MRCS Part A - Sep 2019 Exam - 1 File Download

• MRCS Part A - Sep 2019 Exam

Two patients are being consented for the elective urology list – one nephrectomy followed by a transurethral resection of the prostate (TURP).

When obtaining consent for a TURP, what are the complications you would mention?

Bladder perforation, erectile dysfunction, incontinence, haematuria, retrograde ejaculation, UTI, urethral stricture, deep vein thrombosis (DVT), pulmonary embolism (PE) and death

Bladder perforation, erectile dysfunction, incontinence, priapism, retrograde ejaculation

Bladder perforation, priapism, deep vein thrombosis, urethral stricture

Deep vein thrombosis, pulmonary embolism, death Bladder perforation, erectile dysfunction, pulmonary embolism, retrograde ejaculation, death

Explanation

Bladder perforation, erectile dysfunction, incontinence, haematuria, retrograde ejaculation, UTI, urethral stricture, deep vein thrombosis (DVT), pulmonary embolism (PE) and death

Procedure-specific complications for a TURP include: retrograde ejaculation, erectile dysfunction, incontinence, haematuria, UTI, urethral stricture and bladder perforation. Systemic complications include: DVT, PE and there is a small risk of death. In addition there is a risk of TURP syndrome.

Bladder perforation, erectile dysfunction, incontinence, priapism, retrograde ejaculation

Haematuria should also be discussed when gaining consent for a TURP. Additionally, priapism (a persistent erection without sexual stimulation) is not a recognised complication.

Bladder perforation, priapism, deep vein thrombosis, urethral stricture

While some of these conditions are potential complications of TURP, priapism is not a recognised complication. Furthermore, there are other potential complications such as erectile dysfunction, retrograde ejaculation, UTI and haematuria that need discussion to gain informed consent.

Deep vein thrombosis, pulmonary embolism, death

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When counselling a patient about a TURP systemic complications should be discussed, such as deep vein thrombosis (DVT), pulmonary embolism (PE) and death (which occurs in 0.5–1% of cases). This, however, neglects the other local complications discussed above.

Bladder perforation, erectile dysfunction, pulmonary embolism, retrograde ejaculation, death This does not include all of the potential complications of TURP that require discussion with the patient before surgery.



A 34-year-old man with Crohn’s disease is admitted with vomiting, colicky peri-umbilical pain and abdominal distension. He has had a previous ileocolic resection. A computed tomography (CT) scan of the abdomen reveals multiple small bowel strictures.

What should you be aware of regarding the management of this man?

Intravenous fluids do not have a role in managing this patient

Intravenous hydrocortisone and parenteral nutrition are requiredStricturoplasty is immediately requiredThe patient needs a small bowel resectionThe symptoms are definitely caused by adhesions

Explanation

Intravenous hydrocortisone and parenteral nutrition are required In Crohn’s disease the inflammation is classically described as transmural. ‘Rose thorn’ ulcers are deep ulcers that traverse beyond the lamina propria and have a characteristic appearance. Aphthous ulcers occur anywhere from the mouth to the anus. Short-bowel syndrome is why it is best to try to avoid surgery whenever possible with Crohn’s disease, but in very severe cases in which less than 50 cm of small bowel remains, malabsorption of essential fat soluble vitamins (A, D, E and K) as well as other essential nutrients requires lifelong parenteral nutrition. Crohn’s colitis is not uncommon but the small bowel is more often involved and usually seen by the time colitis occurs. Crohn’s disease spreads as ‘skip lesions’ and, unlike ulcerative colitis, the spread is not usually in a continuous fashion. All of these options are possible in Crohn’s disease. It is usually not possible to differentiate between inflammatory and fibrous strictures and the best course of management is a trial of medical therapy (intravenous steroid and parental nutrition). If this fails then surgery is indicated.

Intravenous fluids do not have a role in managing this patient

Depending on the patient’s current hydration status, they may require intravenous fluids. Furthermore, intravenous fluids will be required during surgery to prevent complications such as acute kidney injury.

Stricturoplasty is immediately required Given the challenges of surgery in patients with Crohn’s disease, a trial of medical therapy would be appropriate before any surgical intervention, including stricturoplasty.

The patient needs a small bowel resection The main aim of surgery is bowel preservation and strictureplasty is the primary option, if not then, small bowel resection together with strictureplasty.

The symptoms are definitely caused by adhesions

The patient has undergone significant abdominal surgery in the past and therefore there is a risk of adhesion formation causing small bowel obstruction, however given the case history it is not possible to say the strictures are definitely caused by adhesions.

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A 25-year-old man is in burns intensive care having sustained 42% burns in a house fire. It is day 12 post injury and he remains intubated and ventilated. The Consultant Anaesthetist feels he will not be ready for extubation for a while and the decision is made to perform a tracheostomy. A size 7 tracheostomy tube is used.

Which one of the following does the tube size relate to?

Distance from tracheostomy tube tip to carinaDistance of tracheostomy tube from vocal cordsInternal diameter of the tracheostomy tubeLength of the tracheostomy tubeOuter diameter of the tracheostomy tube

Explanation

Internal diameter of the tracheostomy tube A size 7 tracheostomy tube relates to an internal diameter (ID) of 7 mm, not the outer diameter or length. Tracheostomy should be performed if prolonged intubation is expected; either percutaneous or open approaches are used. Fenestrated tubes allow air to be diverted superiorly through the vocal cords so speech can be possible, but this can also be attained if the tube is occluded with a finger. The first tracheal ring is complete in children and must not be excised for fear of tracheal stenosis. The preferred method is excision of rings 2–4.

Distance from tracheostomy tube tip to carina Sizing refers to the internal diameter, not the distance from tracheostomy tube tip to the carina.

Distance of tracheostomy tube from vocal cords Given individual anatomical variation, creating standardised sizing in relation to distance from the vocal cords would be challenging.

Length of the tracheostomy tube It is the internal diameter, not the length, of the tracheostomy tube that sizing refers to.

Outer diameter of the tracheostomy tube Sizing refers to the internal diameter of the tracheostomy tube, not the outer diameter.

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A patient diagnosed with a thyroglossal cyst is going to be admitted for surgery.

What is the most important preoperative test?

T3 and T4Thyroid Stimulating Hormone (TSH) levels

Echocardiogram

Isotope scanCyst ultrasound scan

Explanation

Isotope scan Thyroglossal cyst results from the persistence of the thyroglossal tract. It presents clinically as a neck swelling. Although it most commonly occurs at the level of the hyoid bone in the midline, it can be anywhere between the foramen caecum, above the manubrium, and between the sternomastoid muscles. As thyroglossal cysts can contain the only functioning thyroid tissue in the body, isotope scan should be planned before surgery to identify all functioning thyroid tissue.

T3 and T4 Thyroid function tests are usually normal.

Thyroid Stimulating Hormone (TSH) levels As discussed, thyroid function tests, including TSH, are usually normal.

Echocardiogram

While dysfunction in thyroid function may result in dysrhythmias, thyroid function is usually normal in these patients.

Cyst ultrasound scan The cystic nature can be confirmed using ultrasound scan, however, an isotope scan is the most important as thyroglossal cysts can contain the only functioning thyroid tissue in the body.

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A 30-year-old man undergoes a diagnostic laparoscopy for right iliac fossa pain. At operation an inflamed appendix is visualised and removed without spillage of bowel content.

When classifying surgical procedures according to the risk of wound contamination, uncomplicated appendicectomy is an example of which of the following?

Clean

Clean contaminated

Contaminated

Dirty

Infected

Explanation

Clean contaminated

In a clean contaminated wound the viscus wall is breached, but the contents are contained and no spillage occurs.

Clean

In a clean wound the viscus wall is not breached.

Contaminated

In a contaminated wound the viscus wall is breached and contents spilled.

Dirty

In a dirty wound there is already pus or spilled bowel contents.

Infected

Infected is not part of the classification of risk of wound contamination.



You are undertaking an audit and need to record P-POSSUM scores for your patients.

Which one of these is a physiological component of the P-POSSUM score?

CreatinineGenderGlasgow Coma scale (GCS)TemperatureUrine output

Explanation Glasgow Coma scale (GCS)

P-POSSUM score (Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity) comprises 12 physiological factors and six operative factors. Scores for the physiology components can be either 1, 2, 4 or 8 depending on the severity, and operative factors are scored similarly (except for two components where 4 is the maximum score). The overall physiology and operation scores are then applied to a logistic regression formula to calculate morbidity and mortality. It can be used for both emergency and elective general surgical operations, in most UK hospitals it is mandatory before emergency laparotomy. It should be calculated at the time of surgery, not on admission. It should not be used in trauma patients.

Physiological factors Operative factors

Age Operative complexity

Cardiac status Number of procedures being performed

Electrocardiogram (ECG) Blood loss

Respiratory status Peritoneal contaminationExtent of malignant spread

Blood pressure Mode of surgery (elective or emergency)

Pulse rate

Glasgow coma scale


Haemoglobin

White cell count

Urea

Sodium

Potassium

Creatinine Creatinine is not assessed but urea is included in the P-POSSUM score.

Gender

The only demographic parameter included in the P-POSSUM score is age.

Temperature

Temperature does not form part of the parameters assessed by the P-POSSUM score.

Urine output

Renal function, including sodium, urea and potassium are considered by the P-POSSUM score, however, urine output is not.

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You request lung function tests for a pre-operation patient. You are concerned that they will not be fit for their elective procedure and refer them on to the respiratory physicians for optimisation.

To measure which one of the following lung volumes, would you have to additionally request a helium wash-out technique?

Forced expiratory volume in one secondFunctional residual capacityInspiratory capacityMaximum

ventilation volumeVital capacity

Explanation Functional residual capacity

Functional residual capacity (FRC) includes residual volume that cannot be expelled into a spirometer. FRC (residual volume plus expiratory reserve volume) is measured by a helium wash-out technique. Body plethysmography can also be used to assess FRC, and is replacing the helium dilution technique.

Forced expiratory volume in one second

Forced expiratory volume in 1 second is the maximal volume of air the patient can exhale in 1s.

Inspiratory capacity

Inspiratory capacity is the maximum inspiration starting from the normal expiratory position.

Maximum ventilation volume

Maximum ventilation volume is the greatest volume of air that can be breathed in a given time (litres/min).

Vital capacity

Vital capacity is the maximum volume of air that can be expelled from the lungs by forceful effort after a maximum inspiration.

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You are asked to pre-assess a 64-year-old woman who has been listed for elective abdomino-perineal resection for bowel cancer. Among her medications, you find that she is on postmenopausal hormone therapy.

Which one of the following is true of her hormone therapy?

It reduces the risk of breast cancer

It decreases the risk of thrombosis

No changes need to be made before surgery

It should be increased before surgery

It should contain oestrogen alone in patients who have had a hysterectomy

Explanation It should contain oestrogen alone in patients who have had a hysterectomy

Unopposed oestrogen replacement therapy should not be given to women who still have a uterus due to the increased risk of causing endometrial cancer.

It reduces the risk of breast cancer

Postmenopausal hormone-replacement therapy also increases the risk of breast cancer. In addition, hormone therapy may increase the risk of ovarian cancer but lower the risk of colon cancer.

It decreases the risk of thrombosis

Postmenopausal hormone-replacement therapy increases the risk of deep vein thrombosis (DVT) and pulmonary emboli (PE) due the procoagulant effect of oestrogen.

No changes need to be made before surgery

Current National Institute of Clinical Excellence (NICE) guidelines suggest patients should consider stopping hormone-replacement therapy 4 weeks before elective surgery. For emergency surgery, peri-operative thromboprophylaxis is required.

It should be increased before surgery

Hormone replacement should be stopped, not increased, before elective surgery.



As part of the preoperative investigations for a patient requiring urgent surgery the anaesthetist requests that the patient’s functional residual capacity (FRC) is checked.

How can FRC be measured?

Exercise stress testHelium dilution techniqueNitrogen dilution techniqueSpirometryWrights peak

flow meter

Explanation Helium dilution technique

Functional residual volume (FRC) is measured by the helium dilution technique or body plethysmography. The FRC is the residual volume plus the expiratory reserve volume and represents < 50% of the vital capacity. FRC decreases when supine and increases on standing. It also varies with height and body build.

Exercise stress test

An exercise stress test is used to assess patients with suspected ischaemic heart disease. The patient undergoes a set programme on a treadmill while connected to continuous electrocardiogram (ECG) monitoring; a positive stress test would be when there are ischaemic changes on the ECG or the patient experiences chest pain.

Nitrogen dilution technique

It is the helium, not the nitrogen, dilution technique that is used to assess FRC.

Spirometry

Expiratory reserve can be measured directly by spirometry but FRC cannot be assessed by spirometry alone.

Wrights peak flow meter

This is the standard peak flow meter used by asthmatics that measures their peak expiratory flow rate through the bronchi and so the degree of obstruction in the airways.

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A patient presenting with poorly controlled asthma requires a lung function test.

What is lung spirometry routinely used to directly measure?

FEV1FEV1:FVC ratioFunctional residual volumeThe peak expiratory flow rateTotal lung capacity

Explanation FEV1

The spirometer is able to measure the forced vital capacity (FVC) (not the total lung capacity) and the FEV1 (forced expiratory volume in 1 s).

FEV1:FVC ratio

From spirometry measurements the FEV1:FVC ratio can be derived but the spirometer does not directly measure this ratio. FEV1 is the dynamic measure of flow in spirometry.

Functional residual volume

Functional residual volume is measured by helium dilution or body plethysmography.

The peak expiratory flow rate

The peak expiratory flow rate is routinely measured with a Wright’s peak flow meter.

Total lung capacity

This is the total lung capacity and cannot be measured directly by spirometry. It can be calculated by adding the inspiratory reserve volume, tidal volume, expiratory reserve volume and the residual volume.

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You are reviewing a patient in pre-operation clinic before a total knee replacement and he tells you that he has type 1 diabetes mellitus.

Which one of the following should you bear in mind when assessing him?

He will have normal function of the Langerhans cells of the pancreasHe will normally have ketones

present on dipstick testing of his routine pre-op urine sampleHe will be more prone to superficial

infection as a post-op complicationOn glucose tolerance testing he will have a resting blood glucose

of 5 mmol/l which rises to 10 mmol/l in half an hour and then returns to 5 again after 2 hHe will

have low levels of glucagon in the blood

Explanation He will be more prone to superficial infection as a post-op complication

Infection has an incidence of 1–2% following total knee replacement. Factors increasing the risk of infection include diabetes mellitus, rheumatoid arthritis, poor nutrition, obesity and poor surgical technique.

He will have normal function of the Langerhans cells of the pancreas

Type 1 diabetes mellitus results from disruption in the function of B-cells in the islets of Langerhans.

He will normally have ketones present on dipstick testing of his routine pre-op urine sample

Ketonuria is present when the patient is in a catabolic state and metabolising fats instead of carbohydrates. A patient will not routinely have ketonuria in the presence of well controlled diabetes.

On glucose tolerance testing he will have a resting blood glucose of 5 mmol/l which rises to 10

mmol/l in half an hour and then returns to 5 again after 2 h

On oral glucose tolerance testing the plasma concentration of glucose will increase to above 11.1 mmol/L 2 h following administration of 75 g of glucose.

He will have low levels of glucagon in the blood

If the preoperative starvation period results in more than one meal being missed, then National Institute of Clinical Health (NICE) guidance recommends the use of variable rate insulin infusions with glucose and electrolyte infusion to prevent hypoglycaemia.

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You are prescribing pre-operation medications for a patient undergoing elective joint replacement surgery, including prophylactic antibiotics.

What does the choice of pre-op antibiotics in joint replacement depend on?

Age of patientMeans of excretion of the antibioticSensitivity of most likely organismsSurgical

approach usedWhich joint is being replaced

Explanation Sensitivity of most likely organisms

The antibiotic chosen will depend of local resistance patterns.

Age of patient

A patient's age should not alter the choice of antibiotic.

Means of excretion of the antibiotic

This factor should not alter the choice of prophylactic antibiotic, however guidance from British National Formulary (BNF) should be sought with regards to dosing.

Surgical approach used

The surgical approach used should not influence the choice of antibiotic.

Which joint is being replaced

The individual joint should not alter the choice of antibiotic.

The choice of prophylactic antibiotics should be based on the type of operation being performed (but not the individual joint in the case of joint replacement) and the type of bacteria you wish to prevent from causing infection. Antimicrobial susceptibility will vary according to local resistance patterns.

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A 46-year-old woman is consented for laparoscopic cholecystectomy. She is worried about the procedure and wants to know as much information as possible.

Which one of the following would you mention?

Liver cirrhosis alone is an absolute contraindicationOperative cholangiography is mandatory

during laparoscopic cholecystectomyPrevious abdominal surgery is an absolute contraindication

On average, patients go home on the same day as the procedure

20% require conversion to open cholecystectomy

Explanation

On average, patients go home on the same day as the procedure

There is an NHS initiative to ensure that 60% of laparoscopic cholecystectomies are performed as day case procedures.

Liver cirrhosis alone is an absolute contraindication

Cirrhosis is not a contraindication for laparoscopic cholecystectomy, however there is increased risk of bleeding and postoperative infection.

Operative cholangiography is mandatory during laparoscopic cholecystectomy

Cholangiography is only required in the presence of common bile duct (CBD) stones. These can be detected by preoperative MRCP and if this is negative there is no need for intra-operative cholangiography.

Previous abdominal surgery is an absolute contraindication

Previous abdominal surgery can make the procedure more challenging due to the presence of adhesions but is not a contraindication.

20% require conversion to open cholecystectomy

Around 5% of laparoscopic cholecystectomies require conversion to open procedures.

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An overweight 46-year-old woman is being referred to general surgery with gallstones and biliary colic, she has never suffered from cholecystitis. Following careful consultation she is offered laparoscopic cholecystectomy.

Which one of the following should be discussed, as it is a recognised complication?

2% mortality rate

50% risk of conversion to open surgery

5% common bile duct injury

5% risk of venous thromboembolism

Overall 0.5% risk of common bile duct injury

Explanation

Overall 0.5% risk of common bile duct injury

Risk of bile duct injury is around 0.5%.

2% mortality rate

Mortality rates following laparoscopic cholecystectomy are around 0.22–0.4%

50% risk of conversion to open surgery

There is a 5% risk of conversion to open surgery

5% common bile duct injury

Common bile duct injury occurs in around 0.5% of laparoscopic

5% risk of venous thromboembolism

Risk of deep vein thrombosis (DVT) (without prophylaxis) is around 1–2%

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A 67-year-old woman with a recently excised malignant melanoma of the leg returns to the clinic with a palpable groin lump suggestive of lymphadenopathy. She is concerned the cancer may have spread.

What is the next best step in her management?

Computed tomography (CT) scan

Fine needle aspiration

Groin dissectionOpen node biopsy

PET scan

Explanation

Fine needle aspiration

First line investigation is FNA (under ultrasound guidance) to assess for the presence of regional metastases.

Computed tomography (CT) scan

This option should be performed to assess for distant metastases, but fine-needle aspiration (FNA) of the groin lump is indicated.

Groin dissection

This investigation is only required if biopsies are positive for metastatic disease.

Open node biopsy

This biopsy should be performed in the eventuality of inconclusive fine-needle aspiration.

PET scan

A PET scan is not currently recommended by NICE as part of the work-up for metastasis in malignant melanoma.

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A 46-year-old man is seen in clinic seeking an abdominoplasty following rapid weight loss. He currently weights 120 kg, down from 160 kg.

Which one of the following regarding obesity is correct?

Body mass index (BMI) is a widely used means of estimating obesity in patients

A BMI greater than 35 is consistent with 'morbid obesity'

BMI = weight (kg)2/height (m)

Obese patients do not normally require HDU/Intensive Therapy Unit (ITU) care

Vena caval filters should be used to reduce the risk of a pulmonary embolus

Explanation

Body mass index (BMI) is a widely used means of estimating obesity in patients

A BMI is a simple measure for estimating obesity using the patient’s weight and height measurements.

A BMI greater than 35 is consistent with 'morbid obesity'

A BMI of greater than 40 is described as morbidly obese

BMI = weight (kg)2/height (m)

BMI is calculated as weight (kg)/height2 (m2)

Obese patients do not normally require HDU/Intensive Therapy Unit (ITU) care

Obesity increases the risk of requiring mechanical ventilation, tracheostomy placement and stays on critical care.

Vena caval filters should be used to reduce the risk of a pulmonary embolus

Obesity is a risk factor for venous thromboembolism, however the mainstay of prophylaxis is pharmacological and mechanical (TED stockings and/or calf pumps). The routine use of vena caval filters is not currently recommended by NICE


A normal BMI lies between 20–25, while a BMI of between 25–30 is classed as being 'overweight'. A BMI of between >30–40 is obese; and a BMI of over 40 is 'morbidly obese'. BMI is equal to weight (kg)/height (m)2. Obese patients encounter significantly greater complications, both intra- and post-operatively. ITU care must be considered and beds booked before admission.

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MRCS Part A - Sep 2019 Exam

A 21-year-old insulin-dependent diabetic is seen in clinic. He is due to undergo elective circumcision under general anaesthetic.

Which one of the following measures need to be considered?

He should be placed first on the theatre list

He should have a sliding scale, this should be taken down in recovery

He should have addition oral hypoglycaemics on the morning of his surgery

He should not be fasted for 6 h before surgery

He should remain solely on long-acting insulin

Explanation

He should be placed first on the theatre list

Diabetics should ideally be placed first on the list to prevent prolonged starvation. Often other factors may change this, but in an ideal scenario this would be the case.

He should have a sliding scale, this should be taken down in recovery

Glucose/potassium/insulin (GKI) infusions should remain up until the patient is eating and drinking normally.

He should have addition oral hypoglycaemics on the morning of his surgery

There is no need for further oral hypoglycaemics as the patient will be in a state of starvation; this would risk making them dangerously hypoglycaemic.

He should not be fasted for 6 h before surgery

The requirement for fasting is dependent on the general anaesthetic rather than co-morbidities, and so the patient should be fasted for 6 h. If anything, this is more important in diabetics as they often have a degree of gastroparesis.

He should remain solely on long-acting insulin

There is no need for the patient to be solely on long-acting insulin as he will be starved. If he becomes hyperglycaemic, this can be controlled with a sliding scale, which usually


employs short acting insulin. He should go back to his usual insulin regime once the surgery is complete and he is eating and drinking.

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A 56-year-old man is admitted to A&E with a compound tibial fracture. You are asked to book him for theatre urgently.

Which confidential enquiry into peri-operative deaths (CEPOD) category do you use?

CEPOD category 1

CEPOD category 2

CEPOD category 3

CEPOD category 4

CEPOD category 5

Explanation

CEPOD category 2

Compound fractures should be washed out within 6 h and so fall into category 2:

• 2 URGENT – Intervention for acute onset or clinical deterioration of potentially life-

threatening conditions, for those conditions that may threaten the survival of limb or organ,

for fixation of many fractures and for relief of pain or other distressing symptoms. Normally

within h of decision to operate. Compound fractures should be washed out within

6 h and so fall into category 2. Another example is an appendicectomy for acute appendicitis

CEPOD category 1

CEPOD 1 refers to conditions threatening the patient’s life or limb, eg a ruptured abdominal aortic aneurysm, or compartment syndrome:

• 1 IMMEDIATE – Immediate life, limb or organ-saving intervention – resuscitation

simultaneous with intervention. Normally within minutes of decision to operate.

CEPOD category 3

CEPOD category 3 refers to patients in whom early treatment will suffice to improve their prognosis. An example is an acute cholecystectomy (‘hot gallbladder’):


• 3 EXPEDITED – Patient requiring early treatment where the condition is not an immediate

threat to life, limb or organ survival. Normally within days of decision to operate.

CEPOD category 4

CEPOD 4 refers to elective cases:

• 4 ELECTIVE – Intervention planned or booked in advance of routine admission to hospital.

Timing to suit patient, hospital and staff. There are many examples of this, such as a

reducible inguinal hernia.

CEPOD category 5

There is no CEPOD category 5. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) classification of intervention rationalises available theatre resources and delivers them to those who require care by urgency of injuries.

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A 67-year-old man with hypertension requiring two antihypertensives is seen in the pre-assessment clinic. He gets out of breath when walking up two flights of stairs.

What American Society of Anaesthesiologists (ASA) grade is he?

ASA I

ASA II

ASA III

ASA IV

ASA V

Explanation ASA III

The correct answer is ASA III by virtue of the need for two antihypertensives and that he has severe systemic disease with limitation to his activity. The ASA grade predicts patient mortality based on medical co-morbidities. The correct answer is ASA III by virtue of the need for two antihypertensives he has severe systemic disease and his activity is also limited.

ASA

grade Definition

Mortality

%

I Normal healthy individual 0.06

II Mild systemic disease that does not limit activity 0.4

III Severe systemic disease that limits activity but is not incapacitating 4.5

IV Incapacitating systemic disease which is constantly life threatening 23

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V Moribund, not expected to survive 24 h with or without surgery 51

VI A declared brain-dead person whose organs are being removed for

donor purposes N/A

ASA I

A patient who is ASA I is a healthy individual with no co-morbidities.

ASA II

A patient who is ASA II has mild systemic disease that does not limit activity. An example might be a patient with hypertension that is controlled by one agent.

ASA IV

A patient classified as ASA IV has an incapacitating systemic disease that is always life threatening eg someone with unstable angina secondary to coronary artery disease.

ASA V

A patient who is ASA V is moribund, and not expected to survive 24 h with or without surgery. An example would be a patient who has severe systemic disease, and has now suffered further acute pathology eg gross faecal peritonitis.

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A 61-year-old with poorly-controlled asthma is sent for lung function testing as part of his preoperative assessment.

What result would you most expect?

Forced vital capacity (FVC) is reduced but FEV1/FVC is normal

FVC normal or reduced and FEV1/FVC is reduced

Normal FVC and normal FEV1/FVC

All of the aboveNone of the above

Explanation

FVC normal or reduced and FEV1/FVC is reduced

In asthma (an obstructive lung disorder) the forced expiratory volume in 1 second (FEV1) is usually decreased, the FVC is usually normal and the ratio FEV1/FVC is decreased. In restrictive lung disorders, eg fibrosis, the FEV1 is reduced; as is the FVC, but to a lesser extent, and so the FEV1/FVC ratio is normal.

Lung function tests measure for:

1. Forced expiratory volume in 1 second (FEV1) – the volume of air that can be exhaled in the very first second of forced expiration.

2. FVC – total volume of air that can be forcibly exhaled in one breath. 3. The ratio of FEV1 to FVC, usually expressed as a percentage.

Forced vital capacity (FVC) is reduced but FEV1/FVC is normal

If the FVC is reduced, it is impossible for the ratio of FEV1 to FVC to be normal as it would also be reduced.

Normal FVC and normal FEV1/FVC

Patients with obstructive lung disorders eg asthma may not give normal lung function tests as their FEV1 is usually reduced.

All of the above

This is not the correct option; the patient will have a reduced FEV1.

None of the above


This is not the correct option.

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A 56-year-old woman who is due to undergo an elective cholecystectomy is seen in the pre-assessment clinic.

Of the following, which one is an indicator for performing urea and electrolyte (U+E) blood tests?

Age over 50

All women

Diabetics

Respiratory disordersThose undergoing prolonged anaesthetic time > 60 minutes

Explanation Diabetics

Patients over 60 years, those with cardiovascular and renal disease, diabetes and those on steroids/ACE-I or diuretics should have U+Es monitored pre-operatively.

Age over 50

Age over 60 is an indication for urea and electrolyte blood tests.

All women

Gender is not an indication for these blood tests.

Respiratory disorders

Urea and electrolyte blood tests would not give any idea of the extent of respiratory disease. Clinical assessment in combination with chest X-ray and lung function tests are important here.

Those undergoing prolonged anaesthetic time > 60 minutes

This is not an absolute indication for this blood test.

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A 56-year-old man is due to have a laparoscopic sigmoid colectomy for symptomatic diverticular disease. He has a history of atrial fibrillation, controlled with a b-blocker, and angina pectoris. Four months ago he had a small heart attack. He is taking warfarin and has an international normalised ratio (INR) of 2.5.

How would you proceed?

Arrange surgery and obtain consent on the day of the procedureArrange surgery but ensure

Warfarin is stopped 3 days prior to his procedure

Initiate the recommended investigations, which include full blood count, urea and electrolytes, chest X-ray and electrocardiogram

Postpone his surgery

The warfarin should be replaced with therapeutic dose of dalteparin

Explanation Postpone his surgery

Major elective surgery is not recommended within 6 months of a myocardial infarction. The patient needs a more thorough work up and has benign disease; so his operation can be delayed.

Arrange surgery and obtain consent on the day of the procedure

Consent should ideally be performed in the outpatient clinic and confirmed on the day of surgery. This patient is complex and is undergoing major surgery for benign disease, and does not appear to have had a full preoperative work up. He is also not a good candidate for surgery as he has had a recent MI. Routine surgery should be purposed until six months post MI.

Arrange surgery but ensure Warfarin is stopped 3 days prior to his procedure

Warfarin should be stopped approximately 5 days before the procedure and the INR checked to ensure it is less than 1.5. It is not sufficient to simply stop the warfarin without checking the INR. He is also not a good candidate for surgery as he has had a recent MI. Routine surgery should be purposed until six months post MI.

Initiate the recommended investigations, which include full blood count, urea and electrolytes, chest X-ray and electrocardiogram


The patient will need these tests, but also a group and save test and echocardiogram to assess ventricular function. However, it is not advisable for patients to undergo routine surgery within six months of an MI.

The warfarin should be replaced with therapeutic dose of dalteparin

This patient is not a good candidate for surgery as he has had a recent MI. Routine surgery should be purposed until six months post MI. Additionally, a therapeutic dose of dalteparin is not mandatory for a patient taking warfarin for atrial fibrillation. A prophylactic dose together with graduated compression stockings and pneumatic calf compression boots during the surgery are adequate.

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A 64-year-old, otherwise fit and healthy woman, is seen at the pre-assessment clinic beforeundergoing an elective, laparoscopic cholecystectomy. She is found to be hypertensive with a diastolic blood pressure >110 mmHg.

Which one of the following statements is correct regarding preoperative hypertension?

As most antihypertensive agents react adversely with anaesthetics the hypertension should be treated after the surgery

As the diastolic blood pressure is >110 mmHg the procedure should be discussed with the anaesthetist but should still go ahead

Hypertension must be corrected pre-operatively in a patient over 50 years of age undergoing emergency surgery

Hypertension has no bearing on mortality in this type of operation and thus does not require any intervention

Ideally, hypertension should be corrected in all patients undergoing elective surgery

Explanation

Ideally, hypertension should be corrected in all patients undergoing elective surgery

Hypertension needs to be corrected before elective surgery in all patients as it increases the risk of cardiovascular pathology including myocardial complications and stroke. Hypertension is defined as a blood pressure reading persistently at or above 140/90 mmHg with subsequent ambulatory blood pressure monitoring (ABPM) daytime average or home blood pressure monitoring (HBPM) that is 135/85 mmHg or higher.

As most antihypertensive agents react adversely with anaesthetics the hypertension should be treated after the surgery

Most antihypertensive agents are compatible with anaesthetic agents so may be continued as normally prescribed.

As the diastolic blood pressure is >110 mmHg the procedure should be discussed with the anaesthetist but should still go ahead

A diastolic blood pressure of >110 mmHg before elective surgery prompts discussion with the anaesthetist and possible postponement until better control can be achieved.


Hypertension must be corrected pre-operatively in a patient over 50 years of age undergoing emergency surgery

While the presence of hypertension should not delay an emergency operation as the risks of delay will outweigh the dangers of an elevated blood pressure, this is not the case with elective surgery. This is the case for all patients, regardless of age.

Hypertension has no bearing on mortality in this type of operation and thus does not require any intervention

Poorly controlled hypertension in the immediate preoperative period predisposes the patient to perioperative cardiac morbidity and must be avoided.

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A 56-year-old woman is noted to be positive for meticillin-resistant Staphylococcus aureus(MRSA) on a wound swab. Steps are subsequently taken to minimise risk to the other patients on the ward.

What is the appropriate infection control procedure?

All MRSA positive patients must be nursed in the same bay, away from non infected patients

Barrier nursing

Gloves and face masks for all entering the room

None

Reversed barrier nursing

Explanation Barrier nursing

Barrier nursing with apron and gloves is the current accepted method.

All MRSA positive patients must be nursed in the same bay, away from non infected patients

Most hospitals do not place patients with one MRSA positive swab in an exclusive bay. If a single side-room is not available patients may be able to be nursed in a bay alongside other MRSA patients. Some hospitals have made arrangements for patients with multiple MRSA infections to stay in one ward.

Gloves and face masks for all entering the room

Face masks are unnecessary when seeing patients with MRSA.

None

Patients with MRSA do require care with some infection control precautions.

Reversed barrier nursing

Reversed barrier nursing is implemented to protect patients who are at high risk of contracting infection from common organisms carried by other people such as neutropenic individuals.



An 8-year-old boy fell from a monkey bar on an outstretched arm, and sustained a completely displaced distal humeral supracondylar fracture. On examination, his hand is coldwith reduced capillary refill.

What is the most important next step in management?

Admit and prepare for theatre next day

Application of above elbow plaster with the elbow at 90 degrees flexion

Below elbow plasterDischarge home with fracture clinic follow upEmergent fracture reduction

Explanation Emergent fracture reduction

Vascular insufficiency should be managed initially by rapid reduction and fixation.

Admit and prepare for theatre next day

This patient has a fracture with vascular compromise and needs urgent treatment.

Application of above elbow plaster with the elbow at 90 degrees flexion

Reduction of the fracture is needed.

Below elbow plaster

Reduction of the fracture is needed here.

Discharge home with fracture clinic follow up

This patient has a fracture with a vascular injury and needs urgent treatment. Vascular injury is a common and potentially catastrophic complication of displaced supracondylar fractures.

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A 42-year-old man presents to the Urology Rapid Access Clinic with a right testicular lump. He undergoes an ultrasound the same day, which suggests that this is a testicular tumour. He is counselled regarding a radical inguinal orchidectomy.

Which one of these must form part of his preoperative management?

Alpha-fetoprotein (AFP), beta-human chorionic gonadotrophin (ß-HCG) and lactate dehydrogenase (LDH)

Staging CT scan of the chest abdomen and pelvis

Sperm banking

Testicular biopsy to confirm malignancy

Carcinoembryonic antigen (CEA)

Explanation

Alpha-fetoprotein (AFP), beta-human chorionic gonadotrophin (ß-HCG) and lactate dehydrogenase (LDH)

Baseline testicular cancer tumour markers are required before any treatment is instigated. These will aid monitoring of disease.

Staging CT scan of the chest abdomen and pelvis

Full staging with a CT scan can wait until after the orchidectomy and should not delay the operation. However, it is important to get some chest imaging pre-operatively to ensure the patient does not have metastatic disease.

Sperm banking

All patients undergoing an orchidectomy must be counselled about fertility and offered sperm banking. This typically happens after the orchidectomy but in cases in which the patient is known to have fertility problems or their contralateral testis is atrophic it should be offered before orchidectomy.

Testicular biopsy to confirm malignancy


Unlike many other cancers, testicular biopsies are not indicated to confirm malignancy. If suspected on imaging then the patient should undergo a radical inguinal orchidectomy after which it will be sent for histology to confirm the diagnosis.

Carcinoembryonic antigen (CEA)

CEA is not a tumour marker for testicular cancer. The patient should have pre-operative bloods taken for alpha feto-protein, human chorionic gonadotrophin and lactate dehydrogenase. Tumour markers help with staging and monitoring response to treatment.

• Part A - Sep 2019 Exam

Before anaesthetising a patient, staff carry out their checks to ensure that the operation is being performed safely using the World Health Organization (WHO) surgical safetychecklist. This is referred to as the ‘sign in’ stage of the procedure.

Which one of these would form part of these checks?

Antibiotic prophylaxis

Essential imaging displayed

Instrument sterility

Pulse oximeter attached to patient and in working order

Normal coagulation tests

Explanation

Pulse oximeter attached to patient and in working order

This is correct and forms part of the WHO check before induction of anaesthesia. Additional checks at this stage include confirming patient identity, site, procedure, consent, site marked, anaesthesia machine, allergies, difficult airway/aspiration risk and risk of large blood loss.

Antibiotic prophylaxis

Antibiotic prophylaxis forms part of the WHO surgical checklist before skin incision (the ‘time out’ stage) but not at the induction of anaesthesia.

Essential imaging displayed

This is an important part of the WHO surgical safety checklist before skin incision along with ensuring that the site of surgery has been correctly marked and corresponds with that documented in the consent form.

Instrument sterility



It is important to confirm instrument sterility with the nursing team. This takes place during the ‘time out’ stage of the WHO checklist.

Normal coagulation tests

Coagulation tests should be checked by the surgeon and anaesthetist before any procedure but does not form part of the WHO surgical safety checklist.

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A 57-year-old man is scheduled to have a right inguinal hernia mesh repair. He is normally fit and well and takes aspirin 75 mg daily. The surgeon is concerned about the risk of bleeding with aspirin and wishes to stop it.

How long do the effects of aspirin last?

6 h

12 h

2 days

5 days

10 days

Explanation

10 days

Aspirin is an antiplatelet medication with irreversible action. Therefore, the effects of aspirin last for the duration of the life of the platelet which is up to 10 days. Although most surgeons will stop aspirin 7 days before surgery.

6 h

Unfractionated heparin should be discontinued 6 h before surgery to reduce risk of bleeding. Unfractionated heparin can be used for high risk patients normally on anticoagulation to ensure they continue to receive appropriate anticoagulation during the perioperative phase.

12 h

Low-molecular-weight heparins often given prophylactically in hospital should typically be stopped 12 h before surgery, although some surgeons will proceed with surgery provided it was prophylactic not treatment dose, depending on the type of procedure.

2 days


The non-vitamin K antagonist oral anticoagulants (NOACs) including Apixaban and Rivaroxaban are typically stopped 2 days before surgery depending on the patient’s renal function and bleeding risk.

5 days

Warfarin is typically stopped 5 days pre-operatively with the International Normalised Ratio (INR) checked before surgery to ensure it is at an adequate level. INR < 1.5 is usually acceptable to proceed with surgery but some surgeons prefer an INR < 1.3.


A 72-year-old man attends the Emergency Department with severe abdominal pain. Observations are: respiratory rate 22/min, heart rate 102/min, blood pressure 124/78 mmHg,temperature 38.1°C. CT of the abdomen and pelvis suggests a localised diverticular perforation. He is known to have hypertension, and type 2 diabetes, which is well controlledwith metformin.

What is this patient’s American Society of Anaesthesiologists' (ASA) grade?

1

2

3

4

5

Explanation

2

ASA 2 describes a patient with mild systemic disease and this patient would fit into that category. He has well controlled diabetes and there is nothing to suggest from the history that the hypertension is uncontrolled.

1

Patients with an ASA grade of 1 are fit and well.

3

ASA 3 describes a patient with severe systemic disease. In this case if the patient’s hypertension was not well controlled or he was a poorly controlled diabetic then he would fit into the ASA 3 category.

4

ASA 4 describes a patient with severe systemic disease that is a constant threat to life. For example a patient with severe chronic obstructive pulmonary disease (COPD) on long-term oxygen therapy.


5

ASA 5 describes a moribund patient that is not expected to survive without the operation. For example, a patient with a ruptured abdominal aortic aneurysm having an emergency open repair.

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A 72-year-old man is awaiting a left total knee replacement. He has hypertension that is controlled with amlodipine and takes warfarin for atrial fibrillation. He takes no other regular medications.

Which one of these investigations should form part of this patient’s pre-operative assessment?

Full blood count only

Full blood count, renal function, coagulation

Full blood count, renal function, coagulation, ECG

Full blood count, renal function, coagulation, ECG, Lung function tests

Full blood count, renal function, coagulation, lung function tests

Explanation

Full blood count, renal function, coagulation, ECG

According to the NICE guidelines (NG45) on routine pre-operative tests for elective surgery this would be correct. This patient is ASA 2 and is undergoing a major operation.

Full blood count only

This patient is going for a major operation and takes warfarin. He would need his clotting checked before proceeding with surgery although this may not take place until the day of surgery after the warfarin has been stopped.

Full blood count, renal function, coagulation

This would be a suitable request for blood tests for this patient as recommended by for ASA 2 patients. However, he should also have an ECG.

Full blood count, renal function, coagulation, ECG, Lung function tests

The patient has no history of respiratory disease and lung function tests would not be routinely requested for such a patient.

Full blood count, renal function, coagulation, lung function tests


All patients undergoing a major operation that are either ASA 1 and over the age of 65 or ASA 2 and above should have an ECG performed. In addition, lung function tests would not routinely be arranged for patients like this without a history of respiratory disorder.

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A 68-year-old woman has been on the waiting list for an elective hernia repair for one year. It causes occasional discomfort and impacts on her mobility. Her medications include aspirin and clopidogrel, after a myocardial infarction (MI) seven months previously which required two cardiac stents. She wants to proceed with surgery as soon as possible.

What advice should the patient be given?

Proceed with the surgery on current medication

Stop clopidogrel before surgery

Stop all medication before surgery

Postpone surgery

Cancel surgery with no plan to perform in the future

Explanation

Postpone surgery

The patient is on dual antiplatelet therapy and would be high risk for bleeding. She has had recent cardiac stents and therefore these medications cannot be stopped at present. Clopidogrel is typically stopped after the first year and given that this is an elective procedure it would be sensible to postpone the surgery until the risk of bleeding can be reduced.

Proceed with the surgery on current medication

This patient will be at high risk of bleeding if the surgery were performed now as she is on dual antiplatelet therapy following her recent cardiac stenting. As this is an elective procedure, it should be postponed until it can be safely performed.

Stop clopidogrel before surgery

Unless agreed by the cardiologists, the clopidogrel should not be stopped in view of her recent cardiac stents.


Stop all medication before surgery

Stopping all medication including the antiplatelets puts the patient at risk of cardiac stent thrombosis, which could have potentially life-threatening complications for the patient. This patient only had their cardiac stents recently and therefore medications should not be stopped without consultation with the cardiologist.

Cancel surgery with no plan to perform in the future

The patient has been awaiting this surgery for some time and it appears to be impacting her quality of life. There is also a risk that the hernia could strangulate or become incarcerated. At this stage the surgery does not need to be completely cancelled just postponed until it can be safely performed in view of her recent MI.

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Many patients on warfarin that are due to undergo surgery have their anticoagulation stopped pre-operatively. Patients that are high risk of thrombosis require bridging with alternative agents such as low-molecular-weight heparin in the perioperative phase.

Which one of these patients would it be safe to stop warfarin on without bridging?

Metallic aortic valve

Atrial fibrillation in a patient with an ischaemic stroke two months ago

Atrial fibrillation in a patient who is otherwise fit and well

Recurrent pulmonary emboli/deep vein thrombosis with the last episode one year ago

Unprovoked pulmonary embolism two months ago

Explanation

Atrial fibrillation in a patient who is otherwise fit and well

Patients with uncomplicated, low risk atrial fibrillation can have their warfarin stopped pre-operatively and they do not need to be bridged with low-molecular-weight heparin.

Metallic aortic valve

Patients with metallic valves are very high risk for embolic events should their anticoagulation be stopped. Plans for these patients should be made in conjunction with the cardiology team. Often, these patients are admitted pre-operatively and converted onto a unfractionated heparin infusion, which can be stopped 6 h pre-operatively.

Atrial fibrillation in a patient with an ischaemic stroke two months ago

Patients that are on warfarin for atrial fibrillation and have had a previous stroke or transient ischaemic attack (TIA) or a thromboembolic event within 3 months should have bridging when stopping their warfarin pre-operatively.

Recurrent pulmonary emboli/deep vein thrombosis with the last episode one year ago

Even though this patient has had no thromboembolic event for a year their recurrent episodes put the patient at high risk. Therefore, these patients will require bridging for their anticoagulation.


Unprovoked pulmonary embolism two months ago

This patient would be at high risk for a further thromboembolic event and therefore will require bridging with the warfarin being stopped for the shortest time possible.

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It is 10:00 and a 38-year-old man has been awaiting an incision and drainage of a perianal abscess under general anaesthetic. He has been nil by mouth since 02:00 and is now called for his surgery. He is found to be chewing gum when called.

How long does the patient need to wait for the surgery?

The surgery can go ahead now

1 h

2 h

6 h

8 h

Explanation

6 h

This is correct. Chewing gum causes gastric secretions and therefore puts the patient at risk of aspiration. Therefore, the patient should be fasted for 6 h before the surgery goes ahead safely.

The surgery can go ahead now

It would not be safe to proceed with the surgery now. Although the patient has had nothing else to eat or drink since 2 am chewing gum mimics eating and causes gastric secretions. Therefore, there would be a risk of aspiration.

1 h

The patient should be managed as if they have just eaten as chewing gum stimulates gastric secretions and therefore this patient would be at risk of aspiration.

2 h

If the patient had just had water the correct amount of time to wait would be 2 h. However, chewing gum should be managed as if the patient has eaten.

8 h


8 h is too long for a patient to be fasted before surgery. Patients should have nothing to eat, including chewing gum, for 6 h, but can drink clear fluid until 2 h before the operation.

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A 74-year-old man who has been on nasogastric (NG) feed following a stroke, is consented for a percutaneous endoscopic gastrostomy (PEG) tube to be done under a general anaesthetic. He has a history of dementia and hypertension. He does not understand the treatment proposed but his daughters are in agreement.

Which consent form should be used for this patient?

Consent form 1

Consent form 2

Consent form 3

Consent form 4

Verbal consent

Explanation

Consent form 4

Consent form 4 would be the correct choice. This is used for patients who lack capacity and it should be checked whether the patient has a lasting power of attorney or advanced directive before proceeding with this. It would be best practice to also have the daughters sign the consent form.

Consent form 1

Consent form 1 would only be suitable if this patient had capacity to make a decision regarding the proposed treatment, which he does not.

Consent form 2

Consent form 2 is used to consent children and would not be appropriate in this case.

Consent form 3


Consent form 3 is used for patients who have capacity, which this patient does not, and when their consciousness will not be impaired during the procedure. In this case of a general anaesthetic, this would not be the case.

Verbal consent

This patient would not have the capacity to give verbal consent to any investigation or treatment. Even if the patient did have capacity, verbal consent would not be sufficient for a procedure under a general anaesthetic.

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A 13-year-old boy who was previously fit and well presents to the Emergency Department with a 4 h history of severe left testicular pain. He is accompanied by his parents. He is able to give a clear history and understands that he needs a scrotal exploration to investigate a possible testicular torsion.

How should this patient be consented?

Consent form 1

Consent form 2

Consent form 3

Consent form 4

Verbal consent

Explanation

Consent form 2

Consent form 2 is used when parental consent is also required for a child up to age of 16. Although, if the child is deemed to have capacity (can comprehend and retain information relating to the decision, weigh it up and then communicate their decision) they may also sign the consent form.

Consent form 1

Consent form 1 is used for adult patients with capacity who are agreeing to an investigation or treatment in which their consciousness will be impaired as is the case in any procedure performed under general anaesthetic.

Consent form 3

Consent form 3 is used for adult patients when they are consenting for a procedure or investigation that will not impair their consciousness such as a flexible cystoscopy.

Consent form 4

Consent form 4 is used for patients who lack capacity to make a decision regarding a proposed investigation or treatment. It must be deemed that the procedure cannot be delayed until the patient regains capacity and is in the patient’s best interests.


Verbal consent

Verbal consent is not enough for patients undergoing this type of procedure. Verbal consent would be suitable for example for a patient who is going to have a CT scan and agrees that they are happy to have it performed.

MRCS Part A - Sep 2019 Exam - 1 File Download

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