MRCS Edinburgh (Passed) Date: December, 2004
|MCQs 60 questions with 5 parts= 300 questions.
Generally fair with questions on Wilson' disease and corneal dystrophies
among others. I think I guessed too many which is not such a good idea
as there is negative marking.
Day 2 had vivas 1 and 2 with viva 1 being ophthalmology and medicine and viva 2 being ophthalmic pathology and surgery.
In my first viva I started with medicine.
I was first asked to list the causes of atrial fibrilation-I said ischaemia,thrombosis
I was then asked for management of anaphylaxis with FA and gave ABC and was asked about the route for giving adrenaline and said intramuscular but the examiner wanted subcutaneous also.
Next I was asked for the management of a diabetic patient who became unresponsive outside clinic. I said I would suspect hypoglycaemia and would check airway was clear before checking blood sugar and giving glucagon if sugar level was low.
I was then asked for vitamin deficiencies and the eye. I started with vitamin A deficiency and gave night blindness,xeropththalmia and tear problems. The examiner then asked what type of patients in Britain are affected and I gave malabsorption,alcoholics and drug users as the commonest groups as malnutrition is fortunately uncommon.The examiner asked me about vitamin B deficiency which I did not know and then asked about symptoms of Korsakoff's syndrome.
The second half of viva 1 was ophthalmology.
The second examiner had an apple I book with a number of images.
The first patient showed bilateral proptosis,periorbital oedema and erythema of the eyes and I gave the most likely diagnosis as thyroid eye disease. I was asked for management and about treatment of suspected optic nerve compression including pulsed methylprednisolone and which orbital walls are decompressed.
The next patient had a fecial palsy and I was asked what tests I would want to do. I said I would like to exclude a cerebellopontine angle tumour which could cause facial palsy and was asked which tests I would do-corneal sensation,hearing and ocular motility. I was asked for other causes of facial palsy and said idiopathic. I was asked for any other names for this but did not know and was told it is Bell's palsy.
The next patient's picture was a CT scan of an orbital foreign body. I was asked would I do an MRI scan and said no in case it was metallic which could cause movement of the foreign body.
The next patient showed dystopia and I was asked for possible causes and said space occupying lesions.
My second viva started with pathology.
I was asked if a GP rang up with a contact lens wearing patient who
had suspected keratitis whether I would see the patient that evening. I
said yes and that I would want to examine the
I was next asked what I knew about retinoblastoma. I said that it was a tumour of primitive neural rosettes which can form Flexner-Wintersteiner rosettes on histology. I then mentioned that it was due to deletion of a tumour suppressor gene and had different forms of inheritance. Before I could say more the bell rang for the end of the pathlogy part of the viva.
The second half of the viva was on surgery.
The examiner drew a lesion on the lower lid and asked me for my management. I asked how old the patient was so I could decide on the most likely cause as well as how long the lesion had been there. I was told it was a patient in their seventies and the lesion had been there six months. I said the most likely lesion was a basal cell carcinoma and in such a case I would want to do a pentangle-based incision with a clearance of 3mm to try and ensure all the tumour was removed. The examiner asked why I would do that shape of excision and I said that it was so I could close the lesion by apposing the grey line and allow healing. The examiner asked me if any other lesions were possible and I said in a case of squamous cell carcinoma the same shape of excision would be used but a clearance of 5mm would be needed.
Next I was asked my management of a drunk patient in casualty with a
suspected perforating injury. I asked if it was possible to establish visual
acuity and said that it was. I said I would then try and examine the patient
on the slit-lamp with help from one of the nurses but was told that very
limited examination was possible. I next suggested doing a CT scan to see
if there was evidence to confirm suspicions of perforation and was told
that the patient was cooperative and CT scan confirmed perforation. I was
asked whether surgery would be needed that evening and said that examination
under anaesthesia would be required and I would discuss the patient with
the on-call consultant as well as contacting the
Following the vivas we were all asked to attend the college at five
o'clock to see if we were successful in getting to the clinical exam with
a letter indicating failure and an A4 piece of paper indicating success
with the time of the next exam.
The first clinical exam was surgery and medicine.
I had two examiners who were both pleasant and they took it in turns to ask questions.
Patient 1 had bilateral lens opacities and a stage 1 macular hole in
the right eye and a stage 4 macular hole in the left eye. I was asked for
my management and said I would ask the
This seemed to satisfy the examiners and the next patient I was shown
had bilateral corneal
I was then asked to examine a patient with an indirect ophthalmoscope. The patient had been dilated and was sitting in a chair and I asked if I could examine the patient on the couch and after looking at each other the examiners eventually agreed. The patient was not dilated very well but I was not sure whether to mention this and in the end did not. It was a bit difficult to get a good fundal view and it was a bit disconcerting as one of the examiners was looking in the mirror to check my view. I could see some pigmentary changes superotemporally in the right eye and gave the diagnosis as previous retinal detachment with surgery. I was not asked too many questions about this fortunately as the examiners may have taken the poor view into account. We then went to a second room with more patients and I could see the examiners making notes on a clipboard but fortunately did not see what they had written.
I was asked to take a history from a patient at a slit lamp. The patient was in his forties and had poor vision since childhood. There was also a strong family history and I told the examiners I was considering retinitis pigmentosa. However further questioning revealed that vision was worse during the day so it appeared to be a macular dystrophy. I was then asked to say what treatment was possible and I said that there was no treatments for the condition except for visual aids but I would like to confirm the condition by doing electrophysiology. I was the asked to examine the patient's posterior segment and saw a fairly subtle maculopathy worse right than left. I was then asked what electrophysiology would show and said that there would be an abnorlal EOG . The examiners then asked me what the ERG would show but I did not know. The final patient had bilateral atrophic maculopathy and I gave a possible cause as myopia.
That night there was another wait before knowing if I had got through to the final clinical exam.
The final clinical exam was neurology and ophthalmology.
The two examiners were a bit more stern. I was taken into the first
room and asked to comment on a patient with a facial palsy and occlusion
to one of his spectacle lenses. I asked the patient to take off his glasses
and noted a lateral tarsorrhaphy. The examiner asked me the reason for
this and I suggested poor eyelid closure secondary to the facial palsy.
I was next asked to look at a patients hands and saw symmetrical deformity
with proximal swelling in keeping with RA. I was asked to say what abnormalities
occur in the eye
The third patient was examined on the slit-lamp and was a man in his forties. He had a vein occlusion in his right eye with haemorrhages and exudates. I commented that he was young to have had a vein occlusion and said I would like to investigate him for clotting abnormalities as well as routine investigations.
A bell rang and we went to the final room of the examination.
I was taken to a gentleman in his fifties who had been initially referred by his optometrist who had been noted an optic nerve abnormality. On questioning he did not have significant problems apart from slight blurring of vision and headache. At this point the examiner asked me if I noticed any speech problems and said there was a slight dysathria. The examiner said he had some problems with his gait and having realised that he was hinting about a cerebellar problem I asked if the gait was broad-based but the examiner said this had not been noticed. I was asked if there was anything else I could ask and so I asked the patient to say "baby hippopotamus" which was abnormal. I said I suspected cerebellar problems and asked for other tests and I did finger-nose pointing which was abnormal but hand pronation-supination seemed pretty good. Strangely enough I was not to test eye movements which would have been useful. I was asked for possible causes and said space occupying lesions,AV malformations and demyelination. I was asked the chance of optic neuritis being caused by MS and said 50% in males and 70% in females. As the final question the examiner asked if I would tell the patient about possible MS and I said this was a controversial area which seemed to satisfy the examiners.
My next patient was on a slit lamp. He had signs of diabetic retinopathy
and I was asked
My last patient had dilatation of his left eye as well as pseudophakia.
I commented that the patient was fairly young being in his thirties. The
examiner asked if I could see any other abnormalities and looked for heterochromia
but could not find any. The examiner asked me to look at the anterior segment
again and I eventually saw Lisch nodules and diagnosed NF-1. The examiner
said that vision had not improved following surgery and asked why and I
suggested optic glioma. I was then asked if given a dilated pupil in one
eye it is possible to check for an RAPD and said that the other eye should
be looked at and consensual reaction checked.