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HOW TO PREPARE FOR MBBS / MS GENERAL SURGERY PRACTICALS ?-MADE

EASY!!!

Preprint · May 2018

DOI: 10.13140/RG.2.2.17411.60961

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HOW TO PREPARE FOR MBBS /
MS GENERAL SURGERY
PRACTICALS ? — MADE EASY!!!

Hello everyone !!
After a rather successful stint giving an idea about approach
to theory exams in MS General Surgery, I decided to put
together some key issues based on my experience about
the practical exams.
 
Disclaimer : All views personal. I totally understand each
individual works differently. If you think you got a better way
of doing things, feel free to share. Below are a set of general
consensus based on my experience and this scenario can
be highly variable.
 

CREDENTIALS :
1. Due to some extra-ordinary turn of events, I had to take
the practical exam thrice over a 6 month period.
2. I faced a total of 3 long cases, 6 short cases and came
across scores of other exam cases and by extension
multiple examiners.
3. I had to take the MRCS Part B OSCE exam twice
which translated roughly to facing 35-40 examiners, 40
clinical stations, 15-20 different patients etc.
 4. I was involved ( fortunately / unfortunately ) in helping
conduct exams for undergraduate MBBS / BDS
students over the last 2-3 years.
5. I attended FRCS training program involving
international faculty which discussed exam cases in a
broad variety of areas from communication skills,
clinical exam to complete management and follow up of
patients.
 
In short, all I am trying to say is ” I kind of know what I
am talking about”. Any of this is not to brag but to
improve the validity of my statements.
 
SOME KEY CONSIDERATIONS —

1. Overall, it is an easy exam to pass and an easy exam

to fail.
2. One thing that is most important throughout the exam is
“BEING CONFIDENT“. Even if you are not, fake it till
you make it! At least that helped for me.
3. Fear is a dangerous thing throughout the exam. Avoid it
although it may sound impossible not to be scared.
4. Examiner is always right however dumb he may
sound. Your whole goal is to pass the exam, not to
prove anyone right.
5. Morning session far outweighs the afternoon
session in terms of marks weightage and thereby
deciding your fate, so try not to screw it up.
6. Be familiar with the place where the exam is going to
be held.
7. Try not to bother too much enquiring about the
details of external examiners, no examiner in their
right mind wants to fail a candidate unless you mess it
all up horribly.
8. Personally I don’t encourage gathering details of the
patient details that are going to be possible exam
cases, however it would be absolutely foolish to be
completely unaware of possible cases you might
face in the exam. So pick what works for you.
9. The efforts you have put in over the past 3 years will
reflect in your case presentation and answering the
viva, so try not to loose sleep and food preparing for
the exam.
 10.Be flexible when it comes to case allotments,
remember you may not always get a case you are good
at.
 

RESOURCES
(CLICK ON THE HEADING TO
GO TO THE LINK ONLINE)
1.A Manual On Clinical Surgery
13ed by Das
• By far, THE most important book.
• But blindly following this, without some precautions
can get you killed (not literally but figuratively!!)
• The order in which history and examination
should be presented is given well.
• The chapters on general examination, swelling,
ulcer, major long cases are all important.
• The classification of a condition, differential
diagnosis, detailed description of the same at the
end of examination are all good.
• However, the investigations part given in fine
print at the end of chapter is a complete disaster.
• Just because something is given in Das, it needn’t
be followed blindly but rather modified according to
the case.
• Talking of fluctuation, fluid thrill, compressibility etc
in a hard swelling doesn’t make any sense!
2.Bedside Clinics in Surgery by
Makhan Lal Saha
• A larger upgrade to Das.
• Try to limit to the cases which are likely to be
kept in examination.
• More often, the book strays away from important
discussion, so selective reading is recommended.
• A detailed description on “how to do” of most
clinical tests is given.
3.Clinical Surgery Pearls by
Dayanand Babu
• Has checklists of what not be missed during
history and clinical exam.
• Go through discussion part of cases which you feel
are more likely to be kept in exam.
• Putting forward a well worded diagnosis, further
investigations and management are discussed
well.
4.Youtube videos of clinical
examination by Dr Vaidya
• Excellent free resource to refresh your clinical
examination skills.
• Most major cases are included.
• 20-25 minutes for each case.
• Watch the video, then read the books, that way it
sticks well!
5.Case sheet proformas
 • Read, repeat, practice all the list of things you
need to say about a particular case.
• The document covered most important cases in
detailed manner.
6.Drexam Part B MRCS Osce
Revision Guide: Book 2:
Clinical Examination,
Communication Skills &
History Taking
• My personal favourite!!!
• Helped me pass MRCS and MS.
• Basically, the book cuts out the crap and gets to
the point that matters most in a particular case.
• For example, of all the various fancy tests
described for varicose veins, the only ones with
some degree of clinical importance are
Trendelenberg, Perthes, Tourniquet test.
• Ziemann’s technique is totally omitted as it doesn’t
contribute much to diagnosis in most cases.
• If you could get your hands on this book, have a
read.
• Much less stuffing of data and useless facts.
• A word of caution is required as this book is more
suited for UK style exams.
• You still need to get all the tests for varicose veins
done to pass MS although most are of practically
useless!!
 
SOME FAQ’S
1.What is the exam in
question?
• This is the practical / clinical VIVA exam for
passing MS General Surgery exam conducted
by Dr NTR university, vijayawada.
• The same pattern applies to most Indian /
South Asian universities and DNB exams
conducted by natboard / NBE.
•
2.What is the exam pattern?
• The exam is usually conducted from 9 AM to 5
PM.
• The morning session typically consists of 1
long case and 2 short cases.
• The evening session consists of 4 vivas
including surgery specimens, operative
procedures, X- rays of common surgical
conditions, surgical instruments.
•
3.What is the marks
distribution?
• The single long case during morning session
is worth 100 marks.
• Two short cases worth 50 marks each.
• The 4 vivas during the afternoon session are
25 marks each.
 • As is quite evident, the whole exams rather
disproportionately on your ability to
present the morning cases well.
• Try not to worry too much about evening viva,
as it doesn’t make sense on any level.

4.What weapons do I need to

carry to the exam?
• Try not to make the simple technical mistake
of not taking what’s relevant for the exam.
• A torch, measuring tape, stethoscope,
illuminoscope, knee hammer, tuning fork,
tourniquets, disposable tongue depressor
among others.
• Try to carry a clip-board (exam pad) as it can
help writing the long case.

5.How should I be dressed?

• Try wearing a mild coloured shirt that is a bit
easy on the eyes rather than bright colours
intending to send a message.
• Make sure apron is neat and if possible new,
we do not want ugly blood/bile stains all over it
although it may suggest how hard you worked
during your residency.
• Personally, I have an apron reserved only
for such “festive occasions” as exams.
• Make sure your shoes are formal ones ( not
the ugly sneakers, heavy woodland ones !!), if
possible polished ones.
 • Make sure you wear your registered number
tag on your apron, it should be bold and
legible.

6.Anything else with regards

to appearance?
• Keep the hair short, shave and look well
mannered and well behaved however
“jungly” you may be inside.
 
Alright that’s enough of
introduction to the exam!
Let us move to the core ….
 
1.How to approach a long case
in surgery?
• By far the “CORE” of the exam.
• I hate to say this but the exam is highly subjective
and unevenly balanced on your ability to get
this one case right.
• So be careful not to do blunders here.
• Time is money or marks in this case.
• You will have 45 minutes I believe to introduce
yourself, examine, write down the whole thing.
• My suggestion is finish the whole examination in
25 minutes. Yes, it is possible if you know what to
look for.
 • Spend a solid 15-20 minutes in writing up the
case in the answer sheet given.
• DO NOT spend more than required time on
examining, you will screw up the writing part and
end up showing a sorry face to the examiner.

2.What are the routine long

cases?
• This can vary from place to place but overall some
are constant.
• Abdominal mass ( RIF mass, organomegaly i.e.,
liver, spleen, kidney, mesenteric cysts etc)
• Inguinal hernia.
• Varicose veins may or may not be associated with
skin changes and ulcer in the same limb, don’t
forget to check the other limb too.
• Peripheral vascular disease. ( Mostly lower limb, in
case upper limb PVD is given as a case, try to
include elevated arms stress test, Adson’s test and
Allen’s test)
• Thyroid mass ( STN, MNG, hyper/hypothyroid, with
neck nodes)
• Breast lump (most likely a malignancy)
• Oral cavity malignancy.
• Obstructive jaundice with or without mass.
• Parotid swelling.

3.How to go about history taking

?
 • History of present illness if by far the “heart” of
the whole case.
• It should include the whole situation in which the
patient is in now, followed up with history of
aetiology (conditions which can lead to the
present event) and history of complications if
untreated for the same.
• For example, patient has varicose veins for now
and presents with aching pains, ulcers, engorged
veins etc.
• Be careful to include history of hospitalisation
(DVT?), penetrating trauma, prolonged standing
etc.
• Add complications in negative history, bleeding,
ulcers, deformity, discolouration etc.
• Any case history should go with these 3
components, present, past and the future.

4.Anything else in history

taking?
• The chief complaints are all one liners, don’t tell
the whole story here. No one has time.
• For example, pain and swelling in right lower limb
since 5 months.
• That’s it!! End of story, do not prolong it
unnecessarily.
• In the past history, try to add previous hospital
admissions for the similar complaint or
surgeries in the past.
• Try to include other vascular causes of death in
family like MI, CVA, CAD, CKD, mesenteric
 ischaemia in case of peripheral vascular disease
lower limb.
• Drugs and allergies history if can be added at the
end would be great.
• Social history suggestion level of activity limitation
can give the examiner an idea of how severe the
disease is.

5.How to wrap up history?

• More often you may asked to summarise your
history.
• There is no need to panic, try getting all the
positive points which will point to a specific
pathology or area for further physical exam.
• Try not to be too lengthy but at the same time don’t
miss out on the important facts.

6.What really matters in General

examination?
• Now it all depends on which case you are allotted,
an examiner is unlikely to bother you about
detailed general examination in case of a
inguinal hernia which is more of a localised
pathology.
• However in cases of endocrine disease (thyroid),
abdomen cases (build and nourishment may be
affected in chronic cases), malignancies overall
tend to leave their mark systemically, hence the
importance of general exam.
 • Try including details about height, weight, build,
overall wasting if any, be thorough with how to look
for palor, clubbing, cyanosis etc
• I was asked what the BMI of the patient was!!
(Seriously?!)
• Eye signs if significant, tremors etc for a thyroid
can be included in this area as they are important
rather than putting them at the end.
• Make sure you do a quick head to toe
examination so as not to miss anything important.
Takes hardly a few minutes.
• Don’t forget the face, feet and hands as they yield
some critical information in a few cases.

7.How to start off local

examination ?
• Give a general caution as to which area of the
body you are starting off examining.
• “Local examination of venous system of right lower
limb” would be a great start rather than starting
randomly with inspection.
• Try not to “forget” which side the pathology is
on!!
• I remember a friend of mine during MBBS putting
forward a rather good presentation of hernia only to
forget which side it was on in the end!!
• In case of paired areas ( ears, eyes, limbs,
breast ), always examine the normal side first
and compared the diseased area with the “patient
normal”.
8.What is importance of patient
position in clinical exam?
• Unfortunately, at times you are asked to
demonstrate clinical signs at the bed side, try
not to look scared and confidently examine. ( I
know it’s not easy !!)
• Stand on right side of patient at all times.
• Full extent of inguinal hernia and varicose
veins can only be appreciated in standing
position.
• Positioning yourself appropriately to the level
of pathology for inspection is key.
• For thyroid, sit in front of the patient for inspection
and palpate from behind.
• For hernia, reduce the swelling in lying down
position, make the patient stand up and check for
impulse.
• For varicose veins, milk the veins in lying down
position, elevate the limb, apply tourniquet and
demonstrate incompetence in standing position.
• For breast, inspect in sitting position and palpate in
semi recumbent position ( breast tissue pathology
is well appreciated by palpation against chest wall).
• For PVD, whole inspection and palpation can be
finished in supine position.
• For examination of abdomen, supine position
should be good enough, try not to scare the patient
or be over aggressive in palpation as abdominal
wall relaxation is key to successful palpation.
SPECIFIC CASES

1.SWELLING
• I tried to include this first, as an ability to describe
a swelling properly will practically get you half
way through exam.
• Abdominal lump, thyroid mass, breast mass, neck
swelling, hernia all of which have swelling in
common.
• Start with 6″S” in inspection, try not to forget
temperature and tenderness in palpation before
anything else, focus on margins, consistency,
surface.
• In case inspection doesn’t yield much information,
don’t hesitate to say              ” Swelling could
only be vaguely be made out on inspection”,
saves time!
• Plane of swelling is important to elicit in palpation,
it differs for each case.
• Add fluctuation and transillumination for hydrocele.
• Reducibility and expansile impulse for hernia.
• Percussion and auscultation may not yield great
information in most cases.
• Never forget neuro-vascular status and lymph
node status for any case involving extremity.

2.ULCER
• Base, edges, discharge, surrounding area.
• Read up different classifications of ulcers in Das.
 • Don’t forget neuro-vascular status as it gives clue
to the type of ulcer.

3.INGUINAL HERNIA
• Don’t be disheartened seeing a inguinal hernia in
exam, it is much better than a abdominal lump
with complicated diagnosis.
• History of chronic raised abdominal pressure is
key, more so if bilateral.
• Deep ring occlusion is most important to
differentiate direct from indirect, practically I felt
palpating the femoral artery and tracing the deep
ring above the inguinal ligament was more
practical than the mid inguinal point.
• Ziemann’s test is useless and overrated, so is
finger invagination.
• Don’t forget reducibility and expansile cough
impulse.
• Relation to pubic tubercle differentiates inguinal
from femoral.

4.HYDROCELE
• Getting above the swelling, commenting on penis
and rest of scrotum, whether testes is palpable,
fluctuation, transillumination are all important.

5.THYROID
• Functional status, history suggestive of
malignancy if any should be included in history.
• Eye signs, tremors etc should be included in
general exam.
 • Plane of swelling, position of trachea, carotid
status, number of nodules (MNG vs STN),
movement with deglutition, neck nodes if any.

6.PAROTID
• Won’t extend above zygomatic arch, present
around the ear.
• Comment on status of facial nerve, oral cavity
examination for deep lobe enlargement, duct
opening, status of lymph nodes, bimanual
examination.

7.SUBMANDIBULAR
• Marginal mandibular and hypo-glossal nerve
status.
• Lingual nerve (touch sensation), opening of duct,
bimanual exam to differentiate node from gland.

8.BREAST
• Compare always with normal breast.
• Add staging at the end in diagnosis.
• Inspect with sitting, arms raised, against hips,
leaning forward to accentuate the lump and check
restricted motility from pectoral involvement.
• Don’t forget infra-mammary fold and axilla
exam.

9.ABDOMEN
• Inspection cannot yield much information, as
time is limited focus more on palpation.
 • Normal liver can only be percussed.
• Palpation for enlarged liver and spleen both start in
right iliac fossa.
• Knee elbow position can help differentiate inta-
peritoneal from retro-peritoneal swelling.
• Only swellings in upper abdomen with some
relation to diaphragm move with respiration,
not all!
• Amount of fluid to be present in abdomen for
puddle sign, shifting dullness, USG etc.
• Don’t forget external genitalia, per rectal exam,
spine and supra clavicular fossa.

10.PVD
• Look for signs of chronic arterial insufficiency
affecting hair, nails, skin of the limb involved.
• Comment regarding extent of gangrene.
• Capillary refill, venous refill / guttering cannot be
elicited in established gangrene ?!
• Pulses palpation is “heart” of vascular
examination, remember how to palpate each
pulse, against which bony landmark, alternate
methods etc.
• Revise Fontaine classification, ABPI, CLI etc

11.VARICOSE VEINS
• Describe ulcer and skin changes in inspection if
present along with enlarged veins.
• Trendelenberg, Perthes’, tap test, tourniquet test
are most useful. Don’t spend too much time on
other tests as they can’t add much to diagnosis.
 • Revise CEAP classification, treatment modalities.

SHORT CASES
1. Most likely these will be 2 worth 50 marks each.
2. Swelling and ulcer is usual combination.
3. Needn’t write anything.
4. I believe time is 15 min each.
5. If you think you will forget important details, write them
down on an additional but needn’t submit it.
6. Focus on positive history and positive findings.
7. Don’t get disheartened if long case goes bad, short
cases can save your day!
8. Don’t waste too much time on general examination.

EVENING VIVAS
1. Very likely, the examiners will be hypoglycaemic and
tired at the end of the day and  I wouldn’t recommend
spending too much time preparing for these vivas.
2. Be prepared to answer common surgical procedure
steps like appendectomy, hernia repair,
cholecystectomy etc.
3. Most likely, the X rays and specimens are likely to be
repeated from last year, so gather information about
them from seniors and prepare from Makhan lal.
4. Instruments are more likely routinely used ones,
common questions include full name, how to sterilise,
uses etc.
 
VIVA FOR LONG /
SHORT CASES
1. Most likely once you present the diagnosis, the
discussion will be in terms of differential diagnosis,
investigations and treatment.
2. For differentials, start with most common ones and
relevant ones not unusual, unknown diagnoses.
3. Try to justify why you came such diagnosis
conclusion based on your findings.
4. Investigations can roughly be divided to biochemistry
(electrolytes, lipase, LFT, RFT, RBS etc), pathology
( CBP, histopath, FNAC, biopsy etc), radiology
(Ultrasound, doppler, CT/ MRI), microbiology (wound
culture, blood culture etc).
5. Start with simple tests and work your way up ( USG
before CT).
6. Non invasive tests before invasive ( MRCP should be
good enough for diagnostic purposes compared to
ERCP).
7. Don’t blurt out random, fancy investigations
( Radionucleotide scan for thyroid ). They have very
specific indications and try to limit your answer to those
alone.
8. Treatment should involve multi modal approach with
more focus on surgery.
9. For all malignancies, include the word multi
disciplinary meeting prior to outlining treatment
protocol. ( It includes possible radiation and chemo
along with surgery ).
 10.If acutely sick, focus your initial treatment on
resuscitation rather than jumping to surgery directly.
11.Don’t forget to remember common post-op
complications for each case. Try to divide them as
early and late.
12.Don’t forget to mention analgesia, antibiotics, IV
fluids either in pre op or post op setting as need be.
For a PVD with rest pain / pancreatitis, analgesia is
very much important.
13.I distinctly remember a professor from UK mentioning 3
types of surgery for any case. They are open
surgery, laparoscopic surgery and “NO” surgery.
Take into account age and co-morbidities along with
perceived benefit of the procedure before embarking on
surgery.
 

LOG BOOK AND

THESIS
1. I don’t wish to say that these 2 are absolutely useless
during the exam but things may not go your way all
times hence make sure that you finish your log book
with appropriate signs and stamps well in advance.
2. Be prepared  to answer questions regarding your thesis
although this is highly unlikely.
 

OFFBEAT!!
 1. Be generous in contributing to the department fund
which is supposed to be used to take care of externals.
2. A well relaxed, happy external examiner is always a
good thing!!
3. Make sure the postgraduate / senior resident allotted to
pick up and drop the examiners is a sensible person
who knows how to speak appropriately.
4. Please don’t get me wrong as I am not trying to suggest
anyone to do anything illegally, but to make sure no
untoward event happens due to trivial reasons.
5. Try not to spend your lunch break prior to evening
vivas eating a heavy meal, rather have a quick
snack and get back to read up the instruments and
specimens.
6. Be well rested and have a good breakfast before going
to the exam, it’s going to be a long day!
 
What if I fail inspite of
everything???
1. I did. TWICE. Once for MRCS clinical part and again
for MS exam.
2. Nothing happened, took both the exams again and
passed them with a better score actually!! ( The score
for MS exam second time is I believe the highest in
recent years and is likely to stay so for quite some
time )
3. Life always gives you second chances, TILL YOU
DIE!! MS exam is all but a tiny bump.
4. Try to join as a senior resident in some good place
where you still find adequate time to study even after
work hours.
 5. Focus on your previous mistakes and think of how to
overcome it.
6. I know all this is better said than done ( I distinctly
remember being engulfed with so much rage to tear
apart the answer sheet and shout out loudly while
answering initial few questions of paper 1 for
theory exams. But again, life is never fair! )
 
GOOD LUCK ALL !!!
MAY THE FORCE BE WITH YOU !!
 
Feedback is highly appreciated. I would take it seriously if
you have something nice to say and even more seriously if it
is not so !
Feel free to contact me at
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For more answers related to MRCS / Surgery in general
• Quora Megharaj Kesha
• Osmania Alumni Facebook page 
 

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