MRCS Practice Papers Part A: Paper 2 EMQs - PasTest

MRCS Practice PapersPart A: Paper 2EMQsSecond edition

ContentsForewordExamination techniqueAbbreviationsviiixxiQuestionsPractice Paper 1 3Practice Paper 2 55Practice Paper 3 105AnswersPractice Paper 1 153Practice Paper 2 203Practice Paper 3 251Index 295

3QUESTIONSPRACTICE PAPER 1THEME: DIATHERMYPAPER 1 QUESTIONSA Monopolar diathermyB Bipolar diathermyC CuttingD CoagulationE BlendFor each of the following scenarios, choose the most appropriate optionfrom the list above. Each option may be used once, more than once ornot at all. 1 2 3 4 5Requires a patient plate electrode to be applied.This is safer to use in patients with pacemakers.Uses pulsed, short, high-frequency bursts.Safe for use on digits.Can be used for buzzing (touching other instruments to passcurrent through them).

4 MRCS PRACTICE PAPERS PART A: PAPER 2 EMQSPAPER 1 QUESTIONSTHEME: EXTENSOR COMPARTMENTS OF THE WRISTA IB IIC IIID IVE VF VIFor each of the following statements, choose the most appropriatecompartment from the list above. Each option may be used once, morethan once or not at all. 6 7 8Extensor carpi radialis brevis is in this compartment.This compartment lies radial to Lister’s tubercle at the wrist.Extensor digiti minimi is in this compartment.

QUESTIONS5THEME: SEPSISA BacteraemiaB Systemic inflammatory response syndrome (to sepsis) (SIRS)C SepsisD Severe sepsisE Septic shockPAPER 1 QUESTIONSFor each of the following clinical scenarios, choose the most appropriatediagnosis from the list above. Each option may be used once, more thanonce or not at all. 9 10 11 12A 30-year-old man presents with severe right loin pain, radiatingto the groin. A mid-stream urine (MSU) shows blood, proteinand nitrites. A KUB study reveals a calculus. His temperature is39.1 °C, pulse 127/min, respiratory rate (RR) 38 breaths/min andBP 81/43 mmHg despite 3 litres of intravenous fluids, and hiswhite cell count (WCC) is 21 × 10 9 /l.A 79-year-old woman 1 week post-op has a pyrexia of 38.4 °C,pulse 104/min, BP 144/90 mmHg and WCC 14 × 10 9 /l. Chest X-ray (CXR) shows a left lower lobe pneumonia.A 30-year-old male post-op patient had blood cultures taken48 hours ago which are positive. He is currently apyrexial, pulse64/min, RR 12 breaths/min, BP 123/82 mmHg, with a normalWCC.A 27-year-old female post-op patient has a temperature of38.7 °C, pulse 86/min, RR 24 breaths/min, BP 127/74 mmHgand WCC 16 × 10 9 /l. Her CXR is clear, an MSU negative and thewound is fine.

6 MRCS PRACTICE PAPERS PART A: PAPER 2 EMQSPAPER 1 QUESTIONSTHEME: FACIAL NERVE PALSIESA Multiple sclerosisB Acoustic neuromaC SarcoidosisD CholeasteatomaE Parotid tumourF SurgeryG Temporal bone fractureH Ramsay Hunt syndromeIJKChronic suppurativeotitis mediaCerebrovascular accident(CVA)Bell’s palsyFor each of the following scenarios, choose the most appropriate optionfrom the list above. Each option may be used once, more than once ornot at all. 13 14 15 16 17 18An 18-year-old man presents to A&E with a head injury. He has afacial nerve palsy, Battle’s sign and haemotympanum.A 30-year-old woman presents with a sudden-onset facial nervepalsy sparing the forehead. She has a past medical history ofoptic neuritis.An 80-year-old man presents with a facial nerve palsy, precededby severe pain in the distribution of the facial nerve. He reportsvertigo and hearing loss. Papules are seen on the tongue.A 50-year-old man presents with a facial nerve palsy. He has hadan intermittent discharge from his right ear for 2 months. He hasposterosuperior retraction of the tympanic membrane.A 55-year-old woman presents with a facial nerve palsy,sensorineural hearing loss, tinnitus and vertigo.A 23-year-old man presents with a facial nerve palsy and a3-month history of conductive hearing loss. The tympanicmembrane is dull in the left ear.

QUESTIONS7THEME: ANAESTHETIC AGENTSA Thiopentone sodiumB PropofolC EtomidateD SuxamethoniumE AtracuriumF VercuroniumG HalothaneH EnfluraneI IsofluraneJ SevofluraneK Nitrous oxidePAPER 1 QUESTIONSFor each of the following statements, choose the most appropriate agentfrom the list above. Each option may be used once, more than once ornot at all. 19 20 21 22Can cause a ‘coronary steal’ syndrome.The most rapidly acting depolarising muscle relaxant.The only inhalational anaesthetic not known to cause malignanthyperpyrexia.The induction agent with a slight anti-emetic effect, which is theagent of choice with laryngeal masks.

8 MRCS PRACTICE PAPERS PART A: PAPER 2 EMQSPAPER 1 QUESTIONSTHEME: FLEXOR TENDON INJURIESA Zone 1B Zone 2C Zone 3D Zone 4E Zone 5For each of the following injuries, choose the most appropriate zonefrom the list above. Each option may be used once, more than once ornot at all. 23 24 25Laceration across both hypothenar and thenar eminences.Most difficult to repair, often yielding poor functional outcome.Laceration across the metacarpophalangeal (MCP) joints.

QUESTIONS9THEME: DAY-CASE SURGERYABSuitable for day-case surgeryUnsuitable for day-case surgeryFor each of the following patients, choose the most appropriate optionfrom the list above. Each option may be used once, more than once ornot at all.PAPER 1 QUESTIONS 26 27 28A 40-year-old woman listed for varicose vein stripping, with nosignificant past medical history. Weight 90 kg, height 155 cm.Her husband can look after her post-op and she lives 10 minutesfrom the hospital.A 64-year-old with well-controlled asthma listed for rigidcystoscopy. Weight 74 kg, height 173 cm. He lives with his wifeapproximately 10 minutes form the hospital.A 50-year-old man with angina requiring frequent GTN spray,listed for a knee arthroscopy. Weight 70 kg, height 180 cm. Helives with his wife approximately 5 minutes from the hospital.

10 MRCS PRACTICE PAPERS PART A: PAPER 2 EMQSPAPER 1 QUESTIONSTHEME: URINARY SYSTEM TRAUMAA Class IB Class IIC Class IIID Class IVE Class VFor each of the following scenarios, choose the most appropriate traumaclass from the list above. Each option may be used once, more than onceor not at all. 29 30 31An 18-year-old football player who sustained a kick to the loinduring a game subsequently develops microscopic haematuria.A 30-year-old man who has been stabbed in the right loinwith a kitchen knife arrives in A&E with a pulse of 112/min, BP120/100 mmHg. He has frank haematuria. IVU reveals urinaryextravasation.Following a hysterectomy a patient has macroscopic haematuria,ileus, pain and a low-grade fever. IVU reveals leakage from theleft ureter. A 75% laceration with no devascularisation is found.

QUESTIONS11THEME: BURNSA 10 800 mlB 5400 mlC 8640 mlD 4320 mlE 17 280 mlF 14 400 mlPAPER 1 QUESTIONSFor each of the following scenarios, choose the correct volume of fluidreplacement required from the list above. Each option may be used once,more than once or not at all. 32 33 34 35A man weighing 80 kg is admitted as an emergency after beingrescued from a house fire. He has red, painful, blistered burnsto his right arm, chest and abdomen. How much fluid does herequire over the first 24 hours following his injury?A 60-kg woman is admitted to A&E with extensive burns. Herleft arm and leg have dry, white, painless burns, and her anteriortorso has erythematous painful burns with blistering. How muchfluid does she require over the first 8 hours after her injury?A 120-kg chef is involved in a fire at work. He has sustained red,painful, blistered burns to both his arms, and has erythematousareas to his chest that haven’t blistered. How much fluid does herequire for resuscitation over the first 8 hours after this injury?An 60-kg woman is involved in a house fire after falling asleepwith a lit cigarette. She sustains full-thickness burns to botharms and legs, and partial-thickness burns to the front of hertorso. How much fluid should she be given in the first 24 hoursafter this injury?

12 MRCS PRACTICE PAPERS PART A: PAPER 2 EMQSPAPER 1 QUESTIONSTHEME: ANTI-EMETICSA CyclizineB MetoclopromideC OndansetronD LevomepromazineE HaloperidolFor each of the following, choose the most appropriate anti-emetic fromthe list above. Each option may be used once, more than once or not atall. 36 37 38 39A selective 5-hydroxytryptamine antagonist, useful forpreventing vomiting caused by cytotoxic drugs.A dopamine-receptor antagonist that acts in the chemoreceptortrigger zone (CTZ).An H1-receptor antagonist, most effective if given before theonset of nausea and vomiting.A non-phenothiazine antipsychotic used to combat vomitingcaused by emetogenic anti-cancer drugs.

QUESTIONS13THEME: SURGICAL INCISIONSA LanzB Kocher’sC McEvedy’sD InguinalE Lockwood’sF GridironG CollarPAPER 1 QUESTIONSFor each of the following operations, choose the most appropriateincision from the list above. Each option may be used once, more thanonce or not at all. 40 41 42 43A 63-year-old lady presents with a lump in her right groin,lateral and inferior to the pubic tubercle. It is tender to palpationand irreducible, with erythema to the overlying skin. Whichincision would you make for her emergency procedure?A 17-year-old girl presents with a 2-day history of right iliacfossa pain. She has a temperature 37.8 °C and has vomitedtwice. Her blood tests reveal: CRP 142 mg/l, WCC 14.6 × 10 9 /l.She requires an emergency operation. Which incision would youuse?A 52-year-old man undergoes a laparoscopic cholecystectomy.During dissection around Calot’s triangle, unusual anatomy isdiscovered and it is no longer safe to proceed laparoscopicallyand the procedure is converted to an open one. Which incisionwould you make?A 45-year-old lady with Graves’ disease presents with a largegoitre and wants to have her condition corrected as she ishoping to get pregnant within the next couple of years. Whichincision would you make for her elective procedure?

14 MRCS PRACTICE PAPERS PART A: PAPER 2 EMQSPAPER 1 QUESTIONSTHEME: ANATOMICAL RELATIONSABCArteryNerveVeinFor each of the following, choose the most appropriate structure fromthe list of options above. Each option may be used once, more than onceor not at all. 44 45 46 47In the popliteal fossa, which structure lies the deepest?In the cubital fossa, what is the most medial structure?At the hilum of the kidney, what is the most anterior structure?Of the femoral structures immediately inferior to the inguinalligament, which structure lies most lateral?

QUESTIONS15THEME: URINARY TRACT INFECTIONSA ChlamydiaB Escherichia coliC KlebsiellaD Mycobacterium tuberculosisE Proteus spp.F Schistosoma haematobiumG Streptococcus pneumoniaePAPER 1 QUESTIONSFor each of the following scenarios, choose the most likely pathogenfrom the list above. Each option may be used once, more than once ornot at all. 48 49 50A 26-year-old woman presents with ureteric colic. A KUB studyreveals a staghorn calculus in the right kidney.A 32-year-old HIV-positive woman attends clinic with symptomsof recurrent UTIs. Multiple mid-stream urine specimens havebeen sent by her general practitioner and have only revealedsterile pyuria.A 35-year-old businessman presents with a first episode of frankhaematuria. He has just returned from a business trip to Egypt.

154 MRCS PRACTICE PAPERS PART A: PAPER 2 EMQSPAPER 1 ANSWERSEXTENSOR COMPARTMENTS OF THE WRIST6 B – II7 B – II8 E – VTable 1 The extensor compartments of the wrist and their contentsCompartmentIIIIIIIVVVIContentsAbductor pollicis longusExtensor pollicis brevisExtensor carpi radialis brevisExtensor carpi radialis longusExtensor pollicis longusExtensor indicisExtensor digitorumExtensor digiti minimiExtensor carpi ulnarisAt the wrist extensor compartment II lies radial to Lister’s tubercle andcompartment III ulnar to it.

ANSWERS155SEPSIS9 E – Septic shock10 C – Sepsis11 A – BacteraemiaPAPER 1 ANSWERS12 B – SIRSThe important definitions concerning sepsis are:Bacteraemia – the presence of bacteria in the bloodstream.SIRS – a systemic inflammatory response to a range of insults, with two ormore of:• Temperature > 38 °C or < 36 °C• Pulse < 90/min• RR > 20 breaths/min or Pa(CO 2) > 4.3 kPa• WCC > 12 × 10 9 /l or < 4 × 10 9 /lSepsis – SIRS with a documented infection.Severe sepsis – SIRS with a documented infection and hypotension,hypoperfusion and organ dysfunction.Septic shock – sepsis with hypotension persisting despite adequate fluidresuscitation.

156 MRCS PRACTICE PAPERS PART A: PAPER 2 EMQSPAPER 1 ANSWERSFACIAL NERVE PALSIES13 G – Temporal bone fractureThe recent head injury suggests temporal bone fracture, and Battle’s sign andhaemotympanum are both signs of this.14 A – Multiple sclerosisThe sparing of the forehead suggests that the cause of the facial nerve palsyis supranuclear. Optic neuritis is a common presentation of multiple sclerosis.15 H – Ramsay Hunt syndromeRamsay Hunt syndrome is herpes zoster. The history of severe pain prior tothe palsy and associated vertigo and hearing loss, coupled with papules(which can be present in the ear canal or on the tongue), point to thisdiagnosis.16 D – CholeasteatomaThe 2-month history of intermittent discharge is a concerning feature withthe facial nerve palsy. Cholesteatomas should not be missed as a diagnosis,and typically cause retraction pockets in the tympanic membrane.17 B – Acoustic neuromaThe accompanying symptoms, particularly the sensorineural hearing loss, aretypical of acoustic neuroma.18 I – Chronic suppurative otitis mediaThe history of hearing loss, which is found to be conductive, coupled with adull tympanic membrane due to fluid collecting behind it, point to chronicsuppurative otits media.

ANSWERS157ANAESTHETIC AGENTS19 I – Isoflurane20 D – Suxamethonium21 K – Nitrous oxidePAPER 1 ANSWERS22 B – PropofolInduction agents include:• Thiopentone sodium• Propofol• EtomidatePropofol is the only one with a slight anti-emetic effect, and is the choice ofagent with laryngeal masks.Depolarising muscle relaxants:• SuxamethoniumNon-depolarising muscle relaxants:• Atracurium• VercuroniumInhalational agents include:• Halothane• Enflurane• Isoflurane• Sevoflurane• Nitrous oxideAll the inhalational agents except nitrous oxide can cause malignanthyperpyrexia. Suxamethonium can also cause it.Isoflurane is known to be associated with a ‘coronary steal’ syndrome.

158 MRCS PRACTICE PAPERS PART A: PAPER 2 EMQSPAPER 1 ANSWERSFLEXOR TENDON INJURIES23 D – Zone 424 B – Zone 225 B – Zone 2The zones of flexor tendon injury are:Zone 1 – between the distal interphalangeal and proximal interphalangealjoint creasesZone 2 – between the midpoint of the middle phalanx and distal palmarcreaseZone 3 – between the distal palmar crease and the distal margin of the carpaltunnelZone 4 – over the carpal tunnelZone 5 – from the proximal margin of the carpal tunnel up the wrist andforearmZone 2 is often referred to as ‘no man’s land’ and repairs here often have pooroutcomes.

ANSWERS159DAY-CASE SURGERY26 B – Unsuitable for day-case surgery27 A – Suitable for day-case surgery28 B – Unsuitable for day-case surgeryPAPER 1 ANSWERSThe contraindications to day-case surgery are:• ASA > 2 (the patient in Q28)• BMI >35 (The patient in Q26)• Extent of pathology• No one at home after the procedure• Lives more than 1 hour away from the hospital• No access to a phone

160 MRCS PRACTICE PAPERS PART A: PAPER 2 EMQSPAPER 1 ANSWERSURINARY SYSTEM TRAUMA29 A – Class I30 D – Class IV31 C – Class IIIClassification of renal trauma:Class I – renal contusion or contained subcapsular haematomaClass II – cortical laceration without urinary extravasationClass III – parenchymal laceration > 1 cm into renal substance without urinaryextravasationClass IV – laceration across corticomedullary junctionClass V – renovascular pedicle injuryClassification of ureteric trauma:Class I – haematoma or contusionClass II – laceration with < 50% transectionClass III – laceration with > 50% transectionGrade IV – complete transection with < 2 cm devascularisationGrade V – complete transection (avulsion) with > 2 cm devascularisation

ANSWERS161BURNS32 C – 8640 ml33 B – 5400 ml34 D – 4320 mlPAPER 1 ANSWERS35 E – 17 280 mlAccording to ATLS guidelines, the recommended formula for calculating thevolume of fluid required for resuscitation following burns is the Mount Vernonor modified Parkland formula. It calculates the volume of fluid required overthe first 24-hour period following the burn (TBSA = total body surface area):4 ml × %TBSA × weight (kg)Half of this fluid should be given in the first 8 hours post-injury and theremainder over the next 16 hours. The recommended fluid is an isotoniccrystalloid such as Hartmann’s solution or normal saline.When calculating the TBSA, the ‘rule of 9s’ is employed. The head and upperlimbs represents 9% each, the anterior and posterior torso and each lowerlimb represent 18% each, and the perineum is the remaining 1%.The different depths of burns can be estimated from their appearance.Superficial burns have a localised area of pain and erythema, without signs ofblistering. Partial-thickness burns involve the epidermis and the dermis andare red, painful and blistered. Full-thickness burns can be white and waxy orred and leathery. They are dry and painless, and involve the epidermis, dermisand subcutaneous tissues.

162 MRCS PRACTICE PAPERS PART A: PAPER 2 EMQSPAPER 1 ANSWERSANTI-EMETICS36 C – Ondansetron37 B – Metoclopromide38 A – Cyclizine39 E – Haloperidol

ANSWERS163SURGICAL INCISIONS40 C – McEvedy’sThis patient has a femoral hernia which is likely to be strangulated. In thissituation an extraperitoneal approach using a vertical incision over the lateralaspect of the lower rectus sheath is most appropriate. From this position thesac can be withdrawn and, if necessary, bowel resescted. In an elective femoralhernia repair a low inguinal incision (Lockwood) can be made.PAPER 1 ANSWERS41 A – LanzThis patient gives a history consistent with acute appendicitis. For thisprocedure either a gridiron or Lanz incision could be used, although in ayoung female patient a Lanz incision is preferred as this is more in keepingwith Langer’s lines.42 B – Kocher’sA Kocher's incision is a subcostal incision used for open cholecystectomy.43 G – CollarA collar incision is made for a total or subtotal thyroidectomy.

164 MRCS PRACTICE PAPERS PART A: PAPER 2 EMQSPAPER 1 ANSWERSANATOMICAL RELATIONS44 A – ArteryThe contents of the popliteal fossa are (from deep to superficial): poplitealartery, popliteal vein, tibial nerve, common peroneal nerve.45 B – NerveFrom lateral to medial, the contents of the cubital fossa are: biceps tendon,brachial artery, median nerve (TAN).46 C – VeinAt the renal hilum, from anterior to posterior, lie: renal vein, renal artery, renalpelvis and ureter.47 B – NerveThe femoral structures lie (from lateral to medial): femoral nerve, femoralartery, femoral vein, Y-fronts (NAVY).

ANSWERS165URINARY TRACT INFECTIONS48 E – Proteus spp.Staghorn calculi occur in strongly alkaline urine. They are usually associatedwith bacteria that produce urease, which breaks down urea to form ammonia.Proteus is the most common of these.PAPER 1 ANSWERS49 D – Mycobacterium tuberculosisHIV patients and other immunocompromised patients are particularlysusceptible to tuberculosis. Tuberculosis should always be suspected inpatients with sterile pyuria in the absence of any other demonstrableabnormality.50 F – Schistosoma haematobiumSchistosomiasis is endemic to the Middle East, Egypt in particular. The parasitelays eggs in the urinary tract, causing irritation. It can lead to squamousmetaplasia, stone disease, or, if left untreated, squamous cell carcinoma.