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Advice from senior doctors
- See patients in small groups and offer feedback on the examination - reinforce the positive and highlight how to correct any omissions or deficiencies.
- Try to imagine how your examiners may think about a particular case.
- Common things are common - I am sure that you have seen the "Cases for the MRCP" books. These books detail the common conditions seen in the MRCP clinical examination and is equally applicable to the Final MB examination. Remember however that the MRCP is a postgraduate exam, and you should not get bogged down with the small print when preparing for finals.
- From a surgical point of view, most of the cases will be in-patients and therefore a knowledge of stomas, wound types, etc. would be important.
- Know the common signs of liver disease, causes of jaundice, finger clubbing etc. Examiners have to source most of the patients from the wards.
- Try an abbreviated history taking station eg. take social history from someone with AIDS; offer a problem list for a patient.
- Listen to the instructions clearly: "Examine cardiovascular system" is different to "Auscultate the praecordium".
- "What do you see when you look at this patient?" This type of question is a nightmare to the unprepared. State the simple things - it is unlikely to be a trick for Final MB.
- Spend as much time as possible in the clinical environment seeking out and eliciting clinical signs and practising history taking and presentation.
- Always prepare a differential diagnosis (with Pros and Cons for each suggestion)
- Become skilled at suggesting rational investigation plans for any case you see.
- Consolidate the pharmacological and therapeutic knowledge to which you have been exposed over 4 years. It is an integral part of every case you see and will be a topic tested in the clinical final assessment.
- Use your overseas elective and your job shadowing to improve your clinical skills as suggested and to refine your ability to communicate accurately and with compassion with patients and relatives.
- Above all be prepared to identify and act to correct your own deficiencies by seeking help and advice.
The clinical finals in 'Medicine and Surgery' consist of three clinical examinations:
- History Taking Examination (Long Case): lasts one hour. The cases will come from Medicine, Surgery, Psychiatry or General Practice. The examiners will observe you taking a history from a patient for 20 minutes. You then have 20 minutes to complete the examination, following which the examiners will return and discuss the case with you. Please note that patients rarely have only one clinical problem and it is not uncommon for patients to have medical, surgical and psychiatric problems.
- Clinical Examination (Minor Cases - Set One): lasts 30 minutes. There are two examiners (from Medicine / Surgery / Psychiatry / General Practice) and each examiner will lead for 15 minutes.
- Clinical examination (Minor Cases - Set Two): lasts 30 minutes. There are two examiners (from Medicine / Surgery / Psychiatry / General Practice) and each examiner will lead for 15 minutes.
History Taking Examination
This component tests your ability to take an accurate history, complete a relevant examination of the patient (in the time allocated), prepare a list of the patient's problems, formulate a diagnosis and list of investigations, and prepare a management plan. The emphasis is on your clinical critical analysis skills. Patients may not have any physical signs. You will be expected to discuss how you would manage this particular patient. It is helpful to reflect on all the patient's problems. Students should ensure that they cover all the relevant aspects of the clinical history (history of presenting complaint, past medical history, family and social history, drug history, systematic questions). If you have difficulty in establishing the history of presenting complaint, do not spend all 20 minutes on that aspect; after ~10 minutes, explain to the patient that you will return to this part of the history later and then cover all the other aspects of the history.
Use about 3 - 5 minutes of the 20 minutes allocated for examination to reflect on the patient's problems and how you would manage them. If you have been unable to complete a full examination, then simply tell the examiners that time was insufficient. For example, if the patient does not have any neurological symptoms, it is probably unnecessary to carry out an exhaustive examination of the various modalities of sensation. Prepare your problem list. When the examiners return be prepared to produce a very short summary and list of problems. The examiners do not wish to hear the complete history again, as they have already been present for the initial 20 minutes when the history was being elicited. It is very disconcerting for examiners to return to the bedside to find the student is still carrying out aspects of the examination and that they can barely remember the history, never mind produce a problem list or start to formulate a management plan - see below for case scenario.
Clinical examination
This component tests your ability to elicit physical signs, interpret the signs and discuss investigations and management. All of these components are important. It is important to have the opportunity to examine several patients / systems. For this reason, you will not be asked to carry out a full examination of a particular system. It is more likely that the examiners will ask you to auscultate the praecordium, examine the neck, assess the thyroid status of a patient etc. You will be assessed on your technique and it is important not to cause any discomfort to the patient.
General Advice - Summary
- Think before you speak
- Major Case:
- 20 minutes with the examiners: ensure that you cover all the relevant components of the history.
- If the patient's presenting complaint is complex, after ~10 minutes leave it, take the other components and then return to the main problem later.
- During the 20 minutes of examination time use at least 3 minutes to collect your thoughts and prepare your problem list / think about how you would manage this patient.
- Do not regurgitate the history as the examiners have been present during the history taking - the examiners are interested in your interpretation of the clinical problems.
- If you do not understand the question, seek clarification.
- If you do not know the answer to a question, simply state this and try and get to an area of questioning which suits you.
- Minor Cases:
- Use the 15 - 20 secs before you finish the examination to formulate your thoughts.
- Do not delay too much as it is best if you see a reasonable number of cases.
- It is not uncommon for patients to have multiple physical signs affecting several organ systems, so do not worry if you spend a long period with one patient.
- Remember the examiners are on your side.
- They are not trying to trick you.
- This is the last examination where the pass rate will be somewhere between 95 and 100%!
Case Scenario
HPC: 56 yr old man presents with chest pain on exertion. He has several risk factors for atherosclerotic disease, including smoking and diabetes mellitus. He has a history of amaurosis fugax 2 yr ago. He works as a taxi-driver, consumes 40 units of alcohol per week and lives in a 4th floor flat.
Examination: BP= 170/96, left carotid bruit, ejection systolic murmur.
Create a Problem List:
- Chest pain ? Angina
- Smoker
- Diabetes mellitus
- Hypertension?
- Left carotid bruit and.History of amaurosis fugax.
- Systolic murmur ? Aortic stenosis
- Occupation
- Alcohol excess?
- Social
For each problem, think how an examiner may wish to pursue questioning:
- Chest pain ? Angina:
- Differential diagnosis
- Features to support diagnosis of angina
- Investigations
- Management
- Smoker:
- Diabetes mellitus
- Is there evidence of microvascular disease? (eg Fundoscopy, peripheral neuropathy)
- Oral hypoglycaemic agents / insulin
- Hypertension?
- How would you investigate someone with hypertension?
- How would you treat someone with hypertension?
- Left carotid bruit and Hx of amaurosis fugax
- How would you investigate?
- Systolic murmur
- ? Aortic stenosis - ? How to investigate
- Occupation
- Relevance of diagnosis to driving (DVLA) regulations
- Alcohol excess?
- Assessment of alcohol dependence
- Social
- Social worker, re-housing, etc
The following notes give a brief outline of what happens and what is likely to be expected of you if you encounter Psychiatry cases in either the Clinical 'Short Case' or 'Long-Case' examinations in June. Approximately 20% of students are likely to meet a Psychiatrist for one or other part of the clinical examinations.
Sometimes students have feared that this may disadvantage them but there is no evidence from the marks that this is so. There are a number of occasions where one of the main prizewinners has had their 'long case' in Psychiatry. I can also say from many years of examining 'short cases' that the level of agreement between the Psychiatrist and the Surgeon is very high: adequate clinical acumen is readily assessed whatever the type of case you are seeing.
The notes that follow summarise what students will be told during the Psychiatry/Psychopharmacology Revision half-day in January. In this programme one session is devoted to discussing the details of the 'short' and 'long' cases.
Final MB Short Case Examination
In the 'short cases', Psychiatry (as part of Medicine) is generally paired with Surgery. Thus you spend 15 minutes on Surgery and 15 minutes on Psychiatry. Both examiners mark both sections and their agreement, as above, is generally good.
The Psychiatry 'cases' take two forms. First, you may be asked to elicit some aspect of the history or mental state of one of the patients brought to the ward as a medical or surgical 'case'. Many of these patients have some recent or current relevant features. (On one occasion Dr Cooper and Prof Deakin, the External, during a 15 minute pre-examination recce of the patients in the exam ward, identified significant symptoms in 7/10 surgical cases and the symptoms had been unrecognised by anyone in 6 of these!). When we use these medical and surgical 'cases' we will ask you to elicit a fairly specific aspect of the history or mental state, so listen carefully to what you are asked to do. (Don't start asking about 'first rank symptoms' when you have been asked to assess the patient's mood.) You will be asked to describe your findings and remember, where appropriate, to give a general description of the appearance and behaviour of the patient. You are then likely to be asked about other associated or relevant features and/or the implications of what you have elicited.
The other main form of the Psychiatry 'cases' is the videos. We produce a videotape (in future hopefully a CD ROM) of short clips of interviews with a wide variety of patients. Usually you will watch one of these for around 2 minutes and then be asked to describe the patient's phenomenology and/or behaviour. Again you will be expected to discuss the implications of this. Thus, you can expect anything from anxiety to psychosis to aspects of epilepsy and much more. Most students will get through about three different clips during their Psychiatry cases.
Final MB Long Case Examination
Below is a one page briefing that will be given to every student to read just before they go into the Psychiatry 'long case' examination. You will not be allowed to take this into the examination with you but it indicates what happens and what you are expected to do.
Student Aide Memoire for psychiatry long case:
You will have one hour with the patient followed by 10 minutes in which to sort out your findings, make a brief summary of these and consider your management plan for the patient. During your hour with the patient, the Examiners will spend 5 minutes sitting in on the interview.
Following this you will have a 20 minute oral examination. The Examiners will ask you to present the History of Presenting Problem/Illness and Mental State and to summarise the relevant details relating to other aspects of the patient's history and examination. They will then discuss these with you and ask you to discuss diagnosis, investigations, management and any other aspects of the case they feel are important.
Below there is a brief outline of the main headings which you should cover in the assessment of a Psychiatry Long Case. Clearly there are a variety of items to be covered under each of these headings and the extent to which any of these are covered will vary according to the individual case.
There may sometimes be relevant issues which do not fit neatly into one of these headings. Such issues should be included in your summary of the case to the Examiners. Do not leave out something important just because it does not seem to you to fit into one of the headings given.
Main Headings for psychiatry long case:
- Principal problems / Reason for referral (Not always possible to ascertain this accurately from the patient in psychiatric cases.)
- History of present illness.
- Past medical/psychiatric history.
- Current and previous treatment.
- Family history.
- Personal history.
- Previous personality.
- Mental state examination.
- Physical examination - only if there is some indication from History and Mental State that this may help in assessing the case. (If you do feel it is necessary, it should only be of any relevant body systems. It does not have to be exhaustive and should not involve the removal of clothing.)
YOU MAY *NOT* TAKE THIS INTO THE EXAMINATION WITH YOU
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