MRCS Part B Revision · Physical examination
RIF Pain — MRCS Part B Physical examination
By Dr Richard Miller, MBChB FRCS · Reviewed
RIF Pain 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 RIF Pain station
Introduce
Introduce and explain that you are going to examine the abdomen.
Exposure: Nipples to knees (in practice use a sheet to cover external genitalia and maintain dignity.)
Position: Lower bed flat, with patient resting on one pillow. Arms by sides.
Inspect
Distension, scars. drains and stomas (follow the drain and see what is draining and identify the type of stoma), masses, vessels, striae, hernias.
Ask the patient to raise their head off the pillow, breathe in and out, suck their tummy and give a cough. As they do this look for herniae and diversification of the herniae.
Palpation & Percussion
Assess for a triple A by placing hands either side of the umbilicus.
Feel for hernias in the inguinal region and ask patient to cough.
Squat by side of bed so patient’s abdomen is at eye level.
Look at the patient’s face and begin light palpation at the point farthest from pain. Palpate in four quadrants. Once your have palpated lightly repeat pressing more firmly.
If you suspect any herniae ask the patient to cough and follow the detailed hernia exam detailed later in the text.
Palpating a mass: feel for size, shape, surface, consistency, mobility, pulsatile nature, movement with respiration.
Liver: begin in the right iliac fossa, exert gentle pressure and ask the patient to breathe in and out. With inspiration drift your palm upwards towards the liver.
Percuss the liver – map out the upper and lower borders of liver by sequential plapation.
Map out the top from the resonant lung field and then the bottom of liver from the right lower quadrant.
Normal: Around 5th IC midline to costal margin.
Spleen: begin in the right iliac fossa below the umbilicus. Ask the patient to breathe in and out moving towards the left costal margin.
Percuss the Spleen - percuss from the umbilicus to the left costal margin.
Kidneys: Place your left hand behind the right loin. Place your right hand at the costal margin. Push down with your right hand balloting the kidney. Repeat for the left kidney.
Percussion
Ascites – Percuss centrally, from the umbilicus to the flank on the left side. Ask the patient to roll towards you and percuss their back if ascites present.
Auscultate
Listen for 15-20 seconds for bowel sounds
Listen for renal bruits – press down firmly a few cm above the umbilicus at the lateral edge of the rectus muscle.
Listen for femoral bruits over the femoral pulse.
State to Examiners
That you would examine the external genitalia, dipstick the urine and perform a PR examination.
Top Tips
• Never forget a pregnancy test and gynecological causes of abdominal pain in the female patient.
• Always avoid causing the patient unnecessary pain. For example in this case examining for shifting dullness would cause pain and is unlikely to provide clinical benefit.
• If an elderly patient presents with iliac fossa pain ensure you feel for an abdominal aneurysm.
What are you asked at the RIF Pain station?
The station runs to 13 questions over nine minutes. These are the questions as they are put to you; the model answers are in the question bank.
- Although the patient has a level of underlying pain she is comfortable enough to be examined. You have washed your hands, introduced yourself and explained what you are going to do. Please perform an appropriate abdominal examination. Examination: RIF Pain
- Explain how you would introduce yourself
- Explain how you would expose this patient and how you would begin your examination
- The patient has a dry tongue, a strong but fast radial pulse. There are no stigmata of chronic disease. Examination of the abdomen reveals localized peritonism over the RIF and Rosvings sign is positive. No organomegally is found. How would you close the examination?
- What is your differential diagnosis?
- What is your immediate management plan?
- What investigations would you request?
- What are your management options?
- If during an appendicectomy the appendix appears normal which other structures should routinely be sought for/viewed?
- Describe the anatomical layers one would encounter when approaching the appendix during open removal?
- Why does the classical pain of appendicitis move from the umbilicus to the RIF?
- Discuss the principles behind laparoscopic port site placement during an appendectomy?
And 1 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 RIF Pain station ask?
It opens with "Although the patient has a level of underlying pain she is comfortable enough to be examined. You have washed your hands, introduced yourself and explained what you are going to do. Please perform an appropriate abdominal examination. Examination: RIF Pain" and runs to 13 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