The Insider's Guide to the MRCS Clinical Examination

Jonathan Fishman, Vivian Elwell, Rajat Chowdhury

• Publisher: CRC Press
• Year: 2021
• ISBN:
  9780429533389
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

'The MRCS Clinical Examination is the final requirement to obtain the professional qualification for the Intercollegiate Membership of the Royal College of Surgeons. This Membership allows the transition from doctor to surgeon and a career in higher surgical training. This standardised clinical examination requires candidates to demonstrate their ability in examining patients, with effective and clear communication. 'The authors should be commended on producing a book that covers all clinical sections of the Examination, in such a concise, comprehensive and structured manner.This study guide will serve as your personal tutor working closely with you, prompting and providing pointers to improve your examination technique. It includes dozens of clinical scenarios, demonstrating how to examine the system and avoid common mistakes. In addition, the candidates can improve their communication skills, which is an integral part of this Examination. This book complements the "Insider Medical MRCS Clinical Course". It simulates the actual test conditions by providing sample cases and answers, coupling identification of weaknesses and strengths. This book will also prove to be extremely valuable for the new-style MRCS OSCE' - Nigel Mendoza in his Foreword.

SECTION A

DOI: 10.1201/9780429091421-2

The introduction

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When you approach any patient in the exam, do not forget to first wash your hands with the hand gel. Then, as a general principle, remember the three P’s:

• ◗ permission
• ◗ position
• ◗ pain.

It is worth memorising an introductory sentence before approaching any patient in the exam. A useful sentence for introducing yourself and gaining consent might be:

‘Good morning/afternoon. Thank you for coming along today. I’m one of the surgical doctors taking part in the examination today. May I examine you please?’

Consent has then been obtained. To examine a patient without having first obtained consent would constitute battery, resulting in an automatic fail.

Always gain adequate exposure of the area that you wish to examine, and position the patient appropriately.

Always ask the patient whether they have any pain before you lay a hand on them.

You may then begin to inspect around the patient for clues (walking aids, truss, etc.).

There are two ways to summarise your findings at the end of the examination. The first method is to be bold, state the diagnosis and then list the features in favour of the diagnosis. For example:

‘This patient has a toxic multinodular goitre, as evidenced by …’

This method is fine if your diagnosis is correct, but if you are wrong it can have deleterious effects.

The alternative and often preferred method is to summarise your relevant clinical findings (positive and negative) and then conclude with a sentence such as:

‘This is consistent with a diagnosis of …’ or

‘These findings support a diagnosis of …’

Superficial lesions: head, neck, breast and cutaneous lesions

DOI: 10.1201/9780429091421-4

Approach to any lump (or cutaneous lesion)

Examination of the parotid lump

Examination of the submandibular region

Examination of the neck and thyroid gland

Examination of thyroid status

Assessment of thyroid status

‘Please ask this patient some questions …’: thyroid status

Common causes of neck swellings in the MRCS clinical exam

Causes of thyroid goitres

The solitary thyroid nodule

The breast examination

‘Please ask this patient some questions …’: breast

Approach to any lump (or cutaneous lesion)

1. Introduce yourself to the patient and wash your hands.
2. Look.
   The rule of S’s:
   • ◗ Site (distance in cm from nearest joint, anatomical triangle of neck, etc.).
   • ◗ Size (diameter in cm).
   • ◗ Shape (hemispherical, lobulated, etc.).
   • ◗ Surface and smoothness – overlying punctum, smooth/ bosselated surface.
   • ◗ Skin overlying – skin changes/colour, scars (with an overlying scar think of an implantation dermoid, pyogenic granuloma or recurrence following surgery).
   • ◗ Surroundings – other lumps, satellite nodules.
   • ◗ Special characteristics – e.g. moves with swallowing, protrusion of tongue.
   • ◗ Edge – well-defined/ill-defined edge/border.
3. Palpate.
   Tenderness – ask ‘Is it tender if I press it?’
   Temperature – use the back of the hand (which is more sensitive).
   Try to ascertain which layer the lump is in. (Can you pinch the skin overlying the lump, or can you move the skin over it? Does the lump move with the skin?)
   For skin lesions, is it flush with the skin, or is it raised?
   Tense/contract the underlying muscle:
   • ◗ Test for mobility/fixity of the lump at rest in two orthogonal planes.
   • ◗ Then ask the patient to contract the underlying muscle.
   • ◗ Ask yourself whether the lump is more or less prominent.
   • ◗ Ask yourself whether the lump is more or less mobile with the muscle contracted (in two planes).
   Consistency – soft, firm, hard or bony hard. Fluctuance – in two planes at right angles to each other (Paget’s sign).
   Regional lymph node status (NEVER forget this!)

Insider's tip

As a general rule, if the lump:

• retains mobility and is more prominent when the underlying muscle is contracted, the lump is superficial to muscle
• is more prominent but less mobile when the underlying muscle is contracted, the lump is attached to fascia or superficial surface of muscle
• is less mobile and less prominent when the underlying muscle is contracted, the lump is within muscle
• is less mobile and less prominent when the underlying muscle is contracted, the lump is deep to muscle.

The one exception to the rule occurs when there is a defect in the muscle. In such cases, although the lump arises in, or deep to, the muscle, it appears more prominent when the muscle is contracted (e.g. ruptured muscle fibres as in a torn long head of biceps, incisional hernias, divarication of the rectus sheath, etc.).

Extra tests – cough impulse, reducibility, compressibility, thrill, transillumination, pulsatility and expansility.

4. Percuss.
5. Auscultate – bruits, bowel sounds.
6. Surrounding neurovascular status – distal pulses, sensation.
7. Ask the patient some questions/take a full history.
8. Assess the impact of the condition on the patient’s life.
9. Assess the patient’s fitness for surgery.
10. Thank the patient and wash your hands.
11. Summarise and offer your differential diagnosis.

Note: If you suspect lymphadenopathy, do not forget to check the drainage sites and check other areas for lymphadenopathy (cervical, axilla, epitrochlear, inguinal region, spleen, liver).

For example, in a patient with inguinal lymphadenopathy, the areas that drain to the inguinal lymph nodes include the lower limbs, the lower anterior abdominal wall (below the level of the umbilicus), and the perineum, anus, buttocks, scrotum and external genitalia, but not the testes, which drain to the para-aortic lymph nodes. All of these areas need to be checked carefully for sites of infections, or primary carcinomas.

Likewise, in a patient with a pre-auricular lymph node mimicking a parotid swelling, do not forget to check the scalp carefully for a squamous-cell carcinoma or malignant melanoma hidden within the hair!

Examination of the parotid lump

1. Introduce yourself to the patient and wash your hands.
2. Look at both sides and proceed as above. Look carefully for scars.
3. Palpate – proceed as above. Ask whether the lump is tender before feeling it, and ask the patient to tense the underlying masseter muscle by requesting them to clench their jaw. Test for fixity. Define the characteristics of the lump, as you would for any other lump.
4. Examine the regional lymph nodes.
   Look for evidence of scalp infection, or a primary carcinoma hidden in the scalp (if you suspect a pre-auricular lymph node).
5. Check the oral cavity/oropharynx – use two tongue depressors and ask the patient to move their tongue to the right, to the left, place it on the roof of the mouth and then say Aaaaah, so that you can look at the palate and fauces.
   • ◗ Exam...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Table of Contents
• Foreword
• About the authors
• Preface
• List of abbreviations
• Dedication
• Introducing the MRCS clinical exam: the Insider’s guide to success
• Section A
• Section B
• Index