Membership of the Royal College of Surgeons (MRCS) Clinical and Communication Skills (OSCE Part B) Syllabus

In examining a varicose vein patient, what does the Trendelenburg (tourniquet) test assess?

It localises the site of venous incompetence; controlling filling with a high tourniquet suggests saphenofemoral junction incompetence, while filling despite it indicates incompetent perforators below the tourniquet.

What are the key descriptive features to assess when examining any lump?

Site, Size, Shape, Surface, Edge, Consistency, Colour, Temperature, Tenderness, Transilluminance, Pulsatility, Compressibility, Fluctuance, Mobility/fixation, and relation to surrounding structures (skin/deep tissues).

What sign suggests a lump is fluid-filled rather than solid, and how is it elicited?

Fluctuance — pressure on one side of the lump causes a detectable bulge on the opposite side, tested in two perpendicular planes. Transilluminance also supports a clear fluid-filled cyst.

In a breast examination, what is the standard system used to describe and triage findings?

Triple assessment: clinical examination, imaging (mammography and/or ultrasound), and pathology (core biopsy/FNA) — each scored, e.g. P/E1-5, imaging M/U1-5, pathology B/C1-5.

What does 'peau d'orange' appearance of the breast indicate?

Dermal lymphatic invasion causing skin oedema with tethering at hair follicles; it is a sign of locally advanced or inflammatory breast cancer.

When examining a neck lump, which movements help determine its origin?

A thyroid lump moves up on swallowing; a thyroglossal cyst moves up on swallowing AND on tongue protrusion (due to attachment to the foramen caecum via the thyroglossal tract).

What is the standard sequence for examining a peripheral joint (musculoskeletal)?

Look (inspection), Feel (palpation), Move (active then passive range), and special/functional tests; often summarised as 'Look, Feel, Move' plus measure and assess function.

In the MRC grading of muscle power, what does each grade 0-5 represent?

0 = no contraction; 1 = flicker/trace; 2 = movement with gravity eliminated; 3 = movement against gravity but not resistance; 4 = movement against some resistance; 5 = normal power.

Which nerve roots are tested by the biceps, supinator, triceps, knee, and ankle reflexes?

Biceps $C5/C6$, supinator $C5/C6$, triceps $C7/C8$, knee $L3/L4$, ankle $S1/S2$.

What is a positive Tinel's sign and Phalen's test, and which condition do they suggest?

Tinel's: tapping over the carpal tunnel reproduces tingling in the median nerve distribution; Phalen's: full wrist flexion for 60 seconds reproduces symptoms. Both suggest carpal tunnel syndrome.

In a shoulder examination, what does a positive 'empty can' (Jobe's) test indicate?

Pain or weakness on resisted abduction in the scapular plane with thumbs down, indicating supraspinatus tendon pathology or tear.

What are the key steps of the surgical scrub before donning sterile gloves?

Remove jewellery, wet hands/forearms, use antiseptic (chlorhexidine or povidone-iodine), clean nails, scrub each surface of fingers/hands/forearms keeping hands above elbows, rinse from fingertips to elbow, and dry with sterile towel (one per arm).

What is the difference between sterilisation and disinfection?

Sterilisation destroys ALL microorganisms including spores (e.g. autoclaving); disinfection reduces the number of viable microorganisms but may not kill all spores.

Which standard autoclave parameters achieve sterilisation of surgical instruments?

Saturated steam at $121^{\circ}\text{C}$ for 15 minutes at $103\,\text{kPa}$ (15 psi), or $134^{\circ}\text{C}$ for 3 minutes at higher pressure.

When handling a surgical scalpel and passing it to a colleague, what safe practice is used?

Use a hands-free 'neutral zone' (kidney dish) for passing sharps, mount and remove blades with forceps/needle holder (never fingers), and announce the sharp.

What is the correct way to hold needle holders and a scalpel for fine cutting?

Needle holders: thumb and ring finger in the loops with index finger along the shaft for control; scalpel for fine work: held like a pencil (precision grip), for long incisions: table-knife grip.

What is the difference between absorbable and non-absorbable sutures, with examples of each?

Absorbable sutures are broken down by the body (e.g. Vicryl/polyglactin, Monocryl/poliglecaprone, PDS); non-absorbable persist and need removal or remain permanently (e.g. silk, nylon/Ethilon, Prolene/polypropylene).

How do monofilament and braided (multifilament) sutures compare?

Monofilament (e.g. Prolene, nylon) has low tissue drag and lower infection risk but poorer knot security; braided (e.g. silk, Vicryl) handles and knots well but has higher capillarity and infection risk.

What is the standard configuration for a secure surgical reef (square) knot when instrument tying?

Alternating throws in opposite directions — a double throw (surgeon's knot) followed by single throws laid square (left-over-right then right-over-left), with at least 3-4 throws for monofilament and more for greater tension.

How does suture size notation work, and which is thicker: 2-0 or 5-0?

The more zeros, the thinner the suture; 2-0 (written 00) is thicker than 5-0 (00000). Larger numbered single digits (e.g. 1, 2) are thicker still.

When are interrupted versus continuous (running) sutures preferred?

Interrupted sutures are preferred where wound security matters and one failed knot should not open the whole wound, or in contaminated wounds; continuous sutures are faster and give even tension distribution (e.g. mass closure of laparotomy).

What is the 'Jenkins rule' for closing a midline laparotomy?

Suture length should be at least 4 times the wound length, with bites approximately 1 cm from the edge and 1 cm apart, to reduce dehiscence and incisional hernia risk.

What are the key steps and safety landmarks for inserting a urethral catheter?

Aseptic technique, clean the meatus, instil local anaesthetic lubricant, insert to the hilt before inflating the balloon (with sterile water, typically 10 mL), confirm urine flow, then attach the drainage bag and document residual volume.

What are the surface landmarks for safe insertion of an intercostal chest drain?

The 'safe triangle': bordered by the anterior border of latissimus dorsi, the lateral border of pectoralis major, a line above the 5th intercostal space, with the apex below the axilla. The needle/drain passes just above the rib to avoid the neurovascular bundle.

Why is a needle for pleural or chest procedures inserted just ABOVE the rib below rather than below the rib above?

The intercostal neurovascular bundle (vein, artery, nerve) runs in the costal groove on the inferior border of each rib; inserting above the lower rib avoids damaging it.

How is the anion gap calculated and what is the normal range?

$$\text{Anion gap} = [\text{Na}^{+}] - ([\text{Cl}^{-}] + [\text{HCO}_{3}^{-}])$$ Normal range is approximately $8$ to $12\,\text{mmol/L}$ (or up to $16$ if potassium is included).

On an arterial blood gas, how do you distinguish respiratory from metabolic acidosis?

Both have low pH; respiratory acidosis has a high $\text{PaCO}_{2}$ (primary problem), whereas metabolic acidosis has a low $\text{HCO}_{3}^{-}$ with compensatory low $\text{PaCO}_{2}$.

What is the systematic ABCDE approach to interpreting a chest X-ray?

Airway (trachea/carina), Breathing (lung fields/pleura), Cardiac (heart size/borders), Diaphragm (and costophrenic angles, free air under diaphragm), Everything else (bones, soft tissues, devices) — after confirming patient details and adequacy (RIPE: Rotation, Inspiration, Penetration, Exposure).

On an abdominal X-ray, what features distinguish small bowel from large bowel obstruction?

Small bowel: central loops, valvulae conniventes crossing the full lumen, diameter $>3\,\text{cm}$. Large bowel: peripheral, haustra not crossing fully, diameter $>6\,\text{cm}$ (caecum $>9\,\text{cm}$).

What does the surgical sieve mnemonic 'VITAMIN CDEF' provide when forming a differential in clinical reasoning?

A structured list of disease categories: Vascular, Infective/Inflammatory, Traumatic, Autoimmune, Metabolic, Iatrogenic/Idiopathic, Neoplastic, Congenital, Degenerative, Endocrine, and Functional — ensuring a comprehensive differential diagnosis.