common questions asked in the MRCS Viva Examination

Below are common questions asked in the MRCS Viva Examination 2005 - 2009.

¨¨¨ Very Common question
¨ Asked occasionally in last 4-5 years of Examinations


Physiology


Critical Care


Pathology


Principles of Surgery


Anatomy


Operative Surgery














Physiology



¨¨¨ Blood pressure: Definition, Calculation of MAP, Control mechanisms to maintain BP.

¨¨¨ Oxygen dissociation curve.

¨¨¨ Shock: Definition, Classification, Physiological mechanisms involved.

¨¨¨ Body fluid compartments

¨¨¨ Normal blood gas values & interpreting ABG's

¨¨¨ Autoregulation: Definition, example of organ. What is the Kellie-Munro doctrine?

¨¨ CVP and PAWP. Draw the JVP curve with labels and then explain the diagram. How is CVP measured on ward?

¨¨ How is CO2 carried in the blood? Write equations? Where does carbonic anhydrase live? What is the chloride shift?

¨¨ Calcium homeostasis: Hormones involved. Causes of hypercalcaemia. Calcium distribution. What are the consequences of Vitamin D deficiency?

¨¨ What are differant types/classification of Renal failure? How you will manage them? What is GFR?

¨¨ Role of acid-base on calcium transport and symptoms of hyperventilation.

¨¨ Thermoregulation: physiological responses to hypothermia

¨¨ Respiratory physiology, chemoreceptors, mechanics of ventilation. What are the forces acting on the lung?

¨¨ Stress Response.

¨¨ Tell me about the production of thyroid hormones? How would you manage a patient with thyrotoxicosis pre-op?

¨¨ What factors are involved in clotting? What factors can help you intra-operatively to gain haemostasis?

¨ What is a buffer? How does it work? BICARB/co2 equation

¨ Gastric fluids, What is absorbed at the terminal ileum?

¨ White cells and their parameters: Definitions.

¨ What are the causes of hypoglycaemia?

¨ What are functions, half life, site and mechanism of production, of Erythropoiten?

¨ Tell me the effects of bed rest on the body. What problems do bedridden patients face?

¨ cardiac cycle and atrial pressures.

¨ Acid secretion in the stomach. Physiological consequences of total gastrectomy

¨ Vit B12 physiology

¨ ADH - what is it, where produced, actions.

¨ Portal circulation: Definition, causes of portal hypertension and consequences

¨ Pyloric stenosis

¨ RAA axis. What is Renin and what are its functions?

¨ Analgesic ladder. Pain pathways.

¨ Blood - principles of crossmatching, it uses and alternatives. Transfusion reactions.

¨ Asked about small bowel resection and what problems would the individual have.

¨ Asked to explain principles behind CPAP.

¨ Head injury - asked about CPP, equations, how to manage raised intracranial pressures. Was asked about brainstem death and how to certify.

¨ ARDS and how I would manage a patient in this situation.

¨ Draw the graph seen with a PAFC insertion and explain the different traces.

¨ How does aspirin work?

¨ Spleen: functions. Physiological changes after splenectomy

¨ The Loop of henle. Definition and function

Critical Care


¨¨¨ Sepsis management guidelines.
¨¨¨ What is shock? Types? Tell me about anaphylactic shock, how is it managed? blood loss features & categories of haemorrhagic shock
¨¨¨ Pancreatitis: scoring systems and pathophysiology.
¨¨¨ Pneumothorax: definition, classification. Management of tension pneumothorax.
¨¨ Brain stem death. How is it certified? Persistant vegetative state: Definition
¨¨ Small bowel fistulas: Physiological consequences.
¨¨ Surgical airways: Classification. Insertion of Tracheostomy.
¨¨ Premedications: Indications and classification
¨¨ Burns: definition, classification & management
¨¨ ABGs : normal values, metabolic acidosis, henderson-hasselbach equation
¨¨ What are the admission criteria for most ITUs. Criteria for accessing HDU. WHat does HDU provide?
¨ Post thyroidectomy complications: Nerve injuries and respiratory distress how to manage?
¨ Diabetes Mellitus management in critically ill patient.
¨ Fat Embolism Syndrome
¨ Arterial blood gas analysis - what happens in gastric outlet obstruction (ie met alkalosis)
¨ Define restrictive/ obstructive lung diseases & Volume-flow loops in restrictive and obstructive lung disease
¨ Post-op bleeding : Classification & aetiology.
¨ Physiological effect of infusion of 2L Normal Saline.
¨ Oliguria: Causes & Physiology.
¨ Define and discuss physiological and pathological respiratory dead space.

Pathology




¨¨¨ Colitis: classification. Crohns Vs UC

¨¨¨ What different types of aneurysm do you know of? What is the most common cause of false aneurysm?

¨¨¨ What organisms most commonly cause septic arthritis? High risk patients?

¨¨¨ Fistulae: definition & Classification. How do you determine high and low output fistulas?

¨¨¨ Metaplasia, dysplasia, neoplasia: definitions, examples of each.

¨¨¨ Types of jaundice. Investigation

¨¨¨ Mechanisms of Tumour spread. Dukes staging. Advantages & Disadvantages?

¨¨ Pagets disease of bone: definition & complications

¨¨ Types of necrosis. What is the difference between the necrosis and apoptosis.

¨¨ Abscess & Pus. Pelvic Abscess

¨¨ What is a frozen section? Why is it unpopular? indications, advantages/disadvantages

¨¨ DVT prophylaxis

¨¨ Features of a good screening programme. screening and breast cancer,inc triple assessment

¨¨ Types of breast carcinoma.

¨¨ malignant melanoma: definition, classifications, staging/grading

¨ alcoholic pancreatitis

¨ What is a Pathological fracture? Causes? metabolic bone disease

¨ leg ulcers: definition & classification

¨ intracranial bleeding. Management of extradural. Pathology of berry aneurysms

¨ Embolism: definition & classification

¨ Coagulation.Virchow triad.

¨ Granulomas: definition, examples.

¨ Anaemia: Microcytic & Macrocytic Anaemia

¨ UTIs: classification, high risk patients.

¨ Aortic dissection

¨ Amyloidosis: definition & classification

¨ Pathophysiology of septic shock and definitons

¨ Sensitivity, specificity: definition

¨ What is the American classification of colorectal cancer?

¨ Thyroid cancers.

¨ Pathology of pressure sores and treatment

¨ How do you work a COPD patient up pre-operatively? What are the considerations?

¨ Calcification: definitions & classification

¨ Atypical Microbacteria: Definition & classification

¨ Wound healing; physiological and pathological (Keloid scarring)

Principles of Surgery



¨¨¨ DVT prophylaxis: define, predisposing factors, prevention

¨¨¨ What is a graft/Flap? Where do you farm a grafts from? Classification? How do you manage a donor site?

¨¨¨ Name different types of sutures and needles.

¨¨¨ Pancreatitis. Scoring systems. How would you manage a patient with pancreatitis admitted from A&E.

¨¨¨ Diathermy. Definition & Classification

¨¨¨ Difference between G+S, X-M

¨¨ Types of throid cancers, pathology, epidemiology, etc

¨¨ Consequences of splenectomy - abx coverage
¨¨ Local anaesthetics; dosing, uses, and complications

¨¨ Ureteric injury at differant levels and management

¨¨ What are the different causes of lumps in the femoral triangle, how would you manage each one.

¨¨ Closing the abdomen? What is a burst abdomen? What are deep tension sutures?

¨¨ Fat embolism

¨¨ Fistula in ano classification

¨¨ Gall stone complications + investigations

¨ Management of Acute Ischaemic Limb

¨ Blood transfusion reactions

¨ Radiotherpy.Adjuvant radiotherapy and bowel Ca

¨ Parotid tumours. Surgery and complications

¨ DD of swelling in neck

¨ Principles of skin closure

¨ FFP: constituents, indications for use, complications

¨ Complications of a midshaft femur # & open fractures

¨ ERCP: indications & complications

¨ Management of a surgical patient with diabetes

¨ Flail chest -assoc injuries - management (ie ATLS) and also re: Mx rib #s

¨ Gunshot wound classification

¨ Wound healing: Classification, factors involved. Wound dehiscence.

¨ management of head injury patient, equation for cerebral perfusion pressure, monro-kelly doctrine and secondary brain injury

¨ Pyloric stenosis: cogenital and acquired

¨ Mediastinitis

Anatomy



¨¨¨ CT: normally T12, L1 section. Organs, vessels and lesser sac

¨¨¨ The femoral triangle

¨¨¨ Cross section of calf & Compartment syndrome

¨¨¨ Posterior cranial fossa & dural venous sinuses

¨¨¨ Pneumothorax and chest drain anatomy

¨¨¨ Insertion of a subclavian line - the landmarks on live model

¨¨¨ Inguinal ligament, layers dissected through for hernia repair

¨¨¨ Identify knee joint structures & ligaments

¨¨ Assemble bones in the arm.

¨¨ Classification & complications of nerve injury

¨¨ Gross anatomy of brain and functions

¨¨ Intrinsic muscles in hand

¨¨ The foot: the subtalar joint and muscles of inversion and eversion. Names the bones of the foot? What types of amputation do you know in the foot?

¨¨ Skull x-ray and asked questions on the nasal conchae, where the openings were, where they drained. what is the nasal septum made of?

¨¨ Heart - valves and blood supply. What is the surface anatomy of the heart?

¨ Spine: anatomy of disc + complications of prolapse

¨ Facial Nerve: pathway & injury

¨ Blood supply to stomach

¨ Superior mediastinum - identifying contents in cadaver

¨ MRI shoulder: anatomical/surgical humeral neck, rotator cuff

¨ Sapheno-femoral junction and tributaries

¨ Sigmoid colon: blood supply

¨ Post triangle of neck

¨ Surface Anatomy model: Identify the antecubital fossa, what are the landmark boundaries? What are the contents?

¨ Anatomy and segmentation of liver

¨ Path of accessory nerve & complications of injury

¨ Shown a barium study and asked to identify the different parts of bowel and which parts were retroperitoneal.

¨ What is the nervous innervation of the penis?

¨ Chest Cadaver: identification of impressions on left and right lung specimens. What is the hering-breuer reflex? Identify the structures in the lung hilum.

¨ Upper limb cadaver: identification of upper limb nerves and was asked what would happen if this structure was damaged.

¨ Spleen: anatomy & function

¨ A rib: identification of level and facets etc...

¨ A thoracic vertebra: identification of level and facets etc...

¨ Neck (mostly thyroid and nerves)

¨ Ureter and blood supply

¨ Tell me the anatomical location of the parathyroids? How are they identified? What is their embryological derivation?

¨ Tongue innervation & muscles

¨ Hypoglossal nerve: Anatomy & function

Operative surgery



¨¨¨ Inguinal hernia repair. Why can testicular atrophy occur in hernia repair?

¨¨¨ How do you fix a hip? Options and basic operative technique. What is the blood supply to the femoral head?

¨¨¨ Tracheostomy - indications, anatomy, procedure, instruments required

¨¨¨ What types of bowel anastomosis do you know? How are they carried out?

¨¨¨ Breast abscess

¨¨¨ Compartment Syndrome: Risk factors, Clinical presentation, & management.

¨¨¨ Chest drain insertion and care

¨¨¨ Appendicectomy

¨¨ Femoral hernia, with different approaches. High approach

¨¨ Subclavian line. Indications and proceedure

¨¨ Fissure-in-ano

¨¨ Intestinal anastomosis principle

¨¨ What causes fistula. Treatment principles

¨¨ Open Fracture Classification and management priniciples

¨ Paediatric fractures: classification & management

¨ DJ stent: how to insert & complications

¨ Anal Fissures

¨ Bowel obstruction: Aetiology, investigations, & management

¨ Left hemi-colectomy

¨ Indications for toe amputation, Ray excision

¨ Embolectomy - draw important relevant anatomy and op

¨ Crohn's disease of rectum and anus - management. surgical operations

¨ Scars: hypertrophic, keloid

¨ Peripheral nerve palsies: radial, ulnar, sciatic, common peroneal

¨ Acute Ischaemic limb: signs, management

¨ What do you understand about preparing patients in theatre? What is Betadine?

¨ How would you take an Ankle-Brachial pressure index?

¨ When would you use a J shaped needle?

Applied Physiology

1.How is oxygen carried in the blood?

◦What is the mechanism of binding of oxygen to haemoglobin?

◦What is this called?

◦Draw the oxygen dissociation curve?

◦What does 50% saturation mean?

◦What partial pressure does 92% saturation correspond to?

◦What partial pressure does 50% saturation correspond to?

◦What is the right shift called? (Bohr effect)

◦What are the factors determining right shift?

◦What is the physiological consequences? Why is this useful?

◦Draw the shape of the ODC for methaemoglobinaemia

◦What is the pathophysiology of methaemoglobinaemia?

◦What is the affinity ratio in methaemoglobinaemia for oxygen with respect to normal haemoglobin?



2.What is ARDS?

◦What are the defining features? What are the criteria?

◦What are the causes of ARDS?

◦What direct lung causes do you know?

◦What systemic causes of ARDS do you know?

◦How do you manage ARDS?

◦What are the ventilatory options?

◦How do you improve lung compliance?

◦How does nitric oxide work? / prostacyclin

◦How else can you treat pulmonary hypertension?



3.What muscle relaxants do you know?

◦What classes of muscle relaxants do you know?

◦How does suxamethonium work? What is it's structure?

◦How is suxamethonium metabolised at the neuromuscular junction?

◦What other cholinesterases do you know?

◦Why would you want to use a muscle relaxant? When is paralysis useful?

◦What is myasthenia gravis?

◦What is the deficiency in myasthenia gravis?

Critical Care


1.What uses of central lines do you know?

◦What information can you determine from a central line?

◦How would you perform a fluid challenge? What fluid would you give? How much would you give?

◦What is the tracing of the central line waveform?

◦How is the CVP related to the right atrium? What does that mean?

◦How do you insert a CVP line?

◦What do you need to do before you use your central line (check tip, ensure tubing correct, calibrate)

◦What fluid is used for CVP transduction tubing?

◦Draw the graph for CVP change following a fluid challenge in an underfilled patient


2.What options are there for pain control?

◦What is the pain ladder?

◦What routes of administration of analgesics do you know?

◦How can you give opiates?

◦What is the metabolism of morphine?

◦What is the bioavailabilty of morphine? How much is metabolised in the liver?

◦What is the problem with intermittent bolusing of opiates?

◦What is the analgesic effect of morphine?

◦Draw the graph of efficacy/potency of morphine analgesia with regards to its half life

◦What is PCA?

◦How is it delivered?

◦Is it safe? Why?

◦What do you know about epidurals?

◦What drugs are used in epidural analgesia?

3.What is a pneumothorax?

Pathology



1.What is an embolus?

◦Give examples of embolus - fat, thrombus, amniotic fluid, air, nitrogen, septic

◦What is a pulmonary embolus?

◦What is the source of the embolus?

◦What effects would a deep venous thrombosis present with?

◦What are the features of a pulmonary embolus?

◦What are the features of arterial thrombi?

◦What are the sources of arterial emboli (Left atrium/ventricle, narrowed peripheral circulation, atheromatous
diease)

◦What organs are affected and what are the clinical manifestations?

◦What is a fat embolus?

◦What is the aetiology? What are the pathophysiological theories behind fat emboli?

◦What types of patients get fat emboli?

◦What are the clinical features?

◦What are the risk factors for arterial emboli?



2.What is an ulcer?

◦What factors affect ulcer healing?

◦What is the pathophysiology of peptic ulcer disease?

◦What is helicobacter pylori?

◦How does it cause ulcerations in the stomach?

◦What are the ways in which helicobacter can be diagnosed?

◦Do you know of any blood tests?

◦What is the urease breath test?

◦What is the tissue pathological test?

◦What is the CLO test?

◦What does CLO stand for?

◦What infections cause ulcers?

◦What nutrient deficiency causes ulcers?

◦What skin tumours causes ulcers?

◦Name as many skin tumours as you can!


3.What is hyperparathyroidism?

◦How is hyperparathyroidism classified?

◦If 85% is due to a secreting adenoma, what is the rest due to?

◦What is secondary hyperparathyroidism?

◦What are the causes?

◦Who gets secondary hyperparathyroidism?

◦What is teritiary hyperparathyroidism?

◦What are the biochemical changes in each?

◦What is the physiogical effect of parathyroid hormone?

◦What are the effects?

Priniciples of Surgery



1.What is a subphrenic abscess?

◦Have you seen one before?

◦What are the causes?

◦What are the clinical features of a subphrenic abscess?

◦What are the nerve supplies to the diaphragm seeing as you brought it up...?

◦What are the biochemical changes?

◦Do you always get pain?

◦What features would you see on a chest x-ray?

◦What other imaging would you do apart from ultrasound?

◦How would you treat this?

◦What is the principle in treatment of an abscess?

◦What drainage options are there for subphrenic abscesses?



2.What is mediastinitis?

◦What are the defining features?

◦How do you get mediastinitis?

◦What is rupture of the oesophagus known as (Boerhaave's phenomena)

◦What imaging modalities would you do?

◦What can you see on a chest x-ray (surgical emphysema)

◦What are the principles of treatment?

◦What would you treat? When would you treat? How would you treat?



3.What is your approach to scrotal pain?

◦What are the causes of scrotal pain?

◦What is the nerve supply to the testicle?

◦How does it enter the scrotum?

◦What are the causes of testicular inflammation?

◦What is testicular torsion?

◦Who gets testicular torsion?

◦Why do patients have abdominal pain?

Applied Surgical Anatomy



1.Shown a right femur

◦What is this?

◦What type of joint is the hip joint?

◦What six movements are possible at the hip joint?

◦What biochemical property of the femur allows it to be so mobile?

◦What is the blood supply to the head of the femur?

◦How does it get to the head of the femur?

◦What are the ligaments of the femur?

◦Which of these is the strongest?

◦Illustrate the attachments of the femoral capsule? Why is it important to know this?

◦What is the significance of the foveal blood supply?

◦When is the blood supply via the ligamentum teres important?



2.Shown a saggital section of the pelvis

◦What is this? What type of scan is it? What kind of section is it?

◦What are the structures that you can see?

◦What are the limits of the peritoneal markings?

◦How far exactly does the peritoneum extend inferiorly?

◦How much of the bladder is covered by peritoneum?

◦How much of the uterus is covered by peritoneum? What is the broad ligament?

◦What is the space behind the uterus called?



3.Shown the facial nerve

◦What is this?

◦What is this gland (the parotid)?

◦How many branches of the facial nerve are there?

◦Name them

◦How can you test the facial nerve? What muscles in particular can you test?

◦What's this (submandibular gland)?

◦What is the nerve supply to the submandibular gland?

◦If the cervical branch of the facial nerve is injured, what deficits would you expect to see?


4.Shown the Sigmoid colon on a cadaver

◦What is this?

◦How do you know?

◦How can you tell large bowel apart from small bowel?

Operative Surgery



1.A patient presents with a dorsally angulated distal radius fracture in casualty.

◦What is your approach?

◦How would you examine the patient?

◦What features would you look for?

◦What analgesia would you give?

◦How would you perform a haematoma block?

◦What anaesthetic do you use?

◦What is the appropriate dose of lignocaine?

◦What are the features of local anaesthetic toxicity?

◦Would you use anything else with the local anaesthetic (adrenaline)

◦Why would adrenaline help?

◦In what circumstances would you not use adrenaline?

◦What other local anaesthetics do you know?

◦What is special about bupivacaine? Under what circumstances have you used it?

◦What is special about marcaine? What is it's specific gravity? Why is that important to anaesthetists



2.How do you manipulate a fracture?

◦What is Newton's third law?

◦How would you manipulate a distal radius fracture?

◦What are you doing to the fracture when you increase the tilt?

◦Why are you doing this?

◦What is dis-impaction?

◦How would you apply the plaster? How many layers of plaster?

◦Where would you plaster from and to? Why? (immobilise joint above and below) What physical property are you
using?

◦What follow up would you do for this patient?

◦How long does an upper limb fracture take to heal?

3.What is a gastrostomy?

◦When would you use it?

◦What type of patients require it?

◦What methods of insertion do you know of?

general notes ( pesonal eperience ) :

- every candidate who passed the viva had at least one or two very very bad bay performane and was epecting to be disqualified but the put it behind and complete.

- the examiners are truely want to pass you

- u can always ask for eplanation of the question or try general answers and let them lead you through the answer

- the marking system favoures adding marks rather than lowering your score.

- always speak logic systematic approach to any question you know its answer or u don't.

pathology :

- nipple discharge :
D.D
APPROACH AND INVESTIGATIONS
cytology or histopatholgy ( difference ? )
how to get a sample and what to do with it ?
how to stain it ?

-prognosis of colorectal carcinoma :

what factors determine prognosis ?
what is dukes classification
TNM classification
staging and grading
what is R0 R1 ?

PRINCIPLES OF SURGERY :

- empyema :

define ? where ? examples ?
who is predisposed to empyema ?
how it is formed ?
causative organisms ?
management ?

- preoperative C.V.S assesment :

risks of patient with heart problems undergoing operation
what complications may happen ?
how can you manage them ??
which heart diseases could be significant and how?