower abdominal pain 339. Diagnosis of altered bowel habit .240. Diagnosis of altered bowel habit... 241. Investigations of the upper GI tract 243. Management of thromboembolism 244, Investigation of diarrhoea 245. Abdominal conditions 246, Diarrhoea 247, Complications of gallstone disease 248. Presentations of lymphoedema ... 249. Involvement of nerves . 250. Hand... . . 251. Investigations for postoperative complications . 252. Tumour markers . 253. Arterial blood gas analysis . 254. Ulceration .., beeeetees 255. Choice of colorectal surgery 256. Diagnosis of fractures 257. Conditions of the hand 258. Shoulder joint pathologies 259. Disorders of elbow joint . 260. Wrist problems 261, Hand injuries .... 263. Back pain. 264. Diagnosis of back pain 265. Peripheral nerve injuries 266. Lower limb nerve injuries 267, Calcium homeostasis 268. Childhood extremity disorders 270. Complications of fractures 271. Causes of pathological fractures 272. Treatment of back pain .. 273, Bone disease 274, Bony lesions . 275, Hip fractures 276. Abnormalities of synovial fluid . 277. Disorders of the foot . 278. Disorders of the foot 279, Disorders of the hand 3Introduction (Examination Information) COMPOSITION OF THE INFERCOLLEGIATE MRCS EXAMINATION The intercollegiate MRCS part 1 examination tests you on applied ba- sit sciences. It consists of multiple “true or false” items only. The MRCS part 2 consists of clinical problem solving questions and is based on the extended matching items/questions (EMI/EMQ) pattern. You can take MRCS part 1 at any point after the completion of your house officer training (you do not necessarily have to commence your surgi- cal training before sitting forthe exam). However, you should have commenced your surgical training before you are allowed to sit part 2. Though you don’t necessarily have to do the parts in order, you will have three and a half years from your first attempt (even if you failed) at part 2 MRCS to complete all parts of your MRCS (even if you chose to take part 2 before 1). For this reason it is advisable to take the parts sequentially or to take parts 1 and 2 together. Part 2 consists of a total of 180 questions (about 50-60 themes). Each theme will be followed by up to 9-10 choices (they can be as few as 4 in a few thernes). A few questions then follow based on that theme. Read the instructions carefully and then select the correct option SYLLABUS FOR THE EXAMINATION General Surgery The Abdomen Abdominal Trauma » Penetrating abdominal trauma a Blunt abdominal traumaHER MASTERING MRCS PART 2 CLINICAL PROBLEM SOLVING a Assessment and management of abdominal trauma = Specific organ injuries Common Abdominal Problems = Abdominal pain = Abdominal masses # The acute abdomen Abdominal Emergencies «Intestinal obstruction = Peritonitis and abdominal and pelvic abscess «Gastrointestinal haemorrhage Abdominal Hernia = Inguinal hernia = Femoral hernia » Incisional hernia = Rare hernias Intestinal Fistulas « Classification of intestinal fistulas « Assessment and management Gastrointestinal Stomas = Formation and management = Other stomas = Gastrostomy = Ilcostomy = Colostomy Surgery of the Spleen « Splenic disease and injury = Treatment of splenic disease and injury = Post-splenectomy sepsis Upper Gastrointestinal Surgery = Diagnosis of oesophageal disorders = Specific oesophageal disorders (including gastro-oesophageal re- flux disease, motility disorders, oesophageal carcinoma, oesoph- ageal diverticulum and oesophageal foreign body) = Peptic ulcer disease = Carcinoma of the stomachEndocrine Disorders of the Pancreas = Insulinoma = Gastrinoma = Neuroendocrine tumours = Other rare endocrine tumours Hepatobiliary and Pancreatic Surgery «Jaundice Gall stones and gallbladder disease Acute pancreatitis Chronic pancreatitis Carcinoma of the pancreas Benign and malignant biliary strictures = Portal hypertension and ascites Colorectal Surgery Clinical presentation of colorectal and anal disease Surgical disorders of the colon and rectum = Ulcerative colitis and Crohn’s disease « Colorectal cancer «= Diverticular disease » Faecal incontinence Rectal prolapse Surgical disorders of the anus and perineum = Pruritus ani Fissure-in-ano Hemorrhoids Fistula-in-ano Anorectal abscess = Carcinoma of the anus = Pilonidal sinus and abscess Breast and Endocrine Surgery Common Breast Disorders = Breast Jumps = Breast pain « Breast cysts = Nipple discharge 3 ONIAIOS W3A190¥d TYIINITD 7]CLINICAL PROBLEM SOLVING = Gynaecomastia Breast Carcinoma Risk factors = Pathology = Diagn*sis « Treatment » Breast reconstruction Surgery of the Thyroid Gland «Indications for surgery in thyroid disease «Thyroid cancer (types and management) = Complications of thyroidectomy Parathyroid Disorders = Calcium metabolism Clinical presentation of hypercaicaemia Investigation of hyperparathyroidism Management of hyperparathyroidism Adrenal Disorders and Secondary Hypertension «Causes of hypertension = Conn’s syndrome = Phaeochromocytoma Vascular Surgery Arterial Surgery Peripheral vascular disease and limb ischaemia Arterial embolism and acute limb ischaemia Arterial aneurysms Carotid disease Renovascuiar disease Arterial trauma Venous Disorders of the Lower Limb = Venous insufficiency and varicose veins «= Venous ulceration = Deep venous thrombosis and pulmonary embolism LympnoedemaMASTERING MRCS PART 2 Organ Transplantation = Basic principles of transplant immunology = Clinical organ transplantation = Organ donation and procurement = Immunosuppression and prevention of rejection Otorhinolaryngology, Head & Neck Surgery Ear, Nose & Throat Disorders = Inflammatory disorders of the ear, nose and throat = Foreign bodies in the ear, nose and throat DNIAIOS W3190ud IVDINITD Common neck swellings = Congenital and rare swellings = Inflammatory swellings = Head & neck cancer «= Salivary gland disorders > Infections and inflammation of the salivary glands ~ Tumours of the salivary glands. - Stones of the salivary glands - Miscellaneous conditions LJ « Eye surgery - Trauma to the eye - Common eye infections = Endoscopy Oral and Maxillofacial Surgery Maxillofacial Trauma = Ciassification of facial fractures = Presentation of maxiliofacial fractures = Assessment and investigation = Treatment of facial fractures Common conditions of the Face, Mouth & Jaws Principles of Soft Tissue Repair of Mouth, Face, Head & Neck Paediatric Surgery Principles of Neonatal & Paediatric Surgery = History and physical examination of the neonate and child = Maintenance of body temperatureWG MASTERING MRCS PART CLINICAL PROBLEM SOLVING Assessment of respiratory and cardiovascular function Metabolic status « Fluids, electrolytes and the metabolic response «= Vascular access Correctabie Congenital Abnormalities = Congenital abnormalities of GI tract » Congenital heart disease «Abdominal wall defects = Diaphragmatic hernia = Neural tube defects = Urological abnormalities Common Paediatric Surgical Disorders = Pyloric stenosis = Intussusception «Inguinal hernia and hydrocele = Undescended testes «Torsion of the testes Orthopaedic Disorders of Infancy and Childhood » Gait disorders . « Hip problems = Knee disorders » Foot disorders Plastic & Reconstructive Surgery Burns = Classification and pathophysiology Initial assessment and management 2 Treatment including secondary surgery «Burns of spacial areas (i.e., face, eyes, hands, perineum) Soft Tissue Infections Principles of Hand Trauma (tendon, nerve, nail bed) Hand Disorders = Dupuytren’s contraction = Carpal tunnel syndromeMASTERING MRCS PART 2 Benign Skin Lesions Malignant Skin Lesions (Basal Cell Carcinoma, Squamous Cell Carci- noma, Malignant Melanoma) Principles of Skin Cover = Split skin grafts = Full thickness skin grafts = Local flaps = Distant flaps = Free transfer flaps ONIATOS WI180"d TW3INTD Principles of Microvascular Surgery Wound Healing Traumatic Wounds «Principles of management = Gunshot and blast injuries. = Stab wounds = Human and animal bites 4 Management of Skin Loss = The wound = Skin grafts = Skin flaps Neurosurgery Neurological Trauma Head injuries = Spinal cord injuries = Paralytic disorders = Nerve disorders Surgical Disorders of the Brain * Clinical presentation of the intracranial mass = Tumours of the nervous system = Epilepsy = Congenital and developmental problems Intracranial Haemorrhage (Subarachnoid, Intracerebral and Subdu- ral)CLINICAL PROBLEM SOLVING Brain Stem Death = Diagnosis and testing for brain stem death = Principles of organ donation Surgical Aspects of Meningitis = General features of meningitis 2 Surgical considerations Rehabilitation a The rehabilitation team = Pain management a Rehabilitation Trauma & Orthopaedic Surgery Skeletal Fractures Pathophysiology of fracture healing = Classification of fractures Principles of management of fractures = Complications of fractures Management of joint injuries Common fractures and joint injuries - Upper limb = Lower limb Trunk, pelvis and vertebral column Soft Tissues Injuries and Disorders «Nature and mechanism of soft tissue injury «Management of soft tissue injuries Common Disorders of the Extremities » Disorders of the hand « Disorders of the foot Degenerative and Rheumatoid Arthritis = Osteoarthritis » Rheumatoid arthritis = Other inflammatory conditions 2 Surgical treatment of joint diseases Infections of Bones and Joints © Osteomyelitis «Other bone infectionsLocomotor pain = Low back pain and sciatica Pain in the neck and upper limb Bone Tumours and Amputations * Primary bone tumours «Metastatic bone tumours = Amputations General = Imaging techniques » Neurophysiological investigations Urology Urological Trauma = Renal, ureteric, bladder, urethral, penile and scrotal trauma Urinary Tract Infections and Calculi Haematuria «Classification, aetiology and assessment = Tumours of the genitourinary tract Urinary Tract Obstruction = Urinary retention = Disorders of the prostate Pain and Swelling in the Scrotum = Scrotal skin conditions = Non malignant testicular swellings «= Inflammatory conditions = Testicular torsion ® Testicular tumours Chronic Renal Failure = Dialysis = Principles of transplantation Aspects of Pelvic Surgery * Gynaecological causes of acute abdominal pain DNIATOS W31904ud TV3INMD«pelvic inflammatory disease a Disorders of urinary continence Cardiothoracic Surgery Haemodynamic Control a Haemodynamic principles «Cardiovascular homeostasis 4 Pharmacological haemodynamic control uO z > 2 3 a = s BD oO =, Cardiac Surgery « Surgical disorders of the heart vessels and heart valves |. Cardiopulmonary bypass CLINICAL P Thoracic Trauma 4 pathophysiology of thoracic traume Presentation, assessment and management = Specific thoracic injuries || thoracotomy and Chest Drainage i. » Assessment and preparation «Indications for thoracotomy "Chest drainage and pericardiocentesis Surgical Disorders of the Lung = Lung cancer a Other indications for lung resection Complications of Thoracic Operations = General complications = Specific comnplications pneumothorax and Empyema Thoracls EXAMINATION CENTERS England London 7(2 Centres), Birminghamy/ Coventry, Manchester, Newcastle, Leeds, BristolJ Wales—Cardift Io z Ireland—Dublin A > = Scotland—Edinburgh, Glasgow x= = ° Malta 2 . m = Middle East—Oman, Abu Dhabi, Syria, Riyadh uw ° Africa—Malawi, Cairo s 2 a India~Chennai (Edinburgh college), Mumbai (Edinburgh college), Kolkata (England college) Sri Lanka—Colombo, Thailand, Nepal, Malaysia~ Kuala Lumpur, Singapore, Myanmar, Hong Kong SCHEDULE FOR 2006/2007 Date of Examination Closing Date for Application ~ 16 January 2006 28 October 2005 25 April 2006 24 February 2006 11 September 2006 30 June 2006 15 January 2007 27 October 2006 24 April 2007 23 February 2007 HOW TO REGISTER Candidates can obtain application forms and detailed examination regu- lations by viewing any one of the 4 Royal College's websites, The websites also provide specific information regarding fees and venues Fees The cost of registration for the Intercollegiate MRCS exam is £195 for MRCS Part 1 and £195 for MRCS Part 2.0 Zz > 2 ° a = a a 2 « o = = ¥ Z a G EXAMINATION MARKING/RESULTS There is no standard pass mark. There isa standard setting procedure using the Angoft method whereby for every examination, a group of health professionals judge which questions they believe candidates should be able to answer correctly and a pass mark is then set accord- ingly for that paper. You are thus competing with everybody who sits the examination with you. nesults are riormally available on the respective college website within 3 weeks from the examination and posted to you in another week's time, The Edinburgh college does not give you Your marks if you pass However, the English college does. IMPORTANT ADDRESSES 1. The Royal College of Surgeons of Edinburgh The Adamson Centre 3 Hill Place edinburgh EH8 9DS 4 (0) 131 668 9222 Fax: 44 (0) 131 668 9218 Enquiries: mail@résed.ac.uk or [email protected] Website: www.rcsed.ac.uk 2. The Royal College of Surgeons of England 35/43 Lincoln’s Inn Fields London WC2A 3PE Tel: 44 (0) 207 869 6281 Fax: 44 (0) 20 7869 6290 Enquiries: [email protected] Website: www.reseng.ac.uk 3, The Royal College of Physicians and Surgeons, Glasgow 232-242 St. Vincent Street Glasgow G25R) Jel: 44 (0) 141 221 6072 Fax: 44 (0) 141 221 1804[email protected] Website: ww.rcpsg.ac.uk 4. The Royal College of Surgeons, Ireland 123 St. Stephen's Green Dublin 2 Ireland Tel: 00 353 1402 2232 Fax: 00 353 1402 2454 Enquiries: [email protected] Website: www.rcsi.ie EXAMINATION TECHNIQUE The part 2 examination consists of 50~60 themes each consisting of 2~ 5 questions for a total of 180 questions. You have 3 hours to answer these 180 questions, which means 1 minute for each question. It is hence very important to maintain a good speed and pace your exami- nation accurately. Remember, you have to mark your computer read- able mark sheet as well in this one minute. Candidates tend to make 2 big mistakes as far as this examination is concerned: 1. Not reading question correctly 2. Not marking properly. Always read the question very carefully. There could be a world of difference between the next appropriate step and the most appropri- ate step. For example in a patient presenting with upper gastrointesti- nal bleeding, the next appropriate step might be intravenous access and fluid resuscitation; but the most appropriate step might be an upper GI endoscopy. You must also decide on a game plan to mark your answer sheet. 1 think the best way to do it is to mark your answer sheet after each theme. Hurrying up to transfer your answers to your mark sheet in the end could introduce costly mistakes, Never underestimate this part of the examination, The best thing about this examination is the absence of negative mark- ing. Hence do not leave any question unattempted. If you are not ONIATOS W318 0"d TYIINITD onMASTERING MRCS PART 2 CLINICAL PROBLEM SOLVING sure about any answer, make an educated guess. But be sure to at- tempt al! questions. The best way to go about the examination Is to read each theme very carefully. Read the title of the theme first and then the instructions. Quickly glance over the options that have been given, making a men- tal note of them. Then read eack question carefully. Find out the mest appropriate answer based on the instructions. Quickly re-glance over the options to rule out other answers. Then mark your answer by the side on the question paper. Complete the entire theme and then trans~ fer all the answers for that theme to the marking sheet, Laking cere You have to shade the respective box. Mark all answers you are sure about, as well as all answers you are completely unsure about (using an educated guess). Leave questions you think you need more Lime to think about for the end. Mark these questions with 2 big circie or the question sheet for your attention in the end. Spare some time thinking on these questions in the end. In the very unlikely event of finding some time in the end, there might be a temptation to read and and re-read your answers over and over again, Resist that temptation. However, if you are strongly convinced about changing an answer, please do. But remember, do not change a guess for another guess. First thoughts and guesses are usually the best. Remamber that these questions are not designed to trick or confuse you, You will always read them correctly as long as you read them carefully. Take each question at its face value. T hope you find the selection of questions in this book useful. It con- sists of 279 EMQs and 1175 questions. They should provide a flavour for the examination, help assess your knowledge, identify important subject areas and identify potentially weak areas. I have tried to in- clude explanations for all answers where necessary. That should help improve your understanding of the matter under discussion. But that in no way negates the need for a thorough, systematic reading of a standard textbook. Try and finish this book at a stretch at least a month before the exami nation date. That should help give you sufficient time in the end to concentrate on the most important subject areas for the examination.1. THEME : VASCULAR DIAGNOSIS EEE NS IAG OPTIONS . Venography . Colour-flow duplex + Computed Tomography (CT) angiography » Magnetic Resonance (MR) angiography Ankie Brachial Pressure Index (APT) Air plethysmography . Arteriography OA™™7 970m, Which is the most appropriate in vestigation for the following patients? Select an option from those listed above. Each option can be used once, more than once or not at ail, 1. A 59-year-old man, a heavy smoker, had an 8-month history of cramps in the left calf on walking. He noticed a small painful ulcer in his great toe, which is not healing for the past one month. 2. A 67-year-old female underwent emergency laparotomy with re- Section of an obstructive mass of the sigmoid colon 5 days ago. Today her left thigh and leg appear markedly swollen with induration of the calf. 3. An ultrasound of a 63-year-old man showed an aortic aneurysm of 6.5-cm diameter. 4. A 56-year-old male presented with superficial necrosis of the right foot. He is on irregular treatment for diabetes mellitus for the past 14 years. On examination, his popliteal pulse is palpable, whereas dorsalis pedis and posterior tibial pulses are not palpable 4 c z a ONIATOS W31g0¥d TY.Wael master CLINICAL PROBLEM SOLVING 1, ANSWERS 1.G- arteriography — Rest pain, ulceration and gangrenous changes foliowing claudication are classical of critical limb ischemia, which is best evaluated by an arteriography. It may be diagnostic a5 well as Crucial in planning interventions. Tt can aiso be useful therapeutically to treat arterial stenosis by endovascular angioplasty. Colour-flow duplex is an operator-dependent technique with a sensitivity of 70- 90% and specificity of 90-98% for identification of femoro-popliteal arterial stenosis. It may be the preferred initial investigation as It is non-invasive 2.8 - Colour-flow duplex. This patient most probably has deep Venous thrombosis (DVT), the risk factors being advanced age, ma- lignancy, major operative procedure and immobilization. Contrast venography, although the ‘gold standard’ for evaluation of acute and chronic DVT, is used less frequently after the advent of duplex imag- ing. Ascending or descending venography may be useful to detect valvular incompetence. Colour-flow duplex scan has 8 95 to 98% sen~ sitivity and specificity for detection of OVT, although it is less sen- sitive for isolated calf vein thrombosis. 3. C= Computed tomography angiogr-phy Ultrasound is a use- ful screening as well as follow-up tool for abdominal aortic aneurysms: CT angiography is the optimal imaging method for evaluation prior to abdominal aortic aneurysm repair Spiral CT and three-dimensional reconstruction provide important details of anatomical extent of aneu- rysm and its relation to surrounding structures 4.0 -MR angiography, This patient also nas peripheral arterial occlusive disease with critical ischaemia, He needs further evaluation to decide regarding revascularisation. In a diabetic patient, renal fail- ure is not uncommon. MR angiography eliminates the risk of contrast nephropathy and identifies patent distal vessels with high accuracy. ABP! isa simple and rapid test for assessment of limb ischacma, An AgPl< 0.9 indicates presence of lower limb arterial disease, whereas 3 value below 0.5 is suggestive of critical limb ischaemia and Imm ‘ent gangrene. It is unreliable in presence of incompressible vessels pe thiabetes and renal failure. Plethysmagraphy is 2 non-invasive metho vr detecting blood volume changes in extremity and is infrequently used for evaluation of venous reflux and venous pressure in venous insufficiency.