RHABDOMYOLYSIS

Scenario: A case of RTA with fracture tibia, fibula and compartment syndrome
with marked raised S. creatinine level. Urine RME shows plenty RBC, High K+
level!

1. What is your diagnosis?

 ARF due to rhabdomyolysis with compartment syndrome
following RTA.
2. What are Causes of this clinical scenario?
 Crush injury, Compartment syndrome, hyperkalemia, acute
reperfusion injury.
3. What is the pathophysiology of Renal failure?
 Impairment of sarcoplasmic Na-K pump resulting in decreased Na
extrusion, reduce Ca and water efflux and myofibril disruption with
muscle damage specially Type-2 Muscle. That causes release of
myoglobin, Purine, K+ and Phosphate.
4. Why DIC?
 Pathological activation of coagulation cascade by release of muscle
component.
5. What might be the Complications:
Hypovolemia: Sequestration of fluid within injured muscle and
hemorrhage in necrosed muscle.
ARF: Due to myoglobinuria as because iron is toxic to renal tubule and
forms mechanical blockage. Also ARF develops from hypovolemia.
Metabolic complications:
i. Metabolic acidosis
ii. Hyperkalemia: Release of intracellular K + , Rena failure, and
acidosis.
iii. Hyperuricemia: Due to increased hepatic conversion of
purine.
iv. Hyperphosphatemia: Increased release of phosphate from
injured muscle.

1
6. Investigation:
a. Urine R/M/E: Myoglobinuria (positive dipstick test for blood in
absence of hematuria).
b. Serum enzyme:
 CK, CK-MM, CPK (creatinine phosphokinase)
 LDH
 Carbonic anhydrase 3 (more specific marker).
7. What is reperfusion injury?
Revascularization of non-viable acutely injured muscle causes acidosis,
hyperkalemia, rhabdomyolysis and myoglobinuria due to release of toxic
anaerobic metabolites from infarcted muscle.
8. Management:
a. Assessment and maintenance of ABC.
b. Transfer patient to ITU.
c. Iv fluids, O2 inhalation, Analgesics
d. Inform consultant, involve Critical care team.
e. Maintenance of adequate fluid balance-
 Adequate hydration
 Maintain Urine output >300ml/hour (To clear
myoglobin).
 Start Glucose Insulin infusion and IV CaCl2
 Diuretics- Mannitol (30ml/hour)
 IV NaHCO3
9. How will you be monitoring patient?
 CVP Line
 ABG, S electrolyte
 ECG, Pulse oximetry
 Pulmonary artery occlusive pressure
 Vital chart
10. When will you consider renal replacement therapy?
a. Established oliguric renal failure
b. Uncontrolled hyperkalemia
c. Fluid overload.

2
 UTI AND CARCINOMA PROSTATE

Case scenario: A case of urinary tract infection (URE report positive) with
PSA level high with H/O Radical prostatectomy for Prostate cancer.

1. What is your diagnosis?

 Urinary tract infection/ Sepsis due to UTI.
2. How much colony count positive for UTI?
 105 colony/ml or 1lac colony/ml
3. Most common organism for UTI?
 E Coli
4. Suggest 3 blood investigations for this patient?
 FBS with ESR, CRP, Culture sensitivity.
5. What's main component in white cell count?
 Neutrophil
6. What causes of increase WCC post operation?
 UTI, infection, sepsis.
7. PSA normal value is <4ng/ml. 6 months after prostatectomy, PSA level is
3ng/ml. what might be the cause?
 Recurrence of carcinoma of prostate.
8. Biopsy done and histopathology shows presence rectal tissue. What
might be the cause?
 Metastatic involvement of rectum.
9. Why multiple biopsy taken?
 Due to multiple lobe of prostate and cancer may involve one lobe.
10. In Bone metastasis, which blood component will raise?
 Lymphocyte
11. Normally in prostate cancer, one of the treatments is bilateral
orchidectomy. What is your rationale? Is there any role of orchidectomy?
 Yes, it reduces or stop testosterone production, so decrease
chance of recurrence. It also reduces bone pain due to metastasis.
12. Which primary cell in testes produce testosterone?
 Leydig cell and also sertoli cell.

13. What scoring system used in Carcinoma prostate?

 Gleason’s score.

3
 Hypercalcemia and MEN syndrome

Scenario: Patient with parathyroid hyperplasia.

1. What are the causes of secondary hypercalcemia?
 Renal failure, Bony metastasis, Vit-D toxicities, TB, Sarcoidosis,
Thiazide diuretics, Para-neoplastic syndrome in multiple
myeloma, Ca lung.
2. What are the position of parathyroid gland?
 2 Superior glands-
 2 inferior glands-
3. What is hyperplasia?
 Increased volume of organ by increased number of cell.
4. Hyperplasia occurs in which parathyroid gland?
 Hyperplasia occurs in all 4 glands but adenoma developed only in
one gland.
5. Parathyroid hyperplasia belongs to which syndrome?
 MEN-2a Syndrome.
6. In Insulinoma- what is the insulin level?
 Raised
7. How do you diagnose?
 FBS, CT scan of Abdomen, PTH hormone, S Ca++, MRI of brain.
8. What are the Pancreatic tumor causing hypoglycemia?
 Insulinoma, Nesidioblastoma, Addison’s disease.
9. Given that this is having parathyroid and pancreatic involvement, what is
the other pathology? What does it is called?
 Pituitary gland. MEN-1 syndrome and MEN-2a Syndrome.
10. What is Knudson two hit hypothesis?
 Hypothesis that explain cancer is the result of accumulation of
mutation to a cell DNA. In MEN-1, mutation of menin gene either
negatively regulate cell growth or participate in maintenance of
genomic integrity.
11. Apart from tumor suppressor gene, what are the other groups of gene
mutation?
 TNF, Oncogene, Proto-oncogene.

4
12. What's apoptosis? Is it energy driven?
 It’s a pathway of cell death that is induced by a tightly regulated
intracellular programme in which cell destinate to die.
13. What is telomere?
 Telomere is the distinctive structures of DNA found at the end of
our chromosome and consist of the same sequence of bases
repeated over and over.

5
 RHABDOMYOLYSIS

Scenario: A case of RTA with fracture tibia, fibula and compartment syndrome
with marked raised S. creatinine level. Urine RME shows plenty RBC, High K+
level!

1. What is your diagnosis?

 ARF due to rhabdomyolysis with compartment syndrome
following RTA.
2. What are Causes of this clinical scenario?
 Crush injury, Compartment syndrome, hyperkalemia, acute
reperfusion injury.
3. What is the pathophysiology of Renal failure?
 Impairment of sarcoplasmic Na-K pump resulting in decreased Na
extrusion, reduce Ca and water efflux and myofibril disruption with
muscle damage specially Type-2 Muscle. That causes release of
myoglobin, Purine, K+ and Phosphate.
4. Why DIC?
 Pathological activation of coagulation cascade by release of muscle
component.
5. What might be the Complications:
Hypovolemia: Sequestration of fluid within injured muscle and
hemorrhage in necrosed muscle.
ARF: Due to myoglobinuria as because iron is toxic to renal tubule and
forms mechanical blockage. Also ARF develops from hypovolemia.
Metabolic complications:
i. Metabolic acidosis
ii. Hyperkalemia: Release of intracellular K + , Rena failure, and
acidosis.
iii. Hyperuricemia: Due to increased hepatic conversion of
purine.
iv. Hyperphosphatemia: Increased release of phosphate from
injured muscle.

1
6. Investigation:
a. Urine R/M/E: Myoglobinuria (positive dipstick test for blood in
absence of hematuria).
b. Serum enzyme:
 CK, CK-MM, CPK (creatinine phosphokinase)
 LDH
 Carbonic anhydrase 3 (more specific marker).
7. What is reperfusion injury?
Revascularization of non-viable acutely injured muscle causes acidosis,
hyperkalemia, rhabdomyolysis and myoglobinuria due to release of toxic
anaerobic metabolites from infarcted muscle.
8. Management:
a. Assessment and maintenance of ABC.
b. Transfer patient to ITU.
c. Iv fluids, O2 inhalation, Analgesics
d. Inform consultant, involve Critical care team.
e. Maintenance of adequate fluid balance-
 Adequate hydration
 Maintain Urine output >300ml/hour (To clear
myoglobin).
 Start Glucose Insulin infusion and IV CaCl2
 Diuretics- Mannitol (30ml/hour)
 IV NaHCO3
9. How will you be monitoring patient?
 CVP Line
 ABG, S electrolyte
 ECG, Pulse oximetry
 Pulmonary artery occlusive pressure
 Vital chart
10. When will you consider renal replacement therapy?
a. Established oliguric renal failure
b. Uncontrolled hyperkalemia
c. Fluid overload.

2
 UTI AND CARCINOMA PROSTATE

Case scenario: A case of urinary tract infection (URE report positive) with
PSA level high with H/O Radical prostatectomy for Prostate cancer.

1. What is your diagnosis?

 Urinary tract infection/ Sepsis due to UTI.
2. How much colony count positive for UTI?
 105 colony/ml or 1lac colony/ml
3. Most common organism for UTI?
 E Coli
4. Suggest 3 blood investigations for this patient?
 FBS with ESR, CRP, Culture sensitivity.
5. What's main component in white cell count?
 Neutrophil
6. What causes of increase WCC post operation?
 UTI, infection, sepsis.
7. PSA normal value is <4ng/ml. 6 months after prostatectomy, PSA level is
3ng/ml. what might be the cause?
 Recurrence of carcinoma of prostate.
8. Biopsy done and histopathology shows presence rectal tissue. What
might be the cause?
 Metastatic involvement of rectum.
9. Why multiple biopsy taken?
 Due to multiple lobe of prostate and cancer may involve one lobe.
10. In Bone metastasis, which blood component will raise?
 Lymphocyte
11. Normally in prostate cancer, one of the treatments is bilateral
orchidectomy. What is your rationale? Is there any role of orchidectomy?
 Yes, it reduces or stop testosterone production, so decrease
chance of recurrence. It also reduces bone pain due to metastasis.
12. Which primary cell in testes produce testosterone?
 Leydig cell and also sertoli cell.

13. What scoring system used in Carcinoma prostate?

 Gleason’s score.

3
 Hypercalcemia and MEN syndrome

Scenario: Patient with parathyroid hyperplasia.

1. What are the causes of secondary hypercalcemia?
 Renal failure, Bony metastasis, Vit-D toxicities, TB, Sarcoidosis,
Thiazide diuretics, Para-neoplastic syndrome in multiple
myeloma, Ca lung.
2. What are the position of parathyroid gland?
 2 Superior glands-
 2 inferior glands-
3. What is hyperplasia?
 Increased volume of organ by increased number of cell.
4. Hyperplasia occurs in which parathyroid gland?
 Hyperplasia occurs in all 4 glands but adenoma developed only in
one gland.
5. Parathyroid hyperplasia belongs to which syndrome?
 MEN-2a Syndrome.
6. In Insulinoma- what is the insulin level?
 Raised
7. How do you diagnose?
 FBS, CT scan of Abdomen, PTH hormone, S Ca++, MRI of brain.
8. What are the Pancreatic tumor causing hypoglycemia?
 Insulinoma, Nesidioblastoma, Addison’s disease.
9. Given that this is having parathyroid and pancreatic involvement, what is
the other pathology? What does it is called?
 Pituitary gland. MEN-1 syndrome and MEN-2a Syndrome.
10. What is Knudson two hit hypothesis?
 Hypothesis that explain cancer is the result of accumulation of
mutation to a cell DNA. In MEN-1, mutation of menin gene either
negatively regulate cell growth or participate in maintenance of
genomic integrity.
11. Apart from tumor suppressor gene, what are the other groups of gene
mutation?
 TNF, Oncogene, Proto-oncogene.

4
12. What's apoptosis? Is it energy driven?
 It’s a pathway of cell death that is induced by a tightly regulated
intracellular programme in which cell destinate to die.
13. What is telomere?
 Telomere is the distinctive structures of DNA found at the end of
our chromosome and consist of the same sequence of bases
repeated over and over.

5
 MRCS OSCE PATIENT EXAMINATION
[email protected] / www.drmrcs.com

PROCEDURE SKILL

Q-1: IDC insertion on Dummy: Patient presented with lower abdominal pain
and urinary retention. Registrar thinks it is AKI, asked you to perform IDC.

Steps:
1. Introduction, greetings and obtain consent from actor.
2. Hand wash, wear gloves
3. Have to prepare IDC set yourself: Place the catheter (with syringe
for balloon), Jasocaine jelly, in sterile field.
4. Explain to the patient indication of procedure. warn that he or she
might feel discomfort.
5. Perform an IDC insertion as usual.
6. However, no urine coming out. Tried to aspirate and flush, but still
no urine.
 What are the causes for no urine?
 Renal: ARF, ATN,
 Pre-renal: Dehydration, sepsis, shock.
 Post-renal: Ureteric stone, tumor, UB carcinoma.
 What will you do now?
 Don’t inflate balloon, remove IDC
 Look for other causes of abdominal pain
 Plan for USG whole Abdomen.

1
Q-2: Incision & Drainage of thigh abscess: Senior had to go out, you’ve been
asked to do the operation.

Steps:
1. Introduction, and greetings with actor.
2. Confirm about patient identity
3. Hand wash, wear gloves
4. Checked consent
5. Ask any allergy to medication
6. Give anesthetic or question may state that anesthesia is already
given.
7. Asked examiner to wait 10-15mins before proceeding to allow LA
to take effect.
8. Incise along Langer’s lines after checking numbness.
9. Pus will comes out from the abscess cavity and is a blue glove filled
with mayonnaise.
10.Send pus for culture sensitivity
11.Break up septations with your finger and washed the wound.
12.Give post procedural advice to patient while you are doing this. Tell
patient wound won’t be closed.
13.Advised patient about postoperative plan (analgesia, antibiotic,
review in clinic to follow up C/S and wound).
14.Thanks to patient
15.Asked for histopathology and microbiology form.

 How did you decide your direction of incision?

 Langer’s lines
 Show me langers line on thigh?
 What dressing would you use?
 Chlorhexidine soaked ribbon gauze),
 What else would you use to put into the wound?
 Calcium Sodium Alginate dressing (Kaltostat)

2
Q-3: Excision biopsy of nevus from right thigh. Senior had to run just after
giving LA, you are called to do the operation.

Steps:
1. Introduction, and greetings with actor.
2. Confirm about patient identity
3. Checked consent
4. Ask any allergy to medication
5. Hand wash, wear gloves
6. Checked consent, confirmed with patient that LA already given by
consultant.
7. Arrange operative trolley- Pick up instruments from table that you
want to use and place in kidney dish. Instruments available:
toothed forceps, tissue scissors (curved), suture scissors (straight),
ruler, skin hooks, marker, needle holder, BP blade and handle,
prolene suture, gauze.
8. Nevus is marked with a black marker pen dot on the foam.
9. Check for pain
10.Elliptical incision involving nevus at the center of ellipse.
11.Excise the nevus, and suture wound.
12.Simultaneously you should speak with patient about postoperative
outcome and management.
13.Let me know if you feel any pain or discomfort. After surgery, I will
close this wound with stich and after 7 days you will need to
remove off at follow up clinic. This may produce a little scar. You
have to take medicine routinely and for pain we will give you
analgesic also.
14.After completion of surgery, give a dry dressing and asked for send
for histology form.
15.Advised patient about postop plan (analgesia, antibiotics, review in
clinic to follow up histology and wound).
16.Proper disposal of garbage into bin.
17.Thanks to patient.

3
Q-4: Debridement of a dirty wound: Wanted to see us probing the wound
properly, patient was consented (Turkey chicken leg).

Steps:
1. Introduction, and greetings with actor.
2. Confirm about patient identity
3. Checked consent
4. Ask any allergy to medication
5. Hand wash, wear gloves
6. Checked consent, confirmed with patient that LA already given by
consultant.
7. Explain to patient- what you are going to do, benefits and risks,
modes of injury.
8. History- pain, any X-ray report, medication, vaccination.
9. Arrange operative trolley
10.Debridement- trimming of margin, wound wash, feel for bony
injury or foreign body.
11.Advised patient about postop plan (analgesia, antibiotics, review in
clinic to follow up histology and wound).
12.Proper disposal of garbage into bin.
13.Thanks to patient.

 What anesthetic would you use and what’s the dose?

 Injection Lidocaine
 What would you do if radial artery injured?
 We will try to repair but if not possible then will do Allen’s test or
check Oxygen saturation with pulse oximetry. If Oxygen saturation
is 100%, then no need to be worried because hand will have blood
supply from ulnar artery via palmar arch.
 What precautions to take?
 Complete tetanus immunization schedule
 What post-procedural advice?
 Take medicine routinely
 Dressing regularly
 If pain, fever or bleeding, please attend A&E.

4
Q-5: PREPARE FNAC SLIDE: An anxious young man with fake skin or muscle
layers attached to his thigh with swelling (baby tomatoes) in the mid part.

Steps:
1. Introduction, and greetings with actor.
2. Confirm about patient identity.
3. Checked consent, confirmed with patient that LA already given by
consultant.
4. Hand wash, wear gloves
5. Explain to patient- what you are going to do, benefits and risks,
modes of injury.
6. Keep discussing with patient like when will report be available,
further management and assure him not to be worried regarding
malignancy.
7. Examiner usually do not ask to prepare FNAC slide, just wanted to
know an overall method. However please watch video of slide
preparation.
8. Material should be collected with baby needle and puncture should
be made in 3 or 4 directions over swelling.
9. Fix specimen onto slide
10.Put the rest into cytospin bottle.
11.Asked for histopathology form
12.Advised patient about postop plan (analgesia, antibiotics, review in
clinic to follow up with histology report after 7 days).
13.Proper disposal of garbage into bin.
14.Thanks to patient.

 Patient asks if this is likely to be cancer because he has previous history

of melanoma in the same limb?
 Assure him.
 Advise to wait till report available.
 Keep faith on god!

5
Q-6: Suturing

 Tie with non-absorbable braided suture (hand tie) in a rubber band

(SILK)?
 Tie a hook in a cavity with an absorbable braided suture (hand tie)
(VICRYL)?
 Overrun a bleeding spot with a figure of 8 suture with a non-absorbable
monofilament (instrument tie) (PDS)?

 What are the type of knots you know?

 Surgeons knot and reef knot
 What are the advantages of a braided suture?
 Easy knotting, secure knot
 What are the potential complications when tying a knot in a cavity?
 Injury to surrounded structure
 Difficult to exposure
 Difficult to knot tie
 Why do you have to tie prolene so many times?
 Because it is slippery and need to give 7-8 knot.
 How would you broadly classify sutures?
 Monofilament/braided, absorbable/non-absorbable
 What other monofilament absorbable suture do u know?
 Monocryl, PDS

6
Q-7: ATLS- Resuscitation with surgical airway options
Patient involved in RTA, comes in not breathing.

Steps:
1. Introduction, and greetings.
2. Confirm about patient identity.
3. Hand wash, wear gloves
4. Ask for assistant nurse
5. Proceed according to ABC
6. Maintenance of Airway- chin lift, jaw thrust, oro-pharyngeal
airway), breathing (bag-valve mask), C-collar use.
7. Call anesthetist or critical care team.
8. But patient is de-saturating again- recheck airway and breathing.
9. Use umbo bag to inflate the lung.

Basically started asking about options of surgical airways and further

management.
 Which is emergency surgical airways?
 Cricothyroidotomy
 What landmark use for ET intubation?
 2-3rd tracheal rings
 Halfway between cricoid cartilage and sternal notch

 What investigation would your advice the blood sample for?

 FBC, U&E, cross match, Coagulation profile, ABG
 What would your next fluid be?
 I'd like to see the observation chart
 2L warmed Hartmann’s solution.
 Please prescribe this fluid?
 Given prescription chart - be sure to fill in all the details, including
allergies, height and weight, medicine, fluid etc.
 What adjuncts to the primary survey do you know of?
 FAST scan
 Trauma series x-rays
 Would you take this patient to CT?
 No! Fluid non-responder with abdominal pain, therefore
mandates theatre for emergency laparotomy.