MRCS Part B Revision · Physical examination
Neck Lump — MRCS Part B Physical examination
By Dr Richard Miller, MBChB FRCS · Reviewed
Neck Lump is a physical examination station. Three of the seventeen examined stations in the MRCS Part B OSCE are physical examination. The physical examination stations ask you to examine a real patient or a simulated one to a clear sequence, interpret what you find, and present it.
What you need to know for the Neck Lump station
With all examinations first expose the patient, then inspect and examine before going on to comment on important additional points. Thank the patient, and offer the help them get dressed.
Inspect from the front, back and sides, when the patient swallows and when they protrude their tongue.
Site of lump
• Midline, supraclavicular
• Size
• Skin changes
• Scars
Protrusion of the tongue
• Ask patient to open mouth and stick tongue out as far as possible
• Moves on protrusion = thyroglossal cyst (related to base of tongue by patent fibrous track running from the central portion to the hyoid bone)
• Does not move on protrusion = thyroid lump
Swallowing
• Place glass of water in the patient's hands
• Ask to take sip of water, hold in mouth, swallow
• If moves on swallowing = thyroid gland issue / thyroglossal cyst
Palpate
1. From the back
• be gentle, watch for discomfort
• Use fingertips (obviously!) to elicit physical signs
• Demonstrate the boundaries of the triangles of the neck
2. Palpate the triangles
• Anterior triangle: anterior border of Sternocleidomastoid, midline, ramus of mandible
• Posterior triangle: anterior border of trapezius, clavicle, posterior border of sternocleidomastoid
3. Determine whether the lump is solid or cystic
4. Confirm your findings (if necessary) by examining from the front
Auscultation
1. Thyroid bruit (Grave's thyroiditis)
2. Carotid bruit (carotid stenosis)
Differential diagnosis of neck lumps in anterior triangle – area of the neck anterior to sternocleidomastoid:
Lymph nodes
Lipoma – painless / smooth mass
Sebaceous cyst
Salivary gland swelling – doesn’t move on swallowing
Branchial cyst – present from birth – noticed in early adulthood when it manifests as an infected neck lump
Carotid aneurysm – pulsatile mass – bruit present on auscultation
Carotid body tumour – transmits pulsation – can be moved side to side but not up and down (due to carotid sheath)
Laryngocele – reducible tense mass – mass returns on sneezing or nose blowing
What are you asked at the Neck Lump station?
The station runs to 14 questions over nine minutes. These are the questions as they are put to you; the model answers are in the question bank.
- The patient is comfortable, you have washed your hands, introduced yourself and explained what you are going to do. Please examine this ladies neck. Examination: Neck Lump A
- Explain how you would introduce yourself
- Explain how you would expose this patient and how you would begin your examination
- Describe what you see
- What would you do after general inspection?
- 2.5cm hard uninodular swelling. Right lower anterior triangle. No fixity to the overlying skin. No pigmentation or ulceration. Moves with swallowing. No movement with tongue protrusion. Fine tremor Atrial Fibrillation at a rate of 95 What is your differential diagnosis?
- As part of your work up, you order Thyroid Function Tests. These reveal a low TSH with a high free T4 and T3 confirming a Hyperthyroid state. Can you describe the mechanism of production of T3 and T4 through the release of TSH?
- What further investigations would you like to use to further assess this swelling?
- How will you manage this patient?
- What are the boundaries of the anterior triangle?
- The pathology report notes the presence of severe dysplasia with invasion of the basement membrane of the Thyrocytes. Following CT imaging and discussion with the patient, you take informed consent for a Total Thyroidectomy. What General and Specific complications to the operation will you consent the patient for?
- How would you distinguish between the different types of malignant disease of the thyroid?
And 2 more at this station.
How is the physical examination station marked in MRCS Part B?
A physical examination station is marked out of 20: 8 marks for clinical and technical skill, and 4 each for clinical knowledge and its application, communication and professionalism. More than half the marks therefore sit outside your knowledge of the condition, so a silent but technically correct examination scores poorly. You are signalled at six minutes of the nine to present your findings.
FAQ
What does the Neck Lump station ask?
It opens with "The patient is comfortable, you have washed your hands, introduced yourself and explained what you are going to do. Please examine this ladies neck. Examination: Neck Lump A" and runs to 14 questions over nine minutes. A physical examination station is marked out of 20: 8 marks for clinical and technical skill, and 4 each for clinical knowledge and its application, communication and professionalism. More than half the marks therefore sit outside your knowledge of the condition, so a silent but technically correct examination scores poorly. You are signalled at six minutes of the nine to present your findings.
How many examination stations are there in MRCS Part B?
Three of the seventeen examined stations are physical examination. The number was reduced from four when the exam moved from eighteen stations to seventeen, implemented from the October 2020 diet.
How is a physical examination station marked?
Out of 20, with 8 marks for clinical and technical skill and 4 each for knowledge, communication and professionalism. The station also receives a global rating of pass, borderline or fail.
When do I present my findings?
At six minutes of the nine you are signalled to present. Rehearse the examination to finish inside six minutes, because the presentation carries marks that a rushed or truncated one will not earn.
How many stations are in the MRCS Part B OSCE?
Seventeen examined stations of nine minutes each, with a minute to read the task before each one. Two preparation stations and at least one rest station bring the circuit to about twenty, and the exam takes about three and a half hours.
What is the pass mark for MRCS Part B?
There is no published pass mark. The cut score is set separately for Applied Knowledge and Applied Skills, for each circuit, by borderline regression. Published pass rates across the 2024/25 diets ranged from 51% to 66%.
Can I fail a station and still pass?
Yes. There is no rule about how many stations you may fail: the cut score applies to your total mark in each component, so a weak station costs the marks you lost on it and strong stations elsewhere can make them back. Applied Knowledge and Applied Skills are passed separately and must both be passed at the same sitting, so a strong anatomy performance cannot rescue a weak communication one.
Dr Richard Miller, MBChB FRCS
Station summaries are reviewed against the current intercollegiate MRCS syllabus and the published marking blueprint. Guidance changes between diets: check the royal colleges' own pages before relying on a date, a fee or a threshold.
Practise this station
The question bank carries the model answer to every question above, with the rest of the physical examination stations.
More physical examination stations